Day | Health | Strategies

Max: 00:13 Hello and welcome to the day health strategies podcast, unlocking accountable care healthcare podcasts where we talk everything value based care with the top experts in the field.

Sarah: 00:27 Welcome back everyone and thank you for joining us for another episode of unlocking accountable care. I'm Sarah Matousek, a senior consultant at Day Health Strategies and I'm here with my colleague Lisette Roman, who is a consultant with me at Day Health Strategies.

Lisette: 00:42 Hi Sarah, glad to be here and to get to talk to you about case management today. We have a great episode where we sit down with some front-line case management staff to learn a bit more about what the MassHealth Medicaid ACO program has meant for them and how they interact with patients. But before we get there, Sarah and I wanted to talk a bit about what care management is and why it is crucial for caring for patients in a value based care program. So let's start with the definition. Case management is a collaborative process of a number of things. Assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual's and families' comprehensive health needs through communication and available resources to promote quality cost effective outcomes. Case management is really about thinking holistically about a patient and their needs and connecting them to the resources they need while also helping navigate the healthcare system and coordinate patient care.

Sarah: 01:47 Great. I think that's a really good definition. And one interesting thing about case management is that it really comes in many different varieties. So, we've talked to a lot of different folks about case management or care management and typically we get a slightly different variation or definition from different groups and that's okay. And we know that case management can be done by many different people in the healthcare system. Providers can do it. Payers sometimes have programs, community based organizations often have care management programs or independent care management companies even exist specifically to do this work. And these different organizations typically have really different relationships with PCPs. The PCP has a panel of patients and they might have a few patients on that panel that need some type of extra, you know, complex case management or care management. And it really depends on what the type of organization is that's providing that care management, that will drive what the relationship looks like with that office or with that PCP and as you can imagine, depending on what organization that is, they will also have different access levels to data on those patients.

Sarah: 03:02 Some of them might be able to get right in the EHR and may be able to see all the notes, some of them might be able to get information about transitions of care, meaning if some patient ends up in an acute care facility or hospital than they might be able to get that information so they can reach out and help them with that transition. And then others might not get any of that data. So it really varies. And then in addition, case management programs can focus on different patient populations. So there are some programs that are specific to one type of disease, like diabetes. There are other programs that are, you know what we're just going to help provide all the services and care coordination just for people who are in and out of hospitals a lot. They call those high utilizers and some programs are just for high risk patients, so maybe they aren't high utilizers, but there they've got some combination of diseases or issues that lead them to think that they might be high utilizers at some point or maybe they're just high cost.

Sarah: 04:03 And then other programs are for just post-discharge, meaning we are helping people get from hospital to home or a nursing home to home or some type of facility to another in a way that makes sure that they don't land back into that acute care facility just because things weren't managed well on the way out. And then there's just different types of needs that different programs can provide. And so who is actually providing those services can vary by provider types. So who's doing the care management will also vary. So nurses often do care management, social workers, community health workers. There are lots of different types of professionals that can actually provide those services. So I think what we just told you in a long winded way was that care management is a collection of services that help to provide what a patient needs outside of the doctor's office largely, and it can be done by lots of different types of organizations and lots of different people. So it's pretty varied.

Lisette: 05:06 That makes sense. So, right. Whereas there might be variation, in fact we tend to see variation in what case management programs actually look like. The programs themselves across the board tend to be working towards the same goals, and they have these programs largely because providers and payers are trying to succeed in value based care programs like ACOs. So in value based care arrangements providers need to keep patients healthy of course. So it reduced the number of healthcare services they need, and at the same time score well on the quality measures that the providers are being measured against. Also, case management helps to achieve these goals by working with patients to manage their health conditions and stabilize their social problems, to be able to be healthy. Case management programs have been shown to reduce emergency department use and hospitalizations to improve some clinical outcomes, definitely to improve patient satisfaction and also to increase quality of life. You know, these are just some kind of pieces of the puzzle that helped explain, you know, why is case management important, realizing goals for value based care.

