Regional implementation of the Affordable Care Act: Influential factors in the variation of Health Home models nationwide

The Affordable Care Act has offered the opportunity for each state to uniquely transform their Medicaid system, thereby directly impacting quality of care delivered to a fragile population. To this end New York State (NYS) has amended its state plan and has developed Health Homes (HH) statewide – a model for integrated medical and behavioral health care coordination designed to impact population-wide health outcomes. The NYS HH model serves recipients with Serious Persistent Mental Illness, substance use disorders, HIV/AIDS and multiple chronic medical conditions, many co-occurring. To achieve improved health outcomes while reducing Medicaid costs, eight community-based organizations have joined together to form a HH which will, at full capacity, serve approximately 30,000 of these complex, high-cost and high-need Medicaid recipients. Called Community Care Management Partners (CCMP), this HH is a unique partnership of providers that combine their expertise in mental health, medical and primary care, substance abuse counseling and HIV/AIDs services, and includes a prominent hospital and several FQHCs. Serving the Bronx and Manhattan, the CCMP HH has conducted a comprehensive neighborhood needs assessment of the communities that the partner organizations have served for over 30 years. This assessment offered an in-depth view of the neighborhood biopsychosocial needs, ranging from the broad through the granular. Based on the results, CCMP targeted chronic medical and behavioral health issues such as mental illness, Diabetes, HIV, Asthma, Heart Disease and others, to positively impact population health outcomes. This presentation will outline the efforts to date, present preliminary outcomes and outline future directions.