Award-winning Health Home Team Provides Intensive Care Coordination

Kudos to the Health Home team in Aging and Disability Services’ Case Management Program, which completed outreach, new intake, and creation of 12 new Tier 1 Health Action Plans before the end of November 2021—a huge undertaking and effort that met and then surpassed their 2021 caseload goal of 204 one month early. In addition, they have averaged 97 percent billable encounters every month through a combination of voluntary in-person visits or telephonic/virtual meetings. The Seattle Human Services Department recognized the Health Home’s team with a Maximum Achievement Award in December 2021.

The Health Home program provides coordinated services “to high-cost, high-risk Medicare-Medicaid enrollees based on the principle that focusing intensive care coordination on those with the greatest needs provides the greatest potential for improved health outcomes and cost savings.” (Washington Health Home Program)

ADS Health Home team members include Kim Wooding, Heather Dagg, Janelle Jackson, Sharon Young, and Charles Sripranaratanakul. Not pictured is Christy Narvaez.

Recently, Health Home program supervisor Heather Dagg shared several summaries of recent client concerns resolved by the care coordinators on her team:

• Care coordinator Janelle Jackson’s 81-year-old Asian male client was diagnosed with chronic kidney disease and is on dialysis. He also has diabetes Type 2. He does not speak English and needed a variety of help, including coordination of appointments with multiple health care providers—cardiologist, nephrologist, vascular surgeon, and family doctor—and pharmacist, plus Hopelink medical transportation, help applying for incontinent supplies, and more. Since establishing care with Health Home program, the client and his caregiver have learned to trust Janelle and connect with her following every appointment. He has been able get and keep all follow up appointments with health care providers, which has reduced unnecessary trips to the emergency department. 
• Care coordinator Kim Wooding’s 55-year-old African American female client—diagnosed with arthritis, COPD, obesity, depression, and PTSD—received a settlement for a nursing home’s medical negligence in caring for her mother, which led to her mother’s death. The client was concerned about the impact the settlement would have on Medicaid eligibility and considered letting go of Medicaid and SNAP benefits so she could freely spend the money. Kim advised her client to seek legal and Medicaid estate planning advice. She attended the client’s meeting with an attorney, listened, discussed pros and cons, and ensured that her client understood her options. The client also wanted to give up stable housing and move out of state. Kim researched resources and discovered that the client’s criminal history would be a barrier to finding housing in the other state. Ultimately, the client decided to stay put, maintain her much-needed Medicaid benefits, and establish a special needs trust that allowed her to purchase necessary things not covered by Medicaid and protecting against misuse.
• Care coordinator Christy Narvaez has a 55-year-old Latino male client who is diagnosed with osteoarthritis, dwarfism, and diabetes, and he has a tracheostomy. Her client needed a dependable power chair, which was difficult to get due to his height and weight. Also, the client’s primary care provider and diagnosis kept changing and Medicare requires approval by the original medical provider. Christy submitted a referral to American Seating & Mobility and coordinated all parties—her client’s primary care physician, the equipment provider, the client himself, and his caregiver. Eventually, the client got a chair that he says “was meant for me” and it was covered by insurance.
• Care coordinator Sharon Young has a 75-year-old female client who has memory loss and is diagnosed with mental health issues, COPD, hypertension, and kidney disease. The client needed a commode because often she had to rush to the bathroom, and she was afraid of falling. The cost of the commode was not covered by insurance. Sharon coordinated with her client’s long-term care case manager, who authorized payment. Now her client feels safer, has fewer incidents of incontinence, feels less embarrassment, and can manage toileting without the help of a caregiver, so she can continue to live independently.

For more examples of the services provided by Health Home care coordinators, read “Stories from ADS Health Home Care Coordinators” (AgeWise King County, November 2020) and “Providing Support for Clinically Complex Clients” (AgeWise King County, July 2021).

For more information or to check Health Home program eligibility for yourself or a loved one, visit the Washington State Health Care Authority’s Health Home webpage.

For general access to other services and community resources, and answers to questions about aging, disabilities, and caregiving, contact Community Living Connections at (toll-free) 844-348-5464.

Contributor Irene Stewart edits AgeWise King County on behalf of the ADS Advisory Council, manages communication for Aging and Disability Services, and serves on the Seattle Human Services Department’s External Affairs Team.

Photos courtesy of Heather Dagg, Aging and Disability Services.