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Nurse Case Manager Chronicles

The Fragility of Life

When routine surgery went awry and upended a workers' life, her nurse case manager guided her through physical and emotional recovery.
By: | February 1, 2018 • 7 min read

In the blink of an eye, a routine case can turn into a catastrophic claim. And when it happens, nurse case managers lead the push to help the patient recover — physically and emotionally.

A worker — a registered nurse — tore her rotator cuff while moving a patient. It’s a common injury among nurses, and she filed for workers’ compensation. Before surgery, she met with her nurse case manager to review the case and the therapy she would need afterwards.

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But her routine surgery became her worst nightmare when she coded on the operating table.

“She coded a couple of times,” said Becky Mills, a nurse and certified case manager with Ascential Care Partners, headquartered in Lexington, Ky.

In medical terms, this means the patient went into cardiorespiratory arrest, which required CPR to bring her back. After surgery, the patient was placed in critical care on ventilators.

During surgery, the patient’s blood pressure skyrocketed, Mills explained. Medications were administered to lower the spike, but instead of stabilizing the patient, the medications led to her coding. She suffered a stroke.

Mills said it wasn’t clear whether coding led to the stroke or if the stroke led to coding. Either way, the patient fought for her life.

“It was a dim prognosis; there were times I didn’t know if I’d see her out of that hospital,” she said.

But, said Mills, she had an amazing support system and pulled through.

From Crisis to Care

Mills didn’t know what had happened at first.

“I called the day after surgery to check in,” she said. Mills believed her patient was still recovering from a routine rotator cuff repair. When no one answered the phone, she left a message and brushed it off. “It was the day after surgery. Sometimes people are still groggy.”

When she called the next day and received no answer, she knew something was up. The patient’s husband called to tell Mills about the stroke.

“The employer didn’t even know,” she added. The NCM had to inform them of their employee’s condition.

Becky Mills, RN, certified case manager, Ascential Care Partners

Mills met with the patient’s husband in the ICU, determined to get medical records in order and help ease his worry.

“For a while, it was maintaining contact and communicating with the employer,” she said. The employer was investigating the incident, deciding whether or not the stroke and subsequent care would be considered under the workers’ compensation claim already in place.

During this time of uncertainty, the husband told Mills it was nice to have a neutral body there, someone who could handle the work-related needs while coordinating care options for his wife. He told Mills she made him feel safe.

Mills encouraged the husband to speak to his wife while she remained on the ventilators. She also encouraged him to connect with family, friends and their minister, keeping them in the loop and creating a system of support during his wife’s recovery.

The employer, who was self-insured, decided that the ongoing treatment would be covered.

“It was ruled compensable due to the fact she was undergoing surgery for a work-related claim,” said Mills. “The employer and TPA were fabulous in their support.”

When the patient stabilized, she was sent to a rehabilitation center for recuperation. After around three weeks, Mills decided she needed to be placed in a specialized facility where she could receive more aggressive therapy.

The patient had paralysis on her right side. She was aphasic, meaning her speech was limited to short sentences or repeated phrases, and her reading comprehension was low. Mills recommended sending the patient to Shepherd Center, a rehabilitation facility five hours away from where the patient and her family lived.

“Shepherd is on top of the newest research,” said Mills. It specializes in brain and spinal cord injury rehabilitation. “Each team meets weekly per patient — occupational therapy, physical therapy, speech therapy, physicians, nurses — they all work together. It’s a consistent meeting. It’s structured.”

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This type of hands-on care, she said, was what the patient needed most, but the patient was hesitant to go so far away from home. She had her good and bad days, said Mills. The stroke had really left a pressing mark on the patient and her confidence was shaken. Leaving her family behind was a tough decision to make.

But Mills persevered.

“Patients thrive at Shepherd,” she said. The NCM approached the patient’s husband and explained why the center was the best scenario and best chance for his wife’s recovery. He successfully convinced her to go.

Keeping Active

The patient remained at Shephard for two months.

“They would call me with what was going on,” said Mills. Communication between the center and the NCM was paramount in keeping the case moving forward and getting the patient back to her life. Mills was able to inform the patient’s employer on her progress and began coordinating home care before the patient even left the facility thanks to the continued line of communication.

When Shepherd saw the patient progressing in therapy, they moved her from a hospital room to an apartment on the center’s campus.

“That was key in helping her progress from feeling like a patient to living in the real world,” said Mills.

At home, Mills set up a full-time home care worker to be with the patient while she continued her occupational, physical and speech therapies, because the patient lived in a rural area and her therapies were about an hour away.

“Her husband would take her at first, but then the care giver would,” said Mills. “Her confidence was so shaken — just to talk to somebody would make her freeze up. As she got better, her confidence, independence and self-esteem improved.”

When OT, PT and speech therapy came to an end, however, it proved another hurdle for Mills’ patient.

“She came to the realization she had reached her maximum in therapy,” said Mills. The patient had gained back more of her speech but was still aphasic. She had learned how to use her left hand instead of her right, which was her dominant hand before the stroke, and her reading capability had returned, albeit slower than the patient expected.

“This was where she was going to be. She had to grieve for the loss of her life as it had been. But I told her that her life still had meaning and purpose. She could not give up. We would all be there to help her, but she needed to continue to do things around the house, in her church and in her community.”

A patient who lost use of her right hand began coloring to master control of her left hand.

With time and a lot of support from her husband, the patient did just that.

“She’s coloring,” said Mills. The pages the patient colors are from mandala designs, intricate and detailed patterns that are small and precise in shape. The patient, said Mills, has been coloring with her left hand, completely in the lines, and has sent Mills some of her finished pieces.

“Unfortunately, she will not work as a nurse due to the aphasia and limited use of her right hand,” said Mills. But she is able to volunteer at a local nursing home, where she helps with crafts and hands out refreshments.

