Principles of Case Management | 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 casemanagement that's Allce. I'd like to welcome everybody to today's presentation on standards of practice for case management. And I know in some ways, in a lot of ways, that sounds terribly dull. However, I think you're going to find that this might be relatively enlightening. It is based in part on the standards of practice for case management by the Case Management association or Case Management Society of America. Today we're going to explore the benefits of adding case management to your skill set. A lot of you are clinicians, therefore you are probably, you know, doing case management some, but it's really one of those other duties as assigned. However, case management actually can be a business all on its own and it can be quite lucrative. We'll also explain the principles of case management. Identify practice settings that you might be able to get some contracts or find jobs and review risk factors or targets for case management. Why case management? Well, it can be an adjunct to clinical practice. There are only so many hours in a day that most of us are comfortable doing individual or even group counseling. At a certain point, we start getting kind of bleary eyed. And part of that depends if you're working for an organization, how many billables you have. However, a lot of us, especially those of us who are in private practice who have the flexibility to do a variety of different things, would probably rather not see more than three to five clients in a particular day just because it can be so mentally taxing and emotionally taxing to see more than that. What do you do with the other three hours? How can you turn those into billable hours? Case management is one option. Case management does require you to think and do work, but it's different and a different type of mental gymnastics that you're doing. Case management enhances coaching and clinical services. It helps people take what we talk about in coaching or clinical sessions and translate it into practice. Case managers often help the person look at their treatment plan and figure out, okay, what's the next step to implement it. They are the scaffolders, if you want to think of it that way. They're the people who are going to help clients identify and work around obstacles on a relatively regular basis. We see them once a week. A case manager may be touching base two, three, four times a week. Case management can be its own Business. In this high copay, high deductible world, there's a lot of people who don't want to have to pay to be hospitalized. Case management can be really helpful. Case managers can help people stay out of long term care facilities or transfer from long term care to home in or short term care to home in a shorter period of time. They may not be able to just, you know, go home. They may need some assistance, but the case manager is the one that will help bridge the gap of that transition with high copay and high deductible kind of going over a couple of insurance terms here. For those of you who are relatively unfamiliar, your deductible is what you have to pay before insurance will pay a dime. And a lot of people are going with high deductible plans because insurance is so expensive. So they have to pay 3, 5, $10,000 before insurance even kicks in. High copay means that even if they have a low deductible and insurance is paying something, they may still be paying 20 to 40%. 20% of a hospital stay can be really expensive. When my son was in the nicu, just the privilege of having the bed in the nicu, not including the doctors and the treatments and everything else, but just the privilege of having the be was $10,000 a day. So 20% of 10,000 is a lot of money when you consider he stayed there for six weeks. And people are regularly confronted with this when they have elderly family members, when they have family members who have surgery, when they have family members who are unable to live independently, completely independently, intensive case management can be implemented and can be much more cost effective. Another issue with case management, or to help you understand how case management can be profitable, is called capitation. And that's another one of those insurance terms. Capitation basically means if you are at agency ABC and you get the contract with Medicare or Medicaid to be the HMO provider for behavioral health services. Well, that's great, you know, so this organization ABC got this contract. Capitation means their Medicare or Medicaid or the insurance company is going to say, okay, in your service area. We have 100,000 people that are enrolled in our program. 20% of those people are expected to need 10 sessions of brief therapy and we compensate at $45 a session. Therefore, it's expected that in this population to provide the care they need will cost about $900,000 a year. That's, you know, 20,000, 20% of the hundred thousand times $45, times 10 brief therapy sessions is $900,000 a year and you may be seeing that number going, cool, that's a lot of money. But what happens if 30% of those hundred thousand people start needing care? Well, you don't get any more money. You have to make do with the $900,000 you got to serve those people. What happens if only 10% of those people need services? Well, then you have a surplus. And that's a good thing to an extent. A lot of times with capitation, it's sort of a use it or lose it philosophy. If only 10% of the people needed services and you only used, you know, 500,000 of the month, the money that year, then the insurance company may start to rethink what their population utilization rates are going to be. So the next year you may get a lower amount. It's a balancing act that your CEOs and your COOs will worry about. The take home message. If you're working with an agency that is in a capitated contract with an hmo, it behooves them strongly to make sure that the population that is enrolled with that insurance company stays healthy. The less they seek services, the more profitable the year is going to be. That's where case management comes in. Case managers can really