ASAP

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Health Homes Care Coordination A Key to
Integrated Care Positive Outcomes
Presented by Joanna Larson, Senior Director of
Health and Business Services
Empowering Individuals to Strengthen Communities
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Part I What is Health Homes?
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Health Homes

• The Health Home program resulted from of the
  Affordable Care Act and the Medicaid Redesign
  Team for NY State
• The Medicaid Redesign Team was charged with
  reducing cost while increasing quality and
  efficiency in NYs Medicaid program
• The chronically ill represents 25 of Medicaid
  recipients yet, they drive 80 of the cost (6.9B)
• It is estimated that at least 975,000 Medicaid
  individuals meet the criteria for the Health
  Homes program
• Health Homes will improve the health care
  provided to both Fee-For-Service( FFS) and
  Managed Care Plan (MCP) members of the Medicaid
  program

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Triple Aim 3 Dimensions of Value
Population Health
Experience of Care
Per Capita Cost
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Health Homes Goals

• Improve the experience of care
• Improve health outcomes for chronically ill
  clients
• Reduce Medicaid expenditures
• Intended outcomes
• The Health Homes Program will save money by
  reducing preventable hospitalizations, emergency
  room visits, and unnecessary care via the
  provision of a higher level of coordination among
  the patients various care providers

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Eligibility Criteria

• Two Chronic Conditions, or a Severe Mental
  Illness, or HIV/AIDS.
• Chronic conditions include, but are not limited
  to
• mental health disorder
• substance use disorder
• asthma
• diabetes
• heart disease
• obesity (BMI over 25)
• HIV/AIDS
• Hypertension
• certain types of cancer

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Client Attribution to Health Homes

• The State uses a combination of the following to
  assign Medicaid enrollees to Health Homes
• clinical risk groups (CRG),
• an algorithm that predicts hospitalizations, and
• behavioral health indicators
• Medicaid enrollees are assigned to a health home,
  to the extent possible, based on existing
  relationships with ambulatory, medical and
  behavioral health care providers or health care
  system relationships, geography, and/or
  qualifying condition.
• Initial assignments are for members who qualify
  for Health Home services but are not currently
  linked with primary care or case management
  providers.

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How does a Health Home work?

• Clients are either found in the community and
  meet eligibility criteria, or are assigned to us
  directly by the Health Home
• The client is outreached, located, engaged and
  enrolled
• Once enrolled, the Care Coordinator identifies
  areas of need and current providers in the
  clients care team, and referrals are given to
  fill gaps in service
• The Care Coordinator and client collaboratively
  build a care plan that outlines goals, barriers
  and strengths
• The Care Coordinator collaborates with the
  various treatment providers in the care team to
  ensure client compliance and continuity of care
• If the client is hospitalized or otherwise
  involved in a critical event the Care Coordinator
  takes the lead on transitional care planning and
  stabilization

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What are Health Home Services?

• Health Home services in accordance with federal
  and State requirements
• Comprehensive Care Management
• Care Coordination and Health Promotion
• Comprehensive Transitional Care
• Patient and Family Support
• Referral to Community and Social Support Services
• Use of Health Information Technology (HIT) when
  feasible
• Quality Measure Reporting to NYS

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Examples of service provision

• Client Xs qualifying diagnosis are
  Schizophrenia and Diabetes. The client is linked
  with a Therapist and Psychiatrist at an
  outpatient clinic, but does not have a PCP.
• Care Coordinator (CC) will refer Client X to a
  PCP so that their Diabetes can be monitored and
  treated appropriately.
• CC will coordinate with the Client Xs existing
  providers to create a comprehensive client
  centered care plan that is collaboratively
  arrived at with the input of the client and
  his/her care team.
• Client Xs housing is suddenly compromised CC
  works with the clients care team and community
  providers to ensure housing is reinstated, or
  client is relocated.

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Part II Health Homes Results Best Practices
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NADAP Health Home Care Coordination

• Since 1971, NADAP has been working with clients
  diagnosed with Substance Use Disorders (SUD) in
  the early years our primary focus was on
  employment support services for recovering
  addicts
• We have been engaged with multiple Health Homes
  since 2012
• We contract with 7 Health Homes in New York City
  and partner with 30 community based treatment
  providers and 2 hospitals to engage clients in
  Health Homes Care Coordination
• We currently serve approximately1,600 clients in
  outreach and serve 1,000 enrolled members.
• Approximately 50 of our enrolled members are
  diagnosed with a SUD

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Health Home Members with Substance Use Disorders
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Assessment Scores

• The total Average for this sample is 71.55
• from a range of 0 112
• Physical well-being17
• Social well-being10.36
• Emotional well-being10.53
• Functional well-being 12.71
• Health Home Functional Questionnaire 20.95
• Clients in Staten Island have lower overall
  average social well-being scores, followed
  closely by clients in the Bronx
• This sample shows low social/emotional/functional
  well-being scores on average
• Clients who are homeless or who have unstable
  housing have lower overall emotional well-being
  assessment scores.
• Clients who are linked with SUD services have
  higher overall assessment scores.

