Emerging Roles and Responsibilities of Medical Case Managers: A Workshop at the 20th Annual National Conference on Social Work and HIV/AIDS

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Emerging Roles and Responsibilities of Medical
Case Managers A Workshop at the 20th Annual
National Conference on Social Work and HIV/AIDS

• Julia Hidalgo, ScD, MSW, MPHPositive
  Outcomes, Inc. and
• George Washington University
• julia.hidalgo_at_positiveoutcomes.net
• www.positiveoutcomes.net

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This workshop is supported with funds from
Abbott Laboratories. The materials presented do
not necessarily represent the views of Abbott
Laboratories or other funders of Positive
Outcomes, Inc.
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Abbott- POI Medical Case Management Project A
Summary

• In response to the case management (CM) service
  categories defined in the Ryan White HIV/AIDS
  Treatment Modernization Act of 2006, Abbott
  Laboratories is supporting a year-long project to
• Conduct a national assessment of the training
  needs of HIV case managers in adopting medical CM
  techniques
• Identify and learn from HIV medical CM training
  efforts across the U.S.
• Develop and test HIV medical CM curriculum based
  on results of the training needs assessment
• Disseminate the curriculum for local training
  efforts
• Today is the assessments first activity

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Today we will

• Based on our earlier work throughout the U.S. and
  with the HIV/AIDS Bureau (HAB) provide an
  overview of
• The evolution of HIV CM in the U.S.
• The concepts underlying the medical CM service
  category in the Ryan White HIV/AIDS Treatment
  Modernization Act of 2006
• HABs current requirements regarding medical and
  non-medical CM
• Approaches used throughout the U.S. to adopt
  medical CM
• Engage in an informal discussion regarding your
  medical CM roles, responsibilities, and training
  needs
• Conduct a written mini-assessment
• Discuss the medical CM training needs of HIV case
  managers and CM supervisors in your communities,
  and the extent to which these needs are being
  addressed
• Get your feedback about meaningful ways the
  assessment can help you and your colleagues

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Quick History of HIV CM

• Late 1980s and Early 1990s
• Focus on newly introduced HIV testing and
  treatment (AZT)
• Support activities offer alternatives to
  inpatient stays
• A continuum of support services develops
• Volunteers continue to provide support services,
  with CBOs forming
• Populations impacted by HIV become diverse

• Early 1980s
• Focus on hospitalizations and end of life care
• Case managers coordinated care for terminally ill
  patients
• Case managers tend to be from other health care
  or social work systems and have a personal
  commitment to the AIDS epidemic
• Volunteers provide support services

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Quick History of HIV CM

• Mid to Late 1990s
• Focus on HIV voluntary testing, primary care, and
  combination therapy
• Understanding of the roles of medication
  adherence and drug resistance grows
• Number of clients increases steadily and
  diversity of the infected community expands
• CARE Act, Medicaid, and Medicare funds underwrite
  growing costs
• CM is professionalized
• Community-based care continuum grows, with growth
  in minority organizations
• Outreach and retention efforts grow

• The 2000s
• Focus on rapid HIV testing, HAART, and
  increasingly complex specialty care
• CARE Act funds flatten
• Number of clients grows
• They experience longer, more complex lives,
  outstripping service capacity
• Mental health and addictions treatment become
  important component of HIV care
• Case managers seek simplified models, borrow from
  other disciplines, assess outcomes
• Role of adherence and self-management is
  recognized
• Peers role in care continuum is acknowledged

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Quick History of HIV CM Today

• Ryan White HIV/AIDS Treatment Modernization Act
  of 2006 identifies two types of CM
• Medical CM (considered a core medical service)
• Unless a waiver is granted by HAB, Parts A, B,
  and C grantees must allocate at least 75 of
  their funds to core medical services
• Support CM in which referrals for health care and
  support services are made (considered a support
  service)
• Unless a waiver is granted by HAB, Parts A, B,
  and C grantees must allocate no more than 25 of
  their funds to non-core services

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Medical CM Concept is Based in Part on Disease
Management (DM) Approach

• The DM Association of America defines DM as a
  system of coordinated health care interventions
  and communications for populations with
  conditions in which patient self-care efforts are
  significant
• Supports the clinician-patient relationship and
  the care provided
• Emphasizes prevention of complications by using
  evidence-based practice guidelines and patient
  empowerment strategies
• Evaluates clinical, humanistic, and economic
  outcomes on an ongoing basis with the goal of
  improving overall health

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Disease Management (DM) Uses

• Population identification processes
• Evidence-based practice guidelines
• Collaborative practice models that include
  physician and support service providers
• Patient self-management education
• Includes primary prevention, behavior
  modification, and compliance monitoring
• Process and outcomes measurement, evaluation, and
  management
• Routine reporting/feedback loop
• Including communication with patient, physician,
  or practice profiling

