COORDINATING CARE FOR THE UNINSURED: RESOURCES FOR

BUILDING COLLABORATIVE NETWORKS OF CARE IN YOUR COMMUNITY

17th Annual Healthy Carolinians Conference

and NCIOM Prevention Summit

October 8th, 2009

Anne BraswellSenior Analyst for Research and

DevelopmentNC Office of Rural Health and Community

Care

CHANGES IN HEALTH INSURANCE COVERAGE IN NC: 2000 – 2007

More than 1.5 million nonelderly (18.9%) were uninsured in NC in 2006-2007 Approximately the population of the Charlotte

metro area

Between 1999-2000 and 2006-07:North Carolina experienced DOUBLE the

increase in the percentage who were uninsured than nationally (NC: 29%, US: 12% increase)

North Carolinians lost employer-sponsored insurance at nearly DOUBLE the national rate (NC: 12.5%, US: 6.8% decrease)*

* Mark Holmes, PhD, Vice President, North Carolina Institute of Medicine

“The NC Uninsured: Who Are They, Why Do We Care, and What Can We Do?” Annual New Hanover County Health Access Summit, Access to Care

and Impact on Our Community, 19 September, 2008.

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2000: HEALTH RESOURCES AND SERVICES ADMINISTRATION ANNOUNCED

COMMUNITY ACCESS PROGRAM (CAP)

New federal grants program supporting community indigent care initiatives to increase access and quality of care for the uninsured and underserved

Expanded access for the uninsured by increasing effectiveness and capacity of the nation’s health care safety net at the community level

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COMMUNITIES RECEIVING CAP FUNDS EXPECTED TO:

Build integrated health care delivery systems offering a seamless continuum of care for the uninsured and underinsured

Eliminate unnecessary and duplicative functions in service delivery and administration, resulting in savings to reinvest in the system

Increase access to health care for low-income uninsured and underinsured persons

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FIRST COMMUNITY ACCESS PROGRAM IN NORTH CAROLINA

June 2000: Office of Rural Health and Community Care applied for CAP funding on behalf of Community Care Plan of Eastern Carolina for Pitt, Greene, Edgecombe & Bertie Counties

September 2000: ORHCC awarded one of only 23 CAP grants in nation -- $897,000 for Pitt et al

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2000: COMMUNITY CARE PLAN OF EASTERN CAROLINA AND ORHCC CREATED

HEALTHASSIST

Built upon administrative infrastructure of Community Care of North Carolina (CCNC)

Established 4 Community Resource Centers Co-located services with other community non-

profits (e.g. JOY Soup Kitchen; Pactolus’ Fire/Rescue)

Provided health care services, care coordination, wellness and prevention services, adult continuing education, and job skills training for low-income and uninsured 6

BEGINNING 2001: HRSA REPLACED CAP WITH HEALTHY COMMUNITIES ACCESS

PROGRAM (HCAP)

Additional indigent care networks were initiated throughout NC with HCAP funding: Cabarrus, Guilford, Buncombe, Moore, Beaufort, Durham, Henderson, Orange/Chatham

Several communities initiated programs, but were not awarded federal funding: Mecklenburg, Wake, Vance/Warren, Wilkes, Wilson, Mitchell/ Yancey, Watauga, New Hanover, and others

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2005: HCAP NO LONGER FUNDED BY HRSA

After 2005, former HCAP sites and other programs in NC struggled to maintain the same level of programs and services with limited resources

Early in 2007, the last HCAP “carryover” funding ran out

In the summer of 2007, The Duke Endowment provided 4 months of emergency funds

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IMPACT OF HCAP PROGRAM IN NC

Between 2000 and 2005, HCAP helped: Induce physicians and hospitals to provide

more free care and services for the uninsured Local governments and philanthropic

organizations to provide matching investments of funds and resources

Bring about both perceived and measurable improvements in the health and wellness of participants

Reduce inappropriate use of hospital EDs and other costly services by participants

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A KEY LESSON LEARNED FROM HCAP:

There must be sustaining funds to support the infrastructure needed to

effectively operate community indigent care programs.

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2007: “HEALTHNET” INITIATIVE

In SFY 2007-08, NC General Assembly made a one-time appropriation to ORHCC of $2.88 million to implement HealthNet to

support North Carolina’s safety net primary care provider networks and

develop community-based systems of care serving the uninsured.

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NC HEALTHNET:

Links local safety net organizations and indigent care programs providing free and

low-cost health care services with Community Care of North Carolina’s networks

of physicians and services.

