Week 7

Case Management Manual

Assisting Complex Patients Regain Physical and Mental Health

Supplemental Appendices

oger G. Kathol, MD, acquired extensive experience in the clinical integration of general medi- cal and mental health services for complex patients as the director of a Complexity Intervention Unit (the new term for Medical Psychiatry Unit) at the University of Iowa Hospitals between 1986 and 1999. Thereafter, he assisted in the integration of physical and mental health care management as medical director at Blue Cross Blue Shield of Minnesota for several years. As president of Carte- sian Solutions, Inc., he has consulted to numerous national and international organizations, hospitals and clinics, insurance companies, care management companies, employers, and government agencies wishing to coordinate medical and mental health care management services. In these positions, he has designed many integrated case management programs and trained case managers and practicing physicians from varied specialties in cross-disciplinary techniques so that they could coordinate care for patients with multimorbidity. Dr. Kathol has over 150 peer-reviewed publications related to the interaction of general medical and mental health disorders, and, with Suzanne Gatteau, has authored a book, Healing Body and Mind: A Critical Issue for Health Care Reform, (2007) which explains how to transition today’s siloed care to integrated care through purchaser, health plan, provider, and patient

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partnerships.

ebecca Perez, RN, BSN, CCM, has experienced firsthand the impact that segregation of physi- cal and behavioral health has on the coordination of care, health service delivery, and patient outcomes during 15 years in acute care nursing and 15 in case management. As a result, Ms. Perez, a resident of St. Louis, Missouri, coauthored the depression chapter of the Case Management Adherence Guidelines (2006), has written numerous patient education articles on case management integration, and has presented nationally on and contributed to the development of integrated case management curricula. She currently serves on the national board of directors for the Case Management Society of America and has been active in her local chapter. Ms. Perez is president and owner of Carative Health Solutions, which provides direct care/case management services and consults to case management professionals on strategies to apply integrated case management principles in their programs. She has been involved in the creation of the integrated case management training curriculum at the Case

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Management Society of America since its inception and is currently an accredited trainer.

anice S. Cohen, PhD, CPsych, is a clinical psychologist at the Children’s Hospital of Eastern On- tario (CHEO), as well as clinical professor in the School of Psychology at the University of Ot- tawa. Throughout her career, Dr. Cohen’s clinical and research activities have focused on children and youth who have complex medical and mental health issues. As clinical head of the Behavioural Neurosciences and Consultation Liaison Team at CHEO, she has championed integrative collaborative health care, most recently through her initiative to develop a multifaceted clinical decision-making tool, the Pediatric INTERMED Complexity Assessment Grid (PIM-CAG), to improve assessment and treatment planning for children and youth with complex health needs. Dr. Cohen is currently princi- pal investigator of a funded research project at CHEO examining the psychometric properties of the PIM-CAG in children and youth with inflammatory bowel diseases. She is a recipient of an Expertise Mobilization Award from the Provincial Centre of Excellence for Child and Youth Mental Health at CHEO in support of her work on the development of the PIM-CAG. Dr. Cohen’s other ongoing re- search projects include a multisite Canadian study investigating knowledge translation strategies in pediatric procedural pain. For over a decade, Dr. Cohen also served as the Director of Training in Psy-

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S chology at CHEO and has received awards from national and international professional bodies for E her contributions to training.

The Integrated

Case Management Manual

Assisting Complex Patients Regain Physical and Mental Health

Supplemental Appendices

Roger G. Kathol, MD Rebecca Perez, RN, BSN, CCM Janice S. Cohen, PhD, CPsych

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Copyright © 2010 Springer Publishing Company, LLC All rights reserved.

Stratification and Prioritization of Triggered Complex Case Management Candidates*

STRATIFICATION LEVEL DETERMINATION

LEVEL I

· Little impact: Minimal management involvement (e.g. health coaching, wellness programs), such as:

· Education

· Placement assistance

· Anticipated time of involvement: Days or less

· Typical clinical situation:

· Coming out of a high health care cost activity, such as an inpatient stay, with anticipated rapid recovery and little follow-up need

· Minimal interaction of medical and psychiatric illness and/or issues have already been addressed

· Likely IM-CAG score: Below 22

LEVEL II

· Low impact: Brief management involvement (e.g. disease management, disability management), such as:

· Education

· Placement assistance

· Referral to personal nurse or disease management

· Assistance with workplace reentry (Employee Assistance Program [EAP] involvement)

