Health Homes of Upstate New York Transforms Care Coordination with CareManager

INTRODUCTION

A Health Home isn’t a place, but an extensive network of services for Medicaid recipients in the community. Health home services are a team-based approach to providing comprehensive and coordinated care for individuals with complex health needs, such as mental illness, substance use disorders, and/or chronic physical health conditions. The goal of a health home care manager is to improve the quality of life for those enrolled, reduce unnecessary hospitalizations, and emergency room visits. Health home care management is focused on the individual’s needs and goals and includes a team of providers, coordinated by the care manager, who work together to address the physical, mental, and social needs of the individual.

Health Homes of Upstate New York (HHUNY) brings together four organizations and a Management Service Organization (MSO) that serve individuals across 28 counties in upstate NY. The four Health home organizations in the HHUNY network are Chautauqua County Department of Mental Hygiene (HHUNY Southern Tier), BestSelf Behavioral Health (HHUNY Western), Huther Doyle (HHUNY Finger Lakes) and Circare (HHUNY Central). Together they support the care management work of over 90 community-based agencies.

“HHUNY MSO utilizes Netsmart CareManager as a key tool in the delivery of services by care managers. We rely on the team at Netsmart to ensure our electronic health record (EHR) adheres to all Department of Health state requirements, and we work collaboratively to provide the data necessary for care managers, care management agencies and health homes to make informed decisions about how we can best deliver services to those enrolled in the health home program.” says Alison Bottone, CEO of HHUNY Inc., the not-for-profit organization that created HHUNY.

CHALLENGES

Before integrating the Netsmart CareManager system, HHUNY faced significant challenges in coordinating care across various EHRs.

The organization lacked efficient information exchange, resulting in fragmented care, more emergency department visits, and increased hospital stays. This disjointed communication among providers not only hampered patient outcomes but also burdened care managers with extensive administrative tasks, impacting staff morale and the ability to provide holistic, efficient care.

SOLUTIONS

To address these challenges, HHUNY adopted CareManager, a comprehensive solution designed to facilitate the exchange of authorized health information among providers, aggregate clinical data for population-level insights, track clinical quality measures and outcomes, and manage authorizations and claims. The user-friendly interface of CareManager supports coordinators in performing outreach, care management activities, and managing enterprise efficiency.

This holistic approach ensures the service plan addresses not only medical needs but also housing, transportation, and employment services when required.

RESULTS

Following its CareManager adoption, HHUNY processes up to 25,000 care referrals annually.

“Our metrics across the board with our managed care organizations have improved from year to year,” according to Phil Balta, Regional Director. The health home model has notably reduced emergency department visits and hospital stays for participating individuals, validating the effectiveness of CareManager in enhancing care coordination.

A significant success of CareManager is its ability to streamline workflows and reduce administrative burdens. “Netsmart understands the importance of the user experience and they are open to making modifications. Our care managers rely on the electronic health record to be user friendly and intuitive, and I believe that the team at Netsmart understands this and works with us to ensure our care managers truly have a positive experience.” says Bottone.

By collaborating with the Netsmart team, HHUNY has introduced new features that aim to simplify administrative tasks, as well as improve staff morale, retention and recruitment. The intuitive nature of CareManager also facilitates smooth training and adoption, allowing care managers to focus more on patient care rather than paperwork.

Streamlined workflows bring us more money and reduction in the time spent on desk work, giving staff more time to spend with members.”

Phil Balta, Regional Director

CareManager’s effectiveness extends to integrating new organizations into the HHUNY network. In April, HHUNY successfully transitioned approximately 2,000 members, demonstrating strong confidence in their process and reducing anxiety during large transitions.

“It’s important that we adopt and embrace changes,” says HHUNY CEO Alison Bottone. “It’s about driving the technology where it needs to go. Let’s talk about the needs from the user’s lens, not just the technology lens.”

The partnership between HHUNY and Netsmart has further evolved over the years, enhancing the system’s configurability and responsiveness to regulatory changes. Bottone highlights the value of collaboration with Netsmart, especially when adapting to new state requirements. “It’s of huge value to us when Netsmart is at the table with the state," Bottone says, "there’s interest and engagement on the part of Netsmart in understanding what the state is looking for and they are getting the information directly from the DOH technology team. Netsmart’s presence at the table helps us to effectively adapt when changes and deadlines are implemented.”

Looking ahead, HHUNY remains optimistic about the future, aiming to support up to 22,000 individuals at any one time and eventually discharge clients after six months to three years, enabling them to manage their care independently. “Everyone benefits,” says Bottone.

“I appreciate that the Netsmart team understands the importance of the work that we do, and they take seriously our mission to deliver high quality services to individuals enrolled in the health home program,” Bottone shared.

By integrating CareManager, HHUNY has not only improved care coordination and patient outcomes but also streamlined administrative processes, with the goal of fostering a more efficient and effective healthcare system. The ongoing collaboration with Netsmart continues to drive innovation and adaptability, ensuring that HHUNY remains at the forefront of healthcare coordination.