S1E12 - Care Transitions Division
COAAA continues to expand our reach through new contracts, providing emerging services, and innovating through new programs.
Melissa Gualtieri, Director of Clinical Innovation, and Lisa Castro, Clinical Manager, describe four contracted programs managed in their division. Slightly different from other COAAA clinical programs, this episode teaches about the short-term interventions, case management, and care transitions work we provide in our eight-county region.
Let me know what you think of this podcast, as well as any ideas you have for an episode. Email me at kwhite@coaaa.org!
Copyright 2024 Central Ohio Area Agency On Aging
Transcript
Welcome to pretend I know nothing about I'm Katie White, your host administrator of COA. On today's episode, we will hear from Teresa Shane and Erica Coles West about all things provider relations.
Melissa Gualtieri [:Let's get into to it.
Katie White [:Well, welcome. I am joined here today by two leaders in the Care Transitions and SDOH Division. Welcome, Lisa and Melissa.
Lisa Castro [:Thank you.
Katie White [:So let's start with your title and tell me a little bit about your journey to getting here and how long you've been at Coaaa. Melissa, we'll start with you.
Melissa Gualtieri [:Thank you. Melissa Gualteri, and I'm the director of clinical Innovations here at Coaaa. I've been here for over eight years, started at Coaaa to bring the Ohio Home Care waiver to the agency, which was the first time the agency took care of children and young adults. My career started at Nationwide Children's Hospital. I am a registered nurse. I've gone from Nationwide Children's to Franklin County Public Health, where I was a public health nurse, then went to the Ohio Department of Medicaid, worked there for about seven years, started a couple programs there and went to the James Cancer Hospital there for a very short time and then was recruited here to COA.
Katie White [:Wonderful. Thank you so much. And that makes a lot of sense now, knowing all the different kind of pieces and places you've been and how you bring that to your business and innovation mindset. And lisa?
Lisa Castro [: our medical mutual program in: Katie White [:Wonderful. This is such a dynamic duo. If you don't know Melissa and Lisa, they work really well together and they're fun to have in the same room. I feel like your ideas always bounce off each other and it's a good relationship. So this division is one of the most complex, I would say, because you do so many different things. And so I wanted us to just kind of take time and talk about sort of at a high level, all the different programs that you run. So I don't know if one of you wants to name them all, and then we can go back and forth talking a little bit about each one. Do you want to give the overview of all the different programs? I'll take notes.
Katie White [:That way we don't forget.
Melissa Gualtieri [:Sure.
Lisa Castro [:We can go in order from when we started.
Melissa Gualtieri [:Yeah, that's what I was thinking, too.
Katie White [:Historic context. Love it.
Melissa Gualtieri [: Okay. And so in the fall of: Katie White [: Okay, so: Lisa Castro [:Awesome. Everyone on our staff is cross trained in each program, so they are able to jump and provide support to each other if needed. First, our medical mutual program. It is ran by Katie Key, who does a lot of work with tracking new we get a new census every day from Medical Mutual, and it's people who have been admitted to the hospital, so she tracks them through their admission once they go to a sniff or discharged home. And then she works her engagement skills and cold calls them to schedule a home visit with one of our nurses. So she's setting up those visits. We have two nurses on the team, Elise and Amy, who go out and complete the assessments, do a Med rec, and connect these members with any additional resources. The program is short term, solution focused, so they stay involved for 30 days just trying to coordinate any services that they might need.
Lisa Castro [:In our Anthem program, we have one full time person, Haley, who is a social worker, and we recently just started using a Five Nine dialer, so it helps her assist making calls quicker. With the Five Nine dialer, she's on the phone, so she's not necessarily leaving the voicemail. The Five Nine dialer leaves the voicemail for the person they're trying to reach, and once a person answers, she picks up and she's able to engage them and complete assessments. So it helps her the process go smoother. Instead of leaving voicemails and waiting for people to call back, the Five $9 assist with that. Okay, we have a couple of other people that also assist in that program as well. We're going to be starting here soon with the Medicaid population, and our community health workers are going to be assisting with that. Our Humana program, so that is our only program where we keep people long term.
Lisa Castro [:Like Melissa had mentioned, it is more behavioral health and addiction services. So we go out and we complete assessments with the members, identify needs, and then just follow up as needed. Each person, when we complete our assessment, is rated at a tier level. So that creates our contact schedule with them.
