Medicaid and Child Health Plus
New York’s managed care plans have been a strong partner with the state for nearly 30 years. Together, the state and plans have worked to expand coverage and improve quality of care for lower income and underserved populations. More than five million New Yorkers are enrolled in managed care plans through a variety of government-sponsored programs such as Medicaid Managed Care, Child Health Plus and New York’s Essential Plan. The following member* stories offer real examples about how plans support the health care needs of theses members.
* Some names have been changed to protect member privacy
When Jillian M.’s three-year-old daughter got sick in September 2021, she thought it was just a cold. The little girl, Nala, had tested positive for COVID-19 five weeks prior, but experienced no symptoms at the time. Nala is covered by Child Health Plus (CHP), and her care is overseen by CDPHP, one of New York’s managed care health plans.
After several weeks, when Nala stopped eating and drinking, was extremely fatigued and had a fever of 104, Jillian took her daughter to the emergency room where she was admitted to the hospital’s intensive care unit and diagnosed with multisystem inflammatory syndrome in children, or MIS-C, a condition some children develop after being diagnosed with coronavirus. Doctors quickly got the girl’s symptoms under control, and after being transferred to the pediatric unit, CDPHP’s nurse care manager stepped in with its Hospital to Home program designed to keep patients and their loved ones informed during and after a hospital stay. A team helps connect patients with resources they may not be aware of, schedules follow up visits when a patient is ready to be discharged, and oftentimes, just lends an ear to those in need. Through this interaction, Jillian opened up, explaining that she had missed several weeks of work while trying to care for her daughter, falling behind on rent and unsure how she would put food on the table or heat her home. The CDPHP nurse manager and her team sprang into action, connecting Jillian with resources she needed to get back on her feet, helping her apply for heating assistance and connecting her with a local food pantry. They also put her in touch with Building on Love, a local organization that provides emergency financial assistance to families facing medical emergencies.
“What started as a horrible situation turned out to be such a blessing,” said Jillian. “CDPHP was an advocate for me and my family. It didn’t matter if I need help financially or emotionally, they were there for me. I always felt like I was talking to a friend.”
James P.*, a 63-year-old member with behavioral health needs, came to the attention of the Empire BCBS HealthPlus case management team following a behavioral health hospitalization.
Because of his circumstances – he was homeless and had been living in a hotel that he was paying for with limited funds – James had stopped accessing services, leading to a deterioration of his conditions and ultimately requiring him to be hospitalized. Fortunately, the Empire BCBS HealthPlus’s HARP care management team was able to successfully engage him, acting quickly to refer James to an array of resources connecting him with a community case management agency and home and community-based services. Under the leadership of the HARP care management and utilization management team, community service providers are currently working to assist James in applying for long term housing along with securing employment.
Will S*. is an Empire BCBS HealthPlus member diagnosed with severe asthma, requiring regular albuterol treatments. He also had transportation issues because his parents are very sick and could not take him to see his providers regularly. As a result, he ended up in the emergency room twice in 2020, and ended up being admitted for asthma related symptoms.
The admissions were entirely preventable had Will and his mother reached out to his primary care provider and sought care earlier. Another contributing factor was harsh cleaning chemicals being used in the home that were a trigger for him at times. Empire deployed a community health worker to meet with the family. The community health worker educated the mother on ER usage and asthma diagnosis, and Will on his health conditions, helping him become more knowledgeable about his triggers so he can work to avoid them. The community health worker also worked with the family to get transportation to appointments and, as a result, Will has seen his PCP regularly throughout the year as well as his pulmonologist. The family has also switched to less harsh, more environmentally safe cleaning products. All these steps helped and Will did not have a single ER visit in 2021.
Maria C.*, a 27-year-old Spanish-speaking member, was an expectant first-time mother, working part-time at a local restaurant. She was experiencing feelings of stress and occasional hopelessness, especially since her baby’s father and her immediate family resided outside of the U.S. At 21 weeks into her pregnancy, Maria met with Empire’s case management team, forging a connection that would change her and her baby’s life.
Case management in the OB program referred her to a suite of different services and supports to help her and her baby. The array of services included Empire’s Internal Behavioral Health team (who connected her with a Spanish-speaking psychotherapist), the Special Supplemental Nutrition Program for Women, Infants, and Children (commonly known as WIC), the Nurse Family-Partnership program and doula services. The plan also sponsored a Spanish-speaking virtual baby shower for Maria and provided a breast pump.
