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 - - PowerPoint PPT Presentation

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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 - - PowerPoint PPT Presentation

Mar 26, 2024 512 likes •676 views

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

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SLIDE 1

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

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SLIDE 2

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

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SLIDE 3

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

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SLIDE 4

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)

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SLIDE 5

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

  • cates

ates and nd self lf suf ufficient! ficient!

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SLIDE 6

Current Contracted Partners:

Operati rating Agree eemen ent t /Govern verning Part rtners rs

Community Healthcare Network

Mount Sinai Queens

MediSys

New York Presbyterian Queens

iHealth

1.

ACQC

2.

Apicha

3.

Bailey House

4.

BOOM! Health

5.

GMHC

6.

Harlem United

7.

HeartShare

8.

BrightPoint Health

9.

LIAAC/Tri Care Systems

  • 10. NADAP

Downstr tream eam Provi viders ers

  • ACMH
  • Family Services of New York
  • Federation of Organizations
  • Mental Health Providers of

Western Queens

  • Puerto Rican Family Institute
  • Argus (formerly Steinway)
  • The Bridge
  • Transitional Services for New

York, Inc.

  • New Horizon
  • Creedmoor (ACT and Care

Management)

  • VNS ACT Team
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SLIDE 7

Six Core Services

  • Compr
  • mpreh

ehens ensive ive Care re Manage agemen ment t (Assessing, Care Plans & Team Consulting)

  • Care

re Coord

  • ordin

inati tion

  • n & Heal

alth th Promo

  • motio

tion n (Services in Place & Adherence to Treatment)

  • Compr
  • mpreh

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

  • mmuni

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)

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SLIDE 8

Health th Home me Part rtici icipant nt Serv rvice ice Needs: : Pati tient ent Ce Centered ered Ca Care re Plan

 Establ ablis ishin hing g Care e (Dentistry, Primary Care, Behavioral Health, Specialty, Home Care, Long Term Care and Substance Use Treatment)  Income/F

  • me/Finan

inancial cial Maint ntenance enance (Applying for Supplemental Security Income, Temporary Assistance For Needy Families, Representative Payees, Employment Readiness, Budgeting  Trans nsportation portation (Applying for Medical/Non-Medical Transportation, Arranging Transportation)  Housin ing (Transition from Shelter to Permanent Housing, Applying for Subsidized Housing, and Relocation)  Supportive portive Service vices (Nutritional, Peer Support Groups, Socialization, Spiritual, Advocacy and Vocational)

Individual Family School Church Health Family Social Services Food Housing Finances Transportation

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SLIDE 9

What is a Care Plan?

  • Live Document
  • SMART Goals
  • Collaborative

roadmap to care

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SLIDE 10

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

  • f 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

Health Homes can make bulk referrals to clinical agencies after a linkage or partnership is formed

The Mystical Care Plan is an administrative burden that holds no value….

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SLIDE 11

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.

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SLIDE 12

 Early

ly data a across ss New York State te shows: s:

  • 14 %increase in primary care visits
  • 23 % decrease in hospital admissions and emergency

department visits.

 Health

th Homes provide vide:

  • Connectivity between providers
  • Increase compliance with patient care plans
  • The staff connect the patient to additional services
  • Support in medication management and compliance
  • Psycho-social supports to improve patient outcomes

Despite it ALL!!!! Positive Outcomes

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SLIDE 13

 Requi

uirem emen ents ts

  • Medicaid
  • Two or more chronic conditions or one qualifying (HIV, SMI)

 QCCP

CP Con

  • nta

tacts cts

  • Oscar Laluyan: Warm Hand Offs!

Oscar.Laluyan@mountsinai.org 718.906.6243

  • Guillermo Goldwyn Garcia

guillermo.garcia-goldwyn@mountsinai.org 718.906.6246 (Direct/Office) 347-640-1406 (Cell)

  • Secure Email & Referral Form

How Do I Refer patients or clients?

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SLIDE 14

We are all on the same journey to improve people’s health!!!!!!!!!!!!!