Case Management Toolbox: Recent Episodes
Dr. Dawn-Elise Snipes
Case Management Toolbox Podcast will provide case managers with tools and continuing education training related to evidence based practices for behavioral health and medical case management services.
Assisting Families Through Life Transitions
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Dr. Dawn-Elise Snipes PhD, LMHC Executive Director, AllCEUs.com Podcast Host: Counselor Toolbox and Case Management Toolbox Flower Empower • A comprehensive approach • The core of the flower is the clinician-family partnership • Assess need • Sustain a caring environment • Educate • Identify and link to resources • The stem symbolizes advocacy activities • The leaves symbolize vision, values and principles • The roots feed the flower (partnership): • Responsibility and accountability • Recognition of the value of the partnership • Respect uniqueness • Resource identification for emerging needs • Results monitoring Clinician - Family Partnership • Recognize family assessment of the situation as essential • Respect the important role of family • Determine the desired degree of family involvement • Negotiate the roles of clinician and family within the partnership • Listen • Engage in participatory dialog • Recognize patterns • Highlight family strengths Assessment • Within the context of the family • Identify if assistance is required to strengthen the family • Information • Family structure and composition • Culture • Power and Role Structures • Communication • Access to Resources • Environmental characteristics • Family strengths • Family supports • Family perception of events • Degree of involvement desired by family
Sample Questions • Who would you like us to share information with and who not? • How can we be most helpful to you and your family or friends during this transition? (Clarifies expectations, increased collaboration) • What has been most/least helpful to you in past times of crisis? (Identifies past strengths, problems to avoid and successes to repeat) • What is the greatest challenge facing your family right now? (Indicates actual/potential suffering, roles, and beliefs) • What do you need to best prepare you/your family member for dealing with this issue?(Assists with early discharge planning) • Who do you believe is suffering the most in your family at this time? (Identifies which family member requires the greatest support and intervention) • What is the one question you would most like to have answered right now? (Explores the most pressing issue or concern) • How have I been most helpful to you? How could I improve? (Demonstrates a willingness to learn and work collaboratively)
Support • Sources of Resources and Support • Intrafamilial (within) • Extrafamilial (outside) such as community services, training programs • Interfamilial (between) like support groups Values and Principles • Recognize personal assumptions and values about families and cultural beliefs and to adjust their care accordingly. • Families are unique, diverse, and change over time • Families in transition can make informed decisions • Families have expert knowledge and skills that help them determine their own needs and respond to expected and unexpected life events. • Partnerships with families are built upon mutual trust, honesty, and collaboration • Partnerships support and strengthen families • Families should be supported in their choices • Family members and the client may have different and conflicting needs Outreach • Target groups • Clinicians • Families • Policymakers • The public • Provide pre-emptive information to assist families in managing expected or unexpected life events Workplace environment • Ensure staff is oriented to family-centered care • Ensure clinicians can effectively access resources • Provide ongoing opportunities for professional development Implementation • Ensure appropriate staffing levels and placement • Implement family-centered practices and policies • Create work environment conducive to promoting family involvement • Develop employee assistance programs promoting family health • Ensure policies promote work-life balance Advocacy • Lobbying • Family care giving • Public education about the legitimacy of family caregivers • Consistency in funding for respite care and research • Mechanisms within organizations for family Question to Ponder • Think of your collective experience from supporting families during life transitions. • If you could change one aspect of the care and support they received, what would it be? • What would you make different for them?
Implementation • Assessment of organizational readiness • Involvement of direct and indirect members • Dedication • Ongoing opportunities for collaboration • Opportunities for personal reflection Summary • The Flower Empower model provides a simple but comprehensive framework for developing a working partnership.
448 - Post Stroke Psychosocial Issues Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC Executive Director: AllCEUs Podcast Host: Counselor Toolbox, Case Management Toolbox, NCMHCE Exam Review
Objectives • Examine the prevalence of and risk factors for stroke • Identify Post-Stroke Psychosocial Issues Intro • Many of our clients are at high risk of stroke • People with anxiety disorders have a 33% higher risk of stroke partly due to HBP and lifestyle factors such as smoking • Mood stabilizers were collectively associated with a significantly increased risk for stroke in participants with bipolar disorder • Benzodiazepine use is associated with a 20% higher risk of stroke • Almost 40% received 1 or a combination of drugs hypothesized to impair recovery during the first 30 days after stroke.(e.g. clonidine which reduces NE levels, atypical antipsychotics, benzodiazepines) Risk for Stroke • Smokers are 2-4x as likely to have a stroke • Make blood sticky and more likely to clot, which can block blood flow to the heart and brain • Damage cells that line the blood vessels • Increase the buildup of plaque (fat, cholesterol, calcium, and other substances) in blood vessels • Cause thickening and narrowing of blood vessels • Alcohol increases stroke risk by 38% • Causing A-Fib • Development of atherosclerosis, or the hardening and narrowing of arteries • Liver damage impairing blood clotting • HBP during detoxification Risk for Stroke • Stimulant abuse increasing blood pressure • High blood pressure • Sleep apnea • Non-sleep-apnea sleep disorders • Age • Diabetes doubles the risk of stroke • Use of nonsteroidal anti-inflammatory drugs (NSAIDs), but not aspirin, may increase the risk of heart attack or stroke, particularly in patients who have had a heart attack Mini-Strokes • The signs and symptoms of a TIA resemble those found early in a stroke and may include sudden onset of: • Weakness, numbness or paralysis in your face, arm or leg, typically on one side of your body • Slurred or garbled speech or difficulty understanding others • Blindness in one or both eyes or double vision • Dizziness or loss of balance or coordination • Sudden, severe headache with no known cause • 70% reported that their TIA had long-term effects including memory loss, poor mobility, problems with speech and difficulty in understanding. 60% of people stated that their TIA had affected them emotionally
Assessments • When • Just before discharge • One month after stroke • Three months after stroke • Six months after discharge • What to look for • Cognitive functioning • Depression • Anxiety • Social withdrawal • Changes in physical presentation Impacts of Stroke • General Physical Issues • Reduced mobility / independence • Vision problems • Difficulty with ADLs • Difficulty swallowing • Sleep problems (36%) • Chronic headaches • Pneumonia • Pain
Impacts of Stroke • Difficulty understanding or expressing emotions • Post-stroke depression (PSD) (67%) • Post-stroke depression may remit as the person regains function • Correlated with hospitalization, functional loss and particular areas of the brain being damaged • Post-stroke anxiety (25%) • Post-stroke emotional incontinence (PSEI) uncontrollable outbursts of involuntary laughing or crying for no apparent reason (34%) • Functional status, serotonin polymorphisms, and low social support were related to PSEI at three months post-stroke • SSRIs are often effective
Impact • Post-stroke anger proneness (PSAP) • serotonergic dysfunction seems to play a role in the development of PSAP • Post-stroke fatigue (PSF) (50%-86%) • Depression • Neurological deficits • Antidepressants • Sleep disturbances • Post-stroke pain • Changes to thinking, memory and perception after stroke can impact how the person sees, hears and feels the world. This can affect how they feel about themselves and others
Impact • Cognitive skills can be affected by emotional state or tiredness, but brain damage caused by stroke can also cause difficulties with • Ability to learn new skills • Ability to plan • Ability to problem solve • Attention – being able to concentrate and focus • Orientation – knowing the day and time • Short-term memory – knowing what happened recently • Changes in working memory • Intellectual fulfillment
Attention and Memory Intervention • Minimum of 1 hour a day of actively listening to music showed recovery in both verbal memory and focused attention, as early as 3 months after a stroke Impact • Personality changes • Repetitive behavior • Disinhibition – tendency to say and do things that are socially inappropriate • Impulsivity including sudden and socially inappropriate actions.
