Local Initiatives to Integrate the Health Care Safety Net:Laying the Foundation for Health Care Reform

Annette Gardner, PhD, MPH

Study Director

Philip R. Lee Institute for Health Policy Studies

University of California, San Francisco

September 27, 2012

UC

SF University of California San Francisco

“Integration” Defined

Systems approach to the provision of “Comprehensive, coordinated, culturally competent consumer-centered care” Two or more entities establish linkages for the

purpose of improving outcomes Reduce fragmentation and duplication of services and

consequently costs

The Road to Coordinated Care

Integration Under Health Care Form

Affordable Care Act provisions to promote integration: ACOs – Medicaid (S 3022) and Pediatric ACO project for Medicaid or CHIP (S

2706) PCMH - Medicaid health homes (S 2703) Community-based collaborative care network project (S 10333) Bundled payments demonstration projects (S 2704) Global payments demonstration projects (S 2705) Basic health option (S 1331) CMS Innovation Center (S 3012)

Issues: Decreased access to care comprises care coordination Fragmented funding impedes sharing with other safety net

providers ACOs are not mandated No “one size fits all” approach – requires flexible strategies

Source: Ku et al., “Promoting the Integration and Coordination of Safety-Net Health Care Providers Under Health Reform: Key Issues” Commonwealth Fund, October 2011

UCSF Safety Net Integration Study Objectives

Describe safety net integration efforts in 5 diverse California counties where there is evidence of safety net integration;

Identify factors that affect local safety nets’ ability to develop integrated delivery systems;

Develop lessons learned or “best practices” that can be applied elsewhere; and

Develop recommendations for facilitating safety net integration.

UCSF Study Methods Interviews with 4-5 informants representing key

safety net stakeholders in each county Areas of investigation:

Level of integration activity Contextual factors important to planning and

implementation of integration initiatives Resources IT systems Safety net integration best practices

California Counties – Health Stewards, Health Innovators

Five Study CountiesSafety Net

SystemMedi-Cal Model and Study Plan

Study Safety Net Hospital

Study Non-County Clinic, Consortium

HCCI Legacy

County?

Contra Costa

Public/private 2-Plan (Contra Costa Health Plan)

Contra Costa Regional Medical Center

La Clinica de La Raza; Community Clinic Consortium

Yes

Humboldt (CMSP)

Private FFS St. Joseph Health System

OpenDoor CHCs, North Coast Clinics Network

No

San Diego Private GMC UC San Diego Medical Center

La Maestra CHCs; Council of Community Clinics

Yes

San Joaquin

Public/private 2-Plan (Health Plan of San Joaquin)

San Joaquin General Hospital

Community Medical Centers, Inc.

No

San Mateo Public COHS (Health Plan of San Mateo)

San Mateo Medical Center

Ravenswood Family Health Center

Yes

Health Care Safety Net Gaps

Populations

Undocumented uninsured;

Homeless;

Some sub-populations, e.g., Pacific Islanders;

Seniors.

Diseases, Conditions

Mental health, substance abuse;

Chronic diseases;

Obesity.

Services

Primary Care;

Mental Health;

Specialty Care;

Dental health;

Access issues, e.g., same day appointments.

Skill Gaps

Some provider types, e.g., primary care and orthopedics;

HIT, e.g., roll-out;

Connecting services, HIT systems

Findings:Level of Integration by County

Contra Costa

Humboldt San Diego San Joaquin

San Mateo

7.7(ranges from

6 to 9.5)

6.7(ranges from

5 to 9)

6.3(ranges from

5 to 8)

7.2(ranges from

6.5 to 8)

7.5 (ranges from

7 to 8)

“county-run; shared funding of positions”

“no shared funding; regular meetings, project-specific funding.

