Never a dull moment in a health home
CM tasks vary from day to day
The care managers at St. Vincent’s Hospital and Saint Joseph’s Medical Center never know what the day may bring, says John Francis, LSCW, who oversees the care managers.
They may collaborate with a hospital case manager on the discharge plan for a client, conduct a lengthy assessment on a Medicaid recipient who has just been referred to the health home, accompany a client to a doctor’s visit, help someone sign up for programs such as food stamps and housing assistance, or communicate with a primary care provider on strategies to help a patient adhere to his medication regimen.
The typical client in the program has complex medical and mental health conditions and has been hospitalized multiple times in the past year. Many have substance abuse problems and medical issues such as hypertension, diabetes, and obesity.
In addition to their medical and behavioral health needs, clients typically need a lot of social assistance.
"Housing is a huge barrier for our clients. Often, we have to give priority to helping with their social needs. If someone is worrying about where they will live next week, they aren’t going to give priority to going to a physician visit or taking their medication," says Bernadette Kingham-Bez, executive director of St. Vincent’s Hospital Westchester and senior vice president of St. Joseph’s Medical Center. Located in Harrison, NY, St. Vincent’s offers a full range of inpatient and outpatient mental health services and is a division of St. Joseph’s Medical Center.
Health home referrals come from the New York State Department of Health, health plans, the hospital’s own program, and from the local government department that coordinates care for people with complex behavioral health needs.
"When we get the referrals from the state, we get a phone number and address that may or may not be current. Medicaid recipients tend to move around a lot, and sometimes it takes a lot of detective work to find them," Francis says.
When the care management team gets a referral and the individual agrees to participate in the program, a care manager sits down with the client and conducts an assessment using the DLA-20 (Daily Living Activities), a 20-item mental health outcomes measuring tool. "The tool zeroes in on the individual’s functional abilities in five areas: health practices, housing stability, communication, safety, and managing time. The tool stratifies patients into risk levels and helps us prioritize the needs of the person. When we admit people to the program, they typically have a lot of needs until they start to stabilize," he says.
After the assessment, the care manager collaborates on the care plan with the client as well as with the care coordination team, a group of two or three care managers — each with his or her own caseload — who discuss cases and brainstorm solutions. There are three teams at St. Vincent’s and three at St. Joseph’s. "We focus on the people who are struggling and who are at risk. Members of all six teams communicate back and forth on how to engage clients and the best way to get them the help they need," he says.
As they assist patients, the care managers keep other providers that the patients see in the loop. "These patients have very complex needs and most receive care from multiple providers. The beauty of the health home program is that it coordinates care across all providers and eliminates duplication," Kingham-Bez says.
The care managers are assisted by non-licensed staff called peer specialists, who can assist clients. They work closely with the care managers who call on them to perform tasks that do not require a licensed clinician.
"A lot of our clients are isolated and have been marginalized been by their families, friends, and society. It’s very important to engage clients and gain their trust and the peer specialists are very effective at that. Peer specialists play a big role in making this process work" he says.
