1. Medical Case Management: Adopting New Roles and Techniques
Julia Hidalgo, ScD, MSW, MPH Positive Outcomes, Inc. & George Washington University

2. Ground Rules
I do not represent FL DOH, Orange County Part A Grantee’s Office or HAB
Let me know if you do not understand
You will be rewarded for staying awake
Shut off your electronic devices
A 15 minute break means 15 minutes!

3. Today we will discuss The evolution of HIV case management in the US
HIV/AIDS Bureau (HAB) definitions for medical and non-medical case management, as well as adherence
Conceptual models that form the basis for the medical case management model
Roles of medical case managers in managing HIV disease, treatment, access to care, medication side effects, medication adherence, third party payers, and health information
Interactive application of what you have learned today

4. Quick History of HIV Case Management
Late 1980s and Early 1990s
Focus on newly introduced HIV testing and treatment (AZT)
Support activities offer alternatives to inpatient stays
A continuum of support services develops
Volunteers continue to provide support services, with CBOs forming
Populations impacted by HIV become diverse
Early 1980s
Focus on hospitalizations and end of life care
Case managers coordinated care for terminally ill patients
Case managers tend to be from other health care or social work systems and have a personal commitment to the AIDS epidemic
Volunteers provide support services

5. Quick History of HIV Case Management
Mid to Late 1990s
Focus on HIV voluntary testing, primary care, and combination therapy
Understanding of the roles of medication adherence and drug resistance grows
Number of clients increases steadily and diversity of the infected community expands
CARE Act, Medicaid, and Medicare underwrite growing costs
Case management is professionalized
Community-based care continuum grows, with growth in minority organizations
Outreach and retention efforts grow
The 2000s
Focus on rapid HIV testing, HAART, and increasingly complex specialty care
CARE Act funds flatten
Number of clients grows
They experience longer, more complex lives, outstripping service capacity
Mental health and addictions treatment become important component of HIV care
Case managers seek simplified models, borrow from other disciplines, assess outcomes
Role of adherence and self-management is recognized
Peers’ role in care continuum is acknowledged

6. Quick History of HIV Case Management
Today
The Ryan White HIV/AIDS Treatment Modernization Act of 2006 identifies two types of case management
Medical case management (considered a core medical service)
Support case management in which referrals for health care and support services are made (considered a support service)
HAB has not defined these service categories

7. Defining Medical Case Management

8. HAB’s Medical CM Definition
Medical CM services (including treatment adherence)
A range of client-centered services that link clients with health care, psychosocial, and other services
The coordination and follow-up of medical treatments
Medical CM includes the provision of treatment adherence counseling to ensure readiness for, and adherence to, complex HIV/AIDS treatments
These services ensure timely and coordinated access to medically appropriate levels of health and support services and continuity of care
Through ongoing assessment of the client’s and other key family members’ needs and personal support systems

9. HAB’s Medical CM Definition Contd
Key activities include
Initial assessment of service needs
Development of a comprehensive, individualized service plan
Coordination of services required to implement the plan
Client monitoring to assess the plan’s efficacy and
Periodic re-evaluation and adaptation of the plan as necessary over the client’s life
Includes client-specific advocacy and/or review of utilization of services
Includes all types of CM including face-to-face, phone contact, and any other forms of communication

10. HAB’s Non-Medical CM Definition
Provision of advice and assistance in obtaining medical, social, community, legal, financial, and other needed services
Does not involve coordination and follow-up of medical treatments, as medical CM does

11. HAB’s CM Treatment Adherence Definition
HAB does not explicitly define treatment adherence responsibilities or roles for medical case managers
Treatment adherence strategies used throughout the U.S. include
Assess factors likely to contribute to poor adherence and develop individualized care plans to address those factors
Medication, referral, and appointment adherence interventions
Patient HIV education to expand “health literacy”
HIV medication education, including side effects and their management

