Redefining Case Management
I might only spend 15 minutes with the doctor every 3 months, but my case
manager calls me in between to see how I’m doing, remind me of doctor’s
appointments, and to see if I need anything. We have a relationship.
—An HIV-positive consumer, Nashville, TN
Every day, the interaction between client and case manager affects whether
an individual or family accesses and remains in primary medical care. Indeed,
the relationship mentioned in the quotation above from the Nashville consumer
exists between people living with HIV/AIDS and case managers in community-based
agencies, clinics, hospitals, homes, correctional facilities, and even parking
lots all across the country.
Did You Know?
- Medical case management is considered a core medical service.
- In 2006, the Ryan White HIV/AIDS Program spent approximately $135
million on case management.1
|
|
HIV case managers go to great lengths to assess client needs and design individualized
client-centered service plans to mitigate crisis situations and stabilize individuals
and families in the HIV care system. Case management activities occur in a
variety of settings. They are conducted by dedicated professionals with nursing
degrees, masters in social work and, in some cases, no degree but the knowledge
only life experience can bring.
Case managers are an essential part of the Ryan White HIV/AIDS Program service
delivery system, yet many are reexamining their roles and functions in light
of recent changes in the legislation, which encourage Part A and B grantees
to review their case management system and to make adjustments.
Some communities have used the legislative change as an opportunity to collaborate
across Ryan White programs to develop standards for medical case management.
Others are considering the changes necessary to shift from a psychosocial to
a medical model of case management. And others are increasing funding for medical
case management as a core service and increasing the number and availability
of medical managers.
The programs discussed in this article are considering ways to strengthen and
enhance services for people most in need and to foster better life sustaining
relationships between medical providers and patients.
top
Why Now?
In December 2006, the Ryan White HIV/AIDS Treatment Modernization Act changed
to include medical case management as a core service and allow other models
of case management to be funded under support services. Parts A and B of the
Treatment Modernization Act require at least 75 percent of funding available
for services to be spent on core medical services, leaving a maximum of 25
percent for support services.2
According to the FY 2006 Allocations Reports submitted by Part B programs,
case management services nationwide constitute 33 percent of State Direct and
Consortia Services. For that same year, Part A Programs submitted Planned Allocations
Tables indicating that case management services were expected to total approximately
$83.5 million. These reports were submitted before the change in the legislation
and may not capture some types of medical case management previously considered
part of ambulatory outpatient medical care. Also, treatment adherence services,
now considered part of medical case management, were reported separately in
2006. In the 2008 program and fiscal reports, it is expected that a higher
percentage of dollars will be reported under the medical case management category.1
The current service definition from the HIV/AIDS Bureau (HAB) defines the critical
services included in medical case management and the competencies needed by
medical case managers (see box below). It does not specify or require a terminal
degree. The definition takes into account the variety of case management models,
settings, and difficult system changes that could occur with a more stringent
definition.
|
HAB DEFINES MEDICAL CASE MANAGEMENT as
a range of client-centered services that link clients with health care,
psychosocial, and other services. Coordination and follow-up of medical
treatments are components of medical case management. Services ensure
timely, coordinated access to medically appropriate levels of health
and support services and continuity of care through ongoing assessment
of clients’ and
key family members’ needs and personal support systems. Medical
case management includes treatment adherence counseling to ensure readiness
for and adherence to complex HIV/AIDS regimens. Key activities include
(1) initial assessment of service needs; (2) development of a comprehensive,
individualized service plan; (3) coordination of services required
to implement the plan; (4) client monitoring to assess the efficacy
of the plan; and (5) periodic reevaluation and adaptation of the plan
as necessary over the life of the client. It includes all types of
case management, including face-to-face meetings, phone contact, and
any other forms of communication.
NONMEDICAL CASE MANAGEMENT includes advice
and assistance in obtaining medical, social, community, legal, financial,
and other needed services. Nonmedical case management does not involve
coordination and follow-up of medical treatments, as medical case management
does.
|
Yet, the change is much more than a new name for a set of service activities.
