I N T R O D U C T I O N T O H E A L T H H O M E S & Q C C P C O L L A B O R A T I O N J A N U A R Y 2 6 , 2 0 1 7 P R E S E N T E D B Y : V A L E N T I N E H E R N A N D E Z G U I L L E R M O G A R C I A G O L D W Y N
What is a Health Home ? Opening Activity Write down the definition of a Health Home • Write Down the Role of a Care Manager • Group Discussion
What is a Health Home? Health Homes are an administrative oversight agency that oversees Care Management • Agencies who provide case management services. Case Management is a servi vice ce model l that aims to increa ease se communicat cation ion among all • members of the care team. A Care Manager connects cts the care providers and coordinates referrals and access to • the services a members requires. A mutually agreed upon Care Plan (goals) s) address the patient’s medical, behavioral • health and social service needs. Partnerships are important! • Healthcare providers, health plans, community based organizations It is a a volunt untary servi vice ce- no impact on current services if a patient doesn’t enroll •
Eligibility ▶ Active Medicaid status -(Includes: dual eligible, managed care, SNP, MLTC,HARP, FIDA) ▶ 2 Diagnosed chronic medical conditions OR one of the below, -HIV/AIDS -Serious mental illness ▶ Demonstrated need for care management services -(e.g. Inadequate social supports, non-adherence, frequent hospital/ED use, homeless)
Health Home Goals • Improve overall health outcomes • Helps patients address socioeconomic concerns • Reduce preventable hospitalizations & emergency room visits • Avoid unnecessary costs Help lp patien tients ts become come self lf advoc ocates ates and nd self lf suf ufficient! ficient!
Current Contracted Partners: Downstr tream eam Provi viders ers Operati rating Agree eemen ent t /Govern verning Part rtners rs ACMH Community Healthcare Network Family Services of New York Mount Sinai Queens Federation of Organizations MediSys Mental Health Providers of New York Presbyterian Queens Western Queens iHealth ACQC Puerto Rican Family Institute 1. Apicha 2. Argus (formerly Steinway) Bailey House 3. The Bridge BOOM! Health 4. GMHC 5. Transitional Services for New Harlem United York, Inc. 6. HeartShare 7. New Horizon BrightPoint Health 8. LIAAC/Tri Care Systems Creedmoor (ACT and Care 9. Management) 10. NADAP VNS ACT Team
Six Core Services Compr ompreh ehens ensive ive Care re Manage agemen ment t (Assessing, Care Plans & Team Consulting) Care re Coord oordin inati tion on & Heal alth th Promo omotio tion n (Services in Place & Adherence to Treatment) Compr ompreh ehens ensive ive Tran ansitio itiona nal l Care re (Use of other Systems of Care w/i the Hospital & Review discharge summary) Patien ient t & Family mily Supp pport t (Peer Support Groups & Involving Natural Resources) Re Referra erral l to Comm ommuni unity ty & Social cial Supp pport rt Services rvices (Identifying/ Linkage/Referral to Community Based Organizations) Heal alth th Infor formatio mation Techno chnolo logy gy (Utilizing electronic information for meaningful use)
Health th Home me Part rtici icipant nt Serv rvice ice School Needs: : Pati tient ent Ce Centered ered Ca Care re Plan Church Transportation Establ ablis ishin hing g Care e (Dentistry, Primary Care, Behavioral Health, Specialty, Home Care, Long Term Care and Substance Use Treatment) Health Income/F ome/Finan inancial cial Maint ntenance enance (Applying for Supplemental Security Finances Income, Temporary Assistance For Individual Needy Families, Representative Payees, Employment Readiness, Budgeting Family Trans nsportation portation (Applying for Medical/Non-Medical Transportation, Arranging Transportation) Family Housin ing (Transition from Shelter to Housing Permanent Housing, Applying for Subsidized Housing, and Relocation) Supportive portive Service vices (Nutritional, Peer Social Support Groups, Socialization, Spiritual, Services Food Advocacy and Vocational)
What is a Care Plan? Live Document • SMART Goals • Collaborative • roadmap to care
Disconnections sconnections wi with th cl clients ents and pr d provid viders ers Clients: -The care managers purpose is to focus on psychosocial needs such as transportation, housing, and entitlements, the clinical goals of care coordination are seen as secondary. - The care manager must establish a relationship so that clients understand the holistic approach to care and gradually incorporate clinical goals as priorities without making the patient feel the care manager is not understanding there needs. Providers: Communication with Care Managers takes away from the time they need to provide direct services The Mystical Care Plan is Health Homes can make bulk referrals an administrative burden to clinical agencies after a linkage or partnership is formed that holds no value….
Barriers to Collaboration HIPAA rights are vital to protecting patients PHI and they are important … • however, providers often misunderstand HIPAA regulations… as they relate to care coordination and the NYS Health Home Consent.
Despite it ALL!!!! Positive Outcomes Early ly data a across ss New York State te shows: s: o 14 %increase in primary care visits o 23 % decrease in hospital admissions and emergency department visits. Health th Homes provide vide: o Connectivity between providers o Increase compliance with patient care plans o The staff connect the patient to additional services o Support in medication management and compliance o Psycho-social supports to improve patient outcomes
How Do I Refer patients or clients? Requi uirem emen ents ts o Medicaid o Two or more chronic conditions or one qualifying (HIV, SMI) QCCP CP Con onta tacts cts o Oscar Laluyan: Warm Hand Offs! Oscar.Laluyan@mountsinai.org 718.906.6243 o Guillermo Goldwyn Garcia guillermo.garcia-goldwyn@mountsinai.org 718.906.6246 (Direct/Office) 347-640-1406 (Cell) o Secure Email & Referral Form
We are all on the same journey to improve people’s health!!!!!!!!!!!!!
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