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Community Partners Offer Financial Incentives and Support for Primary Care Practices, Improving Access and Reducing Utilization for Children on Medicaid


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Snapshot

Summary

A community collaborative known as the Children's Healthcare Access Program has implemented a variety of complementary strategies to enhance access to quality primary health care for pediatric patients. Major partners are First Steps, a nonprofit organization that is developing a coordinated system of early childhood services in Kent County; Priority Health, a West Michigan–based managed care plan that provides commercial and Medicaid coverage; and Helen DeVos Children's Hospital, a 214-bed children's hospital in Grand Rapids, MI. As part of the 3-year (2009 to 2011) demonstration project, Priority Health offered financial incentives to primary care medical homes to encourage them to open to additional children enrolled in Medicaid, as well as a pay-for-performance incentive for selected utilization and quality measures. In 2012, the program expanded to include additional Medicaid health plans and a variety of practice incentives. First Steps provides Children's Healthcare Access Program family-level services designed to facilitate access for high-risk patients and families in participating practices. Services include navigation of the health care system (including assistance accessing behavioral health services), health education, asthma disease management, transportation, language translation, and assistance in connecting to community resources. During the 3-year demonstration project, the program enhanced access to primary care, increased the percentage of children with asthma action plans, reduced emergency department visits and hospital admissions, increased well-child visits, and reduced costs. Positive results to date have led to continuation and expansion of the program.

See the Description section for new information about number of participating sites and number of children served; the Results section for updated evaluation measures; the Funding Sources section for updated information on funders; the Context section for updates on medical practices participating in CHAP; and the Resources Used section for updates to staffing and costs (updated April 2013).

Evidence Rating (What is this?)

Moderate: The evidence consists of before-and-after implementation comparisons of the number of practice slots allocated for Medicaid patients in participating practices, the number of children with asthma action plans, ED use, and hospitalizations. A more comprehensive evaluation completed after the third year of the program compared three groups (children receiving CHAP services, children eligible for CHAP services, and a comparison group from two outside counties) across an expanded list of measures, as described in the results section.
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Developing Organizations

First Steps; Helen DeVos Children's Hospital; Priority Health
Kent County, MIend do

Use By Other Organizations

Similar models have been implemented in Denver, CO, and in North Carolina; more information is available at the following links:
  • Colorado Children's Healthcare Access Program: http://www.cchap.org
  • Community Care of North Carolina: http://www.communitycarenc.com

Date First Implemented

2008
Augustbegin pp

Patient Population

Vulnerable Populations > Children; Insurance Status > Medicaidend pp

Problem Addressed

Medicaid beneficiaries often have difficulty accessing primary care, primarily because low reimbursement rates dissuade providers from accepting these patients. These access problems often lead to delays in care and to excessive emergency department (ED) use. Practices that do serve such patients (including many emerging "patient-centered medical homes") often do not yet offer the type of support services (e.g., transportation, language translation, chronic disease management) that facilitate the best access to office visits and care.
  • Lack of access, driven by low reimbursement: Many private medical practices do not accept Medicaid beneficiaries due to low reimbursement rates, which average only 56 percent of the price of medical services delivered by private practice physicians.1 In Kent County, MI, approximately 50 percent of children covered by the Priority Health Medicaid managed care plan receive care from a private practice pediatrician; however, few of these private practices are currently open to accepting new Medicaid patients.
  • Leading to excess ED use: Many Medicaid-covered children in Kent County receive care at Federally Qualified Health Centers or at teaching hospitals. These locations often become overwhelmed with patients, causing delays in care, with the ability to secure a same-day appointment for acute health needs (e.g., ear infections) being difficult. As a result, ED use remains quite high, averaging 595 per 1,000 Priority Health pediatric enrollees per year, roughly 3 times the average in commercially insured pediatric populations. Children with chronic conditions such as asthma are most reliant on the ED; in Kent County, for example, nearly 12,000 county residents younger than 18 years have asthma,2 with many of these children (particularly minorities and those from low-income households) being dependent on ED services.3,4
  • Not yet fully realized potential of medical homes to help: The American Academy of Pediatrics defines a medical home as an approach to providing comprehensive primary care that provides accessible care and ensures that all medical and nonmedical needs can be met.5 Fully functioning medical homes offer supportive services that enhance access to needed care. However, practices in the process of becoming medical homes often take time to establish such services.