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Medical CM Concept Also is Based on the Chronic
Care Model

• A population-based model that relies on knowing
  which patients have the illness, ensuring that
  they receive evidence-based care, and actively
  helping them to participate in their own care

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Chronic Care Model
Health System
Community
Health Care Organization
Resources and Policies
Practice Level
Self-Management Support
DeliverySystem Design
InformationSystems
Decision Support
Prepared, Proactive Practice Team
Informed, Activated Patient
Productive Interactions
Improved Outcomes
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What characterizes a informed, activated
patient?
Informed, Activated Patient

• The patient understands the disease process
• Realizes his/her role as the daily self-manager
• Family and caregivers are engaged in supporting
  the patients self-management
• The provider is viewed by the patient as a guide

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What characterizes a prepared practice team?
Prepared Practice Team
At the time of the visit, the team has the
patients information, data, staff, equipment,
and time required to deliver evidence-based
clinical management and self-management support
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Defining Medical CM
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HABs Medical CM Definition

• Medical CM services (including treatment
  adherence)
• A range of client-centered services that link
  clients with health care, psychosocial, and other
  services
• The coordination and follow-up of medical
  treatments
• Medical CM includes the provision of treatment
  adherence counseling to ensure readiness for, and
  adherence to, complex HIV/AIDS treatments
• These services ensure timely and coordinated
  access to medically appropriate levels of health
  and support services and continuity of care
• Through ongoing assessment of the clients and
  other key family members needs and personal
  support systems

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HABs Medical CM Definition (Continued)

• Key activities include
• Initial assessment of service needs
• Development of a comprehensive, individualized
  service plan
• Coordination of services required to implement
  the plan
• Client monitoring to assess the plans efficacy
  and
• Periodic re-evaluation and adaptation of the plan
  as necessary over the clients life
• Includes client-specific advocacy and/or review
  of utilization of services
• Includes all types of CM including face-to-face,
  phone contact, and any other forms of
  communication

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HABs Non-Medical CM Definition

• Provision of advice and assistance in obtaining
  medical, social, community, legal, financial, and
  other needed services
• Does not involve coordination and follow-up of
  medical treatments, as medical CM does

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HABs CM Treatment Adherence Definition

• HAB does not explicitly define treatment
  adherence responsibilities or roles for medical
  case managers
• Treatment adherence strategies used throughout
  the U.S. include
• Assess factors likely to contribute to poor
  adherence and develop individualized care plans
  to address those factors
• Medication, referral, and appointment adherence
  interventions
• Patient HIV education to expand health literacy
  
• HIV medication education, including side effects
  and their management
• Attending medical visits to assist patients to
  understand the information provided by medical
  provider
• Coordinate appointment scheduling to book
  multiple visits on the same day and arrange
  transportation to ensure the patient keeps
  appointments
• Home visiting and other methods of case finding
  for patients that have broken appointments or
  dropped out of care
• Assess and treat mental illness and/or substance
  abuse

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Other Treatment Adherence Activities

• Activities that clients perform to control their
  illness, prevent future complications, and cope
  with the impact of HIV and its treatment
• Collaborative goal setting
• Symptoms monitoring
• Lifestyle behaviors including healthy diet,
  getting regular exercise, and smoking cessation
• Taking medication in the dose and frequency
  prescribed
• Communicating and coordinating with the care
  team, family, and others
• Ongoing problem-solving to overcome potential
  barriers

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Operationalizing Medical CM by Ryan White
Program-Funded Agencies
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Approaches Taken to Address New CM Definitions

• Redefine all CM services provided by HIV clinics
  or other clinical settings to be medical CM
• No specific change to CM scope of practice or
  performance measures
• Redefine CM service provided by community-based
  organizations as medical CM if they are
  co-location with clinics or other strong linkages
  are demonstrated
• Partner RNs and social workers in medical CM
  teams
• Redefine the CM scope of practice, change
  training and credentialing requirements, and
  change performance measures
• Putting the burden on CM programs to reengineer
  their programs and carving out time for training

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Other Approaches Taken to Address New CM
Definitions

• Require that community-based CM programs link
  with HIV clinics to offer clinical CM services
• In turn, HIV clinics have hired case managers to
  expand their core medical services
• Eliminate community-based CM funding
• Employ only RNs to provide medical CM
• This model tends to predate the 2006 Ryan White
  Program reauthorization
• Some grantees and CM agencies would like to shift
  in this direction but cannot afford it or cannot
  identify nurses due to local nursing shortages

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What approaches to implementing medical CM have
been used by your agency?
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What challenges do you encounter in adopting the
medical CM model?
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In what ways can the Abbott-POI project help to
strengthen medical CM services in your
communities?
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What training topics would be helpful to you to
adopt in the medical CM curriculum?