Sarah: 06:21 Great. Thanks for that description. Lisette. I think it might be helpful for our listeners to hear an example patient to better understand what case management is and what the different people on the team could do and then why it can lead to positive outcomes. So let's take Joe. He's a 40 year old man who has uncontrolled diabetes. He's an alcoholic and he doesn't have stable housing. He's been couch hopping since he lost his job a couple months ago. Joe goes to the emergency department about once per month for alcohol related reasons and he was identified by his insurance company on their list of high emergency department users. And so that insurance company contacted the ACO that he's a part of and they assigned him to a case management team. And on this team are a nurse, a social worker and a community health worker.

Sarah: 07:12 And so we'll take each of those team members because each one of them will help Joe in a different way. So the nurse in this team meets Joe at a local coffee shop where she's working with him to stabilize his diabetes and to do this, she does things like scheduling an appointment with his PCP and helping him find a way to get there. She provides some education and then she sets goals with him. Now the social worker on the team is also meeting with Joe and she helps him connect to different resources for his alcoholism. And then she also assesses him for any other behavioral health type needs and then regularly checks in with him to monitor his progress. And then lastly, the community health worker helps Joe find temporary housing and then works with him on finding a longterm housing option. But after a number of months because of the team working to address all of his needs and holistic way, Joe is now in stable housing which allows them to focus on controlling his diabetes and addressing his alcoholism and his diabetes measures are now in the normal range and he hasn't had to visit the emergency department in months.

Lisette: 08:19 We can talk about theoretical patient examples all day, but I think it might be best served by those actually providing case management services people who are actually doing the work.

Sarah: 08:30 Right, and so that's why today we're going to be sitting down with some of the case management staff at the Lowell Community Health Center here in Massachusetts, which is part of the Wellforce Care Plan Medicaid Aco, part of that MassHealth program. So let's get to that interview. Okay. We have a really exciting interview lined up today. I'm sitting here with Becky Williams who is Director of Integrated Care and Case Management at the Lowell Community Health Center and we have the pleasure of having two of her team members with us. Stephanie Gabriel, who is an ACO Pediatric Social Worker on the care team, and Kim Kang who is ACO Community Health Worker on the adult team. So we're going to be asking a series of questions specific to case and care management related to the ACO program and we're going to start by asking the three of you to give us a little bit of a background about yourselves and your journey and how you landed here today at the health center.

Becky: 09:33 So I'll start. This is Becky Williams. And like Sarah said, I am the Director of Integrated Care and Case Management here for the Wellforce ACO at the Lowell Community Health Center. I've been in healthcare for over 20 years. My background is a registered nurse. I really have a strong passion and drive towards value based care. I really like the idea of healthcare providers and reimbursement being based off of putting the work in to create positive outcomes for patients, not just fee for service where you do a test, you get paid, you do an exam, you get paid. We really need to address this spiral of costs and out of control use and really get down to the nitty gritty about making it matter to the patient. So I have a strong background in risk based contracting, shared savings contracting. But as I'm a nurse I always have that clinical flavor at the end and understanding that there's a patient in the center of it.

Stephanie: 10:25 So. Hi, I'm Stephanie Gabriel. I'm the ACO Pediatric Social Worker and I'm a Licensed Social Worker. I have been working in the fields for 10 years. I got my Master's in 2012. So I've been working with children and families for that whole time. My previous job was working with a lot of young children and with early childhood mental health and a lot of those parents would go to their PCPs with questions about behaviors and, you know, looking for services for that. And I felt like a lot of times they left without answers.

Kim: 10:55 Hi, my name is Kim Kang. Again, I'm a Community Health Worker here, at Lowell Community Health Center. I've been for three years and it's a wonderful place to work on. I've been working with social services for about 20 years now. I think it's so important to be part of this new integration because, you know, we come to healthcare and sometimes we don't see as a whole but because this new ACO view, we see everything as a whole and is really interconnected in this way. We can actually go in and actually find out what's going on with our clients and be able to strategize with our client and have a goal plan and have everybody working together as a team. So this is really exciting. Thank you.

Sarah: 11:35 Thank you. So let's jump right in. The first question I'd like the three of you to answer is related to care management or case management here at the health center and specifically with the ACO. So what does care management mean for the Wellforce Care Plan, the Medicaid ACO specifically? What do the care teams look like here? And generally speaking, what do they do?

