Florida State University Community Health Partnership Project

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Npuvyyrf1956

Health Medical

Florida State University

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Community Healthcare Partnership. The task now is to propose a budget to share with your stakeholders who will ultimately approve the partnership and budget. Your budget proposal will provide your stakeholders, consisting of your hospital board of trustees and the community health department governing board, with the amount of funding needed to:

  1. Form your partnership.
  2. Carry out your strategic action plan activities.
  3. Improve the intended outcomes to reduce the over-utilization of the emergency department.
  4. Reduce the readmission rates of patients within 30 days of discharge.

Download the spreadsheet in this week's resources to use in your projections for the funding needed for the salaries and benefits for the professionals who will carry out the activities in your collaborative project. You will notice the line items and projected expenses that the community health department agreed to provide for this partnership project are already inserted into this graphic example and will be pre-populated in your downloaded spreadsheet.

The budget spreadsheet is set up to assist you with calculating salaries and benefits for the professionals and paraprofessionals you will hire. Review the Bureau of Labor Statistics Occupational Outlook Handbook for the median hourly wages information you will need to plug into this budget.

Your report should consist of:

  • Title page
  • An introductory page that includes:
    • an overview of the community health partnership project
    • the goals identified in the strategic action plans
    • the rationale for your budget projections
  • The budget spreadsheet should follow the introductory page(s)
  • References

You will also need to calculate the construction costs for your proposed budget, which was previously established as $55 per square foot. In the Week 3 scenario, the physical resources were identified during your walk-through with your leadership team and facilities director. These spaces included examination rooms, consultation rooms, and the reception area. Space has HVAC, plumbing, and electrical sources; and you will authorize the construction of these joint-use spaces with the community health department in this partnership.

Enter the construction cost into the Budget Projections after the Total Operating Budget on the line for Projected Construction Costs, since this cost will occur only once and there are no recurring expenses associated with this part of the project.

Unformatted Attachment Preview

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 commonwealthfund.org Issue Brief, January 2018 TUhseinCgoCmomomnuwneitayltPhaFrutnedrships to Integrate Health and Social SHeorvwicHeisghfoIrsHAimghe-rNiceae’sd,HHeiaglhth-CCoasrtePCaotisetnBtusrden? 8 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 commonwealthfund.org Issue Brief, January 2018 TUhseinCgoCmomomnuwneitayltPhaFrutnedrships to Integrate Health and Social SHeorvwicHeisghfoIrsHAimghe-rNiceae’sd,HHeiaglhth-CCoasrtePCaotisetnBtusrden? 9 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 commonwealthfund.org Issue Brief, January 2018 TUhseinCgoCmomomnuwneitayltPhaFrutnedrships to Integrate Health and Social SHeorvwicHeisghfoIrsHAimghe-rNiceae’sd,HHeiaglhth-CCoasrtePCaotisetnBtusrden? 10 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 commonwealthfund.org Issue Brief, January 2018 Copyright of Issue Brief (Commonwealth Fund) is the property of Commonwealth Fund 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. 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 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. 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 email alerts. 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. 4 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 6 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. 8 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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Explanation & Answer

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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
48.4...


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