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At Group Health Cooperative in the Puget Sound area of Seattle, nurses perform crucial services in helping integrate the group's health plan with its network of provider services.

"Nurses are involved in lots of development, a really good example being the clinical information system," said Barbara Trehearne, Ph.D., RN, director of nursing operations, who is a graduate of the White Cross School of Nursing in Columbus, Ohio.

"We often see people with technological expertise designing these clinical information systems without interfacing with the clinical people who know how they should work when it comes to patient care," Trehearne said. "Our doctors and nurses work together to help design systems that meet the needs of the clinical staff."

Nurses also are involved in outreach programs for the group health plan the co-op offers that focus on preventive services through periodic checkups, vision care, immunizations, prenatal care and well-adult and well-child care.

Sharon Brodeur, MPA, RN, national case management director for Aetna in Falls Church, Va., said the health plan actively recruits nurses, particularly those with utilization or case management experience.

When Brodeur joined Aetna about a year ago, the plan had 138 case managers, a number that has since jumped to 244 and is growing under her guidance.

"I'm a big believer in case management," said Brodeur, who has come a long way since graduating from the University of Cincinnati nursing program in 1968. "It's an absolutely critical function and nurses are very skilled as coordinators of this kind of care."

Medical management

Case managers coordinate all aspects of care for crisis patients and help identify members at risk for certain diseases or conditions so preventive measures can be taken.

Quick action is taken in critical situations, an example being an HMO member who suffered a spinal cord injury in an auto accident and was paralyzed from the waist down. The health plan nurse worked with family members and caregivers to help the patient cope with the condition and make a smooth transition to rehab and, eventually, home care.

Brodeur said Aetna is in the process of redesigning a "seamless" medical management program for members and providers, and nurses play essential roles in its success. "Rather than focus on denying care, the focus is on managing care with providers so care is provided at the right time and the right place. This is a key to successful outcomes and managing costs."

Glassen, who earned her nursing degree from the University of Pennsylvania and her master's in nursing administration at UCLA, started her practice in pediatrics at the UCLA Medical Center. She entered managed care at Health Net in 1994, where she worked on utilization and quality management issues and helped set up disease management programs for members with diabetes and asthma.

At Cigna, her initial job was to work with various operational units throughout the HMO to prepare for accreditation and compliance surveys by the National Committee for Quality Assurance. She then moved into her present role in customer satisfaction.

"I think of my role today as a consumer advocate," said Glassen, who counts on teamwork among nurses in resolving member appeals of procedures denied by medical groups. She also reviews member satisfaction data to determine where to make changes to make consumers happier.

The health plan has a 24-hour nurse advice line that recently helped one caller bring her husband into an ER after he complained of chest pains, but insisted it was indigestion. On the RN's insistence, he went to a hospital and was diagnosed with a heart attack and stabilized in time to save his life, Glassen said.

Cigna nurses also visit some patients in hospitals in order to help coordinate care and make sure members' needs are met, including transitions to subacute settings, nursing homes or home care.

Other nurses do outreach to members, such as sending reminders for mammograms or other tests. They also serve as case managers and have key roles in preventive services that focus on prenatal and postnatal care, immunizations, cancer screenings and retinal eye exams for diabetic patients.

"Our nurses coordinate care to help keep the healthy healthy and those who are sick get better. And that's a win-win for everybody," Glassen said.

Contact John Leighty at johnsan@aol.com