Case Management

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Behavioral health case management

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involves a collaborative partnership which may include partners/providers beyond those typically involved in medical case management.
may include law enforcement, community agencies, and the legal court system in addition to family, caregivers, providers and the patient.
is a major component within the realm of case management, as conditions affecting mental health status place a tremendous burden on the affected individual and families.
integration of mental health, substance abuse, prevention, and other health care services is vital to providing continuity of care to individuals affected by behavioral health conditions.
is essential for treating the patient, and ultimately achieving successful recovery.

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During the 19th century, mentally ill individuals were mainly cared for by

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their families

NOTE: Recognizing the societal issues relating to this method of care, social policy reforms led to the use of institutionalized asylums as a central treatment component.

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Over the past several decades, the provision of adequate mental health services achieved national recognition due to

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• Individuals suffering from severe and debilitating mental illnesses including schizophrenia, bipolar disorder, or depression being institutionalized in public mental hospitals.
• Shifts in the health care system leading to the provision of other basic life support services including housing, meals, clothing, and social rehabilitation.
• the introduction of neuroleptic medications In the late 1950's for the treatment of mental health illnesses, leading to transformations in mental health policy.
• The development of Medicare and Medicaid programs provided greater incentives for policy makers to facilitate the discharge of mental health patients in an effort to mitigate federal expenditures on institutionalized patients.

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The shift from restrictive care to deinstitutionalization led to a dramatic decrease in the use of ______ for mental health purposes, and more importantly an increase in the utilization of ________ _______ ____.

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hospitals
community-based care

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Among other chronic diseases, HEDIS data is used to assess

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mental health issues including antidepressant medication use and management

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Barriers to effective care in behavioral health can include but not be limited to:

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• Limited resources based upon insurance/plan coverage by the patient
• Under-recognized or unrecognized symptoms and diagnosis
• Socio-economic, cultural, religious attitudes
• Patient's own denial that services are required, or resistance to case management interventions
• Stigma placed on behavioral health by the patient, family, employer, providers
• System barriers, fears related to confidentiality, HIPAA requirements
• Poorly integrated transitions of care for behavioral health services

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the utilization of a multidisciplinary approach to the delivery of care is paramount to achieving successful recovery. Therefore, effective coordination of care remains one of the most important strategies the case manager can perform for a patient with a

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mental health condition

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the mental health service system consists of four main sectors:

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(1) specialty mental health; (2) general medical/primary care; (3) health and human services; and (4) voluntary support network.

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With Specialty mental health

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a team of psychiatrists, psychologists, psychiatric nurses, social workers, case managers and other health care professionals are professionally trained to manage mental disorders.
the majority of treatment is provided in an outpatient setting including private physician offices and clinics.
acute hospital care is provided in general hospitals or specialty psychiatric units.
intensive medical care can be provided for children and adolescents at private psychiatric hospitals and residential treatment centers.
The case manager plays an integral role in assessing a treatment plan for specific needs, modifying the plan of care as situations change, triaging patient-care needs and transitions of care, and supporting services that will benefit the patient's overall well-being.
Individualized goals and strategies for mental health services are developed by the case manager, and necessary changes are made throughout the process to recovery.

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In general medicine, or primary care

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internists, pediatricians, nurse practitioners, physician assistants and psychologists work in community-based clinics, nursing homes, and office-based practices.
mental health care is provided with or without other concomitant factors.
Case managers are usually not providing specific services in this general practice setting, but may be triaging services for patients across diseases. An example of this would be a nursing-home based case manager who coordinates all disease-based services for patients.

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The human services sector

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primarily consists of social services, school counseling services, residential rehabilitation, vocational rehabilitation, criminal justice or prison-based services, and religious professional counselors.
Case managers are an important asset to social service agencies, as they coordinate with police or law enforcement personnel dealing with issues such as domestic violence or custody battles. Also employed by substance abuse clinics and mental health clinics, case managers assist families and individuals who face health, economic, housing, or other issues that cannot be resolved on their own.

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The voluntary support network

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is composed of self-help groups, such as those with 12-step programs and peer counselors used to treat mental and addictive disorders.
Case managers can actively support families or individuals through the coordination of efforts of the clinical staff and service organizations. Case managers can also provide information to patients about voluntary support networks as part of stewardship and resource management

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Outpatient clinics

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include primary health care centers, general hospitals, and community health centers.
trained mental health professionals offer assessment and treatment.

offer flexibility, allowing patients to be referred to other facilities, have walk-in or fixed appointments, private clinical consultations, and direct or indirect payments.

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Community based mental health centers

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are the simplest models used in the provision of care.
main objectives are user satisfaction, continuity of care, and flexibility.
Long-term care may also be provided.
contact patients at home, work, or in other locations to monitor patients and determine treatment adherence and early relapses.
frequent contact and outreach are characteristic elements of this method, providing the flexibility of offering intensive care when needed or lower levels of attention at the appropriate time.

