The Next Generation of Health Care Service Delivery: Strategic Alliances

1. Elizabeth BrosnanExecutive Director, Christie’s PlaceChair, National Women and AIDS CollectiveOctober 20, 2013 The Next Generation of Health Care Service Delivery: Strategic Alliances

2. 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.

3. 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 • 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 *All services are bilingual English/Spanish.

5. Engagement in Care Cascade

6. 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

7. Getting to know you

8. Which best describes where you work? • Clinic • Community-based organization • Health department • University • Hospital • Other

9. Which best describes what you do? • Primary care provider (MD, PA, NP, nurse, dentist, etc.) • Behavioral health care provider • Administrator • Researcher • Consumer representative • Other

10. I feel I can explain ACA to my colleagues. • Yes---100% • Yes---75% • Yes---50/50 • A little bit • No

11. I feel I can explain Patient Centered Medical Homes and Medicaid Health Homes to my colleagues. • Yes---100% • Yes---75% • Yes---50/50 • A little bit • No

12. Review: What does the ACA do? • 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) • 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)

13. Affordable Care Act: Navigating the New Reality

14. 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

15. 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

16. 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

17. 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

18. Considerations for Advocacy & Systems and Program Development

19. “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

20. 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

21. 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

22. 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?

23. 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

24. 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

25. 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?

26. 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

27. 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

28. 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

29. Preparing Staff for ACA • Open and frequent communication and training about ACA • Integrating case managers into enrollment re-certification process for ADAP/RW • Training extended team in enrollment process and eligibility requirements for insurance products • Simple, straightforward tools to use with patients

30. 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

31. 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?

32. PATIENT CENTERED MEDICAL HOMES (PCMH)

33. 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

34. Example: 2011 National Committee for Quality Assurance (NCQA) PCMH Certification PCMH1: Enhance Access and Continuity • Access During Office Hours** • After-Hours Access • Electronic Access • Continuity • Medical Home Responsibilities • Culturally and Linguistically Appropriate Services • Practice Team PCMH2: Identify and Manage Patient Populations • Patient Information • Clinical Data • Comprehensive Health Assessment • Use Data for Population Management** PCMH3: Plan and Manage Care • Implement Evidence-Based Guidelines • Identify High-Risk Patients • Care Management** • Manage Medications • Use Electronic Prescribing PCMH4: Provide Self-Care Support and Community Resources • Support Self-Care Process** • Provide Referrals to Community Resources PCMH5: Track and Coordinate Care • Test Tracking and Follow-Up • Referral Tracking and Follow-Up** • Coordinate with Facilities/Care Transitions PCMH6: Measure and Improve Performance • Measure Performance • Measure Patient/Family Experience • Implement Continuously Quality Improvement** • Demonstrate Continuous Quality Improvement • Report Performance • Report Data Externally ** Must Pass Element Source: HRSA, Presentation “HRSA’s Quality Initiatives – Many Paths to a Patient Centered Medical Home’ (May 2013)

35. 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

36. 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

37. 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

38. 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)

39. 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.

40. A CASE EXAMPLE OF A CBO’S PIONEERING PARTNERSHIPS

41. 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

42. 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

43. 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?

44. 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

45. Steps to the Goal Identify & Screen Against Fit Select Fit Shared Future State Operating Arrangement Finalize Agreement Set Shared Performance Targets, Goals Monitor Progress Identify internal stakeholders Identify and convene the project team biweekly Conduct client (customer) benchmarking Determine which clinical partners Stakeholders have initial meeting with identified partners Agree on partnership benefits Assess joint programming opportunities Identify funding sources for joint programming Determine joint programming scope Develop MOA or contract to formalize partnership Agreement execution Implementation plan Secure funding sources for joint programming Formative phase Cultural integration of program staff Implementation Monitoring Evaluation

46. Outcome

47. 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)

48. 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)

49. 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

50. 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