Impact • Perception is the term that describes how you see, hear and feel the world. After a stroke, your perception can include changes to: • Feeling contact, pain, heat or cold on the side of your body affected by stroke • Judging distance • Performing certain movements even without physical disability (apraxia) • Recognising shapes and objects, or even your own body • Seeing or feeling things only on one side – which can cause you to bump into things • Watching TV or reading – can become difficult • Vision – some people lose half their vision in each eye (hemianopia).
Impact • Communication after stroke • Difficulty in finding the right words or understanding what others are saying (aphasia or dysphasia) • Weakness in the muscles that help speech (dysarthria) • Dysfunction of the nerve connection between your brain and mouth, making speaking difficult (dyspraxia) • Reading and writing problems caused by a weak writing hand or problems thinking or seeing.
Impact • Physical changes after stroke • Difficulty with gripping or holding things • Fatigue or tiredness • Incontinence – many types of incontinence can occur, but it can be caused by medication, muscle weakness, changes in sensations, thinking and memory • Pain – can be caused by actual or potential damage to tissues (nociceptive pain) or by damage to nerves that then send incorrect messages to the brain (neuropathic pain) • Restricted ability to perform physical activities or exercise • Swallowing issues • Vision problems • Weakness or paralysis of limbs on one side of the body.
Impact • Aphasia • Affects about one third of the stroke population and 40% continues to have significant language impairment at 18 months post-stroke • Persons with aphasia (PWA) are especially prone to psychosocial problems, such as • Anxiety and depression • Threatened identity • Changes in interpersonal relationships • Reduced social networks • Unemployment • Abandonment of leisure activities Post Stroke Grief • Losses • Independence • Function/hobbies/employment • Home (if moved to an ALC) • Self-Esteem • Appearance Post-Stroke Guilt • Not being able to do things with kids/family/friends that they used to • Needing assistance from caregivers/feeling like a burden
Post-Stroke Interpersonal Issues • Social life • Personality changes, anger, depression, fatigue may inhibit relationships • Emotional Incontinence may cause social withdrawal • Financial challenges • Loss of employment • Need for an ALC • Need for PT/OT Post-Stroke Caregiver Needs • Caregivers should be assessed for their ability to provide care • Regularly assess caregiver wellbeing • Caregiver Strain Index • Caregiver Burden Scale • Support caregivers in balancing personal needs and caregiving responsibilities by providing community programs, respite care, and educational opportunities Summary • Stroke impacts people physically, affectively, cognitively, and interpersonally. • It is important to explore the causes of mood or cognitive issues to identify the best interventions • Brain damage • Sleep dysfunction • Cognitive issues • Life changes
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
CEUs are available at https://allceus.com/case-management-toolbox-podcast Get two free months of Therapy Notes by using the promocode CEU when you sign up for a free trial at TherapyNotes.com
- Based in part on the Standards of Practice for Case Management by the Case Management Society of America Objectives
- Explore the benefits of adding case management to your skill set
- Learn how Case Management is financially beneficial
- Explain the principles of case management
- Identify practice settings
- Review risk factors (targets) for case management
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
008 CM-Psychosocial Aspects of Disability
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Objectives ~ Define Disability ~ Review the phases of disability adjustment ~ Explore the concept of Disability Identity ~ Identify aspects of disabilities which increase stigma ~ Explore the 5 As of intervention ~ Using ecological theory, explore the psychosocial impact of the disability on the individual and family.
Define Disability ~ Any mental health, addictive or physical health issue which restrict or alter a person’s regular or desired activities. ~ Examples ~ Addiction ~ HIV ~ Paraplegia ~ Deafness ~ Visual Impairment ~ Down’s Syndrome ~ Schizophrenia ~ Autism ~ Muscular Dystrophy ~ Chron’s Disease
Adjustment to Disability ~ Many people experience more than four stages of adjustment to a physical disability: ~ Shock ~ Anxiety ~ Denial ~ Mourning/Depression ~ Withdrawal ~ Internalized anger & Externalized aggression ~ Acknowledgment ~ Acceptance ~ Adjustment
Disability Identity ~ The beneficial self-beliefs that PWDs hold regarding their disabilities, as well as any ties they possess to members of the disability community ~ People with “invisible” disabilities often have a low disability identity ~ Disability identity is negatively correlated with mood disorders ~ Identity development is a fundamentally social process, and identities are formed through mirroring, modeling, and recognition through available identity resources, and so it is imperative that professionals working with individuals with disabilities become aware of this developmental process to be able to better support individuals along this journey Disability Identity Development ~ Key Themes ~ Communal attachment—wishes to affiliate with other PWDs ~ Affirmation of disability—Living in the And ~ Self-worth—values the self and feels equal to nondisabled people ~ Pride—feels proud of identity despite recognizing that disabled is often viewed to be a devalued quality ~ Discrimination—aware of prejudicial behavior in daily life ~ Personal meaning—finds significance in, identifies benefits with, and makes sense of disability Stigmatizing Dimensions ~ Source/responsibility for condition—Is a stigma congenital, accidental, or self-inflicted? ~ Aesthetic—Does the stigma distress or otherwise upset other people? (Addiction, amputation, wheelchair…) ~ Apparent or concealable—Is a stigma obvious (e.g., amputation) or invisible (e.g., psychological or mood disorder, chronic pain, diabetes)? ~ Disruptiveness—Does the stigma’s presence hinder or otherwise prevent social interaction or communication? (aesthetics, cognition, verbalization) ~ Perilous—Can the stigma be seen as contagious or even dangerous to others? (HIV, addiction, psychosis, autism…) ~ Course—Is the stigma getting worse or better? Fundamentals ~ Clients must feel empowered to make decisions regarding self-management ~ Educational and empowerment strategies must be individually tailored ~ Information and support should be consistent with current best practices ~ Collaborative relationships with patients and supporters is critical to success
5 As ~ Assess ~ The condition ~ The client’s and SO’s understanding of the condition ~ Their current coping strategies and efficacy ~ The impact of the condition on the client’s (PACER) ~ Physical Health ~ Affect ~ Cognitions ~ Environment and Economic Well-being ~ Relationships and Recreation ~ Advise/educate the client and significant others 5 As ~ Agree/collaborate to develop a workable plan ~ Short term ~ Long term ~ Assist client and supports in identifying and accessing services ~ Arrange for referrals and follow-up as needed
~ Raise awareness of their rights and of the possibilities and services available to them to ~ Enhance their mental and physical ~ Engage in social/recreational activities ~ Act to eliminate discrimination Ecological Systems Individual Dimensions ~ Risk/Mitigating Factors ~ Age ~ Health (concurrent conditions and health behaviors) ~ Mental Health ~ Cognitive Functioning ~ Socioeconomic Status ~ Employment ~ Education ~ Perception of Disability/ Disability Identity ~ Duration of Disability ~ Cultural Values ~ Social Support Perception
