Transcript Medical Case Management

Medical Case
Management:
Adopting New
Roles and
Techniques
Julia Hidalgo, ScD, MSW, MPH
Positive Outcomes, Inc. & George Washington University
www.positiveoutcomes.net
[email protected]
Ground Rules
 I do not represent FL
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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!
Today we will discuss
 The evolution of HIV case management in the
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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
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
Quick History of HIV Case Management
Mid to Late 1990s
 Focus on HIV voluntary
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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,
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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 selfmanagement is recognized
Peers’ role in care continuum is
acknowledged
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
Defining
Medical Case
Management
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 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
What is
the
chronic
care
model?
Short History of the Chronic Care Model
 Initial experience at large Northwestern
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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
Chronic Care Model
A population-based
model that relies on
knowing which
patients have the
illness, ensuring that
they receive evidencebased care, and
actively helping them
to participate in their
own care
Chronic Care Model
Community
Health System
Resources and
Policies
SelfManagement
Support
Informed,
Activated
Patient
Health Care Organization
Practice Level
Delivery
System
Design
Decision
Support
Productive
Interactions
Improved Outcomes
Information
Systems
Prepared,
Proactive
Practice Team
What characterizes a “informed,
activated” patient?
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
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
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
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
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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
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
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
HIV
Disease
Medications and Their
Side Effects
Information Useful to
Clients to Achieve
Independence and
Successfully Manage
Their Disease
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
HIV
Disease
Interactions Between
Clients and the Health
Care, Human Services,
and Legal System
Information Useful to
Clients to Achieve
Independence and
Successfully Manage
Their Disease
What ways do you help to manage your
client’s HIV disease?
 Monitoring and communicating with clients regarding
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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
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.
Managing Clients’ HIV
Disease
Pop Quiz: In what ways
do you help clients to
manage their HIV
disease? Other chronic
conditions?
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
HIV
Disease
Medications and Their
Side Effects
Information Useful to
Clients to Achieve
Independence and
Successfully Manage
Their Disease
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 reengagement 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
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
Pop Quiz
 How do you assess HIV treatment readiness
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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?
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?
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.
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.
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?
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
HIV
Disease
Medications and Their
Side Effects
Information Useful to
Clients to Achieve
Independence and
Successfully Manage
Their Disease
Methods for Managing Clients’ Participation in Third Party
Health Insurance System, Including the Ryan White Program
 Assisting clients to enroll in third party
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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
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.
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.
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?
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
HIV
Disease
Medications and Their
Side Effects
Information Useful to
Clients to Achieve
Independence and
Successfully Manage
Their Disease
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.
Medications
Management
Pop Quiz: In what ways
can you support your
clients medication
management? What
information should you
provide regarding HIV
medications?
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
HIV
Disease
Medication and Side
Effect Management
Information Useful to
Clients to Achieve
Independence and
Successfully Manage
Their Disease
Adherence and
self-management:
Forging new
partnerships
between case
managers and
clients
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 selfmanagement skill building
 Ongoing support from members of the clinical
team, family, friends, and community
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
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
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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
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 These skills can be applied to other sectors of
clients’ lives
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
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
How can
you assess
your
clients’
health
literacy?
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:
http://www.hsph.harvard.edu/healthliteracy/doakAB.pdf
 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
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
Resources For You and Your Clients
 MedScape offers a weekly HIV clinical
news service: http://www.medscape.com/hiv
 AIDSinfo offers information about HIV
clinical guidelines, vaccines,
medications, clinical trials, and other
materials and is available at:
http://www.aidsinfo.nih.gov/default.aspx
 Kaiser Daily HIV/AIDS Report is a daily news
service:
http://www.kaisernetwork.org/dailyreports/hiv
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.
GROUP
EXERCISE
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
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
Questions
And
Discussion