Management Team
The rapidly expanding field of disease management abounds with opportunities
for culturally diverse nurses who can educate and empower patients with
chronic illnesses to take charge of their own health
by Aaron Dalton
As a disease management nurse manager, Maribel Rivera, BSN, RN, oversees
the daily operations of a disease management unit at the insurance company
Aetna. Under her supervision, a group of nurses make proactive outreach
calls to Aetna health plan members with chronic conditions such as asthma,
coronary artery disease or diabetes.
The work of Rivera and her colleagues is part of a burgeoning trend
in health care. Increasingly, insurance companies, corporate employers,
HMOs, hospitals and other organizations are hiring disease management
nurses or using the services of disease management companies to help
reduce the skyrocketing costs of emergency medical care and hospital
treatment for people living with serious chronic illnesses.
Unlike case managers, who help their patients navigate the health care
system to heal specific conditions or diseases, disease managers take
more of a preventive approach. They are trying to keep people from getting
sick or from having a relapse that might put them back in the hospital.
Essentially, disease management nurses are not trying to manage a patient's
disease for the patient. Rather, their job is to give the patient the
tools, education and encouragement to control his or her own disease.
Disease management
nurse Chrystal Morris, RN |
Take for example the work that Chrystal Morris, RN, does in disease
management for the health management firm McKesson Health Solutions.
McKesson employs more than 250 disease management nurses to offer telephone-based
education and assessment to patients with conditions like asthma, diabetes,
congestive heart failure, coronary artery disease and chronic obstructive
pulmonary disease.
Morris, who has been a nurse for 43 years, started at McKesson seven
years ago working in a call center. But like many of her disease management
colleagues, she now works from home. "People who have been doing
[bedside] nursing for quite a while, as I had, will understand why I
needed a change," she says. "Clinical nursing has changed
a great deal in the last 40-odd years. When I started out, it was more
about getting to know the patient, providing hands-on care, being able
to listen to the patient and do a good physical assessment."
By the time Morris left clinical care, the nursing shortage meant that
on some evenings she was the only RN on a floor filled with 15 to 20
dialysis patients. Now, as a disease management nurse, she handles a
caseload of more than 300 patients, but still feels she is able to make
a better connection and establish a strong rapport with these patients
with whom she talks on a monthly or bi-monthly basis. She works a split
shift from home: 6-10 in the morning and 5-9 at night, five days per
week.
"One of the most rewarding things about disease management is
when you are able to give information to people who do not understand
their condition and tell them what the condition is and what they can
expect," says Morris. She recalls one patient whom she helped manage
his diabetes by helping him lose 60 pounds. When she first started working
with him, the man was taking insulin and other medications to control
his diabetes, but by the time Morris had finished he no longer needed
to take any medication at all to keep his blood sugar in a normal range.
"People need a lot of encouragement to make these changes,"
she emphasizes.
Morris laughs as she recalls another disease management success story
involving a woman who was very obese and had associated health problems.
Morris encouraged her to walk, but the patient had such difficulty walking
that she could only make it to the house next door. "I told her
to walk as long as she could, and pretty soon she could walk to the
next house and the next," relates Morris. "To make a long
story short, she was soon walking around the block and then to the point
where I could never reach her at home when I called. She found out she
could get off the block!"
The Value of Minority Nurses
What skills and background does a nurse need in order to become a disease
management specialist? Many disease management employers want RNs or
LPNs who have a minimum of three to five years experience in clinical
care-but in fact, many disease management nurses have far more experience.
At McKesson Health Solutions, for example, disease management nurses
have an average of 15 to 20 years clinical experience.
Some employers, including Aetna, like to see that a nurse has experience
dealing with the type of patient population usually served by disease
management-i.e., patients with chronic conditions like asthma, congestive
heart failure or coronary artery disease.
Another key requirement is computer literacy. Whether they work from
home or a call center, disease management nurses are expected to do
a lot of typing, so they need to be comfortable with a computer and
even able to have a phone conversation and type at the same time. Clinically
competent nurses with good computer skills could definitely have an
advantage in applying for a disease management position.
All of the employers interviewed for this article said they recognize
the value and importance of having minority nurses as part of a disease
management team. After all, this specialty depends heavily on building
a trusting relationship between nurse and patient. Nurses of color who
share cultural, ethnic or linguistic bonds with their patients can help
strengthen that connection.
"[As minority nurses,] we can communicate more effectively with
some of our [minority] patients," says Rivera. "Communication
is the key to success in disease management. If you can't communicate
with your patient, you are not able to effectively deliver your message."
Though Rivera was the only minority nurse in her department when she
joined Aetna in 2003, she has since recruited two other nurses of color
into her group.
Similarly, Morris, who is African American, believes her ethnicity
helps her to relate to and form a rapport with some of her African American
patients. She also credits some time spent as a nurse in East Harlem
with helping her learn enough Spanish to communicate more effectively
with Hispanic segments of her patient base.
Community-based Disease Management
The biggest difference between clinical care and disease management
for many nurses will be the lack of physical, hands-on contact with
patients. Many disease management nurses work exclusively over the telephone.
But Rivera says nurses can still have an impact over the phone. "By
providing education, we can affect outcomes," she explains. "For
example, if the patient smokes and is asthmatic, we can work with the
patient until she is ready to make a behavioral change."
In addition to providing information over the phone, disease management
nurses can also send printed educational materials through the mail
or guide patients to Internet-based resources if the patient has access
to a computer.
Of course, not every disease management nurse works in a telephonic
environment. Specialty Disease Management (SDM), headquartered in Jacksonville,
Fla., started providing in-person, community-based disease management
services in 1997 to patients with HIV. Gradually, the company expanded
its scope to the point where nurses working with smaller caseloads (less
than 100 patients) engage in disease management education and outreach
services for patients with a variety of conditions (diabetes, cardiovascular
disease, heart failure, asthma, etc.), but it has maintained its community
outreach methodology.
