Transcript The Role of the NCM in Linking Patients with BH Resources

The Role of the Nurse Care
Manager in Linking
Patients with Behavioral
Health Resources
Care Transformation Collaborative of R.I.
TO N I L . S C H L A I S R N N U R S E C A R E M A N A G E R , W O O D R I V E R H E A LT H
SERVICES
“NURSE CARE MANAGERS: MAKING A DIFFERENCE IN PRIMARY CARE”
M AY 5 , 2 0 1 5
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Patient Challenges
Patients often have:
•Limited support systems
•Limited social skills
•Multiple diagnoses
•Difficulty navigating the behavioral health system
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Nurse Care Manager Challenges
•Establishing patient trust and obtaining consent
•Assisting the patient with using the behavioral health
system
•Multiple agencies involved
•Care Coordination
•Behavioral Health may be making decisions without full
knowledge of patients’ medical experiences (i.e.
transitions of care)
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Joe’s Story
•Single, white male in mid 50’s with mother as
only support system
•Multiple diagnoses: COPD, Chronic Cor Pulmonale,
Kidney Disease, Anxiety, compromised respiratory
status
•Frequent utilizer of the ER: 90 visits in 6 months at
approximate cost of $148,000.00
•Not obtaining behavioral health services
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Nurse Care Manager as “the
bridge”
• Team meeting with ER MD, case mangers, social
services, EMS, BCBS representative to understand
patient needs, develop strategies and care plan
• WRHS team meeting to develop treatment plan
•BH referral for counseling and psychiatric
medication management
•Developing trust : accompanying patient to
therapy visit, meeting with patient and mom, ongoing telephone support till patient able to
manage
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Jennie’s Story
•Early 20’s, living with estranged husband and 3 young children
with mental health issues starting in her teens
• Limited coping and parenting skills
•Domestic assault, court appearances, pending eviction
•Involved with multiple agencies with little personal engagement:
DCYF-Family Care Community partnership, NAFI (North American
Family Institute), and Easter Seals
•Reports she sees clinician weekly and psychiatric regularly
•Patient and children frequent ER users
•High rate of no show for PCP visits
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NCM: Working with Community
• Arranged team meeting with multiple agencies to
understand plans of care
• Referral to South County Community Health Team
•Arranged for Behavioral Health meeting for care
coordination; In meeting learned patient not seeing a
clinician, not seeing psychiatrist, unaware of ER usage
•Arranged for clinician and psychiatrist to see patient,
evaluate medications
•Monthly care coordination meetings continue
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Things to Consider
• Need to think “out of the box”
• Willingness to go into uncharted territory
•Takes effort, persistence and leadership: NCM
may need to initiate collaboration with outside
agencies and understand that the initial effort
may be met with resistance
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