Housing is Healthcare: How a PCMH is Caring for NYC’s Homeless Population | Healthcare Informatics Magazine | Health IT | Information Technology Skip to content Skip to navigation

Housing is Healthcare: How a PCMH is Caring for NYC’s Homeless Population

March 14, 2018
by Rajiv Leventhal
| Reprints
Care for the Homeless was able to apply Patient-Centered Medical Home standards across 14 health centers to enhance care quality for New York City’s homeless population

As of January 2018, there were more than 63,000 homeless people, including over 23,000 homeless children, sleeping each night in the New York City municipal shelter system, according to statistics from the Coalition for the Homeless. What’s more, there were an additional 4,000 homeless people on the streets of New York City, per recent data from the Homeless Outreach Population Estimate.

And when it comes to receiving healthcare services, it’s clearly been a struggle for all parties involved. On one hand, having stable housing is an obvious connection to being able to stay healthy. And on the other hand, from a healthcare cost perspective, homeless individuals are more likely to use ER services than members of the general public.

There are a fair share of organizations in New York City that help the homeless with healthcare issues, with one of those such organizations being Care for the Homeless, an institution developed in 1985 with the aim to meet the healthcare and social service needs of homeless people in the city. What separates Care for the Homeless from some other organizations of its ilk, however, is that it was just recently formally recognized by the National Committee for Quality Assurance (NCQA) as a Level 3 Patient-Centered Medical Home (PCMH). The New York City-based organization partnered with the Massachusetts eHealth Collaborative (MAeHC) to apply PCMH standards across its 14 sites.

The team-based PCMH approach gives each person who seeks treatment at Care for the Homeless a comprehensive care plan that is integrated across multiple providers at any of the organization’s health centers. Care for the Homeless’ service delivery model provides care at co-located host sites such as shelters and soup kitchens. Interdisciplinary teams visit these service sites anywhere from one to five days a week to offer certain primary care services; the system also has some behavioral/mental health and podiatry services.

What’s more, Care for the Homeless partners with other organizations, such as the Institute for Family Health, to directly treat patients at mobile health clinics across the city. Overall, the organization serves between 7,500 and 8,500 men, women and children, annually, in the Bronx, Brooklyn, Queens and Manhattan.


Can Informatics Drive Clinical Quality Improvements Alongside Operational Improvements in Cancer Care?

Due to the complexity of the disease biology, rapidly increasing treatment options, patient mobility, multi-disciplinary care teams, and high costs of treatment - informatics canplay a more...

“We provide care to people during a very fragmented time in their life,” says Regina Olasin, D.O., chief medical officer at Care for the Homeless. “Our goal is to not just give them a medical home where they can turn to for care options, but to also provide a place that feels like a home—a warm and welcoming space where the providers know their names. When homelessness strikes, it affects more than a person’s current situation—it can expose them to major health risks with long-term ramifications. We aim to step in and help empower people with a path towards a healthier future.”

Indeed, Olasin says one of the core missions at Care for the Homeless is that “housing is healthcare,” adding that “If you look at all the data of people who are stably housed, they are doing much better on every single health parameter out there than individuals who are not stably housed.”

Undoubtedly, one of the major challenges with caring for the homeless is being able to follow them across the care continuum. As Courtney Beach, senior consultant at MAeHC puts it, “When serving a transient population with a unique set of needs, it is very difficult to track patients to ensure that they are utilizing the services or receiving information about their care.” At Care for the Homeless’ 15 sites, though, the EHR (electronic health record) allows for shared functionality, so that when a site is closed or when someone needs to be seen, the same medical record is available for all affiliated providers, and it enables the organization to provide 24/7 care with access to the EHR, says Olasin.

“A lot of the work we are doing is bridging care; the tragic piece to homelessness in New York City is that more shelters are needed to accommodate the needs of the people who don’t have access to affordable housing,” Olasin contends. “But with EHRs, we can work with health homes to provide bridging services to the next provider of care. So if someone is fortunate and leaves the shelter, we can connect [that person] with a health home and provide the medical information to the next person who is giving the care, with the [permission] releases that are obviously needed,” she says.

What’s more, through the use of the portal, the patient can have his or her own access with complete portability, as Care for the Homeless “web-enables” the population since 80 percent of individuals in homeless shelters have smartphones, explains Olasin. And once the organization’s mobile app gets up-and-running, she adds, the patients “will have access and portability to their health data that was provided during a period of their life when they were in a fragmented situation. And that’s incredibly valuable,” she says.

To this end, Olasin says that using the app could give patients the ability to make appointments with doctors and potentially use the mobile health service for telemedicine encounters. But she notes that one key issue is that these phones are in-and-out of operation for many homeless people who can’t pay their phone bills. “That’s a new type of barrier to care,” Olasin admits.

