January 2017 marks the fifth anniversary of the launch of the New York Medicaid Health Homes program, one of the first to be implemented across the country. Established by the Affordable Care Act, health homes enable states to provide a valuable array of care coordination services for Medicaid beneficiaries with chronic conditions.

New York’s program has served more than 260,000 high-risk adults to date, helping many back on their feet, including individuals like S., a 35-year-old woman in the Hudson Valley with a mood and personality disorder and a history of substance abuse. S. lost her job in 2008 and struggled since then with mental health issues, drug addiction, unstable housing, and multiple emergency department (ED) admissions. Through enrolling in a health home at the Community Health Care Collaborative (CHCC), she received tailored care management from an interdisciplinary team that helped her to get into a rehab program, secure stable housing, and connect to an employment agency, among other efforts. She is now in ongoing group and individual therapy, is in recovery from her substance use disorder, became certified as a peer specialist, and is working at one of CHCC’s care management agencies.

Team-based care, which is central to New York’s health home model, is critical for individuals like S. to help address their often-fragmented care and wide-ranging needs. Yet, while health homes and their community-based partners recognize the importance of team-based care, they often encounter numerous barriers to implementing it. The Primary Care Development Corporation (PCDC) recently released a report, “Delivering Team-Based Chronic Care Management: Overcoming the Barriers,” that highlights approaches health homes are using to implement team-based care, as well as challenges they face in doing so.

Lessons for Supporting Team-Based Care

PCDC launched its Integrated Care Planning Initiative to work with five New York health home pilot sites in addressing challenges for implementing  team-based care, both at the programmatic and policy level. Below are a few of the challenges and solutions outlined in PCDC’s resulting report:

Barrier to Team-Based CareProposed Solution
Patient assignment approaches that do not encourage consistent provider and care coordinator relationships and alignment.Build teams and assign patients with interdisciplinary case conferencing in mind.
Payment structures that do not reimburse physicians for case conferencing.Establish protected provider time for case conferences and leverage opportunities for prospective, risk-adjusted payments to compensate for their costs.
Lack of physical and behavioral health team integration.Embed care coordinators within practices and develop strong protocols for “warm hand-offs” that connect patients to a new point of care.

Applying Team-Based Care Lessons to Improve Health Home Efforts in 2017

In 2017, New York health homes will focus on a variety of priorities, including: (1) the roll-out of health homes serving children (HHSC); (2) ongoing collaboration with Performing Provider Systems (PPS) under the state’s Delivery System Reform Incentive Payment (DSRIP) program; and (3) continued alignment with Health and Recovery Plans (HARP) to provide integrated managed care services for individuals with serious behavioral health needs. The success of each of these efforts, described below, will be bolstered by effective team-based care.

1.   Health Homes Serving Children

While most states with health homes cover both children and adults under one program, New York opted to create two distinct models. Health Homes Serving Children, which began enrolling individuals in December 2016, focuses on Medicaid-enrolled children (under age 21) with chronic conditions, including serious emotional disturbance (SED) and complex trauma. The state is also developing an even more intensive health home model to serve the highest-need children with SED, potentially targeted to those with juvenile justice involvement. This initiative will undoubtedly lead health homes to form partnerships with new community-based organizations, providers, and agencies, necessitating regular case conferencing and other team-based care strategies that foster cross-system communication and integrated care planning.

2.   DSRIP

New York’s DSRIP program aims to reduce avoidable hospitalizations among Medicaid beneficiaries by 25 percent over five years through broad delivery system transformation. The state designated 25 regionally based PPSs to coordinate DSRIP efforts. Notably, the NYSDOH singled out health homes as critical partners for the 18 PPSs focusing on: (1) co-located, primary care services in the emergency department (ED); (2) ED triage for at-risk populations; and (3) behavioral health community crisis stabilization services. The coming year will provide an important opportunity for health homes and PPSs to align their efforts in areas such as workflows, care coordination, and data sharing. In addition, beginning in 2017, payments to PPS will become more dependent on outcomes (rather than process metrics), increasing from 15 to 45 percent of total payments and rising to 85 percent by 2019. Health homes, with their deep experience of providing care coordination services and addressing social determinants of health will be key partners to PPS on this front. Both entities would benefit from focusing their collaborative efforts on developing systems that support team-based care.

3.   Behavioral Health

Health homes will undoubtedly also play a significant role in supporting New York’s efforts to improve care for individuals with behavioral health needs in 2017, as the state continues to transition behavioral health services to managed care and promote physical and behavioral health integration. HARPs, a managed care product available to Medicaid beneficiaries with a serious mental illness or substance use disorder, offer enhanced care coordination to address behavioral and physical health needs and potential access to home- and community-based services (HCBS). Given health homes’ pre-existing relationships with the managed care plans and established networks of community-based partners, health homes will continue to be a linchpin for engaging and enrolling individuals into HARPs. Effectively incorporating HCBS providers into care teams will be critical to effectively serving individuals in both health homes and HARPs.

New York Health Homes Moving Forward

The Center for Health Care Strategies (CHCS) has worked closely for the last five years to support New York’s Medicaid Health Homes program via the New York Health Home Learning Collaborative, which will continue to explore the topics highlighted in the PCDC report and other emerging areas of interest. As the health home program expands in 2017, having processes in place to support team-based care will be critical to the success of health homes, and indeed New York’s Medicaid program as a whole.  The insights, tools, sample workflows, and case studies from the recently published PCDC report have relevance for programs nationwide that serve complex populations, and can serve as a useful blueprint for promoting team-based care and improving health outcomes for individuals like S.

Delivering Team-Based Chronic Care Management: Overcoming the Barriers

This PCDC report explores the findings of the Integrated Care Planning Initiative, a Medicaid pilot effort in New York State designed to address challenges related to delivering chronic care management (CCM) in a primary care setting. The report, which CHCS contributed to, outlines recommendations to inform stakeholders looking to implement effective team-based CCM. It also includes numerous examples of forms, workflows, and case studies of successful large-scale CCM programs across the country. Read more »

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