All across the Empire State, healthcare payers, providers, and community-based organizations have spent several years participating in a grand, national experiment of improving medical care for the highest-risk Medicaid enrollees.

While other states are participating in the Affordable Care Act’s Medicaid health home model, New York has integrated this model with existing case management providers to a greater extent than anyone else.

The New York State Health Home Program has no restrictions on which Medicaid providers can deliver services. Medicaid health home organizations enroll patients who have chronic illnesses and a behavioral health issue. They are assigned to care managers who help them take care of their immediate social and behavioral needs before they receive the medical help they also need.

The program is a resource-intensive method of handling the people who are most likely to ignore health problems until they’re severe enough to require hospitalization or an ED visit.

But if it works, and all the case managers and others discussing their work with the program say they think it will succeed, it could be a model for the rest of the nation.

Triple Aim Goal

The program’s results are still being collected and studied, but leaders of participating organizations express optimism. “Not only do I believe it will work, but we believe it’s the right thing to do,” says Amanda Semidey, LCSW, director of Coordinated Behavioral Care (CBC) Health Home in New York City.

“This integrated model definitely is the way of the future,” says Margaret Leonard, MS, RN-BC, FNP, vice president for Medicaid government and community initiatives for MVP Healthcare, a managed care organization in Schenectady, NY. (For more information on how the health home program works, see related article in this issue.)

“In New York, we’re revising the whole system, especially for Medicaid,” Leonard says. “This is a fantastic opportunity for us to really get it right.”

Under the health home model, each enrollee will have one care manager, Leonard says. “We’ll have the challenge of identifying the member’s needs and getting folks the services they need.”

The lofty goal is the triple aim of improving healthcare: reducing unnecessary ED visits, driving down unnecessary costs, and improving population health, Semidey says.

“We’re talking about system transformation, and transforming healthcare is a process,” Semidey says. “It takes patience and planning and building alliances, especially in healthcare.”

Semidey says she believes the state’s grand experiment will work, but it still is too early to talk about outcomes. “It’s taken a while to build up programs and market them appropriately.”

Many Agencies Embracing Health Home

Both traditional case management organizations and agencies that, previously, did not offer care management services are transitioning over to the health home care management model, says Molly Stuttler-James, CASAC, coordinator of adult care management services at Onondaga Case Management Services, Inc. in Syracuse, NY. (See sample list of quality measures collected for health home programs in this issue.)

“We are one of the larger care management organizations, with 55 to 60 care managers,” Stuttler-James says. “This program gives us an opportunity to be creative with what we’re doing.”

Onondaga can try something new under the health home model, and if it works, the strategy can be employed in other case management programs, she adds. “We’re always trying to adapt and evolve to meet the client’s needs.”

Many of the organizations involved with New York’s program have adapted their programs to fit the broader health home initiative. For instance, Upstate Cerebral Palsy in Utica, NY, has evolved over the decades from one disease-specific focus to a broader wellness focus, including mental health, to its current activity with care management under the health home model, says Tara Costello, MSW, CASAC, vice president of behavioral health services at Upstate Cerebral Palsy.

“In the past 35 years, our behavioral health division has grown substantially to include providing housing for individuals with mental health issues, and our specialty is management,” Costello says. “Not only do we provide health home services for the state, but we also provide homeless care management, mentoring services, drop-in centers for people with mental health and substance use issues, and we have an early recognition/prevention program for screening young children.”

Care managers work closely with patients to prioritize what’s needed to keep someone’s health on track, Costello notes.

“Our goal is to engage and work with the individual to make sure their healthcare needs are being attended to,” she adds. “The care manager is responsible for this.”

Community Healthcare Network (CHN) in New York City also started years earlier as a nonprofit community-based organization with a different focus. CHN has 14 health centers across the city, plus two mobile units and a school-based health center, says Karlo Francis, LMSW, deputy director of care coordination for CHN’s Health Homes Program.

“The care coordination services initially were geared toward persons with HIV under a New York state initiative that provided intensive case management services for persons with HIV/AIDS,” Francis says.

The new health home model is similar, although the focus is on any Medicaid enrollee who has the two qualifying conditions. HIV infection counts as one of the qualifying conditions, Francis says.

CHN has trained outreach staff that identifies patients’ immediate needs and shows them how the health home program could help them out.

“This could be a person who needs food and they’re not sure where to get a warm meal,” Francis says. “Or they might tell us they’re being evicted from their apartment, and we have a list of legal agencies that could work with them on helping them stay in their apartment.”

Outreach personnel then ask patients if they interested in enrolling in the health home, where they could receive that kind of help.

“Our guiding principal is we turn no one away, so if a person is in need of assistance, we collaborate and help that person get the assistance he needs,” Francis says.

Sometimes, care managers hone their detective skills to even locate a particular at-risk patient. “We had a woman we needed to locate who had something like 21 ER visits over an 18-month period of time,” Leonard says. “We finally collaborated with a health center that she visited once in a while, and they said they often saw her at a local laundromat, where she kept warm.”

A peer specialist visited the woman at the laundromat and enrolled her in the health home program. The peer specialist learned that the patient had trouble living in her own federally subsidized home, despite being the most reliable caretaker of a granddaughter, who also lived in the home. The woman’s daughter and her daughter’s boyfriend were addicted to drugs, and she wouldn’t stay in the home when they were both there.

“So we helped her get the daughter help,” Leonard says. “Then she was able to get guardianship of the grandchild.”

Case management also helped the woman straighten out some legal difficulties she had with the housing authority. Finally, after these issues were taken care of, they addressed the patient’s uncontrolled diabetes and assisted her with returning to school, which had been her personal goal.

“Her A1c and blood sugars have been really great, and she is regularly seeing her primary care doctor, as well as a therapist, who is helping her handle the stress in her life,” Leonard says. “It’s those kinds of things that are multigenerational that can really affect how a lot of people live.”