Health Homes: A Tale of Two Problem Lists

Below is the fourth in a series of guest posts from Nirav R. Shah, MD, MPH, the commissioner of health for the state of New York. Look for more of his blogs in the Intel Healthcare Community in the coming months.

Mr. Jones shows up in the emergency room, complaining of severe insomnia. The problem list on his electronic health record highlights his ailments -- diabetes, asthma, anxiety, depression and migraines. A doctor prescribes a stronger anti-anxiety medication, but his insomnia does not subside.

Now imagine if that problem list also reveals that Mr. Jones is homeless, struggles with a substance abuse problem, and has a son who is in and out of prison – a surefire recipe for insomnia, if ever there was one.  Instead of giving him a pill, the staff uses that information to reach out to existing community agencies that help Mr. Jones find stable housing, a new drug counselor and support for his son -- for less than the cost of an emergency room visit.

That’s what happens when you have a health home, a health care model that delivers coordinated care to the state’s neediest patients, those who have complex behavioral, medical and long-term health needs and two or more chronic conditions.

A health home is not a physical place, but rather a model of health care in the Affordable Care Act geared for the 5 percent of the population that accounts for 50 percent of our total health care costs. Maimonides Medical Center has created the Brooklyn Health Home, which targets adults with complex health issues, serious mental illness, HIV and substance abuse issues, and is funded by the New York State Medicaid program.

Each patient in the Brooklyn Health Home has a care team comprised of a care manager, care navigator, and primary care doctor, and if needed, a psychiatrist and/or therapist. Other potential team members include specialty physicians, home care nurses, social workers, residence managers, substance abuse providers and caregivers in the home.

The team members are linked through the Statewide Health Information Network for New York, or SHINY-NY. If a patient sees a specialist or gets a new medication, everyone on his team knows about it.

Medical problems are only part of the equation. Problem lists in the Brooklyn Health Home also include social challenges and together with medical issues, get prioritized from the patient’s perspective. Everyone on the team knows if a patient gets evicted, experiences domestic violence or loses his home health aide. That’s what makes the model unique – an entire team is looking out for patients who not only have multiple medical needs but are vulnerable to social factors that sabotage good health.  After all, the social determinants of our lives – income, education, housing -- have as much of an impact on our health as medical ones, if not more.

With Mr. Jones, we know that connecting him to a new substance abuse counselor is likely to go farther than simply handing him a new medication. By creating a patient-centered problem list, we can lower the use of hospital emergency departments, reduce hospital inpatient admissions and cut back on 30-day readmissions. We can also improve patient care.

When we know the social context of a patient’s life, we get a bigger picture of his health needs. Health data lets us do that and makes it possible for us to address the social hindrances to good health as well as the medical ones.

What questions do you have?