Transcript - PAETC | Pacific AIDS Education and Training Center

The Next Generation of
Health Care Service
Delivery:
Strategic Alliances
Elizabeth Brosnan
Executive Director, Christie’s Place
Chair, National Women and AIDS Collective
October 20, 2013
Who We Are
Christie’s Place is a nationally
recognized nonprofit community
based organization in San Diego
County that provides culturally
competent and comprehensive
HIV/AIDS education, support, and
advocacy.
Our mission is to empower women,
children, and families whose lives
have been impacted by HIV/AIDS to
take charge of their health and
wellness.
Continuum of Services*
Clinical Services
 Medical & family centered
case management
 Mental health services
(groups, individual,
couples & family
counseling)
 Drug & alcohol outpatient
counseling
 HIV counseling & testing
(expanded HIV Testing in
healthcare settings & early
test)
 Family case work
 Peer/patient navigation
Supportive Services
• ADAP
• Adult & infant hygiene products
• Afternoon TEE/Mesa Redonda
• Children’s health insurance
screening & referral
• Childcare/babysitting
• Children’s & families social &
recreational activities
• Clothing
• Complementary (holistic)
therapies
• Computer lab
• Early intervention/coordinated
services center
• Family/peer advocacy services
• Food
• Health education
• Information & referral
• Outreach
• Partner services
• Support groups
• Transportation assistance
• Treatment information, Education
& adherence support
*All services are bilingual English/Spanish.
Empowerment & Leadership
Development Services
Transformations
The Sisterhood Project
 Educational Workshops/
Trainings
 Mujeres
 Nubian Queens
 Project SPEAK Up!
 Lotus Project
Women’s empowerment
retreat: Dancing with Hope
 Annual Women’s Conference:
A Woman’s Voice
 National Women & AIDS
Collective
 30 for 30 Campaign
 AIDS United Public Policy
Committee
 California HIV Alliance
 Positive Women’s Network Ally
Engagement in Care Cascade
Overview
•
•
•
•
Lessons Learned from the California Experience
Importance of Advocacy
Consideration for Program & Systems Development
Health Homes & Community Based Organizations –
Pathways to Collaboration
‒ Case Example: Christie’s Place
• Next Steps for Consideration
• Resources
• Contact Information
GETTING TO KNOW YOU
Which best describes where you work?
a.
b.
c.
d.
e.
f.
Clinic
Community-based organization
Health department
University
Hospital
Other
Which best describes what you do?
a. Primary care provider (MD, PA, NP, nurse, dentist,
etc.)
b. Behavioral health care provider
c. Administrator
d. Researcher
e. Consumer representative
f. Other
I feel I can explain ACA to my colleagues.
a.
b.
c.
d.
e.
Yes---100%
Yes---75%
Yes---50/50
A little bit
No
I feel I can explain Patient Centered Medical
Homes and Medicaid Health Homes to my
colleagues.
a.
b.
c.
d.
e.
Yes---100%
Yes---75%
Yes---50/50
A little bit
No
Review: What does the ACA do?