Katie White [:And how long are we case managing?
Lisa Castro [:Indefinitely.
Katie White [:Oh, ongoing. Yeah.
Lisa Castro [:This is the only one. Ongoing, yeah.
Melissa Gualtieri [:And I wanted to mention, so humana, because of the population that they're targeting, it's really important that we have key personnel who are skilled at developing relationships. Okay. Because what we found, that for ongoing case management with behavioral health and Substance use disorder, if you area able to build that relationship, we're keeping them from going to the Er. They're calling the case manager, and we're stabilizing them. So they're avoiding avoidable readmissions, avoiding Er transports, 911 calls. So it's really beneficial for the entire community.
Katie White [:Okay, interesting.
Lisa Castro [: nce we started the program in: Lisa Castro [:So they're not only working in the Hub getting referrals from them, they're also assisting our agency here with additional referrals that are sent to them.
Katie White [:Okay.
Lisa Castro [:And then our new program, our SDOH program, we have a lot of hands in that as well. With the nurses are the ones who do the home visits. So we have Linda and Tammy, who are out in the community doing the home visits. And then on the phone, we have Angie and then our community health workers, Roz and RC, and Bruce completing SDOH screenings and linking them with the services that they might need based on the findings in the screening.
Katie White [:So we've got all of these different contracts, and the majority are short term interventions. Some of them like Med, Mutual Anthem, those are pretty well prescribed, right? Like, that's their program, and we're contracted with them. And then for the Pathways in SDOH, this is where you all are using your clinical experience and sort of looking out toward what's coming down the pike for aging and disability services and creating it as we go. So tell me a little bit about what excites you about the Pathways or utilizing community health workers and SDOH. Talk a little bit about that work.
Lisa Castro [:Well, one, our community health workers, they come with a wealth of knowledge of community resources, and if they don't know, then they do a deep dive to find whatever they might need for these people. Another thing that they're bringing to our agency is they will service any age group. So it's not just focused on the aging population. They are working with kids, young adults, grandparents, raising kids. So there's no limit to their scope. Of practice.
Melissa Gualtieri [:Yeah. And it's exciting. So RC and Roz are community health workers and they have worked in the community for years, and they are passionate about what they do. They go out and do community events. They're able to engage people like no one else. It's just amazing to watch them. And with our programs, because a lot of it is short term. It's not like a waiver program where we're giving a big service or they're needing ongoing personal care or nursing.
Melissa Gualtieri [:We really have to be able to engage the people quickly that we're reaching out to in all the programs that we're doing. And Roz and RC are just experts at engagement. They relate to the community. They're teaching us all so much. And I think that's one of the things that I get excited about with our know, we have community health workers, social workers, nurses, and we all complement each other and bring something different to the table, which means we're meeting more people where they are. And if we meet them where we are where they are, we're able to make an impact.
Katie White [:Yeah. And that interdisciplinary team is really cool in the cross training, too. So each program sounds pretty different than the other one, but the fact that you've got nurses and social workers and community health workers that can really fill in and backfill in any program, super cool. The podcast with the Take Your Kids to Work Day, roz and RC both had family members speak about them on that podcast. And the things that they said about them were, I mean, almost brought me to tears, honestly. And so I think that's a true testament to just who they are as people. And how you can connect with someone so deeply so quickly to have an impact is a huge talent.
Melissa Gualtieri [:Yeah. And that's what we look for. I mean, we have to have the right people on the right bus, in the right seat, and if they're not, they're not going to be happy. So for our teams, you have to be really comfortable and confident on the phone, comfortable and confident in person, engaging, talking about the Aging and Disability network, but also being able to talk about how dynamic COA is. And we serve everyone. We really want to be the one stop shop you call Coaaa and you know that we're going to figure it out. We're going to get your needs met.
Katie White [:Yeah. You talk about buses, it's like you guys have a whole fleet, right? Like, you've got a bunch of different buses that are going in different directions.
Lisa Castro [:But we all come together and solve the problem.
Katie White [:That's right. And so thinking about who all we serve, when people think about Coaaa, they might not realize that if they're going into nursing or social work or community health worker, that we are in all of these sort of like, specialty areas that they think they might want to be in so we serve all ages. We serve disabilities. We've got behavioral health, substance abuse hospitals, interdisciplinary teams. So I think there's really something to be said about coming and working here and learning how to be a great clinician and a great generalist and where you might be able to go.