help at identifying areas for early intervention. You know, if somebody stops taking medication or they're starting to decompensate, case managers can identify that earlier than people generally independently will reach out for help. Case management gets people in the door sooner. Yes, it does get people in the door, but it gets them in the door sooner so they can address the problem before it becomes a huge issue. Kind of like when you get a cut on your arm. If you treat it right after you get it, the likelihood of it getting infected and you having to go to the doctor is pretty small. But if you get that cut and you don't do anything, you don't pay attention to it, or you wait a week, then there's a chance that you're going to have a much more expensive doctor bill. Case managers ensure wraparound services. Most of us as clinicians, mental health clinicians, especially social workers, are a little bit more involved with case management. But with mental health clinicians, at leave According to NBCC, case management is not part of our job description. Well, in reality, if you've ever worked in community mental health, it is because the places that will pay for case management. The insurance qualifications for case management services are pretty intense. Somebody has to have a severe and persistent mental illness and meet all these other criteria in order to qualify for case management services in most states. You know, I'm not saying everywhere, but most states that's true. A case manager can help though, if your agency is willing to pay for it or if your university or clinic or whatever. We'll get to workplaces pretty soon. The case manager can ensure that the people are getting all of those wraparound services. We've talked in other courses about how if people are not getting those basic needs met on Maslow's hierarchy, they're not getting their nutritional needs met, they're not getting adequate sleep, they're not living in a safe environment, not addressing comorbid medical issues, they are going to likely have mental health problems as well. It's going to contribute to depression, anxiety, grief, frustration. So better health leads to better mental health. Case managers are great at helping people tap into those wraparound services to improve their physical health. Case managers are great at helping people improve their health literacy, their ability to take in information and make informed choices. That's great. And better health literacy is linked to better mental health. Case managers are useful for helping people reduce stress. That's not a diagnosable DSM thing, unless you want to call it adjustment disorder, but we're just going to call it stress. Case managers can be very helpful at identifying some of those ancillary things. Not the cognitive or affective things, but financial issues. If somebody's stressed out because they're having financial problems. Case managers can help people link with financial counselors and services and resources in the community. They can help people with interpersonal stress. Maybe they're having challenges with their child or they're having challenges with their relationship. Case managers can help people link to counselors or support groups. Occupationally, somebody may be really unhappy because they are in a job that they really hate or they're burnt out. Whatever the case may be. Case managers can help people connect with career counselors and resources that can help them find options. You know, not saying that they're necessarily going to take those options, but can help them explore options. Reducing stress reduces improves mental health Treatment plan compliance leads to better mental health. We're assuming that we're writing great treatment plans. And if we can keep people moving forward on that plan toward their goals, then they're going to theoretically have a greater sense of self esteem, self efficacy and contentment. Case managers ensure non fragmentation of services. It's so easy with all the different doctors out there for services to get fragmented and people providers on a multidisciplinary case to not be part of a team. They're Just you've got an endocrinologist over here and a pain management over here and a PCT over here and a counselor over here, and the person's going to all of them, but none of them are talking. Which means they can either overlap in their services, they can contraindicate each other, or lots of different things can happen. Case managers serve as that single point of contact and ensure that everybody is on the same page in terms of the service plan and knows. So the right hand knows what the left hand is doing. It's a little bit of administrative work, but it goes such a long way to enhancing the client's experience. So they don't feel like, well, my endocrinologist has no idea what my pain management physician is doing, and they seem to be giving me mixed messages. If everybody's on the same page, there won't be mixed messages. Case managers are great for providing guidance during service transitions, which leads to better treatment compliance and better mental health. If somebody is released from the crisis stabilization unit or discharges from residential treatment into outpatient, you know, that's a big transition. You know, they went from being hospitalized to, to 24 hour unsupervised situation, and that can be really scary for the family and for the client. Case managers can help people create a safety net so the transition is smoother and they don't feel like they are a fish out of water, just kind of flapping on the ground. Case managers also provide advocacy within the community, talking to leaders and identifying funding service gaps. They can go to the county commission, they can go to different places that may have funding and even foundations. Writing grants for foundations to get money to create programs to fill gaps in services can be really helpful. I know the organization I used to work for, that's one of the things I used to do was write grants. And I loved it, quite honestly. But that was when I saw that there was a need. I would go and I would find grants that were available and we would apply for