2222222222

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.

Advertisement




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.”

Advertisement




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.

Advertisement




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 digital producer and staff writer at Risk & Insurance. She can be reached at [email protected]

More from Risk & Insurance

More from Risk & Insurance

Cyber Resilience

No, Seriously. You Need a Comprehensive Cyber Incident Response Plan Before It’s Too Late.

Awareness of cyber risk is increasing, but some companies may be neglecting to prepare adequate response plans that could save them millions. 
By: | June 1, 2018 • 7 min read

To minimize the financial and reputational damage from a cyber attack, it is absolutely critical that businesses have a cyber incident response plan.

“Sadly, not all yet do,” said David Legassick, head of life sciences, tech and cyber, CNA Hardy.

Advertisement




In the event of a breach, a company must be able to quickly identify and contain the problem, assess the level of impact, communicate internally and externally, recover where possible any lost data or functionality needed to resume business operations and act quickly to manage potential reputational risk.

This can only be achieved with help from the right external experts and the design and practice of a well-honed internal response.

The first step a company must take, said Legassick, is to understand its cyber exposures through asset identification, classification, risk assessment and protection measures, both technological and human.

According to Raf Sanchez, international breach response manager, Beazley, cyber-response plans should be flexible and applicable to a wide range of incidents, “not just a list of consecutive steps.”

They also should bring together key stakeholders and specify end goals.

Jason J. Hogg, CEO, Aon Cyber Solutions

With bad actors becoming increasingly sophisticated and often acting in groups, attack vectors can hit companies from multiple angles simultaneously, meaning a holistic approach is essential, agreed Jason J. Hogg, CEO, Aon Cyber Solutions.

“Collaboration is key — you have to take silos down and work in a cross-functional manner.”

This means assembling a response team including individuals from IT, legal, operations, risk management, HR, finance and the board — each of whom must be well drilled in their responsibilities in the event of a breach.

“You can’t pick your players on the day of the game,” said Hogg. “Response times are critical, so speed and timing are of the essence. You should also have a very clear communication plan to keep the CEO and board of directors informed of recommended courses of action and timing expectations.”

People on the incident response team must have sufficient technical skills and access to critical third parties to be able to make decisions and move to contain incidents fast. Knowledge of the company’s data and network topology is also key, said Legassick.

“Perhaps most important of all,” he added, “is to capture in detail how, when, where and why an incident occurred so there is a feedback loop that ensures each threat makes the cyber defense stronger.”

Cyber insurance can play a key role by providing a range of experts such as forensic analysts to help manage a cyber breach quickly and effectively (as well as PR and legal help). However, the learning process should begin before a breach occurs.

Practice Makes Perfect

“Any incident response plan is only as strong as the practice that goes into it,” explained Mike Peters, vice president, IT, RIMS — who also conducts stress testing through his firm Sentinel Cyber Defense Advisors.

Advertisement




Unless companies have an ethical hacker or certified information security officer on board who can conduct sophisticated simulated attacks, Peters recommended they hire third-party experts to test their networks for weaknesses, remediate these issues and retest again for vulnerabilities that haven’t been patched or have newly appeared.

“You need to plan for every type of threat that’s out there,” he added.

Hogg agreed that bringing third parties in to conduct tests brings “fresh thinking, best practice and cross-pollination of learnings from testing plans across a multitude of industries and enterprises.”

“Collaboration is key — you have to take silos down and work in a cross-functional manner.” — Jason J. Hogg, CEO, Aon Cyber Solutions

Legassick added that companies should test their plans at least annually, updating procedures whenever there is a significant change in business activity, technology or location.

“As companies expand, cyber security is not always front of mind, but new operations and territories all expose a company to new risks.”

For smaller companies that might not have the resources or the expertise to develop an internal cyber response plan from whole cloth, some carriers offer their own cyber risk resources online.