What They Did

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Description of the Innovative Activity

A community collaborative known as Children's Healthcare Access Program (CHAP) has implemented a variety of complementary strategies to enhance access to quality primary health care for pediatric patients who receive Medicaid. CHAP was developed by a partnership led by First Steps, a nonprofit community organization that is developing a coordinated system of early childhood services in Kent County, MI; Priority Health, a West Michigan–based managed care plan that provides commercial and Medicaid coverage; and Helen DeVos Children's Hospital, a 214-bed children's hospital in Grand Rapids, MI. As part of the 3-year demonstration project (2009 to 2011), Priority Health offered financial incentives to primary care medical homes to encourage them to open to additional children enrolled in Medicaid, as well as a pay-for-performance incentive for selected utilization and quality measures. First Steps provides CHAP family-level services to facilitate access for high-risk patients and families in participating practices. Services include navigation of the health care system (including enhancing access to behavioral health services), health education, asthma disease management, transportation, language translation, and assistance in connecting to community resources. This 3-year demonstration project (2009 to 2011) is being continued and expanded; see the Funding Sources section for more information. Key elements of the program include the following:
  • Participating medical practices: As of April 2013, 26 primary care sites that serve Medicaid beneficiaries younger than 18 years in Kent County participate in CHAP, receiving technical assistance and support to improve their "medical homeness." All refer patients to CHAP services when applicable and participate in CHAP initiatives. Private practices agree to accept additional Medicaid patients, and clinics implement other reforms to enhance access and outcomes.
  • Financial incentives to enhance access: As part of the 2009-2011 demonstration project, Priority Health offered providers financial incentives designed to enhance access to care. Payments may depend on performance on certain indicators, such as reduction in ED visits and hospital admissions, which tie directly to access (e.g., fewer ED visits and admissions indicate better access to primary care). These incentives encourage practices to develop systems, such as "open access" block scheduling, to facilitate access to care. For private practices, receiving enhanced Medicaid reimbursement was dependent on the creation of additional openings for Medicaid patients. Now that the pilot has concluded, this payment mechanism has changed to a per-member, per-month incentive for access, and participating health plans provide financial support directly to First Steps to underwrite the cost of delivering CHAP services to their members.
  • Support services for high-risk children and families: First Steps offers a variety of CHAP support services to high-risk children and families who are patients at one of the participating CHAP providers, as outlined below:
    • Referral to program: Providers refer at-risk patients/families by sending a referral form to the CHAP office, through either an electronic health information exchange system or by fax. The form indicates the main reason(s) for referral, such as inappropriate ED use, a high no-show rate for scheduled office visits, or need for transportation, translation services, behavioral health services, asthma case management, and/or community resources. During its first 4 years in operation, CHAP provided tangible services (defined at minimum as including at least one successful telephone contact) to 8,384 children, with the most common reasons for referral being repetitive ED use, frequent no-shows, children not up to date on well-child visits, and transportation needs (updated April 2013).
    • Assignment of CHAP team member: The CHAP manager reviews each referral form and assigns the patient to a CHAP team member (a pediatric nurse, community health worker, social worker, or asthma educator) who can best serve the patient's needs.
    • Provision of CHAP services: CHAP offers families a variety of services tailored to individual patient and family needs; services include the following:
      • Initial and ongoing education: The CHAP team member calls the family to discuss its needs. In general, the team member asks about the child's current health status, reviews current preventive health needs (e.g., well-child visits or immunizations), emphasizes that providers may be contacted 24 hours a day in lieu of going to the ED, and discusses how to access the provider when needed. The frequency of ongoing contact varies with family need; some families receive only one call, whereas others communicate regularly with the CHAP team member. After the initial call, the CHAP team member mails written materials that describe CHAP services, emphasize the value of the medical home, provide contact information for the child's doctor/clinic, and outline circumstances under which the provider (rather than the ED) should be visited. If the team member cannot contact the family by telephone, he/she will drop by the home to provide face-to-face education and printed materials.
      • Asthma disease management: First Steps contracts with the Asthma Network of West Michigan, whose asthma educators and social workers provide services to CHAP. First Steps and the Asthma Network of West Michigan are partners in delivering the home-based case management services, which are Medicaid-billable, and the Asthma Network of West Michigan provides content expertise about asthma to CHAP. For children with asthma, a team consisting of an asthma educator, social worker, and community health worker provide ongoing, home-based asthma care management and education. Services include medication management and education on various asthma-related topics, including elimination of asthma triggers, inhaler use, the importance of regular medical home visits, and appropriate asthma care. The asthma educator helps the family work with the child's primary care provider to develop an asthma action plan that outlines treatment/medications, asthma triggers, how to handle an attack, and when to call the doctor or go to the ED. The social worker connects the family to a variety of community resources, helps parents navigate the social service network, and refers parents for behavioral health services if psychosocial issues prevent an adequate focus on the child's health. The community health worker conducts an environmental assessment; works with the family's landlord to address mold, mildew, and pest control issues if necessary; provides social support; and reinforces the asthma educator's teaching. Under the program, Medicaid health plans will reimburse home visits made by the asthma educator and social worker.
      • Transportation: As needed, CHAP pays for and arranges transportation via a taxi for patients who require a same-day or next-day acute care visit or provides bus tokens for appointments that are scheduled further out.
      • Language translation: Through contracts with local medical translation companies, CHAP arranges for an interpreter to accompany families with limited English proficiency to provider visits. Translation services are available in all of the more than 40 languages spoken in the county. CHAP also employs bilingual community health workers and social workers to work with Spanish-speaking families.
      • Social work services: This component of CHAP services was added during the second year of services for families without an asthmatic child. The CHAP social worker works with families who need assistance navigating the Medicaid behavioral health system, are struggling with overwhelming psychosocial issues, or need significant resources.
      • Connection to community resources: CHAP team members connect families to needed community resources, such as a food pantry, housing assistance, or domestic violence shelters.
    • Followup with physicians: CHAP team members send a followup form to the physician, either through an electronic health information exchange system or by fax, noting whether contact has been made with the family, and if so, what services have been or will be provided.
  • Ongoing meetings and communication: CHAP coordinates and supports ongoing meetings of stakeholders to ensure the continued value of services, as outlined below:
    • Parent input: CHAP periodically meets with parents of children receiving services to gather feedback on CHAP services and materials, and on current community needs.
    • Interpractice communication: CHAP coordinates monthly or quarterly meetings for practice managers, physicians, and other groups (e.g., those interested in asthma or childhood obesity) so that colleagues from different practices can discuss service delivery issues, share best practices, and increase their medical home knowledge and capacity.