· Assistance with community programs

· Anticipated time of involvement: Days to weeks

· Typical clinical situation:

· Coming out of high health care cost activity, such as inpatient stay, with anticipated persistent need for sup- port to prevent delayed recovery and/or poor long-term outcome

· Likely IM-CAG score: 23 to 29

LEVEL III

· Moderate impact: Standard case management involvement, such as:

· Identification of patient needs in the physical, social, behavioral, and health system domains

· Development of a care plan

· Assistance to the patient in understanding illnesses and health system factors that impede receiving appro- priate care

· Systematically working through the care plan

*Note: “Stratification” of potential candidates for case management is based on a triggering process estimate by the enrollment specialist of a patient’s service use pattern, which suggests persistent or worsening illness, functional impairment, and high health care service use (see Appendix 2).

“Prioritization” of potential candidates stratified at a high level and in serious consideration for case manage-

ment intervention relates to practical considerations about who is most likely to benefit (i.e., improvement poten- S tial, motivation to change, ease of contact, and prior case management outcome). E

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· Anticipated time of involvement: Weeks to months

· Typical clinical situation:

· Inpatient and outpatient persistent service use and probability of further difficulties

· Poorly treated psychiatric comorbidity in the face of serious subacute and/or chronic general medical illness, social challenges, and health system issues

· Poorly treated medical comorbidity in the face of serious subacute and/or chronic psychiatric illness, social challenges, and health system issues

· Likely IM-CAG score: 30 to 35

LEVEL IV

· High impact: Extended case management involvement, as in Level III; however, problems are persistent, com- plex, and multiple with long-term high service use or anticipated risk of high service use, thus longer term case management involvement warranted

· Anticipated time of involvement: Months or longer

· Typical clinical situation:

· Complex, concurrent physical and mental conditions with inpatient and outpatient long-term service use

· Likely IM-CAG score: 36 or above

PRIORITY LEVEL EVALUATION AND SCORING

1. Motivation to change: a—none b—some c—good

2. Case management response history: a—poor b—never tried c—good

3. Ease of contact: a—nearly impossible b—complicated c—easy

4. Improvement potential: a—little b—some c—significant

Scoring System:

If no “a” responses and “c” for three or more: High priority If no “a” responses and “c” for at least one: Medium priority If any “a” response combination: Low priority

STRATIFICATION PROCEDURES

The enrollment specialist establishes “stratification” and “priority” levels. While these individuals may have less clinical background and knowledge base about potential clinical and cost outcomes, they will use their assessment of factors that brought triggered patients to their attention to determine whether the patient will be contacted by them and asked to participate in case management. Initially, this means looking at the individuals’ triggers then rank ordering them by apparent complexity and immediacy of need (i.e., the number and/or interaction of illnesses, the amount of practitioner involvement and medication use, the regularity of inpatient admissions, the frequency of emergency room visits, the volume of outpatient encounters, the total cost of care, the patient age, the persistence of problems and/or resistance to treatment, etc.). For patients not identified through claims databases, the narrative call-in, clinic chart review, or hospital admission assessment should be evaluated based on similar factors during the intake determination.

Opportunities for bringing value to patients and the systems from which they come are greatest for patients S who are at stratification Level III or Level IV. Of these, patients with high and then medium priority should be pref- E erentially chosen.

Stratification and Prioritization of Triggered Complex Case Management Candidates 3

The first cut occurs by making a judgment about a patient’s stratification level based on the rank order previ- ously noted, such as the most complicated (Level IV) to least complicated (Level I). Triggering systems differ based on the type of management provided. Thus, triggers for disease management will likely have many more patients in stratification Levels I and II than Levels III and IV. The second cut occurs based on priority. Enrollment special- ists should first contact patients with illnesses or service use patterns most likely to be affected by the case manage- ment process. During the interview, the patient is assessed for illness-based outcome change potential, readiness to change, prior program response, and ease of contact. These personal contacts will determine the final decision about whether a patient will be asked to enter the case management program.

Thus, patients in Level IV with high priority would be asked first, those in Level III with high priority second, those in Level IV with medium priority third, and those in Level III with medium priority fourth. Those falling in Levels II and I with high priority would follow and then those with Levels II and I medium priority thereafter. In general, those identified with low priority but falling in a high stratification level would only be asked to participate if they had much to lose without case management assistance. Even then, they would be asked to participate only if managers with free time were available to pick them up. If not chosen for case management, low priority patients should be primed for potential future participation in the event that circumstances alter their readiness for change, anticipated illness responsiveness, or ease of contact.

