Complex Cases: When to Use a Case Manager vs. an MPCP?

Last month, we described our new model for care delivery in complex cases, the Medical-Psychiatric Coordinating Physician (MPCP). This designation refers to a physician who leads a multi-disciplinary treatment team and provides the required coordination between team members. He or she also monitors the treatment to be certain that outcome objective are being met. Often that monitoring is done formally, using checklists and self-assessment protocols to follow patient progress.

Doesn’t sound like plain ol’ one-to-one psychotherapy, does it? Yet, the MPCP model was developed by two clinicians with psychoanalytic training, Steve Frankel and Phil Erdberg. It has been found especially useful for complex cases with combined medical and psychiatric contributions, or, more properly, medical-psychiatric co-morbidity. This statement seems especially true for complex cases where the presenting problems are balanced toward psychiatric or psychosocial issues.

As an alternative approach to the management and treatment of complex cases, there is a popular movement supporting the use of a non-physician Case Manager (CM) as the liaison between treatment team members, the patient, and his or her family. The decision to move in this direction (toward a non-physician case manager) is often made for financial reasons, especially in managed or publicly-funded care settings where there are an excess of patients to treat and not much money to pay for their care. Two of the major voices advocating for this category of care delivery are Roger Kathol and Wayne Katon (references below). In their models of care, physicians are consultants to the treatment team, and care is stratified according to the needs of the patient, progressing from one type of appropriate intervention to another as a treatment moves forward.

One major problem with formulating and advocating for a particular “system of care,” such as the MPCP model, or those that make use of a CM, is that one size never fits all, especially when the subjects being targeted are human beings. Another problem is the lack of outcome data, so that one doesn’t know which system works best and for whom. This kind of data isn’t abundant for CM models, and what studies exist generally haven’t been carried out for more than a year or two. For our own MPCP project, we actually do have that kind of data for 52 patients, each treated for at least 18 months and for many of the participants much longer. However, our data for the most part is based on clinical observation and not the result of a formal, prospective study. Over time, we will need better and broader data (e.g., from a range of treatment circumstances) to see what kind of treatment arrangement is truly best for which patients. Also important is that a rose by any other name is often not a rose. Different treatment models and target populations may be characterized by similar names (for example, referred to as appropriate for the treatment of “complex” patients), but be associated with different kinds of services and most effective with different patient populations.

Compare the following brief descriptions of three of Kathol’s “complex” patients, ultimately treated according to his CM model, to one of our MPCP cases:

a. Rubin, 57 years old. Back pain progressive over years. Identified as a focus case for their clinical service because of numerous emergency room visits and his requiring multiple medications, including opiates. Add, fear of losing his job, and moving from physician to physician as they stopped being willing to prescribe narcotics.

b. Lucinda, a 37-year-old morbidly overweight woman referred by insurance reviewers looking for patients who use (overuse) “many” health services. She had numerous surgical procedures, emergency room visits, and hospitalizations over the past two years. She was threatened with losing insurance coverage and became depressed to the point of being unable to work and manage her life.

c. Alvin, a middle-aged truck driver, too proud and too stubborn to ask for help when afflicted by “breathing episodes” due to complications of asthma. Progressively, these respiratory episodes were associated with anxiety and depression, impacting Alvin’s work performance. A “disability management team” in consultation with a physician was created, but was ineffective and inefficient for managing Alvin’s medical and psychiatric conditions. A nurse case manager associated with an integrated team was ultimately assigned to the case and functioned more successfully in tracking and engaging Alvin to utilize proper treatments.

As a contrast, Solomon, an MPCP case from my (Steve Frankel’s) office-based practice, had a chronic disabling disease, scleroderma. His wife had left him due to his disfigurement, launching him into a depression and forcing a move across the country to live near his son and daughter-in-law. When I encountered him, he was isolated and despondent, but resolute and anxious to engage in an interpersonal and health management treatment in which he could be an active participant.

Which type of case management fits best for which patient? Clearly Kathol’s “complex cases” are quite different from those we have been writing about. (1) Kathol’s patients have a preponderance of medical pathology and health systems related difficulties, while for our cases, those we have been writing about, treatment issues are skewed toward the psychosocial and psychiatric. (2) Further, the MPCP emerges as a clinician who is interpersonally (therapeutically) engaged with each patient, while Kathol’s Case Manager is likely to be a nurse or nurse practitioner whose attention is focused on medical or medical-psychiatric management geared toward basic maintenance. The coordinators’ objectives in these treatment situations are not the same. Psychologically and psychiatrically, the objectives for the MPCP are interpersonally more far reaching, while the CM’s are more medical, basic, and practical. (3) Of course, at least in some cases, the dominant variable may be the availability of health care services and not the nature of the patients who are being treated. Greater access to services and more consistent attention to the details of patient needs are associated with the MPCP model.

As one similarity, note that both systems of care generally strive to deliver “integrated treatment” where attention is paid to all pertinent aspects of the case. This orientation is to be contrasted with the old-fashioned option of providing minimal case management (and often no formal monitoring of progress), i.e. the “silo” model. This term refers to care delivery by clinicians located in separate offices (silos) and who either have difficulty incorporating other clinicians with different skills as collaborators, or are simply too burdened to do so.

So, what then is so unique about the MPCP model? Why do we feel it has an important place in the future delivery of care for complex cases, especially those with a preponderance of psychiatric and psychosocial pathology? We will continue this discussion in our next issue when we will also describe our 52-patient MPCP pilot study. However, the answer should already be emerging from this discussion.

The MPCP method is, of course, applicable to the management of complex cases in general, not just those skewed toward mental health and psychiatry. Having a physician coordinate a treatment team increases the likelihood of competent case management from both a medical and mental health standpoint. Also, physicians are most likely to be persuasive with other physicians and therefore especially effective as team leaders for these multi-participant cases.

It is noteworthy, however, that the MPCP cases we have treated do, indeed, generally require a leader with competence and interest in psychiatric and psychosocial matters. The associated treatment teams do best when they are headed by a physician who is not only conversant with medical matters, but also has a mental health/psychiatric background and an interest in the interface of mental health and medicine. Further, as an additional requirement, the patients who are likely to benefit best from MPCP treatment are those who have the capacity to work deliberately with the treating clinician. That is, for best results the patient should be able to develop at least a rudimentary treatment alliance.

References:

Roger Kathol and Suzanne Gatteau, 2007. Healing Body and Mind: A Critical Issue for Health Care Reform.

Kathol et al., 2010. The Integrated Health Management Model.

Katon, Unützer, Jürgen, 2011. “Consultation psychiatry in the medical home and accountable care organizations: achieving the triple aim”, General Hospital Psychiatry, 33, 305–310.