“project by project”

“Among county entities – 9; with outside entities – 6 to 7”

“depends on the area; separate budgets but will contribute to a joint project”

“Please rate the level of collaboration or integration that has been achieved by the organizations that work on initiatives to integrate the safety net on a scale of 1 – 10 where 1=information sharing and communication; 3=cooperation and coordination, e.g., do joint planning; 6=collaboration, e.g., sharing of funding/services; 8=consolidation, e.g., regular meetings of key players, cross-training of staff; 10=integration, e.g., shared funding of positions, joint budget development”

Findings – Activities Underway (Y) and Proposed, by County (N=28 activities)

Contra Costa

(25)

Humboldt (26)

San Diego (28)

San Joaquin

(25)

San Mateo (26)

System-level Activities

Participation in an ACO P P Y (ACC)

P Y (DSRIP)

Adoption of an integrated network of safety net providers (coordinate care across levels of care)

Y Y Y Y Y

Provider-level Activities

Adoption of panel management Y Y Y Y Y

Onsite mental health care at PC sites Y Y Y Y Y

Onsite dental health at PC sites Y Y Y Y Y

Expanded communications between primary care and specialty care

Y Y Y Y Y

Expanding provider scope of service Y Y Y Y Y

County contracts with comm. clinics Y Y Y Y Y

Adoption of PCMH Y Y Y Y Y

Addition of new health care services Y Y Y Y Y

Auto enrollment of Medi-Cal patients Y P Y Y Y

ER Diversion Programs Y Y Y Y Y

Activities Underway, Proposed, by County (cont.)Contra Costa

Humboldt San Diego San Joaquin

San Mateo

Health Information Technology

Electronic eligibility and enrollment Y Y Y Y Y

Electronic prescribing Y Y Y Y Y

Electronic health information system (EMR) Y Y Y Y Y

Electronic Disease Registry Y Y Y Y Y

Electronic specialty care referral Y Y Y P Y

Electronic panel management system Y Y Y Y Y

Health Information Exchange P Y Y Y P

Patient-level Activities

After hours and/or same day scheduling Y Y Y Y Y

24/7 nurse advice line Y Y Y Y Y

E-Portals for patients to interact with systems

P Y Y P P

Case management services Y Y Y Y Y

Certified Application Assistors Y Y Y Y Y

Community Health Workers Y Y Y Y Y

Patient Navigators Y Y Y Y Y

Accessible telephone system Y Y Y Y Y

Language access Y Y Y Y Y

Interprofessional Collaboration

Findings - Integration Activities “Underway” by Stakeholder

County Health Agency

Safety Net Hospital

Medi-Cal Plan

Non-County Clinic

Clinic Consor-

tium

0

5

10

15

20

25

30

Contra Costa

Humboldt

San Diego

San Joaquin

San Mateo

# I

nte

gra

tion A

ctiv

itie

s

“Proposed” Integration Activities by Stakeholder

County Health Agency

Safety Net Hospital

Medi-Cal Plan

Non-County Clinic

Clinic Consor-

tium

0

2

4

6

8

10

12

14

Contra Costa

Humboldt

San Diego

San Joaquin

San Mateo

# I

nte

gra

tion

Acti

vit

ies

Patient-Centered Care

Areas of High Involvement by Most Stakeholders

Provider-level Integration Adoption of Panel Management, e.g., Teamlet Mental Health/Primary Care Integration Expanded Communications Between Primary Care and Specialty

Care Electronic Disease Registries

Patient-level Integration: After Hours/Same Day Scheduling Case Management Services Certified Application Assistors Community Health Workers Accessible Telephone Systems; and Language Access

Adopting, Leveraging Information Technology

IT – Progress to-date

All are implementing IT applications on multiple fronts

All counties have One-e-App or something like it and are exploring options to facilitate continuous coverage

Some counties have centralized electronic systems for archiving health information while other counties have it for the hospital/clinic/plan

