The Integrated Case Management Manual: Value-Based Assistance to Complex Medical and Behavioral Health Patients

© Springer International Publishing AG, part of Springer Nature 2018

Roger G. Kathol, Rachel L. Andrew, Michelle Squire and Peter J. DehnelThe Integrated Case Management Manualhttps://doi.org/10.1007/978-3-319-74742-2_1

1. Introduction to Value-Based Integrated Case Management

Roger G. Kathol¹ , Rachel L. Andrew², Michelle Squire³ and Peter J. Dehnel⁴

(1)

Cartesian Solutions, Inc.™ and University of Minnesota, Burnsville, MN, USA

(2)

Premera Blue Cross , Mountlake Terrace, WA, USA

(3)

Manahawkin, NJ, USA

(4)

Twin Cities Medical Society, Edina, MN, USA

"Somewhere along the way, we must learn that there is nothing greater than to do something for others."

–Martin Luther King, Jr.

Keywords

Current case managementValue-based integrated case managementComplexity assessment gridCare planPatient-centered ICM performanceOutcome measurement

Chapter Objectives

To describe the three primary goals in health care and the role of value-based integrated case management in achieving them.

To describe the difference between the application of current case management models versus the value-based integrated case management model.

To describe value-based integrated case management and the value-based integrated case management complexity assessment grid.

To describe the use of the care plan and patient-centered integrated case management performance tool in documenting outcomes related to value-based integrated case management.

Introduction

The variability in care and the experience of individuals getting health care linked to the continued rise of healthcare costs highlight the important opportunity that the profession of case management (CM) has in addressing each of these issues. Currently, CM programs around the world are focused on how to positively impact the quality of care, the experience of the individual in getting care, and healthcare cost, yet most lack a model that systematically addresses all three. Although many case managers and the CM programs in which they participate are independently developing techniques and approaches to do this, as a profession they have lacked an overall standardized approach that can be replicated and then effectively measure outcomes. This has led employer groups, health plans, providers, and others who purchase CM services to push for quantification of the value that CM brings. As an industry, CM has struggled to quantify the value of its services. This is where value-based integrated case management (VB-ICM) plays such an important role. It provides a standardized approach to supporting individuals with complex health conditions, i.e., those with the greatest healthcare costs (Fig. 1.1), by systematically identifying and removing the individual’s specific barriers to health improvement and then quantifying outcomes as the process takes place [1].

Fig. 1.1

Healthcare cost savings opportunity with value-based integrated case management. Modified from Cohen SB, United States. Agency for Healthcare Research and Quality. The concentration and persistence in the level of health expenditures over time estimates for the U.S. population, 2012–2013. Rockville, MD: Agency for Healthcare Research and Quality, 2015. Available from: http://​meps.​ahrq.​gov/​mepsweb/​data_​files/​publications/​st481/​stat481.​pdf

For example, Ashley is the first in a series of individuals with complex health challenges whose clinical presentation will be summarized and then developed as value-based pediatric integrated case management (VB-PICM) is used to help improve her health and life situation. Individuals with health complexity provide challenges that require a systematic, individualized approach to identify and address their barriers to health improvement. VB-ICM takes a whole-person approach, assessing both physical and behavioral health (BH) conditions and associated barriers, such as financial, personal, social, and health system, which prevent individuals from following their provider’s treatment plan. This is accomplished by providing interdisciplinary training to VB-ICM managers so they can serve as the individual’s single point of contact with no (or few) handoffs to other management specialists, as commonly happens with many current CM models. Through this systematic approach, graphically summarized in Appendices A.1 – A.7, VB-ICM managers provide comprehensive assistance and support that addresses both clinical and non-clinical barriers that lead to poor health outcomes.

Ashley

Ashley is a 15-year-old teenage girl who lives with her biological father, Sam; her stepmother, Susan; and two half siblings, Ethan and Sally. Ashley has a rare hereditary disorder which causes her intermittent excruciating pain, nausea, and vomiting with abdominal and respiratory swelling. These typically result in respiratory distress due to the cardiac complication of fluid overload. The severity of Ashley’s symptoms, when they occur, requires medical attention within 30 min of symptom onset to prevent escalation and potential death. Prior to participating in VB-PICM, Sam had hired a home health nurse, who was specially trained by the pharmaceutical company supplying medications to Ashley in the emergent actions needed associated with Ashley’s health crises. This home health nurse administered needed infusion medications which treated Ashley’s symptoms when they flared up. Unfortunately, the nurse was not on call 24 hours a day. This resulted in significant utilization of health services, including 20 emergency department visits and seven inpatient hospitalizations, two of which were to the intensive care unit, over the past 5 years.

Ashley also exhibited signs of depression although she had never been formally diagnosed or treated. She isolated herself in her room for days and displayed anxiety, anger, and irritability. Due to Ashley’s medical condition, she reported having few friends. Ashley’s ability to do things independent of her parents was also negatively impacted. For example, even the thought of spending the night at friends’ houses was terrifying to Ashley and her family due to the quick onset of her symptoms. Ashley had not participated in after-school activities for the same reason. She had missed a significant amount of school over the years, which resulted in her being held back to repeat fifth grade and she reported feeling dumb. Ashley’s illness had significantly impacted her ability to engage in age- appropriate activities, move through normal adolescence, and develop a strong positive self-image.

VB-ICM targets individuals with complex health situations, like Ashley, for outreach. Ashley was identified for VB-PICM by her new health plan when her father switched. The new plan was notified by the local hospital emergency department social worker, Julie, to which Ashley had been admitted. Julie had previously worked with one of this health plan’s VB-PICM managers, Heather, and referred Ashley directly to her for services.

Utilizing motivational interviewing skills, Heather starts by meeting Ashley, Sam, and Susan where they are and engaging them in a conversation about health concerns. Through this narrative, relationship-based assessment approach, the VB-PICM manager identifies Ashley’s clinical and non-clinical barriers to health improvement. For example, Sam shared with Heather how scared Susan and he were about Ashley’s condition. They were afraid that they would not be able to get Ashley to medical care quickly enough to prevent her from dying. Basically, they could not have a normal family life. Activities that other families took for granted they could not do. For example, they were unable to travel or go on vacation as they needed to be 30 min from an emergency department in case Ashley’s symptoms flared up. Due to the cost of Ashley’s care not covered by their prior health insurance, they could not afford a vacation either. They were over $20,000 in debt. Sam and Susan were essentially hopeless that things could change for Ashley and their family.

