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

   Julia Hidalgo, ScD, MSW, MPH

 Positive Outcomes, Inc. Harwood MD
            Today we will discuss
 The evolution of HIV case management in the
   Newly emerging case management roles and
   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
                Ground Rules
 I do not represent DHMH or
    the HRSA HIV/AIDS Bureau
   Let me know if you do not
   We can share our feelings
    at the end of each section
   You will be rewarded for
    staying awake
   Shut off your electronic
   A 15 minute break means 15
 Quick History of HIV Case Management
                            Late 1980s and Early 1990s
                             Focus on newly
Early 1980s                   introduced HIV testing
 Focus on                    and treatment (AZT)
  hospitalizations and       Support activities offer
  end of life care            alternatives to inpatient
 Case managers               stays
  coordinated care for       A continuum of support
  terminally ill patients     services develops
 Case managers tend to      Volunteers continue to
  be from other health        provide support services,
  care or social work         with CBOs forming
  systems and have a         Populations impacted by
  personal commitment to      HIV become diverse
  the AIDS epidemic
 Volunteers provide
  support services
     Quick History of HIV Case Management
Mid to Late 1990s                   The 2000s
 Focus on HIV voluntary             Focus on rapid HIV testing,
    testing, primary care, and          HAART, and increasingly
    combination therapy                 complex specialty care
   Understanding of the roles of      CARE Act funds flatten
    medication adherence and           Number of clients grows
    drug resistance grows              They experience longer, more
   Number of clients increases         complex lives, outstripping
    steadily and diversity of the       service capacity
    infected community expands         Mental health and addictions
   CARE Act, Medicaid, and             treatment become important
    Medicare funds underwrite           component of HIV care
    growing costs                      Case managers seek simplified
   Case management is                  models, borrow from other
    professionalized                    disciplines, assess outcomes
   Community-based care               Role of adherence and self-
    continuum grows, with               management is recognized
    growth in minority                 Peers’ role in care continuum is
    organizations                       acknowledged
   Outreach and retention
    efforts grow
 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
 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
    Limited organized, long term training for
    case management
  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
 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
    Current Challenges For Case Management Clients

 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
   Effective HIV therapeutics have resulted in
    “return to work,” although some clients have
    limited “traditional” work histories
  Current Challenges For Case Management Clients
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
 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
  Case Management Processes: A Quick Review

               Reassess client’s                   Determine
   needs, adjust the care plan, or                 eligibility for CARE Act
                       de-activate                 and other services

 Implement the care plan                                   Conduct a needs
            and document                                   assessment
activities in client’s chart                               using a standardized tool
                                       with the
                                      and care
                                       team to
                                      develop a
                                      care plan
What HIV case
models are used
in other
        Acuity Models Used to Plan Care
 Acuity-based client assessment tools
    “stage” the need for case management and
    other services                                   Example of Acuity or
                                                         Service Levels
      Most acuity models are similar, based on       Level 1: Minimal
       an early San Francisco model                    or no assistance
      Oregon’s acuity forms are included in           needed
                                                      Level 2: Moderate
       your package                                    assistance
   Acuity is related to the amount and nature of      needed
                                                      Level 3:
    case management provided                           Significant
      May be linked to unit-based payment             assistance
   Tend to be subjective, based on client’s self-    Level 4:
    report in the earliest stages of case              Extensive
    management                                         needed
   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
   Refinement of the Acuity Model Approach
New York is moving from a complex, multi-tier model
              to a two-tiered model
Comprehensive Services        Supportive Services
          Proactive                       Responsive

 Comprehensive assessment              Brief assessment

 Comprehensive service plan            Brief service plan

Complex needs, focuses on the    Discrete, maintenance needs or
 client and their families and    the complex needs of clients
     close support system         not ready for comprehensive
                                        case management
          Long term                         Short term
  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
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
    New Roles, New Personnel
 Nurse case managers
 Social work case managers
 Addictions/mental health case
    Certified and/or licensed counselors
 Eligibility determination or benefits
  coordination specialists
 Prevention case managers
 Peer or “near-peer” case managers
       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
      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
          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
   Case finding, home visiting, escort services to
    medical and other appointments, transportation
   Prison or jail outreach and discharge planning
 New challenges for case managers and
     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
 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
                  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
   Adolescent and young-adult centered case
   Working with other service systems
 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
      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
Different Approaches Are Used to Pay for
            Case Management
 CARE Act
   Traditional grant funded case management
   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
Which new case
models make the
most sense for
your program?
For Suburban
What is the
chronic care
      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
Chronic Care Model
               A population-based
               model that relies on
               knowing which
               patients have the
               illness, ensuring
               that they receive
               care and actively
               helping them to
               participate in their
               own care
             Chronic Care Model

Community                  Health System
Resources and           Health Care Organization
Policies                                            Practice Level
           Self-        Delivery    Decision       Information
        Management      System      Support          Systems
          Support       Design

 Informed,                                       Prepared,
 Activated                                       Proactive
                     Interactions              Practice Team

             Improved Outcomes
       What characterizes a “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
      What characterizes a “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
       What are the characteristics of a
          productive interaction?

    Informed,        Productive           Prepared
    Activated                             Practice
                    Interactions            Team

•Collaborative goal-setting and problem-solving
•Tailoring of clinical management by protocol
•Shared care plan
•Active, sustained follow-up
Is the chronic
care model
feasible in
Maryland’s HIV
care system?
Adherence and
Forging new
between case
managers and
    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
  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
   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
    Keep medical, case management, and other
    Communicating with the care team, family, and
    Ongoing problem-solving to overcome potential
  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
     Set realistic therapeutic goals together
     Avoid unnecessary medications
 These skills can be applied to other sectors of
  clients’ lives
         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
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
Are your
clients ready
for a self-
Are you ready
to help?

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