Partnering with MAeHC

To pursue its PCMH recognition, Care for the Homeless turned to MAeHC to provide strategic guidance and project management support. MAeHC’s experts worked hand-in-hand with the organization’s staff to help refine workflows, optimize and configure IT systems, identify patients for care management services, work with key staff in building care plans and workflows for high-risk patients, and enhance coordination of care with outside services such as hospitals and specialists, according MAeHC officials.

Olasin says that the PCMH process has allowed Care for the Homeless to turn the EHR into “a real tool,” in that it’s not only working for population-aggregate data collection for contracting use, but also on a specific basis for each patient. This way, says Olasin, “You can most effectively do care planning when you have a finite time period to work with them. But also, you can put the EHR in patients’ hands. Even if they don’t have a smartphone, maybe they can get to the library and once they are web-enabled, they are able to get to their EHR. The portal is something our population has found unique and surprising in their experience, and it’s not something that has been actively promoted before,” she says.

Importantly, Olasin points out that in addition to being medically disenfranchised, the homeless population are also socially disenfranchised. She explains that while a person might have become homeless in Queens or Brooklyn, he or she might have gone through an assessment in the Bronx and be in a shelter that isn’t close to where his or her children go to school, and where he or she has had prior medical and dental care. As such, with its on-site services, she believes that Care for the Homeless has been able to engender a type of facility in which “people want to know your name as opposed to you being out of many social loops for connectivity.”

Olasin further notes that social determinants of health have not always been addressed in the medical record, and therefore, the ability to effectively coordinate care has been limited. But she says that Care for the Homeless is working with its EHR vendor to integrate such documents, and there is protocol called a ‘prepare’ document, that as part of the patient intake, takes a review of the protocol for responding to and assessing patients’ access, risks and experiences.

“This is a social determinants of health intake tool that has been validated and that lets you stratify the degree of the risk of individuals coming into the system, in addition to the demographic information that is used.” The plan is for all of this together to go into a dashboard for relative risk stratification of the population being cared for, and then be added to the EHR, she says. “We’re starting to use this at the pre-visit planning piece, and [believe] that it will contribute significantly to the documentation of the complexity of patient care,” Olasin says.

This process will also allow clinicians and other medical folks to see what’s being done on the supportive service side of care, and vice versa. “This isn’t a concept that has been generally used in medicine. We always talk about the patient-provider relationship that’s driven from the patient as the person, but there is a mass customization where you want to be able to provide the optimal recommendations consistently across the board to everyone on an individual basis. And that has become a reality due to the effective application of EHR tools,” she says.

In the end, Olasin notes how the homeless population has not always benefited from getting the best in care, so “effectively leveraging technology so that you can have the best in both high-tech and high-touch for the optimal patient personal experience is what we are aiming for. And that’s really unique in this population,” she says.

The Health IT Summits gather 250+ healthcare leaders in cities across the U.S. to present important new insights, collaborate on ideas, and to have a little fun - Find a Summit Near You!


NCQA Moves Into the Population Health Sphere With Two New Programs

December 10, 2018
by Mark Hagland, Editor-in-Chief
| Reprints
The NCQA announced on Monday that it was expanding its reach to encompass the measurement of population health management programs

The NCQA (National Committee for Quality Assurance), the Washington, D.C.-based not-for-profit organization best known for its managed health plan quality measurement work, announced on Dec. 10 that it was expanding its reach to encompass the population health movement, through two new programs. In a press release released on Monday afternoon, the NCQA announced that, “As part of its mission to improve the quality of health care, the National Committee for Quality Assurance (NCQA) is launching two new programs. Population Health Program Accreditation assesses how an organization applies population health concepts to programs for a defined population. Population Health Management Prevalidation reviews health IT solutions to determine their ability to support population health management functions.”

“The Population Health Management Programs suite moves us into greater alignment with the focus on person-centered population health management,” said Margaret E. O’Kane, NCQA’s president, in a statement in the press release. “Not only does it add value to existing quality improvement efforts, it also demonstrates an organization’s highest level of commitment to improving the quality of care that meets people’s needs.”

As the press release noted, “The Population Health Program Accreditation standards provide a framework for organizations to align with evidence-based care, become more efficient and better at managing complex needs. This helps keep individuals healthier by controlling risks and preventing unnecessary costs. The program evaluates organizations in: data integration; population assessment; population segmentation; targeted interventions; practitioner support; measurement and quality improvement.”

Further, the press release notes that organizations that apply for accreditation can “improve person-centered care… improve operational efficiency… support contracting needs… [and] provide added value.”

