Behavioral Health and Integrated Case Management
Rebecca Perez
Deborah Gutteridge
LEARNING OBJECTIVES
Upon completion of this chapter, the reader will be able to:
Define the special needs of individuals with behavioral health conditions, mental health disorders, and developmental disabilities.
Compare and contrast different behavioral health case management models.
Discuss the diagnoses and treatment options of clients commonly referred to case management.
Identify and explore challenges in behavioral health case management practice.
Discuss briefly behavioral health treatment options.
Define Integrated Case Management.
Compare and contrast an integrated approach versus a traditional CM approach to working with complex clients or individuals.
IMPORTANT TERMS AND CONCEPTS
Adverse consequences
Assertive Community Treatment (ACT) Model
Behavioral Health Care
Behavioral Health Case Management
Behavioral Health Home Care
Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5)
Integrated Case Management (ICM)
Self-Neglect
Severe and Persistent Mental Illness (SPMI)
Strengths Model
Substance-Related and Addictive Disorders
Introduction
A. The Case Management Society of America (CMSA) defines case management as “a collaborative process of assessment, planning, facilitation, [care coordination, evaluation,] and advocacy for options and services to meet an individual’s [and family’s comprehensive] health needs through communication and available resources to promote quality cost-effective outcomes” (CMSA, 2010, p. 6).
B. According to the National Alliance on Mental Illness (NAMI), case managers coordinate needed services and supports so that an individual can successfully live in the community (NAMI, 2015a).
C. Mental health promotion is an integral part of helping individuals with behavioral disorders. Promoting mental health is part of the case manager’s duty to advocate for the individual and then to facilitate and coordinate the care and services that will ultimately result in mental health.
D. Mental health is more than just the absence of mental or behavioral disorders but an essential part of health in general. As noted by the World Health Organization (WHO), “There is no health without mental health” (WHO, 2014).
E. Promotion of mental health involves the creation of environments whereby individuals can receive support so that they can adopt healthier lifestyles.
F. Core functions of case management, which are essential when working with individuals who have severe mental health issues, include assessment, treatment planning, linkage, monitoring, and advocacy. Case management plays an integral role in coordination of care, and location and access to needed services and supports.
G. Individuals with mental illness often find it difficult and frustrating to find the right agency or provider. The WHO developed the action plan:
Implementation of this action plan will help persons with mental illnesses find it easier to access services.
Have their care delivered by appropriately skilled health workers in general health settings.
Care will be delivered with treatment that is more responsive to the individual needs.
Improve access to government disability benefits, housing, and employment programs (WHO, 2013).
H. There are many different mental and behavioral disorders that present differently. Generally, the individual will present with abnormal thoughts and abnormal perceptions, emotions, and behaviors (WHO, 2014).
I. Mental disorders include depression, bipolar affective disorder schizophrenia, psychoses, dementia, intellectual disabilities, and developmental disorders including autism spectrum disorders (ASD).
J. There are effective strategies for prevention and effective treatments for mental disorders and ways to help relieve the suffering of others. Depression is one mental disorder that can be prevented.
K. The key is to find health care and social services capable of providing treatment and the necessary support:
Serious mental illness is further complicated when chronic medical conditions, social issues, and problems with access to care are present.
This is known as complexity, and approximately 10% of the population is considered complex.
This small percentage of the population can often use more than 70% of health care resources (Kathol, Perez, & Cohen, 2010).
Mental conditions are more likely to be treated in the general medical sector.
Primary care physicians give 70% of mental condition treatments, and 85% of mental health patients are seen in the physical health sector; these require an integrated approach, and all health and non-health-related issues need to be addressed.
An integrated approach is very effective in addressing individuals with complex health problems (Kathol, Perez, & Cohen, 2010).
L. ICM may be provided in a variety of settings by nurses, social workers, and licensed behavioral health professionals. These professionals may be trained to provide an integrated approach in the acute care setting, clinics, health plans, and the community (Kathol, Perez, & Cohen, 2010).
Descriptions of Key Terms
A. Behavioral health care—A very broad category often used as an umbrella term for care that addresses behavioral problems bearing on health, including patient activation and health behaviors, mental health conditions, substance use, and other behaviors that bear on health. In this sense, behavioral health care is the job of all kinds of care settings and is done by clinicians and health coaches of various disciplines or training, including but not limited to mental health professionals. It is a competency of clinics, not only of individuals (Peek et al., 2013).