Becky: 11:59 So care management here at the Lowell Community Health Center and within the Wellforce ACO is probably a different view than what anybody's used to when it comes to care management. In all my years of doing care management, we did a lot of telephonic outreach and if the patient came into the office, we would sit with them and kind of see what they needed. Where as the Wellforce Medicaid ACO care management has kind of flipped it on its head. We go to where the patient's at. It's not about coming into the office, it's not about catching them when they can answer the phone, it's about going into the patient's home and understanding really what their needs are. It's seeing that the only outfit that they wear to the doctor's office is the only one that they own. It's seeing that, you know, they're not taking their medication because they don't even have food in the refrigerator or running water. It's seeing that not only do they not have a car to come to the health center in, but their house is literally falling apart underneath them. So where we do assessments and figure out what the needs of the patients really are, it's more eyeopening because it's out there in the community.

Becky: 13:00 So the Wellforce ACO care management teams are divided up in kind of a prescribed way, but it really does make sense. So each team is comprised of a registered nurse, a social worker, and then two community health workers. So I'll really briefly talk about the nurse role and then handed off to my colleagues to talk about their roles more specifically. So as you can imagine having patients in a Medicaid ACO, you can quickly realize that some patients have a really complex medical need and other patients have really complex social needs and behavioral health needs. So depending on the needs of the patient really dictates which member of the team takes the lead on the case. So for example, if we have a patient who has a high medical need, the registered nurse on the team might take on the lead of that case while pulling in all the other members together.

Becky: 13:47 So the nurse would do things such as a comprehensive assessment that would include assessing social determinants of health, medical needs, can they afford their medication and things of that nature, educating them about their disease, do they need disease management, do they need help with affording things, and really drives the push on whether it's a VNA assessment or things like that, but the nurse really is tasked with the medical part of it.

Stephanie: 14:09 So then the social worker we would take on the behavioral health cases. And so what that would look like if a child is having a hard time accessing services or getting what he needs, we would help refer the families for a certain service as either mental health or if they need a specific services for autism disorders, we can refer for those as well. We would try to make sure that parents attend the appointments. That's really important and really a challenge for a lot of our families because they forget, they have a lot going on. So we really try to support that follow through with the parents. Of course, as you imagine being the pediatric social worker, we're not only in working with the kids, but of course with the parents as well. So there's a lot of parent education on how to work with children who have behavioral or mental health challenges. I think the beauty of this being a new program is that social workers are still trying to figure out what exactly our role is and how we can help the families and the best way, but a lot of it has been making referrals and then coordinating with anybody that they already have involved.

Kim: 15:04 So as Becky was saying that we have two community health workers in each team. So what we do is we make the initial contact, usually try to make your phone call and then we could also go see them at their home to assess of what they need. So what the community health workers do is we're like the resource pro. So we have clients who will come in for housing issues or they need help with applying for housing, applying for food stamps or social security. So we do all of that and basically we do everything but each client is so different and so complex and then we kinda work together in interdisciplinary system and work with the team and with with our clients as well.

Becky: 15:44 So one piece that Kim isn't mentioning that is so integral to the success of this program, the success of working with these clients is that our community health worker team speaks a number of languages other than English and we also have additional medical interpreters here at the community health center. Here at the health center more of our patients are non-English speaking then the other way around, and if you can imagine trying to enter a healthcare system that doesn't make sense on any given day, having anxiety and stress about their medical needs the community health workers are not only someone who literally speaks the same language as them, but they understand the cultural implications and things that could be perceived as not adherence or noncompliance really have a cultural background to them. And they're able to develop this really great rapport that just opens the door wide open for us to be able to do the case management that the nurses and social workers so desperately want to do.

Sarah: 16:38 Thank you so much for that. I think that's a really good overview of what the teams look like and what they do. And in fact, yeah, I think that we understand what the goal of the program is. Can you describe who a typical patient in care management is? And actually now that you've are all spoken, I can hear that's kind of a crazy question to ask, but you know, maybe just give me an example of what you would think of as a patient in care management.

