Increasing Case Management Effectiveness | 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 slide that's allceus.com Casemanagement welcome to today's presentation of Case Management Toolbox. Today we're going to be talking about increasing case management effectiveness. I AM your host, Dr. Donnelly Snipes. Over the next little while, we're going to identify the benefits of case management, explore the impact of ineffective standard treatment, identify the goals of the case manager, review the research identifying the most helpful factors in case management, review assessment areas that we need to make sure we consider, explore common needs of case management clients and finally, describe characteristics of effective care plans and documentation. So case management can be defined as coordinated, integrated approaches to service delivery, ongoing supportive care, and help to access resources for living and functioning in the community. Case management picks up where clinicians leave off. We're helping as clinicians, we're helping diagnose and treat a particular mental health issue or physical health issue. In the case of a primary care physician or some other kind of physician, a case manager helps clients take that treatment plan and actually implement it. Helps them identify barriers and and ways to around those barriers and helps them identify strengths. So why case management? Well, frequent users of healthcare services are a small group of patients that often have multiple chronic conditions and psychosocial and mental health comorbidities. These people account for a high number of healthcare visits. You may have somebody like me. I don't go to the doctor very often. I really don't like doctors, so I don't go very often. If I didn't have to go for some unforeseen reason, I might go years between seeing a doctor. However, there are people who are in the doctor's office every single month, sometimes every single week, and they account for a lot of the healthcare visits. When I worked in community mental health, we had a certain group of people, a certain cohort who utilized our crisis stabilization unit, our detoxification unit, our residential treatment, a who lot more than other people. We would have them come back in repeatedly within the year. Frequent use of services is often considered a symptom of gaps in accessibility and coordination of care. So we're thinking about it. Why are these people high utilizers of services? What's missing? And for a lot of them, it wasn't that treatment itself. The treatment that was being provided was ineffective. It was great treatment, but they needed more. They needed assistance with Other things outside the realm of what a doctor or a mental health clinician typically deals with because of those gaps in care. For example, transportation. Some of our clients, they would be receiving great treatment, they would be doing great in residential, but then when they got into intensive outpatient, they would quickly fall off the radar because they were living in unhealthy environments. They didn't have transportation to get to treatment, yada yada. Case managers are there to help people figure out, okay, what's going to prevent you from continuing to attend your treatment and continuing to make progress? What might be some obstacles to you implementing this treatment plan? Patients with comorbidities and multiple issues. High users of services are at more risk for incapacity, poorer quality of life and mortality. Case management is the most frequently implemented intervention to improve care for frequent users of healthcare services and to reduce healthcare usage and cost. A clinician, depending on what type of clinician, I'm just gonna go with mental health. Social work, you know, generally is reimbursed somewhere in the area of $50 to $75 an hour by insurance companies. That's just kind of a general ballpark range. Case managers often, you know, when you look at the average salary for a case manager, they make about $20 an hour. So case managers are a lot more cost effective. For every three hours that a case manager spends with a client, it's the same cost as spending one hour with a mental health clinician or maybe 10 minutes with a medical doctor. If we can use these people more effectively, we're going to use our dollars a lot more wisely. Case management interventions resulted in decreases in emergency department use and cost, a better use of appropriate existing resources, and a reduction in social problems such as homelessness and drug and alcohol abuse. What's the impact of ineffective treatment? And when I say ineffective, I'm talking about our standard mode of counseling. For example, once a week, come in, see me, come back in seven days, we'll talk again. In between, you're kind of on your own. That's not effective for some people. Some people need more than that. And intensive case management or regular case management can bridge that gap between the seven days of services. Case managers can also help clients link to support groups and services in the community. To assist in bridging that gap. Case managers can help clients sort of weave that web. When we talk about recovery oriented systems of care, we talk about a safety web or a safety net that exists in the community that provides all of those ancillary or wraparound services to support a client. In implementing their treatment plan and achieving maximal gains when we're just doing our standard come see me, you know, we're not going to talk about ancillary services, yada yada. Treatment dropout tends to be high for a certain cohort of people. And we have dropout, which leads to continued illness, whether it's hepatitis or HIV or depression or substance abuse, it's going to continue. If they're not in treatment, most likely they're not just going to spontaneously recover. All of this can lead to work impairment because they're too sick or too tired or too hungover or all of the above to go to work. So they may end up having a poor work product, may end up getting fired. Who knows? This can all lead to financial problems, not only because of problems at work, but also because of costs associated with their