Melissa Gualtieri [:Yeah, we agree. We are hiring excellent social care clinicians that's right. From all disciplines and learning from each other.
Katie White [:All right, so now that we have an overview of all of the various programs, I'd love to hear from each of you. We'll start with Lisa. Tell me about your typical week. What does that look like?
Lisa Castro [:My typical week is never scheduled or planned unless there is a meeting. I mean, we cover five different programs. So I'm not only providing support for my staff, but I'm also in there with the programs, in there with them doing the work, monitoring their work. So just being able to I don't call it multitask because I don't believe people are effective that way, but being able to jump from one program to the next without things getting left. So my goal is always to finish one, be supportive, move over here so I can't ever plan for a day of just being in one program because I have to be able to jump freely in between all five of them throughout the day because my staff is needing the support.
Katie White [:So you personally are logging in and helping with different programs where needed in all five places?
Melissa Gualtieri [:Yes.
Katie White [:Oh, my gosh.
Lisa Castro [:Yeah. It's fun. I guess for me I like it because I can step in anytime that they do need help or if they had a disruption in their day and they reach out to me that I am going to be available to be able to support them. But then also I know how to work every program so each system so that is something I can take with me or just know that I have learned each program. How do I transform it to teach other people to be able to learn these programs?
Katie White [:So you could jump into the Pathways Hub or Humana or Anthem anytime?
Lisa Castro [:I would say the Pathways Hub would be the most difficult, but I can go in and do that if they needed to. I could follow up on their notes, creating the work. I might need to have to reach out for some help because some of their stuff is very detailed. But yes, I definitely can get in there.
Katie White [:That's wild.
Lisa Castro [:Yeah, it's fun.
Melissa Gualtieri [:It's exciting.
Katie White [:I'm glad you think it's fun. It's overwhelming to me. Somebody's got to be good at it. So I'm glad you are.
Melissa Gualtieri [:Yes. Melissa, how about your typical day or know again? My typical day and week is always changing and evolving. I'm on the Admin team, so that takes up some time, but always looking at new opportunities. How can we improve? Just like this week, I've met with almost everyone on our team individually, that was a priority. So every week it's a little bit different. But I think the end goal is how can we move COA forward, how can we serve more individuals and serve them more effectively? And that's kind of always my goal. So I'm trying to improve myself, trying to improve the team, trying to improve our agency, and then looking forward to see what is next, what's coming down, what are the needs individuals are going to have and how can we meet those?
Katie White [:And so when we think about what is next, I think that's where the SDOH accelerator program really comes into play. And it's like we are carving that path. There isn't necessarily a program that outlines each of the steps that are going on there. And I think it's really fun. I know it's stressful and difficult to create all those paths, but it's pretty amazing what our team is doing there. I don't know if either of you wants to share a little bit more about sort of where we've come and what we're doing so far on a weekly or daily basis with Stoh, but I think that might be interesting.
Lisa Castro [:Well, for me, it is not stressful or difficult. I like the idea of starting something and seeing it transform into more and reaching more people. I'll let Melissa talk more on our SDOH program, but that tool we've used, outside of that, in our other programs, we've been able to take that and implement it into our medical mutual program. Our community health workers are using that tool. We're using something similar with our Anthem program. So not only did we have one program that we designed it for, we're able to extend it to multiple programs and reach more people to identify the needs.
Katie White [:That's great. And then that's also that consistent data around the social determinants of health that people know either struggling with or doing okay with. But we can look across programs and see some population data.
Melissa Gualtieri [:Yeah. And the SDOH program originated, katie, with you and I going to Austin a little over a year ago and hearing about Z codes and billing codes and how they were connected to social determinants and how we could improve health equity. And so we both were very passionate about that. Lisa and I think a lot alike, and we're both very passionate, and we like a challenge and thinking outside the box. We want to be leading edge. And so developing the SDOH tool was just a natural evolution, and we're really proud of it. We copyrighted it. We have the Z codes embedded, so we can use it for billing down the line.
Melissa Gualtieri [:But like Lisa said, we can use it now to collect the data to impact change. So the social determinants of health, I really think, and health in conjunction with health equity, that is the future. We really need to be looking at how 80% of someone's social determinants affect their medical care and their livelihood.
