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


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

    1. 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. 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
    3. 3. The Road to Coordinated Care
    4. 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. 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. 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
    7. 7. California Counties –Health Stewards, Health Innovators
    8. 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; YesCosta Costa Health Medical Center Community Clinic Plan) ConsortiumHumboldt Private FFS St. Joseph Health OpenDoor CHCs, North No(CMSP) System Coast Clinics NetworkSan Diego Private GMC UC San Diego Medical La Maestra CHCs; Yes Center Council of Community ClinicsSan Public/private 2-Plan (Health San Joaquin General Community Medical NoJoaquin 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. 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. 10. Findings:Level of Integration by County“Please rate the level of collaboration or integration that has been achieved bythe organizations that work on initiatives to integrate the safety net on a scale of1 – 10 where 1=information sharing and communication; 3=cooperation andcoordination, e.g., do joint planning; 6=collaboration, e.g., sharing offunding/services; 8=consolidation, e.g., regular meetings of key players, cross-training of staff; 10=integration, e.g., shared funding of positions, joint budgetdevelopment” 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. 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 ActivitiesParticipation in an ACO P P Y P Y (ACC) (DSRIP)Adoption of an integrated network of safety Y Y Y Y Ynet providers (coordinate care acrosslevels of care)Provider-level ActivitiesAdoption of panel management Y Y Y Y YOnsite mental health care at PC sites Y Y Y Y YOnsite dental health at PC sites Y Y Y Y YExpanded communications between Y Y Y Y Yprimary care and specialty careExpanding provider scope of service Y Y Y Y YCounty contracts with comm. clinics Y Y Y Y YAdoption of PCMH Y Y Y Y YAddition of new health care services Y Y Y Y YAuto enrollment of Medi-Cal patients Y P Y Y YER Diversion Programs Y Y Y Y Y
    12. 12. Activities Underway, Proposed, by County (cont.) Contra Humboldt San San San Costa Diego Joaquin MateoHealth Information TechnologyElectronic eligibility and enrollment Y Y Y Y YElectronic prescribing Y Y Y Y YElectronic health information system (EMR) Y Y Y Y YElectronic Disease Registry Y Y Y Y YElectronic specialty care referral Y Y Y P YElectronic panel management system Y Y Y Y YHealth Information Exchange P Y Y Y PPatient-level ActivitiesAfter hours and/or same day scheduling Y Y Y Y Y24/7 nurse advice line Y Y Y Y YE-Portals for patients to interact with P Y Y P PsystemsCase management services Y Y Y Y YCertified Application Assistors Y Y Y Y YCommunity Health Workers Y Y Y Y YPatient Navigators Y Y Y Y YAccessible telephone system Y Y Y Y YLanguage access Y Y Y Y Y
    13. 13. Interprofessional Collaboration
    14. 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. 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
    16. 16. Patient-Centered Care
    17. 17. Areas of High Involvement byMost 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
    18. 18. Adopting, LeveragingInformation Technology
    19. 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. 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. 21. Challenges – Vary by County Presence of a Medi-Cal health plan Geographic barriers Market share competition among providers County financial situation
    22. 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. 23. Capacity Assessment by County“The county has the organizations and resources tocoordinate health care services to meet the needs ofthe newly insured as well as remaining uninsured,e.g., undocumented immigrants.” Contra Humboldt San Diego San Joaquin San Mateo CostaAgree to Agree to Strongly Disagree to Agree toStrongly Strongly Agree Disagree to Agree Strongly AgreeAgree Strongly Agree“Gearing up “Already doing “Increase in “Pitting health “Already doingfor this and it” and “Have uninsured.” care against it” and “Haveare well the And “There is other county the will and thepositioned” organizations, high issues” and ingredients” communication, commitment “Uneven networking and resources” provider capacity” capacity”
    24. 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.
    25. 25. Models of Integrated Care
    26. 26. 30+ Safety Net Integration BestPractices 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 navigationFacilitating factors: New models of leadership Buy-in at all levels Perseverance in the face of delays
    27. 27. Safety Net Integration BestPractices - 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. 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. 29. Thank you!For more information:Annette L. Gardner, PhD, MPHPhilip R. Lee Institute for Health Policy Studies, UCSF(415) 514-1543Annette.gardner@ucsf.eduhttp://healthpolicy.ucsf.edu/article/healthcare_safety_net