Building Bridges for Success: Healthcare
Integration Strategies for Case Management
Presented by Mark Rosenberg MD PhD,
President
BHM Healthcare Solutions
© BHM Healthcare Solutions 2014
Learning Objectives
LO 1
LO 2
LO 3
• Attendees will gain an intrinsic appreciation of the link between
primary care conditions and behavioral health conditions, with an
emphasis on depression.
• Participants will become familiar with strategies which are utilized to
incorporate meaningful integration between behavioral health and
primary care services from the Case Management perspective.
• Attendees will become familiar with the integrated case
management model and learn ways to incorporate elements of the
model into their practice.
© BHM Healthcare Solutions 2014
Presentation Overview
Case Management: Traditional Views and
Emerging Perspectives
Healthcare Integration: The Integrated Case
Management Model
Facilitating the Change: Impactful Strategies
for Integrated Case Management
Practice Example: Depression, the MindBody Connection
Integration Strategies to Address
Depression
© BHM Healthcare Solutions 2014
CASE MANAGEMENT:
TRADITIONAL VIEWS AND
EMERGING PERSPECTIVES
© BHM Healthcare Solutions 2014
The Healthcare Silo
• In the current healthcare system, physical disease and mental
health/substance abuse (behavioral health) issues are typically treated
separately.
• The carve out of behavioral health issues from physical disease often
leads to separation of treatment (15% of all patients) or lack of
treatment (85% of patients).
• The carve out of behavioral health has furthermore resulted in the two
arenas of healthcare being separated into distinct areas, commonly
known as the silo effect
• Currently behavioral health and physical disease issues are separated
according to treatment strategies, diagnostic techniques, clinical
access and atmosphere, as well as funding
Kathol, Roger G., Rebecca Perez, and Janice S. Cohen. The Integrated Case
Management Manual. Manual, New York: Springer Publishing Company, 2010.
© BHM Healthcare Solutions 2014
The Healthcare Silo
65% receive no
behavioral health
treatment
70% of all behavioral
health treatment is
provided by primary care
physicians (PCPs)
Only 3% of behavioral
health providers work in
the general medical
sector
80% of expenses for
patients with mental
conditions are from
medical benefits, half of
which are for physical
health services
85% of behavioral health
patients are seen in the
physical health sector
Only 13% of patients
treated by PCPs get
evidence-based care
Kathol, Roger G., Rebecca Perez, and Janice S. Cohen. The Integrated Case
Management Manual. Manual, New York: Springer Publishing Company, 2010.
© BHM Healthcare Solutions 2014
The Development of Case
Management
• Case Management was originally developed as a means
to efficiently use limited health care resources and falls
within the broader scope of Care Management
• With the average physician visit lasting 9 minutes, care
management was implemented in order to assist in
achieving optimal treatment outcomes and navigating the
fractured health system
2-5% of the
Case managers • This
population utilizes a
usually work
third to a half of health
with the 2%-5% care resources
Kathol, Roger G., Rebecca Perez, and Janice S. Cohen. The Integrated Case
Management Manual. Manual, New York: Springer Publishing Company, 2010.
© BHM Healthcare Solutions 2014
The Development of Case
Management
HEALTHY VERSUS CHRONIC DISEASE
HEALTHY OR HAVE READILY TREATABLE DISEASE
INTEGRATED DISEASE MANAGEMENT
INTEGRATED CASE MANAGEMENT
70%
30%
Kathol, Roger G., Rebecca Perez, and Janice S. Cohen. The Integrated Case
Management Manual. Manual, New York: Springer Publishing Company, 2010.
