Section 3: Strategic Direction
Strategic direction requires health administrators to analyze three key areas:
a.
a. Resources
b. Stakeholder expectations
c. The external environment
In their research, Harrison and Thompson (2014) suggested health administrators
use the results of their analysis to promote organizational innovativeness and to
challenge the status quo. Challenging the status quo requires collaboration across
invisible boundaries to accomplish innovative projects that, together in partnership,
accomplish more than can be accomplished alone.
Strategically directing healthcare organizations into successful new partnership
ventures requires skill in leading teams into uncharted territory outside the comfort
level of one or more stakeholders in the partnership. Through interprofessional
collaboration, areas of uncertainty are addressed by stimulating discussion of these
areas and identifying mutually agreeable solutions.
In Section 1, you reviewed the leadership competencies needed by health
administrators and through the administrator lens critiqued community health needs
assessment, thus examining the external environment. In Week 3, you considered
organizational and community resources and stakeholder expectations through a
SWOT analysis of forming a partnership with community health and design your
strategic plan for this partnership. In Section 2, you examined the role of healthcare
regulatory agencies in partnerships, then considered the legal aspects when forming
formal partnership agreements. Additionally, you reviewed the performance outcomes
of a potential hospital partner.
In this final section, you will use your strategies to finalize your plan to improve
community health and improve organizational performance through a community
health/nonprofit hospital partnership project.
Leaders inspire others to be effective without coercion; rather, they inspire
effectiveness and innovation through the promotion of the value of their work (Sull,
2007).
References
Harrison, J. S., & Thompson, S. M. (2014). Strategic direction. In Strategic
management of healthcare organizations: A stakeholder management approach (pp.
27-37). New York, NY: Business Expert Press.
Sull, D. N. (2007). Closing the gap between strategy and execution. MIT Sloan
Management Review, 48(4), 30-40.
Financial Impact of a Community Health Partnership
In Week 5, you learned the funding burden of community/hospital partnerships is
borne by hospitals. However, according to an expert in multi-sector healthcare
collaboration, hospitals that invest in community partnerships report a greater return
on investment (ROI) for both entities in the partnership.
This week, you will begin preparing your budget for the partnership you are
developing with the community health department.
Figure 5. Goals to Address Healthcare Needs
Given the three goals, you must budget for the added expenditures in operating costs
and salaries and benefits. Remember to consult the Bureau of Labor Occupational
Outlook Handbook for the needed salary information.
Projecting expenses must be completed to ensure resources are allocated to a
project. This week, you are creating a budget plan for the project into which you will
enter with the community health department.
In your scenario as the nonprofit hospital CEO, you are encouraged to learn from
your future partner, the CEO at the community health department, that they will share
the cost of the collaborative project and pay for examination room equipment and
supplies, furniture, office materials, printing costs, and the data software programs for
patient education.
A nonprofit hospital’s investment in community health is mandated by the ACA with
financial penalties for non-compliance. In addition, nonprofit hospitals risk loss of their
IRS status as a tax-exempted without demonstration of contributing to the community
benefit (Carlton & Singh, 2018).
The net cost (i.e., the total costs minus any offsetting revenues) of the hospitals’
spending on community health improvement provides the basis to calculate the return
on investment.
The overarching missions of healthcare organizations are to improve the health
status of their community through the delivery of safe and quality healthcare services.
In recent years, healthcare organizations are seeking partnerships with community
organizations to take a broader approach to improve community health.
In addition to breaking down perceived silos between healthcare organizations and
community-based health organizations, the formation of partnerships is gaining the
attention of research and philanthropic organizations who are making grant funds
available to healthcare administrators to examine how community health/nonprofit
hospital partnerships reduce overutilization of the healthcare delivery system, thus
reducing healthcare costs through proactive activities, especially in older adults. A
search of The Commonwealth Health Fund website will reveal grants awarded for
organizations forming partnerships to improve performance; the value of grant
awards is no less than one-quarter million dollars.
With any partnership that requires a start-up financial stake, there must be an
assessment of the ROI, both from a holistic perspective and fiscal perspective. The
net cost (i.e., the total costs minus any offsetting revenues) of the hospitals’ spending
on community health improvement provides the basis to calculate the fiscal return on
investment (Carlton & Singh, 2018). Communities that have formed partnerships are
reporting the holistic ROI through the promising results to improve health outcomes
and reduce health disparities.
Merely professing that it’s the right thing to do may sway some stakeholders, but not
all. There will be skeptics, and only after providing information on the anticipated ROI
of forming the partnership to carry out clearly established goals will these naysayers
get onboard with the project.
•
Using community partnerships to integrate health and social services for high-need, high-cost
patients
Amarasingham, R., Xie, B., Karam, A., Nguyen, N., & Kapoor, B. (2018, January). Using community
partnerships to integrate health and social services for high-need, high-cost patients. The
Commonwealth Fund Issue Brief, 1-11.
•
Occupational outlook handbook, medical and health services managers
Bureau of Labor Statistics. (2019). Occupational outlook handbook, medical and health services
managers.
•
The community's emerging role in value-based health and social services.
Powers, M. (2018). The community's emerging role in value-based health and social services.
Generations, 42(1), 4-8.
•
Forging community partnerships to improve health care: the experience of four Medicaid managed
care organizations.
Silow-Carroll S, Rodin D. Forging community partnerships to improve health care: the experience of
four Medicaid managed care organizations. Issue Brief (Commonw Fund). 2013 Apr;19:1-17. PMID:
23634464.
•
Budget Projections Worksheet Capstone Assignment
NCU Academic Medical Center
Income Statemen / P&L Statement / Statement of Operations (in thousands)
for the Years Ended December 31, 2015 - 2017
2017
2016
2015
REVENUES
Net patient services revenue
Premium revenue
Other operating revenue
Total operating revenue
$23,000
600
725
$24,325
$22,750
300
680
$23,730
$21,250
400
710
$22,360
EXPENSES
Salaries, wages and benefits
Supplies and other expenses
Depreciation
Interest
Total operating expenses
13250
7000
2500
200
22950
14150
6750
2000
150
23050
14900
6250
1800
100
23050
OPERATING INCOME
NONOPERATING INCOME
$1,375
265
$680
185
($690)
170
EXCESS OF REVENUE OVER EXPENSES
$1,640
$865
($520)
Total change in net assets
$1,640
$865
($520)
NCU Academic Medical Center
Balance Sheet (in thousands)
for the Years Ended December 31, 2015 - 2017
ASSETS
Current assets
Cash and cash equivalents
Receivables, net
Inventory
Total current assets
$700
4,000
750
5,450
$675
3,500
800
4,975
$600
3,750
850
5,200
Noncurrent assets
Land, plant and equipment
Accumulated depreciation
Long-term investments
Other noncurrent assets
Total noncurrent assets
26,500
(18,000)
5,000
8,500
22,000
24,000
(17,000)
4,000
7,000
18,000
23,000
(16,000)
3,000
7,000
17,000
27,450
22,975
22,200
LIABILITIES AND NET ASSETS
Current liabilities
Accounts payable
Notes payable
Accrued expenses payable
Current portion of long-term debt
2,000
900
871
184
2,500
750
408
178
2,300
800
620
152
Total current liabilities
3,955
3,836
3,872
Noncurrent liabilites
Long-term debt, net of current portion
Total noncurrent liabilities
6,500
6,500
8,000
8,000
8,000
8,000
Total liabilities
10,455
11,836
11,872
NET ASSETS
16,995
11,139
10,328
$27,450
$22,975
$22,200
Total assets
Total liabilities and net assets
2017
2016
2015
NCU Academic Medical Center
Ratios
(in '000)
12/31/2017
[X/Y]
Current ratio
Collection period ratio
Days Cash on hand (short-term sources)
Days cash on hand (all sources)
Average payment period (days)
Operating margin ratio
Total margin ratio
Retrun on net assets ratio
Total asset turnover ratio
Age of plant ratio
Fixed asset turnover ratio
Current asset turnover ratio
Inventory ratio
Net asset financing ratio
Long-term debt to capitalization ratio
Debt service coverage ratio
Cash flow to debt ratio
1.38
63.478
12.494
17.224
70.591
5.653
6.742
9.650
0.896
7.200
2.893
4.512
32.787
61.913
27.665
11.302
39.598
12/31/2016
[AA/AB]
1.30
56.154
11.704
14.912
66.515
2.866
3.645
7.766
1.041
8.500
3.416
4.807
28.669
48.483
41.799
9.192
24.206
12/31/2015
[AD/AE]
1.34
64.412
10.306
13.226
66.507
(3.086)
(2.326)
(5.035)
1.015
8.889
3.219
4.333
26.506
46.523
43.649
5.476
10.782
2017
2017
Numerator Denominator
$5,450
$4,000
$700
$965
$3,955
$1,375
$1,640
$1,640
$24,590
$18,000
$24,590
$24,590
$24,590
$16,995
$6,500
$4,340
$4,140
$3,955
$63.014
$56.027
$56.027
$56.027
$24,325
$24,325
$16,995
$27,450
$2,500
$8,500
$5,450
$750
$27,450
$23,495
$384
$10,455
$2,016
$2,016
NumeratorDenominator
$4,975
$3,500
$675
$860
$3,836
$680
$865
$865
$23,915
$17,000
$23,915
$23,915
$23,915
$11,139
$8,000
$3,015
$2,865
$3,836
$62
$58
$58
$58
$23,730
$23,730
$11,139
$22,975
$2,000
$7,000
$4,975
$800
$22,975
$19,139
$328
$11,836
2015
Numerator
$5,200
$3,750
$600
$770
$3,872
($690)
($520)
($520)
$22,530
$16,000
$22,530
$22,530
$22,530
$10,328
$8,000
$1,380
$1,280
2015
Denominator
$3,872
$58.219
$58.219
$58.219
$58.219
$22,360
$22,360
$10,328
$22,200
$1,800
$7,000
$5,200
$850
$22,200
$18,328
$252
$11,872
ISSUE BRIEF
JANUARY 2018
Using Community Partnerships
to Integrate Health and Social
Services for High-Need, HighCost Patients
Ruben Amarasingham, Bin Xie, Albert Karam, Nam Nguyen, and Bianca Kapoor
ABSTRACT
ISSUE: Our health care and social services delivery systems are not well-equipped to effectively
manage patients with multiple chronic diseases and complex social needs such as food, housing, or
substance abuse services. Community-level efforts have emerged across the nation to integrate the
activities of disparate social service organizations with local health care delivery systems. Evidence
on the experiences and outcomes of these programs is emerging, and there is much to learn about
their approaches and challenges.
