Much of the work to improve access to high-quality care and reduce costs of care will occur in the states, according to the website of the Alliance to Reduce Disparities in Diabetes, a Merck Foundation national program. So the alliance and the National Governors Association (NGA) hosted a webinar in November that discussed current state policies and actions needed to address health workforce issues, as well as incentives that may improve patients’ access to the services they need.
Also, panelists from two of the five alliance sites (Chicago and Dallas, Texas) shared their real-world experience in working within the health care system to change care delivery for underserved people with diabetes. Clinics in these cities are partnering with local communities to help people with diabetes manage this chronic condition.
The panel, moderated by Jeff Levi of Trust for America’s Health, included Esther Krofah of the Health Division of the NGA’s Center for Best Practices, Christine (“Chris”) A. Snead of Baylor Health Care System (now called Baylor Scott & White Health), and Marshall Chin of the University of Chicago. Snead is affiliated with the alliance’s site in Dallas called the Diabetes Equity Project, and Chin codirects the alliance’s site called Improving Diabetes Care and Outcomes on the South Side of Chicago.
Following are some highlights from the webinar.
Levi and others discussed a new Centers for Medicare and Medicaid Services (CMS) policy allowing states to amend their Medicaid programs to permit reimbursement for preventive services provided by health professionals not licensed to provide such services—if the services have been recommended by a physician or other licensed practitioner.
Esther Krofah of the NGA, which is “the collective voice” of the fifty-five governors of US states, territories, and commonwealths, described the association’s Health Workforce Technical Assistance project, in which ten states participate. States identified four overarching Health Workforce Challenges—these include coverage expansion occurring as a result of the Affordable Care Act; an aging health professions workforce (for example, citing a recent Health Resources and Services Administration document, the project says that one-third of the nursing workforce is older than age fifty); the poor distribution of health providers; and the aging US population (according to a 2007 American Hospital Association document, more than 60 percent of baby boomers “will be managing more than one chronic condition”).
Krofah pointed out that the biggest difficulty for states is really data collection and analysis. (It is hard for states to get good information about their workforces; having this information would inform key policy questions, she explained to me later.)
The NGA has also noted a “shift in core skillsets” for the health workforce. For example, team-based care, care coordination, and patient navigation are on a list of “core skillsets” now. Even registered nurses and home health aides are listed as “emerging occupations.” (While those are not new occupations, states are looking at those professions and others as they begin to define which professions will serve in care coordination roles, Krofah later explained to me in an e-mail.)
Other challenges for states are professionals who work in “silos” and engage in “turf wars” with workers in other professions; too many job titles for allied health occupations and a lack of standardization in how they are trained, attain credentials, and obtain funding; faculty shortages; the lack of science and math pipelines for children in grades K through twelve; and, of course, scope-of-practice laws and regulations that prevent professionals from practicing to the full extent of their training.
Krofah mentioned ways that states could affect workforce policy. These include changing the licensing regulations for various health professions; initiating repayment programs for health professionals’ student loans that would “incentivize” graduates to work in rural and underserved areas; and amending their Medicaid programs to allow reimbursement of preventive services provided by a range of health professionals (per the new regulation recently approved by CMS).
She reported that states have been embracing the employment of community health workers (CHWs). Texas, Minnesota, and Massachusetts are leading the way in use of these types of workers. Krofah advised that in efforts to formalize this profession, states should make sure that CHWs continue to reflect the community that they are serving and that there are viable career ladders available to them.
Baylor’s Chris Snead spoke about the path to integrating CHWs into clinical teams in Texas. She reminded listeners that the Lone Star State has the highest rate of uninsurance in the country.
The Diabetes Equity Project embedded CHWs into a network of charity clinics in the Dallas area that serve many Hispanics and African Americans. The clinics see a high demand for primary care services, and a high percentage of their patients have diabetes.
Snead mentioned that per the new CMS regulation, states have an opportunity to reimburse for CHW services, effective January 2014.