Evan Fenaroli, an underwriting product manager with the Philadelphia Insurance Companies (PHLY), said his company hosts an eRiskHub, which gives PHLY clients a place to start looking for cyber event response answers.

That includes access to a pool of attorneys who can guide company executives in creating a plan.

“It’s something at the highest level that needs to be a priority,” Fenaroli said. For those just getting started, Fenaroli provided a checklist for consideration:

  • Purchase cyber insurance, read the policy and understand its notice requirements.
  • Work with an attorney to develop a cyber event response plan that you can customize to your business.
  • Identify stakeholders within the company who will own the plan and its execution.
  • Find outside forensics experts that the company can call in an emergency.
  • Identify a public relations expert who can be called in the case of an event that could be leaked to the press or otherwise become newsworthy.

“When all of these things fall into place, the outcome is far better in that there isn’t a panic,” said Fenaroli, who, like others, recommends the plan be tested at least annually.

Cyber’s Physical Threat

With the digital and physical worlds converging due to the rise of the Internet of Things, Hogg reminded companies: “You can’t just test in the virtual world — testing physical end-point security is critical too.”

Advertisement




How that testing is communicated to underwriters should also be a key focus, said Rich DePiero, head of cyber, North America, Swiss Re Corporate Solutions.

Don’t just report on what went well; it’s far more believable for an underwriter to hear what didn’t go well, he said.

“If I hear a client say it is perfect and then I look at some of the results of the responses to breaches last year, there is a disconnect. Help us understand what you learned and what you worked out. You want things to fail during these incident response tests, because that is how we learn,” he explained.

“Bringing in these outside firms, detailing what they learned and defining roles and responsibilities in the event of an incident is really the best practice, and we are seeing more and more companies do that.”

Support from the Board

Good cyber protection is built around a combination of process, technology, learning and people. While not every cyber incident needs to be reported to the boardroom, senior management has a key role in creating a culture of planning and risk awareness.

David Legassick, head of life sciences, tech and cyber, CNA Hardy

“Cyber is a boardroom risk. If it is not taken seriously at boardroom level, you are more than likely to suffer a network breach,” Legassick said.

However, getting board buy-in or buy-in from the C-suite is not always easy.

“C-suite executives often put off testing crisis plans as they get in the way of the day job. The irony here is obvious given how disruptive an incident can be,” said Sanchez.

“The C-suite must demonstrate its support for incident response planning and that it expects staff at all levels of the organization to play their part in recovering from serious incidents.”

“What these people need from the board is support,” said Jill Salmon, New York-based vice president, head of cyber/tech/MPL, Berkshire Hathaway Specialty Insurance.

“I don’t know that the information security folks are looking for direction from the board as much as they are looking for support from a resources standpoint and a visibility standpoint.

“They’ve got to be aware of what they need and they need to have the money to be able to build it up to that level,” she said.

Without that support, according to Legassick, failure to empower and encourage the IT team to manage cyber threats holistically through integration with the rest of the organization, particularly risk managers, becomes a common mistake.

He also warned that “blame culture” can prevent staff from escalating problems to management in a timely manner.

Collaboration and Communication

Given that cyber incident response truly is a team effort, it is therefore essential that a culture of collaboration, preparation and practice is embedded from the top down.

Advertisement




One of the biggest tripping points for companies — and an area that has done the most damage from a reputational perspective — is in how quickly and effectively the company communicates to the public in the aftermath of a cyber event.

Salmon said of all the cyber incident response plans she has seen, the companies that have impressed her most are those that have written mock press releases and rehearsed how they are going to respond to the media in the aftermath of an event.

“We have seen so many companies trip up in that regard,” she said. “There have been examples of companies taking too long and then not explaining why it took them so long. It’s like any other crisis — the way that you are communicating it to the public is really important.” &

Antony Ireland is a London-based financial journalist. He can be reached at [email protected] Dan Reynolds is editor-in-chief of Risk & Insurance. He can be reached at [email protected]