With the help of these various supports, she delivered a healthy full-term child. Maria also remained closely connected to the doula program, her NFP Nurse and psychotherapist after the birth of her baby and obstetrical case management services continued through the postpartum period as she transitioned into her role as a new mother. As a result, Maria remains healthy, and her baby is meeting all expected milestones and continues to thrive!
Before connecting with the Empire Case Management team, Marie P.*, 63-years old, had experienced homelessness for almost four years. Marie has a host of mental and physical health complications, including major depressive disorder, opioid related disorders, generalized anxiety disorder, PTSD and borderline personality disorder. She also suffers from high blood pressure, chronic ischemic heart disease, High LDL and type 2 diabetes.
In 2020, she was evicted from an assisted living facility for nonpayment of rent and attempted suicide. Admitted to Harlem Hospital, she was connected to the Empire case management team, and it was during this time that she got support and resources that eventually led to meaningful housing stability she hadn’t experienced in years. Upon their meeting, the Empire case management team leaped into action and case managers introduced her to peer support services and helped to successfully coordinate an Assertive Community Treatment plan, utilizing a team approach designed to provide comprehensive, community-based psychiatric treatment and rehabilitation. The Empire case management team remained in close contact with Marie throughout her time in and out of the hospital. This relationship has been instrumental in keeping her motivated to apply for housing and to stay engaged with her ACT team to extend her time out of the hospital while receiving crisis residential services and attending housing interviews. There has been tremendous internal collaboration between inpatient and outpatient utilization management, case management and the HARP medical director that has resulted in helping her to get vital documents required to complete her housing application. Because of the tireless efforts and dedication of all involved team members, Marie was able to move into permanent housing through Concern for Independent Living, a non-profit agency committed to helping low income and deniable persons achieve their goals of greater independence.
Jane L. is a 63-year-old English speaking female MetroPlusHealth Medicaid member who also has a history of type 2 Diabetes, hypertension and high cholesterol as well as tongue cancer. When a MetroPlusHealth care manager connected with Jane to support her transition back to her home after being discharged from the hospital, the care manager realized Jane did not have reliable transportation to appointments.
The plan worked with Jane to make sure she had transportation to medical appointments. Because her diabetes was poorly managed, the care manager also recognized Jane needed assistance to address her food insecurity as well as poor access to nutritious foods, and connected her to supplemental nutrition assistance program (SNAP) benefits and food pantries in the immediate area. The care manager also learned that a number of the member’s radiation oncology appointments had been canceled. Unfortunately, the reasons for the cancellations had not been clearly communicated to Jane, resulting in her feeling anxious and abandoned by her clinical team. The care manager was able to facilitate improved communication with the team, allowing Jane to resume her scheduled radiation treatments the next day. Further, the care manager educated Jane on the importance of attending treatment consistently despite painful side effects.
As a result of the advocacy on her behalf, Jane’s care is coordinated and she’s able to access helpful benefits. Best of all, Jane reports her diabetes has improved, her pain is now controlled, and she is stronger and enjoying life again!
The Shelby Family
The five members of the Shelby family, all MetroPlusHealth Medicaid members, have unfortunately experienced longstanding homelessness, moving in and out of Department of Homeless Services shelters since 2017.
The mother, at 25 years old, had recently had her third child after a difficult pregnancy, complicated by anemia and respiratory disease. She had also been struggling with an anxiety disorder, which detracted from her ability to manage her family’s needs.
The family first came to the attention of the MetroPlusHealth housing task force after being notified by DHS. When staff reached the mother, they determined the family was eligible for the Emergency Housing Voucher program due to her previous medical conditions. MetroPlusHealth was able to assist her with the application, resulting in her being housed in a 3-bedroom apartment in the Bronx with her partner and three children in September 2022. The family is happy to have their own private space for the first time in 5 years. Taskforce staff are now helping the family with key next steps towards health and wellness, such as coordinating connections to medical providers, finding behavioral health services for the mother to address her anxiety, and identifying community-based resources for assistance with school/child care.
When Veronique B. was admitted to the hospital her blood glucose and A1C levels were extremely high. The 47 year old, a member of Molina Healthcare of NY, also weighed 286 pounds at the time and was diagnosed as diabetic.
Placed on multiple medications preventatively, including insulin, metformin, and hypertensives, Veronique said she was “scared to death.” She admitted that she went about her life but did not really care much about her health….until this happened. Working with Molina’s case management team, after two months, Veronique’s A1C dropped significantly, her blood sugars are now in normal range and she’s lost 31 pounds as well! Thanks to timely intervention from her plan’s team and Veronique’s commitment and hard work, she is now only taking one medication and is no longer considered diabetic.