System coordinates mental, physical sides of illness

Interventions depend on severity of both illnesses

When they manage the care for patients with clinical depression along with a chronic disease, case managers at CMS Healthcare Integrated coordinate care between physicians who are treating the medical condition and those treating the behavioral condition.

"We want to balance the scales in both directions and act as a conduit between the behavioral side and the medical side," says Sam Toney, MD, a board-certified psychiatrist and founder of the Tampa, FL-based company.

Patients are identified for the program through claims analysis, including ICD-9 codes, DMS-4 codes, and pharmacy claims.

The process tags patients with a chronic disease who are not diagnosed with depression but are being treated with an antidepressant.

Case managers who have behavioral health experience as well as medical management expertise conduct a comprehensive clinical assessment that includes past history, current medication, psychosocial support, and other medical and psychological factors.

The CMS software program guides the case managers as they do the assessment. Once the assessment is completed, patients are stratified into four levels based on the severity of their medical and behavioral problems.

Based on patient answers, the system recommends a frequency of contacts, goals, and milestones but allows the case manager to adjust them depending on his or her clinical judgment.

The level assigned dictates the strategy for managing the care. For instance, if a patient with diabetes has a comorbidity of depression, the stratification takes into account the severity of the depression as well as the diabetes.

"This guides us in terms of care strategy with case management and disease management. It’s the key to where the two interventions link up," Toney says.

Patients with Level 1 or Level 2 depression probably can be effectively treated by the primary care physician and not require psychotherapy.

CMs can empower physicians

The case managers work closely with the primary care physician and assist him or her in making the diagnosis of depression and following the treatment algorithms.

"The case manager can empower the primary care physician to use his or her skills and to write prescriptions that can help the patient get better," Toney explains.

Patients at Level 3 or Level 4 were probably already diagnosed as depressed.

"This may be where the primary care physician is struggling. We may recommend a transition to a specialist to determine whether or not psychotherapy should be part of the treatment plan," Toney says.

The care managers work with the family to help them understand the impact that being depressed can have on medical compliance.

They work with the various providers the patient is seeing, helping coordinate the care to deal with the whole person and the whole illness, including both the mental and physical health components. A key aim of the program is to promote a good relationship among treating providers, alerting them to what is happening with patients as they see various providers.

Physicians receive a monthly summary of patient activity as well as ongoing alerts of any problems the patient may have. Patients receive a newsletter, resource guide, and daily activity planner.

CMs monitor medication

Educational materials are geared to the individual and may include an overview of the disease; symptom recognition; medication information; how diet, exercise and other lifestyle issues can affect outcomes; and information on lifestyle issues such as weight reduction, smoking cessation, and relaxation; and how to manage special situations such as holidays and vacations.

The care managers design a specific care plan for each member, taking into account the patient’s history, problems with medication compliance, and other factors.

Members are monitored throughout their course of management to find out how well they are doing and how they are responding to treatment.

The case managers call the patients at regular intervals, at the patients’ convenience. Since the call center is open 24 hours a day, seven days a week, the case managers may call the patients in the evening or on weekends if that is the most convenient time.

Using proprietary computer software, the case managers monitor prescribed medication to make sure one doesn’t adversely affect the other and that patients are not taking psychotropic medication that may have an impact on their disease.

The program is designed to identify when a patient who is being managed for a chronic disease experiences depression. For instance, a member might tell the case manager, "I didn’t feel like eating today." That is a key for the case manager to conduct a five-question disease management depression assessment.

The Minnesota Quality of Life survey and the SF 36 Health Survey are among the outcomes measures used to track patient progress.

The company has a secure web site and operates a 24-hour-a-day call center at its Tampa headquarters. It is planning to open two additional call centers within the next 18 months.