Individual Dimensions cont… ~ Cognitive Constructs ~ Courage vs. Mental Defeat ~ Knowledge (Health Literacy and Coping) ~ Commitment to Action vs. Hopelessness ~ Emotional and Cognitive Transcendence vs. Pain/Disability Catastrophizing ~ Perceived Burdensomeness ~ Disability Identity vs. Thwarted Belongingness Microsystem ~ Family and Peers ~ Community and family response ~ Impact on their lives (occupational, financial, social, emotional) ~ The insider–outsider distinction is assuming what a disability, must be like—and frequently concluding that it is not only negative and disruptive to daily living but also defining for the individual. ~ Outsiders rarely recognize disability as one quality among many in a person’s life and presume the disability is an ongoing focus, a troubling preoccupation Microsystem ~ School/employment ~ Ability to get jobs ~ Necessary accommodations ~ Reception at school/work ~ Health Services ~ Availability of specialized services ~ Financial impact of services/medicines Exosystem ~ Community ~ Resources ~ Attitudes ~ Government Agencies ~ Services (health care, transportation, housing) ~ Mass Media ~ Culture ~ A disability often represents a stigma that the person has some quality that is construed as being broadly negative in a given context or cultural setting ~ When a disability is stigmatizing, it serves as a social marker so that PWDs are seen and often treated as distinctly different from nondisabled people
Specific Presenting Issues ~ Depressive symptoms ~ Anger problems ~ Harmful habits (e.g. smoking, alcohol misuse, illicit drugs) ~ Lack of healthy social support ~ Poorer perceived mental health ~ Concurrent chronic pain conditions impacting relationships and sleep ~ More frequent episodes of intermittent pain Accommodations ~ Vocational Rehabilitation ~ Job Accommodation Network ~ JAN Searchable Online Accommodations Resource (SOAR)
Summary ~ Both visible and invisible disabilities can impact people’s ~ Physical Health ~ Affect ~ Cognitions ~ Environment and Economic Well-being ~ Relationships and Recreation ~ The degree to which a disability impacts a person psychosocially depends in large part on ~ Individual Characteristics ~ Community and Family Response ~ Cultural Attitudes
Case Management Toolbox 06 -Dementia Case Management Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC Executive Director AllCEUs Continuing Education Podcast Host: Case Management Toolbox, Counselor Toolbox CEUs are available for this presentation at https://allceus.com/case-management-toolbox-podcast/ Objectives Resources - The Dementia Society of Ottawa and Renfrew Counties - Dementia Australia Symptoms of Dementia - Cognitive and sensory changes: - Memory loss - Difficulty in communication, especially finding the right words to communicate or keeping track of a conversation. - Reduced ability to organize, plan, reason, or solve problems - Difficulty handling complex tasks - Confusion and disorientation (Gets lost in familiar places) - Difficulty with coordination and motor functions - Loss of or reduced visual perception - Metallic taste in mouth, decreased sense of smell - Agnosia: loss of ability to recognize objects, persons, sounds, shapes, or smells while the specific sense is not defective nor is there necessarily any significant memory loss “visual agnosia” “Auditory agnosia”
Symptoms of Dementia - Psychological changes: - Changes in personality and behavior - Depression - Anxiety - Hallucinations - Mood swings - Agitation esp. with changes in routine - Apathy - Isolation/withdrawal
Dementia vs Normal Aging - Normal Aging - Occasional forgetfulness - Can use notes as reminders - Slower processing - Increased time for complex tasks - Able to follow written and verbal directions - Longer to learn new information - Difficulty finding the right word - Slowed reaction time - Able to complete ADLs - Some issues with balance
Types of Dementia- Alzheimer’s - Stage 1 means Alzheimer’s has started to develop, but there are no symptoms of memory loss yet — this stage can last up to 20 years. - Stage 2 Mild Cognitive Impairment –MCI) involves mild changes in memory and thinking skills - Stage 3 (Late Stage/Alzheimer’s Dementia) memory and thinking skills are so impaired that a person needs help to complete daily activities of daily living. Types of Dementia- Korsakoff’s Syndrome - Korsakoff’s syndrome and Wernicke/Korsakoff syndrome - Alcohol has a direct toxic effect on the brain cells, or whether the damage is due to lack of thiamine, vitamin B1 - People with anorexia and those who have had bariatric bypass surgery are also at risk. Types of Dementia—AIDS Dementia Complex - 7% in people not taking anti-HIV drugs. Types of Dementia—Vascular Dementia - Vascular Dementia includes a very wide range of symptoms caused by a reduction in blood supply to the brain usually due to strokes or heart attack - Symptoms can develop months after a major stroke - The main symptom of Vascular Dementia is slowness in thinking speed, problems concentrating or difficulty planning and organizing. - It is also common for a person with Vascular Dementia to experience mood changes Types of Dementia- With Lewy Bodies - Dementia with Lewy Bodies is often misdiagnosed as Alzheimer’s Disease - Parkinson’s Disease and Dementia with Lewy Bodies produce similar brain changes - The main symptoms include memory loss, disorientation, visual hallucinations and sleep issues - The disease lasts an average of 5 to 8 years from the time of diagnosis to death, but the time span can range from 2 to 20 years. Types of Dementia--Frontotemporal - The main functions affected by Frontotemporal Dementia are language skills, the ability to focus and the ability to control impulses - More common in those under 65 Other (Reversible-) Causes of Dementia - Clinical hypothyroidism and hyperthyroidism have long been linked with reversible cognitive impairment in patients - Cognitive impairment, dementia, and psychoses have been described in patients with chronic hypocalcemia, hypoparathyroidism, and hypercortisolism - People with PTSD may exhibit hypercortisol responses to stress triggers - Hypercortisolemia is evident in approximately 50% of depressed patients and is particularly characteristic in the melancholic subtype. - Nearly 33% of people with Type 2 diabetes have elevated cortisol levels - A history of recurrent severe hypoglycemic episodes was associated with a greater risk of dementia Causes of Dementia - Carbon monoxide (CO) poisoning can lead to a delayed onset cognitive decline beginning days to several weeks after apparent recovery from the initial insult. - Cognitive decline, personality changes, incontinence, parkinsonism, and even mutism may occur. The majority of victims recover within 1 year. - Carbon monoxide (CO) is a colorless, odorless gas found wherever fuel is burned including small engines, gas ranges, furnaces, fireplaces and grills Other Causes cont… - Sources of carbon monoxide poisoning: - Furnace - Chimney (closed/blocked) - Fireplace - Water heater - Gas stove/oven - Gas-powered space heaters - Clothes dryer - Grill - Power tools and lawn equipment - An attached garage that regularly houses vehicles
Other Causes Cont… - Symptoms of CO2 Poisoning - Dizziness - Blurred vision - Weakness/Fatigue - Confusion - Shortness of breath during mild activity - Nausea - Headache
Dementia Progression - Dementia is a progressive disease - The speed of progression varies depending on - The type of dementia - The person - Early interventions - Medical complications - Genetics Dementia Primary Prevention - Authors estimate that as much as 35% of dementia cases could be prevented by targeting nine modifiable risk factors • Early life education • Midlife hypertension (Vascular dementia) • Obesity • Diabetes • Hearing loss • Old-age smoking • Depression (Hypercortisolism, unstimulating environments) • Physical inactivity • Social isolation Dementia Primary Prevention - Regular Physical Activity - The protective effective was increased as the number of activities increased - Higher levels of intellectual activities and an intellectually stimulating environment may reduce the risk of cognitive decline later in life - A lower level of education increases the risk of having AD by approximately 30%* - Social engagement. Degree of loneliness, decreased social networking and activities seem to be associated with a higher risk - Dietary modulation (Omega-3, antioxidants, B-Vitamins) serves only to bolster normal health mechanisms that are a natural deterrent of chronic health conditions such as AD without really possessing any discrete disease specificity Dementia Secondary Prevention/EI - Reduction or cessation of symptom progression once the symptoms have appeared - cholinesterase inhibitors and NMDA Antagonists (Ketamine) - May improve acute symptoms but does not slow progression - Physical Activity Dementia Tertiary Prevention/EI - Prevent the development of complications from the disorder - Depression - Falls - Nutritional deficiencies - Diabetes
