A Presentation for The California Program on Access to Care (CPAC) of the UC Berkeley School of Public Health. This presentation is intended to assess where the Safety Net as this state proceeds into full implementation of health care reform.
Presentation by Annette Gardner, PhD, MPH, Study Director
Philip R. Lee Institute for Health Policy Studies
University of California, San Francisco
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Local Initiatives to Integrate the Health Care Safety Net: Laying the Foundation for Health Care Reform
1. 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
2. ―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
4. 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
5. 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.
6. 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
8. Five Study Counties
Safety Net Medi-Cal Model Study Safety Net Study Non-County HCCI
System and Study Plan Hospital Clinic, Consortium Legacy
County?
Contra Public/private 2-Plan (Contra Contra Costa Regional La Clinica de La Raza; Yes
Costa Costa Health Medical Center Community Clinic
Plan) Consortium
Humboldt Private FFS St. Joseph Health OpenDoor CHCs, North No
(CMSP) System Coast Clinics Network
San Diego Private GMC UC San Diego Medical La Maestra CHCs; Yes
Center Council of Community
Clinics
San Public/private 2-Plan (Health San Joaquin General Community Medical No
Joaquin Plan of San Hospital Centers, Inc.
Joaquin)
San Mateo Public COHS (Health San Mateo Medical Ravenswood Family Yes
Plan of San Center Health Center
Mateo)
9. Health Care Safety Net Gaps
Populations Services Diseases, Skill Gaps
Conditions
Undocumented Primary Care; Mental health, Some provider
uninsured; substance types, e.g.,
Mental Health; abuse; primary care and
Homeless; orthopedics;
Specialty Care; Chronic
Some sub- diseases; HIT, e.g., roll-out;
populations, e.g., Dental health;
Pacific Islanders; Obesity. Connecting
Access issues, services, HIT
Seniors. e.g., same day systems
appointments.
10. Findings:
Level of Integration by County
“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”
Contra Humboldt San Diego San San Mateo
Costa Joaquin
7.7 6.7 6.3 7.2 7.5
(ranges from (ranges from (ranges from (ranges from (ranges from
6 to 9.5) 5 to 9) 5 to 8) 6.5 to 8) 7 to 8)
“county-run; “no shared “project by “Among “depends on
shared funding; project” county the area;
funding of regular entities – 9; separate
positions” meetings, with outside budgets but
project- entities – 6 to will contribute
specific 7” to a joint
funding. project”
11. Findings – Activities Underway (Y) and Proposed,
by County (N=28 activities)
Contra Humboldt San Diego San San Mateo
Costa (26) (28) Joaquin (26)
(25) (25)
System-level Activities
Participation in an ACO P P Y P Y
(ACC) (DSRIP)
Adoption of an integrated network of safety Y Y Y Y Y
net providers (coordinate care across
levels of care)
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 Y Y Y Y Y
primary care and specialty care
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
12. Activities Underway, Proposed, by County (cont.)
Contra Humboldt San San San
Costa Diego Joaquin 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 P Y Y P P
systems
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
14. Findings - Integration Activities
―Underway‖ by Stakeholder
30
# Integration Activities
25
Contra Costa
20
Humboldt
15 San Diego
San Joaquin
10 San Mateo
5
0
County Health Safety Net Medi-Cal Plan Non-County Clinic
Agency Hospital Clinic Consortium
15. ―Proposed‖ Integration Activities by
Stakeholder
14
# Integration Activities
12
Contra Costa
10
Humboldt
8
San Diego
6
San Joaquin
4 San Mateo
2
0
County Health Safety Net Medi-Cal Plan Non-County Clinic
Agency Hospital Clinic Consortium
17. 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
19. 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
20. 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
21. Challenges – Vary by County
Presence of a Medi-Cal health plan
Geographic barriers
Market share competition among providers
County financial situation
22. 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
23. Capacity Assessment by County
“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.”
Contra Humboldt San Diego San Joaquin San Mateo
Costa
Agree to Agree to Strongly Disagree to Agree to
Strongly Strongly Agree Disagree to Agree Strongly Agree
Agree Strongly Agree
“Gearing up “Already doing “Increase in “Pitting health “Already doing
for this and it” and “Have uninsured.” care against it” and “Have
are well the And “There is other county the will and the
positioned” organizations, high issues” and ingredients”
communication, commitment “Uneven
networking and resources” provider
capacity” capacity”
24. 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.
26. 30+ Safety Net Integration Best
Practices
HCCI/LIHP Specialty Care MH/PC HIT Patient
Integration Coordination,
Access Outreach and
Enrollment
Adoption of Access to Colocation of Telemedicine to Coordinate care
PCMH hospital behavioral expand access for the
specialty care health services to specialty care uninsured
Disease in Family
Management Provider peer Practice Clinic HIE adoption Clinic/hospital
groups patient transition
Clinic MH/PC Clinic access to
initiatives Lifetime Medical Patient
Record navigation
Facilitating factors:
New models of leadership
Buy-in at all levels
Perseverance in the face of delays
27. Safety Net Integration Best
Practices - Challenges
HCCI/LIHP Specialty Care MH/PC HIT Patient
Access Integration Coordination,
Outreach and
Enrollment
Requires Slow, time Resource Difficult. Lack of
advance consuming. intensive – resources to
preparation. staffing, Costly. support
Provider expertise. services.
