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Carmen Eucker, RN, CDE, takes a hands-on approach in helping low-income people with chronic conditions, often driving 250 miles along the Washington state coast to provide resources, ranging from medical supplies to transportation, heat, and even food.

As one of 22 nurses in Washington state involved in a Medicaid-funded disease management program, Eucker enjoys the challenge of trying to bring healthier outcomes to clients suffering from heart failure, chronic obstructive pulmonary disease, coronary artery disease, asthma, and diabetes.

At Ketchikan General Hospital in southeast Alaska, low-income patients with medical problems like appendicitis or bowel obstruction often arrive by boat or plane from remote communities, and are taken home the same way, the expenses covered by Medicaid travel vouchers.

For nurses who provide a wide spectrum of care for some 52 million Americans covered by Medicaid — half of them children — changes are in the wind as many states begin cutting back in the $300 billion program for the needy. With President George Bush committed to cutting Medicaid's budget by $60 billion over the next 10 years, states are looking at ways to reduce the increasing cost of their share of the program that also serves people with disabilities, the elderly, pregnant women, and low-income parents.

In mid-March, meanwhile, the U.S. Senate made $14 billion in Medicaid cuts over five years in its 2006 budget resolution and formed a bipartisan commission to explore long-term changes to the program, an action supported by the American Nurses Association. The House narrowly voted to cut $20 billion from Medicare without making specific proposals, although Bush’s budget calls for reducing mental health services.

In Washington state, mental health programs have already been cut to help ease a projected $2.2 billion budget deficit, and further cuts in Medicaid mental health coverage could be disastrous, says Donna Poole, RN, MSN, a nurse practitioner at the Kitsap County community health clinic in Bremerton. As of July 1, the only reimbursements at the clinic will be for Medicaid-eligible patients because of the state’s cutting $82 million from its mental health programs, she says.

“I know the state’s short of money,” says Poole, “but if we cut back on mental health, we’ll only wind up spending more on people who will end up in jail or in emergency rooms.”

In Alaska, Rebecca Bolling, RN, BSN, says the state attracts a lot of people who like to live in remote areas or on one of the many islands along the peninsula. Cutbacks to the state’s $1 billion Medicaid budget could threaten access to care for some 130,000 recipients by reducing travel funds, she says.

“With reductions in Medicaid, I’m really concerned about the access problem, particularly for the younger population,” says Bolling, discharge planning care coordinator for the hospital and president of the Alaska Nurses Association. “The more strict Medicaid gets, the harder it will be for patients to get in and out — and it’s tightening up already.”

She says a 12-year-old boy was recently brought in for treatment whose only access was by air. “We serve eight to 10 communities that have airplane or ferry access only. They fly in for surgery and fly home the same day. It’s a little crazy, but that’s what they do.”

One of Bolling’s hospital duties is hooking senior citizens up with in-home support services paid for by Medicaid. These services — cleaning, meal preparation, help with bathing — supplement home health care provided by Medicare and help the frail elderly remain independent and in familiar surroundings. Without Medicaid funding, many of these seniors could wind up in assisted living centers that aren’t as therapeutic as the home setting, says Bolling.

A certified diabetes educator, Eucker typically has 100 to 125 clients in various stages of managing their conditions, and she does an initial assessment of each one in their home. She prioritizes their needs and helps them establish goals for improving their health.

“My biggest focus is enabling them to be proactive and have healthier outcomes,” says Eucker. “I open communications so they realize somebody really cares.”

For example, Eucker recently accompanied a woman for a physician visit because the client felt uncomfortable and hadn’t followed a care plan in the past. “I helped her set goals for herself and to be more compliant with what the physician asked her to do,” she says. “In this case, it was simple — getting her the right diabetes supplies to make procedures less uncomfortable.”

Eucker worked for 20 years at Grays Harbor Community Hospital in Aberdeen, Wash., before joining Specialty Disease Management, a Jacksonville, Fla., firm that supplies nursing teams for Medicaid programs in Colorado, Montana, Oregon, Texas, and Mississippi.

The Florida company was launched in 1999 with a successful HIV case management program for the state that demonstrated savings, piquing the interest of other states, says Judy White, RN, vice president of health operations.

White says she expects the service to grow because even with Medicaid cuts, the nursing teams’ approach to chronic care — which includes 24/7 phone triage service — improves patient outcomes and saves health care dollars. For one thing, stabilizing and enhancing a patient’s physical and mental health results in fewer trips to the ED.