1. What is a Health Home and Why Should I Know about Them? Western Region Behavioral Health Organization Presentation- July 31, 2013

2. 2 What is a Health Home ? How is Health Home Care Management work done and what services are provided? Who qualifies? Who is providing Health Home Care Management? What makes this care management different? Why should Health Homes be important to you? How is someone linked to a Health Home & How do I make a referral? How is the WRBHO helping with the Health Home roll out? Questions AGENDA

3. Health Homes What is a Health Home? It is a program that provides Care Management to High Need Medicaid Recipients All of the professionals involved in a member’s care communicate with one another so that all needs are addressed in a comprehensive manner. Medical, behavioral health and social service needs are to be addressed

4. Health Homes How is the work done? Work is done through a care manager who oversees and coordinates access to all of the services a member requires, including those being covered by Managed Care Organizations Care manager ensures that the member receives everything necessary to stay healthy. All the services and partners are considered collectively as the “Health Home.”

5. Health Homes Health Home Provides: Comprehensive care management Care coordination: clinical and non-clinical health care Health promotion Comprehensive transitional care (ex- inpatient discharge) Patient and family support Referral to community and social support services such as: housing, legal assistance, food Uses Health Information Technology to link services

6. Health Home System Individual & Care Manager Community Resources Health Care Providers Services Agencies Education Vocational Services Housing

7. Health Homes Health Home Purpose: Improve health care and health outcomes Lower Medicaid costs Reduce preventable hospitalizations and ER visits Avoid unnecessary care for Medicaid members

8. Health Homes Who qualifies? Medicaid recipient: –May be a Medicaid Managed Care Member or receiving services on a FFS basis. –May have both Medicaid and Medicare Must have one of the following: –Two or more chronic health conditions (such as asthma, diabetes, heart disease, BMI> 25, SUD, mental health condition) –SMI, or –HIV/AIDS

9. Health Homes Program Size : Approximately one million Medicaid recipients (out of 5 million) meet the federal criteria for Health Homes Target enrollment for NYS: – 2013-2014= 151,000 – 2014-2015= 225,000

10. Health Homes Who Is Providing Health Home Care Management? Targeted Case Management Slots are being converted to Health Home Care Management COBRA Care Management slots are being converted as well. New agencies have agreed to provide Health Home Care Management to expand capacity Capacity will be driven by need, not limited to a specific number of approved slots

11. Health Homes What makes this care management different? Access is not limited to those in the Mental Health system. Those with SU needs are eligible Slot capacity is not capped. Capacity will be driven by need Shorter application and simpler process than used for SPOA submissions Access is much timelier. Referral does not need to be processed through County SPOA process, although the county may be asked for input concerning the most appropriate care management agency for the individual. Care managers are encouraged to visit the individual if hospitalized and to work closely with the hospital /facility to support a successful discharge to after care.

12. Health Home – Vision ….Maimonides Medical Center TODAY’S CAREHEALTH HOME CARE My patients are those who can make appointments to see me Our patients are those who are registered in our health home Patient’s chief complaints or reasons for visit determines care We systematically assess all our patient’s health needs to plan care Care is determined by today’s problem and time available today Care is determined by proactive plan to meet patient needs w/o visits. Care varies by scheduled time and memory or skill of the doctor Care is standardized according to evidence-based guidelines Patients are responsible for coordinating their own care A prepared team of professionals coordinates all patients’ care I know I deliver high quality care because I am well trained We measure our quality and make rapid changes to improve it Acute care is delivered in the next available appointment and walk-ins Acute care is delivered by open access and non-visit contacts It’s up to the patients to tell us what happened to them We track tests & consultations, and follow up after ED & hospital stays Clinic operations center on meeting the doctor’s needs A multi-disciplinary team works at the top of our licenses to serve patients

13. Health Homes Why should Health Homes be Important to You? Offers another partner (another resource) in supporting the needs of complex, hard to serve Medicaid clients Important resource for discharge planners Improves provider communication Helps make certain that social needs of individual are met Assists in avoiding unnecessary re-admissions Assists in avoiding unnecessary Emergency Department visits Partner in reducing health system costs

14. Health Homes How is someone linked to a Health Home? Medicaid recipients are being placed on lists by NYS OMH and the Health Homes are reaching out to those on these lists. Referrals may be made by anyone in the community to any Health Home operating in their County. Health Homes will refer individuals to downstream care management providers based upon the needs of the individual

15. Linking to a Health Home Option 1 Person has a need & is eligible State reviews Medicaid claims & places person on HH roster Option 2 HH assigns person to Care Management Agency in network HH Care Management Agency reaches out to person, obtains consent and enrolls HH obtains its Roster via the Health Commerce System Provider or other individual determines need for HH services exists and completes HH Referral Form including consent Referral form is sent to HH HH Care Management Agency reaches out to person, obtains consent and enrolls HH assigns person to Care Management Agency in network

16. Health Homes How do I make a referral? Make a call using the contact information on the following slides Collect and keep the referral forms handy

17. Health Homes in Our Region: Erie County Health Home Name ContactPhone Number Email Address Health Home Partners of WNY (Spectrum) Christopher Hartnett 716-539-1794hartnettc@shswny.org Greater Buffalo United Accountable Healthcare Network (GBUAHN) Kirsten Newby716-247-5282, Ext. 218 Kirsten.newby@gbuahn.org Health Homes of Upstate New York (HHUNY) Tracy Marchese585-613-7642Tracy.marchese@beaconhs.com

18. Health Homes in Our Region: Niagara County Health Home Name ContactPhone NumberEmail Address Niagara Falls Memorial Medical Center Vicki Landes716-278-4647Vicki.landes@nfmmc.org Health Home Partners of WNY (Spectrum) Christopher Hartnett 716-539-1794hartnettc@shswny.org

19. Health Homes in Our Region: Monroe County Health Home Name ContactPhone NumberEmail Address Greater Rochester Health Home Network (GRHHN) Deb Peartree585-737-7522Rihn@rochester.rr.com Health Homes of Upstate New York (HHUNY) Tracy Marchese 585-613-7642Tracy.marchese@beacon hs.com

20. Health Homes in Our Region: Wyoming County Health Home Name ContactPhone NumberEmail Address Health Home Partners of WNY (Spectrum) Christopher Hartnett 716-539-1794hartnettc@shswny.org

21. Health Homes in Our Region: Allegany, Cattaraugus, Cayuga, Chautauqua, Chemung, Genesee, Livingston, Ontario, Orleans, Schuyler, Seneca, Steuben, Tioga, Tompkins, Wayne and Yates Counties Health Home Name ContactPhone NumberEmail Address Health Homes of Upstate New York (HHUNY) Tracy Marchese 585-613-7642Tracy.marchese@beacon hs.com

22. How is the WRBHO Helping with the Health Home Roll Out? Notifies inpatient provider when a case we are reviewing is already engaged with a Health Home to encourage follow up Recommends referral to Health Homes when appropriate in conjunction with the review of discharge plans

23. Health Homes Conclusion: Health Home care management should be seen as a resource to help all of us support our high need, high risk Medicaid clients better.

24. Q And A