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Acute inpatient care

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includes home treatment teams, crisis houses, and acute day hospital care, which can offer treatment for voluntary patients, or urgent accessibility for patients with severe psychiatric relapses, behavioral disturbances, strong suicidal or violent tendencies, or other compulsory conditions.
accounts for the majority of the mental health care budget, which can be mitigated through reductions in the length of stay.

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Long-term community-based residential care

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consists of larger independent systems or units affiliated with integrated systems.
can provide services for psychiatric diseases, traumatic brain injury, dementia, Alzheimer's and other serious cognitive or behavioral issues which require patients to receive long-term care in safe environments.
utilized to promote quality of life as well as safe and efficacious care.

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Occupational and day care centers

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offer care for individuals with disabling mental disorders.
may have conditions similar those accessing long-term residential care, except that patients do not require residential services.

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essential interventions provided by a behavioral health case manager

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Effective transitions of care, and the ability to ensure the patient is receiving optimal care in the least restrictive environment

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PTSD

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is an anxiety disorder that can develop after exposure to a terrifying event in which grave physical harm occurred or was threatened.
is triggered by traumatic events such as violent personal assaults, natural or human-caused disasters, accidents, or military combat.
patients are afflicted by persistent frightening thoughts and memories of their event and feel emotionally numb, especially with people they were once close to.
patients may experience sleep problems, feel detached, or be easily startled.
Factors associated with PTSD of which the case manager should be aware include dissociation and depression.
can spur other psychiatric disorders, although the most common are depression, substance abuse, and anxiety.
Dissociative symptoms are common but may not be spontaneously reported
Depression is a very common comorbid condition and may be secondary or associated with aspects of traumatic events such as losses.
rate of comorbidity increases as PTSD symptoms increase

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PTSD comorbid disorders may include

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obsessive-compulsive disorder, panic disorder, social phobia or generalized anxiety; these can precipitate a cascade of conditions.

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Major depressive disorder

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is one of two serious mood disorders (the other being bipolar disorder) that affect every aspect of life.
predominant symptoms of depression are a general loss of interest and energy, and an inability to experience pleasure.
patients typically withdraw from or becomes impaired in social interactions. Apathy toward work, school, relationships, responsibility, and eventually toward important goals, negatively affects the person and the family.
incidence has risen every year since the early 20th century, with at least one in six people in the US experiencing a depressive episode during their lifetime.

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Comorbid depression

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is very prevalent.
half of all patients with prior depression diagnoses experience at least a second co-occurring diagnosis, and depression is rarely the primary diagnosis.
is commonly associated with anxiety disorders (36%), nicotine dependence (26%), alcohol use disorders (14%) and drug use disorders (5%), as well as with personality disorders (38%).
Some evidence suggests that individuals with comorbid PTSD and depression have more negative consequences than persons with either diagnosis alone.

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Case Manager Implications for patients with a dual diagnosis of depression and PTSD :

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case manager needs to be vigilant of the comorbid depression and the likelihood that this additional psychological burden will cause a greater barrier in behavioral therapy and other self-care management strategies.

Case managers working within managed behavioral health teams are responsible to maximize coordination of care for patients with PTSD and comorbid depression, as well as for patients with major depressive disorder with or without comorbid factors

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The role of the behavioral health case manager can very greatly depend upon the level of integration and care coordination required, as well as upon the complexity of the patient's mental health and diagnoses:

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Coordinating care for the patient with depression may mean coordinating physician visits and then following up with the patient to ensure appointments are not missed.

It may mean providing educational resources for the patient and the family.

It may also mean coordinating benefits for residential rehabilitation or outpatient mental health programs for patients with more significant disease.

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The case manager

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plays an important role in recognizing the complex nature of psychotic disease, and in being able to support the individual through care transitions and levels of services.
Identifying and coordinating benefits available to the patient with psychosis is essential for long-term management.
determine the appropriate treatment plan designed for a specific diagnosis, condition, span of time, and socio-psychological situation.
must recognize important differences in treatment plans and recovery goals for individuals suffering from mild mental issues versus those who are affected by severe, debilitating disease.
be responsible for patient education pertaining to medical adherence, coping strategies and exploring problems which may contribute to the onset of an episode are inherent educational roles that the case manager can effectively play. Individual therapy should focus on issues and concerns of the individual in a non-judgmental manner.

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What step to take with Psychogenic Pain

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When mental, emotional, or behavioral problems are the cause of pain or increase or prolong existing pain, the patient suffers from a disorder called psychogenic pain.1 Common types of psychogenic pain include headaches, myalgias, back pain, and abdominal pain.1 In order for the patient's pain to be considered psychogenic, organic causes must first be ruled out; often, the patient's complaints will not match the signs and symptoms of organic disease.1

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What step to take with Pain Associated with Physical Disease

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In order to enhance quality of life for the individual, the case manager's plan of care should include patient education to foster an understanding of illness outcomes, realistic illness perceptions, and strategies for coping. Often in managing patients with behavioral health illnesses with comorbid physical conditions, pain management comes into play.

