Health homes focus on needs in, out of system
Coordinated care prevents duplication
In the past, the highest-cost Medicaid patients often received care from a variety of different entities that did not always coordinate with each other and often provided duplicative services, says Deirdre Astin, health program administrator, New York State Department of Health. The health home model aims to change all of that, she says.
The Patient Protection and Affordable Care Act provided states with the option to provide coordinated health home services for high-cost, high-utilizing Medicaid enrollees with chronic conditions including, but not limited to, mental health conditions, substance abuse disorders, asthma, diabetes, heart disease, and being overweight.
The health home model expands on the patient-centered medical home and is designed to eliminate fragmented care for complex patients by providing comprehensive care management to address participants’ needs both inside and outside the health care system.
"Health homes offer the opportunity for all stakeholders in the healthcare arena to get together and develop a system that will work and that will provide coordinated care for the people who need it most. They go beyond just providing just medical care, behavioral health services, substance abuse counseling, and/or social services to managing the whole person," says Margaret Leonard, MS, RN-BC, FNP senior vice president, clinical services, Hudson Health Plan, an MVP company.
In New York State, one of the early adopters of the health home model, 32 organizations operate 48 health homes and cover almost the entire state. Health homes are a network of organizations, including providers, health plans, and community-based organizations, that collaborate on providing care. Providers can be a part of many networks. For instance, most health plans contract with all the networks in their geographic area, Leonard says .
For instance, the Hudson Valley Care Coalition, a health home serving six counties in New York State, is a mixture of hospitals, community mental health agencies, primary care providers, and a health plan, says Bernadette Kingham-Bez, executive director of St. Vincent’s Hospital Westchester and senior vice president of St. Joseph’s Medical Center. Kingham-Bez chairs the interim governance steering committee while the coalition develops a non-profit organization which will assume the contract with the state for health home services.
Each health home has a lead health home agency that is responsible for maintaining data and assuring quality.
Health homes are required to have an electronic case management record so everyone who provides services to the patient can log in and see what is going on in other venues of care, says Lena Johnson, director of business process outsourcing for the Hudson Center for Health Equity and Quality, a not-for-profit healthcare technology company
In New York State, participants in a health home must have at least two chronic conditions or a single qualifying condition (HIV/AIDS or severe persistent mental illness), Astin says.
New York State identifies high-risk patients and assigns each patient to the health home that will best fit his or her needs. "Health homes can also take referrals from providers and health plans. For instance, they may know an individual that cycles in and out of the emergency department and can benefit from care coordination," Astin says.
In order to make sure that health home services are targeted to the people who need them most, the New York State Department of Health developed an algorithm that analyzes claims encounters and predicts, based on utilization, the risk level of people who meet the health home criteria.
People who are clearly struggling to manage their conditions and are at high risk by virtual of their diagnoses, acuity, and risk scores are assigned to a health home. In New York State, about 800,000 Medicaid recipients have two or more qualifying conditions or one single qualifying condition but only about half of them have risk scores that indicate they can benefit from care management, Astin says.
The state assigns participants to the health homes that will best fit their needs, based on utilization patterns. "We look at patterns of where the individuals access care most frequently. For instance, if they frequent a primary care provider, they’ll likely be assigned to the health home in which that provider participates. If they use a methadone clinic, they will be assigned to the health home that includes the mental health clinic that provides it," she says.
The health home determines which provider will work best for the patient, based on the patient’s history with various organizations in the coalition.
In some cases, the lead health home handles case management for a client or it may refer the patient to another provider. For instance, a hospital-based health home may have case managers who can work with patients with two chronic medical conditions, but if participants have a mental health condition or HIV, they may be referred to a community-based provider.
