Intense CM approach works for psych disability
Company saves county more than $750,000
When the state of California gave all its state Medicaid money to the counties and put them at risk, the County of San Diego Mental Health Services turned to a private behavioral health company for help in case managing 100 patients with severe psychiatric disabilities. That public-private partnership paid off to the tune of more than $750,000 in reduced medical costs in the first year of operation.
"These were people who had been in the health care system for a long time - most of them unsuccessfully," notes Robert T. Quinlivan, LCSW, director of managed care for Oakland, CA-based Telecare. "We wanted to assist then with basic survival skills. Our goal is not so much to reduce costs by preventing admissions as it is preventing unnecessary admissions due to social issues." (For a look at the population demographics, see p. 156.)
Telecare calls its client-centered approach ACCESS, which stands for Advocates of Care, Choice, Empow erment, Success, and Satisfaction. Nurse case manager/social worker teams provide case management services and crisis intervention on a 24-hour basis with case ratios of one to 10, says Quinlivan. "We have a book with a service plan and a crisis plan for each patient. Every team member is familiar with each patient assigned to the team and has access to the book when they're on call. If a patient calls in with a problem, there isn't just someone covering. A team member familiar to the patient answers the phone."
Attitude is everything
The ACCESS philosophy empowers clients to tell ACCESS professionals what they want in their lives, says Quinlivan. "It's hard to surrender our basic knowledge of how we think people should live their lives. We've adopted a partnering rather than a managing approach. Managing these patients doesn't work very well. We allow the clients to have more power than we do."
In addition, Quinlivan says the ACCESS philosophy requires each staff member to believe there is hope for clients to improve. "There is no cure for mental illness, but there are medications which improve function. Staff must believe in an individual's ability to get better."
Telecare was able to move its ACCESS teams into San Diego and have its program operational in six weeks with almost immediate results. "We take pre-tests and post-tests for all clients at regular intervals," he notes, adding that Telecare uses a variety of functional and quality of life tests. "All of the function scores went up. And quality of life scales showed clients increased contact with families and friends, as well as increased recreational activities." (For a quick look at Telecare's financial outcomes, see box, at right.)
Some of the elements Quinlivan credits for the ACCESS program's success include:
· Identify why each patient typically went into crisis. "We are very specific in our interventions," he says. "Once we identify why patients go into crisis, the team works with the patient to develop a plan to prevent crisis."
· Operate subacute, residential, and day treatment centers throughout the state to relieve the burden on state hospitals. "The greatest opportunity for cost savings is at the institutional level," he says, explaining that Telecare also owns and operates psychiatric facilities. "Moving patients out of state hospitals saves money. It also means people don't have to travel as far for treatment."
· Provide crisis consultation service. "Before a patient can be admitted, Telecare must be notified. We talk about the alternatives to inpatient admission."
In addition, trend data indicated there was a large number of inpatient admissions at the end of the month. "We assumed this was a financial issue," says Quinlivan. "It looked as if patients weren't managing their money well and looking for ways to get into the acute care hospitals at the end of the month to avert a social crisis."
· Take control of clients' money. "We became the payee from the Social Services Administration. We pay for all food, clothing, shelter, and give clients daily spending money. We try not to be dictatorial about how money is spent."
· Send short-term transition teams to inpatient facilities. "We send a team of social workers into the hospital to identify every patient admitted the previous day. The team begins to work immediately with hospital discharge planners on early discharge," he says. "Being in the hospital helped us manage the system."
· Send nurses to review inpatients charts. "Before we came into San Diego county, it was the Wild West. Doctors did whatever they wanted, and patients stayed in the state hospitals forever. Now, we have nurses go in and review patient charts and go over treatment plans with doctors. If doctors disagree with our recommendations, they can use our appeals system."
· Provide transportation for clients. "Many case managers talk about arranging transportation," notes Quinlivan. "We literally move people all the time. Our staff puts up no boundaries. We rent U-Hauls and help clients move."
Mental health professionals use boundary issues as a way to step back from the client, he notes. "We don't allow our staff to have any preconceived notions of what they will and won't do for clients."
· Engage in recreational activities with clients. "Staff members take clients to the movies on the weekends. They go out to dinner with them. It helps staff see new things in their therapeutic relationship, and it gives clients someone to reach out to."
· Provide continuity of care. "Having the same team work with the same clients makes a big difference in clients' lives," he says. "In the public sector, mental health patients are used to being bounced around a lot." Along with continuity of care comes availability. "Staff members are available to clients 24 hours a day."
· Address medication compliance issues. "At least 45% of our clients have a problem with medication compliance. We identify patients who might benefit from longer-acting injectables, and we go out to administer them."
· Encourage interactions with families and friends. "We engage family and friends as often as clients allow," Quinlivan says. "Family members and friends tend to come back into clients' lives as clients stabilize."
· Have a no-close policy. "This was a very empowering message for our staff. We never close a case. It means we must find a way to work with these people. We must help them."
Although Telecare and San Diego County were pleased with the program's success, Quinlivan noticed that not all clients improved equally. "We started to look at how individual case managers work with clients and noticed that some case managers were more successful than others in improving client function and quality of life."
Telecare identified three case managers whose clients were less improved than clients served by other case managers and found that in all three cases, the case managers had lower levels of education than more successful case managers. "It showed me that we needed to work a little harder on team building and education," Quinlivan says.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content