them. And then when we got whichever grants that we got, I would be involved with implementation of that grant. Sometimes it was creating a community coalition and another agency would take the lead. But I was also able to, you know, pass that grant on and go, hey, there's this grant out here that can help you do that. Case managers do really well and it's very effective, especially if you're in private practice as a case manager, you're a contract case manager to be involved in community coalitions so people know that you're out there and you are communicating with all of the stakeholders, not just clients, not just doctors, but all of the stakeholders in the community. And generally, case managers are less expensive than clinically licensed providers. Most states, I'm not going to say all because I don't know all, but most states don't require case managers to be licensed in order to practice. Now, a lot of organizations, if you want to be hired in as a case manager at the highest reimbursement tier then or highest salary tier, then you're going to want to be a certified case manager. But a lot of people are able to be case managers without necessarily being a certified case manager, especially if you're already licensed. If you are licensed as a clinician, then you know you've got that professional practice umbrella that you're working under. Case management can be applied to individuals or groups of clients, such as in disease management or population health services. You may be thinking to yourself, all right, case management sounds like it might be kind of interesting because I love helping people connect with resources and figure out how to make the system work for them. Well, great. Where can we work? You can work at universities targeting underage drinking or STD prevention or dating violence awareness, any of those things. There's often a health educator or a case manager that is employed by universities to do those educational campaigns. You can work for clinical practices or foundations like the Diabetes association or the American Heart association to educate people about. In general, this is going to be one of those universal interventions. Educate people about the condition, whether it's diabetes or heart disease or premature birth, in order to prevent it from happening. But also, if it does happen, you may be involved in helping people access services. If somebody has a preterm infant, most obstetricians and pediatricians know about the resources that are out there now, but not in all situations. Therefore, somebody may call the March of Dimes and want information about what types of resources are available to families who have micro preemie. Well, bada Bing, you're able to make that connection for people. You can work in cancer, diabetes, depression or autism management situations where you're working in clinics or foundations, again, that either educate about the issue or help people manage it. If you're working with a pediatrician or a psychologist that specializes in working with youth with autism, they may have a case manager that sees the client in between clinical visits in order to again ensure the implementation of the treatment plan. Help families when they hit hurdles or obstacles or don't understand something takes a lot of pressure off the primary clinician. You can also work at the area agency on aging, Geriatric physician groups, long term care facilities, short term care facilities, you know, the list goes on. You can provide services to people who are aging. My grandmother and I've talked about her before when she finally got to the point where she could not be independent, live independently anymore, she couldn't live by herself and she didn't want to move in with my uncle or my mother. So she ended up having to go to a long term care facility. And there was a case manager that helped ease that transition and helped her figure out what to do with her belongings and how to put the house on the market and all that kind of stuff helped my family make that transition as she moved to that higher level of care. The goal of case management is achieving client wellness and autonomy through advocacy, communication, education, identification of service resources and service facilitation. Case managers often don't provide a lot of the services they link. No sense reinventing the wheel. They link clients and their families with the services that are currently in existence. It increases utilization of those services, which is great for those practitioners who have other more billable hours, but it also reduces maybe the number of times the person's going to have to see that person. So instead of having to see a mental health counselor for six months, the case manager may be able to help the client implement the treatment plan and do well on 16 weeks. Who knows? Services are best offered in a climate that allows the direct communication between the case manager, the client, and appropriate service personnel. How frustrating is it when you are a client and most of us have been clients, either at doctors or dentists or somewhere else where you felt like you were just being told what to do and you didn't have any say in it. It's exasperating. The case manager is there not only to facilitate communication between the providers on the team, but the client is part of the team in case management. We're really talking about, you know, you're the expert on you. Let's talk about what's your input on this? When an individual reaches the optimum level of functioning for them, everybody benefits. The clients feel better, they're healthier, they're going to have fewer medical visits, fewer mental health visits, they're fewer days off from work. If they're having fewer days off from work, then they're probably going to be making more money, which means they're going to be spending more money, which supports the economy. You can just ripple effect this. We want people to be happy and healthy. The support systems benefit because they're not worried about the client anymore. They're not experiencing financial or time drains from having to take care of the client if that was happening. They