Meanwhile, “Population Health Management Prevalidation evaluates health IT systems and identifies functionality that supports or meets NCQA standards for population health management. Prevalidation increases a program’s value to NCQA-Accredited organizations and assures current and potential customers that health IT solutions support their goals. The program evaluates solutions on up to four areas: data integration; population assessment; segmentation; case management systems.”



More From Healthcare Informatics


Can Informatics Drive Clinical Quality Improvements Alongside Operational Improvements in Cancer Care?

Thursday, December 13, 2018 | 3:00 p.m. ET, 2:00 p.m. CT

Due to the complexity of the disease biology, rapidly increasing treatment options, patient mobility, multi-disciplinary care teams, and high costs of treatment - informatics canplay a more substantial role in improving outcomes and reducing cost of cancer care.

In this webinar, we will review how tumor board solutions, precision medicine frameworks, and oncology pathways are being used within clinical quality programs as well as understanding their role in driving operational improvements and increasing patient retention. We will demonstrate the requirements around both interoperability and the clinical depth needed to ensure adoption and effective capture and use of information to accomplish these goals.

Related Insights For: Population Health


At the D.C. Department of Health Care Finance, Digging into Data Issues to Collaborate Across Healthcare

November 22, 2018
by Mark Hagland, Editor-in-Chief
| Reprints
The D.C. Department of Health Care of Finance’s Kerda DeHaan shares her perspectives on data management for healthcare collaboration

Collaboration is taking place more and more across different types of healthcare entities these days—not only between hospitals and health insurers, for example, but also very much between local government entities on the one hand, and both providers (hospitals and physicians) and managed Medicaid plans, as well.

Among those government agencies moving forward to engage more fully with providers and provider organizations is the District of Columbia Department of Health Care Finance (DHCF), which is working across numerous lines in order to improve both the care management and cost profiles of care delivery for Medicaid recipients in Washington, D.C.

The work that Kerda DeHaan, a management analyst with the D.C. Department of Health Care, is helping to lead with colleagues in her area is ongoing, and involves multiple elements, including data management, project management, and health information exchange. DeHaan spoke recently with Healthcare Informatics Editor-in-Chief Mark Hagland regarding this ongoing work. Below are excerpts from that interview.

You’re involved in a number of data management-related types of work right now, correct?

Yes. Among other things, we’re in the midst of building our Medicaid data warehouse; we’ve been going through the independent validation and verification (IVV) process with CMS [the federal Centers for Medicare and Medicaid Services]. We’ve been working with HealthEC, incorporating all of our Medicaid claims data into their platform. So we are creating endless reports.


Can Informatics Drive Clinical Quality Improvements Alongside Operational Improvements in Cancer Care?

Due to the complexity of the disease biology, rapidly increasing treatment options, patient mobility, multi-disciplinary care teams, and high costs of treatment - informatics canplay a more...

Kerda DeHaan

We track utilization, cost, we track on the managed health plan side the capitation payments we pay them versus MLR [medical loss ratio data]; our fraud and abuse team has been making great use of it. They’ve identified $8 million in costs from beneficiaries no longer in the District of Columbia, but who’ve remained on our rolls. And for the reconciliation of our payments, we can use the data warehouse for our payments. Previously, we’d have to get a report from the MMIS [Medicaid management information system] vendor, in order to [match and verify data]. With HealthEC, we’ve got a 3D analytics platform that we’re using, and we’ve saved money in identifying the beneficiaries who should not be on the rolls, and improved the time it takes for us to process payments, and we can now more closely track MCO [managed care organization] payments—the capitation payments.

That involves a very high volume of healthcare payments, correct?

Yes. For every beneficiary, we pay the managed care organizations a certain amount of money every month to handle the care for that beneficiary. We’ve got 190,000 people covered. And the MCOs report to us what the provider payments were, on a monthly basis. Now we can track better what the MCOs are spending to pay the providers. The dashboard makes it much easier to track those payments. It’s improved our overall functioning.

We have over 250,000 between managed care and FFS. Managed care 190,000, FFS, around 60,000. We also manage the Alliance population—that’s another program that the district has for individuals who are legal non-citizen residents.

What are the underlying functional challenges in this area of data management?

Before we’d implemented the data warehouse, we had to rely on our data analysis and research division to run all the reports for us. We’d have to put in a data request and hope for results within a week. This allows anyone in the agency to run their own reports and get access to data. And they’re really backed up: they do both internal and external data reports. And so you could be waiting for a while, especially during the time of the year when we have budget questions; and anything the director might want would be their top priority.

So now, the concern is, having everyone understand what they’re seeing, and looking at the data in the same way, and standardizing what they’re meaning; before, we couldn’t even get access.

