The Role of Clinicians in Health
and Wellness:
Moving from Case Management
to Care Management
Presented by:
Kathleen Reynolds, LMSW ACSW
kathyr@thenationalcouncil.org
The Health Imperative/Disparity
Individuals with Serious Mental Illness are dying
approximately 25 years earlier than the general
population (NASMPHD, 2006)

Average age of death is 53
Substance Use Disorders and the Person-Centered
Healthcare Home a 2010 report by B. Mauer finds that
those with co-occurring MH/SUD were at greatest risk

Average age of death is 45
How This Stacks Up Worldwide
SPMI Consumers are Dying of Preventable Causes
(NASMHPD, 2006)
● Higher Rates of Modifiable
● Vulnerability due to higher
Risk Factors:
rates of:
◦ Smoking
‒ Homelessness
◦ Alcohol consumption
‒ Victimization / trauma
◦ Poor nutrition / obesity
‒ Unemployment
◦ Lack of exercise
‒ Poverty
◦ Unsafe sexual behavior
‒ Incarceration
◦ IV drug use
‒ Social isolation
◦ Residence in group care
facilities and homeless shelters
Health Reform…What’s it going to be?
Current Reality - Nationally
● Behavioral Health budgets are being cut
everywhere – Care Management is the buzz
● Healthcare Reform will impact your job
● Integration is the future
● Patient Centered Health Homes is the vision
45% of Americans have one or
more chronic conditions
Over half of these people
receive their care from
3 or more physicians
Treating these conditions
account for 75% of direct
medical care in the US
In large part due to the fact that money doesn’t start flowing in the
U.S. healthcare system until after you become sick
7
Wagner Chronic Care Model
Health System
Community
Health Care Organization
SelfResources and
Management
Policies
Support
Informed,
Activated
Patient
www.TheNationalCouncil.org
Delivery
System
Design
Productive
Interactions
Decision
Support
Clinical
Information
Systems
Prepared,
Proactive
Practice Team
Functional and Clinical
Outcomes
Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998;1(1):2-4.]
> “…in essence integrated health care is the
systematic coordination of physical
and behavioral health care. The idea is
that physical & behavioral health problems
often occur at the same time. Integrating
services to treat both will yield the best
results and be the most acceptable &
effective approach for those being served.”
>
Connecting Body & Mind: A Resource Guide to Integrated Health Care in Texas and the U.S.,
> Hogg Foundation for Mental Health
Behavioral Health
Physical Health
Healthcare Integration
is just rediscovering
the Neck
--Partners in Health - Primary Care/County Mental Health
Collaboration Toolkit, Integrated Behavioral Health Project (IBHP), October 2009
What do we do?
Integrate healthcare using and expanding case
management skills to:
 Improve the health of those we already
serve through applying our skills at:
 Chronic disease management
 Health behavior change
 Relationships…in order to…
 Make ourselves indispensable to primary
care and/or MCO’s
 Expand our services
HEALTH INDICATORS
1. Personal History of
Diabetes, HTN, CV disease
6. Lipid Profile
2. Family History of
Diabetes, HTN, CV Disease
7. Tobacco Use/History
3. Weight/Height, Body Mass Index
8. Substance Use/History
4. Blood Pressure
9. Medication: History and Current
5. Blood Glucose or HbA1c
10. Social Supports
PROCESS INDICATORS
1. Screen/Monitor Risk and Health Conditions in MH
2. Access to and utilization of Primary Care Services
Health Navigators/Care Managers will:
> Cross the divide in the current health care system
> Use existing skills in health behavior change and
expand those skills to physical health issues
> Increase their knowledge of questions to ask and
strategies to seek
> Use the community to support wellness
NAVIGATION/CARE
MANAGEMENT SKILL:
CROSSING THE CULTURAL
DIVIDE BETWEEN PRIMARY
CARE AND BEHAVIORAL
HEALTH
Two worlds…
Primary Care
Behavioral Health
Brief, problem focused
communication
Immediate solution driven
care
Productivity measured in
terms of number of
patients seen
Many evidence based
interventions, disease
management as standard
part of practice
Process oriented
Long term planning and
coordination
Productivity measured in
units of service
Individualized approach with
evidence based
interventions moving into
practice
Two worlds, two lenses, one person
Primary Care
> Diabetes
> Hypertension
> Metabolic Syndrome
> Smoking
> ETOH
> Schizophrenia
Behavioral Health
> Schizophrenia, co-morbid
with:
> Hypertension
> Diabetes
> Metabolic syndrome
> Smoking
> ETOH
Supporting people with PCP visits
through preparation:
Handout: Strategies for coordination
Preparing for PCP visit
Recognize the “intimidation factor”
Develop a plan for “waiting”
Role play strategies for communication and calming
NAVIGATION/CARE
MANAGEMENT SKILL:
SUPPORTING HEALTH
BEHAVIOR CHANGE
What works in change:
Think about a time in your own life when you successfully
made a change in your lifestyle.