GOAL: Profile and classify burgeoning initiatives, understand common challenges, and surface
solutions to address those challenges.
METHODS: Mixed-methods approach, including literature search, surveys, semistructured
interviews with program leaders, and consultation with expert panels.
FINDINGS AND CONCLUSIONS: We categorized cross-sector community partnerships in four
dimensions. We also identified five common challenges: inadequate strategies to sustain costsavings, improvement, and funding; lack of accurate and timely measurement of return on
investment; lack of mechanisms to share potential savings between health care and social services
providers; lack of expertise to integrate multiple data sources during health care or social services
provision; and lack of a cross-sector workflow evidence base.
KEY TAKEAWAYS
Programs in communities across the nation are coordinating services between health care
providers and social service organizations to help patients with housing, food insecurity,
transportation, and other issues.
These programs share challenges related to financial sustainability, measurement of health
outcomes and cost-savings, and integrated information technology.
Consensus is needed on the most appropriate payment models and ways to move away from
fee-for- service.
Using Community Partnerships to Integrate Health and Social Services for High-Need, High-Cost
Patients 2
BACKGROUND
Effectively managing patients with complex clinical and social needs requires thoughtful integration of health
care and social services.1 Research has shown that patients with multiple clinical and social needs consume a
large share
of health care services. Social services providers, though historically disconnected from the broader health
system, play an important role in providing services for these patients. 2
Recognizing the opportunity to better address health- related social needs, communities across the United
States have begun experimenting with programs to connect health care providers with community-based
organizations (CBOs) that address social needs. These needs include housing and food insecurity and
assistance with utilities and transportation, among other issues.3 These programs have been accelerated as a
result of top-down reforms initiated by federal policy and demonstration projects and bottom-up innovations
driven by community-led efforts.
In this brief, we survey the landscape of these programs, highlight common challenges, and propose solutions,
using a mixed-methods approach that includes a literature search, interviews, and survey of selected
programs. (See How We Conducted This Study.)
Exhibit 1. Four Dimensions Used in the Framework
KEY FINDINGS, CHALLENGES, AND PROPOSED SOLUTIONS
We identified 301 cross-sector community partnerships across the country that met our criteria. Of these, we
evaluated 64, using web surveys and in-depth interviews. We evaluated the relative advances of these
programs in the four dimensions according to our framework (Exhibit 1, Appendix 4):
• coordination
• financial alignment
• data- and information-sharing • metric reporting.
Based on results of cluster analysis of the survey and interview results, we identified significant variations
among the programs in these four dimensions. Differences notwithstanding, all cross-sector community
partnerships share many common features and face common challenges. Much emphasis was placed on
including social services and nontraditional types of care and services in addressing the needs of at-risk
patients and forming community partnerships. Most programs include participants from a diverse set of CBOs
and a sizable minority (21.5%) includes some risk-sharing mechanism among participating organizations
(Exhibit 2).
DIMENSION DESCRIPTION
Coordination
Financial alignment
Data- and information-sharing Metric reporting
Maps the degree to which a program includes various components in the health care and social services
delivery systems, such as health care providers, public health agencies, and community-based organizations
that provide social services such as food assistance and shelter, and the degree to which participating
organizations coordinate care delivery to enrollees. Examples of care coordination include referral tracking,
transition coordination, and needs assessment.
Maps the degree to which the financial payment incentives of the participating organizations are aligned to
achieve the Institute for Healthcare Improvement’s Triple Aim (i.e., improving patients’ experience,
improving population health, and reducing costs of care).
Maps the degree to which data- and information-sharing occurs among participating organizations.
Maps the degree to which metrics are monitored and reported across participating organizations and their
alignment toward the Triple Aim.
commonwealthfund.org
Issue Brief, January 2018
Using Community Partnerships to Integrate Health and Social Services for High-Need, High-Cost
Patients 3
Exhibit 2
s
%
sharing
Cross-Sector Community Partnerships
Exhibit 2. Cross-Sector Community Partnerships
Among the most referenced theme in our study was
the importance of integrated information technology,
as well as the challenges in using such tools and
improvements needed across technology platforms. All
the organizations cited using IT in program operations,
23.6%
Other (e.g., elderly homes, nursing homes, County health department, AAA)
35.4%
Public hospitals
Community partners in the program
20.8%
Community health center
9.7%
Homeless shelters
10.4%
Food banks
Source: R. Amarasingham, B. Xie, A. Karam et al., Int
The Commonwealth Fund, Jan. 2018.
utilizing risk- sharing
21.5%
Yes
78.5%
No
ity ter
%
ess ers
%
nks
Organizations
Another important theme that emerged was using ting Health anhdoSoscpiailtSaerlviucetsifloirzHaigthi-oNenedm, HieghaCsoustrPeastie(nets.gU.s,inegmComermguenintycPyartnerships,
department use, preventable hospital admissions and readmissions, excess hospital stays) to assess program
performance. A smaller set of organizations used other measures, like prescription drug use and high-cost
imaging. Looking forward, organizations hoped to focus on patient outcomes and population-level indicators.
addition to proposing specific solutions (Exhibit 3), we developed a community playbook to address these
challenges and to assist communities as they work to forge cross-sector partnerships.
but most noted challenges and room for im2p1r.o5v%ement Yes
within existing technology. We identified five common challenges that these programs face (Exhibit 3).
Organizations
IMPLICATIONS AND CONCLUSION
utilizing riskOur findings suggest that there is an emerging and
diverse group of programs formally coordinating
services between independent health care and
social service organizations. These programs differ
in significant ways but have common chall7e8n.g5e%s. In No
To implement solutions, federal and local policymakers,
philanthropic agencies and foundations, and local egrating Health annd cSohcoialrSehrvoicsespfoitr aHilgsh-mNeeuds,
Htigcho-CnosttiPnautieenttsoUspingroCovmimduenistyuPparptneorsrhtip, s,
funding, and expertise. For example, systemwide payment reforms around transitional care activities
and population health are critical to sustain innovation, to facilitate peer learning, and to ultimately integrate
successful elements of these innovations into policy and systemwide practices. Toward this end, the Center
for Medicare and Medicaid Innovation has launched the Accountable Health Communities program. 4
Our findings highlight the key role that payment reforms play in building a more integrated health care and
social delivery system for complex patients. While there is broad agreement on the need for payment reform
that replaces the current fee-for-service system, there
is no consensus on the most appropriate payment model or how to move away from our current system.5
Interviewees cited challenges including the lack of flexible payment models to properly incentivize and
engage social services providers and the difficulty in sustaining programs beyond the initial funding period.
commonwealthfund.org
Issue Brief, January 2018
p
8
nn
7
t
4
a
Using Community Partnerships to Integrate Health and Social Services for High-Need, High-Cost
Patients 4
Exhibit 3. Common Challenges and Proposed Solutions
CHALLENGE DESCRIPTION PROPOSED SOLUTIONS
Sustainability
Measuring outcomes and cost-savings
Shared savings
Data and technology expertise
Cross-sector workflow evidence base
Many programs are grant funded and may not be sustainable after the grant funding is complete; cost-savings
and improvement in outcomes may be difficult to sustain as there will be less room for improvement
Many programs lack the infrastructure and know-how to define and measure the most relevant outcomes and
to accurately estimate cost-savings
Limited mechanisms and knowledge of how to share savings
Many CBOs lack a technical platform, infrastructure, and know-how to integrate data from different sources,
such as EMRs, claims data, and HIEs; many programs lack the infrastructure to consult multiple data sources
during the provision of health care or social services leading to poor coordination
Programs struggle to define cross-sector, multiorganization, clinical, and social workflows
Payment reform around transitional care activities and population health; coalition of CBOs establishing
alignment with hospitals’ strategic plans
Establishing a common data dictionary and data set requirements across hospitals, health systems,
community-based organizations with common methods for analysis; establishing a learning community to
provide resources for members to acquire skills to implement
Identification of local philanthropies, foundations, and trusts that would provide funding to accelerate
experimentation around financial partnerships;
focus on areas where health systems are subject to potential financial penalties or incentives aligned with a
CBO’s specific core competency
Utilize workflow case management systems at the CBO-level that could integrate with EMR systems; use
hospitals’ data and technology expertise to serve as anchors for community efforts
Demonstration grants provide critical support to experiment and establish this evidence base; national
collaboratives, learning networks, and information clearinghouses can also help fill this gap
Note: For more detailed discussion on other potential challenges and solutions, please see the community playbook,
available upon request at: http://www.pccipieces.org/health-care-and-social-service-provider-partnerships-forcomplex-patients/.
At the same time, there is a wide diversity of the payment models powering the programs in our study and
little agreement among the interviewees on what types of financial arrangements are needed.
Establishing an evidence base for cross-sector partnership will require continued funding and
experimentation, as well as additional collaborative projects, learning networks, and information
clearinghouses to disseminate the significant but often isolated work occurring across the country.
commonwealthfund.org
Issue Brief, January 2018
Using Community Partnerships to Integrate Health and Social Services for High-Need, High-Cost
Patients 5
NOTES
1.
2.
S. S. Wallack and C. P. Tompkins, “Realigning Incentives in Fee-for-Service Medicare,” Health Affairs,
July/Aug. 2003 22(4):59–70; K. Minich-Pourshadi, Gainsharing, Shared Savings Examined
(HealthLeaders Media, Aug. 2012); A. J. Demetriou and J. A. Patterson, Jr., “ACO — Legal Structure,
Governance, and Leadership,” ABA Health eSource (American Bar Association Health Law Section,
April 2011); and ACO Update: Accountable Care at a Tipping Point (Oliver Wyman, April 2014).
