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![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](https://image.slidesharecdn.com/seattlehealthygen4-20-16-160616051035/75/Community-Health-Work-Financing-Sustainability-20-2048.jpg)
Uploaded byFoundation for Healthy Generations
Community Health Work: Financing & Sustainability
The document discusses the role of community health workers (CHWs) in addressing health and social system failures in the U.S., emphasizing the need for comprehensive intervention strategies through Medicaid. It highlights the disparities in social services funding compared to other Western countries and the importance of linking clinical services with community resources for improved health outcomes. The 'Chispas' program is mentioned as a model for integrating services to enhance patient support and achieve cost savings.
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- 1. Charlie Alfero, ExecutiveDirector 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 ViceChancellor 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 muchless on Social Services than other Western Countries
- 6. “Saving Money” inthe 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 ofFailed 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 ofthe Medical Model – Patient View Complex Health Systems Strategies for Tomorrow – Brown Where are Social Services, Employment And Education?
- 9. We Get WhatWe 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 inSocial 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 AverageHealth 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 InterventionStrategy 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 InterventionStrategy 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 InterventionStrategy Population Health Strategies Social Assessments Inform Internal Policy and Systems Changes Clinical Priorities Inform Community Health Improvement Community Engagement Stakeholders / Partners Other Vehicles
- 15.
- 16.
- 17. CHISPAS: Links Clinicsand 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 Savingsby 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 toDifferent 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 PMPMService 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 ComprehensivePatent 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 WestCollege, Suite 16 Silver City, NM 88061 Calfero@swchi.org 575-538-1618