When Heather asked about Ashley’s biological mother, Sam shared that she lived locally but was not someone who could be counted on for assistance. She was behind on child support, which was problematic, as Ashley’s care was expensive even with insurance. Ashley’s biological mother was an alcoholic and saw Ashley about once a month.

Heather conversed with Sam and Susan, and then Ashley, to identify barriers to Ashley’s health improvement based on the VB-PICM complexity assessment grid (Fig. 1.2). Heather learned that Ashley’s care was not well coordinated and her symptom flare-ups were unpredictable. Sam and Susan were not able to identify early indicators of an impending respiratory or cardiac event. They were not trained to administer the medication that prevented escalation of Ashley’s symptoms. Thus, Ashley often experienced unnecessary testing at the emergency department due to staff responding to each episode separately. The emergency department did not take into account previous emergency department admissions or prior testing results. Their approach was the same with each visit. As a result, Ashley’s symptoms would worsen while waiting for the emergency department to complete their standard triage process. On two occasions, this led to Ashley being admitted into the intensive care unit. The emergency department’s standard process resulted in additional costs, delayed care, and potentially preventable inpatient admissions.

Fig. 1.2

Ashley’s scored complexity assessment grid (VB-ICM-CAG)

Sam and Susan also shared concerns about communicating with Ashley’s providers. For example, Sam described that they had only one dose of Ashley’s medication. It could be administered either by the home health nurse or their provider to prevent escalation of Ashley’s symptoms. Although the home health nurse was trained, she had other individuals to visit and was often not readily available when a flare-up occurred. Also, with only one dose, it put Ashley at risk at school. Prior to Heather becoming involved, no one had thought to include Ashley’s school nurse as part of her treatment team nor considered training her to administer the medication. Ashley’s school system also had barriers. Ashley was also not allowed to carry the medication to school herself. The process of the family giving it to the school nurse in the morning and picking it up after school daily was nearly impossible. Sam and Susan had tried to convey their concerns to Ashley’s providers; however, no solution was in place. As a result, these situations led to Ashley’s many emergency department assessments for care and, ultimately, hospital admissions.

As the conversation progressed, Heather continued to get to know Ashley, Sam, and Susan as individuals, engaging and building a rapport with them. Over the course of 45–60 minutes, they discussed Ashley’s primary health issues and also other barriers to Ashley’s optimal health in the biological, psychological, social, and health system domains. Given that Ashley was a teenager, Heather also assessed Ashley’s school situation with her parents, her teachers, school nurse, and Ashley. Areas assessed included peer relationships, school attendance, and the impact of missed days due to inpatient stays. The impact of her medical condition on her academic progress and psychosocial needs was substantial.

Based on the pediatric barriers identified, Heather collaborated with Ashley, Sam, and Susan in the development of a care plan that addressed their most immediate concerns. This ensured that she was delivering value as she initiated her interaction with the family. This, of course, was augmented by including items in the care plan that would stabilize Heather and her family’s situation as she neared the time that VB-PICM assistance and support could be closed. Interventions began with reaching out to Ashley’s providers after informed consent had been secured through Ashley and her parents. Heather explored options to improve collaboration for the coordination of Ashley’s care. For example, Heather facilitated Ashley’s pediatrician, cardiac specialist, pharmacist, and the health plan pharmacy department to work together to ensure Ashley had several individual dosages of the medication prescribed available that stopped symptom progression when she experienced a flare-up.

Based on this conversation (connection), Ashley now had one medication dosage at her school, another at home, and one that traveled with her. To address Ashley’s concerns about medication side effects, Heather facilitated a discussion among Ashley’s providers, which included discussions about new medications that might also be available. Ashley’s specialists consulted with the health plan’s clinical pharmacist to try new medications that would provide better stabilization of her condition and reduce her side effects. Ashley’s specialist was not aware of these new medications prior to this consultation. Heather also communicated with Ashley’s school nurse to ensure she had the training needed to administer Ashley’s medications appropriately. She also connected her with Ashley’s treatment team so any changes in Ashley’s treatment plan that may impact care provided by the school nurse were shared.

Heather also reached out to Julie regarding the family’s concerns about having to go through the same battery of tests with each emergency department visit to see if an alternative approach could be tried. Based on Heather’s outreach, the hospital reviewed and changed their protocols, not only for Ashley but also for any individual with Ashley’s condition, resulting in care that was administered faster, removed waste, and cost less since unnecessary tests were avoided and even some hospital admissions were prevented.

Another barrier Heather worked on with the family was to identify early indicators of an impending respiratory or cardiac event. Heather asked them to write down what was happening when Ashley’s symptoms flared to see if there were any patterns. For example, did the flare-up occur on a certain day of the week/month, what was the level of physical activity Ashley was engaged in, had she missed or delayed taking her medications, what was the weather like, etc. Heather encouraged the family to share their insights with their provider. For example, Sam and Susan found that flare-ups occurred just prior to Ashley’s menstrual cycle. Working with Ashley’s provider, an action plan was developed to proactively address triggers which brought some predictability to their life. The family started to feel more confident allowing Ashley to participate in peer-related activities the days and weeks prior to and after her menstrual cycle.

Heather continued to listen to the family’s concerns as she worked to remove barriers. This strengthen her relationship with Ashley and her family. Based on this strong working relationship, Heather was able to address with Ashley her behavioral health symptoms and their impact on her daily life. Ashley shared how hard it was to be sick so suddenly. She felt like no one understood and reported that she wanted to feel better. With Ashley’s permission, Heather facilitated a conversation between Ashley and Sam and shared resources for a mental health assessment and treatment through the new health plan coverage. Heather was able to work with Sam’s employee assistance program (EAP) to locate a therapist who specialized in teenagers with complex medical conditions. Ashley could see this person at no cost for eight sessions and then continue with a small copay under the health plan benefits if needed. The therapist was in-network and at a reasonable copay amount, which Sam stated he could afford.

