about my wife or you’d be sending someone to help me take care of her. I can’t do it all by myself. Three days in and my back is aching from all the lifting, my knees are swelled up from all the bending, and my hips are on fire from running up and down the stairs all day.”
Kira wanted to scream, “You brought this on yourself you ornery old man, now deal with it!” But she’d always prided herself on her professionalism, regardless of the challenging circumstances. Lately circumstances had become quite challenging.
By pulling his wife—she glanced at her computer screen: Primary diagnosis: cerebrovascular accident with residual right-sided hemiparesis and expressive aphasia. Secondary diagnoses: hypertension, osteoporosis, and hypothyroidism—out of an inpatient rehabilitation facility, against medical advice, nine days into an authorized twenty-eight-day stay, he’d assumed full responsibility for her care. Before the patient’s stroke she’d filled out a Health Care Proxy designating her husband as her health care agent, giving him complete control over decision-making should her doctor determine she was unable to act on her own behalf—which she wasn’t. As a result, there’d been nothing the hospital staff could do.
“Mr. Limone, your wife wasn’t ready to come home.” He’d underestimated the amount of care she would require, despite being warned—according to hospital documentation—by the case manager, the social worker, a head nurse, and the patient’s physical and occupational therapists. “Research shows, after a stroke, patients who attend independent rehabilitation facilities for intensive rehabilitation, before returning home, show much more improvement than those who don’t.”
“She wasn’t happy there, Miss Peniglatt. She put up a fuss every time they tried to take her to therapy. She wouldn’t eat or drink.” Now, rather than an ornery old man, he sounded like a concerned old man in love with his wife, desperate to help her. “They were threatening to put a tube in her stomach. Neither of us wanted that. She kept saying, ‘home’. She’d squeeze my hand and look into my eyes and say, ‘home.’ Over and over. So I took her home.”
Kira’s heart went out to him, really, it did. But there was nothing more she could do. “Your insurance plan won’t pay for round the clock care in the home setting.”
“Who’s asking for round the clock? Millie James up the street, her mama’s got an aide six hours a day, seven days a week, and she don’t need nowhere near as much help as my Daisy.”
“Do you have any family—”
“My boys don’t live around here. And they’re busy. They got their own lives.”
Family takes care of family. Kira’s mother had been telling her that, and Kira had been doing it, for as long as she could remember.
“Is there any other insurance coverage we could help you explore?” she asked.
“We don’t have no other insurance. All we have is We Care Health Care. And we need for you to do what your ad says and be there for us when we need you. We need you!”
When marketing had proposed a change to We Care Health Care, We’ll Be There When You Need Us, Kira had voiced her concern that the slogan might feed into unrealistic patient expectations. Case in point. “Then can you afford to pay privately for a personal care aide? I could—”
“Why should I have to pay for an aide when I’ve been paying you every month for years?”
He made it sound like he paid her directly. “Mr. Limone, you pay for medical insurance coverage that does not include custodial care such as bathing and dressing provided by personal care aides,” Kira said, trying to keep calm. “What about a friend or a neighbor? Have you asked around? Maybe—”
“You sit there in your fancy office,” he snapped, “trying to think up ways to get out of paying for the stuff you should be paying for. Then you count up the huge profits you make by withholding care from people who need it and divide the money up into big end-of-year bonus checks. You’re a thief! How the hell do you sleep at night?”
Kira inhaled then exhaled. Don’t let him get to you. You do your best. You sleep fine at night. No she didn’t.
“Mr. Limone, as I explained earlier, your insurance coverage is Medicare HMO. Medicare pays for short term, intermittent, skilled care. It does not pay for personal care for bathing and dressing. We contracted with a Medicare Certified Home Health Care Agency in your area.”
With a few clicks of her mouse she brought up Mrs. Limone’s plan of care. “A nurse came to your home to evaluate your wife. She developed a plan of care that included physical, occupational and speech therapy visits. This plan of care was approved by your wife’s physician.”
Odd that no home health aide hours were recommended considering the amount of skilled services required, Kira jotted herself a note to call the agency to follow up on that.
“Well it sure as hell wasn’t approved by me!” Mr. Limone yelled. “That nurse was in and out of here in under fifteen minutes. Said Daisy wasn’t eligible for an aide. How could she not be eligible? She can’t get out of bed by herself or eat by herself or dress herself. And since that nurse left, no one’s been here. Now she don’t return my calls. You need to come up here yourself to see what I’m dealing with. I can send someone to getcha.”
“Just because I haven’t come to visit your home to see your wife for myself, does not mean I don’t care. And it doesn’t mean I don’t know what is going on up there, either. My office is located a good four hours from you. I am responsible for the case management of, as of this morning, four hundred and thirty-seven patients.” The highest her census had ever been.
“That’s why we work with your wife’s physician and contract with medical providers in your local area for home care evaluations to determine patient care requirements. If you feel there’s been an acute change in your wife’s health status since the nurse visited three days ago or if you are no longer willing or able to safely care for her at home, you need to dial 911 immediately and have her taken to—”
“Then your boss,” he interrupted. “Put me through to your boss.”
It was all Kira could do to keep from laughing. Her new, focused-on-the-bottom-line boss—the main reason she now hated her job—could care less about patient care and customer satisfaction, which put him and Kira in close to constant conflict, day in and day out, for months. It was exhausting.
Despite all of the letters that came after her name, MSN—Master’s of Science in Nursing, MBA—Master’s in Business Administration, and CCM—Certified Case Manager, the letters RN, for Registered Nurse, were the most important to Kira. They were the reason she always put patients first, the reason she sometimes had to get creative to maintain her patients safely in their homes. She could almost hear the CEO’s booming voice when he’d found out she’d agreed to reimburse a home health aide for mileage to get her to travel to a difficult to serve area. Guidelines for a reason. Cost containment...cut spending...budget...bottom line...blah, blah, blah...
Case managers straddled the line that separated compassionate patient advocacy and fiscal accountability to their employer. A job made increasingly more difficult with the stringent utilization review and cost constraints of managed care.
“I report to the CEO. He doesn’t accept calls from customers. However, we do have an appeals process I’d be happy to have my assistant initiate for you. Or, if you feel my staff or I have in any way treated you unprofessionally, we have a complaint process, which my assistant will also be happy to initiate for you. Let me transfer you now.”
Without giving him a chance to argue, she transferred the call. Then she leaned back, let out a breath, and counted to ten.
She’d made it to seven when her office door opened to reveal her assistant, Connie. Her short black hair gelled into random spikes, a tight red blouse and black skirt clinging to her ample curves, and sexy black ankle boots—with silver chains. And a frown on her pretty, round face. “That was mean.” She crossed her arms under her well-endowed breasts.
“You