Patient Challenges

1. The Role of the Nurse Care Manager in Linking Patients with Behavioral Health Resources Care Transformation Collaborative of R.I. Toni L. Schlais RN Nurse Care Manager, Wood River Health Services “Nurse Care Managers: Making a Difference in Primary Care” May 5, 2015

2. Patient Challenges Patients often have: • Limited support systems • Limited social skills • Multiple diagnoses • Difficulty navigating the behavioral health system

3. Nurse Care Manager Challenges • Establishing patient trust and obtaining consent • Assisting the patient with using the behavioral health system • Multiple agencies involved • Care Coordination • Behavioral Health may be making decisions without full knowledge of patients’ medical experiences (i.e. transitions of care)

4. Joe’s Story • Single, white male in mid 50’s with mother as only support system • Multiple diagnoses: COPD, Chronic Cor Pulmonale, Kidney Disease, Anxiety, compromised respiratory status • Frequent utilizer of the ER: 90 visits in 6 months at approximate cost of $148,000.00 • Not obtaining behavioral health services

5. Nurse Care Manager as “the bridge” • Team meeting with ER MD, case mangers, social services, EMS, BCBS representative to understand patient needs, develop strategies and care plan • WRHS team meeting to develop treatment plan • BH referral for counseling and psychiatric medication management • Developing trust : accompanying patient to therapy visit, meeting with patient and mom, on-going telephone support till patient able to manage

6. Jennie’s Story • Early 20’s, living with estranged husband and 3 young children with mental health issues starting in her teens • Limited coping and parenting skills • Domestic assault, court appearances, pending eviction • Involved with multiple agencies with little personal engagement: DCYF-Family Care Community partnership, NAFI (North American Family Institute), and Easter Seals • Reports she sees clinician weekly and psychiatric regularly • Patient and children frequent ER users • High rate of no show for PCP visits

7. NCM: Working with Community • Arranged team meeting with multiple agencies to understand plans of care • Referral to South County Community Health Team • Arranged for Behavioral Health meeting for care coordination; In meeting learned patient not seeing a clinician, not seeing psychiatrist, unaware of ER usage • Arranged for clinician and psychiatrist to see patient, evaluate medications • Monthly care coordination meetings continue

8. Things to Consider • Need to think “out of the box” • Willingness to go into uncharted territory • Takes effort, persistence and leadership: NCM may need to initiate collaboration with outside agencies and understand that the initial effort may be met with resistance