By Matthew N. Skouflos
Years ago, you didn’t hear the term “nurse navigator” or “case management,” said Mike Newell, MSN. Nurses were people who came in and took your pulse and administered medication. Case management was lingo used by lawyers and detectives, and the only navigation experience a patient might have in the hospital involved crutches or a wheelchair.
In fact, in 1979, when Newell was certified in critical care nursing, even that was a new specialty. Twelve years later, when he added a second certification in case management, “this new thing called managed care” was another first for nursing professionals — one that matched neatly with the needs of the private rehabilitation services group with whom he soon landed.
“Nurses are generally altruists, and you get tired of working in the system as a technician,” Newell said. “You’re there to give pills, give your assessment, and take the flak from the patient and families and keep your mouth shut. The way I survived in nursing was to go where they were going to teach me something new.”
At the time, catastrophic auto coverage and worker’s compensation insurance policies costs approached $1 million, he said, because “if you were injured, their only way of [insurers] containing the cost was to make sure you got through the system as quickly as possible.” For Newell, who “already knew how to read between the lines on a medical chart,” he soon discovered the same skills applied to the insurance side of health care, too.
He pursued a master’s degree in nursing and began consulting around managed care and health outcomes management, eventually returning to the bedside as a teaching nurse at Drexel University in Philadelphia. But Newell never lost sight of the need for more intuitive case management services, which only grew, particularly as health care laws became more complex.
Eventually, with the Affordable Care Act tying health care reimbursements to patient outcomes, he saw a natural market opening for someone with his skill set, which had been honed over 40,000 hours in practice. So, Newell founded a private patient advocacy business called LifeSpan Care Management, which he describes as “the same as working for the insurance company, but this time, the customer is the family.”
A large portion of the client population served in the managed care industry is elderly, Newell said; many are cared for by their children, and want merely to be able to return to their home lives after a hospitalization or stint in an assisted living facility. His goal is to ensure that patients have the ability to maintain their independence and safety when they are ready to return home. Newell works with his clients and their families to address issues like installing handholds in the bathroom, home monitoring equipment, and prescription management — the most common reason most people wind up in assisted living, he said.
“If you don’t take your pills safely, the regimen of care doesn’t work, or your overdose yourself and you fall,” Newell said. “If you have an injury, you lose function, and then you’re likely to need to leave home anyway.”
“The more medications a person is on, they’re more likely to have an adverse drug event,” he said. “If you’re over 65, you have a 10 percent chance of an adverse drug event for every drug you’re on, and you won’t know what drug it is because it’s likely to be a combination of those drugs.”
Most of his patients are on eight or nine medications, Newell said, a regimen that can contribute to the specific conditions for which seniors may find themselves at risk. SSRIs may contribute to fall risk, he said; statin drugs, meant to lower cholesterol, may cause muscle weakness or cognitive impairment. Proton pump inhibitors, commonly prescribed for gastrointestinal distress, may demineralize bones, making a fall more serious if it does occur.
For patients who do require hospitalization to recover, Newell said his task is to help them return from such a setting as quickly as possible. With hospitalization typically reserved for patients in need of intensive care or around-the-clock monitoring, there are entire groups of individuals who merely require sub-acute care to rehabilitate.
After as little as three days of being hospitalized, a senior qualifies for Medicare, he said; and in as little as three days, a bed-ridden senior may also have suffered some loss of function, requiring rehabilitation that Medicare would cover. But when such care may not be approved by health insurance companies, patients are at often at a loss as to how to advocate for it.
“The insurance company may not approve the stay because of their criteria in their system,” Newell said. “If this person has potential to make continued gains while they’re in sub-acute, they should have the opportunity to make those gains rather than be shipped home.”
By paying attention to what the client’s needs are “rather than what’s good for the doctor, for the insurance company,” Newell said, patient advocates give their clients the best possible chance of a full recovery as possible.
“At the end of the day, when somebody gets sick, especially if they’re old, they’re dealing with loss – loss of job, loss of function,” he said. “Developmentally, we all have certain stages that we go through, and you’re more likely to be able to deal with that if you get assistance. Your plan of care should be more than a medical, technical approach. It needs to take into account that person’s worldview, their resources, their current function.”
“Obamacare introduced the fact that you need help just to navigate the system,” Newell said. “An outcome, by definition, is a customer-defined utility. We’ve relied on physicians to tell us the outcome for a long time, but we should have been asking the patients. To physicians, the outcome is what interventions they did and whether they got paid. The true outcome is for the person to self-assess, ‘Was this good for me?’ ”