Dmain D. Utilizing Patient Activatin t Expand Access t Cmmunity Based Care fr Special Ppulatins Prject 2.d.i ID Prject Title Implementatin f Patient Activatin Activities t Engage, Educate and Integrate the uninsured and lw/nn-utilizing Medicaid ppulatins int Cmmunity Based Care Objective This prject will be fcused n increasing patient activatin related t health care paired with increased resurces that can help the uninsured (UI) as well as nn-utilizing (NU) and lw utilizing (LU) ppulatins gain access t and utilize the benefits assciated with DSRIP PPS prjects, particularly primary and preventative services. (Nte: While this prject and Prject 2.c.i bth utilize cmmunity-based health navigatrs, the fcus f the tw prjects is very different. This prject is fcused n persns nt utilizing the health care system and wrking t engage and activate them t utilize the system t see primary and preventive care services. Prject 2.c.i is fcused n persns utilizing the system but ding it ineffectively r inapprpriately. The navigatin service in this case assists these persn t access the system effectively and apprpriately by prviding bridge supprt until the patient has the self-cnfidence t manage his/her wn health.) Ratinale and Relatinship t Other Prjects Peple have many reasns they d nt interact with the health care system, including lack f knwledge f health issues, language, literacy and health literacy, lack f insurance r understanding cverage, cultural and religius barriers, embarrassment, fear and ther life pririties, t name a few. Withut targeted activities t address these issues, it will be difficult t engage these persns in managing their health and integrating them int the refrmed health care system. Significant effrts have been undertaken t increase access t health insurance and ther financial resurces t cver the cst f health care; hwever, withut addressing the ther afrementined issues, there will still be a ppulatin that remains disenfranchised frm the system until a serius/catastrphic event is sufficient t frce them t seek care. Engagement with this ppulatin will nt nly require understanding their barriers, but als creating pprtunities fr this ppulatin t gain cnfidence in their ability t understand their health and hw t manage it as well as hw t understand and manage their interactins with the health care system. There is a bdy f literature n patient activatin and engagement, health literacy, and practices t reduce health care disparities that can all be used t develp a prject that increases access t, and use f, the health care system by the UI, NU and LU ppulatins. These resurces include: http://www.ncbi.nlm.nih.gv/pmc/articles/pmc1955271/ http://cntent.healthaffairs.rg/cntent/32/2/223.full http://www.hrsa.gv/publichealth/healthliteracy/ http://www.health.gv/cmmunicatin/literacy/ http://www.ama-assn.rg/ama/pub/abut-ama/ama-fundatin/ur-prgrams/public-health/healthliteracy-prgram.page? http://www.hrsa.gv/culturalcmpetence/index.html http://www.nih.gv/clearcmmunicatin/culturalcmpetency.htm MRT DSRIP Pathway t Achieving the Triple Aim 41
Additinally, when individuals d nt have health insurance, they face significant barriers nt nly accessing the services they need, but als in receiving thse services in a timely manner. Cst becmes a significant barrier fr thse seeking the primary and preventive care they need. Self-pay csts, in mst instances, are generally significantly higher than the discunted rates that the gvernment and ther insurers can negtiate. Persnal barriers nted abve may keep persns frm self-negtiating fr reduced fees r becming aware f the availability f financial assistance r new ptins fr cverage. The lack f cnnectivity t primary care and preventive services results in reliance n emergency departments fr bth minr urgent care and well as true emergent care that was ptentially avidable. Furthermre, health care facility prviders are put in a precarius psitin when prviding care t the uninsured, because, by law, prviders must service this ppulatin when they seek emergency services, while knwing that they may nt receive adequate financial cmpensatin fr services rendered. Furthermre, in additin t the state s uninsured ppulatin, there are als Medicaid members with very lw t n PCP cnnectivity t the prgram. Currently, there are ver ne millin Medicaid members that are enrlled in the prgram, but nt using any services in a given year. Mrever, there is anther grup f Medicaid members that have minimal service utilizatin and little t n cnnectivity with their PCP r care manager. While these may represent generally healthy persns with limited needs fr episdic health care, their lack f cnnectivity with primary and preventive services insures they will nt have an adequate entry prtal shuld they have urgent/emergent