Elizabeth BrosnanExecutive Director, Christie’s Place

Chair, National Women and AIDS CollectiveOctober 20, 2013

The Next Generation of Health Care Service

Delivery: Strategic Alliances

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

TransformationsThe 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. Clinicb. Community-based organizationc. Health departmentd. Universitye. Hospitalf. Other

Which best describes what you do?

a. Primary care provider (MD, PA, NP, nurse, dentist, etc.)

b. Behavioral health care providerc. Administratord. Researchere. Consumer representativef. Other

I feel I can explain ACA to my colleagues.

a. Yes---100% b. Yes---75%c. Yes---50/50d. A little bite. No

I feel I can explain Patient Centered Medical Homes and Medicaid Health Homes to my

colleagues.

a. Yes---100% b. Yes---75%c. Yes---50/50d. A little bite. No

Review: What does the ACA do? 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

• 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 We Learned

• 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

Lessons Learned Cont.

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

• 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

Lessons Learned: Advocacy

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 SurviveConsider:•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 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

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)

• 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

PCMH Certification

PCMH1: Enhance Access and ContinuityA. Access During Office Hours**B. After-Hours AccessC. Electronic AccessD. ContinuityE. Medical Home ResponsibilitiesF. Culturally and Linguistically Appropriate

ServicesG. Practice Team

PCMH2: Identify and Manage Patient Populations

A. Patient InformationB. Clinical DataC. Comprehensive Health AssessmentD. Use Data for Population Management**

PCMH3: Plan and Manage CareA. Implement Evidence-Based GuidelinesB. Identify High-Risk PatientsC. Care Management**D. Manage MedicationsE. Use Electronic Prescribing

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

PCMH5: Track and Coordinate CareA.Test Tracking and Follow-UpB.Referral Tracking and Follow-Up**C.Coordinate with Facilities/Care Transitions

PCMH6: Measure and Improve PerformanceA.Measure Performance B.Measure Patient/Family ExperienceC.Implement Continuously Quality Improvement**D.Demonstrate Continuous Quality ImprovementE.Report PerformanceF.Report Data Externally

** Must Pass Element

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

Example: 2011 National Committee for Quality Assurance (NCQA) PCMH Certification

• 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

The Medicaid Health Home Option for Chronic Disease Management

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

Which Medicaid Beneficiaries Are Eligible for Medicaid Health Home Services?

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

What services are included in the Medicaid Health Home Option?

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)

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

• 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

Understanding the Landscape

• 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?

CBO Provider Considerations -Readiness Planning

• 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

Christie’s Place Response: Strategic Alliances

1. Identify internal stakeholders2. Identify and convene the project team biweekly3. Conduct client (customer) benchmarking4. Determine which clinical partners5. Stakeholders have initial meeting with identified partners6. Agree on partnership benefits7. Assess joint programming opportunities8. Identify funding sources for joint programming9. Determine joint programming scope10. Develop MOA or contract to formalize partnership11. Agreement execution12. Implementation plan13. Secure funding sources for joint programming14. Formative phase15. Cultural integration of program staff16. Implementation17. Monitoring18. Evaluation

Steps to the GoalIdentify & Screen

Against Fit

Select Fit

Shared Future State

Operating Arrangement

Finalize Agreement

Set Shared Performance

Targets, Goals

Monitor Progress

Outcome

• 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)

CHANGE for Women

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

• Patient factors (transient, changing providers)

• Shared access between systems

• Organizational culture

• Communication!

*These challenges also reflect the reasons partnerships are needed

Challenges of Linking Medical Care and CBOs*

• The “partnership” - tactics are strengthening medical home model and improving care coordination– Peer Navigation model has brought 240 out-of-care and sub-

optimally 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

Impact - Measuring Outcomes

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%

• 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

CBO Role in Preparation & Enrollment

• Covered California (State Insurance Marketplace)— Certified Enrollment Entity (CEE)— Certified Enrollment Counselors (CEC)

o Case Managerso 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 patient-

centered medical homes (PCMH)

Enrollment Preparation Cont.

• 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

Next Steps

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-reform-transition-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

• 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

Summary

• 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

Acknowledgements

Elizabeth (Liz) BrosnanExecutive Director, Christie’s Place

brosnan@christiesplace.org(619) 702-4186 x210www.christiesplace.org

Chair, National Women & AIDS Collectivewww.nwac-us.org - Stay tuned for TA Webinars!

For More Information

“It’s what you learn after you know it all that counts the most.” – John Wooden