illness. Relationship impairment. We know when people are sick, are in pain, are struggling, are emotionally pain, that they tend to be less pleasant to be around. And a lot of people who are experiencing dysphoria or pain, physical or emotional, tend to start having relationship problems after a while. Impaired parenting can also be an effect of ineffective treatment because you have somebody who is continuing to have symptoms of whatever the problem is. They may start developing some additional depression or anxiety to go along with that. They're in pain, they're suffering, they're struggling. It's really hard to get excited about going to the park or having a tea party or doing anything else with your kids when you are struggling just to get through the day. These people eventually may start developing stress related health problems. They may start self medicating with substances. They may start developing high blood pressure, obesity. There's a whole range of things that we tend to see in people who are in emotional and or physical pain. And they also may, as I said earlier, develop additional mood issues. At a certain point you get sick and tired of being sick and tired and you may feel hopeless and helpless to change that situation. Let's look at a case example. John has a substance use disorder, major depressive disorder and hepatitis C. This is kind of the run of the mill client that I used to see when I worked in community mental health. He doesn't know how to afford his medication for hepatitis or his depression. He has a history of suicidal ideation and a history of relapse. Currently he's unemployed, living in a local motel and recently got a dui. Okay, so John has a whole bunch of stuff going on as a clinician. I'm seeing him and I'm trying to help him stop using substances and address his depression. However, he's going to need assistance figuring out, where do I get my med, how do I get my medication? Well, the answer is patient assistance programs. A lot of clinicians either don't know about patient assistance programs or they don't have the time because their caseload is so heavy that they can't go and, you know, look up the, the pharmaceutical company that makes his medication, find the patient assistant program form and print it out for him and do everything they need to do, which is where the case manager comes in. The case manager says, okay, you know, Dr. Smith has prescribed this medication for you. What's going to block you from keeping it? Okay, you don't know how to afford it. Let me help you figure out how to do that. Dr. Jones is your counselor and you need to be able to go see her. So how are you going to get there? What might keep you from getting to those appointments? What else might impair your ability to implement your treatment plan? Oh, well, let's think about Maslow's hierarchy. You're living in a motel, and the motel that John can probably afford right now is probably not in the best neighborhood because he is unemployed, which means he's probably in close proximity to people using substances, which puts him at high rate of relapse. It means his consistency of safe housing is probably a little bit wonky because, you know, as soon as he can't pay his bills, he's going to be out on the street again. We need to look at helping him find safe, sober housing. We need to look at anything that's going to block him from getting his medications or fulfilling his treatment plan. But again, a lot of that doesn't get addressed in counseling per se or in the. When you're seeing your primary care physician. How many times is a primary care doctor ever, ever sat down or a physician of any sort ever sat down and go, gone, okay, this is what you need to do now. What things might keep you from actually doing them. Most doctors are going to say, this is what you need to do. You need to figure it out. Many of our clients, for one reason or another, can't figure it out. The healthcare system, we are used to it. We work in it day in and day out. We're used to those navigation things that we need to do. A lot of clients is totally overwhelming. When my grandmother was getting older, she started having significant health problems and navigating that system was completely overwhelming to my mother. I remember being on the phone with her multiple times going okay, mom, this is what you need to do. First step is to call the care manager at Medicare and, you know, helping and walking her through it and advocating for her, because the care managers weren't really, really doing their job, but good case management would have been. So we need to make sure that we recognize the fact that the physicians aren't going to do it. Most clinicians, they can't bill for those services, so they're probably not going to have time to do it. Who's going to do it, and if it's not done, then we're going to see a higher rate of client attrition. So, counselors, if you're listening right now, you may be scratching your head going, well, that sounds all well and good, but I'm in private practice. What am I supposed to do? I don't have a case management department or, you know, if you're working in community mental health or for a practice, you may be scratching your head going, well, we don't have case managers. How do we help people? Go to your provider administration manual and you can do a search online for case management reimbursement and then the name of the insurance provider to find out what their rules are. Blue Cross and Blue Shield, for example, has a number that you can call if you've got someone who has a complex situation that may require care management. I really like this one from Aetna. I didn't link to it anyway. It provides information about who can receive case management services. And basically for people with mood disorders, for example, who are over 14, they will provide an array of case management services or make an array of case management services available. It's really important, you know, as a clinician or a case manager, what types of services that the insurers will provide for the clients that you're seeing. Some of the goals of case managers are to increase and maintain client engagement and motivation. Case