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.
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 community 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,” says Wallace. “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 http://www.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 brand 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.
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