Enrollment specialists should avoid overloading case managers who are already carrying a full complement of patients. Composite IM-CAG and/or PIM-CAG scores can be used to estimate the ability of a manager to accept new patients (see the Chapter 9 section “Caseload Estimation”).

Finally, the number of patients identified by the initial triggering process (e.g., claims database, clinic referrals) can still overwhelm enrollment specialists. When patients are triggered far in excess of the number in which man- agement could be provided, then the system needs to be refined. Rules should be generated that decrease the num- ber triggered yet uncover patients most likely to benefit from case management services. For instance, health plan database algorithms can be changed to triage only members with higher service use, more inpatient admissions, greater pharmacy costs, and so forth. In a clinic, proactive patient triage may be used (e.g., only patients with cer- tain high use and/or complicated clinical need patterns). In the hospital, nursing intake assessments can be used (e.g., readmissions, multi-organ system involvement, multiple physicians involved). The intent is to minimize the use of staff time for screening. On the other hand, triage, stratification, and prioritization are of major importance for effective value-added case management.

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Case Management Candidate Induction Templates*

TEMPLATE FOR LETTERTO POTENTIAL CASE MANAGEMENT CANDIDATE

Dear :

In an attempt to assist its (patients, employees, citizens, etc.) with chronic and/or difficult to manage illnesses, (name of health entity: health plan, clinic, etc.) enlists the assistance of nurses, social workers, and physicians (our case management team members) to help (patients, employees, citizens, etc.) improve their health, to maximize their abil- ity to interact with family and friends, to pursue hobbies and other activities, and to function effectively at work. These team members help (patients, employees, citizens, etc.) with health problems navigate the complicated health system and get the type of care that they and their doctors desire in order to have better health. This is a voluntary and free service since it is a part of your health coverage. If you choose to participate, you can withdraw at any time without affecting your continued care. The program is specifically designed for those who would benefit from ad- ditional assistance by trained health care professionals. (Name of health entity) realizes that the health care system can be complex and that such complexity may play a part in preventing people from getting the care that is most likely to benefit them.

If you choose to become a part of this program, a case manager will work with you and your current doctors to assist you in overcoming any troubling barriers that may be preventing your optimal health care, including: personal circumstances, such as social and financial burdens associated with your illness; difficulty in following through on treatment due to transportation needs; care responsibilities for another member of your family; or just discouragement about your illness. The goal of this program is to improve aspects of your health care delivery by working with you and your doctor.

In the next (number, e.g., two) weeks, you will be contacted by a member of the (name of health entity) staff to de- termine if you qualify for the program. If you do, he or she will set up a telephone appointment between you and a (name of health entity) case manager (nurse, social worker, etc.). When the scheduling person calls, he or she will pro- vide additional details about the case management program and how it might be of benefit to you. Having a chronic or difficult to treat illness is no fun. Through this program, (name of health entity) wishes to improve your ability to address issues that prevent you from working with your doctor and getting the care that will lead to a healthier and more rewarding life.

We look forward to talking with you.

Yours sincerely,

[Name] [Title]

*Note: The italicized portions of the three templates indicate comments to the case manager or choices for ap- S propriate words tailored to an individual patient’s situation. E

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TEMPLATE FOR ENROLLMENT SPECIALIST TELEPHONE SCRIPT (AFTER AN INTRODUCTORY LETTER)

Hi. My name is (give name) and I am calling on behalf of (name of health entity). In follow-up to the letter you received from (name of health entity) about a week ago, I would like to see if you qualify for our case manage- ment program, a free and voluntary service that is a part of your health benefits. As the letter indicated, it is a program designed to help people with complicated medical problems overcome some of the obstacles that

If the enrollment specialist considers the patient to be a candidate for case management, then ask: “Would you be interested in receiving help from a health care spe- cialist trained to assist with health issues and the effect they have on your life?”

If yes, “Can I answer any questions about our case management program?” (Answer questions about pro- gram and then transfer the person to a case manager.)