Context of the Innovation

A community-based 501(c)3 organization, First Steps focuses on developing and improving a coordinated system of early childhood services in Kent County, MI. More than 14 percent of the county's 608,000 residents live below the Federal poverty level, with approximately 40 percent of the county's 158,000 children enrolled in Medicaid.6 The First Steps Commission (board of directors) is composed of influential community members from the fields of business, philanthropy, education, and health care. The impetus for the program came from First Steps' medical director, Dr. Tom Peterson, a pediatrician who was the executive director of quality, safety, and community health at Helen DeVos Children's Hospital in Grand Rapids. He learned about a successful model of community-based pediatric medical home support services in Denver and believed that Kent County children could benefit from such an approach. Priority Health, the largest provider of Medicaid managed care in Kent County, came on board as a founding partner of the collaboration. Spurred by Dr. Peterson's enthusiasm and leadership, First Steps and Priority Health developed CHAP to create more openings in private practices for children enrolled in Priority Health Medicaid, help these practices improve their "medical homeness," and provide support services directly to children and their families. Medical practices participating in CHAP as of April 2013 include seven private pediatric and family practices, four hospital-affiliated practice groups, the Helen DeVos Children's Hospital pediatric resident teaching clinic, the Spectrum Health Family Practice Residency Clinic, the Grand Valley State University School of Nursing Family Health Center, and a Federally Qualified Health Center with 10 sites serving pediatric patients. First Steps manages the operation of the program and employs CHAP staff either directly or through contractual relationships.

