Restoring Lives: How Heart of Case Management Award Winners Make a Difference

 

Tom Kerr (TK): The Enlyte Heart of Case Management Award is a prestigious honor recognizing four case managers of Genex Services selected from a field of more than 2,000 across the country. These professionals are regarded for transcending beyond their traditional job duties to help improve the lives of thousands of injured employees each year.

In Part 1 of our two-part series honoring the 2023 Heart of Case Management Awardees, we welcome Angela Higdon, RN, BSN, CCM, field case management award winner and Sharon Murphy-Potts, BSN, RN, CRRN, catastrophic case management winner. Ladies, thank you for joining us.

Angela, let’s start with you. Why did you become a case manager?

Angela Higdon (AH): Well, it really wasn’t something that I planned when I became a nurse. To be honest my oldest son was only one at the time. He’s 27 now, so, that’s how many years ago it was.

But it was basically so that I would be able to see him as a mom. Working as a nurse in the hospital in the urgent care setting, which is where I was at the time, didn’t allow me to see him for long stretches of time. So that was what started me looking at that path.

It was kind of a unique thing at the time in the hospital setting, case management really wasn’t a thing. They had started in the hospital setting doing utilization review and discharge planning, but as far as having an actual defined role as a case manager in a hospital, that didn’t exist at the time. It was more meted out in the insurance industry, which is where I landed first, then it was in the hospital setting as a role.

And so, it was actually kind of exciting because I was one of the first waves of people in our industry to get CCM (Certified Case Manager) certification. So, I feel like I’ve kind of been growing in my own professional life as a case manager, as the profession itself has been growing in the health care industry.

TK: Sharon, I’m going to switch to you now and ask you the same question. Why did you become a case manager?

Sharon Murphy-Potts (SMP): Well, I’ve been a nurse for a really, really, long time [laughs]. When I first became a nurse, I worked in acute care on an orthopedic and neuro floor, which I really liked and, throughout my career, I kept with trauma patients primarily in one range or another.

So, I did that for about five years, and then I went to a large acute rehabilitation hospital in Philadelphia. I was a nurse manager, a clinic liaison, and then I decided to make a change and went to a post‑acute brain injury rehabilitation program where I stayed for 18 years. And that’s really where I worked closely with, particularly, the Genex case managers, but all workers’ comp case managers. And that’s when I decided to make the change to become a case manager.

TK: Great, and I’m going to stick with you on this one, Sharon. Tell me about your Heart of Case Management award-winning case.

SMP: I received the referral, it was about a month and a half after the initial injury. The file was with another company. Came to Genex and I definitely had an interest in the catastrophic files. My patient was working at a company that built pole buildings and he fell and sustained a spinal cord injury, so he was paraplegic. And he was at an acute hospital for a bit, transferred to a regional spinal cord injury center, which was at least an hour and a half from his home.

So, I met him, and they were actually speaking about discharging him in a couple of weeks. And, at the same time, at the team meetings, I was listening in because I did them telephonically because of COVID.

He was making some functional gains as a complete spinal cord injured patient, but they were still talking about sticking with the original discharge plan. So, at that point, I asked if I was able to get approval from the insurance company for him to stay longer and continue acute rehab, would they extend his stay there? So, the therapists were thrilled. The physician was thrilled. The patient was not so thrilled because he just wanted to get home to his family.

But he did agree, and he stayed another couple of weeks, which did really help him have some access to state-of-the-art equipment that is not available in a lot of acute rehabs. So, he was able to stay until emotionally, he really just wanted to get home and with his family, which he did. And then we coordinated him for placement at a rehab facility 45 minutes from his home where he could continue outpatient intensive therapy for a long time.

He was just anxious to get home to his family and be able to take care of the pasture outside of his home where he had a horse and a pony. He was very upset that friends had to take care of the animals while he was out.

His primary goal was to get home and be able to get back to the chores that he was responsible for in his daily life. He has a wife, three kids, and one on the way at the time.

And I remember I was in physical therapy with him and he just said, “I need to be able to get back to that pasture and take care of this. I’m just going to buy a John Deere riding mower and get on it if you can’t figure out a way for me to get back there.” And I asked him just to please give me a couple weeks, let me gather information, let me talk to the insurance company, see what’s available.

So, he went home with all the equipment that typically you would go home with from an acute rehab. He was able to do a first‑floor setup, which was helpful. Didn’t need any modifications other than a ramp outside of his home, and he continued to have outpatient therapy three times a week.

The insurance company provided transportation, No.1, because he was Amish and didn’t drive.

