How do we get the HMO to work with us?

January 8, 2006 7:20 PM

My parents are members of an HMO, but our dealings with them have been frustrating, and we need help. (*Catheter references inside.)

My parents are members of a popular HMO, and my mom has multiple sclerosis. She has been luckier than many who have it, but a product of it is that she's been catheterized. She's been good about flushing the hose with saline, but sediment from her vitamins and medications does cause it to eventually clog -- usually earlier than the monthly schedule issued by the HMO.

When she first started the catheterization program, my parents would go off to the hospital (exposing themselves to germs) to get the catheter changed. A nice nurse later revealed to us that all along my mother was qualified to have a nurse come to the house to do it when necessary. This worked well for a while.

More often, however, we end up with a nurse (we'll call her the 'bad nurse') who we don't think has much regard for us. We were told by a couple nurses at the HMO that the standard change schedule is one month, and anything off that schedule must be requested on a case by case basis.

* On several occasions, my mother's made requests for changes, only to have days pass, before my father (who received a perfunctory training on this) finally had to change the catheter himself late after work.

* We've asked several questions of the the bad nurse, only to get contradictory answers. We've checked up on simple requests we've made for standard supplies (which she agreed to) only to find that they were never followed up on.

* I noticed the bad nurse's case notes were completely wrong regarding the nature of my mother's incontinence.

* My mother has complained that the nurse's method of installing the catheter is painful/disturbing by comparison to that of the other nurses.

* My mother's questions or comments are often met with unexpected accusations of her not taking her medications.

We want to get a different nurse to come in (several kind and gentle nurses, who've gotten along well with my mother and the rest of us, have offered to be the one to come here each time), but the 'bad' nurse also happens to be the case manager, and is the most local to us; so even when we request someone other than the bad nurse, from her superior, we often end up with her anyway.

We don't know what our rights or options are, and the bad nurse is stonewalling us.

posted by evil holiday magic to health & fitness (6 comments total)

I would talk with the physician that is ordering the visiting nurse and explain the situation. I'm a bit confused about the cather that you are speaking of. You say it gets clogged by vitamins and medications. I've not heard of vitamins or medications being put into a urinary catheter, (well, okay--I can see where maybe chemo. medications or continuous irrigation could be used). I have been out of "floor nursing" for awhile, though and I certainly may be wrong.

I would express your concerns working up the food chain. You and your family have the right to good, compassionate care and to have your questions answered. Go above her head, even case managers have supervisors.
posted by 6:1 at 7:36 PM on January 8, 2006

COuld you try scheduling the changes for a different time of day or different day of the week? Say that you'll be busy most of the week with and can only have it done at 10pm on thurdsdays (when presumably another nurse is on duty?).

I know when I had a nurse coming to my home daily, the nurse I had was chosen was one of the ones who worked late nights because I had class all day and wouldn't be home until late evening. I assume that if my schedule had changed I might well have been given a new nurse.

Otherwise, can't you just say you'd be more comfortable with another nurse and insist that you no longer wish to see that nurse? It seems very strange that they would send her after you've asked for another nurse, are you sure you've made it clear to her superior that you just don't want to see bad nurse anymore (bad nurse is fired. I want a new nurse.) Even an HMO can't force a practitioner on you, can they?

If they refuse to give you a new nurse, you could really play hardball: If they make an appointment for your mom with bad nurse, pick up the day before the appointment and get the catheter changed at the ER. Eventually they'll catch on that it's cheaper to give you a different nurse than to pay for ER visits.

(This all based on the understanding that these catheter changes are semi-scheduled. I'm a little unclear on how scheduled they are.)
posted by duck at 7:41 PM on January 8, 2006

To answer 6:1's question, I didn't mean to suggest anything being administered via urinary catheter, only that the drugs and vitamins produce sediment.

In reply to duck: We'd asked a nurse about scheduled changes, and she said the standard interval is locked at monthly, where anything sooner must be called in a day before. It's usually about three weeks before they must be changed due to clogging, and my mom calls it in accordingly. But, it seems as though the 'bad nurse' has opted to wait it out a couple days, forcing my father to eventually perform the change.

Simply asking the bad nurse's supervisor hasn't helped so far, as the bad nurse just lives so close to us, I guess. We're a little unsure how to approach the supervisor, since we don't just want to end up in the same situation, but with the bad nurse pissed at us.

Something must be done though, since I'm afraid of the bad nurse's disinterest and apparent lies.
posted by evil holiday magic at 8:48 PM on January 8, 2006

Have your mother call her the physician that is ordering the catheter changes and talk with him. He may know how to go "above" this nurse/case manager's head. Contact the insurance company and complain to them, your parents are customers.

I wish I could guide you better.
posted by 6:1 at 10:05 PM on January 8, 2006

I work in health care. Dentistry currently, but I've also worked in an Internal Medicine office.

Are you in a city with enough private duty nursing companies that you might be able to switch services altogether? If so, meet with a few of the supervisors, and without mentioning up front your specific current problem with the bad nurse (nurses have a way of all knowing each other...) ask questions about how the company handles these sorts of problems.

Also, write letters, documenting your specific problems with bad nurse. Send these letters cc'ed to everyone in the company who might have any power to care/ effect change. Cc these letters also to your doctor for inclusion in your chart, if you are comfortable having them as part of your permanent medical record. Call your insurance company directly and send letters to ask for written explanations from them regarding this particular nurses responses and behavior. If your letters to the home health provider and the insurance company get you no satisfactory outcome, you will have to switch companies. Your mother's comfort is just too important to be at the whim of someone so so so so unngh. Insert bad words here.

Also, is your mother old enough that she might qualify for a letter to your local or state person who deals with elder abuse? Because boy, that looks ugly, abusing old people. Seriously, if your mother is of a certain age and is in pain/ caused embarassment by this situation, this particular company would be looking for a hurting in the media/courtroom, not that I am suggesting litigation, but maybe other people have had the same problem. You might also contact the Better Business Bureau and see if they have anything on record.

Best of luck.
posted by bilabial at 11:32 PM on January 8, 2006

Is your involvement with this HMO part of someone's employment benefits? If so, perhaps someone in the HR department would know all the ins and outs of the contract with the HMO.
posted by winston at 5:57 AM on January 9, 2006