This past month, International Community Health Services (ICHS) was proud to open the Health Home Center in its Chinatown-International District (CID) location. The Health Home Center helps establish greater access and resources for the existing Health Homes program, as they hope to meet a greater need.
The Health Home Program is a partnership between the Health Care Authority, the Center for Medicare and Medicaid Services, and the Department of Social Health Services. The program provides services to eligible patients with a chronic condition(s) who could be at risk of developing complications or another chronic condition.
Chronic conditions could include diabetes, hypertension, chronic kidney disease, cardiac-related diseases, etc. Patients in this program work with Health Home Coordinators (HHCC). This team of professionals are care coordinators/case managers accredited by HCA and WA DSHS to work with specific patients on their chronic conditions. They help patients set and achieve goals to manage their chronic condition and improve their quality of life. ICHS Health Home Coordinators are multilingual. In addition, the Health Home Center has interpreter services, allowing ICHS to care for its diverse community of patients in their most comfortable language.
“A Health Home Care Coordinator is what I would call a partner who is walking the journey with you. That way, the patient is not navigating all this on their own,” Roseline Buyeka, Director of Clinical Services, said. “After that clinic visit with their provider, what is the patient going to be doing to manage their chronic illness between that time and their next clinic visit? That is where our Health Home Care Coordinators come in.”
After seeing how beneficial the program was to patients, ICHS established the Health Home Center to expand the program services to more eligible patients. Since opening the Health Home Center, new Health Home coordinators have been hired, with at least one at each ICHS location and the majority at the Health Home Center in the CID.
“ICHS’ preventative care model is focused on improving the quality of life of a patient, and one of the best ways of improving quality of life usually is around prevention,” Buyeka said. “If the patient already has the disease, we support the patient and prevent further complications. Having a Health Home Care Coordinator who is helping the patient set goals [and] manage the disease itself meets the ICHS goal of preventing chronic disease complications in our community.”
For example, when a patient enrolled in the Health Home program is discharged from the hospital, the patient’s HHCC will be alerted and immediately reach out to this patient to make sure they, for example, have transportation to follow up appointment(s), have received the newly prescribed medications, that they have set up their next appointment, etc. The HHCC also asks about any other challenges the patient might face during the discharge period that will prevent them from getting better or put the patient at risk of hospital readmission. The HHCC also connects patients with available resources in the community such as transportation, housing, food resources, etc.
Without personal and professional guidance for patients, pain, quality of life, and even death from chronic illnesses skyrocket. Prevention is the best way to help patients manage these conditions before they become complications. This is what Health Home Care Coordinators step in to do.
“The patient does not exist in a vacuum,” Buyeka said. “The patient probably has other family members that need to walk the journey with this patient. They too will be allowed to be a part of the patient’s care. Sometimes the patient has other issues going on in their lives, known as social determinants of health. SDOHs impact care outcomes. HHCC identify potential SDOHs and connect patients to available resources within ICHS and in the community. As a Health Home program, we treat the patient in a holistic way, it’s a whole person care.”