By Sue Wilson, DBA, RN-ACM, ONN-CG
As we come to the close of CM month, I reflect on key events that led to my passion for being a Case Manager. I started as a Case Manager in the mid-1990s, working in a large academic hospital in southeast Texas. I was assigned to a Pediatric unit that specialized in Pediatric Nephrology. We had one patient who kept getting readmitted because his family could not afford his medication. Back then, medication assistance programs were not as popular as they are today, and with a limited income, they could not afford them.
After a few admissions, I struggled to figure out what I could do to help. I was fairly new to case management, and this was the mid-1990s, so there was no formalized training that we went through, but I did know I needed to try something to help this family. I called the insurance and inquired about why they would not cover this drug.
The insurance representative explained that it was not part of the benefit package they purchased, and there was nothing they could do. I hung up the phone, feeling discouraged and like a failure. Then an idea hit me, if the insurance would pay for this medication, we could reduce his re-admissions and decrease costs associated with his declining kidney function. With that, I took pen to paper, not literally, but typed a passionate letter on how making an exception to cover this drug would benefit the insurance company. I called the insurance company back and identified where I could send this letter. A few days later I received a call from their medical director. We had a pleasant conversation, and I made a promise to tell the family to add pharmacy coverage at next year’s enrollment. The medical director approved it! SUCCESS!!
Moving forward to the next day, while conducting bedside rounds with the entire team, I cheerfully told the team that the drug was now approved. The attending, who was a world-renowned Pediatric Nephrologist, asked in his baritone voice, “how did you do that”? I couldn't tell if I was in trouble for sending a letter or if I had done a good thing. I explained that despite the insurance company telling me no, I rationally considered how I could build a business case to support the need to cover this drug and how the medical director approved it with the stipulation that the family add pharmacy benefits next year. Although he did not always show emotion, he did say, “You made a great impact on this patient”. This solidified my love for case management, knowing my actions changed the life of this child.
Being that voice for your patients and advocating for them, especially when they may not know what else to do, is the greatest gift we give our patients. There are many like stories in my career, but I felt this one was the most defining since it was early on in my career. It was then that I learned how powerful this role could be, not in the authoritative sense, but in the impact on patient outcomes.
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Bio: Suzanne “Sue” Wilson, DBA, BSN, RN-BC has 35 years of nursing experience and 30 years in Case Management. She is a graduate of University of Texas School of Nursing and holds a Doctorate in Healthcare Leadership and Administration. During her multiple years as a Case Manager, Sue has served in various roles, both within the military and civilian settings and truly has a passion for what she does. Her areas of expertise include: acute care, outpatient, military, and leadership. Sue currently works at MD Anderson in Houston, Texas as the Director of Case Management. She is also a retired Colonel with the U.S. Army Reserves where she served patriotically for the last 37 years.