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Diagnosis 100 of clients have a SUD and there
is an overlap among the co-occurring disorders
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What was it like prior to Health Homes?

• In the years from 2000 through 2012, Medicaid
  enrollment grew by more than 80 percent statewide
  to cover about 5 million New Yorkers
• With high rates of chronic illness and
  homelessness the inpatient hospital and ED
  expenditures skyrocketed
• 54 billion in Medicaid expenditures in 2012 in
  NY alone, which is double or triple the majority
  of other states in the US

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Outcomes
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Case Example Client X

• Age 55
• Gender Male
• Race/Ethnicity African American
• Location Brooklyn, NY
• Diagnosis Major Depressive Disorder with
  Psychotic Features, Drug Induced Mood Disorder,
  Diabetes
• Barrier to achieving wellness chronic
  illnesses, history of non-adherence to treatment,
  history of chronic homelessness, history of
  frequent hospitalization
• Strengths Openness to a new service model,
  engaged with his Care Coordinator, close
  relationship with his Brother
• Average number of monthly contacts/attempts to
  serve this client 12 per month sometimes as
  many as 20

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Case Example contd

• Length of enrollment 2.5 years
• Number of months without hospitalization since
  enrollment 29, no hospitalization since
  enrollment, for the past 2.5 years
• Linkages achieved PCP, Therapist, Psychiatrist,
  SUD clinic counselor and outpatient program,
  completed 2010E housing application and was
  placed in permanent housing
• Next Steps Care Coordinator has recently linked
  this client with a GED prep program so that he
  can pursue a degree and employment

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Results Overall

• Clients with SUDs have higher rates of
  hospitalization than other client populations
  even when linked with SUD services
• Hospitalization rates are highest among the
  homeless or clients with unstable housing
• Clients who are linked with mental heath services
  have lower rates of hospitalization
• The most common discharge reasons for the SUD HH
  population Inability to Contact/Locate and
  Enrolled HH Patient Lost to Services
• The average number of attempted
  contacts/interventions required per client per
  month in the sample is 5, but in some cases as
  many as 20 in one month are required

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Summary

• What does this tell us about the role that
  linkage to
• Substance Use and Mental Health services
• play in the success of the triple aim?
• Outcomes are more successful
• Detox and ED admissions are less frequent
• Long-term recovery is being supported
• Care Coordination efforts are more successful
• Interdisciplinary team approaches are fostered
• Continuity of care increases

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Looking to the Future

• Client satisfaction scores

Inquiry Average Answers (15)
I have an understanding of what Health Homes are. 4.2
My urgent needs are being met. 4.5
I have been linked to community based treatment for my Substance Use Disorder. 3.9
I feel that my addiction issues have improved since my enrollment in Care Coordination. 3.9
I would recommend Health Homes services to a friend or family member in need. 4.5
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Next Steps

• Build and sustain more co-location projects with
  Health Homes staff imbedded in emergency
  departments, outpatient psych units, detoxes, and
  rehabs
• Ensure that clients are linked with SUD and MH
  services in the community in order to promote
  better outcomes
• Accurately identify acuity levels amongst clients
  from a care coordination perspective through use
  of a risk stratification tool
• Inform key stakeholders that more resources are
  needed to appropriately compensate staff for the
  intensive work that is required to achieve
  successful outcomes
• Effectively partner with the MCOs to bridge the
  gap between health plans and service providers
• Increase awareness about Health Homes throughout
  the larger health care community

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Empowering Individuals to Strengthen Communities
Joanna Larson Senior Director of Health and
Business Services NADAP jlarson_at_nadap.org (212)9
86-1170 ext. 111
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Resources

• http//www.health.ny.gov/health_care/medicaid/prog
  ram/medicaid_health_homes/
• http//kff.org/medicaid/state-indicator/total-medi
  caid-spending/
• http//www.ibo.nyc.ny.us/iboreports/2013medicaid.h
  tml
• https//www.health.ny.gov/health_care/docs/2010-11
  _medicaid_admin_report.pdf