Roughly 5% of the patient population is complex. Those complex patients typically have a chronic physical issue (e.g., diabetes, renal disease, cancer) and a behavioral health issue (e.g., schizophrenia, depression, anxiety).
Although a small percentage of the patient population is complex, they account for more than half of healthcare costs, says Rebecca Perez, RN, CCM, CPUM, president and owner of Carative Health Solutions in High Ridge, MO.
The separation of physical and mental health services
Hospitals primarily treat patients solely for their physical ailments, ignoring underlying mental health problems. With no incentive for reimbursement, facilities often address a patient's mental health only as an afterthought.
However, an untreated mental condition can prevent patients from properly managing physical health, thus causing the patient to be readmitted to the hospital.
The debate over healthcare reform centers on the effort to reduce costs, and that means reduced readmissions. Addressing the needs of this small, expensive segment of the population could help curb healthcare spending.
"Case managers really are the best professionals when it comes to coordination of care and being advocates for patients, which is why integrated care is a perfect adjunct for what a case manager already does," Perez says.
Integrated care training
Perez is part of a growing movement addressing the mental health needs of complex patients by using an integrated care management model.
"The thinking is coming full circle again where we need to treat the patient as a full person and not just treat a disease," says Perez.
Perez and Roger G. Kathol, MD, CPE, president of Cartesian Solutions, Inc.?, work with the Case Management Society of America's Integrated Care Management Training Program to train case managers. Participants learn how to assess a patient's mental health as part of their interaction with complex patients. This enables case managers to ensure that the patient's care plan includes services that address his or her behavioral and psychological needs.
"Integrated case management is not necessarily designed for every patient a case manager touches," Perez explains. "It is designed to work with those that are the most complex."
Recognizing how this population's mental health contributes to their physical health goes a long way in preventing readmissions, improving patient satisfaction, and enhancing overall quality of care.
The chronic illness demonstration project
The New York State Department of Health is addressing complex patients with a chronic illness demonstration project. The project identifies patients that are most likely to be readmitted due to several concurrent medical conditions.
Hudson Health Plan, a provider of state-sponsored managed healthcare services based in Tarrytown, NY, partnered with Beacon Health Strategies, a company that specializes in assisting health plans and providers to meet behavioral healthcare needs, in order to participate in the project.
Hudson's new program, the Westchester Cares Action Program (WCAP), was designed to assist clients selected through the chronic illness demonstration project using the integrated care management model.
"We believe that good primary care will lead to prevention of ED visits and readmissions," says Sheilah McGlone, RN, CPUM, CCM, director of case management and utilization review at Hudson Health Plan and co-director of the WCAP.
The WCAP's case managers use the INTERMED-Complexity Assessment Grid (IM-CAG) tool to help evaluate complex patients. The INTERMED Foundation developed the IM-CAG tool to help case managers create a detailed profile of the patient and identify barriers in the following four domains:
- Biological. Does the patient have any chronic illnesses?
- Psychological. Does the patient have a history of or currently show signs of psychological issues such as depression, anxiety, or substance use?
- Social. Does the patient have access to social support services? Does he or she have a stable living arrangement?
- Health system. Has the patient had difficulty assessing services? Did he or she have a bad experience with providers?
The case manager shares the results of the assessment with the treatment team as well as the patient to improve coordination of care.
Case managers obtain information by conducting through interviews with patients. Based on their responses, a case manager assigns patients a score and a color designation. The colors correspond to the following categories:
- Red is an area of extreme vulnerability that requires immediate action
- Orange is an area of moderate vulnerability that should be a part of the treatment plan
- Yellow is an area of mild vulnerability that should be monitored
- Green is an area that requires no action
"The IM-CAG tool helps formulate a care plan based on priority levels," says Alan Boardman, LMSW, co-director of the WCAP from Beacon Health Strategies.
For example, if a patient is homeless, the case manager can make the "residential stability" field red.
The three-year demonstration project is still in its first year and is currently focused on assessing patients and developing care plans. Boardman and McGlone say they have not begun measuring the program's success. Nevertheless, they hope the project will help make the integrated care model the preferred method for handling complex patients.
Integrated care in action
Hospital case managers do not need to be experts in mental health to be effective in the integrated model, says Perez. She encourages case managers to become familiar with basic mental health issues and seek advice from experts when dealing with complex patients.
But in order for integrated care to work, case managers need to be willing to address behavioral problems when signs are apparent. For example, if a patient is not progressing through rehab as quickly as anticipated, perhaps depression or some other behavioral problem could be slowing the process.
Identification of the mental health problem is only the beginning of the process. "You can't just say [to the patient], 'You need to go get counseling,' " Perez says. Instead, case managers need to take the time to help the patient discover the problem as well as establish relationships with physical and mental health providers for better communication.
Hudson Health Plan tries to facilitate effective communication between hospital case managers and mental health providers as part of its demonstration program.
Some mental health providers may be hesitant to share information about their patients because of confidentiality concerns. In that case, tell the provider that you are not requesting detailed notes, just basic information that you can use to support the patients' needs, Perez says.
Although the reimbursement model does not lend itself to coordination between mental and physical health, a sharp case manager can make a big difference in the care of complex patients. The willingness to address behavioral health issues and their effect on patient outcomes will help case managers meet departmental goals and better serve their patients.
This article was adapted from one that originally appeared in the April 2010 issue of Case Management Monthly, an HCPro publication.