12. HAB’s CM Treatment Adherence Definition Contd
Attending medical visits to assist patients to understand the information provided by medical provider
Coordinate appointment scheduling to book multiple visits on the same day and arrange transportation to ensure the patient keeps appointments
Home visiting and other methods of case finding for patients that have broken appointments or dropped out of care
Assess and treat mental illness and/or substance abuse

13. Environmental Challenges in Operationalizing MCM
Good news: HAB’s MCM definition is not proscriptive
Bad news: HAB’s MCM definition does provide a roadmap in designing or improving MCM and non-medical CM systems
The CM workforce in many (not all) jurisdictions are in crisis
High caseloads, inadequate compensation and training, minimal supervision, high turnover
HAB grantees are re-engineering their CM systems to address these challenges, as well as to “medicalize” CM practice
One missing component to their efforts to medicalize CM practice is the collateral expectation that clinician embrace the role of MSM on the care team

14. What is the chronic care model?

15. Short History of the Chronic Care Model
Initial experience at large Northwestern group practice
Reviewed and revised by advisory committee
Breakthrough series documented the model’s wider application
Applied in diabetes, geriatrics, asthma, HIV, and depression with over 500 health care organizations participating in collaboratives
Model adopted by HAB as a concept in the early part of this century
HIV quality collaboratives have been funded

16. Chronic Care Model
A population-based model that relies on knowing which patients have the illness, ensuring that they receive evidence-based care, and actively helping them to participate in their own care

17. Self- Management Support
Chronic Care Model
Community
Health System
Resources and Policies
Health Care Organization
Practice Level
Self- Management Support
Delivery System
Design
Decision
Support
Information Systems
Prepared,
Proactive
Practice Team
Informed,
Activated
Patient
Productive
Interactions
Improved Outcomes

18. What characterizes a “informed, activated” patient?
The patient understands the disease process
Realizes his/her role as the daily self-manager
Family and caregivers are engaged in supporting the patient’s self-management
The provider is viewed by the patient as a guide

19. What characterizes a “prepared” practice team?
At the time of the visit, the team has the patient’s information, data, staff, equipment, and time required to deliver evidence-based clinical management and self-management support

20. What are the characteristics of a productive interaction?
Informed,
Activated
Patient
Productive
Interactions
Prepared
Practice
Team
Assessment
Collaborative goal-setting and problem-solving
Tailoring of clinical management by protocol
Shared care plan
Active, sustained follow-up

21. Disease Management (DM) According to the DM Association of America
DM is a system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant
Supports the clinician - patient relationship and the care provided
Emphasizes prevention of complications by using evidence-based practice guidelines and patient empowerment strategies
Evaluates clinical, humanistic, and economic outcomes on an ongoing basis with the goal of improving overall health

22. Disease Management Processes
Population identification processes
Evidence-based practice guidelines
Collaborative practice models include physician and support service providers
Patient self-management education
Includes primary prevention, behavior modification, and compliance monitoring
Process and outcomes measurement, evaluation, and management
Routine reporting/feedback loop
Including communication with patient, physician, or practice profiling

23. What are case managers “managing?”
HIV Disease
Clients’ Care Seeking, Treatment and Appointment Keeping Adherence, and Behaviors
Clients’ Participation in Third Party Health Insurance System, Including the Ryan White Program
Medications and Their Side Effects
Information Useful to Clients to Achieve Independence and Successfully Manage Their Disease

24. What are case managers managing?
HIV Disease
Clients’ Care Seeking, Treatment and Appointment Keeping Adherence, and Behaviors
Clients’ Participation in Third Party Health Insurance System, Including the Ryan White Program
Interactions Between Clients and the Health Care, Human Services, and Legal System
Information Useful to Clients to Achieve Independence and Successfully Manage Their Disease

25. What ways do you help to manage your client’s HIV disease?
Monitoring and communicating with clients regarding their clinical markers (e.g., viral load, CD4 count, resistance test results)
Ensuring access to HIV medications and clinical services
Coordinating referrals to specialists to treat OIs and other clinical conditions
Facilitating receipt of services required to sustain good health
Arranging for mental health and addiction treatment
Coordinating the health care providers serving the clients