TEMPLATE FOR ENROLLMENT SPECIALIST TELEPHONE SCRIPT (WITH NO INTRODUCTORY LETTER)

the health system itself, social factors, and personal is-

sues create, such as the limited time you have with your doctor, making it difficult to get questions about your illness answered; trouble in getting appointments or paying for medications; discouragement about the lim- ited progress you may be having in controlling certain symptoms or with unwanted side effects; and the like. This program was developed because (name of health entity) now realizes that correct diagnosis and treatment are the first steps to good health but that so- cial, personal, and economic factors also play an important role. The case management program is designed to as- sist you with these factors because they can contribute to illness persistence and life impairment as much as if an incorrect diagnosis were made or inappropriate

treatment given. (Address questions/comments.)

Would it be OK if I asked you a few brief ques- tions?

· Do you see your health as a problem for you?

· Are you interested in finding ways to improve your health?

· Have you tried to do things on your own to improve your health?

· How important is it for you right now to change (specific symptom, behavior, etc.)? On a scale from 0 to 10, with 1 being not important and 10 being very im- portant, what number would you give yourself?

0—————————————————————10

Not at All Important Extremely Important

· Why do you feel you are at X and not at 10?

· What would need to happen for you to get from

X to Y?

· If you did decide to change (symptom, behavior, etc.),

how confident are you that you could do it?

0—————————————————————10

Not at All Confident Extremely Confident

· Why do you believe you are at X and not at 10?

Hi. I am (give name) and I am calling on behalf of (name of health entity). I would like to see if you would like to participate in our case management program, a free and voluntary service that is a part of your health benefits. It is a program designed to help people with complicated medical problems overcome some of the obstacles that the health system itself, social factors, and personal issues create, such as the limited time you have with your doctor, making it difficult to get questions about your illness answered; trouble in get- ting appointments or paying for medications; discour- agement about limited progress you may be having in controlling certain symptoms or with unwanted side effects; and the like.

This program was developed because (name of health entity) now realizes that correct diagnosis and treatment are only the first steps to good health but that social, personal, and economic factors also play an important role. The case management program is de- signed to assist you with these factors because they can contribute to illness persistence and life impair- ment as much as if an incorrect diagnosis were made or inappropriate treatment given. (Address questions/ comments.)

Would it be OK if I asked you a few brief ques- tions?

· Do you see your health as a problem for you?

· Are you interested in finding ways to improve your health?

· Have you tried to do things on your own to improve your health?

· How important is it for you right now to change (specific symptom, behavior, etc.)? On a scale from 0 to 10, with 1 being not important and 10 being very im- portant, what number would you give yourself?

0—————————————————————10

Not at All Important Extremely Important

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What would need to happen for you to get from

X to Y?

How can I help you get from X to Y?

· Why do you feel you are at X and not at 10?

· What would need to happen for you to get from

X to Y?

Case Management Candidate Induction Templates 7

· If you did decide to change (specific symptom, behav- ior, etc.), how confident are you that you could do it?

0—————————————————————10

Not at All Confident Extremely Confident

· Why do you believe you are at X and not at 10?

· What would need to happen for you to get from

X to Y?

· How can I help you get from X to Y?

If the enrollment specialist considers the patient to be a candidate for case management, then ask: “Would you be interested in receiving help from a health care spe- cialist trained to assist with health issues and the effect they have on your life?”

If yes, “Can I answer any questions about our case management program?” (Answer questions about pro- gram and then transfer the person to a case manager.)

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Potential Content for a Case Management Brochure

Whether a tri-fold brochure that fits into vertical holders, a full or half-sheet pamphlet, or a glossy flier sheet, the format chosen for printing brochures can be as simple or elaborate as is desired by the case managers and can reflect the style, creativity, and printing budget of those involved.

The following are content areas that could be con- sidered when constructing a case management bro- chure:

NAME AND LOCATION OF CASE MANAGEMENT COMPANY

For example, Redwing Health Solutions, Inc., 112 Mayberry St., Redwing, NH

NAME AND CREDENTIALS OFTHE CASE MANAGERTO BE WORKING WITH

THE PATIENT

For example, Judy Harris, RN, CCM

PICTURE OF CASE MANAGER, FACILITY WHERE COMPANY IS LOCATED, AND/OR HEALTH “SCENES” (OPTIONAL)

For example, photographs or company logos

INFORMATION ABOUT CASE MANAGEMENT, THE PROFESSIONALS WHO PROVIDE IT, AND WHAT PATIENTS CAN EXPECT

See the following sample descriptions

CASE MANAGEMENT PROGRAM

Redwing Health Solutions, Inc. offers case manage- ment services to all eligible members and dependents enrolled in (name of health plan, care delivery system, etc.) who are dealing with serious and complicated health conditions. Our case managers are licensed, profession- als, such as nurses and social workers, with extensive clinical experience. They can help patients navigate an

increasingly complicated medical system, using their health backgrounds to educate about illnesses, im- prove communication between the patient and his or her doctors, ensure and facilitate outcome changing care, and assist patients in overcoming roadblocks to the care that is needed. Case manager support eases worries of individuals and family members experienc- ing distress and frustration when trying to cope with one or more serious illnesses in a complex medical system.