B. Behavioral health case management—It is difficult to find a contemporary definition that is specific to behavioral health case management. Perhaps, this is related to the fact that there is no universally accepted definition of case management in and of itself. For reference purposes, Farnsworth and Bigelow (1997) posited the following definition, a method of providing cost-effective, quality care (cost, process, experience, and outcomes) by managing the holistic health concerns of clients (individuals, families, and groups) who are in need of extensive services. It requires integrating, coordinating, and advocating for complex mental and physical health care services from a variety of health care providers and settings, within the framework of planned behavioral health outcomes (Farnsworth & Bigelow, 1997).
C. Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5)—The Diagnostic and Statistical Manual of Mental Disorders is now in its fifth edition.
This text is used by clinicians and researchers to diagnose and classify mental disorders. It is the product of more than 10 years of effort by hundreds of international experts in all aspects of mental health and is considered an authoritative volume, which defines and classifies mental disorders in order to improve diagnoses, treatment, and research.
The criteria are concise and explicit, intended to facilitate an objective assessment of symptom presentations in a variety of clinical settings—inpatient, outpatient, partial hospital, consultation-liaison, clinical, private practice, and primary care. New features and enhancements make DSM-5 easier to use across all settings (American Psychiatric Association, 2013).
D. Self-neglect—Self-neglect is the result of an adult’s inability to perform essential self-care tasks due to physical and/or mental impairments or diminished capacity. The tasks may include providing essential food, clothing, shelter, and health care; obtaining goods and services necessary to maintain physical health, mental health, emotional well-being, and general safety, and/or managing financial affairs and adhering to prescribed medications.
E. Severe and persistent mental illness (SPMI)—The term mental health professionals use to refer to mental illnesses with complex symptoms that require ongoing treatment and management, most often requiring varying types and dosages of medication and therapy (University of North Carolina, 2015).
F. Substance-related and addictive disorders—Mind-altering substances all yield three basic types of disorders: substance intoxication, substance withdrawal, and what we now call “substance use disorders.” This was formerly referred to as substance dependence and substance abuse (Morrison, 2014).
Behavioral Health Case Management Models
A. The effectiveness of case management intervention in behavioral health and substance use disorder realms is mixed.
For behavioral health, outcomes vary across diagnosis grouping. Ziguras and Stuart meta-analysis demonstrated that the case management types that were studied were more effective than what was defined as usual treatment in three outcome domains: family burden, family satisfaction with services, and cost of care (Ziguras & Stuart, 2000).
Findings were favorable for intensive case management intervention when applied to patients with severe mental health disorders. Intensive case management compared to standard care was shown to reduce hospitalization and increase retention in care; it also improved social functioning (Dieterich, Park, & Marshall, 2010).
For substance use disorder, studies have reported positive effects in terms of the effectiveness of case management as compared with other interventions. Longitudinal effects of case management
intervention remain unclear. It was noted that strengths-based and generalist case management has proven to be relatively effective for substance abusers (Vanderplasschen, Wolf, Rapp, & Broekaert, 2007).
B. Conventional case management has been inconsistent with delivering integrative services located in the community. An assertive model that delivers clinically and cost-effective treatment demonstrates greater reductions in psychiatric rehospitalizations:
This model, known as assertive community treatment (ACT), has demonstrated results of lower arrests, jail days, and hospitalizations. One forensic ACT program showed 85% fewer hospital days, saving $917,000 in 1 year and 83% reduction in jail days, saving the cost of incarceration (Lamberti, Weisman & Faden, 2004).
ACT is a team-based approach that combines clinical services with care coordination, and case management plays a role in care coordination. When this occurs, outcomes are improved especially for those at most risk.
ACT is most effective for individuals with severe symptoms and behavioral impairment, pronounced disability in basic life skills, and/or prolonged course of illness (Bustillo & Weil, 2014). These individuals are not prepared to find the services they need in order to be a functioning member of the community. These services include housing, medical care, medication, and transportation (Bustillo & Weil, 2014).
C. Integrated case/care management is a preferred term pertaining to a parallel approach when there are co-occurring disorders in both medical and mental health realms.