Heather ensured that Ashley’s mental health provider was added to her treatment team and that care was coordinated across specialties. In addition, the stress of parenting a medically fragile child as well as the emotional impact on Ashley’s siblings, who never knew if Ashley would return from the hospital, had also taken a toll on the family. Heather assisted Sam and Susan and their children in receiving mental health support services through the EAP at no additional cost. It helped them deal with their long-term stress in assisting a medically fragile child, how to address the impact on Ashley’s siblings, and provided them with free support group options both in person and online.

At the end of Heather’s work with Ashley and her family over several months, Ashley’s condition had stabilized. Ashley had one emergence department visit within a week of participating in VB-PICM and none since. There were no inpatient admissions. Emergent medication doses needed both at school and in the home were available and in all locations. Plus, there were people who knew how to use them, including Sam, Susan, and Ashley’s biological mother. Ashley also completed therapy for her mild to moderate depression and showed significant improvement. She was now making new friends at school and engaging in age-appropriate activities including spending the night at a friend’s home.

The family was feeling more hopeful and less worried about Ashley dying due to inability to get her medical care fast enough. They were also more confident in the treatment team’s ability to manage Ashley’s condition effectively. Ashley’s family had received EAP support services, and their stress level had decreased significantly. As for the emergency department, the VB-PICM manager’s interventions not only changed the protocol that helped Ashley but also other individuals in the community with her condition. Given that Ashley’s condition is hereditary, both Sam and Susan reported confidence that they could now manage it if one of Ashley’s half-siblings ended up with the diagnosis. Since Ashley’s condition stabilized and there were no further emergency department or inpatient admissions, Sam was able to pay all of Ashley’s outstanding medical bills. The family was now saving for a vacation, which, prior to participating in VB-PICM, was not possible. Ashley graduated from VB-PICM, and the family has Heather’s contact information so if any issues arise in the future, they can contact her for additional assistance.

Ashley’s situation highlights the important role that VB-ICM can play in improving healthcare quality and an individual’s healthcare experience and in lowering total cost for individuals with complex health situations. Next, this chapter will focus on the three big issues facing health care today—quality, patient experience, and cost. They are major issues that need to be addressed nationally. Further, there is an opportunity for VB-ICM to improve all three issues at the individual level, especially in those with health complexity.

The Problem

Ashley’s story highlights the problems facing many individuals with health issues today. Healthcare costs too much both for those with and without insurance. In 2016, the cost of health care was over $10,000 per person, nearly double that of most other countries in the world [2]. The total expenditure in 2016 was projected to be $3.35 trillion of which inpatient care accounted for approximately 32%, outpatient care 20%, and prescription medications 10%. The annual growth increase is projected to be 5.8% from 2015 to 2025, with Medicaid and Medicare growing faster than commercial insurance since they cover those with high social determinants of health (Fig. 1.3) and advancing age [1, 3]. Compare this to a 0.4% rise in personal income and a 3% rise in the gross domestic product (GDP) in the second quarter of 2017 [4].

Fig. 1.3

Social determinants of health

This makes the rise in healthcare costs a significant concern for employer groups paying for many healthcare expenditures and for individuals whose personal earnings are not keeping pace with medical inflation. The Department of Health and Human Services (DHS) reports that rising healthcare costs are driven by a stronger economy. Unfortunately, medical price growth is faster than GDP due to the aging United States (US) population. This results in 47% of all US healthcare spending growing faster than the national economy over the next decade [2]. The Centers for Medicare and Medicaid Services (CMS) reports that the healthcare system is the most expensive in the world making up 17% of the gross US domestic product and projects that the percentage will increase to approximately 20% by 2020 [5]. At our current rate of spending for health, the Congressional Budget Office (CBO) estimates that 25% of our gross domestic product will be allocated to health care in 2025 and reports that US healthcare per capita spending will far exceed that of all other industrial countries [6].

Unfortunately, US higher healthcare expenditures are not resulting in improved healthcare outcomes. The United States is ranked 43rd in life expectancy and has poorer health for each stage of life compared with most industrial countries. Further, there are significant disparities between the top and bottom 1% income levels for US residents. For example, the life expectancy at age 40 for a woman in the bottom 1% income level is 10 years less than for a woman in the top 1%. For men, the difference is 15 years between the bottom 1% compared to the top 1% at age 40 [7]. In 2014, The Commonwealth Fund ranked the US last in overall health care and the most expensive of all industrial countries (Table 1.1) [8].

Table 1.1

Overall healthcare ranking for top 11 industrial countries

Modified from Osborn R, Moulds D, Squires D, Doty MM, Anderson C. International survey of older adults finds shortcomings in access, coordination, and patient-centered care. Health Aff (Millwood). 2014;33(12):2247–55

Key findings from The Commonwealth Fund study revealed the US ranked last in access, equity, and healthcare outcome measures as well as next to last in administrative efficiency. Specific findings include the following:

Access: More Americans do not get needed health care due to cost, compared to other industrial countries who have universal coverage and promote patient medical homes. Subcategories that drove the US to last-place ranking include cost of care (affordability) and timeliness.

Administrative Efficiency: The US performs poorly on the efficiency measures, such as administrative red tape, duplicative medical testing, and potentially preventable emergency department visits as well as overall administrative costs. For example, US physicians reported excessive coverage restrictions and significant administrative burden dealing with insurance and claims issues.

Care Process: This score consists of four subcategories combined together, i.e., preventive care, safe care, coordinated care, and patient engagement. For measures that include a patient-physician component, the US ranks 5th among 11, such as wellness counseling, shared decision-making, chronic disease management, and end-of-life counseling. The US also does well on preventive measures, such as mammogram screening and influenza immunization rates. However, the US lags significantly behind on measures, such as potentially preventable admissions and coordination of care measures, including information flow among primary care, specialty, and social services providers.

Equity: For Americans with below-average incomes, they are less likely to

Visit a doctor when ill.

Follow through with recommended tests, labs, procedures, treatments, or follow-up care.

Adhere to prescriptions, including filling or taking medications as prescribed due to costs.

Overall, Americans reported that waits for specialty appointments were long (2 months or longer), that medical care was fair or poor, that no or poor coordination occurred among providers, that care was skipped due to costs, and that after-hour care was difficult to obtain.