Connectivity issues remain

Facilitating Factors, Challenges

• Similar facilitating factors among counties: Strong commitment at the top Long-standing, shared responsibility for the uninsured Good partnerships, communications Presence of a safety net collaborative, Medi-Cal health

plan, clinic consortium• Similar barriers that impede integration….resource

constraints: Inadequate Medi-Cal reimbursement State and county cuts Provider capacity and workforce shortages

Challenges – Vary by County

Presence of a Medi-Cal health plan Geographic barriers Market share competition among providers County financial situation

Resources - Funding

Piece-meal: mix of public (federal, state, GFS) and private funding that varies by stakeholder, e.g., Specialty Care Access Initiative 10 HCCI Counties

Some differences in strategy to secure funding: “no stone left unturned” vs. aligning resources with organizational goals

Current opportunities: Section 1115 Medi-Cal Waiver (LIHP, DSRIP) ACA, e.g., ACOs, Health Benefit Exchange ARRA Medicare/Medicaid EHR Incentive

Payments

Capacity Assessment by County

Contra Costa Humboldt San Diego San Joaquin San Mateo

Agree to Strongly Agree

Agree to Strongly Agree

Strongly Disagree to Strongly Agree

Disagree to Agree

Agree to Strongly Agree

“Gearing up for this and are well positioned”

“Already doing it” and “Have the organizations, communication, networking capacity”

“Increase in uninsured.” And “There is high commitment and resources”

“Pitting health care against other county issues” and “Uneven provider capacity”

“Already doing it” and “Have the will and the ingredients”

“The county has the organizations and resources to coordinate health care services to meet the needs of the newly insured as well as remaining uninsured, e.g., undocumented immigrants.”

Summary of Study Findings

High county integration activity underway overall; varied stakeholder involvement.

Areas of future involvement—ACOs, HIEs, ePortals—as well as individual stakeholder initiatives.

Study counties have the systems, partnerships, “nimble” organization, and shared commitment but they’re challenged by significant financial barriers and gaps in health care.

IT – tremendous activity underway on all fronts – connectivity issues to be addressed.

Capacity assessment bodes well for implementation of health care reform but there is still work to be done and challenges on the horizon.

Models of Integrated Care

30+ Safety Net Integration Best Practices

HCCI/LIHP

Adoption of PCMH

Disease Management

MH/PC Integration

Colocation of behavioral health services in Family Practice Clinic

Clinic MH/PC initiatives

HIT

Telemedicine to expand access to specialty care

HIE adoption

Clinic access to Lifetime Medical Record

Specialty Care Access

Access to hospital specialty care

Provider peer groups

Patient Coordination, Outreach and

Enrollment

Coordinate care for the uninsured

Clinic/hospital patient transition

Patient navigation

Facilitating factors:New models of leadershipBuy-in at all levelsPerseverance in the face of delays

Safety Net Integration Best Practices - Challenges

HCCI/LIHP

Requires advance preparation.

Inclusion of all stakeholders.

MH/PC Integration

Resource intensive – staffing, expertise.

Finding middle ground.

HIT

Difficult.

Costly.

Potential failure at many points.

Specialty Care Access

Slow, time consuming.

Provider recruitment issues.

Patient Coordination, Outreach and

Enrollment

Lack of resources to support services.

Recommendations

Targeted support for local safety net integration activities Proposed activities, e.g., safety net ACOs IT infrastructure development Support for local infrastructure, e.g., safety net coalitions,

joint leadership models Informing state policy

Tailoring of strategies to meet individual county needs Increased alignment of state and county responsibility, e.g.,

Section 17000 obligations New payment models should be considered, e.g., bundled

payments, to address resource gaps Leverage ACA provisions that support integration, e.g.,

Health Benefit Exchange

Thank you!

For more information:

Annette L. Gardner, PhD, MPH

Philip R. Lee Institute for Health Policy Studies, UCSF

(415) 514-1543

Annette.gardner@ucsf.eduhttp://healthpolicy.ucsf.edu/article/healthcare_safety_net