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Entering the Health Care Space

The Affordable Care Act (ACA) is necessitating and paving the way for experimentation in health care systems, delivery, and funding.

“This is changing the way we do business,” says Paul Castro, CEO of Alliance for Children and Families member Jewish Family Services of Los Angeles (JFSLA). “We are entering a completely different world.”

In order for America to bend the health care cost curve, providers must address patients’ health holistically, coordinate care, and mitigate the social determinants of health.

Several Alliance members have realized this expertise already resides within their own organizations—and have gotten health care systems to take notice.

Doing the Legwork

When the ACA was passed, JFSLA formed a working group of board and staff members to assess opportunities to leverage the agency’s core competencies in working with vulnerable populations. The agency also hired a director of business development and strategic initiatives to focus on entry into the health care space. The working group realized that the agency’s extensive expertise in providing care management aligned well with the ACA’s emphasis on integrated care services.

“This is changing the way we do business,” says Castro. “We are entering a completely different world of how social services are delivered and funded.”

Historically, JFSLA has served as a safety net, particularly for frail, low-income older adults at risk of hospitalization or institutionalization. Early conversations with health care entities, including hospitals, health plans, and medical groups, revealed that many didn’t understand how social services are provided or how a community-based organization could be a viable partner. In fact, most hospitals and health plans did not intend to partner; they planned to expand and coordinate care by hiring hundreds of social workers themselves.

JFSLA saw an opportunity to demonstrate its expertise and the value of collaboration when the Centers for Medicare & Medicaid Services (CMS) launched the Community-based Care Transitions Program (CCTP). CCTP reflects an innovative approach to health care delivery by bringing together providers from across the care spectrum, ensuring that older adults with complex medical and social service needs will receive follow-up care and resources, so they spend less time hospitalized unnecessarily. Because hospitals will be financially penalized for high rates of readmission for Medicare patients with specific diagnoses starting in 2014, they have an incentive to innovate.

JFSLA identified the three local hospitals with high readmission rates and approached them about pursuing the funding. This time, the hospitals were receptive and the collaborative created and led by JFSLA was selected by CMS to participate in August 2012.

“When you have funding to go with your proposal, it can become a partnership, not just a conversation,” Castro says. “The hospitals understood they needed to collaborate with an agency like us, so they signed on.”

Just a year into the pilot, readmissions were reduced by more than 50 percent. “This gives us hard data in addition to our ‘good works’ that shows we have impact,” says Castro. “That’s real money in the government’s pocket paired with better quality of care for the individuals served.

Finding Common Ground

Alliance member Impact NW, Portland, Ore., has worked its way into the health care space by initiating conversations and building relationships. Susan Stoltenberg, CEO of Impact NW, shared her perspective at the Alliance’s meeting for complex organizations in September. She says she thinks community-based organizations have to work diligently to overcome long-held biases in order to bridge the gap between human services and primary health care—and lose some of their own internally-held biases.

“There is a lot of disrespect for our expertise. Health insurers need to see the value of our relationships with clients, and we must demonstrate that you don’t have to be a master’s-level medical social worker to provide effective care coordination,” says Stoltenberg. “On our part, we have to be flexible in considering outcomes-based compensation and lose any sense that our approach is better than theirs. We each have vital expertise and only together can we achieve the best health outcomes and contain costs.”

Impact NW has been able to bridge the gap through conversations around shared goals—and it’s paying off. A recent milestone was the completion of an 18-month pilot project to provide care management designed to reduce emergency room visits and hospitalizations.

The project began with a casual breakfast meeting between Stoltenberg and Linda Nilsen Solares, executive director of Project Access NOW. Project Access NOW coordinates a regional network of medical professionals who provide pro bono services to uninsured residents of Clackamas, Multnomah, and Washington counties in Oregon and Clark County in Washington.

The two women had a mutual interest in using the expertise of community-based organizations to lower health care costs, and they joined forces to develop a care coordination model for individuals who are insured through the Oregon Medical Insurance Pool. This population has unmanaged chronic disease and often struggles with critical co-occurring neurological, psychological, and social challenges such as mental health disorders, chemical or substance abuse, or food and housing instability. They typically underutilize routine care and instead rely heavily upon costly emergency room and hospital care.

