Behavioral Health Case Management



Behavioral Health Case Management


Mary Rosedale

Becky Bigio





LEARNING OBJECTIVES

Upon completion of this chapter, the reader will be able to:



  • Define behavioral health case management.


  • Discuss the history of behavioral health case management.


  • Compare and contrast different behavioral health case management models.


  • Discuss the diagnosis and treatment of clients commonly referred to case management.


  • Identify and explore challenges in behavioral health case management practice.


  • Discuss behavioral health treatment settings and their impact on the role of the case manager.


  • Identify necessary resources for effective performance of case managers in the behavioral health service settings.



IMPORTANT TERMS AND CONCEPTS



  • Adverse Consequences


  • Assertive Community Treatment (ACT) Model


  • Behavioral Health Care


  • Behavioral Health Case Management


  • Behavioral Health Home Care


  • Brokerage Model



  • Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSM-IV-TR)


  • Extended Brokerage Model


  • Self-Neglect


  • Severe and Persistent Mental Illness (SPMI)


  • Strengths Model


  • Substance Abuse


  • Substance Dependence


▪ INTRODUCTION

A. Behavioral health case management is a strategy for the delivery of health care services to all persons with behavioral health disorders, but particularly to high-cost, high-volume and high-risk populations (Gage, 2002; Herrick and Bartlett, 2004).

B. Behavioral health case management is an essential strategy for producing positive outcomes related to hospitalization, quality of life, social functioning, and decreased health care costs (Rosen and Teeson, 2001; Taylor et al., 2005).

C. Case management is especially important in an environment of brief inpatient psychiatric hospitalizations, limited access to care, fragmentation, and haphazard delivery of community-based behavioral health services.

D. Recognizing that persons who have multiple episodes of psychiatric admissions to the hospital account for the major cost of care, some behavioral health insurance plans have shown that 5% of members account for 50% of costs, and 20% of members account for almost 80% of behavioral health costs (Lave and Peele, 2000; Taylor et al., 2005).

E. High-volume users of behavioral health care and services are sometimes referred to as persons with severe and persistent mental/psychiatric illness.

F. In the 1950s when it became evident that some World War II veterans experienced symptoms of psychiatric illnesses following their return to the United States, the Veterans’ Administration initiated a model for psychiatric case management.



  • This model aimed to meet the needs for mental and physical health care services as well as for social services (Herrick and Bartlett, 2004).


  • The concept of the “continuum of care” emerged and a focus on the delivery of client-centered, coordinated, comprehensive care took hold (Tahan, 1998).

G. In the 1960s a new worldview held promise that mental illness could be better treated in the community rather than in mental institutions and deinstitutionalization was initiated on a broad scale (Krainovich-Miller and Gannon-Rosedale, 1999). For many reasons however, the Community Mental Health Construction Act of 1963, amended in 1975, was not able to implement a model of care that met the needs of persons with severe and persistent mental illness.



  • Although the programs were designed with the concepts of primary, secondary, and tertiary prevention, in practice, they were pathology focused.



  • While the term prevention was used, the actual emphasis was largely monolithic, focusing on medication administration and compliance rather than on providing services that developed the strengths and skills needed for community-based living and reintegration (Krainovich-Miller and Gannon-Rosedale, 1999).

H. The majority of persons with a behavioral health condition, including those with severe and persistent mental illness, live at home with their significant others. Reengineering efforts, including shorter hospitalizations and other managed care initiatives to curtail the rise in health care costs, have contributed to the need for innovative and evidence-based models of case management (Krainovich-Miller and Gannon-Rosedale, 1999).

I. A comparison of expert views concerning intensive case management (ICM), a review of the literature, and meta-analysis investigating the effectiveness of clinical case management (CCM) reveal that case management approaches to care facilitate self-efficacy, reduce symptoms, and decrease total number of hospital days and drop out rates from treatment programs (Ziguras and Stuart, 2000; Rosen and Teeson, 2001; Atai-Otong, 2003).


▪ KEY DEFINITIONS

A. Adverse consequences—Conditions that may include failure to fulfill major role obligations, using substances despite obvious physical hazards (e.g., driving under the influence), legal problems resulting from substance use, or recurrent social or interpersonal problems (APA, 2000).

