Typically, referrals to New York’s health home program are made by doctors, probation officers, or mental health clinics, although they could be made by any community organization or provider.

People are eligible for health home care management services with the following:

  • active Medicaid,
  • meet resident requirements,
  • have two or more chronic conditions, or HIV/AIDS, or one or more serious mental illnesses, and
  • significant behavioral, medical, or social risk factors that can be addressed through care management.

The six-page community referral application, used by one health home agency, lists close to 200 chronic conditions, covering everything alphabetically from acquired or congenital hemiplegia and diplegia to vesicoureteral reflux.

The health home care management organization has 48 hours after the referral in which to contact the patient and schedule a meeting, says Tara Costello, MSW, CASAC, vice president of behavioral health services at Upstate Cerebral Palsy.

Organizations assess whether patients are being contacted and given proper informed consent to enroll voluntarily in the health home program, 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.

“Are they being engaged? Do they have a primary care provider? Is the care plan done?” she says. “While we’re waiting for that information to get to us, we’re still managing them.”

The health home program is being improved continuously as organizations figure out ways to perform certain tasks more efficiently and to communicate more effectively. For instance, one improvement might be to have weekly rounds with different care management agencies to go over a list of patients who should be enrolled, Leonard suggests.

Communication between doctors, hospitals, and others has been a challenge because healthcare providers have worked in silos for so long, Costello notes.

“This program is trying to undo those old behaviors and get people back to working together,” she says. “We’re trying to get hospitals to communicate better with community providers.”

It is fun watching the process work as care managers collaborate, Leonard says. “People get excited about it.”

Care management has to be signed off by a licensed professional, but some of the services can be delivered by peer specialists, Leonard says. “There’s total flexibility of the care managers.”

Once a patient agrees to receive the health home service under Medicaid, a case management agency assesses the person’s needs and risk factors, including housing issues, unemployment, and difficulty navigating the health system, Costello says.

“The case management agency does a comprehensive assessment on the individual, looking at all life areas including social, mental, and all major components,” Costello says. “Once it’s complete, it’s patient-driven: What does the patient want today?”

As a first step, the case manager might determine why the patient has missed appointments and help the person solve transportation problems. In some cases, the case manager may even go to the first doctor’s appointment with the patient to ensure he or she keeps the appointment and knows how to discuss his or her problems with the physician.

“A lot of times, patients are not able to communicate their needs effectively, and the case manager acts as an advocate for that individual,” Costello says. “Also, if the patient is not eating properly or not exercising, the care manager can address that with the doctor as part of care coordination.”

Depending on patients’ needs, care managers will meet with them at a minimum of once a month, to several times a month. Some contacts will be by telephone, Costello says.

The meetings can last anywhere from 45 minutes to several hours, and the care management continues indefinitely. “They stay in our care until they no longer have any needs to be met,” Costello says. “They could be with us forever.”

The challenge for care managers is to keep patients engaged and on the caseload if their situations are high risk, such as patients who are homeless and mentally ill.

New York health home organizations also use technology to facilitate more efficient care coordination.

“Health homes have to have a dashboard where all care coordination services can be documented,” says Amanda Semidey, LCSW, director of Coordinated Behavioral Care (CBC) Health Home in New York City.

“All levels of service providers can access the system, with the appropriate information technology requirements, to update care plans,” she says. “It’s a team approach, and it should be individualized to the member’s unique needs and interdisciplinary team.”

Case managers/care coordinators can communicate with individual health home members through Sense Health, a health information technology solution for patient engagement. The HIPAA-compliant program allows direct contact with members for engagement and health motivation purposes.

“It can be as simple as sending a text to remind a member of an appointment,” Semidey says. “It’s all done in a secure way, uploaded into a dashboard.”