By Callie Kaplan, Senior Research Associate, lead researcher/author of Health Neighborhood Evaluation and Olivia Masini, Manager of Care Coordination, Manager of the Health Neighborhood
What is Health Neighborhood?
The Health Neighborhood was an innovative demonstration project, which sought to improve connection of care; improve outcomes and experience of care for a particularly vulnerable population; to generate new revenue; and to, ultimately, enable partners to negotiate value-based payment arrangements with payers. The Health Neighborhood positions all partners at the intersection of health equity, health innovation, and shifts in our healthcare environment in order to improve outcomes.
The Health Neighborhood’s service delivery model embedded Permanent Supportive Housing (PSH) providers into Heartland lance Health’s (HAH) health care teams that are patient-centered, comprehensive, team-based, data-driven, coordinated, and accessible. These unique partnerships leveraged the scope of services found in each setting and harnessed them to provide opportunities for collaborative and coordinated care, creating the data, revenue, and communication systems and infrastructure necessary to advance formal interdisciplinary and inter-organizational coordination and collaboration between a community health organization and PSH providers. Could we add a line about why coordination and collab between these two systems is beneficial.
At its core, the Health Neighborhood was a formal agreement, which allowed HAH to share PSH staff in order to create an interdisciplinary, inter-organizational virtual neighborhood of care around PSH residents. Through this partnership model, shared staff remained PSH provider employees, while also fulfilling HAH job responsibilities. HAH provided shared staff with training and on-boarding support to ensure they have the knowledge, skills and competencies to effectively provide clinical and care coordination services within the Health Neighborhood framework and as part of HAH’s care team. Staff time was reimbursed through HAH’s existing Medicaid billing center.
PSH Care Coordinators and Licensed Clinicians were integrated into HAH’s health care teams, and these new interdisciplinary, inter-organizational care teams worked together to outreach and engage shared participants; develop, implement, and reinforce care plans; utilize and update theelectronic health record (EHR); and coordinate services. HAH credentialed PSH staff, as appropriate, and developed and managed the process and procedures necessary to enable billing for their services.
The Health Neighborhood also leveraged HAH’s robust EHR, as well as its infrastructure and expertise related to billing and working with payers, which is especially invaluable to PSH partners who often do not have the capacity or experience necessary to develop and manage complex billing processes and workflows in an ever shifting healthcare environment. The Health Neighborhood positioned all partners at the cutting edge of the shifts in the healthcare environment toward value-based payment arrangements and models of care that integrate services across disciplines.
What is the biggest takeaway from the report?
The biggest success from the implementation of the Health Neighborhood was observing the positive effects of communication and integration of care on participants and shared staff. Access to the EMR provided seamless care coordination and communication from external organizations to HAH care teams. Shared staff were able to curate a personalized healthcare experience that involved quicker return times on prescriptions, scheduling appointments, and information relayed from a provider. This not only naturally led to improved health outcomes, but also led to participants’ increased trust in their medical home.
The report illustrated that change – even small change- takes time, effort, and relationship-building. Among folks with complex medical and social needs, standard clinical outcomes, may not always capture positive change in short time periods without significant and sustained investment. The outcomes highlighted in the report, appointment completion and compliance with clinical measures did not show significant changes during the project period BUT the stories shared by care coordinators and participants told a different story. That story highlights the complexity of navigating the healthcare system, especially for folks with both behavioral health and physical health challenges, and the key role that care coordinators play in co-navigating they system and providing strong encouragement and support. For people who are unstably housed, healthcare may not be the first priority, and people who are unstably housed may also have had past adverse experiences with healthcare providers which acts as a barrier to care. The influence that care coordinators and therapists had on supporting participants to reach health goals was evident, if not reflected in the quantitative data.
From the policy scan, and reflected in the key informant interviews, our fragmented health system does not support integrated care, especially for folks reliant on the social service sector. Not only does this fragmentation lead to poorer outcomes, it is also more costly. While we were not able to track emergency department visits or hospitalizations to tie to costs, we know from research in the field that investing in housing and holistic care reduces emergency room visits. We estimated the cost of care coordination services from one PSH provider, which, even if reimbursed at an hourly rate, does not fully cover the costs of a comprehensive program like Health Neighborhood. We need to fully invest in our network of community-based organizations, and especially in communities of color, who have existing, trusting relationships to support the clinical care bridge. Investing in prevention rather than paying for hospitalizations or emergency room department visits is not only smart, it is humane.
How can a “failure” really turn out to be a success?
While it proved financially unsustainable in its original iteration, the Health Neighborhood was not a failure but a rich learning opportunity from which to help build, inform and shape the internal infrastructure of care coordination at HAH. We learned care coordination is a priceless service, one that is not appropriately compensated in the current healthcare system.
We learned that health care extends beyond the appointment. It is the call to schedule the appointment, understanding how to get to the appointment, overcoming the financial and physical barriers to attending that appointment, absorbing the information received at the appointment, advocating for patient needs, and beyond. These nuances to health care are often missed. Not by the care team, but by the larger organizations that fund these activities. While they don’t appear to directly address a chronic and severe condition, they do directly support how and whether a patient will be able to adhere to a treatment plan and care for themselves.
A revolutionary model like the Health Neighborhood will not be sustainable, even if the need calls for it. We must advocate for reimbursement for care coordination services that not only improve health outcomes but promote more outpatient follow-up and less inpatient and ER visits. This shift in incentive decreases overall costs for insurance companies and can afford more financial allocation to providing care coordination services.
The Health Neighborhood evaluation pushes our field to think about what ‘success’ means and how it is measured. This will become critically important as we shift towards value-based payments, and outcomes that determine payments are developed or organized. The metrics must be inclusive enough of complex populations, and flexible enough to account for the time that change can take. The development of those metrics should include the opportunity for meaningful feedback, specifically from providers who work closely with populations experiencing housing instability/homelessness, substance use disorders, and serious mental illness, to ensure they reflect the reality of what positive trajectories look like for these populations. Lastly, the payments must also be aligned with the effort and personnel required to meet benchmarks among health centers and community organizations that work with the most vulnerable populations, and right the prevention/treatment reimbursement imbalance to encourage and support primary preventative services.
What is next for Health Neighborhood?
The Health Neighborhood lives on in different ways in the organization. Currently, a partnership between North Side Housing and Supportive Services and an HAH care team has been formed to provide better access to care coordination. While this partnership does not allow access to the EMR as the Health Neighborhood did, it does create increased collaboration and integration across provider type and specialties. Lessons learned from the Health Neighborhood have also helped shape the ongoing development of care coordination and identifying the financial support needed for sustainability.
Also, as the Integrated Health Homes (IHH) rolls out, Illinois Heatlh Care and Family Services (HFS) is looking at partnership with promising models like the Illinois Health Practice Alliance, which Health Neighborhood informed. It is our hope that the lessons learned around community partnerships, holistic and integrated care, and an investment in supportive housing with wraparound health services is carried forward in the future.
