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CREW v. U.S. Department of the Army: Regarding PTSD Diagnoses: 5/24/2011 - Release Part 5

CREW v. U.S. Department of the Army: Regarding PTSD Diagnoses: 5/24/2011 - Release Part 5

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Published by CREW
On April 17, 2009 Citizens for Responsibility and Ethics in Washington (CREW) filed a Freedom of Information Act (FOIA) request with the Department of the Army, seeking records related to guidance given to army staff and contractors regarding the diagnosis of post traumatic stress disorder (PTSD). CREW seeks these records to raise public awareness about the process behind the diagnosis of PTSD and the pressure being placed on doctors to diagnose related anxiety disorders as a cost-cutting measure. The request was filed after Salon.com obtained a June 2008 taped conversation between an Army staff sergeant and an Army psychologist, in which the psychologist revealed he had been pressured not to diagnose PTSD. On July 31, 2009, CREW filed a lawsuit against the Army, CREW v. Dep't of the Army, challenging the Army's failure to produce records in response to CREW's FOIA request seeking documentation of Army guidance that discourages diagnoses of post traumatic stress disorder (PTSD). The Veterans Affairs has issued similar guidance that CREW also is seeking to document through a FOIA request that is also the subject of pending litigation.
On April 17, 2009 Citizens for Responsibility and Ethics in Washington (CREW) filed a Freedom of Information Act (FOIA) request with the Department of the Army, seeking records related to guidance given to army staff and contractors regarding the diagnosis of post traumatic stress disorder (PTSD). CREW seeks these records to raise public awareness about the process behind the diagnosis of PTSD and the pressure being placed on doctors to diagnose related anxiety disorders as a cost-cutting measure. The request was filed after Salon.com obtained a June 2008 taped conversation between an Army staff sergeant and an Army psychologist, in which the psychologist revealed he had been pressured not to diagnose PTSD. On July 31, 2009, CREW filed a lawsuit against the Army, CREW v. Dep't of the Army, challenging the Army's failure to produce records in response to CREW's FOIA request seeking documentation of Army guidance that discourages diagnoses of post traumatic stress disorder (PTSD). The Veterans Affairs has issued similar guidance that CREW also is seeking to document through a FOIA request that is also the subject of pending litigation.

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Using PCL Results to Help Determine Treatment Selection

The following table provides a guide for provisional diagnosis of PTSD which may be used by PCPs.
This table is presented for reference only and should never be used by CMs to advise patients of severity
ofPTSD.
PCL PCL Provisional Treatment
Symptoms &Impairment Severity Diagnosis Recommendations
< 6 symptoms at moderate or
Sub-threshold or no
- Reassurance and/or
greater severity, but < 28
PTSD
supportive counseling
functional impairment - Education
~ 6 symptoms at moderate or
PTSD,
- SSRI
greater severity
~ 2 8
Mild
- If no improvement after

~ 1 intrusion symptom 12 weeks, refer for

~ 3 avoidance symptoms Cognitive Behavioral

~ 2 arousal symptom
> 50
PTSD, Therapy
plus functional impairment Moderate to Severe - Specialty referral *
"Refer for co-management with mental health specialty clinician ifpatient is:
• High suicide risk
• Has substance abuse
• Has complex psychosocial needs and/or
• Other active mental disorders (except depression)
Page 29 of 62
SECTION V: SUICIDALITY
Suicidal thoughts are one of the symptoms of depression and may also be present in those with PTSD.
Approximately 10% of people with major depression eventually commit suicide. Suicidality may not be
an emergent (crisis) or urgent symptom, but it is always serious.
There is no good way to predict in the short term who will commit suicide, although long-term risk is
correlated with the following risk factors:
• Hopelessness
• Prior suicide attempts
• Living alone
• Psychotic symptoms
• Substance abuse
• Male gender
• Caucasian race
• General medical illnesses
• Family history of substance abuse
Levels ofSuicide Risk
Emergent Risk Level:
If the patient has an active desire to commit suicide and has no selfcontrol or external supports (e.g.,
family and friends) for safety, then a safe means for transport to the nearest emergency room setting
should be found.
Urgent Risk Level:
If a patient has suicidal plans but is without an active desire to commit suicide. This is an urgent
situation and could become an emergent one. The patient should receive a behavioral health
assessment within 48 hours from a behavioral health specialist and/or their PCP. Take steps to ensure
that an assessment will occur. Do NOT leave it up to the patient to arrange this!
Low Risk Level:
If the patient has no suicidal plans and no active desire to commit suicide, slhe would be considered a
low risk. Further assessment is not necessary at the time. The CM should continue to monitor any
changes in this status with every contact and report any changes that indicate increased risk to the
PCP or emergency staff according to steps above.
Components ofan Evaluation for Suicidal Risk
• Presence of suicidal ideation including intent and/or plan
• Access to means for suicide and the lethality of those means
• History and seriousness of previous attempts
• Lack of social support
CMs must be prepared to respond to a suicidal patient on the other end of a phone line at any time. CMs
should discuss (talk through) options for emergent events in advance with supervisors and/or clinic
administration to develop a response plan if the CM is faced with an emergent and/or urgent patient
suicidal risk situation.
As a care manager, NEVER be unprepared!
Know how to contact emergency response teams (911) without disconnecting from the patient.
(Use an extra phone line or cell phone and/or access other staffin immediate area to call 911.)
Know your patient as best you can - get them to contract with YOU for safety. Practice in advance.
Do NOT wait until you are on the line with a patient in distress.
Page 30 of62
Need to add and discuss means ofcontractingfor safety here.
Assessing Suicide Risk
The PHQ-9 and a modified version of the PCL in use in our program can be used as a tool to begin to
evaluate suicidal ideation. Specifically, Question 9 on the PHQ-9 and Question 19 on the PCL, asks
patients ... "In the last two weeks, how often have you had thoughts you would be better offdead or of
hurtingyourselfin some way. JJ
Any positive response to Question 9 or 19 - anything more than "not at all" - warrants a determination as
to whether there are "passive suicidal thoughts" (i.e., " ...thoughts you would be better offdead...")
OR
whether there are any "active suicidal thoughts" (i.e., "thoughts ofhurtingyourselfin some way").
There is no way to tell the difference between active and passive suicidal thinking without further
questioning the patient.
The following section provides an easy-to-use strategy to distinguish between passive and active
thoughts of death. Of course, this is only necessary to use for that small percentage of patients who
indicate a positive response to the questions indicated italics above. CMs must know that some patients
who do not originally reveal any active suicidal thoughts may "convert" to the demonstration of active
suicidal thinking. CMs may need to conduct more than one suicide risk assessment on any given patient.
ALL RISK ASSESSMENTS MUST BE DISCUSSED WITH THE SYPERVISING
PSYCHIATRIST - AT THE LATEST DURING THE NEXT SUPERVISION CALL.
(Make contact earlier when in doubt.)
Page 31 of62
CARE MANAGERSllICIDE RISKASSESSMENI FORM
RecordStatements in Detail- RefertoGuidance Notes
Patient Name: ---=-=-=.,.....-- .....lClinid.an: _.....".,, ----.JPt.ID#: _
Date andTime ofeall: Care Manager Name: _
1. "In thep a s ~ ma.nth, hali'f1 J'OI1 made anyplansor considereda method thatyou mightusetoharm
}'ourse!f7' (cirele one)
. TIS 00
(If yes, ask, "Please be specific abouttheseplansor methods you haw cc»tridered.")