26. Antonio’s Story
Antonio is a 45 year old HIV+ construction worker that relocated to Orlando from New York. When we first met him, he and his HIV+ wife lived together with their two children ages five and two. His wife left him last year, and he has cared for his children with the assistance of his case manager, who has facilitated home chore services. Antonio has advanced HIV disease, and chronic orthopedic conditions that prevent him from working. He receives SSDI disability income and Medicare, and his children are enrolled in TANF. Antonio’s CD4 count has been declining, while his viral load has increased steadily in the last 12 months. He now is on salvage therapy. Due to his back problems and HIV infection, he must take numerous medications. He is treated by an orthopedist, an infectious disease specialist, and a psychiatrist. His children have periodic pediatric visits. He has numerous medical appointments every month. Please help him coordinate his care.

27. Managing Clients’ HIV Disease
Pop Quiz: In what ways do you help clients to manage their HIV disease? Other chronic conditions?

28. What are case managers managing?
HIV Disease
Clients’ Care Seeking, Appointment Keeping Adherence, and Behaviors
Clients’ Participation in Third Party Health Insurance System, Including the Ryan White Program
Medications and Their Side Effects
Information Useful to Clients to Achieve Independence and Successfully Manage Their Disease

29. Clients’ Care Seeking, Treatment and Appointment Keeping Adherence, and Behaviors
Move from enabling to empowering clients
Adapt HIV prevention techniques
Stages of change
Motivational interviewing
Case management outreach and re-engagement for clients lost to care
Strength-based social work
Social contracts
Sharing, not guarding, resources such as service directories
Peers “navigators” can lead by example

30. Facilitate applications for benefits
Interactions Between Clients and the Health Care, Human Services, and Legal System
Facilitate applications for benefits
Assist clients to identify community resources that can assist them
Planning discharge of clients from jails, detention centers, prisons,
Facilitating housing referrals
Ensuring continuity of care and resources

31. Pop Quiz How do you assess HIV treatment readiness among new clients?
What intervention do you undertake or arrange to help your clients to get ready?
What actions do you take to ensure that your clients adhere to their treatment regimen?
How do you know if they are adherent?
What communication occurs between you and clinicians to coordinate treatment readiness and adherence activities?

32. Henri’s Story
Henri is a 27 year old HIV+ Haitian who has been enrolled at your HIV clinic for one year. He periodically misses his medical and case management appointments, and fails to call and cancel. When he does arrive for his appointments, he tends to arrive one to two hours late. He has borderline personality disorder, and can be disruptive in clinic. He states that he does not believe in safe sex. He was initiated on HAART six months ago, and was relatively compliant until recently. His last lab report documented that Henri has drug resistance. He reports that he is being evicted and cannot afford another apartment. Yesterday, he missed his case management appointment. You called his apartment, and his phone was disconnected. He left no forwarding address. How would you find Henri and reengage him in care?

33. Mark’s Story
Mark is a 17 year old male of mixed race who tested HIV+ a year ago. He has a history of recreational drug use, and is now addicted to crystal meth. His boyfriend told him he could not longer live in his home due to his addiction. After initiating HAART, Mark did not take his medication as prescribed and then discontinued his medication. Mark was recently diagnosed with Hep C. He was arrested for possession. This is his first arrest. His Public Defender reports that Mark can serve his sentence at a residential drug treatment program. Mark states that he cannot accept his HIV infection and finds the treatment regimen overwhelming. Your mission is to find him a treatment slot, and reconnect him to medical care.

34. Your Story
Many patients you serve at an HIV clinic are medically complex. Some entered HIV care with advanced HIV disease, others have severe mental illness or addiction. Most clients have numerous chronic medical conditions and psychosocial problems. You have identified the need to better coordinate case management with treatment provided by the clinicians at your clinic. Your mission is to convince them of the value of specific multidisciplinary interactions. Explain the approach, its benefits, how you would organize it, the topics to be discussed, and the frequency of these meetings.

