November 2018 HOW TO PAY FOR IT Financing Community Health Workers in Transitions Clinics T he Transitions Clinic model is an evidence- departments less, and being hospitalized less often. based program designed to serve people Training for CHWs in the TCN can be provided in a with chronic diseases who have recently been number of ways, including TCN’s specialized online released from incarceration. Operated by health training or an in-person CHW certificate program centers located in communities with high rates of called the Reentry Specialist Certificate, offered at incarceration, Transitions Clinic Network (TCN) pro- City College of San Francisco. grams assist people in this vulnerable population with reintegration into their neighborhoods and In two different studies, the TCN model has been lives. TCN sites have served thousands of patients demonstrated to reduce emergency department in California and other states. TCN provides training, visits and preventable hospitalizations by half.1 It is coaching, and networking opportunities to help clin- clear that the health plans covering these members ics launch and grow these programs. can save money, and yet clinics operating a TCN program need to consider how they can support the Founded on the idea that people with lived experi- salary of one or more CHWs. Some clinics are imple- ence are best able to support people returning to menting CHW services without specific funding in their communities, each clinic that adopts the TCN the belief that future payment models will incorpo- model employs a community health worker (CHW) rate new staffing models and services. with a history of incarceration as a vital member of its clinical team. CHWs meet with all patients one-on- The items below represent a menu of funding one, connecting them with health and social services options for clinics and health systems to consider in through outreach, assessment, education, counsel- covering CHW services. Some will be more appli- ing, follow-up, and advocacy. Working both inside cable to Federally Qualified Health Centers (FQHCs) and outside the clinic, CHWs act as liaisons that help and others to county clinics; several have relevance ensure that clients receive culturally relevant health for all clinic models. Most Transitions Clinic programs services. They build a unique trust with clients the blend funding from two or more sources. sees them using primary care more, using emergency Health Homes Program HEALTH HOMES PROGRAM: PRO AND CON Under WPC, counties receive federal funding and identify target populations and project partners. Authorized by the Affordable Care Act and California It provides the TCN program with a reliable One of the optional target populations is individuals funding source and engages the health plan(s) AB 361, the Health Homes Program for Patients with with chronic conditions who were recently released in the model. HHP can also be used to support Complex Needs (HHP) is designed to serve Medi-Cal services for non-TCN patients if the clinic wants from incarceration. WPC pilots can pay for care coor- beneficiaries with multiple specified chronic health, to include a broader target population. dination and also for an array of social services. mental health, and/or substance use disorders who frequently use health care services and may benefit The criteria for eligibility in HHP include high community health care use, and not all from enhanced care management and coordination. Transitions Clinic patients will meet this require- At least six counties, including Contra Costa, As of November 2018, HHP programs are being ment because many were recently released from Kern, Los Angeles, and San Joaquin, are pri- implemented in 11 California counties, with many incarceration. TCN programs aim to prevent clients from using unnecessary health care oritizing reentry patients as part of their WPC additional counties to follow in 2019. Clinics can con- services. Because health plans are HHP funders, pilots. In Los Angeles, WPC funding is sup- sult with their counties, or view the implementation clinics with multiple managed care contracts may porting the hiring of 128 CHWs with histories schedule (PDF). find this more challenging to manage or admin- of incarceration to provide services to high-risk ister. Also, CHWs working under HHP need to patients after their release from jail and prison. develop a comprehensive Health Action Plan for HHP cannot reimburse for medical or social services, each patient. This practice is very consistent with but is instead explicitly focused on care coordina- the TCN model, but the volume of documenta- tion, referrals, case management, and transitional tion may be challenging. care. HHPs are therefore an ideal funding source for WHOLE PERSON CARE: PRO AND CON the CHW role. The criteria for eligibility include mul- WPC pilots are well-funded, and the focus on tiple chronic  conditions, an inpatient stay or three emergency department  visits  in  the  last year, and/ Whole Person Care coordination, housing, and systems is a good fit for the work of CHWs serving in TCNs. Funding can support systemic improvements beyond staff or chronic  homelessness. Potentially eligible mem- California’s latest Medi-Cal waiver, Medi-Cal 2020, costs, such as data systems. bers are identified by the Department of Health Care includes a provision for Whole Person Care (WPC) Services (DHCS) and sent to managed care plans; pilots. WPC pilots aim to increase integration and WPC is not a permanent funding stream therefore, this source of financing is likely to cover improve coordination for vulnerable Medi-Cal ben- (although a waiver continuation/renewal is possible). Not all counties are participating. some but not all Transitions Clinic patients. Safety- eficiaries who are frequent users of multiple health net clinics wishing to participate in Health Homes care systems and have poor health