2 L. A. Chwastiak, D. S. Davydow, C. L. McKibbin et al., “The Impact of Serious Mental Illness on the
Risk of Rehospitalization Among Patients with Diabetes,” Psychosomatics, March/April 2014
55(2):134–43; M. Rowland, J. Peterson-Besse, K. Dobbertin et al., “Health Outcome Disparities Among
Subgroups of People with Disabilities: A Scoping Review,” Disability and Health Journal, April 2014
7(2):136–50; E. K. Fry-Bowers, S. Maliski, M. A. Lewis et al., “The Association of Health Literacy, Social
Support, Self-Efficacy and Interpersonal Interactions with Health Care Providers in Low-Income
Latina Mothers,” Journal of Pediatric Nursing, July/Aug. 2014 29(4):309–20; and E. L. Schiefelbein, J.
A. Olson,
1
3.
4.
5.
and J. D. Moxham, “Patterns of Health Care Utilization Among Vulnerable Populations in Central
Texas Using Data from a Regional Health Information Exchange,” Journal of Health Care for the Poor
and Underserved, Feb. 2014 25(1):37–51.
3 Centers for Medicare and Medicaid Services, Center
for Medicare and Medicaid Innovation: Report to Congress (CMS, Dec. 2014); and Centers for Medicare
and Medicaid Services, Accountable Health Communities Model (CMS, n.d.).
4 Centers for Medicare and Medicaid Services, Accountable Health Communities Model (CMS, n.d.).
5 E. F. Taylor, T. Lake, J. Nysenbaum et al., Coordinating Care in the Medical Neighborhood: Critical
Components and Available Mechanisms, White Paper 11-0064 (Agency for Healthcare Research and
Quality, June 2011).
HOW WE CONDUCTED THIS STUDY
For this study, we used a mixed-methods approach. First, an extensive literature search,
semistructured interviews, and email surveys of key informants (including community leaders,
academic experts, national thought leaders, and policymakers) allowed us to identify a robust list of
cross-sector community partnerships across the country. This also allowed us to produce a rubric,
or framework, to assess the relative advances of a community effort, using four dimensions
(available at: http://www. pccipieces.org/health-care-and-social-service- provider-partnershipsfor-complex-patients/). After these steps, we focused on programs that target socially vulnerable,
high-utilization, or medically complex populations, and which also demonstrate at least one of the
following:
•
•
•
formal financial arrangement between two or more distinct organizations or units within an
organization in the health services sector that share similar funding streams and client
delivery goals
care coordination between the clinical sector and another sector
risk-sharing among organizations outside the clinical sector.
We subsequently performed quantitative
surveys of these programs and semistructured, in-depth interviews with key personnel
from a stratified purposive sample of programs. After establishing the key challenges of
these programs, we consulted with national experts and drew
from our own local efforts to propose solutions to problems identified and to establish a
playbook for communities to use going forward (available at:
http://www.pccipieces.org/health-care-and- social-service-provider-partnerships-forcomplex- patients/). For a more detailed description of the methods, see Appendix 1.
commonwealthfund.org
Issue Brief, January 2018
Using Community Partnerships to Integrate Health and Social Services for High-Need, High-Cost
Patients 6
ABOUT THE AUTHORS
Ruben Amarasingham, M.D., M.B.A., is founder, president, and CEO of Pieces Technologies Inc., which builds
and deploys clinical tools for health systems
and community-based organizations. He served as president and CEO for the Parkland Center for Clinical
Innovation (PCCI), a nonprofit research and development organization, until January 2017. Dr.
Amarasingham is
an expert in the development and evaluation of health information technology, the application of informatics
in health care, and the use of innovative care models
to reduce disparities, improve quality, and lower costs.
His research agenda centers on the use of data collected
in electronic health records to support health services research, predictive modeling, and health care systems
innovation. Dr. Amarasingham received his medical degree from the University of Texas Southwestern
Medical School, and received additional training in medical informatics, quality improvement, and operations
and health services research as a Robert Wood Johnson Clinical Scholar at Johns Hopkins University.
Bin Xie, Ph.D., M.E., is director of health services research at the Parkland Center for Clinical Innovation
(PCCI),
and is leading a team of data and health services research scientists to develop and evaluate predictive
models and to conduct research in health care delivery and payment reform. His expertise includes predictive
analytics,
health economics, health services research, and program evaluation. He received a Ph.D. in health economics
from Vanderbilt University and was a faculty member in University of Western Ontario in Canada before
joining PCCI.
Albert Karam, M.S., is data analytics supervisor at the Parkland Center for Clinical Innovation (PCCI), and a
member of the research and data science team. He is an expert in utilizing data from various sources to build
sophisticated models to predict various outcomes in the health care delivery system. He received a Master of
Science degree in mathematics from the University of Texas at Dallas.
Nam Nguyen is an M.B.A. student in the Carey Business School at John Hopkins University. He has served
in various roles at the Parkland Center for Clinical Innovation (PCCI) and Pieces Technologies. His expertise
includes program design and health care delivery system and payment reform.
Bianca Kapoor is currently a student at New York University School of Medicine. Before starting medical
school, Bianca was Collegiate Fellow at the Parkland Center for Clinical Innovation (PCCI).
Editorial support was provided by Deborah Lorber.
ACKNOWLEDGMENTS
The authors are grateful to the Commonwealth Fund for support for this work. They also recognize the
valuable information provided in interviews by the Centers for Medicare and Medicaid Services, Center for
Medicare and Medicaid Innovation, National Association of Medicaid Directors, Pennsylvania Department of
Human Services, Oregon Health Authority, California Department of Health Care Services, America’s Essential
Hospitals, Association for Community Affiliated Plans, Bazelon Center for Mental Health Law, Legal Services
of Eastern Missouri, and Western Center on Law & Poverty.
For more information about this brief, please contact:
Bin Xie, Ph.D., M.E.
Director of Health Services Research Parkland Center for Clinical Innovation bin.xie@phhs.org
About the Commonwealth Fund
The mission of the Commonwealth Fund is to promote a high performance health care system. The
Fund carries
out this mandate by supporting independent research on health care issues and making grants to
improve health care practice and policy. Support for this research was provided by the
Commonwealth Fund. The views presented here
are those of the authors and not necessarily those of the Commonwealth Fund or its directors,
officers, or staff.
commonwealthfund.org
Issue Brief, January 2018
TUhseinCgoCmomomnuwneitayltPhaFrutnedrships to Integrate Health and Social
SHeorvwicHeisghfoIrsHAimghe-rNiceae’sd,HHeiaglhth-CCoasrtePCaotisetnBtusrden? 7
Appendix 1. Detailed Description of the Methods DATA COLLECTION
A three-step mixed methods approach was employed in this study to collect a comprehensive list of
innovation programs, to achieve in-depth understanding of these programs, and to provide a comprehensive
map of these programs in geography and program characteristics. In step 1, an extensive literature search
and a semistruc- tured email survey of key informants (Appendix 2) led to identification of around 300
innovative programs across the country that met inclusion criteria. The programs must target socially
vulnerable, high-utilizers, or medically complex populations, AND fulfill at least one of the following:
•
•
•
program incorporates financial arrangement of two or more sectors (defined as distinct areas of
health services that share similar funding streams and client delivery goals); a few of the health
sectors we define include clinical services, behavioral services, and social, or human, services, OR
program incorporates care coordination between the clinical sector and another sector, OR
program involves risk-sharing among organizations (with involvement beyond the medical sector).
These programs often demonstrated novel care coordina- tion mechanisms or community and
partnership engage- ment that also serve to benefit our research. In step 2, a stratified purposive
sample of 21 programs was chosen to conduct in-depth interviews. This sampling allowed some
diversity in the sample and thus a broad range of programs was explored. Of the 16 programs invited
to participate in the study, 14 agreed to be interviewed (Appendix 3). Semistructured, in-depth
interviews
based on a topic guide were used to allow for a detailed, flexible, and responsive exploration of
programs’ expe- riences. Interviews were recorded and transcribed verbatim with participant
permission and lasted around 60 minutes. The topic guide included the following areas: organization
and governance, including inception and timeline; measuring shared savings and/or description of
the financial model; metrics, including assessment and
accuracy; challenges, both past and future; technology, legal, privacy, and regulatory concerns; and other
questions.
In step 3, based on the findings of the qualitative data, a quantitative survey was sent to all 301 programs
identi- fied to create a comprehensive picture of current inno- vations across the nation. In this survey, we
adapted a framework developed by McGinnis and colleaguesa and modified it using a Delphi method to
develop a list of key domains to summarize the commonalities and differenc- es among these diverse
programs (Appendix 4).b A rubric with four dimensions was created based on the qualita- tive results, and
was then refined and finalized through semistructured, in-depth interviews with domain experts. This
finalized rubric was used in the survey questionnaire. Because of the difficulty of obtaining responses for a
web survey, we scheduled structured phone interviews for a vast majority of the programs.
DATA ANALYSIS
We used a variation of content analysis to develop a coding scheme for performing a qualitative description of the themes discussed by interviewees. The final codebook included both inductive and deductive
codes and was finalized after reaching consensus among the research team. We coded and analyzed the
interview transcripts in NVivo software (NVivo qualitative data analysis software; QSR International Pty Ltd.
Version 10, 2014), with analysis focusing on both overarching themes and specific areas for program
innovations. The analysis focused on five key themes: payment reform arrange- ment, inclusion of
community-based organizations, rela- tionships among partner organizations, future plans and
considerations, and challenges, but also allowed other themes to emerge from the data. Quantitative analysis
of survey results was conducted using R 3.2.0.
T. McGinnis, M. Crawford, and S. A. Somers, A State Policy Framework for Integrating Health and Social Services (The
Commonwealth Fund, July 2014).
a
C. Okoli and S. D. Pawlowski, “The Delphi Method as a Research Tool: An Example, Design Considerations and
Applications,” Information & Management, Dec. 2004 42(1):15–29.
b
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Appendix 2. Interview Questions and Key Informants
Questions asked:
• Are there any community-based organizations — defined as those that provide services to vulnerable populations, such
as homeless shelters, food aid organizations, and community health centers — that are financially aligned, in any capacity,
with a health care provider that you know of?
• Is there a group, that you are aware of, that is trying to incorporate community-based organizations into a health care
financial arrangement? Or any project similar to ours?
