Care Process Redesign

Getting to Know Patients in Their Homes

July 25, 2018 4:49 pm

With an 80-year legacy of providing health coverage to communities in New York City, we at EmblemHealth understand that our city is a marvelous melting pot of different cultures. We learned early on that being able to treat individuals in their language improves not only member satisfaction but, even more important, our members’ ability to communicate effectively with their physicians and build connections with the care team.

Furthermore, as one of the nation’s largest not-for-profit health insurers, EmblemHealth takes pride in being a market leader in value-based care. As we considered our population health initiatives, we realized that the concept of “right care at the right time in the right setting” might need to include settings other than traditional healthcare venues.

That’s why we are collaborating with the Coalition of Asian-American IPA Inc. (CAIPA) to provide comprehensive health assessment services in the homes of Asian families.

CAIPA is the largest independent physician association (IPA) serving Asian-American communities in New York City, and one of the most successful IPAs in the region. It includes more than 1,000 physicians who serve more than 450,000 publicly and privately insured members in the New York market.  

Through our collaboration, CAIPA staff make home visits to gather a full picture of an individual’s healthcare needs. Staff then customize programs, resources, and supports as needed to improve healthcare interventions and the effectiveness of primary care. This program serves members who are homebound, who have multiple chronic conditions, or who have not had a primary care visit in the past year or have other gaps in care.

Strengthening Connections

Let’s paint a picture of what this means for an EmblemHealth member.

Mr. Chu, an EmblemHealth Medicare member, is waiting anxiously for his 11 a.m. appointment.

A few days earlier, Mr. Chu got a phone call from Alex, a physician assistant from CAIPA, telling him about the Health Assessment Initiative offered by EmblemHealth and CAIPA. Mr. Chu was grateful that Alex spoke to him in his home dialect so he could understand why CAIPA wanted to visit him.

During the visit, Alex explained in more detail the benefits of getting a health assessment. Alex told him that by working together, physicians and a health plan can better anticipate his health needs and identify any gaps in care that may need to be addressed. This collaboration would help him be his healthiest self.

While there for the assessment, Alex gave Mr. Chu a physical exam and reviewed his medications to make sure he understood the directions. He also asked questions to help identify any gaps in care that Mr. Chu was experiencing. After identifying several gaps that needed further attention, Alex immediately scheduled an appointment for Mr. Chu to see a primary care physician for a more thorough exam. He recorded the information provided by Mr. Chu in his tablet so it could be stored in the program’s main database, where it can be accessed by the patient’s primary care provider.

Because these visits occur in their homes, patients are more likely to feel at ease and, in turn, to discuss their complete medical history and any nonmedical factors that may impact their well-being. The visits also provide an opportunity to review the patients’ prescription and non-prescription medications and to discuss the importance of good nutrition and exercise.

Promising Results

Since this initiative began last fall, the CAIPA team has identified 40 instances where members needed additional help to stay well. Some members needed to be enrolled in case management programs or mental health support. Others simply appreciated the companionship.

To date, 100 percent of the members identified for assessments have agreed to participate. Many have praised EmblemHealth and CAIPA for taking a proactive interest in improving their health and well-being.

Joe Shen is vice president-multicultural marketing, EmblemHealth, New York City. 


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