2. "Haveyoueverattempted to harm.VOllTself!" (eircle one)
'YES
(If yes, ask, "When was this? J'fhathappened?'')
NO
3. "Theres a bigdiffmmce between haVing a thought andactingana thought. Doyouthink}'Ou mightactually
makeanattempt to hUrl.vourselfin thenearjUture?" (ende one)
'YES NO
(If yes, ask, "Can.vou be spectfic abouthowyoumightdo this?'')
4. "In the~ t month hav«youtoldanyone thatj'ouWeJ1l goingto commit ,suicide, or threatened thatyoumight
doit? •(circle one)
X'ES NO
(If yes, ask, "Who haw1you toldcmd whathave yousaidto tllem?')
5. "Doyouthinkthere is anyriskthatyou mighthurtyourselfbefore youseeyourdoctor the nexttime?"
x'ES NO
(If yes, ask, "Whatdoyou thinkyoumight do?")
ActionTabn: to Contact Clinician (Indicate "None" ifpt. determinedat "LowRisk') _
Page 32 of62
Guidance Notes Regarding Response to Risk Levels
These guidance notes are intended to facilitate the gathering of appropriate information/detail during the
conversation and assessment with the patient. That information/detail would then be shared with the PCP
and/or supervising psychiatrist. This should not be considered a basis for decision making by the CM;
however, they would guide the action plan to be taken as outlined in the various scenarios below.
Positive ("YES") Response to Question 5: "Active suicide thoughts: ACUTERISK"
1. If patient's response is "YES" to question 5, the patient will be considered
"EMERGENT /HIGH SUICIDE RISK".
2. The CM must contact the patient's PCP (or the covering/on-call PCP) immediately to expedite a
clinical evaluation. (If there is on-site mental health, this will serve as a primary alternative to
PCP assessment. The PCP must still be contacted)
3. If the patient presents an obvious acute risk, stay on the phone with the patient, call 911, and/or
initiate best actions to ensure that the patient goes immediately to an emergency room.
4. If there is another adult with the patient, then attempt to speak with that person and get assurances
that s/he will accompany the patient to an emergency room OR that s/he will dial 911 if they do
not have ability or means to transport.
5. Inform the patient's PCP (or on-call PCP) immediately by telephone or direct contact.
6. If the PCP or on-call PCP is not readily available, then the CM should next attempt to reach the
supervising psychiatrist (or the covering/on-call psychiatrist/mental health specialist).
Positive ("YES") Response to Questions 1-4: "Active suicidal thoughts: MODERATE TO HIGHRISK"
1. If the patient has any positive answer ("YES") to questions 1-4, the patient will be considered
"URGENT / MODERATE TO HIGH RISK".
2. This information must be communicated to the patient's PCP (or the covering/on-call PCP)
immediately via telephone or direct contact.
3. Patients at this level of risk should be assessed by a qualified mental health specialist within 48
hours.
4. If the PCP or on-call PCP is not readily available, then the CM should next attempt to reach the
supervising psychiatrist (or the covering/on-call psychiatrist/mental health specialist).
Negative ("NO") responses to Questions 1-4: "Active suicidal thoughts: LOWRISK"
1. If the patient answers "NO" to questions 1-5, the patient will be considered a
"LOW SUICIDE RISK". This information should be communicated to the PCP via usual CM
reporting mechanisms.
Adapted/rom Cole S, 'Care Manager Suicide Assessment Form', developed/or the Collaborative on Depression in Primary
Care, Bureau 0/Primary Healthcare, unpublished document. (DO WENEED TO INCLUDE HERE?)
Page 33 of62
SECTION VI: CONTINUATION AND MAINTENANCE
Risk ofRelapse - DEPRESSION
Figure V-A above identifies the definition of treatment outcomes during the long-term treatment of
depression. The goal of the acute phase of treatment is to achieve full symptom remission defmed as a
PHQ-9 score of < 5 points. The outcomes are similar for PTSD with remission defined as a PCL score of
< 24 points.
The risk of relapse during the first six months after achieving remission from depression is as high as
50%. Over a person's life time the risk of recurrent episodes of depression is even higher, averaging 60-
75%. The goal of continuation phase treatment is to keep patients in remission. Continuation of
antidepressants for 4 to 9 months after achieving remission considerably reduces risk for relapse.
Some patients with recurrent episodes of depression are at significantly higher risk for future episodes of
depression. The goal of maintenance phase treatment is to identify these patients and keep such patients
on active treatment. Many depressed patients decide on their own to discontinue to take prescribed
antidepressants after remission begins. Even fewer patients with a high risk of recurrent episodes receive
maintenance treatment. These characteristics of depression treatment make it similar to other chronic
diseases like asthma or diabetes which require a chronic disease approach, not just an acute disease
approach.
Continuation
All patients with depression and/or PTSD who enter remission should receive education to recognize
signs of relapse early on and to request an appointment with their PCP or behavioral health clinician as
soon as possible.
Medications
Patients who successfully achieve remission on medication during the acute phase should take the
same dose of that medication for 4 to 9 months once remission occurs and then taper off the medication
over several weeks under the direction oftheir PCP. Many patients do not refill antidepressant
prescriptions during the continuation and maintenance phases. The absence of symptoms often will give
the patient a sense that the disorder is "cured" so there is no need for further treatment. As with many
illnesses, the new absence of symptoms does not mean the problem is completely resolved. Therefore,
the CM plays an important role in ongoing monitoring and promoting adherence to long term treatment
plans.
Psychological Counseling
A decision to use psychological counseling during continuation depends on the symptoms,
psychosocial problems, and recommendation of the behavioral health specialist.
Care Manager Role
Regardless of the selection of continuation drug therapy or psychological counseling or
discontinuation of treatment, the CM plays a pivotal role by monitoring remission by assessing PHQ-
9 and/or PCL response at a minimum ofat least one call during the continuation phase.
During the continuation phase, the CM also assesses risk factors (see Table V-I below and the
Maintenance Questionnaire on page 36) for recurrence to assist the supervising psychiatrist and PCP
in recommending whether or not to continue treatment into a maintenance phase. At the end of the
continuation phase, patients who sustain their remission are considered to have achieved recovery
Page 34 of62
(see Figure V-A). Those without risk factors should generally discontinue antidepressants, again with
the advice of their PCP.
Table V-I
FACTORS FOR RISK OF HIGH RECURRENT DEPRESSIVE EPISODE
1. Dysthymia (chronic depression)
2. History of two or more previous episodes of depression
3. History of recurrence of depressive episode within one year
4. History of one other episode within three years and that the current episode was sudden and life
threatening
Chronic Depression (Dysthymia)
What is Chronic Depression?
The essential feature of dysthymia (or dysthymic disorder in DSM-IV) is a chronically depressed mood
that occurs for most ofthe day more days than notfor at least two years. The mood may be one of
irritability rather than depression. In addition, a minimum of two other symptoms must be present such as
poor appetite, overeating, insomnia, hypersomnia, low energy, fatigue, low self-esteem, poor
concentration, and/or difficulty making decisions.
