Partnerships and Collaborations: A Model for Enhancing Access and Enrollment of Children and Families into Health Home Care Management

Community-based case management (CM) services, in general, and specifically those geared toward children and families, have historically been fragmented. Prior to the Patient Protection and Affordable Care Act (ACA), New York State had a wide array of disparate CM services, including Targeted Case Management (TCM) serving children with severe emotional disturbances, Voluntary Foster Care Agencies (VFCA) 29I providing case management to children separated from their caregivers, State Plan Services, and 1915c Waiver Programs to name a few. In 2012, New York State opted to implement Health Home (HH) under Medicaid Redesign (MRT). Health Home was thus defined as the mechanism/vehicle to address health care fragmentation and ballooning population health concerns (Thomas E. Smith, Matthew D. Erlich, & Lloyd I. Sederer, 2013), intended to support a more integrated model of service delivery shifting the practice standard from siloed to collaborative practices (Mechanic, 2013). “The health home model’s whole-person approach—encompassing comprehensive care management and coordination, integration of physical and mental/behavioral care, and links to non-clinical supports—thus has the potential to improve the overall health and quality of life for some of the most vulnerable Medicaid beneficiaries” (U.S. Department of Health & Human Services Assistant Secretary for Planning & Evaluation Office of Disability, 2017).

In New York State the Health Home was identified as the hub and gateway to Community-Based Care Management services and the Health Home Serving Children (HHSC) model was expected to provide “no wrong door” access to an array of critical Care Management services for children beginning in December 2016. By linking individuals to behavioral health and medical providers, Community-Based Care Management is expected to monitor and more successfully transition children and families to appropriate needed services. Despite this, many medical providers remain unfamiliar with the process of enrolling children and are reluctant to make referrals to Health Home Serving Children programs (Citizens Budget, 2018). This fact remains true even when providers recognize that comprehensive care management is needed and will result having in social determinants of health needs addressed, and behavioral health services offered to some of the youngest and most vulnerable patients they serve. The challenge for many medical providers has been in understanding how they can refer their patients, while parents and caregivers may continue to have difficulties accessing the right services at the needed intervals due to “separate social-service realms and divergent funding streams” (Center for New York City Affairs, 2018).

Coordinated Behavioral Care (CBC), a member-led organization, established in 2011 by many of New York City’s behavioral health and human services providers, offers a vast array of medical, behavioral health, rehabilitation and supportive housing services across the 5 boroughs, was designated a Lead Health Home in 2012. CBC’s Health Home provides city-wide Community-Based Care Management services, through 48 Care Management Agency (CMA) partners, operating one of the largest behavioral health HHs in NYS, serving 18,000 enrolled members with an additional 2,500 potential members in outreach and engagement services. Building on the technology platform, training and technical assistance, quality and administrative oversight established in the adult HH, CBC was formerly designated as a HHSC Lead in December 2016. Our HHSC program oversees 24 Children’s CMAs, serving nearly 2,400 young people and their families, with a core mission of delivering high quality Community-Based Care Management that support cost effective, integrated health care services across developmental stages and functional needs.

Over the years, CBC has collaborated and partnered with many stakeholders on multiple projects with the goal of developing and identifying best practices and opportunities designed to enhance the utilization of Community-Based Care Management. In Brooklyn, CBC partnered with Maimonides Medical Center (MMC) and one of our largest children’s serving CMAs: JCCA, a founding member agency of CBC. JCCA has a nearly 200-year history of providing comprehensive care to more than a million abused, neglected, and traumatized children, young people and families who come from New York’s diverse communities.

The early partnership included case conference reviews and strategic planning in the identification of potentially eligible and appropriate individuals for HH services. It was with this concept in mind, and leveraging this long-established relationship, that CBC, JCCA, and MMC, first developed the vision of a Co-Location Care Management Model in the fall of 2017. The goal was to ensure that medical staff and families understood clearly the concept of Care Management and the value add of HHSC services toward improving access to care while addressing behavioral health and health outcomes. CBC, JCCA, and MMC had numerous collaborative meetings to level-set expectations, develop the design and tenets of the model, and identify workflows for the seamless identification of referents with the best practice goal of a closed loop referral process.

