Op-Ed: Hudson Valley Care-Determined to Improve Transitions of Care

As of July 1st a well-known Yonkers drop-in closed its doors for the last time. These resources are invaluable to our communities and should remind us how important transitions of care really are in today’s healthcare system. Getting people young and old to the point where they can maintain their own health is crucial if we want to establish healthier communities.

The Montefiore Hudson Valley Collaborative (MHVC) funded Hudson Valley Care Coalition (HVC), a Lead Health Home in the Hudson Valley area, with an Innovation Grant that focused on developing effective engagement models. More specifically, the purpose of this project is to outreach and engage “hard-to-reach members,” enroll them into Health Home care coordination services or connect them to other resources. The Health Home program is a wrap-around service to connect Medicaid recipients with chronic conditions to necessary healthcare services and resources. The project initially focused in Yonkers but the benefit from collaborations like this can help all communities.

Southern Yonkers near Getty Square is considered a “hotspot” for people that can benefit from receiving social support services. Through support from the Westchester County Department of Community Mental Health and Department of Social Services (DSS), HVC was able to create a partnership with The Sharing Community, a shelter/soup kitchen in the Yonkers area.

The community-based soup kitchen and homeless shelter provided hot meals Tuesday through Friday, acted as a transitional shelter for up to 19 individuals placed by the Westchester County DSS, and was an emergency shelter for the public which holds around 67 individuals.

The money received for this project funded the salaries of two Peer Specialists, who are employed by the Sharing Community. These individuals are responsible for engaging members at The Sharing Community who could benefit from Health Home services. The Peers administrated a short survey which helps identify what matters most to the member.  The information assists the Health Home Care Manager to begin working with the member.

The goal of the project: to enroll 20 percent of Sharing Community members engaged by September 31, 2018. As of June, 2018 this HVC project not only reached its goal but surpassed it by eight percent. Out of 399 members surveyed at The Sharing Community approximately 139 were eligible to receive Health Home services and 39 of those members were enrolled into the program. This model was able to surpass the State-wide engagement rate of approximately 15 percent by 13 percent.

The need for the project: New York State Health Homes rely predominantly on two types of referrals: top-down referrals sent to the Lead Health Home based on Medicaid claims, and bottom-up referrals sent from within the community. To date a majority of the engagement models that rely on information from Medicaid claims have proven ineffective, while receiving referrals from within the community usually have higher enrollment rates. This information forces Lead Health Homes to come up with creative ways to reach target populations. HVC believes having a strong presence in the community and connecting directly with the members will yield an even greater response.

What HVC has learned:  working with community based organizations like The Sharing Community not only gives HVC a place for its care managers to put their boots on the ground but it also embeds the network into the community dynamic which is important. It is not just about finding members within the healthcare system that could benefit from Health Home services but stepping out of the bubble and bridging a gap to the individuals that otherwise might be “invisible.” Establishing relationships such as these within our communities is the key in gaining trust within the Hudson Valley.

The Hudson Valley Care Coalition (HVC) is a non-profit Lead Health Home network of health and community agencies that have agreed to work together.  Our network works to help Medicaid members with serious and chronic health issues get additional support services to stay healthy & safe within their communities.  HVC seeks to improve its member’s access and engagement in health services that will result in better health outcomes and an improved quality of life.

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About the Author: Brianna Rodriguez