Making The Case For Case Management

Case Management involves facilitating the access of a patient to appropriate medical, rehabilitation and support programs, and coordination of the delivery of linkages. This role may involve liaison with various professionals and agencies, advocacy on behalf of the patient, and arranging for purchase of linkages where no appropriate programs are available. Case management differs from therapy in that the case manager is something of a broker-advocate. Many patients who need case management services would have difficulty advocating for themselves, knowing what services are available and coordinating those resources. Unfortunately, in many states, only those who have severe mental illness qualify for case management services to be covered by their insurance. The responsibility often lies with the Licensed Professional Counselor or rehabilitation counselor to perform case management services. Billing for these services is often tricky. In Florida, during the initial assessment we create a list of needed referrals. If the patient is capable of following up and making those linkages on his/her own, then the therapist assigned to the case merely follows up with the patient on the progress with the referrals. More often than not, by the time patientS made it in for an assessment, they were in crisis. Therefore, I set aside 20 minutes or so at the end of the assessment to facilitate the referrals (i.e. make the calls and make sure appointments were set and transportation to those appointments was feasible or arranged.). The primary therapist I assigned to the case spent the first session reviewing the status of the referrals, advocating where necessary, making additional recommendations as the situation dictated. This allowed the therapist to get to know the patient, the therapist to provide case management-esque services in a billable setting and ensured the patient was getting those basic needs met so therapy could be reasonably expected to progress.

Many of my staff struggled at first with the biopsychosocial model I brought as a Rehabilitation Counselor. They were used to dealing with the mental health diagnosis as if it existed in a vacuum. Once they saw the logic to a comprehensive approach, they were eager to learn more. The first principle for anyone is that you have to have your basic needs met before you can focus on any sort of "therapy." Adequate food, shelter, medical care and clothing and a feeling of safety are paramount. For parents, this includes food, shelter, medical care, daycare and clothing for their children as well. Unfortunately we cannot just wave a magic wand to make these things available---usually. In solution focused counseling, we often have clients identify where they are at. This is a "1." Then we have them identify what their life would be like if things were going well. This is a "10." The next step is to figure out what small steps need to be taken to just get the person to a "2." Emotionally, this often means helping the person find some supports (a crisis line perhaps) and some hope. Hope often starts to blossom once their is a plan of action in place. So the first "referral" is to have the person write down on a 3x5 index card 3 people or places they can call when they start to go into a crisis. At least one of the numbers should be a 24-hour crisis line. This is to be kept with them.

Physically many of our patients had dental and medical problems that had been untreated due to lack of insurance. Many also had no prescription coverage, so they were not taking necessary medications. Keep a list of the free and low cost medical and dental clinics in your area. United Way Information and Referral also often has lists of charities that will help people with one-time medical expenses and can provided limited transportation to doctors appointments. Help them make these appointments and ensure they have transportation. We all know how overwhelming making doctor's appointments can be, not to mention how difficult it is to arrange for a medicaid van or figure out what busses to take. Al so keep copies of medication vouchers in your desk. These can be printed out from the pharmaceutical company websites or websites such as rxassist.org. It astounds me how few physicians assist their patients in linking with these resources. If the patient brings the voucher to his physician, it can be filled out in under 5 minutes and provide the patient with medication that is often free or less than $15/month. To find out who makes a certian drug, go to http://www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm?fuseaction=Search.Search_Drug_Name type in the brand name if you do not know the generic name. The brand name will tell you the generic name. From there, go back to the above website and search for the generic. It will give you a list of all of the companies who make the generic. For example, if you want to know who makes the generic for sertraline hydrochloride (Zoloft), search under "s" for sertraline. Once on the sertraline page, you can peruse each manufacturer's website for information about their particular prescription drug programs. It sounds arduous, but many of your patients are going to be on the same 15 or 20 medications beause this is what your doctors are used to prescribing. (Zoloft, Paxil, Lithium, Haldol, Risperdal, Remeron, Prozac etc...)

A patient who is medication compliant, sleeping well, eating well and not in pain is much more likely to benefit from therapy. This brings me to food. If your patients do not qualify for food stamps, or if the food stamps are not enough, you may need to work with them on reducing their budget. Powedered milk is cheaper than liquid. Beans, rice, peanut butter, crackers, oatmeal, ramen noodles are far cheaper than cheese and meat. I made up a recepie book for my patients that had super low-cost meal ideas in it. We also made healthy snacks available to our patients during each therapy session. Our food services director would by these from the food bank each week at less that wholesale. You might also consider maintaining a food closet where people can donate canned and nonperishable goods. Additional referrals might include a victim advocate, a grief counselor from hospice, vocational rehabilitation, any local programs that rehabilitate cars and donate them to people in need, agencies that provide vouchers for subsidised child care, homeless shelter/temporary housing, Housing and Urban Development (HUD) to get on the subsidized housing waiting list and self-help/support groups.

Often there are many organizations in your community that can help with specific needs. Establish a relationship with your local information and referral. They are a wonderful resource. Ultimately, ask yourself, "If I was in this person's shoes, what would I need to do before I could focus on feeling better?" These are the referrals/linkages you need to make.