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Community Health Work: Financing & Sustainability


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Charlie Alfero, MA presents on financing for community health work.

This workshop will report on the development of “CHISPAS” a Medicaid Community Health Worker service and payment model that is being piloted in New Mexico. CHISPAS provides PMPM (per member per month) for Basic Patient Support, Intensive Care Coordination and support policy, systems and environmental changes to improve health and reduce costs. It is a national model for providing an on-going financing / payment source for CHW services.

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Community Health Work: Financing & Sustainability

  1. 1. Charlie Alfero, Executive Director Southwest Center for Health Innovation NM Primary Care Training Consortium National Center for Frontier Communities Community Health Workers Address Health and Social System Failures, Cost (Financing and Sustainability)
  2. 2. Arthur Kaufman, MD Vice Chancellor for Community Health University of New Mexico
  3. 3. San Leucio, Benevento, Campania, IT
  4. 4. Santa Paolina, Avellino, Campania, It
  5. 5. US Spends much less on Social Services than other Western Countries
  6. 6. “Saving Money” in the US  Means Testing  In or Out  Qualified or Out of Luck  Engraining Discrimination and Divisiveness  Age, Sex, Race, Economic Condition Based Criteria  Disproportionate / Targeted Responses and Exacerbation of the Problem (Divide and Conquer) Social Justice Is Systemic If Everyone is IN – No one is OUT!
  7. 7. The Language of Failed Policy Racism Minority Poverty Social Determinants of Health Disparities / Inequities Unaffordable Education Rural Disproportions (Older, Sicker, Poorer, Life Expectancy)ACES Home Less Ness Categorical and Soft Money Discretionary / Entitlement
  8. 8. A Diagram of the Medical Model – Patient View Complex Health Systems Strategies for Tomorrow – Brown Where are Social Services, Employment And Education?
  9. 9. We Get What We Pay For! 0 1 2 3 4 5 6 7 8 9 0 5 10 15 20 25 Diminishing Returns of Complexity Complex Systems And Cost ROI – Health / Well-Being US – Spend More / Get Less
  10. 10. Clinical Involvement in Social Issues Social Determinants Referral to Community Health Worker for:  Food Assistance  Housing Assistance  Utilities Assistance  Transportation Assistance  Daycare Assistance  Legal Assistance  Employment Assistance  Education Assistance  Substance Abuse Assistance  Safety Assistance  Domestic Violence Assistance  Other Each Social Determinant of Health has an ICD-10 code ex. Lack of Food – Z59.4 Inadequate Housing – Z59.1 Lack of Education – Z55.9 Lack of Transportation – Z59.8 Problems Employment - Z56.89 Insufficient Income – Z.56 Also Abuse Codes – T74
  11. 11. Excellent Health Average Health Very Poor Health % Population Population Health Strategies Comprehensive Patient Support Intensive Care Coordination % of Cost Primary Care Linked Strategies Specific Strategies are Necessary to Address the Underlying Causes of Ill Health
  12. 12. Medicaid: Comprehensive Intervention Strategy  Comprehensive Patient Support with Community Health Workers (CHWs)  Social Assessments Support Clinical Strategies  Non-Clinical Interventions and Education  Facilitated Access to a Wide Range of Services as Indicated  Supportive Services to Achieve Primary Care Goals
  13. 13. Medicaid: Comprehensive Intervention Strategy  Intensive Care Coordination Lead by CHWs  High Risk / Cost Patients with Favorable Patient Ratios  Patient-Specific Plans  100% Case Review by MCO  Cost Evaluation
  14. 14. Medicaid: Comprehensive Intervention Strategy  Population Health Strategies  Social Assessments Inform Internal Policy and Systems Changes  Clinical Priorities Inform Community Health Improvement  Community Engagement Stakeholders / Partners Other Vehicles
  15. 15. We Call it…………
  16. 16. 16 CHISPAS Means SPARKS
  17. 17. CHISPAS: Links Clinics and Communities  CHW links within Clinic  Providers  Front Desk  Medical Assistants  EHR, Referral System, Warm Handoffs, Team Huddles  CHW links in Community  Community-Engaged CHWs  Social Services Referrals and Development  Other Sectors (ex. Transportation, Food, Utilities)
  18. 18. Anticipated Cost Savings by Program Maurice Moffett, PhD Health Economist, Office for Community Health Mmoffett@salud.unm.edu0.0% 1.0% 2.0% 3.0% 4.0% 5.0% 6.0% 7.0% 8.0% Year 1 Year 2 Year 3 Comprehensive CHW
  19. 19. CHISPAS Contract Features  Contracts with Medicaid and MCOs to Develop Pilot Program – Still There – Will do One more Year  Contract / Service Standards and Guidelines  Targeted Curriculum  Training and Technical Assistance  Tele-Education and Program Support  Roll Out Plan – Adding Four More Sites  Evaluation, Research, Publication
  20. 20. Standards and Guidelines – (Excerpt/Draft) COMPREHENSIVE PATIENT SUPPORT Standard Requirement Framework/Model Element A – Assess and stratify members’ individual needs 1. Document the number of Medicaid members that access the clinic annually for preventive services and / or care.  Policy showing how the information is consistently collected.  Monthly report CMS Accountable Health Communities (CMS-AHC) 1. Verify Medicaid eligibility, contact and demographic information.  Log of contact or record review  Proof of Medicaid eligibility documented in patient record. CHISPAS – protocol 1. 100% of CE patients who access the clinic are surveyed to identify social determinants of health [using the Well Rx and / or CMS Z-Codes in patient health records]  Policy  Completed WellRx in patient record  Annual report with analysis of Well Rx results  Analysis of Z Coding in EHR CMS-AHC PI-CCHH PCMH CHISPAS Protocol SIM
  21. 21. What Incentives to Different Payment Systems Have? Model Volume Cost Quality Fee-For-Service High / Low High / Low High / Low Capitation High / Low High / Low High / Low Global Budgets High / Low High / Low High / Low Value-Based, Shared Savings High / Low High / Low High / Low
  22. 22. We Chose PMPM Service Contracting  Budget-able  Scalable  Service Contracts  Report-Based Payments  Specific  Separate from Medical Payments  Moves Health Equity from a Soft Money Concept to an Administrative Unit
  23. 23. PAYMENT MODEL  Comprehensive Patent Support and Community Health $5.75 PMPM  Intensive Care Coordination $321 PMPM Limited Numbers
  24. 24. Primary Care Providers • Medical • Dental • Behavioral • Patient / Family / Community Health Range of Care • Prevention • Diagnosis • Treatment • Management 4 Core Primary Care Service Payment Equity Model PAYMENT SYSTEM
  25. 25. Charlie Alfero 301 West College, Suite 16 Silver City, NM 88061 575-538-1618