The Affordable Care Act Post Enrollment: How Will Health Care Reform Affect the Health Care Workforce. April 10, 2014

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1 The Affordable Care Act Post Enrollment: How Will Health Care Reform Affect the Health Care Workforce April 10, 2014

2 The Affordable Care Act Post Enrollment: How Will Health Care Reform Affect the Health Care Workforce Presenters: Illinois Healthcare Action Coalition (IHAC), Pamela S. Robbins, MSN, RN EverThrive (formerly the Illinois Maternal & Child Health Coalition), Kathy Waligora, M.S.W. HealthConnect One, Rachel Abramson, MS, RN Sargent Shriver National Center on Poverty Law, Andrea Kovach, J.D. 2

3 Continuing Education (CE) Requirements Participation in the entire program and completion of the evaluation is necessary to receive your certificate. The evaluation will be ed to you at the address you provided during registration. Certificates will be ed within 7-10 days of completion of the evaluation. This program is being presented without bias, conflict of interest or commercial support. 3

4 The Affordable Care Act Post Enrollment: Goals and Objectives Goal: The learner will be able to state the essential changes for all health insurance, describe the changing role of the nurse in the transition of care from acute care including non-acute services in the home and community, describe the collaboration of nurses with an inter-professional team in the context of the ACA and CMS innovations. Objectives: Discuss the Affordable Care Act (ACA) - important changes for all insurance Explain why nurses should provide leadership in the transition of care coordination Describe the roles of nurses in the ACA health care environment that have a greater incentive on the use of home and community care services Explain how immigrants can meet the individual mandate to obtain ACA coverage Describe collaboration of nurses with Community Health Workers (CHW) Summarize resources for Illinois nurses to use to guide uninsured. 4

5 Agenda Review key Affordable Care Act (ACA) Insurance Reform and Coverage Provisions Discuss the ACA important changes for all insurance Explain why nurses should provide leadership in transition of care coordination Describe the ACA s individual mandate/shared responsibility provision Explain how lawfully present immigrants can meet the individual mandate to obtain ACA coverage Describe the roles of nurses in the ACA health care environment that has a greater incentive on the use of home and community care services Describe collaboration of nurses with Community Health Workers (CHW) Discuss inter-professional collaboration and the ACA Summarize resources for Illinois nurses to use to guide uninsured 5

6 A Brief Overview of the Affordable Care Act s (ACA) Major Insurance Industry Reforms and Health Insurance Coverage Provisions 6

7 1.5 Million Uninsured Non-Elderly Adults in IL Connecting Communities to Coverage

8 ACA 101 The Affordable Care Act puts in place comprehensive reforms that: Protect consumers from insurance industry practices which limited access to coverage for many, and Improve access to affordable health coverage. If you are already insured, you saw new benefits, better consumer protections, and more value for every dollar you spend on care. If you are uninsured, new pathways to coverage helped make it easier to get covered and stay covered. Financial assistance may be available to help pay for coverage.

9 Key Reforms to Insurance Industry Practices Extended dependent coverage to age 26 No pre-existing condition exclusion for children or adults Preventive services without cost sharing No lifetime limits on care No annual limits on care Small business tax credits No insurance rescissions (unless fraud/intentional misrepresentation) All plans must cover Essential Health Benefits No gender rating 9

10 Three ways to get connected: 1. On the web 2. On the phone 3. In Person Work with a Navigator to get support and advice

11 Who is Eligible for the Medicaid Expansion? and not eligible for other Medicaid category Meets Citizenship/Immigration Requirements No asset or disability test Under 138% FPL or about $1400 per month Coverage and Services are similar to regular Medicaid CountyCare continues as Medicaid expansion 11

12 Medicaid in Illinois At A Glance Pre-ACA Post-ACA FamilyCare for parents and other caretaker relatives of children under 19 All Kids Moms and Babies Aid to the Aged Blind and Disabled (AABD) Health Benefits for Workers with Disabilities (HBWD) Health Benefits for Persons with Breast and Cervical Cancer (apply with Illinois Dept. of Public Health) ACA Adult Former Illinois Foster Child FamilyCare for parents and other caretakers of children under 18 All Kids Moms and Babies Aid to the Aged Blind and Disabled (AABD) Health Benefits for Workers with Disabilities (HBWD) Health Benefits for Persons with Breast and Cervical Cancer (apply with Illinois Dept. of Public Health) 12

