lessons learned from states increasing coverage & preventive visits for adolescents and young...
TRANSCRIPT
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Lessons Learned From StatesIncreasing Coverage & Preventive Visits for
Adolescents and Young Adults (AYAs)
Claire D. Brindis, DrPHCo-Project Director, AYAH-NRC
Lauren Twietmeyer, MPHResearch Associate, AYAH-NRC
University of California, San Francisco
September 23, 2015
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Acknowledgements
• Funder: Maternal and Child Health Bureau, Health Services and Resources Administration, USDHHS, U45MC27709
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Background
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The Promise of the Affordable Care Act
• Insurance Expansion- Medicaid- Marketplace/“State Exchanges”- Dependent coverage to age 26
• Access to Preventive Services- Provided by plans without cost-sharing to members- Requirements established by:
US preventive Services Task Force “A” and “B” recommendations Bright Futures Guidelines for Children and Adolescents ACIP Immunization RecommendationsHRSA-supported IOM recommendations for women’s health
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ACA: Opportunities• Medicaid Expansion- 31 States including D.C. have expanded as of Sept 2015
• CMS Navigator Grants* (2013-present)- Awards to hospitals, universities, Indian tribes, and
patient advocacy groups, etc.
• CHIPRA Outreach and Enrollment Grants (2009-2013)- Awarded to state and local governments, tribal
organizations, community groups, schools, etc.
*Available to states with Federally-Facilitated & State Partnership Marketplaces
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Project Objective
• Identify best-practices to increase access to and utilization of insurance enrollment & preventive visits among AYAs
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Methods
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Project Steps
1. Identify top performing states
2. Develop survey protocol
3. Recruit key stakeholders
4. Conduct Interviews
5. Analyze Data
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1. Calculated Insurance and Preventive Visit Rates- Data Sources: National Survey of Children’s Health & Behavioral
Risk Factors Surveillance System
Pre- and post- ACA rates of insurance coverage Pre- and post- ACA rates of preventive visits Pre- and post- ACA change rates
2. State-Level Medicaid Data
3. Final Selection- Preliminary list of top-performers refined to ensure
broad geographic and demographic representation
Step 1: State Selection
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Step 1: Identify States
Seven states: CA, CO, IL, IA*, OR, TX*, and VT*
*AYAH-NRC CoIIN State Texas only finalist state that did not expand Medicaid
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Step 2: Guided Questions for Selected States
• Specific strategies to enroll:- Eligible populations? - AYAs?- Vulnerable groups?
• Previous efforts to increase enrollment
• Barriers
Outreach and Enrollment Preventive Care Visits
• How were high rates accomplished?
• Initiatives to encourage annual preventive visits
• Strategies to help AYAs access care
• Barriers
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Step 3: Recruit Stakeholders
• Targeted outreach based on:- Internal knowledge of AYA state-level leadership- Recommendations from Adolescent Health Coordinators- Research of state-level youth advocacy organizations
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Step 4: Conduct Interviews
Title V MCH Directors
Adolescent Health Coordinators
Youth Advocacy Organizations
State & County Health Employees
3
6
4
12
Twenty-five respondents were interviewed between May and July 2015
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Step 5: Qualitative Analysis of Interviews
• Conducted interview analysis to identify promising practices to increase enrollment and preventive visits among AYAs in top-performing states
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Results:Outreach & Enrollment
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Major Themes: Outreach & Enrollment
Use of Community Agencies and Networks
Focus on Special Populations
Youth Engagement
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Major Themes: Outreach & Enrollment
Use of Community Agencies and Networks
Focus on Special Populations
Youth Engagement
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• In 2006, Department of Public Health & Department of Human Services collaborated to increase enrollment and retention in Medicaid and hawk-i. - Contract with 22 local Title V MCH agencies to serve all
99 counties
- Outreach focused on adolescents (ages 13-19) and parents through activities: youth athletics, after-school programs, and youth employment agencies.
• Results: In 2014, 36,000 kids were enrolled in hawk-i (69% increase since 2006)
Community AgenciesIOWA
Source: Iowa Department of Human Services, 2014; Askelson et al., 2013.
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Community AgenciesILLINOIS• In 2005, Healthcare and Family Services utilized All
Kids Application Agents (AKAAs) to enroll uninsured children
- Community-based organizations (e.g., faith-based, day care centers, and school districts) enrolled as AKAAs
• In 2006, AKAAs conducted over 275 enrollment events in supermarkets, malls, schools, etc.