To qualify as medical case management, activities must be tied to providing,
facilitating, and keeping a client in primary medical care. The requirements
include ensuring that medical case managers are part of clinical care teams
to help clients navigate medical care. They also include a comprehensive clinical
assessment of need that is reassessed and reevaluated periodically. The medical
case manager need not be located in the primary care facility, but he or she
must work closely and directly with the primary care provider.
Failure to address this paradigm shift could result in case management activities
that are impermissible under core medical services, thus jeopardizing the ability
of providers to meet the requirement that 75 percent of service dollars be
allocated to core medical services.
Through the use of future evaluation projects, HAB will work to further define
core competencies and identify measures to assess the quality of Ryan White
case management services.
top
Collaboration Across Programs
Connecticut and Medical Case Management
HIV case management in the State of Connecticut is funded by Ryan White HIV/AIDS
Program Parts A–D. During FY 2007, 39 agencies received more than $4
million in Ryan White HIV/AIDS Program funding to provide case management
services.3 Last summer, the Part B program took the lead in convening representatives
from Parts A–D to discuss the creation of statewide medical case management
standards. With the assistance of a facilitator, the group began discussing
current models of case management and the needs of different geographical
areas across the State to obtain a statewide perspective on the issue.
At the time of the first meeting, the Part B provider had not made final funding
decisions for the year. The Part B program had had internal discussions about
medical case management centered on the need to create efficiencies in the
model(s) of case management, the possible use of an acuity scale to assess
need, data collection, and the creation of performance indicators. Connecticut
had begun a series of training meetings for case managers entitled “Introduction
to Medical Case Management.” The goal was to familiarize case managers
with the new medical model.
Connecticut has two transitional grant areas (TGAs): Hartford and New Haven.
(TGAs are cities with a total population of at least 50,000 and between 1,000
and 1,999 reported AIDS cases in the past 5 years.)2 The State includes several
urban, suburban, and rural areas.
HIV service delivery is always challenging in rural areas. Stigma, transportation,
and a lack of services are just a few of the major barriers affecting access
and retention in care services. To address the need for primary medical care,
a significant portion of the medical care in Connecticut’s rural areas
is provided by private physicians. The State also has a large network of community-based
case managers in rural and urban areas; many of them already perform some,
if not all, service components of medical case management. Ryan White HIV/AIDS
Program providers across the State often receive funding from more than one
Ryan White Program component.
Part A Programs
Part A TGA programs in New Haven and Hartford had already developed service
definitions, which were approved by their respective Planning Councils when
this collaboration first began. Both Part A programs acknowledged that service
definitions were only a small part of the work ahead; other tasks included
the development of standards, the need for training among providers and clients,
and discussions of the need to create or enhance linkages of medical case
management to other service categories. They welcomed the opportunity to
work with others in completing this task and made the group aware of the
role of the Planning Councils and other timeframes and deadlines specific
to their local city procurement and quality management processes.
Part C Providers
Several Part C providers discussed their work and the role of medical case
managers in their programs. Because of the focus on primary care for the
Part C program and its origins in the Bureau of Primary Health Care, medical
case management is the predominant model of case management. The processes
and procedures, forms, standards, and best practices were already in place,
as was the requirement to spend at least 75 percent of funding on core medical
services in place. The Part C representatives agreed to share their knowledge
and expertise in the effort to create statewide standards.
Part D Programs
Part D programs are structured on a family-centered model that allows providers
to work with the affected family member. Medical case management for these
programs involves partnerships between case management service providers
and nursing or clinical coordination. Some of these partnerships involve
other Ryan White-funded clinics. The close connection between case management
and clinical care is integral to Part D programs and has also allowed them
to develop and track clinical indicators for their patients. The Part D programs,
too, offered to share their experience and knowledge with the working group.
Process and Results in Connecticut
Over the course of several meetings, the group agreed on a uniform definition
of medical case management that contained all the critical activities as
defined by HAB. The collaborative working group developed a set of core standards
of care, with indicators and outcomes reflecting the minimum expectations
for the delivery of medical case management in Connecticut for all Parts.
Core standards are applicable in both community and clinic-based case management
programs. Each Part was given the option of adding to (but not deleting from)
the core standards to meet the needs of its service populations. The standards
will also go through an approval process by the Part A planning bodies. The
group agreed to reconvene in 6 months to discuss successes and challenges
and make adjustments to the core set of standards as needed at that time.
