Emerging Roles and Responsibilities of

Medical Case Managers: A Workshop at the 20th Annual National

Conference on Social Work and HIV/AIDS

Emerging Roles and Responsibilities of

Medical Case Managers: A Workshop at the 20th Annual National

Conference on Social Work and HIV/AIDS

Julia Hidalgo, ScD, MSW, MPH

Positive Outcomes, Inc. and George Washington University

julia.hidalgo@positiveoutcomes.netwww.positiveoutcomes.net

This workshop is supported with funds from Abbott Laboratories.

The materials presented do not necessarily represent the views of

Abbott Laboratories or other funders of Positive Outcomes, Inc.

This workshop is supported with funds from Abbott Laboratories.

The materials presented do not necessarily represent the views of

Abbott Laboratories or other funders of Positive Outcomes, Inc.

Abbott- POI Medical Case Management Project: A Summary

In response to the case management (CM) service categories defined in the Ryan White HIV/AIDS Treatment Modernization Act of 2006, Abbott Laboratories is supporting a year-long project to Conduct a national assessment of the training needs of HIV case

managers in adopting medical CM techniques Identify and learn from HIV medical CM training efforts across

the U.S. Develop and test HIV medical CM curriculum based on results of

the training needs assessment Disseminate the curriculum for local training efforts

Today is the assessment’s first activity

Today we will Based on our earlier work throughout the U.S. and with

the HIV/AIDS Bureau (HAB) provide an overview of The evolution of HIV CM in the U.S. The concepts underlying the medical CM service category in

the Ryan White HIV/AIDS Treatment Modernization Act of 2006 HAB’s current requirements regarding medical and non-

medical CM Approaches used throughout the U.S. to adopt medical CM

Engage in an informal discussion regarding your medical CM roles, responsibilities, and training needs Conduct a written mini-assessment

Discuss the medical CM training needs of HIV case managers and CM supervisors in your communities, and the extent to which these needs are being addressed

Get your feedback about meaningful ways the assessment can help you and your colleagues

Quick History of HIV CM

Early 1980s Focus on

hospitalizations and end of life care

Case managers coordinated care for terminally ill patients

Case managers tend to be from other health care or social work systems and have a personal commitment to the AIDS epidemic

Volunteers provide support services

Late 1980s and Early 1990s Focus on newly

introduced HIV testing and treatment (AZT)

Support activities offer alternatives to inpatient stays

A continuum of support services develops

Volunteers continue to provide support services, with CBOs forming

Populations impacted by HIV become diverse

Quick History of HIV CM

Mid to Late 1990s Focus on HIV voluntary

testing, primary care, and combination therapy

Understanding of the roles of medication adherence and drug resistance grows

Number of clients increases steadily and diversity of the infected community expands

CARE Act, Medicaid, and Medicare funds underwrite growing costs

CM is professionalized Community-based care

continuum grows, with growth in minority organizations

Outreach and retention efforts grow

The 2000s Focus on rapid HIV testing,

HAART, and increasingly complex specialty care

CARE Act funds flatten Number of clients grows They experience longer, more

complex lives, outstripping service capacity

Mental health and addictions treatment become important component of HIV care

Case managers seek simplified models, borrow from other disciplines, assess outcomes

Role of adherence and self-management is recognized

Peers’ role in care continuum is acknowledged

Ryan White HIV/AIDS Treatment Modernization Act of 2006 identifies two types of CMMedical CM (considered a core medical

service) Unless a waiver is granted by HAB, Parts A, B, and C grantees

must allocate at least 75% of their funds to core medical services

Support CM in which referrals for health care and support services are made (considered a support service) Unless a waiver is granted by HAB, Parts A, B, and C grantees

must allocate no more than 25% of their funds to non-core services

Quick History of HIV CM: Today

Medical CM Concept is Based in Part on Disease Management (DM) Approach

The DM Association of America defines DM as a system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant Supports the clinician-patient relationship and the

care provided Emphasizes prevention of complications by using

evidence-based practice guidelines and patient empowerment strategies

Evaluates clinical, humanistic, and economic outcomes on an ongoing basis with the goal of improving overall health

Disease Management (DM) UsesPopulation identification processesEvidence-based practice guidelinesCollaborative practice models that include

physician and support service providersPatient self-management education Includes primary prevention, behavior modification,

and compliance monitoringProcess and outcomes measurement,

evaluation, and managementRoutine reporting/feedback loop Including communication with patient, physician, or

practice profiling

Medical CM Concept Also is Based on the Chronic Care Model

A population-based model that relies on knowing which patients have the illness, ensuring that they receive evidence-based care, and actively helping them to participate in their own care

Informed,Activated

Patient

ProductiveInteractions

Prepared,Proactive

Practice Team

Improved Outcomes

DeliverySystemDesign

DecisionSupport

InformationSystems

Self-Management

Support

Health System

Resources and Policies

Community

Health Care Organization

Chronic Care Model

Practice Level

What characterizes a “informed, activated” patient?