managers typically don't treat illnesses. They don't treat kidney disease, they don't treat major depressive disorder. They're there to help the clinicians and client most effectively implement the treatment plans. So how can they do that? Well, one is to improve the client's health literacy. There are a lot of things that are common to a variety of issues. You know, good nutrition, good sleep, pain management, stress management, yada yada. Helping clients learn about those things, why they're important, and where to find more information. Most case managers are not registered dietitians. They're not going to be able to make a nutritional plan for somebody, but they can Say, let's look at this website from health.gov on healthy eating and let me point you in the direction of some good resources that you may be able to look at to learn about, you know, easy recipes you can make or something. Health literacy involves empowering clients to take charge of their health. Help them learn where to find information about different treatment interventions and evaluate what's going to be best for them, and empower them to make decisions in their best interest instead of just being passive consumers where they show up at the doctors and they're like, you know, I feel like crap. Make me feel better, I don't care, just do it. We want them to be actively engaged. Case managers identify and address obstacles to, to implementing the treatment plan. Whether it's looking for payers, sometimes insurance companies are not wanting to pay for certain services. Okay, so how do we get that paid for? Or sometimes insurance companies have a lot of services that are available that the client doesn't even know anything about. The case manager can say, oh, let me tell you, here's all the things that are available to you. Case managers can identify issues like transportation, you know, getting to and from appointments or to and from the grocery store are really important. Language and literacy issues. If, when clients go to appointments, a lot of times they're given handouts, or if they're lucky, they're given handouts. And those handouts are written at, you know, an eighth grade level to a tenth grade level most of the time. Well, for some of our clients, that may be too intense for them. They may need something at a lower literacy level. Case managers can assist in helping them with that. And child care is another example. These are just examples of obstacles to implementing the treatment plan. And you really want to take a wide angle perspective. What could keep you or what might prevent you from implementing this plan? Case managers also identify and enhance strengths. They look at the person and the person's situation and they say, okay, what do you got going for you here? What's worked for you in the past? What are your supports right now? What resources do you have? Okay, let's make a list of all these strengths that you've got going for you and let's build on those. Case managers serve as a healthcare guide, helping people navigate the system. And this enhances engagement and motivation. Because if people don't know what they're doing and when they're supposed to make what appointment, and if they need a referral and this and that, it can get overwhelming and they may not do it, so they may not become Engaged. If they know what the next step is and they feel empowered to take that step, then they're going to be more motivated to do it. Case managers also just provide support and encouragement. Case management contacts are often shorter but more frequent than clinical contacts. That case manager is there to reach out to somebody and go, how you doing today? Another goal, and I said before that they don't treat issues that are going on, but another goal is the reduction of symptoms. How do they do that? By making sure that the client can effectively implement the treatment plans that the clinicians have set forth. If they're having difficulty, a case manager can help them self advocate. Maybe the medication the doctor prescribed is having some really bad side effects. The case manager can encourage the client to self advocate with the physician and in some cases may do the advocacy for the client, depending on the client's functional status at that point in time. Case managers also can increase client engagement and keep clients involved in the process by reducing the burden on caregivers. When we reduce the burden on caregivers, whether that's people who are living in the household or people who are actually directly responsible for that person's care, it improves the psychosocial environment. People aren't as stressed out, people aren't as frustrated. It improves social support. Case managers can reach out and look for services to assist the caregivers, like domestic help or transitional services. I remember again when my grandma was getting ready to go into an assisted living facility, she did not want to go. She did not want to sell the house that she had lived in with my grandpa for almost 40 years. The transitional services were really important to help navigate this process for her. Getting into a facility that would meet her needs. And, you know, the number of facilities out there was kind of overwhelming. So the case manager was really helpful at helping my family try to pare down and figure out, okay, which ones do we need to visit and interview, and what kinds of services might grandma need so we know what to look for. And case managers increase confidence in both caregivers and clients for self management. Many times, caregivers, depending on the issue they're dealing with, if they've got a loved one with Alzheimer's or autism, they may be a little unsure of whether they have the capability of best meeting the needs of that particular person. When we talk about clients, clients may have some apprehension about their ability to meet their own needs and do what they need to do because it may just seem totally overwhelming to them. So case managers are there to use some scaffolding to help Them figure out, okay, what's the next thing I need to do. Helpful factors in case management. Access to medical, social and community resources. Well, that's