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
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
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
“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
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
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
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 .
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
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
Me dic a id Re c ipie nts Sing le Qua lifying Co nditio n (SMI
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 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
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)
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
re c o mme nda tio ns
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
ma na g e me nt
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
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 .
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.
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 .).
SJCCN
e wis, Ma diso n, Co rtla nd
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)
Circ a re / HHUNY Ce ntra l
Ma diso n, Co rtla nd, T
io g a , Che mung
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)
CNYHHN I nc .
e wis, St. L a wre nc e , Je ffe rso n (Adults a nd Childre n)
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)
SJCCN
ib e rty Re so urc e s
a mily o f Ag e nc ie s
Ono nda g a
a mily Co unse ling Se rvic e s o f Co rtla nd
Ce nte r
Circ a re , I nc ./ HHUNY Ce ntra l
He a lth
lmira Psyc hia tric Ce nte r
a mily Se rvic e s o f Che mung Co unty
a mily o f Ag e nc ie s
ib e rty Re so urc e s, I nc .
Oppo rtunitie s
Se rvic e s
ie r Ca re Co o rdina tio n
He a lth
CNYHHN, I nc .
ib e rty Re so urc e s
ids One ida
Ce nte r
ra nsitio nal L iving Se rvic e s o f No rthe rn NY
a wre nc e Psyc hia tric Ce nte r
a wre nc e Co mmunity Se rvic e s
Co unty
Co mmunity
duc a tio na l Se rvic e s
SJCCN
ric Sto ne
ric .Sto ne @ sjhsyr.o rg Circ a re
CNYHHN I nc .
Ge ne ra l Que stio ns/ Co nc e rns: