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The Integrated Case Management Program: Essential for Today’s Case Manager

BY MARY MCLAUGHLIN-DAVIS, DNP, ACNS-BC, NEA-BC, CCM

I thought that most health professionals, and certainly case managers, were beyond segregating physical health, mental and behavioral health. However, I was mistaken. As recently as last week, I overheard a hospital case manager tell her manager she was not trained in mental health, and therefore she did not want to be assigned to a patient who had fallen at a group home and suffered from paranoid schizophrenia, diabetes and hemiparesis from a previous stroke. It was then that I realized that breaking the paradigm of a divided mental health and physical health case management approach had been a process for me — not one in line with all case management practices. I was fortunate to be immersed in the Case Management Society of America (CMSA) Integrated Case Management (ICM) Training Program, which hastened my own shift to the integrated case management paradigm.

The emerging Population Health Model focuses on managing the disease states present in a designated population. This model requires efficiencies and patient-centric quality outcomes in order to be successful. The Population Health Model, in any of its settings, will not demonstrate these outcomes without a solid case management program. Case managers in all settings, from workers’ compensation to acute care, must be trained in ICM. They must be confident in their ability to manage all aspects of a patient’s presenting diagnosis and comorbid conditions, and to manage them simultaneously. These aspects include the medical and cognitive/behavioral diagnosis with the social determinants of health.

The Population Health Model is similar to the established Public Health Model. The public health organization focuses on wellness and health maintenance, even though many of the clients are chronically ill. The public health professional counsels the family or inhabitants in the home and not just the patient. She understands that everyone is linked in important ways to one another and that what happens to one person in the family affects everyone in the family.

Public health, as a discipline, focuses on disease tracking and prevention; however, the focus of treatment is not necessarily the disease. The focus here is on the social and environmental elements affecting the disease, its origin, progression and cure for the individuals of the population served. Public health professionals have long understood the serious impact social determinants have on the health of an individual as well as a community or population.

The Medical Model, prevalent in acute and ambulatory care, focuses on the disease, and typically the disease is treated by a specialist for that disease. The treatment can occur simultaneously with other professionals treating other diseases for the same person, or the diseases are treated in sequence. However, the treatment is often provided in silos and with a minimal acknowledgement of the role that the social determinants, cognitive and behavioral health, and health literacy play in disease management.

The Medical Model cannot be sustained as healthcare costs in the United States continue to escalate, and as the underlying causes of diseases such as obesity, diabetes, heart disease and stroke and chronic obstructive lung disease are not thoroughly addressed. The Integrated and Population Health Care Models are essential because they link the social and medical problems, which allow for comprehensive patient-centric care plans and realistic outcomes (Valentijn, Schepman, Opheij, Bruijnzeels, 2013). Hence, the need for case managers working collaboratively with the interdisciplinary team within an Integrated Population Health Model.

Seventy percent of adults in the United States experience a traumatic event at some time in their lives. That is approximately 223.4 million people. In public behavioral health, at least 90 percent of individuals have experienced trauma. There is a direct correlation between trauma and chronic diseases such as hypertension, COPD, heart disease, cancer and diabetes (National Council for Community Behavioral Healthcare, 2013). In addition, drug overdoses are a leading cause of injury death in the United States, resulting in approximately 52,000 deaths in 2015 (Mack, Jones, Ballesteros, 2017).

An estimated 5 percent of the population uses 50 percent of healthcare resources. The 5 percent are patients presenting with comorbid medical and behavioral conditions. Until very recently, these patients received episodic care for the condition they presented to their practitioner. The presence of comorbidities between mental and medical conditions is more common than not. Greater than 80 percent of individuals with a mental health condition diagnosed by clinical interview also have at least one general medical condition, and 29 percent of individuals with a medical condition have mental health comorbidities (Goodell, Druss, Walker, 2011). The silo approach to treatment has resulted in higher healthcare costs and lack of quality in the care received. This fragmentation has also created an environment for duplication of services and medication errors (Perez, 2017).

Medically complex patients are among the most challenging for any healthcare worker. These are the patients assigned to a case management program or an individual case manager. However, if these medically complex patients also had a behavioral health diagnosis, chances are in the recent past they would have two separate case managers who often were not aware of each other, much less coordinating their individual care plans.

Case managers, in addition, to working with patients, families and systems holistically, also must work efficiently. They are experts in managing a care plan in the most cost-effective manner possible. Case managers also understand that quality must not be compromised for fiscal goals or incentives. This is a unique skill set and one based on the CMSA Standards of Practice for Case Management. The standards of assessment, identification and planning speak to the need for an integrated approach in developing a case management plan in collaboration with the patient or the patient’s caregiver. The CMSA Model Act describes the case management process to include physical/medical, behavioral/cognitive and social determinants in the assessment, intervention and evaluation phase of the process (CMSA, 2016; CMSA, 2017).

Healthcare reform policies implemented in recent years predicted and prioritized the necessity to improve quality and efficiency within healthcare systems. There are some healthcare systems and plans with impressive results. However, improved patient and fiscal outcomes have not been consistent across the country. Healthcare policies provide the template for better healthcare outcomes. “To truly improve quality and efficiency, those at the highest risk for poor quality outcomes and significant costs require a special focus. CMSA’s Integrated Case Management approach can be that specific focus” (Fraser, Perez, Latour, 2017). The CMSA ICM Program is a structured clinical path to guide the case manager in the integration of the patient’s goals with short- and long-term medical, behavioral and social goals. It is comprehensive in scope, allowing the case manager to collect patient information from the past history, current condition and level of risk if a case management intervention is not implemented.

Clearly, medical, social and behavioral conditions are integrated; therefore, it is critical that our case management practice is integrated and linked to both the past history as well as the future risk of the patients we serve. Integrated case management is essential to providing value-based care, and the Case Management Society of America provides a program to move case managers to integrated practice. Based on the Standards of Practice, the Integrated Case Management Program offered by CMSA provides a framework and training to successfully prepare case managers to take on this new role and function (Perez, 2017).   ■

Mary McLaughlin-Davis, DNP, NEA-BC, ACNS-BC, CCM

President, CMSA National Board 2016-2018

References

  • Case Management Society of America (CMSA). Case Management Model Act: Supporting Case Management Programs (2017). Little Rock, Arkansas.
  • Case Management Society of America (CMSA). Standards of Practice for Case Management (2016). Little Rock, Arkansas.
  • Goodell, S., Druss, B. G., Walker, E. R., & MAT, M. (2011). Mental disorders and medical comorbidity. The Synthesis Project. Robert Wood Johnson Foundation.
  • Fraser, K., Perez, R., & Latour, C. (2017). Integrated case management: A manual for case managers by case managers. New York. Springer.
  • Mack, K. A., Jones, C. M., & Ballesteros, M. F. (2017). Illicit Drug Use, Illicit Drug Use Disorders, and Drug Overdose Deaths in Metropolitan and Nonmetropolitan Areas—United States. American journal of transplantation, 17(12), 3241-3252.
  • National Council for Community Behavioral Healthcare. (2013). How to manage trauma. Retrieved from: https://www.thenationalcouncil.org/wp-content/uploads/2013/05/Trauma-infographic.pdf.
  • Perez, R. (2017). The CMSA Integrated Case Management Program. Rebecca Perez CMSA, Little Rock, Arkansas.
  • Valentijn, P. P., Schepman, S. M., Opheij, W., & Bruijnzeels, M. A. (2013). Understanding integrated care: a comprehensive conceptual framework based on the integrative functions of primary care. International journal of integrated care, 13.

Photo credit: Trompinex/Shutterstock.com

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