Preparation for Health Care Reform: Sharing Strategies from

Preparation for Health Care Reform: Sharing Strategies from

Preparation for Health Care Reform: Sharing Strategies from California Anne Donnelly Project Inform Courtney Mulhern-Pearson San Francisco AIDS Foundation Michaela Hoffman Mission Neighborhood Health Center Liz Brosnan Christies Place September 9, 2013 Getting to know you Which best describes where you work? a. b. c.

d. e. f. Clinic Community-based organization Health department University Hospital Other Which best describes what you do? a. b. c. d. e. f.

g. Clinician (MD, PA, NP, nurse, dentist, etc) Case manager/benefits counselor Health education (peer educator, promotora) Administrator Researcher Consumer representative Other I feel I can explain ACA to a friend a. b. c. d. e. Yes---100%

Yes---75% Yes---50/50 A little bit No California Context: Early Transitions as part of our bridge to health care reform Medi-Cal: 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 Considerations for Advocacy & Systems and Program Development Working toward the future of HIV Care? Lessons Learned: Advocacy Opportunities & challenges with transitions and service integration, maintaining quality HIV care for all who need it and monitoring new coverage

No one agency in charge of planning, transitions, & changes Need cross agency collaborative planning processes at all levels federal, state, and local Issues cross several systems and payers HIV advocates and providers need to be involved New decision-making forums may have to be developed to encourage collaboration i.e: cross agency work groups, liaisons to departments, joint stakeholder groups Lessons Learned: Advocacy Advocates will have new roles Need to work more closely with programs and delivery systems to understand what is working & what isn't Increased focus on program development and policy

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 SYSTEMS DEVELOPMENT Considerations for Systems Development How are new local and state HIV program policies being developed? Broad stakeholder input is necessary Do you have an effective HIV communications

network? What are your state and local health departments plans for interacting with new coverage? Can you get useful information about other health care systems ? Do you have effective, HIV specific education and training for all who need it? Information is complex hard to anticipate what is and will be needed Providers and clients need education Consideration for Systems Development Do you have a network ready to provide quality counseling and education for PLWH prior to new enrollment decisions? Clearer for Medicaid expansion - need information on how to stay connected with current providers

Choices in Marketplaces are extremely complex, especially in the first year Limited funding available for needs Not all formal enrollment counselors will have HIV and RW experience Training offered through ACA funded mechanisms may not be adequate for people with HIV 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 PROGRAM DEVELOPMENT 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 Considerations for HIV Medical Providers Overview of Mission Neighborhood Health Center (MNHC) FQHC, established 1969 Specializing in culturally competent primary care for Spanish-speaking Latinos, historically a high rate of recent immigrants ~12,000 patients per year (~70,000 visits), prenatal through geriatrics HIV specialty clinic Clnica Esperanza opened in 1989. Now the Latino Center of Excellence MNHC HIV Services

Client Demographics - 2011 100% 90% 80% 0.05 0.05 4% 7% 0.03 0.21 0.17 0.08

0.08 0.03 0.09 0.19 0.3 0.37 0.23 70% 60% 0.43 50% 89%

40% 0.31 0.76 0.73 0.7 30% 0.6 20% 0.22 0.28

10% 0% 0.08 Ethnicity Gender Sexual Orientation Age 0.01 % FPL Insurance Status

Citizenship MNHC HIV Services Breakdown of Services - 2012 HLS; 1200; 8.46% Testing; 809; 5.70% PMC (w/Psych,Derm, Outreach/TLS; 940; 6.63% Nut); 2528; 17.82% MH; 1093; 7.71% SAC; 1125; 7.93% CM (w/ PWP); 4583; Peer Advocacy; 718; 32.31% 5.06% Tx Adh; 1190; 8.39%

Outcomes 100% 100% 100% 96% 100% 92% 90% 85% 84% 79%80%

80% 68% 70% 59% 57% 60% 51% 50% 44% 40% 40% 30%

24% 19% 20% 10% 0% 0% HIV-Infected HIV-Diagnosed Linked to Care Retained in Care References:

US: Gardner, et al 2011 San Francisco: Benbow, Scheer, et al 2012 On ART Virally Sup. National 2011 San Francisco 2009 MNHC 2012 Ryan White Funding UOS to Funding Allocation 80% 70% 60% 50%

40% 30% 20% 10% 0% C M P (w D h, c sy /P

30% 30% 46% 10% 18% 15% 16% ) ut ,N m er

M C (w P, W /P A Tx , dh PA 7%

) SA H /M C UOS L /T h c ea r ut O

RW Funding S 7% 6% g in t s Te 7% 8% LS

H Challenges facing Ryan White Providers Ryan White program (RW) patient centered comprehensive HIV care Payer of last resort : RW cant 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 Experience with Transitions California 1115 Waiver

