Behavioral care management in sync with outcomes models


Financial incentives will be linked to comprehensive care which includes the mind and body

Most healthcare executives agree that the task of finding greater efficiencies, improving patient outcomes, cutting costs and addressing other aspects of healthcare reform requires a firm dedication to embracing innovation, advanced technologies and emergent best practices. While the quest for the “new” is an obvious part of the equation, executives must also be careful to keep the “old” practices in their arsenal.

Such is the case with care management, also known as system navigation and care coordination. When done well, care management helps patients access health resources, adhere to care plans, avoid hospital readmissions and enjoy better health outcomes.

While care management methodologies vary across industries, most are oriented toward traditional healthcare, with little thought given to duality: The mind being as important as the body. Care management’s focus on addressing physical health, unfortunately, often separates the mind from the body.

Yet, it is no secret that the most expensive and frequent utilizers of the healthcare system are people with chronic illnesses such as diabetes, heart disease and cancer. They are, studies show, highly likely to develop mental health issues such as depression and other behavioral conditions.

In the post-reform industry landscape, when financial incentives are linked to positive  health outcomes, behavioral care management  will become essential for both improvement in patients’ health and the financial success of the health system.

As employers participate in a reformed healthcare system, their challenge will be to provide a quality health benefit to their employees that will be affordable to the company. For many, behavioral care management can be the glue that pulls together a variety of healthcare and related services so they work for the benefit of both the employee and the employer. The model, cultivated for decades by behavioral health organizations, melds together traditional case management concepts with a clear comprehension of behavioral science.

What sets behavioral care management apart from traditional case management is its grasp of the key drivers of human behaviors-the motivations, the internal conflicts, the fears, aspirations and other mechanisms at the root of human decisions and actions. Though this model has flourished among behavioral health providers, there is additional potential for them to be applied to a broader health consumer population.

Just how important is the mental health of a patient in relation to his/her physical health? Consumers react to a medical diagnosis in vastly different ways. Work, family and other stressors vary from person to person. Their individual responses to treatment, medication and therapy of course are unpredictable too.

When an already vulnerable patient  must deal with  disparate systems of care-mental health, medication management, primary care, health insurance, medical bureaucracies, to name a few-the result is often heightened increased levels of stress and anxiety. Often, compliance with physician orders suffers greatly.

Experts from the nation’s Substance Abuse Mental Health Services Administration (SAMHSA) report that many people with such chronic medical conditions as diabetes, cancer, cardiovascular disease and respiratory disease also have untreated mental illnesses or substance abuse disorders. Even those who do not have persistent mental health issues are at risk. According to a study conducted by WebMD, people with chronic health conditions face a 25% to 33% higher risk of depression.

In 2009, PricewaterhouseCoopers’ Health Research Institute reported that approximately $25 billion is wasted annually in the United States on avoidable hospital readmissions. Depression, anxiety and emotional disturbances contribute to unhealthy lifestyle choices and disruptions in patients following their care plans. Overall, the links between mental and physical wellness present a credible case for better integrating care and directing behavioral care management models to the effort.

So, what should executives expect as they contemplate a shift toward behavior-based care management models? Are these models even right for their industry or healthcare patients? While the issues are complex and do require extensive evaluation, the recommendations below address some of the high priority issues executives should consider.  

1 Your Customers

A thorough and perhaps deeper analysis of your patient population will enable you to better understand their holistic needs.  To determine whether you need to adopt or integrate behavioral care management models, this comprehensive assessment of the existing-and emergent-populations should prove useful in identifying the type of expertise required to meet patient needs.

Behavioral health surveys, data analysis, type of diagnoses supported, the breadth of healthcare services utilized, care plan adherence rates and other behavioral health data should yield valuable information. You should also evaluate and assess your current care management program to ensure that behavioral health is an integral strategic component rather than a secondary tactical facet. 

2 Infrastructure

Evolved care management systems will bear little benefit if your organizational infrastructure and corporate culture remain largely unchanged. It will not be enough to simply add new behavioral health personnel to your care management team without larger changes elsewhere within the organization. Culturally, your company must embrace significant changes to organizational communication practices, information sharing and reporting, as well as business, technology and operational processes to achieve a supported care management program.

3 Team Recruitment

Typical care management teams consist of one or more registered nurses, social workers and case managers. While behavioral health training for some of your care management professionals presents a clear benefit to you and your patients or members, a more strategic approach is (after assessing team strengths and weaknesses) to identify and add personnel fluent in mental health, chemical dependency and psychiatric best practices.  To ensure that your behavioral care management team is truly optimal, personnel should possess strong leadership and communication skills, have experience with co-occurring and co-morbid conditions and have a proven track record working on cross-disciplinary teams.

It is not enough to have skilled staff trained in a medical model who is able to translate the medical orders.  The team truly needs to be able to understand the personal, familial, societal, and cultural barriers that have stood in the way of success and be able to help the individual identify their own path to health.  This path must be realistic, supported, and sustainable.

4 Optimal Skill Sets

The Patient Protection and Affordable Care Act’s mental health parity provision does not just mean serving more people with mental illness. It also means that healthcare professionals must be better equipped to handle a broader and more varied number of diagnoses. It will be a challenging new world and care management teams should, collectively, possess some of the following skills and traits:

  • Familiarity and training based on the Diagnostic and Statistical Manual of mental disorders;

  • Cultural competency;

  • Experience using evidence based practices such as cognitive behavioral therapy and motivational interviewing;

  • Chemical dependency training/certification;

  • Knowledge of and experience working with regional and federal disability systems and insurance plans; and

  • Knowledge of local resources for basic needs and in-home support.

Nimble care management teams more efficiently deliver appropriate care to your patients, so cross-training them ensures greater flexibility and increased cost-effective use of existing team members.

Healthcare navigation that holds fast to the old, antiquated rules is likely to fail spectacularly in the dynamic future that awaits. It is increasingly recognized that effective care management benefits patients and improves the health delivery system, reins in runaway costs, reduces expensive hospital readmissions, better optimizes care plans and produces consistently better health outcomes. With healthcare reform and its mental health parity provision, we can expect behavioral health issues to become the new normal in everyday healthcare scenarios.

Without adequately addressing the powerful emotional and mental wellness of the more vulnerable healthcare consumers, care management and healthcare navigation programs are missing critical opportunities. Billions of dollars alone are lost each year due to unnecessary hospital readmissions. The chronically ill, whose physical symptoms have been the healthcare system’s historical focus and whose care has brought the greatest cost, often experience short- and long-term emotional difficulties that change behaviors, disrupt care plans and worsen overall health.

Because of the strong links between a patient’s mental and physical health, behavioral care management programs hold the key to treating the patient or member, in totus, and potentially optimize care quality, improve patient outcomes and bring efficiencies to the healthcare industry.


David Stone, Ph. D., CEO, Trish Blanchard, chief clinical officer, and Katrina Egner, director of Sound Response, are with Sound Mental Health, a behavioral health services provider.


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