Inclusion of all recruitment Potential failure
stakeholders. issues. Finding middle at many points.
ground.
28. 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
29. 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.edu
http://healthpolicy.ucsf.edu/article/healthcare_safety_net
Notes de l'éditeur
Good afternoon. Thank you for attending today's presentation. I'm delighted to have an opportunity to share our findings from the study on safety net integration activities underway in 5 California Counties.I thought I would present for about 20 minutes, stopping periodically for questions and closing with a 20-Q/A session. I also have some questions for you.
I thought it would be helpful if I shared a definition of “integration” and what we are striving for. As everyone here knows, we’re grapping with a fragmented, siloed health care delivery system that comes up short in providing appropriate care. This comes from the human services arena but it speaks to many of the goals in the health care arena, e.g., patient-focused, coordinated care.
How will we get there? The ACA affords many opportunities. However, there will still be many hurdles to overcome.
But where do things stand with safety net integration now? How might we proceed? We decided to look five counties and their safety nets to address these questions. Why counties? In California, they are where the “action” is at when it comes to expanding coverage…something we’ve been studying since 2000. They play a major role in delivering and/or paying for health care services for the medically indigent under their Section 17000 obligations, as well as the administration of Medi-Cal. They are also diverse.
We developed a simple, quick study.
The criteria for selecting our 5 study counties is detailed in the report. Basically we were looking for five “mature”, diverse counties in terms of their safety net models.
We drilled down in the gaps in the health care safety nets in the five counties. Here are some of the challenges that cut across the five counties. This isn’t news to you but I was surprised to see that lack of primary care services figured prominently. In the past its been specialty services. The Skill gaps provides helpful information on points of intervention for facilitating integration.This reinforces the earlier point that access and integration are related.
At the macro level, we corroborated our assumption that these counties were well down the path to increased integration of their safety net systems. The two counties that don’t have public health care delivery systems were slightly less integrated but not by much.
Drilling down, here are the findings for the 28 integration activities by county. Our cover the water front approach to understanding what activities are underway and which ones are proposed. A high amount of activity overall with three areas in the Proposed Stage. We categorized the activities by System-Level, Provider-Level and Patient-Level.
Continuing with our 28 activities. I’ve clustered the IT activities. It was a little bit of a moving target, i.e., one county flipped from Proposed to Underway for its HIE initiative.
For those of you viewing these next two slides on your computer screen, this comparison will be fairly apparent. For everyone else, just bear with me. We can pause for questions. I’m going to present the data on number of activities underway for each county, by stakeholder. Contra Costa – high overall except for consortium; Humboldt – high except the county and hospital; San Diego – high despite low county involvement in providing services; San Joaquin – except for the Medi-Cal plan, it’s lower overall; and San Mateo – high overall. The one other difference is that there are differences among the safety net hospitals.
Similarly, here are the “Proposed” Activities by county, by stakeholder. San Joaquin County has more activities “proposed” as well as the Non-County Clinics.
When we look at what stakeholders are involved with, we see that no single type of stakeholder engaged in more integration activities than others. Instead, there were many areas where there was high involvement by nearly all stakeholders in all counties.
All are busy with implementing multiple IT systems.
Stepping Back - we identified the factors that facilitate integration, many of which were the same from county to county. These could also be considered points of intervention.The barriers or systemic challenges were fairly universal
The differences in factors//challenges in the 5 counties are worth noting. The presence of a Medi-Cal plan – we understand them to be vehicles of change. I should have added clinic consortia or what we call “nimble” organizations in the report.Geographic barriers figure prominantly in Humboldt countyMarket share competition might be widespread but it was more prominent in San DiegoSimilarly, county financial circumstances are dire but they maybe more so in San Joaquin County
Drilling down in the area of resources and what is the current situation. Some initiatives such as the specialty care access initiative and HCCI/LIHP programs cut across multiple counties.
To end this section on an upbeat note…despite these challenges, the informants from the five counties thought their counties have the resources and wherewithal to coordinate health care services and implement health care reform. There was some disagreement in San Diego and San Joaquin counties, i.e., the findings were more mixed than in the other three counties.
Here are the findings from the survey of integration activities and facilitating factors/challenges boiled down to five points.
I’m going to shift gears and talk about the 30+ safety net best practices we documented. They broke out in to five categories.
Each of the five types of initiatives had their unique challenges.
Based on the stakeholder interviews and best practices, we developed the following recommendations for supporting safety net itnegration more broadly. We were mindful of the state’s financial situation and opportunities under the ACA.
I have some questions for you:What information about county-level integration is more valuable?Would more detailed case studies of individual counties be valuable?Would a follow-up study of 4+ counties or “later adopters” be valuable?