B. Behavioral health care—Evaluation and treatment of psychological and substance dependence/abuse disorders (National Committee for Quality Assurance, 1997).

C. Behavioral health case management—A method of providing cost-effective, quality care (cost, process, experience, and outcomes) by managing the holistic health concerns of clients (individuals, families and groups) who are in need of extensive services. It requires integrating, coordinating, and advocating for complex mental and physical health care services from a variety of health care providers and settings, within the framework of planned behavioral health outcomes (Farnsworth and Bigelow, 1997, p. 319).

D. Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSM-IV-TR)—Manual that describes the various psychiatric, psychological, and substance-related disorders categorically. The DMS-IV identifies diagnostic and associated features, differential diagnoses, and incidence and prevalence of disorders, and describes the course of illnesses. The DMS-IV codes and terms are compatible with International Classification of Diseases, 9th version (ICD-9-CM) and 10th version, (ICD-10-CM). This manual promotes a multi-axial system of diagnosis, which includes the clinical disorder that is the focus of treatment, associated personality disorders, general medical conditions, psychosocial and
environmental problems, and a global assessment of functioning (GAF) for each patient (APA, 2000).

E. Self-neglect—The result of an adult’s inability to perform essential self-care tasks due to physical and/or mental impairments or diminished capacity. The tasks may include providing essential food, clothing, shelter, and health care; obtaining goods and services necessary to maintain physical health, mental health, emotional well-being and general safety; and/or managing financial affairs and adhering to prescribed medications.

F. Severe and persistent mental illness (SPMI)—A diagnosis of nonorganic psychosis or personality disorder that is characterized as prolonged illness or requiring long-term treatment, and operationalized as a two-year or longer history of mental illness or treatment and disability including three of eight specified criteria (NIMH, 1987).

G. Substance abuse—A maladaptive pattern of substance (e.g., alcohol and narcotics) use manifested by recurrent and significant adverse consequences within a 12-month period (APA, 2000). The majority of these patients are diagnosed with schizophrenia or schizoaffective disorder.

H. Substance dependence—A cluster of physiologic, cognitive, and behavioral symptoms caused by repeated self-administration of substances, resulting in tolerance, withdrawal, and compulsive drug-taking behaviors (APA, 2000).


▪ BEHAVIORAL HEALTH CASE MANAGEMENT MODELS

A. A major problem with research, training, and clinical application of behavioral health case management is that even when models are specified, they frequently fail to delineate the critical behavioral elements of the interventions or treatments they employ.



  • It is often unclear what interventions or set of interventions are being compared, whether these behavioral elements are standardized, and how results should be attributed (Chan et al., 2000; Rosen and Teeson, 2001).

B. The following typology illustrates the defining attributes of different behavioral health case management models as well as the overlap and ambiguity.

C. The brokerage model



  • Entails an individually assigned case manager who assumes case management functions of coordinating care among all involved parties.


  • The case manager may or may not be a mental health professional.


  • Some literature suggests that targeted telephonic case management can improve client outcomes (Taylor et al., 2005).


  • This model has been criticized as a “passive-response” form of case management that involves few interventions other than monitoring and maintaining contact with the client.


  • There is little evidence-based support for its efficacy (Chan et al., 2000; Rosen and Teeson, 2001).


D. The extended brokerage model



  • Leadership is assumed by mental health professionals who are more actively involved in the patient’s assessment and assume some additional direct care responsibilities (Chan et al., 2000).


  • Designed to provide services for persons with SPMI, a psychiatrist often provides clinical leadership for the interdisciplinary treatment team (ITT).


  • Case managers have varied experience (e.g., some are psychiatric nurses, others are social workers).


  • The efficacy of this model has been difficult to evaluate due to lack of standardization (i.e., the heterogeneity of members and interventions in clinical case management and intensive case management programs).


  • Functions of case managers include:



    • Advocacy


    • Transportation of consumers to and from treatment sites


    • Symptom and medication monitoring


    • Assessment and teaching of skills for community living


    • Initiating and coordinating referrals and benefits/entitlements

E. The strengths model



  • Differs from the brokerage model in that most services are provided outside an office setting.