• Is there anyone you know of that may have further insights into these questions?
TITLE (IF APPLICABLE/KNOWN)
Senior Vice President for Quality and Safety and Chief Quality Officer
Assistant Professor Executive Director
Founder
Director of Medical Assistance Programs
Assistant Professor of Law
Director of Policy Development Assistant Professor
Assistant Professor Steering Committee Head
President, CEO
Project Director
Physician & Founder, HealthBegins Partner in Healthcare Practice Director, ReThink Health
Executive Director
Director of State Policy & Programs Deputy Director
Chief Impact Officer
IBM Fellow and Vice President of Integrated Health Services
Director
Director Program Director
CONTACT NAME
Alan Baronoskie
David Bates, M.D., M.Sc., Ph.D.
Christina J. Bennett, J.D. Sue Birch
Hunt Blair
George Bo-Linn, M.D. Amy Boutwell, M.D. Elizabeth Bradley Rhonda Busek Stephen Cha
Sandy Chang, M.D.
Glenn Cohen, J.D.
Patrick Conway, M.D.
Anne De Biasi
Carolyn L. Engelhard, M.P.A. Martin Entwistle
Gabriel Escobar, M.D. Lynn Etheredge Alexandra Gorman Laura Gottlieb Robert Hanna
Brad Hirsch, M.D.
Justin Hunt, M.D.
Frederick Isasi
Laura Landy
Brian Lee
Georgia Maheras
Rishi Manchanda, M.D., M.P.H. Deven McGraw
Bobby Milstein Jennifer Nelson-Seals Kathleen Nolan
Ross Owen
Neil Powe, M.D. Rahul Rajkumar Darshak Sanghavi
Jill Scigliano
Martin J. Sepulveda
Bruce Siegel, M.D. Prabhjot Singh Jeanene Smith Ron Stretcher Clare Tanner
Paul Tarini
ORGANIZATION/HOSPITAL
PwC
Brigham and Women’s Hospital
College of Public Health, University of Oklahoma Colorado Department of Health Care Policy and Financing HHS Office of the National
Coordinator for IT
Alvarez & Marcel
Collaborative Healthcare Strategies
Yale University
Oregon Health Authority
CMS Center for Medicare and Medicaid Innovation
Yale University
Harvard Law School
CMS Center for Medicare and Medicaid Innovation
Trust for America’s Health
University of Virginia School of Medicine
Palo Alto Medical Foundation
Kaiser
Independent Consultant
North Texas Accountable Healthcare Partnership University of California, San Francisco
Nassau County Savings Initiative
US Oncology
University of Arkansas
National Governors Association
Rippel Foundation
Centers for Disease Control and Prevention
Vermont Health Care Innovation Project
University of California, San Francisco
Manatt, Phelps, & Phillips, LLP
Rippel Foundation
Interfaith House, Chicago
National Association of Medcaid Directors
Hennepin Health, MN
University of California, San Francisco
CMS Center for Medicare and Medicaid Innovation
CMS Center for Medicare and Medicaid Innovation
United Way of Metropolitan Dallas
IBM Corporation
America’s Essential Hospitals
Columbia University
Oregon Office of Health Policy and Research Criminal Justice (Dallas)
Michigan Public Health Institute
Robert Wood Johnson Foundation
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Appendix 3. List of Programs Interviewed
ORGANIZATION
Camden Coalition of Healthcare Providers, NJ
Colorado Department of Health Care Policy and Financing Hennepin Health, MN
Interfaith House, Chicago, IL
Live Well San Diego, CA
Medical Legal Partnerships
Michigan Public Health Institute
Montefiore Medical Center, NY
Nassau County Savings Initiative, NY
Oregon Health Authority
Partnership for a Health Durham, NC
Pueblo Triple Aim Coalition, CO
Together 4 Health, Chicago, IL
Vermont Health Care Innovation Project
NAME AND TITLE OF INTERVIEWEE
Jared Susco, COO, & Matt Humowiecki, Legal Counsel Sue Birch, Executive Director
Ross Own, Deputy Director
Jennifer Nelson-Seals, Executive Director
Dale Fleming, Julianne Howell, Wilma Wooten, & Peter Shih Ellen Lawton, Co-Principal Investigator
Clare Tanner, Program Director
Anne Meara, Associate VP, Network Management
Bob Hanna, Steering Committee Director Rhonda Busek and Team, Director
Mel Piper, Partnership Coordinator
Matt Guy, Managing Director
Jill Misra, Interim CEO
Georgia Maheras, Project Director
DATE INTERVIEWED
February 9, 2015 November 17, 2014 November 13, 2014 November 17, 2014 January 30, 2015 January 26, 2015
November 20, 2014 March 20, 2015 November 13, 2014 November 14, 2014 January 27, 2015 February 2, 2015 March
17, 2015 November 20, 2014
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Appendix 4. Rubric for Mapping Cross-Sector Community Partnerships
The purpose of this rubric is to map the programs we identified across four different dimensions. We solicited input from
several experts to internally validate the rubric, but it should not be used for other organizations or purposes.
The 1-to-5 scale is intended to signal degree of integration and alignment among participating organizations in a
program’s implementation. The scale is ordinal, not interval, and higher numbers in the scale do not imply or predict
better performance or any outcomes measures and are not necessarily preferable to lower numbers.
For this purpose of this rubric we define sectors as distinct areas of health services that share similar funding streams and
client delivery goals. A few of the health sectors we define include clinical services, behavioral services, and social, or
human, services.
COORDINATION
Maps the degree to which a program includes various components in the health care and social services delivery systems, such as health care
providers, public health agencies, and community-based organizations
that provide social services such as food assistance and shelter, and the degree to which participating organizations coordinate care delivery
to enrollees (examples of
care coordination include referral tracking, transition coordination, and needs assessment)
1.
1 Program includes participating organizations in two sectors (including but not limited to clinical, behavioral, and social) but
there is no integration and communication between participating organizations beyond simple referrals
2.
2 Program includes participating organizations in two sectors, and are engaged in some early care coordination, which may
include the use of case managers
3.
3 Program includes participating organizations in three or more sectors, which are engaged in some care coordination, and
may include the use of case managers
4.
4 Integrated health delivery through care coordination between participating organizations in three or more sectors that
includes the use of referral tracking to coordinate and monitor patients as they move among organizations
5.
5 Integrated health delivery with participating organizations in three or more sectors and an increasing focus on long-term
goals and creating a culture of health
FINANCIAL ALIGNMENT
Maps the degree to which the financial payment incentives of the participating organizations are aligned to achieve the Institute for
Healthcare Improvement’s Triple Aim (i.e., improving patients’ experience, improving population health, and reducing costs of care)
No financial relationship among participating organizations beyond fee for services
The financial relationship among participating organizations is based on fee-for-services, but has an extra portion of payment based on
the receiving organizations meeting some pre-defined quality measures (e.g., one-sided shared-savings model)
The financial relationship between at least two participating organizations is based on some alternative payment arrangements, such as
patient-centered medical homes
or social impact bonds. (A social impact
bond, also known as pay-for-success financing, pay-for-success bond, or a social- benefit bond is a contract with the public sector in
which a commitment is made to pay for improved social outcomes that result in public sector savings.)
The financial relationship among all participating organizations is some kind of population-based, risk-sharing payment system, such as
partial capitation, or per- member per-month bundles
Total financial alignment: all participating organizations under central budgetary control (although not single-payer)
DATA- AND INFORMATION-SHARING
Maps the degree to which data- and information-sharing occurs among participating organizations
No data or information-sharing between participating organizations
Data- and information-sharing within a single sector across multiple providers
Sharing of data (such as monthly or quarterly discharge data) on a regular basis from multiple sectors
Data- and information-sharing with real- time updates that includes data from multiple sectors
Integrated data- and information- sharing across all providers with analytics and real-time data from multiple sectors
METRIC REPORTING
Maps the degree
to which metrics
are monitored and reported across participating organizations and their alignment toward the Triple Aim
No metrics reported
Metric reporting based on utilization within a single sector
Regular report of metrics incorporating both utilization and quality measures within a single sector
Regular reporting
of metrics incorporating both utilization and quality measures across multiple sectors
Regular reporting
of metrics incorporating utilization and quality measures that includes a focus on prevention and wellness across multiple sectors
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copyright holder's express written permission. However, users may print, download, or email
articles for individual use.
The Community's Emerging Role in ValueBased Health and Social Services
By Margie Powers
The role of community-based organizations is expanding as they partner with
healthcare entities.
ith the simultaneous movement in the
healthcare industry toward value over vol ume, and population-based health management, there is
growing recognition that non-medical services are as important as those received in a provider’s office,
especially for people with high needs, who engender high costs. Social determi nants of health—
economic stability; education and income status; access to healthcare, food,
and housing; and environmentally safe communi ties (Centers for Disease Control and Prevention,
2017)—are known to substantially determine negative or positive health outcomes, and have a
disproportionate impact on health, compared to health behaviors and clinical care (Amarasing- ham,
2016).
The combination of social, behavioral, and environmental factors contributes substantially to specific
health issues, including to more than 70 percent of some types of cancer, 80 percent of heart disease
cases, and 90 percent of stroke
cases (Bradley et al., 2016). Healthcare organiza tions are starting to more closely examine how to
address social determinants’impact on health, and one strategy is exploring closer partnerships with
community-based organizations (CBO),
'States with higher levels of spending on social services performed better on a list of
health outcomes.'
establishing contracting relationships to support high-need, high-cost individuals.
Traditionally, CBOs deliver services that aim to address the social needs of this population. While these
services also can affect health, in most cases they are not directly reimbursed by plans or provider
organizations. Given the cur rent evolution of the healthcare industry, there is ample opportunity to
develop cross-sector payment mechanisms to support high-need,
-♦ABSTRACT Social determinants of health are known to impact health outcomes, and there is growing recognition that nonmedical services are as important as those received in a provider's office, espe cially for high-need, high-cost populations.
Healthcare organizations are exploring closer partnerships with community-based organizations (CBO), especially in support of this
group. There is ample oppor tunity to develop cross-sector payment mechanisms to support these individuals and to provide
financial stability to valued community organizations. 1keywords: high-need,high-costpopulations,CBOs,social
determinants of health, Partners in Care
4 [Spring 2018
high-cost populations, while at the same time providing financial stability to valued commu nity
organizations.
