SW CMs free up RNs to assist members

Program takes care of clients' day-to-day needs

When people in financial hardship are worried about being evicted from their homes or don't know where their next meal is coming from, they aren't likely to remember to take their blood pressure medication or check their blood sugar levels on a daily basis.

That's why WellPoint started its community outreach initiatives, which include a social work care management program to help Medicaid beneficiaries get help with their day-to-day psychosocial needs.

"Because Medicaid beneficiaries face numerous challenges just to meet their everyday needs, our RN case managers were spending most of their time dealing with psychosocial issues like assisting with transportation to the doctor after a hospital visit, helping them access community resources, or getting them connected for mental health services, instead of working with clients on their medical health care needs, " says Joyce Adams, RN, CCM, MN, manager for case management for WellPoint's southern California region.

WellPoint's social work care management program received an honorable mention at URAC's Quality Summit and Awards Program.

The social workers help get the members connected to services to meet their psychosocial needs, freeing up the RN case managers to concentrate on helping members focus on their medical issues, she adds.

"Having social workers as part of the team brings a different professional expertise to the issues the members confront. When you support the Medicaid population, overcoming economic and social issues has to be tackled first before they can manage their health care," Adams says.

In a small pilot study, members who received interventions from social workers for just one month showed a 43% reduction in symptoms of depression, a 60% reduction in symptoms of anxiety, and a 40% improvement in knowing what resources are available in the community.

"This was just a small study to show the effectiveness of our social workers," Adams says.

The WellPoint social work case managers are master's-prepared licensed social workers who are fluent in English and Spanish and understand the Latino culture. One of the social workers is a naturalized U.S. citizen who was born in Mexico. The lead social worker has a doctorate in social work.

The social work case managers participate in daily virtual case rounds during which the interdisciplinary team reviews the members who are in the hospital and those with complex case management needs and collaborates on what services the members need. The medical director and the case management team also participate in the telephonic rounds.

In addition, the social workers alternate being "social worker of the day" to handle any urgent issues that arise. If there's a crisis situation, the social worker of the day contacts the client immediately.

"The social worker of the day typically handles one crisis situation every month or so when there are members who are threatening suicide or are decompensating from a behavioral health standpoint and need an immediate intervention," Adams says.

Routine referrals come to the social workers directly from the case management and medical management staff and through the daily multidisciplinary case rounds.

The social work case managers provide telephonic interventions and are regionally based so they know the resources that are available in the community.

When they are referred to the social work program, Medicaid members are assigned to a specific social worker in their region. The social worker makes an outreach call, performs an assessment, and evaluates the member's psychosocial needs.

If it's a referral from an RN case manager, many of the social issues already have been identified, and the social worker begins to work on them, Adams says.

The social worker uses the Short Form 12 (SF-12) quality-of-life assessment to get a baseline reading of the members' perception of their medical and psychosocial conditions as well as anxiety and depression scales, a substance abuse scale, and a scale that measures the client's skills in accessing community resources.

The social worker case manager collaborates with the RN case manager to address the member's medical and psychosocial needs, Adams says.

Interventions could be as simple as assisting the client in getting connected with assistance with utilities, a housing assistance program, or a food bank or they may be as complex as dealing with significant behavioral health issues, she says.

"We try to take care of their psychosocial needs as soon as possible so the client can concentrate on his or her medical needs. Because of the challenges this population faces, one of the last things they are worried about is their treatment plan. If they don't have a place to stay, they're not going to worry about taking their medication correctly or checking their blood sugar. It's very important to address the other barriers first," she says.

Transportation is a big issue with the Medicaid population who often miss appointments with their doctors because they have no way to get there.

In rural areas, there often is no public transportation and few social services, Adams points out. That's when the social workers have to use their ingenuity and partner with community-based resources to get the clients the services they need.

"One of our areas has a large homeless population. Getting clients linked from the hospital to a homeless shelter or another type of alternative housing is a big problem," she says.

The social worker-RN case manager team in southern California collaborated to develop a plan of care for a homeless man who had diabetes and significant mental health issues, Adams recalls.

"The social worker was able to get him a room at a center that specializes in homeless people with behavioral health issues and got him linked to mental health services. When that part was completed, the case manager linked him with a primary care provider so he could get better management for his diabetes and avoid being rehospitalized," she says.

When clients are in the hospital, the RN case managers and social worker case managers make outreach calls to them if they are well enough to talk on the telephone and collaborate with the hospital discharge planners to ensure that the members have a safe discharge to home.

The case managers make sure that the hospitalized Medicaid members have follow-up physician appointments, and the social workers make sure they have transportation and other post-acute services.

"We want to make sure clients don't come back to the hospital because they have a problem getting their medication or their durable medical equipment. We help them access assistance programs and make sure they have what they need to follow their treatment plan at home," Adams says.

As they work with their clients, the social workers try to schedule telephone calls at a time when the clients will be available and able to talk.

"If it's not a good time for the client to talk, a telephone call doesn't accomplish much," Adams says.

One challenge with Medicaid clients is to improve their engagement, Adams says.

On average, the engagement rate with clients who have identified needs for social work is about 50%. The team is working to develop better ways to reach out to the Medicaid members, she adds.

If social workers or RN case managers cannot reach members or have trouble engaging them in an intervention, they can call on WellPoint outreach program community resource coordinators, who are bilingual non-clinical staff who live in the communities they serve.

"If we can't reach a client because he or she has changed locations or no longer has a telephone, we give the community resource coordinator specific information about the member's last known address and they go to the home and talk to the members," she says.

The community resource coordinator explains the program and tells them why the social worker or RN case manager needs to reach them, gives them the social worker's phone number and asks them to call.

Since they live in the community and meet with the clients face-to-face, the community resource coordinators often have success in engaging the members who may not understand the program or who are reluctant to talk to someone they don't know.

"There's a lot of distrust among this client population. If they don't know who's calling, they might not answer. Sometimes they mistake the health plan social worker for someone from a county agency or child protective services. Often they are fearful that they will lose their Medicaid benefits and they are anxious when they receive a call from a case manager or social worker. The community resource coordinators develop a rapport with the clients and help us overcome this obstacle to providing care," she adds.