Remember, nurse care managers work for you and your family to ensure the best possible health outcome.

WHAT CASE MANAGEMENT ENROLLEES CAN EXPECT

Continuity of Care: The case manager will work with your physician(s) to provide timely, continuous care. The case manager will know your treatment plan and will be able help coordinate services needed. Case managers will never contradict a physician’s orders.

Education: Your case manager will educate you about your condition and the prevention of complica- tions in order to avoid hospitalizations or unnecessary services. Knowledge is power. When you understand your condition, a better outcome can be expected. The treatment process is less frightening as well.

Personalized Care: Case managers make every ef- fort to meet with you face to face. They will meet you in your home, in the doctor’s office, or in the hospital, whichever is most convenient for you. Developing a trusting relationship with your case manager is very important.

An Advocate: The health system can be very in- timidating and confusing. Case managers will act as your advocate and will help teach you to advocate for yourself.

Cost Containment: Case managers are able to coor- dinate various health care services. Health care is very costly, so experience is critical to helping you access the right care to best meet your needs, including assistance with reducing out-of-pocket expenses for medications, medical tests, office visits, and hospitalizations.

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Notification Letter to Patient’s Clinician(s)*

Sample Notification Letter to Patient’s Clinician

Date

Dr. Name Address

Re: Patient

Dear Dr.,

The Referring Entity has contracted with Case Manager/Company to provide case management services for your patient: name. The Referring Entity is committed to assisting its members in achieving the best possible health out- comes. The role of the case manager is to be an adjunct to the care you are providing. The Case Manager is available to assist with appropriate health education, coordination of care, support, and to act as a patient advocate.

By establishing a collaborative relationship between the physician, patient, and case manager, the Referring Entity believes their participants will achieve good health outcomes and be adherent to prescribed treatment plans. Enclosed you will find a consent signed by Patient allowing Case Manager access to the protected health information. Case Manager is available to assist with any coordination of care or services, and may contact you for updates on the patient’s condition. You may contact Case Manager at

Phone number.

Please place copies of this letter and the enclosed HIPAA authorization in the patient’s chart for easy reference. The Referring Entity thanks you in advance for your consideration and looks forward to assisting in your patient’s care.

Sincerely, Signature Name in Print Title

*Note: In constructing a notification letter, the sender will need to replace the italicized portions of the letter with S the words appropriate to the patient’s and sender’s situation. E

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Scripted Questions: Integrated Case Management Assessment for Adults

Preliminary Steps:

A. Explain and answer questions about case management, the request for your involvement with the patient, and how you might be able to help.

B. Clarify confidentiality issues, such as how sensitive information will be handled (nondisclosure), and legal ob- ligations about reporting information considered potentially dangerous related to the patient or others (e.g., suicidal thoughts, homicidal thoughts, public health risks, etc.)

C. Summarize your understanding of the patient’s personal health situation and give the patient a chance to elabo- rate and/or correct the information.

Notes:

QUESTION 1

CONTENT AREA: GENERAL LIFE SITUATION

“Is it okay to ask some questions to get to know you better before we focus on your current health situation?” If okay, “Can you tell me a little about yourself—for example, where you live, who you live with, how you spend your days, what your hobbies and interests are?”

Follow-up questions (The case manager can fill these in later if there is reticence to divulge personal informa- tion at this point.):

1.1 “What kind of job do you have?”

1.2 “Can you tell me about your financial situation/pressures?”

1.3 “Do you require assistance in getting out of the house?”

1.4 “Who helps you when a crisis arises?”

1.5 “Who are your friends?”

1.6 “How do you spend your free time?”

1.7 “Do you help take care of others, such as a family member or a friend?”

Notes:

QUESTION 2

CONTENT AREA: PHYSICAL HEALTH

“How is your (name main medical illness) affecting you today?”

Follow-up questions:

2.1 “Have you had (other) physical problems or long-term conditions or illnesses?”

2.2 “Were these difficult to diagnose?”

