Case management best practices that pave the way for real world success☆

Background 

The Balanced Budget Act of 1997 mandated an evaluation of coordinated care services. Mathematica Policy Research was awarded a contract to conduct this evaluation, and Arnold Chen, Randy Brown, Nancy Archibald, Sherry L. Aliotta, and Peter Fox published a report of their findings in 2000. A copy of the full report, “Best Practices in Medicare Coordinated Care,” is available at www.mathematica-mpr.com.

This article describes the study, discusses the application in day-to-day case management practice, and illustrates the use of the key components in a case study.

Identification of the programs for study 

The Mathematica Team attempted to identify as many programs as possible for evaluation. They contacted professional organizations, such as the Case Management Society of America, and universities; researched professional journals, websites, and Internet boards; and published their intent in the Federal Register. In addition, the team conducted literature searches to identify eligible programs. Programs then indicated their interest and proceeded through the selection process.

Of the 157 programs that provided information for the study, 24 were selected for further interview based on their reported reductions in hospital use or cost and meeting the other inclusion criteria. Three programs that also reported significant process success without reductions in costs or hospital use chose to identify factors that may have led to the lack of success.

Study strengths and limitations 

The study contained numerous strengths. Only programs with a demonstrated success in decreasing cost were included, increasing the likelihood that the programs were financially sound and could be successfully implemented. The methods used to evaluate the savings claims were rigorous and verified the reported savings. The study set forth a working definition of care coordination and separated it from programs primarily focused on decreasing cost through reduced length of stay, either through patient criteria or substitution of a lower level of care. It also contained both disease management and case management programs.

Another significant strength was the study's ability to look at both disease and case management in a way that allowed direct comparison of the approaches. Finally, the team had no preconceived notions of what we would find or what would define success.

Among the study's limitations was the fact that we relied on the programs for data. We did not independently verify the data through site visits or other methods. However, we conducted extensive interviews with the programs. The programs studied were not picked at random from a sample of all programs, meaning that some selection bias may have existed. Only programs willing to respond to the data request and interview process were included. Despite this, we do not believe the inclusion of additional programs would have significantly altered our findings. We also lacked the ability to verify cost-effectiveness and were unable to determine whether any of the managed care impacts would affect the program's ability to be cost-effective in a fee-for-service environment.

The 3 components 

The programs tended to deal with chronically ill individuals, first those at higher risk of adverse health outcomes and those whose problems were mainly the result of one chronic illness. Regardless of which category the individual fit, the programs went through the following 3 steps:

As shown in Table 1, each step has a number of components.

Table 1. Process Components

	Assess and Plan
	Uncover all important problems.
	Address all important problems and goals.
	Draw from an arsenal of proven interventions.
	Produce a clear, practical plan of care with specific goals.
	Implement and Deliver
	Build ongoing relationships with the primary care physician and other providers.
	Build ongoing relationships with patients and families.
	Provide excellent patient education.
	Reassess and Adjust
	Perform periodic reassessments.
	Be accessible.
	Nurture relationships with the primary care physician and other providers.
	Nurture relationships with patients and families.
	Make adjustments to plan of care as needed.

Assess and plan 

The assessment and planning for Marie S. began at the university's brain injury rehabilitation program before her admission. The center's internal case manager (ICM) reviewed the information gathered by the admission coordinator and, meeting with the medical director, determined that Marie was likely to benefit from treatment. The external case manager (ECM) provided extensive and extremely useful information that allowed the interdisciplinary rehabilitation team to anticipate some of the challenges they would encounter with Marie.

Marie was a 32-year-old woman whose early life was plagued by an endless quest for illicit substances. An illness in adolescence introduced her to drugs, and although her body recovered, her craving for drugs lingered. An underlying personality disorder, tending toward borderline characteristics, gave her a sense of unrelenting anxiety. She established a pattern of self-mutilation when tensions escalated, leading to hospital admissions that resulted in a welcome deluge of drugs. She became an obsessive pharmacologic expert and orchestrated her medications like a maestro. When thwarted, her anxiety escalated and she cut herself, ensuring an inpatient admission and resumption of the cycle.

With intense effort and support by the community mental health system, Marie had achieved a full year of drug-free life. This major accomplishment was derailed in 2000 when an auto accident during work caused physical injuries, including a brain injury. The road to recovery mandated the use of medications, and the old patterns returned, compounded by the cognitive deficits frequently associated with brain injury. In the 18 months since the injury, Marie bounced between psychiatric admissions and various rehabilitation programs, all to no avail other than to cement her obsessive reliance on medications for anxiety management.

The university-based rehabilitation program was selected for its depth of provider resources and innovative approaches to therapy. Marie's case manager (ECM) and guardian brother were desperate to find an alternative approach to the management of her problems so that the drug-seeking cycle would be interrupted. Both were hopeful that Marie once again could achieve a drug-free life, or at least one that relied on a minimal, stable regimen of medications. Even if that could be achieved, the question remained about her returning to work performing the cleaning and housekeeping duties she had done before her accident.

Armed with a wealth of information and insight into Marie's complex history, the ICM met with her interdisciplinary team to identify challenges and lay plans. The staff knew they had to be vigilant about preventing self-harm. Marie's room was to be searched routinely and all activities supervised. The psychologist reviewed plans to manage her anxiety, the medical director consulted with the psychiatrist about medications, and the staff-certified substance abuse counselor was involved. Therapists scheduled evaluations to begin addressing the cognitive deficits that compromised Marie's ability to appreciate the significance and severity of the challenges she faced.