are able to focus on their jobs, their families, their recreation, their mental health. It benefits healthcare delivery systems. Like I said, we're going to potentially reduce the number of people that need services, which means we're going to free up slots for the people who really, really need services. And we are potentially going to be able to help reduce the duration of services by ensuring that the care is. Goes through smoothly and in community mental health. I know. You know, again, part of one of the clinics I supervised was an outpatient clinic. And a lot of the clinicians didn't like discharging the clients who showed up every single week. That was a guaranteed billable hour. Gosh darn it. And they got. Part of their evaluation was based on billable hours. Now we can talk about what's right and wrong about all that at a different point. The point being they didn't want to discharge those people. So then when there were new clients who had emergent needs, there wasn't a slot open for them. Case management can really help ensure that people are not staying, people are benefiting from brief therapy. Let's just say that. And that when one seat empties, that something else flows in there. So you're not having, you know, people worried about it. Yes. In an ideal system, if it's functioning great and case management is working like it should, you may not need as many clinicians. They may have to transfer to other job titles. That's possible, but highly unlikely. We know how mentally emotionally distressed a lot of people in America are right now. I find it hard to believe that if a slot is open, it can't be filled. Case management process and I abbreviated this actme assess client resources, needs and goals. We're going to go in there as case managers now. We're not diagnosing or treating mental illness. We're assessing their resources, needs and goals. We're going to collaborate with the client and the team, identify service plan goals and needed resources. And we're going to put the plan together. We're going to collaborate on what this is going to look like. You're here at a 1, you want to be at a 10. What needs to change? What needs to stay the same? What needs to change? What resources do you need? Okay, now how are we going to do this? What do we need to do to get you to a 2? What does a 2 look like? And then identify those objectives? And those resources. What does A3 look like? Identify those objectives and those resources. So you create this collaborative treatment plan. Imagine that. And then you implement the darn thing. You know, that's great. It's down on paper now we got to do it. And just like anything else, implementation of a treatment plan is not always people's favorite thing to do. There are certain things they may have to do that they're like, oh, really, I don't want to do that. But it's important that they do it. So a case manager can serve the other function of helping people maintain motivation, helping them do things that they may be apprehensive about doing. If they've got to ride the bus somewhere in order to make an appointment, or if they've got to go see a dentist. Some people are really afraid of dentists. Case managers can be there to be a support system, a cheering squad, provide encouragement. They can monitor people for how they're doing and how well they're implementing things. And if they see that the person is backsliding on their treatment plan implementation or their behaviors, you know, if their depression is increasing or they're obviously starting to not shower, forgetting to eat, something like that, the case manager can monitor, is monitoring and can intervene early. And as things go along, the case manager and the client and the team are going to work together to evaluate the person's progress and see, you know, whether they're making the benchmarks that they had hoped to make, whether that is reduction of inpatient visits or increased number of days attending work, whatever the goals are. Primary case management functioning functions include positive relationship building with clients, their families, providers, insurance companies, and potentially community leaders. Effective written and verbal communication negotiation skills. Sometimes you need to negotiate with clients to increase their motivation. Sometimes you need to negotiate with providers to, you know, get them to work as part of a multidisciplinary team. I've worked with some providers before that are very resistant to having to communicate with a single point of contact. They do their thing and they want to be left alone. Getting any sort of feedback is like, kind of like pulling teeth. Knowledge of legal, ethical and risk management issues regarding confidentiality, informed consent, and any risks associated with that particular client. If you're working with somebody with Alzheimer's, you're going to be concerned about wandering and other things. You want to know what risk issues are there that you need to be aware of. Other risk management issues can, can include things like knowing. If you, if you refer somebody to somewhere and they start having a nurse come in or a cna Come in. What's the risk with that risk for elder abuse that may be going on? You need to be aware of, you know, all of those things. Not saying it will, but it could. Cultural responsiveness in all services is, you know, that's a primary function of counseling, case management, social work, whatever. We need to be able to work with the client and the rest of the team to develop goals, enhance motivation and evaluate progress. We're going to talk about different ways to measure progress in a minute. You want to be able to promote client autonomy and self determination. We don't want clients and their families expecting the clinician to fix the client, to expect the case manager to, you know, basically babysit the client and take them everywhere. That's not what case managers do. Case managers are there to assist and facilitate and empower individuals to do what they can. You need to have knowledge of funding sources, healthcare services, human behavior dynamics, healthcare delivery and financing systems, clinical