The Co-Location Care Management Model pilot was launched in April 2018, with JCCA co-located at MMC’s Newkirk Family Health Center in Flatbush, Brooklyn several times per week. The workflows were designed to optimize access to needed services and facilitate HHSC eligibility screenings with an on-site JCCA intake/outreach coordinator. The collaboration involved all stakeholders working closely with MMC’s clinicians to ensure access was timely and meaningful to each enrolled child and his/her family into CBC’s HHSC program. The closed loop referral process supported workflow adherence, strengthened rapport, and assured individual stakeholder accountability so that medical providers would know the status and disposition of each referral.

MMC invested resources and allowed JCCA to train their providers and administrative support staff on HHSC services, the co-location model and vision, and the full array of JCCA services well beyond Care Management. JCCA reinforced the same educational programming and training with its own workforce and hired a dedicated Master’s Level intake/outreach coordinator specific to the co-location pilot. This staff person served as the liaison for MMC staff and the families served by the Newkirk Family Health Center. The coordinator was equipped with mobile technologies affording her the flexibility to enroll the families at a time and location that was most convenient for them, whether it was on site at MMC or at a later time in the community.

Convening frequent joint meetings had the dual focus of macro as well as micro-system change implications. HHSC 101 trainings were offered to the medical staff, including specialty staff, such as neurologists and psychiatrists, with an emphasis on Community-Based Care Management intended to improve the continuity of care and address issues of social determinants of health, particularly how these gaps jeopardize or impede improved behavioral health and health outcomes (Braveman & Gottlieb, 2014). Studies indicate increased parental satisfaction when Care Management services were co-located into pediatric settings. Parents reported an increased capability and fluidity in discussing concerns with nursing and medical staff, a greater ability connecting to community resources, and an enhanced aptitude related to both the “goals for care” and adherence in filling prescriptions (Antonelli & McAllister, 2009).

This pilot involved the co-mingling of teams, departments and programs and required a significant culture shift. There was an early acceptance and understanding that both MMC and JCCA would need to modify their traditional referral processes. Both entities rallied their workforces, guided by the goal of creating access, engagement and enrollment to HHSC services, with a shared understanding that this focus would improve the health and behavioral health outcomes of all enrolled children. Promoting an efficient enrollment process was paramount to the success of the pilot. A few tenets have guided this collaborative endeavor, including a unique focus on the intersection between the provider (MMC), the Lead Health Home (CBC) and the Care Management Agency (JCCA), while at the same time not losing sight of the child and family served. Here are some best practices and lessons learned from our pilot:

Staffing Skill & Level: The Care Management staff involved in the pilot were selected to ensure skills and competency in interacting with MMC providers, as well as being able to engage and interact with children and families swiftly and fluidly. The staff also had a strong foundation in social determinants of health and their overall impact on behavioral health and health outcomes. The investment of Master’s Level staff, oftentimes at a higher salary, was nonetheless made to safeguard that the pilot was initiated with skilled staff with expertise in delivering personalized engagement and care planning. This seasoned staff was the gateway to JCCA’s broader services, but also educated and engaged families in a professional and person-centered way related to Community-Based Care Management services offered by CBC’s HHSC program. The staff needed to be nimble, and despite the multiple stakeholders involved, an expectation was set that alliance would be in the best interest of the child and family served. The expectation was established that the intake/outreach coordinator would ensure a warm hand-off to CBC’s HHSC and JCCA’s Care Management program and communication of the disposition of the referral was shared with the referent.