Margrett Davis, RN, MPH, has been working in disease management for
a couple of years and has been on staff with SDM for a year now. A nurse
for more than 30 years, 14 of them in cardiovascular nursing, Davis,
who is African American, also worked in home health nursing before going
back to school to earn her master's in public health.
Though she loved home health care, Davis says she enjoys disease management
nursing even more. "It's just wonderful," she declares. "I'm
trying to make a difference, trying to increase disease awareness and
bring education, providing the community with the resources that are
there for them-especially the underserved populations that may not be
aware of those resources. We also do lots of provider education and
try to bridge the gap between the medical community and the patient."
Many of SDM's disease management nurses meet with patients face-to-face
in the community. As a provider outreach coordinator, Davis engages
in provider education, but she is also involved in community education
through health fairs and partnerships with national organizations such
as the American Diabetes Association, the American Lung Association
and the American Heart Association, as well as faith-based organizations.
"The population on Medicaid can have such a distrust of the medical
community," she notes. "We try to bridge that gap."
Minority disease management nurses working in the commu-nity can also
play a crucial role in helping to break down barriers caused by cultural
differences. When one of their patients does seek medical care, community-based
disease management nurses may send a note to the doctor before the patient
arrives to try to bridge any potential linguistic or cultural gaps that
may exist between physician and patient. The nurse may then talk with
the physician and patient after the appointment has taken place to make
sure that the patient understood all of the physician's instructions.
All this hard work in the community pays off, clearing up misunderstandings
and miscommunication and forging bonds of trust between community members
and medical providers. As a result, patients who might only have gone
to seek medical help in a crisis situation are now more receptive to
the sort of proactive, preventive care that can improve their health
in the long run, decreasing their risk of complications from chronic
illnesses.
Rivera says it can be very rewarding to educate a patient and see that
person arrive at a better outcome with decreased visits to the ER and
fewer hospital admissions. Once the patient is in better control of
his chronic condition, a disease management nurse may gradually lessen
his or her contact with the patient while empowering the patient with
the ability to keep utilizing the disease management resources as needed.
Opportunities for Advancement
As the disease management field grows, it offers many opportunities
for advancement as well as an attractive alternative for nurses looking
to expand their careers beyond the bedside. When Rivera joined Aetna
in 2002, her unit had seven nurses. Now it has more than 40 nurses and
Rivera has progressed through the ranks to become first an educator,
then a staff developer and finally a supervisory manager.
Many disease management companies say their biggest challenge is attracting
qualified nurses, especially minority nurses with specialized language
skills.
Take the example of LifeMasters, a disease management service provider
that has grown from employing eight nurses to several hundred nurses
in just the last few years. Nancy Wallace, RN, BS, a clinical practice
manager with LifeMasters, says the company has major call centers in
Sacramento and Albuquerque and just opened a 300-seat call center in
San Antonio.
In its new center, LifeMasters has a goal of hiring 30% bilingual nurses,
providing many opportunities especially for Hispanic nurses. LifeMasters
serves a diverse population and seeks to hire minority disease managers
capable of reaching out to the various ethnic groups in their own language
and cultural context.
"We build one-on-one relationships with our program participants
and tailor the education to the individual needs of each participant,"
Wallace explains.
"Bilingual skills are key because we have a large population of
members who speak Spanish, Cantonese, Mandarin, Russian and so forth.
Even within the Spanish-speaking community there are different dialects-in
Florida we have a lot of Cuban members while in New Mexico the population
has more of a Mexican dialect."
Wallace believes a career in disease management can be a welcome change
of pace for nurses who may have spent decades in clinical care. "They
may be looking for a change from an acute care environment, but they
still want to be able to utilize their acute care knowledge," she
says. "Disease management does not have the heavy physical demands
you find in a hospital setting. The bedside becomes a telephone and
a computer, but the nurses are still able to use all their expertise."
While switching to a less physically strenuous practice setting may
be appealing to many veteran nurses, Wallace has found that for most
new hires at LifeMasters, the real attraction is having the opportunity
to finally do patient education. "Our nurses can follow patients
as they make improvements in their health," she says. "In
a hospital, you take care of a patient, patch her up and send her home.
You don't often have a chance to find out what happens to her later.
Here in disease management we may follow the same program participant
for two to three years. We consistently hear from our nurses that seeing
the progress patients make is a big contributor to their job satisfaction."
Changing Patients' Lives
There are many paths to finding a position in disease management. Many
employers looking to hire disease management nurses sponsor job fairs,
offer application information on their Web sites, place recruitment
ads in industry publications or post listings of open positions on Internet
job boards like Monster.com and MinorityNurse.com.
Looking back over her years in disease management, Maribel Rivera has
many good memories of the positive impact she has made in the lives
of her patients. She has reached out to numerous diabetic Aetna health
plan members who did not have glucose monitors to check their blood
sugar or who did not know about mail order pharmacies and helped them
start the whole process of maximizing their benefits.
She has helped patients know their rights and entitlements under their
health plans. She has counseled asthma patients who were using rescue
inhalers 10 times a day, encouraging them to go see their doctors. Now
she talks to them and hears they have abrand new peak flow inhalers
and are not using their rescue inhalers as often.
Thanks to Rivera and others like her, thousands of patients have more
control over their chronic diseases and are managing their own conditions.
With help from their disease management nurses, they are living healthier,
more educated, more empowered lives.
Aaron Dalton (www.imaginationwins.com)
is a New York City-based free-lance journalist who writes regularly
on health topics.
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