CBOs' Role in Improving Health Outcomes
CBOs by their nature have close ties with com munities, and often work directly and intimately with
people in their home setting, something healthcare providers are rarely able to do. This unique access
gives CBOs insights into unmet social needs affecting health status, and even healthcare, hospital, and
emergency department utilization patterns. A recent study showed that states with higher levels of
spending on social services performed better on a list of health out comes than states with lower spending
levels (Bradley et al., 2016).
Older adults find that managing multiple health issues becomes more difficult when comTable 1. CBO Services That Can Impact Health
pounded by challenging social situations, and CBOs can play an important role in alleviating these
stressors. For example, health problems can be worsened by a lack of adequate housing, nutrition,
transportation, and family or care giver support. If providers are aware of this, and can connect people to
community services, clini cal treatments are more likely to be successful. Many CBOs view themselves as
“non-clinical,” but their services influence the health of high- need, high-cost people every day. Table
1(on this page) shows examples of CBO services that can impact health outcomes.
The Partnership for Healthy Outcomes (Miller, Nath, and Line, 2017) surveyed more than 200
organizations about their partnerships between healthcare organizations and CBOs. The survey revealed a
wide variety of partner ships, with no two alike; notably, the survey results also revealed a movement
toward finan cial partnerships between organizations. Some key and promising findings are as follows:
V Most partnerships focused on immediate clinical needs, such as care transitions, reducing readmissions,
and length of stay;
V Most partnerships have a formal agree ment between entities;
V A majority of partners (65 percent) report achieving some cost-savings as a result of the partnership;
and
V Funding partnership programs is depen dent upon multiple sources, but there is interest on both sides in
creating a long-term sustainable funding model.
Consistent, Sustainable Program
Funding Is Key
CBOs are embracing their expanding roles in community health, but can struggle with secur ing
consistent funding sources to sustain their programs. They seek new payment mechanisms, yet have little
expertise in negotiating payment arrangements between healthcare and non medical service providers.
They need guidance on how to integrate social services into the care
Interventions/Services
Home visits to frail older adults and medically complex patients, provid ing social support and companionship
Care coordination of transitions between home and hospital or skilled nursing facility
Falls prevention in the home for at-risk older adults
Caregiver respite services
Transportation of older adults to medical appointments
Potential Impacts on Health
Consistent health mon itoring, even by non- licensed staff, can flag potential problems before they occur.
Assessing a person's home, including adequate food and caregiver sup port, can reduce readmis sion risk.
Instructing older adults and caregivers on how
to reduce risk of falling can reduce accidents and hospital admissions.
Providing support to family and caregivers can improve quality of care for the individual.
Ensuring people get necessary primary and follow-up care can reduce risk of hospitalization.
Source: Pacific Business Group on Health, 2017.
Fundamentals of Community-Based Managed Care: A Field Guide
Volume 42- Number 1 | 5
GENERATIONS - Journal o f the American Society on Aging
Table 2. Payment Methods for High-Cost, High-Need Populations
Payment Model Fee-for-Service
CBOs negotiate a payment amount that they will re ceive for a single event or service. A CBO may contract with a health plan to deliver falls prevention
education to patients recently discharged from the hospital. CBOs would then bill the plan for each patient receiving the intervention.
Flat Rate
CBOs negotiate to be paid a specific amount over a certain period of time. A CBO may contract with a health system to be paid a specific amount for a
one-year period, during which they deliver meals to a defined number of homebound older adults. CBOs may then bill the system monthly or quarterly
for a pro-rated amount of the total.
Population-Based Payment
CBOs negotiate a payment based upon outcomes for a specific population. A CBO may negotiate with a health plan to be paid a certain amount per
person, per month for care coordination services. The CBO may be asked to ensure certain clinical outcomes or cost-savings.
Source: Pacific Business Group on Health, 2017.
of high-need, high-cost individuals, as well as to create a reimbursement strategy to sustain these valuable
programs.
'CBOs can directly contract for their own services.'
Existing payment models
Traditionally, CBOs receive funding through government agencies or grants, which can be financially
generous but are unpredictable, and dependent upon the changing priorities of the government and
funders. Another challenge is that funding often is limited to a specific service or set of services. CBOs
then structure their organizational offerings around this specific funding source and provide the necessary
ser vices outlined in grants. CBOs can become siloed
Considerations
VCBOs have the ability to negotiate a reimbursement that covers the total cost of each intervention.
VThe provider or plan may not be willing to reimburse the total amount, and the CBO would need to find oth er funding sources to cover the cost
difference. CBOs may find that the service costs more than expected, and would need to wait for another contracting period to re-negotiate.
VCBOs are guaranteed a predictable amount of income, and can build capacity to meet the exact requirements of the contract.
VCBOs need accurate cost information to ensure that the flat rate will cover all of the program expenses.
VCBOs have the flexibility to provide any services
that they deem valuable, within the constraints of their monthly payment amount.
VAs CBOs may have a portion of their payment "at risk" if they do not achieve outcomes or cost-savings, they need to provide adequate time to
achieve the desired outcomes.
around funding streams, making it difficult to have a cohesive set of services.
Fortunately, with increased awareness about social determinants’impact on health outcomes, and the
valuable roles that CBOs play in commu nities, trends show that partnerships between CBOs, providers,
and payers are moving from informal, ad hoc arrangements to formal agree ments that outline service
delivery requirements. More than 80 percent of CBOs partnering
with health systems create an agreement to address such items as roles and responsibilities of each
partner, services covered by each orga nization, and the duration of the arrangement (Bradley et al.,
2016).
Just as traditional provider organizations con tract with health plans, CBOs can directly contract for their
own services. Some of the emerging pay ment methods are summarized in Table 2 (above).
6 !Spring 2018
Howto create successful payment arrangements
CBOs and healthcare organizations are increas ingly receptive to formal agreements around ser vice
delivery. To sustain programs and solidify the valuable role CBOs play in improving health, funding
arrangements must evolve from a depen dence upon grant funding to robust payment con tracts. To
achieve that goal, CBOs can benefit from guidance on selecting partners for payment agreements, as well
as on how to create contracts.
Selecting an organization with which to partner on service delivery is an important foun dational step in
relationship development. The Center for Health Care Strategies, Inc. (2017), highlights attributes of
successful partnership, including the following:
V Mission and values alignment;
V Ability to leverage complementary areas of expertise;
V Clear and well-communicated referral process between organizations; and
V Transparent, frequent communications. Once partners have established a trusting
relationship, they can explore contracting for services.
Opportunities for Expansion Abound
Healthcare systems contracts offer CBOs myriad opportunities to expand their ability to identify and
serve those in need and to garner support for their programs. Health providers and pay ers are increasingly
open to these new financial arrangements, and the movement toward value'For a contract to make financial sense, there must be an appropriate patient volume.'
based payment and recognition of the significant impacts of social determinants upon health cre ates an
environment conducive to contracting out for CBO services—a process that can be lengthy, but is in
many cases feasible.
CBOs can benefit from shifting the orga nizational mindset from outputs to outcomes.
Fundamentals of Community-Based Managed Care: A Field Guide
Partnership Components Necessary for Success
Partners in Care Foundation (Partners), a Los Angeles-based nonprofit, has extensive experience in direct con tracts with providers
and plans, with between 20 percent and 30 percent of its revenue generated by contracts with providers and payers. When creating
contracts, Partners recommends investing substantial up-front effort in defining contract terms—including realistic volume targets,
clear workflows for each organization, and an up front payment component for start-up costs. Partners also stresses that contracts
are more likely to be success ful if they include the following components:
Broad service area. Health plans and payers are more likely to contract for services that cover their entire geographic area,
including their whole provider network. CBOs will have greater success if they provide services across a wide geography. This may
lead to working with other CBOs in their community to provide services.
Clear value proposition. CBOs must understand the health system's needs and demonstrate how their programs can meet these
needs. In most cases, this requires collecting program outcomes data and using it to demonstrate program effectiveness. It is also
common for a contract to require that a CBO program meet a min imum return on investment, so understanding and controlling
program costs are critical. It is vital for the payer to realize that in order to have a real impact, the value proposition cannot be
achieved without sufficient volume.
Realistic volume requirements. For a contract to make financial sense, there must be an appropriate patient volume. It is difficult
to meet contract terms if there are too few or too many patients; thus it is crucial to use experience to calculate a realistic and
reasonable volume. In some of Partners' recent contracts there were arrangements to provide for a guarantee of minimum volume—
this provided a better alignment at all levels for both organizations.
Volume 42 Number 1 7
GENERATIONS - Journal ofthe American Society on Aging
This requires a concerted effort to collect data that demonstrate the value and effectiveness
of their programs, and to use such data to develop contracting arrangements with health systems. Instead
of operating separate, stand alone programs, CBOs can move toward a coor dinated approach within their
organizations
to deliver care. New contracting practices will
provide stability to CBOs, allowing them to continue to fulfill their vital roles within their
communities.^^
Margie Powers, M.S.W., directs the Medically Complex Patient Program at the Pacific Business
Group on Health in San Francisco, California. She can be contacted at mpowers@calquality.org.
References
Amarasingham, R. 2016. “The Potential of Shared-savings Mod els to Support Integrated Health and Social Services for
Complex Patients.” Grantee presentation to the Commonwealth Fund
via web seminar, August 16,2016; goo.gl/L9n6fe.
Bradley, E. H., et al. 2016. “Varia tion in Health Outcomes: The Role of Spending on Social Services, Public Health, and Health
Care, 2000-09.” Health Affairs 35(5): 760-8.
Center for Health Care Strategies, Inc. 2017. “An Inside Look at Part nerships Between Community- based Organizations and
Health Care Providers.” goo.gl/6pZkSY. Retrieved November 14, 2017.
Centers for Disease Control and Prevention. 2017. “Social Deter minants of Health: Know What Affects Health.” goo.gl/plCmlL.
Retrieved November 20,2017.