His family members would hire a driver to come to bring his wife with him to appointments or if he had other activities he needed to do, because, being Amish, he didn’t drive.

But then being paraplegic and his wife being Amish, she did not drive either. So that was a major challenge. This individual’s primary concern was how he was going to get back to caring for those farm animals.

So, I did some research, got some quotes regarding an all‑terrain wheelchair, which was extremely expensive. It was $28,000, and this was in addition to a regular wheelchair, all the other equipment an individual would need going home. And I needed to do a home visit after he was discharged per the insurance company to make sure that what he was requesting was absolutely necessary. He showed me in the trial all‑terrain wheelchair how he would be able to feed the horses, he could go in the barn.

So, it was a quality‑of‑life goal, which I was very clear about. It was not a medical necessity; the insurance company is responsible for things that are medically necessary, but it was quality of life.

And, luckily, there was at the insurance company a nurse case manager on the file there, as well as an adjuster who recognized the importance for his emotional stability and his quality of life with his family to be able to do that. So that was the biggest hurdle and the thing that was most appreciated.

TK: OK, so let’s step back for a moment. You said you were assigned this case about a month-and-half after the incident. Was another case manager assigned to this case? Was it a Genex case manager?

SMP: No, it was a totally another company.

TK: So how did you get assigned to this case?

SMP: There’s another case management company that handles catastrophic files. Oftentimes, they will be initial and then it’s decided by the insurance company whether they want to continue with that company or if they want to go to another company.

The branch manager had to provide résumés of case managers that would be able to manage catastrophic files, so I guess they liked the rehab experience I had. I worked with spinal cord and brain injury patients for a long time.

TK: And the fact that this injured employee was Amish is very unique. I’m assuming this was the first time you had worked with someone in the Amish community, which keeps fairly isolated from society and has electricity and technology restrictions. Can you tell us about that experience? 

SMP: Yeah, this gentleman was very private. He was no-nonsense. If he needed something, he’d call me. Sometimes it was an emergency because he forgot to order supplies. He would provide information, but he was just private. So, I asked him, “Well, if we get this all‑terrain vehicle and a bed that may need to be adjusted, do you use electricity?” He said, “Oh, yeah. We use electricity.”

I later found out through research that, apparently, if Amish people are renting a house, which he was, they are permitted to use electricity. If they own the home, they are not. So initially, he just said, “Oh yeah, I can charge it.”

That’s kind of a basic thing we need to know. And transportation was a big issue, but again, if he needed to go somewhere, they would hire a driver. So, he had transportation for himself to go to outpatient therapy.

And then, they had the baby I did meet her a couple of times in outpatient appointments. A big surprise came when my patient texted me one day and said, “Hey, we have decided to leave the Amish church. So, do you think I could get adaptive controls on a car?”

I said, “Oh, interesting. Do you have a car?”

“Yes.”

“You have a driver’s license?”

“Yes. Haven’t used either in 10 years.”

So, that was a shock. And one of the things I did ask him about was what made him leave the Amish church. I was just curious, but again, needed to be respectful. And he would tell me things, but not elaborate with details, very matter‑of‑fact. So, he said, “Oh, you know, transportation was one of the big things that was just a barrier, so we’ve decided to leave the church, and we’re transitioning.”

So, he had gotten adaptive controls that he got off the internet on his car, and I said, “Please, can we do this safely, and I believe you’re entitled to getting it on one car.” He asked for adaptive equipment for two cars, because the smaller car, he would like to drive to work. And he was working at that point two days a week

So, again, I researched the information, got quotes, and presented the information why he needed two cars. Why it was important that he be able to drive his family, in addition to his wife who had never had a driver’s license. So, she did get one. But it just wasn’t reasonable to expect that she would be the driver every time the family all went somewhere. So, I did research it. Presented the information. It was initially denied, and then reconsidered. So, he did get the adaptive controls legally on two cars so that he could drive either car when needed.

TK: Thank you, Sharon. Angela, let’s hear about your Heart of Case Management award‑winning case.

AH: Well, my injured worker, she is a human resource professional. She’s a recruiter for her company. She was walking to the ladies’ restroom, and there was a wet spot on the floor. She slipped, landed on her knees, but also hit her forehead hard against the frame of the restroom door and had a laceration from scalp to forehead that went almost down to the top of her eyebrow on that side.

So, they sent her to the emergency room. She was treated there. They did X-rays, sewed up the laceration, determined that she had a fractured patella on the right, and then they sent her home with orders for physical therapy.