2.3 “Are medical assessments underway?” S

2.4 “What kind of treatments have you received?” E

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2.5 “Have you had difficulty following through on recommended physical health treatments?”

2.6 “How have the treatments worked?”

2.7 “Do physical symptoms interfere with doing the things you like to do?”

Notes:

QUESTION 3

CONTENT AREA: EMOTIONAL HEALTH

“How do you feel emotionally—worried, tense, sad, forgetful?”

Follow-up questions:

3.1 “Has your physical health situation affected your emotions (or your memory)?”

3.2 “Have you had mental health problems in the past?”

3.3 “Have mental health issues required treatment or hospitalization, such as for depression, anxiety, confu- sion, memory problems?”

3.4 “What kinds of treatments have you received and from whom?”

3.5 “Have you had difficulty in following through on mental health treatments?”

3.6 “Are you getting any treatment now?”

3.7 “Has treatment been helpful?”

3.8 “Do emotional factors interfere with doing the things you like to do?”

Notes:

QUESTION 4

CONTENT AREA: INTERACTION WITH TREATING PRACTITIONERS

“Can you tell me who you see for health problems?”

Follow-up questions:

4.1 “Do you see a primary care physician/nurse practitioner?”

4.2 “Do you see any medical specialists?”

4.3 “Do you see any mental health providers, such as psychiatrists, psychologists, social workers, nurses, and so forth?”

4.4 “Do you see any other providers, such as a chiropractor, naturopath, church counselor, and so forth?”

4.5 “Can you tell me how you get along with your doctors?”

4.6 “How do those giving you care talk with each other and coordinate your treatment?”

4.7 “Do you have difficulty communicating with them?”

4.8 “Are their offices near each other and easy to get to?”

4.9 “Have you had conflicts or disagreements with any of your doctors/providers, your hospital/clinic, or your insurance company that have led to bad feelings or mistrust?”

Notes:

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Scripted Questions: Integrated Case Management Assessment for Adults 15

QUESTION 5

CONTENT AREA: HEALTH SYSTEM ISSUES

“Can you tell me whether you have difficulty in getting the health care you need?”

Follow-up questions:

5.1 “What type of medical insurance do you have and does it cover the services you need?”

5.2 “Do you have trouble finding medical doctors who will accept you as a patient?”

5.3 “Do you need to go to separate clinics for mental health treatment?”

5.4 “Are there separate payment rules for mental health care?”

5.5 “Have you or your primary care physician had difficulty in finding a mental health provider for you?”

5.6 “How far do you live from the medical clinics and doctors you need to improve (control) your health?”

5.7 “Do you need a translator or someone from your culture to assist with health needs?”

5.8 “Can you afford your medical care, such as medications, needed tests, copays for appointments and hos- pital costs, needed medical equipment/devices, and so forth?”

5.9 “Is transportation a problem in getting to your appointments?”

5.10 “Are there long waiting lists for the kind of care you need?”

Notes:

QUESTION 6

CONTENT AREA: MORE SENSITIVE PERSONAL INFORMATION

“What kind of person are you—outgoing, suspicious, tense, optimistic?”

Follow-up questions:

6.1 “Do you smoke?”

6.2 “On average, how many alcoholic beverages do you drink a day (week), such as glasses of wine, beers, and so forth?

6.3 “Do you use painkillers—how often, how long, more often than prescribed?

6.4 “Do you use cocaine, marijuana, or other recreational drugs?”

6.5 “Have you ever been treated for substance abuse problems?”

6.6 “How do you handle difficult situations?” (alcohol or drug use, talkative, silent, procrastinate?)

6.7 “What are your biggest health concerns at this time?”

6.8 “During the next 1 to 3 months, what about your health would you like to have under better control (clinical)—for example, have less foot pain, have no asthma attacks for a solid month, and so forth?”

6.9 “What would you like to be able to do that you can’t do now (functional)—for example, attend church regu- larly, participate in family events, return to work, and so forth?”

Notes:

QUESTION 7

CONTENT AREA: ADDITIONAL INFORMATION FROM PATIENT OR CAREGIVERS/PARENTS

“What things did I not ask about that you think are important?” Notes:

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Scripted Questions: Integrated Case Management Assessment for Children/Youth

Preliminary Steps:

A. Explain and answer questions about case management, the request for your involvement with the child/youth, and how you might be able to help.

