Improving%20Care%20Through%20Effective%20Medical%20Case%20Management

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HIV Medical Case Management Addressing the
Training Needs of Front Line Workers and Ryan
White HIV/AIDS Program Grantees
Luncheon SeminarOmni Shoreham HotelAugust 27,
2008
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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
• HABs 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

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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

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Defining Medical CM
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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 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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Medical Case Management Training Strategies

• Approaches Taken by Three Communities

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Adopting Medical Case Management in the Broward
County Eligible Metropolitan Area Challenges
and Opportunities

• William Green, Broward County Human Services Dept

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Nationally
Focus on newly introduced HIV testing and
treatment (AZT)
Focus on HIV voluntary testing, primary care,
and combination therapy
Focus on rapid HIV testing, HAART, and
increasingly complex specialty care
Ryan White HIV/AIDS Treatment Modernization Act
of 2006 identifies two types of CM

Focused on hospitalizations end of life care
2003
2002
2004
1980s
Late 1980s-Early 1990s
Mid to Late 1990s
2000s
2006
Service Provider Networks (Consortia)
Established
Broward County Fiscal Impact Study, 2002- Basic
HIV training is needed and might be coordinated
with the local AETC performance site.
Broward County developed a Case Management Task
Force.
Broward County Case Mgmt. Training Needs Survey
Report, 2003 -Using the strengths approach to
motivate treatment adherence.
Ft. Lauderdale Broward County EMA
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• HAB/HRSA Project Officer
• Technical Assistance
• Training Initiatives

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What components did Broward have to implement
medical case management?
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• Converting a non-medical case management system
  to medical case management

Changing Clinician Attitudes About Case Managers
Psychosocial Model Used by CBOs and Clinics
Low Case Manager Salaries
High Turnover
High Caseloads
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Medical Staff

• Treatment Plan Medically Focused
• Incorporate Multi-disciplinary Staffing
• Provide ongoing forums for Continuous
• Medical Case Management Training

Non-Medical Staff
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Continuous Training

• Florida Caribbean/AIDS Educational Training
  Center (AETC)
• AIDS Community Research Initiative of America
  (ACRIA)
• Grantee Sponsored MCM and MCM Supervisor Training

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• Medical Case Management Training Series
• Training 1-Treatment Adherence
• Training 2-Lab Tracking 101
• Training 3-HIV/AIDS The Latest Research and
  Treatments
• Training 4-Assessing Clients Medical/Clinical
  Needs
• Training 5-Cultural Competency

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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

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• 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

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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 clients health is the
most important consideration for the MCM and the
ability to provide the highest quality of care is
directly dependent upon the staffs performance
and skill level.
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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

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Philadelphia EMA

• 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

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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

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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

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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

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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

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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

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AACO Medical Case Management Committee

• Priority Areas
• Treatment adherence, clinical supervision, and
  linkage/retention in medical care
• Tasks
• Identify responsibilities and roles of MCM
  providers
• Identify key implementation activities for the
  CSU, ISU, and PSU
• Revise training curriculum to reflect the
  paradigm shift

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Training Curriculum Changes

• Emphasis on treatment adherence
• Assessment of clients adherence to HIV treatment
  
• Treatment adherence activities
• Documentation
• Health literacy
• Continue focus on medical follow-up by fostering
  collaboration between community-based case
  managers and medical providers

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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

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Medical Case Management

• Implications for Training and Service
  Implementation
• Pat Balducci, LCSW

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Presentation Overview

1. Historical Perspective
2. The Baltimore Experience
3. Training Strategies

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• 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

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HIV In the Beginning

• Few tools
• Evolving understanding of disease
• Limited medications
• Limited entitlements
• Limited staff training
• Developing Standards of Care

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• Section II
• The Baltimore Experience

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Baltimore EMA Standards of Care

• 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)

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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

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Recruitment of Community-Based Providers

• 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

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Case Management Cycle
CM Cycle
Assessment
Develop Care Plan
CM Cycle
Case Closure
Plan Implementation
Monitor Plan
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• Section III
• Training Tools Strategies
• For Front Line Case Managers

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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

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CM Training Contd

• Comprehensive TA offered by multi-disciplinary
  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

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Comprehensive Training Contd

• Practice Care Plan development, emphasizing SMART
  goals (Specific, Measurable, Attainable,
  Realistic, Time-Limited)
• 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

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Ongoing Training/TA
Virtual Learning Lab
Case Management Training
Web-cast Case Conference
Direct TA
Technical Support 24-7 via e-mail and Virtual
Learning Lab Phone support as needed
Virtual Learning Lab-Online Resource
for providers
Monthly Case Conference Web-cast and Web- Tools
Multiple Training Sessions For All Case Managers
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Summary

• Case managers need support and comprehensive
  technical assistance to shift to a MCM Model
• Facilitation of the initial commitment and
  buy-in of front-line staff must occur
• 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

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Sources

• Greater Baltimore HIV Health Services Planning
  Council, Case Management Standards of Care,
  http//www.baltimorepc.org/v2/main/page.php?page_i
  d64
• HAB, HIV Case Management Standards of Care,
  http//hab.hrsa.gov/
• http//www.taylor-wilksgroup.com/

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HIV Medical Case Management Project
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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

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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

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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

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Project Activities

• The curriculum will be developed based on results
  of the training needs assessment
• The curriculum will be design using the train-of
  the-trainer (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.

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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

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HIV Medical Case Management Addressing the
Training Needs of Front Line Workers and Ryan
White HIV/AIDS Program Grantees
Discussion