System plans to use CMs to prevent costs
System plans to use CMs to prevent costs
The challenge of meshing managed care and behavioral health has case managers looking for innovative solutions. Integrating medical and psychosocial case management in a proactive wellness and prevention role is one possible solution a large regional health system plans to soon make a reality.
Northeast Health Systems in Boston recently merged five social service agencies and placed them under the management of Health and Education Services (HES). That strategic move made HES the largest regional behavioral health care organization in Massachusetts with 10,000 members, 600 full-time staffers, and revenues of roughly $17 million. HES’ mission is to offer comprehensive mental health and substance abuse services with a strong emphasis on prevention and continuity of care.
To help HES fulfill its mission, Northeast launched the Health Link Program in 1996. Health Link puts an integrated team of primary care physicians and behavioral health clinicians into the community where they provide assessment, early intervention, and education services. Now, Northeast Health Systems has developed a case management model it calls the "lifestyle specialist concept" to coordinate services provided by Health Link providers.
"Our vision for the lifestyle specialist is to serve as a strong pathway, or bridge, between behavioral health and medical health," says Phillip Salzman, director of prevention and community services for HES. "Lifestyle specialists will plug gaps between the health providers delivering medical care and the behavioral health clinician at the other end of the street, so that there’s an integrated continuity of services. The lifestyle specialists will also help prevent many behavioral health problems by careful needs assessment and proactive intervention of potential psychosocial problems."
The position of lifestyle specialist was not yet fully implemented at press time, but months of careful development have gone into the lifestyle specialist concept. Here’s how Salzman explains this integrated case management model:
• The first function of the lifestyle specialist is to conduct a health risk assessment for each member which focuses on health practices which relate to both physical and behavioral health risk. Issues covered on the assessment will include diet, exercise, stress level, sleep, incidence of episodic trauma, smoking, substance abuse, and home environment. For example, one environmental issue included in the assessment is whether the member has someone with a chronic illness living in their home. "We know that caring for someone with chronic illness causes stress that members often don’t realize can impact their mental and physical health," notes Salzman.
• Lifestyle specialists will use information from health assessments to develop both individual and group intervention and prevention programs. For example, a recent survey of members found a high incidence of rheumatoid arthritis in one area, notes Joan Kwiatkowski, LISCW, director of social work and community programs at Beverly Hospital in Beverly, MA, a Northeast Health System’s facility. Kwiatkowski directs a Senior Wellness program which will be the first HES program to use lifestyle specialists. "We worked with a local rehab facility to design aquatic exercise classes and targeted individuals with arthritis to participate in the program," she adds. (See story, p. 18, to learn how HES plans to fund the new position.)
An ounce of prevention
Prevention is the key to reducing costs, stresses Salzman. "At all levels, we want to identify potential problems before they lead to serious medical or behavioral health problems and intervene with lifestyle change programs," he notes. Salzman stresses that all the activities of the lifestyle specialist will be data-driven. Individual member data will be collected and necessary interventions made, but also, aggregate data on group practices will be used to develop targeted interventions for specific populations, he explains. "For example, if the data show that in one group practice there were 10 preventable falls by members over age 65 in the bathroom environment, then the lifestyle specialist would embark on a prevention campaign to modify the bathroom environment with handrails and then educate members on their use," Salzman explains.
The whole system relies on both individuals and communities taking an informed, responsible role in managing their own health, notes Salzman. "Members must internalize health information to personally change their environment and behavior in a way that promotes medical and behavioral health," he says. "Under a capitated, managed care system, the only effective way to truly reduce overall costs is to lower the need for them by spending time and money improving the well-being of members," says Salzman.
Northeast Health Systems is literally banking on wellness and prevention services reducing overall health costs. It budgeted $200,000 to support a range of ongoing community-based prevention programs in its first year alone. "The network choose to link up with local community services hard hit by declining government support," says Salzman. "The community programs were successful in achieving their goals and filling community service needs but lacked the capital to continue to run independently."
The health system saw linking up with community programs as a unique opportunity to provide cost-effective care under a managed care system that had little time or money to focus on a patient’s total well-being. "Physicians would recognize risk factors such as stress or depression, that were endangering a member’s health, but the managed care model didn’t allow for these conditions to receive attention until an injury occurred or a situation worsened to the point where intervention became a medical necessity," notes Salzman. "At that point, intervention becomes more expensive, more difficult, more time-consuming, and even less effective than preventing the illness or injury would have been," he adds.
Northeast Health Systems hopes that by supplying existing community programs with its health expertise, financial, and administrative support, the community agencies can continue to provide system members with established wellness and prevention programs well-suited to be cost-effective because they already reached members in their daily lives, explains Salzman. The lifestyle specialist will be a necessary link between members, medical providers, behavioral health providers, and community programs.
The next step is to measure the effectiveness of this integrated wellness approach to preventing high cost injury or illness, he adds. In the coming year, Salzman says Northeast Health Systems will be collecting the data necessary to answer the following questions:
• What significant improvements in wellness result from the integrated community-based system?
• How has the health status of the systems service region changed?
• What ways has the community benefited?
• Have individual members altered their behaviors?
• Is the value to the health system worth the cost of sustaining the integrated delivery model?
"We really believe that health systems must look at the whole community and pioneer new forms of community partnerships that promote positive behavior changes," concludes Salzman.
[See: Salzman P. Integrating community services for prevention: Northeast Health system may be taking the ultimate money saving measure. Behavioral Health Management, July/August 1996: 9-13.]
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