Cross-Disciplinary Training for Value-Based Integrated Case Managers

Chapter Objectives

• To develop comfort in talking about health behaviors, cognitive issues, and emotional problems in the context of physical disease and about physical illness in the context of behavioral health issues and disorders.

• To discuss how to include behavioral health and physical conditions during standard value-based integrated case management assessments.

• To review general characteristics about how to handle special medical, behavioral health, and pediatric situations as a value-based integrated case management manager.

• To describe the knowledge and skill base needed to integrate assistance for common physical and behavioral health conditions in value-based integrated case management.

“The important thing to you is not how many years in your life, but how much life in your years!”

—Edward J. Stieglitz, M.D.

FormalPara Chapter Objectives

• To develop comfort in talking about health behaviors, cognitive issues, and emotional problems in the context of physical disease and about physical illness in the context of behavioral health issues and disorders.

• To discuss how to include behavioral health and physical conditions during standard value-based integrated case management assessments.

• To review general characteristics about how to handle special medical, behavioral health, and pediatric situations as a value-based integrated case manager.

• To describe the knowledge and skill base needed to integrate assistance for common physical and behavioral health conditions in value-based integrated case management.

Introduction

VB-ICM is the process in which a single case manager assists individuals with all barriers to health, including those related to physical illnesses or to mental health and substance use (BH) conditions. Handoffs among VB-ICM managers are minimized, and total health outcomes for their assisted individuals are the responsibility of each VB-ICM manager. Case assignment is based on the availability of a VB-ICM manager with the time to initiate VB-ICM activities and the training needed to address issues in four domains, the biological, psychological, social, and health system, which retard return to health. The specific clinical background of the VB-ICM manager is relevant, not so much from the standpoint of the discipline in which they have clinical skills, as their understanding of the health system and the barriers it creates for individuals. This requires that VB-ICM managers have:

• A sound understanding of VB-ICM manager goals when working with individuals (Table 7.1)

• Educational and work-related backgrounds that provide a grounding about physical and BH conditions, the system in which healthcare is provided, and the value that VB-ICM brings when appropriately applied

• Management skills required to alter barriers to improvement in the domains in which they exist, with the participating individual as a partner

• The ability to document outcomes of the care plan (CP) and patient-centered ICM performance (PCIP) and make adjustments in VB-ICM management activities when goals are not being achieved

Table 7.1 VB-ICM manager goals

The primary purpose of this Chapter is to equip VB-ICM managers: (1) with backgrounds in physical health disorders with basic information about general BH conditions, their assessments, and their treatments; (2) with backgrounds in BH care with basic information about general medical illnesses, their assessments, and their treatments; and (3) with backgrounds in allied professions, e.g., occupational therapy, activity therapy, etc., with needed information about general medical and BH conditions, assessments, and treatments. By learning the information in this Chapter, licensed VB-ICM managers, will be able to legally provide “independent” assessments and assistance based on their professional backgrounds and should be able to coordinate physical and BH assistance to individuals found to have such a combination of problems.

The Chapter first describes how to talk with individuals about emotions, behaviors, and cognitions, whether they are related to difficult life circumstances or to BH disorders in the context of their general medical illnesses. It then discusses the differences between access to and payment for clinical services in the physical and BH sectors, reviews the basics on handling adult and child/youth general medical and BH emergencies, and defines the training and capabilities of various BH practitioners. Finally, it ties the unified management of general medical and BH conditions into a package for VB-ICM managers in terms of total health for the individual.

To effectively provide VB-ICM, personnel with general medical backgrounds do not need to be “experts” in BH conditions. In fact, there are few VB-ICM managers with general medical backgrounds who could claim to be experts in more than a small number of the myriad of physical conditions for which they provide help to individuals in the medical sector. Likewise, VB-ICM managers with BH backgrounds need not be experts in general medical disorders. VB-ICM managers assist individuals in obtaining the type of treatment that improves the likelihood that they will get better but do not provide the treatment itself. To give such assistance requires a mixture of common sense and basic illness understanding that allows them to work with individuals, most of whom have little healthcare sophistication, in hopes that they make better decisions related to the direction of their care. VB-ICM managers help reverse barriers to improvement and monitor progress as individuals move to illness stabilization and in some cases recovery.

For instance, it is not necessary for a VB-ICM manager who has spent most her/his career in obstetrical nursing to know all the medications and dosing regimens that could be used in individuals with major depression or, for that matter, end-stage renal disease. Nor is it necessary for her/him to know how the psychotherapies shown as effective for depression should be administered or to be aware of all the foods included in a diet for an individual with gluten intolerance. VB-ICM managers, on the other hand, must be familiar enough with the basics of common illnesses to know:

• Core symptoms, e.g., nine in the case of syndromal depression

• The common classes of medication with evidence of benefit for the individual’s condition or how to look them up to understand them, if needed

• The types of additional therapies important for recovery other than medication, e.g., effective psychotherapies, such as cognitive behavioral therapy (CBT), interpersonal psychotherapy (IPT), or problem-solving therapy (PST) for depression, physical therapy approaches for back pain, etc.

• How often individuals should be followed to ensure adherence and to monitor clinical improvement

• How to document outcomes related to the CP and PCIP as a way to confirm health improvement

• When symptom improvement typically starts and how symptoms resolve

• What to do when the individual is not improving

Likewise, it is not necessary for a VB-ICM manager, who has spent much of her/his career in assisting those with BH conditions, to know all the oral hypoglycemic medications and dosing regimens that could be used in an individual with Type II diabetes. The VB-ICM manager, on the other hand, must be familiar enough with the basics about such illnesses as diabetes and its treatment to know:

• General interventions for Type I and Type II diabetes, such as diet, oral hypoglycemic agents, and insulin

• Goal levels for HbA1c, which document control of diabetes, and how to follow levels

• The types of complications that individuals with diabetes mellitus experience

• How often individuals should be followed when diabetes is in poor control

• The approximate frequency of screening necessary for potential complications of diabetes, e.g., retinal examinations, kidney tests, depression, diabetic foot care, etc.