“She even brings the mandala coloring books and pens for them to use, and they all work on them together,” she said.

Volunteering has opened the door for this patient to continue to recover mentally and emotionally. “She feels like she’s a part of something and is helpful and useful.”

Throughout recovery, Mills spoke with the husband on how to keep the patient active and push her to be as independent as possible. Her husband, said Mills, is the patient’s number one cheerleader.

Valuing Each Day

“We have the greatest impact when we get the file early on, so we can be there from the very beginning,” said Mills. She likes the face-to-face aspect of nurse case managing, where she sees her patients’ progress from day one till recovery.

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With this particular case, being there from the start was key in getting the patient back on her feet.

Insurers and employers, said Mills, have a bottom line — cost. But sometimes having the NCM on board from the start of injury can have a greater impact. The benefits of their service far outweigh the costs, she said.

“This patient went in thinking she was going to have a routine repair and would be back to work,” said Mills. “Aside from the physical [injury and recovery], I’ve learned a lot about the emotional impact and the fragility of life. But there is always tomorrow. It’s beautiful to see how she’s opened back up.”

When the stroke first happened, Mills recalled the patient’s husband was never frustrated or angry.

“He said he’s so grateful that she’s alive and that taught me something, too,” said Mills.

“It isn’t about what you had or what’s been taken away, it’s about what you do with what you’ve got now.” &

Autumn Heisler is a staff writer at Risk & Insurance. She can be reached at [email protected]

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Risk Management

The Profession

As a professor of business, Jack Hampton knows firsthand the positive impact education has on risk managers as they tackle growing risks.
By: | April 9, 2018 • 4 min read

R&I: Who is your mentor and why?

Ellen Thrower, president (retired), The College of Insurance, introduced me to the importance of insurance as a component of risk management. Further, she encouraged me to explore strategic and operational risk as foundation topics shaping the role of the modern risk manager.

Chris Mandel, former president of RIMS and Risk Manager of the Year, introduced me to the emerging area of enterprise risk management. He helped me recognize the need to align hazard, strategic, operational and financial risk into a single framework. He gave me the perspective of ERM in a high-tech environment, using USAA as a model program that later won an excellence award for innovation.

Bob Morrell, founder and former CEO of Riskonnect, showed me how technology could be applied to solving serious risk management and governance problems. He created a platform that made some of my ideas practical and extended them into a highly-successful enterprise that served risk and governance management needs of major corporations.

R&I: How did you come to work in this industry?

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From a background in corporate finance and commercial banking, I accepted the position of provost of The College of Insurance. Recognizing my limited prior knowledge in the field, I became a student of insurance and risk management leading to authorship of books on hazard and financial risk. This led to industry consulting, as well as to the development of graduate-level courses and concentrations in MBA programs.

R&I: What was your first job?

The provost position was the first job I had in the industry, after serving as dean of the Seton Hall University School of Business and founding The Princeton Consulting Group. Earlier positions were in business development with Marine Transport Lines, consulting in commercial banking and college professorships.

R&I: What have you accomplished that you are proudest of?

Creating a risk management concentration in the MBA program at Saint Peter’s, co-founding the Russian Risk Management Society (RUSRISK), and writing “Fundamentals of Enterprise Risk Management” and the “AMA Handbook of Financial Risk Management.”

A few years ago, I expanded into risk management in higher education. From 2017 into 2018, Rowman and Littlefield published my four books that address risks facing colleges and universities, professors, students and parents.

Jack Hampton, Professor of Business, St. Peter’s University

R&I: What is your favorite book or movie?

The Godfather. I see it as a story of managing risk, even as the behavior of its leading characters create risk for others.

R&I: What is your favorite drink?

Jameson’s Irish whiskey. Mixed with a little ice, it is a serious rival for Johnny Walker Gold scotch and Jack Daniel’s Tennessee whiskey.

R&I: What is the most unusual/interesting place you have ever visited?

Mount Etna, Taormina, and Agrigento, Sicily. I actually supervised an MBA program in Siracusa and learned about risk from a new perspective.

R&I: What is the riskiest activity you ever engaged in?

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Army Airborne training and jumping out of an airplane. Fortunately, I never had to do it in combat even though I served in Vietnam.

R&I: If the world has a modern hero, who is it and why?

George C. Marshall, one of the most decorated military leaders in American history, architect of the economic recovery program for Europe after World War II, and recipient of the 1953 Nobel Peace Prize. For Marshall, it was not just about winning the war. It was also about winning the peace.

R&I: What about this work do you find the most fulfilling or rewarding?

Sharing lessons with colleagues and students by writing, publishing and teaching. A professor with a knowledge of risk management does not only share lessons. The professor is also a student when MBA candidates talk about the risks they manage every day.

R&I: What is the risk management community doing right?

Sensitizing for-profit, nonprofit and governmental agencies to the exposures and complexities facing their organizations. Sometimes we focus too much on strategies that sound good but do not withstand closer examination. Risk managers help organizations make better decisions.

R&I: What could the risk management community be doing a better job of?

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Developing executive training programs to help risk managers assume C-suite positions in organizations. Insurance may be a good place to start but so is an MBA degree. The Risk and Insurance Management Society recognizes the importance of a wide range of risk knowledge. Colleges and universities need to catch up with RIMS.

R&I: What emerging commercial risk most concerns you?

Cyber risk and its impact on hazard, operational and financial strategies. A terrorist can take down a building. A cyber-criminal can take down much more.

R&I: What does your family think you do?

My family members think I’m a professor. They do not seem to be too interested in my views on risk management.




Katie Dwyer is an associate editor at Risk & Insurance®. She can be reached at [email protected]