kind of part and parcel of case management. Case managers need to have these resources available. They need to know, oh, my gosh, there's this program over here that is great for you. Case managers need to be plugged in to that recovery web and able to make effective referrals efficiently. A calm and trusted case manager. So a case manager needs to have their wits about them and not be frustrated and harried and rush in and go, okay, I'm here for our visit. Is there anything you need? Okay, nothing you need. I'm out. The case manager needs to walk in and actually treat the person like a person and engage with them at that appointment. Case managers that have strong relationships to referral sources tend to be much more effective, which means communicating with them effectively about patients that you have in common, but also connecting with them periodically to know what services they're continuing to provide, who the contact people are. It's recommended that you follow up with your referral resources at least once a year, but preferably once every six months just to see if there have been any changes in the contact person or the eligibility criteria or anything like that. Effective communication between a case manager and treating clinicians via a unified treatment strategy is also super helpful. You may have a client who is seeing a medical doctor, a pain management specialist, an endocrinologist, and a clinician. Well, each one of those people may have a different sort of treatment plan. A case manager can help synthesize those treatment plans. So there's one unified strategy and the person doesn't feel like they're being pulled in six different directions. That makes navigating the system a whole lot more effective and less overwhelming, which increases engagement. There's a multidisciplinary care plan instead of, like I said earlier, we don't want to just focus on, okay, this client is a client that has severe and persistent mental health issues. We're going to focus on him taking his meds and staying out of the crisis stabilization unit. Well, there's more to it than that. You know, you've got to look at housing, nutrition, sleep, meaningful activities, a lot of stuff that may contribute to treatment plan compliance and staying out of the crisis stabilization unit. Life skills coaching was found to be another effective intervention for case managers to use with certain populations of people. They may not know what they need to do. They may need some assistance with basic life skills for others. I remember Having a child in the neonatal intensive care unit, when he came home, it was my first child. You know, most parents are kind of going, I'm not sure what to do. I wish there was instruction manual. Well, it was even more so with my son because he had been in the hospital for six weeks and I felt like he was really fragile. So coaching on ways to best help him and ease that transition might have been helpful. Frequent contacts with the case manager are also very, very helpful. Like I said, some clients have difficulty going an entire week or two weeks between contacts. Frequent, shorter contacts are often helpful, especially in the acute phases of treatment, until the client feels empowered and sort of gets their wits about them. Regularly reviewing the care plan with the client was also found to be a helpful factor at increasing engagement and motivation because the client could see how far they come, they could see what they'd accomplished. They could also see if there were sticking points in their treatment plan. It becomes more obvious when you review regularly what is going on and where the problems might be so they can be addressed early on. So this regular review is really important and it's not just a clinician going over it going, yeah, this person has an accomplished goal, A, E and C, A, E and F. It's going over it with the client and going, okay, what have you accomplished? Great, you've done awesome. Look at all the progress you've made. Now, there are a couple things that you're still not achieving on a regular basis or you still haven't crossed off your list. I'm wondering what's keeping you from achieving that? What are the obstacles that you're facing right now and how can I help you? It's a collaborative process, but it helps the client become more mindful of the process and what they may need. Case managers that assist with healthcare navigation, like I said earlier, are huge or are super effective at reducing anxiety with regard to implementing that treatment plan, and which doctor do I go to and who do I call? And is insurance going to pay for this? And yada yada. Patient education and health literacy enhancement was also identified as a really helpful factor in improving patient satisfaction and engagement in the treatment process. If they understand what their condition is and what they're supposed to do, imagine that they become more engaged and assistance with coordination and prioritization of care. If you've got six different treating clinicians, it's hard to know what you're supposed to address first and which appointment to make, when, when to get an mri, when to get your blood work done. It can get Overwhelming. A care manager can take all those treatment plans and synthesize them. So the client just has to look at one document and okay, know, okay, the next step is this. It's very simple for them or relatively simple for them, and it feels a lot less overwhelming. As a case manager or all case managers are going to do some sort of an assessment for their clients. And yes, they do assessments with their clinicians, but those clinicians are doing assessments for a particular issue, if you will, whether it's depression or substance abuse or kidney disease or Alzheimer's or autism. The clinicians are looking at something that they're going to diagnose and treat. A case manager is looking at everything else. So a case manager is going to assess what are the client's emotional needs right now? Do they need social support? Do they need a support group? Are they grieving? Are they depressed? Are they anxious? What's going on? Identifying kind of what's going on, going on emotionally