Medi-Cal Managed Care Transition in 2010 Payer source changed, requiring patient to select medical home Did not necessarily require a transition in care Low Income Health Plan (LIHP) transition in 2012 MNHC was not in-network; requires care transitions Preparing for HCR/ACA Began in early 2012 Initiated conversations with staff Invited guest presentations Exploring how expansion/integration of HIV services may allow for preservation Expand to Survive We considered: The model of HIV care is applicable to many other

medical issues, including most chronic diseases Our approach could be useful for diabetics, CVD, Hep C, etc. think through what impacts our clients most now not AIDS as much as Hep C, Diabetes, etc. To keep certain services (full component of CM, peer support, dedicated Tx Adherence) we will need to expand its relevance Other external forces: PCMH, pay-for-performance How to expand? Team Structure Capacity Training Putting the pieces in place now to improve our efficiency, quality, client outcomes and client satisfaction so we can continue to meet the needs and exceed the expectations of our HIV+ clients

while preparing to expand our services to others Preparing staff for ACA Integrating case managers into enrollment recertification process for ADAP/RW Training extended team in enrollment process and eligibility requirements for insurance products Open and frequent communication about ACA Simple, straightforward tools to use with patients Preparing Patients for ACA Began early, through simple FAQ, developed inhouse with support from the SF HIV Health Care Reform Task Force 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? MNHC Funding Streams and Payers Now and post ACA 100% 0.03

0.08 90% 0.09 80% 70% 0.1 0.37 0.23 70% 60% 0.6

50% 0.31 40% 30% 0.6 20% 0.29 30% % FPL Citizenship 0.3

10% 0% Insurance Status - Now Ins. Eligibility post-ACA Provider Consideration Prepared by the SF HIV Health Care Reform Task Force Generic checklist available today to support you in your local response Patient FAQ Sample

Considerations for Community Based Organizations Christies 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

Supportive Services Medical & family centered ADAP Adult & infant hygiene products Afternoon TEE/Mesa Redonda Childrens health insurance screening & referral Childcare/babysitting Childrens & 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 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 Empowerment & Leadership Development Services Transformations The Sisterhood Project Educational Workshops/ Trainings

Mujeres Nubian Queens Project SPEAK Up! Lotus Project Womens empowerment retreat: Dancing with Hope Annual Womens Conference: A Womans Voice National Women & AIDS Collective 30 for 30 Campaign AIDS United Public Policy

Committee California HIV Alliance Positive Womens Network *All services are bilingual English/Spanish. Ally 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

CBOs & the Affordable Care Act Navigating the New Reality CBO Strategic Options in ACA 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 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? 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/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 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 Arrangem ent Finalize Agreemen t Set Shared Performa nce

Targets, Goals Monitor Progress Outcome Case Example: 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) Strengthening Medical Homes Created and expanded Peer Navigator model at clinical partner sites and through a mobile, homebased approach 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) Strengthening Medical Homes Cont. 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 Womens 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

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 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 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% Lessons Learned Californias Bridge to Reform Report documents challenges with transitions to managed care plans beneficiaries struggled to understand the written materials they received regarding the process beneficiaries experienced anxiety due to their confusion and concerns regarding continuity of care stakeholders reported that healthcare plans did not make information, support, or care coordination available to beneficiaries early enough in the process Transitions were very problematic (LIHP, Medi-Cal expansion)

Most of our clients were passively enrolled Loss of PCMH Loss of primary medical care provider with HIV experience/knowledge Barriers with new providers Dropping out of care Lessons Learned Cont. Need for staff training . . . and on-going training All staff More comprehensive trainings with key staff (Peer Navigators, Care Coordinator, Outreach Coordinator, Case Managers) 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 Power & role of Peer Navigators & Community Health Workers critical component Advocacy Preparation & Enrollment 4 Es: 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 a service our client need Peer Navigators 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 Care Coordinator Serves as agencys 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) Identify and address institutional and provider level barriers to collaboration (documentation) utilization management concerns related to benefits or service authorization issues with prescription formularies delays in receipt of updated lab reports Next Steps Working with State partners on how to certify/credential Peer Navigation can this become a reimbursed service?

Updates on Community Health Workers $ 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 Acknowledgements AIDS United MAC AIDS Fund Johnson & Johnson Alliance Healthcare Foundation UCLA/Johnson & Johnson Health Care Executive Program HealthHIV (Fiscal Health Technical Assistance) Macys 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 For More Information Elizabeth (Liz) Brosnan Executive Director, Christies Place [email protected] (619) 702-4186 x210 Chair, National Women & AIDS Collective - 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 MORE INFORMATION Resources State HCR Information Enroll America Center for Budget and Policy Priorities - Treatment Access Expansion Project Kaiser Family Foundation Families USA National Health Law Program NASTAD Health Resources and Services Administration Resources SF HIV Health Reform Task Force ransition-2/ Covered California Health Access - Western Center on Law and Poverty National Senior Citizens Law Center Health Consumer Alliance Please Visit to access slides from todays presentation Evening Town Hall: Health Care Reform Open Forum Presented by the HIV Health Care Access Working Group, Ryan White Working Group, Federal AIDS Policy Partnership and Join national and state policy experts and your peers for a relaxed, open forum where you can ask burning questions about health care reform implementation, share your concerns, and learn more about implementation efforts. Monday, September 9 6:15 8:00 p.m. Strand 12A, Level 2 Hyatt Regency New Orleans Evaluation

Session ID: 748 Short URL Link: QR Code: Contact Information [email protected] [email protected] [email protected] [email protected]

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