Healthcare Outcomes: The US ranked last on this measure which focuses on population health, mortality, and disease-specific health outcomes. The US also performed low on population health subcategories, such as infant mortality and healthy life expectancy at age 60. It, however, performed well on measures such as 30-day inpatient mortality after a stroke or heart attack and breast cancer 5-year survival rate [9].

What is most interesting is that Americans seem more concerned about cost (27%) and access (20%) to health care. They named these two things the most urgent health problems facing this country in a 2016 Gallup poll, even over treatment for conditions like obesity (15%) and cancer (14%) [10]. There is no doubt that healthcare costs must be addressed. If left unchecked, they not only threaten the US ability to provide quality care to individuals but also threaten our ability to economically compete on the global stage [6].

Big Picture Solutions

Currently, a variety of efforts are in place to improve the quality of care, the individual’s experience, and the rise in healthcare costs, known as the Triple Aim (Fig. 1.4). For example, the Institute for Healthcare Improvement (IHI) created the Triple Aim framework, which simultaneously focuses on population health, the individual’s care experience within the targeted population (e.g., quality of care and satisfaction), as well as the cost of providing the care. The ultimate goal of this initiative is to improve the system overall [11]. The Triple Aim framework has been adopted throughout the US by hospitals and large and small health systems. It is the US national strategy for addressing healthcare issues [12]. Core to the Triple Aim is ensuring that learning systems are established to rapidly test, measure, and then implement health-improving and cost-saving results.

Fig. 1.4

The Triple Aim

Based on measured findings, thus far, IHI organizations can scale effective projects and tailor them to the unique needs of targeted populations for whom they provide services. Measuring outcomes is not only core to the Triple Aim, but it is a requirement. VB-ICM is aligned with the Triple Aim approach by focusing on quality, experience, and cost and by trying to quantify results as more and more programs use it. Examples on how this works will be discussed later in this chapter and throughout this manual.

Other efforts to improve healthcare quality, the individual’s experience, and health-related cost include value-based reimbursement contracts between health plans and providers, also known as paying for value. These financial arrangements move from a fee-for-service to a pay for performance model. Instead of providers being paid based on the number of patients seen or tests ordered, providers are paid on the value of the care they deliver. For example, value-based contracts may include metrics, such as seen with Healthcare Effectiveness Data and Information Set (HEDIS) targets, e.g., meets 90th percentile on HbA1c tests completed in the measurement year for attributed individuals diagnosed with diabetes; individual satisfaction scores, e.g., 90% or greater overall individual satisfaction; or total cost of care targets that result in shared savings between the provider group and health plan.

Another form of paying for value is through accountable care organizations (ACOs). These have emerged since the 2010 Affordable Care Act (ACA) [13]. The ACA seeks to reduce healthcare costs by encouraging doctors, hospitals, and other healthcare providers to form networks that provide coordinated, high-quality individual care. The goal is to ensure that individuals, and especially those with one or more chronic condition, are getting coordinated care at the right time, in the right place, and by the right professionals. Thus, the ACA spends as much time on assuring preventive care, avoiding unnecessary and duplicative services, and preventing medical errors as it does on encouraging delivery of high-cost specialty services. In other words, ACO providers are incentivized for keeping their individuals healthy rather than maximizing use of delivery system services. ACOs that demonstrate high-quality care at a reduced cost become eligible to share in savings with participating health plans or on their own if they assume payer and provider accountability [14].

According to CMS, the 2015 total program saving for ACOs was over $466 million with more than 400 Medicare programs participating. Of the 400 ACOs, 125 met quality performance standards and saving thresholds and qualified for shared savings payments in 2016. This is just one example of changes in financial agreements that can drive enhancements in all areas of the care delivery system. By requiring improvements in quality and the individual’s experience, as well as focusing on lowering the total cost for care, health-improving and cost-saving practices are leading to better approaches to care. Both providers and health plans are aligning. They are incentivized to collaborate together to achieve results.

As with the Triple Aim, ensuring that learning systems are in place to continuously measure results is key to achieving the stated goals. Important components of these new financial arrangements are that all participants, health plans, care delivery systems, and the individuals cared for by them understand what is working and what is not. Ultimately, these stakeholders need to work together to figure out root causes of failure and then implement changes likely to lead to improvements.

A third approach being used to address poor quality and rising healthcare costs is by altering outcomes associated with the social determinants of health (Fig. 1.3). The World Health Organization (WHO) defines social determinants of health as the complex, integrated, and overlapping social structures and economic systems that are responsible for most health inequities. The social structures and economic systems include social environment, physical environment, health services, and structural and societal factors. Social determinants of health are shaped by the distribution of money, power, and resources throughout local communities, nations, and the world [3].

The impact of poverty, which is at the core of most social determinants, is well known. It limits access to healthy foods, safe neighborhoods, stable housing, quality health care, and education. According to the Office of Disease Prevention and Health Promotion, the goal, associated with the social determinants of health in 2017, is to create social and physical environments that promote good health for all. Eighty percent of healthcare costs are suspected to be due to the social determinants of health, while 20% due to the way that clinical care is provided. Many individuals with health complexity have barriers associated with the social determinants of health. If not addressed, these non-clinical factors impact the individual’s ability to obtain services from providers who adhere to evidenced-based treatment plans and to follow through on them.

VB-ICM can play an important role in supporting value-based contracts and ACO arrangements that address the impact of social determinants of health on an individual’s ability to self-manage their conditions and access evidence-based care. Since VB-ICM’s introduction into the United States in 2010, over 20 health plans and provider groups have implemented adult and/or pediatric VB-ICM. These groups are demonstrating its value in addressing all three of the key Triple Aim problems—quality, experience, and cost. For instance, many of the more than 1200 trained VB-ICM managers are now being employed by health plans and provider groups to ensure that services required to remove barriers to improvement for individuals with complex health situations are more easily found within individuals’ delivery systems.

What Is Value-Based Integrated Case Management?

