Behavioral Health Issues Social Work | Comprehensive Case Management Certification

Welcome to Case Management Toolbox Podcast, sponsored in part by All CEU's Continuing Education. I'm your host, Dr. Donnelly Snipes. Case Management CEUs are available for these podcasts@allce.com that's allceus.com Casemanagement hey there everyone, and welcome to this episode of Case Management Toolbox Podcast. Today we're going to be talking about case management for mental health. We're going to review what a mental health case manager does, or in some cases, what a counselor does if the client doesn't qualify for case management services that are reimbursable by insurance. And we'll also identify common issues clients with mental health diagnoses have and ways we can address them. So what does a mental health case manager do? Well, one of the big things that he or she does is serves as the single point of contact. The behavioral health care arena, especially if you're looking at a biopsychosocial approach, can get really intricate and cumbersome and overwhelming to a lot of clients. So the case manager serves as the single point of contact for the medical providers, for the occupational therapist, for the rehabilitation counselor, for the mental health counselor, for the addiction counselor, for the pain management. You get my point. Everybody kind of converges and communicates through the mental health case manager, who helps the client navigate the system. The mental health case manager also facilitates patient engagement and helps the person get motivated for doing what they need to do, as well as helping them navigate this system. Each one of their providers probably has stuff that they're supposed to do, and the case manager can help the client prioritize and make a plan to actually do the things that each one of the referral sources wants them to do. Case managers also screen patients for common mental health and substance abuse disorders and identify necessary services to aid in achieving their optimal level of recovery. Case managers do not diagnose or treat mental health issues. However, as a part of being a case manager, they do screen. Anybody can do a screening. You know, your human resources provider can do a screening to see if maybe there might be mental health or substance abuse issues. It doesn't take a degree to implement a screening instrument. The key is case managers are often in contact with clients a lot more than other providers. So when they do the screening, if they see a problem and decide to do a screening, then they can make a referral for early intervention before it becomes a problem. Case managers provide patient education about common mental health and substance use disorders and the available treatment options. So maybe the client thinks, you know, I might have depression. I might maybe need to see a therapist. I don't know. I don't know anything about depression. A case manager might help that patient access resources. A case manager might help that client access support groups or, you know, whatever they may not may need. Case managers also provide education to clients and stakeholders. So that includes referral sources and people in the community about the utility and effectiveness of wraparound services for goal attainment. We can, you know, as clinicians, if you're a clinician, we do a lot with cognitions and social support and yada yada, but we don't really do a lot with making sure people have the ability to pay their light bill, making sure people have access to adequate childcare or transportation. Those are things that fall kind of outside of the scope of our day to day practice. Case managers help everybody see why it's important for a client to have lights in their house and transportation. You know, they need to be able to function and do the things that everybody does. And part of that means having electricity. And in order to get to appointments, for example, they need to have transportation in order to get to a job, in order to get to the grocery store to get the food they need so they can be healthy and support their recovery, they need transportation. So case managers really step in and say, hey, you know, it's not just about medical, it's not just about the mental health. It's about looking at this person and making sure they're getting all of their needs. Think about Maslow's hierarchy of needs, getting all of their needs met. Some of these things can include safe housing, Supplemental Nutrition Assistance Program, enrollment, transportation, employment, education and financial counseling. If our clients, for example, have anxiety and depression, let's just stick with common diagnoses or substance use disorders in their recovery, they're going to need to have a safe, stable place to lay their head, which is housing. And they're also going to be able to need to afford the basics in life in order to keep their stress down to prevent relapse, which is where financial counseling comes in. A case manager participates in regularly scheduled, which are usually weekly caseload consultations with the entire team and communicates resulting service recommendations to the patient's team. That way you don't have six people trying to communicate every which way. Everybody communicates to the case manager. The case manager puts it together in a happy little summary and says, okay, this is what we got for John Smith this week. Consultations focus on patients new to the caseload and those who are not improving as expected under the current treatment plan. So generally when I've been a part of these team case consultations, we'll go down the whole list of people that are on the caseload. But if John Smith is progressing as planned and everything seems to be fine, there are no changes, then we'll just indicate John Smith, no changes. That way we are recording the fact that we are checking the block so John Smith doesn't, quote, fall through the cracks. Case managers regularly meet with key team members to determine which benchmarks they are most interested in and identifying barriers to care. So the case manager might meet with the physician, the pain management physician, and say, okay, what are the key benchmarks you want to see John Smith accomplish in order to demonstrate progress in his pain treatment? Then the case manager may go over to the mental health counselor and say, okay, what are