Miller, E., Nath, T., and Line, L. 2017. Working Together Toward Bet ter Health Outcomes. Final report to the Partnership for
Healthy Out comes. goo.gl/3mh7wU. Retrieved November 20,2017.
8 iSpring 2018
Copyright of Generations is the property of American Society on Aging and its content may not
be copied or emailed to multiple sites or posted to a listserv without the copyright holder's
express written permission. However, users may print, download, or email articles for individual
use.
April 2013
Issue Brief
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this mandate by supporting independent research on health care issues and making grants to improve health care
practice and policy. Support for this research was provided by
The Commonwealth Fund. The views presented here are those of the authors and not necessarily those of The
Commonwealth Fund or its directors, officers, or staff.
For more information about this study, please contact:
Sharon Silow-Carroll, M.B.A., M.S.W. Health Management Associates ssilowcarroll@healthmanagement.com
To learn more about new publications when they become available, visit the Fund’s website and register to receive
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Commonwealth Fund pub. 1687 Vol. 19
Forging Community Partnerships to Improve Health
Care:
The Experience of Four Medicaid Managed Care
Organizations
Sharon Silow-Carroll and diana rodin health ManageMent aSSoCiateS
ABSTRACT: Some managed care organizations (MCOs) serving Medicaid beneficiaries are actively engaging in
community partnerships to meet the needs of vulnerable members and nonmembers. We found that the history,
leadership, and other internal factors of four such MCOs primarily drive that focus. However, external factors such
as state Medicaid policies and competition or collaboration among MCOs also play a role. The specific strat- egies
of these MCOs vary but share common goals: 1) improve care coordination, access, and delivery; 2) strengthen the
community and safety-net infrastructure; and 3) prevent illness and reduce disparities. The MCOs use data to
identify gaps in care, seek community input in designing interventions, and commit resources to engage community
organiza- tions. State Medicaid programs can promote such work by establishing goals, priorities, and guidelines;
providing data analysis and technical assistance to evaluate local needs and community engagement efforts; and
convening stakeholders to collaborate and share best practices.
OVERVIEW
Responding to severe budget pressures and the Affordable Care Act’s impending expansion of Medicaid
eligibility, more states are shifting their Medicaid popula- tions into managed care organizations (MCOs).
At the same time, however, many states are demanding greater accountability for improving access to
care, quality
1
In this issue brief we explore how four MCOs serving vulnerable popu- lations are tackling these barriers
and changing the way care is delivered, by
of care, health outcomes, and efficiency.
is a tall challenge, particularly when considering the myriad socioeconomic, cul- tural, and logistical
barriers to care faced by vulnerable populations that often lack access to affordable services and supports
in their communities.
For MCOs, fulfilling all of these goals
2
the CoMMonwealth Fund
investing in partnerships and a strong community presence. They are Gateway Health Plan (Gateway)
in Pennsylvania, HealthPartners in Minnesota, L.A. Care in Los Angeles County, Calif., and
Neighborhood Health Plan (NHP) in Massachusetts. Three solely or primarily serve Medicaid and other
vulnerable popula- tions, while only about 6 percent of members of the fourth (HealthPartners) are
Medicaid beneficiaries. (For more information on the MCOs and how we selected them, see the
Appendix.)
These organizations are leaders in community engagement. To obtain information on their interven- tions
and community-based activities, we interviewed MCO staff members as well as directors of commu- nity
organizations with which they partner. The MCO respondents defined the vulnerable populations they
target as follows:
•
•
•
•
•
•
•
•
•
•
•
high-risk members with any of eight chronic conditions or at least two inpatient admissions
within the past 12 months;
plan members with diabetes and a gap in moni- toring that disease;
frail seniors in nursing facilities that are “hotspots” for complex cases that include both social and
medical needs;
plan members eligible for both Medicare and Medicaid who are receptive to home preven- tive
care;
dual-eligible seniors living in low-income housing;
seniors with Alzheimer’s and dementia;
racial minorities in neighborhoods with large health disparities by race, regardless of whether
they are plan members;
adults without dental coverage;
children ages 0–5;
patients who visit community health centers or other safety-net providers;
all plan members;
• all residents of a community where many have unmet health care needs.
All of these organizations are reaching out
to vulnerable individuals where they live, shop, and pray. They are building relationships with community
health, social service, and faith-based organizations, as well as local retail, communications, and
transporta- tion entities. They are leveraging their own and their partners’ expertise and resources to offer
counseling on illness prevention, chronic diseases, nutrition, domestic violence, and self-care; classes on
parenting, exercise, literacy, and first aid; screenings for high blood pressure, depression, breast cancer, and diabetes;
and team-based, integrated care in homes and day centers. They also are providing funding to expand
local dental clinics, strengthening the information technology used by safety-net providers, and
supporting local markets that offer healthy foods. And they believe they are see- ing signs of success.
(Case studies of the four MCOs are available at http://www.healthmanagement.com/ news-andcalendar/article/132.)
This brief explores these promising strategies and presents early results reported by the plans. We also identify factors that appear to contribute to
successful MCO–community partnerships, as well as policy options for state Medicaid programs that seek
to foster these approaches―with the understanding that our sample of MCOs is too small to apply lessons
to all MCOs or in all circumstances.
DRIVERS OF THE MCOS’ COMMUNITY- BASED EFFORTS
Internal factors such as the history, leadership, and business case of these MCOs appear to be the primary
drivers of their community-based efforts. However, external factors also appear to play some role.
Internal Drivers: History, Governance, Visibility, and Return on Investment
The MCOs’ history and leadership emphasize community health, and a sustained commitment of
resources to that focus. For example, NHP was
Forging CoMMunity PartnerShiPS: the exPerienCe oF Four MediCaid MCoS 3
founded by community health centers in 1986, which established its emphasis on community health and
equity. NHP started to focus on disparities in 2008 at the urging of its board of directors. NHP’s mission
statement includes promotion of equity, and its annual quality plan (required by the National Committee
for Quality Assurance) and its business plan include strat- egies for promoting community health and
reducing disparities. NHP interviewees stressed that strong lead- ership makes resources available for this
mission and “lights a fire” throughout the organization, so everyone is working toward the same goal.
Gateway interviewees emphasized that both leaders and staff are invested in the plan’s public
health mission and approach. The plan’s CEO has a degree in public health, and infuses public heath principles into the plan’s philosophy and its Prospective Care Management® (PCM) model. Using a tool that
assesses each plan member’s behavioral, environmen- tal, economic, medical, social, and spiritual needs,
PCM emphasizes being proactive and helping members move beyond narrow health care needs, with the
under- standing that such a short-term investment pays long- run dividends. Nearly half of Gateway staff
members were involved in designing the PCM model, and all employees now undergo PCM education
and training.
As a public entity, L.A. Care is governed by a stakeholder board—which includes Medicaid beneficiaries—that drives its community activities and focus. The plan established a Community Health
Investment Fund in 2001 to improve the health of the communi- ties it serves, regardless of whether
residents are health plan members. For example, the plan has funded expansions of dental clinics to fulfill
growing demand for dental care in Los Angeles County. That funding has built the capacity of the broader
safety net while also strengthening L.A. Care’s own network.
The structure and history of HealthPartners as an integrated, consumer-owned system contributes to its
dedication and ability to provide care in the most appropriate patient-centered setting, and to avoid
unnecessary hospitalizations and readmissions. The plan is accustomed to having clinicians work outside
clinics in nontraditional community-based settings, such as nursing facilities and adult day health centers.
Community engagement helps promote each health plan’s brand. Beyond a desire to be “good citizens” by addressing member and community needs, the MCOs acknowledge that community engagement
helps attract and retain members, providing a business case for these activities. Investments that build
relationships with community providers, in particular, help position the MCOs to benefit as Medicaid
coverage expands under the Affordable Care Act.
L.A. Care, for example, cited “visibility and recognition” as key criteria when selecting locations for its
Family Resource Centers. These centers offer classes on health, nutrition, disease management, exer- cise,
and parenting; determine area residents’ eligibility for public programs; provide preventive care such as
flu shots and mammograms; refer residents to health care providers; and help them navigate the health
care system (see box on next page).
The MCOs expect community investments to reduce long-term health costs, improving their
bottom line. Many interviewees are convinced that preventive care and screening offered through
commu- nity activities and partnerships will improve the health of plan members and reduce the need for
more expen- sive interventions later, bolstering the plans’ financial performance—though they insist the
latter is not their primary motivation.
For example, Gateway staff attributes a 9 per- cent decline in the plan’s inpatient admission rate from
2009 to 2012 to both the plan’s holistic approach and its community initiatives. HealthPartners
interviewees say the plan does not expect a financial return from its community-based activities.
However, both the plan and its community partners report that their efforts
are producing better-coordinated and patient-centered care, improving the management of chronic illness,
and enabling people to receive more care outside the hospi- tal—which can reduce overall costs.
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the CoMMonwealth Fund
Community Needs and Enrollment Growth Drive Decisions at L.A. Care
To determine the best locations for its Family Resource Centers, L.A. Care uses HEDIS 2 performance
measures to identify health disparities among its members, and also examines demographics, access to
care, health outcomes, health status, and concentration of individuals receiving public assistance to
identify high-risk neighborhoods. The organization then uses several criteria to decide where to site the
centers:
Visibility. Locations that could provide visibility and recognition for the plan, particularly those with many
people enrolled in public programs, opportunities for membership growth, high population density, good
pedestrian access and access to public transportation and freeways, and proximity to commercial and
retail centers.
Need. Areas with compelling community needs, particularly those with significant disparities in health care
outcomes and access. Safety-net support. Locations with high-volume health providers through which
L.A. Care could offer health education and promotion and
disease management services.
Proximity. Proximity to L.A. Care’s downtown offices, to allow more effective program oversight.
External Drivers: The MCO Market and State Policies
A history of MCO collaboration, competition, or both—plus state flexibility—help drive the plans’
community-based efforts. HealthPartners representa- tives cited both collaboration and strong
competition among MCOs in the Minneapolis–Saint Paul area, along with flexibility to innovate afforded
by the state, as fostering new approaches to integrating care for vul- nerable populations. HealthPartners’
approach aligns well with the aim of the state Medicaid agency to bet- ter coordinate and integrate care
for people eligible for both Medicaid and Medicare.
