By Brenda Sutliff, MSN, RN
Fred has been developmentally disabled since birth. He was non-verbal and came to our hospital with a bowel obstruction due to Pica. He lived in a long-term nursing home known to have a less-than-desirable reputation, but it was one of the few places that took Medicaid patients in our area. Upon admission, we learned that the facility was now being closed due to multiple violations.
As I reviewed his case to prepare a plan for his discharge, I was surprised to find that he had visitors. We had not been aware that he had any family because he had a state guardian. These were distant relatives who were unable to care for him but still made the effort to visit. In researching his history, I knew each time he came into our facility, all he did was sit in bed with the TV on with no other stimulation. I learned from reviewing the facility's notes that he had previously walked at his facility and enjoyed coloring. This was new information. Why did we only ever have him in bed?
Staff who had had him in prior admissions tried to discourage the care team from ordering a PT evaluation. They assured me that he did not walk. I forged ahead and collaborated with the physician to order the PT evaluation. Physical therapy saw him, and the next thing we knew, Fred was walking down the hall. He would not win a race, mind you, but he was doing it.
It had also been known that he had loved to color. I spoke to our social worker, and she was able to get crayons and coloring books for him from our Child Life Specialist. Fred immediately started coloring. He brightened up, seeming to really enjoy this and no longer just sitting in bed staring at the television hour after hour. After seeing what he could do, I reached out to his guardian to begin a discharge plan that was more appropriate to Fred's needs. Together, we were able to find him a group home that was familiar with Pica care and had an opening for him. It took quite a bit of time, 96 days to be exact, but Fred was going to a real home in a place that could meet his needs.
A place where he would not sit in bed day in and day out, but would instead receive the care he needed and the interaction and programming vital to his quality of life. Hopefully, he will not come back for another surgery due to his Pica because he was going to a place where they really understood his needs. This patient remains a reminder to me to be an advocate and to learn about my patients. Never give up on finding creative solutions to meet the specific needs of the patient and to achieve the best care and outcome available. We positively impacted Fred's life, and we were effective in enhancing the quality of his life simply by taking the time to learn more about him and advocate for him. More importantly, Fred had a profound impact on me and my practice as a case manager. This episode occurred in 2010, and I still carry Fred in my memory today.
One of the most dreaded responsibilities of a case manager is having to issue a letter of non-coverage to a patient or their family. It’s the moment when the care team determines that the patient no longer meets medical necessity for acute care—or for continued stay—and the responsibility to explain that reality falls squarely on the case manager’s shoulders. I’ve encountered many of these situations over the years, but one particular case has stayed with me.
We had a long-stay patient who had reached a point where a discharge plan had been created: transfer to a nursing home under hospice care. The plan had been discussed and agreed upon with the patient and her family. Everything seemed in place—until the financial realities came to light.
The nursing home informed us that the patient had used all of her Medicare days. When we looked deeper, we discovered she had nearly exhausted her lifetime reserve days as well. She wasn’t enrolled in Medicaid. And when the topic came up, the family refused to consider it. They were adamant about not spending down assets or taking any financial steps that could impact what they felt should be protected. The patient’s family member, who also served as Power of Attorney (POA), told us repeatedly, “She has always paid her bills,” and felt strongly that asking for help from Medicaid would go against the patient’s values.
We tried to explain the reality of the situation. In the state of Indiana, Medicaid requires applicants to meet financial eligibility criteria, which include using assets to pay for care before qualifying for coverage. We explained that the patient’s assets needed to go toward her care, not toward preserving them for others. To offer additional support, we connected the family with an elder law attorney who could help them explore legal options to protect some of the assets while navigating the Medicaid application process. The attorney worked diligently with them, but even with expert guidance, the family still refused to move forward.
The discharge planner kept trying to coordinate a safe discharge, but without a viable payment source or agreement from the POA, we had no path forward. At this point, the patient no longer met medical necessity to stay in the hospital. We had to issue a Hospital-Issued Notice of Non-Coverage (HINN) for continued stay.
This was not a decision we took lightly. These conversations are hard. They’re emotional. But in the end, we must advocate not only for the patient’s care but also for responsible and appropriate use of healthcare resources.
Eventually, the situation escalated to involve the Quality Improvement Organization (QIO), which independently reviewed the case and confirmed that the patient no longer required acute care. That ruling meant the family would be responsible for the cost of the hospital stay beginning the day after the QIO’s determination.
Only after this did the family agree to move forward with the original discharge plan. The patient was successfully transferred to the nursing facility where she had always wanted to go, and the elder law attorney continued working with the family to preserve what assets they could, within the limits of the law.
This case reminded me that being a case manager is not only about coordinating services—it’s about navigating incredibly difficult situations with empathy, integrity, and persistence. Sometimes, we have to be the bearer of hard truths. And sometimes, we’re the bridge between families and the tough decisions they need to make.
It’s never easy to say “no,” but saying it with compassion—and backing it up with knowledge and resources—can help families move forward, even when the road is rocky.
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Bio: Brenda Sutliff, RN, is the dedicated Manager of Utilization Management at Lee Memorial Hospital, part of the Lee Health system serving Southwest Florida. A registered nurse with over fifteen years of experience in hospital case management, Brenda has managed care coordination across high-acuity areas including ICU, orthopedics, neurology, and pediatrics. She oversees utilization review processes, collaborates with interdisciplinary teams, and ensures alignment with regulatory and patient care standards.