payment under health reform opportunities and outlook for community health worker programs sim...
TRANSCRIPT
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Payment Under Health Reform
Opportunities and Outlook for
Community Health Worker Programs
SIM Emerging Professions Learning Community
December 2, 2015
Joan Cleary, M.M., Executive Director
Minnesota Community Health Worker Alliance
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Presentation Outline
• Background and Context
• Current Payment
• Payment Models
• Considerations
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About the Alliance
We’re a broad-based partnership of CHWs and stakeholder organizations, governed by a voluntary nonprofit board.
\
www.mnCHWalliance.org
Our Vision Equitable and optimal health outcomes for all communities
Our Mission
Build community and systems’ capacity for better health through the integration of community health worker strategies
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What are we trying to accomplish?
Adapted from NM Department of Public Health presentation
FullIntegration
of CHWs in MNSystems of
Care
ReduceHealth
Inequalities
AdvanceTriple Aim
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CHW Definition
A Community Health Worker (CHW) is a trusted frontline health professional who applies his or her training and unique understanding of the experience, language and/or culture of the populations he or she serves in order to carry out one or more of the following roles:
•Providing culturally-appropriate health education, information and outreach in a variety of settings such as homes, clinics, hospitals, schools, shelters, local businesses, and community centers;
•Bridging/culturally mediating between individuals, communities and health and human services, including actively building individual and community capacity;
•Assuring that people access the services they need;
•Providing direct services, such as informal counseling, social support, care coordination and health screening; and
•Advocating for individual and community needs.
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American Public Health Association Community Health Worker Definition
“A community health worker (CHW) is a trusted publichealth worker who is a member of and/or has an unusually close understanding of the community served. This trusting relationship enables the CHW to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery.
A CHW also builds individual and community capacity by increasing health knowledge and self-sufficiency througha range of activities such as outreach, community education, informal counseling, social support and
advocacy.”
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Who is a CHW?
Adapted discussion tool used with permission by the CHW Initiative of Sonoma County, CA.
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CHWs are uniquely equipped to advance health equity and the Triple Aim
Reducing Ethnic/Racial Asthma Disparities in Youth (READY) For more information, visit: successwithchws.org/asthma
They typically reside in the communities they serve, and share the same language; ethnic, cultural and educational background; and/or life experience.
Adapted from NM Department of Public Health presentation
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An Emerging Workforce
Adapted from NM Department of Public Health presentation.
Tribal CHRs
Lay Health Advisors
Promotores(as)
Patient Navigators
Community Health Advocates
CHWs
Community Educators
Care Guides
Outreach Workers
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Recognized by Leading Public and Private Authorities
• American Public Health Association (APHA)
• Centers for Disease Control (CDC)
• Center for Medicare and Medicaid Services (CMS)
• Community Preventive Services Task Force
• Health Affairs
• Health Resources and Services Administration (HRSA)
• Institute of Medicine (IOM)
• Institute for Clinical and Economic Review (ICER)
• U.S. Dept. of Labor Standard Occupational Classification (DOL)
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What are We Learning from Recent CHW Studies on Return on Investment?
3 1Net Return
Carl Rush, “CHWs: A National Perspective,” Indiana CHW Coalition Community Symposium, 10/15/2012
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Minnesota CHW Building Blocks
Scope of Practice
Statewide Standardized Competency Based
Curriculum
Payments UnderMinnesota Health Care
Programs
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Current CHW Coverage under Minnesota Health Care Programs (MHCP)
• Specific to diagnostic-related patient education services
• Face-to-face services, individual and group, FFS & PMAP
• Signed order for patient education in patient record
• Standardized patient education curriculum consistent with established or recognized health or dental care standards
• Provide service with clinical supervision in clinical setting, home or community; document services provided
• Alliance & partners seeking coverage improvements in follow-up to 2007 statute; monthly cap raised to 12 hrs/mo and increase in group size for patient education expected in 2016
• For more on coverage, contact: [email protected]
• Visit: http://successwithchws.org/mental-health/2014/12/23/community-health-worker-enrollment-coverage-and-payment-under-minnesota-health-care-programs/
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Provider types authorized to bill for CHW services under MHCP
• Advance Practice Nurses
• Certified Public Health Nurses in a unit of government
• Clinics
• Dentists
• Family Planning Agencies
• Hospitals
• IHS and Tribal Health Facilities
• Mental Health Professionals
• Physicians