• General characteristics of diabetic diets and exercise regimes

• The need to pursue evaluation and get treatment for diabetic complications

• Parameters for the frequency of follow-up when diabetic complications are present

• The effect of depression and other BH conditions on diabetic control

Even with this base knowledge, seasoned VB-ICM managers will have questions about assessments and interventions for selected individuals. Thus, good VB-ICM managers, as any clinician, also know when to ask those with more expertise for help or how to look up information about conditions of concern.

Cross-Disciplinary VB-ICM

Becoming familiar enough with cross-disciplinary conditions to provide effective assistance to complex individuals seems like a daunting task, particularly for VB-ICM managers who have concentrated on either general medical or BH issues during an extended career. VB-ICM managers without medical science backgrounds, such as social workers, psychologists, or pharmacists, would appear to be at an even greater disadvantage since they have less understanding about many illnesses that their managed cases would be experiencing.

To address the angst associated with plunging into a world in which the VB-ICM manager is accountable in multiple domains, including for the physical, psychological, social, and health system, VB-ICM management programs, as described in this Manual, are encouraged to incorporate several supports that aid successful transition from focused and fragmentary assistance to VB-ICM with individuals. First, as mentioned in Chapter 5 (see Integrated Interdisciplinary VB-ICM Teams), cross-disciplinary “geographic pods” of five to nine VB-ICM managers, preferably composed of professionals from multiple disciplines, facilitate access to help while assisting individuals with problems outside the VB-ICM manager’s specific area of expertise.

Second, VB-ICM managers receive weekly to biweekly assistance and/or supervision from physicians that routinely review active challenging cases and graduating individuals. They educate, brainstorm, and troubleshoot with each VB-ICM manager to assure improvement progression and positive outcomes. Finally, ongoing onsite cross-disciplinary educational programs, e.g., lectures, case conferences, etc., should cover pertinent VB-ICM topics.

This Chapter does not intend to give the impression that those with more extensive backgrounds in either physical or BH care cannot or do not have an advantage in providing VB-ICM assistance than those with less experience. Clearly, it is preferable to recruit VB-ICM managers with greater knowledge and skills in all components of health. It is the supposition of VB-ICM, however, that the ability of VB-ICM managers to coordinate assistance in the biological, psychological, social, and health system domains, which create barriers to improvement, trumps greater expertise in any single area, even if it is the primary source of the individual’s complexity.

Often, it is the interaction of barriers in multiple domains that leads to non-improvement, rather than failure to recommend the best treatment for an individual’s primary illness. For example, it may be that an individual with chronic lung disease has been prescribed a combination of medications that are less effective than those suggested in the most recent studies. A knowledgeable manager with a background in pulmonary disease may pick this up but fail to realize that the individual is non-adherent to all his/her medications because he/she is depressed or has insufficient funds to purchase even drugs with lower cost.

In another example, it may be that an individual with congestive heart failure is having trouble controlling her/his fluid status. A knowledgeable manager with a background in cardiac disease may realize the need for the individual to do daily weights and to see her/his doctor about changing her/his “water pill” but fail to recognize that the individual is too embarrassed to say that she/he has no bathroom scale at home and is functionally illiterate (in English). Thus, the individual does not know which or how many pills to take since she/he can’t read the labels on her/his medication bottles. In fact, she/he does not need a change in the number or type of water pills; she/he just needs help in finding “less expensive” pills, which pills to take, and a scale so that she/he can consistently take the correct dose of effective medications as she/he follows and doses based on weight changes.

The above examples indicate that greater knowledge about physical and BH conditions, while important, may be less important than seemingly peripheral issues in many individuals. Depth knowledge of a “disease” and its treatment is certainly helpful, but the context of the individual’s health situation cannot be lost during the VB-ICM assistance process. This is one of the reasons why case management (CM) professionals from a variety of disciplines, including nursing, psychology, and occupational therapy, can contribute substantially, especially when VB-ICM teams with overlapping expertise work together in pods and have the support of medical, BH, pediatric, and potentially other physician backup.

General Medical Professionals Talk About Cross-Disciplinary Conditions

All individuals have personal issues that get in their way of health and effective functioning, whether they are unhealthy behaviors, such as smoking, dysfunctional eating habits, or sedentary lifestyle, ineffective coping skills, or BH conditions [1]. Many case managers with medical backgrounds have been directly or indirectly instructed to avoid talking about them and to do the best they can in assisting complicated individuals with physical health issues while avoiding problem areas about which there is less understanding or workplace instruction that would effect change.

Virtually all individuals entering VB-ICM also have one or more chronic medical condition even if their primary health concern is BH [2]. In fact, often these medical conditions are spiraling out of control, perhaps due to the severity of the illness but also possibly due to low motivation resulting from an ineffectively treated BH condition. These individuals cost so much money that it leads to many VB-ICM first contacts even though primary problems are BH. Many BH managers fastidiously avoid discussion of concurrent chronic and non-chronic medical conditions with individuals with BH conditions because their backgrounds include only BH understanding and skills. Professionals with BH expertise and experience target assistance to individuals for their BH issues, not medical.

Seasoned VB-ICM managers all know that life and social circumstances, health system factors, and the way that individuals react to them, as well as their physical and behavioral conditions, affect their ability to return to health and function. Unless VB-ICM managers are willing to take the time and put forth the effort to include physical, BH, social, and health system questions as part of their assessments and assistance activities, little will be accomplished on behalf of many complex individuals.

In fact, the VB-ICM manager’s professional role is purposely designed to assist individuals in getting treatment, but not “personally” treating physical or psychological issues. Health system issues and social challenges are a bit different. There is not a set “go to” person that takes care of these issues. Thus, it is the responsibility of VB-ICM managers to bring all issues that impact health, life, and cost outcomes into the open. They do not necessarily personally correct social and health system issues, just as they don’t treat medical and BH conditions, but they do provide needed understanding of these issues to start the process of correction in motion or to help the individual do so.

