Mental Health Case Management

[SteveDE]

Ok, here goes, I have been an RN for about 5 years, live in a rural area in southern Illinois, I have been a diabetes educator and house supervisor together for just over a year. This week, I have been moved from my house supervisor duties to diabetes educator and an entirely new position for me, as well as, a new position for my facility and that is as mental health case management/some case management type duties with medicare.

I have been told that I can build and make this mental health position what I want it to be, to be creative, think out of the box, and help our primary medical providers (MD and NP) with managing their patients that deal with mental health illnesses. The idea for me is to help these patients in making sure they get the healthcare they need to manage all of their illness issues (such as diabetes, chf, bipolar, depression, etc.). Even dealing with the pediatric population and making sure they are getting their meds, making their appointments, and such. We do NOT have any mental health providers in our facility, we do have a counseling service in our county, but in this area and others proper mental health care is lacking whether it deals with chronic illnesses or maybe a temporary grief situation that a patient needs help dealing with that can also affect their other illnesses.

So I start next week, our facility (hospital and clinic) employs a total of about 200 employees, so we are small. This is an entirely new position at our facility. I am excited about the possibilities and how it can help our patient population and facility continue to succeed in the future, I've seen far too often how mental health illnesses affect physical well-being and vice versa through our ER, medical floor, and even as diabetes educator. It won't necessarily be a role where I am a counselor, but an educator to help these people understand why they need certain care, labs, and follow up and hopefully be able to help them better manage their situation for the long-term.

What suggestions do you have? Comments, Questions? Where to look for, for a role model or guidelines? Any feedback is appreciated! Anyone out there doing something like this or does this not make any sense?

Thank you!

[nurseprnRN, BSN, RN]

Case management is not primarily a patient education role (though there is always education in any nursing role, it's not the way a diabetes educator is)-- are you saying they want you to do something analogous to that, or do they really need a case manager?

If so, you will have some big challenges. Insurance issues are so huge for this population; getting them psych-specific care is very difficult. If their insurance coverage doesn't cover inpatient care (think geri-psych, such a limited number of beds) or there are innumerable hurdles to jump, the case manager gets to be very creative and persistent in getting them what they need. (To the best of my knowledge I am still the only person ever to get a geri-psych bed admission for somebody without a psychiatry consult based upon my own nursing assessment, the consistent statements from family members, patient, and neighbors, and sheer dogged persistence on a Friday afternoon. He really did qualify, but I had to be able to get past some of the bureaucracy to get it.)(And I am not a psych expert.)

If they are looking for something like a disease-management thing, then you will need to get up to speed on psych in a big way. See if you can call the university hospital /medical school in your state and develop a consulting relationship with some psychs and psych nursing experts, somebody who would be willing to chat and help you with quick questions as you go along. The more you now about the different diagnoses the better you will be able to case manage them. I know that's a totally "D'oh!" statement, but psych is such a specialty. Perhaps the Psych nurse specialty forum would be a better place to ask, unless we all get lucky and there are some psych case managers that come here; there are good people there.

I'd love to hear how this works out!

[SteveDE]

I would say something along the lines of case management in terms of making sure these patients successfully obtain the proper healthcare, but at the same time also trying to help educate these patients to be able to better manage their illness and understand what they need to do to manage their illness.

This week will be my first official week, so I will be in the process of contacting various social service agencies, counseling centers, and etc. to find out their thoughts and ideas, as well. It will be a BIG learning curve for me and everyone else, but I believe it will be an interesting journey that can be helpful to all of us involved.

Thanks for the feedback, our facility is in the process of obtaining an experienced psych NP, which should be a nice addition and a big help in this situation. I will let you know how it all goes over the coming months. Any other ideas, experience, etc. would be greatly appreciated.

[SteveDE]

I know that most of the time when any of us have moved into a different position, there is a guideline or former role to fill, this is not one of those positions, so any ideas are welcome.

[SummerGarden, BSN, MSN, RN]

I am confused too... Do you have a captive audience? If so, you can set up classes and force your population to show up with mandatory points etc.... If this is completely outpatient and not attached to a group home-like setting, then I do not know how you force your population to show. I worked with Psych patients for a long time. They are very non-complaint with everything no matter his/her age. Thus, simple classes may not be enough.... educating them as you take care of them is probably your best bet.

