Central New York Health Home, Inc. (CNYHHN, INC)

History of Central New York Health Home Central New York Health Home Network (CNYHHN, Inc.) offers comprehensive Care Management services to New York State Medicaid recipients in 7 counties which included, St. Lawrence, Jefferson and Lewis counties. CNYHHN has been providing Care Management services since July of 2013 for adults with complex combinations of chronic conditions and/or severe mental illness. CNYHHN was designated to serve children on March 1, 2017 and has added Rensselaer Falls, Schenectady and Albany counties to our catchment areas.

What is a Health Home? A Health Home is a care management service model where all of the professionals involved in an individual’s care communicate with one another so that all of a patient’s needs (medical, behavioral health and social services) are addressed in a comprehensive manner Coordination is achieved primarily through the care manager who oversees and coordinates a patient’s access to needed services

CNYHHN, Inc. Jefferson County Care Management Agencies (CMA) Children’s Home of Jefferson County ACR Health Transitional Living Services Central New York Heath Home HCR Credo

Jefferson County Enrollment Numbers 479 Active Outreach 368 Hiatus 881 Enrolled

CNYHHN, INC. Lewis County Care Management Agencies (CMA) Transitional Living Services of Northern New York Children’s Home of Jefferson County

Network Partners Alcohol and Substance Abuse Council of Jefferson County Canton Potsdam Hospital St. Lawrence Psychiatric Center River Hospital Claxton-Hepburn Medical Center Family Counseling Services of Northern New York Jefferson County DSS Jefferson County Public Health Northern Regional Center for Independent Living Samaritan Medical Center Dr. Charles Moehs Watertown Urban Mission

Health Home Eligibility Criteria SMI Serious Mental Illness (exclusive) or HIV/AIDS (exclusive) or 2 or more Chronic Conditions (review 200+ conditions in referral ) Must have risk factors to be eligible

Core Health Homes Services Goal of the Core Services is to ensure access to appropriate services, improve health outcomes, reduce preventable hospitalizations and emergency room visits Comprehensive Care Management Care Coordination and Health Promotion Comprehensive Transitional Care from Inpatient Settings Individual and Family Support Referral to Community and Social Support Services Use of HIT to Link Services

Outreach and Engagement Begins immediately upon assignment (no later than 5 business days) Document efforts in the member’s record with an Outreach Note Upon assignment CMA is required by policy to contact referent within 72 hours

CNYHHN Receives Referrals From CM Program Receives Assignment: Begin Outreach services immediately Obtain Member Consent Complete Comprehensive Health Risk Assessment Develop Care Plan Report efforts back to CNYHHN Begin Care Management! DOH MCOs SPOAs Community Hospitals Criminal Justice System Social Service Providers Health Care Providers Designated Health Homes Assigns to Care Management Program HH sends Welcome Letter. If MCO – they also send their own Welcome Letter Assignments from DOH and MCOs will be in the form of a tracking file

CNYHHN, Inc. Referral Process Complete the Community Referral Application Form, including as much detail as possible to allow CNYHHN, Inc. to verify eligibility for health home care management services. Attach a signed Consent to Disclosure of Health Information Form. Attach supporting documentation of diagnosis (if available). Send the completed application and consent via secure e-mail or fax, or mail to: Attn: Referrals CNYHHN, Inc. referrals@cnyhealthhome.net Fax: 315-624-9428 Questions? Call 1-855-784-1262

Primary Goal of Health Home Care Management is to: Reduce avoidable hospital admissions and readmissions; Reduce avoidable emergency room service; Provide timely follow up care; Reduction in health care costs; Less reliance on long term care facilities and Improved experience of care and quality of care outcomes for the individual

How can your agency be a part of this change? Promote the Health Home care model with clients, community Make referrals when appropriate Collaborate with Care Managers when consented

CNYHHN, Inc. Health Home Team www.cnyhealthhome.net Amy Schmid Executive Assistant 315-624-9670 ext. 5231 amy.schmid@cnyhealthhome.net Betsey Weaver Applications Support Specialist 315-624-9670 ext. 6985 betsey.weaver@cnyhealthhome.net Jane Vail Vice President of Health Home 315-624-9670 ext. 5233 jane.vail@cnyhealthhome.net Kim Pecor Dir. Quality Assurance & Systems Operations 315-624-9670 ext. 5226 kimberly.pecor@cnyhealthhome.net Jillian Gross Dir. Adult Health Home Relations 315- 624-9670 ext. 6982 jillian.gross@cnyhealthhome.net Lynne Young Operations Manager of North Country 315-948-3410 ext. 2 Lynne.young@cnyhealthhome.net Christina Lounsbury Janelle Luley Referral Coordinator Referral Coordinator 315-624-9670 ext. 5215 315-624-9670 ext. 5225 Referrals@cnyhealthhome.net