Putting the Care in Care Management

Monroe Plan’s Health Home Care Management Agency (CMA) was initiated in 2013 and currently serves 28 counties and approximately 3000 members. Monroe Plan’s CMA contracts with 8 Health Home hubs and has earned a reputation for providing effective, high quality care management to qualified Medicaid recipients in the counties we serve. Building on our 50 + year history of partnering with providers, community-based organizations, and the members themselves, our care managers are uniquely qualified to help Medicaid members navigate complex health care and community service networks to be sure they get the care and services they need. Every day, person by person, Monroe Plan’s team puts the care in care management.

What is a Health Home?

A “Health Home” is not a physical place; it is a group of health care and service providers working together to make sure that qualifying Medicaid and Dually Eligible Medicaid/Medicare enrollees receive the support and care they need to stay healthy. This is done through a dedicated Care Manager who works with the individual to develop a care plan that maps out the social, physical and behavioral services needed to put the enrollee on the road to better health. The ultimate goal is coordinated care for each enrollee ensuring access to all the services an individual needs to stay healthy, out of the hospital and emergency room.

How Can a Health Home Care Manager Help?

The care management support provided is driven by the goals of the individual. Care Managers can provide linkage to housing and legal assistance, support the person in becoming more socially connected, and facilitate access to medical and mental health services. One key advantage of the Health Home CMA program is that Health Home Care Managers can meet with members in person (*limited during the pandemic). The in-person visits allow the Care Manager to better assess the individual and their environment and build the necessary supports in to their care management plan.


Health Home Program Objectives and Results

Improves Outcomes for Members

Health Homes improve outcomes for members through communication with providers which results in:

        • Increased engagement in treatment,
        • Support for members and their caregivers,
        • Improve member connections with culturally competent providers that understand and can meet their needs, and
        • Address underlying social determinants of health (such as housing, employment, and education).

Improves Outcomes for Health Systems

Health Home Care Management improves the outcomes that the entire healthcare system is working towards, including:

        • Reduction of avoidable or preventable inpatient stays,
        • Reduction of avoidable emergency department visits,
        • Improved health outcomes for persons with mental illness and/or substance use disorders,
        • Improved management of disease-related care for chronic conditions including HIV,
        • Improved connectivity to preventive care and appropriate outpatient providers, and
        • Address social determinants of health such as homelessness, lack of food security and benefit connectivity.

Our Health Home Partners