Treatment of all disorders by the same clinician, collaborative goal setting with the individual, and demonstrating strength and empathy to develop a trusting relationship are the guiding principles of an integrated approach (Campbell, Caroff, & Mann, 2013).
Integrated case/care management means that all treating providers are aware of what the other is ordering. A common treatment plan is created. Communication is facilitated between providers, frequently by a case manager. The response to treatment is monitored and shared, and there is one case manager coordinating and communicating with the member and providers (Campbell, Caroff, & Mann, 2013).
D. Patient Protection and Affordable Care Act of 2010 (PPACA or ACA)—As pertains to behavioral and integrated health care, the ACA created an optional state benefit through Medicaid to coordinate care for individuals with chronic conditions. This whole person approach is known as a health home.
Health homes integrate and coordinate primary medical, acute, behavioral, and long-term care and support services, typically within the community. Health homes are for Medicaid recipients who have two or more chronic conditions, those who have one chronic condition but are at risk for another, and those who have one serious mental illness. Health home services include comprehensive care management, care coordination, health promotion, comprehensive transitional care, patient and family support, and referrals to community and social support services.
Applicability to CMSA’S Standards of Practice
A. The Case Management Society of America (CMSA) describes in its standards of practice for case management (CMSA, 2010) that case management practice extends across all health care settings, patient populations, and providers of various professional disciplines. This without a doubt applies to the practice of behavioral health case management.
B. Behavioral health case managers may use the CMSA standards as a guide for the implementation of their roles. All standards are relevant to caring for patients/clients with behavioral and emotional health issues, mental health conditions, and substance use and addiction. The standards include the clinical practice, legal and ethical expectations.
C. Case managers caring for the behavioral health patient population (whether combined with medical conditions or not) and across the various care settings must be aware of the CMSA standards of practice. They also must inform their employers and other professionals they collaborate with when dealing with a client with behavioral health concern about their existence, value, and need to adhere to them.
D. This chapter introduces case managers to the basic concepts of behavioral health case management practice and the role of the case manager in such settings and explains how collaboration may occur between case managers and other providers regardless of the care setting or specialty practice. This collaboration is necessary especially because behavioral health patients seek care not only in behavioral health settings but medical, surgical, and human services as well.
Behavioral Health Care Conditions and Implications for Case Management
A. Mental health is an integral part of overall health. Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. Mental health is a state of well-being in which the individual is aware of his or her own abilities, can cope with the normal stressors of life, can function productively, and can make a contribution to the community (WHO, 2015).
B. Disparities remain as pertains to mental health treatment. For individuals in low- to middle-income countries, between 75% and 85% of people with mental disorders receive no treatment. But interestingly, those in higher-income countries, 36% to 50% receive no treatment (WHO, 2009).
C. Persons with SPMI frequently have physical health problems, in addition to other mental health and substance use disorder problems that require treatment.
Comorbid medical, mental health, and substance use present significant challenges. Individuals with these comorbidities need access to treatment, rehabilitation, and often support services that are easily accessible in the community. The case manager is integral in coordination of these often hard to access care and services. Good care coordination by the case manager is the glue that binds together an effective plan of care (De Hert et al., 2011; Scott & Dixon, 1997).
There are many mental health disorders and they present differently. Generally, mental disorders present with a combination of symptoms and behavior. These include abnormal thoughts, perceptions, behaviors, and abnormal behavior and relationships with others (National Institutes of Health, 2007).
D. The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the standard classification of mental disorders used by health professionals in the United States.
The most recent edition, DSM-5, was published by the American Psychiatric Association (APA) in 2013.
The DSM-5 uses three major components in order to make a diagnosis: diagnostic classification, diagnostic criteria sets, and descriptive texts.
Some organizations have begun using the DSM-5 for criteria and coding, while others await the ICD-10 release to begin using both. The case manager should be mindful of the edition used for diagnostic coding, as it affects his/her respective job.
E. Depression
Depression is a common illness, affecting an estimated 350 million people worldwide. Depression may become a serious health issue when it lasts longer than a brief fluctuation in one’s mood, which is a response to day-to-day life challenges. Individuals suffering from depression experience functional difficulties at work, at school, and in the family. At its worst, depression can lead to suicide. Suicide results in an estimated 1 million deaths every year (WHO, 2012).
