Integrating medical, mental CM saves money

Models calls for collaboration among clinicians

In the past, if a member of Capital District Physicians' Health Plan (CDPHP) in Albany, NY, was hospitalized for a suicide attempt and ended up in the intensive care unit, or was hospitalized with a medical problem and diagnosed with a behavioral health issue as well, the medical case manager would give him or her a referral to a toll-free number for an out-of-state vendor that provided behavioral health management for the health plan.

In 2009, the physician-guided organization reviewed the process and determined that the clinical staff were not happy with that arrangement. "They felt that behavioral health issues were part of the whole medical picture," says Bob Holtz, MA, MBA, LMHC, vice president of behavioral health services for CDPHP. The board of directors of the physician-guided organization decided in 2009 to integrate medical and behavioral health care and not separate the two, Holtz says.

Now the CDPHP social worker assigned to the hospital collaborates on the discharge plan with the health plan's medical case manager, and the two collaborate on subsequent care if the patient needs follow up for a medical issue. If the patient needs only behavioral health management, only the social worker follows up. It took about a year to build a model that integrated behavioral health into the medical health structure and to recruit hospitals and clinics to participate in the behavioral health side of care, Holtz says.

"It's too soon for us to have firm statistics about the specific impact of the integrated case management program, but we know our overall program has been successful," Holtz says. In the first year of the program, the health plan saved $8.4 million off of what the vendor would have charged. In addition, the health plan experienced a drop in readmission rates for behavioral diagnoses from 12% in 2009 to 9% last year. "We can't say it's all because of the case management program, but we do know that case management is a contributing factor in reducing readmissions and the overall dollar amount we spend," he says.

The health plan's behavioral health staff includes a full-time psychiatrist, 15 social work case managers, a nurse, four bachelor's-prepared clinical assistants, and an operations manager. The social work case managers are clinical social workers with experience in a clinic or private practice performing psychotherapy. They work side-by-side with the medical case managers and can easily collaborate on a care plan.

"This model integrates care completely. When we have a case where patients have both a chronic disorder and a mental health disorder, we call that complex cases and work together. The social work case managers and the medical case manager have a meeting to collaborate on care and sometimes reach out to the member together," Holtz says.

When patients are hospitalized, CDPHP care coordinators go into the hospital, review the charts, and talk to doctors to identify comorbidities such as bipolar disorders, depression, anxiety, or substance abuse. They visit the patients in the hospital and work with the health plan case manager on a discharge plan.

Everyone who is being followed by the medical staff is screened for depression. In addition, in talking with patients, medical case managers may uncover behavioral health issues.

Other candidates for behavioral case management are identified through health risk assessments or referrals from a physician.

When members are identified for the behavioral health case management program, a case manager calls them and introduces the program. "The majority of patients are a little resistant," Holtz says. "The case managers are skilled in motivational interviewing geared toward engagement and focus on the importance of support as part of the recovery process whether the patient has a comorbid medical condition, a primary diagnosis of a behavioral health problem, or a substance abuse problem."

If people are still resistant, the case managers ask if the health plan can send out literature and call the member back. "The key is developing the relationship. We tell them that we'd like to engage them in case management because other members have found it helpful," he says.

The behavioral health case managers work with patients to establish goals and plans for meeting their goals. For instance, the goal for a patient with depression might be taking medication on a regular basis or attending a counseling session. The case managers encourage members to get involved in physical activities and try to establish some kind of support system for the patient, such as a relative who can support the patient through recovery.

"The plans are all unique to the individual," Holtz says.

The case managers work with individuals to remove barriers to adherence with both the medical and the behavioral health treatment plans. For instance, if patients can't afford the co-payment to see a therapist or have housing issues, the case manager refers them to community services. If the patient is struggling with drug abuse and lives in a neighborhood with a lot of drug use, the case manager would suggest that the patient find another place to live while he or she recovers, or if the problem is severe, would work to get the patient into a residential program.

"There are often barriers to getting the care they need, and we try to help them think through ways to overcome them," Holtz says. For instance, Medicare members have free transportation services to medical appointments but many don't know it. The case managers can help Medicare members identify volunteers, such as those at senior centers, who will drive patients to their doctors' appointments.

Sometimes the medical and behavioral health case managers collaborate in helping the patient overcome barriers to adherence to the plan.

In one instance, a patient with diabetes had an adult child who had a drinking problem. The woman was so preoccupied and worried about her son, who would drink heavily and call her in the middle of the night, that she forgot to take her pills. "She was having reactional depression to life's circumstances and was neglecting herself," Holtz says.

The medical case manager asked the behavioral case manager to join the next conversation with the member. The medical case manager introduced the behavioral case manager as her colleague who was working jointly on the case. The behavioral case manager discussed counseling options, including Al-Anon, the support group for family members of alcoholics. During the ongoing conversations, the behavioral health case manager arranged for the woman to have a therapy visit with an alcohol treatment program to consult about her son's problem.

"By following up on the patient together, the two case managers were able to engage the member, and the result was that the woman learned to cope with her day-to-day problems and improved her self-care for diabetes," he says.