Whereas many CM programs in today’s world focus on educating individuals about their conditions or helping them access care by qualified healthcare providers, e.g., a medical or behavioral health generalist or specialist, VB-ICM managers build relationships during their initial cross-disciplinary clinical and non-clinical narrative assessment with complex individuals and then create a collaborative care plan designed to overcome mutually agreed upon barriers to improvement in multiple domains. Key differences between current CM and VB-ICM can be found in Table 1.2. The comprehensive assessment is the start of a several months but, occasionally, a several year engagement. It is needed to identify and assist individuals with complex health problems as they make necessary changes that lead to successful reversal of challenging health and life situations. It is at this point that they can then self-manage their remaining chronic conditions since general health stabilization has been achieved.

Table 1.2

Current case management models versus VB-ICM model

Core to VB-ICM is identifying and addressing an individual’s unique barriers (not just illnesses) to improvement in the biological, psychological, social, and health system complexity domains, using the VB-ICM complexity assessment grid (VB-ICM-CAG). As we saw with Ashley (see Fig. 1.2), barriers to health improvement can include the inability (1) to access medical and BH evidence-based care; (2) to coordinate care across specialties (e.g., physical health, behavioral health, pharmacy) and health-related systems (e.g., primary care, specialty care, home health, mental health clinics, school, emergency department, and pharmacy); (3) to address personal, social (family), and financial upheaval; and (4) to rectify difficulties in communication among providers. Each of these may impact an individual’s (and/or their caregiver’s) ability to effectively follow a provider’s treatment plan.

In Ashley’s case, she and her parents are assisted using the value-based pediatric integrated case management complexity assessment grid (VB-PICM-CAG), which contains many similar risk items as the adult VB-ICM-CAG version (Fig. 1.5). However, several of the grid items in the pediatric grid have wording adjustments, which are parallel to the adult grid however address similar risk characteristics more pertinent to children/youth, e.g., school functioning rather than job and leisure. Additionally, five grid risk factors have been added for children/youth, such as developmental history and adverse developmental events to cover areas not needed for adults. More will be said about this in later chapters. Despite these changes in the VB-PICM-CAG, essentially: (1) the same outcomes related to VB-ICM assistance and support are measured, i.e., clinical, functional, fiscal, satisfactions, and quality of life, based on defined goals and actions in the care plan; (2) VB-ICM managers rarely need to hand individuals to other managers due to skill limitations, including from the medical to the BH sector or to address clinical and non-clinical issues; and (3) caseloads are determined by grouped individuals’ complexity and outcome expectations rather than process targets, e.g., the number of individuals touched, the number of calls made, or other non-value-based contract requirements.

Fig. 1.5

The adult VB-ICM complexity assessment grid

VB-ICM is relationship based and targets the top 15% of individuals with complexity, who have reversible or stabilizable health needs. One third of these individuals (5%) account for over 50% of population healthcare costs, so effective assistance and support cannot only improve health but also lower cost in some of the health system’s most challenging and costly individuals [15]. VB-ICM is focused on removing barriers and then measuring the effectiveness of interventions that then become possible. Included in the model is uncovering health barriers, whether related to known physical conditions or other clinical and non-clinical factors, such as depression or anxiety, a need for social support, or problems with medication adherence.

The initial assessment, using a guided interview with a full range of topics at the start of VB-ICM, establishes baseline measurements. During care plan activities, the VB-ICM manager measures progress to ensure that interventions are making a difference and, if not, changes tactics with guidance from a Medical Director and/or other VB-ICM leadership. At the end of services, measurements are taken during VB-ICM to document outcomes, i.e., an individual’s and/or the program’s level of success in improving health and life for participants, using the VB-ICM complexity assessment grid (CAG) and the patient-centered ICM performance (PCIP) tool.

Many current medical CM models focus on identifying individuals at risk for poor outcomes using sophisticated algorithms based on (1) health plan claims data and predictive modeling schema, (2) health risk assessments and/or clinical characteristics of hospitalized individuals, or (3) high outpatient service utilization in general medical and/or surgical settings. BH issues/problems, if identified, are typically not included among medical case manager responsibilities. Individuals with them rather are transferred to BH programs, which target those at risk for mental health or substance use disorders in their own inpatient, residential, and/or outpatient BH service treatment locations. Of course, the reverse is also true. When individuals with primary, serious and persistent mental illness (SPMI) or substance use disorders, treated in the BH sector and being assisted primarily by BH case managers for BH problems, have concurrent medical conditions, they are referred to medical CM if it is available. This paradigm is replaced in VB-ICM, i.e., all medical and BH, which includes mental health and substance use, issues are part of core VB-ICM manager’s accountability, whether the manager has a medical or BH background. This is why all VB-ICM managers are trained in providing cross-disciplinary assistance and support before initiating VB-ICM work.

Targeting individuals for outreach in VB-ICM considers more than just an individual’s health conditions. VB-ICM is focused on identifying those things that make individuals complex. Health complexity consists of factors that interfere with achieving expected or desired health and cost outcomes due to the interaction of biological, psychological, social, and health system clinical and non-clinical barriers. Health complexity factors include the age of the individual; the number of chronic conditions (medical and behavioral health); the cost and utilization of healthcare services, including potentially preventable emergency department visits, admissions, and readmissions; predictive risk areas uncovered by health risk assessments; condition-specific care gaps; medication adherence; financial, legal, and/or personal upheaval; social support needs; health literacy; and culture barriers, just to name a few. VB-ICM targets individuals with health complexity when there is an opportunity for services to impact quality, the individual’s health-related experience, and healthcare and other costs.

Take, for example, Ashley. She has a rare disease, which leads to a significant number of potentially preventable emergency department visits and inpatient admissions. This is complicated by an untreated co-occurring depression and other personal, social, financial, and health system barriers. Ashley’s health complexity and associated healthcare costs made her a prime candidate for VB-PICM services. Her VB-PICM manager, Heather, could improve her healthcare quality by facilitating the coordination of care across specialty areas and systems, e.g., school, home health, pharmacy, mental health therapist, primary care, and specialty providers, and to impact her total cost of care by removing waste during emergency department visits and reducing inpatient hospitalization needs. Further, Heather augmented Ashley’s health experience by listening to and meeting Ashley and her family where they were and by providing them with a single point of contact to address all of Ashley’s barriers to improvement.

VB-ICM differs from current CM since it provides a dedicated case manager to address medical, BH, social, and health system contributors to an individual’s clinical and non-clinical health improvement barriers. Existing CM models typically do not do this. Rather, they focus on addressing either medical or BH issues, usually not both, and, most often, target only focal components of these before closing the case.