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In a report published in 2011, the Institute of Medicine (IOM) outlined a comprehensive plan for addressing the effective treatment and management of pain as a national priority in health care.2 The report—Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research—established a set of principles to improve the overall care of patients with pain and the training of health care professionals who treat them--foundational pillars:

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understanding chronic pain as a disease entity in itself, acknowledging effective pain management as a moral imperative, appreciating the value of comprehensive treatment plans, incorporating interdisciplinary management approaches, and properly executing primary and secondary strategies for preventing the misuse, abuse, and diversion of controlled substances for treating pain.

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Chronic pain

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is defined as an ongoing condition that lasts longer than normal periods for healing from tissue injury or recovery from illness and persists for up to 3–6 months or more

Underlying causes include any injury or illness that is not related to cancer; thus, chronic pain is sometimes referred to as chronic noncancer pain (CNCP).

Classified by its pathophysiology, the etiology may be nociceptive, or due to physical tissue damage that stimulates sensory nerves to signal pain; neuropathic, or due to abnormal processing of sensory input by the peripheral or central nervous system; a combination of nociceptive and neuropathic factors; or unknown

When inadequately treated, chronic pain can cause great suffering and severely impair the physical, psychological, and social function of affected individuals

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breakthrough pain (BTP)

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occurs as a transitory condition despite analgesia for chronic pain.

the time to maximum intensity ranges from 10–15 minutes, and the median duration of pain experienced is 30–60 minutes.

is estimated to affect approximately 33%–65% of patients with chronic cancer-related pain and 70% of patients with CNCP

is a burden not only on patients, but to their families and caregivers as well

Patient survey data indicate that in addition to the pain and stress , patients with this condition experience significantly reduced function, productivity, and quality of life.

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For many patients with moderate-to-severe, chronic, cancer-related or noncancer pain

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opioids (eg, codeine, fentanyl, hydrocodone, and morphine) are the mainstay pharmacologic therapy following the failure of nonopioid analgesics, adjunctive agents, and nonpharmacologic therapies -- such as acceptance and commitment therapy, biofeedback, cognitive behavioral therapy, and counseling.

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. The abuse or misuse of substances contributes to a wide range of adverse conditions requiring medical care, including

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depression and other mental health disorders but also cancer, respiratory disease, cardiovascular disease, HIV/AIDS, pregnancy complications, cirrhosis, ulcers, trauma, and insomnia.

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Recognizing an alarming increase in the prevalence of substance abuse in the U.S., the 2010 Affordable Care Act included treatment of substance use disorders as one of the ten elements of “essential health benefits”. The law ensured that

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effective 2014, all health insurance provided by Medicaid or sold on Health Insurance Exchanges would include services for substance use disorders.

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. Although a multitude of services are available for substance abuse treatments, the lack of coordination among services and providers leads to a fragmented system which becomes inadequate to meet the needs of the patient. The role of the case manager is needed to

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coordinate these systems, and to empathize with the patient in order to encourage positive behavioral changes

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Substance abusers have an increased probability of contracting

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HIV or Hepatitis C from injection practices

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In order to facilitate strategies to prevent substance abuse, a case manager needs to understand important barriers to effective change (two of them).

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First, one must identify what is causing the individual to abuse the substance.

Secondly, the individual must determine whether or not the net benefits of altering his or her negative health behavior will ultimately outweigh the outcome.

NOTE: In order to promote the positive healthy behavior, the motivation behind the negative behavior must be understood.

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Once understanding the motivation behind the negative behavior of an addict

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the case manager may then effectively engage the individual in ongoing patient education strategies to empower and build self-efficacy and trust, reinforcing concepts provided by the treating practitioner.

The case manager may be able to support interventions to assist the individual in seeking methods under which the addictive behavior can be minimized or prevented.

the case manager will play an active role in identifying other ways to substitute these negative behaviors in an effort to facilitate the recovery of the patient.

the case manager will play an integral part in informing the individual of harm reduction strategies and empowering the patient to take control of his or her own health.

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The ability of families to adapt to crisis situations is important to the mental health status of the affected individual. Maladaptive families have difficulties in maintaining the balance between family roles and caring for the patient. The inability to maintain a healthy, flexible family balance can lead to patient dependence, or on the opposite end of the spectrum, abandonment. The case manager should determine how the family will deal with

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each event in order to develop an appropriate management strategy, which must include short-term goals as well as long-term goals for the patient.

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When treating patients with behavioral health issues, case managers may face ethical conflicts.

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achieving a balance between helping the patient to achieve maximum recovery and respecting the individual's autonomy.
there is a moral obligation to respect the attitudes and beliefs of the individual, displaying an understanding of the motivations behind the patient's actions.
Knowledge of the customs and traditions important to the patient are essential in crafting an effective treatment plan and successful intervention.
Other important implications are the patient's attitudes toward seeking help, cultural beliefs regarding disease, and language barriers. For develop a trusting relationship with the patient, respect and understanding of these components is essential.
The responsibility of the case manager is to inform and educate the patient, identifying strategies for harm reduction. Values and spiritual beliefs of each person should be respected and treatments should be planned in a way that does not compromise these ideals.