with that client and with the caregiver. And I use that term, caregiver broadly because it may not be somebody who's directly making meals or providing care, as may have to happen in, you know, cancer treatment or somebody with advanced stages of Alzheimer's. It could be just the people living in the household that are part of the client's life. But we need to assess their emotional needs. What do they need? We need to assess the client's cognitive functioning. Can they read this treatment plan and interpret it? Can they follow instructions or are they having difficulty with that? Clients who are in early stages of detoxification or who have some sort of cognitive impairment due to stroke, Alzheimer's, Korsakoff syndrome, there are a variety of things that can contribute to impairment and cognitive functioning. We need to be aware of those physical complaints. This can be over and above what the clinical providers have already assessed. Do they have any other physical complaints that are going on? If so, the case manager may need to make referrals for additional provider assessments or may need to refer that client back to their primary treating physician and get those physical complaints addressed. It's important for the case manager to encourage the client. I've said it before, I'll keep saying it to self advocate because sometimes physicians can be so focused on, okay, you came in here for fibromyalgia. We're going to focus on that. That they're missing the back pain or they're missing the other complaints the client has. I know when I go to my physician, I find it extremely frustrating because I don't go very Often, but when I do go, I usually have two or three things I want to talk about. And they're like, what are you here for today? And it's almost like you can only say one thing. They don't want to hear anything else. And it can be really frustrating. A case manager will help clients figure out how to navigate that. Case managers may assess the client's sleep quality. Are you getting good quality sleep? And educate them about the importance they're going to learn about the client's current physicians, medications, diagnoses, and treatment plans. They may. You know, where I used to work, it was a community mental health center. And if we had a case manager step in, the case manager was aware of my treatment plan. The case manager may be aware of the treatment plan of the psychiatrist, but if the client had external providers, the case manager may not be aware of those. It's up to the case manager in this initial assessment to go, okay, I need to know all the doctors you're seeing, all the medications you're on, all the diagnoses that you've got, and so I can coordinate these treatment plans. Case managers assess motivation. Some clients are gung ho and gangbusters and ready to hit it, you know, as it comes. That's great. Other clients feel completely overwhelmed or they're depressed, or in the case of early detox, they may still be in kind of a fog. In the case of cancer, once you've gotten that diagnosis, some people see it as a challenge and they're just ready to go and hit it hard. Other clients get that diagnosis and they feel very resigned and overwhelmed. The case manager needs to assess their level of motivation to be treatment compliant and also figure out, okay, what can I do to improve their motivation? Case managers need to assess the client's knowledge about the condition. The clients may have already gone online and read everything there is to read, ordered books and, you know, taken classes. I don't know, whatever that was me when my son was in the nicu, I ordered every book I could find on premature infants and what you are supposed to do and yada yada. Whereas other people may know nothing about that particular topic and they haven't had the opportunity to go down that path yet. So the case manager needs to figure out, what does this client know about the condition, the prognosis, etc. Again, the case manager needs to assess health literacy. How much does this person know about what's required just for the average person to live a healthy life? Exercise, sunlight, sleep, nutrition, all those basics that form the foundation of keeping the body healthy so it can help people feel happy and feel excited and feel less pain, all those things. Access to safe housing is another thing that a case manager is going to assess whether the person is living in an unsafe environment or they're living in a very stressful environment. Case manager needs to figure out, is there anything we can do to make this person's living environment feel safer and more relaxing and more conducive to recovery. Access to healthy meals. And this isn't just nutrition. This isn't just going to the food bank or going to the grocery store and getting ingredients. It means actually putting the ingredients together and ingesting them. And I know that sounds silly to say that way, but I've got a teenager at home and he can look at a full pantry and go, there's nothing to eat, mom. Oh, goodness gracious. Cook something. So some people can't get to the grocery store, Some people can't afford the food. Some people just don't know how to cook and have no idea how to put together a healthy meal. The case manager can assess where that client's obstacles may be, if any, in that area and provide them resources to help them along. You can find a lot of really easy recipes online now. You can find community education classes that teach cooking. You can find, you know, worst case scenario, healthy, healthy, ish frozen dinners. There are things that people can do to make sure that they're getting healthy meals. Case managers need to assess the ability of the person to perform activities of daily living such as cooking. And I said just a minute ago, some people may not know how to cook. Okay, well, if they know how to cook, are they safe to cook? Again, I'm going to pick on my grandmother here. God love her. She stayed as independent as she could for as long as she could. But once she got into her 90s, she started forgetting things like the fact that the stove was on. And that can be really dangerous. Making sure that clients can do what they need to