Chronic depression can present in several different ways. In one mode, it begins in adolescence or young
adulthood and is frequently more likely a long-term personality style than an affective disorder. A
second type is associated with major depression. Dysthymia can follow an episode of major depression
and subsequently co-occur with recurrent episodes of major depression. A third mode occurs following
chronic medical disease and/or bereavement, particularly in older persons. In each case, the duration of
the pattern is a minimum of two years.
Major depression consists of one or more discrete episodes distinct from usual mood and function. In
contrast, dysthymia is chronic, less severe, present for many years, and hard to distinguish from one's
usual function and mood.
Why is a Chronic Depression Diagnosis Important?
Evidence based reviews of antidepressant treatment for dysthymia suggest antidepressants are effective.
Short-term studies suggest some patients with dysthymia respond to placebo, but in the long term this
response is not well maintained. Thus, all patients with dysthymia should generally be advised to have at
least one twelve-month trial of adequate doses of an antidepressant. This is often difficult because of
poor adherence for this length of time.
What Questions Can Help Elicit a Diagnosis ofChronic Depression?
See page 36 for a brief interview guide for DSM-IV dysthymia in the maintenance phase. Interpretation
ofthe answers can be helped by additional questions. A standard question is, "In the past two years have
you felt depressed or sad most days, even if you felt okay sometimes?" Another alternative is, "Have
you been bothered by feeling depressed or low much ofthe time for the past two years? How much of the
time have you felt this way?" In addition, asking when the patient last remembers being really happy is a
useful question that gets more at the concept and is more open ended. Someone with dysthymia since
young adulthood will have difficulty remembering period(s) of being really happy of more than a couple
of months. Such persons often see everything in shades of gray and can convey such an outlook
whenever you are with them.
Page 35 of62
Asking about any episodes of past, more severe, depression (or other psychiatric disorders requiring
treatment) and the relationship of these episodes to the onset of a chronic period of low mood or
anhedonia is helpful. Sometimes another chronic psychiatric disorder is associated with the onset.
Some persons can clearly remember and convey lengthy periods of feeling happy and do not have any
past history of major depression. Instead they experience one or more difficult or challenging life events
in adulthood that result in a persistent change in confidence and mood.
Each of these three types can have a positive response to antidepressants and warrant at least one
adequate trial, for a year or longer.
When should the Maintenance Questionnaire be administered?
Care Managers should plan to administer the questionnaire AFTER the patient has maintained remission
(score of <5 on the PHQ-9) for at least 2 months. For example, a patient achieves remission at 8 weeks
with a score of 4, but regresses at 12 weeks to a score of7. At the 16 week contact, the score has
improved to 3. The measure of maintained remission would begin again at 16 weeks. PHQ-9 measures
would then be taken at 20 and 24 weeks with the Maintenance Questionnaire completed at 24 weeks
assuming remission was continuously maintained since the 16 week measure.
Maintenance
After assessing risk factors for recurrent depression, a decision is made whether or not to continue
prophylactic maintenance treatment for at risk patients.
For those continuing in maintenance with prophylactic treatment, education of the patient regarding early
signs of recurrent depression should be completed. It is important to help them try to remember how their
depression first appeared so they can identify recurrence as early as possible. Periodic PHQ- assessments
should also be completed by the care manager or PCP (i.e., once or twice annually). Figure V-B displays
typical timing for integration of care manager and PCP visits. If at any time depression recurs, the acute
phase schedule of contacts is resumed.
Figure V-B
Page 36 of 62
MAINTENANCE QUESTIONNAIRE
FORMTOBE COMPLETED WITHTHEPATIENTWHEN
REMISSIONHASBEENMAINTAINED FORTWOMONTHS
RESULTS TOBEDISCUSSEDDURINGSUPERVISION.
Pt. Name: --:Date Administered: _
Date Remission Achieved: Current PHQ-9: _
How many times have you had depressive episodes like this current one in your life? _
When was the last episode prior to this current one?
Dysthymia
(FOUR ANSWERS INBOLD* MUST ALL BECIRCLED TO MAKE ADIAGNOSIS OF DYSTHYMIA.)
1. Have you felt sad, low or depressed most of the time for the last two years?
NO If No, done YES*- continue
2. Was this period interrupted by your feeling OK for two months or more? NO* YES
3. During this period of feeling depressed most of the time:
a. Did your appetite change significantly? NO YES
b. Did you have trouble sleeping or sleep excessively? NO YES
c. Did you feel tired or without energy? NO YES
d. Did you lose your self-confidence? NO YES
e. Did you have trouble concentrating or making decisions? NO YES
f. Did you feel hopeless? NO YES
ARE TWOORMORE 3ATO3F ANSWERS CODED YES? NO YES*
4. Did the symptoms of depression cause you significant distress or impair NO YES*
your ability to function at work, socially, or in some other important way?
NO YES
*ARE ALL FOUR ANSWERS INBOLDCIRCLED?
IF SO, THEN CIRCLE YES. OTHERWISE, CIRCLE NO. DYSTHYMIA
CURRENT
DATE REVIEWED IN SUPERVISION: _
NOTES & RECOMMENDATIONS: _
Page 37 of62
SECTION VII: IMPLEMENTING THE CARE MANAGEMENT PROCESS
Care Management Patient Calls
Calls to patients are typically initiated 7 to 10 days following the initial office visit where the patient was
diagnosed ("index visit") and referred to care management. Subsequent calls then occur every 4 weeks
until the patient is in remission and less frequently thereafter based on supervision decisions and
individual patient needs. Other calls at more frequent intervals may be warranted and are referred to here
as PRN calls.
New Referral Activities
New referrals are initiated by PCPs through CHCS II / AHLTA to the CM. There is referral
documention of the PHQ-9 and/or PCL symptom/scores, the treatment plan selected, and when the PCP
would like the patient to return for a follow up visit. Effective practice also entails the PCP forwarding
the actual completed PHQ-9 and/or PCL to the CM for detailed references for patient contact. If the CM
is contracted and located off post, then there may be a need for a consent form which will be developed
specific to the clinic/post. That consent along with the PHQ-9 and/or PCL should be delivered to the CM
(often occurring through FAX).
As noted earlier a review by the CM of PHQ-9 and PCL forms is important to verify accuracy of
symptom count and scoring. If the forms are incorrectly scored, the CM should provide appropriate
feedback to the PCP (phone call, face-to-face, or electronic CM report in CHCS II / AHLTA). The
method of feedback will be determined by the CM based on working relationship status with the PCP.
Record Keeping Set-Up
An identifying code number should be assigned for each new patient referred. Files should be created for
each patient and labeled with the code number. These individual files will be used to store CM specific
anecdotal notes and documents relating to that patient. The code numbering system is important for
referencing patients during supervision calls when specific patient identity is not used in order to protect
confidentiality. All files and patient records will be maintained in a secure manner in accordance with
the clinic/post requirements/guidelines for PHI and that complies with all local, state and federal
regulations regarding patient health care and treatment.
Progress Notes & Communication
Generally two types of documentation and/or forms support the RESPECT-MIL process; namely, the
Care Manager Log and the Care Manager Report. Most Care Manager Reports will be T-Cons, however
a hardcopy form is available for any sites that do not have CHCS II / AHLTA access. Care Manager
Logs are used to both guide the call during early phases of treatment and to record anecdotal notes during
each patient contact. The logs also serve as a source of data which specific sites may decide to monitor,
for example, time length of calls or number of failed call attempts. The Care Manager Report serves to
provide routine and summary information communication to the PCP following each routine contact,
PRN calls with significant information obtained, and/or after weekly supervision where there is
information to communicate from the supervising psychiatrist.
