The following is how WellCare’s HealthConnections program helps case managers provide social service support to their patients:

  • Connecting members to community aid. WellCare patients are connected with care management because of their chronic illnesses, including diabetes. If a care manager finds that the person needs access to healthy food or rent assistance, then the care manager can look on the HealthConnections database for local organizations that provide that type of help, says Pamme Taylor, vice president for advocacy and community-based programs for health insurer WellCare.

“The database lists all the social services, including rental assistance, utility assistance, food pantry, farmer’s market, and others,” she says. “This is right in the middle of our care coordination model, so care managers look up services, reach out to the organization, and let them know we have a patient in need.”

Each of these connections is captured in the health record, alongside the clinical care and comorbid conditions, Taylor adds.

“It’s all at the case manager’s fingertips,” she says.

  • Collecting information. “We maintain network information, and it’s constantly growing and evolving,” Taylor says.

The team working on HealthConnections consists of 65 people, half of whom are spread across the states covered by WellCare. Their job includes maintaining data on which resources in the database were used by plan members.

  • Connecting with community organizations. Part of the team’s work is to find available services that could meet patients’ gaps. They search in areas where WellCare has members who might need the help. They reach out to churches, nonprofits, and any group that provides services for economically disadvantaged people, says Charles Talbert, regional communications manager for WellCare Kentucky.

“They say, ‘Do you provide services for these things?’ and then we put them in the database,” he says. “That’s through our advocacy program.”

Sometimes, a community doesn’t have adequate transportation, housing, or other types of help, so community advocates will convene organizations and discuss how many people have obstacles to receiving healthcare, Talbert explains.

Together, the groups might start a pilot program to help with unmet needs. For example, in Hopkins County, KY, a community advocate worked with a local transportation company to create a voucher system that patients could use to get to medical appointments, Talbert says.

“We find organizations, identify a gap, and create a resource,” he adds. “This is a living organism that continues to grow.”

  • Provide a community assistance line. The program has 32 people who work on the community assistance line to help people in the community who are not in the case management program, but who also might need help.

“Oftentimes, people in the community who need services don’t know how to find them,” Taylor says.

The database is available to the larger community, including plan members’ family and friends, she says. “We wanted to make it available to our caregiver network.”

Expanding access to the database is a way to do outreach.

“We wanted to see if we could capture some of the audience that is not in care management, but could be, and we can make them aware of options,” Taylor says. “As part of our diversity and inclusion program, we set up a call center and hired individuals through the workforce innovation programs like Welfare to Work.”

These workers have been enrolled in Medicaid or Medicare, and they can be seniors with disabilities, caregivers, students, and individuals who know how to navigate the social safety net but need a little help to get to the right social services, Taylor explains.

  • Empower care managers. “While every care manager completes a health risk assessment, they’re also trained on how to identify when a member has a social need,” Taylor says. “So if a case manager is meeting with a member face-to-face, they can pick up on visual cues that show what’s happening in the person’s environment.”

Case managers develop rapport with members and quickly figure out what they need. “Then they turn to the online database to find those resources,” Taylor says.

One common need involves food, says Kendra St. Vincent, RN, CCM, senior field service coordinator for WellCare Kentucky.

“I see people who have difficulty accessing healthy food or who can’t buy enough food to last the month,” St. Vincent says. “The database can pull up the food bank in a member’s area, and we can give the person that information about where they can get fresh food and vegetables that meet their budget.”

Housing is another basic need that some members lack. “Here in Bowling Green we have Hotel Inc., which is a street medicine program with homeless members,” she says.

Through a partnership with Hotel Inc., WellCare case managers can help with health check-ups, while Hotel Inc. helps WellCare workers find homeless patients.

“The ultimate goal of the program is we want to find long-term housing for the homeless,” St. Vincent says. “We have found that a lot of homeless members fear getting a healthcare check-up, getting a colonoscopy or mammogram, and we realize we can make a real difference in their lives.”

For instance, one member who was found by Hotel Inc. had not seen a doctor in years. His vision was poor, and a case manager helped him connect with an organization that gave him glasses, Talbert says.

In another case, a plan member needed dentures, and HealthConnections didn’t have the resources to give them to the member, St. Vincent says.

So St. Vincent put a “gap” need in the database, asking for dental care, and someone responded with a solution, she says.

The man got his dentures and could again eat his favorite food of steak, she recalls.

“If a person’s basic needs are not met, then they cannot focus on health needs,” St. Vincent says. “Our ultimate goal is to get them healthy.”