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‘Health home’ deals with more than just medicine for Medicaid patients

Walter Dean has high blood pressure, arthritis, borderline diabetes, a degenerative hip bone and esophageal stricture, which can cause his throat to close while he tries to eat.

But the medical conditions are only part of his problem. The 50-year-old East Side resident has had trouble finding rides to the doctor, finding someone to accompany him – as required – to certain procedures and trouble getting his medications sent to the correct address.

All of those challenges add to his medical problems – and to the cost of care.

But his prognosis brightened once Dean enrolled in a new “health home” initiative made possible by the Affordable Care Act of 2010, the controversial federal law that expands Medicaid eligibility while redesigning the program.

The new one-stop system not only coordinates all of a patient’s medical care, it also links low-income patients with assistance for housing, food stamps, food or help with electricity and transportation. It’s a seamless model that meets all of a patient’s needs, medical or otherwise.

The goal is to both improve health and save money by also tackling some nonmedical issues that can stop low-income people from getting the care they need.

The version Dean enrolled in, called the Greater Buffalo United Accountable Healthcare Network, began in January and is an outgrowth of the 2010 reform that gives states new options for providing services for Medicaid patients with chronic conditions like Dean’s.

“We no longer treat for the cure. We now treat the whole patient,” said Kirsten Newby, director of clinical services at the new network, currently in temporary offices downtown. A new 20,000-square-foot facility on Seventh Street on the Lower West Side is expected to open this fall, and an East Side center is planned.

The program uses a “person-centered” approach that helps patients stay healthy, out of costly emergency rooms and out of hospitals, said Dr. Raul Vazquez, one of the network’s founding physicians.

Since mid-February, the new network has enrolled more than 1,000 patients, including Dean. Its target group comprises low-income people and those likely to use emergency services as primary care.

Each patient is assigned a community health worker or care manager, who assesses their needs, including medical and nursing care, social services, mental health services, rehab counseling for addictive disorders or other needs. An individualized plan is drawn up, and the patient is assigned to a health navigator, who oversees execution of the plan.

“Right now, the physicians are the only people who sit down and talk with patients,” Vazquez said. “Under this approach, a team is involved with the patient focused on prevention and wellness. It’s managing care. It’s a plan that focuses on providing medical, mental, addiction services to prevent rather than treat.”

Another component of the program is the sharing of patients’ health records so that everyone on the team has access.

The file-sharing “marries all services,” forces providers to communicate and ensures that services are not duplicated or neglected, administrators said.

“Everyone is talking to everyone. When everyone has access, they can share” a patient’s plan, Newby said.

Perhaps most important to Dean is that the team is focused on knocking down barriers – even if it’s just a matter of transportation to appointments.

“They make sure I make appointments and get to them. They are helping me get new housing,” Dean said from his studio apartment.

When the esophageal strictures flare up, Dean has to go through a procedure in which a scope is maneuvered down his throat and balloons are used to open it back up. He has been getting the treatment as needed since the mid-1980s.

Since enrolling with the health care network in February, he has undergone two such procedures.

Dean said he has “no idea how I would’ve made it” without the health care network’s assistance. “The last two times I had to depend on them to get me there and back because I had no one,” he said.

The network also follows up with him after hospital and doctor visits, and the health navigator makes sure hospitals and physicians get his prescriptions to him promptly, Dean said.

Rosa Gonzalez, a Puerto Rican-born patient of Vazquez, has arthritis, diabetes and high cholesterol. The West Side resident speaks only Spanish and has lived in Buffalo the past 10 years.

During a recent medical appointment, Gonzalez said through an interpreter that it feels “really good to have” the network behind her.

“I don’t have to worry about anything,” she said, such as challenges associated with the language barrier.

As a Medicaid-based program, the federal government finances 90 percent of the cost of the health home program, while New York State pays the remaining 10 percent.

Vazquez says it’s too soon to quantify the savings from the new approach, but he expects it to be substantial.

“You need to measure things before you find out if what you’re doing is working, but it’s a lot of money. By the end of the year we’ll have a better concept,” he said.

The remote possibility that congressional Republicans may succeed in their threat to repeal the Affordable Care Act does not concern Vazquez, who said this part of the reform effort has progressed too far to be blocked.

“The train has already left the station,” he said. “So much money has been invested in the infrastructure that you couldn’t turn this back even if you wanted. You can try to repeal it. You just can’t. ... This is a high-speed train at maximum speed that has passed its halfway point. You can’t derail it.”

Service providers under the network umbrella include Jewish Family Service, which provides psychiatry, psychology, nursing, social services and rehabilitation counseling; Kaleida Health, which includes Buffalo General Medical Center on the Buffalo Niagara Medical Campus; Lake Shore Behavioral Services, which treats individuals with mental illness and addictive disorders; and UB Family Medicine, which has offices in Buffalo, the Town of Tonawanda and Amherst that provide primary and preventive care for all ages.

There also are two other Medicaid health homes serving Erie County: Health Homes of Upstate New York–Western and Health Home Partners of WNY, which also serves Niagara County.


To be eligible for the Medicaid-based health home program,

a client must meet these criteria:

• Be on Medicaid or eligible for Medicaid

• Be 18 or older

• Live in Erie County

• Have 2 or more chronic conditions such as diabetes, high blood pressure, asthma or heart failure OR

• Have 1 chronic condition and be at risk for a second OR

• Have 1 serious mental health condition such as major depression, bipolar or schizophrenia

• Have a doctor ready to work with the plan