Problem Addressed

• Lack of access, driven by low reimbursement: Many 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 under age 18 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.

Description of the Innovative Activity

• Participating medical practices: Fifteen sites that serve Medicaid beneficiaries under the age of 18 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 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; information provided in February 2012 indicates that now that the pilot has concluded, this payment mechanism has changed to a per member-per month incentive for access.
• 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 faxing a referral form to the CHAP office. 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. Information provided in February 2012 indicates that during its first 2 years in operation, CHAP served 3,681 children, with the most common reasons for referral being repetitive ED use (24 percent) and frequent no-shows (23 percent).
  • Assignment of CHAP team member: The CHAP clinical 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, while 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 provider 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.
  • 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. Information provided in February 2012 indicates that CHAP also uses 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 fax a followup form to the physician 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 Advisory Councils: CHAP has two Parent Advisory Councils (one for English and one for Spanish speakers) that provide regular input and 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.

References/Related Articles

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Results

• More slots in primary care for Medicaid patients: Information provided in February 2012 indicates that during the first 2 years, participating practices opened an additional 1,966 slots for children covered by Medicaid in Kent County. In year 1, patients also expressed high levels of satisfaction with the accessibility of care, as evidenced by an average score of 3.27 for accessibility (on a scale of 1 to 4) on the Primary Care Assessment Tool. 
• Increased use of asthma action plans: Among those receiving asthma case management services, the percentage with an action plan more than tripled, from 14 to 44 percent.
• Less ED use among all patients in participating practices: ED use by Priority Health Medicaid enrollees being cared for in participating practices fell by 8.7 percent during the first year of implementation. Information provided in February 2012 indicates that during the from the baseline year to the end of year 2, practice level ED visits declined by 13.8 percent. This figure includes all CHAP-eligible patients, regardless of whether they received CHAP services. ED visits among CHAP clients (who received at least one direct CHAP service) declined by 35 percent.   
• Fewer hospitalizations: During the first year of the program, hospital admissions fell by 3.1 percent among all CHAP-eligible patients and by 3.3 percent among patients referred for CHAP services. Information provided in February 2012 indicates that during the from the baseline year to the end of year 2, inpatient admissions declined by 12.3 percent including uncomplicated births and by 5.6 percent excluding uncomplicated births. Again, this figure includes all CHAP-eligible patients, regardless of whether they received CHAP services. Inpatient admissions among CHAP clients declined by 62 percent in the 12 months following CHAP involvement compared to the 12 months prior to involvement.
• Positive cost-benefit: Information provided in February 2012 indicates that, to better assess the costs associated with CHAP and those costs avoided, two cost benefit analyses were conducted: a fiscal cost-benefit analysis, which takes into account the costs accrued and the benefits realized by the health plan and a social cost-benefit analysis, which conveys whether the investment makes sense from the perspective of society. Both are legitimate ways to evaluate CHAP, but they are designed to answer different questions. The analyses revealed that, after 2 years of the demonstration project, Priority Health has recouped the cost of its financial investment in increased Medicaid reimbursements and performance-based incentives to providers, through the reductions in ED visits and hospitalizations. Second, and perhaps most important, the social benefit-cost analysis is positive. Looking at the data from a variety of perspectives, the immediate social benefits exceed the costs by one-fifth; this conservative estimate and can be expected to increase over time, because the benefits of good health in childhood are compounded as people age.
• Positive feedback from families: Information provided in February 2012 indicated that feedback from the families served by CHAP continued to be positive in 2010. Specifically, clients reported highly favorable opinions of the CHAP asthma counselors, their interactions with them, and the positive impact their education and assistance has had on their child's health.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• 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 (available at http://www.firststepskent.org/wp-content/uploads/2008/07/CHAP-Research-Article-Jan.-2011.pdf).
• 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 and media coverage. In addition, Priority Health sent a letter to every eligible patient/family describing CHAP and its services, and all participating practices place written materials (in English and Spanish) in their waiting rooms that describe CHAP services.
• Expansion and replication: Information provided in February 2012 indicates that based on the success of the 3-year demonstration project, the program is being expanded and replicated across the state.

Resources Used and Skills Needed

• Staffing: The CHAP program employs a program manager, a pediatric nurse who serves as the clinical manager, one resource coordinator, two community health workers, one social worker, and an administrative assistant; several staff speak both 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.
• Costs: First-year service delivery costs totaled $460,000, 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, data analyst); this figure excludes overhead, the value of in-kind donations, and Priority Health-funded incentives to providers. Second-year costs increased to $592,000.

Funding Sources

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 a 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: Currently, CHAP depends largely on foundation funding that could eventually run out. To address this issue, First Steps' board is considering how to generate ongoing funding for the CHAP program team. Within the next few years, it is possible that any one of the following scenarios, or a combination of several, might be in place:
  • CHAP remains a free-standing, community-based pediatric medical home improvement project that is funded through a blend of philanthropic dollars and contributions from health plans that pay a per-patient capitated rate (per member per month), depending on the number of their Medicaid patients CHAP serves.
  • Michigan Medicaid accesses additional federal funding to accommodate those prevention-oriented services provided on behalf of health plan patients.

Use By Other Organizations

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