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
Christie’s Place
September 9, 2013
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
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
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 department’s 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
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
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 “Clínica Esperanza” opened in
1989. Now the Latino Center of Excellence
MNHC HIV Services
Client Demographics - 2011
100%
90%
80%
OTHER 5%
AA 5%
Trans 4%
Female 7%
White
17%
Bi 3%
Hetero
21%
60+
8%
50 to 59
19%
200+
8%
151 - 200
9%
101 - 150
23%
70%
Private 3%
Medi's
37%
Non-Citizen
30%
60%
50%
40%
Latino
73%
Male
89%
40 to 49
43%
Gay
76%
51 - 100
31%
HSF/No Ins.
60%
30%
30 to 39
22%
20%
10%
19 to 29
8%
0%
Ethnicity
Gender
Sexual Orientation
Age
US Citizen
70%
26 - 50
28%
0 - 25, 1%
% FPL
Insurance Status
Citizenship
MNHC HIV Services
Breakdown of Services - 2012
Testing, 809, 6%
HLS, 1200, 8%
PMC
(w/Psych,Derm,
Nut), 2528, 18%
Outreach/TLS,
940, 7%
MH, 1093, 8%
SAC, 1125, 8%
CM (w/ PWP),
4583, 32%
Tx Adh, 1190,
8%
Peer Advocacy, 718,
5%
Outcomes
100%100%
100%
96%
100%
92%
90%
85%
84%
79%80%
80%
68%
70%
59%
57%
60%
National 2011
51%
50%
44%
40%
MNHC 2012
40%
30%
24%
19%
20%
10%
0%
0%
HIV-Infected
HIV-Diagnosed
Linked to Care
References:
US: Gardner, et al 2011
San Francisco: Benbow, Scheer, et al 2012
Retained in Care
San Francisco 2009
On ART
Virally Sup.
Ryan White Funding
UOS to Funding Allocation
80%
70%
60%
50%
40%
30%
20%
10%
0%
30%
30%
18%
46%
10%
16%
UOS
15%
7%
RW Funding
7%
6%
7%
8%
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
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%
90%
Private
3%
200+
8%
151 - 200
9%
Medi's
37%
80%
70%
101 - 150
23%
60%
Private
10%
Citizen
70%
Medi's
60%
50%
40%
51 - 100
31%
HSF/No Ins.
60%
30%
20%
10%
26 - 50
29%
Non-Citizen
30%
% FPL
Citizenship
HSF/No Ins.
30%
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
Christie’s 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
 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
Transformations
The 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
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
Arrangeme
nt
Finalize
Agreement
Set Shared
Performanc
e 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 Women’s 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 suboptimally 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
• California’s “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 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 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 agency’s healthcare reform lead
• Lead on coordination of managed care plan
benefits counseling and enrollment
• Ensure client ability to access and remain in patientcentered 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)
• Macy’s 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, Christie’s Place
brosnan@christiesplace.org
(619) 702-4186 x210
www.christiesplace.org
Chair, National Women & AIDS Collective
www.nwac-us.org - 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
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
Resources
SF HIV Health Reform Task Force http://www.sfhiv.org/resources/health-care-reformtransition-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
Please Visit
www.HIVHealthReform.org
to access slides from today’s 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 HIVHealthReform.org
• 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: http://goo.gl/8lLPIb
• QR Code:
Contact Information
▫
▫
▫
▫
michaelahoffman@mnhc.org
cpearson@sfaf.org
adonnelly@projectinform.org
brosnan@christiesplace.org