Stories from ADS Health Home Care Coordinators

You may wonder, “what in the world is a health home?” Not to be confused with “home health,” a health home is a network of services that provide close coordination of primary and behavioral health services. According to the Centers for Medicare and Medicaid Services, a health home network provides six specific services beyond those typically offered by a primary care provider:

• Comprehensive care management
• Care coordination and health promotion
• Comprehensive transitional care and follow-up
• Individual and family support
• Education about advance directives, client rights, and health care issues for the client, family members, and caregivers
• Referral to community and social support services
• Use of information technology to link services, if applicable

The Health Home program is a partnership between the Health Care Authority, the Centers of Medicare and Medicaid Services, and the Department of Social and Health Services (DSHS) aimed at achieving Washington State’s vision of integrated services.  Washington targets its demonstration 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.  An actuarial study in 2019 showed that the Health Home program had an estimated $167 million in Medicare savings by supporting clients to receive the right care, at the right time with the right provider.

Among 12,000 long-term services and supports clients served by Aging and Disability Services (ADS) are 178 individuals who receive health home care coordination services. Care coordinators emphasize patient activation and engagement—helping clients set goals and increase self-management skills—and support clients in receiving the care they need across multiple delivery systems.

What services do ADS Health Home Care Coordinators provide?

ADS care coordinators are skilled in motivational interviewing, person-centered care planning, health promotion, transitional care follow-up, and individual and family support, and highly knowledgeable of social services available in the local community. We believe these services are vital for optimal physical and cognitive health for our clients. The goal of the Health Home program is to improve coordination of care, quality, and to increase an individual’s participation in their own care. Care Coordinators do not duplicate, change, or replace other services that individuals receive. It is simply an added benefit. Participation is voluntary.

Following are some recent examples of ADS Health Home care coordination services and advocacy on behalf of our clients.

Supporting aging in the right place

COVID-19 has affected ADS clients in many ways. For one Health Home client, it changed his life completely. When COVID broke out in King County in March 2020, the family of Health Home care coordinator Jeni Spight’s client decided it would be best to have him stay with a family member in another area. Her client—an 86-year-old Black man with osteoarthritis, a history of cancer, incontinence, and memory concerns—has a son who lives on a farm area outside of Sacramento, was closest and most willing to assume care. Jeni’s client flew to California in late March. With the virus becoming worse in both states, our client felt stuck in California, waiting for the stay-in place orders to rescind, but as the weeks turned into months, he become more and more used to his surroundings. He found that aging is easier on the farm, where he is neither rushed nor overburdened with responsibility.

The client’s son and daughter-in-law encouraged him to make the farm his permanent home. With continuing concern about getting COVID, he agreed that this would be best. Jeni was able to coordinate services during his extended absence and communicate his needs to family members. With his decision to move permanently, Jeni helped him move his Medicaid services to the State of California, ensuring that services were initiated there before Medicaid support ended in Washington.

Identifying housing solutions

The HSD/ADS Health Home program recently helped a client who is terminal with less than six months to live remain in his home. Kim Wooding’s 71-year-old African American client has cancer, end-stage renal disease, and is on dialysis and chemotherapy. Until recently, he lived with his daughter, with Section 8 support. When she moved, he was notified he could not remain in the two-bedroom apartment. He was reluctant to negotiate because of bad experiences in the past as a minority asking for help. Our client’s daughter encouraged him to allow Kim to advocate on his behalf. Kim contacted his Section 8 case manager and suggested that the client be allowed to apply for a reasonable accommodation (staying in his home). With verification of his terminal illness, and especially during the COVID crisis, it was not a good time for him to move. Section 8 approved the request.

Another housing success story from Health Home care coordinator Kim Wooding involved a client who needed an accessible apartment unit and more support in the evenings. He was fearful of falling when alone due to obesity, arthritis, emphysema, and depression. Kim assisted him in applying for a reasonable accommodation with his Shelter Plus Care voucher so he could move to a two-bedroom unit and have a live-in caregiver. He was initially denied because he had not been granted full-time caregiving hours, but Kim suggested that the caregiver call his long-term care case manager and explain all the tasks she did that were unpaid. The client’s caregiver hours were increased, and reasonable accommodation was approved. Kim collaborated with the long-term care case manager to request funds for his new apartment deposit. This case exemplifies multi-agency collaboration and the importance of the caregiver relationship.

Promoting social connections and meaningful activity

Health Home care coordinator Kim Wooding helped her 65-year-old client—who reported loneliness and isolation and whose diagnoses included fibromyalgia, substance use disorder, and PTSD—to connect with Path with Art, an arts engagement program for individuals with low or no income who have experienced addiction or trauma. Kim also helped her client get Internet Essentials set up in her apartment and collaborated with her client’s long-term care case manager to get a Community Choice Guide referral (via Roads to Community Living). The Community Choice Guide trained the client to use a tablet computer borrowed from Path with Art. The client signed up for a singing class during Path with Art’s summer quarter of classes.

Supporting effective communication with providers and others

Janelle Jackson’s client—a 76-year-old Japanese-American woman with anxiety and arthritis—struggled to communicate effectively with her care team. Janelle built rapport with her client, who became receptive to health promotion services and coaching. The client learned about communication styles and the benefits of choosing a style that helps her access what she needs.

Over the course of two years, with consistent coaching, modeling, and road-mapping to help the client recognize the benefits of healthy communication versus the chaotic communication she previously experienced, the client became more self-aware. She learned that receiving counseling services does not mean that “someone is crazy;” rather, counseling empowered her to strategize on how to cope with difficult circumstances and difficult people.

Since then, Janelle’s client accepted a referral to PEARLS, an in-home counseling program for people with depression. She is also more receptive to learning about how asserting boundaries with others and herself can improve her health and mental health.

Helping clients understand benefits

This past summer, a new Health Home client with a cancer diagnosis and incontinence learned from Sharon Young, his new care coordinator, that his insurance would cover the cost of incontinence supplies. Previously, he used his personal funds to purchase supplies. Our client expressed his happiness in learning that he had (in his own words) “an insurance-covered diaper.”

For more information on the Health Home program or to refer clients to the program, visit the Washington State Health Care Authority’s Health Home webpage.

To access long-term care services and supports in Seattle-King County, contact Community Living Connections (toll-free 844-348-5464). Community Living Connections supports Medicare enrollment for people age 60 and older and provides access to a broad range of additional services and supports. Those under age 60 should contact the DSHS Home and Community Services office for King County at 206-341-7600.

Contributor Heather Dagg is a Case Management Program supervisor at Aging and Disability Services, a division of the Seattle Human Services Department designed as the Area Agency on Aging for Seattle-King County.

Photo at top (left to right): Kim Wooding, Heather Dagg, Janelle Jackson, Sharon Young, and Charles Sripranaratanakul. Not pictured are Jeni Spight and Christy Narvaez.