Local Initiatives to Integrate the Health Care Safety Net: Laying the Foundation for Health Care...
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Transcript of Local Initiatives to Integrate the Health Care Safety Net: Laying the Foundation for Health Care...
Local Initiatives to Integrate the Health Care Safety Net:Laying the Foundation for Health Care Reform
Annette Gardner, PhD, MPH
Study Director
Philip R. Lee Institute for Health Policy Studies
University of California, San Francisco
September 27, 2012
UC
SF University of California San Francisco
“Integration” Defined
Systems approach to the provision of “Comprehensive, coordinated, culturally competent consumer-centered care” Two or more entities establish linkages for the
purpose of improving outcomes Reduce fragmentation and duplication of services and
consequently costs
The Road to Coordinated Care
Integration Under Health Care Form
Affordable Care Act provisions to promote integration: ACOs – Medicaid (S 3022) and Pediatric ACO project for Medicaid or CHIP (S
2706) PCMH - Medicaid health homes (S 2703) Community-based collaborative care network project (S 10333) Bundled payments demonstration projects (S 2704) Global payments demonstration projects (S 2705) Basic health option (S 1331) CMS Innovation Center (S 3012)
Issues: Decreased access to care comprises care coordination Fragmented funding impedes sharing with other safety net
providers ACOs are not mandated No “one size fits all” approach – requires flexible strategies
Source: Ku et al., “Promoting the Integration and Coordination of Safety-Net Health Care Providers Under Health Reform: Key Issues” Commonwealth Fund, October 2011
UCSF Safety Net Integration Study Objectives
Describe safety net integration efforts in 5 diverse California counties where there is evidence of safety net integration;
Identify factors that affect local safety nets’ ability to develop integrated delivery systems;
Develop lessons learned or “best practices” that can be applied elsewhere; and
Develop recommendations for facilitating safety net integration.
UCSF Study Methods Interviews with 4-5 informants representing key
safety net stakeholders in each county Areas of investigation:
Level of integration activity Contextual factors important to planning and
implementation of integration initiatives Resources IT systems Safety net integration best practices
California Counties – Health Stewards, Health Innovators
Five Study CountiesSafety Net
SystemMedi-Cal Model and Study Plan
Study Safety Net Hospital
Study Non-County Clinic, Consortium
HCCI Legacy
County?
Contra Costa
Public/private 2-Plan (Contra Costa Health Plan)
Contra Costa Regional Medical Center
La Clinica de La Raza; Community Clinic Consortium
Yes
Humboldt (CMSP)
Private FFS St. Joseph Health System
OpenDoor CHCs, North Coast Clinics Network
No
San Diego Private GMC UC San Diego Medical Center
La Maestra CHCs; Council of Community Clinics
Yes
San Joaquin
Public/private 2-Plan (Health Plan of San Joaquin)
San Joaquin General Hospital
Community Medical Centers, Inc.
No
San Mateo Public COHS (Health Plan of San Mateo)
San Mateo Medical Center
Ravenswood Family Health Center
Yes
Health Care Safety Net Gaps
Populations
Undocumented uninsured;
Homeless;
Some sub-populations, e.g., Pacific Islanders;
Seniors.
Diseases, Conditions
Mental health, substance abuse;
Chronic diseases;
Obesity.
Services
Primary Care;
Mental Health;
Specialty Care;
Dental health;
Access issues, e.g., same day appointments.
Skill Gaps
Some provider types, e.g., primary care and orthopedics;
HIT, e.g., roll-out;
Connecting services, HIT systems
Findings:Level of Integration by County
Contra Costa
Humboldt San Diego San Joaquin
San Mateo
7.7(ranges from
6 to 9.5)
6.7(ranges from
5 to 9)
6.3(ranges from
5 to 8)
7.2(ranges from
6.5 to 8)
7.5 (ranges from
7 to 8)
“county-run; shared funding of positions”
“no shared funding; regular meetings, project-specific funding.