Becky: 17:03 So whenever I think about the patients that come into our Wellforce ACO, there's kind of a couple of buckets of patients that we're looking at, right? We have the patients who are extremely high utilizers, so maybe they're in and out of the emergency room. They either have diagnosed behavioral health conditions, they have undiagnosed behavioral health conditions, hopefully they don't have behavioral conditions, but they're the ones that have the super high utilizers. We know about them. Every doctor knows who they are. They could probably name you five or 10 right off the bat. So there are those people that interject with the healthcare system and then we have the people who have chronic medical problems that don't seek care and don't seek services that we don't know about because they only crop up during or maybe a onetime hospital discharge or maybe they got sick and they came in for a visit, but we have these kind of, the rising risk of under the surface and those patients can take on any sort of flavor. They could be your uncontrolled diabetics or it could be something as simple as just again, those basic housing needs. Maybe they don't have a house, they can't have food, you know, I say to physicians all the time, those patients don't care about their cholesterol med when they literally have nothing to eat.

Stephanie: 18:08 One case in particular, we got a referral for, he's about 18 months because he has significant medical concerns. He is trached dependent so we can't breathe on his own regularly. I'm the social worker so I'm not going to go into all the medical jargon, but he's a lot, he's a immobile, he has no speech, so he, he really has is very complex and so he was referred to us, actually he was at hospital discharge, so the insurance company had let us know to reach out because he may need some support. So when we went out to meet with a mom who is Spanish speaking, my community health worker went out with me. There's six kids, they were evacuated from Puerto Rico and they're living in a hotel so you can imagine things are a little hectic and crowded. Mom was also had just given birth when we went out to meet with them and that baby had medical issues as well. On a feeding tube and her liver or kidney was grown outside of her stomach wall. So it was complex medical stuff. And then the four older children, a lot of them were having behavior issues in school. So you go out for one patient and you ended up picking up six. And so we're working with them on. It's a lot of collaborating, so they had a lot of people in place already. So we're working with their housing workers, the school, social workers, well now our patient is actually in a rehab so we're working with the staff there on kind of getting him what he needs for when he's ready to discharge. So it's a lot of connecting the pieces, meeting the needs of medical, behavioral and social needs of the entire family, not just that one patient. And just trying to do connect to them to whatever resources we can find.

Sarah: 19:47 So the children in the hotel room that, you know, we're not your patient that you were um, you know, so you kind of get the whole family. Those might be considered rising risks because they have housing issues, they've got some behavioral health issues so they aren't necessarily on your list and they aren't being discharged from a hospital, but they certainly could be. You could prevent a hospitalization or some major issue.

Stephanie: 20:05 Yeah, absolutely. So I think one of the bigger goals is definitely to reduce cost to the insurance company with emergency room visits. With inpatient hospitalizations, and so, you know, there they actually have a five year old who had already seen the crisis team because of significant out of control behavior. So exactly, it's getting in there, referring them to the services, trying to connect them to things in the community to keep them out of those places. And the insurance company will benefit too because the costs are driven down. So a lot of my efforts on the pediatric team when I get those behavioral discharges is definitely trying to make sure that they stay out of the hospitals.

Sarah: 20:37 So I'd like to spend a couple of minutes on impact. I think we're, we know that we're early on in the ACO, but we would love to hear some, you know, some things that are happening that are actually making a difference. So what impact has care management program had so far, especially given that I'm, as listeners might not know, the health center actually didn't have a care management department prior to this ACO program.

Becky: 21:09 So here at the health center, we're actually in a really unique circumstance where our ACO team, although we're out in the community caring for patients, we're physically located at the health center. So that means that we're on this shared electronic health record as the primary care providers. We're just an elevator ride or a few stairwells away, if we need to run up. So if there's a patient in say the walk in center that literally just signed up for Wellforce minutes before and they identify needs, we can literally run down the hallway and go see that member. If I'm a patient on the phone, they can send a message right through the system, so others have to physically go and hope they can find a space at the primary care physician's office or pick up the phone and hope the message doesn't get lost along the way.