Lessons Learned
Having an outside facilitator help explain HAB’s expectations provided
everyone with an opportunity to hear the same message regarding the issue of
medical case management and thereby helped unify the group around a common
understanding. This approach enabled the group to begin its tasks with clear
direction and purpose. The process also enabled participants to share their
expectations and then come to a consensus on a set of medical case management
standards and outcomes that could be used statewide and adapted to the specific
needs of each Part and geographic area.
The expertise of the Part C and D grantees helped enrich the process and may
have enabled the group to complete its tasks in less time than expected. These
programs brought important working knowledge of existing medical case management
practices and assessment tools to the meetings. The “real-life” perspective
focused discussions as the group brainstormed on what to include as part of
the core standards.
|
The close connection between case management
and clinical care is integral to Part D programs. |
The assistance of staff and program support was invaluable to the group in
compiling and analyzing data from the programs; geomapping case management
services; and tracking changes and updates as the group moved through the process
of revising draft standards, outcomes, and indicators. The work group always
remained client centered in its approach and gave careful consideration to
specific actions that might affect clients if those actions were included as
standards.
With the development of new medical case management standards, the State Department
of Public Health has developed and initiated several trainings to increase
the core competencies of current case managers to provide medical case management
services. These trainings (which include a component on the new standards of
care) are now part of a mandatory comprehensive training curriculum for all
new Part B medical case managers. The plan is to provide training for all medical
case managers funded by Part B. Those funded by Ryan White Parts A, C, and
D are invited to attend.
Workgroup discussions have included approaching the AIDS Education and Training
Centers regarding some of the training needs. The Part A Planning Councils
in New Haven and Hartford have acknowledged that this paradigm shift requires
education and training for their current case managers and clinicians who may
not be accustomed to working with consumers in this manner. The work group
also acknowledged that consumers need training on how to use medical case managers
effectively. Many consumers may have to adjust their assumptions or let go
of past experience with case managers with the change to a chronic disease
management model.
top
Medical Case Management and the Continuum of Care in Nashville
The Nashville TGA program recently completed its first year of operations.
During FY 2007, everything—including hiring staff, forming a Planning
Council, developing contracts, and learning the Ryan White HIV/AIDS Program
and legislation—had to happen quickly. In April of this year, the grantee
hosted a 1-day medical case management meeting to help providers of case management
services understand the new definition and discuss the key activities now included
in the definition of medical case management. The grantee wanted to create
a welcoming environment where providers felt free to raise issues and concerns
to foster an honest discussion of case management services.
Process and Results
A facilitator helped manage the meeting and move the discussion forward. The
meeting was not held at a service agency, nor was it held at the grantee’s
office. A conference room at a city-owned golf course was the selected venue.
Taking participants out of their offices helped them focus more on the topics
for discussion. It was also important that providers not feel that they were
being summoned to the grantee’s office to be reprimanded. Judi Grimes,
the clinical quality manager for the Nashville TGA, said, “I think
the neutral territory changed the climate, and then the timbre of the conversation
became more acceptable for everyone.”
In addition, the meeting opened with a panel of three Nashville consumers,
who talked about their case managers, medical services, and the activities
their case managers perform to help keep them in care. They presented their
impressions of case management and reminded the meeting participants of the
important role these services play in the lives of clients.
The session clarified the difference between medical and nonmedical case management.
Information on HAB’s intent and expectations regarding medical case management
was also shared with all participants.
There was positive interaction between the providers and a discussion of tasks
that could be done to move community- and clinic-based case managers in the
direction of HAB’s definition. Several good models currently exist in
the TGA, and future meetings will focus on the ability to replicate key components
at other agencies.
|
Consumers need training on how to use medical
case managers effectively. Many consumers may have to let go of their
past experiences with case managers with the change to a chronic disease
management model. |
The clinical quality manager shared a process for developing standards of care.
In addition, she discussed the need for providers to assist the Planning Council
with the development of standards as the grantee moves forward to define minimum
expectations for the delivery of all Ryan White HIV/AIDS Program Part A services.