Did It Work?

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Results

In its 3 years of operation, CHAP has produced results in the three “aims” that reflect a common approach to optimizing health system performance: better quality care, improved health outcomes, and reduced cost. A rigorous evaluation completed in 2012 showed that the program enhanced access to primary care for children covered by Medicaid, increased provider use of asthma case management services, increased the percentage of children with asthma action plans, improved health outcomes for children receiving asthma services, reduced ED visits, reduced hospital admissions, increased well-child visits, and reduced costs (updated April 2013).
  • Improved Quality of Care: In an effort to improve the care for children on Medicaid in Kent County, CHAP has shown the following results (updated in April 2013).
    • Increased access: Partnering primary care practices have expanded access to medical care for children on Medicaid by increasing openings (1,445 new openings as of 2013) and increasing and maintaining practice hours of service. The program has also facilitated integration of services and coordination of care among health care practice partners and strengthened community partnerships between community organizations and those practice partners, thereby promoting increased access to health care for children in Kent County.
    • More providers using asthma case management: Since program implementation, participating practices have increased their use of the Asthma Network of West Michigan (a key provider of asthma case management services for children) and their fidelity to asthma control and management best practices.
    • Reaching children beyond Kent County: Program leaders have improved the quality of care for children on Medicaid outside of Kent County through the provision of leadership and technical assistance to program managers and physicians implementing the model in other Michigan communities.
  • Positive Health Outcomes: Below are updated health outcomes demonstrated by the program during its first 3 years of operation (updated in April 2013).
    • Lower ED use: ED use fell 5 to 15 percent for the CHAP-eligible population (children who are patients at a CHAP health care practice and have Priority Health Medicaid) from baseline to subsequent calendar years. CHAP clients (children who actually received direct support services from CHAP) showed a 35 percent decrease in ED visits after 1 year of program involvement, and there was a 43 percent decrease in ED visits for CHAP clients aged 1 to 5 years. In addition, ED visits for otitis media–related issues decreased by 25 percent and the number of ear-numbing drop prescriptions for the CHAP-eligible population increased by 36 percent after the start of CHAP’s otitis media initiative.
    • Fewer hospitalizations: The program saw a 46 percent decrease in inpatient hospitalization visits for CHAP clients after 1 year of program involvement and a 45 percent decrease in CHAP clients aged 1 to 5 years.
    • More well-child visits: The number of children up to date on their well-child visits increased by 24 percent between 2010 and 2011 by practices participating in CHAP and Priority Health joint well-child initiative.
    • Positive outcomes for asthma patients: Among those receiving CHAP asthma services, the number of children who had an asthma action plan increased by 23 percent; and the number who improved their scores on an asthma control test to acceptable levels rose by 54 percent. Additionally, children receiving asthma services reported a 50 percent decrease in exposure to tobacco smoke in the home environment, and saw a 78 percent decrease in the average number of school days missed because of asthma.
  • Positive Cost-Benefit: The results of cost benefit analyses conducted for CHAP demonstrate cost savings in as few as 2 years; these savings will grow over time as additional benefits are realized (updated April 2013). The benefits of a program such as CHAP are longer term and are expected to span financial, health, and social aspects of a child’s life over several decades.

Evidence Rating (What is this?)