  • Training of staff in this model is provided and reflects the broad areas of engagement, strengths assessment, personal planning, and resource acquisition (Marty, Rapp, and Carlson, 2001).



    • The behavioral elements of engagement include:



      • Identifying achievements, interests, and aspirations of the client


      • Meeting at times and in places that reflect client preference


      • Purposeful use of case manager’s self-disclosure


    • Strengths assessment is prioritizing the client’s past and present achievements, resources, and future interests versus problematic behavior and crisis response.


    • Personal planning focuses on the specific, measurable steps toward achieving what the client wants and reflects consumer strengths.


    • Resource acquisition requires designing activities with the client that increase consumer contact with desired community resources and entitlements.


  • Although a survey of experts in the strengths model of case management concluded that ideal caseloads range from 10 to 20 consumers to case managers (Marty, Rapp, and Carlson, 2001), it is not clear that this ideal is reflected in actual practice.


  • Research on the strengths model has shown consistently positive outcomes related to hospitalization, quality of life, and social functioning, but the strength of the evidence is limited by sampling and methodological problems.


F. The assertive community treatment (ACT) model



  • The most clearly articulated model; is recognized as an evidence-based practice with more than 25 randomized-controlled trials supporting the following outcomes: it reduces hospital use, increases housing stability, controls psychiatric symptoms, improves quality of life, and is cost effective (Bond et al., 2001; Ziguras and Stuart, 2000; Rosen and Teeson, 2001; Schaedle et al., 2002).


  • Key elements of the ACT model include:



    • Team-delivered services


    • Shared caseloads


    • An average of 10 consumers to a case manager


    • Provision of direct services in the community rather than mostly office-based services


    • Employing brokerage functions


    • Mobility


    • Seven-day operation


    • Capability of responding to crises of all consumers


    • Having a policy to not close cases


    • A controlled rate of admitting new clients


    • Professionally skilled multidisciplinary staff competent in providing psychosocial and pharmacological interventions


    • Provision of services to a highly and continuously disabled subpopulation of psychiatric service users (i.e., those with SPMI)


    • Supervision and ongoing training


    • Team support and debriefing

G. Other models



  • Include the generalist model (Franklin et al., 1987) and the rehabilitation model (Goering et al., 1988, Antai-Otong, 2003). These are case management models that theoretically differ from the others and lack specification of and standardization of practice.


  • For example, Atai-Otong’s psychosocial rehabilitation model is described as using psychiatric nurses with an intensive case management approach; however, this description is consistent with the extended broker model.


  • Cox et al. (2003) describe an intensive case management model that, like ACT, uses a multidisciplinary team approach; but, unlike ACT, provides services onsite in a medical center rather than in the community.


  • Disease management models focus on populations both within hospitals and in the community setting (Herrick and Bartlett, 2004).


  • Research concerning each of these models has suffered from lack of clear definitions of the providers, services, and set of interventions distinct to each model (Chan et al., 2000).



▪ BEHAVIORAL HEALTH CARE CONDITIONS AND THEIR IMPLICATIONS FOR CASE MANAGEMENT

A. According to the American Psychiatric Nurse’s Association (APNA) (2000), global projections of mental illness and worldwide increases in the aging population will contribute to a sizable increase in the elder component of society as well as the incidence of chronic illnesses and disability.

B. Behavioral health disorders are projected to account for 11% to 15% of the global disease burden in this century (APNA, 2000).

C. Persons with SPMI frequently have alcohol-related problems as well as physical health problems that require treatment (APNA, 2000).

D. The presence of a psychiatric or substance-related disorder may complicate the diagnosis and/or treatment of general medical conditions.

E. The World Health Organization (WHO) has listed depression, alcohol use, bipolar disorder, schizophrenia, and obsessive-compulsive disorder among the ten leading causes of disability worldwide (APNA, 2000).

F. There exists a growing need for evidence-based behavioral health case management models and interventions.

G. Definitions of the psychiatric disorders cited below are based on criteria from the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSM-IV-TR) (APA, 2000).



