263181 Re-envisioning patient-centeredness: Strengthening care coordination in a Health Home

Tuesday, October 30, 2012 : 9:10 AM - 9:30 AM

Marcie Sara Rubin, MPH , Business Development/Ambulatory Care Services, Metropolitan Hospital Center, New York, NY
Ethan Jacobi, BA , Ambulatory Care Services, Metropolitan Hospital Center, New York, NY
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.

Learning Areas:
Administer health education strategies, interventions and programs
Administration, management, leadership
Chronic disease management and prevention
Clinical medicine applied in public health
Public health or related public policy

Learning Objectives:
Understand the process of developing a Health Home. Discuss the objectives of a Health Home. Assess the tools needed to implement a Health Home.

Keywords: Case Management, Primary Care

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I currently serve as the Chief of Staff and Director of Ambulatory Care Services at Metropolitan Hospital Center. In this role, I oversee the implementation of the program being presented. I have been engaged in hospital management for the last 8 years.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.