Thus, the first step in becoming effective VB-ICM managers for those with medical backgrounds is to recognize that the psychological domain is a part of their responsibility. It is to accept that questions about personal habits and a person’s emotional state are as important as knowing about an individual’s understanding of their physical illnesses and adherence to their treatments. For instance, elderly individuals often have chronic medical illnesses with complications that require the use of numerous medications and health enhancing behaviors. However, unless assessment:

• 1. For cognitive impairment, e.g., dementia, which decreases the ability to remember to take medications

• 2. For the individual’s emotional state, e.g., depression, which leads to non-adherence with treatment recommendations

• 3. For coping skills, e.g., ability to activate problem-solving activities is recognized as a part of the VB-ICM manager’s role and action is taken to correct them, important components related to the individual’s return to health will be missed and improvement will not occur.

The second step in becoming VB-ICM managers is to know that assistance with control of physical health conditions is a core activity. VB-ICM managers must ensure that time is spent stabilizing the individual’s identified medical and surgical disorders, even if the VB-ICM manager possesses a primary BH background. It does not matter that the VB-ICM manager’s training originated in BH; physical health assistance is also important to improve the individual’s BH maladies and return the individual to total health. Further, it does not matter whether the medical or BH disorder is primary.

The third step in becoming a full-service VB-ICM manager is to recognize that social circumstances and health system factors play a critical role in the VB-ICM process. They are not well addressed in either medical or BH settings. This has to do with the fact that non-clinical factors that can make or destroy a therapeutic situation are often not addressed. For instance, not having a sitter for an elderly relative of an individual may be the reason that “no-shows” so often occur for wound care appointments. This unattended to “social issue” may prevent the delivery of outcome-changing care and lead to persistent disability due to poor wound healing.

The message here is that VB-ICM managers, whether working with the adult/elderly or children/youth, expand their area of accountability to include physical, behavioral, social, and health system issues. This need is concretely translated into an assessment that includes uncovering barriers to improvement in all of these areas, not just questions about physical or BH conditions.

Interactions with adult individuals, using the VB-ICM-CAG approach, include a series of open-ended questions, designed to allow a relationship between the individual and the VB-ICM manager to develop. Table 7.2 summarizes the content areas in which these discussions begin. Each of these open-ended questions are followed by more detailed exploratory queries that, when completed, allow anchor point scoring for each of the VB-ICM-CAG grid items during a guided dialogue with an adult/elderly individual (Appendix I). While the initial assessment can often be completed in one interview, lasting on average 45 minutes divided and more lengthy interviews are occasionally necessary since the time needed to uncover barriers to improvement in individuals with health complexity frequently taxes the stamina of those with compromised health. More will be said about this in Chapter 9.

Table 7.2 Content areas of open-ended VB-ICM-CAG assessment questions

The skilled VB-ICM manager opens a dialogue that allows an individual to share their perspectives and their concerns and to know that they have been heard (reflective listening and responses from the manager), which builds trust and engenders a relationship. This is a significant change from current CM models where individuals are merely asked numerous questions, many of them single answer. Individuals typically walk away from such encounters feeling they have been given the “third degree.” As a result, they are less likely to engage in future conversations.

Similar, but expanded, questions are used in pediatric complexity assessments with children/youth and their caregivers/parents (Appendix J). As with adults/elderly, using open-ended questions facilitates the ability to ask “personal” questions of a child/youth and their family/caregivers, which are beyond the usual physical or BH approach prevalent in today’s CM environment. For instance, in VB-PICM, it is a natural activity when talking with a child/youth or their caregiver/parent about a poorly controlled, functionally impairing chronic medical illnesses to include questions about discouragement (depression) or trouble with stress (anxiety). Such emotional responses could be due to poor control of illness; illness-related behavioral changes; life concerns caused by impairment in extra-curricular activities, school, or peer and family relationships; or limitations about how the child/youth and her/his parents obtain and/or seek help (coping skills) for the things that they need. It could also be evidence of the presence of major depression or anxiety disorder in a medically compromised child/youth. Questions like these do not routinely occur in other non-VB-ICM forms of management.

Based on the information obtained, the VB-ICM/PICM manager and/or their clinicians can take steps to educate, e.g., smoking cessation or weight loss literature/programs; to support, e.g., listening and reflecting with the individual on intervention options; and/or to talk with the individual and/or providers about referral for relevant services, e.g., coping skill training and BH treatment. To the extent that health behaviors, coping skills, and emotional conditions interfere with return to health, it is the responsibility of the VB-ICM manager to assist individuals and their providers in obtaining the help needed for the adult or child.

Addressing Behavioral Health Issues

VB-ICM managers with physical health backgrounds who have had little experience in dealing with psychological issues may be hesitant to open Pandora’s box and address the conversations that might ensue, especially since they do not have experience in addressing difficulties in this area of health. Their willingness to tackle BH issues, however, may be enhanced when they recognize that:

• The VB-ICM manager, even with limited understanding of illnesses and the BH system, may be the only person available to uncover and assist with BH barriers since it is so commonly neglected in medical settings

• BH barriers lead to assistance measures, based on VB-ICM/PICM-CAG findings, very like measures that are taken for physical illnesses, albeit often by BH professionals.

• Overcoming BH barriers in individuals with physical illness may be more important than making sure that the correct general medical interventions have been chosen.

• Individuals often experience a sense of relief when these BH issues are addressed by a professional in an open, nonjudgmental fashion.

