2025 CASE MANAGEMENT PRACTICE IMPROVEMENT AWARD
PROJECT TITLE: Improving Outcomes for Individuals with Substance Use Disorders
RECIPIENT: Healthfirst
CATEGORY: Behavioral Health / Readmission Prevention
ABSTRACT: Behavioral health readmissions are costly to the healthcare system and negatively impact both patient well-being and support networks. As key indicators in value-based care, reducing these readmissions, especially among Medicaid beneficiaries who experience poorer health outcomes, is essential for advancing health equity. Healthfirst, a New York-based health plan serving over two million members, launched a Behavioral Health Case Management (BHCM) Program to address this issue. Healthfirst members have over 13,000 admissions for detox, psych, other mental health conditions, alcohol and drug dependency, and medically supervised withdrawal. These members tend to be hospitalized periodically throughout their lives with more than 50% using the emergency department and less than 25% without patient therapy appointments on an annual basis.
They are often difficult to reach or are reluctant to speak via the telephone. Traditional telephonic engagement rates for this population are typically in the 30% range. Members are identified and targeted based on various historic factors as well as models predicting their likelihood to readmit or have frequent emergency room visits with little to no outpatient therapy. Without additional support, they are likely to relapse and experience periodic admissions causing financial and emotional hardship for them and their families.
Healthfirst’s onsite program embeds independently licensed Behavioral Health clinicians at high volume Substance Use Disorder facilities, psychiatric hospitals, and general medical centers to better engage and serve complex members using a client centered approach. By introducing a face-to-face element during admission, we are able to establish a relationship and trust with the member. This enables us to support and empower them to tackle barriers to recovery. The Healthfirst onsite case management program is rooted in CMSA’s integrated case management (ICM) principles. In fact, Healthfirst made a significant investment in CMSA’s ICM Training. The ICM tenets and guiding principles are foundational to this program. An assessment driven process is employed to formulate individualized care plans that address both the Behavioral Health and physical health needs of the individual. Additionally, the impact of Social Determinant of Health (SDOH) matters is well understood, and the team identifies and addresses issues that impede access to care like transportation, food insecurity, and unstable housing. Face-to-face interactions with some of our most vulnerable members have built trusting relationships that will lead to better health outcomes. Embedding staff at these sites also facilitates a stronger rapport with the treatment teams leading to improved care coordination activities and comprehensive discharge planning. Our onsite team continues to follow members post discharge to ensure engagement in community-based resources that promote recovery and wellness.
RESULTS / OUTCOMES: Members discharged from facilities with Healthfirst staff onsite have higher engagement rates than those without. We are seeing engagement rates of over 40% for these members. Members are more likely to continue talking to staff and completing post discharge plans. The readmission reductions for both 30- and 90-day, all-cause and behavioral health specific rates, were all statistically significant. Current program performance (matched population) shows 14% point lower all-cause readmission rates and 13% point lower behavioral health readmission rates at Healthfirst clinician onsite facilities.