Outreach
How do you know when a patient is assigned to you?
CC’d Chart from coordinator
“My Identified Cases” on Care Coordination Dashboard
What if the patient agrees to enroll?
What are the next steps?
Congrats!
Schedule in-person appointment to complete the enrollment process
DOH 5055 (Consent form)
DOH 5234 (Notice of Determination for Enrollment)
Welcome Enrollment Letter (includes Health Home Member Bill of Rights)
Confirm which Health Home they are part of (see Assignment note)
Make sure enrollment documentation matches the correct Health Home!
What is a Care Plan?
A road map to reaching individuals’ own goals for their health and well-being, which they play an active role in creating
Takes into account their strengths and supports
Proactively addresses barriers that may get in the way
Identifies clear goals and timeframes for steps to improve health
When should I make my first phone call?
Call within two business days of assignment
How to complete a DOH 5055 - Health Home Consent Form for Adults?
Completed and signed by patient AND care navigator
Where can I find it?
Copies are pre-filled & distributed during your training, and will be re-sent today!
Consent can be found on Epic (Program tab à “Documents”)
Document type:
HH Patient Information Sharing Consent (DOH 5055)
Scan it to the chart (may also be e-signed via Topaz scan pad or MyChart)
Who do we need consent to coordinate care with?:
The Care Management Agency (IFH)**
The PCP (may also be IFH; add specific provider’s name)**
The Managed Care Organization (MCO) (Ex. Fidelis, HealthFirst)**
Any other important contacts in the patient’s care. Ex. Emergency contact, pharmacy, family members, home health aide, specialists, outside programs
Is a Care Plan a living document?
Yes
The Care Plan is a “living document” that changes along with the person
Mark your goals as “On Track” or “Not on Track” each month, or whenever there is an update
Mark goals as “Completed” when done – and celebrate the successes!
Delete or edit goals as needed (Ex. Edit the timeframe, if something came up along the way and we are now a month behind of the original timeline)
Add new SMART goals as they arise
How to document it?
Use “New member outreach” note template
Switch program status from Identified to Outreach
What is a Notice of Determination of Enrollment (DOH 5234)
Completed and signed by Care Navigator
Does NOT need to be signed by patient. This doc is informing the patient that they have signed consent and are now enrolled
Where can I find it?
Copies are pre-filled & distributed during your training, and will be re-sent today!
Can be found on Epic (Program tab à “Documents”)
Document type:
HH Notice of Determination for Enrollment (DOH 5234)
Scan into chart or generate via Documents section of chart
When should you complete the Initial Care Plan?
Complete initial care plan within 30 days of enrollment
How long is the outreach period for a new patient?
30 days
Example: If Ms. Brown was assigned to me on March 15, I have until April 14 to complete the outreach workflow, in attempt to engage and enroll them.
Document one outreach attempt/activity per week for 4 weeks.
What is included in the Enrollment note “HH Enrollment"
Note Template: HH Enrollment Note
Was the DOH 5055 Health Home Consent completed? Y/N
Was the DOH 5234 Notice of Determination for Enrollment in the New York State Health Home Program completed? Y/N
Was the “Welcome Enrollment letter” provided? Y/N
Was the Member Bill of Rights provided? Y/N
Chart sent to supervisor for review
May also include any additional info in your note
Change status from Outreach to Enrolled (Program tab)
Mark target complete (“Complete outreach for enrollment”)
When should Care Plans be updated?
Care Plans must be updated every 6 months
If I don’t reach the patient on my first try, when/how often should I follow up?
Call each week over the next month (30 days)
What else should I try, other than a phone call?
•Refer to “New Member Outreach” note template for upcoming appointment information and try to coordinate a warm handoff with the care team
•MyChart message
•Text message
•Care team conference or collateral contact
Where can you find the "Welcome Enrollment Letter"
Program tab “Communication Management”
CCMP HEALTH HOME WELCOME ENROLLMENT LETTER
What does S*M*A*R*T stand for when describing goals?
Specific- The goal should identify a specific action or event that will take place, as clearly as possible.
Question: What exactly do you want to accomplish?
Think: Who, what, when, where, why?
Ex. Bryan will get screened for colon cancer.
Ex. Lilly will use medical transportation to get to her appointments.
Measurable-The goal and its benefits should be quantifiable.
Question: How will you know that you’ve reached your goal? How will you know you’ve made progress towards your goal?
Ex. Bryan will complete a colonoscopy at Mount Sinai Hospital.
Ex. Lilly will use Medical Answering Services (MAS) to get to her next psychiatry appointment.
Achievable- The goal should require some work, be attainable given available resources.
Question: Can this realistically happen? What resources do you need to achieve this goal?
Ex. Bryan will arrange for his care navigator to escort him home from Mount Sinai after the procedure
He will need to speak with the GI nurse the week of the procedure to learn about how to prepare safely
The colonoscopy is fully covered by Bryan’s insurance!
Ex. Lilly will call MAS with her care navigator on three-way call to book her first ride
Care Navigator will fully explain the service in advance so that Lilly knows what to expect
Relevant-The goal should specifically link back to an identified need (discussed in the Comprehensive Assessment) or barrier they face regarding their health and wellbeing. At least one goal should relate to their eligibility for care management (ex. Managing a chronic health or mental health condition, addressing the social determinants of health, etc.)
Question: Why is this goal important to me?
Ex. Bryan has been noticing some concerning GI symptoms, and he is at higher risk for colon cancer due to his family history. He wants to get screened so that any issues can be caught early.
Ex. Lilly gets overwhelmed taking public transportation due to her PSTD and anxiety symptoms. She needs a safe and simple way to get to her mental health appointments.
Timely-The goal should state the time frame in which it will be accomplished.
Attach a date to each goal. State what you intend to accomplish and by when.
Try a mix of long and short term goals. Don’t get overwhelmed trying to complete 10 new tasks within the next month.
Even goals for ongoing practices (ex. Take my insulin every day) should have a planned time for trial and check-in, to see what worked
Ex. Bryan and care navigator will call to schedule the colonoscopy within the next two weeks. Plan to complete the procedure by the end of September, 2023
Ex. Lilly will take MAS to her psych appointment on 9/12/2023. She will call MAS by the end of August to book her ride.