Major depression is a mood disorder manifested by a depressed mood or loss of interest or pleasure in almost all activities for at least 2 weeks.
Additional symptoms such as weight changes, disturbances in sleeping pattern, change in psychomotor activity, persistent feelings of guilt or worthlessness, difficulty concentrating or thinking, impairment of social or occupational role expectations, or suicidal ideation may also be present.
Despite effective treatments, less than half of people affected receive adequate treatment. This number rises to upward of 90% in some countries (WHO, 2012).
Barriers to effective care include a lack of adequate assessment, inaccurate assessment, lack of resources, lack of trained health care providers, and social stigma associated with mental disorders (WHO, 2012). The case manager should be mindful of barriers, which may be addressed as part of the case management plan.
The depressed patient may present for evaluation or treatment following a suicide attempt, a past history of suicide attempt along with depression should trigger high risk for suicide. Major depressive disorder can last 6 months or longer if left untreated.
Alcohol or other substance abuse can mask symptoms of this disorder. Clients may abuse substances in an attempt to self-medicate symptoms. A careful history of substance use including nicotine should be taken.
Depression is diagnosed and treated by trained health professionals delivering primary health care. Once the diagnosis has been
established, management should include psychosocial aspects, including identification of stress triggers such as financial problems, poor work performance, physical or mental abuse, or presence or absence of social support (Box 23-1) (WHO, 2012).
Case managers should ask patients if they are considering suicide or self-harm.
Patients may demonstrate increased suicide potential by giving away belongings, making a will, saying goodbye to loved ones, or hoarding medications.
Some patients act on suicidal ideation after initiating treatment for depression, when energy levels begin to improve.
Case managers should be vigilant about the suicide risk in these patients and be watchful of signs that a patient is considering suicide. Refer to Appendix A for additional details on suicide precautions.
F. Alcohol Use Disorder, Substance-related, and Addictive Disorders
Persons exhibiting alcohol abuse show a maladaptive pattern of alcohol use that results in one or more of the following in a 12-month period; DSM-5 defines substance use disorder as core behavior of persons who misuse substances. DSM-5 lists over 300 numbered (in ICD-10) substance-related disorders (Morrison, 2014). Addiction includes behavioral, physiological, and cognitive symptoms.
Alcohol use disorder (AUD) is the medical condition diagnosed when a patient’s drinking causes distress or harm. The DSM-5 integrates previously identified separate disorders, alcohol abuse and alcohol dependence, into a single disorder called AUD with mild, moderate, and severe subclassifications (National Institute on Alcohol Abuse and Alcoholism, 2015).
In 2013, 24.6% of people ages 18 or older reported that they engaged in binge drinking in the past month; 6.8% reported that they engaged in heavy drinking in the past month (Substance Abuse and Mental Health Services Administration, 2013).
Case manager must determine the substance involved, resulting problem, and how the substance use impacts the problem behavior.
Essential features of substance use disorder fall into three main categories (Box 23-2) according to the US Department of Health and Human Services (MentalHealth.gov, 2015).
Substance withdrawal
A physiologic dependence that is characterized by evidence of tolerance (needing more of the substance to produce a desired effect) and withdrawal when administration of the substance is discontinued.
Type of withdrawal dependent on substance used may include alteration in mood (anxiety, irritability, depression), abnormal motor activity (restlessness, immobility), sleep disturbance (insomnia or hypersomnia), or other physical problems (fatigue, changes in appetite) (Morrison, 2014).
Delirium tremens may be considered a more severe form of withdrawal of alcohol and is considered to be a medical emergency.
Substance-related and addictive disorders are diagnosed by history, physical examination, and interview. The condition can go undiagnosed if the patient continues to use substances and no withdrawal symptoms are observed. Over time, patients with this disorder may be increasingly unable to fulfill occupational or social expectations, which may cause distress.
Treatment of substance-related and addictive disorders is dependent of the substance used and may include the following:
Inpatient hospitalization
Support groups
Individualized psychotherapy
Group psychotherapy
Partial hospitalization/day treatment
Abstinence
Treatment should include an integrated team approach, to include person’s family and/or available support systems.
Care plan development by the case manager should include thorough assessment of available resources to cover potential treatment options, as mental health benefits are often limited.