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HEALTHNET NETWORKS INCLUDE: Physicians Hospitals Public Health Free Clinics Rural Health Centers Community Health

Centers Departments of Social

Services Behavioral Health Other Community-Based

Safety Net Organizations 13

HEALTHNET TARGET POPULATION:

Uninsured adults, 18-64 years old, whose family income is below 200% of FPL

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HEALTHNET ENROLLEES:

Provided a Primary Care Medical Home and access to:

Specialty Care Wellness Education Prevention Services Prescriptions Medications Care Coordination for Chronic Medical

Conditions Other Needed Services

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HEALTHNET NETWORKS:

Receive technical assistance and grants from ORHCC to support the community’s ongoing efforts to:

Increase access and quality of care through a coordinated delivery system

Share and conserve limited resources through collaborative partnerships

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2007: HEALTHNET IN YEAR 1

Funded 16 HealthNet Networks providing services for the uninsured in 27 counties

40,000+ individuals were provided a medical home

25,000+ individuals had access to needed prescription medications

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2008: HEALTHNET IN YEAR 2

In SFY 2008-09, ORHCC received $2.8 million in recurring appropriations to sustain

existing HealthNet Networks and $975,000 in non-recurring funds to develop new

collaborativenetworks.

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2008: HEALTHNET IN YEAR 2

Funding 21 HealthNet Networks that provide services for the uninsured in 38 counties

50,000+ individuals have a medical home 38,000+ individuals have access to

needed prescription medications

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2009: HEALTHNET IN YEAR 3

For SFY 2009-10, ORHCC has received$4.8 million in recurring appropriations tosustain the existing HealthNet Networksand develop new programs as available

funding will permit.

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ORHCC TECHNICAL ASSISTANCE:

Office of Rural Health andCommunity Care staff provides: Community Needs & Gap Analysis Strategic & Business Planning Network Development Medical, Dental, and Psychiatric

Provider Recruitment for Underserved Areas & Educational Loan Repayment

Architectural Design Support for Capital Projects 21

ORHCC TECHNICAL ASSISTANCE (CONTINUED)

Coordination with: Community Care of North

Carolina (CCNC) and MedicaidCritical Access Hospital ProgramFarmworker Health ProgramMedical Access Program Medication Assistance ProgramCommunity Health Grants

Program

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ORHCC TECHNICAL ASSISTANCE (CONTINUED)

Free software applications for access, referral, eligibility, enrollment, and care management (CARES and CMIS) and for the Medication Access & Review Program (MARP)

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PARTICIPATING IN HEALTHNET

Health care providers and safety net organizationsthat would like to partner with the local HealthNetNetwork or want help with planning and organizing a new HealthNet Network should contact:

CCNC’s Community Care Coordinator for the county

Office of Rural Health and Community Care 919-733-2040

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HEALTHNET PARTNERING WITH CARE SHARE HEALTH ALLIANCE

ORHCC helps support the Care Share Technical Assistance Center with HealthNet funds

ORHCC is also a part of Care Share’s Funders’ Collaborative where grant decisions are coordinated to eliminate duplication and identify gaps

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CARE SHARE HEALTH ALLIANCEShelisa Howard-Martinez

Care Share Health Alliance's mission is to improve the health of low-income, uninsured North Carolinians by supporting

local Collaborative Networks of care.

Care Share Health Alliance

Is an independent, statewide resource that brings people together to improve the health of low-income, uninsured persons.

Our basic tenet is to meet communities where they are and to build on their strengths and resources.

Successful Collaboration

Includes:• Broad stakeholder participation – everyone comes together

around an intersecting issue (caring for the uninsured);• Effective & Passionate Leadership (Sparkplugs); • Group staying focused on what is best for the health of the

individual/patient;• Shared vision and goals;• Creating something new together (shared ownership &

responsibility);• Celebrating success and having fun together!

Continuum of Collaboration

Informal, episodic collaboration, letters of support

No collaboration, silos, lack of

trust

Integrated system – common systems, coordination of care across partners – i.e. Project Access

Continuum

of

Collaboration

Partners meet on a regular basis, planning

to implement a project/system

together

All safety net providers at the table, coordinated for

all the uninsured, prioritized needs, funding

PatientMedical/Primary Care

Home

Dental

Chronic Disease

Management

Specialty Care

Wellness & Health

Education(Prevention)

Public Health

Medications

Hospital

DSS

Mental Health

Convening, Facilitation and Support through:• On-site technical assistance and phone consultations to support

communities who want to enhance their collaboration and/or develop Collaborative Networks of care.

• Webinars – “Emergency Department Utilization Reduction” with the NC Hospital Association and “Central Fill Pharmacy” with the NC Association of Free Clinics.

• Web-based tools, templates and resources, an interactive Knowledge Bank of best practices, and a 2010 conference.

Care Share Offers New Resources

Menu of Technical Assistance Services

• Capacity Building: organizational development, financial management, leadership building, Information Technology expertise, programs/systems design;

• Identifying new resources for communities;• Referrals to other agencies to leverage resources;• Advisory/coaching with leadership;• Conflict Resolution;• Community-Wide Planning.

Knowledge Bank

Is an interactive resource for communities who want to enhance their collaboration.

• Capacity development resources,• Online Tools and Templates,• Monthly Webinars and teleconferences,• Calendar of events.

Sign up at www.CareShareHealth.org.

