Hudson Valley Care on Managing Change and the Intersection of Health Homes & Technology

Hudson Valley Care is on a mission: to provide the highest quality support to individuals living with multiple chronic illnesses and/or serious behavioral health conditions. Operating as a New York State Health Home, they are a coalition of hospitals, federally qualified health centers, and community-based organizations, termed Care Management Agencies (CMAs). They connect their members — high risk, high-need utilizers of Medicaid — to the services they need, in an effort to improve their quality of life. 

As Executive Director Amie Parikh describes: “Care Managers for Health Homes are responsible for the whole human being — caring for them on a daily basis. Do they have food? Do they have their medication? Or, is their fridge working so that they can keep their medication in the fridge? It’s coordination to make sure [members] have access to resources in the community to improve their quality of life.”

In order to successfully connect members to these community resources, technology is crucial to ensuring that each Care Manager has a clear picture of the individual they’re serving. Hudson Valley Care and the CMAs in their network rely on platforms that can provide full member charts, efficient reporting, straightforward documentation, and reliable data. Perhaps most importantly, Health Homes and CMAs need to be able to trust the data that they are getting out of their systems. Without accurate data, ensuring that a member is getting the support they need and tracking their progress becomes nearly impossible. 

Using Technology to Better Serve Health Home Members

When Hudson Valley Care decided to move their whole network onto the Foothold Care Management platform, they found that they already had 100% buy-in from their CMAs to make the switch. As Parikh describes, half of their network was already using Foothold Care Management and loved it, while the other half was excited to make the switch. Still, understandably, they had their anxieties about the transition. They found that with even-keeled support from the Foothold team and a clearly documented implementation plan, they were able to make the transition seamlessly. Through regular meetings, high visibility into the implementation plan, and clear communication about the timelines, they felt that they always knew what to expect. 

According to Program Specialist Brianna Rodriguez, “Everything was laid out clearly . . . the timeline for everything was really clean and we always knew what to expect. It went 2000x better than we expected.” 

Hudson Valley Care also prepared their staff internally for the change, by letting their entire network know about the status of the transition. They began by communicating about the implementation monthly and gradually increased the frequency of communication to weekly when implementation was drawing to a close. Their team also worked to clean their data in advance so that they could ensure their members’ information was transferred over smoothly. 

Their advice for other Health Homes looking to make a change? Their team recommends going through the current care management platform and looking at all the processes and features — both big and small — and asking the right questions so that teams know how the old platform’s functionality will map onto the new care management platform. 

One month out of implementation, Hudson Valley Care is looking forward to the myriad ways that technology will continue to support care management. Already, their CMAs are finding it easier to track contact with members every month, enter their encounter notes, and check the status of members’ Medicaid eligibility.

In the future, enhanced connectivity to other providers will enable Health Homes and CMAs to do their work even more effectively. In particular, the team is excited about the possibilities of closed loop referrals. Rather than following up with community providers for multiple days after making a referral, Care Managers will know exactly when a referral was picked up. By reducing this administrative burden, Care Managers will be able to spend more time doing the coordination of care that’s so crucial for their members.

To learn more about Hudson Valley Care, reach out to Program Specialist Brianna Rodriguez at: [email protected]. For more information on Foothold Care Management, feel free to connect with Sales & Implementation Manager Ben Bar at [email protected].