Health Care Integrator Case Study

Health Information Exchange (HIE) has become a major component in today’s healthcare. Health information exchange provides a secure way for providers to appropriately access and electronically share a patient’s medical information. Therefore, reducing duplicate testing, minimizing medication errors and providing a link among electronic health records (EHR) in order to provide quality healthcare.

Partners HealthCare is a non-profit, health system located in Boston that created a data based transformation (Davenport, 2013). It integrated a new system that aligned the participating organizations to cohesively run as one and to help shape the future of the organization. The system didn’t stop there as it was responsible for bettering the patient financing experience and the delivery of healthcare information to other organizations (Davenport, 2013). The initial goal of the organization was making patient care more affordable and accountable by providing integrated, evidence based, patient-oriented care.

Session 1: During this face to face session on 8/8/16, MHS addressed the following ADLs: Medication Monitoring, Community Involvement, and Functional Skills. MHS asked the client if he had taken his medication today. The client reported that he did take his medication. The client mood was cheerful and inviting. The stated he is still looking forward to working when he can. The client stated he gets bored sometimes just sitting at home. The client requested to be accompanied to the library. MHS praised the client in making progress for independent living (20 mins). MHS accompanied the client to the library to view educational videos on how to display appropriate social skills in the workplace (25 mins). MHS suggested visiting the library gives

On Tuesday July 7, 2015, at approximately 3:01 PM, Kiana Beekman, (MFCU Investigator) (Beekman) received a call on the state office telephone from HILL, Lucy (Service Facilitator of Lucy Hill Services (LHS). During the conversation, Beekman asked HILL to clarify her role and responsibilities as a service facilitator, in addition to the role and responsibilities of HARRIS, LaFrance as the Employer of Records (EOR) for Medicaid Recipient DANIEL, Rose and MCGHEE, Inocencia as DANIEL’s aide. She was also asked to provide any documentation of training on timesheet submission and approvals that she provided HARRIS and MCGHEE under the Department of Medicaid Services (DMAS) Consumer-Directed care aide program.

Social Services Meeting: On 11/21/2016, Ms. Medina and her children met with her assigned Case Manager for the family ILP Document Review. Ms. Medina is expected to meet with assigned Case Manage bi-weekly. Ms. Medina’s next ILP Document Review is on 12/05/2016. Case Manager encouraged Ms. Medina to continue attending meetings. Ms. Medina stated that she was a sad and upset, due to that her doctor informed her that she is not going to be able to work as a Home Health Aid due to a back injury. Ms. Medina stated that her doctor recommended that she would benefit from physical therapy and that she should avoid to lift anything heavy until further notice.

I take pride in my direct contributions at MEDVAMC. I have completed the Social Work Leadership modules in TMS. I am the first line of communication regarding various HBPC related issues with patients and staff for pertinent issues. I also provide coverage for VCTS Extended Care Line (ECL) Social Work supervisor. Both roles require me to effectively communicate and collaborate with various levels of leadership including the Medical Director, ECL executives, nurse managers, and my immediate supervisor. As the HBPC Program Coordinator, I have organized a retreat for HBPC Social Workers and provided training opportunities with guest speakers during the one day session. In 2017, HBPC Social Workers will take the lead by in increasing home visits based on acuity and hospital discharges. MEDVAMC’s HBPC is one of the few programs using Clinical Video Tele health (CVT). This will allow us to complete more

Vertically integrated health care system that I have chosen is the Veterans Administration (VA) it's accountable for a large patient population for military veterans. As stated, The Veterans Health Administration is America’s largest integrated health care system with over 1,700 sites of care, serving 8.76 million Veterans each year (VA.GOV). The services that's provided to veterans is health care, rehabilitation, employment, education, home loan guaranties, and life insurance coverage. VA control costs by buying in bulk and control costs by engaging in a deep, single-source relationship with each patient. The Assistant Secretary for Management oversees all resource requirements, development and implementation of agency performance measures,

On 7/11/2015, CM did a visual and had client come to the social service office. CM completed Bi-Weekly ILP Review. In the meeting client appears to be wear out, and tired. She was constantly throbbing her forehead, like if she was having headache. CM inquires what the problem is. Client replies “she doesn’t like the shelter food and sometimes she doesn’t eat” CM advised the client to eat and nourished her body. CM also observed that client is depressed but she continues to refuse medical referral to see a psychiatrist and medical doctor. Client continues to mention her son who is in foster care, and the physical altercation she sustained many months ago here at this shelter. CM mentioned to the client she was a transferred from another shelter due to physical altercation, CM continues to relate to the client she

There are several different reasons as to why a long term care facility would seek to join either an integrated health system (IHS) or an integrated health network (IHN). The motivation to participate typically comes from either a requirement or eagerness to enhance the organization's situation within the long term care environment. Organization chose to incorporate an integrated system or network when the goals of the whole outweigh the goals of the individual organization's current state.