Community-Wide Planning

• Goal is to develop a three-year, community-wide plan to care for the uninsured

• Builds on existing community health assessments and plans

• Streamlines planning and other efforts

• Leverages all resources in the community

Opportunity to develop:

• A new or updated Strategic Plan,

• A Finance plan,

• Evaluation plan,

• Sustainability plan to enhance long-term financial viability.

Technical Assistance Team

West

Rachel Rosner

(828) 232- 2976

Central

Linda Kinney

(919) 800-8967

East

Shelisa Howard-Martinez

(919) 861-8359

How to connect with Care Share

• Call or email a Care Share Team member to discuss your needs.• Invite us to your community to learn more about how we can help you build collaboration to care for the uninsured.• Register for the Knowledge Bank• Check calendar for upcoming Webinars

17th Annual Healthy Carolinians Conference & 17th Annual Healthy Carolinians Conference & NCIOM Prevention SummitNCIOM Prevention Summit

October 8, 2009October 8, 2009

Coordinating Care for the Uninsured in Gaston CountyCoordinating Care for the Uninsured in Gaston County

Presented byPresented byVeronica Feduniec, Executive DirectorVeronica Feduniec, Executive Director

BackgroundBackground IssuesIssues

High non-urgent ED utilizationHigh non-urgent ED utilization Admissions to ED for access to pool specialistsAdmissions to ED for access to pool specialists No physician follow-up after dischargeNo physician follow-up after discharge

PartnersPartners Gaston Memorial HospitalGaston Memorial Hospital Gaston Family Health ServicesGaston Family Health Services Gaston Together (GCHC)Gaston Together (GCHC) Community Health PartnersCommunity Health Partners

MilestonesMilestones First meeting: First meeting: December 2006December 2006 First grant application: First grant application: February 2007February 2007 First grant award received: First grant award received: January 2008January 2008 First patient enrolled in HNG: First patient enrolled in HNG: January 2008January 2008

HNG Target PopulationHNG Target Population

UninsuredUninsured Gaston County resident, 18 and olderGaston County resident, 18 and older Income <= 100% FPGIncome <= 100% FPG Chronic Conditions or High User of the Chronic Conditions or High User of the

EDED DiabetesDiabetes AsthmaAsthma Congestive Heart FailureCongestive Heart Failure

HNG Patient BenefitsHNG Patient Benefits(Full continuum of care)(Full continuum of care)

Medical Home/Primary CareMedical Home/Primary Care Specialty ServicesSpecialty Services Hospital Services Hospital Services Case Management/Health CoachingCase Management/Health Coaching Medication AssistanceMedication Assistance Health at Home Self-Care GuideHealth at Home Self-Care Guide

Health at Home GuideHealth at Home Guide

Self-management Self-management resource guideresource guide Recipients of book receive Recipients of book receive

face-to-face education on face-to-face education on its useits use

Move individual toward self-Move individual toward self-sufficiencysufficiency

Community-wide initiative Community-wide initiative for book distribution to low-for book distribution to low-incomeincome

Survey component includedSurvey component included Printed in English and Printed in English and

SpanishSpanish

Health at Home SurveyHealth at Home Survey

520 surveys distributed520 surveys distributed 9% return rate 9% return rate (lower than community rate of 12-18%)(lower than community rate of 12-18%)

Mobile population - Mobile population - 20% returned “undeliverable”20% returned “undeliverable”

Health at Home SurveyHealth at Home Survey

Prior Prior to to

H@HH@H

After After H@HH@H

Had a regular place to go for Had a regular place to go for health concernshealth concerns 41%41%

Go to a Dr./Clinic for regular Go to a Dr./Clinic for regular health carehealth care 53%53% 75%75%

Go to the ED for regular Go to the ED for regular health carehealth care 28%28% 6%6%

Health at Home SurveyHealth at Home Survey

61%61% report that H@H has helped report that H@H has helped treat a health problem at hometreat a health problem at home

61%61% report that H@H has helped to report that H@H has helped to identify a needed visit to the doctor identify a needed visit to the doctor

57%57% report H@H has saved an report H@H has saved an unnecessary ED visitunnecessary ED visit

AchievementsAchievementsCurrent:Current: 1,7001,700 members members 182182 Medication Assistance Program members Medication Assistance Program members 241241 active primary care, specialty and hospital active primary care, specialty and hospital

providersprovidersYear-to-Date 2009:Year-to-Date 2009: 3,4133,413 primary care appointments primary care appointments 902902 specialty care appointments specialty care appointments 33%33% reduction in ED visits reduction in ED visits 11%11% reduction in charge/visit for all hospital services reduction in charge/visit for all hospital servicesSince Inception:Since Inception: $8.6$8.6 million in charity care donated million in charity care donated Return on Investment of Return on Investment of 1111 times times

Community-Wide PlanningCommunity-Wide Planning

HNG pilot program for Care Share HNG pilot program for Care Share Health AllianceHealth Alliance Addition of strategic community Addition of strategic community

partnerspartners Growth of “full continuum of care”Growth of “full continuum of care” Expansion of program to all uninsuredExpansion of program to all uninsured