SIM Community Linkages Work Group #2 December 16, 2015 1
Agenda Current and Envisioned Healthcare Landscape Health Homes for Individuals with Chronic Physical Conditions, and Homeless Individuals (HH2) Overview Goals & Objectives Design Considerations HH2 Services HH2 and PSH Provider Collaboration Incentives HH2 Timeline and Milestones Homework: HH2 Providers and PSH/Outreach Provider Communication Next Steps 2
Current DC Healthcare Landscape Patient enters health care Patient leaves the hospital system with inappropriate ED with minimal support to use or preventable IP admission navigate the system Nursing Rehabilitative Facility Services Hospital / Govt ’ Social Service Entitlement Provider(s) Emergency Programs Department Housing Case Provider Manager(s) School-Based Primary Care Behavioral Transportation Specialist(s) Health Provider Health Providers Outpatient Post-Acute LTC Services Pharmacist(s) Services Care 3
Envisioned DC Healthcare Landscape Accountable entity takes responsibility for the patient’s ‘whole’ health Team-Based Community Accountable Care Linkages Entity Human Primary Care Specialty Care Housing Services Post-Acute Lead Patient Acute Care Transportation Food Security Care Navigator Behavioral Employment Pharmacy Physical Safety Health Training 4
HEALTH HOMES FOR INDIVIDUALS WITH CHRONIC PHYSICAL CONDITIONS, AND HOMELESS INDIVIDUALS (HH2) OVERVIEW
HH2 Goals To meet patient (client) needs and preferences in delivery of high quality, high value healthcare Assess individual’s needs and preferences Communicate needs and preferences at right time to right people Use information to guide delivery of safe, appropriate effective care 6
HH2 Federal Requirements & DC’s General Design Considerations REQUIRED SERVICES: MODEL: ELIGIBILITY: • Comprehensive care mgmt. • Providers integrate and • Have 2 or more chronic • Care coordination coordinate all primary, acute, conditions • Health promotion behavioral health, and long- • Comprehensive transitional term services and supports • Have 1 chronic condition and care/follow-up are at risk for a 2 nd (e.g. • Patient & family support • Integrated into primary care chronic homelessness) • Referral to community & social support services • Must include FFS and MCO POPULATION SIZE: FINANCING: • Target Size = ~25,000 – • 90% federal / 10% local for 30,000 first 8 quarters of benefit • Majority are Medicaid fee- • P4P in years 2-4 for-service beneficiaries 7
Crosswalk: Medicaid Allowable Services to Potential HH2 Services ‘Social’ Service Activities HH2 Service Category (s) • Gathering documents for determining eligibility for housing assistance and services Assessment & • Comprehensive Intake interview(s) for program(s) & services identifying • Conducting assessments & reassessments Care Mgmt. client needs • Arranging for further testing & evaluation • Documenting assessment activities • Developing service plan with client Comprehensive • Writing and updating a service plan / documenting service plan Service plan Care Mgmt. development development • Determining who (which people or organizations) will provide needed services • Help consumers complete applications and provide documents needed to qualify for housing assistance • Help with housing search and coaching for interviews Helping people • Patient & Family Help with communicating with landlords, understanding lease terms, get housing requesting reasonable accommodations if needed Support • Help with setting up utilities • Help to get furniture and household supplies • Move-in assistance • Help consumer with ongoing communication with landlords, problem- solving for needed repairs or resolving disputes Ongoing Patient & Family • Help to communicate with and resolve conflicts with neighbors • tenancy Support Help to understand and comply with lease terms • Help to pay rent on time and negotiate agreements for paying past due rent supports • Help with paying utilities 8 • Eviction prevention
Crosswalk: Medicaid Allowable Services to Potential HH2 Services (cont.) ‘Social’ Service Activities HH2 Service Category (s) • Personal hygiene and self care • Health Promotion • Housekeeping • Patient & Family • Apartment safety Independent Support • Cooking / meal preparation living skills • Referral to • Nutrition education coaching • Shopping on a budget, getting free or low-cost food community & • Using public transportation social support • Access to community resources (e.g. libraries, parks, opportunities for services integration) • Help to make appointments and re-schedule as needed • Help to find / use transportation to get to appointments • Accompany the consumer to appointments as needed to build • Care Coordination Coordination confidence, understand / communicate with health care providers, and • Patient & Family with primary support skill-building care and other Support • Help to arrange or schedule visits with needed medical services • Comprehensive medical services • Helping consumers communicate with medical providers and pharmacy Care Mgmt. about potential side effects or interactions related to multiple medications for medical and behavioral health conditions and other substances • Motivational interviewing • Patient & Family Services to • Substance abuse counseling address • Support Coordination with substance abuse treatment programs and/or • Care Coordination problematic Medication-Assisted Treatment • Help to keep drug dealers and friends / family members with substance use problematic substance use out of the consumer’s apartment 9
Crosswalk: Medicaid Allowable Services to Potential HH2 Services (cont.) ‘Social’ Service Activities HH2 Service Category (s) • • Patient & Family Help to facilitate consumer’s participation in AA/NA or other existing Support Groups support groups Support • Facilitate support groups for consumers with shared needs and interests • Health • Peer support, mentoring Promotion • • Referral to Identify and connect consumers to mainstream / community services and resources to meet identified needs and goals community & • Make formal referrals and provide documentation as needed for services social support Referral, provided by other organizations services monitoring, • Help to make appointments and re-schedule as needed • Care and follow-up • Help to find / use transportation to get to other services Coordination • Accompany the consumer to appointments, other services as needed to • Patient & Family build confidence and support skill-building Support • • Health Educating consumers about psychotropic medications or other medications, including effects (and side-effects) and interactions with other Promotion Medication medications / substances • Patient & Family • management/ Helping consumers manage their own medications (e.g. help set up pill Support boxes or reminders) monitoring • Reminders / encouragement to take medications as recommended and get refills • • Patient & Family Identifying and engaging (or re-engaging) with people who are un-served, under-served, or not effectively connected with needed services Support Outreach and • Building trusting relationships using trauma-informed approaches • Comprehensive engagement • Engaging with people who have frequent / avoidable use of other crisis or Care Mgmt. 10 inpatient services
Crosswalk: Medicaid Allowable Services to Potential HH2 Services (cont.) ‘Social’ Service Activities HH2 Service Category (s) • • Comprehensive Helping consumers identify employment goals • Financial literacy / asset building and assist with establishing & using bank Care Mgmt. accounts and managing credit / debts Increasing • Patient & Family • Helping consumers access education and training opportunities income and job Support • Helping tenants understand the potential impact of earned income and skills / income disregards on other benefits and rent contributions employment • Job coaching and employment support for skills needed to get and keep a opportunities job • Help to get work clothing, tools, etc. • Supported employment • • Patient & Family Facilitating community activities (with other residents / neighbors) that include people with and without disabilities (e.g. celebrations, community Support Facilitating garden, neighborhood safety meetings) • Referral to community • Helping consumers learn to use public transportation community & • Helping consumers access cultural events or other resources and activities integration social support in the surrounding community services • • Patient & Family Parenting education, supports and mentoring • Connections to child care Support • Assistance / coordination with child welfare services • Referral to Family and • Educational and recreational activities for children and youth children’s community & • Youth development and leadership opportunities services social support • Counseling for children and youth services • Training in household safety • Family counseling • 11 Conflict resolution/ mediation
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