State guidelines encouraging health plans to provide community benefits encourage that focus.
Neither states nor the federal government traditionally require health plans to provide “community
benefits.”3 However, three of the four MCOs we examined are
in states that do have guidelines that encourage health plans to work with partners to improve health in
their communities:
• Massachusetts has long-standing voluntary guidelines that encourage health maintenance organizations
to collaborate with commu- nity organizations to identify and address local needs, formalize their
approach to this work, and report on their activities annually.
These guidelines do not recommend specific
4
• In Minnesota, health insurers must file “col- laboration plans” every four years (and updates every two
years) that show how they will sup- port high-priority public health goals, measure and evaluate progress,
and collaborate with local public health and other community orga- nizations.5 The collaboration plans
focus on the under-65 population. However, the state
is moving toward formal requirements for innovative efforts to integrate care for seniors, with
HealthPartners’ strategies as one possible model.
• In 2011, Pennsylvania’s Medicaid agency began including in its MCO contracts four broad “pillars” to
promote community involve- ment, although these do not include numeri- cal targets or financial
incentives. The pillars are: 1) embed care managers in medical practices; 2) develop transitions of care; 3) help primary care
physicians achieve medi- cal home status; and 4) work with collabora- tive learning networks. The state
Medicaid agency also uses “efficiency adjustments” that increase or decrease payments to health plans
if their region does much better or worse than
6
activities.
expected on measures of population health.
Forging CoMMunity PartnerShiPS: the exPerienCe oF Four MediCaid MCoS 5
California does not have requirements or guidelines for MCOs on community benefits. However, nine
counties organize Medicaid managed care under a two-plan model: enrollees can choose between a public
“local initiative” plan (including L.A. Care, established by the county in 1997) and a commercial plan.
Local initiative plans are accountable to the community through their transparent, public governance
model. Further, the local initiative plans are designed to incor- porate safety-net providers in their
governing boards, quality improvement committees, and peer review and credentialing committees. This
ensures that “safety-net needs and concerns have a voice in the operations of local community health
plans.”8
State Medicaid contracts and the state’s convener role promote community engagement.
The four states also share other Medicaid managed care policies that encourage plans to expand beyond
a traditional medical model and engage the commu- nity. State Medicaid contracts require MCOs to target
high-risk enrollees; coordinate and integrate care
for physical, behavioral, and social needs; and meet enrollees’ special needs. The Medicaid programs also
convene MCOs to collaborate on quality improvement and share best practices, work with other agencies
and community providers to integrate services, and promote community health through educational campaigns, region-based financial incentives, and efforts to reduce hospital readmissions.9
PROMISING COMMUNITY-BASED GOALS AND STRATEGIES
As noted, the MCOs we studied are pursuing a wide range of strategies to improve care for vulnerable
pop- ulations through community partnerships. Their efforts reflect three overarching goals: 1) improve
health care coordination, access, and delivery; 2) strengthen the community and the local safety-net
infrastructure; and 3) promote preventive care and reduce disparities.
Goal 1. Improve Health Care Coordination, Access, and Delivery
MCOs can develop tools to coordinate and track member referrals to social and medical services in the
community. For members who are frail or otherwise have difficulty getting to health care providers,
MCOs can bring medical services and care coordination to them. Examples include:
• Community repository. Gateway developed a database of some 3,000 community resources that care
management and member services staff use to refer patients. Health plan staff members continually
update the database through local meetings and personal relation- ships with organizations and through
member feedback. Some 40 percent of care manage- ment cases rely on the repository.
• Clinical teams placed in health care “hot spots,” including nursing and assisted- living facilities,
adult day health centers, and public housing. HealthPartners places clinical teams at institutional and
day facilities with high concentrations of Medicaid patients with complex medical, mental health, and
social needs, including those with dementia for whom travel is particularly challenging. These specialized
teams provide and coordinate pri- mary, urgent, and behavioral care. An incentive payment program
rewards nursing facilities and housing partners for better managing care for their residents. Hospital
readmission rates at nursing facilities and low-income housing facilities with such teams dropped nearly
30 percent and 50 percent, respectively (see box on next page).
• In-home care management and treatment.
Gateway assesses patient data to identify high-risk members, and arranges home visits to them by
physicians and nurse practitioners. These clinicians perform comprehensive health assessments, provide
care management, and arrange laboratory and other services.
• Telehealth specialty care initiative. L.A. Care leads a collaboration that developed Safety
Net eConsult, a tool that enables primary care providers and specialists to share information.
7
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the CoMMonwealth Fund
Clinical Team in Low-Income High Rise Helps Reduce Readmissions
An onsite HealthPartners team—including a physician, a nurse practitioner, a case manager, and home
care staff from the nonprofit Presbyterian Homes—is providing and coordinating care for 42 residents of a
low-income high-rise in downtown Saint Paul who have a high rate of mental illness. The team provides
care in residents’ apartments or an exam room in the building. The team meets regularly to solve
problems, and the nurse practitioner reassesses patients’ status as needed.
When patients miss appointments, staff can easily reach out to them or visit them in their apartments.
Residents have come to see the clinicians as accessible and trusted. From 2009 to 2012, the hospital
readmission rate among these residents has dropped from 24 percent to 12 percent. Medicare and
Medicaid provide financial support for the program.
Physicians using eConsult resolved about half of requests for specialty care without the need for face-toface visits with specialists, and wait time for necessary specialty appointments
county-initiated effort to advance the exchange of health information among safety-net pro- viders. By the
end of 2013, the Los Angeles Network for Enhanced Services expects to enable the county Department of
Health Services, community-based clinics, and safety- net hospitals to exchange information on more
than 5 million patients.
• Vouchers for local markets. As part of an ini- tiative to reduce high blood pressure and man- age
diabetes, NHP supports local supermarkets that supply healthy foods by mailing coupons and vouchers
for fresh groceries to targeted members.
• Funding for health events organized by community organizations. Gateway provides financial
support to community organiza- tions that organize events promoting illness prevention, health education,
and health care outreach.
• Community repository. As noted, Gateway’s database facilitates referrals to about 3,000 community
agencies that provide safety-net services, including child care, counseling, housing, food assistance, social
supports, and transportation.
Goal 3. Promote Prevention and Reduce Disparities
To reduce racial and ethnic disparities in screenings and health outcomes, the four MCOs have developed
a number of illness prevention and health education pro- grams in their communities. These include:
10
Goal 2. Strengthen the Community and Safety-Net Infrastructure
Medicaid managed care plans are part of a broader safety-net system that could better coordinate health
care and integrate it with other services, but often lacks the resources to do so. To help close that gap,
L.A. Care established a Community Health Investment Fund to equip safety-net providers with the
technology and resources to expand access and coordinated care. This fund provides:
•
Grants to expand access to dental care.
L.A. Care has made grants totaling almost $9 million for 91 projects to expand dental clinics and services and establish new clinics for vulnerable populations. These programs were
motivated by the urgent need for dental care after adult Medicaid beneficiaries in the state
lost dental coverage, and by the recognition that dental and physical health are closely con-
nected. L.A. Care estimates that its latest round of grant funding will support some 66,000
den- tal visits for about 22,000 people.
•
Funding and leadership for public–private collaboration on exchange of health information.
L.A. Care provides funding and sits on the steering committee for a
dropped by 60 percent.
Forging CoMMunity PartnerShiPS: the exPerienCe oF Four MediCaid MCoS 7
•
•
•
Neighborhood centers that provide free health education, screenings, and refer- rals. Since
establishing two Family Resource Centers in high-need neighborhoods in 2007, L.A. Care
has recorded nearly 113,000 visits. Most users are repeat visitors. Input from staff and
outside organizations suggests that the services are highly valued and fill health care gaps,
particularly the exercise and nutrition classes.
Home-based screening and self-manage- ment. Gateway analyzes patient data to iden- tify
members with gaps in diabetes monitoring, and sends a technician to their homes to help
with glucose testing and educate them about self-care. The MCO also sends home screening kits for colorectal cancer to members who are eligible for both Medicare and Medicaid
and are willing to pursue preventive care, with instructions tailored to their level of health
lit- eracy (see box below).
A “care gap” system that alerts care manag- ers. Gateway care management and member
services staff receive specialized alerts based on a member profile system when a member is
due for preventive care. Staff members contact the family to arrange appointments. This
sys- tem supplements quarterly reports that identify households that are due for screenings
and members who are frequent no-shows for doctor visits, triggering care management
outreach. Gateway reports that this system helped them
•
reach the 98th percentile among providers in prenatal visits.
Partnerships and tools that reduce racial and ethnic disparities. NHP and Gateway have several
campaigns to reduce disparities in care and outcomes among African Americans and Latinas:
o NHP partners with local grocery stores and pharmacies to address high blood pressure and diabetes
among African Americans. The MCO places a facilitator in local grocery stores to survey consumers and
help raise awareness of good nutrition and healthy eating, and mails coupons and vouchers for fresh
produce to members. The health plan also provides diabetes education and glucose and blood pressure
screenings at health fairs at local pharma- cies, and reimburses members for blood pressure cuffs.
o To expand postpartum care and early well- child visits among Latinas in neighbor- hoods with large
disparities, NHP is build- ing a coalition among local organizations serving the Latina community,
conducting focus groups to identify promising strate- gies, and training medical staff in cultural
competency.
o NHP has collaborated with local busi- nesses, churches, the YWCA, com- munity health centers, a
cancer center, and local media to eliminate disparities
Home Screenings Identify Problems and Trigger Follow-Up
Gateway’s home-based screening programs, which identify and target at-risk patients with diabetes or
those eligible for both Medicaid and Medicare, show promising results. Among 3,950 members with
diabetes visited by nonclinical technicians for testing and education, some 1,200 have completed a blood
glucose test. About 14 percent of those tests identified members with high A1c (>10), who were then
referred for follow-up care.
Of 3,985 Gateway members who received home screening kits for colorectal cancer in 2011, 22 percent
mailed in samples. Of those, 8 percent had abnormal results and were contacted for follow-up care.
Gateway expanded this campaign in 2012, and expects to evaluate its cost-effectiveness in the near
future.
