In-home behavioral health case management: An integrated model for high-risk populations

In-home case management 

The in-home program was designed first to empower patients to improve their unhealthy lifestyles and poor environmental conditions and then assist payers in reducing medical and behavioral health costs. The state of Wisconsin mandates that CM services be available to patients of the Medicaid-serving HMO populations. This clinic implemented an in-home behavioral health CM program, in collaboration with a large HMO in southeastern Wisconsin. Evidence-based results include increase in level of functioning, decrease in risk assessment, and increase in medication compliance.

Historically, managed-care insurance companies have been the gatekeepers. They determined when, where, and how often services were received. With this program, however, the provider, not the managed-care company, determines eligibility criteria for referral into the CM program. This paradigm shift in the preauthorization process distinguishes this collaborative model from any other. The empowerment delegated to the provider allows it to focus more on patient care than on authorization protocols and procedures. The concurrent review process exists but does not create obstacles or other managed-care mechanisms to deter the CM process. These features have allowed both the managed-care organization and the provider to maintain patient care and services as the top priority.

The Request for Reauthorization for Case Management (Figure 2) is initiated by the provider to the managed-care organization (MCO) and sent via e-mail through a secure e-mail address. Typically, 1–3 months of CM services are authorized at the level requested. Before the end of the authorization period, the provider resubmits a request for additional authorization. The provider and the MCO perform concurrent reviews on targeted cases during monthly conference calls designed to enhance the collaborative model.

View Large Image Download to PowerPoint

Figure 2. Case Management Request for Reauthorization©

The CM program is very cost-effective because it is proactive. Patients call the case manager, often before the crisis escalates, because they have formed a therapeutic alliance with the case manager, and together they work to prevent problems before they become a crisis. Case management helps to prevent crises and crisis management reduces the need for expensive emergency care.

The case managers often are immediately accessible in times of crisis. For example, one night a family became violent and called their case manager. The identified patient had a history of psychosis with numerous hospitalizations and noncompliance with medication. Crisis intervention was prompt, and the case manager avoided an unnecessary hospitalization while creating a safety plan, follow-up psychiatric appointment with a language interpreter, and community resources (woman's shelter, domestic violence programs, etc). Because the case manager was able to respond quickly, the situation stabilized and there were no further episodes of crisis. This intervention prevented an unnecessary psychiatric admission and emergency room visit.

The in-home program provides 24/7 mobile triage and crisis intervention teams, as well as office appointments. The program extends itself as an advocacy service by going to jails, churches, and schools and meeting with people at fast-food restaurants. The program also has a system in place to assist people with appointments before their discharge from hospitals and has created resources for supervised apartments in therapeutic environments in the community.

For many patients with severe physical conditions, quality of life is often compromised, so the mere convenience of in-home services is extremely helpful. The provider works with individuals who are bedridden as a result of chronic pain; those who have frequent health emergencies because of chronic health conditions—such as diabetes, AIDS, multiple sclerosis, and fibromyalgia—that coexist with depression, anxiety, and other mental health disorders; in addition to people facing such overwhelming life stressors as unemployment and lack of housing. Family crises often arise, and supportive counseling and CM assist in dealing with the overwhelming sense of hopelessness and helplessness under these conditions.

Since 1992, the clinic has provided a wraparound approach and integrates this approach for high-risk patients.1 The use of a single agency to coordinate and triage services for disease management has resulted in higher compliance. In-home treatment has enabled collaboration among the psychotherapist, psychiatrist, case manager, and health plan disease-management resources to monitor patient compliance and safety and, if necessary, to mobilize crisis intervention while providing in-home counseling and to refer to other community resources available to assist with problems of daily life and meet practical needs. Through immediate CM interventions, these cost-effective responses meet the needs of high-risk HMO users who would likely otherwise depend on costly hospital emergency rooms or be admitted for observation. This small percentage of HMO users represents the costliest consumers of total health care resources.

Satisfying results 

This unique CM program fills a crucial gap. For those who take part in the program, proactive interventions and intensive services provide a foundation for individuals to gain better coping skills and decrease stress and subsequent crises. They also have demonstrated a preventive component in mitigating factors that contribute to domestic violence, child abuse, and neglect in families. Obstacles that prevent people from receiving the care they need cause an increase in health care costs associated with these high-risk populations, and these costs often are unnecessary. Integrated, strength-based CM, combined with medication compliance and intensive counseling, has reduced unnecessary utilization of health care services.