B. Clarify confidentiality issues, such as age of majority and consent; how sensitive information will be handled (nondisclosure); legal obligations about reporting information considered potentially dangerous to the child/ youth or others (e.g., suicidal thoughts, environmental dangers, etc.).

C. Summarize your understanding of the child’s/youth’s personal health situation, giving the child/youth and/or caregiver/parent a chance to elaborate and/or correct the information.

QUESTIONS FOR CHILDREN/YOUTH AND CAREGIVERS/PARENTS

For children too young to answer for themselves, all information related to the initial assessment is obtained from the caregivers/parents. Children/youth able to provide information on their own should be involved in the assess- ment process to the extent possible. In general, this means that there will be a combined interview with the child/ youth and the caregiver/parent and independent interviews with the child/youth and the caregiver/parent.

In the combined interview, questions in “unbolded print” will be first addressed to the child/youth and secondly to the caregiver/parent, except for questions in underlined print. For some families, the content of the underlined questions may be sensitive and can be skipped during the combined interview but then addressed in independent in- terviews. The decisions about when to ask the more sensitive, underlined questions are at the discretion of the case manager.

Questions in bold print are addressed to the caregiver/parents only and are typically used during their in- dependent interview. When possible, it is helpful to confirm conflicting and/or uncertain findings with information from other sources, including health practitioners, teachers, peers, clergy, and so forth. Notes will be consolidated and anchor points scored in the PIM-CAG assessment instrument based on the best evidence from the information sources.

QUESTION 1

CONTENT AREA: GENERAL LIFE SITUATION

“Is it okay to ask some questions to get to know you better before we focus on your current health situation?”

If okay, “Can you tell me a little about yourself, such as where you live, who your friends are, what you like to do (hobbies/interests, extracurricular activities), and with whom you like to do things?”

Follow-up questions:

(The case manager can fill these in later if there is reticence to divulge personal information at this point.):

1.1 “Can you tell me about the members of your family?”

1.2 “Who are your close friends or relatives?”

1.3 “Whom do you* rely on when you need help?”

*Note to case manager: the “you” in this question is the child/youth S

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1.4 “Can you tell me about how you like your school?”

1.5 “How do you do in school?”

1.6 “What things do you like to do outside of classes, such as, clubs, sports, music, and so forth?”

1.7 “Have you had difficulty with attendance or getting along at school?”

1.8 “Have you gotten in trouble in school, at home, or with the law?”

1.9 “How do you spend your free time?”

1.10 “Can you tell me about your spouse/partner?”

1.11 “Are there custody issues related to the child/youth?”

1.12 “Where does the child/youth live?”

1.13 “Have you moved often?”

1.14 “Who supervises and feeds your child/youth during nonschool hours?”

1.15 “What kind of job do you have?”

1.16 “Can you tell me about your financial situation/pressures?”

1.17 “Can you tell me about current stresses/changes in your family situation or things that are worrying you about the future?”

1.18 “Can you tell me about any physical or mental conditions or disability that you or your spouse/partner have?”

1.19 “Who helps you, the caregiver/parent, when a crisis arises?”

1.20 “How does your child’s health situation affect your family?”

1.21 “Do you help take care of others, such as family or friends?”

1.22 “Can you tell me about behaviors, friendships, school, or legal concerns related to your child/youth?”

Notes:

QUESTION 2

CONTENT AREA: PHYSICAL HEALTH

“How do you feel physically?”

Follow-up questions:

2.1 “Have you had (other) problems with your health for a long time?”

2.2 “Are the doctors doing tests on you now?”

2.3 “What kind of treatment are you getting?”

2.4 “Have you had difficulty doing what the doctors ask you to do?”

2.5 “Have the doctor’s treatments worked?”

2.6 “Do health problems keep you from doing the things you like to do?”

2.7 “How serious are your child’s/youth’s health problems?”

2.8 “Is your child/youth disabled or impaired?”

2.9 “Were your child’s/youth’s health problems difficult to diagnose?”

Notes:

QUESTION 3

CONTENT AREA: EMOTIONAL HEALTH

“How do you feel emotionally, such as worried, tense, sad, forgetful?”

Follow-up questions:

S 3.1 “Do you get in trouble very often?”

E 3.2 “Have you ever seen a doctor or counselor because you got in trouble or because you felt so upset?”

Scripted Questions: Integrated Case Management Assessment for Children/Youth 19

3.3 “Have you gotten treatment for this or gone into the hospital?”

3.4 “Do you have trouble doing what your doctors ask you to do?”