standards and outcomes. If you're a case manager, you're probably going to pick a field or an area in which you work. You may work with people with autism, you may work with people with addictions, you may work with people who have, who have had kidney transplants. You may work with people through hospice who have terminal cancer diagnoses. Whatever your little niche is, you need to be fully aware of all of the resources and clinical standards and outcomes that exist. So you can educate clients, help them increase their health literacy, and you can make sure that you're accessing and helping them access all of the resources that are available to start to gather information about all of these areas, funding sources, health care services, etc. The first thing, pick your specialty and then look and see if there's a national or state organization that works with that. So the Autism Awareness Foundation, I don't know exactly what their name is, but if you're working with autism, if you're working with families with premature infants, the March of Dimes, you may start there to identify the needs that these particular clients may have and their families may have the resources that are often needed. And then you can start calling United Way Information and Referral to find out about resources in your local area that might help them with durable medical equipment or even electric payments. If they're paying so much money for medical care that they're having a hard time paying their electric bill. That's one of those places where a case manager can say, okay, these are places where you can go. I would also look to specialists in the area and start getting, becoming aware of what specialists might exist. I know for my son being a micro preemie, he had an occupational therapist and a physical therapist and a. I don't. A case manager, slash some other kind of therapist that used to do home visits three days a week for about three months after he came home from the hospital. If you are a case manager, you want to have feelers out and you want to be aware of and have relationships with those types of providers in your area and then go online and start looking at best practices for addressing that issue. If you are working with people with postpartum depression. Okay, so let's start looking on PubMed. Go to PubMed and put in the key phrase postpartum depression. Start looking there or the Cochrane Database for currently reviewed best practices for addressing postpartum depression. That'll give you some more ideas or information on clinical standards and outcomes that you may use as targets. Guiding principles. You want to use a client centric comprehensive holistic approach. You are not just there to help them stay on their medication. You are not just there to make sure that they are taking a bath. You want to make sure that you're looking at all of their biopsychosocial needs. You want to facilitate self determination and self care with advocacy, collaboration and education. It doesn't matter the level of intellect, the IQ of your clients. 99% of clients, especially adult clients, are going to be able to understand some level of what you're talking about. Therefore it's important to work with them, to empower them to do what they can and to advocate for them, collaborate with them, make sure they feel like they have a sense of personal agency again, remain culturally responsive, promote the use of evidence based care. And I did mention the Cochrane Database earlier. There we go. Enhance client safety. Another thing that you need to do, paying attention to what these that particular client might need in order to stay safe. The Cochrane Library. As I mentioned earlier, just to kind of segue back there, you go to cochranelibrary.com there's an advanced search and let's do, let's just do depression. La de da de da. And it thinks for a minute and Then there are 632 reviews of interventions for depression. Music therapy, acupuncture, different medications, dietary supplements, collaborative care. Let's just open that one. It tells you about how they did the literature review, data collection and analysis, main results and then the author's conclusions. You can read through all that or you can just jump down to the plain language summary which takes out all that jargon and tells you basically is this an evidence based best practice or is this really weakly supported in the literature? I love the Cochrane database, but I digress. Link with community resources assist with navigating the healthcare system. It can be really confusing, especially with Medicare. I remember with my grandmother knowing what you had to do because you've got the gatekeeper that's the primary care provider. For what things do you need a referral? What don't you need a referral for? Who's going to pay for what? How do I know where I can go? When you go to the hospital anymore, you can't guarantee that every practitioner that sees you is going to be on your provider plan. So there's a lot of stuff that gets very complicated and stressful when dealing with insurance. So somebody who understands that can help people navigate it and relieves a lot of anxiety. We need to maintain, maintain competence and practice, promote quality outcomes and measurement and support and maintain compliance with federal, state, local, organizational and certification rules and regulations. If you are certified then you a case management body, then obviously you need to keep, keep up your CEUs and everything. But also just federal, state, local and organizational rules and regulations need to be followed. You know, not surprising. The degree of complexity of case management varies based on the context of the care setting. It can be a wellness or prevention setting, it can be an acute setting like crisis stabilization, or it can be a rehabilitative setting setting. For example, a short term care facility where somebody may go after they have a hip replaced. You may be thinking, well you know, I'm a counselor, why would I work there? Well, counseling has a really big place in short and long term care to address grief and depression and anxiety and social transitions