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Care Management Model for Integrated Settings

The Care Management model in an integrated health care setting is rapidly evolving and expanding. Although there have been many improvements in coordination of health care, barriers persist for patients and medical providers which diminish the quality of care being delivered. Primary health care centers have developed into a single point of access for both physical and behavioral health services. Care Managers collaborate with behavioral and medical providers within their respective care teams in order to assist in the provision of care. Care management plays a crucial role within this integrated care setting by connecting patients with access to services tailored to the individual patient through coordinated care planning increasing health literacy and improving communication between patients and providers.

Individuals with a mental health diagnosis have an increased mortality rate resulting from untreated and preventable chronic illnesses such as: hypertension, diabetes, obesity, and cardiovascular disease. These conditions are usually aggravated due to a lack of physical activity, poor nutrition, smoking, and substance abuse (Bartels S, Desilets R. Health Promotion Programs for People with Serious Mental Illness Pg7. Prepared by Drathmouth Health Promotion Team. Washington, D.C. SAMHSA-HRSA Center for Integrated Health Solutions. January 2012).

Colton and Mandersheid surveyed mortality data from eight states and concluded that, on average, Americans with major mental illness die 13 to 30 years earlier than the general population. The average life expectancy of individuals that were examined with mental illnesses was from 49 to 60 years. Care Managers work to remove the barriers that exist in access to primary care and meaningfulness in their interactions with their providers (Colton CW, Manderscheid RW. Congruencies in increased mortality rates, years of potential life lost, and causes of death among public mental health clients in eight states,2006).

Colton and Mandersheid’s study illustrated that the delivery of quality care to patients with behavioral disorders is hindered because of fragmentation between the patient’s primary care providers and the mental health provider that the patient may be seeing. Often these high risk patients’ PCPs and mental health clinicians are not communicating with each other. In some instances, the patient is not linked to a PCP at all. This can create many barriers to care and cause a lot of confusion especially when it comes to medication management, palliative care, and disease management.

The Care Management program provides care coordination for these patients by ensuring that the PCP is aware of all the specialty providers that the patient is seeing and further, linking patients to missing services. Care Managers are the crucial link between providers to ensure that there is an open line of communication between all members of the interdisciplinary team. Care Managers play an integral role in linking patients with behavioral issues to primary care in order to address underlying health issues. Care Management is oftentimes referred to as “the glue that holds all the pieces of the puzzle together.”

While linking patients to care, Care Managers are also mindful of teaching opportunities to promote autonomy and to get patients involved in their own care. This can be a very challenging task due to many unforeseen variables such as physical and social determinants that hinder successful engagement. Care Managers are trained to assess patients holistically, in order to identify any barriers and fill any gaps that may exist.

As a Transitional Care Manager in a family medicine care center, I have encountered many different situations where implementation of Care Management has demonstrated positive outcomes. One of the issues that occur commonly with patients who are diagnosed with a mental illness is a high rate of avoidable emergency room utilization. Many of these patients are known to be receiving mental health services and not primary or vice versa.

One example of this is with a patient I have worked with at the 16 St. family clinic at The Institute for Family Health. Mr. J, a 58-year-old patient who is diagnosed with schizophrenia and depression had 10 emergency room visits from June 2014 to December 2014. His top 4 diagnosis for ER visits were pneumonia, asthma, hypertension, and diabetes mellitus. I was unable to contact the patient because he does not have a telephone, so I visited him at the hospital upon receiving an electronic emergency room visit notification through the electronic health record system. I spoke to his mental health clinician and she stated that they have attempted to set up many appointments for the patient to follow up with a PCP; however, the patient has failed to show up to any of the appointments. During the visit, I was able an important barrier to care of homelessness for the last 2 years and no access to communication (i.e. telephone). The patient stated this was the reason that he does not attend any of the appointments was because he is very forgetful and would like someone to remind him.

In care management we were able to address the patient’s main concerns which were housing and access to a telephone. I was able to work with a Social Worker to get the patient into a three-quarter house upon discharge and I also applied for a telephone through a grant-funded program. The patient was appreciative and we agreed to a hospital follow up date after ensuring to him that he would receive a reminder call prior to his appointment.

Prior to the appointment I set up a case conference with the PCP and mental health clinician and we were able to make up a plan of care for the patient. We were also able to get the diabetes educator and nutritionist involved to offer additional support to the patient. During the appointment I was able to assist the patient in communicating concerns that patient had with his PCP and explained concerns that the PCP had to the patient. As a result of a collaborative effort, ER utilization drastically decreased and his overall health has improved.

This one example of how a patient can “slip between the cracks” when navigating through our complex health care system. As the previous example clearly portrays, Care Management is a vital component of the integration model of care which ensures high quality care is delivered in a patient-centered manner.

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