Health Care Story of the Week - 10/28/09

Julie is a 40 year-old mother of 3 in Jackson, Tennessee. In 2005, Julie was in a car accident that left her paralyzed from the neck down. She has a tracheotomy and requires a ventilator to breathe. Nevertheless, she is able to raise her children, attend church, and remain active in the community because of the nurses that TennCare provides for her at home. Now, TennCare is telling her that she will lose her nurses, because it is cheaper to care for her in a nursing home that is almost 75 miles away.

After Julie’s accident and rehabilitation, she was transferred to a nursing home. Unfortunately, her needs were so persistent that the nursing home was unable to provide enough one-on-one care for her. She would frequently come down with pneumonia or develop bedsores. She spent several years of her life bouncing back and forth between nursing homes across the state that could not adequately care for her and hospitals that treated her when she got sick due to lack of care. On several occasions she lost her spot at a nursing home because her recovery in the hospital lasted so long.

In April of this year, she moved home with 24/7 private duty nursing services. Since then, her health has improved, she has not been hospitalized for avoidable illnesses, and she has spent time with her family every day. She lives with her mother, and her sons live with her husband in their old house. Her sons frequently spend the night at their grandmother’s so they can be with their mother, and she is able to help them with their homework after school and see them almost every day.

Recently, Julie was told that TennCare would reduce her nursing hours. TennCare rules say that they will not pay more for nursing than a nursing home would cost. This is called the “least-costly adequate alternative” clause of Tennessee’s medical necessity definition. Julie was also told that she only qualified for TennCare originally because she was institutionalized. Now that she has moved home, TennCare says that she no longer qualifies under that category or any other. Julie used to have private primary insurance, but she reached her lifetime benefit earlier this year and lost it.

Julie currently has a pro bono attorney helping her appeal both issues. She recently had her hearing about keeping her nursing hours. Her doctors and nurses testified that a nursing home would not be a safe place for her to live. Her eligibility hearing will be in November. Julie would be eligible under the Spend Down category, which Tennessee is obligated to keep open due to the state’s acceptance of federal stimulus money. However, this category remains closed. Julie’s story is a perfect example of how gaps in the health care system can tear apart families.