A Health Home is a care management service model whereby all of an individual’s caregivers communicate with one another so that all of a patient’s needs are addressed in a comprehensive manner. This is done primarily through a “care manager” who oversees and provides access to all of the services an individual needs to assure that they receive everything necessary to stay healthy, out of the emergency room and out of the hospital. Health records are shared (either electronically or paper) among providers so that services are not duplicated or neglected. The health home services are provided through a network of organizations- providers, health plans and community-based organizations. When all the services are considered collectively they become a virtual “Health Home”.
To be eligible for Health Home service an individual must meet two basic criteria.
If an individual has HIV or SMI, they do not have to be determined to be at risk of another condition to be eligible for Health Home services. Substance use disorders (SUDS) are considered chronic conditions and do not by themselves qualify an individual for Health Home services. Individuals with SUDS must have another chronic condition to qualify.
UPS partners with Bronx Lebanon to provide Health Home services to enrolled clients. Enrolled clients are those who have consented to receive care coordination services from UPS staff. UPS provides:
A comprehensive health assessment and an individualized plan of care is developed that identifies medical, behavioral health (mental health and substance use) and social service needs and integrates the continuum of medical, behavioral health services, rehabilitative, long term care and social service needs and clearly identifies the primary care physician/nurse practitioner, specialist(s), behavioral health care provider(s), care manager and other providers directly involved in the individual’s care.
UPS staff is responsible for engaging and retaining Health Home enrollees in care; coordinating and arranging for the provision of services; supporting adherence to treatment recommendations; and monitoring and evaluating individual’s needs, including prevention, wellness, medical, specialist and behavioral health treatment, care transitions, and social and community services where appropriate through the creation of an individual plan of care.
UPS in partnership with Bronx Lebanon has a system in place with hospitals and residential/rehabilitation facilities in their network to provide the Health Home prompt notification of an individual’s admission and/or discharge to/from an emergency room, inpatient, or residential/rehabilitation setting
Enrollee’s individualized plan of care is accessible to the individual and their families or other caregivers based on the individual’s preference.
UPS Health Home utilizes support groups and self-care programs to increase enrollees’ knowledge about their disease, engagement and self-management capabilities, and to improve adherence to prescribed treatment.
UPS Health Home staff identifies available community-based resources and actively manages appropriate referrals, engagement, follow-up and coordination of services
Services vary by individuals but include face-to-face visits in the home or a pre-determined off-site location, wellness counseling, escort to medical appointments, ADL skills training and community integration skill building. Phone calls are made to augment services both to clients and their collateral providers. Services are also aimed at obtaining and maintaining entitlement benefits.