• Results: 1.6 million children are enrolled in All Kids (33% increase since 2005)
Source: All Kids Preliminary Report, 2008; About All Kids, 2015.
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Community AgenciesTEXAS - Enroll Gulf Coast• Began in 2013 to coordinate, network and streamline
efforts to efficiently and effectively engage eligible population of Greater Harris County
• Comprised of 21 organizations (e.g., Change Happens, Children’s Defense Fund, and Young Invincibles)
- Internal committees include: Intelligence, operations, and logistics
• Results: 190,000 Houstonians were enrolled in the first open enrollment period (Oct. 1, 2013 - March 31, 2014)
Source: Atkinson-Travis, 2014.
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Major Themes: Outreach & Enrollment
Use of Community Agencies and Networks
Focus on Special Populations
Youth Engagement
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• Categorization of adolescent sub-populations
- Demographically-defined
Racial/ethnic groups Immigrant
- Legally-definedFoster care Incarcerated
- Other Youth PopulationsHomeless
Special Populations
Source: Knopf et al., 2007.
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• Six states focused on Hispanic/Latino, mixed-status, and undocumented youth- Oregon Health Authority designated state employees to
directly oversee and coordinate outreach events (e.g., 3-day soccer tournament)
- Texas’ Enroll Gulf Coast partnered with Univision to hold enrollment telethon
- Boulder County (CO) co-located Health Coverage Guides every two weeks at a Spanish family resource center
Special PopulationsRacial/Ethnic
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• Children Now, a California non-profit, spearheaded CoveredTil26 campaign- Informational flyers- Social media campaigns- Direct outreach- County contact list of individuals who would help
navigate enrollment in Medicaid (Medi-Cal)- Toolkit with sample language and resources for outreach
to Former Foster Youth
Special PopulationsFormer Foster Youth
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Major Themes: Outreach & Enrollment
Use of Community Agencies and Networks
Focus on Special Populations
Youth Engagement
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Youth Engagement3 States utilized innovative youth engagement
strategies
Policy
Marketing
Outreach
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Youth Engagement• State-level Policy:- Youth Partnership for Health (CO): Public health
department employs youth to provide feedback and recommendations on programs, practices, and policies
• State-level Media:- Oregon Health Authority: Youth advisory group created
“one of the most successful” teen-friendly flyers
• Local-level Outreach:- Beacon Therapeutic (IL): Peer advocates that lived in
homeless shelters and assisted in recruiting homeless AYAs
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Source: Oregon Health Authority, 2011.
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Outreach & Enrollment: Lessons Learned
Approaches in top-performing states:
Use of multiple, concurrent, and reinforcing strategies
Focus on families: “All boats will rise” - Two generational effect
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Results:Preventive Care Visits
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Major Themes: Preventive Care Visits
Commitment to Bright Futures Guidelines
Focus on Medical Homes
Capacity-Building
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Major Themes: Preventive Care Visits
Commitment to Bright Futures Guidelines
Focus on Medical Homes
Capacity-Building
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Commitment to Bright Futures Guidelines
• Vermont, 2008:State’s Medicaid program adopted Bright Futures as
standard of care
AAP Chapter organized ‘roadshows’ to educate providers about Bright Futures
• Illinois, 2011:State’s Medicaid program adopted Bright Futures as
standard of care
• Colorado, 2014:
Adopted Bright Futures as state’s EPSDT Periodicity Schedule
Source: States & Communities, 2015; EPSDT, 2015.
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Major Themes: Preventive Care Visits
Commitment to Bright Futures Guidelines
Focus on Medical Homes
Capacity-Building
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Focus on Medical HomesColorado• Medical Home Initiative, 2011
- Goal to ensure all children receive care within a medical home
- Brings together over 40 representatives from government agencies, health providers, NGOs, and policy-makers
• Legislation in 2007 established medical homes for children in Medicaid
• Results: By 2012, 45% of children in Medicaid/CHIP had a medical home compared to 41% in 2007
Source: Fast Facts, 2015; National Survey of Children’s Health, 2015.
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Focus on Medical HomesIllinois• Primary Care Case Management Program, 2006- Founded on the medical home concept called Illinois
Health Connect
• SMART Act, 2012- Required 50% of Medicaid recipients be enrolled in care
coordination by 2015
• Results: By 2012, 29% of children in Medicaid/CHIP had a medical home compared to 20% in 2007
Source: Illinois, 2015; National Survey of Children’s Health, 2015.