1) Insurance Reforms
–
–
Ends discriminatory insurance practices
Making insurance more affordable/accessible
• Expands access to Medicaid and private
insurance and requires core set of Essential
Health Benefits (EHB)
2) Encourages new coordinated care
delivery models
–
–
Health Homes
Other initiatives, e.g. dual-eligible projects and
others supported by the Center for Medicare &
Medicaid Innovation (CMMI)
Affordable Care Act:
Navigating the New Reality
California Context: Early Transitions as Part
of Our “bridge to health care reform”
• Medi-Cal (Medicaid): mandatory movement of all seniors and
people with disabilities into managed care plans – 2011
– Not including dual eligibles
• Partial and temporary Medi-Cal expansion (Low Income
Health Programs): RW clients to LIHPs – mandatory, if eligible
– 2011 - 2013
California Context: Upcoming Transitions
• Ryan White clients to Medi-Cal – mandatory for those
who are eligible; RW clients to private insurance
through Covered California (CC) – voluntary but
encouraged by HRSA
• LIHP beneficiaries to Medi-Cal expansion – mandatory;
to private insurance through CC – voluntary but
encouraged
• Pre-existing Condition Insurance Program (PCIP) clients
to Medi-Cal expansion – mandatory; qualified health
plans in CC – voluntary
Lessons We Learned
• California’s “Bridge to Reform” Report – documents
challenges with transitions to managed care plans
• Transitions were very problematic (LIHP, Medi-Cal
expansion)
– Most of beneficiaries were “passively” enrolled
– Loss of medical home and/or loss of primary medical care
provider with HIV experience/knowledge
– Barriers with new providers
– Patients dropping out of care
Lessons Learned Cont.
• Need for staff training . . . and on-going training
• Need for Care Coordinator
– care management position to serve as the healthcare reform lead
for the agency and care liaison through direct collaboration with
local healthcare providers
• Need to prepare and educate clients/patients
• Power & role of Peer Navigators & Community Health
Workers – critical component
• Need for panel management
• ADVOCACY
CONSIDERATIONS FOR ADVOCACY &
SYSTEMS AND PROGRAM
DEVELOPMENT
“The vast majority of local organizations are
pure service providers. It has become clear
that if all organizations on the local and state
level do not reserve a portion of their
agenda for advocacy, coalition building, and
public policy, they are no longer doing right
by their constituents.”
-Pablo Eisenberg
Lessons Learned: Advocacy
• Opportunities & challenges with transitions and
service integration, maintaining quality HIV care
for all who need it and monitoring new
coverage
• New decision-making forums may have to be
developed to encourage collaboration
– i.e: cross agency work groups, liaisons to
departments, joint stakeholder groups
Lessons Learned: Advocacy
• Advocates will have new roles
• Develop relationships and find ways to provide
substantive input to programs
– Medicaid
– Marketplaces – private insurance
– State and local health departments
• Develop relationships with other
health advocates
Considerations for Systems Development
• How are new local and state HIV program
policies being developed?
• Do you have an effective HIV communications
network?
• Do you have effective, HIV specific education
and training for all who need it?
Considerations for Systems Development
• Do you have a network ready to provide
quality counseling and education for PLWH
prior to new enrollment decisions?
– Medicaid expansion - need information on how to
stay connected with current providers
– Choices in Marketplaces are extremely complex,
especially in the first year
Considerations for Systems Development
• Do you have an adequate system to assist clients
with troubleshooting access problems in new
coverage?
– System was insufficient in CA; overwhelmed with new
coverage issues during transitions
• Do you have a system to monitor and report HIV care
problems in new plans?
– New systems will have problems; we will need to be part
of solutions
– No system to monitor right now – monitoring is up to us
– Without data, very hard to make changes
Considerations for Program Development
• Is your Medicaid moving to managed care?
– Are your HIV providers signed up with managed care plans – do
they need TA to complete process?
– How will clients be transitioned?
– Are working protections in place?
– Do you know where to get help for your clients with problems?
• What are your state and local health departments plans
for HCR implementation?
– Do they plan to assist with out-of-pocket costs for people with
new coverage?
• If so, what costs and how will it work for your clients?
– Do they plan to screen RW clients for other coverage eligibility?
If so, how will that happen? Who will be screening, for what
programs and what kind of information will clients and “helpers”
receive?
Considerations for Program Development
• How will you engage Medicaid and plans in the Marketplace
on program/policy development?
– Will need to engage with policies
• Ex. Out of county contracting, mail order pharmacy etc.