do, and if not, what are the workarounds? If she can't cook for herself or she can't use the stove anymore, what can she do? Can she use the microwave? You know, those are different things that a case manager could assess. Can the person bathe by themselves? Number one, are they going to remember to do it? Number two, as in grandma's case, can the person get in and out of the tub safely? If not, what do we need to do to facilitate that? Because, you know, sitting in your own filth? We've all done it we've gone to the gym or something and we've gotten all sweaty and dirty and then we've gotten sidetracked and haven't gotten to take a shower right away or whatever. Gone to sleep at night and gotten all sweaty. And you wake up in the morning, you just feel gross. You're like, ugh. Bathing is essential to not only physical health, but also mental health. People feel a lot better when they are cleaned up. Dressing. Can people choose appropriate clothes for the weather? Can they do their own laundry? Can they take their medication as prescribed? Can they remember to take it? If not, what interventions such as apps on the phone can be used to prompt that person to take their medications? They've got services now that will prepackage all your medications. And especially for people that are on a lot of meds, sometimes this is really helpful because they don't have to think, you know, and remember, well, I take two of these and one of these and a half of this one twice a day. And it can get overwhelming. It's prepackaged. They just have to remember to take the packet. And if it comes around to 10 o' clock and they're like, well, did I take my morning meds? And they look and the 8am packet is still sitting there, they know they didn't take their medication. So then, you know, they probably could take it. Depending on the medication. A case manager is going to help identify roadblocks or obstacles. And I keep using the word obstacle instead of barrier because obstacle is something that you can go over or around. It's not something that prevents you from getting somewhere. Case managers identify obstacles and solutions. Paying bills is another thing that can be overwhelming for clients for a lot of reasons. Can they. What can they do to make that easier? Do they need a proxy to pay their bills? Can they set up autopay? Which is usually not a good idea with somebody on a fixed income or with no income. But how can they make sure that happens? And then domestic chores. There was one client I worked with that was in independent living and he had copd and you know, he would. And schizophrenia. One of the things that he had difficulty with was remembering to clean. It wasn't because so much because he couldn't remember, it was because he didn't like to clean. So he would intentionally forget and he would just sit there and watch tv. He needed help not only getting motivated to clean, but remembering to do it. So one of the things that we did was we broke the chores down instead of doing everything on one day, which was Exhausting to him. He was supposed to do one chore each day, every day. So one day he would swiffer. His unit wasn't that big, so he would swiffer and that was his chore. The next day he would wipe down the tub and so on and so forth. Case managers assess social supports and help people figure out, where do I find help with this? You know, my kid was just diagnosed as with autism. Where do I find social supports? Where do I find people who get it? Case managers can help with those linkages. Case managers help ensure meaningful activities. As clinicians, a lot of times we're so focused on recovery, we forget about the other meaningful activities. Going to the park, going to the gym, doing things that you like, doing your hobbies, engaging in something during the day. That quote gives your life meaning. Case managers can help clients figure out what that looks like for them. For example, for me, a meaningful activity is snuggling with my dog. If I didn't get to do that, I would feel like something was missing that day. It doesn't have to be something super active, but we want to make sure that the client is having, as much as they can, a high quality quality of life, as they define it. Transportation issues, financial stability, and vocational issues are other things that a case manager will address. And vocational issues, if you're not familiar, rehabilitation counselors. Vocational rehabilitation counselors can help with a lot of that. If somebody is displaced because either they lose their job or they get laid off, or they can't do what they used to do because of their current illness or injury, a rehabilitation counselor may be able to help them find a different job. Job coaches are there to help people get back into the workforce and sometimes people. And this can be done either by rehabilitation counselors or even to an extent, by case managers helping people advocate for themselves in order to get reasonable accommodations that are guaranteed to them under the Americans with disabilities. So what do people need? We've talked about interventions that have found to be especially useful in case management. They reviewed, you know, hundreds of cases and found that the particular interventions we talked about were common among the clients who successfully completed treatment. We've identified things that a case manager is going to look for in an assessment in in order to help round out that treatment plan and make sure that the person can most effectively implement it. Now let's talk about needs. What do individuals and caregivers need? Early diagnosis and intervention. The earlier we can start treating it, the better the prognosis is. In most issues, education regarding the condition or conditions what will make them worse? What can help make them better? And the expected course of the illness. Some things, you know, are expected to go into remission or to go away. If somebody has an accident in a vehicle and they break their back and maybe they're going through physical therapy and, you know, trying to regain their ability to walk, okay, what is the prognosis? What is the expected course for this person? Are they expected