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Overcoming COVID-19: How CCOR's Health Homes Continues to Help

By Elizabeth Hoertz

COVID-19 has changed the way companies and agencies around the world operate. People have had to change their normal ways of working, many lost their jobs, business owners had to shut down, and people have endured financial crises. One aspect, however, that many do not hear about or consider is how the closing of food banks, shelters, and clothing closets affect low-income individuals and families. Low income individuals and families tend to have multiple barriers preventing them from connecting to mental and physical health providers; the pandemic has made access to these providers and community resources more difficult. Fortunately, low income individuals and families who meet the eligibility requirements for Health Homes have additional support from a care manager. A Health Homes care manager coordinates and assists with connecting clients to physical health, mental health, and substance abuse services in addition to assisting with any other needs.

Throughout the COVID-19 crisis, care managers at CCOR have found creative ways to connect with and assist our clients. CCOR care managers continue to successfully enroll clients in need of services into the Health Homes program. This process looks different than it used to. Prior to COVID-19, care managers would meet with their clients face to face to build rapport and complete the necessary documents for enrollment. Since COVID-19, however, care managers have been utilizing a system called Fluix. This system allows all enrollment paperwork to be completed via email, creating a more efficient process than mailing all documents to be signed and returned.

Despite the challenges COVID-19 has caused, CCOR care managers remain able to assist clients with their needs. Care managers have been able to collaborate with client providers to implement aide services within a client’s home, complete a referral for Single Point of Access (SPOA), and complete an application for temporary cash assistance. Additionally, one of CCOR’s care managers was able to connect two people to the Golisano Grant, which allows clients to obtain necessary furniture up to $500. Not only are the care managers working with individuals who have stable housing, but there are clients who are homeless, need to transition out of supportive housing, or are not living in appropriate housing for their physical needs. CCOR care managers have been able to assist with housing applications, emergency housing, and follow-up calls. Other services provided include connection with food banks that have remained open, educating clients about COVID-19 precautions and symptoms and where to obtain free masks, and linking clients to providers via phone.

Since the start of the COVID-19 pandemic, CCOR Health Homes care managers have seen an increase in independence in some clients as well as an increase in engagement with care managers and other providers. One CCOR care manager was able to build trust with a client who had hesitancy due to not being able to rely on previous providers. This same client, at the beginning of COVID-19, was not actively engaged with his own care, often needing assistance from social support to manage his paperwork. This client now reaches out to his care manager when any questions arise regarding his care and connection to services. This client also started making his own life choices, became vocal about his life goals and ambitions, and became connected with Home and Community Based Services. Another CCOR care manager had a client who has post-traumatic stress disorder (PTSD) and a traumatic brain injury (TBI); rapport development has been slow due to his trust issues. The care manager engaged in phone check-ins with the client to let the client know he has support and to make sure the client has everything he needs as he adjusts to remembering he has a care manager to ask for help. During a phone call, this client reported he did not have food and was too nervous to walk to the nearest food bank, which was far from his apartment. The care manager was able to have a food box delivered to the client the next day from a local food pantry, and the client was able to stock his supply for the long weekend. The same care manager had another client who was able to utilize the same service to get food and diapers delivered to her and her child. With care managers losing the ability to go out and see clients in person, and the clients not being able to navigate their usual transportation methods safely, care managers are an important bridge between ensuring our clients are aware of these resources and receiving them when needed.

During COVID-19, CCOR care managers have been able to show their clients support by making a simple phone call to let them know they are not alone and have someone they can reach out to, which for many of our clients is vital and very much appreciated! COVID-19 cannot and will not stop Health Home care managers from working with their clients even if it does not look the same as it used to. These individuals need assistance and CCOR Health Homes is here to deliver.

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