Janet Stoeckl

Health Home Integration Update

By Janet Stoeckl RN, CCM, Clinical Director

Health Homes are not just a location. They are free community care management services that serve eligible high need/high cost Medicaid beneficiaries with multiple and chronic conditions. Health Home enrollees receive a dedicated Care Manager who oversees and provides access to all the services individuals need to stay healthy, out of the emergency room and out of the hospital.

To date, Millennium has continued to support partner integration of Health Homes across each key care setting including Acute, Post-Acute, Primary Care, and Behavioral Health.

As the Delivery System Reform Incentive Payment (DSRIP) Program progresses into DY3, Millennium partners will need to achieve performance measure targets to receive funding. (Health Homes are being held to the same Healthcare Effectiveness Data and Information Set (HEDIS) measures followed by Managed Care Organization and State payers.) Together, as a care management team, we look forward to continuing to support each other in meeting these targets.

Information Technology Update
Over the past quarter, Millennium has performed current New York State assessment of information technology capabilities across our partner network. In addition to identifying critical gaps and partner readiness for data sharing, we also reviewed the implementation of interoperable information technology platforms for all partner types. In addition, we have been working closely with HEALTHeLINK to identify real time opportunities for patient status within Health Homes.

Health Home Work Group Meetings Update
Recent Health Home Work Group meetings have focused on creating and deploying a strategy for Health Home integration across each of the care settings. This team has developed a universal education plan, referral document, and information sheets both for providers and patients, and has deployed the comprehensive plan to Millennium partners. Through this process, workflows are being enhanced in support of increased care, coordination and communication of care management services. We are continuing to build and modify this process to best maximize each partner’s integration plan.

Community Alignment of Health Home Meetings
The purpose of these monthly meetings is to bring together Health Plans, Health Home Agencies, and Performing Provider Systems to discuss ways to improve the quality of care for our Health Home community. Key areas being addressed include:

  • How Managed Care Organizations can support GAPS in reports to Health Homes?
  • How to identify a patient in Health Home in HEALTHeLINK?
  • How best to integrate Health Homes into care settings?

Master Participation Agreements Support Health Home Integration
All Millennium partners have received requirements that support Health Home integration. Educating our partners on the value Health Homes bring to the community they service is key. Each relationship manager at Millennium will continue to collaborate with their respective affiliates to educate and develop work flows that continue to support Health Home integration. By breaking down barriers, identifying gaps and modifying processes as needed, Millennium will continue to implement the plan that results in enhancement of Health Home integration for each organization.


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