  • Major depressive disorder



    • Persons with this condition display a depressed mood or loss of interest or pleasure in almost all activities for at least 2 weeks.


    • Additional symptoms such as weight changes, changes in sleeping patterns, changes in psychomotor activity, persistent feelings of guilt or worthlessness, difficulty concentrating or thinking, impairment of social or occupational role expectations, or suicidal ideation may also be present.


    • The depressed patient may present for evaluation or treatment following a suicide attempt, and all depressed clients should be considered “at risk” for suicide.


    • The major depressive patients are diagnosed by a careful interview, including personal and family history.


    • Alcohol or other substance abuse can mask symptoms of this disorder. Clients may abuse substances in an attempt to “self-medicate” symptoms. A careful history of substance use including nicotine should be taken.


    • Major depressive disorder can last 6 months or longer if left untreated.


    • Once the diagnosis has been established, treatment consists primarily of a combination of antidepressant medications and cognitive behavioral therapy (Donohue et al., 2004).


    • Some clients with severe depression who are not responsive to antidepressant treatment may be acutely treated with electroconvulsive therapy (ECT) on an acute and outpatient basis.



    • Case management services for this patient population focuses on:



      • Suicide prevention


      • Supporting antidepressant therapy and monitoring for side effects


      • Psychotherapy and significant other(s) involvement and education. Some clients find the support and structure of group psychotherapy beneficial, especially if social dysfunction has occurred as a result of depression.


      • Education of family members about the illness, treatment, and signs of recurrence.


    • Case managers should not hesitate to ask patients if they are considering suicide or self-harm.



      • Patients may demonstrate increased suicide potential by giving away belongings, making a will, saying goodbye to loved ones, or hoarding medications.


      • Some patients act on suicidal ideation after initiating treatment for depression, when energy levels begin to improve.


    • Case managers should be vigilant about the suicide risk in these patients and be watchful of signs that a patient is considering suicide.


  • Alcohol-related disorders



    • Persons exhibiting alcohol abuse show a maladaptive pattern of alcohol use that results in one or more of the following in a 12-month period:



      • Failure to fulfill major role obligations at work, school, or home (e.g., repeated absences)


      • Recurrent alcohol use in situations where it is physically hazardous (e.g., driving a car)


      • Recurrent alcohol-related legal problems (e.g., arrests for disorderly conduct)


      • Continued alcohol use despite social or interpersonal problems caused by or worsened by alcohol use (e.g., arguments with spouse, physical fights) (APA, 2000)


    • Persons with alcohol dependence exhibit:



      • A physiologic dependence that is characterized by evidence of tolerance (needing more of the substance to produce a desired effect); and


      • Withdrawal when administration of the substance is discontinued (a syndrome that may include sweating, tachycardia, hand tremor, insomnia, nausea or vomiting, agitation, anxiety, hallucinations, or grand mal seizures).


    • Delirium tremens may be considered a more severe form of withdrawal and is considered to be a medical emergency.


    • Alcohol-related disorders are diagnosed by history, physical examination, and interview.


    • This condition can go undiagnosed if the patient continues to use alcohol and no withdrawal symptoms are observed.



    • Over time, patients with this disorder may be increasingly unable to fulfill occupational or social expectations, which may cause distress.


    • Treatment focuses primarily on alcohol abstinence and an Alcoholics Anonymous (AA) group therapy program (or an equivalent recovery program such as Rational Recovery).



      • Initially, to elicit their agreement, patients may be asked to contract not to drink for three months so that they can see what abstinence is like and how one’s life is affected.


      • Patients whose withdrawal symptoms are severe may need to be hospitalized and monitored by expert clinicians during initial alcohol detoxification.


    • Case managers support the treatment plan as well as provide encouragement to patients and their significant others (who may be referred to support groups such as AA).


    • Case managers should be alert to the fact that chronic alcohol dependence is associated with social deterioration, decreased tolerance, medical complications of every organ, including liver impairment, which may interfere with the elimination of medications the patient may be on, causing risk for drug toxicity.


  • Bipolar disorder

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Jul 14, 2016 | Posted by in PEDIATRICS | Comments Off on Behavioral Health Case Management

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