For instance, a medical or BH case manager may help find a discipline congruent practitioner or funding for a high-priced medication but then close the case when these problems are taken care of. It does not matter that the same individual, who had an incomplete assessment due to time constraints as a part of current CM services model, may have no transportation to appointments, that appointments are located at a distance from one another, or that practitioners treating health needs in various areas, e.g., cardiology and BH, put notes into non-connected health records and do not otherwise talk with each other. VB-ICM interventions include unified instructions to individuals about their general medical and BH conditions, addressing factors that have resulted in treatment non-response, and, in more robust VB-ICM programs, such as is suggested in this second edition, confirm that progress toward recovery is occurring through outcome documentation. The goal of the VB-ICM approach is to decrease total health complications and to maximize benefit from healthcare service use. When done well, studies suggest that positive results in those with specific complex health conditions can be expected but most often studies only include outcomes for those with primary medical conditions [16].

Assisting and supporting services for BH problems, including psychosocial issues, are a major part of the VB-ICM process. This is because 60–80% of high-cost individuals with health complexity have comorbid medical and BH conditions (more on this in later chapters). This is one of the primary reasons why VB-ICM trains VB-ICM managers to perform cross-disciplinary medical and BH management services. Current CM, medical or BH, models attempt to hand individuals off to case managers with discipline-specific skills rather than attempting to address the cross-disciplinary problems themselves. What programs doing this have found, however, is that individuals in medical settings won’t go to the BH setting for care (the clear majority) or even to BH case managers. The reverse is not as much of an issue, i.e., when transferring those with BH conditions to the medical setting—often they go. The issue is that information about their comorbid conditions is not shared between treating medical and BH practitioners. Therefore, care continuity becomes much more of a challenge, and collaboration between medical and BH specialists is often non-existent.

VB-ICM advances CM practices by providing cross-disciplinary training about both medical and BH conditions to both medical and BH personnel. Using this model, VB-ICM managers effectively address all the barriers that are contributing to the individual’s poor health outcomes. Where current CM models fail is in trying to provide coordinated medical and BH CM through two CM operations to complex individuals when these programs work out of separate systems in discrete service locations using practitioners who rarely talk. VB-ICM addresses this system-based challenge by recognizing that the individual treated is a whole person that does best when medical and BH practitioners practice primarily in the same setting, routinely communicate about health issues, and are a part of the same medical record system. As a part of this system, VB-ICM managers fit nicely. They help practitioners see the individual as one who has a complex set of health issues, often medical and BH, that do best when coordinated care is provided. Interestingly, VB-ICM managers help this link to occur.

One of the primary reasons that VB-ICM works is because there is no expectation that case managers performing VB-ICM treat illness, either medical or BH. Rather, they assist individuals in getting outcome-changing care and stabilizing health by using their understanding of health and the health system to guide individuals through the maze. Case managers who choose to enhance their CM practice by providing VB-ICM must develop the skills required to assist individuals with co-occurring and often treatment-resistant physical and BH conditions. It is a critical skill to assist individuals in overcoming their challenges in getting the type of care that will return them to health or, at a minimum, get them to their highest level of functioning. This manual provides the cross-disciplinary information needed by case managers using VB-ICM techniques. Further, it includes additional resources, such as directions on how to access training by certified VB-ICM trainers, and enhancements that can be made within an organization’s clinical documentation systems to support VB-ICM.

Let’s return to Heather, the VB-ICM manager working with Ashley and her family. Heather’s background was in BH, but she received cross-disciplinary medical and BH training as a part of her entry requirements for participation in VB-ICM. This was important for Ashley’s care. Heather could seamlessly address Ashley’s health system barriers by facilitating coordination among providers, including medical, BH, as well as pharmacy. Heather addressed large health system issues too, by working collaboratively with the emergency department social worker. This resulted in system changes that improved access to health-improving services, not only for Ashley but also for others with her condition. Simultaneously, Heather worked directly with the EAP program associated with Sam’s health plan through his business to secure accessible and reasonably priced mental health treatment for Ashley (and ultimately other family members).

As time progressed and Heather became more familiar with Ashley’s family, she could discuss medical, BH, and other barriers with the family utilizing her knowledge of the healthcare system. She utilized motivational interviewing (MI) skills to sustain Ashley’s engagement and to elicit change talk with Ashley and her family. (Motivational interviewing, covered in Chapter 6, is an evidenced-based collaborative, goal-oriented style of communication used by VB-ICM managers to strengthen an individual’s motivation for and commitment to making necessary behavioral and lifestyle changes to manage their conditions.) [17]

In addition, Heather identified during the narrative assessment process that other barriers were present, such as depression. Each, once identified, could be assisted through care plan actions as she, Ashley, Ashley’s family, and Ashley’s clinicians worked toward care plan goals. She ensured that her interventions, many of which required Ashley’s active involvement, addressed issues of concern and led to total health improvement. By documenting and addressing all barriers during unified single VB-ICM manager assistance, Heather made sure that no barrier to improvement was overlooked or lost. Further, when it was time to transfer Ashley back to standard care, i.e., care provided primarily by her pediatrician and her/his clinical team, the transition would be smooth and well organized, with little difficulty for Ashley’s doctor to reassume full responsibility. For Ashley and her family, the VB-ICM experience was enhanced by having a single point of contact to address all issues and to provide the support needed to make the changes necessary to improve Ashley and the family’s overall health both medically and emotionally.

How Does Value-Based Integrated Case Management Work?

At the heart of VB-ICM is the narrative, relationship-based assessment. It is designed to build a trusting relationship between the VB-ICM manager and the individual with health complexity while gathering critical information that will guide the care plan. As a part of this process, the individual seeking help also engages and participates in the health-improving process. Through the narrative assessment process, the VB-ICM manager takes the time to get to know the individual as a person, not just their conditions, and uncovers the individual’s true motivators for change. While VB-ICM program methods are key to helping individuals overcome barriers to health, it is the relationship between the VB-ICM manager and the individual seeking help and the motivation of the individual to put forth the effort to change that create success in VB-ICM. Of course, while the understanding of illness(es) and knowledge about options that may lead to improvement are important factors, it is the relationship between the VB-ICM manager and the individual and the individual’s motivation that create the change environment.