– Many have stakeholder or consumer input processes
– Develop a relationship with the insurance regulator in your state
– Develop relationships with the Medicaid and private plans in your area
Challenges Facing Ryan White Providers
• Ryan White program (RW) – patient centered
comprehensive HIV care
• Payer of last resort : RW can’t pay for services that can be
provided under other coverage
• HCR expanded coverage means transitions
– Transitions to new plans, providers, pharmacies
– Once in new coverage, may need continued access to some RW
services:
• Those not offered by other coverage: specific types of case
management, adherence, linkage to housing
• Help with costs: out of pocket and premium costs for care and
medications
Expand to Survive
Consider:
• The model of HIV care is applicable to many other
medical issues, including most chronic diseases
• Our approach could be useful for diabetics, Hep C, etc.
– think through what impacts your clients most now
(not AIDS as much as Hep C, Diabetes, etc.)
• To keep certain services (full component of case
management, peer support, dedicated Tx adherence)
you may need to expand its relevance
• Other external forces: PCMH, pay-for-performance
Preparing Staff for ACA
• Open and frequent communication and training
about ACA
• Integrating case managers into enrollment recertification process for ADAP/RW
• Training extended team in enrollment process and
eligibility requirements for insurance products
• Simple, straightforward tools to use with patients
Preparing Patients for ACA
• If you haven’t started already – start ASAP
• Tools are available such as a simple FAQ (examples of
tools from the SF HIV Health Care Reform Task Force)
• Clinic in-reach
– Letter and in person communication
• Providing as much outreach, enrollment and benefit
counseling on site as possible
• Formalizing relationship with professional benefit
counselors and legal support
Preparing the Organization
• Analyze current funding streams
– Considering patient demographics, how will they
change?
• Are there opportunities to diversify to obtain
alternative sources of funding?
– Or specialize, to attract specific donor attention?
• Will you continue to be an in-network
provider for your patients?
– If not, how will you support transitions in care?
PATIENT CENTERED MEDICAL HOMES
(PCMH)
PCMH Certification
• Standards often focus on primary care
providers (medical)
• But, standards for accreditation may include
services that CBOs can provide
CBO skills sets and services are complimentary and
integral to making PCMHs work
Example: 2011 National Committee for
Quality Assurance (NCQA) PCMH
Certification
PCMH1: Enhance Access and Continuity
A. Access During Office Hours**
B. After-Hours Access
C. Electronic Access
D. Continuity
E. Medical Home Responsibilities
F. Culturally and Linguistically Appropriate
Services
G. Practice Team
PCMH4: Provide Self-Care Support and
Community Resources
A. Support Self-Care Process**
B. Provide Referrals to Community Resources
PCMH2: Identify and Manage Patient
Populations
A. Patient Information
B. Clinical Data
C. Comprehensive Health Assessment
D. Use Data for Population Management**
PCMH6: Measure and Improve Performance
A. Measure Performance
B. Measure Patient/Family Experience
C. Implement Continuously Quality
Improvement**
D. Demonstrate Continuous Quality
Improvement
E. Report Performance
F. Report Data Externally
PCMH3: Plan and Manage Care
A. Implement Evidence-Based Guidelines
B. Identify High-Risk Patients
C. Care Management**
D. Manage Medications
E. Use Electronic Prescribing
PCMH5: Track and Coordinate Care
A. Test Tracking and Follow-Up
B. Referral Tracking and Follow-Up**
C. Coordinate with Facilities/Care Transitions
** Must Pass Element
Source: HRSA, Presentation “HRSA’s Quality Initiatives – Many Paths to a
Patient Centered Medical Home’ (May 2013)
The Medicaid Health Home Option for
Chronic Disease Management
• New state Medicaid option under the ACA:
implement health homes for individuals with
chronic conditions
• States must file a State Plan Amendment (SPA) and
must provide public notice
• Builds on PCMH models to focus specifically on
people living with chronic conditions
• Emphasis on integrating primary and behavioral
health care
Which Medicaid Beneficiaries Are Eligible
for Medicaid Health Home Services?