Page 38 of62
PROCESS FOR REFERRAL TO BESPECT-MIL
CABE MANAGEMENT
Soldier completes reports for primary care visit and
RESPECT-Mil screening forms
PCC reviews screening and evaluates Soldier
> - - - - - - - - - N O - - - - - - ~ ~ ~ ~ DONE ~
Does Soldier have a
diagnosis of depression
and/or PTSD?
PCC discusses diagnosis and treatments options (including
care management) with Soldier and elicits preferences
Soldier declines
care management
option
PCC handles all
monitoring
Soldier wants
care management

PCC makes referral to CM via CHCS II/ AHlTA
regarding diagnosis and treatment plan
~
II
PCC forwards copies of PHQ-9 and/or PCl to CM
II
Page 39 of62
MAKING T.HI; INITIAL
CAREMANAGI;MENTCALL
CM receives referral and completed PHQ-9 and/or
PCl forms
Are forms scored
NO
accurately?
CM makes Initial CM call 7 to 10 days from referral
(diagnosis).
~
CM introduces self, relationship to PCC and
describes process of care management
(what s/he can expect from the CM).
~
CM reviews exact details of treatment wan
(as they apply to each case):
- what was prescribed for Rx (if any)
- has Rx been filled and begun
any side effects
- has Soldier gone for counseling
- did Solder receive educational
information
- has Soldier reviewed educational
information
- did PCC help Soldier set self-
management goal(s)
- is Soldier acting on self-management
goal(s)
~
CM encourages adherence to treatment
plan by supporting actions taken and
assisting with problem solving barriers
. ~
CM schedules next call 4 weeks from date
of referral/diagnosis and reminds Soldier
that the PCC will receive a brief update
regarding progress
~
Care Management Report (T-Con) sent to
PCC briefly stating progress/treatment plan
adherence level
Advise PCC of corrected
scores for medical record
Page 40 of62
4 WEEK CARE
(Scoring CalIsl
CM makes call at week 4,8,12, 16, etc.
CM reviews exact details of treatment Wan
(as they apply to each case);
- confirm what prescribed Rx is being taken
(if any)
- review for any side effects
- has Soldier gone for counseling
- has Soldier reviewed educational
information
- how is Soldier doing with self-management
goal(s)
- assist with adjusting self-management
goals if set too high or no progress
CM encourages adherence to treatment
plan by supporting actions taken and
assisting with problem solving barriers
CM re-administers PHQ-9 and/or PCl as
appropriate to diagnosis; calculates
score(s); and offers general feedback on
progress.
CM inquires if there are eventsl
circumstances that could be
influencing scores.
NO
>----NOor INCREASE
YES
CM schedules next call 4 weeks later and
reminds Soldier that the PCC will receive a
brief update regarding progress
YES
Care Management Report (T-Con) sent to
PCC briefly stating progress/treatment plan
adherence level
CM sets time to call in next 1-
2 weeks for PRN
Page 41 of62
SECTION VIII: PLANNING CARE MANAGEMENT CONTACTS & CONDUCTING CALLS
There are a number of useful principles for CMs who are engaged in telephonic management of
chronically ill patients. The principles listed here will help with efficiency and workload over time.
• Maintain a balance between efficiency (staying on task with completion of the CM Log) and
focusing on the needs of the patient.
• Acknowledge the patient's issues and concerns, yet focus on the patient driving solutions rather
than extensive discussion of the details and giving direct instruction.
• Encourage that the patient define his/her own clear and attainable self-management goals.
• Offer appropriate assistance with scheduling appointments; connecting with mental health
specialists; setting self-management goals; and problem solving to overcome barriers to
treatment.
CMs are not the patient's mental health specialist or counselor and must be on guard not to slip into that
role during the course of calls. Calls should take approximately 20 minutes unless there are unique
circumstances during the call. If calls are running well over 20 minutes and the patient is not in crisis,
then there a need to better define boundaries for future calls/discussions. This is often a sign that the
patient would benefit from mental health counseling and a referral should be initiated (may require PCP
involvement). CMs that engage routinely in calls of30 minutes or more are likely providing "therapy",
counseling, etc. and should evaluate how to focus calls on immediate issues of adhering to the treatment
plan only.
Nonresponsive/Elusive Patients
CMs should have an understanding with the organization/practicelPCPs and the supervising psychiatrist
regarding the maximum number of failed call attempts they will make before referring the patient back to
the PCP for follow-up. CMs should attempt contacting the patient at varying days and hours (including
early evening) through the week. There should also be a very clear limit on number of messages left
with individuals for the patient or via voicemail. Too many messages can easily be viewed as harassing.
It is better to set a limit and then attempt to make contact in writing to determine if the patient is
passively attempting to withdraw from care management.
Notations should be made on the Care Manager Log for each failed attempt to reach the patient.
Information to be included is the date, time, and outcome of the call (i.e., left message, talked to spouse,
etc.). A typical protocol is to make four attempts to reach the patient, leaving messages at each call unless
the patient has requested otherwise, and then advising the PCP through a Care Manager Report (T-Con)
of inability to reach the patient. There should also be advice to the PCP regarding the CM's plan to
either continue attempting contact (e.g., sending a letter to patient requesting s/he call CM directly) or to
suspend efforts pending PCP action (e.g., scheduling an office visit). It is then the responsibility of the
PCP to contact the patient and notify the CM if and when to attempt to reach the patient again.
A friendly inquiry letter (see Appendix A - need to redraft) to the patient is appropriate prior to
"disenrolling" the patient in care management. The letter should offer the patient the option to continue
with care management and to verify the best phone number and times of day/week when they can be
reached. The letter should also offer the patient the option to decline further contact. CMs should
include a prepaid self-addressed return envelope so the patient will have less to do in order to respond.
If the patient does not return the letter in the time allowed (again agree on this with the clinic and key
parties - 2 weeks is usually a reasonable interval) or indicates they no longer wish to be contacted, then
the CM should notify the PCP immediately so that they are aware their patient no longer has CM support.
Page 42 of62
CMs should forward copies to PCPs of all letters from patients that have clear responses indicating their
desire to withdraw from care management.
Preparation for the Call
The CM's file on the patient should be carefully reviewed prior to each call to ensure familiarity with
accurate patient information (i.e., medications currently prescribed; schedule of office and/or counseling
visits; established self-management goals; and any questions requiring follow-up). Where appropriate,
the CM should transfer information from the file onto a Care Manager Log prior to the call.
The more familiar the CM is with the patient's particular information is beforehand, the less likely it will
appear a checklist is being filled out and the CM's interest in the patient's status is being reflected
throughout the call. A hardcopy Care Manager Face Sheet for patient files is available for organization
of overall CM information for each individual patient. The form offers "at-a-glance" access to key
information regarding progress, contact history and treatment change history. This form may not be
useful when the CM is very familiar with and has ready access to CHCS II / AHLTA. See Appendix A
for form samples.
