Transcript Improving Care Through Effective Medical Case Management

HIV Medical Case Management:
Addressing the Training Needs of Front Line Workers
and Ryan White HIV/AIDS Program Grantees
Luncheon Seminar
Omni Shoreham Hotel
August 27, 2008
Today we will …
Provide an overview of
The concepts underlying the medical case
management (MCM) service category in the Ryan
White HIV/AIDS Treatment Modernization Act of
2006
HAB’s current requirements regarding medical
and non-medical case management (CM)
Approaches used throughout the U.S. to adopt
medical CM, with presentations from three
metropolitan areas
The Abbott Laboratories and Positive Outcome
assessment and curriculum development project
Today we will
…
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
Conduct a written mini-assessment
Get your feedback about meaningful ways our project
can help you and your colleagues
Defining
Medical
CM
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
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
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
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
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
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 nonmedical CM systems
 The CM workforce in many (not 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
Medical Case Management
Training Strategies:
Approaches Taken by Three
Communities
Adopting Medical Case Management
in the Broward County Eligible
Metropolitan Area:
Challenges and Opportunities
William Green, Broward County Human Services Dept
Medical Case Management Timeline
Nationally
2002
1980s
Late 1980s-Early 1990s
Ft. Lauderdale Broward County EMA
Mid to Late 1990s
2000s
2003
2004
2006
Defining Medical Case Management in Light of Limited Definition

HAB/HRSA Project
Officer
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Technical Assistance

Training Initiatives
Proactive Response
• Broward County Fiscal
Impact Study, 2002
• Recommended transition
to Medical Case
Management
Anticipated the
Change
Implemented Medical
Case Management
Training
• Florida Caribbean/AETC
• AIDS Community Research
Initiative of America
• National Quality Center
• Other Grantee Sponsored
• Implemented adherence
practices by utilizing the
key HRSA MCM key
activities as a guidance.
Medical Case
Managers
What components did Broward have to implement medical case management?
8 Providers:
2 Hospital Districts
1 Health Department
1 Federally Qualified Health Center
3 Community-Based Organizations
Service Setting:
Medical Settings
Non-Medical Settings
Experience & Credentials:
Bachelor Degree to Master Degree
Non-Medical Case Managers
Medical Staff
Near Peers (Indigenous Outreach Workers &
Case Managers)
Broward’s Medical Case Management Infrastructure
What Barrier did Broward need to address?

Converting a non-medical case management system to medical
case management
Psychosocial
Model Used
by CBOs and
Clinics
High
Caseloads
Changing
Clinician
Attitudes
About Case
Managers
Low Case
Manager
Salaries
High
Turnover
How did Broward address the barriers?
Medical Staff
• Treatment Plan Medically Focused
•Incorporate Multi-disciplinary Staffing
•Provide ongoing forums for Continuous
Medical Case Management Training
Non-Medical
Staff
Continuous Training

Florida Caribbean/AIDS Educational Training Center (AETC)

AIDS Community Research Initiative of America (ACRIA)

Grantee Sponsored MCM and MCM Supervisor Training
Florida Caribbean/AETC
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Medical Case Management Training Series
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Training 1-Treatment Adherence
Training 2-Lab Tracking 101
Training 3-HIV/AIDS: The Latest Research and
Treatments
Training 4-Assessing Client’s Medical/Clinical Needs
Training 5-Cultural Competency
AIDS Community Research Initiative of America
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HIV Health Literacy Training
Two 8-Hour Days – Offered Twice
Required For All Case Managers
Optional For Outreach Workers
Treatment Adherence Focused
Grantee Sponsored Trainings

Part A Grantee developed training curriculum and
contracted with a training subgrantee to train Medical
Case Managers and Medical Case Manager
Supervisors
Pre-requisite Basic Training (16 hours)
 Advanced Training (36 hours)
 Trainings are conducted annually

