DM behavioral health case managers work together

Case managers sit together, share notes

A team of behavioral health case managers and disease management case managers work together to manage the care for members with chronic diseases and depression at Health Alliance Plan.

"We integrated our disease management and behavioral health programs a year ago and are beginning to see positive outcomes, including a reduction in multiple admissions to the hospital," says Mary Clare Solky, MA, LLP, director of behavioral medicine at the Detroit-based health plan.

"It is important to treat depression in chronically ill members because depressive symptoms can make it difficult for people to take care of their chronic diseases. We have had some very good outcomes when two case managers work jointly with a member who has a chronic disease and depression," she adds.

The case managers in the behavioral medicine and disease management programs work collaboratively and use software that enables them to share information. The team has formal meetings to discuss care plans for members in both programs and talks daily on an informal basis to discuss the care of members.

"Because the two departments work so closely together, we find a lot of opportunities for case management. A behavioral specialist may be on a call with someone who is depressed and learn that he has diabetes, then refer him to a nurse case manager," Solky says.

When someone enters the disease management program for a chronic medical illness such as asthma, diabetes, or congestive heart failure, a short depression screening is part of the initial case management assessment.

If someone screens positive for depression, the disease management case manager refers the member to a depression management case manager, either by scheduling an appointment or transferring the member directly to the behavioral medicine specialist if the nurse identifies that the member is in crisis.

The behavioral health case manager conducts a more indepth assessment, begins working with the member on an action plan and goals, and schedules a time for a follow-up call.

The case managers can talk to each other informally about the patient's condition and collaborate on treatment plans and the best way to intervene with the member. They use a software system that allows them to reach each other's notes so they are always aware of what is happening with the member.

The behavioral health team and disease management team hold case conferences every two weeks, or more often if needed, to discuss complicated cases. The teams also bring in difficult cases that they have successfully managed and talk about how they solved the problems.

"The case conferences are a learning opportunity for both sets of case managers and serve as a forum for crosstraining. The behavioral health specialists increase their knowledge of medical conditions, and the nurses enhance their skills for working with people on behavioral issues," Solky says.

The conferences also include an educational component, often reports from team members who have attended an educational conference or seminar.

"If someone on one of the teams attends a seminar on medication compliance, we'll look for a case where they can apply what they learned and discuss that at the case conference," Solky says.

The depression case management program is staffed by a team of 12 behavioral medicine specialists who are masters-prepared social workers or who have a master's degree in psychology.

In addition to the screening by case managers in the disease management program, HAP identifies members for its depression management program through self-referral by phone or HAP's web site, and through referrals from physicians who refer patients for extra followup and monitoring for compliance.

When a member is identified for the program, the behavioral medicine case manager makes an outreach call and conducts a detailed screening.

The case manager works one-on-one with the member to educate him or her about the condition and to develop an action plan for getting the depression under control, and sets an appointment for a followup call. With the member's permission, they notify the member's physician that he or she is in the program, along with information on treatment recommendations.

In some cases, the case managers may refer members to specialty care, such as a clinical therapist or a psychiatrist.

"The behavioral case managers spend a lot of time educating the members on the importance of staying on depression medications for at least six months to retain remission. People often feel better much sooner and need a lot of encouragement to stay on their medicine," Solky says.

The case managers explain how it sometimes takes several tries for patients to find an antidepressant medication that works for them.

"It's not always a straight shot. Many people do feel better with the first medication, but for some, it may take trying a second or even a third medication to feel significant improvement," Solky says.

The length of the program and the number of followup calls depends on the needs of the member. Some receive only one or two telephone calls.

Some members go into long-term depression management, particularly if they have a chronic medical condition that needs assistance over time.

Members are typically in the depression management program for three to six weeks.

If the member has mentioned a time that he or she feels particularly depressed, such as during the Christmas season or the anniversary of some significant event, the case manager sets up a reminder and calls the member during the difficult period.

If a member has missed filling a prescription for an antidepressant, the health plan's computer system triggers the case manager to make a reminder call.

"We usually know within a day or two if a member has missed filling a prescription," Solky says.

When the case managers call members who have failed to fill an antidepressant prescription, they educate them about the value of staying on the medication long enough for it to be effective and help them work with their physician to find a medication that works best for them.

"A lot of people go off the medication, either because it didn't fully eliminate their symptoms or they felt better and stopped taking it before they were on it long enough to sustain change," Solky says.

The case managers are assigned to patients depending on their primary care physicians. "Each case manager is linked to a group of primary care physicians and the specialists who work with them. The physicians and members like the consistency because they know that they will be working with the same case manager," Solky says.