General SRC #34, Attachment 1: IHN Overview, Flowchart and Flyer

Integrated Health Neighborhood Overview 

Magellan’s Integrated Health NeighborhoodsMagellan has a long history of assuring access to quality healthcare and community-based supports for individuals with complex needs. Our history is what makes us unique. It’s at the center of everything we do.

With our dedicated focus on partnering with individuals with complex needs, our job—our mission—is to assist each individual member in finding his or her path to independence and well-being. Through our experience, we know improved overall health and wellness can only be achieved where members live—in neighborhoods and communities. This is where members make decisions about, and receive support for, their health, wellness, independence and personal goals. That’s why Magellan developed and implemented Integrated Health Neighborhoods.

Maintaining community connectionsWe understand each member’s ability to achieve and maintain a healthy and vibrant life is tied to multiple factors beyond healthcare—namely social determinants, such as housing, poverty, education, and access to transportation and healthy food. Individuals who use long-term services and supports need to stay connected to their families, friends, neighbors and others in their communities to maintain independence and achieve optimal health and well-being. Doing so makes the difference between surviving—and thriving.

Magellan deploys person-centered, community-based teams through Integrated Health Neighborhoods, which work within existing informal neighborhood networks and local public health systems to strengthen and extend their reach. Our local teams help each member navigate these systems and supports, facilitating their access to community-based resources on the road to well-being.

Redefining traditional health plan rolesOur teams comprise Magellan associates who live in the same communities as the members they serve. Team members have established relationships with individuals, organizations and local resources they can call on, person-to-person. The teams bring together associates with different skillsets who are responsible for and accountable to the same group of members residing in the same community, allowing them to be nimble and flexible as they work collaboratively with each individual member to meet his or her personal goals.

Speak with your Community Outreach Specialist or call 1-800-327-8613 to find out more.

The Integrated Health Neighborhood (IHN) team• Service Coordinator. Leads the IHN team. Works in partnership with the

member to identify/support the member’s access to needed services andsupports. While this one-to-one relationship is primary, others on the IHNteam assist the Service Coordinator when needed so that nothing—and noone—falls through the cracks.

• Community Outreach Specialists. Unlike traditional health plans,individuals in this role work hands-on to develop partnerships withcommunity agencies and with informal networks, providing the ServiceCoordinator with a robust array of local resources in support of the member.

• Health Guides. “Feet on the street” that improve access to services byworking directly with the member to navigate systems of care, services andsupports. For members who are difficult to locate, the individuals in thisrole use every means available to find and engage with them.

• Provider Support Specialists. Licensed clinicians who support providers’ability to deliver integrated healthcare and work with providers, includinglocal providers of community-based supports, to improve access to andquality of healthcare, services and supports for members.

• Peer and Family Support Specialists. Trained and certified individualswith lived experience who assist individuals with complex mental healthand substance use conditions by applying whole-health resiliency andrecovery principles and tools.

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Integrated Health Neighborhood Workflow 

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Integrated Health Neighborhood WORKFLOW (A road to wellness for SMI population in local communities)

Scope: The overall goal of the IHN project is to create a comprehensive system of care in high need neighborhoods that integrates clinical

healthcare services with community based agencies to increase support and promote wellness. The IHN project will occur in each active

MCC region, will start immediately and be executed throughout 2017 (and ongoing) by the COS and PSS teams as a combined effort.

This project will specifically focus on:

- Improving members well-being and support the recovery process by increasing connections to community based supports that will

enhance the effectiveness of formal healthcare services

- Addressing the members needs through the context of their environment and focusing on the social determinants of health

- Promote and facilitate the development and implementation of collaborative partnerships between clinical practices and community

resources

Within the scope of the IHN project MCC will assume a supportive, broker role between the providers and community based agencies in the

identified neighborhoods. The MCC field ops teams will work to connect a comprehensive group of service providers (both clinical and non

clinical) to promote wellness and better healthcare outcomes through coordination of services and integration of community based supports.

