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Point / Counter-Point 2

Posted By Elizabeth Horevitz and Randall Reitz, Thursday, March 08, 2012

Biopsychosocial Collaborative Care: Innocent Until Proven Guildy

Elizabeth Horevitz

Overheard conversation between two psychology post-doctoral fellows:

Psychologist 1: "I was so frustrated when I got to my community-based placement because I realized that all of my patients needed serious case management. I couldn’t do any of the psychological interventions I was trained to do!”

Psychologist 2: "I had the same thing happen to me! So, what did you do?”

Psychologist 1: "I sent them down the hall to the social worker for case management”.

Psychologist 2: "Yeah, so frustrating. I would’ve tried to do some of it myself, but I just feel like case management is too far below our pay grade”.

Psychologist 1: "Yeah. It’s not what we were trained to do.”

As a clinical social worker, it is not the first time I’ve heard an allied profession dismiss case management as "less than”. Case management is broad term with multiple definitions[i]. In the field of social work, case management has been defined as "a method of providing services whereby a professional social worker assesses the needs of the client and the client’s family, when appropriate, and arranges, coordinates, monitors, evaluates, and advocates for a package of multiple services to meet the specific client’s complex needs… social work case management addresses both the individual client’s biopsychosocial status as well as the state of the social system in which case management operates”[ii]

Integrated behavioral health in primary care is the new frontier for behavioral health practice. If you’ve been following the CFHA facebook debates, you’ll recall this request for people to weigh-in on who they would hire as a behavioral health consultant if they were starting a new integrated clinic. Many people gave their opinions, and the general theme was that focus should not be placed on "guild of origin” (psychologist, social worker, family therapist, etc.), but rather on assessing the individual’s attitude, openness, curiosity and flexibility to be able to effectively meet the demands of this new frontier of integrated behavioral health practice.

Importantly, a general consensus about collaborative care is that a good behavioral health consultant should approach health and well-being from a biopsychosocial perspective which allows us to understand how biological/physiological factors; psychological factors; and social factors converge and act on each other to affect health, and to intervene accordingly.

Unfortunately, my experience has been that the field, in actuality, tends to emphasize the biological (physical health) and psychological (mental health) aspects of assessment and intervention ("biopsycho”), and dismiss or altogether ignore the social components.

Full disclosure: when I first started out as an MSW student, the idea of case management didn’t exactly have me champing at the bit like my classes on motivational interviewing or cognitive behavioral therapy. The fact of the matter is this: case management isn’t sexy. But what I learned right out of the gate, my first day of internship is that case management is just as important (and to be done well, requires just as much skill) as any other behavioral or psychological intervention. It goes back to Maslow’s hierarchy of needs- if a client doesn’t have their basic needs met, even the fanciest most in-depth psychological intervention for, say, depression will simply not work (let alone the brief psychological interventions we tend to offer in primary care).

Social workers are trained in the biopsychosocial model and take a person-in-environment approach to assessment and intervention. Because we are committed to working with vulnerable and underserved populations, a good social worker recognizes that helping a client navigate our fractured systems of care and access needed resources is a matter of social justice. The ability to engage in good case management and client advocacy is just as important as delivering the latest evidence-based psychotherapeutic intervention. You can’t have one without the other.

Try working with a depressed client on "maladaptive thinking” (or behavioral activation, for that matter) when she is unemployed and was just served an eviction notice. And she has three children. And she is about to run out of her diabetes medication. And she doesn’t speak English. Anyone worth their salt as a clinician would say that doing anything other than assisting her with immediate concrete needs would be silly and, in some cases (I would argue) unethical.

It isn’t that the two psychologists didn’t recognize the importance of case management for their clients (on the contrary); it was their perception that this activity, although necessary, was beneath their professional scope of practice that seems so antiquated in this new era of integrated care.

To be effective in behavioral health practice in integrated/collaborative care, case management must be part of every clinician’s toolbox, regardless of guild of origin. There are likely many reasons why case management and client advocacy have not been emphasized in the conversation in integrated/collaborative primary care; ranging from lack of reimbursement structures for case management to residual stigma about case management and the plight of behavioral health practitioners to be recognized as highly skilled professionals within a medically-dominated professional hierarchy.

With the passage of the Affordable Care Act, state and federal reimbursement will increasingly be linked to coordination of care and to "effective case management”[iii]. While it is likely that care teams will increasingly include specific positions for case managers, behavioral health consultants, regardless of guild, should have basic case management within their scope of practice. This is especially true given that we can expect to see an increase in patients with complex needs accessing the health care system in 2014 via the expansion of Medicaid coverage.

