Face-to-face CM is key to HIV-AIDS program
CM helps with medical, social issues
When a member of Worcester, MA-based Fallon Community Health Plan is newly diagnosed with HIV-AIDS, the first person he or she is likely to see is Rita Wesolowski, RN, BSN, ACRN, the HIV-AIDS on-site care manager.
Wesolowski works at the Fallon Clinic's division of infectious disease, where the majority of the health plan's HIV-AIDS patients are treated.
Most of Fallon Community Health Plan's disease management care managers work with their clients over the telephone, according to Wally Mlynaryk, MHA, director of disease management for the health plan.
"When we developed the protocol for HIV-AIDS, we looked at what was working in other programs. We decided that it would be more effective to work with the patients directly in the clinical setting. Rita has a clinical focus and performs nursing duties, but she goes beyond that in terms of helping patients," Mlynaryk adds.
Fallon Community Health Plan covers about 185,000 members, about 70% of whom receive services from Fallon Clinic physicians. About 85% of the patients seen at the clinic are covered by Fallon Community Health Plan.
Fallon Community Health Plan has not completed any outcomes studies for the HIV-AIDs program but has concentrated instead on delivering a higher quality of care.
"When you're dealing with quality of care, it's tough to show outcomes. Our prophylaxis rates are consistently high, which is especially important when CD4 T cell levels are low. In addition to focusing on quality, we would like to see the increase in the cost of medication offset by a decrease in overall utilization," Mlynaryk says.
Like many of Fallon's other disease management nurses, Wesolowski was recruited from the clinic setting and has been working with some of the HIV patients whose care she has managed for many years.
She is the primary contact point for HIV patients and follows an average of 160 HIV patients at a time.
The clinic gets referrals from primary care
physicians, local AIDS organizations, or self-referrals from people
who have friends who
are patients.
First contact
For many patients with HIV, a phone call from Wesolowski is their starting point in getting the health care they need.
When new patients are referred, Wesolowski calls them in advance to answer any questions and invites them to come in for a face-to-face visit with her before their physician appointment.
"We get them in fairly quickly. If they are newly infected with HIV, we try to see them within a week. Often, I can see them within a couple of days and, in many cases, I see them before their physician appointment to talk about the disease and answer any questions," she says.
Some of the patients don't have insurance or have limited coverage. Others are homeless.
"This is a group of people with an illness that has a stigma attached to it. They're not always willing to tell friends and family they have HIV. We try to help them deal with the issue and understand that they do need support," she says.
A diagnosis of HIV is overwhelming for people, she adds. "That's why I like to meet them first and find out their pressing questions," she says.
During the initial meeting, Wesolowski takes a medical history, personal history, and family history from the patient and discusses his or her health insurance and psychosocial needs.
"I can get a complete history and have it ready when they come for their first visit with the physician," she says.
She also can help them get plugged into community organizations that can help with their needs.
Each morning, Wesolowski reviews the list of patients who are coming in for a visit that day, reviews their medications, and makes sure their lab work is up to date and that they have had the inoculations recommended by national AIDS guidelines.
For instance, she checks to make sure patients have had a tetanus shot and their annual flu shots and are current on their pneumonia shots. If the patients are female, she makes sure they have had their annual Pap smear.
Typically, she sees patients with the physicians and does nursing visits on her own for minor problems, such as a sore throat, calling in the physicians when necessary.
She enters all the laboratory work in an intranet-based data registry database that allows her to keep close tabs on the patients' health.
For instance, if a patient's CT4 count falls below pneumonia, she knows he or she has an increased chance of contracting pneumonia and sees to it that the patient is prescribed an antibiotic.
As a quality initiative, she routinely pulls up lists of patients who have CT4 counts below 200 and compares it with the list of medications to make sure all of them are on preventive medication.
A month into the flu season, she checks to see which patients have not yet had their flu and pneumonia shots and calls them to remind them to come in for a shot.
If she notices that someone's virus level is increasing, she pulls up the pharmacy screen to make sure the patient has been refilling his or her medication every month.
"I take a lot of proactive measures with medication. The medications for HIV-AIDS can be extremely complicated. The whole focus here is on people staying healthy, so we make sure they are taking their medications," she says.
If patients don't take their medication correctly or if they miss doses, they are likely to become resistant to that medication, or maybe an entire class of medications, she says.
When the physician prescribes medication for a patient with HIV-AIDS, Wesolowski reviews the medicine, the side effects, and the importance of taking it as prescribed.
She assesses what patients' educational level is and gives them materials in the kind of language they can understand. For instance, if patients are illiterate or have limited reading skills, she uses a series of pictures to describe when they should take their medicine.
She helps them set up pillboxes that will remind them of which medication to take when.
When a patient starts a new medication, Wesolowski calls them a few days later asking if they're having problems or side effects and how she can help.
She goes over the potential side effects and what can be done about them so the patient will understand what to expect.
Although social work is not her primary focus, Wesolowski can help members locate community services such as transportation, help with housing, or agencies that will deliver meals to their homes.
She keeps a supply of applications for the State of Massachusetts' drug reimbursement program and helps them fill it out.
"I'm very familiar with the social services in the area and can refer people to a program that can help. But I'm only one person, so I can't do everything for them," she says.
Wesolowski has had a face-to-face, ongoing relationship with some of her patients for years.
She is available by voice mail and beeper to her patients and occasionally has been called in the middle of the night when a patient was in the emergency department.
When patients are confined to their homes with hospice care, she makes home visits to check on them.
"I'm not providing care for them; but from a continuity standpoint, I don't want them to think they've been abandoned by Fallon Clinic just because they can't come in," she says.
Wesolowski offers the following tips for other case managers who are dealing with HIV-AIDS patients:
- Network with other case managers and problem-solve together.
- If you have questions, talk to the experts. She recommends the Johns Hopkins Internet AIDS site (www.hopkins-aids.edu).
- Join other organizations such as the Association of Nurses in AIDS Care (www.anacnet.org).
- Plug your patients into community agencies that can help.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content