It was just shy of a month later that I was added to the file to help coordinate her outpatient follow up care at the Florida Orthopedic Institute treating her knee. And when she called me, she wasn’t feeling well. She said she was feeling achy. She felt like she was maybe coming down with something. She was having a difficult time breathing. And I said, “Well, you can always go to the emergency room.” And she said she didn’t really want to go back to the emergency room. She wanted to go to an urgent care center instead that she was familiar with. So, I worked with the adjuster. That was on a Wednesday.

Thursday she called me and said she still wasn’t feeling good and felt like her breathing was getting a little worse, but still felt like it might be a cold or something. But by Friday morning, it had gotten much worse and I told her, “You need to get seen today, go to the emergency room, if nothing else.”

And she said, “No, I really want to go to the urgent care center.” So, I worked with her adjuster to get her seen at the urgent care center.

They, thankfully, had a CT scan machine available at that urgent care center and found she had a saddle embolism in her lungs, which is a critically emergent situation, life-threatening situation. So, they immediately transported her to St. Joe’s Bay Care Hospital, where she underwent an emergency thrombectomy, had the thrombus removed from her lungs. They also, at the same time, placed what they call an IVC filter, because they did an ultrasound of her knee, and determined she still had other deep vein thromboses or blood clots around that knee that could potentially also move to other larger arteries. So, they put that filter in to keep that from happening.

I went and saw her after she had the procedures at St. Joe’s. So that was when I met her face-to-face for the first time. After that, she spent a week in ICU recovering, and she had to see a whole slew of physicians in follow up, in addition to her orthopedic doctor.

She now also had to see a cardiologist, a hematologist. a psychiatrist because she had a lot of trauma from that whole experience and was having anxiety. The laceration on her forehead wasn’t healing correctly, so I ended up having to get her in to see a plastic surgeon to try to address that. She ended up having surgery to revise the scar which did help that tremendously.

So, it was a matter of having to coordinate and getting her into all of those different specialists to help her recover from what she went through.

TK: Was this a situation that was really unexpected that you had to handle for the first time?

AH: Well, the thrombosis was a pretty unexpected thing. I mean that’s always a risk whenever you have any kind of fracture, but the severity of hers was unexpected.

The only other thing that has really been a challenge has been the psychological impact that it has had on her, because she’s recovered remarkably. She was released to full duty back in January and has been working full duty even though she’s still continuing to work out different things that have come up along the way.

But mentally, she’s had a really hard time focusing on the positive and instead tends to gravitate towards, “Well, now this has happened. Well, now that has happened.” So, honestly, the biggest challenge has been helping her through that piece of it and overcoming the mental fear, but also trying to help her celebrate the good things that have happened because she’s done remarkably well given everything that she went through.

TK: Angela, if this employee hadn’t had a case manager assigned to her, would it have affected the outcome?

AH: Oh, I definitely think that had she not gotten the attention she needed when she got it, it could have gone a very different way. Thankfully, it didn’t.

And she’s gotten really good care through the whole process. She was also seen by the concussion team at USF because she did suffer a concussion when she hit her head.

And, so the good part has been when she’s had the follow‑ups with all these different physicians and they said, “Now you’re at MMI (maximum medical improvement), and that’s like another achievement.” It’s like, “You got through this part of it. You’re doing great.” And, I hope it gives her more peace of mind knowing that she’s crossed another hurdle.

TK: What was your takeaway as a case manager in working this case?

AH: I think what this has taught me more than anything as a case manager is that you really do have to always look at the person as a whole. A lot of times her biggest barrier had been not the physical aspects, but the psychological aspects of what she’s been going through.

You can’t separate one from the other. They both impact each other. I’ve always been taught as a nurse we always have to see the person as a whole and treat the whole person. Not just a broken body part or a disease process. You’re treating the person.

And this has really brought that home in a very tangible way. I mean, she’s needed the support of her husband, she’s needed the support of friends she’s needed the support of her employer throughout this process to help her get through each step.

TK: Thank you, Angela. Sharon, you had mentioned the progress the injured employee had made in terms of becoming more independent. What about the return-to-work outcomes? Is he back to work?

SMP: Yes.

He had a very benevolent employer who was very happy to create a position for him so that he could work at a desk. And he was very motivated, wanted to return to work and did.

It was less than a year, which was really astounding, and that was his personal goal. He got back to work two days a week, continued outpatient PT three days a week for some time. And then he did just go back to full time work.

He just wanted to move on with his life and work full time. But then also, he revised his personal goals. He was walking with crutches, but it was extremely hard and just not as functional for him. So, he’s able to walk some in his home using a walker, which was good for him. So, he uses a manual wheelchair and a walker at times,

But his employers were very happy to have him back in any capacity and created a job for him. He was very grateful to continue working with that employer.