Some suggest that it is better to assign assessment and assistance duties for BH issues only to case managers with backgrounds and/or experience in BH fields. While there is truth to the fact that those with BH training may have a greater appreciation for options, at least initially, failure to link BH condition assessment and assistance with other factors retarding improvement, such as impairment caused by one or more medical condition (biological domain), poor access to needed providers (health system domain), or marginal support in following through on recommendations (social domain) may be more likely to lead to persistent health problems than the way that a BH issue is addressed. Further, many individuals with health complexity will have no BH condition per se, nevertheless will need BH assistance in the form of referral for coping skills training, education, and suggestions about healthy behaviors, etc.

Addressing Physical Health Issues

There have been positive changes in the BH field, with an emphasis on the mind and body connection in recent years. However, some BH modalities/theories still discouraged BH clinicians from discussing medical topics in those with BH conditions to avoid creating transference and counter-transference problems. For the remainder, who bear none of this misinformation, discussions about medical comorbidity are avoided because many mental health practitioners just do not feel competent to include such questions in their evaluations.

In VB-ICM, it is the case manager’s professional role to personally uncover general medical issues during individual assessments and to initiate activities that have the potential to reverse and/or attenuate barriers to health resulting from them. For this reason, it is critical for VB-ICM managers coming from BH backgrounds to develop a knowledge base about issues in the general medical domain so that they can:

• Comfortably discuss them

• Assure that appropriate assistance for them is given

• Connect medical barriers with barriers to health in other domains

Seasoned VB-ICM managers with BH backgrounds all know that assistance in overcoming barriers to improvement related to medical illnesses is essential for return to health and function. Unless a VB-ICM manager includes physical health issues in their assessment and assistance activities, little will be accomplished on behalf of many, if not most complex individuals, even when the primary problem is in the BH domain.

This is accomplished when VB-ICM managers accept that questions about medical illnesses, their treatment, and their complications are a core part of VB-ICM evaluations. Further, it requires that they learn what is necessary to routinely address them. For instance, an individual may have major cognitive difficulties and a limited support system. Such an individual is an obvious candidate for significant psychosocial intervention. However, if the VB-ICM manager fails to uncover, either from the individual herself/himself or from a second source, that the individual, with a history of heart attacks and hypertensive crises, has not been taking prescribed antihypertensive medications, medical complications may far outweigh psychosocial needs.

With appropriate training, such as what occurs in the VB-ICM program, and based on the information gleaned from a multidisciplinary assessment, VB-ICM managers with BH backgrounds can take steps to (1) educate, e.g., about kidney failure diets and weight control; (2) support, e.g., listening and reflecting with the individual on approach alternatives or connecting the individual with disease advocacy groups; and/or (3) talk with the individual and/or providers about referral, e.g., specialist care and employee assistance. To the extent that ineffectively treated general medical problems interfere with return to health, it is the responsibility of the VB-ICM manager to assist individuals in finding appropriate care. All VB-ICM managers, whether working with adults/elderly or children/youth, with BH expertise must overcome their discomfort in asking and assisting with physical health problems since they may be the only line of access that complex individuals have in getting the panoply of coordinated treatments that they need.

The bottom line is that BH personnel wishing to do VB-ICM/PICM need to be willing to expand their skill set to include medical issues. This allows a holistic approach to support for care in the individuals that they manage. Importantly, they must know enough about the general medical conditions and the health system to give sound advice that leads to health improvement. It is a bit like a husband making sure that his wife with breast cancer gets good and appropriate healthcare. Common sense helps him know when provider support and intervention is doing little to improve her situation. It is this common sense with a background in and/or growing knowledge about physical illnesses and the health system that ultimately brings value to the VB-ICM manager’s assisted individuals.

Health System Handling of Physical and Mental Conditions

Since the 1980s, when managed behavioral health organizations (MBHOs) came into existence, psychiatry holds the distinction in being the only allopathic medical discipline to be segregated from the rest of medicine (Fig. 3.4). It can rightly be stated in today’s healthcare environment that the separation itself creates significant barriers to outcome-changing care for individuals with complex and/or chronic health problems (Table 7.3), most of whom have concurrent physical and behavior conditions [3,4,5]. For this reason, part of the training for VB-ICM managers coming from general medical backgrounds requires that they develop an understanding of BH business practices, the special administrative needs for individuals with BH conditions, and an appreciation for what is available and where, based on the training and experience of those providing VB-ICM services.

Table 7.3 Practical effects of segregated physical and mental condition business practices

Likewise, VB-ICM managers coming from BH backgrounds require training, which allows them to understand general medical business practices and differences in the administrative approaches to individuals with physical disorders [5]. Understanding these health system-related issues makes it possible to create a context in which individuals with concurrent physical and BH conditions can receive coordinated care and treatment with the potential to improve their composite clinical conditions.

Independent General Medical and BH Business Practices: Natural Consequences

Most reimbursement systems worldwide pay for behavioral and physical health services from segregated pools of money, even when a discrete country or company administers the total health budget. For those who wish to better understand the cascading effect of this business decision, readers are directed to the book Healing Body and Mind: A Critical Issue for Health Care Reform [6]. The end result of separate payment pools is that it is virtually impossible for physical and BH clinicians to practice in the same settings, for treatment to be coordinated, and for communication between general medical and BH professionals to allow collaborative care (Table 7.4).

Table 7.4 Independent versus integrated general medical and BH care delivery and payment practices for discrete patients

Individuals with concurrent physical and behavioral conditions, which includes approximately 70% of those with health complexity, have a challenge getting consistent and timely care since independent payment has led to discriminatory practices in terms of what is covered (benefit restrictions, e.g., BH exclusions), where treatment can be delivered (the physical vs. BH settings), who can deliver the care and under which benefits (BH or general medical professionals; medical or BH benefits), and how much is paid for the services delivered (lower reimbursement to BH providers and facilities for the same or, often, more effective services). While this has improved in the United States with passage of the Affordable Care Act [7], it is once again in limbo while awaiting recommended changes by the current US administrative and legislative branches of government.

