Pathways to Collaboration: Integrating Community-Based Organizations and

New Health Home Programs

June 20, 2013

Malinda Ellwood Center for Health Law and Policy Innovation of Harvard Law School

&

Liz Brosnan, Christie’s Place, San Diego CA

Download the slides & materials at www.HIVHealthReform.org

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• Founding partners: AIDS Foundation of Chicago, The Center for Health Law and Policy Innovation of Harvard Law School, Treatment Access Expansion Project, Project Inform

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Opportunities for Integrating CBOs into Patient Centered

Medical Homes and Medicaid Health Homes

(Overview)

June 20, 1013 Malinda Ellwood, JD

Health Law and Policy Clinical Fellow Center for Health Law and Policy Innovation (CHLPI)

of Harvard Law School Treatment Access Expansion Project (TAEP)

Download the slides & materials at www.HIVHealthReform.org

Overview: Patient Centered Medical Homes

(PCMH)

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 – Our focus today: Health Homes

– Other initiatives, e.g. dual-eligible projects and others supported by the Center for Medicare & Medicaid Innovation (CMMI)

Delivery Reform: Need for Coordinated, Whole-Person Care

• Current fee-for-service system leads to fragmentation across many providers

• Tendency not to pay for care coordination and case management services

• Incentive to see many patients = not enough time with each patient individually

• Often insufficient cultural competence and health navigation

• Increasing emphasis on reduced costs (less use of ER services, etc.)

Existing system not ideal for chronic disease management

One solution- Patient-Centered Medical Home (PCMH)

Coordination and integration of whole person care • Physician arranges care with subspecialists and consultants, oversees and

coordinates the team

• Use electronic health records; patient registries; care coordinator services

• Comprehensive care including preventive and end-of-life care

Enhanced access • Flexible scheduling system; easy access to members of the team

Quality and safety

• Decision support based on updated practice guidelines

Payment • Quality-based, shared savings; reimbursement for care coordination;

account for complexity and severity of illness

Taken from “Joint Principles of Patient-Centered Medical Homes, American Academy of Family Physicians; the American

Academy of Pediatrics; the American College of Physicians; and the American Osteopathic Association.

PCMH Certification

• Standards often focus on primary care providers (medical)

• But, standards for accreditation may include services that CBOs can provide

Market CBO skills sets and services as necessary and complimentary 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 PCMH2: Identify and Manage Patient Populations A. Patient Information B. Clinical Data C. Comprehensive Health Assessment D. Use Data for Population Management**

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

PCMH4: Provide Self-Care Support and Community Resources A. Support Self-Care Process** B. Provide Referrals to Community Resources

PCMH5: Track and Coordinate Care A. Test Tracking and Follow-Up B. Referral Tracking and Follow-Up** C. Coordinate with Facilities/Care Transitions 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 ** Must Pass Element

Source: HRSA, Presentation “HRSA’s Quality Initiatives – Many Paths to a Patient Centered Medical Home’ (May 2013)

Ongoing PCMH/Care Coordination Opportunities

• Many different health home initiatives are ongoing

– For example: HRSA initiative targets FQHCs with the goal of helping them to become certified as PCMHs, for more info, visit: http://bphc.hrsa.gov/policiesregulations/policies/pal201101.html

• Medicaid Health Homes

Medicaid Health Homes for

Chronic Disease Management

The Medicaid Health Home Option

• 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

• Development of health homes can help states:

- Improve care for people with chronic conditions - Restrain growth in Medicaid costs

Financial Benefits to States

• 90% federal matching funding for health home services for the first two years

• States are also eligible for up to $500,000 in planning funds to explore the feasibility of creating health homes

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

Each state has the flexibility to decide from among these options (can choose to include all three, and/or set additional certification criteria):

A Designated provider

– May be a physician, clinical/group practice, rural health clinic, community health center, community mental health center, home health agency, pediatrician, OB/GYN, or other provider

A team of health professionals operating w/ a desig. provider

– May include physicians, nurse care coordinators, nutritionists, social workers, behavioral health professionals, or others

– Can be free-standing, virtual, hospital-based, or a community mental health center or another appropriate setting

Health team

– Must include medical specialists, nurses, pharmacists, nutritionists, dieticians, social workers, behavioral health providers, chiropractic, licensed complementary and alternative practitioners

• Any of these designations could include an opportunity for CBOs to subcontract with designated Medicaid Health Homes, even if the CBO is not the actual health home

Who can be designated as a Medicaid health home?

