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The Business Journal - 4/8/2021

No Wrong Door - An Integrated System of Care


CNYHHN is a lead health home and care management agency that works to engage individuals with serious and complex physical, mental health, and substance-use disorders to achieve better health outcomes and overall cost of care reduction. As one of 32 lead health homes in New York state, we work with members by coordinating health care and social services through a trauma-informed, evidence-based individualized comprehensive plan of care and helping them navigate the health-care delivery system. CNYHHN serves an average of 5,200 Medicaid members annually and provides services across a population of 10 counties. We work to meet the needs of this population by connecting individuals with resources provided by our network of partners to ensure priority access to care, improve health outcomes, and reduce preventable hospitalizations and emergency room visits. Many of our care managers are co-located in hospitals, primary-care physician offices, mental-health clinics, and local-government offices.

What has been the outcome of this collaborative project?

No Wrong Door - An Integrated System of Care. CNYHHN, Upstate Cerebral Palsy (UCP) and Upstate Family Health Center (UFHC), have developed a centralized hub for coordinating care for vulnerable populations. The collaboration was developed to meet the unmet health-care needs of vulnerable populations in Oneida County that: (1) face barriers to quality health care; and, (2) are more likely to have poor health outcomes. This population is also most at risk of under-utilizing primary and preventive services and over-utilizing hospitals and emergency rooms. The goal is to ensure that this at-risk population can immediately and seamlessly connect with the right services and supports through a well-orchestrated screening, referral and care coordination process paired with embedded services within community-based organizations. Unfortunately, many agencies that work closest with at-risk populations and understand their needs are grass roots/small agencies that are not included in opportunities to shape the health-care delivery system. The No Wrong Door model creates integrated networks of care with a strong centralized hub that engages grass roots agencies to better serve at-risk populations with nuanced needs. The model is centered around five key activities:

* Identification of agencies that interact with target populations (Spoke Agencies)

* Engaging agencies and subject matter experts in discussions to determine key gaps in service delivery

* Development of tools and resources to standardize and coordinate care

* Embedding targeted care and support within spoke agencies

* Achieving sustainability of embedded care through development of case loads

We have developed a shared-data platform that allowed us to identify and track over 700 clients, as well as identify the best way to coordinate their care. Our shared population often has complex health needs that require primary and behavioral health care, and the patients are often health home eligible. We have also created standardized social determinant of health screening tool to connect clients with additional support services through our network. Since the 2020, about 1,300 'screenings' to assess needs which led to 251 comprehensive social determinants of health assessments. Of those individuals, 75 percent have been referred to one of the hub agencies for Care Management, Primary Care, or Behavioral Health services. The long-term goals are to achieve a 10-15 percent decrease in appointment no shows and cancellations across all three agencies. Because of treatment in place and telehealth and 10-15 percent increase in Pharmacy use and Medication Adherence because of increased engagement with patients through high-touch care management. This would ultimately lead to a reduction in preventable ER visits. No Wrong Door allows for the whole person to be cared for by a system, rather than in siloes, increasing overall access to care.

The project owes an immense amount of gratitude to our partnership with The Center (the area's refugee resettlement agency) and M.S. Hall & Associates (Healthcare Consultants). The Center has been a core collaborator from the inception of No Wrong Door; providing our agencies' staff with cultural competency training, as well as facilitating interpretation. M.S. Hall has provided invaluable guidance in the implementation of our data integration and evaluation plan. They have allowed us to develop a sophisticated system and dashboards demonstrating health outcomes and process measures.

How has developing this collaborative partnership impacted the community?

The No Wrong Door initiative is tearing down siloes between agencies addressing social determinants of health and breaking barriers to access to care for some of the neediest Central New Yorkers. It directly improves the health and well-being of poor, underserved, vulnerable, and disadvantaged individuals while enhancing the health-care delivery system to address social determinants of health. Of the 700 shared clients that we collectively serve through our No Wrong Door initiative, we performed an analysis on a group of clients to compare the number of Emergency Department (ED) visits before No Wrong Door implementation and after. We found that after receiving care through our program the ED-visit rate went from eight visits per client to two. So, we could conservatively estimate that our model potentially reduces ED visits for our shared clients by 50 percent. The result on Medicaid cost savings would be significant. A 50 percent reduction in ED visits for our 700 shared clients, from 5 ED visits per client to 2.5 visits, leads to an estimated savings of over $3 million in Medicaid costs.