Medicaid Beneficiaries who:
• Have two or more chronic conditions, or
• Have one chronic condition and are at risk for a second,
or
• Have one serious and persistent mental health
condition
Chronic conditions listed in the ACA:
• mental health, substance abuse, asthma, diabetes,
heart disease, and being over weight
• HIV specifically designated as an eligible condition
What services are included in the
Medicaid Health Home Option?
All Medicaid Health Homes must include six core services (with
an emphasis on use of Health Information Technology (HIT):
• Comprehensive care management
• Care coordination
• Health promotion
• Comprehensive transitional care/follow-up
• Patient & family support
• Referral to community & social support services
But, individual states decide what each of those services actually
involves.
• As with PCMH standards, many could involve skills/services
that CBOs specialize in
PCMHs vs. Medicaid Health Homes
Similar goals but a few important differences:
•
PCMH is a general term that could apply to many different types of
practices, for example, PCMHs may also become Medicaid Health Homes,
and many Medicaid Health Homes may require providers to obtain PCMH
certification to be eligible
•
Medicaid Health Homes are specifically targeted towards individuals with
chronic illnesses who are on Medicaid
•
Medicaid Health Homes have specific requirements they must meet, which
do not necessarily apply to all PCMHs, for example:
•Medicaid Health Homes must coordinate with behavioral health
providers
•Medicaid Health Homes are required to help enrollees obtain nonmedical supports and services (e.g. referral to public benefits, housing,
transportation)
Integrating CBOs into
Medicaid Health Homes
• Medicaid Health Homes emphasize connection to community,
and whole-person needs (including social supports)
• CBOs can become a member of provider teams
• CBOs can subcontract to provide specific core services and/or
to generally make the Medicaid Health Home more
successful:
– e.g., CBOs have expertise and experience in cultural
competence, adherence and retention in care, care
coordination, non-medical case management, obtaining
community resources, connection to family members,
patient trust, etc.
A CASE EXAMPLE OF A CBO’S
PIONEERING PARTNERSHIPS
A Matter of Relevance & Sustainability
• Strategic positioning (and repositioning)
has always been a constant
• Not only does the landscape change,
community & client needs change
–
–
–
–
Need for greater cultural, gender and trauma responsiveness
Need for for health systems navigation
Need to integrate whole person care
Need for better care coordination
• Reform = Opportunities
Understanding the Landscape
•
Must know the “speak” – learn the language
–
–
–
Coordinated Care methodology
Medicaid Health Home
NCQA Standards and Guidelines for Patient-Centered Medical Homes
(PCMH 2011)
•
•
accreditation includes services CBOs provide, we help to make this work
Organizational readiness
–
–
–
Assess – what services are (or could be)
reimbursable?
Relationships with medical clinics?
Develop plan with tactics to position your
organization
CBO Provider Considerations Readiness Planning
• How do your services promote linkage and engagement in
testing, risk-reduction, and primary care for persons who are
HIV positive or at high risk for HIV?
• Are there services for which you can bill Medi-Cal/ Medicaid or
other payers, such as mental health and/or substance abuse
services, or insurance enrollment specific services such as
Assistors or Navigators?
• How do you/will you document the outcomes of your services?
• Have you explored options for diversification of services?