© BHM Healthcare Solutions 2014
10%
20%
Case Management The
Traditional View
Medical Case Management
Behavioral Case Management
• Medical case managers
are often nurses or other
clinicians
• Assistance is provided to
patients who have a
higher level of
severity/acuity than
expected
• Behavioral Case
Management is often
conducted by social
workers, psychologist,
and substance abuse
counselors in addition to
nurses
© BHM Healthcare Solutions 2014
Case Management The
Traditional View
Medical Case Management
Behavioral Case Management
• Background in
management and general
medical care
• Concentration on
biological factors that
contribute to poor
physical health
• Rarely focus on access to
care, personal behaviors,
or client ability to pay
• Background in mental
health and substance
abuse
• Concentration on
diagnosis and treatment
of mental health
conditions and behaviors
that predict poor
outcomes
© BHM Healthcare Solutions 2014
Case Management The
Traditional View
• Just as healthcare has experienced a fracture between the
treatment and approaches to Mental Health and
Behavioral Health, there is a corresponding divergence
between the approach of Medical Case Management and
Behavioral Case Management
Medical
Case
Management
Behavioral
Case
Management
© BHM Healthcare Solutions 2014
Emerging Perspectives:
Healthcare Integration
Medical
Integrated
Care: A
Holistic
Approach
Behavioral
• There is currently a
movement toward
integrated care, which
has been shown to
improve overall
outcomes by
combining physical
and behavioral health
treatment while
reducing total
healthcare cost
© BHM Healthcare Solutions 2014
Emerging Perspectives:
Healthcare Utilization
Top 5% of Patients Using 50%
of Healthcare Resources
60-80%
have comorbid
mental
conditions
70-85%
receive no
mental
health
treatment
Kathol, Roger G., Rebecca Perez, and Janice S. Cohen. The Integrated
Case Management Manual. Manual, New York: Springer Publishing
Company, 2010.
80-90% with 5-15% get
a mental
mental
health
health
condition
treatment
see no
that would
mental
be expected
health
to improve
specialist
outcomes
© BHM Healthcare Solutions 2014
Emerging Perspectives:
Healthcare Integration
Mental Condition CoMorbidity in Physically Ill
Physical Condition CoMorbidity in Mentally Ill
Condition
Prevalence
Condition
Prevalence
Neurological
37.5%
Pulmonary
31%
Heart Disease
34.6%
Heart Disease
22%
Chronic
Obstructive
Pulmonary
Disease
30.9%
Gastrointestinal
Disease
25%
19%
Cancer
30.3%
Skin and
Connective
Tissue
Metabolic
15%
Diabetes
12%
Any medical
illness
75%
Arthritis
25.3%
Diabetes
25.0%
Hypertension
22.4%
Kathol, Roger G., Rebecca Perez, and Janice S. Cohen. The Integrated Case
Management Manual. Manual, New York: Springer Publishing Company, 2010.
© BHM Healthcare Solutions 2014
Emerging Perspectives:
Healthcare Integration
• A high percentage of a few patients with health complexity
use the majority of healthcare resources
• These patients have concurrent physical and behavioral
issues which contribute to poor outcomes
• Integrated Case Management, and a better understanding
in the mind body connection in complex cases is critical in
bridging the gap between physical and behavioral
healthcare
Medical
Case
Management
Integrated
Case
Management
© BHM Healthcare Solutions 2014
Behavioral
Case
Management
HEALTHCARE INTEGRATION
AND THE INTEGRATED CASE
MANAGEMENT MODEL
© BHM Healthcare Solutions 2014
Making the Case for BH/PC
Integration
• Mental health issues are frequently unrecognized and,
even when diagnosed, are not treated adequately.
• Recognition and treatment of mental illness are significant
issues for primary care physicians who provide the
majority of health care.
• In a recent national survey, 18% of the surveyed
population with a DSM-IV diagnosis of a mental health
disorder sought treatment, with 52% of those visits
occurring in the general medical sector.
• Estimates are that 11% to 36% of primary care patients
have a psychiatric disorder.
AAFP. www.aafp.org. Nov. 3, 2010.
http://www.aafp.org/online/en/home/policy/polici
es/mentalhealthcare (accessed April 4, 2012).
© BHM Healthcare Solutions 2014
BH/PC: The Treatment Gap
• Surveys show that 40% of
patients with major depression
do not want, or perceive the
need, for treatment.
• Only 20%-30% of patients with
mental health disorders report
them to a primary care
physician.
• 33% of patients presenting in
the ER with acute chest pain
are suffering from either panic
disorder or depression.
• 80% of patients with depression
initially present with physical
symptoms such as fatigue or
chronic aches.
© BHM Healthcare Solutions 2014
BH/PC: The Treatment Gap
“There are analogous problems of under-recognition and
under-treatment of medical problems for persons with
mental conditions.”