Katie White [:Right?
Melissa Gualtieri [:And if we focus on that, everyone's going to win. It's going to be a win win for the insurance companies, for the community, and especially for the individual.
Katie White [:The Social Determinants of Health Accelerator program is our way of trying out this new future of social equity. And so we're screening people for their needs. We're attaching it to Z codes, which for those listening that aren't familiar, Z codes area way to bill for your work on social determinants of health. And as far as I know, nobody's trying this yet. There's a lot of research around it, there's a lot of people saying this is where we're headed, this is where we're headed. But we're here in the trenches trying it, working with a software company called Monomi to co design what that needs to look like. So it's just this totally out of the box innovation that I think is really reflective of the talent that we have here. And so I don't know, I just think it's one of those programs where I love when we meet and I love tracking what we talked about in the last meeting and how far you've come and how things are just progressing really quickly.
Melissa Gualtieri [:Yeah. So the Social Determinants of Health is really helping us guide the interventions, the screening tool we use. And then based on that, we're looking at what are the biggest needs? And we've completed probably about 350 screenings since the end of March.
Katie White [:That's great.
Melissa Gualtieri [:A lot of them are in person. And what we're finding is food insecurity, housing insecurity, behavioral health, social isolation, all those things that we had a hypothesis that this was going to be the issue, but now we're getting the data. So surrounding that data, Katie, you've come up with some really great innovation sessions and I think the whole staff here at Sierra Treboy are excited about. So from that we realized in the population that we're serving that we're targeting first for Molina is a diabetic population. So looking at that and what the challenges were, we were able to quickly develop an RN intervention. So what we're trying to do with this accelerator pilot is to figure out the need, figure out a pilot intervention that we could try out, see if we're making an impact and then be able to go back to the health plans and say, this is what your members are experiencing. And we trialed, we researched, we have the data, we tried these interventions and this is what's improving health equity.
Katie White [:And CMS recently put out some regulations around the fact that there are at least three questions that need to be asked to every individual on Medicaid every year. Am I getting that right? And I think it's about housing insecurity, food insecurity and transportation. So that came out when we were already sort of in motion with our program, which was exciting to see. And we're obviously asking a much more robust set of questions. But hopefully if you're listening to this, you can start to see that we area sort of carving out this template of what's required. But then how do we put our Holistic lens as an Area Agency on Aging to meet requirements and then make sure we're really meeting the individual where they are and getting their needs met too? Challenges and Successes I like individuals to kind of share some of those. Some of them are similar across departments, but also they might look a little bit different. So we'll start with the challenges.
Katie White [:What area some of your biggest challenges?
Lisa Castro [:Our program is a little different since we are cold calling people, they're not expecting our calls initially. So we run into some issues of learning how to when the referrals change, how to change our engagement to meet the member. So we're adjusting as a team, sharing ideas of how to be able to create engagement to get these members to utilize the services or I don't want to say convince them that they need help, but completing these assessments, to be able to have a conversation with them, to see what we're doing to or like, what we can do to support them. So I would say it's a challenge of people not feeling like we are a what's the word I'm looking for? Scam. Like we're not scammers. I could not think of the word. No, it's okay. So we really have to have an idea of who we're calling, but also to present ourselves that we're not scammers and we're there to be able to provide the support to them.
Lisa Castro [:So I would say that is a challenge for us. And then also in our area, we're dealing with a population of more of a commercial population as well. So not everybody is Medicaid eligible. So we run into people who might need services in the home, home health services that might not qualify for our other waiver programs here. So being able to still help them feel supportive and remain safe in their home is a bit of a challenge for our nurses and social workers and community health workers to be able to get creative and find additional solutions to support them.
Katie White [:Is there any kind of challenge with morale when you're having to cold call, or is that not an issue?
Lisa Castro [: , we've been doing this since: Lisa Castro [:Interesting, it is just changing verbiage, but we thought we've known it all and somebody came over and was like, well, I get calls back and I'm saying this. So we're like, what? Let's use it.
Melissa Gualtieri [:And it wasn't a lot, I mean, it wasn't a big change, it was just two words. Maybe that was changed in the verbiage. That has been successful for us with Medical Mutual, but again, with the SDOH accelerator program, we're outreaching a lot of medicaid clients and so we weren't getting them to call us back. She changed a couple of words and boom, we're getting some results.