Becky: 21:56 But here at the health center were looked at just like any other employee. We mix in with the rest of the nurses and the MAs and the social workers. And we're just another piece of the puzzle the other way that the case management team or the care management team has really integrated themselves within the health center is having team meetings, so interdisciplinary team meetings, so this could be a nurse or the social worker meeting with their primary care provider, maybe pulling in the clinical pharmacist and myself as the director, I love sitting in on those meetings because I'm not as intimately involved with the cases. So I can give, you know, third party unsolicited advice. But another great success is we have lots of little specialty clinics here at the health center and that might be our OB-GYN and family planning department. It might be our Carino, which is an HIV focused department, which is an offshoot of adult medicine. And I think Kim can speak a little bit more about how we really can work between our ACO case management team and the Carino team to really wrap our hands around these highly sensitive members.

Kim: 22:54 Yeah. So ACO like we said is really unique. And by saying that is because we work with not just our department, we have so many department in Lowell Community Health Center. So for example, if somebody in OB may need clothes for their unborn child, they will reach out to me and I would then, you know, go out to the community, go to the giving tree or the wish project, they are wonderful agencies, and get to get those clothes for our clients and give it to them and actually bring it to their home. So that's the thing about ourselves, our CHW, is that we don't just stay in that desk, we're outside, we're in the community, so they want to meet us at Dunkin Donuts, will go meet them at Dunkin Donuts, if they need us to bring the close to their home, we will. So this is really great that we could all work together in this whole, this whole clinic. And whether whatever resource we have, we share with each other.

Sarah: 23:42 And it's not just medical services that you're helping connect to, right? I heard from other staff here, the great story about a family getting bunk beds. How did that happen?

Kim: 23:51 Yeah. So, we have health promotion as well. They emailed me to see if I can make up some magic. And we did, we got the bunk bed for the kids. They got new pillows, mattresses, everything. It was really exciting. And then the lady from health promotion brought it to their homes, so it was really great effort. We took one day and I'm glad that it was a team effort. It was great that we did it for the client and they were so happy. And we also have a pregnant mother as well too when. This is actually a great example, you know, we have our licensed social worker that's actually helping. We also have the BHs here that's helping us long, the PCP is here, the peer and us a CHWs as well. It is really such an incredible story and we're still working on it. And because of this whole new ACO integration it is better, it is working for our clients.

Sarah: 24:42 Yeah. Yeah. What about you, Stephanie? Do you have an example?

Stephanie: 24:46 Well, I think the biggest examples is just again, keeping these kids out of these inpatient hospitalizations. So one case specifically, he was hospitalized four times last year even though he's in an alternative school setting. They sent him from school constantly because of out of control behaviors. And since the intake over the summer with myself for case management, I've just connected the pieces, you know, I've just, I went to the meeting at the school, I brought the outpatient therapist, I brought my team, I explained some of the medical stuff he has going on which could be impacting behaviors and just pull the pieces together and he's been doing so much better and with some advocacy on some changes on his IEP, they haven't called mom at all. So I think a lot of it is just connecting these pieces, making sure people are communicating, you know, we all have so much to do every single day, that I get it, but sometimes these kids are suffering because the adults around them can't kind of come together. So that's definitely an example and I think how we know it's working is that for me, like my parents call me, they respond to my calls, they respond to my text messages, they're reaching out for help. So for me, that's how I know I'm being helpful because they keep talking to me.

Sarah: 25:50 That's a really good point actually.

Kim: 25:54 The client that you and I worked with to, that one is really great too. That just shows how I'm working with Stephanie and she's the licensed social worker. We worked with this client since the beginning and now you know, he's, he's working, he's working, he's doing what he wants to do and we're helping him with everything.

Sarah: 26:12 Oh, fun. Biggest challenges, what's been hard? I'm sure you've, I'm sure you have a few things.

Becky: 26:19 So in terms of biggest challenges, I think from what I've seen thus far is that unfortunately the ACO, we're kind of the victims of having to play catch up from years and years of unchecked utilization. This is the first time we've had to tell people, I'm sorry, no, you can't take your child to Boston children's, Tufts is in network. Or I know you want to go do this, that's a really high cost, you know, exam or test or provider, let's talk about it again. You know, VNA, I understand you've had a visiting nurse coming to your home five times a day everyday for the past five years. But now we need to sit down and really evaluate, do you really need that nurse? Let's talk about, you know, what you can do on your own because we all know in case management there are some patients that have to continue to be managed forever, but the goal of case management is always self management.

