By Deborah Jeanne Sergeant
Modern healthcare is inherently complex. Finding the way through the labyrinth challenges most patients, especially since they’re also facing struggles with their health at the same time.
That’s why healthcare coordination can assist patients and their families in their time of need.
Sarah Connolly, regional director of Trinity Health NY Health Home, has a master’s in nursing and is board-certified nurse executive and is a certified in ambulatory care nursing. She manages home health through a New York State Medicaid program, providing non clinical care management.
“Patients would be referred to us if they have two chronic conditions like obesity and asthma or a qualifying chronic condition,” Connolly said. “As long as they have those diagnoses, an active Medicaid and they have needs we can help with like lack of social or family support, we can help with non clinical needs.”
This could include referring patients to agencies that can help them obtain proper housing, affordable utilities, address food insecurity, arrange transportation, and follow up after in-patient stays to ensure patients understand their discharge instructions and medication protocols. Some patients do not understand how to apply for benefits and Trinity can help with that as well.
“It’s important that we do this as there are so many needs in the community,” Connolly said. “I think those needs will continue to increase.”
The needs outside of medical, including behavioral health and physical supports like transportation and housing are social determinants of health. Making doctor’s visits is hard for people who lack a ride. It’s less likely a patient will adhere to doctor’s orders such as resting if that means he will not earn enough to pay rent.
In addition, many patients with complex medical needs struggle to keep up with their medical protocols. Connolly said that healthcare coordination can aid in patients better managing their own health.
“The goal is for them to be able to do this on their own,” she said.
Technology can help for some patients; however, for those who cannot access the internet independently, Trinity can help develop workarounds like printing applications or accompanying a patient to the library to fill out online applications on community computers.
Typically, Medicaid patients with complex health needs and limited support and resources benefit the most from Trinity’s services.
Complex medical situations are not exclusive to older people or those recently discharged from the hospital. People identified as HIV positive face a plethora of new medical protocols. When followed carefully, these protocols can help support patients in remaining healthy and reduce risk of transmitting HIV to others. ACR Health in Syracuse provides service coordination for this patient population.
“That helps with medication adherence and hooking them up with other services they need,” said Michelle McElroy program manager at ACR.
As with Trinity’s services, supporting patients’ social determinants of health is one way that ACR helps promote better health. ACR offers case management services for people with additional chronic health issues.
“We will refer people to other services we don’t provide,” McElroy said.
This includes primary medical care, substance abuse treatment, mental healthcare, financial benefits, housing, legal assistance, nutrition, treatment adherence, and transportation to medical visits.
“We have a wound care clinic for people who use substances and a syringe exchange,” McElroy added. “We also have a youth program.”
Eligibility for help includes receiving Medicaid or Medicaid and Medicare; having one qualifying condition of HIV-AIDS or a serious mental illness; or having two or more chronic health conditions, including mental illness, substance abuse, asthma, diabetes, heart disease, and a BMI over 25.
Healthcare can be difficult to understand and even more challenging to navigate while a patient; however healthcare coordination is available to help lead the way.
