Biopsychosocial Collaborative Care: Innocent Until Proven Guildy
Overheard conversation between two psychology
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”.
"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
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.
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 firstname.lastname@example.org
I Beg to Differ
Elizabeth, while you make a very compelling and insightful case, I beg to
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
|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.