to be able to walk again? And what things could help them improve and what things might not? Part of the exacerbating and mitigating factors is from the research we know that doing this tends to slow your progress, or doing this tends to improve your progress. But part of it comes from the client. What have you done before if you've had a situation like this that's helped you? People need to be actively involved in their care planning. And this is where a case manager really comes in and goes, okay, let's talk, what do you need? Case managers provide clear explanations of treatments and expectations. When clients are just handed a care plan, they're not sure why they're going to this doctor or why they're doing this, or they get these instructions for doing something and it's, it doesn't make any sense to them. They're not going to be engaged. A case manager is going to make sure that clients understand their treatment plan, what they're doing, why they're doing it, and what the expected outcome is. Clients need meaningful guidance on addressing emotional and behavioral issues and their caregivers too. When they start feeling depressed, when they start feeling frustrated, when, when they start having behavioral issues. And this could be anything from substance abuse relapse to self injurious behaviors. When something like that starts to happen, what can they do? How can they address it? A lot of times clients and caregivers need information referrals for legal assistance regarding issues related to guardianship, power of attorney, or advance directives. Clients and caregivers may need assistance with financial planning and resources, especially if the client or caregiver has to quit their job. If house remodeling needs to be done, or if there are expected long term care expenses or expensive medications, they may need a referral to a financial advisor of some sort. And they may also need advanced care planning for future problems. Diabetes, for example, is an ongoing issue. And if it's well managed, it may never get to this point, but it may get to the point where the person needs to have a limb amputated or have a pump. I don't know what the word is installed in order to administer their insulin. In the case of Alzheimer's, you know that that's going to be a progressively degenerative disease. What is the person going to need now, six months from now and 10 years from now? So the person can, the caregiver can plan ahead for what exactly is going to be needed. And they have an idea about this is what I need to look for in terms of when it's time to potentially move my loved one into some sort of an assisted care facility. Clients and caregivers both need social and emotional support for what they're going through and access to specialists primarily for the client. Depending on the issue, this could include geriatric physicians, pain management physicians, psychologists who are also addictionologists, or palliative care specialists. In the case of terminal illnesses. People, as I said before, need meaningful activities, preferably every day. Case managers can help clients figure out how to work that in. And a lot of us, you know, don't do that ourselves. You know, we get up, we go to work, we come home, we eat dinner, we relax for a minute, and we go to bed. And you know, if your work is meaningful, that's great, but if it's not, then what did you do that was meaningful to you that day? Encouraging clients to be able to write that down. What did I do today that was meaningful to me? Clients and caregivers may need assistance with activities of daily living, management of behavioral, mood, and cognitive issues, and safety management. Safety management is pretty broad depending on the issue. You know, if you're working with somebody with Alzheimer's, you're going to worry about wandering. For example, if you're working with somebody with autism, you may worry about self injurious behaviors. If you're working with somebody who has a physical disability, you may worry about slips and falls. There are a lot of different things we want to make sure that this person, person is going to be safe 24 7. And you know, when we bring children home from the hospital or when we have toddlers around, we assess our environment. We make sure the door is locked so they can't, you know, wander out. We make sure that all the chemicals are put up high or and in locked cabinets, yada yada, we want to make sure that our client's environment is safe too. And when we're talking about substance abuse, for example, that also means making sure that substances are not available to them. You know, having opioids in the medicine cabinet or alcohol in the liquor cabinet is not safe for somebody who is in especially early recovery Effective care plans relate directly to the assessment. And the best way I can explain this is to kind of give you an example. You want to make sure that it answers the what, when, who and how. I think those are the ones I wanted to do of everything. And it needs to be directly tied to the treatment plan goals. So, for example, a goal would be for Sally to improve her mood as evidenced by an average self report of happiness of 3 out of 5 each week. So that gives Sally a little bit of wiggle room. She can have a couple of two days and a couple of weeks, four days, but we want an average of three. Right now we're setting her up for success. Eventually we're going to get to an average of a four out of five, but let's go for a three right now. Bathing daily, completing daily chore list and connecting with at least one friend each day. So theoretically those are benchmarks that Sally has identified as I will know I'm not depressed when, you know, I'm bathing daily, completing my chores and connecting with friends again. So score. So we've set that up based on Sally's definition of what recovery looks like to her. The goals, Sally will attend outpatient therapy with Dr. Smith once per week. So we know who is going to do it. Sally, how often is she going to do it? Once a week. With whom? Dr. Smith. But there could be some hiccups in there. So the case manager will link Sally with transportation services to ensure her ability to attend