Executive Summary

“Social determinants of health” greatly affect some patients’ health, leading to worse outcomes unless those issues are resolved.

  • New York’s health home model of care for Medicaid patients includes case management to address social and behavioral health issues.
  • Case managers identify barriers and work to resolve them.
  • Patients with health issues that could be cured sometimes fail to take medication because of a mental health challenge.

CMA Series: New York Case Management Model The Leads Way

This is the second of a two-part series on how the health home model works and seeks to improve healthcare coordination and case management services for at-risk Medicaid patients. This issue includes articles about the model’s reliance on helping people with social determinants of health and the program’s enrollment obstacles.

The state of New York’s health home model of care for Medicaid patients has built-in flexibility for organizations to handle patients’ socio-behavioral needs, including mental illness, homelessness, and other social determinants of health.

For example, a patient can be referred to the program because of a mental illness, such as depression, and a chronic illness like diabetes. Many organizations involved with health home have long expertise on connecting the dots between patients’ poor health outcomes and their social determinants of health, which are also called social-behavioral issues.

“We’re primarily a care coordination model, providing medical and behavioral care,” says Amanda Semidey, LCSW, director of Coordinated Behavioral Care (CBC) Health Home in New York City.

“We engage clients and address social determinants of health,” Semidey says. “We strongly believe health can improve significantly over time when an individual is not struggling with homelessness and food insecurity.”

Organizations like Onondaga Case Management Services of Syracuse, NY, have provided case management for people with mental health issues for years and were well-positioned to continue the work when the state changed the way case management would be delivered, says Molly Stuttler-James, CASAC, coordinator of adult care management services.

“Years ago, our focus was primarily on mental healthcare, and we were known in the community for providing case management for mental health,” she says. “Now the shift is to behavioral health, dual recovery, and the new emphasis for us is to physical healthcare.”

Health home-eligible patients are Medicaid recipients who have a diagnosis of a severe mental illness or a chronic condition, including substance abuse or a physical illness.

“The idea was to look at better integrating services within the community for clients,” Stuttler-James says. “There’s more of a focus on helping clients become self-managing.”

The clients the program reaches are people who use the ED often, but no one has had the resources to find out why or to follow up with the patient to make sure he or she does not get sick again.

The health home program seamlessly integrates behavioral and medical health case management, says Margaret Leonard, MS, RN-BC, FNP, vice president for Medicaid government and community initiatives for MVP Healthcare in Schenectady, NY.

“This can only be a win-win for everyone, but especially the member, as you’ll no longer have someone looking at you and saying, ‘Well, I’m going to send in the social worker,’ because that person is coordinating it for you,” Leonard says. “Many more behavioral health facilities are taking on medical care, and medical facilities are taking on behavioral healthcare.”

The key is to get people to visit their providers when needed.

Under the health home model, case managers work with community providers and care providers to identify what is happening with a client, to identify barriers, and get services in place to help the person better manage his or her health, Stuttler-James says.

“We may meet with the person and learn they’re in the hospital all the time because they’re not managing their diabetes and not taking their medications,” she explains. “Or we meet with the client and see there are housing issues, so it doesn’t make sense to work on all of their health issues if they’re concerned about housing.”

Social determinants of health drive ED visits, Stuttler-James adds.

Care coordination relies heavily on communication and collaboration between providers, case managers, and patients. “We encourage doctors to talk with each other and collaborate,” Semidey says.

“We have care coordination across a network of providers, involving them throughout the engagement process,” she adds. “Doctors and therapists need to share information to figure out how to help a person live longer and better, which are the goals of the health home.”

Addressing patients’ social problems has a twofold benefit. First, it helps to build a trusting relationship with care managers and providers. Secondly, clients are more likely to engage in their own care if someone shows them how they’ll benefit from care coordination, Semidey explains.

“You have to answer the question of, ‘What’s in it for me?’” she says. “This often means we have to address the social determinants of health at the same time we address the health and behavioral health needs.”

The reality of healthcare with Medicaid enrollees, and perhaps with most people, is that a social problem or mental health issue can overlap or exacerbate a medical problem. “There may be a confluence of factors that exacerbate a mental health condition,” Semidey says.

“For example, there is a lot of research finding that individuals with chronic or acute medical conditions are often impeded from receiving life-sustaining treatment because of untreated behavioral health disorders, including unaddressed trauma.”

When it comes to homeless patients, their social issues have a huge effect on their health outcomes.

For instance, a diabetic patient who is homeless might not have the means to take insulin or other diabetes medication and cannot maintain a healthy diet. Add to those obstacles the likelihood that the person is depressed and using alcohol or other substances, and the person’s healthcare suffers, Semidey notes.

When a care manager helps the homeless patient find stable housing, regular meals, and transportation to doctor’s appointments, the person’s healthcare utilization increases in a positive way. The person is seeing a doctor regularly and taking prescribed medications appropriately, instead of having episodic and unnecessary ED visits.

“If you have a well-coordinated care coordination team that is nimble, you are walking toward better engagement with the provider and also addressing a member’s priorities and chronic health needs,” Semidey says. “Oftentimes, we need to meet with members when they’re in an acute crisis and initiate coordination at that time.”

The homelessness issue has become important enough to result in a new Medicaid program in which a person who qualifies for the health home program also can receive assistance in finding housing, says Karlo Francis, LMSW, deputy director of care coordination for the Community Healthcare Network’s (CHN’s) Health Homes Program in New York City.

“We assist them with interviews once they go for housing, help them complete a form, and when we get to the shelter, we escort the person,” Francis says. “That’s proven to be very successful, and we hope to expand that.”

Very few traditional case management programs could provide the in-depth kind of help people receive from New York’s health home model.

For example, CHN had one patient who was diagnosed with hepatitis B, diabetes, and who was homeless. He also had post-traumatic stress disorder (PTSD) after a fire destroyed his house. Because of his PTSD and fear of enclosed spaces, he lived on a train platform alone. He refused to live in any building or shelter, Francis says.

“We worked with the corner store, the family, and other people who knew him when he was vibrant in the community, and they helped him manage his medication, having it delivered to the corner store,” he says. “Whenever we needed to find him, we would ask people at the store, ‘Have you seen him today?’”

The man began to see a therapist to treat his PTSD. After a year of this kind of support, the man agreed to live in a shelter. The case management team continued to visit him, and helped him enroll in a program that provides apartment vouchers.

“We partnered with a foundation that helped the patient with furniture, and he now is living in his apartment and comes to the clinic, bringing us candy and thinking of us as part of his family,” Francis says. “It’s a fantastic story, and he’s almost done with this hepatitis B treatment and will be cured soon.”