Christie’s Place Response:
Strategic Alliances
• Staying true to our mission and expertise
– Understanding and articulating what we bring to the table – the “value
added”/ROI for clinical partners
• Developed/developing strategic alliances with clinical partners
– Co-location with primary care
• Peer navigation/community health workers
• Behavioral health
• Medical case management
– Part of clinic health teams
– Whole person care
• Patient and family support
• Social support services
• Strengthening medical home models
Steps to the Goal
1. Identify internal stakeholders
2. Identify and convene the project team biweekly
3. Conduct client (customer) benchmarking
4. Determine which clinical partners
5. Stakeholders have initial meeting with identified partners
6. Agree on partnership benefits
7. Assess joint programming opportunities
8. Identify funding sources for joint programming
9. Determine joint programming scope
10. Develop MOA or contract to formalize partnership
11. Agreement execution
12. Implementation plan
13. Secure funding sources for joint programming
14. Formative phase
15. Cultural integration of program staff
16. Implementation
17. Monitoring
18. Evaluation
Identify & Screen
Against Fit
Select Fit
Shared Future
State
Operating
Arrangement
Finalize Agreement
Set Shared
Performance
Targets, Goals
Monitor Progress
Outcome
CHANGE for Women
• Network of Care Model: a system-wide care coordination approach
– Involves multiple collaborating organizations
– Pursue balanced and coordinated array of strategies to address access to
care
• Partners include:
–
–
–
–
–
–
–
–
–
–
University of California, San Diego (UCSD) Antiviral Research Center
UCSD Mother, Child, and Adolescent Program
UCSD Owen Clinic
North County Health Services
County of San Diego HIV, STD & Hepatitis Branch
The San Diego LGBT Community Center
Vista Community Clinic
Casa Cornelia Law Center
American Friends Services Committee: US Mexico Border Project
Cardea Services (evaluation)
Clinic/CBO Partnership in Practice:
How does it work?
• Referral connection from the CBO
• CBO co-location at clinic
• Utilization of all existing clinic resources
• Peer or case manager attends clinic visits (patient
preference, strongly encouraged)
• Plan formulated together with shared understanding
between patient, physician, and case manager
• “Wrap around” of medical plan from clinic to community
setting (and vise versa)
Benefits of Linking Medical Care
and CBOs
• Leverage existing connections for patient retention
• Address the whole patient
• Expand Cultural Competency as applied to women:
– Layer 1: language and cultural understanding
• i.e. working with immigrant and cross-border populations
– Layer 2: understanding of women's issues.
• i.e. parenting, relationships, past traumas
– Layer 3: understanding the patient’s community, their
connections, respecting where they feel comfortable and
partnering to provide services in the settings preferred by
the patient
• i.e. connecting to CBOs
Challenges of Linking Medical Care
and CBOs*
• Patient factors (transient, changing providers)
• Shared access between systems
• Organizational culture
• Communication!
*These challenges also reflect the reasons
partnerships are needed
Impact - Measuring Outcomes
• The “partnership” - tactics are strengthening medical
home model and improving care coordination
–
–
–
–
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Peer Navigation model has brought 240 out-of-care and suboptimally engaged in care HIV+ women back into care
Reducing “no show” rates
Reducing lost to follow-up
Medical visit preparation/agenda setting
Improved health outcomes of clients enrolled in CHANGE for
Women
•
•
89% saw a medical provider within 30 days of enrollment
100% of those enrolled six months or longer had a lab-verified CD4
increase from the time of enrollment
• Launch of “Retention in Care” initiative: trauma informed
& trauma responsive
Outcomes
• Cost-saving and cost-effective
–Only 0.82 HIV transmissions need be averted to be cost-saving
–Only 2.90 QALYs need be saved to assert cost-effectiveness
• Co-location of services and integration with provider
teams has resulted in enhanced culturally appropriate &
person-centered care; comprehensive care
management; care coordination
• Since program implementation, local unmet need
decreased from 69% in 2010 to 64% in 2011, and then
to 57% in 2012
– Increased access to care for HIV+ women by 12%
CBO Role in Preparation & Enrollment
• 4 E’s: education, eligibility, enrollment, engagement
– Navigation and support around understanding and enrolling in Medicaid expansion
and Marketplace insurance opportunities
• Education
– adapting/tailoring the SF HIV Health Care Reform Task Force sample Client FAQ
document to help clients prepare for health care reform
– Key staff communicating about enrollment opportunities for Medicaid expansion
and/or the Insurance Marketplace
• Enrollment
– Peer Navigators & Case Managers working as “assisters”
• Looks different across the country, but figure out what it is because it’s a service our clients
need
– Staff encouraging clients to explore their options
– Helping clients communicate with their medical provider(s) to see which plans they
accept
– Discussing and helping client decipher their health insurance benefit coverage needs
and what plan would best meet those needs
Enrollment Preparation Cont.
