Emerging Roles for HIV Case Managers A Workshop Funded by the Suburban MD Title I Program

1. Emerging Roles for HIV Case ManagersA Workshop Funded by the Suburban MD Title I Program Julia Hidalgo, ScD, MSW, MPHPositive Outcomes, Inc. Harwood MDwww.positiveoutcomes.netjulia.hidalgo@positiveoutcomes.net

2. Today we will discuss • The evolution of HIV case management in the US • Newly emerging case management roles and strategies • Basic and advanced case management skills • Strategies for successful participation in the clinical care team • Methods for effectively coordinating clinical and support services • Techniques for assisting clients to adhere to their medications and other components of their treatment regimens

3. Ground Rules • I do not represent DHMH or the HRSA HIV/AIDS Bureau (HAB) • Let me know if you do not understand • We can share our feelings at the end of each section • You will be rewarded for staying awake • Shut off your electronic devices • A 15 minute break means 15 minutes!

4. Quick History of HIV Case Management Late 1980s and Early 1990s • Focus on newly introduced HIV testing and treatment (AZT) • Support activities offer alternatives to inpatient stays • A continuum of support services develops • Volunteers continue to provide support services, with CBOs forming • Populations impacted by HIV become diverse Early 1980s • Focus on hospitalizations and end of life care • Case managers coordinated care for terminally ill patients • Case managers tend to be from other health care or social work systems and have a personal commitment to the AIDS epidemic • Volunteers provide support services

5. Quick History of HIV Case Management Mid to Late 1990s • Focus on HIV voluntary testing, primary care, and combination therapy • Understanding of the roles of medication adherence and drug resistance grows • Number of clients increases steadily and diversity of the infected community expands • CARE Act, Medicaid, and Medicare funds underwrite growing costs • Case management is professionalized • Community-based care continuum grows, with growth in minority organizations • Outreach and retention efforts grow The 2000s • Focus on rapid HIV testing, HAART, and increasingly complex specialty care • CARE Act funds flatten • Number of clients grows • They experience longer, more complex lives, outstripping service capacity • Mental health and addictions treatment become important component of HIV care • Case managers seek simplified models, borrow from other disciplines, assess outcomes • Role of adherence and self-management is recognized • Peers’ role in care continuum is acknowledged

6. Quick History of HIV Case Management • Today • The Ryan White HIV/AIDS Treatment Modernization Act of 2006 identifies two types of case management • Medical case management (considered a core medical service) • Support case management in which referrals for health care and support services are made (considered a support service) • HAB has not defined these service categories

7. Current Challenges For Case Managers • Current HIV medications and treatment strategies require a strong link between medical care, case management, behavioral health, and support services • Funders expect greater accountability, linking clinical outcomes with case management and other processes • HIV training tends to focus on clinicians • Limited organized, long term training for case management

8. Other Challenges For Case Managers • HIV case managers tend to be overworked, underpaid, and unable to keep up with advances in knowledge about HIV treatment and case management practice theory • HAB payer of last resort requirements require knowledge of resources in other systems • HIV clinicians tend to be unfamiliar with case managers’ potential roles and contribution to the care team • In Maryland, as in several other states, Medicaid managed care programs are required to provide disease management and/or case management services

9. Clients’ low income and barriers to health insurance require substantial skills in understanding how to gain income assistance and health insurance The growing diversity of the HIV infected population requires greater multiculturalism among their providers, including case managers Effective HIV therapeutics have resulted in “return to work,” although some clients have limited “traditional” work histories Current Challenges For Case Management Clients

10. Clients commonly Respond well to HIV treatments and are ready to reclaim their lives Are challenged by side effect management Experience treatment failure and face end of life issues May drop in and out of care periodically during the course of their treatment Co-occurring conditions (mental illness, addictions, other chronic diseases), poverty, and lack of education or job skills impact their ability to be self-sufficient and economically independent For some, the overwhelming need to survive from day to day overshadows HIV infection as a concern Current Challenges For Case Management Clients