Becky: 27:13 We want to give them the tips and the tools and the education they need to meet their own goals and to be able to care for themselves and whether that means their families wrapped around them or something, but we don't want to make them dependent on the system. So sometimes we're like those bad guys that have to do the assessments and the evaluations. And what we've seen is patients who have had these services and even if the services aren't going well, the fear of you taking something away is so much stronger than pushing back and saying, this just isn't working for me. So having to come in cold sounds like you're from the insurance company, sounds like you're worried about cost. And it even, it's even hard with providers because they feel like they've been doing the right things for their patients all along. And here we come in sounding like we're the payer trying to eliminate services when really all we're trying to do is assess the situation and make sure that the patient's receiving the right service from the right provider at the right time.

Sarah: 28:07 I can see how that'd be challenging. And just because it's new.

Stephanie: 28:10 I think because it's new also, it's been, it's still a work in progress and how we kind of explained to professionals and family what we do, who we work for, you know, they hear the connection to the health insurance and, you know, that people want help, everybody wants help. So sometimes we get requests that we can't really do much with, but we're trying to just, you know, navigate the system and the new program together and I think for sure one of the challenges with working with the families is the lack of resources, the lack of mental health services, especially for children but also for adults. There's a real lack of that in this community. And so, you know, people suffer. And I think, you know, housing is a huge, huge barrier for these families. You know, if they can't get stable housing and feel like they're safe in their home, then how are they going to be able to even care about getting to their appointments or meeting their medical or behavioral health needs. So there's definitely a huge issue with housing in the area.

Kim: 29:04 Definitely from the view point of view, housing and transportation are the two biggest challenges that we, we deal with. I mean we already know that the prices here in Lowell are so expensive, even ourselves can't even do it. So that's one of the biggest challenges. But we're hoping that the ACO will be able to help next year in our new budget and so forth. And the other one is transportation as well too, because a lot of our clients, they can't come here. Not because they don't want to, they can't come here because they don't have money to drive taxi or they're too sick to be, you know, to be leaving their home. So there's so many different challenges and it's why it's so important when we going to their home and do these home visits, we see what they have in their home. We can see that they don't have food or they don't, they don't have clothes. They wear the same clothing as I saw them last week. It's so important to go to the home and to see what they have. But I'm just hoping that, you know, that we'll have a plan for better for the housing and for transportation.

Sarah: 30:05 So it is a new program, but it's five years, so we've got four more. Can't believe we're almost coming up around the one year mark. What are your hopes for the future? What do you think is possible?

Becky: 30:18 I have kind of two ideas for the hope for the future. So at a closer 5,000 foot view, I suppose, I hope that we're able to prove how successful case management is here at the community health center. So as Sarah mentioned before, we haven't had case management. Traditionally we've had some community health workers and they were typically funded through a variety of grants. So maybe there was an asthma grants and we could have community health workers that really focused on asthma. We know here that the Wellforce population does make up the majority of members here in the health center, but it's not everybody. So I'm really hoping that we can scale this program and expand it and really taken everybody regardless of their payer source, whether it's no insurance or health safety net members which are so at risk, or Medicare beneficiaries. But at a greater, you know, 30, 50, 100,000 thousand foot view. The idea of this demonstration project, the fact that, you know, when it comes to risk adjustments and really understanding what the risk of a member is, traditionally it's only medical claims and costs. And you know, if you have a provider that can really code to specificity, then you can get those dollars from the federal government. But the benefit of this demonstration project is that it pulls in these social determinants of health and it understands that factors like homelessness, food insecurity, inability to read, all of those pieces impact health. So if you take those into account and you pile those into your risk adjustment, then you really do understand that providers or whomever should be paid at a higher rate when they're taking care of these extremely complex patients because we know that those issues are what gets in the way of treating the diabetes and the hypertension and the rest of their chronic medical diseases.

