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

1. Charlie Alfero, Executive Director
Southwest Center for Health Innovation
NM Primary Care Training Consortium
National Center for Frontier Communities
calfero@swchi.org
Community Health Workers
Address Health and Social
System Failures, Cost
(Financing and Sustainability)

2. Arthur Kaufman, MD
Vice Chancellor for Community Health
University of New Mexico
akaufman@salud.unm.edu

3. San Leucio, Benevento, Campania, IT

4. Santa Paolina, Avellino, Campania, It

5. US Spends much less on Social Services than other
Western Countries

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. 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. A Diagram of the Medical Model – Patient View
Complex Health Systems
Strategies for Tomorrow –
Brown
Where are
Social Services,
Employment
And
Education?

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. 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. 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. 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. 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. 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. We Call it…………

16. 16
CHISPAS
Means
SPARKS

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. 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. 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. 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. 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. 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. PAYMENT MODEL
 Comprehensive Patent Support and
Community Health
$5.75 PMPM
 Intensive Care Coordination
$321 PMPM
Limited Numbers

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. Charlie Alfero
301 West College, Suite 16
Silver City, NM 88061
Calfero@swchi.org
575-538-1618