11. Case Management Processes: A Quick Review

12. What HIV case management models are used in other communities?

13. Acuity-based client assessment tools “stage” the need for case management and other services Most acuity models are similar, based on an early San Francisco model Oregon’s acuity forms are included in your package Acuity is related to the amount and nature of case management provided May be linked to unit-based payment Tend to be subjective, based on client’s self-report in the earliest stages of case management Acuity can change overnight, due to presentation or resolution of crises No evidence that there is a link between acuity level and future use of case management services Example of Acuity or Service Levels Level 1: Minimal or no assistance needed Level 2: Moderate assistance needed Level 3: Significant assistance needed Level 4: Extensive assistance needed Acuity Models Used to Plan Care

14. New York is moving from a complex, multi-tier model to a two-tiered model Refinement of the Acuity Model Approach

15. Integrated HIV Case Management Systems • Centralized, single point of entry into CARE Act funded services • Philadelphia and Ohio • Centralized eligibility determination and referral to case management services • A case management program is selected based on geographic preferences, one-stop model in which clinical services are available, family-center settings, behavioral health settings • Ability to account for full caseloads to ensure equitable distribution of clients

16. Independence-Based Case Management Models • Once eligibility for the CARE Act is determined, clients are free to move about the system without a “navigator” • Case managers are no longer the “gate keeper” of CARE Act-funded services • Clients “opt in” to case management rather than it being assumed they need or want it • Clients receive group and individual training regarding how to navigate the system

17. New Roles, New Personnel • Nurse case managers • Social work case managers • Addictions/mental health case managers • Certified and/or licensed counselors • Eligibility determination or benefits coordination specialists • Prevention case managers • Peer or “near-peer” case managers

18. Prevention Case Management • CDC-funded prevention activity commonly provided in a public counseling and testing setting • Assists HIV seropositive and seronegative persons in adopting risk-reduction behaviors • Intended for persons having or likely to have difficulty initiating or sustaining practices that reduce or prevent HIV transmission and acquisition • Provides intensive one-on-one prevention counseling and support • Provides assistance in accessing needed medical, psychological, and social services that affect clients' health and ability to change HIV-related risk-taking behavior

19. Prevention Case Management • Hybrid of HIV risk-reduction counseling and traditional case management that provides intensive, on-going, and individualized prevention counseling, support, and service brokerage • Client-centered counseling done in an interactive manner responsive to individual client needs and focusing on • Developing client-centered prevention objectives and strategies rather than simply providing information • The client’s unique circumstances including behaviors, sexual identity, race/ethnicity, culture, knowledge, and social and economic status

20. New Roles for Peers • Peers or “near-peers” are trained to provide • Information and referral to individual clients or in group training sessions • Treatment adherence and side effect management counseling • Case finding, home visiting, escort services to medical and other appointments, transportation • Prison or jail outreach and discharge planning services • New challenges for case managers and supervisors

21. New Roles, New Settings • Community-based case managers are co-located at HIV clinics • HIV clinicians co-located in HIV case management or drug treatment programs • Mobile case management units assigned to HIV counseling and testing vans, mobile homeless program outreach units, or otherwise out-stationed in community settings on regular schedule

22. New Skills • Creating client-friendly service environments • Secondary HIV prevention • Assessing sexual risk behaviors and harm reduction counseling • Family-centered case management • Motivational and other interviewing strategies • Adolescent and young-adult centered case management • Working with other service systems

23. Disease Management (DM) According to the DM Association of America • DM is a system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant • Supports the clinician - patient relationship and the care provided • Emphasizes prevention of complications by using evidence-based practice guidelines and patient empowerment strategies • Evaluates clinical, humanistic, and economic outcomes on an ongoing basis with the goal of improving overall health

24. Disease Management (DM) Uses • Population identification processes • Evidence-based practice guidelines • Collaborative practice models include physician and support service providers • Patient self-management education • Includes primary prevention, behavior modification, and compliance monitoring • Process and outcomes measurement, evaluation, and management • Routine reporting/feedback loop • Including communication with patient, physician, or practice profiling

