Howard* is a 39-year-old single man who lives alone and is diagnosed with schizophrenia. He has been prescribed several medications that require monitoring and adjustment to keep his symptoms in check. Even on medication he is tormented by voices, fearful of strangers and experiences sleep disturbances.
Howard has been in and out of the hospital many, many times. He lives alone because his parents and siblings can’t understand why he doesn’t take his medications regularly and often enough to stay “normal.” He has been evicted several times. His symptoms sometimes make him disruptive and difficult to engage.
Howard receives intermittent case management services from a local mental health agency but he sometimes disappears for weeks, often misses appointments and doesn’t take good care of himself.
Heavy tobacco use and untreated bronchitis have resulted in Howard developing chronic obstructive pulmonary disease (COPD), a lung disease that makes it difficult to breathe. He is a frequent patient in the emergency room, and is often brought there by his case worker or a crisis worker.
Chronically ill patients such as Howard too often fall through the cracks. That’s about to change in Niagara County, thanks to a pioneering state-designated program for multiple-needs patients who struggle to navigate the healthcare system.
The new resource, introduced today by Niagara Falls Memorial Medical Center and 46 community partners, is the Niagara Health Home.
More than an office or a single site for service, the Niagara Health Home is a one-stop care management network that provides an unprecedented level of care coordination and service linkages to patients and their families.
The network consists of collaborating care providers from across Niagara County who supply services ranging from specialized medical and mental health care to food, housing, home care and heating assistance.
“Comprehensive care provides better outcomes and lower long-term costs,” said Congressman Brian Higgins. “I commend Niagara Falls Memorial Medical Center for leading as an outlier in this transition, which takes a holistic approach to patient care.”
“We must collaborate with community partners if many of these patients are to not only have their healthcare requirements met but receive the social support they need to avoid emergency services or hospitalization,” said Memorial President & CEO Joseph A. Ruffolo. “This is an entirely new approach, a groundbreaking process that changes the role of our hospital in a profound way.”
Niagara Health Home clients will have a dedicated case manager to help manage their care. That case manager will schedule regular primary care and counseling appointments, call or visit them periodically to check on their welfare and remind them to take their medications, connect them with community resources such as housing, food, transportation, heat and legal services, and provide valuable support services to their family members.
“No single organization has the resources or the expertise to do what needs to be done for clients such as these, people with multiple chronic and medical and psychiatric diagnoses,” Ruffolo said. “Community partners must collaborate in meaningful ways to provide the health care, social and community supports that will avoid their frequent use of the emergency room, and prevent community tragedies.”
The health home program is a New York State Department of Health effort to improve patient outcomes and control Medicaid costs. Led by Memorial Medical Center Vice President & Chief Operating Officer Sheila K. Kee, Memorial and its partners participated in a very competitive process that led to the Niagara Health Home’s state designation.
Kee emphasized the health home’s collaborative strength and its countywide reach, noting that the YWCA of Niagara, the Dale Association and Eastern Niagara Health System, with hospitals in Lockport and Newfane, are among the participating partners.
“This collaboration between independently operated health networks at opposite ends of the same county is unprecedented,” Kee said. “The Niagara Health Home will benefit community members from Lewiston to Middleport, from Wilson to Wheatfield.”
“Eastern Niagara Hospital is pleased to serve as co-lead of the Niagara County Health Home,” CEO Clare Haar said. “Providing comprehensive care management to its participants, the Health Home furthers the hospital’s mission, to meet the healthcare needs of the community with quality, compassionate, state-of-the-art and personalized medical care."
“Niagara Falls Memorial Medical Center has again led the way in transforming the way health care is delivered by partnering with the Eastern Niagara Hospital and more than 40 other care providers to form a new, multi-disciplinary network that will dramatically improve health care and social support services to chronically ill patients with complex care needs. I commend these hospitals and their health home partners for demonstrating a willingness to work together to keep patients out of the hospital and control Medicaid costs,” state Senator George D. Maziarz said.
Leadership at the Niagara Health Home will be provided by Medical Director Amarpreet Grewal Bath, M.D. and Administrative Director Vicki Landes, R.N., B.S.N.
Dr. Grewal Bath, who is board certified in Family Medicine, previously worked as a primary care physician at Marine Corps Air Station Miramar in San Diego and as a family physician at the Cleveland Clinic.
Landes has 14 years of experience in the case management field and is the former director of clinical service at Fidelis Care New York, where she was responsible for designing, implementing and directing all case management and quality assurance activity functions statewide.
“As Memorial Medical Center continues its transformation from acute care hospital to a center for community health, we need to reinvent ourselves as a people-centered, integrated primary care and behavioral hub for care coordination. The implementation of the Niagara Health Home moves us another step closer to realizing that vision,” Ruffolo said.
* Not his real name.