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Major Themes: Preventive Care Visits
Commitment to Bright Futures Guidelines
Focus on Medical Homes
Capacity-Building
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Capacity-BuildingVermont• Youth Health Improvement Initiative
- Started in 2001 to support pediatric and family practices to improve preventive services delivery for youth ages 8-18
- Results: 69 practices have been assisted in improving the quality of health care they provide
• Child Health Advances Measured in Practice- Started in 2012 to increase the efficiency, economy, and
quality of care provided to Medicaid-eligible children and families
- Results: 40 practices (95% pediatric) have participated in annual QI projects
Source: YHII, 2015;_____________
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Capacity-BuildingOregon Pediatric Society• Adolescent Health Project
- Purpose: Increase universal screening, brief interventions, and referral to treatment for depression and substance use within the context of an adolescent well-visit
- Trained 173 PCPs and clinic staff between March and November 2014
- Results: By October 2014, enrolled practices reported improvements on a number of systems related to confidentiality, privacy, screening and QI capacity
Source: 2014 Annual Report.
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Preventive Care Visits: Lessons Learned
Features of top-performing states:
Built on experiences to expand access to AYAs
Committed to providing comprehensive, coordinated care to all children
Leveraged state-private partnerships to build capacity and train providers
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Influencing AYA Health Care:Where Can CoIINs Make a Difference?
Providers Local Government
Agency Networks
State Federal
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Stayed Tuned
• Brief outlining ‘Lessons Learned’ from ACCESS interviews
• Compendium of best practices that promote increased access to and utilization of preventive visits among AYAs
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References2014 Annual Report. START (Screening Tools and Referral Training): Oregon Pediatric Society. http://oregonstart.org/wp-content/uploads/2015/07/Annual-Report-Year-6-2014.pdf. Accessed on September 10, 2015.
About All Kids. ALL Kids: State of Illinois. http://www.allkids.com/hfs8269.html. Accessed on September 17, 2015.
Askelson, N, Gikembiewski, E, Turchi, J, Elchert, D, Tegegne, M. Report on evaluation of Iowa’s CHIPRA II outreach and enrollment project. 2013. Available at http://ppc.uiowa.edu/publications/report-evaluation-iowas-chipra-ii-outreach-and-enrollment-project.
Atkinson-Travis D. Gulf coast health insurance marketplace collaborative leading the way!Presented at: Gulf Coast of Texas African American Family Support Conference; November 7, 2014; Houston, TX.http://gcaafsc.net/wr/wp-content/uploads/2014-conference-prog-book.pdf.
Early and Periodic Screening, Diagnostic, and Treatment (EPSDT). Colorado Department of Healthcare Policy and Financing. https://www.colorado.gov/pacific/hcpf/early-and-periodic-screening-diagnostic-and-treatment-epsdt. Accessed on September 10, 2015.
Fast Facts about the Colorado Medical Home Initiative. WONDERbabies, University of Colorado Denver.www.wonderbabiesco.org/UserFiles/Media/MHFactSheet.doc. Accessed on September 10, 2015.
Illinois. Patient-Centered Primary Care Collaborative.https://www.pcpcc.org/initiatives/Illinois. Accessed on September 10, 2015.
Iowa Department of Human Services. Annual report of the hawk-i board to the governor, general assembly, and council on human services. 2014.Available at http://dhs.iowa.gov/sites/default/files/2014_hawk-i_Board_Annual_Report.pdf.
Knopf D, Park MJ, Brindis CD, Mulye TP, Irwin CE. What gets measures gets done: assessing data availability for adolescent populations. Matern Child Health J. 2007; 11(4): 335-345.
National Adolescent and Young Health Information Center, University of San Francisco. National Survey of Children’s Health [private data run] 2015. Centers for Disease Control and Prevention. Available at: http://childhealthdata.org/.
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References, cont.States & Communities. Bright Futures, American Academy of Pediatrics. https://brightfutures.aap.org/states-and-communities/Pages/default.aspx#. Accessed on September 10, 2015.
Youth Health Improvement Initiative (YHII). Vermont Child Health Improvement Program (VCHIP): The University of Vermont.https://www.uvm.edu/medicine/vchip/?Page=VTYHI.html. Accessed on September 10, 2015.