• What was the process like of getting to the change?
• What helped?
• What didn’t help?
Think about a time you have supported someone
else in making a change :
• What did you do that worked?
Habits & Health Behavior Change
> “40% of the actions people perform each day weren’t
actual decisions, but habits.”
> Bad habits never die they are replaced by better
habits.
> All habits have a Cue-> Routine-> Reward
> Golden Rule of Beh. Change: Use the same cue &
the same reward but replace the routine
Charles Duhigg--The Power of Habit: Why We Do What We Do in Life & Business
Motivational Interviewing basics: what
we know about change
> Motivation for change is malleable & particularly
formed in relationships & through belief
> Motivation is gained in the presence of active
collaboration and shared decision making
> People have inherent resources for change when the
change is connected to their goals, values and
dreams
> Honoring the right not to change can make change
possible.
Four key strategies
>
>
>
>
Listen for change talk
Deal with ambivalence
Look for degree of commitment
Look for degree of confidence
What Does This Look Like In Real Life?
Diet basics
>
>
>
>
Eat low
Eat color
Divide your plate
Consider your portions
Principle: Even small (5-10%) weight loss makes a big
difference!
American Dietetic Association:
www.eatright.org
Challenging Health Behavior: Exerciseprinciples
>
>
>
>
>
Anything is better than nothing
Adding a small change will improve health
Small steps can lead to big changes
Support and accountability contribute to change
3 months to make a habit
(see resource list for websites that can help)
CHRONIC ILLNESS
CHALLENGE: DIABETES
What do you already know about
diabetes:
> Cause?
> Impacts?
> Management?
Diabetes and Persons with SPMI
1-Year Weight Gain:
MeanChange FromBaseline Weight
Olanzapine(12.5–17.5 mg)
Olanzapine(all doses)
Quetiapine
Risperidone
Ziprasidone
Aripiprazole
Change FromBaseline Weight (kg)
12
10
30
25
20
8
15
6
10
4
5
2
0
Change FromBaseline Weight (lb)
14
0
0
4
8
12 16 20 24 28 32 36 40 44 48 52
Weeks
Nemeroff CB. J Clin Psychiatry. 1997;58(suppl 10):45-49; Kinon BJ et al. J Clin Psychiatry. 2001;62:92-100; BrecherMet
al. American College of Neuropsychopharmacology; 2004. Poster 114; Brecher Met al. Neuropsychopharmacology.
2004;29(suppl 1):S109; Geodon®[package insert]. New York, NY:Pfizer Inc; 2005. Risperdal® [package insert]. Titusville,
NJ: Janssen Pharmaceutica Products, LP; 2003; Abilify® [package insert]. Princeton NJ: Bristol-Myers Squibb Company
and Rockville, Md: Otsuka America Pharmaceutical, Inc.; 2005.
Routine medical examinations and tests for
people with diabetes*
> Measure blood pressure at every visit
> Check feet for sores at every visit, and give a thorough foot exam at least
once a year
> Give a hemoglobin A1C test at least twice a year, to determine average blood
glucose level over the past 2 to 3 months
> Test urine and blood to check kidney function at least once a year
> Test blood lipids (fats) – total cholesterol at least once a year
•
•
•
>
>
>
>
LDL, or low-density lipoprotein (“bad” cholesterol)
HDL, or high-density lipoprotein (“good” cholesterol)
Triglycerides
Dental checkup twice a year
Dilated eye exam once a year
Annual flu shot
Annual pneumonia shot
*www.CDC.gov
Know your diabetes ABCs
> Talk to your health care team about how to manage your A1C, Blood pressure, and
>
>
>
>
>
>
>
>
Cholesterol. This can help lower your chances of having a heart attack, stroke, or other
diabetes problems. Here's what the ABCs of diabetes stand for:
A for the A1C test (A-one-C).
It shows what your blood glucose has been over the last three months. The A1C goal
for many people is below 7. High blood glucose can harm your heart and blood vessels,
kidneys, feet, and eyes.
B for Blood pressure.
The goal for most people with diabetes is below 130/80.