Placing the Call
CMs should initially introduce themselves by indicating that s/he is working with Dr, NP or PA "X" and
inquire ifpatient recalls being informed of the care management service. An introduction might go
something like this;
"Hello, this is (your name) andI work with Dr. Smith. Is this (patient's name)? DidI catch you at good
time when you have afew minutes andsome privacy? As you may remember, Dr. Smith toldyou that I
would be calling tofollow up after your visit with him/her. Do you recall this? ..... "
CMs must be prepared to field questions about such topics as medication side effects, what depression
and/or PTSD treatments have been prescribed (per the referral), and setting or modifying self-
management goals. Inevitably, a patient will ask a question the CM is not prepared to answer or would
more appropriately be answered by their PCP. When and if this occurs and the issue cannot wait,
patients should be advised to call their PCP or to schedule an office visit. If the question is appropriate
for the CM to respond to but the CM needs to obtain more information, s/he should advise the patient
when to expect a call back with the requested information. The CM should note patient
concerns/questions on the CM Log along with the plan of action.
It is recommended CMs use the data sections on the CM Logs as a guide to forming questions while
talking with the patient. Ifbarriers are identified, prompts are outlined in Section VIII, which may be
used to offer assistance or help the patient.
It is important to systematically review the details ofthe patient's treatment plan as prescribed by their
PCP during each call. The initial CHCS II / AHLTA referral should provide a great deal of information
needed to assess adherence during the initial one week call.
Key Care Manager Discussion Points
Medications:
• Verify medication has been obtained (a good tip is to have the patient bring the Rx containers
to the phone and read the information on the label)
• Confirm level of dosage/time of day being taken
• Confirm the date when medication was started
• Inquire about any side effects
Page 43 of62
• Identify any barriers to taking medication as prescribed
• Offer suggestions about how to counteract side effects (see page 13)
In some cases, the PCP will ask the patient to start with a half dose for a week then increase to the
full dose. If this is the case, be sure the patient is complying with this plan. In the cases when this
gradual approach is used, a repeat call one week after the initial call is recommended to be certain the
patient has increased the medicine appropriately and no new side effects have occurred.
When the side effects are difficult for the patient, this information will often be communicated
readily. When the side effects are more subtle, the patient may need prompting/questioning. Patients
may not understand that what they are experiencing is a side effect and/or that it will subside or go
away over time. This is an opportunity for the CM to educate the patient about side effects or to
guide the patient to contact their PCP or pharmacist (they are often able to provide specific
information regarding less common side effects). Side effects that appear abnormal or extreme
should be brought to the PCP's attention by the CM as well as advising the patient to contact the
clinic promptly.
Psychological Counseling:
• Verify name and type of mental health specialist (MD, PhD, MSW, clergy, etc.)
• Inquire whether appointment(s) was been scheduled and/or completed
• Verify the recommended frequency of visits
• Identify any barriers to participating in psychological counseling
Patients may also be involved with support groups (PTSD groups are commonly offered).
• Verify that the patient has been referred, knows the location and schedule of the group, and
that the patient is attending accordingly.
Patient Education:
• Verify what written materials the patient has received
• Verify whether patient has reviewed written materials and set goals if not
• Send/mail appropriate materials or resource listings (books, etc.)
• Discuss key points within the materials
• Provide information in response to patient questions or concerns
Self-management goals:
• Determine if self-management goals were established with PCP
• Assist patient in setting goals if none were set with the PCP and/or different goals are needed
that can more easily be attained
• Assess what progress has been made
• Assess appropriateness of current goals and likelihood of success and/or assist patient to
modify goals ifset too high (simple, small steps to begin with will lead to a stronger sense of
accomplishment and self-management)
Re-administering the PHQ-9 and/or PCL:
• Remind the patient of the formes) s/he completed at the PCP's office
• Administer the PHQ-9 first (skip to PCL if there is no depression diagnosis)
• As a timesaver, run through each questions asking for only a yes or no to whether s/he has
been bother my the symptom noted. THEN return to the ''yes'' items and provide the rating
scale (e.g., not at all, some of the days, most ofthe days, nearly everyday).
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• Quickly calculate the score and give the patient feedback and general information about a
decrease in the score and offer encouragement that slbe is on the right track.
• If there is no change, be supportive and encourage the patient to "hang-in" with the treatment.
This may be a patient that should be called again sooner than 4 weeks to check on progress.
• If there is an increase in score, provide general feedback and ask if there has been anything
different going on since the last scores were obtained that might indicate why they are feeling
worse. This will be very helpful during supervision in making decision whether to bump up
an Rx dose or to stay the course when the increase may be situational.
• If there is any positive endorsement of the suicide question, then complete a risk assessment
immediately as outlined in Section V.
Next Office Appointment:
• Confirm schedule of all follow-up PCP appointments for depression and/or PTSD
• Communicate importance of attending all follow-up visits
• Identify any barriers to attending follow-up visits with PCP
Ending the Call
Patients should always be given a final opportunity to verbalize any concerns regarding their treatment
by asking, "Before we hang up, is there anything at all that you are concerned about regarding your
treatment that you haven't already mentioned? sr
By asking this question directly, the patient is encouraged to voice things that may not have surfaced
earlier in the call. Also, patients should be reminded that a brief summary of the conversation and the
results of the PHQ-9 and/or PCL (ifre-administered during the call) will be sent to their PCP. The next
CM call should be scheduled before hanging up in hopes of decreasing failed contacts for subsequent
calls.
Typical Reasons for Initiating PRNCalls
PRN calls may be required for a number of reasons and are generally initiated based on the CM's own
decision. There are also times, however, when the PCP and/or supervising psychiatrist will request more
frequent calls based on patient status. These calls are often shorter than routine calls as outlined earlier
but are often of great importance for those struggling with treatment. CMs often give one or more ofthe
following as reasons for a PRN call:
• Patient has not begun the full dose of medication; has had a change in dosage; medication has
been changed; or additional medication was added.
• Concern the patient will not continue (or start) their medication due to ambivalence regarding
diagnosis; presence of side effects; concern about addictiveness of medication; etc.
• Patient is having difficulty with or wants to discontinue counseling; needs help getting an
appointment; and/or is seeking alternatives to counseling (clergy, support groups, etc.).
• Lack ofprivacy for the patient or chaotic situation during scheduled call (e.g., children present).
• If a suicide screen was conducted during a CM contact and there is a need to follow up.
Communication and Coordination with the PCP
A summary of each patient contact should be prepared using a Care Manager Report form (T-Con). Only
essential specific details regarding the patient's adherence to the treatment plan should be noted as well
as any specific critical barriers identified. These reports should be sent to the PCP at least by the end of
the working day and prior to known scheduled follow-up office visits for depression.
Page 45 of 62
Matters that appear urgent / emergent should also be conveyed by phone as soon as possible. Electronic
or Faxed reports should still be initiated but should not be considered the sole or primary means of
communication under such circumstances.
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Expectations ofa Care Manager: A Guide for PCPs
What Should a PCP Expect from a CM?
• The CM will call the patient at routine intervals (at 1,4,8, 12, 16, etc. weeks) and administer the
PHQ-9 and/or PCL approximately at monthly intervals.
• At the request of the PCP, the supervising psychiatrist, or at the discretion of the CM him/herself,
more frequent calls may be made.
• A written Care Manager Report will be sent through CHCS II / AHLTA (or Faxed when
electronic connection is not possible) to the PCP after each routine call and after PRN calls as
appropriate (some will not warrant a note).
• The CM will review newly referred patients, patients who are not responding, and problem cases
with the consulting psychiatrist during weekly supervision.
