Medical Case Management: Adopting New Roles and Techniques

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Medical Case Management Adopting New Roles and
Techniques
Julia Hidalgo, ScD, MSW, MPHPositive
Outcomes, Inc. George Washington
University www.positiveoutcomes.netjulia.hidalgo_at_
positiveoutcomes.net
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Ground Rules

• I do not represent FL DOH, Orange County Part A
  Grantees 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!

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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

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Quick History of HIV Case Management

• 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

• 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

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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

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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

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Defining Medical Case Management
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HABs 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 clients and
  other key family members needs and personal
  support systems

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HABs 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 plans efficacy
  and
• Periodic re-evaluation and adaptation of the plan
  as necessary over the clients 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

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HABs 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

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HABs 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

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HABs 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

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Environmental Challenges in Operationalizing MCM

• Good news HABs MCM definition is not
  proscriptive
• Bad news HABs 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

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What is the chronic care model?
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Short History of the Chronic Care Model

• Initial experience at large Northwestern group
  practice
• Reviewed and revised by advisory committee
• Breakthrough series documented the models 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

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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

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Chronic Care Model
Health System
Community
Health Care Organization
Resources and Policies
Practice Level
Self-Management Support
DeliverySystem Design
InformationSystems
Decision Support
Prepared, Proactive Practice Team
Informed, Activated Patient
Productive Interactions
Improved Outcomes
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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 patients self-management
• The provider is viewed by the patient as a guide

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What characterizes a prepared practice team?
Prepared Practice Team
At the time of the visit, the team has the
patients information, data, staff, equipment,
and time required to deliver evidence-based
clinical management and self-management support
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What are the characteristics of a productive
interaction?
Prepared Practice Team
Informed, Activated Patient
Productive Interactions

• Assessment
• Collaborative goal-setting and problem-solving
• Tailoring of clinical management by protocol
• Shared care plan
• Active, sustained follow-up

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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

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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

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What are case managers managing?
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What are case managers managing?
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What ways do you help to manage your clients 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

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Antonios 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. Antonios 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.

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Managing Clients HIV Disease

• Pop Quiz In what ways do you help clients to
  manage their HIV disease? Other chronic
  conditions?

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What are case managers managing?
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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

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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

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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?

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Henris 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?

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Marks 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.

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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.

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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?

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What are case managers managing?
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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

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Sandras 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.

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Jazmines 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.

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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?

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What are case managers managing?
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Billies 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.

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Medications Management

• Pop Quiz In what ways can you support your
  clients medication management? What information
  should you provide regarding HIV medications?

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What are case managers managing?
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Adherence and self-managementForging new
partnerships between case managers and clients
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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 clients 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

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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

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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

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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

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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 clients chart
• Review the client's personal barriers and
  enablers to link daily tasks leading to positive
  self-management behaviors

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How can you assess your clients health literacy?
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Health Literacy

• REALM, the Rapid Estimate of Adult Literacy in
  Medicine, is a screening tool that assesses an
  adult patients 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

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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
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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

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Sheilas 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.

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Group Exercise
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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

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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

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Questions And Discussion