ecic 2013 a look at chap efforts around the state

ECIC 2013 Article: A Look at CHAP Efforts Around the State

A Look at CHAP Efforts

Around the State

09/30/2013

By Brenda Brissette-Mata

There is a universal truth that children don’t learn as well if they aren’t healthy.

That’s why the Early Childhood Investment Corporation convenes and supports MI-CHAP

(Children’s Health Access Program) in communities across Michigan: Kent, Wayne, Kalamazoo,

Saginaw, Ingham, and Genesee counties and a collective group of counties in Northwest Michigan

(Charlevoix, Emmett, Otsego, and Antrim).

In Michigan, CHAP works exclusively with children on Medicaid and helps them access quality

health care using a more efficient system. In 10 years, from 2001 to 2011, the number of children in

Michigan enrolled in Medicaid grew from 23 percent to nearly 40 percent. And, Medicaid covers

more than half of all births in Michigan.

Working together within the community, MI-CHAP efforts create better outcomes for publicly

insured children at the same or lower costs by switching from disjointed acute/episodic care to

coordinated preventive care through the creation of a medical home.

Having a medical home ensures that a child has a single place for immunizations, well-child visits

and care for acute and chronic illnesses. MI-CHAP supports physicians with coordinated care

delivered in comprehensive and culturally sensitive manners.

And children who use quality coordinated health care through medical homes have fewer

hospitalizations, fewer trips to the emergency room, miss fewer days of school and have less risk of

developing costly chronic diseases.

In June, the Investment Corporation convened the first MI-CHAP Learning Collaborative in Lansing

with 11 Michigan counties represented, including counties interested in CHAP for the future,

counties in the early stages of forming programs and Kent County, where the first CHAP project

began five years ago.

Here’s a look at some of the CHAP efforts in Michigan:


KENT COUNTY: The birthplace of CHAP

CHAP started in Michigan as a broad based community effort with the First Steps Commission of

community, business, and philanthropic leaders in the Grand Rapids area, and the Kent Great Start

Collaborative. Together, they worked with Dr. Tom Peterson to implement the model in August

2008. Priority Health, a locally based health plan and Kent County’s largest Medicaid managed care

provider, also has been involved from the beginning.

One of the keys to CHAP’s early success in Kent County was that Priority Health agreed to pay

participating physicians an enhanced rate in exchange for taking on more Medicaid patients. In

addition, Priority developed a “pay-for-performance” incentive structure to reward CHAP practices

for improving child health outcomes and lowering ER and inpatient rates.

In 2011, an independent review by Durham, N.C.-based SRA International found that through the

reduction in emergency department visits and hospitalizations, and despite increased Medicaid

reimbursements and performance-based incentives to providers, Priority Health already had

recouped its initial financial investment in the CHAP model.

Since then, Kent CHAP has added more pediatric practices and Molina Health Care, the second

largest Medicaid health plan in Kent County, said Maureen Kirkwood, director of health initiatives

for First Steps.

“We also have six practices in various stages of coming on board with CHAP and we’re adding a

piece working with children who are in need of dental services,” Kirkwood said.

The dental care is important because Kent County is one of four counties in Michigan not covered

by Healthy Kids Dental, Michigan’s nationally acclaimed public-private partnership between the

state’s Department of Community Health and Delta Dental of Michigan to improve the

reimbursement rate for participating dentists so that more dentists to see children covered by

Medicaid.

Wayne, Oakland and Macomb are the other three counties.

Kirkwood said in the next six months, CHAP will be transitioning out of First Steps, the early

childhood agency, and that plans are underway to develop a Kent County Community Health Care

hub that will retain CHAP’s focus of a medical home for children, but also have opportunities for

families.

“(With) health care reform and Medicaid expanding to adults in March or April, we decided that it

made sense to be more family centered,” Kirkwood said “We’ve learned just how important it is to

involve primary care providers. The future involves applying what we’ve learned with CHAP and

addressing the needs of family in order to move the needle, to make real change. It’s a natural

expansion of what we’ve been doing with CHAP.”


WAYNE COUNTY

Following the success of Kent county, and with the support of the Early Childhood Investment

Corporation, CHAP took on a slightly different form in Wayne County.

But in Detroit and Wayne County, the problem for young children is a combination of access,

utilization and knowledge about the significance of the medical home. accessing physicians. More

than 90 percent of primary care practices, private and public, accept Medicaid patients, but there

continues to be a deficit of doctors, particularly pediatricians.

In 2010, funding from the Investment Corporation, the Wayne Great Start Collaborative and

significant local in-kind provided the planning phase for CHAP-Wayne, which covers Detroit and

Wayne County. . The Kresge Foundation provided $1 million in funding for two years, allowing the

medical home project to begin in February 2011.

