What Happened to My Patient? The HIE Knows
One of the New York State Health Home program’s goals is to coordinate care for some of Medicaid’s most costly recipients—those who depend on emergency rooms for primary care, and require hospitalization because their chronic conditions are not well managed. So, as a lead Health Home in the Southern Tier, Catholic Charities of Broome County (CCBC), now doing business as Encompass Health Home, LLC, goes to extraordinary lengths to enroll high-utilization Medicaid recipients as Health Home members and provide hands-on care management to get them the preventive care and regular treatment they need.
But CCBC/Encompass Health Home would be hard-pressed to coordinate care for more than 1,100 members without the HealthlinkNY Health Information Exchange (HIE). HealthlinkNY gives care managers access to essential information—including how to get in touch with members whose contact information is out-of-date.
Health Home care managers visit members in their homes at least once a month, and speak frequently by phone. “Members move around and don’t always tell us,” says Laura Atwood-Holiavko, program manager of Care Management Services at CCBC, which is based in Binghamton. “If they’ve been to see a provider, their updated contact information is available through HealthlinkNY, and we can get in touch with them.”
Home Health members lead complex lives and are typically financially insecure. To be eligible for Health Home care management, a client has to be covered by Medicaid and have a qualified health condition (either HIV/AIDS or a mental health diagnosis) or two chronic health conditions (i.e., diabetes, COPD, or substance abuse, among others). Health issues often are exacerbated by housing insecurity (hence the frequent moves) and lack of transportation. CCBC helps members obtain suitable housing and arranges transportation to and from appointments.
Care managers rely on a daily report from HealthlinkNY to know when their members visit the emergency department or are admitted to the hospital. Access to medical records through HealthlinkNY lets care managers know why their members went to the hospital and what treatment they received. “Members cannot always report or articulate why they were hospitalized or what their discharge instructions are,” explains Vinnette James, Encompass Health Home’s Director of Health Home Care Management. “We can follow up with the member within 24 hours and go over the information we got from HealthlinkNY so he or she understands what has happened and what needs to happen now.”
When the member has visited an emergency room, the care manager can assess if the issue was a true emergency or could have been treated elsewhere. For example, Atwood-Holiavko describes a member with chronic mental health issues who went to the emergency room because his foot had fallen asleep. “In that case, the care manager met with the member and went over the information we got [from HealthlinkNY]. It helped the member gain an understanding of when to use the emergency room and when to go to his primary care physician or a walk-in clinic.”
Coming Next: Live-Feed Alerts
HealthlinkNY will soon send alerts triggered by emergency room visits and hospitalizations directly into Encompass Health Home’s care management information system. HealthlinkNY has been working with Gary Tucker, Director of Health Information Systems at Encompass Health Home, and technicians at the care manager system vendor Netsmart CareManager, to design an interface that feeds the alerts directly to the care manager’s screen. “It will get the information right to care managers when they are using the system without interrupting their workflow,” Tucker says. “That’s important because the more time care managers have to spend typing and clicking, the less time they can spend with members.”
The interface also will automatically feed important data from Encompass Health Home back into HealthlinkNY. That will give the multiple providers who care for a member a greater understanding of a member’s health. “The ultimate goal of a Health Home is to share the care plan,” Tucker explains. “So when providers call up the records, they can see what the care managers and members are focused on. It will be a better experience for both the member and the provider.”
Tucker lauds HealthlinkNY’s total immersion into the world of Health Homes. “They delved into the concept of the Health Home. They also know that even though all Health Homes have the same mission, each one has a unique approach. HealthlinkNY has had one-on-one conversations to understand our workflows, the consent process, and those types of things,” Tucker says. “They understand what matters.”