Re-envisioning patient-centeredness: Strengthening care coordination in a Health Home

Background: The Affordable Care Act's most notable goal is to provide health insurance to the vast majority of uninsured Americans. Several other lesser know provisions are intended to shape the way primary care is provided. Among these, Health Homes (HH) use best practice research and financial incentives to encourage practices to better manage patients with complex social needs and multiple co-morbidities. Methods: Metropolitan Hospital Center (MHC), as a part of New York City Health & Hospitals Corporation, has been selected as a HH for Medicaid patients. New York State will assign patients to MHC's health home over time. Four tiered levels of care have been created for these patients ranging from low to high levels of supportive services needed. Community-based organizations (CBOs) have been engaged in the HH through contracts and memorandums of understanding to provide care coordination, legal and housing services along with MHC's existing HIV COBRA teams. Results: Efforts to address HH standards established a new care coordination system and widened the role of the HIV COBRA teams. The engagement of CBOs has strengthened the tie between hospital-based medical care and supportive services within the community, leading to greater patient engagement. Success is measured by the number of patients who remain linked to care and experience clinical improvements. Conclusion: As the HH program develops, the strengthening of care coordination through the use of contracted CBOs will forge new partnerships that expand the services available to patients with complex medical and social needs. Further research is needed over time to determine the clinical and financial results of the HH initiative.