her therapy appointments. So the case manager is going to figure out, okay, how can we help Sally get to these appointments? Dr. Smith is going to seek pre approvals for Sally's appointments at least three days before the final approved session. That way they don't run out of sessions and have a three week gap or something. While Dr. Smith is waiting to hear back from the insurance company, Sally, that's the who, will set a reminder on her phone to complete between session assignments from Dr. Smith. So that's what she's going to do and how she's going to remember. Sally will take her Sertraline as prescribed each day. Sally will put a reminder in her phone to make an appointment with Dr. Jones at least two weeks prior, prior to needing a refill. And this may be something that case manager needs to help her figure out. So she's got a 90 day prescription and today is May 1st. So when is she going to need a refill? And then let's count back two weeks and that's when she needs to call and get an appointment. With Dr. Jones and have her put that in her calendar and set a reminder alarm for that. That way she doesn't get caught unawares and go, oh, I'm out of medication. Oh, my gosh. Sally will set a reminder on her phone to connect with one friend each day. Jane, Sally's partner, will assist Sally in identifying depression triggers and engaging in distress tolerance activities. So if Sally's sitting around the house and just feeling depressed and not doing what she wants to be doing, Jane may identify that, you know what, you seem like you're really struggling today. Try doing something from this list of your distress tolerance activities. Sally will keep a daily log of her mood. If she takes a bath, what she eats, her chore list, and if she connected with a friend. So we're going back up to that first overarching goal and she's identifying her progress at meeting those benchmarks each day. We want to tie everything back. You know, like the transportation thing, that kind of seems like it came out of left field. But if Sally doesn't have transportation, then it's going to be important to make sure that we arrange for transportation or she arranges for transportation to get to those appointments. When we document case management activities, it's essential to capture relevant data and elements. What is the client doing? What is the client's progress? You're going to look at the service plan and you're going to say, okay, Sally did these three things related to Goal 1. Sally did these three things related to Goal 2. Sally had these challenges related to Goals 1 and 2, and we identified these interventions to address those challenges. You want to present an accurate customer snapshot. How is Sally doing that day? And by reviewing Sally's logs, you're going to get a pretty good idea. You want to identify and note deficiencies and barriers and link directly to those services and activities. So if Sally wasn't able to complete her chore list every day that week, you know, that would be considered a deficiency. So what was it that kept her from meeting that goal? And why is meeting that goal important to her? Sequential tracking and reporting of client contact and progress. We need to make sure that, you know, those notes are done in a timely fashion and are complete in order to, A, get reimbursed, but B, also, again, remember, every time you do these notes, it's effective and helpful to do it with the client. That way they can see their progress and they can help brainstorm interventions. You want to describe any newly emerging barriers and revise the action plan as needed. That should be pretty much in every single note. Why are notes important? Well, because if it isn't written, it didn't happen. And that's what any auditor is going to tell you. It helps clients and providers conceptualize progress, identify and ameliorate barriers. And in house sharing of notes is critical to customer service. I know it used to frustrate clients and me to no end. If I would get the chart and there wasn't data, the note from the psychiatrist wasn't in there yet and they had already seen the psychiatrist two weeks ago and I was trying to figure out what the status was. It's important for continuity of care to make sure that those notes are done for in house sharing, for external sharing, it's critical to optimizing referral relationships. So if I'm working with pain management physician Dr. Smith and we have the same client, then I'm going to want to be communicating with them and sharing with Dr. Smith my progress notes. And, you know, obviously within the realms of HIPAA and yada yada, access to and close partnerships with healthcare providers and community service resources are key factors of successful case management interventions that should target patients with the greatest needs and promote frequent contacts with the healthcare team, particularly frequent contacts with the case manager. Assessments and interventions must be biopsychosocial in nature, not just focused on your particular ally. But really look at what could assist the client in complying with treatment and what could prevent the client from succeeding in treatment. And these assessments, interventions and plans should identify who is going to do what, when they're going to do it, and why they're going to do it. What's the point in going to these sessions with the therapist? Well, to address her depressive disorder, what's the point in going to the registered dietitian? It is to help Sally develop a better nutritional plan so her body can help her be happier and healthier and naturally balance those neurotransmitters, yada yada. But it's important to tie all those things together. So when an auditor's reading your treatment plan and you have something in there that seems like a non sequitur, they don't go, well, why did you refer her to a dietitian? And you have the reason right there so the auditor can see, oh, she went to the dietitian because she wasn't eating and that may have been contributing to her depression. Okay, got it. Make sure you connect the dots in the chart so everybody knows who's doing what, why and when. 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.