Multidisciplinary Team - Physical therapists can help with movement problems through exercises, gait training, and general physical fitness programs. - Speech therapists may help with voice volume and projection, and swallowing difficulties. - Occupational therapists help find ways to more easily carry out everyday activities, such as eating and bathing. - Music or expressive arts therapists may provide meaningful activities that can reduce anxiety and improve well-being. - Mental health counselors can help people with LBD and their families learn how to manage difficult emotions and behaviors and plan for the future. - Palliative care specialists can help improve a person's quality of life by relieving disease symptoms at any stage of illness. Goals - Goals - Independence - Safety - Sense of meaning - Happiness/contentment - General methods - Safety from falls, wandering, burns, guns, and CO2 - Adequate quality sleep - Adequate nutrition - Medication compliance - Physical Activity - Social Interactions - Meaningful Daily Activity Special Issues for People with Dementia - The needs of a person with Early Onset Dementia can be very different from traditional onset dementia because they may be actively working and raising a family and be otherwise healthy and strong - Early stage of dementia, a person can still function rather independently and requires little care assistance. - Appointment reminders - Daily to-do list and / or a schedule of when medications - Hang complete outfits - Go shopping together (or auto-deliver) - Regular check-ins while the person is still living independently - Family counseling to deal with grief issues related to the diagnosis - Financial planning - Note on microwave (i.e. no metal, duration for common foods) - Coffee maker that automatically shuts off
Special Issues for People with Dementia - Middle Stage Dementia - No longer able to function as independently - Greater difficulty communicating (see communication tips) - Assistance with activities of daily living, such as bathing, grooming, and dressing, is often required - Initially, an individual may only need prompts or cues to perform these tasks, such as reminders of the need to shower or clothes laid out on the bed - Transportation will be required - Supervision is necessary Special Issues for People with Dementia - Late Stage Dementia - Requires a significant amount of care 24-hours / day. - Mobility issues - Swallowing becomes an issue in late stage dementia, and caregivers have to make sure food is cut into small pieces, is soft, such as yogurt and applesauce, or is pureed. - Options for care, such as hiring a part time caregiver or moving your loved one to a nursing home. Monitoring Tools - Functional Assessment Staging Test - Stage-Expected Untreated Duration-Mental Age-MMSE-A Score - Weight - Infections/Pain/Illness (60% may have untreated issues) - Falls and injuries - Behavior changes - Medication compliance, effects/side-effects and changes - Mood and ADLs: Ambulation, hygiene, feeding, toileting - May indicate disease progression or another acute issue - Social engagement - Note: Abilities may fluctuate General - Review medications - Consider whether any might be contributing to cognitive deficits, especially anticholinergics, antihistamines, narcotics, sedatives, and benzodiazepines* - Address treatment compliance - Add social activities - Add intellectual stimulation and meaningful daily activities - Focus on activities with tangible results - Painting - Life-story book - Gardening - Playing or listening to music - Picture books
General - Assess mobility issues - In house - Getting out of bed - Getting in and out of the shower/tub - Stairs - Slick floors - Tripping hazards - With preferred activities (walk the dog, woodwork, crochet, painting) - To get supplies (driving, shopping) - Address long-term care planning - Advanced directives - Power of attorney - Living transitions General - Evaluate behavioral issues and safety - Driving, wandering, cooking, bathing, shopping - Sundowning—confusion and agitation increase throughout the day - Mitigate vulnerabilities/triggers - Recognize the function of the agitation - Use visual cues for orientation and comfort - Avoid arguing - Consider bright light therapy to adjust circadian rhythms—Full spectrum light at least 100 watts (not soft) within 3 ft. or sitting by a sunny window - Increase daytime activity and limit day naps - Avoid stimulants after noon - Minimize stress (TV or reading might be too difficult) painting, pets, baking with assistance, gardening - Address caregiver stress Addressing Behavioral Issues - Functional assessments - Preferred activities - Problem behaviors - Aromatherapy (esp. Lemon Balm, rose, lavender, bergamot) - Music therapy - Animal assisted therapy - Relaxation training - Reminiscence therapy helps recall past happy times despite current issues with short term memory - Difference between reminiscing and remembering - Use favorite music, keepsakes/ornaments/jewelry, magazines, familiar scents or foods Addressing Behavioral Issues - Validation therapy - Often prevents argumentative and agitated behaviors. Validation may require you to agree and validate with a statement that has been made, even though the statement is neither true or real, because to the person with dementia, it may actually be both true and real - Light therapy (sundowning) - Activities of Daily Living - Strategies may include verbal or visual cues, demonstration, physical guidance, partial physical assistance and problem solving Addressing Behavioral Issues - The reasons that underlie the problem behaviors can be one or more of the following basic human needs: - Resolution of unfinished issues, in order to die in peace - To live in peace - Adjusting to new normal when sight, hearing, mobility and memory fail - To make sense out of an unbearable reality - For recognition, status, identity and self-worth - To be useful and productive - To be listened to and respected - To express feelings and be heard - To be loved and to belong - To be nurtured, feel safe and secure, rather than immobile or restrained - For sensory stimulation as well as sexual expression - Reduce pain and discomfort Caregiver Needs - Resources - The signs and symptoms of dementia - The course and prognosis of the condition - Treatments - Knowledge of how to help their loved-one - Communication - Behavior issues - Safety—wandering, falling, hazards - Local care and support - Sources of financial and legal advice, and advocacy - Medico-legal issues, including driving - Local information sources, including libraries and voluntary organizations. - Respite care—In home or clubhouse/day care Communicating with People with Dementia - Get their attention - Remove distractions - Ensure they have glasses or hearing aids - Be patient. Allow enough time for them to respond, and be careful not to interrupt - Use visual reminders (memory books and charts) - Keep questions and requests to one at a time - Break larger tasks into smaller chunks - Empathize with frustration - Anticipate misunderstandings - Enjoy the good times
Communicating with People with Dementia - Reduce input late in the day - Do not talk to the person with Alzheimer’s like a baby or speak about them as if they weren’t there. - If they struggle to find a word or communicate a thought, gently try to provide the word(s) they are looking for. - Frame questions and instructions in a positive way. - Be open to the person’s concerns, even if he or she is hard to understand. - If you can’t understand what they are trying to say, look for clues in their emotions and body language and take their surrounding environment into consideration.
