Communicating with vulnerable patients effectively, whether it’s about medication non-adherence, or simply what is or isn’t working, requires a certain level of cultural competency between the case manager and patient, says Jay Hale, LPC, CEAP, director of quality improvement and clinical operations at Carolina Behavioral Health Alliance (CBHA). Once the case manager sidesteps cultural sensitivities, they can then get into the problem-solving arena, which ultimately leads to patient engagement and retention.
Question: When you match case management to members, how important is cultural competency?
Cultural competency is certainly a significant issue for us. In North Carolina, we have a varied population, especially in some of our metro centers. We consider how other people think about their mental health. Individuals who are first generation here from non-Western countries are not going to have the same view of mental health as individuals from Western countries. We talk about how we are calling from the health plan, and that it is a medical issue. We try to get around the idea of this being behavioral health for those people because it is medical. We are setting them up with their doctor and we ask how things are going with their doctor. We want to talk in those terms. We also talk about having successful behavior. We ask, “What’s working for you and is that helpful for you?” That gets us out of the behavioral health arena and into the problem-solving arena, which helps us get around some of those cultural issues.
If we have someone who does not speak English, but speaks Spanish, which is our other major language here, then we would get an interpreter. We have an interpreter line that we would use to help in that case. Most of the individuals who engage with us tend to be people who have been in the United States for a number of generations. That is where we are most successful with engaging individuals. However, the culture competency is definitely an issue in engagement and retention.
Question: How do you help with adherence to medication?
With our case management staff, we not only have therapists, but we also have nurses available who can talk to individuals about issues they may have with their medications. One question we ask is about treatment side effects. We ask about adherence. We want to know not just are you adhering, but what is happening that you are not adhering to treatment. Sometimes, it is either side effects or a concern about, “I’m not really sick, I’m better now.” We are able to talk about that and possibly talk about what has happened. If it is side effects, we can talk about the concerns, and say things like, “Have you talked to your doctor about that?” Then we do a brief role play such as, “Let’s talk about how you can talk to your doctor about this concern,” or ‘When is your next appointment?” To get individuals ready, we say, “Maybe you need to write that down before you go there next time.” These are some basic problem solving ideas.
With the second concern, it is more problem solving around a greater range. We are looking at things like, “I’m not sick any more,” “Let’s talk about that, has this ever happened before where you got better and what happened that time? Were you successful with that?” The answer is usually ‘no’ because that is what happens, the person ends up in the hospital. We can try to do some problem solving. We have a relationship with their provider. Therefore, we talk with their provider about adherence with their permission. We try to get them into their provider sooner to talk face to face about adherence in a non-threatening, non-judgmental way. We get them there to help reconnect them with that provider. Those are the main tools that we have over the phone.
Telephonic Case Management Protocols to Engage Vulnerable Populations describes a suite of tools to facilitate identification, interaction, surveys, follow-up action, resource matching, and member engagement and outreach for a behavioral health population that is also a template for case management and care coordination of any organization’s hard-to-reach or vulnerable members.