Patients
• Symptoms of mental illness may reduce a patient’s
ability to initiate and follow through with treatment
PC Providers
• PC providers may feel uncomfortable treating patients
with mental illness
BH Providers
• May lack knowledge or expertise to provide medical
care for their patients
System Gap
• Fragmentation between BH and PC can result in
patients receiving inadequate or uncoordinated care
Druss, Benjamin G., and Elizabeth Reisinger-Walker. Mental Disorders and Medical Comorbidity. Research Synthesis Report
© BHM Healthcare Solutions 2014
Four Concepts Common in
BH/PC Integration Models
Medical
Home
Health
Care
Team
Stepped
Care
Approach
Four
Quadrant
Clinical
Integration
© BHM Healthcare Solutions 2014
Medical Home
• Practice-based care coordination within the medical home
is a direct, family/patient-centered, team oriented,
outcomes focused process designed to:
• Œ
Facilitate the provision of comprehensive health promotion and
chronic condition care;
• Œ
Ensure a locus of ongoing, proactive, planned care activities;
• Œ
Build and use effective communication strategies among family,
the medical home, schools, specialists, and community
professionals and community connections; and
• Œ
Help improve, measure, monitor and sustain quality outcomes
(clinical, functional, satisfaction and cost)
© BHM Healthcare Solutions 2014
Health Care Team
Health Care Team - In this
approach the doctor-patient
relationship is replaced with
a team-patient relationship.
• Members of healthcare
team share
responsibility for a
patient’s care.
• A visit is coordinated
between various
members of a team.
• The healthcare team
has full knowledge of
what the other team
members are doing
regarding patient care.
© BHM Healthcare Solutions 2014
Stepped Care Approach
Stepped Care Approach healthcare providers should
offer care that is the LEAST:
• Disruptive for patient
• Extensive needed for
results
• Intensive needed for
results
• Expensive needed for
results
• Expensive in regard to
staff training required to
provide service
© BHM Healthcare Solutions 2014
Four Quadrant Clinical
Integration
Quad I
Quad III
• Patients with low BH and low
physical needs
• Served in PC setting
• E.g., patients with moderate alcohol
abuse and fibromyalgia
• Patients with low BH and high
physical needs
• Served in PC setting
• E.g., patients with moderate
depression and uncontrolled
diabetes
Quad II
Quad IV
• Patients with high BH and low
physical needs
• Served in PC and specialty MH
setting
• E.g., patients with bipolar disorder
and chronic pain
• Patients with high BH and high
physical needs
• Served in PC and specialty MH
setting
• E.g., patients with schizophrenia
and hepatitis C
© BHM Healthcare Solutions 2014
Practice Models of Integration
• Effective Primary Care Behavioral Health collaboration
models are dependent upon a number of variables, but
should aim toward the following care goals:
• Lessen the stigma of accessing care
• Improve use of MD time and availability
• Increase referrals to BH providers that PC physicians
actually know
• Help patients with chronic illness manage disease
• Identify patients with depression and other chronic
illness
• Increase cost efficiency of treatment
• Increase treatment adherence
© BHM Healthcare Solutions 2014
Practice Models of Integration
• Developing an effective model of integration is dependent
upon many community/facility limitations, including:
• Array and capacity of services in the community
• Trained workforce – do behavioral health providers and PC
physicians have the right skills to deliver services on-site?
• Organizational support in providing service – do managers
provide encouragement/support for collaborative initiative?
• Reimbursement factors – do payers support collaborative
care and make it easy for PC and BH providers to work
together?
• Organizational impact – what is the organizational impact on
documentation, billing, risk management, etc.?
© BHM Healthcare Solutions 2014
Practice Models of Integration
Coordinated
Co-Located
Integrated
Routine screening for BH
problems conducted in
PC setting
Medical services and BH
services located in same
facility
Medical services and BH
services located in same
facility, or separate
locations
Referral relationship
between PC and BH
settings
Referral process for
medical cases to be seen
by BH specialist
One treatment plan with
BH and medical
elements
Routine exchange of
information between
treatment settings
Enhanced informal
communication between
PC and BH providers due
to proximity
Typically, a team working
together to deliver care,
using formal protocol
© BHM Healthcare Solutions 2014
FACILITATING THE CHANGE:
IMPACTFUL STRATEGIES FOR
INTEGRATED CASE
MANAGEMENT
© BHM Healthcare Solutions 2014
Integration 101: Utilizing Case
Management
Case Management May
Include:
Coordination
of Care
Assisting
members
accessing
community
based
resources
Providing
disease
specific
education
© BHM Healthcare Solutions 2014
Any other
options aimed
at improving
quality of life,
functionality of
members, and
efficiently
using
healthcare
resources
Integrated Case Management
• Case Management occupies a unique position in
improving member health and reducing health care costs
• Core concepts for effective case management include
targeted programs across the care continuum, including
but not limited to:
•
•
•
•
•
•
•
Targeted prevention health
Disease management
Behavioral health management
Pharmacological management
Wellness incentives and reimbursements
Community resources
Healthcare access
© BHM Healthcare Solutions 2014
Integrated Case Management
• The goal of Integrated Case Management should be to
break down complexity-based health barriers across
multiple domains in order to appropriately address and
treat patients from a holistic perspective
Biological
Psychological
Social
Health
System
© BHM Healthcare Solutions 2014
Integrated Case Management
• Example Complexity Assessment Domains
Biological Domain
Historical
Current
Future Vulnerability
1.
