In the Community

Health plans and their employees are a vital part of their communities. In addition to providing health care to their members, plans work in other ways to improve the health of their communities, and to provide innovative programs that support members and the community as a whole. Year after year, plans are also active participants in community activities and generous supporters of various organizations in the regions they serve. The following are examples of health plans’ innovative member support programs and other ways that plans give back to their communities.

Pregnancy Notification Program

CDPHP’s pregnancy notification program identifies pregnant members to connect them to resources that support a healthy pregnancy, including breastfeeding support, healthy eating, staying active during pregnancy, mental health support, and the importance of prenatal and postpartum care. The program links pregnant members to the CDPHP Care Team, comprised of specially trained professionals including nurses, dietitians, and licensed social workers, to provide 1-on-1 support to individuals with high-risk conditions and resources to reduce barriers to a healthy pregnancy. This includes assisting members with arranging transportation for medical appointments, obtaining necessary pregnancy and baby supplies, finding and applying for affordable housing, and applying for applicable benefits such as WIC.

In 2022, CDPHP expanded the program, partnering with Ovia Health, a clinically-backed, digital health platform, to support members by providing personalized guidance, robust educational content and unlimited access to the Ovia Health coaching team. Compared to families not using the platform, Ovia Health reports: a 28% reduction in dangerous and costly preterm delivery and NICU stays; a 15% reduction in c-sections; and an 18% reduction in preeclampsia. Following delivery, 92% infant vaccination adherence and a 31% increase in perinatal mental health treatment utilization were reported.

Book Bikes

During the summer of 2022, CDPHP forged a partnership with the local not-for-profit organization Grassroot Givers to bring two “book bikes” to events across the City of Albany. With the support of CDPHP, Grassroot Givers’ book bikes are earth-friendly “mobile libraries” that pedal to local neighborhoods and events to share books and promote literacy and book ownership. The goal of the program is to ensure kids continue reading over the summer and avoid the so-called summer reading slump. The book bikes are also be equipped with toothbrushes, toothpaste and educational information on oral health, courtesy of Delta Dental. These are the first bikes of this kind in the Capital Region, making visits to Albany Department of Recreation Playstreets events each Friday, as well as several other camps, parks, and even splash pads. To date, Grassroot Givers has shared more than half a million books with people in the Albany.

Empire BlueCross Blue Shield offers members an array of member support programs, including:

Improving Maternal/Child Health

In partnership with Public Health Solutions, Empire/HealthPlus developed a referral pathway to support pregnant mothers and families with maternal-infant services and resources. Through the Jamaica Southeast Healthy Start initiative, members in Jamaica, Queens are screened to determine need for community services. The partnership has monthly check-ins on referral status and outcomes, with opportunities to discuss process improvements and program evaluation. Empire has referred 798 women to PHS, 88% of whom were contacted and screened. Of those screened, 59% were referred to home visiting (HV) programs and 26% were referred to other services, including SNAP/WIC application assistance or mental health support services. Of those referred to HV programs, 49% enrolled. The typical enrollment rate is 30%.

Post Discharge Management

Empire Blue Cross Blue Shield has developed a program that provides members with outreach following a hospital discharge to support and educate members to prevent a re-admission and improve understanding of disease process.

Asthma Outreach programs

The plan has care management specialists who educate members on management of this chronic disease. These efforts help to improve members’ overall health status to prevent serious asthma attacks, which also prevents emergency room visits.

Emergency Department outreach program

Through this program, Empire Blue Cross Blue Shield reaches out to members 23-48 hours post emergency room visit to assist with any follow up needs. This can include follow up appointments with primary care and other providers and social determinants of health needs, as identified.

Wellness and Recovery Support

A Wellness and Recovery Specialist (WRS) from the plan works with members in the hospital to help them strive toward recovery goals. WRS have experience working through treatment to recovery to develop a “peer” environment. They offer emotional and practical support, as well as informational resources.

Member Support Programs

Expanding Telehealth

Fidelis instituted a new telehealth pilot program, looking to use telehealth services to engage members living in rural communities who are not currently seeing their assigned PCP. The plan targeted 15,000 rural members with no recorded PCP visits within at least the last 12 months and high potential risk. Reaching out to members through a large variety of channels – email, text, phone and mail – the program offers care management services that are specialized for the individual member. Success of the pilot will be measured by better health outcomes, lower urgent care utilization, and high member satisfaction. The following are examples of the program at work.