The need to continue meeting and working through some of the issues of medical
case management, including models for clinic- and non-clinic-based case managers,
was clear. How medical case management should coordinate with other HIV and
non-HIV services still needs to be decided. Nashville is using the new service
definition as a catalyst to examine several of its HIV services by asking questions
and collaboratively developing the answers.
Lessons Learned
The session answered many questions, but Pam Sylakowski, Part A program director
for the City of Nashville, says, “This is the beginning of a conversation
regarding our continuum of care. The session raised many questions we have
yet to explore—not only defining and understanding medical case management
but how it will coordinate with early intervention services and primary care
to create a seamless system.”
Sylakowski adds, “The answers to many of the questions are obtainable,
but only if we create the opportunities and the time to continue asking key
questions in order to distinguish the similarities and differences between
each of our providers of medical case management. The answers to the questions
may also be affected by the different populations each of the agencies serves
and whether the setting is urban, suburban, or rural.”
Coordination and linkage with other services is an important activity of medical
case management, but the need and level of coordination and linkage may vary
according to the populations served by each agency and locale.
Participants agreed that having everyone together at the meeting, including
consumers, nurses, case managers, the Part B grantee, and Planning Council
members, helped foster greater appreciation for each other’s role.
top
Part A and Part C Medical Case Management in Indianapolis
In the Indianapolis 2002-2005 needs assessment, 20 percent of respondents
indicated that case management, including medical case management, was the
single service most necessary to ensuring good health. The need for case management
services ranked just slightly lower than dental services in the same series
of needs assessments. Two different Indianapolis hospitals historically provided
medical case management in their clinics.
Part A funds will expand the current Part C medical case management model to
other area clinics that only have had psychosocial case managers. The new medical
case managers will work to decrease system fragmentation and the number of
patients lost to care. One of the new medical case management positions will
focus on the Hispanic population and will include a medical interpreter as
part of the clinical care team to work with newly diagnosed Spanish-speaking
clients.
Helen Rominger works as a nurse practitioner at the Wishard Memorial Hospital
infectious disease clinic, which receives Ryan White HIV/AIDS Program funding
under Parts A, B, and C. “I welcome any effort to better assist clients
and am surprised to learn that my work is defined as medical case management,” she
says.
Until recent conversations with the Part A program director, Rominger thought
medical case managers were social workers with specific clinical skills. She
is the nurse who facilitates clinical issues. At Wishard, Rominger is part
of a multidisciplinary care team that includes dentists and mental health professionals.
Social workers, or care coordinators, are also part of the team. The care coordinators
handle enrollment for third-party payment programs, such as Medicaid and Medicare.
They also facilitate referrals for external services outside the Wishard Care
system.
Sometimes, care coordinators identify medical issues for the nurses or medical
case managers. Rominger does not seem to be worried about service category
definitions or funding streams: “My job and my role [are] to facilitate
things for the patient, particularly those things which are clinically related
or affect their health. It might include prescription refills, disability paperwork,
assessing the need for specialty care, handling acute health issues, or just
calling and following up after a doctor’s visit.”
Lessons Learned
Training psychosocial case managers is critical to increase the number of people
who can provide quality medical case management services. An assessment of
the current skill sets is a good starting point.
Rominger also mentions that “many nurses and clinical providers will
need training [because] they understand their roles and what they do but may
not have considered them in terms of medical case management.”
Case management continues to be an essential service that enables individuals
and families to receive care. The change in the legislation emphasizes that
medical case management should be used as an opportunity to examine this vital
service. Many grantees are already engaged in efforts to comply with HAB service
definitions and to ensure that medical case management—like all Ryan
White HIV/AIDS Program services—extends and enhances life for those most
in need.
top
- U.S. Department of Health and Human Services. Health Resources
and Services Administration, 2006 CARE Spending, FY 2006. [Unpublished
data].
- Ryan White HIV/AIDS Treatment Modernization Act of 2006. Public
Law No. 109-415. December 19, 2006. Accessed June 3, 2008. Download PDF (164KB)
- State
of Connecticut. Part B 2007 program document on case management
services.
2007. [Unpublished data].
|
top
|