He a lth Ho me s Adults with Chro nic He a lth Co nditio ns CE NT - PowerPoint PPT Presentation

He a lth Ho me s Adults with Chro nic He a lth Co nditio ns CE NT RAL NE W YORK HE AL T H HOME NE T WORK CI RCARE – HHUNY CE NT RAL ST . JOSE PH’ S CARE COORDI NAT I ON NE T WORK

L e a rning Outc o me s  He a lth Ho me Ove rvie w a nd Histo ry  E lig ib ility Crite ria  Ca re Ma na g e me nt Ac tivitie s  Be ne fits o f He a lth Ho me Ca re Ma na g e me nt  T ype s o f Re fe rra ls  Re fe rra l Pro c e ss a nd Me mb e r E ng a g e me nt Ove rvie w

De finitio n o f a He a lth Ho me  “A He a lth Ho me is a c a re ma na g e me nt se rvic e mo de l whe re b y a ll o f a n individua l's c a re g ive rs c o mmunic a te with o ne a no the r so tha t a ll o f a pa tie nt's ne e ds a re a ddre sse d in a c o mpre he nsive ma nne r. T his is do ne prima rily thro ug h a Ca re Ma na g e r who o ve rse e s a nd pro vide s a c c e ss to a ll o f the se rvic e s a n individua l ne e ds to a ssure tha t the y re c e ive e ve rything ne c e ssa ry to sta y he a lthy, o ut o f the e me rg e nc y ro o m a nd o ut o f the ho spita l. He a lth re c o rds a re sha re d a mo ng pro vide rs so tha t se rvic e s a re no t duplic a te d o r ne g le c te d. He a lth Ho me se rvic e s a re pro vide d thro ug h a ne two rk o f o rg a niza tio ns – pro vide rs, he a lth pla ns a nd c o mmunity-b a se d o rg a niza tio ns. Whe n a ll the se rvic e s a re c o nside re d c o lle c tive ly the y b e c o me a virtua l ‘ He a lth Ho me .’ ” – NYS DOH De finitio n www.he a lth.ny.g o v

Wha t Ma ke s Up a He a lth Ho me  L e a d He a lth Ho me  Pro vide s Ove rsig ht, Suppo rt, T ra ining , Billing E ntity  He a lth Ho me Ca re Ma na g e me nt Ag e nc y  Pro vide He a lth Ho me Co re Se rvic e s to He a lth Ho me Me mb e r, b o th Adults a nd Childre n  He a lth Ho me Ne two rk o f Pro vide rs  Ho spita ls, Priva te Pra c tic e s, Outpa tie nt Clinic s, Spe c ia lists, E duc a tio na l Se rvic e s, Vo c a tio na l Se rvic e s, Ho using Se rvic e s, e tc .

Brie f Histo ry  Curre ntly He a lth Ho me s c a n b e fo und in 20 Sta te s plus the Distric t o f Co lumb ia  Ala b a ma , I da ho , I o wa , K a nsa s, Ma ine , Ma ryla nd, Mic hig a n, Misso uri, Ne w Je rse y, Ne w Yo rk, No rth Ca ro lina , Ohio , Okla ho ma , Ore g o n, Rho de I sla nd, So uth Da ko ta , Ve rmo nt, Wa shing to n, We st Virg inia , a nd Wisc o nsin  Va ria tio ns o n T a rg e t Po pula tio n, Pro vide r, E nro llme nt, Pa yme nt, a nd Ge o g ra phic Are a  Ne w Yo rk He a lth Ho me I mple me nta tio n re sult o f the Me dic a id Re de sig n T e a m (MRT ) e sta b lishe d b y Go ve rno r Cuo mo in Ja nua ry 2011.  Go a ls o f Adult He a lth Ho me s fo r I ndividua ls with Chro nic He a lth Co nditio ns:  Impro ve q ua lity o f c a re  Re duc e c o sts  Re duc e pre ve nta b le ho spita liza tio ns a nd E R visits  30 Adult He a lth Ho me s/ 16 Childre n’ s He a lth Ho me s a c ro ss Ne w Yo rk  13 He a lth Ho me s a re de sig na te d fo r b o th Adults a nd Childre n  At le a st 1 He a lth Ho me a nd Ca re Ma na g e me nt Ag e nc y in e a c h c o unty  I mple me nte d in Pha se s (Pha se 1, 2, 3) a c ro ss Ne w Yo rk  Pha se 1: Ja nua ry 2012  Pha se 2: April 2012  Pha se 3: July 2012  SJCCN, CNYHHN, Circ a re a ll Pha se 3 I mple me nta tio n  He a lth Ho me s Se rving Childre n I mple me nte d De c e mb e r 2016  He a lth Ho me s Se rving I DD I mple me nte d July 2018

Adult He a lth Ho me Qua lifying Crite ria  Me dic a id Re c ipie nts  Sing le Qua lifying Co nditio n (SMI o r HI V/ AI DS) OR  2 Qua lifying Chro nic He a lth Co nditio ns AND  Ca re Ma na g e me nt Ne e d

Co re Se rvic e s  Co mpre he nsive c a re ma na g e me nt  Ca re c o o rdina tio n a nd he a lth pro mo tio n  Co mpre he nsive tra nsitio na l suppo rt  Pa tie nt a nd fa mily suppo rt  Re fe rra l to c o mmunity a nd so c ia l suppo rt se rvic e s  Use o f he a lth info rma tio n te c hno lo g y to link se rvic e s

