ATR Care Coordination Traci Kodeck, MPH Sadie Smith, MSW HealthCare Access Maryland

Vision We envision Maryland as a place where all people have equal access to health care and where there are no disparities in health outcomes based on income or race. HealthCare Access Maryland will be a state and national leader in reforming the healthcare system

Mission We are making Maryland healthier by connecting residents to insurance and care, educating the community about healthier living and advocating for a more equitable healthcare system

HealthCare Access Maryland (HCAM)  Non-profit agency created in 1997  Formerly Baltimore HealthCare Access (BHCA)  Originally 2 Core Functions – Eligibility – Ombudsman Services/Care Coordination

Four Areas of Expertise  Eligibility/Enrollment  System Navigation  Case Management/Care Coordination  Advocacy and Public Policy

Programs and Services

Eligibility Services  Maryland Children’s Health Insurance (MCHP) Program  Medical Assistance for Families (MA4F)  Primary Adult Care (PAC) Program  HCAM Hotline

Medicaid Outreach Services  Maternal and Child Health  Immigrant Services  Care Coordination  Ombudsman Services  MD Prenatal Risk Assessments

Homeless Services  Street and site based outreach to homeless or persons at risk for homelessness  HPRP: Homeless Prevention and Rapid Rehousing  Operation Care

Making all the Children Healthy (MATCH)  Collaborative program with Baltimore City DSS  Health care coordination and medical case management  Physical Health  Behavioral Health  Dental Health

Addiction Outreach Services  Baltimore Buprenorphine Initiative (BBI)  Information and Referral Line  Drug Treatment Court  HOPE

Special Initiatives  Second Chance Jail Project  Jurisdictional Care Coordination  Access to Recovery

Access to Recovery/ RecoveryNet  Presidential initiative that provides vouchers to individuals to purchase services and supports linked to their recovery from substance use disorders  Emphasizes client choice  Services: Care Coordination, Recovery Housing, Job Readiness Counseling, Transportation, Vital Records, Gap Services, Pastoral Counseling

HCAM’s Role in ATR  HCAM = Care Coordinators – Vital Records – Transportation Public Transportation Cab Services – Gap Services Dental Home Depot, stylist supplies, big and tall stores  Anne Arundel County & Baltimore City

Key Components of HCAM Care Coordination  Knowledge of the region - resources  Familiarity with public benefits, eligibility and enrollment  Awareness of substance use disorders  Community-based  Cultural competency  Partnerships with key providers  Data driven – qualitative and quantitative  A Flexible Structure  Motivated employees

HCAM Model Care Coordinators  Manage referrals  Conduct Outreach  Home Visits  Community  Office  Caseloads  Work with clients 6- 8 months, longer if needed Management  Maintain partnerships  Problem Solve  Build Bridges  Data and Billing reports  Support outreach efforts Administrative Support  Process referrals  Manage supplemental service requests and partners  Track insurance and medical appointments

Oversight Manager  Support  Open door policy  Maintain caseload  Communication  Transparency  Data tracking  Training Care Coordinators  Manage relationships with portals  Communication  Bump it up  Manage responsibilities

Management Ethics 1. My team is my biggest asset. 2. Decision making should be inclusive not exclusive. 3. Open the door. 4. Respect and loyalty should be mutually given and earned. 5. Focus on people’s strengths. 6. Stay committed and focused. 7. Set clear expectations. Everyone is different, manage them as such. 8. It’s my job to know my job. It’s their job to know their job. 9. Ask questions, often.

ABCs of Care Coordination ADAPATBILITY is a must. BELIEVE. CARE. DEMONSTRATE understanding. EVERYONE deserves a chance to change. FLEXIBILITY is key. GIVE love. HONESTY is the best policy, be trustworthy and reliable. IT’S all in the details. JUST breathe. KEEP things in perspective. LISTEN, actively. MEET people where they are. NEVER give up, persistence pays off. OPEN your mind. PAY attention. QUALITY control: Be well- prepared, detail-oriented, and organized. REMAIN calm. SOLVE problems. TEAMWORK makes the dream work. USE your resources. VIRTUE - patience is a virtue. WHEN in doubt, ask. EXHIBIT compassion. YOU are a motivator for yourself and everyone around you. Be Zealous.

ATR Challenges  Rapid roll-out  High Caseloads  Services at capacity  Administrative Procedures  Implementation of supplemental services  Dueling Priorities  Population

Lessons Learned  Teamwork  Hard Work  Overstaff  Relationships/Partnerships are key  You’re going to do things you didn’t think possible

Questions? Contact Information Traci Kodeck Sadie Smith