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  1. 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

  2. Getting to know you

  3. Which best describes where you work? • Clinic • Community-based organization • Health department • University • Hospital • Other

  4. Which best describes what you do? • Clinician (MD, PA, NP, nurse, dentist, etc) • Case manager/benefits counselor • Health education (peer educator, promotora) • Administrator • Researcher • Consumer representative • Other

  5. I feel I can explain ACA to a friend • Yes---100% • Yes---75% • Yes---50/50 • A little bit • No

  6. 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

  7. 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

  8. Considerations for Advocacy & Systems and Program Development Working toward the future of HIV Care?

  9. 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

  10. 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


  12. 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

  13. 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

  14. 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

  15. Program Development

  16. 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?

  17. 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

  18. Considerations for HIV Medical Providers

  19. 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

  20. MNHC HIV Services

  21. MNHC HIV Services

  22. Outcomes References: US: Gardner, et al 2011 San Francisco: Benbow, Scheer, et al 2012

  23. Ryan White Funding

  24. 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

  25. 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

  26. 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

  27. 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

  28. 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

  29. Preparing staff for ACA • Integrating case managers into enrollment re-certification 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

  30. Preparing Patients for ACA • Began early, through simple FAQ, developed in-house 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

  31. 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?

  32. MNHC Funding Streams and Payers – Now and post ACA

  33. Prepared by the SF HIV Health Care Reform Task Force Generic checklist available today to support you in your local response Provider Consideration

  34. Patient FAQ Sample

  35. Considerations for Community Based Organizations

  36. 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.

  37. 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 • 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 *All services are bilingual English/Spanish.

  38. 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 A Matter of Relevance & Sustainability

  39. CBOs & the Affordable Care Act Navigating the New Reality

  40. CBO Strategic Options in ACA

  41. 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

  42. 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?

  43. 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

  44. Steps to the Goal Identify & Screen Against Fit Identify internal stakeholders Identify and convene the project team biweekly Conduct client (customer) benchmarking Determine which clinical partners Stakeholders have initial meeting with identified partners Agree on partnership benefits Assess joint programming opportunities Identify funding sources for joint programming Determine joint programming scope Develop MOA or contract to formalize partnership Agreement execution Implementation plan Secure funding sources for joint programming Formative phase Cultural integration of program staff Implementation Monitoring Evaluation Select Fit Shared Future State Operating Arrangement Finalize Agreement Set Shared Performance Targets, Goals Monitor Progress

  45. Outcome

  46. 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)

  47. Strengthening Medical Homes • Created and expanded Peer Navigator model at clinical partner sites and through a mobile, home-based 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)

  48. 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

  49. 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%

  50. 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