I was interested to find out that Texas has a CHW certification program, which has been in existence for some twelve years. After 160 hours of training, one can become certified by the state as a CHW. Snead said CHWs are trusted by patients, culturally competent, and skilled at patient navigation and health education. CHWs also have continuing education requirements.
So, the seven clinics of the Alliance’s Diabetes Equity Project embed CHWs in a patient-centered medical home. Primary care physicians at the clinics can then shift some of the work to CHWs, such as diabetes education, nutrition counseling, and patient follow-up. They are part of a team. (Baylor also has a Community Care Navigation project that uses CHWs.)
Snead reported some results from the Alliance’s Diabetes Equity Project.
* 800 patients had a statistically significant drop in their A1c hemoglobin levels.
* Frequency of hospital admissions for this project’s population decreased by 50 percent.
* Emergency department (ED) use did not change, she reported. However, the cost of ED care per case fell by 19 percent.
During the Q & A, Snead said CHWs for the Diabetes Equity Project also have fifty additional hours of training on diabetes. The project tries to recruit people who are already medical assistants and add on the CHW training. After a CHW is certified, Baylor also routinely does “competency checks” in which a supervisor goes along on a visit to a patient to make sure the CHW’s competency levels are OK.
Marshall Chin was the next presenter. He spoke about states creating and maintaining connections between the community and clinics. The goal is to integrate work in the health care setting with work in the community to improve outcomes of care for people with diabetes. Chin noted that efforts have to be made in the community, or else physicians will see the same issues over and over again at patient appointments. For diabetes patients, those issues often focus on the need to eat healthier food and to exercise more.
Chin and Monica Peek codirect the Alliance to Reduce Disparities in Diabetes project on the South Side of Chicago. The project offers healthy lifestyle classes, including instruction on how to read food labels and how to shop at a local grocery store. In an area of the city considered a “food desert,” the project partners with a farmers market, as well as with Walgreen’s, and also promotes the use of food “prescriptions” from physicians that offer discounts on healthy food.
The project also includes a public education component. It offers general information about healthy living and how to care for diabetes; works with a local radio station program during which listeners can call in their questions; arranges for diabetes education programming on a local cable TV channel by partnering with health professionals; and runs a cooking contest—awards are offered for the best preparation of healthy and delicious recipes for people with diabetes.
So what should states be doing? Chin said they should align financial incentives so that providers are rewarded for improving population health. Specifically, he recommends use of global payments that reward preventive care (and keep people out of the ED); adequate funding of primary care; reimbursement of team-based care that includes care coordination and CHWs; and creation of incentives to reduce disparities and protect the vulnerable. In the Q&A, he noted that the private marketplace is moving toward the concept of value, while cutting costs, so the financial incentives are starting to align now.
State agencies, such as departments of public health, parks and recreation, and housing can collaborate with each other and the private sector, Chin said. For example, a recreation department could offer a bicycling program, and a housing department could collaborate on making housing healthier.
During the Q&A, a listener asked how the food prescription program was financed. Chin said that initial grant funding came from the Merck Foundation and from a National Institutes of Health project. The LINK Up Illinois Double Value Coupon Program doubles the value of the federal government’s Supplemental Nutrition Assistance Program (SNAP) vouchers if enrollees shop at certain farmers markets, he added.
In response to another question, Chin mentioned the importance of data. By collecting and recording data, one can see where health disparities are and then motivate health care providers and patients to change their behaviors. Also, he noted that hot-spotting is a popular method used to identify high-risk patients—it helps such patients and the community and helps to reduce health care costs.
To listen to the webinar, go here.
To view the panelists’ PowerPoint slides, go here.
Read a January 2012 Health Affairs article coauthored by Marshall Chin, “Early Lessons from an Initiative on Chicago’s South Side to Reduce Disparities in Diabetes Care and Outcomes” (free abstract).