The natural consequences of this for individuals are summarized in Table 7.5. Unless payment for BH services becomes a part of general medical benefits and are paid using the same adjudication business practices, this most important barrier, i.e., recognition and accountability for cross-disciplinary physical and BH treatment and outcomes by all health practitioners, will not change. While one might expect this to be better addressed in other health systems, e.g., the United Kingdom, Japan, Germany, etc., in which there is “universal” medical and BH coverage, in fact, it is not because medical and BH benefits are handled independently in almost every country in the world.

Table 7.5 Consequences of an independent physical and BH condition payment system

The importance of understanding the effect of the current independent reimbursement environment on care is so that VB-ICM managers can work with their assigned individuals as they overcome the barriers to improvement that are created by a fragmented health system. To date, most non-VB-ICM case managers have avoided this thorny area of assistance, focusing rather on issues in either the medical or BH domains, but not both. With VB-ICM management, it is as important to help the managed individual find BH assistance and to link it to general or specialty medical treatment, as it is to assure that proper physical health treatment is being provided.

For instance, it is within the sphere of responsibility for VB-ICM managers to help an individual with multiple sclerosis find a psychiatrist or psychotherapist for interferon-induced depression, to assure access to and coordination of neurological and BH appointments, and to document adherence and response to multiple sclerosis and depression treatment. No longer can a case manager concentrate on treatment and outcome for multiple sclerosis alone. In fact, responsibility does not end as assistance is given for the disorders experienced by the individual. The individual’s social support system, insurance coverage, and relationship and communication with providers, among others, constitute potential barriers to improvement and, thus, are within the VB-ICM manager’s accountability.

Practice Issues of Importance to VB-ICM Managers in Physical and BH Condition Care

There are differences in practice needs for virtually all disciplines within medicine. Surgeons need operating rooms. Radiologists need imaging equipment. Gerontologists need nursing homes. Pathologists need laboratories. BH specialists need commitment laws, special procedures for suicidal or homicidal individuals, and long-term care facilities for those with SPMI.

VB-ICM is no different. VB-ICM managers coming from general medical backgrounds will not be familiar with special BH needs, core issues related to providing treatment against an individual’s will (competence and commitment), and in dealing with suicidal and/or homicidal individuals or other psychiatric emergencies. Likewise, most VB-ICM managers coming from BH backgrounds will have little experience in dealing with medical emergencies and other physical health activities discrete from those used in the BH world. Finally, while general pediatric and child psychiatry emergencies are addressed in much the same way that adult emergencies, there are special considerations in dealing with child/youth emergencies since there are laws relating to decision-making that need to be understood. These will all be discussed in the sections below.

VB-ICM Assessment Primer

Before going into detail about specialized medical and BH issues in adults/elderly and children/youth, however, it is important to provide a primer on content that will be gathered, scored, and used via the VB-ICM assessment process. For adults/elderly, the structured individual-VB-ICM manager “discussion,” taking from 20 min to an hour or so to complete, will allow content related to 20 high-risk areas (Table 7.6) to be documented and then used in the process of VB-ICM. Readers have already viewed a scored VB-ICM-CAG (Fig. 2.4) and will, thus, know the format from which VB-ICM managers work.

Table 7.6 VB-ICM-CAG complexity items

The VB-PICM-CAG (scored example seen in Fig. 1.2) is a modified version of the adult complexity grid. It covers areas of importance for children/youth. The adult and child CAGs are comparable yet contain differences pertinent to the age group being evaluated (Table 7.7). In the child/youth CAG, there are five new content areas. In addition, there are 13 of 20 modified adult items that make them pertinent to children/youth. For instance, instead of the adult item covering job and leisure, in the child/youth CAG, there is a social replacement that assesses school functioning (HS1). More will be said about this later.

Table 7.7 VB-PICM-CAG complexity items

Special BH Issues

We will now turn to the discussion of content areas in the BH area about which VB-ICM managers must be familiar in order to perform their work responsibilities appropriately. What is written below will provide the basics; however, almost every program will need to supplement this information based on the location of services. For instance, laws on competence and commitment, handling emergencies, and addressing issues of dangerousness differ among US states and in different countries. Thus, each VB-ICM program will need to fill in needed additional information related to these areas of localized, but important, practice to assure legal and appropriate action by the practitioners delivering VB-ICM services.

Competence and Commitment

There are situations in which “forced” treatment is necessary. Even in the nonmental health arena, it is legally possible, and in some situations necessary, to require treatment for tuberculosis, HIV, or other communicable diseases in non-psychiatrically ill individuals for public health reasons. While, in individuals with BH conditions, the reason for mandated detention and treatment is due to adjudicated impairment of decision-making capabilities, the principle is the same. If treatment is not given, danger is introduced to the individual or to members of the public.

For virtually all, it is uncomfortable to initiate or be a part of proceedings in which a person may be held or treated against their will. Nonetheless, it is a part of quality healthcare for a segment of the population. In the general medical sector, such activity commonly occurs, albeit generally without the involvement of the court, on behalf of vulnerable individuals with medical causes for incapacity. For instance, many individuals with dementia are subtly forced by family and/or their care providers to give up personal autonomy in the name of safety, e.g., driver’s licenses, independent living arrangements, etc. In more acute settings, hospitalized individuals with delirium can also be restrained and given treatment against their will even at times when there is not imminent danger.

In the BH setting, forced detention and treatment in most jurisdictions can only be given when (1) a BH illness is present that impairs judgment, such as dementia, psychosis, substance dependence, severe eating disorder, mania, or depression, and (2) the impaired judgment puts someone in danger. When these criteria are thought to be present, a series of clinical and legal procedures are taken to detain the individual and systematically establish decision-making capacity, based on illness and dangerousness. Only then can non-emergent treatment be given. Health professionals, both medical or BH, or law enforcement officers typically initiate these adjudication procedures.

