Montana Frontier Community Health Care Coordination Demonstration Grant
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1 Montana Frontier Community Health Care Coordination Demonstration Grant A demonstration project funded by the U.S. Department of Health and Human Services Office of Rural Health Policy through the Montana Department of Public Health and Human Services, subcontracted to MHA s Montana Health Research and Education Foundation
2 Background Montana Frontier Community Health Care Coordination Demonstration Grant was awarded in The purpose of this grant is to improve the health status of clients with multiple chronic conditions who are Medicare and Medicaid beneficiaries living in frontier areas
3 Structure of Project Minimal part-time (10 hours per week) Community Health Workers hired at about $10-$12/hour Frontier/very small rural communities Supervision from the hiring healthcare facility Training, overall project supervision from MHREF (Heidi Blossom, Care Transitions Coordinator)
4 Project Structure, con t. Generally, no hospital offices or equipment available to Community Health Workers No benefits Profile of those accepting the 10-hour/week, $10/hour position: usually retired; almost all non-clinically-trained; a few affiliated with the healthcare facilities in other capacities
5 Project structure, con t. Curriculum modeled on Minnesota s Emphasis is on non-clinical intervention and care coordination Multiple trainings and ad hoc trainings offered to accommodate rapid turn-over in CHWs
6 Project structure, con t. Budget for first year $194,954 Budget for second year $171,040 Budget for third year $146,602
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8 Community Health Workers CHWs are paraprofessionals who work directly with members of the community with chronic conditions and are preferably Medicare or Medicaid beneficiaries, to support clients in improving their health, reducing avoidable hospitalizations, and readmissions as well as to link these individuals with health and social services needed to achieve wellness.
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10 What do the CHWs Do? Preform face-to-face and phone contact with their clients on a scheduled basis and as needed. Supports and educated clients in medication management and adherence; exercise; nutrition; health care system navigation; health promotion and management of chronic illnesses. Provides support and notifies clinical team and program manager regarding changes in: behavior, medication compliance, and other issues as related to the established care plans. Help and coordinate patient transportation and accompaniment as needed to scheduled appointments.
11 What CHWs Do Assure patients get appropriate and timely services by making referrals and motivating/teaching people to seek care. Participate in regularly scheduled staff development training to improve self-knowledge of chronic illness Communicate all concerns to the Care Transition Coordinator. Communicate with patients, families, and providers to keep them informed and help bridge barriers to patient s health care goals. Create a non-judgmental atmosphere in interactions with individuals and their identified families
12 Community Outreach Red Hat Ladies Pot-Luck Dinners Transportation Coordination Stepping on Program City Planning Harlowton Neighbors Helping Neighbors
13 Who Provides Referrals Providers Senior Centers Low Income Housing directors Sherif Communities of Faith Families and Friends
14 Barriers Clients Like being ill Will not participate because this is a grant Do not believe they need help Facilities Unsure why they participated Are fearful that this will impact the bottom line No space for the CHWs to work Poor communication between the CEO and the providers Champion for the program has left the facility
15 Barriers Providers Believe that anyone dealing with patients should be nurses Do not want the government telling them what to do Lack of control Fearful that this will impact the bottom line
16 Successes Prevented elder abuse Prevented disaster Lowered ER visits and EMS calls Assisted clients to receive needed care Helped clients understand their disease and treatment
17 Successes We do believe we ve been able to collect enough information concerning the client base and enough information about their outcomes to provide indicators that a CHW project holds huge promise in both frontier and other communities. Information is anecdotal Information is assessed based on reports from CHWs, clinic managers and DoNs, public safety personnel (e.g. county Sheriffs) and some client self-reports
18 Successes While some outcomes are speculative ( we believe we ve saved this much money because we believe the client would have returned to the ED or clinic without this intervention ) the projection methods used are not dissimilar to the assumptions used in putting together CMMI proposals or those recommended as estimates for preparing FCHIP waiver proposals. The savings and health impacts reported here are therefore not empirically validated, but are conservative estimates and judgments about program impact which we believe warrant further exploration of this model.
19 Cost Savings Cost savings calculated from Comp Data, MT DPHHS Medicaid data, survey of sites for average clinic visit costs; est. cost on 911 calls (no state or national data available, see footnote and website) Calculations for 26 out of the 113 total cases 6-month Costs saved, CMS/Medicaid $513,725 6-month Costs saved, other tax sources $23,000 One year ( ) full program cost $171,040 6-month Medicare-Medicaid estimated costs saved minus one full year program expenses ( ) $342,725
20 Lessons Learned Need a champion in each facility Community Health Workers should be from the community they serve Turn-over is a constant People with a medical or social work back ground do not make the best Community Health Workers
21 Billing for CHW Services Medicare Benefit Policy Manual- Chapter 13-Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Transitional Care Management (TCM) Services (rev.201, Issued: , Effective: , Implementation: )
22 Billing Cont. Billing for TCM services must be within 30 days of the date of discharge from a hospital, SNF or Community Mental Health Center. Communication must happen within 2 business days of discharge and a face-to-face visit must occur with 14 days of discharge. CHW have to work under the supervision/direction of a licensed provider
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