Katie White [:That's great.
Lisa Castro [:So overall, our morale is up because everybody is although they're all different programs, everyone is doing a similar outreach. So we're all supportive of that process. And then we just started as well. Like making sure people identify success stories so we can see the work that they're doing, they can see the work that they're doing and the impact they truly are making.
Katie White [:I think highlighting those daily successes is so important and I think did you recently share a voicemail that somebody left? I received the information, the survey, and I filled that out and mailed that and I was very good because I was very impressed with you, your concern, your questions, your follow up, all the benefits that I received. And I wanted that to be known. So if it's not received, please let me know and send me another one. I have no problem filling out again. Or if someone wants to call me, I have no problem letting them know how pleased I am with your service and with Medical Mutual. Those stories are so important to share in your team and just having that open, supportive environment of like, try this know, once you kind of get used to maybe a different style of work. Yeah. And Melissa.
Katie White [:How about you? What are some of your challenges?
Melissa Gualtieri [: hear this idea that we had in: Katie White [:Yeah. And a lot of starting new programs. It's kind of like sales, right? It's like, this is the way that the insurance companies and the healthcare industry is moving. We're at the forefront of getting individuals to sort of understand this shift and get in there. And so while sales is really hard, the reward piece does feel that much better when you know exactly like, okay, we did that. Right?
Lisa Castro [:Since we're on the topic of success, just looking how big our program has grown since we started, I think we started with three, maybe four of us. And in September, we'll be up to 16 staff members in five different programs.
Katie White [:That's awesome.
Lisa Castro [:Yeah.
Katie White [:And you're getting your MBA, right?
Lisa Castro [:I am, yeah.
Katie White [:And do you feel like were you motivated by getting into this role and working on so many different contracts?
Lisa Castro [:Yes and no. Honestly, I chose the social work path because I was always intimidated by math, if I'm being honest. I was like, oh, I'm kind of great at this stuff, let me do that. But it has always been a goal of mine to get my MBA.
Katie White [:Okay.
Lisa Castro [:But this has definitely shown that I am really good at seeing a vision and starting with nothing and carrying out that vision. And not only for the people we serve, but also our team. Like being able to create environment where other people like this type of work area, like not doing being able to go from one program to the next. And also their support that they bring from the top down in our area. They know that they can lean on each other, but also lean on their supervisors, their managers as well.
Katie White [:Yeah. And I think there's a real talent that you have in sort of liaising between starting something new, which can be really overwhelming, bringing along interdisciplinary staff, but also being really open and honest. Like one of the first SDOH meetings that we had and we had kind of laid out, like, here's what we're thinking. And you were like, well, that's not going to work. And it was like in this really constructive, smart way of saying, cool idea. No, that's not how the real world works. And then again, four months later where we are now, and it's just like this fully operational efficient machine. I don't know, it's pretty impressive.
Melissa Gualtieri [:Yeah. When you say that Lisa and I are the dynamic mean, I do believe that we. Complement each other very like, we know what we're know before we even say know. So we have the same vision and the same goal, and we're both determined to figure out how do we start with this concept, this idea, and then pull in the constraints of the contracts and the requirements, but then sell this idea to the team and get them passionate. Because we are both pretty passionate people, and the team feels that, and they know that we're right there with them. So we really want to know, what are the challenges? And we're always asking them, tell us what we can do better. You're doing this now. We had this idea, what do we need to change?
Katie White [:And again, we say, you being able to drop into any system that has to hold a huge amount of respect with your team, too. I would think so.
Lisa Castro [:Yeah, definitely. They love me. No, I'm probably the more relaxed one when it comes to starting new programs, just because I go by the saying everything's figureoutable. I don't believe that. Barriers, we run into barriers. But I mean, working together and the team that we have, we've already proven over the years that we can overcome them with our team and being able to grow, it's just a huge you know, working with Melissa, I mean, the idea of starting the care transitions when I left Aetna, my care was like a jump. I didn't know what I was getting myself into. I didn't understand this new role that we were doing when I left a pretty structured job.
Lisa Castro [:And the idea of having a blank slate to create a program white how it works best for your team and the community, it's wonderful. It's a great opportunity and experience. So to be able to keep developing four additional ones has been a great.