Design of Payment Methods

Payment methodologies:

– Monthly management care fee (most states)

• Can vary based on the severity of a person’s condition or the capabilities of health home provider

– Fee-for-service

– State may propose alternative approach

States’ Movement Toward Medicaid Health Homes

As of 6/17/13, 11 States have had their Health Homes SPAs approved by CMS: • Missouri (2 SPAs approved 10/20/11 and 12/22/11) • Rhode Island (2 SPAs; approved 11/23/2011) • North Carolina (approved 5/24/12) • Iowa (approved 6/8/12) • Ohio (approved 9/17/12) • Idaho (approved 11/21/12) • Maine (approved 1/22/13

States that specifically include HIV: • Oregon (approved 3/13/12) • New York (approved 2/3/12) • Wisconsin (approved 1/29/13) • Alabama (approved 4/9/13)

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 non-medical supports and services (e.g. referral to public benefits, housing, transportation)

Opportunities for CBOs

Integrating CBOs into Medicaid Health Homes

• Medicaid Health Homes emphasize connection to community, and whole-person needs (including social supports)

– Also need to make use of existing care coordination infrastructure (e.g. Wisconsin SPA refers specifically to ASOs)

• CBOs can become an MHH, or 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.

Ongoing Challenges

• Emphasis tends to be on clinical/primary care sites rather than CBOs. Requirement is only to refer to non-medical support services.

• No requirement that PCMHs or Medicaid Health Homes contract with CBOs (but, you can advocate that your state incorporate these)

• Reimbursement levels are not high = less motivation/ability to subcontract

• States may have Health Information Technology (HIT) requirements that can be expensive for CBOs

Next Steps for CBOs

• If not already doing so, reach out to medical clinics (FQHCs, etc.) and begin to build relationships – Demonstrate/communicate your expertise in reaching and assisting

hard to reach clients with complex care needs

– Use PCMH/MHH language to describe your services

• Quantitative + Qualitative Data Collection: identify health outcome criteria and track them – and cost reductions if possible – for all clients – Use data to argue for cost-effectiveness and inclusion in health

homes and other coordinated care opportunities

Be on the Lookout for Other Care Coordination Opportunities

• ACA coordinated care opportunities:

– E.g. dual eligibles projects through the Centers for Medicare & Medicaid Innovation (CMMI); Accountable Care Organizations (ACOs); Managed Care Organizations (MCOs)

– These could represent additional opportunities for CBOs to form partnerships

Resources on PCMHs and Medicaid Health Homes

Patient Centered Medical Homes: – NCQA PCMH certification programs: http://is.gd/YNn7XH –Agency For Healthcare Quality and Research (AHRQ), PCMH Research Center: http://is.gd/Uruphe

Medicaid Health Homes

Resources from the Centers for Medicare and Medicaid Services (CMS):

– Overview: http://is.gd/FHIUtu

– Medicaid Health Home Information Resource Center: http://is.gd/13je87

Resources on Medicaid Health Homes from Families USA:

– Medicaid Health Homes: Challenges and Opportunities for Advocates: http://is.gd/Wgangi

– Medicaid Health Homes: Designing Consumer Friendly Health Homes: http://is.gd/8fKwLn

– Medicaid Health Homes: Holding Health Homes Accountable: Quality & Payment Measures http://is.gd/y5fPGD

Health Homes/Delivery System Reform:

– Families USA, Health system reform generally: http://www.familiesusa.org/health-system-reform/

– National Academy for State Health Policy (NASHP), Medical Home Resource Center: http://is.gd/E7WHrR

– Center for Medicare and Medicaid Innovation (CMMI): http://innovation.cms.gov/

– CARE Act Target Center – medical home resource center https://careacttarget.org/mhrc

Health Reform and HIV: HIVHealthReform.org: http://www.hivhealthreform.org/

Treatment Access Expansion Project (TAEP): www.taepusa.org

Be on the Look-Out for Other Care Coordination Opportunities

Malinda Ellwood, JD

Health Law and Policy Clinical Fellow

mellwood@law.harvard.edu

Remaining Relevant in the New Reality

A Case Example of CBOs Pioneering Partnerships With

Patient-Centered Medical Homes

June 20, 2013

Download the slides & materials at www.HIVHealthReform.org

Who We Are

Christie’s Place is a leading 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

Family Case Work Peer/Patient Navigation

Mental Health Services (groups, individual, couples & family counseling)

Drug & Alcohol Outpatient Counseling HIV Counseling & Testing (Expanded HIV Testing in Healthcare Settings & Early Test)

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 -USA Ally

32

Darwinism

If you don’t evolve, you become extinct.