the most important things for John Smith to accomplish this month in treatment? And you know, you'll look at the treatment plan, the clinician will look at the treatment plan and say, we identified these as our three top goals and great, okay. The case manager takes the information back from all the different referral sources, puts it into an integrated summary and disseminates it to everybody on the team. Case managers track patient follow up and clinical outcomes, including treatment adherence. Is the person showing up medication side effects? Whether the side effects are being reported to the case manager or to the counselor or medical provider, we want to identify medication side effects, changes in clinical symptoms and effectiveness of treatment. And effectiveness of treatment is really defined as how well is John Smith achieving the benchmark goals that have been identified by the different service providers? If John Smith isn't achieving those goals, then we want to step back and talk to John Smith and say what's going on? Are these goals that we've identified no longer relevant or important to you? And if so, what goals are or are you having difficulty achieving these goals and if so, why? What are the obstacles that you are facing? Let me help you overcome these obstacles. Case managers will document in person and telephone encounters in the electronic health record and use the system to identify and re engage patients. So the case manager will go down through their list. And case managers generally have a huge caseload, so they'll go down their list and they'll identify clients who seem to have been less attentive to treatment or may have seen, maybe they haven't come to their last two weeks worth of appointments. The case manager can easily see that in the EHR and can flag that patient for follow up to find out what's going on. With them and make sure that they don't fall between the cracks. Case managers document patient progress and service recommendations in the electronic health record and other required systems to be shared with other treating providers. Now, ideally, all the treating providers can access the electronic health record that this client's file is being maintained in. That's not necessarily always true. So it's important, if you're working with external referral sources, to figure out, okay, how are we going to make sure that everybody is literally on the same page with this client? Case managers facilitate plan changes for patients who are not improving as expected or who have reached maximal gains in consultation with the treatment team. So the case manager will go back to the treatment team and say, okay, John Smith isn't progressing as expected, and these are the things he identifies as being current obstacles to his progress. These are the things that I've heard from you guys as current obstacles to his progress. So what needs to happen? How do we need to change our approach as a team to help John smith start moving forward again? Or if John smith has reached maximal gains, then the case manager will come back to the table and go, hey, he's achieved every benchmark you wanted him to achieve. I don't think that he needs to be at this level of care anymore. So what's the next step? How do we step him down to the next level of care, Whatever that looks like? Case managers facilitate referrals for clinically indicated services within and outside of the organization. Some organizations, like one of the ones I used to work for, we had a little bit of everything. We have primary care. We had crisis stabilization. We had addiction treatment, detoxification, outpatient day treatment. We had the whole gamut of behavioral health services and some health services. But we didn't offer housing assistance, vocational rehabilitation, legal assistance. So those were things that we needed to refer to outside agencies for. And the case managers that worked at our. At our agency knew what services we offered and knew what services were available in the community where the client lived. We served a 13 county region, so there were a lot of things to kind of keep your finger on the pulse of. Case managers follow up with clients and referral services to ensure effective linkages. So whether it's within your agency or outside of your agency, the case manager is going to follow up with the client and say, hey, did you meet with the vocational rehabilitation counselor? And the client will give a report about how well it went or if it went. But the case manager also needs to reach out to that vocational rehabilitation counselor and go, hey, how did the meeting with John Smith go. Obviously, assuming there's a release of information or appropriate protocol is in place and get information from the VR counselor. The VR counselor may say, you know what, I really don't think he's an appropriate referral at this point in time because he's not stable enough on his medication. Or he showed up, but it smelled like he hadn't bathed in about three weeks. So we need to address some of these other things before he starts looking for a job that helps the case manager make appropriate referrals. It helps the case manager help the client identify anything that may prevent them from taking full advantage of the referral and just make sure everything goes smoothly. Case managers develop and complete relapse prevention plans with patients at admission and review those plans with those who have achieved their treatment goals and are being discharged. So yes, counselors and pretty much every service provider is going to develop a discharge plan beginning at admission. Why do we do this? Number one, to increase client engagement. But number two, we never know with any client if it's going to be their last session. Sometimes clients come once and never show up again. Well, if they only come that once, I want them to have some resources and tools that they can use in order to keep moving forward at their own pace. Most insurance companies require that discharge planning begins at admission. So this is not strange to do as a case manager. The case manager will assess the biopsychosocial needs of the client and will identify linkages and resources in the community that the client can pursue and will help them as much as they can access those resources. And that's where we start with discharge planning for case management and relapse