and all that other stuff. These people are still a motive if you will. Working in a rehabilitation facility as a case manager, you can also help them navigate their transitions and make sure they have all their proverbial ducks in a row for when they're discharged. It also varies. The complexity varies on the health conditions and needs of the patient and the population served, as well as the needs of family caregivers such as critical care, asthma, renal care, hospice care. Some people will need a whole lot more stuff and involved activity. Other people, you know, for example, somebody who is discharging after a crisis stabilization admission may not need as much. The reimbursement method applied, such as Medicaid, Medicare, workers compensation or other managed care also may affect the degree of complexity. You may or may not be able to link with certain resources and reimbursement and paperwork can get Kind of overwhelming sometimes. But you know, that aside, case management is not, I don't want that to put you off. The healthcare professional discipline designated as the case manager, whether you're a registered nurse, a social worker, a physician, a rehab counselor, etc. Can also affect the complexity. A person who has a physician or an RN as a case manager may have a more complex case or maybe more medically complex than something else. But you know, that's really kind of loosey goosey. I think it depends on the client themselves. There are a lot of clients who are in hospice who really don't require a whole lot of case management. And then there are other clients who are on the phone, you know, every two hours. Practice settings, just going to go through this really quick. Hospitals, long and short term care facilities, outpatient mental health or physical health clinics like your, you know, walk in clinics, student health centers. Corporations. A lot of corporations benefit from case management because it reduces their employee absenteeism. Health insurance companies, private case management companies, jails, the va, community, behavioral health, geriatric facilities, hospice, medical group practices, life care planning organizations, and disease management companies. A lot of these we already talked about, but I've seen in a lot of the groups that I'm in, people saying, you know, I'm really starting to get burned out. I want something to do part of the time. I still want to see clients some, but I want something else to do to diversify my workload because I'm starting to get exhausted looking at these things, figuring out, you know, putting together a proposal for a larger corporation like where I live. Cracker Barrel Restaurant is based in Lebanon. You know, that might be somewhere that I would approach to see if I could help them reduce their employee injuries and maybe insurance rates if we could get a wellness program going. Roles and functions. Conducting a comprehensive assessment of the client's health and psychosocial needs, including health literacy status and deficits, and developing a case management plan collaboratively with the client and family or caregiver. Kind of like we do in counseling, planning with the client, family or caregiver and the multidisciplinary team, the payer and the community to maximize quality and cost effective outcomes. So this is again where we may be going to the city council or the county commission or the county health department and identifying a gap in services or trying to negotiate a way to make services more affordable for our clients. Facilitating communication and coordination to minimize fragmentation. Educating the client, caregivers and team about treatment options, resources, benefits, psychosocial concerns, etc. So timely and Informed decisions can be made. I have a friend right now who has a son who has, you know, pretty significant autism. And you know, when we're talking about the spectrum and he's not working with a case manager right now, they don't have access to one, which is making some of his anxieties a lot higher because he's worried that, you know, his son is never going to be able to live independently and he's not sure, you know, he's, he thinks way ahead. He's not, he's not sure what's going to happen to his son when he eventually passes away and, or if, heaven forbid, something happened to him. A case manager would be able to help him create a plan to reduce some of that anxiety. We want to empower the client to problem solve by exploring options of care to achieve desired outcomes. Provide them that menu. Encourage the appropriate use of healthcare services and improve quality of care and maintaining cost effectiveness. Encouraging them to get help when they need it, to take care of themselves, to not wait until they've got to go to the emergency room. Assist the client in safe transitioning of care from a higher level to a lower level, especially if they're going from residential to home or if they're going from the hospital to home. Striving to promote client self advocacy and self determination. Advocating for both the client and the payer to facilitate positive outcomes for all involved. But if there's ever a conflict, the client is the one that you have primary responsibility to. With advocacy, you want to promote the client's self determination, informed and shared decision making, autonomy, growth and self advocacy. Regardless of the age of the client or the intellectual ability of the client. This is important and you want to do the same thing. Especially if you're working with a child. You want to make sure to involve the family and encourage their sense of self determination and shared decision making, autonomy, growth and self advocacy. We need to educate other health care and service providers in recognizing and respecting the needs, strengths and goals of the client. Sometimes professionals can. Providers can get into a rut where, you know, they've seen people who are wanting to get their meds renewed or whatever every 15 minutes for 40 hours a week for, you know, three months. And all of them just start looking the same. You know, it's another person with paranoid schizophrenia. It's another person with