• The CM will communicate those recommendations for treatment made by the supervising
psychiatrist via T-Con, e-mail and/or phone call to the PCP and/or patient as directed by the
supervising psychiatrist (e.g., take an Rx in the AM rather than before bed). The supervising
psychiatrist may call the PCP directly to discuss treatment options.
• The PCP (or hislber covering PCP) will receive a telephone call if there is an emergency
situation, e.g., when a patient is at risk for suicide.
• The CM will provide basic patient education about depression, PTSD, medications, counseling
options, and self-management goal setting.
• The CM will facilitate adherence to all aspects of the prescribed treatment plan and report patient
inability or resistance to implementation to the PCP.
• The CM will identify barriers to implementing the treatment plan and help the patient problem
solve and identify solutions.
• The CM will make at least 4 attempts to locate the patient for initial calls. If, after this "good
faith" effort, the patient cannot be located by phone, a letter will be sent to the patient (copy to
PCP) indicating that if slbe wants to continue care management s/he should contact the CM.
• The CM will provide notification to PCPs ofpatients who are disenrolled from care management,
along with the reasons for disenrollment. Reasons may include patient withdrawal from the care
management process, failure to respond to calls for extended intervals (not due to work
assignment), ETS, etc. Patients relocating within the military to another CONUS post may
continue to be followed by the CM.
• The CM will assist as appropriate getting follow-up or specialty visits scheduled with PCPs,
Division Mental Health, etc. The CM will advise the PCP when slbe is unable to assist.
What Should a Clinician NOT Expect from a Care Manager?
• The CM will NOT review extensive historical, medical or psychosocial information about the
patient in CHCS III AHLTA. If the CM would benefit from some specific information contained
in a medical history, PCP should advise such a review.
• The CM will NOT provide counseling or therapy. If PCP believes the patient would benefit from
psychological counseling, and the patient has chosen not to accept this recommendation, the CM
will attempt to gain agreement from the patient and then facilitate a referral.
• The CM will NOT have in-depth discussions of family difficulties, loss and grief, or other
psychosocial issues. The CM may suggest options for social support services for families.
• The CM will NOT make home visits.
• The CM will NOT speak separately with family members outside the presence of the patient and
only at the patient's request if it is appropriate.
Page 47 of62
Sample Scripts
Initial Week One Call- Barriers to Treatment
Patient Has Not Begun Taking MedJcatlonfor the Following Reason(s):
A. Not comfortq1Jle wit" _r,ssign diaposis
PATIENT MIGHT SAY:
• "I don't ,.enUyfeel tkp,.essed "
• "I don't think that.I amthat dep,.essed .,
• "I amreally just stressed out. "
EXPLORE BYASKING:
"Jfllat doyoll think is gob'8 0111"
INTERVENE BY:
• Explaining to the patientthat their primary care clinician believedtheyare depressed
andthattrealmetlt would be helpftit
• E:q>lore. what is uncomfortable ,aboutthediagnosis(do they knowsomeonewhois
depressed or seriously mentally UJ and perhaps tIUs is ftigbteningto them).
• Explore what theybelieve having"depression" tne\\fl$ anddispel someoftbe myths.
• If a patient continues to be adamantthll1they do Jll)t have depression, acknowledge
their stance and focusmote on what symptot1ls they have.
• F"r exmnp.Je. suggeslthatJhe medication hnvebeenpres.cribed wiIlheJprelieve
their difficulty sleeping.
• If aftert;tllcin&furtherwiththe patient,. youtbink that he ccshe is. retaKingmoreabout
the "diagnosis" - youmight mentitmtbat"depression" is a combination of the various
symptotnsthat they areex.pe.riencing.• difficulty sleeping, feelinghQpeless, etc(areas
they checkedotfQn1fte PHQ-9).
B. Not cgm[tn14ble taJsiDz mtHlicilw
PATIENT MIGIIT SAY:
-t amjtul nOI a lfflYlkalion kU.,d ofpel'J/m. If
EXI'LORE BVASKING:
"WhtJt Jutl'e you had'WiIhnttdicatitm in tneptut?"
INTERVENE BY:
• He;lping the; Plludlt ex:ploresituatioh& whenmcdicatiM ill or hIlS bCellIlCCi:$llllty.
• Helpthem to see lhatmedielltwrtlbr depreuion is nodiff«enl Jhan a medication Iorhigh
bloodpressureordmbeteslor other conditioflll that thoymay ttldltion}.
• Sometimesgivill8 tbe"bil$ analogy" ishelpful. Explaining to·11 patient that theymay
be able to get better without mellieinchowever. it will be a great dew more difficult.
Muchlike a personwhohas Mprained legand has to frompointAtopoint
B. that person oou10 walkbuttakingthebus would be a lot easierlU1d faster. Itt the
bus analogy. thepl:t$()r'l's leghas healed$Ihewitlootneed the busbut .fotthe
sbort-term, person istaking oftb.e that iSll.vldll\b)e. This istruefOf
goingon modicati.on. Medication canbe II. temporaryhelpfor a plltiimt duringdifficult
times. Eventually. people developthe skills to not need the mediCIl11tmWlyntQre.
Page 48 of62
• Also, it is helpful to mention here that some patients even find that they feel 80 much
better on the medicine that they choose to remain on it indefinitely.
• Gently remind themthat their problems and concerns have not gone away on their own
and usually do not go away spontaneously for most people.
C Worried about the "sUtpnll' ofmgdicqtion (or "mental healthII
PATIENT MIGHT SAY:
• i'l don': want to be on a depression medication. "
• "I wouldn't "''4111 to knowthat I was on a medicationfor depression. "
EXP.LORE BYASKlNG:
• "Whali$ jiOHl'conceJ'n tWoUt be;"g On (l medicotionfor tkpff!$sion(they mIU' knmv
someOne wllO dfiWIs)?"
• Or tbeymay be cOllcemedabotlt the general stigma iJl
particular.
• "Who doyoutltink willjudReyolIhnnhlyJorbein,.OIf medication?"
INTERVENE BY:
• FramiJlg tho issueoftaJdngInedieationastakingcare ofthenlsc1vesandl.lSk themto
thinkabouthowothel'1\tnightjud,ge themlfthey wet»perceiveda.<t not takingcare of
tbe111Sclves.
• EA'Plafu that depression is a medicalCQndition that happetlSwhen someonei$ lacking
certain brain.
• It is not 11 chlltl1Ctcr flaw or matter of willpower or a need for tojust "pull
thentselve8 up. by bo()tsttlljl$".
• Ask if theyhave cvcrbadpt know someone who bas had diabetcsor pneumonia and
has to tde medication. Wouldwe expect them1Qjust "pull themselves up by their
OOOtJllraps"?
• Rehearse what the patient cantelltfulir flUpily abQw the tneciicadQn that theyare
takins at\d the conditiontbat theybave. Offerto send tllamthe medication educational
packet.
D.UllCkgr ghOut what medlcgJl(Jl(· does
PATIENT MI(1HT SAY:
."[don't Imderllfllldwhy the priJnaTJ' cue dillicion prucribedthu medicmwn.. ..
• "Ido,,', even kntIW ••"'at this medicoJiondol!$."
EXPLORE BYASKING:
"What foI'ereyoll toldbYYOIuprimnry coreclUricitUl?"