2.
1.
Symptom
severity/impairment
Diagnostic,
therapeutic challenge
Complications and life
threat
Resistance to
Treatment
Mental Health
Symptoms
Mental health threat
Chronicity
Diagnostic Dilemma
2.
Psychological Domain
1.
2.
Barriers to coping
Mental Health History
1.
2.
Social Domain
1.
2.
Job and leisure
Relationships
1.
2.
Residential Stability
Social Support
Social vulnerability
Health System Domain
1.
2.
Access to care
Treatment experience
1.
Getting needed
services
Coordination of care
Health system
impediments
2.
Kathol, Roger G., Rebecca Perez, and Janice S. Cohen. The Integrated Case
Management Manual. Manual, New York: Springer Publishing Company, 2010.
© BHM Healthcare Solutions 2014
Integrated Case Management
• Integrated Case Management should be grounded in a
relationship based approach to interaction with patients
• Develop and carry out a plan collaboratively with the patient
• Incorporate the patient’s family
• Incorporate the primary care provider and facilitate collaboration
with other care providers
• Examine the situation from the payer perspective and the
community perspective to take advantage of programs that can
optimize health, quality of life, appropriate use of services, and
conservation of healthcare resources
© BHM Healthcare Solutions 2014
Integrated Case Management
Patient Responsibilities
• Willingness to form a relationship with the case manager
and maintain trust
• Participate and be willing to learn about illness recovery
• Initiate agreed upon treatments and recommendations
• Participate actively in the improvement process
• Provide timely feedback regarding treatment success, failure,
and roadblocks
Case Manager Responsibilities
• Build a positive collaborative relationship with the patient
• Provide educational resources along with an adequate
understanding of the illness
• Identify and reverse barriers to improvement
• Facilitate interventions and be willing to serve as a patient
advocate
• Confirm improvement and adjust treatment based on efficacy
Kathol, Roger G., Rebecca Perez, and Janice S. Cohen. The Integrated Case
Management Manual. Manual, New York: Springer Publishing Company, 2010.
© BHM Healthcare Solutions 2014
Integrated Case Management:
Strategies for Change
• Include comprehensive patient assessments which
evaluate both physical health and behavioral health issues
into your case management strategy
• Do not ignore social factors; find out if there are any social
factors which negatively impact treatment outcomes such
as lack of housing or transportation and level of family
involvement
• Actively encourage family and community involvement and
support
• Assist and facilitate patient education at every opportunity
• Provide a collaborative link between Primary Care and
Mental Health providers and ensure that there is open
communication across provider channels
© BHM Healthcare Solutions 2014
Integrated Case Management:
Strategies for Change
• Actively assist the patient in
navigating the healthcare
system, whether from a
provider or a payer
perspective
• Address any financial
barriers to care and assist
in finding workable
alternatives
• Ensure that you, the Case
Manager, receive ongoing
education about both
primary care and behavioral
health issues
© BHM Healthcare Solutions 2014
INTEGRATION STRATEGIES
TO ADDRESS DEPRESSION
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Integration 101: First Steps to
Making it Work
Screening Tools For
Primary Care
• Utilization of appropriate
screening tools in primary
care for BH diagnosis
Relationships &
Communication
• Building relationships with
BH providers and
facilitating communication
Technology
• Effectively using
technology to overcome
obstacles
© BHM Healthcare Solutions 2014
Integration 101: Screening
Tools Additional Resources
• What factors to consider when determining which
screening tools to incorporate in your practice:
•
•
•
•
•
Method of screening delivery - interview/pre-screen
Proprietary Tools - are the tools free and readily available?
Reliability - is the tool proven to provide reliable results?
Sensitivity - is the tool accurate in identifying a problem?
Specificity - is the tool accurate in identifying those who do not
have a problem?