“We really see this as a systems change model that makes a difference for kids and the health and

community organizations that serve them,” said Jametta Lilly, project director for CHAP

Wayne. “(The Kresge) grant was a profound investment because it helped us build the capacity to

do this work in a stressed community with complex, fragmented systems. Kresge’s initial

investment is now supplanted by a $1.5 million three-year grant from the W. K. Kellogg

Foundation. The Foundation support has enabled us to really test and further develop the excellent

framework that Kent has built.”

Lilly said the original focus of the framework was to receive referrals only from pediatricians and to

link those families to the resources they need. But it has grown to include children on Medicaid who

are receiving services from community based organizations and works with several individual

practices, providing care coordination, transportation and specialty services, collaborative learning,

technical assistance and data dashboards.

“Now we’re working with about 10 different clinics. We went from 4 practices in 2011 to 7 practices

in 10 locations by mid-2013 including Michigan’s largest children’s hospital, multiple federally

qualified health clinics, school based health and a private pediatric practice,” she said.

Funding from the Kellogg Foundation allows Wayne CHAP to work with other grantees, such as

the Children’s Center’s Head Start program, where young children could benefit from the services.

“Our dynamic in Detroit-Wayne was different from the beginning because we wanted to increase the

number of children getting in to their pediatrician, particularly for well child visits versus the ER,”

Lilly said.

“Issues and barriers to access here are different. The very size of the community makes it

challenging for the thousands of health providers to know each other and have meaningful

connections to the schools and agencies that also touch the children and families they serve.

Lilly said she and the WCHAP Board and team never miss a chance to advocate for quality and

more pediatricians, family physicians, more and nurse practitioners.


There are challenges in every community, and Lilly said Wayne CHAP has had to adapt and

innovate with every challenge.

“We learned pretty quickly that Detroit and Wayne County providers are extremely stressed,” she

said. “There’s not enough money and too many kids in need.”

The vast majority of Medicaid practices in Detroit-Wayne are not part of the practice transformation

grants such as the MI-PCT, thus are not privy to the significant training and technical assistance

those projects provide. In response, WCHAP created the Innovations and Incentives Program, which

supports practices attending local and state professional development workshops.

Lilly said another innovation created within the CHAP model are “practice liaisons.”

“They are team members who build an on-going relationship with local practices to provide

resources and feedback on the families we serve,” Lilly said. The liaisons visit participating

practices twice a month to collect referrals, share data and take to the practices information about

other resources available for families.

Wayne CHAP has also incorporated FIT Kids 360 (Fitness Initiative Targeting Kids), an evidence-

based healthy lifestyle course that started with Kent CHAP. The program provides nutrition, goal

setting and fitness activities for the entire family. WCHAP is expanding its obesity prevention

programming and now partners with MSU Extension Services to offer their Eating Right is Basic

course.

“Supporting families in their lifestyle change is key, from providing mentors to gas cards as

stipends. Lilly said. “We’re hoping that along with promoting the benefits of a family centered

medical home we can convene Fit Kids and Families Moving Together throughout the community in

2014.”

Acquiring nonprofit status is another key development for Wayne CHAP that Lilly said enables the

project to work on quality improvement across various sectors.

“When Kellogg learned about the work we were doing they approached us, and like Kresge, and

others, they recognized the importance of investing in this medical home implementation model for

Medicaid enrolled children,” Lilly said. “Our work with WKKF and the other grantees is an exciting

platform to both deepen our core mission and expand understanding of what it’s going to take to

truly improve the health of vulnerable communities, thereby improving the vitality of nation.”

“Through our collaboration with Kent and other new partners in MI-CHAP, we’ve learned a great

deal,” Lilly said.

“All of us have the benefit of learning from each other and assuring fidelity to key CHAP elements

while being responsive to our own communities. While WCHAP has a large Medicaid population,

once more CHAPs are implemented throughout the state, the return on investment will be profound .”


KALAMAZOO

Other communities, including Kalamazoo County, working to adapt the CHAP model have

encountered unexpected barriers.

What began as Kalamazoo CHAP was renamed Southwest Michigan Children’s Healthcare Access

Program (SWMI CHAP) shortly before it started in 2012. The name was changed to reflect

providers with patients from both the Battle Creek and Kalamazoo areas, but the program

partnership never really gelled.

Dr. Thomas Akland, champion of the earliest form of CHAP in Kalamazoo, moved to private

practice outside of Kalamazoo County. The Kalamazoo County Mental Health and Substance Abuse

Services (KCMHSAS) absorbed the work and the CHAP model, but with a very specific focus.

Pat Weighman, senior executive officer for KCMHSAS, said there are plenty of pediatric practices

in Kalamazoo, but there remains a need to reach out to young children covered by Medicaid.

“We’re trying to use the CHAP model,” Weighman said. “But with the loss of Dr. Akland, we’ve

lost a little bit of steam. What we’re doing now is focusing on making health care and behavioral

services more accessible to families and we’ve chosen a highly targeted area to start.”

That area is related to infants exposed to certain illicit drugs while in the womb.

“We’re trying to get these children access into medical care,” Weighman said. “We have found, in

our community, no one wants to take these babies and we have about 40 born a year.”

