Executive Summary

People who have mental health issues and social problems are difficult to enroll in a healthcare program, even if it would greatly benefit them.

  • Enrollment criteria in the New York State Health Home Program includes people with ongoing chronic mental health or behavioral health and physical conditions.
  • Referrals come from doctors, therapists, treatment centers, and other sources.
  • Case management teams meet with people about the health home program, but have found it difficult to convince a large majority to enroll.

One of the major challenges of a sweeping care coordination management program that targets people with the trio of medical, behavioral, and social problems is that this very population is among the most difficult to enroll in any kind of sustained healthcare effort.

The New York State Health Home Program has the triple aim of improving healthcare for its target population, reducing costs, and redesigning the current Medicaid system. Enrollment criteria include having significant, ongoing, chronic mental health or behavioral health and physical conditions, says Molly Stuttler-James, CASAC, coordinator of adult care management services at Onondaga Case Management Services in Syracuse, NY.

“Referrals can come from community providers, therapists, treatment centers, or self-referrals — someone walking in the door,” she says. “The first point of contact is the referral source.”

Once a referral is made, the case management organization starts outreach services including visiting a person in the hospital or calling the patient to schedule a first intake appointment, Stuttler-James says.

“We ask them if they understand why they’ve been referred and how our service can help them,” she explains.

“Our services are entirely voluntary and they can opt out,” Stuttler-James says. “But our hope is that we engage very quickly with people and get them in to see an assigned primary care manager, who helps them identify their personal goals.”

The health home program’s goal is to collaborate with the state and community partners to develop services that will help high-risk patients stay out of the hospital, says Tara Costello, MSW, CASAC, vice president of behavioral health services at Upstate Cerebral Palsy in Utica, NY.

Enrolling patients through community referrals is taking longer than hoped, Costello says.

“The conversion rate has not been the most successful,” says Karlo Francis, LMSW, deputy director of care coordination for the Community Healthcare Network’s (CHN’s) Health Homes Program in New York City.

“That is something where we are working with the state to figure out ways to change it,” Francis says. “Across the state there is a 12% to 14% conversion.”

One of the chief obstacles to enrollment is the program’s “health home” name, he says. “It connotes a place where people think they’ll be placed, so there’s that confusion.”

Another problem is that the people following up on referrals often have to show up at someone’s home without a prior phone call, and it unnerves clients to learn that someone they don’t know has their name and information. This creates distrust, Francis says.

CHN has invested many resources into integration and care coordination, Francis says.

For example, CHN receives a list of patients in the city, including those who do not have a primary care provider. The organization conducts community outreach and embeds people in the clinic to educate patients about the New York State Health Home Program’s services. The next step is to enroll patients and assist providers by taking the new patients to doctor’s appointments when needed, Francis explains.

“That has helped our conversion rate significantly because these are people that can relate to how we’re working with their providers and are seen as part of the team,” he says. “We’re also embedded in some of the shelters in the city with outreach and care managers who are connecting with patients to make sure they get primary care.”

CHN’s system includes having interdisciplinary team members meet with providers and assign a care manager to each patient. Physicians set health goals, and care managers help patients meet those goals. For instance, if a physician decides a diabetic patient’s blood glucose level needs to be reduced, the care manager follows up with the patient to make sure he or she is checking sugar levels, engaging in healthy activities, meeting with a nutritionist, and visits the patient at home as needed, Francis explains.

Keeping people enrolled in the program also is challenging. For instance, one community provider planned to discharge a client because she did not show up for appointments. The patient’s medication caused sleeping problems, so the case management team met with her, her doctors, and family members and set up a new plan, Stuttler-James says.

“We had a collaborative meeting, solved the problem, and had the client continue on a recovery path,” she adds.