• Patient population - is the tool age specific, and are there any
cultural considerations to take into account?
• For a comprehensive list of mental health screening tools
for utilization in a primary care setting please visit:
https://www2.aap.org/commpeds/dochs/mentalhealth/docs
/MH-ScreeningChart.pdf
© BHM Healthcare Solutions 2014
Integration 101: Relationships
and Communication
• After deciding what screening criteria will be utilized,
decide what metrics will be used to determine if a patient
will be treated in primary care, or referred to a behavioral
health specialist
• Develop a referral network
• Develop a relationship with area behavioral health
specialists who will be a part of your referral network
• Ensure that your network covers a range of services
• Work to cultivate these relationships and refer patients to
providers who you actually know
© BHM Healthcare Solutions 2014
Integration 101: Communication
and Relationships
• Appreciate the differences between Primary Care and
Behavioral Health Treatment and Environments:
Primary Care
Behavioral Health
Pace
15 minute appointment
50 minute session
Setting
An exam room
An office setting
Language
Diagnosis, medical
terminology, complaints
Assessment, mental
health terminology, issues
Hierarchy
Physician is in charge
Diffused hierarchy that
differs widely by provider
Flow
Flexible patient flow
Scheduled client flow
© BHM Healthcare Solutions 2014
Integration 101: Utilizing Case
Management
• The goal of the Case Management Solutions Program is to provide
high quality, integrated, culturally-competent case management
services to members assessed as having high medical and/or nonmedical case management needs.
• The Program meets this goal by doing the following:
• Utilizing qualified staff to collaboratively identify and assess the physical,
behavioral, cognitive, functional, and social needs of members for case
management services
• Developing a comprehensive case management plan with input from the
member and caregiver
• Working with the member and caregiver to complete a planned and
prioritized set of goals and interventions tailored to the individual needs of
the member, caregiver and their family/support system
• Program staff encourages members to take action to improve their overall
quality of life, functional status, and health outcomes, and strive to ensure
the delivery of services in the most cost-effective manner.
© BHM Healthcare Solutions 2014
Integration 101: Realizing
Opportunities
• Mental and physical health
problems are interwoven.
• Integrated primary care
helps to ensure that
people are treated in a
holistic manner, meeting
the mental health needs of
people with physical
disorders, as well as the
physical health needs of
people with mental
disorders.
Collins, Chris, Denise Levis-Hewson, Richard Munger, and Torlen Wade. Evolving Models of Behavioral Health Integration in Primary Care. New Yort:
Millibank Memorial Fund, 2012.
© BHM Healthcare Solutions 2014
Integration 101: Realizing
Opportunities
• The treatment gap for
mental disorders is
enormous.
• In all countries, there is a
significant gap between
the prevalence of mental
disorders and the number
of people receiving
treatment and care.
• Coordinating primary care
and mental health helps to
close this divide.
Collins, Chris, Denise Levis-Hewson, Richard Munger, and Torlen Wade. Evolving Models of Behavioral Health Integration in Primary Care. New Yort:
Millibank Memorial Fund, 2012.
© BHM Healthcare Solutions 2014
Integration 101: Realizing
Opportunities
• Primary care settings for
mental health services
enhance access, but when
this is not available Case
Managers provide a vital
link between the two
health systems
Collins, Chris, Denise Levis-Hewson, Richard Munger, and Torlen Wade. Evolving Models of Behavioral Health Integration in Primary Care. New Yort:
Millibank Memorial Fund, 2012.
© BHM Healthcare Solutions 2014
Integration 101: Realizing
Opportunities
• Integrated Depression/Medical Case Management Clinical
Outcomes
Mental Health Survey
Condition
Intake
Discharge
Outcome
Depression
79%
44%
35% drop in depression
Energy level
49%
75%
26% increase in energy
Work limitations
63%
29%
34% drop in work limitations
Social limitations
71%
41%
30% drop in social limitations
Physical Health Survey
Condition
Intake
Discharge
Outcome
General health
5%
9%
4% increase in general health
Work limitations
61%
48%
13% drop in work limitations
Does less work
64%
45%
19% increase in work
Bodily Pain
12%
5%
7% decrease in bodily pain
Aetna-www.academyhealth.org/2006/Tuesday/611/unh.ppt
© BHM Healthcare Solutions 2014
Question and Answer Session
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Email: results@bhmpc.com
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Phone Number: 1-888-831-1171
Fax Number: 1-888-818-2425
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