outcomes. Pilots must do so by contracting with the clinics’ local in 25 counties are approved, with incentive payments Medi-Cal managed care plans. Although details and contracts along with processes for care coordi- about how plans will compensate providers for HHP nation across a spectrum of services and supports. services are just emerging, it is a good time to begin Funding can also help support data sharing and data negotiations, even for those counties facing later tracking for outcomes. One goal of the WPC pilots is implementation. to reduce inappropriate use of emergency and hos- pital care. California Health Care Foundation 2 Flipped Visits If a CHW sees 20 patients in a typical week, and Short-Doyle Mental Health In FQHCs and FQHC Look-Alikes, where Medi-Cal only five of these are “flipped” to the medical pro- vider, (assuming an average PPS rate of $220 and 45 (County Mental Health) Prospective Payment System (PPS)  reimbursement 2 work weeks per year) this strategy would generate For patients who meet diagnostic criteria, Short- is only available for face-to-face visits with licensed approximately $50,000 per year in visit revenue — Doyle Medi-Cal is a funding source that covers not medical, mental health, and dental providers, about the average salary for a CHW before benefits only mental health treatment but also intensive case there are options to help support CHW visits with and indirect costs. management services. Providers must be certified Transitions Clinic clients using a warm handoff to a by their local county as fully eligible Medi-Cal men- medical clinician. tal health providers and have a current contract to FLIPPED VISITS: PRO AND CON provide Short-Doyle (also known as county mental Does not require any special contracts but health) services. Patients must be enrolled with that instead builds on billing structures already in contracted provider to receive mental health treat- Flipped visits are used commonly by health place. Payments can be quite substantial and cover a good portion of CHW costs. Using this ment services from licensed mental health clinicians centers inside and outside of TCNs. For exam- system can also help shorten the amount of in order to access Short-Doyle case management ple, many health centers flip visits from health time medical providers spend with each patient, funding. Case management activities include com- coaches or nurses to clinicians in the context of allowing them to see more patients and gener- blood pressure management or diabetes care. ate additional billing revenue (not included in the munication, coordination, and referral; monitoring calculation above). service delivery to ensure patient access to service and the service delivery system; monitoring the All staff must be trained to document appro- patient’s progress; placement services; and plan The model is simple. A visit is scheduled with the priately in the various billing and medical records. For example, procedures are needed development. CHW, who conducts an intake with the patient, to adjust the appointment so it reflects the time updates changes in health status, counsels and with the licensed provider. Executives should coaches, and documents the visit in the electronic consider how to reflect flipped visits in produc- SHORT-DOYLE MENTAL HEALTH: PRO AND CON health record or care record. Then, toward the con- tivity reports and calculations. Clinicians can Offers safety-net clinics with mental health sometimes experience these warm handoffs as clusion of the visit, especially for patients who have service infrastructure the potential to leverage disruptive to their patient flow, unless they have medical needs beyond the CHW scope, the medi- a variety of nonfederal funding sources and lightened loads or are designated the “provider realignment funding. Although the program has cal provider spends a brief amount of time with the of the day,” and should understand what is been restrictive in the past, some counties are patient without displacing other scheduled appoint- expected of them in advance. now expanding the range of provider types with ments, reviews and updates the treatment plan, and which they contract. discharges the patient. This level of engagement is more than sufficient to qualify for a PPS rate. The visit Patients must meet medical necessity crite- ria, have a mental health diagnosis, and meet is then submitted with the medical provider as the specific impairment and intervention criteria. rendering provider, and the provider’s signature is Providers must be contracted by the county and the one included on the progress note. bill for services provided. Matching funding is required. The program requires licensed staff and specified amounts of clinical supervision. Clinics must have the infrastructure to manage the care of patients with serious mental illness and be able to track and bill by service units. How to Pay for It? | Financing Community Health Workers in Transitions Clinics 3 Shared Savings SHARED SAVINGS WITH MANAGED CARE ORGANIZATIONS: PRO AND CON Contracts and Grants with Managed Care Constructed well, this arrangement can be Traditionally, time-limited grants from private foun- dations, donors, community benefits, or government Organizations mutually beneficial and help forge strong commitments to the Transitions Clinic program agencies provide the majority of funding for CHW over time. If successful, managed care organiza- services and programs. These grants are often Because there is compelling evidence to suggest that tions may want to expand this arrangement to TCN programs can reduce health care costs, some targeted toward specific populations 3 or health con- other at-risk populations. Additional cost savings health plans or managed care organizations may be that can accrue through the TCN model, such as ditions and typically end after three years or less. willing to help fund the