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

Presentation Outline

• Background and Context

• Current Payment

• Payment Models

• Considerations

About the Alliance

We’re a broad-based partnership of CHWs and stakeholder organizations, governed by a voluntary nonprofit board.

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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

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

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.

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.”

Who is a CHW?

Adapted discussion tool used with permission by the CHW Initiative of Sonoma County, CA.

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

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

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)

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

Minnesota CHW Building Blocks

Scope of Practice

Statewide Standardized Competency Based

Curriculum

Payments UnderMinnesota Health Care

Programs

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: Susan.Kurysh@state.mn.us

• Visit: http://successwithchws.org/mental-health/2014/12/23/community-health-worker-enrollment-coverage-and-payment-under-minnesota-health-care-programs/

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

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

Limitations

• Covers single function of broader CHW role

• Monthly cap

• Rate

• Encounter-based

• Leaves out FQHCs and community-based CHW employers

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

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/

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

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

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

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

“Are we there yet?”

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

Bridging Strategy

Community Health Worker

programs need to work in a

variety of financing contexts.

Shreya Kangovi, MD, MS

U Penn Center for CHWs

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

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

CHWs Address the Social Determinants of Health

Adapted from Dahlgren and Whitehead, 1991

For more information, please contact

Joan Cleary, M.M., Executive Director

Minnesota Community Health Worker Alliance

joanlcleary@gmail.com

www.mnCHWalliance.org

www.successwithCHWs.org/asthma

www.successwithCHWs.org/mental-health

Thank you!