Has budget been an issue?

So far, budget has not been an issue; I know the warehouse cost more than originally anticipated; but we haven’t had any constraints so far.

What are the lessons learned so far in going through a process like this?

One big lesson was that, in the beginning, we didn’t really understand the scope of what really needed to happen. So it was underfunded initially just because there wasn’t a clear understanding of how to accomplish this project. So the first lesson would be, to do more analysis upfront, to really understand the requirements. But in a lot of cases, we feel the pressure to move ahead.

Second, you really need strong project management from the outset. There was a time when we didn’t have the appropriate resources applied to this. And, just as when you’re building a house, one thing needs to happen before another, we were trying to do too many things simultaneously at the time.

Ultimately, where is this going for your organization in the next few years?

What we’re hoping is that this would be incorporated into our health information exchange. We have a separate project for that, utilizing the claims data in our warehouse to share it with providers. We’d like to improve on that, so there’s sharing between what’s in the electronic health record, and claims. So there’s an effort to access the EHR [electronic health record] data, especially from the FQHCs [federally qualified health centers] that we work closely with, and expanding out from there. The data warehouse is quite capable of ingesting that information. Some paperwork has to be worked through, to facilitate that. And then, ultimately, helping providers see their own performance. So as we move towards more value-based arrangements—and we already have P4P with some of the MCOs, FQHCs, and nursing homes—they’ll be able to track their own performance, and see what we’re seeing, all in real time. So that’s the long-term goal.

With regard to pulling EHR information from the FQHCs, have there been some process issues involved?

Yes, absolutely. There have been quite a few process issues in general, and sometimes, it comes down to other organizations requiring us to help them procure whatever systems they might need to connect to us, which we’re not against doing, but those things take time. And then there’s the ownership piece: can we trust the data? But for the most part, especially with the FHQCs and some of our sister agencies, we’re getting to the point where everyone sees it as a win-wing, and there’s enough of a consensus in order to move forward.

What might CIOs and CMIOs think about, around all this, especially around the potential for collaboration with government agencies like yours?

Ideally, we’d like for hospitals to partner with us and our managed care organizations in solving some of these issues in healthcare, including the cost of emergency department care, and so on. That would be the biggest thing. Right now, and this is not a secret, a couple of our hospital systems in the District are hoping to hold out for better contracts with our managed care organizations, and 80 percent of our beneficiaries are served by those MCOs. So we’d like to understand that we’re trying to help folks who need care, and not focus so much on the revenues involved. We’re over 96-percent insured now in the District. So there’s probably enough to go around, so we’d love for them to move forward with us collaboratively. And we have to ponder whether we should encourage the development and participation in ACOs, including among our FQHCs. Things have to be seen as helping our beneficiaries.

What does the future of data management for population health and care management, look like to you, in the next several years?

For us in the District, the future is going to be not only a robust warehouse that includes claims information, vital records information, and EHR data, but also, more connectivity with our community partners, and forming more of a robust referral network, so that if one agency sees someone who has a problem, say, with housing, they can immediately send the referral, seamlessly through the system, to get care. We’re looking at it as very inter-connected. You can develop a pretty good snapshot, based on a variety of sources.

The social determinants of health are clearly a big element in all this; and you’re already focused on those, obviously.

Yes, we are very focused on those; we’re just very limited in terms of our access to that data. We’re working with our human services and public health agencies, to improve access. And I should mention a big initiative within the Department of Health Care Finance: we have two health home programs, one for people with serious mental illness issues, the other with chronic conditions. The Department of Behavioral Health manages the first, and the Department of Health Care Finance, my agency, DC Medicaid, manages the second. You have to have three or more chronic conditions in order to qualify.

We have partnerships with 12 providers, in those, mostly FQHCs, a few community providers, and a couple of hospital systems. We’ve been using another module from HealthEC for those programs. We need to get permission to have external users to come in; but at that point, they’d be able to capture a lot of the social determinants as well. We feel we’re a bit closer to the providers, in that sense, since they work closely with the beneficiaries. And we’ve got a technical assistance grant to help them understand how to incorporate this kind of care management into their practice, to move into a value-based planning mode. That’s a big effort. We’re just now developing our performance measures on that, to see how we’ve been doing. It’s been live for about a year. It’s called MyHealth GPS, Guiding Patients to Services. And we’re using the HealthEC Care Manager Module, which we call the Care Coordination Navigation Program; it’s a case management system. Also, we do plan to expand that to incorporate medication therapy management. We have a pharmacist on board who will be using part of that care management module to manage his side of things.



See more on Population Health

agario agario---betebet sohbet hattı betebet bahis siteleringsbahis