Our case management program and what it means for our members

Most seemingly minor health symptoms don’t signal a serious medical problem. But sometimes they do. Elizabeth Franklin, Aaron’s mother, believed her son’s exhaustion was just his adjustment to middle school. A new routine, harder classes, the pressures of entering young adulthood. But when exhaustion turned into unquenchable thirst and constant trips to the bathroom, it seemed more than just an adjustment to a new routine.

Elizabeth took her son to the doctor for some blood screening. That’s when they heard that Aaron has type 1 diabetes. He needed to be admitted to the hospital immediately. “The doctor told me that Aaron wasn’t in danger, but he had to be admitted,” she said.

They spent three days at a local hospital learning how to manage Aaron’s blood sugar. Aaron learned to give himself injections and what supplies he would need. “It was very overwhelming to figure all of this out,” according to Elizabeth.

“I got insulin at our pharmacy, but I had to get on mail order for efficiency and cost,” Elizabeth said. She struggled to get on mail order. Doctors said they faxed the appropriate information to the mail order service. However, the insulin never came.

Somewhere in the middle of back and forth conversations with doctors about mail order, Elizabeth received a call. A nurse case manager at Blue Cross and Blue Shield of North Carolina (Blue Cross NC), was on the other line.

“Case management is a service available to all Blue Cross NC members,” said Susan Baillargeon, a case manager at Blue Cross NC. “We have a lot of opportunities to help people. A parent of a child newly diagnosed with diabetes – you can imagine that’s pretty scary.”

“You try to learn about a complicated disease. Then you find out that insulin is expensive and you need tools to manage blood sugar.”

Another case manager called a local pharmacy and got Aaron insulin to hold him over until the mail order started. Susan gave Elizabeth a wealth of information about type 1 diabetes and how to manage it.

Susan, who has a background in pediatrics and home health care, says there are about 70 case managers at Blue Cross NC. Each case manager handles about 60 to 80 cases at a time. The team is also staffed with case managers who specialize in social work, diet and behavioral health. “A big part of the job is to provide resources,” Susan said. “Sometimes we direct people to programs and refer to our social workers who look at community resources.”

Nurses within the Case Management program also make calls to members who have been scheduled for specific procedures. These include knee or hip replacements or coronary artery bypass surgery to provide pre- and post-operative education. They also use this time to address any questions members have prior to or after the surgery.   “It’s a great opportunity to talk about safety and how to prepare for discharge,” Susan said.

Susan said all cases are different and some require a weekly or monthly follow-up. “Sometimes case managers discuss the basics like taking a new medication. Sometimes we coordinate care with different specialists, or we talk about coverage.”

“It’s a big job,” Susan said as she reflected on an experience with one member. Susan had connected with her after she was diagnosed with breast cancer. Susan provided case management throughout the member’s chemotherapy, radiation and surgery until finally she became cancer-free. “You can’t cut them loose in the middle of their health care journey,” Susan said.

The process to connect with a case manager is simple. If a member has a planned surgery, the hospital contacts Blue Cross NC. Then, the request travels to the utilization management (UM) team at Blue Cross NC. “They’ll see that a member is going to be admitted. If it looks like a situation where case management might be helpful, they will make a referral to us,” Susan said.

It’s a little different if an event occurs that is not preplanned, like a car accident. In this case, Blue Cross NC UM staff members will be notified that a member is in the hospital. UM staff monitors the hospital stay. Where members face potential challenges after discharge or if they need rehabilitation, case managers are assigned.

Members also have the opportunity to connect with a case manager by calling the number on the back of their Blue Cross NC identification cards.

As for Aaron, he is now a freshman in high school and manages his diabetes on his own. He uses an insulin pump and is a pro at counting his carbohydrates to calculate the amount of insulin he will need.