Ho w do e s this b e ne fit yo u? HH Ca re Ma na g e rs:  Ac t a s a lia iso n b e twe e n HH Me mb e r a nd Pro vide r  Pro vide insig ht a nd suppo rt ta rg e ting So c ia l De te rmina nts  Suppo rt HH Me mb e r in ide ntifying a nd o ve rc o ming b a rrie rs le a ding to inc re a se d pa rtic ipa tio n in pro vide r visits a nd tre a tme nt re c o mme nda tio ns  F re e up limite d PCMH Ca re Ma na g e me nt re so urc e s b y ta rg e ting HH Me mb e r’ s a re a o f ne e ds o utside o f PCMH sc o pe  Addre ss c linic a l impro ve me nt pe rfo rma nc e thro ug h c a re pla nning a nd c o lla b o ra tio n with pro vide rs  E ng a g e a nd c o lla b o ra te with pro vide rs inc luding sha ring Ca re Pla n Quic k turna ro und fo r a ssig nme nt (HH a nd CMA)

VBP Re c o g nitio n L e ve ra g ing HH Ca re Ma na g e me nt  I de ntific a tio n o f So c ia l De te rmina nts  Co o rdina te with F ro nt-line sta ff a nd Pro vide r b a se d na vig a to rs  E nc o ura g ing use o f “MyCha rt” type syste ms  Pro vide r F o llo w-Up re c o mme nda tio ns

T ype s o f Re fe rra ls  Co mmunity Re fe rra ls  PCP  Ho spita l  Be ha vio ra l He a lth Outpa tie nt  Sub sta nc e Ab use Clinic  Othe r c o mmunity pro vide rs a nd se rvic e s  Se lf-re fe rra ls  MCO Hig h Risk Assig nme nts

Pro c e ss: fro m re fe rra l to a c tive c a re ma na g e me nt 1. Pe rso n is ide ntifie d a s b e ing po te ntia lly e lig ib le (Do c to r, the ra pist, nurse , spe c ia list, se lf, e tc .) 2. Co mmunity re fe rra l sub mitte d to HH (pa pe r re fe rra l, se c ure e le c tro nic po rta l, pho ne , e tc .) 3. HH pro c e sse s re fe rra l a nd se nds to a ppro pria te CMA within 24 ho urs o f re c e ipt a . CMA within c o unty b . Ca n b e ide ntifie d a s pre fe rre d b y individua l, if no pre fe re nc e HH will de te rmine b a se d o ff o f the individua l’ s se rvic e histo ry o r a re a s o f ne e d. 4. CMA imme dia te ly b e g ins o utre a c h to the re fe rre d individua l a . Po te ntia l o utre a c h e ffo rts: pho ne , ho me visit (ma y inc lude she lte r o r ho spita l), c o nta c t with re fe rra l so urc e , re a c h o ut to MCO, le tte rs, e tc .

Pro c e ss Co ntinue d 5. Onc e lo c a te d, HH Ca re Ma na g e r e xpla ins HH Ca re Ma na g e me nt to the individua l. I f the individua l is inte re ste d, the HHCM will c o mple te the inta ke pa pe rwo rk. 6. HHCM suppo rts HH Me mb e r in ide ntifying the ir Ca re T e a m. HHCM no tifie s ide ntifie d Ca re T e a m Pa rtne rs o f the ir a dditio n to HH Me mb e r’ s Ca re te a m. 7. HHCM c o mple te s c o mpre he nsive a sse ssme nt a nd Ca re Pla n with HH Me mb e r a nd o the r te a m me mb e rs (if a b le ). 8. HHCM se nds c o py o f c o mple te d/ a ppro ve d Ca re Pla n to Ca re T e a m Pa rtne rs. 9. HHCM b e g ins a c tive c a re ma na g e me nt (Co re Se rvic e s) with HH me mb e r. 10. HHCM no tifie s Ca re T e a m o f a ny c ha ng e s (e x: disc ha rg e o f HH Me mb e r, c ha ng e s in Ca re T e a m a s pe r HH Me mb e r, ne w/ upda te d g o a ls in Ca re Pla n, e tc .).

L o c a l He a lth Ho me s •Co untie s Co ve re d: Ono nda g a , Ca yug a , Oswe g o , L e wis, Ma diso n, Co rtla nd •E nro lle d He a lth Ho me Me mb e rs: 2,528 (a s o f Se pte mb e r 2018 MAPP) SJCCN • Co untie s Co ve re d: Ono nda g a , Ca yug a , Oswe g o , Ma diso n, Co rtla nd, T o mpkins, T io g a , Che mung Circ a re / HHUNY • E nro lle d He a lth Ho me Me mb e rs: 3,338 (a s o f Se pte mb e r 2018 MAPP) Ce ntra l •Co untie s Co ve re d: Ca yug a , Ma diso n, One ida , He rkime r, L e wis, St. L a wre nc e , Je ffe rso n (Adults a nd Childre n) •Alb a ny, Sc he ne c ta dy, Re nsse la e r (Childre n) CNYHHN I nc . •E nro lle d He a lth Ho me Me mb e rs: 5,226 (a s o f Se pte mb e r 2018 MAPP)