The case manager followed the best practice and its components by identifying all relevant problems. The multiple and complex layers of old and new problems could have thwarted (and did) the best intentions of Marie and the care team. Next, the team set clear goals for each of these problems with a plan and interventions. The team clearly established a goal of providing a safe environment that reduced or eliminated the risk of self-injury. They also made a clear plan with interventions to achieve their desired goal.

The team tackled the risk of self-harm with a multifaceted approach that took advantage of each member's expertise. These interventions had been proved effective in the past in addressing the identified problem. The plan of care was clearly written; all those involved participated in and agreed with the goals and how and when Marie would achieve them.

Implement and deliver 

Moving to a new environment is always stressful to a person with a brain injury, but the consistency and structure of the rehabilitation program eased Marie through her first few weeks as a resident in the facility. The nearly constant access to therapy staff and extra attention given by students receiving clinical training at the facility gave Marie a sense of security and attention that initially held her anxiety at bay. The ICM developed a behavioral plan, in conjunction with the therapists' observations, which paved a simple path for incremental successes. The therapists' frequent meetings with Marie led her to understand the reasons for some of her anxiety. For example, although improving personal hygiene and appearance was a goal, Marie found these tasks difficult because mirrors, make-up, and hair reminded her of a girlfriend killed in the accident with whom Marie used to sell cosmetics.

In the third week, Marie obviously became more focused on her medications, requiring frequent reassurances from physicians and psychologists. The staff sensed her heightened distractibility and anxiety, and her status was changed to 5-minute checks around the clock. Despite these efforts, Marie succeeded in gashing the back of her hand with a jagged pebble she had hidden in her shoe and was taken to the Emergency Department for sutures and a psychiatric evaluation. Very articulate about her expectations for admission and a litany of the medications that would help her, Marie was rejected for psychiatric admission. She returned to the rehab facility with what the staff feared was a heightened resolve to “prove” that she intended to harm herself and required admission. She sank into a deep depression, coaxed from her bed with extreme difficulty only for sporadic meals eaten in isolation.

The ICM met with the medical director, psychiatrist, 2 psychologists, personnel manager, and the ECM. The question before the group was not only could Marie be managed safely at the rehabilitation facility, but should she be? Where would she receive the best quality care to suit her individual needs? After thoughtful discussion, they concluded that Marie would be better off clinically if she were not admitted to a psychiatric unit. She had been demonstrating cognitive progress and integration into the program of daily life skills and activity groups. If there was an element of conscious manipulation, it was better left unsuccessful. Her brother was consulted, and he was vehement in his wish to avoid hospitalization!

Given the group's consensus, the task of implementing the plan fell to the case managers. A breakthrough came when the ECM offered to provide additional funds to augment traditional staff levels, which would allow the 24-hours-a-day, 1-on-1 staffing necessary for the duration of Marie's acute self-harm threat. The psychiatrist consulted daily, and the psychologist agreed to see the patient for therapy at least once a day. Marie was to be encouraged frequently by staff to rejoin the resident group in the patterns of life that she had known previously. The case managers communicated on a weekly basis, sharing provider reports and clarifying resource allocation decisions. The brother expressed great appreciation for the plan's ingenuity.

Implementing and delivering the plan created in the first of the 3 key steps proved to be a challenge. However, the team maintained the best practice principles by establishing ongoing relationships with all the providers, the patient, and the guardian. Clearly, without this level of collaboration, failure of the plan was ensured. Despite the instability of the situation, the team continued educating Marie on the core components of her brain injury rehabilitation. Furthermore, they worked together to implement the planned interventions.

Reassess and adjust 

Four weeks later, the psychologists decided the round-the-clock supervision could be safely relinquished. In that time, Marie had returned from her state of withdrawal and joined the group for common meals and partial participation in individual therapies. She had become more communicative when spoken to, willing to engage in more than a monosyllabic response. Her psychiatrist adjusted her medications with wariness and attention to her history.

Anxiety management continued to be a central theme in Marie's care. With the goal of substituting positive alternatives for the automatic response of harm, the case managers brought some alternative therapists from the university. A doctoral candidate in the school of music therapy worked with Marie and established a very strong therapeutic relationship. Listening to music and learning relaxation techniques proved to be an effective distracter, as evidenced by periodic delays in frequency of requests for PRN (take as needed) medications. Given Marie's obsessive concern about drugs, this small step represented a major change in her long-standing pattern of self-destructive behaviors.

As Marie's progress continues to evolve, all parties are aware that her troubles are likely to be cyclical. The feedback, provided by staff and therapists, directed to both case managers about anxiety levels continues to be closely monitored and plans adjusted accordingly.

This case study illustrates the need to reassess and adjust throughout. Because the team was accessible to each other and the patient, they were able to quickly detect the need for changes in goals or interventions to achieve the goals. The case managers did a masterful job of nurturing all the key relationships with the patient, the guardian, and the providers. Further, they creatively readjusted the plan to include music therapy. This addition underscores the need for an arsenal of interventions and resources, especially when the initial approach does not yield the desired outcome. The changes were made promptly and sometimes urgently, certainly in light of Marie's escalating attempts at self-harm. Furthermore, the team encountered and effectively resolved numerous ethical dilemmas. This case proves that reassessment and adjustment are critical in the real world and that even the best plans can produce a lot of unexpected results.

Outcomes and measures of effectiveness 

In addition to noting the delays in Marie's requests for medication as indicative of success, all parties thought it important to demonstrate the multiple positive outcomes the team achieved. The two case managers met and shared perceptions and data. This collaboration led to the identification of the following categories in which measurable outcomes had been achieved.