Though it emerges in different ways, non-compliance with care plans drives telephonic case management protocols for three distinct populations at Carolina Behavioral Health Alliance (CBHA), explains Jay Hale, its director of quality improvement and clinical operations.
Prior to his presentation on Telephonic Case Management: Protocols for Behavioral Healthcare Patients, Hale defines the distinct groups of behavioral health patients, indicators of non-compliance for each, barriers faced by telephonic case managers, the involvement of PCPs and red flags signaling the need of an in-person visit.
HIN: What is the number one reason behind high levels of inpatient or ER use by the behavioral health population?
(Jay Hale): When we look at the behavioral health population, we’re looking at three different groups of individuals, but with one reason driving all of their care. The three groups are adult mental health, adults with substance abuse issues and children/adolescents, which is generally mental health but can be substance abuse as well. The number one condition that we see is non-compliance with treatment. This comes out in various ways with our mental health population. It comes out as having suicidal thoughts or homicidal thoughts, or other impulsive or dangerous actions that would cause someone to be referred to the ER.
With our substance abuse population, we often see people who stop going to meetings, and/or who stop working with their sponsor and return to the behaviors that they were doing when they were drinking or using, which leads them back to drinking or using. Many of the relapse behaviors lead to using.
Our child/adolescent population is usually a little more complex. Because they don’t have the same control over their environment that adults do, many times they will act out more in either school or home, and that acting out escalates to a point where they’re referred to an ER.
Ultimately, it all comes back to failing to follow through with treatment for various reasons. Many times we begin to get some treatment early on and we get past the crisis, but it’s hard for people to accept that they have a chronic ongoing illness that needs ongoing treatment. Once they start to feel better, they stop or cut back on treatment, but then things begin to deteriorate for them and they don’t catch it until it’s at a crisis point where they’re back in the ER.
HIN: What barriers may a telephonic case manager encounter when contacting someone with a mental health issue? What advice do you give the case managers on establishing rapport during these calls?
(Jay Hale): One big barrier that we see is making sure that we have the member’s correct phone numbers. We want to make sure that we have updated information so that we’re calling the correct people. Another barrier is having the member on the other end trust us enough to accept our help, or accept our support, in their care.
I advise our case managers to work with other people who are working with the member early on. We want to work with the hospital earlier before the person is discharged to get correct contact information and to let the member know that we’re going to be contacting them. We want to be part of that discharge plan and operation, and we want our case management program to be part of that plan as well — a plan that shows that the patient is going to the psychiatrist, or a therapist, and that they’re going to be followed up by us telephonically.
When one of our case managers calls a member to invite them to be part of our program, we want to talk to the member about how the program helps them. We want to emphasize how this is helping them in their recovery for either a mental illness or for a substance abuse episode. With substance abuse individuals, we want to make sure that we are using the language that they are comfortable with in early recovery — language where we’re making sure we’re supporting their recovery program, they’re working their steps, they’re following through with their meetings, etc. We are letting them know that we understand their situation and that we’re supportive of them in their recovery. With mental health individuals, we want to make sure that they feel comfortable with us, that we are understanding their situation, and that we are not here to do counseling. Rather, we are here to support them in their recovery and to help them see the improvements that they’re seeing as they follow through with treatment.
With our child/adolescent population, we’re usually working with the parents. Many parents are appreciative of the support that we can give them as they try to help their child or adolescent do better in school, do better at home and have a more successful life early on. We’re about letting the parent know that we’re not here to blame anyone for any situation that the child is in, but rather, we’re there to support them in having a healthier family and a healthier child.
HIN: How involved is the individual’s primary care provider or any other providers in this process?
(Jay Hale): The member’s providers are a very important part of our program. We want to make sure that the member is going to their sessions, is seeing their psychiatrist or therapist, is going to meetings, etc. We reach out early to those behavioral health providers to let them know the member is involved in the program, that we are not there to be between their relationship — we’re an adjunct to support that ongoing relationship — and to let them know we solicit their support in this service so that the member understands that we’re all working toward one goal. And that one goal is improvement of the member’s care and helping them be and live successfully outside of a hospital environment. One of the things we’re looking at in care management, or case management, is making sure that they’re attending sessions. Behavioral health providers often like to hear that the insurance company is encouraging people to go to sessions rather than limiting sessions. We usually get a lot of support from our providers for what we’re doing.
HIN: You defined three very different groups. What are some indications or red flags that might arise during a call with a behavioral health client that could mean an in-person visit with a provider is warranted?
(Jay Hale): One of the things we’re looking for is changes in symptoms. Those changes in symptoms, or changes in habits, could be asking the individual at each call about their depression; any type of mania that they may be experiencing, if there’s a history of such. We’re asking about any other psychiatric symptoms that they’re having and asking the member to rate them. Then, we look at our information to see how much of a change that is from the last time we spoke.
If we start to hear about any kind of deterioration, we explore those issues further to see how serious it is — if it’s something that is temporary or something that is more ongoing. We’re also going to be looking for other factors, such as medication compliance. Is the person still following through with their medication? Did they have any difficulty with it? If they have, have they let their provider know they’re having difficulty with those medications? If we start to hear any kind of decompensation when we’re concerned about someone’s safety, or we’re concerned that someone is starting to slide back and return to the more unhealthy behaviors that they had in the beginning, we will make a phone call to that provider to see if we can get an appointment set up for that member to be seen quickly. This way, they can be assessed and changes in treatment can be arranged. Or it could be getting the member back into treatment again if they’ve fallen back or stopped going.
With our substance abuse individuals, often we’re looking for frequency of going to AA meetings, frequency of contact with their sponsor or any kind of irritability, especially over going to meetings. Many times individuals will start to talk about how the meetings are not helping them. We want to help them problem-solve around other things that could help them more and encourage them to start going back to those meetings or start working with that sponsor. If that’s not working, we may help them get in contact with an outpatient therapist who specializes in substance abuse issues to help see if there are other mental health concerns that are driving some of these relapse behaviors.