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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
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
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
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