• Covered California (State Insurance Marketplace)
— Certified Enrollment Entity (CEE)
— Certified Enrollment Counselors (CEC)
o Case Managers
o Care Coordinator
• Care Coordinator
― Serves as agency’s healthcare reform lead
― Lead on coordination of managed care plan benefits
counseling and enrollment
― Ensure client ability to access and remain in patientcentered medical homes (PCMH)
Next Steps
• Working with State partners on how to certify/credential
Peer Navigation
– Can this become a reimbursed service?
– Recent updates on funding for Community
Health Workers
• Electronic Health Record technology
• Public and commercial third party insurance
reimbursement for behavioral health services
– Joining panels on the CC Marketplace plans
– Behavioral heath reimbursement through sub-recipient
agreements
Resource: Provider Consideration
• Prepared by the SF HIV
Health Care Reform
Task Force
• Generic checklist
available today to
support you in your
local response
Resource: Patient FAQ Sample
More Resources
 State HCR Information www.statereforum.org
 Enroll America
www.enrollamerica.org
 Center for Budget and Policy
Priorities - www.cbpp.org
 Treatment Access Expansion Project
– www.taepusa.org
 Kaiser Family Foundation –
www.kff.org
 Families USA – www.familiesusa.org
 National Health Law Program –
www.nhelp.org
 NASTAD – www.nastad.org
 Health Resources and Services
Administration –www.habhrsa.gov
More Resources Cont.
 SF HIV Health Reform Task Force http://www.sfhiv.org/resources/health-care-reformtransition-2/
 Covered California – www.coveredca.com
Health Access - www.health-access.org
Western Center on Law and Poverty – www.wclp.org
National Senior Citizens Law Center – www.nsclc.org
Health Consumer Alliance – www.healthconsumer.org
Summary
• Power of advocacy and policy
– No one agency is in charge; it will take a village
• Know the data, the drivers and the deliverables required
• Collaboration is essential – no one can do this transition
alone; strategically align with CBOs
• Never underestimate the value of relationship capital
• Readiness planning is a must
– Take time for strategic thinking . . . be proactive, forecast and don’t do it in a
bubble or in the AIDS silo
Summary
• Prepare staff, organizations and patients/clients
• Be willing to take smart, calculated risks
–
–
–
–
Release early
Fail fast
Iterate often
Listen to your ‘users’
• Must constantly evolve the way you do business –
“evolve or become extinct”
– CBOs can subcontract to provide specific core services
and/or can make the health home more successful
Acknowledgements
•
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AIDS United
MAC AIDS Fund
Johnson & Johnson
Alliance Healthcare Foundation
UCLA/Johnson & Johnson Health Care Executive Program
Macy’s Foundation & Passport Fund
Janssen Therapeutics LINCC Initiative
Kaiser Permanente Foundation Hospitals, Southern CA Region
Qualcomm Foundation
San Diego HIV Funding Collaborative
HealthHIV (Fiscal Health Technical Assistance)
Anne Donnelly, Director of Health Care Policy – Project Inform
Courtney Mulhern-Pearson, Director of State and Local Affairs - San Francisco AIDS
Foundation
• Michaela Hoffman, Mission Neighborhood Health Center
For More Information
Elizabeth (Liz) Brosnan
Executive Director, Christie’s Place
[email protected]
(619) 702-4186 x210
www.christiesplace.org
Chair, National Women & AIDS Collective
www.nwac-us.org - Stay tuned for TA Webinars!
“It’s what you learn after you know it all that counts
the most.” – John Wooden