The Role of Clinicians in Health and Wellness:

Moving from Case Managementto Care Management

Presented by:Kathleen Reynolds, LMSW ACSW

kathyr@thenationalcouncil.org

The Health Imperative/DisparityIndividuals 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

Risk Factors: ◦ Smoking◦ Alcohol consumption◦ Poor nutrition / obesity◦ Lack of exercise◦ Unsafe sexual behavior◦ IV drug use◦ Residence in group care

facilities and homeless shelters

● Vulnerability due to higher rates of:‒ Homelessness‒ Victimization / trauma‒ Unemployment‒ Poverty‒ Incarceration‒ Social isolation

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

The U.S. has a SICK CARE SystemNOT a HEALTH CARE System

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

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www.TheNationalCouncil.org

Wagner Chronic Care Model

Informed,ActivatedPatient

ProductiveInteractions

Prepared,ProactivePractice Team

Functional and Clinical Outcomes

DeliverySystemDesign

DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Health SystemCommunity Health Care Organization

Resources and Policies

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

--Partners in Health - Primary Care/County Mental Health Collaboration Toolkit, Integrated Behavioral Health Project (IBHP), October 2009

Integrated CareReconnection of the Head and the Body

Healthcare Integration is just rediscovering

the Neck

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

NASMHPD Integrated Healthcare Vision Standard Set of Health Indicators

HEALTH INDICATORS1. 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 INDICATORS1. 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

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

Behavioral Health

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 personPrimary 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 coordinationPreparing 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: Exercise- principles> 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

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Nemeroff CB. J Clin Psychiatry. 1997;58(suppl 10):45-49; Kinon BJ et al. J Clin Psychiatry. 2001;62:92-100; BrecherM et al. American College of Neuropsychopharmacology; 2004. Poster 114; BrecherM et 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 Disease1. 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/my-diabetes-care-record.pdf

• Self Checks of Blood Glucose http://ndep.nih.gov/media/self-checks-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%20Heart%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