Summary - Dementia can be permanent or temporary and caused by a variety of factors including - Diabetes - HIV - Stroke/Heart attack - Depression - Thiamine deficiency - CO2 poisoning - Lewy bodies - Genetics
Summary - A variety of interventions can be used to assist the person with dementia and their caregivers - Ensure sufficient sleep - Assist with communication - Conduct functional assessments of preferred and problem behaviors
Increasing Case Management Effectiveness Dr. Dawn-Elise Snipes PhD, LPC-MHSP Executive Director, AllCEUs Counseling Continuing Education Host: Counselor Toolbox and Case Management Toolbox Podcasts Objectives - Identify the benefits of case management - Explore the impact of ineffective “standard” treatment - Identify goals of the case manager - Review the research identifying the most helpful factors in case management - Review assessment areas - Explore common needs of CM clients - Describe characteristics of effective care plans Intro - CM can be defined as a “coordinated integrated approach to service delivery, ongoing supportive care and help to access resources for living and functioning in the community” Why Case Management - Frequent users of healthcare services are a small group of patients with multiple chronic conditions and psychosocial and mental health comorbidities accounting for a high number of healthcare visits - Frequent use of services is often considered a symptom of gaps in accessibility and coordination of care. - These patients are more at risk for incapacity, poorer quality of life and mortality. - Case management (CM) is the most frequently implemented intervention to improve care for frequent users of healthcare services and to reduce healthcare usage and cost - CM interventions resulted in decreases in ED use and cost, a better use of appropriate existing resources, and a reduction in social problems such as homelessness and drug and alcohol abuse Impact of Ineffective Treatment - Treatment dropout - Continued illness - Work impairment - Financial problems - Relationship impairment - Impaired parenting - Stress related health problems - Development of (additional) mood issues
Case Example - John has a substance use disorder, major depressive disorder and hepatitis C. He doesn’t know how to afford his medication for hepatitis or his depression, has a history of suicidal ideation and has a history of relapse. Currently he is living in a local motel. He recently lost his job and got a DUI.
- Counselors review your provider administration manual. Most insurers offer care/case management programs.
- http://www.aetna.com/healthcare-professionals/documents-forms/bh-provider-manual.pdf
Goals - Increase/maintain client engagement/motivation by: - Improving health literacy - Identifying and addressing obstacles (payors, transportation, language/literacy, childcare) - Identifying and enhancing strengths - Serving as a healthcare guide - Providing support and encouragement - Reducing symptoms - Reducing the burden on caregivers thereby improving the psychosocial environment (emotional support, social support, domestic help, insurance, transitional services) - Increasing confidence in caregivers and clients for self-management Helpful Factors in Case Management - Helpful Factors - Access to medical, social and community resources - Calm and trusted case manager - Case manager with strong relationships to referral sources - Effective communication between CM and treating clinician(s) via a unified treatment strategy - Multidisciplinary care plan - Life skills coaching - Frequent contacts with care provider - Regular review of the care plan with the client - Assistance with healthcare navigation - Patient education/Health literacy enhancement - Coordination and prioritization of care
Assessment Areas: Client and Caregiver - Emotional needs - Cognitive functioning - Physical complaints - Sleep - Current physicians, medications, diagnoses and treatment plans - Motivation - Knowledge about the condition - Health literacy - Access to safe housing - Access to healthy meals - Ability to perform ADLs (cooking, bathing, dressing medication, paying bills, domestic chores…) - Social supports - Meaningful activities - Transportation - Financial stability - Vocational issues (CRC, Job coach, ADA-advocacy)
Needs - Early diagnosis and intervention - Education regarding the condition(s)’, exacerbating and mitigating factors and the course - Active involvement in care planning - Clear explanations of treatments and expectations - Meaningful guidance on addressing emotional and behavioral issues - Legal assistance (referrals) regarding guardianship, power of attorney, advanced directives - Financial planning and resources if caregiver has to quit a job, house remodels, long term care expenses, medication… - Advanced care planning for future problems
Needs - Social and emotional support - Access to specialists (geriatric physicians, pain management, addicitionologist psychiatrists, palliative care specialists) - Meaningful activities - Assistance with ADLs - Management of behavioral, mood and cognitive issues - Safety management
Effective Care Plans - Relate directly to the assessment - Improve mood as evidenced by an average self-report of happiness of a 3/5 each week, bathing daily, completing daily chore list and connecting with at least 1 friend each day - Sally will attend outpatient therapy with Dr. Smith once per week - Case Manager will link Sally with transportation services to ensure ability to attend therapy appointments - Dr. Smith will seek preapprovals at least 3 days before the final approved session - Sally will set a reminder on her phone to complete between-session assignments from Dr. Smith - Sally will take her sertraline as prescribed each day - Sally will put a reminder in her phone to make an appointment with Dr. Jones at least 2 weeks prior to needing a refill - Sally will set a reminder on her phone to connect with one friend each day - Jane, Sally’s partner, will assist Sally in identifying depression triggers and engaging in distress tolerance activities - Sally will keep a daily log of her mood, if she takes a bath, what she eats, her chore list and if she connected with a friend. Documentation - Assessment summary and notes - Capture relevant data elements - Present accurate customer “snap shot” - Deficiencies and barriers should link directly to services and activities - Sequential tracking and reporting of client contact and progress - Describe newly emerging barriers - Revise action plan Documentation - Why are notes important - If it isn’t written, it didn’t happen - Helps clients and providers conceptualize progress, identify and ameliorate barriers - “In-house” sharing of important data and action plans critical to customer service - “External” sharing is critical to optimizing referral relationships Summary - Access to, and close partnerships with, healthcare providers and community services resources are key factors of successful CM interventions that should target patients with the greatest needs and promote frequent contacts with the healthcare team - Assessments and interventions must be biopsychosocial and identify who, what, when, when and why
004 -Health Coaching in Case Management Health Coaching Case Management Toolbox Podcast Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC Executive Director: AllCEUs Continuing Education Host: Case Management Toolbox Podcast & Counselor Toolbox Podcast
CEUs can be earned for this podcast here: https://allceus.com/member/cart/index/product/id/1125/c/
Objectives - Explain what health coaching is - Differentiate it from counseling or medical practice - Describe different skills a health coach needs - Discuss how to develop an individualized service plan
Give a man a fish, he eats for a day. Teach a man to fish, he eats for a lifetime.
Overview of Health Coaching - Health coaches: - Providing self-management support - Educate clients - Bridge the gap between clinician and patient - Help patients navigate the health care system - Offering support and encouragement Health Coaching Research - Significant improvements in one or more of the following - Nutrition - Physical activity - Weight management - Exercise frequency - Perceived social support - Patient engagement and “activation” - Medication adherence - Common features of effective programs are goal setting, motivational interviewing, and collaboration with health care providers
- The Care Transitions Intervention is a widely-used coaching method that imparts skills, tools and confidence to patients and family caregivers as they move from hospital to home.13 It is focused on “four pillars”:
- Having an effective, understandable management strategy
- Overcoming barriers to follow-up appointments,
- Knowing how to recognize and respond to worsening signs and symptoms
- Using a personal health record to identify and record 30-day goals, health information and key questions to be shared with the physician at upcoming health care encounters.