13 Potentially eligible: for Premium Tax Credit/ Marketplace Potentially eligible: AllKids Marketplace Potentially eligible: Moms and Babies (Pregnant or child under 1) Marketplace Household Size Potentially eligible: ACA Adult Medical or Family Care Marketplace 100%* 133% 138% 200% 250% 300% 400% 1 $11,490 $15,282 $15,856 $22,980 $28,725 $34,470 $45, ,510 20,628 $21,404 31,020 38,775 46,530 62, ,530 25,975 $26,951 39,060 48,825 58,590 78, ,550 31,322 $32,499 47,100 58,875 70,650 94, ,570 36,668 $38,047 55, , , ,590 42,015 $43,594 63,180 78,975 94, , ,610 47,361 $49,142 71,220 89, , , ,630 52,708 $54,689 79,260 99, , ,520 For each additional person, add $4,020 $5,347 $5,548 $8,040 $10,050 $12,060 $16,080 * lawfully present residents below 100% FPL and ineligible for Medicaid may qualify 13

14 Essential Health Benefits Connecting Communities to Coverage

15 Nurse Leadership and the Transition of Care Coordination 15

16 The Affordable Care Act Post Enrollment Nurse Leadership and the Transition of Care Coordination The Future of Nursing: Leading Change, Advancing Health - Institute Of Medicine (IOM) Report (2010) Key Message Recommendation #3: Nurses should be full partners, with physicians and other health professionals, in redesigning health care in the United States. Leadership styles must change: collaboration & partnership vs giving directions & expecting them to be followed Code of Ethics for Nurses (2001) #8: The nurse collaborates with other health professionals & the public in promoting community, national & international efforts to meet health needs. (Code is part of IL NPA Rules Section b) IL RN Scope of Practice (2007) #11: Participating in development of policies, procedures, and systems to support patient safety. (IL NPA Rules Section 60-35: RN Scope) 16

17 The Affordable Care Act Post Enrollment Nurse Leadership and the Transition of Care Coordination The Affordable Care Act will likely impact the places where RNs work and the skills they need to be successful in these settings The 2015 Department of Health and Human Services (DHHS) budget proposes to increase the number of providers trained and to better match the supply and distribution of well-trained health care personnel to meet the needs of the nation s evolving health care delivery system RNs will be expected to serve as care coordinators, case managers, patient educators, and chronic care specialists RNs with strong skills will continue to be in high demand in the labor market 17

18 The Affordable Care Act Post Enrollment Nurse Leadership and the Transition of Care Coordination The American health care workforce includes more than 14 million people, about 10% of the national workforce Reimbursement for chronic case management services for beneficiaries with complex needs across provider types & location are planned to begin by Medicare in 2015 BLS forecasts RN employment in hospitals in 2020 to be about 58% of RNs, compared to about 60% in 2010 In addition to newly insured utilizing ambulatory care, the ACA has specific provisions that focus on preventive care much of which can be delivered by RNs, NPs & PA s in non-acute care settings BLS forecasts RN employment in home care industry to grow by 55% between ; the home care team will include RNs, who will play a key role in care coordination including supervising unskilled workers (2/14: USDHHS: A 21 st Century Health Care Workforce for the Nation) 18

19 The ACA s Individual Mandate/ Shared Responsibility Provision 19

20 Individual Shared Responsibility Most individuals without insurance will pay a penalty (with their federal income tax return). Individuals must maintain Minimum Essential Coverage (MEC) for themselves and dependents. Taxpayers filing a joint return are jointly liable for penalties. Some individuals will be exempt from the penalty. 20

21 Exemptions from Shared Responsibility Income or Affordability Hardship or domestic circumstances Lacks coverage for less than three months (one 3- month period per year) Household income below threshold for federal taxes Contribution for single coverage exceeds 8% of household income Membership/ Affiliation Religious conscience Membership in a health care ministry Member of an Indian tribe Legal or Residential Incarceration Not lawfully present in the U.S. or non-resident aliens U.S. citizens living abroad for 330+ days in 12-months Residents of U.S. territories 21

22 The ACA and Immigrants 22

23 Lawfully Present Immigrants Lawful Permanent Residents (LPRs) Applicants for Adjustment to LPR status with Approved Visa Petitions Persons fleeing persecution, such as refugees, asylees Humanitarian immigrants, such as Cuban and Haitian entrants, individuals paroled into the U.S., TPS status, DED status, deferred action status,* special immigrant juveniles Survivors of domestic violence, trafficking & other serious crimes Non-immigrant visa holders Lawful Temporary Residents and Applicants for Legalization under IRCA; Legalization under the LIFE Act; Family Unity *not included: Deferred Action for Childhood Arrivals per CMS Amendment to Interim Final Rule Lawfully present or residing is much less restrictive than the requirements for Medicaid. See complete list at: https://www.healthca re.gov/immigrationstatus-and-themarketplace/ 23

24 Immigrants who are lawfully present in the U.S. can: Purchase health insurance in the state marketplace. Apply for premium tax credits and cost-sharing subsidies. Are subject to the individual mandate. May be eligible for newly expanded Medicaid and existing Medicaid if children under age 19; pregnant women; Medicaid qualified non-citizen such as LPR over 5 years, refugee/asylee, etc. 24