Grantee Sponsored Trainings cont.
• Definition of Medical Case
Management
• Purpose of MCM
• Interviewing Techniques
• Assessing Needs
• Use of Level of Care Tool (acuity level)
• Developing Plans of Care
• Writing client contact/progress notes
• Evaluating your work
• Mental Health assessment for referral
• Substance Abuse assessment for referral
• HIV & Hep/C disease progression &
interaction
• Domestic violence assessment for referral
• Crisis intervention skills
• Time management skills
• Cultural competency
• Recently incarcerated re-entry populations
• Homeless re-entry populations
Grantee Sponsored Trainings cont.
Medical Case Management Supervisor Training modules include:
Characteristics of an
Effective Supervisor
Employee
Performance
The SUPPORT Model
One-on-One
(Supervision, Utilizing, Coaching
Practical, Professional, CompletionFollowing
of 3-Day
Organized, RealityTraining
based, Techniques)
Imbedded in the SUPPORT model is the 4-1-1 Supervision Format. The 4-1-1 Format specifies that one
hour of supervision should include 40 minutes of case review, 10 minutes discussing professional growth,
and 10 minutes discussing administrative functions. This model is premised on the belief that the client’s
health is the most important consideration for the MCM and the ability to provide the highest quality of
care is directly dependent upon the staff’s performance and skill level.
HIV Medical Case Management:
Addressing the Training Needs of Frontline Workers and
Ryan White Program Grantees
Evelyn Torres, MBA
Philadelphia Department of Public Health Philadelphia EMA
Philadelphia EMA
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Nine counties across two states
70 funded providers
15,000 consumers
PDPH, AIDS Activities Coordinating Office administers
– Part A
– Local Part B - Pennsylvania
– CDC Prevention & Surveillance
– Local HIV funding
Philadelphia EMA Service System
• Decentralized system
• 24 medical agencies
• 28 edical case management agencies
– 6,600 clients receiving case management
services
– 1,800 intakes a year completed through
the Client Services Unit
Profile of Medical Case Management (MCM)
Services in Philadelphia
• Funding: $7 million (RW A, B, and local)
• Services are provided through:
– CBOs
– ASOs
– Hospital outpatient infectious disease clinics
– Stand-alone HIV clinics
• 2/3 of providers are either ASOs or CBOs
MCM Model
• Broker model with goals of:
– Facilitating access to and retention in
medical care
• Tracked since 2001
– Providing treatment adherence counseling
• Standards of care and outcomes established
• Educational requirements for case managers and
supervisors
• Grantee conducts yearly training and certification of
Parts A and B-funded case managers and supervisors
MCM Training
• Annual training and certification process,
coordinated with the local AETC
• Core training: nine days on six specific topics for
newly hired case managers and supervisors
• Ongoing training: 20 hours of mandated training of
which 6 hours must be medical
• Providers are notified of those employees not
completing the annual requirements
• 130 case managers and supervisors in the
Philadelphia EMA
Grantee Response to HAB MCM Model
• Fund only MCM
• RFP emphasis
– Treatment Adherence
– Retention in medical care
– Supervision
– Case closure
• Mandates policies and procedures for
each of above
AACO Medical Case Management
Committee
Priority Areas
Treatment adherence, clinical supervision, and
linkage/retention in medical care
Tasks
1. Identify responsibilities and roles of MCM providers
2. Identify key implementation activities for the CSU,
ISU, and PSU
3. Revise training curriculum to reflect the paradigm
shift
Training Curriculum Changes
• Emphasis on treatment adherence
– Assessment of client’s adherence to HIV
treatment
– Treatment adherence activities
– Documentation
• Health literacy
• Continue focus on medical follow-up by
fostering collaboration between communitybased case managers and medical providers
Pearls of Wisdom
• Do not re-invent the wheel
– Look at what is out there
• Take an integrated approach
– Training cannot be done in a vacuum
• Highlight best practices
• Stress the benefit
• Get input from key stakeholders
– Surveys
– CQI Meetings
– Focus Groups
Medical Case
Management
Implications for Training and
Service Implementation
Pat Balducci, LCSW
Presentation Overview
I.
II.
III.
Historical Perspective
The Baltimore Experience
Training Strategies
Section I:
Historical Perspective
Historically, Case Managers focused on
helping HIV+ patients and their loved
ones grapple with issues such as
chronic disease management with few
medications, limited entitlements,
lifestyle issues, and too often, death
and dying
HIV – In the Beginning
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Few tools
Evolving understanding of disease
Limited medications
Limited entitlements
Limited staff training
Developing Standards of Care
Section II:
The Baltimore Experience
Baltimore EMA Standards of Care
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Part A (formerly Title I) Standards of Care were
ratified November 1998 and revised October 2003
Case Management (CM) Standards evolved as a
Medical Model
Addressed:
 Assessment
 Care Plan Development
 Plan Implementation
 Monitoring and Evaluation
 Case Closure
 Qualifications (RN or licensed SW with a minimum 3 years
experience)
Standards of Care Contd
 Delineated
CM Services
 Ensure timely and coordinated access to
medical care and support services
 Timeline for intake and Care Plan development
addressed
 Provision of comprehensive forms and related
CM tools
 Levels of care defined
 Emphasis on care coordination, appointment
tracking, and access to medication
 Technical Assistance/CQI
Recruitment of Community-Based
Providers
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Recognition early on in the Baltimore EMA that consumers
and community partners needed to play a greater role in
care development and service delivery
Demand for culturally competent HIV CM services grew in
conjunction with targeted outreach and care retention
strategies
Non-medical, community-based providers were identified
through capacity building resulted in additional training
needs
HAB requirements further define MCM
 Care linkage role broadens to include care coordination
and management of medical care plan
Case Management Cycle
CM Cycle
Assessment
Case
Closure
Monitor
Plan
Develop
Care Plan
CM Cycle
Plan
Implementation
Section III:
Training Tools & Strategies
For Front Line Case Managers
CM Training
 Diagnostic
Assessment
 Review local CM Standards and
relevant Performance Measures
 Conduct individual provider meetings
 Perform chart reviews
 Offer Corrective Action Plans that
emphasize MCM practices and
documentation
CM Training Contd

