Care management: Focus on vulnerable populations

Care management: Focus on vulnerable populations

September 22nd, 2017 | Clinical ConnectionsNews

By Daryl Sharp, PhD, PMHCNS-BC, NPP

AHP’s care management team is working closely with our DSRIP colleagues to explore ways to strengthen support for vulnerable populations in our network. We currently provide centralized social work care management (based at Noyes Hospital) for 8 rural primary care practices. Earlier this summer, URMC social work, primary care network and DSRIP leaders met with AHP’s care management team to strategize about expanding social work care management across rural counties throughout our network. We are in the process of hiring a second social worker to join our rural health team. We are also working on strengthening collaborative relationships with local behavioral health organizations and are considering adding an embedded RN care manager for one of our larger community-based rural practices as well as a centralized RN care manager to support several of our smaller practices.

A parallel focus is on developing an optimal care management staffing model for AHP’s safety net practices. A safety net advisory group has been meeting throughout the summer to explore how we might standardize approaches to data coordination as well as optimize collaboration between embedded RN and Health Home care managers. We are also exploring how to creatively engage other members of the clinical team—social workers, RNs, LPNs, MAs, pharmacists and behavioral health specialists—in working toward realizing population health, complex and transitions care management goals for our most vulnerable populations. All of these initiatives are aimed at expanding our capacity to effectively address the social and behavioral determinants of health, which often adversely impact patients’ abilities to successfully meet their health goals.

Please contact me here if you have questions or ideas about care management approaches for vulnerable populations—we welcome your input and collaboration!