Integrated CM cuts ED visits, hospitalization
Integrated CM cuts ED visits, hospitalization
Medicaid members assessed for behavioral issues
Since Fallon Community Health Plan in Worcester, MA, began integrating medical case management and mental health case management, members in the health plan's Medicaid HMO with medical issues have experienced fewer inpatient days and emergency department visits and those in behavioral health have less need for unplanned medical care, says Dena Miller, RN, MSN, vice president of clinical innovation and implementation for the health plan.
All Medicaid members who have been in the hospital receive a welcome-home call and an assessment to determine if they are in further need of case management for their medical condition or have a behavioral issue. Patients are referred to case management for either medical or behavioral health issues. If the case manager determines the patient has both issues, the medical and behavioral case managers may co-manage the case, or one case manager may serve as the lead and the other as back-up.
At Fallon Community Health's Medicaid HMO, mental health case managers and medical case managers are located in close proximity so the two groups of clinicians can have a free exchange of information. They have weekly rounds during which they discuss brand-new cases as well as challenging cases to brainstorm on managing the issues the individual patients face and overcoming barriers to care.
When the medical case managers get a referral, they ask the members a series of questions designed to identify signs of depression, anxiety, or substance abuse. For instance, they ask about their eating habits and what medications they are taking.
"If their medication use sounds inappropriate, the case managers try to find out if the patients are getting prescriptions from multiple providers. If this is the case and the patient is having chronic pain, we may refer them to a pain management program," she says.
If the assessment indicates behavioral health issues, the medical case manager consults with the behavioral health case manager on availability of treatment and whether the member would benefit from behavioral health case management. If so, the medical case manager asks the member if he or she is willing to speak with someone from behavioral health.
"Sometimes, they manage the case together. Other times, the two types of case managers consult on cases. Because they are co-located, they can always walk over and talk to each other about their patients," she says.
A separate program NaviCare, for members who are over 65 and eligible for both Medicare and Medicaid also combines medical and behavioral case management and includes face-to-face interventions.
When members enroll, a medical case manager visits the members in their homes or another location if the patient is more comfortable meeting outside the home, and conducts a thorough assessment to determine what services they need. "Every member in NaviCare is assessed upon admission to determine the additional assistance they need," Miller says.
"Face-to-face visits give us a more thorough way of assessing than conducting the assessment by telephone. When you see someone face-to-face, you can pick up on the non-verbal clues as well as verbal clues. The more vulnerable the population, the more important it is to see them face to face," she says. "By going into members' homes, case managers can see how they function, if they have physical challenges or if there are home safety hazards, like scatter rugs, or if they have to climb stairs to get to the bathroom."
Since medication management is a big part of the care management program, case managers can see the member's prescription bottles and get a complete picture of what medications he or she is taking. Most dually eligible members have complicated medication regimens and often need help understanding them, or they may be taking the medication they took before they were hospitalized as well as those they were prescribed in the hospital, she adds.
After the initial assessment, the case managers visit the members in person periodically depending on the members' needs and follow up by telephone between visits. When members have both behavioral health and medical issues, the behavioral health and medical case managers may visit together.
Case managers in the NaviCare program typically have a case load of about 100 members at a time. They are assisted by non-clinical navigators who handle the non-clinical work such as making appointments, arranging for transportation, and facilitating communication between specialists and the members' primary care physicians.
Since Fallon Community Health Plan in Worcester, MA, began integrating medical case management and mental health case management, members in the health plan's Medicaid HMO with medical issues have experienced fewer inpatient days and emergency department visits and those in behavioral health have less need for unplanned medical care, says Dena Miller, RN, MSN, vice president of clinical innovation and implementation for the health plan.Subscribe Now for Access
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