1. Emerging Roles and Responsibilities of Medical Case Managers: A Workshop at the 20 th Annual National Conference on Social Work and HIV/AIDS Julia Hidalgo, ScD, MSW, MPH Positive Outcomes, Inc. and George Washington University julia.hidalgo@positiveoutcomes.net www.positiveoutcomes.net

2. This workshop is supported with funds from Abbott Laboratories. The materials presented do not necessarily represent the views of Abbott Laboratories or other funders of Positive Outcomes, Inc.

3. Abbott- POI Medical Case Management Project: A Summary  In response to the case management (CM) service categories defined in the Ryan White HIV/AIDS Treatment Modernization Act of 2006, Abbott Laboratories is supporting a year-long project to  Conduct a national assessment of the training needs of HIV case managers in adopting medical CM techniques  Identify and learn from HIV medical CM training efforts across the U.S.  Develop and test HIV medical CM curriculum based on results of the training needs assessment  Disseminate the curriculum for local training efforts  Today is the assessment’s first activity

4. Today we will  Based on our earlier work throughout the U.S. and with the HIV/AIDS Bureau (HAB) provide an overview of  The evolution of HIV CM in the U.S.  The concepts underlying the medical CM service category in the Ryan White HIV/AIDS Treatment Modernization Act of 2006  HAB’s current requirements regarding medical and non- medical CM  Approaches used throughout the U.S. to adopt medical CM  Engage in an informal discussion regarding your medical CM roles, responsibilities, and training needs  Conduct a written mini-assessment  Discuss the medical CM training needs of HIV case managers and CM supervisors in your communities, and the extent to which these needs are being addressed  Get your feedback about meaningful ways the assessment can help you and your colleagues

5. Quick History of HIV CM 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

6. Quick History of HIV CM 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 funds underwrite growing costs  CM 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

7.  Ryan White HIV/AIDS Treatment Modernization Act of 2006 identifies two types of CM  Medical CM (considered a core medical service)  Unless a waiver is granted by HAB, Parts A, B, and C grantees must allocate at least 75% of their funds to core medical services  Support CM in which referrals for health care and support services are made (considered a support service)  Unless a waiver is granted by HAB, Parts A, B, and C grantees must allocate no more than 25% of their funds to non-core services Quick History of HIV CM: Today

8. Medical CM Concept is Based in Part on Disease Management (DM) Approach  The DM Association of America defines DM as 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

9. Disease Management (DM) Uses  Population identification processes  Evidence-based practice guidelines  Collaborative practice models that 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

10. Medical CM Concept Also is Based on the 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

11. 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

12. 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

13. 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

14. Defining Medical CM

15. 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

16. HAB’s Medical CM Definition (Continued)  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

17. 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

18. 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  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

19. Other Treatment 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  Communicating and coordinating with the care team, family, and others  Ongoing problem-solving to overcome potential barriers

20. Operationalizing Medical CM by Ryan White Program- Funded Agencies

21. Approaches Taken to Address New CM Definitions  Redefine all CM services provided by HIV clinics or other clinical settings to be medical CM  No specific change to CM scope of practice or performance measures  Redefine CM service provided by community-based organizations as medical CM if they are co-location with clinics or other strong linkages are demonstrated  Partner RNs and social workers in medical CM teams  Redefine the CM scope of practice, change training and credentialing requirements, and change performance measures  Putting the burden on CM programs to reengineer their programs and carving out time for training

22. Other Approaches Taken to Address New CM Definitions  Require that community-based CM programs link with HIV clinics to offer clinical CM services  In turn, HIV clinics have hired case managers to expand their core medical services  Eliminate community-based CM funding  Employ only RNs to provide medical CM  This model tends to predate the 2006 Ryan White Program reauthorization  Some grantees and CM agencies would like to shift in this direction but cannot afford it or cannot identify nurses due to local nursing shortages

23. What approaches to implementing medical CM have been used by your agency?

24. What challenges do you encounter in adopting the medical CM model?

25. In what ways can the Abbott- POI project help to strengthen medical CM services in your communities?

26. What training topics would be helpful to you to adopt in the medical CM curriculum?