17 th Annual Healthy Carolinians Conference and NCIOM Prevention Summit October 8 th , 2009

1. COORDINATING CARE FOR THE UNINSURED: RESOURCES FOR BUILDING COLLABORATIVE NETWORKS OF CARE IN YOUR COMMUNITY 17th Annual Healthy Carolinians Conference and NCIOM Prevention SummitOctober 8th, 2009 Anne Braswell Senior Analyst for Research and Development NC Office of Rural Health and Community Care

2. CHANGES IN HEALTH INSURANCE COVERAGE IN NC: 2000 – 2007 • More than 1.5 million nonelderly (18.9%) were uninsured in NC in 2006-2007 • Approximately the population of the Charlotte metro area • Between 1999-2000 and 2006-07: • North Carolina experienced DOUBLE the increase in the percentage who were uninsured than nationally (NC: 29%, US: 12% increase) • North Carolinians lost employer-sponsored insurance at nearly DOUBLE the national rate (NC: 12.5%, US: 6.8% decrease)* * Mark Holmes, PhD, Vice President, North Carolina Institute of Medicine “The NC Uninsured: Who Are They, Why Do We Care, and What Can We Do?” Annual New Hanover County Health Access Summit, Access to Care and Impact on Our Community, 19 September, 2008.

3. 2000: HEALTH RESOURCES AND SERVICES ADMINISTRATION ANNOUNCEDCOMMUNITY ACCESS PROGRAM (CAP) • New federal grants program supporting community indigent care initiatives to increase access and quality of care for the uninsured and underserved • Expanded access for the uninsured by increasing effectiveness and capacity of the nation’s health care safety net at the community level

4. COMMUNITIES RECEIVING CAP FUNDS EXPECTED TO: • Build integrated health care delivery systems offering a seamless continuum of care for the uninsured and underinsured • Eliminate unnecessary and duplicative functions in service delivery and administration, resulting in savings to reinvest in the system • Increase access to health care for low-income uninsured and underinsured persons

5. FIRST COMMUNITY ACCESS PROGRAM IN NORTH CAROLINA • June 2000: Office of Rural Health and Community Care applied for CAP funding on behalf of Community Care Plan of Eastern Carolina for Pitt, Greene, Edgecombe & Bertie Counties • September 2000: ORHCC awarded one of only 23 CAP grants in nation -- $897,000 for Pitt et al

6. 2000: COMMUNITY CARE PLAN OF EASTERN CAROLINA AND ORHCC CREATED HEALTHASSIST • Built upon administrative infrastructure of Community Care of North Carolina (CCNC) • Established 4 Community Resource Centers • Co-located services with other community non-profits (e.g. JOY Soup Kitchen; Pactolus’ Fire/Rescue) • Provided health care services, care coordination, wellness and prevention services, adult continuing education, and job skills training for low-income and uninsured

7. BEGINNING 2001: HRSA REPLACED CAP WITH HEALTHY COMMUNITIES ACCESS PROGRAM (HCAP) • Additional indigent care networks were initiated throughout NC with HCAP funding: Cabarrus, Guilford, Buncombe, Moore, Beaufort, Durham, Henderson, Orange/Chatham • Several communities initiated programs, but were not awarded federal funding: Mecklenburg, Wake, Vance/Warren, Wilkes, Wilson, Mitchell/ Yancey, Watauga, New Hanover, and others

8. 2005: HCAP NO LONGER FUNDED BY HRSA • After 2005, former HCAP sites and other programs in NC struggled to maintain the same level of programs and services with limited resources • Early in 2007, the last HCAP “carryover” funding ran out • In the summer of 2007, The Duke Endowment provided 4 months of emergency funds

9. IMPACT OF HCAP PROGRAM IN NC Between 2000 and 2005, HCAP helped: • Induce physicians and hospitals to provide more free care and services for the uninsured • Local governments and philanthropic organizations to provide matching investments of funds and resources • Bring about both perceived and measurable improvements in the health and wellness of participants • Reduce inappropriate use of hospital EDs and other costly services by participants

10. A KEY LESSON LEARNED FROM HCAP: There must be sustaining funds to support the infrastructure needed to effectively operate community indigent care programs.

