Educator Of The Month: Persistence Pays Off: Nurse Persuades HMO To Augment Patient’s Plan

How many times have you skipped a blood sugar test because you didn’t want to waste a meter strip?

Liz, a 43-year-old who has had diabetes for 27 years, tested only twice per day in an effort to conserve strips. She had multiple complications and only very basic HMO coverage through her employer. She had trouble “feeling” her insulin needs yet depended almost entirely upon physical signals when managing her diabetes. On one fateful day this method broke down completely. Her blood sugar measured 217 in the morning, but later that afternoon, Liz was in a serious car accident after passing out behind the wheel. Her blood sugar level had plummeted without warning to 24.

Luckily, Liz survived. But despite her best intentions, lack of money seemed like an insurmountable obstacle to correctly managing her diabetes. That’s where Caroline Trapp, RN, came in.

Trapp is a diabetes educator at Providence Hospital in Southfield, Mich. Impressed by Liz’s sincere desire to get her diabetes under control, Trapp felt that a ready supply of meter strips was the ticket to better health. However, Liz’s HMO did not include a Durable Medical Equipment (DME) clause, and this prevented her from being reimbursed for her strips. First, Trapp directed Liz through the usual channels-her doctor and the customer service department of the insurance company. When these efforts failed, Trapp knew it was her own responsibility to get tough.

Trapp began at the bottom of the HMO hierarchy and worked her way up through the chain of command. Explaining that the insurance company would save more in the long run by paying for strips now rather than treating acute and chronic complications later, Trapp was finally invited to fax a letter to the company on Liz’s behalf. After reading Liz’s history and efforts at control, the HMO approved coverage of her meter strips that same day.

Liz is now able to test her blood sugar six times per day. She will have to renew her request for strips every six months, but for now she is doing well.

Says Trapp, “Part of the challenge is educating the insurance companies that there’s a benefit to paying for this upfront instead of waiting for complications. You can fight the insurance companies, and you can win.”

She notes that many companies fear funding meters and other equipment that will sit in patients’ medicine cabinets, never to see the light of day. Trapp says she understands both sides. Many patients set out with good intentions only to find that blood glucose monitoring is too complicated. But Trapp insists that “this is something anyone can manage with support.”

Trapp claims that if the HMO had not cooperated, she would have contacted the person in charge of benefits at Liz’s job. It may have been possible to convince that person that employees with diabetes requires more than the “basic” HMO.

“I’m passionate about this,” Trapp says. “Once you’ve had somebody tell you they’ve been turned down for help 12 times, you want to help. Especially when I know the patient. She comes to class, tries the things I suggest, and does all the right things.”

Trapp wants us to understand that we have more power than we often imagine. “I was successful because I was persistent. Patients and educators should be prepared to make many phone calls and write several letters until the desired information and answers are obtained. Medical insurance companies, employee benefit managers, and legislators need to hear from us. All are potential sources of help.”

Fighting insurance companies is not Trapp’s only mission. This busy educator is also involved with the Southeast Michigan Diabetes Outreach Network (SEMDON), a program funded by the Michigan Department of Health. SEMDON focuses on educating nurses about how to help their patients avoid the complications of diabetes. The program is free to any health agency that requests its services

Trapp works for three primary-care physicians, meeting one-on-one with their patients to help teach self-care. But perhaps she is most enthusiastic about her work with children.

The mother of two boys, Trapp enjoys helping kids with diabetes get a handle on their disease. Though neither Trapp nor her sons have diabetes, she and her five-year-old learned a great deal at ADA-sponsored summer camps these past two summers. During July 1995, Trapp and her eldest son went to camp in Indiana where she taught the youngsters about taking care of themselves and learned more about meal-planning.

At the camp, Trapp met a person with diabetes who made a deep impression upon her. A young woman recently accepted to college and hoping to study sign language, was prone to blackouts as a result of her diabetes. Her parents were terrified of letting her move into an apartment alone, far from where they could keep an eye on her. Trapp learned that the girl was in a situation that was similar to Liz’s-she had a basic HMO and the financial inability to test her blood sugar more than twice each day. Trapp has gone to bat for this girl, too, and is hopeful that she’ll be successful once again.

Trapp also conducts a support group for kids with diabetes. Thirty families participate in the group which includes children from six to 14 years of age. Student nurses assist Trapp, creating new programs each month.

“All these things are very connected for me,” says Trapp. “The experience of one patient relates to others, and I can share their stories.”

Trapp believes that diabetes nurses, in addition to being great patient advocates, have much to offer in terms of care and support. She hopes to see diabetes become a recognized area of advanced-practice nursing, with services covered by insurance. This would make diabetes nurses similar to midwives and nurse practitioners. “Everyone should have access to a diabetes nurse as part of their healthcare team.”

This is her tenth year as a nurse, and Trapp loves working with diabetes. “This is such an exciting area for nurses because there is so much we can do.”

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