prevention planning. If a client comes into the program and they are intoxicated, they are homeless, they have legal charges and clinical depression, well, okay, let's make sure you know where the resources are so you can address each one of those issues. Because ideally, if you come back into the system, we want you to come back in at a less intense level of care. Common issues for people in mental health and substance abuse. Medication access. And this can be for two reasons. Medication access for affordability. And most case managers, if not all of them, are very aware of patient assistance programs. You go on to the pharmaceutical company's website. Every pharmaceutical company that I know of has a patient assistance program to assist patients who cannot afford their medication and don't have insurance coverage in acquiring the medication that they need. Generally, it's just a matter of the physician filling out a one page form and faxing it into the insurance company. Medication access can also be a problem if the client can't get to the store to pick it up if they don't have transportation. And this is especially true in our rural communities. We want to make sure you know what needs to happen so you can get your medication. Does it need? Some pharmacies will actually ship medication now costs a little bit more. But if a client can afford it, then you know that that may be one thing. Other clients may not have transportation, not because they don't have a car, but because they're not allowed to drive anymore, because they've lost their license, because of a seizure disorder, because of substance abuse, because of too many driving while, license suspended or whatever. There are a lot of reasons clients may not have transportation to get to the pharmacy. Another reason issue clients may have is medication effectiveness. Antidepressants only work for about 30% of people and your antipsychotics and even your atypical antipsychotics and your newer generation medications. A lot of times the first medication a patient tries doesn't do the job or doesn't do it completely. So they may need to try multiple medications. It's important for clients to be able to advocate for themselves with their providers and say, you know what, this is not working for me. This antidepressant that you just gave me, I've been taking it for two weeks, I've been giving it a good try and yes, you know, six weeks before it takes full effect. I understand that. But during this first two weeks I can't wake up, I can't seem to get out of bed and I'm not going to be. I don't want to live life feeling like a zombie all the time. And that's a way that a patient can advocate for themselves with their primary care provider to maybe switch medications. Case managers may need to step in and encourage the client to self advocate. One way we can do this is talk to the client about what they don't like about their medication or what the problems are or why it's not effective. Write that down and then give that to the client to give to their prescribing physician. It's also something as a case manager that you can bring to the treatment team meetings and present to the physicians client reports these side effects. Right now, medication compliance is another issue. And this is for both physical medications like heart medications and blood pressure and HIV medications as well as psychotropic medications. One of the reasons people may not be compliant with their medication is side effects. It makes them feel Too groggy, it gives them headaches, it upsets their stomach, whatever. These things need to be addressed with the prescribing provider in order to address the side effects. The provider may say, oh, those will go away in three to five days, and if not, get back with me, because obviously we don't want you to discontinue your medication because of the side effects. Other times the provider will say, well, that is a side effect of this medication. Let's see about addressing it. For example, with certain atypical antipsychotics, they are very sedating. So some patients need to take their medication, their atypical antipsychotic in the evening. And I had one patient I worked with who figured out that the groggy period for the atypical antipsychotic for her was about the first 10 hours after she took it. So she did the math and figured out what time she wanted to get up and counted backwards 10 hours, and that's when she started taking her medication. And that made it a lot easier. I've had patients on certain antidepressants that found the antidepressants very sedating and found it more effective to take those antidepressants at dinner time or right before bed as opposed to first thing in the morning. Likewise, other antidepressants that patients have been on have been too stimulating, and it was important for them to take that medication in the morning so it didn't keep them up half the night. Another medication compliance issue is just plumb forgetting. The nice thing. There are wonderful apps now, because I'm really bad. If I get put on antibiotics for something and I have to take it three times a day, I will not remember that, or if my kids do or whatever, I will not remember that. So there are apps that you can download that are medication reminders, and they will bug the living daylights out of you until you actually take your medication. Most clients are going to have some sort of a mobile device that can prompt them to remember, if not figuring out some other sort of visual stimulus to remind them to take their medication. Getting the little medication boxes that say morning, noon and evening, so they don't wonder, you know, I can't remember, did I take my medication this morning? Well, if it's in those little boxes, they can look. And if that box is empty, they took their meds. If that box is not empty, then they forgot. Counseling access is another common issue, partly because of cost. And I saw in one place today a provider that. Well, a lot of providers I've seen lately are charging upwards of 120 to $150 per hour for individual sessions. Most of my clients, heck, most of my friends can't afford that. So cost can become very prohibitive. And you say, well, insurance will pay for it. Well, no, insurance won't pay for it until the person has met their deductible. And a lot of people, because insurance has gotten so expensive, have such high, such incredibly