Comprehensive TA offered by multidisciplinary training teams in multiple
sessions
Provider engagement/rapport building
Encouragement of provider collaboration and
sharing of expertise and experience
Integration of documentation training
emphasizing CM indicators
Quality indicators/measurements review
Use of detailed case conferences as mechanism
to discuss/learn MCM interventions
Comprehensive Training Contd
 Practice Care Plan development, emphasizing SMART
goals (Specific, Measurable, Attainable, Realistic, TimeLimited)
 Facilitated dialogue with other care providers (Medicaid,
VA, Social Security, homeless services, etc.) to create
linkages and seamless service integration
 Provision of CM tools:
 Chart and forms templates
 EMA specific benefits grid
 Web-based tools, online resources, trainings, virtual
learning lab, ongoing provider-specific technical
support
 Training/Updates on available insurance programs and
entitlements
Ongoing Training/TA
Virtual
Learning
Lab
Virtual Learning
Lab-Online
Resource for
providers
Web-cast
Case
Conference
Monthly
Case
Conference
Web-cast
and WebTools
Case
Management
Training
Multiple
Training
Sessions For
All
Case
Managers
Direct
TA
Technical
Support
24-7 via email and
Virtual
Learning Lab
Phone support
as needed
Summary


Case managers need support and comprehensive technical
assistance to shift to a MCM Model
Facilitation of the initial commitment and “buy-in” of frontline staff must occur
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Requires multiple contacts via face-to-face meetings, web
support, and individual telephone contact
Multi-disciplinary, multi-session training
Creation of training tools for case managers that are linked
to medical CM performance measures and Standards of
Care
Creation of web-based tools that include chart templates,
TA presentations pertaining to specific EMA needs, and
ongoing support
Sources



Greater Baltimore HIV Health Services
Planning Council, Case Management
Standards of Care,
http://www.baltimorepc.org/v2/main/pa
ge.php?page_id=64
HAB, HIV Case Management Standards of
Care, http://hab.hrsa.gov/
http://www.taylor-wilksgroup.com/
HIV Medical Case Management
Project
Project Objectives
 Conduct a national assessment of the training needs
of HIV case managers in adopting MCM techniques
 Identify HIV MCM training efforts being undertaken
by the AETCs, other HAB-funded grantees, or
subgrantees
 Develop and test an HIV MCM curriculum that can
easily be used by trainers or supervisors and that
can be adopted by Part A and B grantees and AETCs
Project Activities
 Steering committee is being formed now
 Several jurisdictions will be selected to participate in the
assessment of training needs of HIV case managers and their
supervisors
 The assessment tool was field tested at the HIV and Social Work
Conference and several local CM training conferences
 Participating jurisdictions will receive a report summarizing
assessment results
 The HIV MCM training efforts undertaken by the AETCs, other
HAB-funded grantees, or subgrantees will be identified and
materials gathered
 Please share your materials
 The curriculum will be developed based on results of the
training needs assessment
Project Activities
 Steering committee is being formed now
 Several jurisdictions will be selected to participate in
the assessment of training needs of HIV case
managers and their supervisors
 Assessment tool was field tested at the HIV and Social Work
Conference and several local CM training conferences
 Participating jurisdictions will receive a report summarizing
assessment results
 The HIV MCM training efforts undertaken by the
AETCs, other HAB-funded grantees, or subgrantees
will be identified and materials gathered
 Please share your materials
Project Activities
 The curriculum will be developed based on results of
the training needs assessment
 The curriculum will be design using the train-of thetrainer (ToT) approach for introductory, intermediate,
and advanced HIV MCM topics
 One module will focus on how to integrate HIV
medical case managers into staffing and care
models. The ToT approach will be used so that case
management supervisors can easily use the training
modules for in-service training sessions.
Project Activities
 Two cities will be selected to participate in a series
of four workshops to test the curriculum: beginning,
intermediate, and advanced medical CM topics and
how to integrate HIV medical case managers into
staffing and care models
– To ensure the workshops are relevant to the audience,
information will be gathered from RWHAP grantees in the
jurisdiction to ensure an understanding of the organization,
delivery, and financing of HIV medical and other CM
services
 The curriculum will be disseminated to grantees,
AETCs, and other interested groups
HIV Medical Case Management:
Addressing the Training Needs of Front Line Workers and
Ryan White HIV/AIDS Program Grantees
Discussion