In most situations, VB-ICM managers are only peripherally involved since they do not themselves provide care. On the other hand, it is important for them to understand the procedures necessary for forced detention and treatment so that they remain objective in working with the individual, the individual’s guardian, and the individual’s clinicians. Importantly, VB-ICM managers must remember that they are advocates for the individual’s health within the law. In some situations, this means that they support forced treatment despite the individual’s objections. VB-ICM managers, however, may find themselves helpful arbiters of collaboration between the individual, the individual’s family, and the individual’s providers since they may be the only impartial bystanders to contentious clinical intervention.

This updated Manual does not go into detail related to competence and commitment since specific laws regulating their administration vary from state to state and country to country. For this reason, those reading this Manual should plan on talking with BH personnel in their local jurisdiction, reading about, or going to a lecture on this topic after training in VB-ICM is complete. Details about how incompetence is determined and/or commitment proceedings are initiated are not within the scope of action by the VB-ICM manager. It can, however, be helpful to have this knowledge or where to find it when working with family members or physicians who are dealing with an individual receiving poor care due to BH-related non-adherence.

Suicidal or Homicidal Concerns

Nothing is more uncomfortable than having an individual tell you that he/she is thinking about killing himself/herself or another, especially when this is something that has not been dealt with the past, such as by “medical” VB-ICM managers. While such situations are necessarily emergent in nature, depending on the level of intent, when a VB-ICM manager understands the steps that need to be taken, it takes some, but not all, of the sting from the situation.

Unlike issues related to forced detention and treatment for incompetent and committed individuals, VB-ICM managers will likely, at some time during their work with individuals, encounter situations legally requiring action. For this reason, in all settings in which VB-ICM is provided, part of the early onsite training for VB-ICM managers coming from general medical backgrounds (and some with BH backgrounds who have dealt only with less severely ill individuals) should include how to respond to suicidal or homicidal ideation or behavior in their assigned individuals.

General guidelines for handling concerns about suicidal behavior can be found in Table 7.8 and for homicidal behavior in Table 7.9. Additional onsite training about these topics can be given when emergency medical procedures are reviewed for VB-ICM managers coming from BH backgrounds, e.g., what to do for an individual describing cardiac-type chest pain or a person who has suddenly become non-responsive while talking on the phone. The reason for doing this as an onsite procedure is that specifics about what is done are determined by the setting in which the circumstance arises, i.e., in a clinic, over the phone, at an individual’s home, etc., and the laws in the region of delivered VB-ICM services.

Table 7.8 Procedures for handling patients with suicidal concerns

Table 7.9 Procedures for handling patients with homicidal thoughts

Suicidality and homicidality constitute a special clinical situation, which, in most jurisdictions, requires action, e.g., emergency response team activation, if needed, or notification of life threat to a “named” individual, by any health professional that encounters it. This is a personal responsibility, including for the VB-ICM manager, and requires swift and decisive attention and potential action. Lack of informed consent to speak to BH professionals or law enforcement when suicidality is present or a threatened individual in the case of homicidality is superseded by the potential danger associated with the situation. When possible, it is helpful to involve the individual’s health professionals but accountability for action rests with the VB-ICM manager if this is not possible.

It is, thus, imperative for VB-ICM managers when first initiating health privacy parameters with a new individual to indicate that confidentiality will be maintained in all situations except when the individual describes potential danger to self or others. With this, individuals know that dangerousness legally obliges the VB-ICM manager to protect the individual or a threatened person. It is much better to explain this at the beginning of contact than in the heat of a “situation.”

Special Medical Issues

In many ways, it is easier for professionals with BH backgrounds to adapt to and deal with medical emergencies than it is for those coming from general medical backgrounds to learn how to deal with forced treatment (competence and commitment) and dangerous behavior (suicidal and/or homicidal ideation). In individuals with medical illness, less contentious interventions are usually required. Since VB-ICM managers are not involved in the direct treatment of individuals with whom they work, in emergency situations, they merely need to know how to activate the emergency medical response system or how to direct the individual to an appropriate provider.

Medical Emergencies

Perhaps a greater challenge for VB-ICM managers with nonmedical backgrounds will be to know when an emergency exists rather than what to do when one is identified. Again, it is not the VB-ICM manager’s responsibility to know about all medical emergencies or how to treat them. On the other hand, they should use common sense and be proactive when potential emergency situations arise. Unlike the individual, VB-ICM managers will usually have colleagues and/or a medical director to draw on for assistance. Thus, they can more easily obtain further information and advice about what to do. If no one is available, then hot transferring the individual to their primary physician’s office, to a 24-hour nurse line, or to an emergency department may be in order. If it is obviously an emergency situation, a hot transfer or personal call to the local emergency response number may be the appropriate course of action.

In all circumstances, the VB-ICM manager should act with the safety of the individual in mind. Often this involves getting immediate acute medical assistance onsite. For this, few will fault the VB-ICM manager. After the crisis is over, it is a good idea to review the course of events with a supervisor to ensure that appropriate steps were taken on behalf of the individual. Finally, follow-up with the individual to find out how things turned out is always a good idea.

Special Pediatric Issues

Just as addressing medical and BH problems in the adult/elderly, VB-ICM requires a special understanding of discipline-specific issues. VB-PICM managers who work with children/youth also require additional knowledge as they initiate assistance to this population with special needs (Table 7.10). Both a child/youth and a caregiver/parent present special situations for VB-PICM managers as they interact during support for health in a child/youth. For instance, as children mature, they increasingly develop the capacity to understand and consent to their medical care and to have control about who has access to information about their personal healthcare. Further, there are a few decisions in a child’s/youth’s situation that are ruled by subtle differences in jurisdictional laws. Finally, a subset of children is at risk for abuse and neglect. This section addresses the pediatric areas in which rules are defined related to support given to children/youth.