25. Different Approaches Are Used to Pay for Case Management • CARE Act • Traditional grant funded case management positions • Unit-based reimbursed services • One or more rates paid for specific case management services • In New York, State funds purchase bundled clinical and case management services • Covered Medicaid fee for service or managed care covered benefit • Each approach varies in licensure and professional requirements

26. Which new case management models make the most sense for your program? For Suburban Maryland?

27. What is the chronic care model?

28. Short History of the Chronic Care Model • Initial experience at large Northwestern group practice • Reviewed and revised by advisory committee • Breakthrough series documented the model’s wider application • Applied in diabetes, geriatrics, asthma, HIV, and depression with over 500 health care organizations participating in collaboratives • Model adopted by HAB as a concept in the early part of this century • HIV quality collaboratives have been funded

29. Chronic Care Model A population-based model that relies on knowing which patients have the illness, ensuring that they receive evidence-based care and actively helping them to participate in their own care

30. Chronic Care Model Community Health System Health Care Organization Resources and Policies Practice Level Self-Management Support DeliverySystem Design InformationSystems Decision Support Prepared, Proactive Practice Team Informed, Activated Patient Productive Interactions Improved Outcomes

31. What characterizes a “informed, activated” patient? Informed, Activated Patient • The patient understands the disease process • Realizes his/her role as the daily self-manager • Family and caregivers are engaged in supporting the patient’s self-management • The provider is viewed by the patient as a guide

32. What characterizes a “prepared” practice team? Prepared Practice Team At the time of the visit, the team has the patient’s information, data, staff, equipment, and time required to deliver evidence-based clinical management and self-management support

33. What are the characteristics of a productive interaction? Prepared Practice Team Informed, Activated Patient Productive Interactions • Assessment • Collaborative goal-setting and problem-solving • Tailoring of clinical management by protocol • Shared care plan • Active, sustained follow-up

34. Is the chronic care model feasible in Suburban Maryland’s HIV care system?

35. Adherence and self-management:Forging new partnerships between case managers and clients

36. Case Management Strategies: A New Psychology • Move from enabling to empowering clients • Adapt HIV prevention techniques • Stages of change • Motivational interviewing • Case management outreach and re-engagement for clients lost to care • Strength-based social work • Social contracts • Sharing, not guarding, resources such as service directories

37. Self Management and Adherence • Clients need support and information to become effective managers of their own health • Medical and behavioral interventions are required • Each client is at a different place in the process • Appropriate interventions are driven largely by each client’s desired outcomes • Clients should have a • Basic information about HIV and its treatment • Understanding of and assistance with self-management skill building • Ongoing support from members of the clinical team, family, friends, and community

38. Self-Management and Adherence Activities • Activities that clients perform to control their illness, prevent future complications, and cope with the impact of HIV and its treatment • Collaborative goal setting • Symptoms monitoring • Lifestyle behaviors including healthy diet, getting regular exercise, and smoking cessation • Taking medication in the dose and frequency prescribed • Keep medical, case management, and other appointments • Communicating with the care team, family, and others • Ongoing problem-solving to overcome potential barriers

39. Setting and Documenting Self-Management Goals Collaboratively With Clients • Address medication adherence with standardized training and goal-setting • Before beginning HAART, assess client's treatment readiness, understanding of the disease, attitudes about HAART, and understanding the importance of adherence • Review treatment options, client's lifestyle, dosing schedules, and number of pills to be taken • Educate clients about side effects and their management • Set realistic therapeutic goals together • Avoid unnecessary medications • These skills can be applied to other sectors of clients’ lives

40. Self-Management Goals • Address other self-management issues needing collaborative goal-setting • Self-management goals may include • Disclosure of HIV status • Safer sex practices • Entering drug or alcohol treatment programs • Attending support groups • Seeking help for abusive situations • Re-establishing or maintaining a support system • Returning to work • Maintaining a stable living situation • Maintaining body weight • Preventing or controlling medication side effects

41. Practical Steps in Self-Management • Assess clients' skill, understanding, and confidence in managing HIV • Give clients a copy of their goals, and place a copy in the client’s chart • Review the client's personal barriers and enablers to link daily tasks leading to positive self-management behaviors

42. Are your clients ready for a self-management? Are you ready to help?