Imagine being dropped in the center of a bustling city you’ve
never visited before. You have in your hand an address of where you’d like to
go, but you have no map, no GPS. The locals may speak a different dialect, or a
completely different language. Will you reach your destination quickly, if at
all? Will you get lost along the way, sidelined by wrong turns despite the best
intentions? Maybe the trip will simply be too overwhelming or tiring, and
you’ll decide to head home instead.
Having a destination and knowing how to get there can be
dramatically different, but the right guide can make all the difference. It’s
like that with “access to care,” a concept at the heart of countless stories on
healthcare reform. Without access to quality care, well people may not be able
to keep up with the preventive care they need—and sick people will get sicker.
But the phrase “access to care” is deceptively simple, touching on everything
from literal proximity to care providers, to having the right insurance plan,
to making appointments, to getting medications and understanding how to use
them. It’s the combination of having a healthcare destination and the ability
to get there. For many patients, a nurse care manager, provided through their
health insurance company, is the guide who helps make sense of it all.
Nurse case managers are essential members of some patients’
healthcare teams—especially those with complex healthcare needs. But they
aren’t your typical nurses. In many ways, they’re more like healthcare guides,
helping patients to navigate both their administrative and medical challenges.
And many patients have them on speed dial.
Think, for example, of an elderly man with diabetes. He has been
prescribed insulin, in addition to medications for other conditions. He only
tests his blood sugar occasionally, because the diabetes testing equipment is
expensive. He also struggles to afford his insulin, so he starts taking it half
as often as he should, to stretch it further. On top of it, the cost of another
medication is adding up, so he stops calling in refills. His health worsens,
but he doesn’t make an appointment to see his primary care provider, thinking
he can wait a few more weeks, though the weeks turn into months. At this point,
his prognosis isn’t good.
Now picture the same elderly man, only this time, he has a nurse
care manager. She sent a coupon for a free glucometer covered by his health
plan, so he’s on top of his blood sugar, and she was able to spend time
teaching him about the relationship between his blood sugar levels and insulin,
so he understands why stretching those insulin injections does more harm than
good. She also noticed that his new prescription should have had a $0 copay, so
she spoke with his pharmacist and then arranged for a prior authorization on
his behalf. Not only did she schedule his next doctor’s appointment, but she
called him a few days later to check in and make sure he understood the
follow-up instructions his doctor gave him. She changes the whole picture of
his long-term health.
In this context, “access” alone is almost a misnomer. Some
patients don’t just need “access,” they need education and guidance in order to
make their healthcare work for them. A variety of situations can trigger a
nurse care manager’s involvement—we often get involved after someone has been
hospitalized and is transitioning out of the hospital, or when they have
certain types of interactions with the insurer’s customer service related to
specialty pharmacy needs or other complex issues.
If you’re feeling overwhelmed, know this -- there is support for
you to help you navigate this complicated healthcare world. Nurses are here to
help beyond just the clinical elements. We’re here for you when you need
it, and though we may work for your health insurance company, we really work