25 Legal Immigrants and Medicaid Current federal immigrant eligibility restrictions are maintained including the five year bar for LPRs. Only Medicaid qualified non-citizens or immigrants are eligible for Medicaid including LPRs who have been in US over 5 years, refugees/asylees, etc. Children up to age 19 and pregnant women. 25

26 How are Undocumented Immigrants Included in Health Care Reform There is no federal coverage for undocumented immigrants. Not allowed to purchase private insurance through state insurance exchange. Not eligible for premium tax credits. Exempt from individual mandate. Not eligible for Medicare, Medicaid, or SCHIP. Only eligible for emergency Medicaid, children up to age 19 or pregnant women up to 60 days postpartum. Additional funding to community health centers through the Affordable Care Act targeted for undocumented uninsured individuals.

27 Undocumented Immigrants Remain eligible for health programs that are available regardless of immigration status (e.g., public health.) Undocumented children remain eligible for All Kids in Illinois (until age 19.) Can purchase private insurance outside the state Marketplace and through employer and through SHOP. Can receive health care at community health centers such as Federally Qualified Health Centers. 27

28 Children of Undocumented Immigrants U.S. citizen or legal immigrant children of undocumented parents should have the same access to health insurance and health services as other children. Eligible for All Kids (including undocumented children.) Eligible to buy health insurance and get tax credits in the Marketplace with child only plans. Can seek health care services anywhere, including community health centers or school based clinics. 28

29 The ACA Post Enrollment and Nurses 29

30 The Affordable Care Act Post Enrollment Nurse Leadership and the Transition of Care Coordination Health care post ACA initial enrollment will focus on building the health care workforce and improving the delivery of health care services, particularly primary care services RNs will continue to be essential caregivers, but the ACA will impact the places where care is given, growth will be most rapid in outpatient settings, primary care offices and home health RN knowledge of social services, community resources as well as collaboration with social workers, primary care providers will be critical to care of the elderly, the chronically ill, as well as preventive care and health maintenance 30

31 The Affordable Care Act Post Enrollment Nurse Leadership and the Transition of Care Coordination The Future of Nursing: Leading Change, Advancing Health - IOM Report (2010) Key Message Recommendation #3: Nurses should be full partners, with physicians and other health professionals, in redesigning health care in the United States, collaboration and partnership Americans, particularly women, are dying at younger ages than people in almost all other high income countries (IOM, 2012) HRSA Advisory Committee on Interdisciplinary, Community-based Linkages: 12 th Annual Report, August 2013 The focus now is to prepare all health professions & paraprofessions to deliberatively work together with the common goal of building a safer & better patient-centered care and community/population oriented US health care 31

32 The Affordable Care Act Post Enrollment Nurse Leadership and the Transition of Care Coordination The ACA encourages new or reconfigured healthcare models, such as patient-centered medical homes, nurse-managed health centers. Team based care Technology, electronic health record systems Patient self-management Academic medical centers 32

33 The New Health Care Team: Nurses in Collaboration With CHWs 33

34 CHW Definition: American Public Health Association Community Health Workers (CHWs) are frontline public health workers who are trusted members of and/or have an unusually close understanding of the community served. This trusting relationship enables CHWs to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery. CHWs also build individual and community capacity by increasing health knowledge and selfsufficiency through a range of activities such as outreach, community education, informal counseling, social support and advocacy.

35 On the front lines -- As we shift toward... keeping people healthy in their community... we need some foot soldiers in the community that are embraced, that are understood, that are familiar and can translate the jargon into real, actionable items. -- Dr. LaMar Hasbrouck, Director of IDPH

36 CHW integration within the health care team Community health workers are increasingly recognized as an essential part of the health care team, working with physicians, nurses, social workers and others who must better coordinate care to reduce medical expenses under the ACA Many titles: outreach workers, peer educators, promotoras de salud, community-based doulas, health advocates, home visitors, peer advocates, paraprofessionals

37 Example of CHW Integration: Community-based doulas provide extended, intensive home visiting and support to families during pregnancy, birth, breastfeeding and early parenting. They connect their clients to prenatal care and other services, provide physical and emotional support during labor and birth, and refer to licensed clinical providers when indicated. Their close relationship with clients may result in identifying issues that may not be brought directly to MDs or nurses.