  • Addressing Challenges with Traditional Providers — One patient had a PCP in the community that they utilized to manage prescriptions but felt like their health needs were not being met otherwise. Fidelis co-managed the patient with their PCP services to get the patient’s health needs addressed, medications updated, and initiate a care management program. When the patient also indicated they had lost access to their mental health provider within the community, the program was able to establish a relationship with a telehealth mental health provider. The patient said this was the best healthcare experience they have had in their life, specifically mentioning how great it was to have someone call back when they indicated that they would and be able to quickly address their needs.
  • Addressing LGBTQIA+ community unmet needs in Rural Geographies — A patient, who struggles with a mental health condition decided to book a telehealth appointment after receiving mailers outlining the services offered by the Fidelis pilot program. Going to a PCP is especially uncomfortable for the patient and results in the patient not obtaining services. After the initial appointment with a telehealth PCP, the patient was able to refill prescriptions and have routine lab work ordered. The patient expressed that they have had a wonderful and comfortable experience with telehealth and felt that they were able to receive both preventive and routine medical care that they were not receiving through traditional medical systems.
  • Addressing Food Insecurity as a Social Determinant of Health Risk — A patient with a hormonal disorder does not have a support system that helps them make healthy lifestyle choices and changes. Fidelis’s Community Health Worker reached out to schedule an appointment to discuss government-funded programs such as SNAP that the patient may be eligible to enroll in that could assist them both financially and nutritionally. In order to educate the patient on healthier habits and promote an understanding of the components of a well-balanced diet and overall nutrition, techniques such as motivational interviewing were leveraged, as well as providing educational materials to the patient. Fidelis is continuing to meet with the patient to provide support and accountability during their health journey.

Timely Post-Partum Care

Healthfirst established a partnership with Mount Sinai to develop an intervention and payment redesign program to improve timely post-partum visits for low-income, high-risk mothers, age 18 and over, who spoke Spanish or English. The intervention provided education about health conditions (examples include gestational diabetes and depression) and health behaviors (such as nutrition and exercise), and additional engagement included education about common postpartum symptoms, taught self-management skills, provided enhanced social support and connected patients with community resources. The program included a cost sharing arrangement between the plan and the hospital to cover costs related to employing a social worker and community health worker, and provided financial incentives for completed postpartum visits (as defined by HEDIS guidelines).

RedShirt Program

Independent Health’s RedShirt Program is focused on helping members who sometimes need a little extra – whether it be finding a provider for particular care needs, getting answers quickly and accessing benefit information, or forging a path to healthier life styles or staying active. For Steve M., after he had open heart surgery two years ago, the RedShirt team members were there to coordinate follow up care and provide motivation to keep up with exercise and diet, helping him to lose 40 pounds. The program also routinely connects patients with Independent Health’s Medication Therapy Management team who step in to help those patients who are non-compliant with their prescriptions, assisting them with proper drug utilization or managing multiple medications that often result in members realizing significant savings on their prescription costs. The RedShirt Program also partners with a variety of local organizations to offer programs designed to help Western New Yorkers get healthy and have fun at the same time.

Virtual Primary Care

MVP Health Care and Galileo have a groundbreaking partnership to offer all MVP members access to virtual comprehensive care including primary care, chronic disease management, and multispecialty health care. The program enables members to use an app to connect with a primary care physician (PCP) at any time, day or night, within minutes and without making an appointment. Galileo’s highly experienced and culturally inclusive, bilingual providers can quickly address a wide range of patient needs, delivering fully integrated primary and behavioral health care, providing faster access to multispecialty care, improving chronic condition management, and avoiding unnecessary ER visits.

Therapy Dog Program

Therapy dogs, which are specially trained to provide affection, comfort and support to people, are often found in settings such as hospitals and hospice, retirement homes and nursing homes, schools and libraries. Thanks to a substantial donation from MVP Health Care, the Albany Police Department was able to stand up its own therapy dog program. As a result of the donation, the Department received three therapy dogs to build meaningful relationships and bring positive health benefits to the Albany community and members of the Albany PD. The therapy dogs have been deployed in emergency situations to help provide comfort to traumatized children who have been involved in car accidents and helped citizens who are at risk of hurting themselves from harm. This therapy dog program, supported by MVP, has been so successful that it has been replicated in other parts of the state and the country.

Patriot Plan

In October 2021, MVP Health Care expanded the offerings of its innovative Patriot Plan that adds an extra layer of health care to complement veterans’ existing VA benefits and empower veterans to have more freedom and control over their health and wellbeing. MVP’s expansion provides individuals who have served in the military with access to free on-demand transportation to and from the VA, free meals after an inpatient hospital stay, free mental health support, and an “over-the-counter allowance” of more than $100 per year veterans can use to help pay for basics such as aspirin, antacids or similar medicine cabinet necessities. Ken A, a Vietnam War Veteran and MVP Medicare Patriot Plan member, credits the programs with giving him “flexibility, choice, and management beyond the services that I am receiving from the VA,” adding that without the Patriot Plan’s additional transportation coverage, it would have been difficult for him to get to follow up appointments with specialists that he accessed through MVP.