clinical depression. And we want to make sure that providers are seeing that person as an individual. Facilitate client access to necessary and appropriate services. Recognize, prevent and eliminate disparities in accessing care and outcomes. This is really important as a case manager. Again, if you are working in downtown Los Angeles, access is probably, there's public transportation. Access is probably not as difficult as if you are working in the middle of rural Utah where there may not be. I'm sure there's not the same level of services and resources and transportation and access. It's important that the case manager say, okay, well here's a problem. We need to make sure that people can actually get to services, whether that's through telehealth means or implementing public transportation or whatever the case may be. And we want to advocate for the expansion or establishment of services and for client centered changes in organizational and governmental policy. One of the clinics I worked at, one of the changes they kind of had to make when they went to capitation. They had to make sure that any client who called for a mental health assessment was able to be seen within 48 hours period. It's not two working days, it was 48 hours. Well, that kind of threw us in a tizzy and we had to redo some of our standard operating procedures. However, it enabled clients to get services when they needed them. Go figure. When they were in crisis, we also, because we didn't have enough clinicians to see all these people, one on one, instituted intervention level groups. So people who were on the waiting list for individual therapist would be able to attend groups up to three times a week. They were able to step in, start getting services, start getting psychoeducation at the very least in order to help them feel like they were getting help and help them develop that hope. There were a lot of clients and I can't tell you what the percentages were right now, but there were a lot of clients who completed treatment and discharged before they went to see an actual individual counselor. So it saved money, it saved time, it got the clients in when they needed it, it made sure that they weren't just seen for an assessment and then, okay, our first appointment is six weeks from, from Monday. Well, that doesn't do me any good. So we were became much more client centric. Client selection, you want to look at the duration of the diagnosis. People who've recently been diagnosed are going to have a lot of questions and really not know about a lot of resources. If you're working. Our farrier son has multiple sclerosis and is, you know, older. They've been dealing with that for, you know, nearly 20 years now. They know in general what the resources are in this community. They need less assistance, case management wise than somebody who just had a child that was diagnosed with multiple sclerosis. The level of pain control can also be an issue that indicates a need for increased case management services. People who don't have well controlled pain are at higher risk of opioid overdose, substance misuse, physical health problems, high blood pressure, a lot of things we want to help them get that pain under control. Not necessarily through medication, but sometimes that's the way it goes. Functional status or causes is bleeding or having difficulty, you know, thinking through the things they need to do on a day to day basis, they may need some intervention. One of my friend's brothers had schizophrenia and he lived in an assisted living situation for people with severe and persistent mental illness. But he would regularly forget to eat and bathe and that's a problem. You know, those are big problems for his overall health and well being. So targeted case management was important for him. If the person has had a lot of previous home health and durable medical equipment usage, then they may need case management. If there's a history of mental illness or substance abuse, suicide risk or crisis intervention, that's a risk factor that may indicate the person may benefit from some case management. It doesn't mean you're going to have to have case management three times a week, but it may be nice and it may be helpful to have a case manager that connects with them by phone once a week or once a month to make sure that their transition goes smoothly. If the person has had a chronic, catastrophic or is diagnosed with a terminal illness, obviously that's something that requires adjustment. Chronic illnesses generally progress or they have ebbs and flows and there may be periods where they need more case management like if they have lupus. Social issues such as a history of abuse, neglect, no known social support, or lives alone can put them at a higher risk for service utilization and negative health outcomes. If they've had repeated treatment admissions, then you know, we know that they're having a hard time continuing on that positive path after their, after their treatment ends. So they may need somebody that's there to keep them going, keep them going forward. And if there's been need for admission or transition to a post acute facility, then case management obviously, as we have talked about a lot, would help ease that transition. Opportunities for intervention if there's a lack of established evidence based plan of care with specific goals, then obviously we want to step in and go, okay, let's sit down and really define where we're going with this. If the person over utilizes services, we can look at what's the benefit to them of service utilization is and you know, why are they going to the emergency room all the time versus something else versus, you know, a primary care. And sometimes it can be because they don't have insurance to cover primary care and they know the emergency room has to treat them. That's a problem. We need to look for free and low cost health clinics. If there's underutilization of services, we may need to educate the client about resources that are available and figure out why they're underutilizing. Are those services not culturally responsive? Do they not feel heard? Are they afraid they can't afford