It is well known that health behaviors do not occur in a vacuum. Case management puts the "social” into the biopsychosocial model of practice and is a necessary component of improved patient outcomes. So, in addition to the list of requisite adaptations and skills for effective behavioral health practice in collaborative care settings (e.g., brief behavioral interventions, frequent interruptions during sessions, curbside consultation with medical providers), case management skills should be included on the list if we are going to be true to the biopsychosocial framework to which the we (proponents of collaborative care) lay claim. Otherwise, we risk reifying the very same professional ("that’s not my job”) and system-level silos that we have, and are, working so hard to overcome.

[i] For an excellent discussion of case management, its history and purpose, see Case Management: Uses, Critiques and Recommendations for Social Work Practice, Moore, M. (2010) unpublished manuscript available upon request

[ii] National Association of Social Workers (1992). NASW Standards for Social Work Case


[iii] For a summary of the Affordable Care Act, see:


I Beg to Differ

Randall Reitz


Elizabeth, while you make a very compelling and insightful case, I beg to differ.

I share your conviction that case management is a vital service in integrated settings, However, I don’t share your belief that clinicians and staff members of all stripes should embrace it equally. You see, this cantankerous collaborator is old-school beyond his years. I assert that the primary reason to integrate behavioral health and primary care is to expand access to different services in the same setting. The goal is not to have all clinicians and staff provide the same kinds of services.

Primary care is all about hierarchies of licensure and certifications: CNA, MA, LPN, RN, NP/PA, MD/DO. Each of these levels is qualified to do a different scope of medical/nursing care and is salaried based on the spectrum of what they are competent to do. While it is obvious that a CNA should not prescribe medications or order diagnostic tests, it should be equally obvious that it doesn’t make sense for an MD to do all the vitals on her patients. Yes, she is qualified to check vitals and should be willing to pitch-in and check-in a patient if things are backed up. But, in order for the clinic to run efficiently and economically, her principal concern needs to be doing things that only she is qualified to do.  She needs to "practice at the top of her license”.

The same is true for behavioral health services. Yes, I know a number of family physicians and pediatricians who are excellent counselors, but they should rarely, if ever, engage a patient in weekly 30-50 minute counseling sessions. As a behavioral health clinician, counseling sessions are at the top of my license.

I will grant to you that the behavioral health hierarchy is much more flat and fluid than the medical/nursing hierarchy (as are the income levels). But, the differences in training and credentialing are still important. Yes, a well-qualified case manager should engage in some motivational interventions, but should shy away from diagnostics and insight-based psychotherapy. Similarly, as I have worked in safety net settings my entire career, I am very well versed in community resources and governmental programs. I recommend them for patients all the time, and will often make a call to an agency myself to ensure the patient encounters "no wrong door”. With fragile patients I feel ethically bound to maintain the case management duties throughout because of the higher risk of things going awry.

However, the harsh reality is that a seasoned, licensed clinician of any behavioral health guild will command a salary that is 1.5 times what a case manager will make. At the doctoral level it is 2 times as high. As my clinic could hire 2 case managers for what they pay for me, if case management is the main job duty, then they should take away my badge, give me a cardboard box for my belongings, and hire 2 case managers.

This is especially true as it relates to "care management” (i.e. services to activate people with chronic illnesses through outreach and follow-up). Our doctors have really embraced the idea of sending care managers EMR "action items” to call a patient in 1 week to follow-up on a new medication, an exercise goal, or suicidal ideation. Our care managers spend hours on this every day, and have had amazing results. I will eagerly do it myself, but generally only if I already have a counseling relationship with the patient or if the physician judges that it is a sensitive situation.

And finally, even among licensed clinicians, we choose our specialty based on our passion and interests. Just as psychologists might not find case management "sexy”, I don’t find psychological testing sexy. (Nor is it relevant to primary care, but that is for a different blog post).

I have the fortune of working in a diversified setting that includes an LMFT, LCSW, addictions counselor, psychologist, and 2 case managers. In reality, all of us are generalist in scope and perspective. But, I would hope that if a patient requires sophisticated diagnostics, that the referring party would seek out the psychologist. If the patient needs family therapy, then all things being equal, they had better come find me. If the patient wants to break his wake and bake habit, then I hope they would seek out my addictions counselor colleague. If the case involves multiple agencies or is more socially-focused, then I'd hope they’d look for the LCSW. If the patient just needs a heads-up about how to apply for Medicaid or an outreach phone call, then the case manager should be the go-to person.

To do otherwise, would be lesser patient care, less financially wise, and wouldn’t promote the job satisfaction of the members of our team.

Elizabeth Horevitz
Randall Reitz
Elizabeth Horevitz MSW, is a doctoral candidate at the University of California, Berkeley.  Her research focuses on evidence-based primary care interventions for Latinos and other underserved populations.  In a previous CFHA blog post she cast aspersions at the "warm hand-off".

