Transcript Leadership Briefing Outline - Texas Primary Care and Health Home

Community Health Workers (CHWs) as
Members of Interdisciplinary Health Teams:
Practical and Financial Considerations
Rosalia Guerrero-Luera, Program Manager
Carisa Magee, Special Advisor
Texas Public Health Training Center
Community Health Worker Training Program
University of Texas School of Public Health
Medicaid/CHIP Division, Health
and Human Services Commission
Beatrice Smith, Program Coordinator
CHW Training and Certification Program
Texas Department of State Health Services
Houston, Texas
June 9, 2016
Learning Objectives
At the end of the session, participants will be able to:
• Describe the framework for certification of community
health workers (CHWs) in Texas
• Discuss current challenges related to sustainable
financing of CHW services
• Discuss the practical and financial considerations in
integrating certified CHWs as members of
interdisciplinary health care teams
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Promotor(a)/Community Health Worker (CHW)
Certification in Texas
- Texas Primary Care and Home Health Summit Beatrice Smith
CHW Training and Certification Program Coordinator
Texas Department of State Health Services
Background/
Governing Authority
• Texas was the first state to pass legislation
creating a statewide training and certification
program for CHWs. Implemented in 2001.
• Governed by Ch. 48, Health and Safety
Code; Ch. 146, Tex. Admin Code
• Department of State Health Services – Office
of Title V and Family Health
http://www.dshs.state.tx.us/mch/chw.shtm
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Description
Promotores or community health
workers:
• Serve as liaisons and are trusted members
of the community
• Have a close understanding of the ethnicity,
language, socio-economic status, and life
experiences of the community served
• Assist people gain access to needed
services
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Activities
They perform many vital functions:
• Outreach
• Patient navigation and follow-up
• Community health education and
information
• Informal counseling, social support,
advocacy
• Participation in clinical research
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Certification
CHW Training and Certification Program
• Promotores or community health workers
who receive compensation for services
provided must be certified.
• Certification Types:
o Promotores or Community Health Workers
o Instructors
o Training Programs
http://www.dshs.state.tx.us/mch/chw.shtm
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Certification cont.
• Competency based (communication, interpersonal,
capacity building, service coordination, advocacy,
teaching, organization, knowledge base on specific
health issues)
• Completion of an approved 160-hour competencybased training program certified by DSHS
OR
• Experience – At least 1000 cumulative hours of
community health work services within the most
recent six years
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Training and Education
• Standardized framework
• Eight core competencies
o
o
o
o
o
o
o
o
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Communication
Interpersonal
Service Coordination
Capacity building
Advocacy
Teaching
Organizational skills
Knowledge base (specific health issues)
Training and Education
Sources
• Community Colleges
• Health Science Centers
• Community Health Worker Association
• Area Health Education Centers (AHECs)
• Community-based organizations
• Federally Qualified Health Centers
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Leadership
• Advisory Committee
o CHWs serve as Presiding and Assistant
Presiding Officers
o CHWs comprise two-thirds of total membership
(6 of 9 members)
• 10 CHW networks and associations
(http://www.dshs.state.tx.us/mch/chw.shtm)
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Leadership cont.
• Membership in CHW networks and
associations located in Texas range from
25 to over 500.
• Locations
•
•
•
•
Panhandle
Dallas/Fort Worth
Northeast Texas – Tyler
East Texas – Gulf Coast
Region
• Central Texas – Austin
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• South Texas (Health Service
Region 11 and Maverick
County, Brownsville and San
Antonio)
• West Texas – El Paso
Growth in Texas
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CHWs in Texas
Total: 138 Counties & 3,628 Certified CHWs
Source: Office of Title V and Family Health, 12/31/2015
Mapped by Office of Program Decision Support
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Challenges and
Considerations
• Integration as professionals in mainstream health
care and social service systems
• Varying job classifications and pay levels
• Sustainable funding/reimbursement
• Training/professional development
• Recruitment
• Supervision
• Incorporating community health worker
skills/attributes within positions with a more defined
role
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National Activities
• Standard Occupational Classification (SOC)
• 21-1094 Community Health Workers
• http://www.bls.gov/soc/soc_2010_definitions.pdf
• U.S. Department of Labor Office of
Apprenticeship
• CHW added as an “apprenticeable” occupation – July
2010
• National Steering Committee for Promotores
de Salud
• 15-member committee including individuals from Texas
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Looking Ahead
• Continued collaboration/sharing
• Share successes and lessons learned with
other states
• Continue to explore reimbursement
mechanisms for CHW services
• Additional awareness for supervisors and
employers
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Potential CHW Roles
• 1115 (transformation waiver) projects
• Expanded primary health care contractors
• Health plans
• Medicaid outreach/informing
• Affordable Care Act – navigators, certified
application counselors
• Other
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CHW Contact Information
Family and Community Health Services Division
Promotor(a)/CHW Training and Certification
Program
Moreton Bldg.
1100 West 49th Street
(512) 776-6663; (512) 776-2208; or (512) 776-3860
[email protected]
http://www.dshs.state.tx.us/mch/chw.shtm
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Questions?