TK: That’s awesome.

SMP: Yeah, he’s awesome.

TK: Sharon, what would you say was the most rewarding part of this case for you?

SMP: Being able to really help my patient with quality of life, being able to intervene and get him the altering chair, the adaptive equipment, get him what he needed to just meet his personal goals, which was not standard.

One of the things — I’m probably going to start crying now — was the one time I asked his wife, because it was such a big expense with that alternating wheelchair, if he was regularly using and if it made a big difference in their lives. I just like to give feedback to the insurance company.

His wife told me “Oh, he actually gave the kids a pony ride using that chair.” And I was like, wow, that was something that just couldn’t happen without that. It just couldn’t happen. And that was just really important to him. HE was able to continue to do things with his kids in a different way at a wheelchair level.

TK: If he not had a case manager assigned to the case, what do you think might have happened or not happened?

SMP: I think he would have bought a John Deere lawn mower and figured out a way to get out back to that pasture and, heaven forbid, he could have fallen off and gotten hurt. I think he did not realize how unsafe that would be.

So, that was one thing, and he would have not had continued outpatient therapy as long as he did, to really exhaust the options that he had. And he may not have made the same gains if there was not a case manager to continue to advocate to as much outpatient therapy as he wanted to do.

So, I think he would not have been as mobile. He would not been able to participate as much in his daily activities in a safe manner. Honestly, that was the biggest issue I had was, you know, “Please don’t get a John Deere mower, and please just let’s get the adaptive equipment on the cars installed per state regulations.” And so, I had to ask for his patience, which he did agree to reluctantly [laughs].

TK: So, Angela, I'm going to go back to you. What would you say to someone about the work you do and the role you play as a case manager in workers’ comp?

AH: Well, I would say that it’s been an experience for me that has always been eye-opening in that, yes, I’ve been a nurse a long time. I’ve done a lot of different aspects of case management.

But I feel like in the workers’ comp world, it’s such a complex thing. It’s not just their health. It’s their job and their livelihood.

They have so much stress on them just because of whatever situation they’re in. There’s so many regulations and rules around the workers’ comp. The average person is oblivious to all of that and it can all be overwhelming in and of itself on top of an overwhelming health situation and an overwhelming job situation.

So, to be able to be the calm in the middle of the storm, to be that voice to let them say, “OK. I don’t have to be overwhelmed by this. I can just focus on this one little thing right now and know it’s going to be OK.” To me, that’s the reward of what it is that I do every day.

Is being able to help somebody see that, “OK. This isn’t as horrible as I think it is right now. There is a path forward. And now I can see at least the first step right in front of me.”

TK: Sharon, same question. What would you say to someone about the work you do, and the role you play in workers comp?

SMP: I can’t follow Angela. She said it all really.

And I was going to say you saved that woman’s life. No doubt about it.

So, the role of a case manager, you had mentioned before, it’s really helpful to create a personal relationship with our injured employees and that’s very challenging at times.

With some people, you have a good relationship. Some people are very defensive. They’ve never been through anything like this before. Even if it’s not a catastrophic injury, it’s overwhelming to them to be dealing with injury, pain, employment issues, and then having to work with someone, even if we’re advocates for them, it’s another person they have to think of sometimes making appointments and asking questions.

So, I feel, as a case manager, we’re educators, we’re supportive. We are doing the medical coordination, but really hoping to have a good relationship with the physicians, with the complicated workers’ comp world.

Every insurance company has different rules for how we’re to report to them, how we’re to obtain information and communicate.

So I find it very rewarding. It’s like a puzzle. When I get a file, OK, what do we need to identify what needs to be done first? How are we going to hopefully bring this all together and, and really get people back to the best quality of life and hopefully back to work if that’s their goal? Which, for most people, it’s their goal, but oftentimes it may be a different role they have to return to.

AH: And I think it helps to be in a company where teamwork has such high value. I’m sure Sharon can attest, there are many days where situation comes up and I’m like, “Oh, this is a new wrinkle. I’ve never had this before.” And it’s so nice to just be able to shoot an email out to all the other case managers out there, and say, “Hey, this is what I’m dealing with. What are your thoughts?”

When it comes to parenting, you hear people say, “it takes a village.” And, in the same way, it takes a good, strong team of case managers to accomplish all that we need to accomplish. And I’m so thankful that I have that in Genex.

SMP: I agree. And the professionalism at Genex is really helpful. There’s a lot of experience. My supervisor and our assistant branch manager and branch manager have a lot of experience in case management. So that’s really helpful, too.