salary of a CHW. They can reduction in hospital stays, are not included in the illustration above. do this in different ways: reimbursing clinics directly for CHW services using a negotiated fee schedule, This agreement may be more challenging to In addition to traditional philanthropy, the cur- supplementing the per member per month capita- negotiate if TCN clients belong to multiple rent climate in California is supportive of proj- tion rate, and/or paying for CHW salary through a managed care organizations, since the benefits ects like TCNs through various criminal justice will not accrue to a single payer (although it grant or transfer agreement. may be possible to structure agreements across reinvestment options. Santa Clara County is us- multiple plans). FQHCs should be aware that ing some of its AB 109 realignment funding to revenue received from health plans under shared support TCN programming, and in Los Angeles savings arrangements may be subject to the PPS County the Office of Diversion and Reentry is The Value Proposition reconciliation process, and so they may want to using SB 678 and Proposition 47 funding to pay seek advice on how to ensure it will be protected Reduction of ED use by Transitions Clinic or excluded. for CHWs in primary care settings. program (TCP) patient-members . . . 50% ED visits per TCP member (average) . . . . . 3.2 ED cost to health plan (average) . . . . . $1,233 CONTRACTS AND GRANTS: PRO AND CON 3.2 visits × $1,233 = . . . . . . . . . . . . $3,946 Grants can be very helpful when starting a new Transitions Clinic program because funders Per member savings to health plan understand the need for start-up costs when of TCP . . . . . . . . . . . . . . . . . . $1,973 initiating a new program and because it may allow the program to explore and establish other Typical annual number of TCP patients funding from the menu listed here. served by CHW . . . . . . . . . . . . . 50 The lack of sustainability can disrupt continuity Overall savings per CHW . . . . . . . . $98,640 of care and may require a program to shift priori- Cost of average CHW with benefits . . . $70,000 ties midstream. Some clinics are willing to take this risk, with the belief that the move toward Net benefit . . . . . . . . . . . . . $28,640 value-based payment over time may allow global capitation that covers CHW services. California Health Care Foundation 4 Medi-Cal Administrative MEDI-CAL ADMINISTRATIVE ACTIVITIES: PRO AND CON As with Medi-Cal Administrative Activities, agencies must either be a “local government agency” or con- Activities May be an attractive option for county clinics in particular, and for partners willing to explore this tract with one to access targeted case management funding. Typically, the local county health agency Medi-Cal Administrative Activities is a funding stream collaboration. Because Medi-Cal Administrative Activities is well-established, most counties have is the local government agency and subcontracts used by most California counties to pay for services experience and expertise with administering it, with a community-based provider. Unlike Medi-Cal such as Medi-Cal outreach, eligibility determina- and it should therefore be sustainable over time. Administrative Activities, counties must first be iden- tions, program planning, and coordinating health tified as providing targeted case management in care access. This funding stream reimburses based Requires participating employees to complete time surveys; these can seem burdensome to California’s State Plan Amendment (SPA) or request on costs determined through a time study method. those not accustomed to this kind of documen- that DHCS submit a change in the SPA to the Centers The program requires a nonfederal match similar to tation. for Medicare & Medicaid Services. the state share for other Medi-Cal programs. Several aspects of the CHW role in a Transitions Clinic are eligible activities under Medi-Cal Administrative Targeted Case Several counties contract with community orga- Activities, including making referrals, coordinating Management nizations for targeted case management. The Alameda County Health Care Services Agency client health care needs with other health care pro- The Medi-Cal Targeted Case Management pro- contracts with a community clinic based in viders, and arranging transportation. gram reimburses participating counties 50% to 90% Oakland for this service in its Transitions Clinic for the federal share of the cost of providing case program. To use Medi-Cal Administrative Activities, agen- management services to target populations. As with Los Angeles County hires and trains CHWs us- cies must either be a “local government agency” Medi-Cal Administrative Activities, a nonfederal ing Whole Person Care funding with the long- (as defined by the state) or contract with one. match is required. Three of the five target popula- term plan that the CHWs will meet the targeted Community clinics and other community-based tions include people who are medically fragile, at risk case management work experience require- organizations can contract with county local govern- of institutionalization, and in jeopardy of negative ments by the end of the WPC project, at which ment agencies to receive Medi-Cal Administrative health or psychosocial outcomes. Most TCN patients point the county can transition CHW costs to Activities funding. should be eligible for targeted case management targeted case management financing. based on their health and/or incarceration status. Alameda, Santa Cruz, San Diego, and Plumas Targeted case management funding can be used to Counties contract with community organiza- support case management services that assist those tions for Medi-Cal Administrative Activities eligible for Medi-Cal in accessing needed medical, services; however, there are not any known social, educational, and other services. Service com- TCN programs using this