Community Health Worker
Services in Medicaid
Carisa Magee
Special Advisor, Medicaid/CHIP Division
Texas Health and Human Services Commission
Sources of CHW Funding
for Medicaid Clients
• Medicaid fee-for-service (FFS)
• Medicaid managed care
• Pilot and State Innovation Model (SIM)
funds
• Medicaid 1115 demonstration waiver
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Texas Medicaid Enrollment
• The majority of Texas Medicaid services are
delivered in managed care
• Enrollment statistics as of June 2015:
o 4,030,139 clients in Medicaid
o 3,531,587 members in managed care
o 498,552 in Medicaid fee-for-service
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Medicaid CHW
payment challenges
• Federal and state laws and regulations govern the
services for which Medicaid can pay
• Medicaid State Plan is the contract between the federal
Centers for Medicare & Medicaid Services (CMS) and a
state Medicaid program
• Under the state plan, a Medicaid program receives federal
matching funds for strictly defined categories of services
• No state has successfully amended the Medicaid state
plan under a 2013 regulatory change deemed promising to
open the Medicaid preventive services category to
payment for CHWs [42 CFR 440.130(c)]
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Fee-for-service example:
Minnesota Medicaid
• Diagnosis-related patient education
• Services provided under medical supervision
and billed by supervisor
• Approved Medicaid state plan
• As of July 2015, less than 100 claims annually
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Medicaid Managed
Care Delivery Model
• 19 Medicaid managed care organizations (MCOs)
• Goal to deliver quality, cost-effective care through
medical home
• State pays MCOs a capitated rate for each member
enrolled, rather than paying for each unit of service
• MCOs must offer services required by Texas Medicaid
• MCOs may offer value-added services (e.g., sports/
community membership, pest control, respite care, etc.)
• Certain MCO costs must be classified as administrative
due to federal requirements – includes CHW services
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February 2016 Texas Medicaid
MCO Survey: Use of CHWs
• 5 MCOs are aware of physician
practices in their networks using CHWs
• 15 MCOs use CHWs directly:
o 1 contracts with a CHW network but
does not directly employ CHWs
o 14 directly employ CHWs (3 among
these also contract for CHW services)
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CHW Services Delivered by
Texas Medicaid MCOs
Service
Health education/promotion
Information and referral
System navigation/service access
Ask members about their health and needs
Individual and community advocacy
Informal counseling and social support
Cultural liaison/mediation
Ask about medication and other treatments
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MCO Count
15
14
12
11
10
9
7
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Grant-funding example:
South Carolina Medicaid
• CHWs part of care team improving patient
compliance with screenings, office visits, and
medications
• Nineteen primary care practices participating in a
grant-funded pilot program that bills under physician
education codes already authorized under the
Medicaid state plan
• Billing by the clinical supervisor
• State not successful in implementing a preventive
services state plan amendment with CMS
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Texas Medicaid 1115
Demonstration Waiver
• Federal law allows states to apply to CMS for
permission to deviate from certain Medicaid program
requirements through waivers
• 1115 waivers are designed specifically to test new
service delivery and management models
• Texas currently has approval for an 1115 waiver with
a Delivery System Reform Incentive Payment
(DSRIP) component
• DSRIP is an incentive program to transform delivery
systems through infrastructure development and
testing innovative care models
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Texas Medicaid 1115
Demonstration Waiver
• CHW Delivery System Reform Incentive
Payment (DSRIP) projects include:
o CHW integration in care teams, such as for
behavioral health services
o Patient navigation, particularly to divert
nonemergent ED visits
o Disease-specific prevention and education, such
as for asthma and diabetes
o Compliance with appointments and following care
regimens, such as prenatal care
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Questions?
Integrating CHWs into
Your Health Care Team:
5 Lessons Learned
Rosalia Guerrero-Luera, Program Manager
Texas Public Health Training Center
Community Health Worker Training Program
University of Texas School of Public Health
Background
• University of Texas School of Public Health –
CHW training center
• Partner: UT Physicians
• Project: 1115 Waiver DSRIP project to train
and integrate CHWs in clinical settings
• Types of Clinical Settings: Medical Homes,
Specialty Clinics, Hospital, Behavioral Health,
other DSRIP projects
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Lesson 1 –
Start at the End
• Understand how CHWs will help you meet
organizational goals
Increase patient satisfaction
Reduce no-shows
Patient education
• Your decision to integrate CHWs should be
strategic, not emotional
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Lesson 2 –
CHWs are Unique
•
•
•
•
•
Job description not determined by certification
Flexibility – double-edged sword
Can carry out several roles; not at the same time
CHWs – neither clinical nor clerical
Focused on health literacy and social
determinants, not medical knowledge
• They change the relationship with patient
population and community
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Lesson 3 – CHW is
a Model, Not a Person
• Impacts several aspects of organization
• Communication is key
• Rest of staff needs to understand roles
and competencies of CHW
• CHWs augment and leverage existing staff
activities; does not replace them
• Can be tied to continual quality
improvement activities
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Lesson 4 –
Beyond CEUs
• Continuing education is integral to CHW
work
• Training is source of resources and
referrals
• Leads to specialties
• CHWs learn from other CHWs
• CHWs learn from the community
• CHWs as teachers
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Lesson 5 –
Management Matters
• CHW projects fail due to poor
management
• Can get lost in a team
• Need for one supervisor, mentor, teacher
• Specific work plan and measures
important
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Questions?
Contact
Beatrice Smith, Program Coordinator
CHW Training and Certification Program
Texas Department of State Health Services
E-mail: [email protected]
Phone: 512-776-2208
Carisa Magee, Special Advisor
Medicaid/CHIP Division
Texas Health and Human Services Commission
E-mail: [email protected]
Phone: 512-707-6106
Rosalia Guerrero-Luera, Program Manager
Texas Public Health Training Center
Community Health Worker Training Program University
of Texas School of Public Health
E-mail: [email protected]
Phone: 713-500-9395