high deductibles that they are not going to make that deductible without causing themselves significant financial hardship. So it comes down to they're just never going to be able to afford counseling. Now clients who are on Medicaid and Medicare are in a bit of a different group because their deductibles are and co pays are significantly lower. That doesn't mean it's easy. You know, just because somebody's copay is only $5 doesn't mean they can afford it. Some people don't have that $5, you know, they're trying to get change from the couch cushions just to buy dinner. We do need to pay attention to that and figure out how we can best assist clients in accessing services that are affordable to them. And transportation is another issue as well as work. And we'll get to work in a minute. If for example, the client lives in a remote area, they may not be able to get from a rural town into the suburbs to see a clinician. So if you have satellite offices, that's great. But most of the time anymore telemental health is kind of the go to option for clients in rural areas. And we need to advocate with agencies to really start implementing telemental health. Most phones can do VC or any of your HIPAA compliant telemental health Things and jobs. Many clients work jobs where they can't afford to take time off. They don't have paid leave. So if they take time off, they're actually losing money because they're just not going to get that back. So they look for counseling services that are either before or after their work hours. Well, most clinicians operate on bankers hours, which is when most clients are actually working, which makes it more difficult for them to access services. If your agency is willing to have a rotating schedule where there is a clinician available in the evening, you know, two nights a week or something that can be really helpful and or on the weekends. Counseling effectiveness is another issue. A lot of clients don't realize that all clinicians are not made the same and all approaches are not appropriate for every single condition or for Every single person. Not everybody's going to respond to cognitive behavioral therapy. Not everybody's going to respond to humanistic or experiential. It's important for the clinician to be able to understand the client's needs. Additionally, sometimes counseling is not effective just because there is no rapport. The client walks into the clinician's office the first time they plop down. The clinician almost never makes eye contact, just works furiously on the assessment intake and then makes a follow up appointment. And the client feels very much like a head of cattle being herded in and just a number. It's so important to develop rapport. Many clients have bad experiences or many clients I've worked with have had bad experiences with the system. So when they come in, they're already a little bit suspicious and leery and not confident that we can help them. And then if the first session, or worse yet, first two sessions, make them feel like they're not being heard and that they are not an important individual, then they will likely not engage, which can obliterate, not even reduce, but obliterate the effectiveness of counseling. As case managers, we can ask them how their appointments are going, how they feel about their clinician, whether they feel they're being heard, what the rapport is like, if they feel it's working. If yes, then great. If not, tell me a little bit more about what you think would help instead or what might work better. And then advocate for the client to discuss that with the clinician, but also talking with the client about getting permission to share that with the clinician so the case manager and clinician can have a powwow. Support system is another common issue. A lot of times support systems of the identified patient, the person with the severe and persistent mental illness or the addiction or whatever, may not have any clue how to help the individual. They're just like, we want to help, but we're at our wit's end and we don't know what to do. It's important for case managers to reach out to those support people with appropriate releases of information and say, what information can I provide you or what services can I link you with to help you better support your loved one? Respite care is another important service. If you have, for example, a child who has severe autism or some other mental health conditions, since this is mental health case management, some other mental health condition that requires a lot of intensive supervision and care and can be challenging at times, the primary care provider is going to need a break. They are going to need a time where they can make sure that the child is well taken care of, but they can get time for themselves to take a break and take a breather and be their own person. So case managers can help facilitate linking the family with respite care resources. Caregivers support system may also need counseling to deal with grief or other issues surrounding the issues of the client. Maybe you're working with a client who had some sort of an accident and had a traumatic brain injury and is also experiencing major depression or something. And if the caregiver, for example, happened to be driving when this accident took place, the caregiver may need to deal with grief surrounding that. If the child is born with some sort of mental health issue, then the parents may need counseling to deal with grief issues surrounding the fact that this child may never be able to live independently because of their cognitive or mental health problems. Yet another common issue is child and respite care. Like I said earlier, the caregivers need respite care if they are taking care of a child or an adult with significant illnesses. Obviously you can have people who are chronologically adults who are not able to live independently and they still have still are living with their primary caregivers. Some people in mental health case management in mental health counseling, especially those with severe and persistent mental illnesses, we found that many people with severe and persistent mental illnesses and in recovery from addictions and stuff, benefit from employment or some sort of meaningful activity. It may be volunteer work, it may be supported employment, or it may be full out employment. Case managers can help link the person