“project by project”
“Among county entities – 9; with outside entities – 6 to 7”
“depends on the area; separate budgets but will contribute to a joint project”
“Please rate the level of collaboration or integration that has been achieved by the organizations that work on initiatives to integrate the safety net on a scale of 1 – 10 where 1=information sharing and communication; 3=cooperation and coordination, e.g., do joint planning; 6=collaboration, e.g., sharing of funding/services; 8=consolidation, e.g., regular meetings of key players, cross-training of staff; 10=integration, e.g., shared funding of positions, joint budget development”
Findings – Activities Underway (Y) and Proposed, by County (N=28 activities)
Contra Costa
(25)
Humboldt (26)
San Diego (28)
San Joaquin
(25)
San Mateo (26)
System-level Activities
Participation in an ACO P P Y (ACC)
P Y (DSRIP)
Adoption of an integrated network of safety net providers (coordinate care across levels of care)
Y Y Y Y Y
Provider-level Activities
Adoption of panel management Y Y Y Y Y
Onsite mental health care at PC sites Y Y Y Y Y
Onsite dental health at PC sites Y Y Y Y Y
Expanded communications between primary care and specialty care
Y Y Y Y Y
Expanding provider scope of service Y Y Y Y Y
County contracts with comm. clinics Y Y Y Y Y
Adoption of PCMH Y Y Y Y Y
Addition of new health care services Y Y Y Y Y
Auto enrollment of Medi-Cal patients Y P Y Y Y
ER Diversion Programs Y Y Y Y Y
Activities Underway, Proposed, by County (cont.)Contra Costa
Humboldt San Diego San Joaquin
San Mateo
Health Information Technology
Electronic eligibility and enrollment Y Y Y Y Y
Electronic prescribing Y Y Y Y Y
Electronic health information system (EMR) Y Y Y Y Y
Electronic Disease Registry Y Y Y Y Y
Electronic specialty care referral Y Y Y P Y
Electronic panel management system Y Y Y Y Y
Health Information Exchange P Y Y Y P
Patient-level Activities
After hours and/or same day scheduling Y Y Y Y Y
24/7 nurse advice line Y Y Y Y Y
E-Portals for patients to interact with systems
P Y Y P P
Case management services Y Y Y Y Y
Certified Application Assistors Y Y Y Y Y
Community Health Workers Y Y Y Y Y
Patient Navigators Y Y Y Y Y
Accessible telephone system Y Y Y Y Y
Language access Y Y Y Y Y
Interprofessional Collaboration
Findings - Integration Activities “Underway” by Stakeholder
County Health Agency
Safety Net Hospital
Medi-Cal Plan
Non-County Clinic
Clinic Consor-
tium
0
5
10
15
20
25
30
Contra Costa
Humboldt
San Diego
San Joaquin
San Mateo
# I
nte
gra
tion A
ctiv
itie
s
“Proposed” Integration Activities by Stakeholder
County Health Agency
Safety Net Hospital
Medi-Cal Plan
Non-County Clinic
Clinic Consor-
tium
0
2
4
6
8
10
12
14
Contra Costa
Humboldt
San Diego
San Joaquin
San Mateo
# I
nte
gra
tion
Acti
vit
ies
Patient-Centered Care
Areas of High Involvement by Most Stakeholders
Provider-level Integration Adoption of Panel Management, e.g., Teamlet Mental Health/Primary Care Integration Expanded Communications Between Primary Care and Specialty
Care Electronic Disease Registries
Patient-level Integration: After Hours/Same Day Scheduling Case Management Services Certified Application Assistors Community Health Workers Accessible Telephone Systems; and Language Access
Adopting, Leveraging Information Technology
IT – Progress to-date
All are implementing IT applications on multiple fronts
All counties have One-e-App or something like it and are exploring options to facilitate continuous coverage
Some counties have centralized electronic systems for archiving health information while other counties have it for the hospital/clinic/plan
Connectivity issues remain
Facilitating Factors, Challenges
• Similar facilitating factors among counties: Strong commitment at the top Long-standing, shared responsibility for the uninsured Good partnerships, communications Presence of a safety net collaborative, Medi-Cal health