Goal Attainment Scaling Educate Clients - Help clients learn where to find reliable, valid information about their concerns or conditions - Help clients learn how to evaluate that information - Educate clients about the impact of nutrition, sleep, exercise, sunlight, relaxation, thoughts and mood on their condition and their goals - Teach clients about SMART Goals - Teach clients about motivational enhancement Patient Centered Care: Engagement & Rapport - Employ a person centered model - Respect for client as an individual (UPR) - Respect for client’s preferences for goals and interventions - Collaborative approach providing choice and self-determination - Coordination and integration of care - Validation, support, encouragement, empathy - Involvement of social supports Enhancing Motivation - Emotional (How will this help client be happier-) - Mental (How does this make sense to the client-) - Physical (How can this improve the client’s health and energy-) - Social (How will it enhance important relationships- Who is supportive of this change-) - Environmental (What things can be placed in the environment to enhance motivation) - Spiritual (In what ways does this change help the client live more in harmony with personal values and feel a greater sense of connection-) Motivational Techniques (ROADS) - Reflective Listening - Open Questions - Affirmations of Self-efficacy and Optimism - Develop Discrepancy - Summarizing Adult Learning Theory - Provide explanations of why specific concepts are being taught - Ensure learning that is connected to their health goals (make room for meaning) - Use self-assessments to assess different levels of prior experience and education - Remember prior learning will be the filter with which they conceptualize new information - Use multiple methods of instruction (auditory, visual, kinesthetic) - Ensure access to sufficient resources - Adult students prefer a self-directed approach that allows for discovery on their own.
Behavior Change Theory - When presented with a need to act (behave) people choose the most rewarding - One issue many people have is delay of gratification. They choose what is most rewarding in the moment instead of overall. - Rewards (reinforcers) encourage a behavior to be repeated - Consequences (punishments) discourage a behavior - Stimuli prompt a person to engage in a behavior Behavior Change Examples - Emotional Eating - Food is associated with pleasure and happy times - Food is readily available (stimulus) - When people are stressed or bored the sight or smell of food IRL or in the media can prompt eating behaviors - Habit - Sally smokes a cigarette when she is driving to work, after lunch, on the way home from work, after dinner and before bed “to relax” - Smoking strongly activates pleasure centers in the brain - Triggers: Car, meal time, when she needs to relax - Goal: Make not smoking more rewarding and less punishing Readiness for Change - Precontemplation - I don’t have a problem with my blood sugar. The test must be wrong - Contemplation - My symptoms are not that bad. I can control it by eating healthier. - Preparation - I am having difficulty controlling my blood sugar and I don’t want it to get worse. Let me evaluate my treatment options. - Action - I need information and tools to help me manage my blood sugar and make better lifestyle choices - Maintenance - I know what I need to do. I just need to maintain the motivation and willingness to do it. - Relapse* - I am starting to fall back into old habits or “cheat” on my plan. Creating a Wellness Vision - Describe your body and mind in their ideal state - What would you look and feel like- - What types of things would you be doing (or not doing)- - What are the most important elements in your vision- - Why are these elements important- (i.e. How will they improve your life-) - Which one do you want to work on first- - On a scale of 1-5 what is your level of confidence you can achieve this- - What types of assistance might you need in achieving it- - What obstacles do you anticipate and how can you deal with them- - What strengths and resources do you have that will help you accomplish these goals Visualize Goals - Pictures/collages/scrapbooks - Push notifications - Narratives - Charts - Mental Imagery Goal Setting - KSAs - Knowledge of - Physical, emotional, cognitive, behavioral factors that exacerbate and mitigate the problem - Physical, emotional, cognitive, behavioral factors that enhance goal attainment - Skills - Abilities
Goal Setting - SMART - Specific - Measurable - Achievable - Relevant - Time Limited Scaffolding (GROW-ME) - Goals are specific and shared - Rescue (Help) is immediately available - Optimal level of help - Encourage self-efficacy - Concrete prompts - Use prior knowledge - Use preferred learning method - Whole-task, holistic approach - Cognitive: What is the goal- - Emotional: What are your concerns- Elicit confidence. - Behavioral: What do you need to do- - Model desired behaviors - Empower to take chances
Behavioral Health & Chronic Conditions - Treatment plan developed by a clinician OR by an individual for wellness enhancement - Overcoming barriers to participation: Follow-up appointments, homework assignments - Knowing how to recognize and respond to worsening signs and symptoms - Using a personal health record to - Identify 30-day goals and record progress - Journal health information (nutrition, sleep, mood, etc) - Key questions to be shared with the physician/therapist at upcoming health care encounters(including annual exam),
Health Coaching: Self-Improvement - Help client identify goals for 30, 60, 90 days - Develop an effective, understandable management strategy based on SMART goals - Overcoming barriers to achievement including prior failures - Identify triggers for and signs and symptoms of backsliding/relapse and develop a prevention/ intervention plan - Have client record - progress toward 30-day goals daily - health information - key questions to be shared with the physician at upcoming health care encounters.
Sample Wellness Plan - Wellness Vision: Have good energy, maintain mental functioning, stay physically healthy (sleep, nutrition, exercise, stress management, smoking cessation) - Six month goals - Three month goals - One month goals - This weeks goals: Do what, how often, how much - Log - What I did for each of my goals - My energy 1-5 - My ability to concentrate and remember 1-5 - My weight - My blood pressure
Summary - Health coaching is a valuable resource to improve client retention and success - Health coaches can help with treatment plan implementation, relapse prevention - Health coaches have the opportunity to - Increase people’s health literacy - Teach people how to enhance motivation - Teach people how to set SMART goals - Help people attain those goals
Improving Health Literacy Case Management Toolbox Podcast Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC Executive Director, AllCEUs Counseling CEUs Objectives ~ Define health literacy ~ Explain why health literacy is important ~ Explore health literacy in a recovery oriented system of care ~ Identify at least 5 ways to improve health literacy
What is a ROSC ~ Recovery-Oriented Systems of Care (ROSC) is a coordinated network of community-based resources that is person-centered and builds on the strengths and resilience of individuals, families, and communities to achieve improved health, wellness, and quality of life ~ In order to access and benefit from these services, people must have a high level of health literacy ~ Case Managers and clinicians can work together in communities to identify ~ Needs and resources to prevent health and mental health issues ~ Needs and resources to recover from health and mental health issues
What is Health Literacy ~ Health literacy is the degree to which individuals can obtain, process, and understand basic health information to make appropriate health decisions. ~ Includes math skills to manage levels, understand risks, measure medication, understand nutrition labels and even manage insurance. ~ Includes general health information about requirements for good health including exercise, sleep, nutrition and regular checkups as well as ways to prevent or mitigate common risk factors for disease ~ Only 12 percent of adults have proficient health literacy, or the skills needed to manage their health and prevent disease. What is Health Literacy ~ Health literacy (what a person needs to know and how to help them understand and use that information) is dependent on: ~ Communication skills of lay persons and professionals ~ Lay and professional knowledge of health topics ~ Demands of the situation/context ~ Health literacy affects people's ability to: ~ Find information and services ~ Communicate their needs and preferences and respond to information and services ~ Process the meaning and usefulness of the information and services ~ Understand the choices and consequences of the information and services ~ Decide which information and services they need and take action
Health Literacy Skills ~ Anyone who provides health information and services needs health literacy skills to ~ Help people find information and services ~ Effectively communicate information about health promotion and conditions to people of varying ages, cultures and cognitive abilities.(teach back) ~ Understand what people are explicitly and implicitly asking for ~ Decide which information and services work best for different situations and people so they can act
Health Literate Services ~ A Health Literate Case Manager or Clinician ~ Integrates health literacy into planning, evaluation measures, patient safety, and quality improvement ~ Has a high level of health literacy ~ Works with clients in the design, implementation, and evaluation of the service plan ~ Uses health literacy strategies in communications and confirms understanding ~ Provides easy access to health information and services ~ Designs and distributes print, audiovisual, and social media content that is easy to understand and act on. ~ Regularly addresses health literacy in high-risk situations, including care transitions and medication changes ~ Communicates clearly what services are available free and cost Health Literate Services ~ A Health Literate Case Manager or Clinician ~ Integrates health literacy into planning, evaluation measures, patient safety, and quality improvement ~ Evaluate client understanding of the condition, treatment options, and services available at admission ~ Evaluate client’s understanding of general health and wellness behaviors ~ Assess client’s ability to seek out, obtain and use health-related information ~ Ensure clients understand what evaluations are asking of them ~ Identify obstacles to client health literacy and set goals for improvement (unclear videos, handouts with small type, lack of clear way to transition knowledge to practice– “It is important to get enough sleep.”)
