By Anna Zimmerly, BSN, RN
Case management is never one-size-fits-all. Each member brings a unique story, shaped by their health history, environment, and lived experience. As a Case Manager with the World Trade Center Health Program, I recently worked with an 82-year-old female first responder whose resilience was matched only by the complexity of her medical needs.
This member, a retired Navy veteran, RN, and a first responder at the World Trade Center, lives in a rural area more than two hours from any specialty provider. Her diagnoses include asthma, rhinitis, GERD, chronic cough, obstructive sleep apnea (OSA), porphyria cutanea tachycardia (PCT), hypoxia, pulmonary nodules, and a history of acute respiratory failure. Most recently, due to acute respiratory failure, she was diagnosed with Achromobacter xylosoxidans, a rare and opportunistic pathogen that poses serious risks to immunocompromised individuals.
Coordinating care for someone with this level of complexity is never simple, especially when geography works against access. The member’s rural location meant limited access to pulmonologists, infectious disease specialists, and even basic respiratory therapy services. Her condition required urgent attention, but the logistics of travel, scheduling, and continuity of care created barriers that could easily delay treatment.
After weeks of managing symptoms remotely and coordinating fragmented care, the member’s condition worsened. She suffered from a barking wet cough, increased shortness of breath, fatigue, and mobility loss. At her local hospital, she was diagnosed with Achromobacter xylosoxidans. However, no sensitivity testing was performed. Instead, she was placed on high-dose steroids and multiple broad-spectrum antibiotic treatments that failed to address the root cause and contributed to a fall, breaking her right tibia in several places and further deteriorating her musculoskeletal health.
This moment shifted everything. What had been a slow unraveling of symptoms became a race against time to stabilize her condition and preserve her independence. The lack of precision in her initial treatment underscored the need for specialized oversight and reinforced the value of case management in bridging the gap between rural care and evidence-based protocols.
Finding resources to support her treatment plan was difficult, but I included coordinating with pulmonologists in New York and executed a visit to New York, sending her medical information from many sources, showing the overuse of multiple antibiotic therapy, and the lack of local resources. The provider set up an initial visit with the member, then set up follow-up monitoring for respiratory function and infection control. Her care plan expanded to include repeated visits (telephonic and in person) to this provider, as well as additional testing, such as pulmonary function testing and lab work, including Sed rate, CBC, and IG testing. He provided a new referral for orthopedic evaluation by her former orthopedist in Ballimore, Maryland, and physical therapy, addressing the damage caused by prolonged steroid use. I coordinated both providers and arranged durable medical equipment, as well as telehealth options, to reduce the burden of travel.
Throughout this process, I remained in close contact with the member, explaining each step, advocating for her needs, and offering reassurance. Her strength as a Navy Veteran/ RN / first responder was evident, but so was her vulnerability in navigating a fragmented healthcare system. Case management gave her a lifeline: someone to connect the dots, fight for timely care, and ensure her voice was heard.
This case is a reminder that rural members, especially aging first responders, face unique challenges that demand creative, compassionate solutions. As case managers, we are not just coordinating care—we are bridging gaps, removing barriers, and restoring dignity to those who’ve spent their lives serving others.
Behind every diagnosis is a person. And behind every person is a story worth honoring.
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Anna Zimmerly, BSN, RN, is an experienced Case Manager dedicated to navigating complex healthcare landscapes for individuals with intricate medical needs. Her work underscores her passion for advocating comprehensive patient care, particularly for medically complex and rural patients. Committed to advancing the nursing profession and case management practices, Anna is awaiting results of her Certified Case Manager (CCM) exam taken in August 2025. She is active in the Case Management Society of America (CMSA) and the Sigma Theta Tau International Honor Society of Nursing. She has also pursuing self-education in grant writing and developing provider, nurse, and patient apps.