Smooth Sailing
Nurses who work for health plans assure appropriate care delivery and provide patients with the tools to manage their conditions

By John M. Leighty
January 22, 2003

Tracy Bodtker, RN, exercises regularly, eats well and uses her enthusiasm for preventive health care to help soothe the fears and anxieties of patients in a major health plan who are headed for surgery.

"I'm really into prevention medicine-giving people tools that will empower them to manage their own health care issues," said Bodtker, a 1985 graduate of the nursing school at California State University, Chico.

Today, Bodtker is program director of an innovative presurgical guided imagery program for Glendale, Calif.-based Blue Shield of California, the first HMO in the nation to offer the mind-body technique as a healing tool to its members free of charge.

One woman about to undergo a total knee replacement-her second-enrolled in the visualization program because of the severe emotional difficulties she had the first time around.

"She went into surgery with a positive mind-set, the recovery was quicker, the blood loss less and there was a significant difference in her anxiety level from the first surgery," said Bodtker, whose team of nurses contacts and assists members who can benefit from the program.

The guided imagery program uses tapes and relaxation techniques developed by Health Journeys to calm preop patients and instill positive attitudes that result in better outcomes, said Bodtker, who started her nursing career at John Muir Medical Center in Walnut Creek, Calif.

About 100 members a week use the imagery program with positive results, and its success has prompted Blue Shield to expand the technique to help patients cope with asthma and cardiovascular disease and to deal with lifestyle risk factors, such as smoking cessation, weight loss, stress and depression.

After seven years of working at Muir in med/surg, oncology and other capacities and a brief stint at a therapy bed company, Bodtker joined Blue Shield, and doesn't regret her career move. She isn't alone. Thousands of nurses across the nation have left hands-on bedside care to join health plans, where they apply their expertise to a broad scope of patient care issues.

Bodtker said her role at Blue Shield opens a door that allows her to look at more global issues. "I can help see that the HMO has certain interventions to aid some patient populations and that's rewarding to me."

Aetna employs 1,250 RNs throughout the nation, about 244 of them in case management. Cigna HealthCare uses 3,000 nurses in various strategic capacities, particularly in disease management, patient education and member satisfaction roles. Nurses in these and other plans often tread a fine line between meeting patients' needs and offering ways to help them handle certain aspects of their medical problems themselves.

Natural advocates

"Nurses, by nature, are advocates, and with their clinical backgrounds in hospitals and home health care, [they] have skills that are really valuable in helping health plan members navigate through the system," said Terri Glassen, MN, RN, a regional vice president of customer satisfaction for Cigna.

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