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Thousands of nurses have left hands-on bedside care to join health plans, where they apply their expertise to a broad scope of patient care issues. In critical situations, case managers may work with family members and caregivers to help patients cope with their condition and make a smooth transition from hospital to home.

When people discover that Yolanda Segura, RN, works at Texas Children's Cancer Center, they often tell her she must have the hardest job in the world.

"I hear that all the time, but it's not as morbid as you'd think it would be," said Segura, who has worked on the oncology unit at Texas Children's Hospital for 10 years.

One patient suffered a relapse of leukemia when she was 17. The girl endured a round of chemotherapy that sent her into remission. Next, she underwent a bone marrow transplant, but she developed complications that kept her in the hospital for months.

Segura met the girl when she started coming in for checkups, which started as weekly visits that gradually dropped off to annual trips. These days, the young woman is back on the cancer unit, this time on the other side of the needle-working as a nurses assistant, Segura said.

"Working with chronic kids, you get to see outcomes," Segura said. "It's very rewarding to know I am making a difference in somebody's life and to see them overcome the disease."

Medical advances in leukemia treatment mean that more of Segura's patients leave the hospital and go on to send their high school graduation invitations, wedding and even baby announcements.

She and other nurses who work with chronically ill patients are on the cusp of an evolving field. Science has added years to the lives of people who have diseases including leukemia, lung cancer, diabetes and HIV. For nurses, these medical developments mean they need to provide even more-and often complicated-services for their patients.

Treatment turnaround

Joan Schneider, RN, works with HIV patients at Sister Mary Philippa Health Center in San Francisco's St. Mary's Medical Center. She has seen a turnaround in the ability to treat her people since the mid-1990s, when antiretroviral therapy became available.

"It's pleasant to see patients do well as opposed to being admitted to the hospital and going downhill and losing them," she said. Instead of watching her patients die, Schneider sees them getting older and becoming prone to the same diseases as the rest of the aging population, such as high blood pressure.

A patient on antiretroviral medications-the drug cocktails prescribed to people with HIV who have low T-cell counts-is treated no differently than any other patient facing newly diagnosed illnesses, she said.

The only medical difference between her patients and those who do not have HIV, she said, is that the clinic is extra vigilant in checking for potential problems in its patients who have a low T-cell count, such as giving biannual Pap smears to women to check for cervical dysplasia, for example.

Because Schneider's patients get well, they require more help with social service issues. The nurses work with social workers to help clients make the transition back into healthy living, which includes getting off disability payments, locating new housing or finding psychiatric resources.

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