needs. This cntinues the cycle f being frced t use urgent/emergency services. As part f the public cmment perid n the waiver and attachments, advcates strngly encuraged the state t include uninsured members in DSRIP, s that this ppulatin culd utilize the benefits f a transfrmed health care system als. Als, cncerns were raised abut the NU and LU ppulatins and the ability f PPS t affect their health. This prject will fcus n these three ppulatins and will require the PPS: t develp activities that prmte cmmunity and patient activatin and engagement with the abve resurces as a starting pint, t prvide cmmunity bridges that allw access t health cverage resurces, and t build linkages t cmmunity based primary and preventive services and create cmmunity based health educatin t sustain and grw the cmmunity and patient activatin in the regin they serve. The PPS will be required t undertake training t perfrm the Patient Activatin Measure and will be required t assess their cmmunities and individual patients n this measure befre and at regular intervals during this prject. This will prvide the quality utcme metrics fr this prject. In rder t be eligible fr this prject, a PPS must already be pursing 10 prjects and must demnstrate in its Prject Plan applicatin its netwrk capacity t handle an 11th prject and hw the netwrk is in a psitin t serve the UI, NU and LU ppulatins. Any public hspital PPS in a specified regin wuld have the first right f refusal in taking n this additinal prject and having the specified ppulatins in their regin attributed t their PPS. Only the uninsured as well as nn-utilizing and lw-utilizing Medicaid member ppulatins will be attributed t this prject. Prject Index Scre 56 Cre Cmpnents MRT DSRIP Pathway t Achieving the Triple Aim 42
PPSs undertaking this prject will be required t cmplete the fllwing activities which are gruped in three primary activities: patient activatin, financially accessible health care resurces, and engagement and linkage t primary and preventive care services. 1. Patient Engagement Establish a team f apprpriate staff wh are frmally trained in the Patient Activatin Measure (PAM ) and have expertise in develping patient activatin and engagement activities t serve as trainers fr the PPS. DSRIP applicatins that chse the 11 th prject must identify the relevant staff that will be designated fr this team as part f its prpsal. Identify ht spt areas fr UI, NU and LU within the PPS partner netwrk (e.g., emergency rms), while als wrking with partnering CBOs wh are familiar with, and trusted by the cmmunity, t perfrm utreach in identified ht spts within the service regin s cmmunity. Wrk with PPS partners t develp activities, including cmmunity frums, surveying the targeted ppulatin abut health care in the PPS regin. PPS Prviders lcated in ht spt areas shuld be trained by the abve trainers in patient activatin techniques, including shared decisin making, measurements f health literacy, and cultural cmpetency. PPS is expected t partner with CBOs t assist in engagement effrts t the prject s targeted ppulatins. PPSs must prvide versight and ensure that engagement is sufficient and apprpriate. T ensure cntinuity f care and the imprtance f an assigned PCP, MCOs will prvide PPS with the PCPs assigned t NU and LU enrllees. The PPS must wrk with the member's MCO and assigned PCP t help recnnect that beneficiary t their designated PCP (see utcme measurements belw). This patient activatin prject is nt t be used as a mechanism t inapprpriately mve members t different health plans and PCPs; but rather, shall be fcused n establishing cnnectivity t resurces already available t the member. The PPS will wrk with the managed care plan and PCP t assure that there is practive utreach t the beneficiary and that the beneficiary is prvided infrmatin abut insurance cverage, language resurces and availability f primary and preventive services. The state must review and apprve educatinal materials prvided t beneficiaries that managed care plans r prviders develp as part f this effrt. Materials shuld cmply with state marketing guidelines and federal regulatins at 42 CFR 438.104. PPS base line fr each beneficiary chrt (a methd will be develped by the state t apprpriately identify this chrt) will be measured during first year f the prject and at set intervals utilizing the PAM. A baseline must be set fr each chrt and intervals twards imprvement must be set at the beginning f each perfrmance perid. The PPS will establish the intervals twards imprvement that must be achieved at the beginning f each perfrmance perid. PPS will include beneficiaries as part f a develpment team t prmte preventative care Measurement f PAM PPS will be respnsible fr screening patient status (UI, NU, LU) and fr cllecting the mst recent cntact infrmatin fr the patient when they visit PPS designated facility r ht spt area fr health service. MRT DSRIP Pathway t Achieving the Triple Aim 43