•The patient understands the disease process•Realizes his/her role as the daily self-manager

•Family and caregivers are engaged in supporting the patient’s self-management

•The provider is viewed by the patient as a guide

Informed,Activated

Patient

What characterizes a “prepared” practice team?

PreparedPractice

Team

At the time of the visit, the team has the patient’s information, data, staff, equipment, and time required to deliver evidence-based clinical management and self-management

support

Defining Medical CM

HAB’s Medical CM Definition

Medical CM services (including treatment adherence) A range of client-centered services that link clients

with health care, psychosocial, and other services The coordination and follow-up of medical treatments Medical CM includes the provision of treatment

adherence counseling to ensure readiness for, and adherence to, complex HIV/AIDS treatments

These services ensure timely and coordinated access to medically appropriate levels of health and support services and continuity of care Through ongoing assessment of the client’s and other key

family members’ needs and personal support systems

HAB’s Medical CM Definition (Continued)

Key activities include Initial assessment of service needs Development of a comprehensive, individualized

service plan Coordination of services required to implement the plan Client monitoring to assess the plan’s efficacy and Periodic re-evaluation and adaptation of the plan as

necessary over the client’s life Includes client-specific advocacy and/or review of

utilization of services Includes all types of CM including face-to-face, phone

contact, and any other forms of communication

HAB’s Non-Medical CM Definition

Provision of advice and assistance in obtaining medical, social, community, legal, financial, and other needed services

Does not involve coordination and follow-up of medical treatments, as medical CM does

HAB’s CM Treatment Adherence DefinitionHAB does not explicitly define treatment adherence responsibilities or roles for medical case managersTreatment adherence strategies used throughout the U.S. include

Assess factors likely to contribute to poor adherence and develop individualized care plans to address those factors

Medication, referral, and appointment adherence interventions Patient HIV education to expand “health literacy” HIV medication education, including side effects and their

management Attending medical visits to assist patients to understand the

information provided by medical provider Coordinate appointment scheduling to book multiple visits on

the same day and arrange transportation to ensure the patient keeps appointments

Home visiting and other methods of case finding for patients that have broken appointments or dropped out of care

Assess and treat mental illness and/or substance abuse

Other Treatment Adherence Activities Activities that clients perform to control their illness,

prevent future complications, and cope with the impact of HIV and its treatment Collaborative goal setting Symptoms monitoring Lifestyle behaviors including healthy diet, getting

regular exercise, and smoking cessation Taking medication in the dose and frequency

prescribed Communicating and coordinating with the care team,

family, and others Ongoing problem-solving to overcome potential

barriers

Operationalizing Medical CM by Ryan White Program-Funded Agencies

Approaches Taken to Address New CM Definitions

Redefine all CM services provided by HIV clinics or other clinical settings to be medical CM No specific change to CM scope of practice or

performance measures Redefine CM service provided by community-based

organizations as medical CM if they are co-location with clinics or other strong linkages are demonstrated

Partner RNs and social workers in medical CM teams Redefine the CM scope of practice, change training and

credentialing requirements, and change performance measures Putting the burden on CM programs to reengineer their

programs and carving out time for training

Other Approaches Taken to Address New CM Definitions

Require that community-based CM programs link with HIV clinics to offer clinical CM services In turn, HIV clinics have hired case managers to

expand their core medical services Eliminate community-based CM funding Employ only RNs to provide medical CM

This model tends to predate the 2006 Ryan White Program reauthorization

Some grantees and CM agencies would like to shift in this direction but cannot afford it or cannot identify nurses due to local nursing shortages

What approaches to implementing medical CM have been used by your agency?

What challenges do you encounter in adopting the medical CM model?

In what ways can the Abbott-POI project help to strengthen medical CM services in your communities?

What training topics would be helpful to you to adopt in the medical CM curriculum?