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the CoMMonwealth Fund
o
in mammography rates among African American women in five counties. The mammography screening
rate rose by 4 percentage points over two years, and a racial disparity in screening disappeared. In fact,
the screening rate among white women is now below screening rates among other ethnic groups (Exhibit
1).
Gateway has partnered with a university- based health center to place MCO staff
at African American–owned businesses, including barbershops and beauty salons. These staff members
conduct blood pres- sure screenings and educate customers and employees about healthy lifestyles, nutrition, body mass index, and other health topics, using materials created targeting African American
women. A Gateway sur- vey showed increasing health knowledge among customers and employees in
these shops and salons.
implement initiatives. HealthPartners, for example, reported that six to nine months typically elapse from
when it first approaches a community organization to when it deploys providers on site.
Evaluating the impact of communitywide interventions can be difficult. The MCOs have faced
challenges in assessing the effects of interventions
and services that target both plan members and non- members. L.A. Care, for example, has been unable to
measure the impact of its Family Resource Centers largely because 68 percent of users are not L.A. Care
members. The plan cannot track their health status and use of services.
Without a documented return on investment, sustaining and expanding these programs is difficult. The
MCOs also face a chicken-and-egg dilemma: they need support from other entities to build strong initiatives, but they also need to show positive results to garner support. One solution is to start initiatives by
building on existing relationships, and to expand the programs once some evidence—even if anecdotal—
is in hand.
Funding may be unpredictable. Even with commitment from an organization’s leaders, funding for
community-based initiatives may be uncertain. For example, the amount available for L.A. Care’s
Community Health Investment Fund depends on the plan’s performance. As a result, funding for priority
programs can be unpredictable from year to year.
CHALLENGES
The four MCOs have faced several challenges in implementing their community-based strategies:
Establishing trusting partnerships takes time and commitment. Partnerships with outside
organizations require time to develop and maintain the relationships, establish roles and responsibilities,
and
Exhibit 1. Breast Cancer Screening Among Neighborhood Health Plan Enrollees, by Race
and Ethnicity, 2010
100% 95% 90% 85% 80% 75% 70% 65% 60% 55% 50%
79%
76%
82%
Notes: Neighborhood Health Plan created materials targeting African American women. No disparity is shown comparing African American women to
white women.
Source: Neighborhood Health Plan.
72%
Plan-wide average
Asian American African American Latina White
Forging CoMMunity PartnerShiPS: the exPerienCe oF Four MediCaid MCoS 9
MCOs may fail to enlist affected groups in organizing new initiatives. The MCOs admit that they
sometimes do not involve other entities enough in plan- ning initiatives and solving problems, which
dilutes the effectiveness of the initiatives.
Strategies that target the highest-risk mem- bers of a health plan pose particular challenges. These
include:
•
•
•
Contacting patients. One MCO reported
that about one-third of the phone numbers it receives from state records are disconnected or
otherwise not functioning.
Managing logistics and home visits. Members with multiple health conditions often have trouble
getting to appointments. Meanwhile, the plans report that obtaining consent from members for
home visits can be difficult.
Ensuring member compliance. Members with complex health conditions often have trouble
managing multiple medications and following care plans.
See the Appendix and case studies for more detail on these activities.
CONCLUSIONS AND POLICY IMPLICATIONS
Managed care organizations that serve Medicaid and other vulnerable populations face
particular chal- lenges in reaching and serving their members. These challenges threaten
members’ access to high-quality primary care, illness prevention, screenings, health education,
chronic care, and care management and coordination.
The four MCOs we studied—and many more across the United States—are addressing these
chal- lenges by partnering with and supporting community- based health, social service, and
faith-based organiza- tions, as well as local retail, housing, and transportation entities. These
partnerships leverage both resources and expertise, with potentially significant benefits for plan
members and other local residents.
The plans report evidence of success in reduc- ing disparities in screening rates, curbing
inpatient
readmissions, and improving access to dental,
chronic, and interdisciplinary care. MCO interviewees believe—based on participation and feedback from
members and staff—that these activities have improved or will improve access to preventive care and
coordina- tion of health care and social services.
Overall, however, evidence of the impact of community engagement on health outcomes and efficiencies is limited, particularly for programs that offer services to people outside the MCOs, as they
cannot measure service use and health outcomes among those participants. The impact on population
health is also difficult to quantify—especially over a short period
of time, and with most interventions still serving rela- tively small numbers of people. Limited resources
and methodological challenges also present barriers to evaluating the impact of these programs, even
among MCO members.
The MCOs we studied have devoted staff
and other resources to improving community health without expecting a short-term return. However, they
do acknowledge that community partnerships and initiatives improve the plans’ image and build relationships with providers. That, in turn, could help make the MCOs an attractive choice as Medicaid coverage
expands under the Affordable Care Act and new indi- viduals select plans. To expand such efforts,
stronger evidence of return on investment or other benefits to the plans is needed.
What State Governments Can Do
A key challenge for policymakers is to spur more health plans to improve community health and share
informa- tion on best practices. While state governments have not been the primary drivers of the
initiatives we stud- ied, the MCOs see state government as a valued partner that could help nurture and
promote such initiatives.
States that are establishing their own insur- ance exchanges under national health care reform are working
quickly to contract with health plans to meet deadlines, and may therefore be reluctant to create more
requirements for MCOs. However, states can set expectations for the new marketplace by issuing
10
the CoMMonwealth Fund
voluntary guidelines on community benefits; asking health plans to include community activities in their
proposals to participate in insurance exchanges and Medicaid contracts; establishing priorities, goals, and
baselines for community health; and engaging plans and community stakeholders in a collaborative
process (see box below).
States could also fund efforts to evaluate community activities by MCOs to identify successful
approaches, and provide forums for sharing best prac- tices and technical assistance to promote
proliferation. Through health information exchanges, data reposito- ries, and other technologies, states
could help health plans assess local needs and identify health care gaps and disparities. States could also
pilot payment reforms that reward MCOs for coordinating and integrating community-based providers
and services.
The four health plans we studied are rooted
in their communities. That does not necessarily mean that larger, multistate health plans are less able to
form local partnerships. However, it does mean that those plans must balance standardization across
states— which allows sharing of best practices and economies of scale—with the flexibility and tools that
allow each subsidiary to identify and address local needs.
Based on our interviews with Medicaid offi- cials and leaders of community-based organizations,
it is clear that not all Medicaid MCOs are alike. Some place a strong emphasis on community
engagement, while others have much work to do in this area. With growing evidence that MCO–
community partnerships promote care coordination, prevention, and a stronger safety net, state
governments should seek to encourage and support these activities.
Information That States Could Request to Spur Community Engagement by MCOs
State governments could pose questions to MCOs in several arenas to encourage community
engagement. The following are based on key “ingredients” that appear to contribute to successful
community partnerships among the four MCOs studied:
Using data to identify gaps and target interventions. Does the MCO use data (HEDIS measures, health
care claims, administrative data) to identify gaps and disparities in screenings, health care use, and
outcomes related to age, race, ethnicity, and geography? Does the MCO use this information to target
interventions toward specific populations and neighborhoods in greatest need?
Learning about local needs through community interaction. Does the MCO supplement data with frequent
interaction with community residents and organizations? Do designated staff members attend
neighborhood meetings and visit health centers, shops, religious organizations, and other venues to track
community needs and gaps in care?
Involving the community in developing solutions. Does the MCO enlist stakeholders in developing
solutions to these needs and gaps?
Integrating community health into the MCO’s mission and priorities. Does the health plan’s mission
include a focus on community health? How do plan leaders communicate this priority? Has the plan
committed staff time and resources to this focus? Are staff members dedicated to improving the health of
the broader population and building relationships in the community?
Developing the right messages and materials. Does the MCO deliver culturally sensitive messages,
relying on people with backgrounds similar to those of local residents? Are all educational materials at an
appropriate level of health literacy?
Keeping primary care physicians informed. Is the MCO alerting physicians to its community-based
initiatives, to encourage them to participate?
Forging CoMMunity PartnerShiPS: the exPerienCe oF Four MediCaid MCoS 11
APPENDIX: SELECTION, ATTRIBUTES, AND ACTIVITIES OF THE MCOS
Health Management Associates interviewed state Medicaid officials and asked them to identify MCOs
that have been leaders in pursuing community-based strategies to improve access and care for vulnerable
populations. We then used websites and initial conversations with representatives of 19 MCOs to explore
their activities and assess their willing- ness to share information.
With input from The Commonwealth Fund, we selected four of these MCOs for further study, with the
pri- mary goal to investigate a number of different community-based strategies in a range of geographic
areas.
We conducted in-depth, semistructured interviews with staff members most knowledgeable about the
MCOs’ community-based initiatives, and with directors of community-based organizations with which
they partner. We also reviewed material on their programs and results.
Appendix Tables 1 and 2 provide details on the plans and their activities.
Plan
Gateway Health Plan, Pennsylvania
HealthPartners, Minnesota
L.A. Care, California
Neighborhood Health Plan, Massachusetts
Appendix Table 1. Overview of the Four Medicaid Managed Care Organizations
Overview
Gateway Health Plan is a Medicaid MCO serving more than 250,000 children and adults, and an HMO
special needs plan serving about 30,000 individuals dually eligible for Medicare and Medicaid.
Established in 1992 as an alternative to the state’s traditional medical assistance program, Gateway
offers coverage in 45 of 67 Pennsylvanian counties (as of January 2013). Its network includes some 100
hospitals, 2,800 primary care physicians (PCPs), and 9,000 specialists and other providers.
In 2013 Gateway intends to introduce a special needs plan for people who are partially eligible for both
Medicare and Medicaid, and a special needs plan for individuals with cardiovascular disorder, chronic
heart failure, and diabetes. Founded in 1957, HealthPartners is a consumer-governed nonprofit that is
both an insurer and a health system. Its medical group consists of 70 medical and dental clinics, 17
pharmacies, 780 physicians (including 350 PCPs), and 60 dentists. Four HealthPartners hospitals
operate in Minnesota and Wisconsin.
The HealthPartners health plan has 1.4 million members in total nationwide, with a network of 38,000
care providers in Minnesota, western Wisconsin, South Dakota, and North Dakota. M...
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