Katie White [:Opportunity, and for everyone on the team, too, to kind of see how that all works and plays out and knowing that their contributions matter and they're a valued team member. All right, let's talk about a favorite story or one of your biggest successes. What's something that sticks out for me.
Lisa Castro [: Just coming over here in: Lisa Castro [:So a whole year after his accident, I start here and I'm like in orientation and I'm like, oh, there's services in the community that could help, um, in our situation. And that is how Melissa and I got in contact with each other because I was in the Aetna Eye care program. She was in Ohio Home Care Waiver, which that was the type of waiver services we needed. And ever since that day, we had the conversation of how important a care transitions program would be for somebody who doesn't have any services in place and being able to have somebody go out to your home and help you navigate the system. So for me, how it all started and a vision of an experience that I had that I never knew would lead me to this. From the day we met, we had the same idea of how amazing this would be. And then a whole nother year later, we are doing it.
Melissa Gualtieri [:Wow.
Katie White [:So it's really thinking about what you needed and making sure other people have that and know about it.
Melissa Gualtieri [:Yeah, I mean, I guess that would be a big success story for me too, because when we started other programs, I mean, I've started different care SRS, you know, different things like that. We had a know, Medicaid was telling us what to do. And when we started the care transitions program, there was no script. It was on me to figure out how to staff this, what would be our staffing model, who did I need on that? Know, in the again I talked to you earlier, Katie, I had a vision of who I needed for my engagement specialist and it know, essentially the personalities of a drug representative. And when Lisa came and applied again, it was know, like an have. She's passionate about care transitions. It affected her life personally and we were able to make the connection. She was the perfect person to start the engagement and helped me figure out we threw so many things against the wall to see what would stick, be able to get a commercial population to not only engage with us on the phone, but agree to a nurse coming out into their home in their business.
Melissa Gualtieri [:And Lisa was the perfect person, and we just complimented each other and then she's just moved up and kept helping me with every program that we're starting.
Katie White [:That's so fun. I feel like a lot of the programs here, not just in your division, but whether it's my care or even front door and screening, we do have this cool culture of not only great teamwork, but also thinking about how to get better, how to be more efficient, how to be more effective. And so it's just easily played out to see in all of these different programs that you are starting. But I do think we have a culture of that here across the agency, too. And I guess I don't know if that's unique, but it feels special, I should say.
Melissa Gualtieri [:Oh, I think it is. I think everyone is. We all have the same goal. Someone calls us with an issue or a problem and we want to figure out how to solve that, how to get them connected. And we don't stop with yes. We go yes. And someone asks you a question and you say, yes, we do that and we're able to do this. And I think that's the culture of the whole agency.
Katie White [:I do too. So we're already on to the final thoughts. See how fun and easy this is. What are your final thoughts or specific things that you want staff to know about your division and your programs? Melissa I'll start with.
Melissa Gualtieri [:Know because I do know. Again, I'm on the Admin team. I look at the agency holistically and then also obviously my division. But I want people to know within our agency and then everyone outside of our agency to understand. We have dynamic social care clinicians, we have dynamic support staff and support teams. We are all in this to win it. We're in here to make a change and we're doing everything. We don't serve just the aging and disability community.
Melissa Gualtieri [:We're serving all ages. And if you have a question or a concern, reach out and we'll figure out how to get that need met.
Katie White [:That's right.
Lisa Castro [:Yeah. Just to add to that one that our program exists. So we have been one of the things we have been doing is attending team meetings, one, to talk about our programs, but also emphasize on the work that our community health workers can do as well to be supportive within the agency. But for me, everyone here and everybody in the community that they recognize that we are here to service all ages.
Katie White [:That's major one stop shop, like Melissa said. So before we wrap up, I just do want to make sure that people know that the Spark program as well as CarFit fall under your division, but because they're so specialized and different, we're going to have separate episodes on each of those. But just so that listeners know the depth and breadth of all of the different programs in your division. Wanted to mention that. Well, thank you both so much for being here. I really appreciate it. Per usual, I learned a lot and thanks so much.
Melissa Gualtieri [:Thank you.
Lisa Castro [:Thank you.
Katie White [:I hope now you know something about provider relations.
Melissa Gualtieri [:Thanks for listening.