What do I mean by that? As a case manager you may have found that Psych patients are very needy... So as you are assisting them with what he/she needs at the moment, you can slip in education about diabetes. For example, your client needs to pay his/her rent and is anxious to talk to his/her landlord. You assist patient with getting rent to landlord and then follow up with asking about the management of his/her diabetes.... assess knowledge... then educate. Good luck... :)

[SteveDE]

There is not a force component to this role, forcing patients of any area will not work long term, I don't see that as an option. I understand that the psych patient is often non-compliant, my question would by why? Is it simply their fault, they don't care, so we just move on and keep filling up our ER and providing substandard care for chronic illness, keep having missed PMP appointments, keep having them fall through the cracks...OR have we failed them in someway, is there something we have missed, is there something we can do to help guide them to better themselves?

I believe the last statement in your first paragraph sums up a big part of this role...to educate them as we take care of them. Education dealing with how to afford care, why follow through with care, why have labs drawn, how to get there to get things taken care, how to manage their diabetes, copd, chf, and etc. all while controlling their mental health issues. How to guide or educate even the healthiest of people that was once a working class person, but due to a car/work accident now can't provide for themselves, fall into depression and give up on taking care of their injury and they spiral further down. The person with bipolar that does not follow any kind of self-care plan, visits the ER routinely, doesn't follow up with a PMP, and doesn't get the follow up they should because they just use the ER. What kind of issues do these people create in our society? Police, first responders, ER, other healthcare facilities, social services, and etc., what if we could have someone take time, sit down, and guide them to better health by educating them rather than looking at them as a 15 minute appointment. What if we could take just a few of those people, help them better their life, what kind of relief on our resources would that be? What kind of a relief on them and their family would that be?

I'm excited for this challenge. I know it will be a challenge. I will keep everyone up to date on how things go and please keep throwing out ideas, suggestions to me. Our facility is rural and small. I built the diabetes education program to what it is, a lot of diabetes education, successful diabetes education, deals with lifestyle management, lifestyle changes. I know this is a different area with a wide open area of possibility, but how can I help show others with different illnesses to better manage their life and healthcare?

[Squingelle]

I couldn't agree more with how you've described the possibilities here. I too, just started performing home assessments/admissions for the dual population, and am looking forward to help change the way they have been receiving care. We have a new Health Program called "One Care, which combines SSDI and State Health Ins benefits together. The goal is for this population to be an active participant, and help decide what THEY feel would be most helpful for themselves, and coordinate the appropriate services. So far, it is going extremely well. Most truly appreciate the opportunity to be heard, and then play an active role in what care they receive. Best of luck! Would love to talk more in the future.

[nurseprnRN, BSN, RN]

I'm excited for this challenge. I know it will be a challenge. I will keep everyone up to date on how things go and please keep throwing out ideas, suggestions to me. Our facility is rural and small. I built the diabetes education program to what it is, a lot of diabetes education, successful diabetes education, deals with lifestyle management, lifestyle changes. I know this is a different area with a wide open area of possibility, but how can I help show others with different illnesses to better manage their life and healthcare?

I strongly recommend you take a deep breath and always remember the following: "You can lead a horse to water but you cannot make him drink." Doubly true with a psych population. Good luck.

[SteveDE]

I couldn't agree more with how you've described the possibilities here. I too, just started performing home assessments/admissions for the dual population, and am looking forward to help change the way they have been receiving care. We have a new Health Program called "One Care, which combines SSDI and State Health Ins benefits together. The goal is for this population to be an active participant, and help decide what THEY feel would be most helpful for themselves, and coordinate the appropriate services. So far, it is going extremely well. Most truly appreciate the opportunity to be heard, and then play an active role in what care they receive. Best of luck! Would love to talk more in the future.

Sounds very interesting! This sounds similar to what I may be dealing with, maybe you explained it better than I did. What part of the country are you in? I'm in Illinois. How long has your facility had this program? Any certain guidelines or process that you have with this, that you would care to share? how did it come about?