High blood pressure makes your heart work too hard. It can cause heart attack, stroke,
and kidney disease.
C for Cholesterol (ko-LES-ter-ol).
The LDL goal for people with diabetes is below 100.
The HDL goal for men with diabetes is above 40.
The HDL goal for women with diabetes is about 50.
LDL or “bad” cholesterol can build up and clog your blood vessels. It can cause a heart
attack or a stroke. HDL or “good” cholesterol helps remove cholesterol from your blood
vessels.
Body Mass Index (BMI)
● An approximate measure of body fat based on height
●
●
●
●
and weight.
A BMI between 19 and 25 is considered a normal
amount of body fat.
If someone's BMI is 25 to 29.9, that person is said to
be overweight.
A person is said to be obese if his or her BMI is 30 or
higher.
The higher your BMI, the greater your risk for diseases
such as Diabetes, Heart Disease, Arthritis, and certain
cancers.
Assisting People in Managing Their
Diabetes
•
•
•
•
My Diabetes Care Record Example
Self Checks of Blood Glucose
My Game Plan for Diabetes
Does the organization collect the needed lab work for
diabetes?
CHRONIC ILLNESS
CHALLENGE: VASCULAR
DISEASE
With substantial credit to www.familydoctor.org
Vascular Disease
Coronary Artery Disease (CAD):
• Caused by a thickening of the inside walls of the
coronary arteries. This thickening is called
atherosclerosis.
• A fatty substance called plaque builds up inside the
thickened walls of the arteries, blocking or slowing the
flow of blood.
• If your heart muscle doesn't get enough blood to work
properly, you may have angina or a heart attack.
Angina is a squeezing pain or pressing feeling in your
chest
Reducing Risks for Vascular Disease
1. Don't smoke. Nicotine raises your blood pressure because it causes your
body to release adrenaline, which makes your blood vessels constrict and
your heart beat faster. If you smoke, ask your doctor to help you make a
plan to quit. After 2 or 3 years of not smoking, your risk of CHD will be as
low as the risk of a person who never smoked.
2. Control your blood pressure. If you're taking medicine for high blood
pressure, be sure to take it just the way your doctor tells you to.
3. Exercise. Regular exercise can make your heart stronger and reduce
your risk of heart disease. Exercise can also help if you have high blood
pressure. Before you start, talk to your doctor about the right kind of
exercise for you. Try to exercise at least 4 to 6 times a week for at least
30 minutes each time.
4. Eat a healthy diet. Add foods to your diet that are low in cholesterol and
saturated fats, because your body turns saturated fats into cholesterol
Consumers’ take on integration
> People receiving integrated services report higher
quality of life and greater satisfaction with:
•
•
•
•
•
Access
Attention to their treatment preferences
Courtesy
Coordination & continuity of care
Overall care
Druss et al, Arch Gen Psychiatry. 2001; 58(9): 861-8.
Unutzer et al, JAMA. 2002; 288(22): 2836-2845.
Ell et al, Diabetes Care. 2010; 33(4): 706-713.
Integration as Part of the Strategy
• Integration does not mean return to a medical model
• Provides access to multiple services at one time and
place
• Improves the quality of all services
• Creates space within the current public sector for more
consumers
• Ultimately reduce the early loss of life for those with a
serious and persistent mental illness
Resources for Diabetes Assistance
● American Diabetes Association www.diabetes.org
● CDC Diabetes Public Health Resource
http://www.cdc.gov/diabetes/
● National Diabetes Education Program
http://www.ndep.nih.gov/index.aspx
● Tools
• Small Steps Big Rewards – Your Game Plan
http://www.ndep.nih.gov/media/GP_Booklet.pdf
• My Diabetes Care Record http://ndep.nih.gov/media/mydiabetes-care-record.pdf
• Self Checks of Blood Glucose http://ndep.nih.gov/media/selfchecks-of-blood-glucose.pdf
RESOURCES for Heart Disease
• Mind Your Heart website: http://www.mindyourheart.org.uk/
• Mind Your Heart: Healthier Lifestyles Toolkit for Workers in
Mental Health
http://www.mindyourheart.org.uk/Docs/Mind%20Your%20Hear
t%20Toolkit%20Eng.pdf
• American Heart Association www.heart.org
• National Heart, Lung, and Blood Institute - NIH
http://www.nhlbi.nih.gov/health/health-topics/topics/cad/
• Center for Disease Control and Prevention
http://www.cdc.gov/heartdisease/
• Million Hearts http://millionhearts.hhs.gov/index.html