Wellness Case Management

The Montgomery Area Community Wellness Coalition (Wellness Coalition) provides Wellness Case Management services (WCM) as a means to improve health and wellness for under/uninsured individuals with chronic illness who live in the River Region counties of Montgomery, Autauga, Elmore, Lowndes, and Macon. WCM is currently limited to eligible individuals identified by Coalition providers and/or referred from 2-1-1 Connects, and who present with one or more of the following risks:

Wellness Advocates are located at the following Wellness Coalition provider sites:

Comprehensive Health, Psychosocial, and Environmental Assessment: This is a determination of risks relating to specific health, social , or environmental needs that a Client may have that affects their health/wellness as well as a determination of strengths that will help them achieve their wellness goals. This assessment also includes such things as determining whether the Client has a medic al home, whether the Client is eligible for some form of financial assistance or other resource, or whether the Client has barriers to needed he al th services. Strengths include such things as their knowledge level about their chronic disease, whether or not they can self-manage their condition, or whether they have family or other support for making healthy lifestyle changes.
Case Planning: This is the development of a Wellness Plan that is co-created between Client and Wellness Advocate so that the Client can achieve specific goals by taking action specific to their risks, strengths, and chronic disease(s). The Wellness Plan will identify and include resources and services that reduce barriers to self-management, and improve access to a medical home and appropriate health services use.
Crisis Intervention: This level of services (Level 1) consists of assisting a Client through a healthcare crisis situation and arranging for resource(s) by others. This is typically provided through the Jackson and Baptist Medical Center South hospital emergency rooms.
Resources and Linkage: Wellness Advocates provide information on other River Region health and human service resources accessible through 2-1-1 Connects, including Steps to a Healthier AL River Region resources for information and access to healthy life style changes such as nutrition classes and exercise facilities, etc.
Education: Wellness Advocates provide health education material and information for health promotion, prevention, health services utilization, medication use, and/or for specific disease self-management strategies related to existing diagnoses. Education will also provide information and support for making healthy life style changes.
Medical Transportation: Clients enrolled in WCM who need medical transportation may receive it. Available information related to transportation resources or contacts for nonmedical or nonhealth-related transportation is provided to the Client if needed.
Advocacy: Wellness Advocates obtain services and benefits based upon Client needs on their behalf when the Client is unable to do so alone; however, Clients are provided education, skills and support when indicated so that they are empowered to obtain their needed resources and services.
Contacts: Clients are responsible for initiating the contact with their Wellness Advocate each week to co-assess progress toward meeting their wellness goals until the case is closed. Follow-up contacts are conducted with Clients either by phone or in person. One home visit is required for all Level 3 Clients during the initial assessment and may occur at other times if necessary.
Follow-up and Case Closure: Services include monitoring and follow-up to assure progress, revise actions/goals when necessary, or case closure after determination is made wellness goals have been met.

During FY 2005, WCM is provided in the Emergency Departments of Baptist Medical Center South and Jackson Hospital; at the Lister Hill Clinic and Montgomery Primary Care Clinic of Health Services Inc.; at the Montgomery Area Mental Health Authority; and at the Medical Outreach Ministries Family Health Clinic. WCM is available during regularly scheduled clinic and provider agency operating hours; however provider agency staff may disseminate and receive WCM applications that are picked up and processed the following workday by Wellness Advocates.

For FY ‘05 (ending August 31, 2005) Clients must be residents of Montgomery, Autauga, Elmore, Lowndes, and Macon Counties.

For Crisis Intervention (Level 1), the length of service may be minutes, hours or days, but is typically short term by the nature of a single need linked with resource(s), such as transportation for a primary care appointment. Level 2 or Level 3 Clients, on the average, are provided wellness case management for an average of two or three months to provide sufficient time to set and achieve goals that allow them to manage their chronic conditions and/or achieve improved access to and utilization of health services.

During FY ‘05, individuals meeting the criteria listed above in Nature and Scope of Services who present in one of the Coalition partner sites who are either (1) identified, screened and referred by staff at each site, or (2) who complete a self-application/release, or (3) who enter as a caller to 2-1-1 Connects will be provided services.

One of the priorities of the Wellness Coalition is that WCM should not duplicate existing services. For that reason, the Wellness Coalition implemented a shared management information system among partners called the MAIN (Montgomery Area Information Network) that allows all partner agencies to consult a shared database for key patient/Client data and Client tracking. This priority for coordination also means that there may be instances when a referral is received that either requires a consult with the referring agency’s existing social worker/case manager(s) to determine if a “co-case manage approach” is appropriate. In either case, careful attention to identification and referral according to WCM admission criteria or eligibility for other existing case management services in the community will assure nonduplication.

Client did not present at or is not referred from a Wellness Coalition partner agency or 2-1-1 Connects
Client resides outside River Region
Client refuses services at any time during case management
Client does not meet the eligibility criteria or during the intake and assessment appears to have sufficient resources documented to end the intake process
Client’s condition is dangerous to himself or herself or serious enough to warrant initial, primary referral to other case management services that exist in the community for conditions such as homelessness, seriously mentally ill or frail elderly. However, if a Client is currently enrolled in case management for any of these situations and is uninsured, that Client is a candidate for a “co-case management approach, during which time both the case manager and advocate would confer and work together to assure wellness goals and Client needs are met without duplicating services. One example of this is the MAMHA Outreach Services Program that serves seriously mentally ill adults. Uninsured persons who are seriously mentally ill or who meet other admissions criteria of that program should be referred first to the MAMHA Outreach Services Program, where a case manager could screen for other conditions requiring WCM and make a written referral of their Client to the Wellness Advocate stationed at MAMHA.

WCM staff is either employees or subcontractors of Wellness Coalition partner organizations. WCM is provided by Wellness Advocates who are community health workers that serve as both peer support and change agents. Wellness Advocates work with Clients to improve their self-management of their chronic conditions. The Wellness Coalition also has two Wellness Case Managers who each possess a bachelor’s degree who have additional assignments. WCM training and continuing education is arranged by the Wellness Coalition and Wellness Advocates are required to work with a preceptor for a minimum of two (2) weeks. Wellness Advocates are also provided training in entering data and using the MAIN database to track their Clients and document services. The WCM Coordinator monitors quality and productivity using MAIN reports, case reviews and staff meetings.

There is no formal appeal procedure; however, a person denied services may discuss this with the WCM Coordinator to obtain an understanding of the reasons for denial. Complaints are received through the QA process.

MAIN provides for the electronic documentation of WCM services and as such is the primary source of information; however HIPAA compliant Client signature on required forms such as the consent for services must be maintained in a permanent WCM Client record. A list of forms and Client materials is found in the policy and procedure manual.

Within six months of case closure, the WCM Coordinator, in order to determine the success of WCM, will conduct an outcome evaluation. At the time of case closure, the Client completes the Client Satisfaction Questionnaire. Outcome indicators are reviewed quarterly for progress in achieving the goals the Wellness Coalition set for the case management component. Staff is evaluated within the employment parameters of their hiring organization and/or Wellness Coalition contract deliverables. Documentation includes the following forms: