St. Joseph's Health – St. Joseph's Care Coordination Network

What is it?

A Medicaid Health Home is a care management program in which lead Health Home organizations take responsibility for the comprehensive needs of its patients, including not only clinical needs but socioeconomic needs. Health Home Care Managers work with eligible patients to fully assess their patients’ needs, develop a plan of care, and progress patients along the plan of care to include these socioeconomic barriers – resolving issues such as housing, transportation or social service benefits, as well as navigation of the health system to include scheduling primary care appointments, ensuring clinical access for specialty care, physician visit follow-up, medication access and compliance and more.

These socioeconomic needs often are more prohibitive to a patient’s improving their health and wellness than traditional clinical care, yet frequently are not included in the definition of care management. Care Managers also act as a hub for Health Home patients, supporting the sharing of information across providers and care/clinical environments to facilitate communication on patient needs and solutions. Ultimately, the goal of the Care Managers is to improve patient health, decrease avoidable emergency department (ED) use and/or hospital inpatient visits, and improve patient self-sustainability.

Medicaid Health Home programs exist in various forms in 19 states, first enabled by the Affordable Care Act. St. Joseph’s Health Home, the St. Joseph’s Care Coordination Network (SJCCN), is a lead Medicaid Health Home (a designation provided by NYS) in six Upstate New York counties. SJCCN is able to subcontract care management with a network of organizations including community-based organizations (CBOs), providing a unique opportunity for collaboration on patient health. As of August 2016, there were approximately 2,700 patients enrolled in the SJCCN.

Who is it for?

Medicaid patients (including Medicaid/Medicare, or dual-eligible patients) with two or more chronic medical conditions, or one chronic medical condition or behavioral health condition but at high risk of developing another.

Why do they do it?

In 2012, St. Joseph’s Health (SJH) launched a population health management initiative, examining its health care delivery system utilizations and piloting new initiatives to better connect care for patients between the system’s points of care, and optimize patient utilizations when it was to the benefit of the patient’s health and the system’s capacity. Predominantly this was done for two reasons: (1) indicators at that time demonstrated the evolving role and level of accountability health systems would be facing for the long-term health of its patient population, beyond the quality care provided in each fee-for-service encounter; and (2) faced with a high inpatient census and a desire to affect inpatient length of stay, SJH sought to proactively affect medical inpatient utilizations to free much-needed inpatient capacity.

Impact

SJCCN has been tracking the clinical outcomes of its enrolled population since program launch. While some data is limited (utilizations outside of the SJH system of care, for example), they are able to determine a considerable impact when measuring utilizations of the SJH pre-enrollment versus post-enrollment. Immediately, they were able to demonstrate an impact on ED utilizations and avoidable medical admissions with SJCCN enrollees. ED visits per 100 members per 30 days shrunk from 18.0 to 12.1, and medical admissions per 100 members per 30 days decreased from 5.3 to 2.8.

Contact: Betsy Bedigian
Manager, Marketing and Communications
Telephone: 315-744-1673
Email: betsy.bedigian@sjhsyr.org