3.5 “Has the treatment been helpful?”

3.6 “Do emotional factors or things that get you into trouble affect how you get along with others?”

3.7 “Do emotional factors or things that get you into trouble interfere with your ability to do the things you like to do?”

3.8 “Can you tell me if there were challenges in your child’s/youth’s development?”

3.9 “Can you tell me if special services or school assistance was needed because of your child’s/youth’s cog- nitive development?”

3.10 “Has your child/youth had mental health problems, such as depression, eating disorder, or severe anxiety?”

3.11 “Has your child/youth been treated for mental health or cognitive problems?”

3.12 “Can you tell me if your child/youth experienced early life events that might have affected his/her health, such as head trauma, lead exposure, prenatal alcohol or drug exposure, abuse, or in utero infections?”

Notes:

QUESTION 4

CONTENT AREA: INTERACTION WITHTREATING PRACTITIONERS

“Can you tell me who you see for health problems?”

Follow-up questions:

4.1 “Are your doctors (counselors) easy to talk to?”

4.2 “Do you trust your doctor (counselor)?”

4.3 “Have any of them done something that you do not like or disagree with?

4.4 “What about a pediatrician/nurse practitioner?”

4.5 “What about medical specialists?”

4.6 “What about mental health providers, such as psychiatrists, psychologists, social workers, nurses, and so forth?”

4.7 “What about other providers, such as a chiropractor, naturopath, church counselor, and so forth?”

4.8 “How do those giving your child/youth care talk with each other and coordinate his/her treatment?”

4.9 “Do you have difficulty communicating with them?”

4.10 “Are their offices near each other and easy to get to?”

4.11 “Have you, the caregiver/parent, had conflicts or disagreements with your child’s/youth’s doctors/pro- viders, your hospital/clinic, or your insurance company that have led to bad feelings or mistrust?”

Notes:

QUESTION 5

CONTENT AREA: HEALTH SYSTEM ISSUES

“Can you tell me whether you have difficulty in getting the health care you need?”

Follow-up questions:

20 The Integrated Case Management Manual

5.5 “Have you or your primary care physician had difficulty in finding a mental health provider for your child/youth?”

5.6 “How far do you live from the medical clinics and doctors you need to improve/control your child’s/ youth’s health?”

5.7 “Is transportation a problem in getting your child/youth to appointments?”

5.8 “Do you need a translator or someone from your child’s/youth’s culture to assist with health needs?”

5.9 “Can you afford your child’s/youth’s medical care, such as medications, needed tests, copays for ap- pointments and hospital costs, needed medical equipment/devices, and so forth?”

5.10 “Are there long waiting lists for the kind of care your child/youth needs?”

5.11 “Have you had difficulty in transitioning your child’s/youth’s care from his/her pediatric practitioners to adult doctors?”

Notes:

QUESTION 6

CONTENT AREA: MORE SENSITIVE PERSONAL INFORMATION

“What kind of person are you,** such as outgoing, suspicious, tense, optimistic?”

**Note to case manager: the “you” in this question is the child/youth. For the independent interview with the care- giver/parent the question becomes “What kind of person is your child/youth, such as outgoing, suspicious, tense, optimistic?”

Follow-up questions:

6.1 “How do you handle difficult situations?” (talkative, silent, procrastinate?)

6.2 “What are your biggest health concerns at this time?”

6.3 “If I worked with you for the next several months, what would you most like me to help you make better about your health, such as no shots, stop being sick from meds, and so forth?”

6.4 “What would you most like to be able to do that you cannot do now,*** such as, play in the band, stay overnight with friends, lose weight?”

***Note to case manager: functional personal goals of the child/youth

6.5 “Do you (think your youth) smoke?”

6.6 “Do you (think your youth) use alcohol?”

6.7 “Do other family members have alcohol or drug problems?”

6.8 “Do you (suspect that your youth) or your (his/her) friends use drugs?”

6.9 “Have you (your youth) ever been treated for substance abuse problems?”

6.10 “What kind of person are you, such as outgoing, suspicious, tense, optimistic?”

6.11 “How do you**** handle difficult situations?”

****Note to case managers: in the bold print questions such as 6.10 and 6.11, the “you” refers to the caregiver/ parent

Notes:

QUESTION 7

CONTENT AREA: ADDITIONAL INFORMATION FROM CHILD/YOUTH OR CAREGIVERS/PARENTS

“What things did I not ask about that you think are important?” Notes:

S E