35. Clients’ Care Seeking, Treatment and Appointment Keeping Adherence, and Behaviors
Pop Quiz: In what ways do you intervene in your clients’ care seeking, treatment and appointment keeping adherence, and behaviors?

36. What are case managers managing?
HIV Disease
Clients’ Care Seeking, Treatment and Appointment Keeping Adherence, and Behaviors
Clients’ Participation in Third Party Health Insurance System, Including the Ryan White Program
Medications and Their Side Effects
Information Useful to Clients to Achieve Independence and Successfully Manage Their Disease

37. Assisting clients to enroll in third party insurance
Methods for Managing Clients’ Participation in Third Party Health Insurance System, Including the Ryan White Program
Assisting clients to enroll in third party insurance
Becoming familiar with payers’ benefits packages, benefit caps, coverage, prior authorization process
Assisting clients to enroll or disenroll from managed care plans
Coordinating benefits among payers
Advocating with payer to assist the client to obtain services

38. Sandra’s Story
Sandra is a 19 year old HIV+ White woman who is three months pregnant with her first child. She is enrolled in a Medicaid TANF managed care organization. There are no obstetricians in her county that accept Medicaid managed care payments. She was diagnosed as being HAART multidrug resistant , diabetic, and has high blood pressure. She reports being concerned that her baby not be born with HIV infection. Please help her achieve her goal.

39. Jazmine’s Story
Jazmine is a 26 year old HIV+ Hispanic transgender client (male to female). She is enrolled in AICP, as she works and is not disabled. She mentions at your last meeting that she has been using hormones for several years. She can no longer afford prescribed hormones. Her insurance plan will not pay for the medication, as they are considered a cosmetic treatment. Her only alternative is to buy hormones from a friend. She is worried that the hormones might be unsafe. Several of her friends have gotten sick from street hormones. She asks you to help her find a way to pay for her medication.

40. Methods for Managing Clients’ Participation in Third Party Health Insurance
Pop Quiz: In what ways do you intervene in your clients’ participation in third party health insurance?

41. What are case managers managing?
HIV Disease
Clients’ Care Seeking, Treatment and Appointment Keeping Adherence, and Behaviors
Clients’ Participation in Third Party Health Insurance System, Including the Ryan White Program
Medications and Their Side Effects
Information Useful to Clients to Achieve Independence and Successfully Manage Their Disease

42. Billie’s Story
Billie is a 24 year old HIV+ African-American male with a history of depression, high blood pressure, and attention deficit disorder. He recently was diagnosed with HIV, and is treatment naïve. His initial laboratory tests indicate that he is multiply drug resistant. Selection of ARVs is further impacted by his use of prescribed psychotropics. He is started on combination therapy, and experiences nausea mad diarrhea. At his first HIV medical case management visit, he mentions that he does not understand what the drugs are that he is taking. He comments that the medications are making it difficult to go to work. He asks your advise about how to manage his symptoms.

43. Medications Management
Pop Quiz: In what ways can you support your clients medication management? What information should you provide regarding HIV medications?

44. What are case managers managing?
HIV Disease
Clients’ Care Seeking, Treatment and Appointment Keeping Adherence, and Behaviors
Clients’ Participation in Third Party Health Insurance System, Including the Ryan White Program
Medication and Side Effect Management
Information Useful to Clients to Achieve Independence and Successfully Manage Their Disease

45. Adherence and self-management: Forging new partnerships between case managers and clients

46. Self Management and Adherence
Clients need support and information to become effective managers of their own health
Medical and behavioral interventions are required
Each client is at a different place in the process
Appropriate interventions are driven largely by each client’s desired outcomes
Clients should have a
Basic information about HIV and its treatment
Understanding of and assistance with self-management skill building
Ongoing support from members of the clinical team, family, friends, and community