Service Coordinator (SC), Jennifer Stoker met personal staff, Aiesha Crayton at the home of consumer Jonathan .SC asked was Jonathan meet his outcome would like is medical expenses to cover. Aiesha noted he has Medicare and Medicaid which cover all his medical expenses. SC asked if money covering his want and needs. Aiesha noted yes. He wants and needs are being meet. Jonathan wants his cell to be paid every month. Aiesha noted he cell is being paid every month. SC asked is Jonathan maintain good health. Aiesha noted he when to his PCP on June the 1st. She noted he is health and there was no change in medication.

Thank you for mentioning health care IT system. As you stated, health IT system helps health care providers review patient's vital information, it also assists patients to be more informed with their health. As a patient and health care provider, I like to see my laboratory work-up and tests. The increased awareness will help me work toward a preventive solution. For example, if my cholesterol levels are borderline high, or my glucose is elevated, it will prompt me to find ways to prevent progression to diabetes. Staying on top of your health and keeping an open communication with your primary care physician will promote better outcomes and patient satisfaction.

Tara informed me that she has over 20 years of experience in the behavioral health field. Tara stated she started out working at a home health agency that worked with the geriatric population. Tara is a Behavioral Health Technician, and holds a High Needs Case Manager position with Southwest Network. Tara explained that Southwest Network provided counseling services, medication management, and various behavioral health services to adults and children. In Tara’s role she works primary with children with high behavioral needs. Tara main role as a case manager is to be the liaison for the agency in regards to the behavioral health services with the child’s team or family. Tara explains although she does not do the initial assessments she with the clients she does complete annual assessments to determine if the services the child is receiving are appropriate; while making changes if necessary. Tara explained Southwest Network is funded by Mercy Maricopa Integrated Care (MMIC). MMIC makes the determination on if and when a client will receive services. If there is a case where a child is having major behaviors Tara can complete an assessment and request for a behavioral coach. MMIC is able to approve or deny the request based off the data Tara provides to them. Subsequently, if a child is not doing well in their home and the family or team is looking at a high level of inpatient care this too has to be approve. Tara would submitted a packet with supporting documentation to MMIC. MMIC again as the ability to approve or deny this request. Tara is also responsible for filing appeals when cases are denied for services. Tara would work with the child’s family or team to ensure the child is getting the services they need to be able to function within their daily

Client and this CM was able to complete all three forms. Client stated to this CM working on Friday at 12PM to Monday at 12PM each week as home health aide in New Canaan for an 89-year-old women. Client expressed happiness to be employed. Client stated being homeless since June of 2016 when due to getting kicked out of father's household. Client stated needing help to get housed is the reason for requesting case management services. Client stated to this CM being kicked out of father's house was due to drug usages. Client is currently receiving $383 monthly from SNAP and make roughly $1890 monthly from job. Client stated to this CM utilizing the Day Street Clinic in Norwalk CT as a primary care provider. Client also stated to this CM receiving therapy from Rebecca at Day Street Clinic for pass history of trauma. Client stated to this CM being raped three years ago and have a history of sexual abuse. Client stated to this CM medical history contains heart murmur. Client currently is taking 500mg of trazadone nightly. Client is diagnosed with depression and bipolar disorder. Client stated to this CM having 8 children, 6 biological and 2 adopted. Client family history contains depression and high blood pressure. Client scored 8 on the CAGE Assessment and scored 15 on the Modified

I- CM inquired if client received a phone from LA Family Housing to schedule a CES assessment appointment. CM inquired if client visited the Bob Hope Patriotic Hall to fill out VA claims for service connected disabilities, and to start his “Veteran” California Driver’s License application process. CM informed client the procedures of referring him to dental. CM conducted a 90 day ISP with client. CM continued to inquire if client was interested in creating a savings plan. CM continued to assess client’s mental health and medication compliance

Mrs. Walker is the Unit Supervisor for the Health Homes program which is a case management model bases on person-centered care where all client’s needs are addressed in a comprehensive manner. The population that is serviced through the health homes program is individuals who are diagnosed with a chronic illness (HIV/AIDS, hypertension, asthma, diabetes, heart disease etc.) and frequently utilizes the emergency room for medical care. Mrs. Walker is responsible for overseeing the delivery of services among the various Health Home programs including Adult home, Home Community Based Services and Health and Recovery Plan. The services provided though the health homes program include but are not limited to coordination of medical care, mental health and substance abuse treatment services. Mrs. Walker’s other duties include supervising a staff of twelve, conducting quality assurance and evaluation, participating in the