Health homes: The new frontier for case managers
CMs coordinate care across the continuum
Executive Summary
Health homes, which provide care management across the continuum for high-risk Medicaid beneficiaries, offer opportunities for case managers.
• Providers, health plans, and community-based organizations join together in health homes and provide coordinated medical, behavioral health, and social services to participants.
• Every health home participant has a care manager who collaborates with all entities providing services to the client, and keeps each informed about what others are doing.
• Care managers work closely with clients and family members to develop goals and support them in attaining goals.
Health homes, a patient-centered initiative that provides coordinated care for high-risk Medicaid beneficiaries with multiple or severe chronic conditions, offer huge new opportunities for case managers, says Margaret Leonard, MS, RN-BC, FNP, senior vice president for clinical services at Hudson Health Plan, in Tarrytown, NY.
Health homes are collaborative networks of community-based organizations, health plans, providers, and other agencies that join together to provide coordinated services to high-utilizing, high-cost Medicaid recipients with chronic conditions. Participants may include managed care organizations, hospitals, behavioral health providers, federally qualified health centers, community-based organizations, and other frontline providers that offer case management. (For details on how the health home system works, see related article on page 52.)
"Care managers are the key component of the health home model. This is definitely an area where people are hiring care coordinators. It’s an exciting new area for us, and it’s a great opportunity for experienced case managers to step to the head of the line," Leonard says.
The purpose of health homes is to connect and integrate physical health care, behavioral health care, and community-based social support and services, adds Deirdre Astin, health home program manager at the New York State Department of Health.
In a health home, care managers oversee and provide access to all of the services that patients need and ensure that they receive everything necessary to stay healthy and out of the emergency department and the hospital.
"The idea of health homes is to provide integrated care management so that one person makes sure that all of a person’s needs are addressed in a comprehensive and coordinated manner," Astin says.
The care managers bring together all of the providers treating a patient and share the care plan with everyone who comes in contact with an individual, making sure that all of the clinicians are aware of what the others are doing and that everyone is on the same page, Leonard adds.
"Before we were part of a health home, we provided case management to individuals with serious mental illness, but, like other providers, we operated in a silo. The health home gives us the opportunity to broaden our work and to connect the medical, behavioral health, and social services our clients are receiving," says Bernadette Kingham-Bez, executive director of St. Vincent’s Hospital Westchester in Harrison, NY, and senior vice president of Saint Joseph’s Medical Center in Yonkers, NY. St. Vincent’s and its parent organization, Saint Joseph’s Care Management Programs, are part of the Hudson Valley Care Coalition, a health home serving six counties in New York State.
"Saint Joseph’s and its St. Vincent’s Hospital Westchester Division is a major behavioral health provider with inpatient, outpatient, and residential programs and many initiatives that aim to reduce inpatient hospitalization," she says. "I believe the health home program will ultimately be one of our most important tools to pull together a more coordinated approach for those with complex needs."
Every person who joins a health home has a case manager who works with the individual and his or her family and providers, Astin points out. Because the health home focuses on patient-centered care, the patients must agree to work with their assigned care manager and sign an Information Sharing and Consent form that allows the care managers to share information with all the partners across the network. The care manager meets with patients and completes a comprehensive assessment to determine their medical, mental health, and social service needs.
Then the care manager works closely with the individual and the family members to determine what the patient needs and to develop a care plan that is agreeable to everyone.
The care plans vary according to the needs of the participants. Some individuals may need someone to advocate for them with their landlord, help them obtain assistance with utility bills, sign up for food stamps, and accompany them to doctors’ visits. Others may do well with a phone call every month, Astin says. The case manager may help patients identify a primary care physician, connect them with a medication assistance plan, or educate them on seeking non-emergent care in an appropriate setting rather than the emergency department.
In the integrated model adopted by health homes, the assigned case manager sticks with patients and family caregivers until they are stable. "The care managers work with the patient and caregivers to develop goals and stay with them as they try to attain those goals. They remove the socio-economic barriers that prevent patients from reaching their goals, and they’re there to pick patients back up when they stumble and slide backwards," Leonard says.
Providers and health plans may participate in more than one health home network, which means that some case managers may work for multiple health homes. "It’s a great opportunity for case managers but it can be a confusing process because one health home’s processes may differ from another’s. Eventually, best practices will emerge," Astin says.
Before the health home initiative began, New York state provided targeted case management for people with HIV-AIDs, serious mental illnesses, or other conditions. These services are all being folded into the health homes, Astin says.
The targeted case management program had caseload limits and requirements for the number of interventions and intervals between them, depending on the intensity of services the participants needed, Astin says.
"There are no minimum requirements for face-to-face interventions. Case managers can see people twice a week when they are in crisis and see other people once a month," she says.
Health home care managers have access to participants’ records through the health home business portal called Insight Plus, developed by Hudson Center for Health Equity and Quality, a nonprofit healthcare technology company. Insight Plus is used to assign patients to care managers, collect care management records, and to allow care managers to create, print, and share a care plan for their patients, according to Lena Johnson, director of business process outsourcing for the Hudson Center for Health Equity and Quality in New York state.
Technology is invaluable in helping care managers coordinate care for multiple patients with intensive needs, Johnson says. "Insight Plus can be used as a stand-alone system or can interface with existing systems which eliminates duplicate data entry for case managers. The health home is asking case managers to do more, and this streamlines the reporting requirements so case managers can manage their caseloads efficiently and effectively," she says.
Health home care management offers clinicians the opportunity to meet with patients and develop a close relationship with them, and it gives them the satisfaction of seeing their clients’ progress over time, Leonard says.
"Our health home care managers work with clients who typically start out in a crisis with complex medical and mental health conditions and a lot of social needs. Over time, the care managers watch them recover and take control of their lives. They’re really proud of their success," Kingham-Bez says.
The home health initiative also offers opportunities for case managers, particularly those who are certified, to train unlicensed people to handle tasks that do not require the expertise of a clinician. For instance, a licensed case manager can help train lay people to use the screening tools to identify patients who need a full assessment or who may need less help and would benefit from a shorter interaction with the case manager
"There are only so many resources available, and frontline providers will not be able to afford to hire licensed clinicians for all of their care coordination needs. They will need to hire and train lay people to maximize the time of a licensed case manager. This will create opportunities for certified case managers to help train and supervise the unlicensed people who work closely with patients," Leonard says.
For instance, many providers are hiring lay people who live in the communities with the people they serve to act as peer specialists or patient navigators. Many of the people in those roles have been recipients of social services themselves, and because they understand the process and the challenges individuals face, they can build rapport with the patients because they have been in the same situations themselves.
"Case managers have the opportunity to take a leadership role with the lay employees and mentor people into positions where they can help the members in the program succeed," Leonard says.