Alcoholism is very common substance disorder. Treatment focuses primarily on alcohol abstinence and 12-step meetings (e.g., Alcoholics Anonymous) or a recovery program (e.g., Rational Recovery, Self-Management and Recovery Training [SMART] Recovery).
Case managers support the treatment plan through assessment, monitoring, planning, and resource utilization.
Use of proven screening tools as part of assessing high-risk individuals (e.g., CAGE questionnaire, Alcohol Use Disorder Identification Test [AUDIT]). CAGE refers to the four clinical interview questions (CAGE questions) that have proven useful in helping to make a diagnosis of alcoholism. The questions focus on Cutting down, Annoyance by criticism, Guilty feeling, and Eye-openers. The acronym “CAGE” helps health care professionals recall the questions.
Monitor adherence to medication and treatment program.
Provide resources and encouragement to patients and their significant others (e.g., 12-step programs, private treatment centers).
Remain mindful of the fact that chronic alcohol dependence is associated with social deterioration, decreased tolerance, medical complications of every organ, including liver impairment, which may interfere with the elimination of medications the patient may be on, causing risk for drug toxicity. Monitor for other health-related complications and coordinate care with primary providers (e.g., medical home, behavioral health home).
BOX 23-1 Caring for Patients with Depression
Recommended treatment options for moderate-severe depression consist of basic psychosocial support combined with antidepressant medication or psychotherapy, such as cognitive-behavior therapy, interpersonal psychotherapy, or problemsolving treatment.
Psychosocial treatments are effective and should be the first-line treatment for mild depression. Medicines and psychological treatments are effective in cases of moderate and severe depression.
Antidepressants along with talking therapies can be very effective for moderate to severe depression. Prescription of an antidepressant should not be the first line of treatment in mild depression. They should not be used for treating depression in children and are not the first-line treatment for adolescents (WHO, 2012).
Case management services for this patient population focus on the following:
Suicide prevention.
Referral for psychotherapy and significant other(s) involvement and education. Some clients find the support and structure of group psychotherapy beneficial, especially if social dysfunction has occurred as a result of depression.
Supporting antidepressant therapy and monitoring for side effects.
Education of family members about the illness, treatment, and signs of recurrence.
BOX 23-2 Categories of Substance Use Disorders
Behavioral
Drop in attendance and performance at work or school
Frequently getting into trouble (fights, accidents, illegal activities)
Using substances in physically hazardous situations such as while driving or operating a machine
Engaging in secretive or suspicious behaviors
Changes in appetite or sleep patterns
Unexplained change in personality or attitude
Sudden mood swings, irritability, or angry outbursts
Periods of unusual hyperactivity, agitation, or giddiness
Lacking of motivation
Appearing fearful, anxious, or paranoid, with no reason
Physical
Bloodshot eyes and abnormally sized pupils
Sudden weight loss or weight gain
Deterioration of physical appearance
Unusual smells on breath, body, or clothing
Tremors, slurred speech, or impaired coordination
Social
Sudden change in friends, favorite hangouts, and hobbies
Legal problems related to substance use
Unexplained need for money or financial problems
Using substances even though it causes problems in relationships
G. Bipolar disorder
Persons diagnosed with bipolar disorder, a mood disorder, and experience episodes of major depression and mania or hypomania. The individual is either elated and expansive or irritable.
For the diagnosis to be made, a change in mood must be present for at least 1 week (unless the individual is hospitalized with these
symptoms) or three of the following symptoms must be present for a 2-week period: inflated self-esteem or grandiosity, decreased need for sleep, pressured speech, flight of ideas, distractibility, psychomotor agitation, overinvolvement with pleasurable activities to the point of damaging consequences, reckless spending, or reckless behavior.
There are no diagnostic tests for bipolar disorder. Diagnosis is made through careful history, interview of client and family or care giver, and observation of both verbal and nonverbal behaviors.
The Young Mania Rating Scale (YMRS) may sometimes be used to quantify the quality and degree of mania (Psychology-Tools.com, 2015).
Brain scans and blood tests may be helpful in ruling out other factors contributing to mood problems such as stroke or brain tumor. Bipolar will worsen if left untreated or undiagnosed.
About 50% of clients with bipolar disorder have concurrent substance abuse disorders. There are four basic types of bipolar disorder described in Box 23-3 (National Institute for Mental Health, 2015a).
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