Many providers are concerned about their Medicaid members with complex needs. Are they receiving the social services they need? Are they adhering to their treatment plans? Do they need behavioral health care?
And with the introduction of value based payments, it’s more important than ever to treat your members in a holistic way.
Health Homes can decrease risk and improve outcomes for your members by addressing the social determinants of their health. They manage care that your members need between their medical appointments – in the communities where they live and work. Health Homes can also help alleviate some of the stress on medical teams, who often end up dealing with housing issues or other social determinants of health that are greatly impacting a member’s healthcare.
Care coordination
Each member gets a dedicated care manager. They work together on a care plan that is 100% tailored to the member. Care managers help connect members to the appropriate levels of service, with the goal of getting them into the right outpatient programs, and decreasing the inappropriate utilization of hospitals.
Care Managers work with members to address what matters most to them. Care Managers can:
- Collect information from the member on their medical, behavioral health, substance use needs, activities of daily living, socioeconomic status and housing status, then develop a care plan with the member
- Assist with Medicaid recertification process
- Assist with completing benefits applications
- Work with the member to secure safe and affordable housing, if needed
- Connect member to social services such as securing access to food, vocational services, resume writing workshops, etc.
- Schedule appointment for the member and reminds the member of the appointment
- Arrange transportation to the doctor appointments or at times takes the member to the doctor’s appointment
- Work with the member to ensure the member takes medication and adhere to treatment as prescribed by the doctor
- Provide education and information on the member’s chronic medical condition
- Communicate with all of the member’s providers and encourage the member to involve family or other social supports
- Remind the member to attend their follow-up appointment after being discharged from an inpatient facility; or actually taking the member to the follow-up appointment
- Assist the member to understand their discharge and if they do not, assists in writing questions to ask the doctor or nurse
Health Home services are reimbursed by Medicaid and managed care organizations. There is no cost to referring providers or to members.