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The Affordable Care Act has led to community-based approaches for super utlilizers like health homes that appear to be making inroads.
The term “super utilizer” has become shorthand for patients with multiple chronic conditions who access care frequently, resulting in the highest cost to public health and uncompensated care.
They’ve typically not had regular healthcare membership and may have one, or even all, of a group of common chronic conditions such as diabetes, cardiovascular disease, obesity, asthma, and Chronic Obstructive Pulmonary Disease.
In addition, many are homeless, have literacy issues, low or no income, and lack transportation and family support. They may have been incarcerated, suffer from substance abuse or alcoholism, and nearly all are burdened with some form of mental illness.
It’s no surprise, then, that managing super utilizers is a challenge. The good news is that the creation of the Affordable Care Act (ACA) has led to community-based approaches like health homes that appear to be making inroads.
MosesIn 2010, the Medicaid Health Home State Plan Option was created under the ACA to provide “a way for states to finance intensive care management,” for Medicaid beneficiaries with chronic conditions, says Kathy Moses, senior program officer for the Center for Health Care Strategies (CHCS).
“It’s a simple formula: If a patient has two or more chronic conditions as defined by the state, patients enrolled in Medicaid can receive care coordination through a health home,” says Moses. There is not always a brick and mortar home involved, she adds. “It’s a concept, not necessarily a physical place.”
CHCS, a national policy center based in Hamilton, New Jersey, partners with states to improve care access and quality, promote payment reform, and foster integrated care for the nation’s highest-need, highest-cost patients. It also operates the Complex Care Innovation Lab with support from the Kaiser Permanente Community Benefit. The lab offers a forum for health leaders to collaborate, share ideas and bring new strategies to healthcare facilities and state and federal programs focusing on Medicaid, which serves many super utilizers.
Medicaid health home programs are developed at the state level and authorized by the Centers for Medicaid & Medicare Services (CMS), says Moses. They can be implemented statewide or regionally; and they serve a subset of Medicaid-eligible individuals, focusing on one or more of the chronic diseases or conditions that a state chooses.
In order to be certified as a health home, applicants must meet state requirements. Depending on the state, these requirements can range from having specific IT systems in place to having contracts signed with managed care plans and community-based organizations. “Most of the care coordination takes place outside of the medical office, such as member engagement and assessments, care planning and goal setting,” Moses explains.
DavisStates can use the health home concept to address specific areas that contribute to high utilization of hospital and emergency department services. Rachel Davis, senior program officer who oversees the Complex Care Innovation Lab, describes how some health homes in New York state are addressing incarceration issues. “There are a high number of super utilizers in New York who are involved with the criminal justice system, and that’s really challenging,” says Davis. In many states, including New York, people who have been incarcerated for more than 30 days lose their Medicaid benefits, making it difficult for them to maintain continuity of care, she explains. “They get discouraged, they don’t have their Medicaid status turned on when they’re released, and they may or may not have medicines they need. This can lead to a variety of problems, including not being able to access needed medications or doctors in a timely fashion after release. Davis notes that it’s “not unusual to see these individuals show up in the emergency room a few days or weeks after they are released from jail or prison due to this lack of coverage.”
In response to this challenge, Maimonides Health Center in Brooklyn hired a staffer to liaise with Rikers Island, which is the entry point for most incarcerated people in New York City, Davis explains. Any time one of their health home members shows up in the Rikers database, an electronic alert is sent to the Maimonides health home. The alert lets the staff person know that the health home needs to step in and start coordinating with the member and jail staff to ensure that the incarcerated member’s medical needs are met. The health home also works with jail staff to create a discharge plan for the member, including working to reinstate Medicaid benefits upon release.
In another scenario, Davis describes how a health home staff person works in a probation office. “Anytime a probation officer thinks their client is a good fit for health home services, they can walk them across the hallway and connect them to the health home’s representative and get them enrolled in the [Medicaid] program,” she says.
Finding patients with chronic conditions and engaging them in health home programs is often the biggest challenge, says Moses, who adds it’s unlikely that patients with no phone, transportation or computer access will engage on their own. With some health homes posting only a 20% engagement rate, Moses says states need to do more than leave it to chance that people will actively participate. In addition, the health home team’s initial efforts must be focused on showing eligible patients how health home services can be beneficial.
To bring more people into care, Davis says that a number of health homes are turning to non-traditional health workers. “Individuals who are hired from within the community to be peers or community health workers can be very successful in engaging patients. They share lived experiences with the patients, and can connect with them about the challenges they’ve faced and how they have worked to overcome them,” she notes.
There is often a high level of mistrust of the healthcare system among health home eligible individuals, and these non-traditional healthcare workers can be better at connecting with patients and gaining their trust, says Davis.
Prior to the ACA and Medicaid health homes, “care management systems were often organized around specific conditions such as HIV or mental health, which could lead to fragmentation,” Davis says. “New York saw an opportunity in health homes to look at the patient holistically, rather than divvying them up by condition. This is really an evolution of the original disease management concept.”
Now they’re finding more clues to the already complex super utilizer profile. “One of the more interesting things that’s come across our radar is there is evidence that these folks as children or young adults experienced some kind of physical, sexual or social trauma, and there is very good evidence that this kind of trauma in childhood plays a role in adult health outcomes,” says Davis.
Adds Moses, “There are probably opportunities for commercial insurers to learn from innovative efforts being implemented to help high-cost, high-need populations in publicly financed care.”
Barbara Hesselgrave is a freelance writer in Baltimore, Maryland.