The Oregon Health Authority, which operates the Medical Insurance Pool and Regence, the medical insurer, jumped at a proposal from Impact NW and Project Access NOW to provide a care management and patient navigation program. Upon patient discharge from the emergency room or hospital, Regence refers frequent health care users with complex needs to the program. The multidisciplinary team connects clients with a medical home; works to overcome barriers; provides services such as counseling, medication management, and addiction treatment and recovery support; and connects clients with housing, nutrition, or energy assistance.

Impact NW analyzed a random sample of the 127 program participants in the first nine months and projected a cost savings of $3 million over the 18 month period. The savings are based on a 70 percent reduction in emergency visits and almost a 90 percent reduction inpatient hospitalizations.

“This approach works. Our trauma-informed, client-centered model addresses the social determinants of health, and is guided by asking our clients what they need to be healthy and how we can help them achieve those goals,” says Stoltenberg.

Impact NW attributes its success to its client-centered, community-based philosophy, which has helped it build the trusting relationships with local residents it needs to influence disease prevention and early intervention. More than 30 languages are spoken among Impact NW staff, and many of the care coordination program staff are longtime residents of the communities they serve.

Impact NW is now targeting the program to other medical insurers, employers interested in reducing insurance costs, and hospitals and providers.

Bundling Capacities

Alliance member NRI Community Services Inc. (NRICS), Woonsocket, R.I., is involved in Rhode Island, along with Alliance member, Family Service of Rhode Island, Providence, in the Ocean State Network for Children and Families, a reengineering of the child welfare system. Similarly, NRICS is also a key agency in forming a behavioral health network in Rhode Island, Horizon Healthcare Partners.

Christian L. Stephens, president of NRICS, presented at the 2013 Alliance National Conference on opportunities emerging with health care reform. Stephens’ specific experience is in creating various kinds of management services agreements, strategic alliances, co-locations, affiliations, asset-purchase agreements, and mergers with other nonprofits.

Stephens believes grant-funded, multiservice, community-based organizations are viewed by hospital-centric health systems and health plans as if they are quasi-public social welfare organizations. Health care administrators do not immediately recognize how child care, housing, employment, and safety net services of Alliance members relate to health care reform.

NRICS has worked to convince health providers and payers that a multiservice, community-based agency is actually well versed on the psychosocial factors that cause overuse of urgent care centers, emergency rooms, and inpatient beds.

As an example, NRICS and its affiliates rapidly diversified from supervised and independent living apartments for adults with mental illness, which were supported by the U.S. Department of Housing and Urban Development and Medicaid, into assisted living, sober housing, homeless veterans recovery house, acute and longer term residential care for co-occurring mental health and substance abuse, and other forms of supported housing, reimbursed by multiple health care services. The cost of a stay in the acute stabilization/hospital diversion unit is a third of the cost of a similar hospital stay.

Organizations can leverage their experience with trauma, incarceration, homelessness, HIV, and dually diagnosed individuals. Stephens recommends:

  • get past egos, control issues, and competitive thinking to creative win-win discussions about improving community services;
  • bundle your capacities within the organization, and with other organizations to serve new payers;
  • embrace new governance structures like preferred referral agreements, staff leasing agreements, management services agreements, strategic alliances, and affiliations;
  • understand best practices and adopt promising practices, but, ultimately, do what you do well with new partners and new client groups;
  • build robust capacity to collect, analyze, and report data;
  • clarify both client and system outcomes expected
  • from contracts;
  • consider projects with low return on investment or no strong potential for excess revenue if they generate business for other programs that carry overhead or generate surplus; and
  • the best platform for taking risks on new projects is well developed system of business processes, risk management, and corporate compliance reviews—do not applaud yourself for low overhead if your management infrastructure is a “house of cards.”

NRICS’ presentation also highlighted their multiple experiences with agencies that waited too long.

NRICS provides technical assistance, consultation, and training services for modest fees that support its Client Emergency Fund.

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