Table 7.10 Key areas of knowledge expansion for “adult” managers doing PICM

Consent and Confidentiality

It is important for pediatric VB-ICM managers to be aware of relevant legislation in the jurisdiction in which they work about issues of consent and confidentiality. In most countries, the age at which a youth can make independent health decisions is 18 years. In less common locations, the age of majority can be as high as 21, e.g., Mississippi and Egypt, or as low as 14, e.g., Samoa and Puerto Rico. The age of majority in specific locales can be found on the Internet though local officials should confirm this.

Decision-Making Capacity

While the age of majority is the most common arbiter of who makes health-related decisions, there are some situations in which younger individuals can become their own decision-makers. For instance, in some states and countries, youth aged 14 can become “emancipated minors” and thus make their own decisions by declaration, by legal petition, by marriage, or by joining the armed services. Factors concerning decision-making become even more complicated in relation to sexual activity, e.g., the age of consent for sexual activity is most often 16–18 years but can be as low as 14 years or as high as 21 years in some countries.

Another common area of early health decision-making, again generally related to early sexual activity, relates to a youth’s right to initiate birth control, to have an abortion, or to be treated for a sexually transmitted disease without parental notification/consent. Legal authorities and/or the Internet can usually clarify local laws but it is preferable for the VB-PICM manager to be familiar with them through educational activities at their location of practice.

Pediatric case managers must be informed of local legislation guiding decisions about who is able to give health consent in various situations, who requires notification and at what ages, and whether there are exceptions. Without having a firm understanding of these rules, VB-PICM managers are at risk of acting based on information from the wrong decision-maker, providing personal health information without proper consent, or alienating one or the other party because of lack of information about regional laws.

Having provided these cautionary notes, VB-PICM managers are most effective when they can facilitate child/youth and caregiver/parent communication as assistance related to barriers to health is given. In most situations, the child/youth and the caregiver/parent have the same goals and work together to maximize health. Information provided by the VB-PICM manager, or alternatively from an informed treating provider, to them about what constitutes the age of majority, can often obviate a dispute that would otherwise arise about who makes final health-related decisions.

Mandatory Child Abuse Reporting

VB-ICM managers also need to be well versed in legislation governing mandatory reporting of child abuse or neglect in the jurisdictions in which they practice. Typically, when there is “reasonable suspicion” that child abuse or neglect is occurring, any health professional, teacher, and law enforcement officer is required to report it. Child abuse and neglect is generally defined as any type of cruelty inflicted upon a child, including emotional abuse, physical harm, neglect, and sexual abuse or exploitation. For most types of abuse, it relates to children/youth under the age of 18, though there may be lower age limits in some locations regarding the mandated reporting of sexual abuse and exploitation.

Since this is an area in which a VB-ICM manager, all of whom will be health professionals, can be criminally prosecuted for not reporting to child protective agencies, it is important for them to understand laws on mandatory reporting in locations where they provide VB-PICM services. This is the VB-PICM manager’s responsibility, though she/he may collaborate with other clinicians involved in the care of the child/youth in providing information.

Practitioners for BH Disorders

All BH clinicians do not have the same intervention capabilities, e.g., a physical therapist does not prescribe medication yet may be an expert in rehabilitation procedures, a chiropractor can treat back pain but not pneumonia, and a psychologist can perform evidence-based psychotherapy but does not possess the training needed to administer psychotropic medications. This seems self-evident; however, there has been a tendency in the past 25 years to assume that exposure to any BH professional can be expected to result in an improved outcome. Nothing could be further from the truth.

Table 7.11 summarizes the training and skill sets of several BH practitioners. While it provides general guidelines for the type of services to which an individual participating in VB-ICM may be exposed, it does not guarantee that outcomechanging care will be given. For instance, it is unreasonable to expect that a person with schizophrenia or bipolar affective disorder will have a good outcome if treated by a general practitioner coupled with a psychologist or social worker. Certainly, psychological and social interventions are important in such individuals; however, a core component of treatment for individuals with these diagnoses requires specialists versed in the nuances of psychopharmacology. This is particularly true for individuals with health complexity, in whom comorbid medical conditions are also present and multiple interacting medications are typically being used.

Table 7.11 BH personnel clinical practice skill sets

In these situations, diplomacy is critical as attempts are made to guide an individual to the set of clinicians most likely to be of benefit. It is for this reason that outcome monitoring is so important. For instance, if an individual with unipolar major depression has persistent Patient Health Questionnaire-9 (PHQ-9) scores fluctuating around 20 while on medication prescribed by her primary care physician in adequate doses and for adequate duration, then assisting with involvement by a psychologist who has expertise in CBT or another efficacy-based form of psychotherapy or a psychiatrist who might try an alternative antidepressant may turn non-response into response [8]. Not infrequently, using the assistance of the VB-ICM manager’s Medical Director can facilitate such an adjustment in care.

Even after such an adjustment is made, it remains within the purview of the VB-ICM manager to follow continued intervention and outcomes. Other factors may play a role in non-response, such as poor coordination of interventions among practitioners, workplace conflicts that have not been dealt with, no-shows for appointments, etc. It may be that the relationship between the individual and VB-ICM manager allows factors retarding improvement to come to light. In these situations, the VB-ICM manager can truly tip the scale toward recovery.

Assisting Individuals with BH Conditions

The VB-ICM approach is built on the principles of communimetrics (Table 7.12), developed prior to the creation of the VB-ICM-CAG [9, 10]. Of particular importance in relationship to the discussion of BH conditions is the principle that psychological items are agnostic to etiology. It is not the job of the VB-ICM manager to explore or try to understand the cause of distressing psychological symptoms. Rather, the VB-ICM manager is responsible for identifying the presence or concern about the presence of symptoms and for assisting the individual in finding treatments most likely to quickly reverse symptoms. Just as in individuals with physical illnesses, symptoms of psychiatric illnesses are associated with suffering, impaired function, and increased need for health services. Reversing symptoms is the best way to alter these consequences.