If the beneficiary is UI, des nt have a registered PCP r is attributed t a PCP in the PPS netwrk, the PPS will be respnsible fr assessing patient, thrugh PAM survey and designating a PAM scre fr baseline measure. Individual member scre will then be averaged t calculate a baseline measure fr that year s chrt. The chrt will be fllwed fr the remainder f DSRIP. On an annual basis, the PPS will be respnsible fr assessing individual member and the verall chrt s level f engagement, with the gal f mving the beneficiary t a higher level f activatin. If the beneficiary is deemed t be LU & NU, but has a designated PCP that is nt part f the PPS netwrk, the PPS will be respnsible fr cunseling the beneficiary n hw t better utilize their existing health care benefits, while als encuraging the beneficiary t recnnect with their designated PCP. The PPS will NOT be respnsible fr assessing the patient thrugh PAM survey. PPS will als be respnsible fr prviding the mst current cntact infrmatin t the beneficiary s MCO, s that MCO may help the assigned PCP reach ut t the member. PPS shuld prvide member engagement lists t relevant insurance cmpanies (fr NU & LU ppulatins) n a mnthly basis and t DOH n a quarterly basis s that the state can track engagement and utreach effrts assciated with the prject. 2. Linkage t Financially Accessible Health Care Resurces Thrugh engagement PPS will increase the vlume f nn-emergency (primary, behaviral, dental) care prvided t uninsured persns and lw utilizing Medicaid beneficiaries thrugh its partner prviders. 3. Linkage t Health Care Systems and PPSs In cllabratin with CBO, the PPS will develp a grup f cmmunity Navigatrs wh are trained in linkages t health care cverage, cmmunity health care resurces including fr primary and preventive services, and patient educatin. The PPS must keep recrd and reprt t the state, the number f Navigatrs that it emplys. PPS must have a means fr Medicaid recipients and prject participants t reprt cmplaints and receive custmer service. Cmmunity Navigatrs will receive training in patient activatin and educatin including use f the PAM s they can apprpriately assist prject beneficiaries. Navigatrs will be prminently available t the cmmunity at PPS ht spts, PPS partner CBOs, Emergency Departments and cmmunity events t ensure there is the ability t have direct hand-ffs t the Navigatr t educate n health insurance cverage (if applicable), educate n age-apprpriate primary and preventive health care services, and t cnnect with primary and preventative care resurces. PPS will practively infrm and educate navigatrs abut insurance ptins and health care resurces available t ppulatins in this prject. PPS will practively ensure when Navigatrs call fr primary and preventive services fr a cmmunity member there is apprpriate and timely access available. MRT DSRIP Pathway t Achieving the Triple Aim 44
Outcme Metrics Nn- and Lw Utilizer Medicaid Members 1. Interval change in PAM Percent f members measured at Level 3 r Level 4 n the PAM -- Using n less than the 13 item versin f PAM and specific health related behavirs such as self-management behavirs including fllw a lw fat diet, manage stress in a healthy way and knw recmmended weight, ask abut medicatin side effects when taking a new prescriptin; disease specific self-management behavirs including hypertensin, arthritis and diabetes; and ther variables related t health related quality f life, a measure f depressin and a measure f scial desirability. 2. Use f primary and preventive care services-- Percent f attributed Medicaid members with n claims histry fr primary care and preventive services in measurement year cmpared t same in baseline year. Uninsured Ppulatin 1. Interval change in PAM Percent f members measured at Level 4 n the PAM -- Using n less than the 13 item versin f PAM and specific health related behavirs such as selfmanagement behavirs including fllw a lw fat diet, manage stress in a healthy way and knw recmmended weight, ask abut medicatin side effects when taking a new prescriptin; disease specific self-management behavirs including hypertensin, arthritis and diabetes; and ther variables related t health related quality f life, a measure f depressin and a measure f scial desirability. 2. Emergency department use by uninsured persns as measured by percent f Emergency Medicaid emergency department claims cmpared t same in baseline year 3. CG-CAHPS dne by the PPS dcumenting the uninsured experience within the PPS Prject Dmain Prject ID Clinical Imprvement Prjects (Dmain 3) A. Behaviral Health 3.a.i MRT DSRIP Pathway t Achieving the Triple Aim 45