DePaul’s care management program provides an extra layer of support for DePaul residents who face medical and/or mental health issues, particularly those experiencing frequent emergency room visits or hospitalizations. Care managers work with clients to identify problem areas and create a plan to improve their overall health. Care managers partner with residential staff as well as a client’s current providers in order to streamline care, clarify recommendations, and support clients in following through on recommendations for care.
- Individuals with a serious and persistent mental illness (SPMI) diagnosis who have current active Medicaid
- Individuals with a chronic health issue (examples: diabetes, heart disease, COPD)
- Individuals who are able to identify goals and are willing to be part of the program
- Individuals who are not already enrolled in a similar program through another organization
The final step in determining whether to enroll a member in a Health Home is to determine appropriateness for Health Home services. Simply meeting Medicaid eligibility and qualifying conditions is not sufficient to confirm appropriateness for Health Home enrollment. For example, an individual can have two chronic conditions and be managing their own care effectively thereby not requiring health home care management assistance. To qualify for enrollment and ongoing care management services under health home, an individual must be assessed and found to have significant behavioral, medical, or social risk factors that require the intensive level of Care Management services provided by the Health Home Program.
Individuals who are living in a DePaul residential mental health program may be referred by speaking with a care manager about a potential client’s need for services, and how they may benefit from the program. The care manager will review the client’s chart and complete a referral. Referrals must be approved by the county.
- Comprehensive Care Management
- Care Coordination and Health Promotion
- Comprehensive Transitional Care
- Patient and Family Support
- Referral to Community and Social Support Services