Most current CM models focus on short-term interventions that address initial individual needs in a short time period, e.g., one to three calls/encounters. VB-ICM works with individuals over time. Thus, an investment in the initial assessment strengthens the alliance between the individual and their VB-ICM manager resulting in the overall change process moving more quickly.

A differentiating component of VB-ICM is its use of INTERMED methodology, the VB-ICM-CAG, an adult multi-domain complexity assessment tool developed in Europe. After 25 years of research with extensive study in more than nine European countries and the use of a tool translated into seven languages, it was introduced into the United States in the early 2000s and officially deployed with the publication of this manual’s first edition in 2010 [18].

The INTERMED itself was designed to connect siloed factors in the health system that influence individual’s health outcomes and to identify and quantify, based on this, an individual’s health complexity. Health complexity includes two components: complexity of the individual (the case) and complexity of the health system (the care) [19, 20]. For example, individuals diagnosed with both diabetes and depression may have their care complicated by the impact of each condition. Depression can negatively influence adherence to diabetes management (a case characteristic). Having two chronic cross-disciplinary illnesses, however, also necessitates communication between medical and BH service providers (a care characteristic). The INTERMED addresses both case and the care complexity components.

In VB-ICM, the VB-ICM-CAG (and VB-PICM-CAG) is focused on identifying barriers that lead to poor outcomes. These barriers fall into four domains: the biological, e.g., ensuring an individual has an accurate diagnosis and appropriate treatment; the psychological, e.g., identifying the presence and importance of BH conditions, such as depression or substance utilization disorders, and health behaviors, such as problem-solving and treatment adherence; the social, e.g., assessing for contributions by social determinants of health and other social factors affecting outcomes; and the health system, e.g., ensuring access to evidence-based care with effective communication among providers.

The VB-ICM-CAG (and VB-PICM-CAG) gives equal attention to and priority for problems in all four domains, whether clinical or non-clinical or medical or BH. All can create negative health outcomes with equal potency. For instance, while homelessness is non-clinical, it is a powerful predictor of deleterious health outcomes. Through the INTERMED, health complexity is expanded to include a composite of interacting historical, current state and vulnerability health risks and health needs from each domain in which barriers to care arise. The INTERMED was developed based on the assumption that return to health was dependent on addressing clinical and non-clinical factors that interfere with the individual’s ability to get better [20]. This includes seemingly peripheral things, such as whether:

Significant family members agree with the diagnosis and treatment.

An individual has a co-occurring behavioral health condition.

A person has transportation to an appointment and the money to fill prescriptions.

Providers communicate with each other.

Inherent in the VB-ICM-CAG is the understanding that an uncomplicated and otherwise easily treatable physical condition could be made complex by the presence of one or more factors in other domains in an individual’s life. For instance, pneumococcal pneumonia in most individuals can be effectively treated by the administration of penicillin. However, if the individual lives on an Indian reservation and has a cultural aversion to taking oral medication or the individual has paranoid psychosis and is concerned about being poisoned by their doctor, a simple course of antibiotics becomes much more complicated. Cultural or mental health factors must be considered to effectively treat an otherwise uncomplicated yet potentially serious health problem. All that may be required to effectively treat the Native American would be a shot of benzathine (long-acting) penicillin. The paranoid individual, on the other hand, may require a partial hospitalization program, observation stay, or short admission where supervised administration of the medications can occur.

The concept of health complexity, using INTERMED methodology with the VB-ICM-CAG, paints a more complete picture of the individual so that assistance in all domains is brought to the individual. The VB-ICM-CAG is designed to assist the VB-ICM manager in identifying and prioritizing individual goals and in optimizing the complexity assessment’s impact. The VB-ICM-CAG quantifies the severity of the barriers and quickly identifies the intervention intensity needed. After the complexity assessment, each subsection of the four domains is scored utilizing a standardized tool based on anchor point scores for each subsection. The scores are prioritized in the VB-PICM-CAG and VB-ICM-CAG (see Figs. 1.2 and 1.5) as follows:

Level 3 (red): High priority requiring immediate action

Level 2 (orange): Moderate priority requiring treatment administration or the development of a treatment plan

Level 1: (yellow): Monitoring or preventive action needed

Level 0: (green): No action needed

Enhanced communication is supported by this standardization and organization of risks and needs into the VB-ICM-CAG in which the seriousness of risks or needs can be visualized with colors and easily communicated once interpretation of the grid is understood. In fact, early in the VB-ICM process, VB-ICM managers share information about how to interpret the VB-ICM-CAG (or VB-PICM-CAG) with the individual’s practitioners (Appendix D) as applicable. This, as well as how the VB-ICM manager utilizes the VB-ICM-CAG tool in the narrative assessment process, is covered in greater detail later in this manual.

Due to the unique needs of children/youth, there are two versions of the CAG—an adult and a pediatric version. Pediatric VB-ICM, outlined in this manual, parallels the adult model but also addresses several substantially different health complexity factors that impact children/youth, such as school attendance, learning disorders, physical growth and developmental issues, family/caregiver issues, community and peer influences, and the pediatric healthy system. As such, the CAG model for children/youth has five additional barrier items (25 total) that must be assessed, scored, and used to address barriers and ensure the best health outcomes. With these new items are altered items for several other existing adult grid barriers that make the VB-PICM-CAG truly pertinent to children/youth.

Just as adult VB-ICM managers, VB-PICM managers use a systems approach. They reach out and incorporate contributions from the child/youth and from the child’s/youth’s parents/caregivers, teachers, coaches, and peers during completion of the assessment process. For children under 7 years of age, relatively little information comes from the child. Child/youth contributions to VB-PICM-CAG scores, however, increase progressively to the age of majority. From scored VB-PICM-CAGs, care plans with intervention strategies are designed to move toward outcome-changing care; to improve health; and, when stabilized health is achieved, to help ensure that self-management skill development is completed in preparation for the child’s/youth’s and family’s return to standard care.