Moderate: The evidence consists of before-and-after implementation comparisons of the number of practice slots allocated for Medicaid patients in participating practices, the number of children with asthma action plans, ED use, and hospitalizations. A more comprehensive evaluation completed after the third year of the program compared three groups (children receiving CHAP services, children eligible for CHAP services, and a comparison group from two outside counties) across an expanded list of measures, as described in the results section.

How They Did It

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Planning and Development Process

Key elements included the following:
  • Introducing model to First Steps Commission: In the summer of 2007, Dr. Tom Peterson presented the idea of developing a community-based model of pediatric medical home support services to the First Steps Commission.
  • Assessing scope of problem: Dr. Peterson researched hospital admissions and ED visits in Medicaid and commercially insured pediatric populations in Michigan to determine the scope of the access problem faced by Medicaid beneficiaries. His research report was published in the Journal of Pediatrics in January 2011.
  • Conducting site visits: First Steps staff and commission members visited Colorado to understand the model in place there and to determine the optimal structure and design of medical home support services for Kent County.
  • Designing practice incentives: Priority Health worked with CHAP leadership to design a pay-for-performance and enhanced reimbursement plan (depending on the type of CHAP practice) to reward practices for increasing access to Medicaid patients.
  • Hiring staff: First Steps hired staff for the CHAP program, including a program manager, pediatric nurse, resource coordinator, social worker, and community health workers.
  • Obtaining commitment from practices: The CHAP medical director, program manager, and Priority Health leadership visited practices to solicit their interest in participating. To encourage participation, they presented data on the access problem in the county and described CHAP services and how they could help address this problem. The presenters appealed to providers' sense of community responsibility for providing better care to the county's low-income children and also laid out exactly how they could benefit from financial incentives by agreeing to treat more children enrolled in Medicaid.
  • Launching program: The program launched in August 2008 with a public announcement held on the grounds of the Gerald R. Ford Museum with media coverage. In addition, Priority Health sent a letter to every eligible patient/family describing CHAP and its services, and all participating practices placed written materials (in English and Spanish) in their waiting rooms that describe CHAP services.
  • Expansion and replication: Based on the success of the 3-year demonstration project, the program is being expanded and replicated within Kent County and across the state.

Resources Used and Skills Needed

  • Staffing: As of April 2013, the CHAP program employs a program manager, a pediatric nurse, two community health workers, two social workers, a data analyst, and an administrative assistant; several staff speak English and Spanish. CHAP also contracts with the Asthma Network of West Michigan for two asthma educators [representing 1.5 full-time equivalent (FTE) positions] and a 0.5 FTE social worker. First Steps' Director of Health Initiatives provides oversight and strategic leadership for the program.
  • Costs: Annual service delivery costs average approximately $525,000, including staffing, patient transportation and interpretation, development and printing of patient education materials, meeting costs (for practice manager, provider, and workgroup meetings), and contractual services (outside evaluator, consultants); this figure excludes administrative overhead, the value of in-kind donations, and Priority Health–funded incentives to providers (updated April 2013).
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Funding Sources

Molina Healthcare; W.K. Kellogg Foundation; Priority Health; Helen DeVos Children's Hospital; First Steps
Note that major funders of First Steps include the Douglas & Maria DeVos Foundation, Early Childhood Investment Corporation, Frey Foundation, Heart of West Michigan United Way, PNC Grow Up Great initiative, Sebastian Foundation, Steelcase Foundation, and Mike and Sue Jandernoa.

Information provided in April 2013 indicates that the 3-year demonstration project ended in 2011; however, based on its success, it has been continued and expanded. Priority Health is providing funding to First Steps to partially support the cost of services and is in the process of expanding the services to all Kent County practices that see Priority Health's Medicaid members. In addition, Molina Healthcare, the second largest Medicaid health plan in Kent County, is contracting with First Steps to offer CHAP services to its members. Kent County Health Department also provides Medicaid outreach funding.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Ensure that pediatric providers lead effort: Although many community organizations should be involved in developing and leading this type of program, pediatric providers should remain "front and center." Given their credibility with peers, leaders of these practices often can encourage other providers to participate.
  • Allow time for planning: The CHAP program required 1 full year of planning before implementation.
  • Enlist support of many constituents: Support from a wide variety of community stakeholders helps to ensure that the program is perceived as independent and neutral, rather than as an institution-specific initiative.

