Disease management: Learning to cut costs while meeting a broad range of patient needs
Disease management: Learning to cut costs while meeting a broad range of patient needs
Disease management techniques used by behavioral health practitioners for the past 20 years can be instructive for those trying save money by better managing patients with chronic diseases, according to three executives from Connecticut’s Department of Mental Health and Addiction Services (DMHAS) in Hartford who shared their expertise and experiences at a recent Congress on Medicare and Medicaid.
DMHAS senior policy advisor Wayne Dailey tells State Health Watch that general medical services and behavioral health services have "grown up in different silos," even though they’ve had to deal with many of the same problems and have arrived at some of the same solutions.
"We haven’t been sharing our ideas as much as we should have," he says. "We’ve been doing behavioral health case management for more than 20 years, and now it’s becoming popular in medical case management. We’ve learned that managing chronic behavioral diseases requires meeting a broad range of patient needs."
Mr. Dailey told the Congress that chronic disease management is becoming a hot topic because there is no good fit between the nation’s health care system and health care needs. And that has an impact on overall spending on health care. Although nearly half of all Americans are affected by a chronic disease and more than 75% of health care dollars are spent on chronic diseases, he says, our health care system is focused primarily on acute care.
Lessons learned
Areas in which there can be a greater sharing of information and solutions between behavioral and physical health include implementing preferred practices, client outreach and engagement, client education, and information sharing across episodes of care and among providers.
DMHAS deputy commissioner Arthur Evans says public sector agencies such as his must deal with the most complex clinical situations, attend to a full spectrum of client needs, deal with clients involved in multiple systems, and cope with a provider system that is under intense pressure.
"Given all that’s happening, we must maintain our safety-net responsibility, deal with the consequences of cost shifting, improve care quality within limited resources, address health disparities, address increased acuity/chronicity, and build and maintain a culturally competent system of care," he says.
To control costs through implementing effective large-scale systems of behavioral health care, Mr. Evans recommends:
- emphasizing the whole person and not the disease;
- communicating expectations for recovery;
- ensuring timely intervention and an ability to vary service intensity at times of crisis or when symptoms worsen;
- providing incentives to encourage adherence to treatment;
- energizing the provider system and involving consumers;
- ensuring continuity of care across treatment episodes and among service providers;
- addressing cultural competence;
- integrating self-care approaches into the treatment system.
These steps can be applied to physical health conditions as well as mental health, he adds.
Providers not always involved
The two executives say that while chronic behavioral health illnesses generally have cyclical periods of acute symptoms followed by periods of quiescence, providers often see patients until the end of the acute phase but are unavailable during nonacute periods. The time for self-care recovery, education, and rehabilitation is in lulls between acute phases, they say, so that patients are better able to recognize their need for help and participate in their own care during the acute periods. Rather than simply trying to achieve symptom reduction, Dailey and Evans say providers should try to improve functional status while reducing symptoms.
When the goal is recovery, according to this model, services for chronic behavioral health disorders should include support services, skill building, and effective clinical treatment using a systems approach that determines what services are needed, ensures that services are available, evaluates service effectiveness, and monitors progress for the client, provider, and system.
A third presenter at the Congress, DMHAS managed care executive Reginald Simmons, described how the agency uses data and evidence-based practice to bring about systems change.
Mr. Simmons says lessons that can be learned from the behavioral health sector and applied to physical health include:
- Holistic approaches are necessary.
- A systems approach is essential.
- People should be viewed and treated within a sociocultural context.
- Evidence-based and cost-effective services should be implemented.
- Access to care should be based on psychosocial necessity, not just narrow medical necessity criteria.
- Availability of services should mirror the course of the illness.
- Data should be used to create a sense of urgency and competition among providers.
- Contacts must clearly articulate the providers’ clinical and administrative accountability for a client.
- Performance must be monitored to identify provider outliers.
Mr. Dailey tells SHW it is important that providers remain involved with patients between acute phases because that’s when patients can learn relapse-prevention skills and how to identify the onset of a chronic phase so they can participate in the recovery process by intervening and preventing a relapse.
"We need to empower patients to have a recovery-oriented treatment approach," Mr. Dailey says. "Providers need to take advantage of the benefits of patient participation instead of treating them passively." This type of approach is important, he says, because most of what people do in their lives occurs outside the presence of their treatment provider.
"They’re out there on their own, so if you can get them involved, you’re ahead of the game," he says. When people recover, that’s what saves money. Acute-care treatment is the most expensive."
[Contact Mr. Dailey, Mr. Evans, and Mr. Simmons at (860) 418-7000.]
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