plan, clinic consortium• Similar barriers that impede integration….resource
constraints: Inadequate Medi-Cal reimbursement State and county cuts Provider capacity and workforce shortages
Challenges – Vary by County
Presence of a Medi-Cal health plan Geographic barriers Market share competition among providers County financial situation
Resources - Funding
Piece-meal: mix of public (federal, state, GFS) and private funding that varies by stakeholder, e.g., Specialty Care Access Initiative 10 HCCI Counties
Some differences in strategy to secure funding: “no stone left unturned” vs. aligning resources with organizational goals
Current opportunities: Section 1115 Medi-Cal Waiver (LIHP, DSRIP) ACA, e.g., ACOs, Health Benefit Exchange ARRA Medicare/Medicaid EHR Incentive
Payments
Capacity Assessment by County
Contra Costa Humboldt San Diego San Joaquin San Mateo
Agree to Strongly Agree
Agree to Strongly Agree
Strongly Disagree to Strongly Agree
Disagree to Agree
Agree to Strongly Agree
“Gearing up for this and are well positioned”
“Already doing it” and “Have the organizations, communication, networking capacity”
“Increase in uninsured.” And “There is high commitment and resources”
“Pitting health care against other county issues” and “Uneven provider capacity”
“Already doing it” and “Have the will and the ingredients”
“The county has the organizations and resources to coordinate health care services to meet the needs of the newly insured as well as remaining uninsured, e.g., undocumented immigrants.”
Summary of Study Findings
High county integration activity underway overall; varied stakeholder involvement.
Areas of future involvement—ACOs, HIEs, ePortals—as well as individual stakeholder initiatives.
Study counties have the systems, partnerships, “nimble” organization, and shared commitment but they’re challenged by significant financial barriers and gaps in health care.
IT – tremendous activity underway on all fronts – connectivity issues to be addressed.
Capacity assessment bodes well for implementation of health care reform but there is still work to be done and challenges on the horizon.
Models of Integrated Care
30+ Safety Net Integration Best Practices
HCCI/LIHP
Adoption of PCMH
Disease Management
MH/PC Integration
Colocation of behavioral health services in Family Practice Clinic
Clinic MH/PC initiatives
HIT
Telemedicine to expand access to specialty care
HIE adoption
Clinic access to Lifetime Medical Record
Specialty Care Access
Access to hospital specialty care
Provider peer groups
Patient Coordination, Outreach and
Enrollment
Coordinate care for the uninsured
Clinic/hospital patient transition
Patient navigation
Facilitating factors:New models of leadershipBuy-in at all levelsPerseverance in the face of delays
Safety Net Integration Best Practices - Challenges
HCCI/LIHP
Requires advance preparation.
Inclusion of all stakeholders.
MH/PC Integration
Resource intensive – staffing, expertise.
Finding middle ground.
HIT
Difficult.
Costly.
Potential failure at many points.
Specialty Care Access
Slow, time consuming.
Provider recruitment issues.
Patient Coordination, Outreach and
Enrollment
Lack of resources to support services.
Recommendations
Targeted support for local safety net integration activities Proposed activities, e.g., safety net ACOs IT infrastructure development Support for local infrastructure, e.g., safety net coalitions,
joint leadership models Informing state policy
Tailoring of strategies to meet individual county needs Increased alignment of state and county responsibility, e.g.,
Section 17000 obligations New payment models should be considered, e.g., bundled
payments, to address resource gaps Leverage ACA provisions that support integration, e.g.,
Health Benefit Exchange
Thank you!
For more information:
Annette L. Gardner, PhD, MPH
Philip R. Lee Institute for Health Policy Studies, UCSF
(415) 514-1543
[email protected]://healthpolicy.ucsf.edu/article/healthcare_safety_net