INTERVENE BY:
• Taking theopportunity toeducate lhcpaticnl. onhow their medicationworks {oil\:rtolIend
Jnedication edueatiQllal in(onnat.ron packet, ifthey it..oftertore'Yiewit \v:itb
them),
• Recommend thaUhcy also talkto thl;ir primary careclinicianai tbeir rtextvisit about the
medication andwhyth<:y werepreecn'bed it..
Page 49 of62
E. Concemed about addiction
PATIENT MIGHT SAY:
• "I tbJn', want to be on the medicineforever, ..
• "1don't want to becomeaddictedto it. »
EXPLORE BYASKING:
"HtlVeyO" "etml or /mown aboll/someone'''0"fill trouble wit" tlre medication being
lUIdidi:ve?"
IN1'EItVENE BY:
.. ltlforming the ptltiqnt·that it! not\lddic;.t&(l.
• E,"(plain thatit isconunonfor peoplQ tobcon tht: forsixmonthswa year andin
llmnC lQJ\ger. 8ClSutQ thllfthedeci.siQq lI'hQut bowlcmgtfi qnthe
should bemade with tlteirprimary can: cliniCian,
• Emph81li:z<: thattheylIhoul<inol stopor clilll18\1 ilieif ntediCCltiQII <lose withouttalkingwtheir
priromy clinician first.
• Mention thatofumpeople 1\ootl' of theirmedieatfuntoo soonbeeausc they ate feeling better,
• Bystopping mcdictltiontoo soon.. they l'Utlningtlwrilk
F. CtJIIC811Ie4 abput gbilf(r·to ME (or tlfemedidrte
PATIENT MIGHT SAY:
• "f dtm', hl1"e Ur$lntitrCe this lIIedieti/kJn."
KXPLOREBYASKING:
• "Haveyou numt'omulthisroy(Jurpriltfar). CJIN! clioic'lI1I ?"
• If tbey insutanee but l,lte unsure Iloouttbeir /llen'W bealth coverage, ask:
"Havey011. cttJlp4the 8MHontlll'lbI1ck 01.1011' inIJIrOlfce canlto tiS!l aboutyour
mental heolth (:f)vutlge?"
INTERVENE
• Suggestingthat tIleY discuss fuilt withtheirprimary becauselhere aregeneric
dnJg voucher ·f« poqple\YithOl!1prl:l1eOptioni!lsuTj1ncecovCfage
or tCimbunement.
• Help them tofind themental heaJthlsuJ,stanceabuse 800#011 theirinsUJ'iUtcecard.
• Offer to call theitinllurance companyfor themifyousCllIeJbat they arejust too
oVerWlwlmed,
Page 50 of62
Initial Week One Call- Barriers to Treatment
Patient Has Not Scheduled Their Appointment With a Mental Hea/Jh Specialist li't
for the Following Rea.'wn(s):
A. Patient htu had a ne,ative experience
PATIENT MIGHT SAY:
"Lhave been before Qlldfoundthnt it wasn't veryhelpful"
EXPLORE BYASKING:
• "How long ago was it that you »oelll to coum;eJing?"
• "Didyou like the ntDItal health specialist you saw?
• "How100'g were you ill counseling?"
• "Do you know specijkaUy wl,at it was that you didn': like about the experience?"
INTERVENE BY:
• Encounaging the patient to ex..plore the reasons whythe counselingwas not helpful,
• Byhelpinga patient to understand more about what they didn't like in their previous
counseling experience, a patient can becomeclearer on what they do want and you
may be able to helpthemfindthe right situation.
B. Patient hqs never been before and is nervous about what it win belike
PATIENT MIGHT SAY:
• "Oh, I haven't hada chance to call someone yet, I've been busy:"
• "I just am 1I0t sure abollt whether I want to go rigl,t now. "
EXPLORE BYASKING:
• "Do you have aI'yquestions about what cow,selil'g is like?"
• "If(mldyou like help $'cheduling 01. appointnumt?"
INTERVENE B\':
• Educatingthe patient about what to expect fromcounseling.
• Certainlyvalidatethe personsfeelingof busy (this may be verytrue), however,
often it is the underlyingnervousness or ambivalence that is behindthe person
procrastinatingschedulingan appointment.
C. Wordell a/lOltt ".,t;gma" aflolar to a mental health .Weciaiiu
PATIENT MIGHT SA\':
• "1amnot that bad of/. "
• "Thaven't gone tl,OI('Tat)' yet. "
BYASKING:
• "Duyou know tIn)'One wlluhmgonetIJcuunseling?"
·Ifyes. ask; "What didthatpersOll tell you'l"
INTERVENE BY:
• Assuringthem that the truly "crazy" or mentally ill people do not goto counseling,
Rather, it is the healthypeople who seek help by goingto lie mental health specialist.
Page 51 of62
P, EXRRiencinr difficulty settinrHR thefIlRoJntmenl
PATIENT MIGHT SAY:
• "1 have left mulliple messages at the mental health center and no one hos gotten
hackto me. "
• "No one seems to answNthe phone when I call. "
EXPLORE BYASKING:
"Wouldyou like help scheduling the appoint"umt?"
INTERVENE BY:
• Offeringto helpthemset upthe firslltppOintOlehl. Youmay run into difficulty 11.<;
welt but often caUingfrQIl1a primnry carecliniqian:s office can obtain II quicker
response.
Page 52 of62
Week 4,8,12, 16 - Barriers To Treatment
Patient is Comiluring or Has Stopped Taking Medicinefor the Following Reason(s):
At Concern ghOUls/ded[ect(v
PATIENT MIGHT SA\':
"I hm'e afeeling ofdryness in "9' mouth. ,r
EXPLORE BYASKING:
• "Howlong has tl,is been going on?"
• "How bothersome is the dT)' mouth for you7"
INTERVENEDV:
• EX1>lniniog that 010&1 side will subside OrgO' away within a few weeks and if
the side etf.el.1 i'l notvery bothersome, be patiellt
• Givetips 011 howto manage their symptoms. For example., suckingon hard sugarless
candies ll1ld drinkingwater Qfte.rJ can help with drymouth.
• taking111e medicinewithfoad can helpwilli stomaeh upset.
• !Side effect i'l very bi,ltl1ersome, ex-plain thalfirtdiog the righl medioine cantake
sometrial and. error.
• A patiertt may11ced to try several diffin-ent riled1cines before finding the.rightoile tOr
them.
• Acknowledge that this process canbe.fhlstratlng. as people want to justfeel better, not
experiment with medications,
• fIDIphusize theirnIXlFtl)nce al'ta,1kfug to11leir primarycare clinician abeuUheir side
effects.
• Certainly, if1hepatient has stopped tokin, their Qryou sense titey are
goingto, encourage the patientto calltheIr primary careclinician!s officewhenyou
conclude your call. (SeeAntidepressant Side Effectl;)
B. Patient is(<<Unr better
PATIENT MIGHTSAY:
"1 aln/lteUng much htllttlTso, , dtm'tneedt/) keep taking theme4icine. I'
EXPLORE BYASKlNG:
• First say thatit is great thatthelnedicinebashelped them.
• £:...plaintMt oftenwhenpeople feef better theywant to.stopthe medicine but. for these
medicines. it isbest to remamon flu' periodofli01eev011 when feelingbI.'1W'.
• The decision whento stopmedicine should. bemade with Olcirpril1lary care clinician.