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Strengths
• Includes both 1:1 and group education
• Covers patient education in different settings including home and community
• Allows many provider types to order and supervise CHW services
• Benefit for both FFS and managed care enrollees
• MN is one of only several states with Medicaid coverage of CHW services through a state plan amendment
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Limitations
• Covers single function of broader CHW role
• Monthly cap
• Rate
• Encounter-based
• Leaves out FQHCs and community-based CHW employers
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Provider Experience
• Where CHW programs are seeded in provider organizations, they take root and often grow (e.g. HCMC, HealthEast)
• Many Medicaid-eligible CHW employers are not as yet using MHCP funding for a variety of reasons
• Challenges with both FFS and managed care claims payment
• Current coverage does not support CHW services provided by FQHCs and community-based CHW employers
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National Trends: Growing interest in CHW Workforce and Sustainable Financing
Federal Level:
• CMS Work Group on CHW Care Coordination
• CMS rule change proposed in May 2015: CHW services may be counted as cost of “quality improvement” or “cost control” efforts and therefore not administrative
State Level:
• FL, ME, MA, MI, MD, OR, NV, SC, TX, VT, UT
For more info:
• State Reforum website: https://www.statereforum.org/weekly-insight/community-health-workers-in-a-reformed-healthcare-system
• National Academy for State Health Policy website for national map of state CHW models including financing and legislation: http://www.nashp.org/state-community-health-worker-models/
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State Spotlight: Michigan Medicaid
• Contractor must provide or arrange for the provision of CHW or peer support specialist services to enrollees who have significant behavioral health issues and complex physical co-morbidities who will engage with and benefit from these services
• Contractor agrees to establish a reimbursement methodology for outreach, engagement, education and coordination services provided by CHWs or peer support specialists to promote behavioral health integration
• Contractor must maintain a CHW to Enrollee ratio of at least one FT CHW per 20,000 Enrollees
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State Spotlight: NM Medicaid
• Medicaid contracts must encourage use of CHWs for care coordination
• MCO contractors required to describe CHW role in providing patient education
• MCO contractors must include CHW services in list of services in Medicaid benefit package
• CHW care coordination services are factored into the cost of services
• State has waiver to cover CHW care coordination
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Examples of Evidence-based CHW Models
• Molina Health, New MexicoReduced ER utilization
• Pathways Community HUB, Ohio and under replication Improved birth outcomes, chronic conditions & other benefits
• Sinai Pediatric Asthma Intervention, IllinoisImproved child asthma management, reduction in asthma symptoms and ER use
• GRACE Model, Indiana, and IMPaCT, University of PennsylvaniaReduction in hospital readmission rates and improved post-hospital outcomes
• Arkansas Community Connectors ProgramAverted nursing home placement
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Payment ModelsHigher Risk – Greater Provider Integration and Accountability
Accountable Care Models
• Capitation and PBC
• Shared Risk
• Shared Savings
Centers of Excellence
• Bundled/Episode Payments
Performance-Based Arrangements
• Performance-Based Contracts (PBC)
• Primary Care Incentives
• FFS
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“Are we there yet?”
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Payment reform + transformation in health systems20th c health system will not get us there…CHW services integral to culturally-competent, equitable and accountable health model
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Bridging Strategy
Community Health Worker
programs need to work in a
variety of financing contexts.
Shreya Kangovi, MD, MS
U Penn Center for CHWs
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Next Steps
(1) Seek coverage for CHW Care Coordination
• Statutory authority
• Major CHW function and core competency
• Strong interest by CHW employers
• Opportunity to move away from encounter-based payment
• Door is open
(2) Improve CHW enrollment process and claims payment
(3) Create CHW Awareness Campaign
(4) Launch CHW Leadership Development Pilot
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Challenges and OpportunitiesDrivers of CHW Integration
• Increasingly diverse and rapidly aging population
• ACA increasing access to thousands of previously uninsured with projected primary care shortage
• Focus on Triple Aim and team-based care
• Payment shift from fee-for-service to value-based purchasing and total cost of care
• Incentives and penalties under health reform
• Greater emphasis on performance measurement and reporting by race, ethnicity, preferred language and country of origin, statewide and by region
• Health equity growing in priority
• Recognition of the impact of social determinants of health
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CHWs Address the Social Determinants of Health
Adapted from Dahlgren and Whitehead, 1991
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For more information, please contact
Joan Cleary, M.M., Executive Director
Minnesota Community Health Worker Alliance
www.mnCHWalliance.org
www.successwithCHWs.org/asthma
www.successwithCHWs.org/mental-health
Thank you!