As a panelist at a recent presentation, I shared the example of a client with whom we are actively working. Maura, a 49-year-old woman, was beside herself trying to manage a very sick mom who had been hospitalized, while also managing a demanding work schedule and two teenage children.
When she called, my first thought was how clearly she fit the classic definition of a caregiver:
A woman in her late 40s or early 50s, who provides unpaid care for a family member with a chronic illness, disability, or age-related condition. She works outside the home and dedicates significant additional time each week (20-25 hours) to caregiving tasks (e.g., errands, meal preparation, financial tasks and/or physical caregiving, including assisting with activities of daily living such as dressing and personal hygiene). As a result, caregivers may experience substantial personal and financial strain from their responsibilities.
Despite being an experienced leader who manages a team of professionals and has succeeded at implementing major projects, in this situation, Maura was at a complete loss on where to start.
So before we tackled the specifics, I asked Maura to keep two things in mind:
- The only thing you truly have control over is yourself. So while the healthcare and insurance systems are incredibly complex and can be both confusing and frustrating, you can work within them to achieve your goals.
- Most healthcare and insurance professionals want to do good. When you encounter frustrating situations, consider that the system may be the issue and not the person. Be curious, rather than accusatory.
Maura went on to tell us how she works at her job. We showed her how many of these same skills and approaches can be used successfully in a healthcare setting.
“I always do my homework, so I can be prepared.”
For most people, having a sick and hospitalized parent is one of the most stressful situations they will encounter. Fear and anxiety, together with limited familiarity about how the healthcare and insurance systems intersect, tends to immobilize people.
Of course, the clinical status of your loved one is the primary focus. But if you ignore the pressures that come from insurance coverage and requirements, you will be caught off guard.
For Maura, “doing her homework” was the best strategy. We began by helping her get the information she needed about her mom’s insurance coverage, so when she spoke with the case manager — whose job it is to facilitate a safe and appropriate discharge — she would be speaking the same language and be aligned with the case manager’s goals.
As a first step, that meant calling the customer service number on the back of her mom’s insurance card. Here is what we coached her to say:
I’m calling on behalf of my mother who was recently hospitalized. Can you please help me to understand the following?:
- Do her inpatient benefits cover her at the hospital she is in? What is her cost per day?
- What are the criteria she must meet to stay in her current hospital?
- If she is too sick to come directly home, what benefits does she have for care in other settings and, specifically, a skilled nursing facility?
- Is my mom limited to which skilled nursing facilities she can go to? If so, how do I identify those facilities?
- Does she have coverage for care when she comes home? What criteria must she meet to have coverage and what does that care consist of? How long can she receive in-home care?
Lastly:
- If a decision is made about coverage of my mom’s care that I disagree with, what are my rights to appeal and what is the specific process to file an appeal?
“I develop relationships.”
We coached Maura to proactively seek out the case manager/discharge planner assigned to her mom. We explained that it may be a nurse or a social worker and that this person would have already begun that planning and have a tentative date for discharge (this was eye-opening to Maura).
During their discussion, we suggested Maura begin by mentioning the following:
“My priority is to receive information about my loved one’s clinical status. I believe you can help me with that, as I understand you meet with the clinical team every morning.”
Then, we coached Maura on asking the case manager to help her…
- Understand the process
- Figure out the best way to communicate going forward
- Understand her mom’s insurance and the benefits she is entitled to
- Understand how a transition to another level of inpatient care would work, what her options are, and what needs to be done now to get ready
- Do whatever can be done to avoid having her mom re-admitted
- Understand what her options are if they run into any issues or disagreements
“I adjust according to the circumstances, overcome barriers, and maintain positive relationships along the way.”
We encouraged Maura to apply these same project management skills in helping her mom who was quite ill and had a difficult hospital course that left her severely deconditioned. Short Term Rehabilitation from a Skilled Nursing Facility was needed, but placement was complicated by delirium, which is quite common in hospitalized older adults.
Maura presented the case manager with a list of facilities she’d visited in order of preference. Unfortunately, at the point the hospital determined her mom was ready for discharge, the facilities would not admit her until she had a geriatric-psychiatric evaluation and some of her difficult behaviors improved. Delays in placement ensued and eventually, Maura was told her mom’s insurance would no longer cover the cost of inpatient care.
But Maura had done her homework and knew about the appeals process. She filed an appeal while simultaneously pushing for the psychiatric assessment to occur while her mom was still an inpatient. During that process, she developed a relationship with an individual at the insurance company who handled appeals, specifically asking for their help:
You obviously know much more about the appeals process than I do, so I am counting on you to educate me. I want to be sure I do all the right things as you outline them, and I want to be sure you receive the clinical information you need to make an informed decision. My mom is depending on me.
She also maintained a positive relationship with the case manager, working together to achieve a safe and appropriate discharge for her mom:
I assume you are involved in appeals processes all the time. This is new to me, so please educate me so I can follow the rules as outlined. I understand medical information needs to come from mom’s clinical team and I would like to understand what is being sent to the appeals department so I can feel assured it accurately reflects her status. My mom is depending on me.
Along the way, Maura kept the admissions director at her preferred skilled nursing facility in the loop:
Your facility is my first choice for my mom. I understand you cannot admit her now and I appreciate the advice about how to prepare my mom for this transition. I am filing an insurance appeal for continued care and pursuing the psychiatric evaluation with the hospital team. I will keep you posted and am hopeful my mom’s status will improve and that you will reevaluate her for admission.
In the end, Maura’s appeal was successful, her mom’s inpatient care was covered for more time, the psychiatric assessments were done, appropriate medications were prescribed, and her mom transitioned to the preferred skilled nursing facility about 10 days later.
Summary
Coaching Maura to use skills she demonstrated so beautifully in her work life, in the advocacy of someone she loved, was both challenging and incredibly rewarding. She came to recognize the healthcare and insurance systems are interrelated, and that she had effective tools she could employ to achieve her goals.
She now knows how to take control and be a leader of her own healthcare, as well as how to be a leader for those she loves. You can too!