Q&A: Case management involvement in seeking food and shelter for patients

August 8, 2018
Medicare Web

Q. How can case managers in the population health model ensure their patients have access to food and shelter once they leave the hospital?

A. Population health is closely related to the model of public health. The popula­tion health case manager will need to be cognizant of his or her patient’s ability to obtain the necessary food and shelter for sustenance and health. In the new value-based payment model, it is not an option to intervene; it is a necessity.

The case manager will develop relationships and partnerships with community agencies and organiza­tions. Referrals to food banks and safe housing are essential. The case manager will not just refer the patient to the resources; the verbal hand-over between the case manager and a contact at the community organization must occur. In addition, the community organization will need to report back to the case manager the patient’s status. Patients may not have access to nutritious foods and exercise, and as a result are obese with the multiple comorbid conditions that accompany obesity.

Case managers as caregivers in the accountable care organization are joining community organizations, consortiums, and public health committees to improve the health of the neighborhoods and communi­ties in which they work.

For more information, see Case Management Guide to Population Health: Management Across the Continuum of Care.

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