Communication & Relationship Building: Community providers have historically competed for contracts and staff, MRT has afforded stakeholders an opportunity to view each other as collaborators, yet it remains important to address “buy-in.” The longstanding “what’s in it for me?” question must be first acknowledged and then addressed. A focus on the inherent synergy among the stakeholders and the children and families that could be engaged via this model remained at the forefront of our work. Designated “point-persons” were identified to troubleshoot issues, provide guidance and/or address barriers. Workforce development and cross-training of front-line staff as well as supervisors and administrators was necessary and determined to be an ongoing requirement. Stakeholders developed workflows jointly, cross-trained key staff in tandem, and collaboratively envisioned the inherent value in creating a clinical pathway of access to Community-Based Care Management toward improved outcomes. These collaborative activities each addressed “buy-in” as well as provided a streamlined and efficient referral procedure, and what ultimately emerged was an infused passion for community-based partnership.

Data Collection & Workflow Development: In order to minimize the length of time from referral to outreach/enrollment activities, MMC provided access and trained JCCA staff on their electronic health record (EHR) systems. This enabled the intake/outreach coordinator to quickly access referrals, connect with the families immediately at the clinic or in the community, and begin the engagement and enrollment process promptly. This workflow enhancement also mitigated concerns about secure methods of obtaining necessary supporting documentation used to determine HHSC eligibility and appropriateness criteria for Care Management services.

Outcomes & Programmatic Enhancements: There was an understanding that roadblocks and obstacles would need to be addressed along the way. The goal was to start small and learn as we progressed. MMC provided space several days a week for JCCA staff to engage families privately. Space, always being a scarcity, proved to be both invaluable as it communicated a formal extension of the services rendered at the Newkirk Family Health Center and, on occasion, a challenge as space at most sites is limited. Leadership at both MMC and JCCA capitalized on these interactions as a creative time to reinforce the collaboration toward further stakeholder engagement. Jointly, the entities began to approach space limitations as opportunities to engage newer providers into the co-location model and increase child and family referrals.

Over the co-location pilot’s first 5 months, MMC has referred 83 children to CBC’s HHSC program. JCCA has successfully enrolled 49 children (59%) and 24 children (29%) are receiving outreach services, thus far representing an impressive combined engagement and conversion rate (88%). It’s well documented that enrollment in HHSC has remained a challenge; for example, since December 2016, CBC’s HHSC year-to-date has received a total of 327 referrals for all potential NYS referents combined. The Co-Location Care Management Model at MMC’s Newkirk Family Health Center therefore represents over a fifth (22%) of all external stakeholder referrals into our Community-Based Care Management services since the inception of our HHSC program.

The Co-Location Care Management Model has allowed CBC, JCCA, and MMC to strengthen the service delivery system, while working toward the ultimate goal of integrating care for children and their families. While these findings demonstrate early successful collaborations, CBC, JCCA, and MMC continue to focus on building a strong alliance, with the identified undertaking of community access to Care Management services aimed at prevention and improved outcomes. In July 2018, the Co-Location Care Management Model was expanded to include referrals from MMC’s Pediatric Emergency Department and Pediatric Inpatient units. The numbers thus far are modest, with only 20 referrals from the hospital directly, nevertheless this reinforces the commitment to creating pathways to healthcare and Community-Based Care Management services.

CBC, along with our partners JCCA and MMC, aim to be at the forefront of changes in the overall health care delivery system in order to ensure all individuals receive needed services in their community in the most expeditious and appropriate manner. Our mission has allowed the stakeholders to focus on both short and long-term goals, while recognizing that system transformation must include all stakeholders to ultimately be successful. The longer-term impact of these transformations remains to be seen. The Co-Location Care Management Model has yielded early modest successes and CBC, JCCA, and MMC continue to coalesce our programs around the goals to provide the quadruple aim: better care, improved health outcomes, lower healthcare costs, and improved experiences by individuals meaningfully engaged in their health outcomes. We remain committed to designing collaborations such as this one toward the ongoing improvement of children and young adults’ system of care, while simultaneously adapting to the larger healthcare system transformation.

About the authors: Amanda Semidey, LCSW, is Vice President of Care Coordination Services at Coordinated Behavioral Care (CBC). Kathleen Rivera, LCSW, is Senior Vice President of Care Management Services at the Jewish Child Care Association (JCCA). For more information regarding CBC’s HHSC Co-Location Models, contact Amanda Semidey at or visit our website at

Have a Comment?