Table 7.12 Principles of communimetrics used with VB-ICM-CAG

Some consider BH conditions untreatable. In fact, in today’s world, nothing could be further from the truth. Granted, some illnesses and individuals are harder to treat than others, but this is true for both physical and BH illnesses (Table 3.2).

General Physical and BH Assistance

The first step for any VB-ICM manager is to help individuals understand their illnesses and the things that they can do to get better. This most often means that the individual is provided with information about their illnesses and is given an opportunity to have questions about them answered. The VB-ICM manager should recognize that most literature sent to individuals about illnesses finds its way into the wastebasket, often without being read. For this reason, the VB-ICM manager must have a “discussion” with the individual about their illness(es) to assure that there is a basic understanding of symptoms, treatments, anticipated time to improvement, and parameters that document outcomes. During these discussions, it is helpful to find out about the individual’s or a family member’s reluctance for the individual to enter treatment. This is common with BH conditions due to misinformation about the value of treatment; biases against BH interventions, especially when delivered in the BH setting; or the individual’s feeling that they can use their willpower or prayer to overcome symptoms. This is one area in which motivational interviewing skills are particularly valuable.

The second step is to assure that the individual is getting treatments that are likely to lead to the quickest and most effective improvement. In Chapter 9, VB-ICM managers will become familiar with several common BH and physical conditions and with how to document symptom improvement. For instance, in individuals with depression and anxiety, both medication and psychotherapy can be effectively used alone or in combination. What frequently occurs in the primary care setting, however, is that an individual is given a prescription, often not filled, or is referred to a counselor, who provides support but no evidence-based therapy for depression or anxiety. In neither of these situations would individual improvement be expected to occur. Thus, it is also often necessary to educate primary care physicians about depression and/or anxiety treatment adherence problems and/or efficacy-based psychotherapies, such as CBT, PST, and IPT, so the individual-physician collaboration can be enhanced and benefit to the individual result.

In individuals with general medical disorders, such as those with diabetes, medication, diet, and exercise play an interacting role in symptom improvement and blood sugar control. What frequently occurs, however, is that an individual is given (1) a prescription for oral hypoglycemics, which is either not filled or taken in lower doses than prescribed to “save on cost”; (2) a diet, which is too difficult to understand let alone to follow; and (3) an exercise program for which there is no time or interest. Unless each of these barriers to improvement is discussed and reasonable alternatives are uncovered, the situation heralds a low likelihood of improvement for the individual. Thus, it may be necessary to educate the primary care physician about the individual’s treatment adherence problems and/or to discuss compromises that might be more acceptable to the individual. Again, the challenge is in creating a therapeutic win for the individual in concert with the suggestions for care by their doctor. MI skills play a significant role in this process.

Finally, VB-ICM managers need to connect BH symptoms and treatment with general medical illness treatment and its adherence. Worse outcomes for medical conditions, documented in individuals with concurrent physical and BH disorders, will not improve unless equal attention is given to the administration of and follow-through for the individual’s combined health conditions. Part of this connection process will likely include either having the individual tell their general medical clinicians about the co-existing BH condition or making sure that descriptions of it are included in the reports that the individual’s clinician receives about progress through VB-ICM.

To effectively complete the tasks described above, the VB-ICM manager must learn basic information about:

• The symptoms experienced by the individual when they have chronic illnesses.

• Complications that can occur due to existing illnesses and the steps to prevent them.

• First-, second-, and third-line treatments (since VB-ICM managers will be working with complex individuals).

• Measures used to follow whether diseases are coming under control and whether progressive improvement is occurring (physical, laboratory, imaging, number of visits to the emergency room, and other findings). For this, VB-ICM managers need to know how to interpret common follow-up tests or examinations. (This is one of the areas of great value that staffing active cases with a medical director brings. Such supervision can be the difference between VB-ICM success and failure.)

• A general timeline for when outcomes should be expected if effective treatment is being given.

VB-ICM managers cannot be expected to have the same level of understanding about illnesses as the clinicians treating the individuals or even, to some extent, the individuals themselves. They, however, should have sufficient understanding to be able to identify common sense barriers to improvement, how to try to support the individual and clinician in reversing them, and what measures to use to document that the changes are effecting improvement.

In individuals with chronic physical and BH conditions not included in Chapter 9, VB-ICM managers will likely be less familiar with symptoms and treatments. This is, perhaps, a greater challenge and concern for VB-ICM managers who come from BH backgrounds but who have little or no training in medical illnesses, e.g., psychologists, substance abuse counselors, etc. Clearly, additional and systematic training is necessary for these individuals if they are to be considered for roles as VB-ICM managers. Even for VB-ICM managers with nursing or social work training, however, many individuals will have illnesses about which they are unfamiliar. When this is the case, they should elicit suggestions from their medical director during supervisory sessions; present the case at an internal case conference; seek information from a company educational resource, such as Healthwise™ and point of care; and/or ask for suggestions from their supervisor or colleagues who may have reversed similar problems in the past.

Of course, as VB-ICM managers work with individuals in VB-ICM, they should continue to learn about new physical and BH conditions. Luckily, we live in the information age. It is easy to Google medical topics at reputable websites, e.g., WebMD, Medscape, Centers for Disease Control (CDC), the National Institutes of Health, and the National Institutes of Mental Health. Through quick focused searches, VB-ICM managers should have sufficient understanding of the basics of most medical conditions, whether common or rare, to be able to help their assigned individuals ask questions to their providers so that they can better understand their illnesses, illness treatments, and the steps needed to get better. In fact, it may be as simple as translating what the doctor told them to do into understandable language.

For instance, one provider could not understand why an individual was having so much trouble with fluid balance since the individual insisted that she was strictly adhering to a liter and a half 24-hour water restriction. It was only after the VB-ICM manager uncovered that the individual did not include coffee, tea, and soft drinks as “water” that it became clear that the individual was literally limiting herself to six cups of H₂O. Recognition of this fact led to appropriate “fluid” restriction, fewer water pills, and better control.