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

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Presentation on theme: "Medical Case Management: Adopting New Roles and Techniques Julia Hidalgo, ScD, MSW, MPH Positive Outcomes, Inc. & George Washington University www.positiveoutcomes.net."— Presentation transcript:

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 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 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

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  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 Quick History of HIV Case Management

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 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 HAB’s Medical CM Definition Contd

10 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 HAB’s Non-Medical CM Definition

11 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 HAB’s CM Treatment Adherence Definition

12 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 HAB’s CM Treatment Adherence Definition Contd

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

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 Informed, Activated Patient

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

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?” 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 HIV Disease

24 What are case managers managing? 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 HIV 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? 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 HIV 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 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  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. Your Story

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? 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 HIV Disease

37 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? 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 HIV 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? 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 HIV 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 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 RD 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 th to 6 th Grade Will need low literacy materials may not be able to read prescription labels th to 8 th Grade Will struggle with most patient education materials; will not be offended by low literacy materials 61-66High 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  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 Task Forces: Group Exercise

58  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 Task Forces: Group Exercise

59 Questions And Discussion


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