California State University, Northridge Certificate in LGBTQ+ Health

The Case for Integrated Care

Often, individuals seeking services report that finding quality healthcare services can be like searching for a needle in a haystack. However, it does not have to be this way. There is an emerging trend in healthcare, Integrated Care that can radically shift this challenging experience. Integrated Care, also known as Comprehensive Care or Collaborative Care, is a type of care management that amplifies care services for the “whole person” by providing channels for open dialogue between all parties involved. An example is Health Homes Care Management, which is integrated care in the truest form.

The Care Managers for Health Home refer, connect, communicate, and coordinate care for the individuals they serve. Think of the model as a bicycle wheel, with the client at the center and the Care Manager alongside the client. Thus, individuals are never alone in organizing their own care. Metaphorically, the Care Managers have access to the clients’ “spokes” (connections), such as medical, mental health, and housing services, and networks of friends and family; and are tasked with coordinating care across the “spokes.” To help with this arduous communications challenge, Health Homes Care Management has implemented case conferencing, which facilitates the sharing of important health information and increases the probability of quality care. Health Homes is also connected via RHIO (Regional Health Information Organization) which permits electronic access to medical records, hospital alerts, and other important information. Utilizing this resource eases the burden of communication, and multiple-party access increases the effectiveness and efficiency of the program.

For our integrated care management program at the Mental Health Association of Westchester, we provide every client with a dedicated care manager at the heart of each case. In addition, we also provide our clients with a valuable team including access to a nurse care manager, HARP (Health and Recovery Plan) care manager (if applicable) and a care management peer support specialist. The premise behind the wealth of resources is to assist the client with anything and everything they need to achieve quality care. Our care managers document client interventions into an electronic care management platform that is also permitted to receive hospital and emergency room visit alerts from the RHIO. This creates a vital feedback loop through which our nurse care manager can respond accordingly, and the care management team can intervene on the client’s behalf as needed. Often these responses include contacting the hospital, reaching out to family, assisting with discharge planning, making follow-up appointments, and liaising between the program and essential medical providers involved in transitions of care.

Similar to Health Home, our care managers at MHA of Westchester also utilize case conferences to support communication and collaboration. With case conferences as a central part of the care manager’s role, our program stresses the critical nature of getting everyone together to discuss clients’ care and promote open dialogue. During these sessions, both the client and all applicable providers are invited, so together we can address any potential issues and coordinate roles and responsibilities. Simply put, the case conference is there to make sure everyone is putting the client’s needs first.

Where else can integrated care serve as the missing piece to the proverbial jigsaw puzzle? Integrated care is not limited to healthcare providers by any stretch of the imagination. It also has practical application across client-identified natural supports and social service providers as well. Remember, it is absolutely vital for medical providers to grasp a deep understanding of what may be happening inside a client’s home as this has an impact on the support a client needs for improving their physical and/or mental health. Take for instance a client on a fixed income that lives in a low-income area. This person may find challenges with affording transportation costs or having access to fresh fruits and vegetables to enrich their diet. Since integrated care is designed to enhance and facilitate communication, in this case, the appropriate medical professions would have access to disseminated information as to why this client is missing an appointment or unable to follow a healthy diet.

While integrated care is a positive solution to a complex problem, nothing good comes without its challenges. Often times in the chaotic world of healthcare, care managers report difficulty navigating time constraints and scheduling conflicts in order to plan effective case conferences. While unfortunate, the truth is that there are more and more demands on healthcare and social service providers, which make it incredibly problematic to find time to discuss client care. This is unequivocally an issue and deserves more attention to maximize the effectiveness of integrated care.

To combat this issue, MHA of Westchester’s Care Management Agency (CMA) has implemented an innovative solution. We have embedded care managers at behavioral health clinics, local homeless shelters and at primary care practices. Currently, there are care managers residing at two of the three MHA of Westchester clinic-based sites, and there are plans to expand to all three clinics in the near future. The care managers at these sites primarily work with current clinic clients and provide Health Home Case Management services. Their physical presence at the clinics improves the flow of communication and increases the likelihood of scheduling effective case conferences – it’s a much easier process. Further, through DSRIP’s specialized innovation pilot projects, MHA of Westchester has inserted care managers at a local shelter and at primary care locations. The care managers at these facilities are available to provide education on health home care management services, assess clients who may be eligible for service, enroll folks into a program on location, and provide help to clients who are currently enrolled in Care Management services that need immediate assistance.

Another solution is the partnership between MHA’s CMA and Hudson Valley Care Health Home whereby both groups are part of a project with Westchester Medical Center that has placed an emergency department navigator on-site at the hospital. This navigator refers and connects patients with care management agencies upon discharge, which greatly increases the likelihood that these patients will engage with outpatient providers and attend to any follow up appointments.

The trend is such that integrated care can improve health outcomes, lower hospitalization and emergency room visits, and advance the positive relationship between providers and clients. It also has a measurable effect to reduce overall costs, which is why many believe integrated care is the present and future of healthcare. Perhaps we have finally found that needle in the haystack after all.

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