Randall Reitz PhD, is CFHA's Director of Social Media and the Director of Behavioral Science at the St Mary's Family Medicine Residency in Grand Junction, CO.  He does more case management than he cares to admit.

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Comments on this post...

Barry J. Jacobs says...
Posted Thursday, March 08, 2012
A splendid, well balanced debate. It reminds me of the controversy in the field of physical medicine and rehabilitation in the early-1990s about whether care should be mutlidisciplinary (practitioners from different disciplines with their respective goals working with the same patient), interdisciplinary (practitioners from different disciplines working on a common set of goals with the same patient) or transdisciplinary (practitioners from different disciplines who could each provide the range of treatments to address all the common goals for the same patient). I worked on a purportedly transdisciplinary traumatic brain injury team in a PMR hospital where the physical therapists were supposed to do counseling when with the patients in the PT gym and the psychologists were supposed to reinforce proper physical transfer techniques with those patients when they were in the psychology offices for counseling. This was called "role release"--giving up the boundaries of your guild-defined practice to work as a team for broader prescribed goals. It all sounded good in theory but was difficult to work out in practice. Turf issues still abounded. Not everyone was competent to practice everyone else's discipline. After a while, we evolved back into a more interdisciplinary mode of working where the boundaries between disciplines were maintained.

All that may sound like I favor Randall's viewpoint. But I don't. I think Elizabeth makes a persuasive argument that case management isn't just another guild-defined practice but is a foundation upon which all other biological and psychological interventions must depend. We all have to abet helping our patients obtain the resources to give themselves a fighting chance. I know I spend much of my time as a psychologist with patients helping them with the basics--food, shelter, work. (Isn't there a story about Freud serving herring to a psychoanalytic patient who was hungry?) I don't believe we should operate in a transdisciplinary fashion but believe case management is within all practitioners' purview.
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Elizabeth Horevitz says...
Posted Sunday, March 11, 2012
Thanks for your thoughtful, well-written counterpoint. I think we agree more than we disagree, at least with respect to the kinds of day-to-day activities you describe engaging in (gaining familiarity with local resources, client referral, and follow-up phone calls). This is the type of “basic” case management that can and should fall squarely within the scope of generalist behavioral health practice in primary care. Ideally, of course, complex cases should be referred to case managers (in settings that are lucky enough to have them) who have the time and ability to follow-up on multiple referrals, build relationships with community agencies, etc. This is consistent with the primary care model of stepped care. In team-based care, as Barry Jacobs has astutely pointed out, each team member brings unique skills to the table to round out comprehensive care management. My argument is that the basics of case management and client advocacy need to be part of every generalist clinician’s toolbox (as they are yours). The neglect of case management in the professional literature on behavioral health consultation in primary care is a serious flaw in this model of care which fancies itself the coming of true biopsychosocial care.
In regards to your argument about professional hierarchy, your reasoning breaks down in relationship to behavioral health consultation (which you acknowledge to be much more fluid then the medical hierarchy). Given all of the modifications to traditional psychotherapy practice required for working in primary care, the basics of case management should not be a stretch for any behavioral health practitioner that fancies him/herself a “generalist”. Moreover, there are no risks to engaging in case management as there would be for, say, a non-prescriber prescribing medication. The true risk here is to the client in need of services when their behavioral health consultant refuses to pick up the phone to make a connection or advocate on his/her behalf because of an antiquated notion of professional domain.
Finally, if you still don’t buy my case and want to fall back on guild-identified activities, check out the new competency requirement for MFT licensure (at least in California): Client-Centered Advocacy ( It seems MFTs are getting on board with this activity, so imperative for client success… who’s next?
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Randall Reitz says...
Posted Wednesday, March 14, 2012

There is a clear role for motivational interviewing in case and care management. M.I. is all about assessing traits like “readiness for change” and “self-efficacy” using 1-10 sliding scales. So, here are my conclusions:

Importance of case management: 10 (FTW!)

Speed of referral to case managers: 9

In my toolbox: 7

Passion for case management: 2
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Randall Reitz says...
Posted Tuesday, April 03, 2012
An update on my counter-point: last night I received a phone call from a distraught friend whose child had had a very bad meltdown at school. She was informed that he was not to return to school until he'd had a psychosocial evaluation. I am very familiar with the services and clinicians in my community and can usually get my referrals in with anyone by calling on a favor. So, who did I call?

The Psychology intern who wowed me earlier in the day with her case management knowledge and commitment. For my friend, I knew I needed someone who would go through all the hoops with the teachers and school district, and for my friend I wanted the person who would do the hoop jumping herself rather than pawning it off on someone else.

Lesson learned.
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