Health Homes & LCSWs - 5-19-11

Here is a further clarification of the implementation of 'health homes' model of health care re-organization based on information from the Substance Abuse and Mental Health Services Administration (SAMHSA, May 18, 2011).        
 
      The idea behind health homes (also called 'medical homes') is that coordination of all patient care for a given patient will lower health care costs.  This concept was included as part of the Patient Protection Affordable Care Act (PPACA), passed in March of 2010.   The structure of health homes is still in process, but it appears that providers who treat patients with severe and chronic conditions may have stronger requirements to belong to health homes than providers who treat patients with less severe or chronic conditions.

      Accountable Care Organizations (ACOs) are another piece of the health home model which would be the way that the finances of health homes are managed. ACOs will manage part of what insurers have done up till now, i.e., decided what treatments are clinically effective and cost effective, and make insurers more of a clearing house for medical payments.  PPACA has an incentive for ACOs and health homes that meet their target service goals with less cost than predicted.  There are also incentives for the effectiveness of outcomes.  

      One way in which health homes could be developed is the "Four Quadrant Model" developed for the National Council for Community Behavioral Health Care.  This model (which can be reviewed in detail at 
http://www.thenationalcouncil.org/galleries/business-practice%20files/PC-BH%20Environment-State%20Policy.pdf) divides all patients into four groups based on the severity of medical conditions and mental health/substance abuse conditions, following the guidelines in PPACA.  Patients with high severity of medical conditions and mental health/substance abuse disorders (about 15-20% of all patients) are the group that must be managed by a health home where all providers communicate about patient care regularly.  The coordinator of care for these patients could be a mental health provider. 

     There are concerns about whether health homes will be a return to the 'gatekeeper' model which was used when managed care began about 20 years ago, whether the coordinator of the health home is a mental health provider or a medical provider. The way that LCSWs and other clinicians are included in health homes for patients with less severe mental health and/or medical conditions is still in flux, but new requirements for any LCSW who receives third party payments are likely. 

      One of these requirements may be the use of an outcomes predictor tool and outcomes measurement tool to be part of third party payment systems.  As noted in previous posts and the recent The Aware Advocate, any LCSW who intends to work in health homes will need to have outcome tools in place.  This may be a significant shift for some LCSWs from current practice.  CSWA supports the use of outcome measures, especially when LCSWs are working with third party payers, though the principle of outcome tools for private pay patients as well is a best practice.

     There are many details to be worked out before health homes are fully developed.  LCSWs should be informed about the way that we could be involved in the development of the health home model and the changes that this may create in the ways that we run our practices.