During work on the care plan, outcomes are monitored for health improvement. When needed (worsening or lack of progress are found), adjustments are made in the care plan to maximize child/youth return to health and normal life activities. Since children/youth are at as great, if not greater, risk for multiple factors contributing to health complexity as adults, the approach to VB-PICM can be complicated and time-consuming, at least at first. This is further complicated by the fact that the child’s/youth’s parents/guardians can have equally challenging issues that must be dealt with for success to occur with the child/youth. Greater time is spent describing this process later in manual.

VB-ICM: Achieving Big Picture Improvement

VB-ICM advances the practice of CM by redefining how the process of CM is delivered, especially to individuals with health complexity. VB-ICM is aligned with the Commission for Case Management Certification (CCMC) definition of CM, i.e., a collaborative process that assesses, plans, implements, coordinates, monitors and evaluates the options and services required to meet the client’s health and human service’s needs. It is characterized by advocacy, communication, and resource management and promotes quality and cost-effective interventions and outcomes [21]. VB-ICM expands CCMC’s definition by adding the following skills, capabilities, and focus areas:

Listening to and engaging individuals where they are

Providing a dedicated VB-ICM manager for all the individual’s needs, i.e., no (or few) handoffs between specialty case managers

Identifying an individual’s barriers to health improvement by utilizing a narrative, relationship-based approach to assessing health complexity

Leveraging the individual’s motivators for change

Prioritizing interventions based on the individual’s goals, reflected by the multi-domain VB-ICM-CAG/VB-PICM-CAG

Establishing a baseline and then monitoring and evaluating the impact of interventions on removing the individual’s barriers throughout and at the end of the CM process

Establishing, measuring, and reporting not only care plan outcomes but also pertinent big picture clinical, functional, economic, satisfaction, and quality of life outcomes

The upcoming chapters will describe each of these skills, capabilities, and areas of focus in greater detail.

The move from current CM practice to VB-ICM is a critical step in magnifying a case manager’s effectiveness in improving health quality, the individual’s care experience, and the total cost of treatment. VB-ICM’s core value is aligned with this Triple Aim. Further, it allows systematic documentation of outcomes by focusing attention on these three issues and then measuring results. VB-ICM establishes the baseline situation of each participating individual in the PCIP at the beginning of services. It then monitors the effectiveness of interventions while prioritized assistance and support are given, adjusting care plan goals and activities when necessary if interventions are not improving the individual’s health. As a result, outcomes occurring during VB-ICM can be systematically measured and reported as each individual involved in VB-ICM graduates from their VB-ICM program. In fact, this manual second edition allows consolidation of outcomes for individuals participating in the VB-ICM process so that total program effectiveness can be clearly delineated. The outcomes shared in the following section exemplify a start in this activity.

Value-Based Integrated Case Management Outcomes

Since the first edition of this manual, VB-ICM programs have measured and demonstrated their effectiveness in a variety of healthcare settings. Three examples about how this is done will be discussed, and some results provided. The first was performed by a New York health plan in which ICM was chosen for use in 61 chronically ill members, many of whom lived on the streets of New York City. The intent of the intervention was to improve outcomes in this chronically ill and highly expensive population. While the study was never published, it was presented at a national CM meeting. Outcomes were remarkable for those who participated over a 2-year period (Table 1.3). Participants exposed to ICM practices demonstrated decreased annual costs, lower average annual and total emergency department visits, and treatment adherence in association with reduction in ICM-CAG scores.

Table 1.3

Outcomes with VB-ICM at 2 years in 61 NYS-DOHa chronically ill members

Modified from Hudson Health Plan, Westchester Cares Actions Program (WCAP), presented at CMSA Annual Meeting, 2012

aNYS-DOH = New York State Department of Health

The second, a study compiled by a research group at the University of Pittsburgh Medical Center, uses a variant of VB-ICM, which focuses on assistance to individuals diagnosed with inflammatory bowel disease (IBD) [22]. These individuals participated in an IBD patient-center medical home (PCMH) that utilized VB-ICM activities to reverse complexity issues and improve health. The multidisciplinary team involved addressed not only medical issues seen in IBD patients but also comorbid behavioral health conditions and psychosocial factors that impacted participants’ ability to follow their providers’ treatment plan, including self-managing their condition. The team incorporated VB-ICM into their IBD PCMH’s interventions, assessing the individual’s barriers to improvement in the biological, psychological, social, and health system domains. It created individualized care plans to address all the barriers identified, including the psychosocial barriers that were driving increased medical utilization and decreasing the individual’s ability to function successfully in life, such as at work.

In this study, 308 participants (62% with Crohn’s disease and 38% with ulcerative colitis) were actively engaged. Ninety-four percent of the those involved, average age of 35 years and 60% female, completed 1 year in the IBD PCMH. The results showed a 51.9% decrease in overall emergency department visits, a 53.1% decrease in hospitalization (Table 1.4), and a statistically significant improvement in the quality of life for those that participated [23]. Other results indicated improved adherence to medications and the care plan, an improved relationship with their IBD treatment team, and a reduction in overall healthcare utilization [22–24].

Table 1.4

Hospitalizations and emergency department visits after 12 months of IBD-based VB-ICM

Modified from Regueiro, Hashash, McAnallen, Ramalingam, Perkins, Manolis, Kogan, Watson, Binion, McGowan, Anderson, Click, Bell-Temin, Weaver, Fultz, Graziani, Smith-Seiler, and Szigethy (April 2016). Decreased emergency room utilization and hospitalizations and improved quality of life in the first year of an inflammatory bowel disease (IBD) patient-centered medical home (PCMH). Research finding provided by Eva Szigethy on January 26, 2017

Of particular interest raised by these two sets of individuals exposed to ICM is that there appears to be a net return on investment associated with the delivery of ICM in those with complex health issues. In the former, the cost of personnel supporting the care of the 61 individuals in NYC was conservatively estimated to be around $175,000 over 2 years, while the saving, just in terms of reductions in hospitalizations and emergency department visits, was in the range of $880,000, a return on investment of $5–$1 spent. The findings for those with IBD suggest that the cost of additional personnel involved in ICM would have been relatively similar. Approximately $250,000 covered the cost of ICM managers over 1 year, whereas the savings for the 308 individuals supported in care was nearly $1.1 M, a return on investment of $4 to $1 spent. More will be said about this in Chapter 4.

The third set of data came from a commercial health plan. It implemented VB-ICM and VB-PICM system