with vocational rehabilitation services to facilitate that. But if the person also has children, then they may need help accessing child care so they can participate in that aspect of their treatment plan. Some people may also need help with parenting education or assistance. Whether it's their first child and you know, Maybe it's a 15 year old mother, or if it's a child that they have with that who has autism or adhd, they may. The caregivers may need assistance with parenting education in order to understand how to help this child with their particular unique needs. Another case that may come up if you're working with families is you may be working with a parent who has a substance use disorder and a case plan with the Department of Children and Families. It may be important to help that parent successfully complete their case plan in order to achieve one of their goals of having unrestricted parental rights with their children. Housing is another issue. Affordable safe housing. There's affordable housing, but a lot of times affordable housing ain't in the best areas. Affordable, safe housing is important to reduce stress levels and ensure our clients can get the quality rest they need. Safety is another issue. We don't want clients in environments where they are unsafe, where they can be taken advantage of because of their mental health issues, or in the case of substance abuse, where, as one of my clients put it, dealers come to your door like the Avon lady. We do want to make sure that we, as case managers, we assess the environment. Nutrition. Nutrition is important. It provides the building blocks for the person to be as happy and healthy as possible. Given their current physiological and environmental circumstances, they need to be able to afford it. So making sure they're connected with supplementary nutritional assistance programs. They may need help shopping. Not everybody knows how to go to the store and shop and figure out what to get. They walk in there and there was one meme I saw one time and Homer was looking in. Homer Simpson was looking into a pantry and it was completely full. And he goes, there's no food. I see things to make food, but there's no food. And a lot of people, especially these days, it seems, really have no clue about how to make a shopping list to get the ingredients they need to put together food, if it's not already pre assembled. Teaching basic cooking, teaching basic grocery shopping is important for a lot of people to help facilitate their independence and activities of daily living, like how to pay your bills and balance your checkbook or balance your bank account. A lot of people don't have checkbooks anymore. In the case of certain mental health conditions, the person may not be able to pay their own bills or may not want to have access to the money that's in their account because they may spend it. And that can be true for somebody in recovery from substance abuse or somebody who has bipolar disorder. They may choose to have a proxy, if you will, who is a cosigner on their account or somebody who has financial power of attorney. That gets into a sticky wicket because that's a big deal to give somebody financial power of attorney. But sometimes it ends up becoming important. And hygiene, you know, helping people recognize that, you know, yeah, when, when you take a bath, you need to do it every day and you need to use soap and, you know, don't forget to, you know, wash behind your ears or whatever. Meaningful engagement is another issue that's important for a lot of clients. And we talked a little bit earlier about this with employment. Supported employment is one thing that case managers can link clients with. Supported employment is paid employment for people with developmental disabilities who without long term support are unlikely to succeed in a regular job. It facilitates competitive work in integrated work settings for individuals with the most severe disabilities who need ongoing support services in order to perform their job. Supported employment provides assistance such as job coaches, transportation, assistive technology, specialized job training, and individually tailored supervision. And there are a lot of places that are willing to work with people who need supported employment and, you know, a lot of grocery stores and. Chain big box stores. Those types of places are often willing to take on a few people who require supported employment. Some people may not be able to engage in supported employment. Their mental illness, for whatever reason, is prohibiting that. So they may do better in clubhouse or day treatment. And that's when they leave their house, they're picked up or they're taken to a place where they engage with peers throughout the day. And the clubhouses that I was involved with when I was in Florida, they had games, they had television, they had recreation therapists, they had counseling, they had a variety of things to enhance the lives and skills of the participants. Hopefully, maybe one day to get the person to the point where they can engage in school supported employment. But maybe not. But this at least got them out and provided them some social support. People with severe and persistent mental illness benefit greatly from case management. Case managers pick up where counselors leave off and help identify needs and services and coordinate the referrals for those services. Case management principles can be applied by counselors or nurses for patients whose level of severity does not qualify them for case management services. And if you're a clinician listening to this podcast, you know, I think all of us at one point or another have had to engage in case management services because the client just didn't meet that threshold for severe and persistent mental illness. But they weren't. They also weren't able to access the resources and proactively seek out the resources on their own. So they needed our help identifying and linking with those resources. Additional reading can be found in these two articles and you'll be able to click on them once I publish the PDF. Have a great day and I will see you next time. Thank you for listening to Case Management Toolbox podcast. Go to allce.com casemanagement to access the CEU course for this episode. You can also subscribe to Case Management Toolbox Podcast to be notified when new episodes are released.