Stephanie: 31:57 I think for me, you know, what's been really cool that I've learned so far is how, it's been so awesome to work with all these different disciplines. With the nursing team, the social workers and the community health workers, you know, the knowledge that we all have combined is so amazing to me and there's never nothing we can't offer a family and I think it's just been so rewarding to be able to work as teams like this and to see, you know, really what we can offer these families because some of these families would have never come into contact with a bunk bed, or have made it to their appointments to see the psychiatrist if we weren't involved. And I think, you know, those small gains eventually we'll just show how important this case management really is.

Kim: 32:36 I want to piggyback on what Stephanie said, that's why it's so great with ACO is we have each person to help with each issue, you know, we have myself if they need resources, we have Stephanie as a licensed social worker, we have our registered nurse. So we have everybody in hand and right now it's doing well and I do hope that it's going to work better and I think it will. It was really nice to call the clients and they know who we are now and they will come and they will say just come to my house anytime, like our friend, come over anytime. So I think it's going to keep growing. I think we're a great team, so I think it's definitely going to work.

Becky: 33:12 I actually, this, this recording was perfect timing. I actually received an email with a thank you note today from a family member who said, you know, this was so wonderful, you know, thank you for caring so much to come into my home and you know, not only did you meet my needs but you asked me questions if there was anything else I really needed, you know, I think clinicians traditionally they get those 15, 20, 30 minutes and I think a lot of them are left kind of feeling at a loss.

Becky: 33:38 You know, we do a lot of the shoulder shrug and the I wish I could do something, but now they know that there's a group of people that can do things. All you have to do is reach out and ask.

Sarah: 33:47 That is exciting. Those connections.

Kim: 33:49 That was nice. I got the, excuse me, I got the email and I was like, wow, you know, to have a client, you know, email the director of Metta. You know, that you know, we met with the children, the kids and we went and got clothes for them and brought it to their home. I mean, yes, they were thankful but he know that they sent an email to, you know, to director there and then that, that's something. It's so rewarding. Our work is just rewarding. Really, really rewarding.

Sarah: 34:17 Well that is a good note to end on. Thank you so much for joining us today. I think this was really enlightening and uplifting and positive and we look forward to talking to you again because I would love to hear more about how this is going in the future.

CM Team: 34:31 Thank you. Thank you. Thank you.

Sarah: 34:36 Alright. That interview was really fun to do. It's so exciting to hear that the program's working and actually changing lives. So at the beginning of this episode we talked to you a little bit about how case management programs differ. And we also heard from the Lowell Community Health Centers' program team and so taking those two together, I think it'd be helpful to just highlight how the health center is different from what many case management providers are able to do and how that has been setting them up for success in this particular program.

Sarah: 35:09 And so one of the things is that the health center program embodies many of the case management best practices like doing in-person case management as opposed to just being on the phone. And they also have a strong connection between the case management team and the providers, the PCPs at the health center. In fact the, we heard from the health center team that they're located in the same building as the PCPs. And they actually have access to the same electronic health records as the PCPs use. And so those two things really enabled them to be more successful. And frankly it's just a luxury that many case management teams don't have and might not ever be able to have.

Lisette: 35:51 Agreed. But Sarah, you know, aside from best practices, I think another aspect of the health centers program, another aspect that makes it so successful is that their case management management model includes a multidisciplinary team that works together to address medical, behavioral and social needs of their patients. And it's those, those features, right? Holistic care management, multidisciplinary teams that are really given a lot of lip service in the healthcare industry. And so it's nice to hear from teams actually doing this and doing it well. You know, I just want to say in general, I agree, I thought that was a great interview. And I do hope we get a chance to hear more about the work that the case management team is doing at the health center. I was happy to hear that. It sounds like this program is actually working. Working not only from a cost or quality measure perspective, but also from a patient perspective, right? Where patients and families are getting what they need. You know, it was encouraging to hear that the case management team is able to work to meet their patients needs in a way that they really were not able to before the ACO. So, you know, if I had to sum it up, if you made me go out on one sentence, Sarah, I'd say that this is not business as usual and that's exactly the idea behind value based care.

Max: 37:15 If you are interested in learning more about accountable care or how organizations can succeed in today's healthcare system, please visit our website www.dayhealthstrategies.com. Check out our blog, follow us on twitter and join our mailing list. We regularly post content relevant to current healthcare issues and overcoming challenges in delivering value based care.