Presentation on theme: "Medical Case Management: Adopting New Roles and Techniques"— Presentation transcript:
1 Medical Case Management: Adopting New Roles and Techniques Julia Hidalgo, ScD, MSW, MPH Positive Outcomes, Inc. & George Washington University
2 Ground RulesI do not represent FL DOH, Orange County Part A Grantee’s Office or HABLet me know if you do not understandYou will be rewarded for staying awakeShut off your electronic devicesA 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 adherenceConceptual models that form the basis for the medical case management modelRoles of medical case managers in managing HIV disease, treatment, access to care, medication side effects, medication adherence, third party payers, and health informationInteractive application of what you have learned today
4 Quick History of HIV Case Management Late 1980s and Early 1990sFocus on newly introduced HIV testing and treatment (AZT)Support activities offer alternatives to inpatient staysA continuum of support services developsVolunteers continue to provide support services, with CBOs formingPopulations impacted by HIV become diverseEarly 1980sFocus on hospitalizations and end of life careCase managers coordinated care for terminally ill patientsCase managers tend to be from other health care or social work systems and have a personal commitment to the AIDS epidemicVolunteers provide support services
5 Quick History of HIV Case Management Mid to Late 1990sFocus on HIV voluntary testing, primary care, and combination therapyUnderstanding of the roles of medication adherence and drug resistance growsNumber of clients increases steadily and diversity of the infected community expandsCARE Act, Medicaid, and Medicare underwrite growing costsCase management is professionalizedCommunity-based care continuum grows, with growth in minority organizationsOutreach and retention efforts growThe 2000sFocus on rapid HIV testing, HAART, and increasingly complex specialty careCARE Act funds flattenNumber of clients growsThey experience longer, more complex lives, outstripping service capacityMental health and addictions treatment become important component of HIV careCase managers seek simplified models, borrow from other disciplines, assess outcomesRole of adherence and self-management is recognizedPeers’ role in care continuum is acknowledged
6 Quick History of HIV Case Management TodayThe Ryan White HIV/AIDS Treatment Modernization Act of 2006 identifies two types of case managementMedical 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
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 servicesThe coordination and follow-up of medical treatmentsMedical CM includes the provision of treatment adherence counseling to ensure readiness for, and adherence to, complex HIV/AIDS treatmentsThese services ensure timely and coordinated access to medically appropriate levels of health and support services and continuity of careThrough 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 includeInitial assessment of service needsDevelopment of a comprehensive, individualized service planCoordination of services required to implement the planClient monitoring to assess the plan’s efficacy andPeriodic re-evaluation and adaptation of the plan as necessary over the client’s lifeIncludes client-specific advocacy and/or review of utilization of servicesIncludes 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 servicesDoes 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 managersTreatment adherence strategies used throughout the U.S. includeAssess factors likely to contribute to poor adherence and develop individualized care plans to address those factorsMedication, referral, and appointment adherence interventionsPatient 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 providerCoordinate appointment scheduling to book multiple visits on the same day and arrange transportation to ensure the patient keeps appointmentsHome visiting and other methods of case finding for patients that have broken appointments or dropped out of careAssess and treat mental illness and/or substance abuse
13 Environmental Challenges in Operationalizing MCM Good news: HAB’s MCM definition is not proscriptiveBad news: HAB’s MCM definition does provide a roadmap in designing or improving MCM and non-medical CM systemsThe CM workforce in many (not all) jurisdictions are in crisisHigh caseloads, inadequate compensation and training, minimal supervision, high turnoverHAB grantees are re-engineering their CM systems to address these challenges, as well as to “medicalize” CM practiceOne missing component to their efforts to medicalize CM practice is the collateral expectation that clinician embrace the role of MSM on the care team
15 Short History of the Chronic Care Model Initial experience at large Northwestern group practiceReviewed and revised by advisory committeeBreakthrough series documented the model’s wider applicationApplied in diabetes, geriatrics, asthma, HIV, and depression with over 500 health care organizations participating in collaborativesModel adopted by HAB as a concept in the early part of this centuryHIV quality collaboratives have been funded
16 Chronic Care ModelA 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 ModelCommunityHealth SystemResources and PoliciesHealth Care OrganizationPractice LevelSelf- Management SupportDelivery SystemDesignDecisionSupportInformation SystemsPrepared,ProactivePractice TeamInformed,ActivatedPatientProductiveInteractionsImproved Outcomes
18 What characterizes a “informed, activated” patient? The patient understands the disease processRealizes his/her role as the daily self-managerFamily and caregivers are engaged in supporting the patient’s self-managementThe 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,ActivatedPatientProductiveInteractionsPreparedPracticeTeamAssessmentCollaborative goal-setting and problem-solvingTailoring of clinical management by protocolShared care planActive, 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 significantSupports the clinician - patient relationship and the care providedEmphasizes prevention of complications by using evidence-based practice guidelines and patient empowerment strategiesEvaluates clinical, humanistic, and economic outcomes on an ongoing basis with the goal of improving overall health
22 Disease Management Processes Population identification processesEvidence-based practice guidelinesCollaborative practice models include physician and support service providersPatient self-management educationIncludes primary prevention, behavior modification, and compliance monitoringProcess and outcomes measurement, evaluation, and managementRoutine reporting/feedback loopIncluding communication with patient, physician, or practice profiling
