HealthVine Care Management
HealthVine's Care Management Team: Strengthening Continuity of Care
Across the Greater Cincinnati area, most children have low-level healthcare needs. However, there is a population of pediatric patients who are part of a vulnerable group that faces significant healthcare concerns. They face complex medical and behavioral health conditions and are consistently impacted by negative social determinants of health.
According to data from CareSource, in 2021, there were 2,193 HealthVine members designated as “high risk”. These patients have complex health and social needs, and they have higher healthcare services utilization than most individuals. To ensure these members receive the primary care and specialty services they need, HealthVine created and launched its Care Management program in 2021.
Using a risk stratification strategy, the Care Management team identifies HealthVine members who have gaps in care and which ones may be more likely to need higher-level services. For example, as of 2021, approximately 5,400 members faced a rising risk of an emergency department visit or hospitalization. Having this information helps the team prioritize resources while balancing day-to-day monitoring for the overall HealthVine membership
Expected Percentage of HealthVine Members by Risk Stratification
Low Risk (Level 2)
Medium Risk (Level 3)
High Risk (Level 4)
Intensive (Level 5)
What We Do
Care management is the comprehensive approach to maximizing care coordination for high-risk members. To do this, HealthVine brings together care managers trained in chronic and acute physical and behavioral conditions, as well as social workers, community health workers and operations coordinators.
These teams perform individual assessments and screenings to identify gaps in care. They use those findings to determine which members and families could benefit most from care management services, including:
- Care transitions
- Chronic/complex care
- Emergency department utilization
- Pregnancy/prenatal services
- Newborns
- Foster care
- Transition-to-adulthood
By bringing together all stakeholders involved in a member’s care, the Care Management team ensures they stay in close communication to provide the highest level of care possible.
How We Do It
HealthVine has invested in a variety of innovative resources to maximize the Care Management team’s impact. Through these efforts, HealthVine members and their families have the tools they need to seek out and receive care.
Leveraging Technology for Better Health
HealthVine has implemented two different technological solutions that can help its members mitigate the challenges they face when they try to access healthcare services:
- CincyKids Health Connect: This free mobile app allows families to have virtual urgent care visits with pediatric providers. These consultations can reduce unnecessary emergency room visits while caring for children more quickly when they are ill.
- TytoCare™: This telemedicine technology is currently being piloted by families who have children with complex needs. It allows a physician or nurse practitioner to perform some examinations remotely by checking a child’s temperature, heart, lungs, ears and throat remotely.
In many situations, high-risk members have limited transportation options. Consequently, it is harder for them to access the urgent or ongoing health services they need. By giving families these digital tools, the Care Management Team breaks down this barrier to care.
Meeting Needs Through Social Innovation
In many instances, a family’s extenuating circumstances make it harder for a child to receive necessary services. These hurdles can reduce their chances of achieving their best outcomes.
HealthVine designed and launched a safety net—the Social Investment Fund—that can help families navigate these emergencies when they have exhausted all other community resources. To date, over 20 families have received assistance through the program.
The Care Management team partners with community agencies and social workers to bring together resources for secure housing, furnishings and utility bill payments, among other resources.
Some examples of successful Social Investment Fund intervention include:
- Purchasing a lockbox for medication to prevent a child with suicidal ideation from accidentally or intentionally overdosing
- Purchasing home furnishings for a family affected by an apartment fire
- Buying a double stroller for a mother who needed assistance to bring her children in for necessary pediatrician visits
Although these types of needs are not directly related to healthcare, they can hinder a member’s ability to achieve optimal healthcare outcomes. By addressing these needs, the Care Management team can remove these obstacles to help support the holistic care of members and their families and reduce risk for future healthcare events.
Our Impact
During its first year, the Care Management team has made a significant impact on the level and coordination of care provided to HealthVine’s high-risk patients and their families.
Between January and Dec. 2021, the Care Management team performed:
Outreaches, including phone calls, emails and face-to-face meetings
Health Risk Assessments (HRAs)
Member enrollments in the Complex Care program
For any given month, the team provides some level of support to 4,500 children and their families.
The team has also had additional impacts.
Unplanned inpatient admissions through the emergency department for HealthVine members engaged in care management services have dropped by 50%, a higher-than-average rate of members between ages three and 21 who were engaged in care management received annual Well Child Care services, and 788 members benefitted from care management specialty program services.
Unplanned Inpatient Admissions Through the Emergency Department
From Jan. 1, 2021 to June 30, 2021, 653 members were engaged by the HealthVine Care Management team. The reduction in unplanned emergency department visits illustrates the promise and positive impact of care management supports for members in need.
Care Management Specialty Program Enrollment
Chronic and Complex Conditions Program Enrollees
Total Foster Care Program Enrollees
Newborn Program Enrollees
Care Transitions, Pregnancy, ED Utilization, and Transition to Adulthood Programs Enrollees
788 members were enrolled into a care management specialty program during calendar year 2021. Specialty program enrollment partners members in need with HealthVine care managers who are experts in supporting specific clinical conditions and populations.
Annual Well Child Visits
Based on initial findings from Jan. 2021 through March 2022, members aged three to 21 engaged in care management services successfully completed a Well Child Care visit 12 months prior to their birthday at a higher-than-average rate 8 out of 15 months of analysis period. Care managers help connect and support members in seeking out important preventative care services.
Success Story: Care Management
The Care Management team intervened on behalf of a child with asthma.
A child living in a home filled with mold and other environmental toxins had been admitted to the hospital repeatedly due to asthma exacerbation. The property owner and property management company repeatedly ignored the family’s requests to have their home cleaned.
A HealthVine community health worker reached out to the health department. As a result, a health department representative personally investigated the home and documented the presence of the toxins causing the child’s worsening asthma. The department sent the property owner an official notice to address the problems.
Within a week, the property owner had scheduled and paid for all repairs.
“We identify the children affected by high-risk circumstances, and we identify gaps in their care. If they are not connected with a primary care provider, we ensure they have one. If they need specialty care, we make sure they receive it. We even address their transportation needs. When we work with a child, we bring together everyone we can who is involved in that child’s care, and we stay in close communication.”
Mary Burton, RN, senior clinical director, HealthVine Care Management