47. Self-Management and Adherence Activities
Activities that clients perform to control their illness, prevent future complications, and cope with the impact of HIV and its treatment
Collaborative goal setting
Symptoms monitoring
Lifestyle behaviors including healthy diet, getting regular exercise, and smoking cessation
Taking medication in the dose and frequency prescribed
Keep medical, case management, and other appointments
Communicating with the care team, family, and others
Ongoing problem-solving to overcome potential barriers

48. These skills can be applied to other sectors of clients’ lives
Setting and Documenting Self-Management Goals Collaboratively With Clients
Address medication adherence with standardized training and goal-setting
Before beginning HAART, assess client's treatment readiness, understanding of the disease, attitudes about HAART, and understanding the importance of adherence
Review treatment options, client's lifestyle, dosing schedules, and number of pills to be taken
Educate clients about side effects and their management
Set realistic therapeutic goals together
Avoid unnecessary medications
These skills can be applied to other sectors of clients’ lives

49. Self-Management Goals
Address other self-management issues needing collaborative goal-setting
Self-management goals may include
Disclosure of HIV status
Safer sex practices
Entering drug or alcohol treatment programs
Attending support groups
Seeking help for abusive situations
Re-establishing or maintaining a support system
Returning to work
Maintaining a stable living situation
Maintaining body weight
Preventing or controlling medication side effects

50. Practical Steps in Self-Management
Assess clients' skill, understanding, and confidence in managing HIV
Give clients a copy of their goals, and place a copy in the client’s chart
Review the client's personal barriers and enablers to link daily tasks leading to positive self-management behaviors

51. How can you assess your clients’ health literacy?

52. Health Literacy
REALM, the Rapid Estimate of Adult Literacy in Medicine, is a screening tool that assesses an adult patient’s ability to read common medical words and lay terms for body parts and illnesses:
REALM is designed to help health care providers to estimate patients’ literacy level so that the appropriate level of patient education materials or oral instructions can be used
REALM takes two to three minutes to administer and score

53. Health Literacy Score Raw Score Grade Equivalent 0-18
3RD Grade and Below
Will not be able to read most low literacy materials; will need repeated oral instructions, materials composed primarily of illustrations, or audio or video tapes
19-44
4th to 6th Grade
Will need low literacy materials may not be able to read prescription labels
45-60
7th to 8th Grade
Will struggle with most patient education materials; will not be offended by low literacy materials
61-66
High School
Will be able to read most patient education materials

54. Resources For You and Your Clients
MedScape offers a weekly HIV clinical news service:
AIDSinfo offers information about HIV clinical guidelines, vaccines, medications, clinical trials, and other materials and is available at:
Kaiser Daily HIV/AIDS Report is a daily news service:

55. Sheila’s Story
Sheila is a 51 year old HIV+ developmentally delayed African-American woman who lives with her 81 year old father, who supports her with his pension. She receives SSI and Medicaid. She can read at the fourth grade level, resulting in a low health literacy score. She has a history of missing medical and case management appointments and cannot recall taking her HIV medications as prescribed. She was diagnosed last year with PCP. She needs education regarding taking her medication and strategies to help remind her when to take her pills. Please design a protocol to help Sheila self-manage her HIV infection to the extent she can.

56. Group Exercise

57. Task Forces: Group Exercise
Divide into five “task forces”
Each group is assigned a topic
HIV Disease
Care Seeking, Treatment and Appointment Keeping Adherence, and Behaviors
Participation in Third Party Health Insurance System, Including the Ryan White Program
Medication and Side Effect Management
Information Useful to Clients to Achieve Independence and Successfully Manage Their Disease

58. Task Forces: Group Exercise
Identify three significant, common challenges that clients experience related to your topic
Identify ways that medical case managers can address the identified challenges
Identify three proposed strategies for overcoming the identified challenge
Address the role of clients in overcoming the challenge
Identify at least two performance measures to be used to assess the impact of your proposed changes

59. Questions And Discussion