Health Literate Services ~ Promote changes in the health care system that improve health information, communication, informed decision-making, and access to health services ~ Educate patients ~ Provide choice ~ Support and expand local efforts to provide adult education (English and math), and culturally and linguistically appropriate health information services in the community. ~ Support efforts to provide services in people’s native language ~ Build partnerships, develop guidance, and change policies ~ Schools, churches, ~ Increase basic research and the development, implementation, and evaluation of practices and interventions to improve health literacy Good Resources ~ Develop and disseminate health and safety information that is accurate, accessible, and actionable… ~ Use plain language instead of technical terminology or confusing statistics in communications (1 in 10) (1 in 1000 vs 1/10th of a percent) ~ Organize information so that the most important points come first ~ Break complex information into understandable chunks ~ Ensure recommendations and explanations of risk and benefits are clear, concrete, understandable to the person ~ Advocate to increase accuracy of health information in all media programming Good Resources ~ Develop and disseminate health and safety information that is accurate, accessible, and actionable (Print, audiovisual, and electronic media) ~ Use multiple modes of communication, not just text (videos (importance of nutrition in prevention and recovery), pictures (food pyramid), experiential (measuring food)) ~ A focus on translating information from increased awareness to specific steps for action and behavioral changes. (Sleep, physical activity) ~ Respect cultural preferences and practices when targeting and tailoring information and interventions ~ Involve members of the target population in planning, developing, implementing, disseminating, and evaluating effectiveness of information. Dissemination Strategies ~ School curricula—daycare-college ~ YouTube ~ Social Media ~ PatientsLikeMe.com ~ Podcasts ~ Handouts from MDs, pharmacists, CMs, counselors, teachers, etc. ~ CDC, NIMH, SAMHSA, N4A, NIDA ~ News Broadcast “Minutes” ~ Local magazine columns ~ Mobile Apps ~ Health Fairs ~ Church circulars ~ Libraries ~ T-Shirts ~ Peer facilitated education
~ Where else does your population frequent?
What Do People Need to Know ~ Basic health promotion behaviors and how to implement them ~ Basic health needs by developmental stage ~ Parenting and Self-Parenting Skills ~ Basic coping and distress tolerance skills ~ Basic math and reading skills to manage nutrition and medication ~ Time management skills ~ Communication and assertiveness skills including self-advocacy
What Do People Need to Know ~ How to identify and mitigate risk and enhance protective factors for development of mood disorders, addictive behaviors and stress-related health conditions including adverse childhood experiences ~ How to access accurate, understandable health-related information to identify wellness behaviors as well as symptoms of mental health, addictive or physical health problems (self-advocacy) ~ How to identify community based resources (support groups, housing, medical care, transportation, childcare, respite services, etc.) ~ Risks and effects of use of pornography, gambling, internet games, substances
Summary ~ Health literacy is imperative to empower people to take charge of their health and wellbeing. ~ As clinicians and case mangers we need to ensure clients understand their current condition, the causes and treatment options and use that information to make an informed choice about what to do next ~ In the spirit of beneficence, we can also advocate for preventative steps to enhance health literacy from birth.
Case Management Toolbox Podcast Sponsored in part by AllCEUs Continuing Education I’m your host, Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC Case Management CEUs are available for these podcasts at allceus.com/CaseManagement Case Management for Mental Health Best Practices Case Management Toolbox Podcast Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC AllCEUs Continuing Education Host: Counselor Toolbox & Case Management Toolbox Podcasts Objectives ~ Review what a Mental Health Case Manager does (or a counselor if the client does not qualify for case management services) ~ Identify common issues clients with mental health diagnoses have and ways to address them
What Does a MH Case Manager Do? ~ Serve as the single point of contact ~ Facilitate patient engagement ~ Screen patients for common mental health and substance abuse disorders and identify necessary services to aid in achieving their optimal level of recovery ~ Provide patient education about common mental health and substance abuse disorders and the available treatment options. ~ Provide education to clients and stakeholders about the utility/effectiveness of wrap-around services for goal attainment ~ Housing ~ Supplemental Nutrition Assistance ~ Transportation ~ Employment/Education ~ Financial counseling What Does a MH Case Manager Do? ~ Participate in regularly scheduled (usually weekly) caseload consultation with the team and communicate resulting service recommendations to the patient’s team. ~ Consultations focus on patients new to the caseload and those who are not improving as expected under the current treatment plan. ~ Regularly meet with key team members to determine which benchmarks they are most interested in and identify barriers to care ~ Track patient follow-up, clinical outcomes including treatment adherence, medication side effects, changes in clinical symptoms and effectiveness of treatment. ~ Document in-person and telephone encounters in the EHR and use the system to identify and re-engage patients.
