Case managers across the continuum work closely to coordinate care in New York state’s health homes, aimed at improving care for high-cost Medicaid beneficiaries.

  • Health homes are a coalition of hospitals, physician practices, clinics, mental health organizations, community-based organizations, health plans, and other providers and agencies that join to provide coordinated services.
  • Instead of providing piecemeal care, case managers in a variety of settings consult each other and collaborate on the care plan.
  • The New York initiative developed a system so case managers at all entities can share information in real time and identify when a client is receiving services at a different site.

In New York State’s health homes, case managers throughout the continuum are reaching out to their counterparts on the payer side and in other venues for information about patients, reports Margaret Leonard, MS, RN-BC, FNP, senior vice president, Medicaid, Government and Community Initiatives for MVP Health Care in Schenectady, NY.

“Case managers are developing a new appreciation for each other,” she says. Her health plan is part of the larger healthcare community of Delivery System Reform Incentive Payment (DSRIP) Performing Provider Systems/Health Homes, and other providers who are collaborating to improve the health in their community.

New York was one of the early adopters of the health home initiative, created by the Affordable Care Act. The program aims to provide coordinated services for high-cost, high-utilizing Medicaid beneficiaries with chronic conditions such as mental health conditions, substance abuse disorders, asthma, diabetes, HIV, heart disease, and obesity.

“Now, we have all these care managers from community-based organizations and healthcare providers who are willing to coordinate new services,” Leonard says. “In the past, our members struggled to find assistance. Now, case managers at all of the components of the health homes program are coordinating and consulting about the care plan. It’s fun to watch as everyone has a new appreciation for each other, realizing that we’re all in this for the benefit of the patients.”

Health homes are collaborative networks of community-based organizations, health plans, providers, and other agencies that join to provide coordinated services to high-utilizing, high-cost Medicaid recipients with chronic conditions. Instead of receiving piecemeal services from several providers, the members are assigned one person who coordinates everything.

The care managers bring together all the providers treating a patient and share the care plan with everyone who comes in contact with an individual, ensuring that all clinicians are aware of what the others are doing and that everyone is on the same page, Leonard adds.

The health home system in New York was designed so that providers can identify patients who are in the health home and get in touch with their case managers right away.

“A major piece is that hospitals, health plans, clinics, ambulatory sites, and other providers are all collaborating to create healthy communities and sharing information in real time,” Leonard says.

For instance, a case manager in the hospital may alert a health plan case manager when a member is hospitalized with a chronic illness. The health plan case managers can contact the patient in the hospital or the health home’s care management agency and get a head start on post-discharge education and support.

“One of the most opportune times to enroll patients in a disease management program is when they are in the hospital. Nobody wants to be in the hospital, and patients often are ready to think about changing to prevent being hospitalized in the future. When the hospital case manager, the health plan case manager, and case managers in other settings collaborate, everybody wins,” she says.