In 2016 Community First Health Plans became one of two Health Insurance Plans in the Bexar Service Region awarded a State STAR Kids contract. STAR Kids members are medically fragile/special needs children (birth to age 21 years) that require diligent, ongoing Service Coordination to ensure appropriate access to medical and behavioral health services across the continuum of health care. The most medically fragile STAR Kids members are assigned RNs to conduct in home (face to face) assessments with the child and their parent or legally authorized representative. The intensity of this work requires a level of professionalism, compassion, and advocacy that is beyond high-tech. Service Coordination also requires emotional intelligence and a sense of humanity that is important to the quality of life of members and their families. CFHP staff have grown extensively in their experiential knowledge and demonstrate the rebirth of the important impact that Community Health Nursing can have on a very fragile population of children and their families. This hands-on approach to facilitating home-based care is allowing the special needs community of children to remain at home with their families and out of the hospital.
Our team wants to share a very special story of an RN Service Coordinator who exemplifies the seldom recognized, super-human work done by the Population Health Management team at CFHP. This story highlights Amanda Lucas, RN, and the important work that she engaged in with one special member. In 2018, Amanda was assigned to coordinate the care of a member with complex medical needs including; Muscular Dystrophy, Giant Axonal Neuropathy, Dysphagia, Reflux, visual impairment, generalized weakness, and hydronephrosis. This member was a victim of abuse and neglect by her mother and relocated to San Antonio with her father. When she arrived, she had no supplies or services in the home whereby the father and his significant other could care for her. She was bedridden and cachectic. In partnership with the child's PCP, Amanda conducted an expert assessment and Plan of Care and orchestrated an amazing and coordinated deployment of home resources including nursing, supplies, and durable medical equipment. The support that Amanda provided for this child and her family resulted in outstanding and compassionate care over a three-year period. This dedicated nurse left no stone unturned and through her vigilant efforts at Service Coordination and ongoing professional engagement, this member received outstanding care at home for her complex needs. Unfortunately, despite all of Amanda's efforts - the complexity of her patient's chronic medical problems were not survivable and she passed away. During the last years of her life, Amanda's role as her assigned RN Service Coordinator made an important difference in the quality of life for her and her family.
Amanda Lucas is a very special nurse. We believe she typifies the extraordinary efforts of a DAISY Nurse. While doing her job, she provided this patient coordinated, compassionate care in a safe place with her loving father at her side during the last few years of her life. During her care journey with CFHP, the patient never spent time in an inpatient hospital setting. For those of us who are familiar with this complex pediatric population, this is quite unusual. While Amanda Lucas was "just doing her job" as a CFHP Service Coordinator, she is our greatest example of a fellow nurse who deserves our highest recognition. We want to recognize her for going above and beyond the traditional role of a nurse. She ensured time and again over a three-year relationship with this member that she was reliable and always there to help her special patient. It was Amanda's expertise, critical thinking, prioritization, and commitment that facilitated compassionate care for both the member and her father in the comfort of their own home.
Amanda is a wonderful example of this important workforce of nurses at CFHP who are dedicated to their patients (our members). Her story is evidence of the strength and compassionate professionalism on the front-line, making it possible for people with complex chronic mental and physical health issues to overcome tremendous barriers to living. Amanda Lucas is a professional dedicated to going upstream. Her work in homes and neighborhoods where children and their families live is changing the nature of the future of healthcare and facilitating a more inclusive community where families can stay together and live a more functional life.