CHWs and the ACA 5/20/16

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1 ASPIN Annual CHW/CRS Spring Conference Indianapolis, May 20, 2016 Carl H. Rush, MRP Project on CHW Policy & Practice UT-Houston, Institute for Health Policy The CHW is a frontline public health worker who is a trusted 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. 5/20/16 2 The CHW also builds individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support and advocacy. APHA Policy Statement , November /20/16 3 carl.h.rush@uth.tmc.edu 1

2 q Do not provide clinical care q Generally do not hold another professional license q Expertise is based on shared life experience and (usually) culture with the population served 5/20/16 4 Affordable Care Act does not offer specific paths to CHW sustainability Opportunities mainly consist of fitting in Most payment sources have a hard time with the full range of possible CHW roles May need to let go of language like CHW program that isolates the CHW 5/20/16 5 Primary prevention and community development: long term investment in addressing social determinants Health care: Help control costs Help providers address accountability in new care/payment structures: outcomes, not units of service Help increase productivity of scarce clinical personnel 5/20/16 6 carl.h.rush@uth.tmc.edu 2

3 National Health Care Workforce Commission ( 5101) includes CHWs as primary care professionals Grants to Promote the Community Health Workforce ( 5313) CDC to award grants to employ CHWs (not yet funded) To promote positive health behaviors and outcomes In medically underserved communities 5/20/16 7 Area Health Education Centers ( 5403) CHWs added to mandate for training Hospital Readmission Reduction ( 3025) high potential for CHW role in meeting standards Patient-Centered Medical Homes ( 3502) natural role for CHWs as part of Community Health Teams 5/20/16 8 Patient Navigator Program ( 3509) HRSA favors employing CHWs (grants awarded August 2010). Maternal, Infant, and Early Childhood Home Visiting Programs ( 2951) grants to States. CHWs not mentioned; note Delaware Health Ambassadors Center for Medicare and Medicaid Innovation ( 3021) not mentioned in law but interested! 5/20/16 9 carl.h.rush@uth.tmc.edu 3

4 Hospital community benefits strengthened: 501(r) requires nonprofit hospitals to conduct community health needs assessments..and to adopt an implementation strategy to meet those needs 5/20/16 10 Medicaid Expansion New populations with subsidized Marketplace coverage Preventive services by non-licensed personnel (rules changed effective Jan. 2014) Health Homes (State Plan Amendment) 5/20/16 11 Outreach for Health Insurance Marketplaces note: Navigators not same as Patient Navigators New models for global payment, P4P, and Accountable Care Organizations Standards for preventive care benefits Rules for Medical Loss Ratios 5/20/

5 Urges states to include Medicaid MCOs in Medical Loss Ratio requirements Sets standard MLR at 85% Payments for CHW services may be counted as cost of quality improvement or cost control efforts and therefore not administrative 5/20/16 13 Requires SPA Must specify qualifications, but does not require certification Specific procedure codes for services related to a diagnosis Most states not actively pursuing Medicaid is too busy Scope of services is too narrow as a basis for defining CHWs 5/20/16 14 q Establishing close relationships with patients q Building trust: overcoming power distinctions and historic mistrust of institutions q Fostering candid and continuous communication q Managing Social and Behavioral Determinants of Health q Providing context to team members on whole picture of patient s life; servings as the SDOH expert on the team q Assisting patient/family in dealing with non-medical circumstances and issues q Mobilizing community to deal with macro issues 5/20/16 15 carl.h.rush@uth.tmc.edu 5

6 Like PCMH for patients with 2+ chronic conditions and/or behavioral health issues May only be at risk of one of the chronic conditions Secondary preventive services t reduce risk may qualify for non-clinical providers SPA 5/20/16 16 Approved Medicaid Health Home State Plan Amendments (effective December 2015) As of December 2015, 19 states and the District of Columbia have a total of 27 approved Medicaid health home models. Alabama, District of Columbia, Idaho, Iowa (2), Kansas, Maine (2), Maryland, Michigan, Missouri (2), States with Approved Health Home SPAs New Jersey (2), New York, North Carolina, Ohio, Oklahoma (2), Rhode Island (3), South Dakota, (number of approved health home models) Vermont, Washington, West Virginia, Wisconsin Note 5/20/16 that Oregon has withdrawn its Medicaid health home state plan amendment and is no longer providing services under a 2703 SPA. 17 Health Care Innovation Awards State Innovation Models Accountable Communities for Health Grantee CHW Learning Collaborative 5/20/16 18 carl.h.rush@uth.tmc.edu 6

7 q CHWs on Care Teams: CA, HI, ID, ME, MD, MA, MN, VT q Major CHW workforce elements in CA, DE, HI, OR, IL, MI q AR: CHWs as community reinforcement mechanisms q OR: statutory role in Coordinated Care Organizations q CA: CHWs as one of two workforce building blocks q MD: Community-Integrated Medical Homes q NY: Medicaid Redesign Team recommendations 19 Use existing flexibility (managed care) 5/20/16 20 Go with the flow It s about them, not us Use existing flexibility (managed care) Play up CHW capabilities in new care settings Weaving costs of CHWs into payment systems Stakeholders need basic education 5/20/16 21 carl.h.rush@uth.tmc.edu 7

8 1. Health care reform brings tremendous opportunities for inclusion of CHWs in Medicaid financing, e.g.: a) increasing flexibility for MMCOs and value-based payment b) Integration in team-based care in PCMH and ACO c) Integration of population health and behavioral health d) Prominent roles in State Innovation Models 5/20/ What resources are in place for transforming health care delivery on the front end: e.g. primary care, population health? 3. Make sure payment calculations include costs of CHWs - otherwise providers may balk 4. Invest time in basic education and awareness among stakeholders few actually understand CHWs! 5/20/16 23 Go with the flow Use existing flexibility (managed care) Show payers and providers how CHWs can meet objectives they are already pursuing Play up CHW capabilities in changing care settings Make case for weaving costs of CHWs into payment systems Many stakeholders need basic education on CHWs 5/20/16 24 carl.h.rush@uth.tmc.edu 8

9 q Crowne Plaza Atlanta Midtown, July CHWs: Social Change Agents Advancing Health Equity and Improving Outcomes 5/20/16 25 APHA Annual Meeting, Denver, Oct 29-Nov. 2 CHW Section full scientific program and business meetings Registration opens June 1 5/20/16 26 Carl H. Rush, MRP carl.h.rush@uth.tmc.e du /20/16 27 carl.h.rush@uth.tmc.edu 9

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