Kerri Tamer, Lead Quality Improvement Specialist at EmblemHealth was grateful for the opportunity to represent the company at the fourth annual New York Population Health Summit, “Working Across Sectors to Address Social Determinants of Health.” The event was held on December 12, 2016 at the New York Academy of Medicine in New York City. EmblemHealth presented a poster entitled Closing Gaps in Care: An Integrated Approach, based on work they have been conducting in the Quality Management department. Last year, Kerri and her colleagues, Andrew Phillips and Meredith Clark developed a collaborative integrated care approach aimed to improve both physical and behavioral health outcomes for a high-risk Medicaid population. This model involves collaboration among health homes, care management agencies, primary care providers, and behavioral health clinicians and managed care staff. This was accomplished by training and empowering front line care coordinators with basic education, and the tools and resources needed to assist members in closing important preventive and chronic disease health care gaps. Key interventions include:
- Two-way data sharing
- Training on gaps in care and why they matter
- Training on engagement, cultural competency, collaborating with health care professionals and follow-through
- On-site and remote support
EmblemHealth’s support and training has assisted care coordination teams in closing gaps. As of this past September, 75-percent of the 9,860 identified preventive and screening gaps have been closed. Health homes and their care management agencies have expressed that this initiative helps them better engage members and coordinate their care, develop more integrated plans of care, and ultimately improve behavioral and physical health outcomes.