38 Issues in collaboration among professionals & CHWs Scope of practice, clarify definition of scope of practice and roles Training and education how extensive is the training (experiential, or popular education) Successful integration of CHWs into the team of care with salary, strong, reflective supervision, and continuing education Open communications and trust within health care team maintaining patient care focus

39 Policy Development: Illinois Health Care Workforce Report & Recommendations (January- 2014) Adopt the American Public Health Association s definition of CHW. Establish a CHW State Advisory Board at the Illinois Department of Public Health to assist in the development of training, curriculum and certification of CHW. Members of the board should include, but not be limited to: CHW (at least 50% plus one); CHW employers; educators; social services professionals; members of public health associations; health researchers; and members of the public. Support legislative action to formalize and standardize CHW training, curriculum, and certification. Provide training through various levels of educational and geographic settings; consider a tiered system of classifications within the CHW field; develop a grandfathering protocol for existing CHW ensuring adequate levels of competency Educate health professions about the APHA CHW definition, the role of CHWs as members of the health care team, and examples of health impact (e.g decreased ER visits and hospital admissions for patients with chronic illnesses such as asthma and diabetes) %20Workforce%20Workgroup%20%20FINAL%20VERSION% pdf

40 The Affordable Care Act Post Enrollment Nurse Leadership and the Transition of Care Coordination Community health nurses coordinate patient & family health care received through the center s program. They function in the roles of facilitators, expediters, coordinators, and potentiators. They often enter into a co-professional relationship with MDs by suggesting changes Community Health Aides are from the area and function as co-equal members of the team. They have been invaluable in helping the nurse understand the community and its attitudes toward health, so as to put into the proper perspective normal and abnormal behavior as it relates to the community. (Iris Shannon, AJPH, September 1970) 40

41 The Affordable Care Act Post Enrollment Nurse Leadership and the Transition of Care Coordination Physician Orders Life Sustaining Treatment (POLST) (ILSB #3076) The POLST Paradigm is an approach to end-of-life planning based on conversations between patients, loved ones, and medical providers. The POLST conversation is about: (a) the patient s specific disease, treatment options (including benefits and alternatives), and what will happen as the patient s disease continues; and (b) the patient s goals of care and values. Using the POLST form gives patients and their primary care givers the ability to frankly discuss the care they wish to receive during the final months of life, which provides them a better quality and dignity. The POLST form compliments Advanced Directives & is a tool for conversation amongst family members, caregivers & those providing care. 41

42 POLST Physician Orders for Life- Sustaining Treatment-Centered POLST promotes quality care through informed end-of-life conversations and shared decision-making: A POLST form is intended for a person that is seriously ill or with a life-limiting illness It is a signed medical order reflecting a person's wishes into actionable medical orders It travels with the person across settings of care that must be honored by all healthcare providers. It is a process, not a single conversation Connecting Communities to Coverage

43 The Affordable Care Act Post Enrollment Nurse Leadership and the Transition of Care Coordination Public Health Nursing is the practice of promoting and protecting the health of populations using knowledge from nursing, social and public health sciences. Key characteristics of practice include: A focus on the health needs of an entire population, including inequities and the unique needs of sub-populations Assessment of population health using a comprehensive, systematic approach Attention to multiple determinants of health An emphasis on primary prevention Application of interventions at all levels individuals, families, communities, and the systems that impact their health Connecting Communities to Coverage

44 Three ways to get connected: 1. On the web 2. On the phone 3. In Person Work with a Navigator to get support and advice

45 Resources 45

46 Resources National immigration Law Center, FAQs: The Affordable Care Act & Mixed-Status Families, October 2013, available at National immigration Law Center, Federal Guidance on Public Charge, When is it Safe to Use Public Benefits? October 2013, available at U.S. Department of Health and Human Service, The Affordable Care Act: Coverage Implications and Issues for Immigrant Families, April Available at U.S. ICE, Clarification of Existing Practices Related to Certain Health Care Information. October 25, 2013, available at Clarification of Existing Practices Related to Certain Health Care Information; Spanish: 46

47 Resources (continued) ANA Code of Ethics for Nurses RWJF: Future of Nursing, Leading Change, Advancing Health: IOM 2010 Report: ANA-Illinois: 3 Step Call to Action for Illinois Nurses: Illinois Department of Financial and Professional Regulation: Nursing Act: RN Scope: Section HRSA: Redesigning Health Professions Education and Practice to Prepare the Interprofessional Team to Care for Populations fthreport_.pdf IWIB Health Care Workforce Task Force e/illinois%20healthcare%20workforce%20workgroup%20%20final%20version% pdf Physician Orders Life Sustaining Treatment 47

48 Resources (continued) Illinois Healthcare Action Coalition Illinois Health Matters EverThrive Illinois ACA The Shriver Center on Poverty Law Kaiser Family Foundation 48

49 + Questions? Kathy Waligora, EverThrive Illinois Andrea Kovach, Shriver Center Pamela S. Robbins, IHAC, ANA-Illinois, Rachel Abramson, HealthConnect One, IL

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