Sustaining This Innovation

  • Cultivate passion for initiative: Passion for the program's mission among all participants helps to ensure its sustainability.
  • Ensure ongoing funding: Initially, CHAP depended largely on foundation funding that eventually will come to an end. Currently, approximately 40 percent of the CHAP budget is funded through earned revenue (contracts with Medicaid health plans and drawdown of Medicaid Outreach dollars through a partnership with the county health department). As of April 2013, community conversations are ongoing regarding the expansion of CHAP services to the newly eligible adult Medicaid population, as well as the dual-enrolled (Medicaid and Medicare), which will allow for a much larger return on investment because of the higher burden of chronic disease among adults and the cost of readmissions and ED use. The result of this expansion and partnership with adult health care entities rests to a large extent on the outcome of the current conversation in Michigan regarding Medicaid expansion as a result of the Affordable Care Act.

Use By Other Organizations

Similar models have been implemented in Denver, CO, and in North Carolina; more information is available at the following links:
  • Colorado Children's Healthcare Access Program: http://www.cchap.org
  • Community Care of North Carolina: http://www.communitycarenc.com

More Information

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Contact the Innovator

Maureen Kirkwood
Director of Health Initiatives
First Steps
118 Commerce Ave. SW
Grand Rapids, MI 49503-4106
(616) 632-1010
E-mail: mkirkwood@firststepskent.org

Tom Peterson, MD
Medical Director, First Steps
Vice President, Patient Safety, SCL Health System
2420 West 26th Avenue
Denver, CO 80211
(303) 813-5172
E-mail: tom.peterson@sclhs.net

Jim Byrne, MD
Vice President and Chief Medical Officer
Priority Health
1231 East Beltline NE
Grand Rapids, MI 49525-4501
(303) 813-5172
E-mail: james.byrne@priorityhealth.com

Innovator Disclosures

Ms. Kirkwood, Dr. Peterson, and Dr. Byrne have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

CHAP Web site. Available at: http://firststeps.handsup.co/childrens-health-care-access-programs/.

First Steps. Children's Healthcare Access Program Demonstration Project Evaluation Report. September 2012. Available at: http://firststepskent.org/wp-content/uploads/2013/11/CHAP-Evaluation-2011_FINAL.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).

Footnotes

1 Guram G, O'Shea J. How Washington pushes Americans into low-quality health care. The Heritage Foundation. 2009 Apr. Available at: http://www.heritage.org/research/reports/2009/04
/how-washington-pushes-americans-into-low-quality-health-care
.
2 Asthma Initiative of Michigan. AIM for healthy lungs. Kent County. Available at: http://www.getasthmahelp.org/county-asthma-statistics.aspx?couID=41.
3 Akinbami L. The state of childhood asthma, United States, 1980–2005. Advance Data From Vital and Health Statistics, No. 381. Atlanta, GA: Centers for Disease Control and Prevention. 2006 Dec. Available at: http://www.cdc.gov/nchs/data/ad/ad381.pdf.
4 Asthma Health Outcomes Project. EPA-funded study finds key elements of successful asthma programs. Washington, DC: U.S. Environmental Protection Agency. 2008.
5 American Academy of Pediatrics. National Center for Medical Home Implementation Web site. Available at: http://www.medicalhomeinfo.org.
6 U.S. Census Bureau. State & county quickfacts. Kent County, Michigan. Available at: http://quickfacts.census.gov/qfd/states/26/26081.html.
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Original publication: July 31, 2013.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: March 12, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: April 15, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.