48
Page 53 of62
CLack ofimDl'9vement
PATIENT MIGHT SAY:
• "I don't feel ,my different than 1did beforetaking the medication. "
• "I don " undeuandwhythings are not getting better. "
EXPLORE BYASKING:
• "JVhen did you expect that you. wouldfeel better?"
• "What didyour primarycareclinkiilll tellyou aboutwhenyou $llOul4 begintofeel
better?"
INTERVENEBY:
• E"'Plaining that it can take up to 6 weeks before patients feel the oftect of a
mediellfiou,
• fr afterthistimethe patient nop<>sitivc effect, thenthey$llQUld talk t() their
primarycarecHnician abpul tryinga different mcclicin.c m¢dication sec(hm for
suggestions l)11 howto educateit patielltabOuttnedication ttel,\ttUent titUeliue).
D. Waltrine tofirm.counselingbeetlllle ittlgem" seemto/w·!te/J!in.I
PATIENT MIGHT SAY:
• "1stoppedseein(J hlJ' me.tdlll helllJltspf!Cihlist /1ecIlUSe itj,.$/ diJun'tseemto be
hefping ftfUch. ,.
.ilImUsed a couple of,a,iOl,aand well, I dqn'ttltinlc thatI'm going to gt1 back, '0
EXPI.<>RE ByASKING.
• .. Wllat werey01l1' expecIlItiolJS abollt ClJumeJing Wllell )'011 begm,.",
• "Diilyt1lifeel ,1IUIyim c:mmecttd with health$ptcitlli8t'l"
• "Haw! you e)'(!J' been. in CQlltlleJin8 in tire past?"
• IfyC$, explore what thatW$ ll]<e fQrmeUl.
INTERVENEBY:
• Helpingthe patient understand wIlY theywantto c()un})cli,lg.
• Sometimes it ismore a matterQfa patient beingwiththe wrong mental health
specialistthancO\UlScling itself beingnothelpful forthe patient.
• Usethis opportunity to cd.ucatc the patient on what to expect fromcowlselingandthe
time frame to oxpect changt}s.
Page 54 of62
SECTION IX: CARE MANAGEMENT SUPERVISION ANDDATA MANAGEMENT
Care Management Supervision Calls
CM supervision calls/meetings are generally scheduled weekly. Participants typically include the CM(s),
the supervising psychiatrist and CM supervisor. The CM and the psychiatrist, based on a standardized
supervision agenda created for this care process, establish the format for the call. In some cases, the
clinic or organization's primary care physician leader may also be a regular participant.
Care Management Supervision Agenda
An Excel spreadsheet (see sample on following page) has been developed and serves as the supervision
agenda and helps to structure the call. This CM Agenda should be forwarded via encrypted e-mail to all
call participants in advance of each call.
In some cases where several CMs participate in the supervision call, data may be compiled separately
then consolidated into a single supervision agenda for the meeting. It is recommended the agenda be
completed and forwarded 24 hours in advance of the supervision meeting to ensure access. Participants
will also benefit by familiarizing themselves with the information in advance. Use of a CM specific
patient ID system will provide confidentiality when more than one CM is involved in the call, etc.
Reporting and Discussion during Supervision
The following sections will serve as a guideline for the type and level of detail to be summarized for
review with the supervision psychiatrist. Other info may be needed to provide clarification ofa patient's
status and the "Note" section for each entry offers a good mechanism for that.
Enrollment Status
• Total number of patients in "registry" (total number of the patients that are being actively
monitored)
• Total new patients referred since last supervision call
Review ofCases
For an initial period (3 to 6 months), all new patients referred should be discussed to allow the
supervising psychiatrist and CM to gauge what level of detail is required for effective review of
cases. This will also allow the participants to gain a sense of whether information is being presented
appropriately, at the right frequency and with an efficient amount of detail.
In addition, this provides an opportunity to look for trends in PCP treatments that might benefit from
a general communication by the supervising psychiatrist or the CM to the PCP (e.g., need for
information to PCPs about benefits of sleep aids for those with PTSD; best SSRIs for PTSD; when to
bump up the Rx dose, etc.). After this initial interval, the CM should bring up only those new
referrals/cases that raise red flags.
Agenda Spreadsheet
The following page displays the categories of information that are reviewed each week for individual
patients. Cases are brought up by CM specific ID code rather then by patient name. These ID codes
do not reflect ID numbers within CHCS II / AHLTA. Clinics with in-house behavioral health and
care management may, however, choose to discuss individual patients by name as long as
confidentiality is maintained. The agenda form for patients with recent PHQ-9 and/or PCL scores are
presented at each meeting as well as for those patients who may be having difficulty with treatment
adherence, side effects, or other events that may interfere with treatment.
Page 55 of62
SAMPLE SUPERVISION AGENDA PAGE FOR AN INDIVIDUAL PATIENT
101
Gender
lADe
RM.By
RM.Date
IODlvmt
Ox
DEPRESSION {PHQ9} PUC WCll
lmerval Date SYMP/SCORE Risll Interval Date SYMP#SCORE Risll
Baseline Baseine
4Wks 4 WlIs
SWks BWlIs
12Wks 12 WlIs
16Wks 16Wb
2OWk.s 20Wks
24Wks 24Wks
Start} Change Date
IE..
- - - - - - - + - - - - ~
~ _ - - - ' - - __I
jCounseJ
I ~ T '
Reason
f-----t----I
'---- I
10....... IS",_IT.1ssues
'---- I
Next CMCal Dale
ISUPEIMSION NOTES
Page 56 of62
APPENDIX A
SAMPLE FORMS FOR THE CARE MANAGEMENT PROCESS
Page 57 of 62
CAREMANAGER CONTACT FACESHEET
M F DOB: __ 10#:__-=__._---,,--
Alternate Phone# __• (fype )
IIMEl Mornins Noon Afternoon Evening
_____FAX: _
Patilll1tName:
Primary Phone # C-) __- (fwe
Messages Allowed? No Yes- =----:- _
BwDAj'S&TlME$TOCrw,; Mon. rues. Weds. Thurs. Fri.
AddreS6:
Clinician:--------::::Qini ... ·-:"·ct-:"·an--:-·s-=T""'c1,-.------::-:":':------------------
SCHEDULE0' VISITS WlTHPCC
JJldex Oflke NettOflke NettOllke NettOlllce NeltOlllce Ne1tomce NtltOlllOl!: Ne1tOlllce .Nextomce .Neltomce
VIsit Vlsil Visit VIlli Villt V&It Villi Villi Visit V111t

....:.c:.:,",""tlL..._


$t3rt

Ib n.rr DIt_ 1'Imt-al Dare Noil!s lDCdlIles.dr.)
.PHQ.9lJISTOR:V
)W. BASELINE "Weeks BW&!eb ltW_kI V;WeeJa 10W-' 24Weeb ( lWeeb (
o.te

.Sc.ore.
OUestlon ..... •
FtmciJlInbll(
PeL UlsroRY
BASELINE 4W-w IWeeb nw... 16Weeb lOWteb )4Wteb ( }Weeb r )Weekt
JJa2!.
--
Score
Q"'lon"19""
•C()JnpleieSilicideAsst!8SlftetftIIQIlest1o/t "I" (H' -(19" licoreis1, RecOI'dtktmlf!dMlesoJf. pt. !>'(HImel/oN" eMRt/JOrt.
{!pt/NS,ElJr>ro:
Page S8 of 62

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