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Case management and behavioral health

In 2007 the HIP Health Plan of New York restructured its case management program for clients at highest risk of re-hospitalization for psychiatric conditions to capitalize on previ- ous lessons learned and advances in the field of case management. Early results, utilizing an intent-to-treat, historically controlled design, have demonstrated a 70-percent reduction in 30-psychiatric readmission rate corresponding to savings of over $500,000 in 30-day inpatient psychiatric costs.

Program Overview

Upon psychiatric hospitalization, a risk of re-hospitalization score is calculated based on an internally developed predictive model (developed by the author and colleagues). Clients scoring above a risk threshold are identified for intensive case management services (ICM). The most common diagnoses include psychotic disorders, bipolar disorder and depression. Licensed social workers contact identified clients directly and provide case management services via telephone. Services are provided with the aim of helping clients overcome barriers to condition management while promoting high-quality treatment, safety, community tenure and cost-effective outcomes.

Essential Case Management Components

The program incorporates five key components, explained in greater detail below.

1. Enrolling and engaging clients.
2. Advocacy and mobilization of community resources.
3. Providing education to clients, families and caregivers.
4. Promoting treatment adherence.
5. Assessment and monitoring of symptoms.

Enrolling and Engaging Clients

Incorrect phone numbers and address changes make finding clients identified for ICM challenging. Several strategies were implemented, resulting in an enrollment rate improvement from 33 percent to approximately 90 percent.

Rather than wait for clients to be dis- charged from the hospital before pursuing them for ICM, clients are contacted while still inpatient. By contacting the inpatient social worker or unit discharge planner, case managers arrange to speak with clients on the telephone. During this call correct telephone numbers and collateral contacts are confirmed, allowing for easier post-discharge contact.

By speaking with a client during hospitalization the case manager becomes associated with the treatment team, allowing for a smooth transition once the client is discharged. When presenting the pro- gram to clients, case managers do not emphasize the many benefits of the service but rather present case management as something to which the client is entitled, a service provided by the individual case manager. Throughout the entire process, case managers communicate empathy and concern for the well-being of all clients.

Advocacy and Mobilization of Community Resources

Symptoms of a psychiatric condition can make it difficult for a person to advocate for oneself and to identify resources. Case man- agers advocate for clients to ensure appropriate care and connection with services in the community to which clients are entitled.

For example, case managers help clients obtain entitlements (e.g., SSI, SSD, public assistance, food stamps), transportation assistance (e.g., Access-A-Ride, Medicaid trans- clubhouses, social and medical model day programs), protective services (e.g., APS, ACS, shelters), housing assistance (e.g., section 8, assisted living), medication assistance (e.g., EPIC, pharmaceutical company hard- ship programs), vocational assistance (e.g., VESID), and other community services (e.g., AOT, ACT, community ICM).

Providing Education

Case managers provide education to clients, their families and caregivers. Education typically centers on promoting a better under- standing and management of the psychiatric condition. Clients, families and caregivers are taught to recognize early signs of worsening symptoms and what to do in response to changes in symptom severity.

For example, one client expressed consider- disorder diagnosis received from a psychiatrist. The case manager provided education about the condition to both the client and her husband and addressed the client’s concerns that the diagnosis means that she “is always sick.” This led to a very useful discussion about how the condition can be man- aged, resulting in considerably less anxiety.

The case manager also provided the spouse with strategies for helping his wife manage the condition. Mailing educational materials and informing clients, families and caregivers about organizations such as the National Alliance on Mental Illness has also proved highly beneficial.

Promoting Treatment Adherence

Successful management of a chronic psychiatric condition usually requires adherence to medication and treatment appointments. It may also involve consistent involvement in social clubs and other programs.

Case managers use motivational interviewing techniques to address ambivalence about medication and treatment adherence while helping clients safely follow treatment recommendations to achieve optimal, cost- effective outcomes.

Assessment and Monitoring of Symptoms

Case managers monitor changes in symptoms over time using interview techniques and validated assessment tools. For example, depressive symptoms are monitored using the PHQ-9 and alcohol screening, and brief intervention is provided using the AUDIT and protocol specified by the World Health Organization.

By carefully monitoring symptoms case man- agers quickly identify changes in mood or functioning, such as a change in sleep for a client with bipolar disorder that may indicate early signs of a switch toward a manic cycle. Once identified, case managers alert and link providers so that changes to the treatment plan may occur to prevent a worsening of symptoms.

End Game

Psychiatric symptoms can directly impact a person’s ability to adhere with treatment and to advocate for his or her health needs. For example, the lack of energy and concentration seen with major depression and the paranoid ideation often associated with schizophrenia can prevent proper medication adherence and ability to complete entitlement applications.

Case managers working with clients with chronic psychiatric illness have the rewarding opportunity to provide individuals with need- ed education about their conditions to empower informed decision-making. Case managers also help these clients adhere to safe, effective treatment plans and ensure that each client receives all necessary sup- portive services and entitlements to have the highest quality of life possible with reduced reliance on acute care services. Early results from this program demonstrate that the skills and expertise of case managers can have a profound impact on the lives of individuals with chronic psychiatric conditions.

Dr. Andrew Kolbasovskyis the Director of Mental Health Disease Management and Clinical Development, HIP Health Plan of New York. He is the author of the book A Therapist’s Guide to Understanding Common Medical Conditions. ( This e-mail address is being protected from spambots. You need JavaScript enabled to view it )