Posted: Friday, January 17, 2014

Rhode Island’s early adoption of one of the provisions of the Affordable Care Act has launched a program that coordinates care for some of The Providence Center’s most complex clients, improving health outcomes and, in the long run, saving the Medicaid program money.

Medicaid’s new “Health Home” option allows a provider to coordinate all medical services for clients with chronic illnesses. In 2012, Rhode Island became one of the first two states to implement Health Homes, a program providing a structure and incentives for community mental health centers to coordinate services of Medicaid clients with severe mental illness.

Health Homes are based on the concept of person-centered care, a tenet of The Providence Center’s approach to care. As a provider, The Providence Center develops a treatment plan for each client that addresses all of their health needs: primary care, mental health and substance use treatment, chronic disease management and non-clinical services such as connections to community supports and identifying family supports.

“We focus on caring for the whole person and Health Homes supports our vision for an integrated system of health care,” said Deb O’Brien, The Providence Center’s vice president and chief operating officer.

While comprising only five percent of the Medicaid population, individuals with behavioral health needs make up over half of Medicaid spending nationally. In Rhode Island, 5,000 Medicaid beneficiaries have severe and persistent mental illness, many of whom don’t access primary care regularly. For a high-cost patient, enrolling in a Health Home ensures consistent coordination of all aspects of care, including psychiatry, primary care, specialty care, medication, hospital discharge and wellness needs.

“This coordination helps us sharpen our focus on client care and improves health outcomes while controlling Medicaid costs,” said Jim Pinel, director of community services. Nearly 1,000 Providence Center clients have benefitted from Health Homes.

A benefit of Health Homes is the full access to the information staff need to help clients achieve optimal health. “Prior to Health Homes, we wouldn’t know if a client was hospitalized and they would be discharged without a treatment plan, possibly causing a client to lose the gains they had made in treatment,” said Russ Cooney, associate director of community support programs. “Now, the hospital liaison coordinates care between the discharge planners at the hospital and the team in the community so that the appropriate supports are in place for recovery when they are discharged.”

Several unique features already in place at The Providence Center enhance the organization’s effective implementation of Health Homes. The Providence Community Health Centers clinic and Genoa Pharmacy located on-site simplify primary care and medication coordination. Two registered nurses embedded on community treatment teams facilitate follow-ups to medical specialists and lab tests and connect clients to wellness services.

Health Homes are a valuable tool for improving care and advances the integration of physical and behavioral health care. For individuals with complex health needs, Health Homes are an innovative solution to coordinating all the services that allow clients to achieve wellness.