Identify neighborhood

• Utilize data to determine high member populated areas/zip codes/neighborhood in which to focus efforts and

project

Research

• Determine top 3 physical health and behavioral health providers in community

• Compile comprehensive list of community agencies which address or assist with the social determinants of

health or are resources for members to tap into i.e. food banks, NAMI, transportation, drop in centers,

• Create Community Map visual map of all providers and community organizations within the community

• Complete community member health profile

• Demographics for general population

• Population

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• # of MCC members within community

• Health indicators

• # of ultra high, high risk, moderate risk members

• # of members engaged in healthy behaviors program

• Information on hospital admissions and re-admissions

• # of members engaged in disease management program

• Community connectedness

• # of members engaged in BH levels of care i.e. case management, PSR programs,

• # of members who are homeless

• # of members residing in ALF level of care

Community Engagement/ initial meetings

• Utilize marketing materials developed to engage and start conversations

• Compile and take inventory of community needs, gaps in care, areas for improvement

• Coordination of community stakeholder meetings to gather subjective and objective community needs

• Promote and facilitate the development and implementation of collaborative partnerships between

clinical practices and community resources

Create Road Map to Wellness

• Road to recovery considering levels of care in that particular community

• Map outlines and addresses access to care, community connectedness, and direct relationships between the key

players within that community.

Regional Plan

• Report of outcomes, important relationships and connections, community stakeholder engagement and investment• Improving members well-being and support the recovery process by increasing connections to community based supports

that will enhance the effectiveness of formal healthcare services• Addressing the members needs through the context of their environment and focusing on the social determinants of health• Promote and facilitate the development and implementation of collaborative partnerships between clinical practices and

community resources

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Ongoing collaborative conversations and agreements

• Collaboration between COS, PSS, PH providers, and BH providers

• Reinvestment into the community

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Scope and Potential Impact:

Potential Impact

Increased preventive visits per year /per provider (HEDIS PH and BH)

Some level of coordination between clinical –community agencies (referrals)

Reduction in readmissions per hospitals

Reduction in ER visits

Increase in member engagement and self advocacy

Increase enrollment in Healthy Behaviors Program (SA, weight management, tobacco cessation)

Increase enrollment in Disease Management Program (cancer, asthma, diabetes, hypertension)

Reduction in no show up rates for PCPs

Increase social engagement of MCC members and family and community participation

Reduce the impact of stigma in the community and start a dialogue on mental health

Integrated Health Neighborhood Flyer 

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Through our experience, we know improved overall health and wellness can only be achieved in the neighborhoods and communities live. We also understand that each members’ ability to achieve and maintain a healthy and vibrant life is tied to multiple factors, beyond just access to quality healthcare.

What are Integrated Health Neighborhoods?

A comprehensive system of care in high-need neighborhoods that blends traditional healthcare services with community-based support for optimal health outcomes. They:

• Are built upon partnershipsand collaborations betweenproviders, clinicians,organizations and each member

• Address each members’ needsthrough the context of theirenvironment

• Improve members’ well-beingand support their recoveryprocess

What is Magellan’s role?

Magellan deploys person-centered, community-based teams within existing informal neighborhood networks and local public health systems to strengthen and extend their reach.

The team:

• Works to identify and supportthe member’s access to neededservice and support

• Works to develop partnershipswith community agencies andwith informal networks

• Engages directly with membersto help them navigate systemsof care, services and supports

• Supports providers’ ability todeliver integrated healthcare

• Assists members by applyinglived experience and whole-health resiliency and recoveryprinciples and tools.

What is the provider’s role?

• Recommend care for otherhealth or social-relatedchallenges

• Focus on preventative care andprograms

• Connect members withavailable community resources

• Support members’ psychosocialrehabilitation programs

What are the benefits?

• Reduction in no-shows atappointments

• Reduction in emergency roomvisits

• Improved engagement andself-advocacy

• Increased participation inhealth behavior programs

• Increased involvement indisease management programs

• Increased social engagementand community participation

• Reduction of stigma

Magellan Complete Care is a Managed Care Plan with a Florida Medicaid contract.

Integrated Health NeighborhoodsSupporting members’ independence, well-being & recovery

To learn more, speak with your Provider Support Specialist or call us at 1-800-327-8613.

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