Coordinated Care Helps Kids Pursue Their Potential
Managed Care Improves Outcomes
Care management staff are sometimes called on to be miracle workers. And often, they deliver.
Take, for example, the story of an immigrant family—a single mother with eight children, one of whom had recently undergone one of many orthopedic surgeries and was in a spica cast that encompassed both legs and hips. A community health worker from HealthVine went to visit the family in February and learned that they were living in a home that had no heat and the windows were broken out. The mother spoke little English and had difficulty navigating the health and human services system.
The community health worker helped get the family into stable housing with electricity, water and windows that were intact. She also arranged for assistance with transportation to and from appointments and connected them with Refugee Services to address other needs. Or consider the patient from a rural county who had been hospitalized for several months. She was eligible to be discharged but could not be released because there was only one home health option that could provide the level of care she needed. The patient’s mother refused to work with the agency because she’d had a bad experience with them. The care manager mediated a meeting with the mother and the agency so the mom could express her concerns. The meeting went well, the mother felt like she’d been heard, and the patient was able to come home.
Behavioral Health Aims for Holistic Approach to Care
Ask Kate Junger, PhD, about HealthVine, and she’ll tell you she could talk about it all day long.
That’s how excited she is to be on the ground floor of making systems-level changes that will make behavioral healthcare more accessible to patients and families. Junger is a psychologist and the behavioral health administrative director for HealthVine. She and Jessica McClure, PsyD, clinical director of Behavioral Health for HealthVine, have been working closely on creating the vision and strategies that HealthVine will employ to improve the behavioral health functioning of kids across the southwest Ohio eight-county region. The team also includes Emily Harris, MD, who helps with medication consultation and support of the care management team.
“Our responsibility is to bring data-driven programs to the HealthVine network to elevate access to evidence-based care, to help providers in our region get trained in the delivery of that care, to reduce health disparities, and improve the connections between the physical and behavioral health systems,” says Junger. “Behavioral health is a big, innovative and transformative part of HealthVine.” Their goals for behavioral health span the care continuum from prevention all the way through the most intensive interventions, with a specific focus on getting as far upstream as possible. For example, they are working to expand universal behavioral health screening, especially in young children. They aim to make behavioral healthcare more robust in primary care and build awareness of and access to more intensive services for families who need them. Their intent is to get children connected to the right care at the right time in the least restrictive setting.
Utilization Management Brings Pediatric Expertise to Approval Process
Last year Stacey Ishman, MD, MPH, could not have given you an accurate definition of what utilization management was.
“I’d always thought of it as the group of people that was in my way when trying to care for my patients,” says the ear, nose and throat surgeon half-jokingly. In her new role as medical director of utilization management for HealthVine, Ishman knows differently now, and she’s excited about exploring how she and her 26-member team can make a difference for kids.
Utilization management is the process of reviewing requests for tests, services and procedures to determine medical necessity for treatment of patients. The review is conducted on behalf of an insurance payor (in this case, CareSource) and follows standard evidence-based guidelines designed to ensure the patient is getting the best care.
Says Ishman, “The rationale is that, when treating a condition, you start with a less invasive therapy, and if that fails, you progress to a more invasive one that involves more risk and recovery time, and typically, more expense.” Cincinnati Children’s has never had an in-house utilization management team before. The group they’ve assembled to review requests consists of physicians, nurses, social workers, a licensed practicing counselor and a psychologist. Many have worked on utilization management at other organizations.
Community Engagement Is Critical to HealthVine Success
Mona Mansour, MD, medical director of community engagement for HealthVine, is on a mission.
She and program manager Sarah Soule have been connecting with pediatric practices in the eight-county southwest Ohio region to let them know about the new network and the resources and tools it offers to help them improve outcomes for their patients. There is no cost to join HealthVine. But the benefits to member practices are many—access to care management and behavioral health supports, programs for high-risk patients, Project ECHO training for primary care providers on how to manage depression and anxiety in their patients, help with behavioral health screenings, supports to reduce social determinants of health, use of the Epic Healthy Planet care and population management platform, and much more.
In return, practices agree to meet with members of the HealthVine team quarterly to share information and data as part of a combined effort to solve the health challenges their patients and families face. Says Mansour, “Due to COVID, we’ve mostly been doing virtual education right now because we’re new, but our goal is to meet in person with practices so we can build better relationships. With the data we’ll be gathering, we’ll have a better understanding of how we can best support improved outcomes for the patients and families we share.”
The community practices they’ve met with have given Mansour and Soule a warm welcome. Many have opted to join, while others have taken a wait-and-see approach. Still others have been so swamped due to COVID-19, they’re feeling like they can’t focus on anything new right now.
“For those practices that are hesitant, we’re working hard to connect with them around their patients who are delegated to us through CareSource,” Mansour explains. “Since we are responsible for delegated functions regardless, we are saying, ‘Hey, look at these great things we are able to do for your patients. We’d really love to do this in a more coordinated way.’”