What Does a MH Case Manager Do? ~ Document patient progress and service recommendations in EHR and other required systems to be shared with other treating providers. ~ Facilitate treatment plan changes for patients who are not improving as expected or who have reached maximal gains in consultation with the treatment team ~ Facilitate referrals for clinically indicated services within and outside of the organization(e.g., housing, vocational rehabilitation, legal assistance, substance abuse treatment, clubhouse/day treatment). ~ Follow up with client and referral services to ensure effective linkages. ~ Develop and complete relapse prevention plans with patients at admission and review those plans with those who have achieved their treatment goals and being discharged Common Issues ~ Medication Access ~ Medication Effectiveness ~ Medication Compliance (Physical and psychotropic) ~ Side effects ~ Forgetting ~ Counseling Access ~ Cost ~ Transportation
Common Issues ~ Counseling Effectiveness ~ Rapport ~ Approach ~ Support System ~ Education regarding how to help the individual ~ Respite care ~ Counseling to deal with grief or other issues ~ Child/respite care ~ Respite care for a child or adult with significant illness ~ Childcare so parent can attend counseling, seek employment ~ Parenting education or assistance (i.e. child with Autism or ADHD; parent with SUD and DCF plan)
Common Issues ~ Housing ~ Affordability ~ Safety ~ Nutrition ~ Affording ~ Shopping ~ Cooking ~ Activities of Daily Living ~ Paying bills (financial counseling or power of atty) ~ Hygiene Common Issues ~ Meaningful Engagement ~ Supported Employment ~ Paid employment for persons with developmental disabilities who, without long-term support, are unlikely to succeed in a regular job. ~ Supported employment facilitates competitive work in integrated work settings for individuals with the most severe disabilities who need ongoing support services in order to perform their job. ~ Supported employment provides assistance such as job coaches, transportation, assistive technology, specialized job training, and individually tailored supervision. ~ Clubhouse or Day Treatment
Summary ~ People with severe and persistent mental illnesses benefit greatly from case management ~ Case managers pick up where counselors leave off and help identify needs and services and coordinate the referrals ~ Case management principles can be applied by counselors or nurses for patients whose level of severity does not qualify them for case management services. Additional Reading ~ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1262729/ ~ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690181/
Case Management and Counseling Ethics and Scope of Practice Case Management Toolbox Podcast Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC Executive Director: AllCEUs Continuing Education Host: Counselor Toolbox Podcast & Case Management Toolbox Podcast Objectives ~ Explain the scope of practice and code of ethics for case managers ~ Compare and contrast the code of ethics and scope of practice for case managers to that of Rehabilitation and Mental Health Counselors and Social Workers
Scope of Practice ~ CM ensure that the treatment team has provided education about the injury/disease/condition ~ CM provides information to the team and the client and family regarding available resources and benefits ~ Identify clinical, psychosocial, financial, operational and/or environmental issues which may need to be addressed to ensure quality care and reimbursement ~ CM will use assessment complimentary tools that identify risks associated with client needs ~ CM and client will develop a plan of care that matches the patients needs, preferences and available resources ~ CM will help sequence and organize the implementation of services to ensure efficient, effective care delivery Scope of Practice ~ CM documentation focuses on acquisition and utilization of resources as they pertain to reducing risk and enhancing treatment delivery. ~ Risks include ~ Early termination/sporadic participation ~ Ineffective treatment (i.e. for someone who is hearing impaired or has limited literacy) ~ Worsening of symptoms due to medication noncompliance ~ Additional complications due to difficulty with ADLs ~ Readmission
Scope of Practice ~ CM and Counselors will identify available community resources and advocate for the resolution of gaps in services and/or problems in process implementation ~ CM and Counselors ensure all elements of the transition plan are communicated to all stakeholders as appropriate. ~ CM and Counselors will track avoidable delays and identify and communicate opportunities for improvement ~ CM and Counselors will proactively prevent denials based on medical necessity by documenting relevant information and educating key stakeholders Ethical Principles of Counseling and CM ~ Beneficence ~ Act in the best interest of the client. Includes advocacy. ~ Nonmalfesance ~ Do no harm ~ Fidelity ~ Be faithful to your word ~ Justice ~ Ensure clients receive equal and fair treatment ~ Autonomy ~ Empower clients for success
Public Interest ~ Place the public interest above your own at all times (B, N, J) ~ False billing leads to higher insurance rates and loss of trust in the profession ~ Continuing to work while “burned out” or psychologically unavailable can harm clients and negatively impact perception of the profession ~ Report/address known misconduct ~ Make referrals when other providers are more appropriate due to case content or caseload ~ As a client advocate identify options and provide choices Respect Rights and Inherent Dignity ~ Respect Rights and Inherent Dignity of All Clients (B, N, J, A) ~ Do not make decisions for clients which they can make for themselves ~ Advocate for client empowerment and autonomy ~ Respect the cultural values and personal preferences of clients ~ Inform clients about confidentiality restrictions
Maintain Objectivity ~ Maintain Objectivity with Clients ~ Is able to clearly articulate reasoning behind recommendations ~ Avoids making referrals to “preferred” vendors ~ Respects their cultural values and perspectives ~ Does not impose their own values or perspectives ~ Is aware of and addresses any transference or countertransference issues ~ Regularly self-evaluates performance ~ Avoids any dual relationships Dual Relationships ~ Can exist between the case manager or counselor and ~ Client ~ Payor (insurance, state contract) ~ Employer (of the professional or client) ~ Friend/Relative (of the professional or client) ~ Other entities Act with Integrity and Fidelity ~ Act with Integrity and Fidelity with Clients and Stakeholders ~ Recognize and demonstrate joint accountability ~ Contributes to decision making ~ Do not promise things you cannot deliver ~ Do not bend the rules ~ Do what you say when you say you will do it ~ Comply with directives from the Ethics Committee ~ Do not accept or provide kickbacks or “gifts” for referrals ~ Ensure clients are provided a warm referral for all necessary services ~ Ensure clients are fully informed about the costs, benefits and risks of all services ~ Advertise services accurately ~ Complete documentation in an accurate and timely manner ~ Ensure all clients are providing informed consent Maintain Competency ~ Maintain Competency to Provide the Highest Level of Service ~ Take care of your own health and mental health ~ Seek additional training if working with a new population ~ Regularly seek out continuing education, collaboration and consultation to enhance your ability to provide effective services with your population ~ Maintain awareness of all changes in regulations including ADA, HIPAA, reimbursement (i.e. capitation and reimbursable services) ~ Maintain all case notes as required by regulations (i.e. HIPAA) and laws (i.e. 7 years) Honor the Integrity of the Certification/License ~ Honor the Integrity of the Certification/License ~ You represent the entire profession in your interactions with clients, stakeholders and the public. ~ Practice within your bounds of competence (even if that is more narrow than your legal scope of practice)
Obey All Laws and Regulations ~ Obey All Laws and Regulations ~ Americans with Disabilities Act ~ HIPAA ~ HITECH ~ Reimbursement ~ Scope of practice ~ Mandatory reporting ~ Good citizen laws
Provide Input to Review and Revise the Code ~ Provide Input to Review and Revise the Code ~ Ex. Adding a section for ethical considerations when providing virtual services ~ Ex. Advocating for the ability for people with substantial recovery from substance use who have a felony on their record to be able to provide services after a given period of time Values ~ Believe that case management (counseling) is a means for improving the health, wellness and autonomy of the individual through ~ Advocacy ~ Communication with the patient, family, stakeholders ~ Education of the patient, family, stakeholders and community ~ Identification of service resources ~ And facilitating remediation of gaps (ROSC) ~ Service facilitation (CM) Values ~ Recognize the dignity and worth of all people and strive to help them be the best version of themselves that they can be (as they define it) ~ Socioeconomic status ~ Health conditions ~ Mental health conditions (cognitive and emotional) ~ Culture ~ Religion ~ Race ~ Sexual orientation ~ Sexual/relationship preferences ~ Appearance
Values ~ Commit to quality outcomes, appropriate use of resources and empowerment of the individual ~ Evidence based practices ~ Do not over-refer or change diagnostic codes to enhance billable hours ~ Use scaffolding to assist clients in achieving outcomes Values ~ Embrace the premise that when individuals reach the optimum level of functioning the client, stakeholders (healthcare delivery and insurance reimbursement systems) and the community all benefit ~ Financially ~ Occupationally ~ Interpersonally ~ Legally
Summary ~ Both counselors and case managers are bound by the principles of beneficence, nonmalfeasance, autonomy, justice and fidelity. ~ Whereas counselors focus on the diagnosis and treatment of mental health issues, case managers assess client needs and facilitate access to services and resources necessary to achieve the highest quality of life (as defined by the client)