it? What's keeping them from utilizing those services then? Obviously you want to chart appropriate utilization of services. Use of multiple providers and agencies. Some people need multiple providers and agencies because they've got complex issues. But intervention isn't necessarily reducing the number of providers and agencies, but coordinating and making sure that they're not overusing any particular provider or agency and the treatment is integrated. Make sure they're using appropriate services or levels of care like in the example I used earlier. You don't want somebody going to the emergency room for an earache. What other options do you have that the person can access? Non adherence to a plan of care. Case managers are great at helping people keep moving forward. Case management, as I said, can be done preferably not exclusively, but your interim, you know, your touch bases between face to face visits can be done with a five minute phone call. Lack of education on the client's part or understanding of the disease process, their current condition, the medication list or provider treatment plan. Especially when my mother was undergoing chemotherapy, wow, that treatment plan was really complicated and she never got the answer to why certain things were happening. The doctor just said this is what we're going to do and be gone with you. Case managers would be able to help answer those questions and advocate for the client. Medical, psychosocial, mental health or other functional limitations are also great areas for case managers. As case managers, if somebody has emotional and cognitive needs, whether they have autism, adhd, paranoid schizophrenia, whatever, depression, we can make referrals for counseling and help them be aware of the different best practices for treatment, including medication. For some, you know, I'm not a fan of medication, but for some it may be necessary physical needs, making sure that they are able to get adequate sleep, nutrition, safe housing, they're able to get their medical needs met, their co occurring diabetes and high blood pressure and all that kind of stuff because we know that all impacts mood as well as health and safety. So that bottom level of Maslow's hierarchy Social needs Making sure they have access to social support. They're not just out there all by themselves. They have interpersonal skills and child or respite care as needed. Case managers can help connect people Local area Agency on Aging or your, you know there can't. There are day programs. I hate to call them daycare because that sounds so condescending. Day programs for people who are older, who may live by themselves and need that social interaction. Vocational needs. Case managers can connect people with job coaching, help them learn about reasonable accommodations and the Job ACCommodation Network or JAN, which is online employment or meaningful activity. We all need to engage in meaningful activity on a daily basis that helps us feel happier. Content, purposeful and environmental needs like transportation. Case managers can help people figure out how they're going to get to these medical appointments, how they're going to get to the grocery store, et cetera. We can also look at patterns of care or behavior indicating worsening of the condition. You really want to get a case manager in there as quickly as possible so you don't have to increase the amount of clinical services. Case managers can help prevent inappropriate discharge or delay of discharge from other levels of care. They can advocate for the client to say, you know what? We don't have everything ready. You know, Jim Bob needs to stay in for another week or another day, whatever it is. And if the person has frequent transitions between settings, they go from the hospital to short term care, back to the hospital back to short term care. We may want to look at why that is and help the person find somewhere where they can stop having to bounce around. Case manager qualifications include a current active and unrestricted licensure or certification or baccalaureate or graduate degree in health or human services, which allows the professional to conduct an assessment independently as permitted within the scope of practice of the discipline. So if you're licensed or certified as a case manager, then you're just going to be assessing needs and resources, screening for mental health, physical health, or addictive issues. If you identify a need for that to be further assessed, then you're going to refer out to a clinician that's licensed to do that. The demand for case managers is growing rapidly as insurance companies restrict reimbursement, move toward capitation, and as individuals start to have higher co pays and try to reduce expenses. Not only are case managers employed by hospitals and treatment centers, but increasingly by organizations like businesses and universities that have a strong motivation to keep their employees and students healthy and relatively happy. Case managers provide assessment, advocacy, education and assistance with treatment coordination and implementation often in a multidisciplinary team. But again, remember, case managers do not diagnose or treat any illness. We're done. Thank you for staying with me today. Does anybody have any questions? And I saw somebody talking about the stigma about paid case managers, hired contract case managers versus organizational case managers, if you will. And it is an interesting topic. Where I came from, where I've worked, there really hasn't been that much of a stigma because the private pay case managers were taking care and providing services to people who otherwise would not get case management services because they didn't qualify for insurance reimbursed case management. So there really hasn't been an competition for resources in that particular area. That doesn't mean that it doesn't exist. And yes, there was a little bit of resentment on the part of organizational case managers just because the private pay case managers were getting paid more. That wasn't really so much stigma as, you know, a financial social issue. 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.