Care Management
Social needs, healthcare access challenges, and mistrust in the healthcare system often prevent patients from receiving necessary care. In UI Health Two-Gen, families are assigned a care manager (i.e., a social worker if there are behavioral health needs, otherwise a care coordinator) to help overcome these barriers. The care manager uses a high-touch approach to coordinate the family’s visits, help the family resolve social needs, and ultimately establish rapport and build trust. The care manager provides referrals and links families to community resources for needs such as benefit eligibility, housing, food security, transportation, utilities, childcare, finances, legal assistance, and access to essentials such as menstrual supplies, formula, and diapers.
Care management services can be invaluable in helping families access services and resolve social needs that may impact their wellbeing. Healthcare organizations may not have staffing resources available (i.e., care coordinators, social workers, or trained community health workers) to engage directly with every family for these services. If so, the highest-need families should be identified, prioritized, and provided these services to the extent possible. Directly partnering with a community-based family case management or home visiting program might be a strategy that an organization can undertake to extend its staff resources. A directory of local community resources could also be made available to families to access services they may need, although this approach does not provide the “touch” that many families need to navigate the health and social service systems.
If staffing resources prevent ongoing patient communication and follow-up calls with every family, automated communication systems can be set up to remind patients of upcoming visits and allow patients to request additional help.
Helping patients access transportation to visits, including Medicaid-provided services, can increase access to care and visit adherence.
Who provides care management services in your organization, including coordination of care and providing support for social needs? If there are no individuals in your organization who are available to provide these services, is there a community organization that could fill this role for Two-Gen patients? Do you have connections with an organization that provides family case management or home visiting such as Healthy Start or MIECHV?
How does your organization communicate with patients outside of the healthcare visit setting? Are there mechanisms to help patients schedule visits, remind patients of upcoming visits, or allow them to ask questions or get help?
If many of your patients have Medicaid insurance, is there a Medicaid Webpage or Medicaid Toolkit available in your state that provides clear information on how to access transportation services?
If your organization is in a state with a high degree of Medicaid Managed Care, is information about Medicaid covered transportation available on the websites of each Managed Care entity?