23 What are case managers “managing?” HIV DiseaseClients’ Care Seeking, Treatment and Appointment Keeping Adherence, and BehaviorsClients’ Participation in Third Party Health Insurance System, Including the Ryan White ProgramMedications and Their Side EffectsInformation Useful to Clients to Achieve Independence and Successfully Manage Their Disease
24 What are case managers managing? HIV DiseaseClients’ Care Seeking, Treatment and Appointment Keeping Adherence, and BehaviorsClients’ Participation in Third Party Health Insurance System, Including the Ryan White ProgramInteractions Between Clients and the Health Care, Human Services, and Legal SystemInformation 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 servicesCoordinating referrals to specialists to treat OIs and other clinical conditionsFacilitating receipt of services required to sustain good healthArranging for mental health and addiction treatmentCoordinating the health care providers serving the clients
26 Antonio’s StoryAntonio 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 DiseaseClients’ Care Seeking, Appointment Keeping Adherence, and BehaviorsClients’ Participation in Third Party Health Insurance System, Including the Ryan White ProgramMedications and Their Side EffectsInformation 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 clientsAdapt HIV prevention techniquesStages of changeMotivational interviewingCase management outreach and re-engagement for clients lost to careStrength-based social workSocial contractsSharing, not guarding, resources such as service directoriesPeers “navigators” can lead by example
30 Facilitate applications for benefits Interactions Between Clients and the Health Care, Human Services, and Legal SystemFacilitate applications for benefitsAssist clients to identify community resources that can assist themPlanning discharge of clients from jails, detention centers, prisons,Facilitating housing referralsEnsuring 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 StoryHenri 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 StoryMark 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 StoryMany 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 DiseaseClients’ Care Seeking, Treatment and Appointment Keeping Adherence, and BehaviorsClients’ Participation in Third Party Health Insurance System, Including the Ryan White ProgramMedications and Their Side EffectsInformation 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 ProgramAssisting clients to enroll in third party insuranceBecoming familiar with payers’ benefits packages, benefit caps, coverage, prior authorization processAssisting clients to enroll or disenroll from managed care plansCoordinating benefits among payersAdvocating with payer to assist the client to obtain services
38 Sandra’s StorySandra 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 StoryJazmine 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 DiseaseClients’ Care Seeking, Treatment and Appointment Keeping Adherence, and BehaviorsClients’ Participation in Third Party Health Insurance System, Including the Ryan White ProgramMedications and Their Side EffectsInformation Useful to Clients to Achieve Independence and Successfully Manage Their Disease
42 Billie’s StoryBillie 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 DiseaseClients’ Care Seeking, Treatment and Appointment Keeping Adherence, and BehaviorsClients’ Participation in Third Party Health Insurance System, Including the Ryan White ProgramMedication and Side Effect ManagementInformation 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 healthMedical and behavioral interventions are requiredEach client is at a different place in the processAppropriate interventions are driven largely by each client’s desired outcomesClients should have aBasic information about HIV and its treatmentUnderstanding of and assistance with self-management skill buildingOngoing 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 treatmentCollaborative goal settingSymptoms monitoringLifestyle behaviors including healthy diet, getting regular exercise, and smoking cessationTaking medication in the dose and frequency prescribedKeep medical, case management, and other appointmentsCommunicating with the care team, family, and othersOngoing 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 ClientsAddress medication adherence with standardized training and goal-settingBefore beginning HAART, assess client's treatment readiness, understanding of the disease, attitudes about HAART, and understanding the importance of adherenceReview treatment options, client's lifestyle, dosing schedules, and number of pills to be takenEducate clients about side effects and their managementSet realistic therapeutic goals togetherAvoid unnecessary medicationsThese skills can be applied to other sectors of clients’ lives
49 Self-Management Goals Address other self-management issues needing collaborative goal-settingSelf-management goals may includeDisclosure of HIV statusSafer sex practicesEntering drug or alcohol treatment programsAttending support groupsSeeking help for abusive situationsRe-establishing or maintaining a support systemReturning to workMaintaining a stable living situationMaintaining body weightPreventing or controlling medication side effects
50 Practical Steps in Self-Management Assess clients' skill, understanding, and confidence in managing HIVGive clients a copy of their goals, and place a copy in the client’s chartReview 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 LiteracyREALM, 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 usedREALM takes two to three minutes to administer and score
53 Health Literacy Score Raw Score Grade Equivalent 0-18 3RD Grade and BelowWill not be able to read most low literacy materials; will need repeated oral instructions, materials composed primarily of illustrations, or audio or video tapes19-444th to 6th GradeWill need low literacy materials may not be able to read prescription labels45-607th to 8th GradeWill struggle with most patient education materials; will not be offended by low literacy materials61-66High SchoolWill 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 StorySheila 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.
57 Task Forces: Group Exercise Divide into five “task forces”Each group is assigned a topicHIV DiseaseCare Seeking, Treatment and Appointment Keeping Adherence, and BehaviorsParticipation in Third Party Health Insurance System, Including the Ryan White ProgramMedication and Side Effect ManagementInformation 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 topicIdentify ways that medical case managers can address the identified challengesIdentify three proposed strategies for overcoming the identified challengeAddress the role of clients in overcoming the challengeIdentify at least two performance measures to be used to assess the impact of your proposed changes