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:
"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.