approach. ponents include needs assessment, goal setting, service planning, scheduling, crisis assistance, and periodic evaluation of service effectiveness. Targeted case management funding is based on time surveys, actual costs, and service documentation. How to Pay for It? | Financing Community Health Workers in Transitions Clinics 5 TARGETED CASE MANAGEMENT: PRO AND CON Funding for Medication- Like Medi-Cal Administrative Activities, targeted case management is a relatively stable funding Assisted Treatment California’s MAT Expansion Project will offer many funding opportunities for clinics starting source, and one that might be especially well Funding specific to medication-assisted treatment or expanding MAT services, as part of its MAT suited to a county TCN program. County staff (MAT) for opioid use disorder is increasingly avail- Access Points project. Funding opportunities typically have experience with time study will be announced in early 2019. documentation. Funding is based on actual able through the Health Resources and Services costs. Administration (HRSA), the Substance Abuse and Mental Health Services Administration, and other To bill for targeted case management services, sources. Some FQHCs already receive this funding CHWs must meet specified levels of education enhancement as part of their HRSA Section 330 and/or work experience — a minimum of four years total — that many CHWs would not have base funding grants. upon hiring. Interested agencies should plan sufficient time for due diligence, relationship building, and training. Ongoing time studies are FUNDING FOR MAT: PRO AND CON also required to claim targeted case manage- ment funding. Historically, very few FQHCs have MAT and other addiction-related services are participated in the program because of a belief aligned with the goals of the TCN program, that they are ineligible and the fear that the state and CHWs are ideal team members for patients will include the revenue in the agency’s annual struggling with addiction. Because of this PPS cost-reconciliation process. alignment, MAT funding can be one of a comple- mentary group of Transitions Clinic funding tools. A growing body of technical assistance is emerging for clinics that want to provide effec- tive MAT services. Not all clinic patients face opioid addiction, and MAT is only one component of an effec- tive approach to reducing opioid dependence. It is also only one of the many services needed by TCN patients. Clinics considering using this source of funding should become familiar with the specific funding requirements and ensure that using this funding source will not artificially limit the scope of their Transitions Clinic CHW. California Health Care Foundation 6 About This Series About the Foundation Endnotes The California Health Care Foundation commis- The California Health Care Foundation is dedicated 1. Emily A. Wang et al., “Engaging Individuals Recently to advancing meaningful, measurable improvements Released from Prison into Primary Care: A Randomized sioned How to Pay for It, a series of short papers that in the way the health care delivery system provides Trial,” American Journal of Public Health 102, no. 9 focuses on reimbursement mechanisms for strate- (Sept. 2012): e22 – e29, doi:10.2105%2FAJPH.2012.300894. gies that advance integration of behavioral health care to the people of California, particularly those Publication pending with data showing lowered and medical care. with low incomes and those whose needs are not hospitalizations and re-arrest rates. well served by the status quo. We work to ensure 2. “Medicaid Prospective Payment System,” Natl. Assoc. that people have access to the care they need, when of Community Health Centers, www.nachc.org. they need it, at a price they can afford. Medicaid payment rules for FQHCs differ from those for other providers because federal law has established CHCF informs policymakers and industry leaders, a prospective payment system prescribing how FQHCs are to be paid for each encounter or visit. The Medicare, invests in ideas and innovations, and connects with Medicaid, and SCHIP Benefits Improvement and changemakers to create a more responsive, patient- Protection Act of 2000 (BIPA) replaced the traditional centered health care system. cost-based reimbursement system for FQHCs with a new prospective payment system. This payment is a unique About Pacific Health Consulting For more information, visit www.chcf.org. payment rate for each FQHC. The Pacific Health Consulting Group provides man- 3. Realignment AB 109 (2011) transfers responsibility agement consulting services to public sector and for supervising certain kinds of felony offenders and community-based health care organizations. With state prison parolees from state prisons and state parole agents to county jails and probation officers. a focus on managed care development and health Proposition 47 was a ballot initiative passed by California care delivery service improvement in the California voters in 2014. It reduces certain drug possession safety net, Pacific Health Consulting Group’s clients felonies to misdemeanors. SB 678, the California include state and local health agencies, public hos- Community Corrections Performance Incentives Act pitals, local public Medi-Cal managed care plans, of 2009, establishes a system of performance-based funding that shares state general fund savings with community health centers, and other organizations county probation departments that reduce their that deliver or finance health care services. For more probation failure rate. At the center of SB 678 is the information, visit www.pachealth.org. use of evidence-based practices and incentive-based funding to improve public safety. The Authors Laura Hogan, MPA, and Tracy Macdonald Mendez, MPP, MPH, Pacific Health Consulting Group How to Pay for It? | Financing Community Health Workers in Transitions Clinics 7