INGHAM

Despite a great deal of momentum in 2011 and 2012, Ingham County had to put the CHAP effort on

hold, according to Debbie Edokpolo, assistant deputy health officer of the Ingham County Health

Department.

Edokpolo said that she strongly believes a medical home would benefit young children in Ingham

County and she hasn’t given up.

"I'm still hopeful that we will one day be able to implement the program, but right now in Ingham

County we are back to the planning stage,” she said. "You really need the right people at the table.

We need to find a champion. In 2012, we had identified a medical director to lead, but that person

left. Then the former assistant deputy health officer, who was instrumental in working to bring a

CHAP to Ingham County, left and moved to another position.

“We think CHAP is great. We really want it, but currently there is no funding. We continue to look

for opportunities that might help us regain the momentum around a Ingham CHAP.”


MACOMB

Sue Gough, executive director of Macomb CHAP, believes there are three important pieces that need

to be in place for successful implementation: a champion pediatrician, community support, and great

partnerships.

With $125,000 in seed money provided by the Macomb Great Start Collaborative and Macomb

HealthPlan, Macomb CHAP was able to complete the readiness assessment in August.

Data collection in the fall of 2012 by the Human Service Coordinating Body revealed statistics that

determined a CHAP program could provide profound impact on young children in Macomb.

“We found that Macomb had definite declining health outcomes of children in our community, in

particular related to quality of life indicators,” Gough said, noting in particular a four-fold increase

in food assistance, doubling of the poverty rate, and increasing homelessness among school-age

children.

Gough said she approached Dr. Charles Barone, director of pediatrics for Henry Ford Health

Systems to discuss a choice for a pediatrician to help champion the CHAP effort. Barone put her in

contact with Dr. Bridget McArdle of Sterling Heights.

“It’s been a terrific partnership,” Gough said. “Her practice is dedicated to better health outcomes for

kids, and her office became one of the first of our participating practices.”

“We’re targeting communities based on statistics that tell us Macomb has a large number of children

on Medicaid, a lack of pediatric providers and a lack of pediatricians in general that accept

Medicaid,” Gough said.

Gough also acknowledged a growing list of collaborating community partners, including

Community Mental Health, the Macomb Great Start Collaborative and Children’s Toothfairy

Foundation, which provides dental funding to uninsured children in Southeastern Michigan with a

focus on Wayne, Oakland, Macomb and Washtenaw Counties.

“You really need community support and we’ve been overwhelmed by the support here,” Gough

said. “And it’s important to work outside the box.”

Outside the box in Macomb means creating a neighborhood health hub through a partnership with

VanDyke Schools in Warren where Superintendent Joe Pius has offered free use of an empty school

building. Rev. Roger Facione of Warren’s Mt. Calvary Lutheran Church also opened his church and

is reaching out to the faith-based community to promote the project.

“We already have five pediatric practices that stand ready to come with us, from single practitioners

all the way up to the Henry Ford Practice with seven pediatricians. We have three health plans ready

to participate, United Healthcare Community Plan, Meridian Health Plan and Midwest Health Plan,”


Gough said, adding that the plan is to go slow. “We want to build the infrastructure as much as

possible. Try not to bring on staff too quickly. The priority right now is to get sustaining funding.”

That’s why Gough is spending much of her time writing grant proposals.

“I can’t say it enough, community investments are out there, communities just have to keep looking

for the champions,” she said. “It is so gratifying to see the community so excited about our efforts.

You have to engage other people. I can honestly say I never would have guessed at the beginning

that we would have a school district so excited about this work, but we do, and it makes a world of

difference.”

SAGINAW

Much like Ingham County, Saginaw’s lack of a champion has meant the delay of a full

implementation of CHAP.

“What we’ve been working on is centralized home visiting,” said Linda Tilot, director of care

management and quality systems at Saginaw County Community Mental Health Authority. “We’ve

put our heart and soul into creating a hub for early home visiting.”

Using five or six different models, including Nurse Family Partnership, Maternal Infant Health,

Early Head Start, Head Start and Healthy Start, the hub would create a central intake and patient

registry that would allow for seamless transition between programs.

“While it’s not exactly medical home like CHAP, we’re hoping to establish outcomes like a

reduction of infant mortality and increased kindergarten readiness through focus and efficient

placement of resource,” Tilot said.

“I think we’d love to have CHAP, and at some point I think we’d look at lining up the models and

see if we can’t find a way to make everything fit together.”

Kent County’s Kirkwood called this an historic time in the medical field.

“I can’t think of another time in our country, other than when Medicare came into being in the 60s,

when we were in the midst of such a big social change,” she said.

To other CHAP programs in early stages in other communities in Michigan, Kirkwood said, “I urge

them, no matter what their state of development, to take advantage of all the things that are

happening now. Don’t be behind. Lead. Keep the voice strong for children.”

ecic 2013 a look at chap efforts around the state

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