11. 2007: “HEALTHNET” INITIATIVE In SFY 2007-08, NC General Assembly made a one-time appropriation to ORHCC of $2.88 million to implement HealthNet to support North Carolina’s safety net primary care provider networks and develop community-based systems of care serving the uninsured.

12. NC HEALTHNET: Links local safety net organizations and indigent care programs providing free and low-cost health care services with Community Care of North Carolina’s networks of physicians and services.

13. Physicians Hospitals Public Health Free Clinics Rural Health Centers Community Health Centers Departments of Social Services Behavioral Health Other Community-Based Safety Net Organizations HEALTHNET NETWORKS INCLUDE:

14. HEALTHNET TARGET POPULATION: Uninsured adults, 18-64 years old, whose family income is below 200% of FPL

15. HEALTHNET ENROLLEES: Provided a Primary Care Medical Home and access to: • Specialty Care • Wellness Education • Prevention Services • Prescriptions Medications • Care Coordination for Chronic Medical Conditions • Other Needed Services

16. HEALTHNET NETWORKS: Receive technical assistance and grants from ORHCC to support the community’s ongoing efforts to: • Increase access and quality of care through a coordinated delivery system • Share and conserve limited resources through collaborative partnerships

17. 2007: HEALTHNET IN YEAR 1 • Funded 16 HealthNet Networks providing services for the uninsured in 27 counties • 40,000+ individuals were provided a medical home • 25,000+ individuals had access to needed prescription medications

18. 2008: HEALTHNET IN YEAR 2 In SFY 2008-09, ORHCC received $2.8 million in recurring appropriations to sustain existing HealthNet Networks and $975,000 in non-recurring funds to develop new collaborative networks.

19. 2008: HEALTHNET IN YEAR 2 • Funding 21 HealthNet Networks that provide services for the uninsured in 38 counties • 50,000+ individuals have a medical home • 38,000+ individuals have access to needed prescription medications

20. 2009: HEALTHNET IN YEAR 3 For SFY 2009-10, ORHCC has received $4.8 million in recurring appropriations to sustain the existing HealthNet Networks and develop new programs as available funding will permit.

21. ORHCC TECHNICAL ASSISTANCE: Office of Rural Health and Community Care staff provides: • Community Needs & Gap Analysis • Strategic & Business Planning • Network Development • Medical, Dental, and Psychiatric Provider Recruitment for Underserved Areas & Educational Loan Repayment • Architectural Design Support for Capital Projects

22. ORHCC TECHNICAL ASSISTANCE (CONTINUED) • Coordination with: • Community Care of North Carolina (CCNC) and Medicaid • Critical Access Hospital Program • Farmworker Health Program • Medical Access Program • Medication Assistance Program • Community Health Grants Program

23. ORHCC TECHNICAL ASSISTANCE (CONTINUED) • Free software applications for access, referral, eligibility, enrollment, and care management (CARES and CMIS) and for the Medication Access & Review Program (MARP)

24. PARTICIPATING IN HEALTHNET Health care providers and safety net organizations that would like to partner with the local HealthNet Network or want help with planning and organizing a new HealthNet Network should contact: • CCNC’s Community Care Coordinator for the county • Office of Rural Health and Community Care • 919-733-2040

25. HEALTHNET PARTNERING WITH CARE SHARE HEALTH ALLIANCE • ORHCC helps support the Care Share Technical Assistance Center with HealthNet funds • ORHCC is also a part of Care Share’s Funders’ Collaborative where grant decisions are coordinated to eliminate duplication and identify gaps

26. CARE SHARE HEALTH ALLIANCEShelisa Howard-Martinez Care Share Health Alliance's mission is to improve the health of low-income, uninsured North Carolinians by supporting local Collaborative Networks of care.

27. Care Share Health Alliance • Is an independent, statewide resource that brings people together to improve the health of low-income, uninsured persons. • Our basic tenet is to meet communities where they are and to build on their strengths and resources.

28. Successful Collaboration • Includes: • Broad stakeholder participation – everyone comes together around an intersecting issue (caring for the uninsured); • Effective & Passionate Leadership (Sparkplugs); • Group staying focused on what is best for the health of the individual/patient; • Shared vision and goals; • Creating something new together (shared ownership & responsibility); • Celebrating success and having fun together!

