Standards of Practice for Case Management Dr. Dawn-Elise Snipes PhD, LPC-MHSP Executive Director, AllCEUs.com Podcast Host: Counselor Toolbox and Case Management Toolbox
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Why Case Management- - Adjunct to clinical practice - Enhances coaching and clinical services - Can be its own business (High copay/high deductible) - Understanding capitation - It pays the doctor a set amount for each enrolled patient whether a patient seeks care or not. - Compensation is based on the average expected utilization of each patient in the group. - 100,000 people 20% expected to need 10 sessions of brief therapy @ $45/session 20,000*450= 900,000/year - Use it or lose it caveat
How Case Management Reduces BH Cost - Ensures wrap-around services (i.e. housing, transportation, medical care, public assistance) - Better health --> Better mental health - Improved health literacy - Better mental health - Reduced stress (financial, interpersonal, occupational) --> Better mental health - Treatment plan compliance - Better mental health - Nonfragmentation of services --> Better mental health - Guidance during service transitions - Better treatment compliance --> Better mental health - Advocacy with community leaders for funding service gaps- improved service access - better mental health - Case managers are less expensive than licensed providers
Case Management Principles - It can be applied to individuals or groups of clients, such as in disease management or population health services. - Underage drinking or STD prevention at universities - Diabetes, heart disease, premature birth prevention (Clinical or foundations) - Cancer, diabetes, depression, autism management (Clinics or foundations) - Ageing services (AAA, geriatric physician groups, LTC & STC facilities) - The goal is achieving client wellness and autonomy through advocacy, communication, education, identification of service resources and service facilitation. Case Management Principles - Services are best offered in a climate that allows direct communication between the case manager, the client, and appropriate service personnel - When an individual reaches the optimum level of functioning, everyone benefits: the client(s), their support systems, health care delivery systems, reimbursement sources, communities. Case Management Process - Assess client resources, needs, goals - Collaborate and Plan – Identify service plan goals and needed resources - Implement - Monitor - Evaluate Primary Case Management Functions - Positive relationship-building - Effective written/verbal communication - Negotiation skills - Knowledge of legal, ethical and risk management issues - Cultural responsiveness - Ability to develop goals, enhance motivation and evaluate progress - Promotion of client autonomy and self-determination - Knowledge of funding sources, health care services, human behavior dynamics, health care delivery and financing systems, and clinical standards and outcomes Guiding Principles - Use a client-centric, comprehensive, holistic approach. - Facilitate self-determination and self-care with advocacy, collaboration, and education. - Remain culturally responsive - Promote the use of evidence-based care - Enhance client safety - Link with community resources. - Assist with navigating the health care system - Maintain competence in practice. - Promote quality outcomes and measurement - Support and maintain compliance with federal, state, local, organizational, and certification rules and regulations. Degrees of Complexity - Varies based on the following four factors - The context of the care setting, such as wellness and prevention, acute, or rehabilitative. - The health conditions and needs of the patient population(s) served, as well as the needs of the family/caregivers, such as critical care, asthma, renal failure, hospice care. - The reimbursement method applied, such as managed care, workers’ compensation, Medicare, or Medicaid. - The health care professional discipline designated as the case manager, such as registered nurse, social worker, physician, rehabilitation counselor, etc. CM Practice Settings - Hospitals - Long and short term care facilities - Outpatient clinics - Student health centers - Corporations - Health insurance companies - Private case management companies - Jails - VA - Community behavioral health - Geriatric facilities and practices - Hospice - Medical group practices - Life care planning organizations - Disease management companies Roles and Functions - Conducting a comprehensive assessment of the client’s health and psychosocial needs, including health literacy status and deficits, and develops a case management plan collaboratively with the client and family or caregiver. - Planning with the client, family or caregiver, the multidisciplinary team, the payer, and the community, to maximize quality, and cost-effective outcomes - Facilitating communication and coordination to minimize fragmentation in the services. - Educating the client, caregivers, and team about treatment options, resources, benefits, psychosocial concerns etc., so timely, informed decisions can be made. Roles and Functions - Empowering the client to problem-solve by exploring options of care to achieve desired outcomes - Encouraging the appropriate use of health care services and improving quality of care and maintaining cost effectiveness - Assisting the client in the safe transitioning of care - Striving to promote client self-advocacy and self-determination. - Advocating for both the client and the payer to facilitate positive outcomes for all involved Advocacy - Promotion of the client’s self-determination, informed and shared decision-making, autonomy, growth, and self-advocacy - Education of other health care and service providers in recognizing and respecting the needs, strengths, and goals of the client - Facilitating client access to necessary and appropriate services through education and advocacy - Recognition, prevention, and elimination of disparities in accessing care and outcomes - Advocacy for expansion or establishment of services and for client-centered changes in organizational and governmental policy Client Selection - Duration client has had the diagnosis - Level of pain control - Functional status (ADLs) or cognitive deficits - Previous home health and durable medical equipment usage - History of mental illness or substance abuse, suicide risk, or crisis intervention - Chronic, catastrophic, or terminal illness - Social issues such as a history of abuse, neglect, no known social support, or lives alone - Repeated treatment admissions - Need for admission or transition to a post-acute facility Opportunities for Intervention & Goals - Lack of established, evidenced-based plan of care with specific goals - Over-utilization or under-utilization of services - Use of multiple providers/agencies - Use of inappropriate services or level of care - Non-adherence to plan of care - Lack of education or understanding of: - The disease process - The current condition(s) - The medication list and/or provider treatment plan Opportunities for Intervention & Goals - Medical, psychosocial, mental health and/or functional limitations - Emotional & cognitive needs: Counseling, medication - Physical needs: Sleep, nutrition, housing, co-occurring physical conditions, safety - Social needs: Social support, interpersonal skills, child or respite care - Vocational needs: Job coaching, accommodations, employment or meaningful activity - Financial needs: Housing, utilities, medication, food, transportation - Environmental needs: Transportation
Opportunities for Intervention & Goals - Patterns of care or behavior indicating worsening of the condition. - Inappropriate discharge or delay from other levels of care - Frequent transitions between settings Case Manager Qualifications - Current, active, and unrestricted licensure or certification or baccalaureate or graduate degree in a health or human services discipline that allows the professional to conduct an assessment independently as permitted within the scope of practice of the discipline - *Case managers assess needs and resources and may screen for mental health, physical health or addictive disorders Summary - The demand for case managers is growing rapidly as insurance companies restrict reimbursement, move toward capitation and as individuals with high copays try to reduce expenses. - Not only are case managers employed by hospitals and treatment centers, but increasingly by organizations like businesses and universities that have a strong motivation to keep their employees/students healthy and (relatively) happy - Case managers provide assessment, advocacy, education and assistance with treatment coordination and implementation, often in a multidisciplinary team - Case managers do not diagnose or treat illnesses