Intensive CM keeps patients in community
Constant contact makes it work
Imagine the immense task of helping a formerly institutionalized psychiatric patient thrive in a fast-paced urban setting in the 1990s. Case managers with the Creative Alternatives Program at Johns Hopkins Bayview Medical Center in Baltimore are doing just that with great success and for a capitated rate that equals less than one-third the cost of one year in a state institution.
"It costs about $100,000 to institutionalize a patient for one year," notes Wendy C. Shephard, MSN, CCM, a clinical nurse specialist and team leader for the Creative Alternatives program. "We’re capitated at $29,000 annually per patient to provide all the mental health needs for our members. Every time a member goes to a traditional provider, we pay the bill. We are very conscious of the big-ticket items and work hard to keep inpatient admissions down," she notes.
Creative Alternatives is one of two five-year demonstration projects for Baltimore Mental Health Systems. The voluntary program provides psychiatric services designed to help patients with major mental illness who have been institutionalized for six months or longer return to the community. The case management model Creative Alternatives uses involves intense individual attention. The first steps are small but essential to the patient’s successful return to the community, notes Shephard.
Holding out the carrot
When a patient is assigned to the Creative Alternatives program, a team member visits the patient at the institution and begins the "engagement" process, says Shephard. "Of course, we get the patient’s records from the state hospital and any providers, but that’s just the thumbnail sketch. We need to know what each patient’s triggers are, what exacerbates their illness. We’re taking on a high-risk situation, and we provide high support," she stresses.
"We explain what we can offer the patient. We spend time with the patient. We take them out to lunch and try to understand their needs," she explains. "These people are often very comfortable in the institution and aren’t really interested in returning to the community. Because the program is voluntary, we have to find the carrot, or motivator, to entice them out of the hospital."
The "engagement" process can take as little as a month or as long as a year, because the program is "tailor-made" for each patient, she explains. "We build the services and support each patient’s needs by first getting to know each member thoroughly."
Eventually, patients are introduced to other members of the Creative Alternatives team. Team members come from a variety of nursing, psychiatric, and social work backgrounds, adds Shephard. Services case managers coordinate for patients include:
• housing options;
• employment options;
• vocational training;
• public transportation training;
• grocery shopping;
• money management;
• utilities;
• leisure activities;
• family visits;
• routine provider visits and other health care needs;
• medication monitoring.
"We have a 24-hour emergency line for patients. There is someone on our staff on call 24 hours a day to prevent crises and, hopefully, hospitalization," notes Shephard. "We do everything we can to help patients comply with their medications. We provide medication boxes and help patients fill them. We phone them to remind them to take their meds daily, if necessary.
"We encourage members to call us, if they need help. We don’t want them to end up in the emergency room without us knowing that they are in need," says Shephard. "If they do end up in the hospital, we show up in the hospital for rounds early the next morning. We try to find out what went wrong and how we can fix it.
"If possible, we ask providers for permission to take the patient out of the hospital the same day, if only on a day pass. We tell the patient that we’ll return them to the hospital if they need us to. We don’t take control away from other providers, and we don’t expect perfection from our patients," she says.
Above all else, case managers give patients a lot of support through each step of their return to community life and through every crisis. "We also ask members who have been through a crisis to help other patients through peer counseling. Nobody understands what an experience is like better than someone who has been there before," she notes.
How about a movie?
Creative Alternatives does not overlook the social needs of its members. "Many of these patients have never had the experience of going to a fast food restaurant where you select your own condiments. If you ask them what they want to do, they can’t think of an answer. We have to help them by providing choices. We ask, Would you rather go bowling or see a movie?’"
In fact, case managers provide many opportunities for patients to relearn how to set their own social calendars and live in a community setting, says Shephard. "We set up group outings to the movies or dinner. It’s very important that we go with them to eat in a restaurant or go to the movies. How can we expect them to model normal behavior unless we set an example for them?" she asks. "When they’re ready, we help patients plan activities with each other that they do on their own."
Every Tuesday a van picks up patients and brings them to the Creative Alternatives office to receive a small personal allowance, have lunch, pick up an activity calendar, and have a weekly blood test, if laboratory levels are necessary, notes Shephard. "All monies members receive from state and federal funding sources come to us. We distribute an allowance of $15 to $20 a week for personal needs," she explains. "We intentionally keep the amount small, so that patients will be more likely to return the next week."
Meeting each patient’s needs
Case managers visit patients in their homes a minimum of twice a month. "Some patients we visit more often, especially patients who need help with medication monitoring," notes Shephard. "We constantly reassess each patient’s needs and hold team meetings faithfully each week to make sure each patients’ needs are met," she adds.
The program works. Halfway through their five-year project, Creative Alternatives has far exceeded the criteria set by the Baltimore Mental Health Systems. "We have a great many people providing oversight and evaluation of this program," notes Shephard. "We have to meet certain criteria for basic care such as housing, routine eye and dental exams, regular functional assessments, but we’ve gone way beyond that basic care," she says.
"We really like these people, and they know that. We become their families. That’s why this program works. We feel really privileged to give someone a new life. This type of program doesn’t work without long-term commitment," stresses Shephard.
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