29. Continuum of Collaboration Partners meet on a regular basis, planning to implement a project/system together All safety net providers at the table, coordinated for all the uninsured, prioritized needs, funding No collaboration, silos, lack of trust Continuum of Collaboration Informal, episodic collaboration, letters of support Integrated system – common systems, coordination of care across partners – i.e. Project Access

30. Continuum Hospital Dental Specialty Care Patient Medical/Primary Care Home DSS Medications Mental Health Wellness & Health Education (Prevention) Chronic Disease Management Public Health Of Care

31. Care Share Offers New Resources • Convening, Facilitation and Support through: • On-site technical assistance and phone consultations to support communities who want to enhance their collaboration and/or develop Collaborative Networks of care. • Webinars – “Emergency Department Utilization Reduction” with the NC Hospital Association and “Central Fill Pharmacy” with the NC Association of Free Clinics. • Web-based tools, templates and resources, an interactive Knowledge Bank of best practices, and a 2010 conference.

32. Menu of Technical Assistance Services • Capacity Building: organizational development, financial management, leadership building, Information Technology expertise, programs/systems design; • Identifying new resources for communities; • Referrals to other agencies to leverage resources; • Advisory/coaching with leadership; • Conflict Resolution; • Community-Wide Planning.

33. Knowledge Bank • Is an interactive resource for communities who want to enhance their collaboration. • Capacity development resources, • Online Tools and Templates, • Monthly Webinars and teleconferences, • Calendar of events. • Sign up at www.CareShareHealth.org.

34. Community-Wide Planning • Goal is to develop a three-year, community-wide plan to care for the uninsured • Builds on existing community health assessments and plans • Streamlines planning and other efforts • Leverages all resources in the community • Opportunity to develop: • A new or updated Strategic Plan, • A Finance plan, • Evaluation plan, • Sustainability plan to enhance long-term financial viability.

35. Technical Assistance Team West Rachel Rosner (828) 232- 2976 Central Linda Kinney (919) 800-8967 East Shelisa Howard-Martinez (919) 861-8359

36. How to connect with Care Share • Call or email a Care Share Team member to discuss your needs. • Invite us to your community to learn more about how we can help you build collaboration to care for the uninsured. • Register for the Knowledge Bank • Check calendar for upcoming Webinars

37. 17th Annual Healthy Carolinians Conference & NCIOM Prevention SummitOctober 8, 2009 Coordinating Care for the Uninsured in Gaston CountyPresented byVeronica Feduniec, Executive Director

38. Background • Issues • High non-urgent ED utilization • Admissions to ED for access to pool specialists • No physician follow-up after discharge • Partners • Gaston Memorial Hospital • Gaston Family Health Services • Gaston Together (GCHC) • Community Health Partners • Milestones • First meeting: December 2006 • First grant application: February 2007 • First grant award received: January 2008 • First patient enrolled in HNG: January 2008

39. HNG Target Population • Uninsured • Gaston County resident, 18 and older • Income <= 100% FPG • Chronic Conditions or High User of the ED • Diabetes • Asthma • Congestive Heart Failure

40. HNG Patient Benefits(Full continuum of care) • Medical Home/Primary Care • Specialty Services • Hospital Services • Case Management/Health Coaching • Medication Assistance • Health at Home Self-Care Guide

41. Health at Home Guide • Self-management resource guide • Recipients of book receive face-to-face education on its use • Move individual toward self-sufficiency • Community-wide initiative for book distribution to low-income • Survey component included • Printed in English and Spanish

42. Health at Home Survey • 520 surveys distributed • 9% return rate (lower than community rate of 12-18%) • Mobile population - 20% returned “undeliverable”

43. Health at Home Survey

44. Health at Home Survey • 61% report that H@H has helped treat a health problem at home • 61% report that H@H has helped to identify a needed visit to the doctor • 57% report H@H has saved an unnecessary ED visit

45. Achievements Current: • 1,700 members • 182 Medication Assistance Program members • 241 active primary care, specialty and hospital providers Year-to-Date 2009: • 3,413 primary care appointments • 902 specialty care appointments • 33% reduction in ED visits • 11% reduction in charge/visit for all hospital services Since Inception: • $8.6 million in charity care donated • Return on Investment of 11 times

46. Community-Wide Planning • HNG pilot program for Care Share Health Alliance • Addition of strategic community partners • Growth of “full continuum of care” • Expansion of program to all uninsured