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) responsiveness

– Need for for health systems navigation

– Need to integrate whole person care

– Need for better care coordination

• Reform = Opportunities

CBOs & the Affordable Care Act

Navigating the New Reality

• National HIV/AIDS Strategy (NHAS) • Goals:

• Reduce HIV incidence

• Increase access to care for people living with HIV and optimize health outcomes

• Reduce HIV-related disparities

• Affordable Care Act • Investments in community health centers

• Insurance reforms

• Medicaid expansion

• Medical homes (NCQA 2011 PCMH Standards)

• Patient navigation & care coordination

• Future of Ryan White

Understanding the Landscape

• Must know the “speak” – learn the language • Coordinated Care methodology

• Medical homes

• 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

Strategic Options in ACA

Our Response: Strategic Alliances

• Why choose this option? ACA, funding, positioning in community, diversification of services

• 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 • 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

Download a printer-friendly one-pager listing these steps from HIVHealthReform.org

Outcome

Access to Care & Retention in Care Initiatives

Case Example: CHANGE for Women

• Innovative, responsive & relevant approach

• Addresses 2nd & 3rd goals of NHAS & positions for ACA

• 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)

Strengthening Medical Homes

• Patient/consumer education - 4 E’s: education, eligibility, enrollment, engagement – Navigation and support around understanding and enrolling in

Medicaid expansion and marketplace insurance opportunities

• Expanded linkages to community/social supports

• Co-location of services and integration with provider teams = enhanced culturally appropriate & person-centered care; comprehensive care management; care coordination

• Patient & family support; provision of social service support (i.e. transportation, food , childcare)

• Created and expanded Peer Navigator model at clinical partner sites and through a mobile, home-based approach

• Medical Home via My Chart – Increase self-efficacy by training HIV+ women to access and utilize their

electronic medical records

– Increase communication with healthcare providers

• Center of Excellence in Women’s HIV Care & Research – UCSD Owen/Fem-Owen Clinic Medical Home

– Enhanced coordination of medical and behavioral healthcare (integrated model)

• “I Am More Than My Status” social marketing campaign

Strengthening Medical Homes (continued)

Impact - Measuring Outcomes

• The “partnership” - tactics are strengthening medical home model and improving coordinated care • Peer Navigation model has brought 212 out-of-care and sub-optimally

engaged in care HIV+ women back into care

• 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

• Expansion of Fem-Owen Clinic/development of Center of Excellence

• 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%

Next Steps

• Working with State partners on how to certify/credential Peer Navigation

—can this become a reimbursed service?

• Electronic Health Record technology

• Public and commercial third party insurance reimbursement for behavioral health services

• Becoming providers on the Health Exchange/Marketplace plans

• Reimbursement through sub-recipient agreements

Lessons Learned

• Relevance, positioning, sustainability

• 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

• Know the data, the drivers and the deliverables required

• Be willing to take smart, calculated risks

• Must constantly evolve the way you do business – “evolve or become extinct”

• Power of advocacy and policy

Acknowledgements

• AIDS United

• MAC AIDS Fund

• Johnson & Johnson

• Alliance Healthcare Foundation

• Macy’s Foundation & Passport Fund

• Janssen Therapeutics LINCC Initiative

• Kaiser Permanente Foundation Hospitals, Southern CA Region

• Qualcomm Foundation

• San Diego HIV Funding Collaborative

• The California Wellness Foundation

• UCLA/Johnson & Johnson Health Care Executive Program

Strengthening the Health and Resilience of Women and Families Impacted by HIV/AIDS

49

For More Information

Elizabeth (Liz) Brosnan Executive Director, Christie’s Place

brosnan@christiesplace.org (619) 702-4186 x210 www.christiesplace.org

Chair, National Women & AIDS Collective www.nwac-us.org - Upcoming TA Webinars!!

“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, National Center for Responsive Philanthropy

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