1. Community Health Workers (CHWs) as Members of Interdisciplinary Health Teams: Practical and Financial Considerations Beatrice Smith, Program Coordinator CHW Training and Certification Program Texas Department of State Health Services Rosalia Guerrero-Luera, Program Manager Texas Public Health Training Center Community Health Worker Training Program University of Texas School of Public Health Carisa Magee, Special Advisor Medicaid/CHIP Division, Health and Human Services Commission Houston, Texas June 9, 2016

2. At the end of the session, participants will be able to: Describe the framework for certification of community health workers (CHWs) in Texas Discuss current challenges related to sustainable financing of CHW services Discuss the practical and financial considerations in integrating certified CHWs as members of interdisciplinary health care teams Learning Objectives 2

3. Promotor(a)/Community Health Worker (CHW) Certification in Texas - Texas Primary Care and Home Health Summit - Beatrice Smith CHW Training and Certification Program Coordinator Texas Department of State Health Services

4. Texas was the first state to pass legislation creating a statewide training and certification program for CHWs. Implemented in 2001. Governed by Ch. 48, Health and Safety Code; Ch. 146, Tex. Admin Code Department of State Health Services – Office of Title V and Family Health http://www.dshs.state.tx.us/mch/chw.shtm 4 Background/ Governing Authority

5. Promotores or community health workers: Serve as liaisons and are trusted members of the community Have a close understanding of the ethnicity, language, socio-economic status, and life experiences of the community served Assist people gain access to needed services 5 Description

6. They perform many vital functions: Outreach Patient navigation and follow-up Community health education and information Informal counseling, social support, advocacy Participation in clinical research 6 Activities

7. CHW Training and Certification Program Promotores or community health workers who receive compensation for services provided must be certified. Certification Types: o Promotores or Community Health Workers o Instructors o Training Programs http://www.dshs.state.tx.us/mch/chw.shtm 7 Certification

8. Competency based (communication, interpersonal, capacity building, service coordination, advocacy, teaching, organization, knowledge base on specific health issues) Completion of an approved 160-hour competency- based training program certified by DSHS OR Experience – At least 1000 cumulative hours of community health work services within the most recent six years 8 Certification cont.

9. Standardized framework Eight core competencies o Communication o Interpersonal o Service Coordination o Capacity building o Advocacy o Teaching o Organizational skills o Knowledge base (specific health issues) 9 Training and Education

10. Community Colleges Health Science Centers Community Health Worker Association Area Health Education Centers (AHECs) Community-based organizations Federally Qualified Health Centers 10 Training and Education Sources

11. Advisory Committee o CHWs serve as Presiding and Assistant Presiding Officers o CHWs comprise two-thirds of total membership (6 of 9 members) 10 CHW networks and associations (http://www.dshs.state.tx.us/mch/chw.shtm) 11 Leadership

12. Membership in CHW networks and associations located in Texas range from 25 to over 500. Locations 12 Leadership cont. Panhandle Dallas/Fort Worth Northeast Texas – Tyler East Texas – Gulf Coast Region Central Texas – Austin South Texas (Health Service Region 11 and Maverick County, Brownsville and San Antonio) West Texas – El Paso

13. 13 Growth in Texas

14. 14 CHWs in Texas Total: 138 Counties & 3,628 Certified CHWs Source: Office of Title V and Family Health, 12/31/2015 Mapped by Office of Program Decision Support

15. Integration as professionals in mainstream health care and social service systems Varying job classifications and pay levels Sustainable funding/reimbursement Training/professional development Recruitment Supervision Incorporating community health worker skills/attributes within positions with a more defined role 15 Challenges and Considerations

16. Standard Occupational Classification (SOC) 21-1094 Community Health Workers http://www.bls.gov/soc/soc_2010_definitions.pdf U.S. Department of Labor Office of Apprenticeship CHW added as an “apprenticeable” occupation – July 2010 National Steering Committee for Promotores de Salud 15-member committee including individuals from Texas 16 National Activities

17. Continued collaboration/sharing Share successes and lessons learned with other states Continue to explore reimbursement mechanisms for CHW services Additional awareness for supervisors and employers 17 Looking Ahead

18. 1115 (transformation waiver) projects Expanded primary health care contractors Health plans Medicaid outreach/informing Affordable Care Act – navigators, certified application counselors Other 18 Potential CHW Roles

19. Family and Community Health Services Division Promotor(a)/CHW Training and Certification Program Moreton Bldg. 1100 West 49th Street (512) 776-6663; (512) 776-2208; or (512) 776-3860 chw@dshs.state.tx.us http://www.dshs.state.tx.us/mch/chw.shtm 19 CHW Contact Information

20. Questions?

21. Community Health Worker Services in Medicaid Carisa Magee Special Advisor, Medicaid/CHIP Division Texas Health and Human Services Commission

22. Sources of CHW Funding for Medicaid Clients Medicaid fee-for-service (FFS) Medicaid managed care Pilot and State Innovation Model (SIM) funds Medicaid 1115 demonstration waiver 22

23. Texas Medicaid Enrollment 23 The majority of Texas Medicaid services are delivered in managed care Enrollment statistics as of June 2015: o 4,030,139 clients in Medicaid o 3,531,587 members in managed care o 498,552 in Medicaid fee-for-service

24. Medicaid CHW payment challenges Federal and state laws and regulations govern the services for which Medicaid can pay Medicaid State Plan is the contract between the federal Centers for Medicare & Medicaid Services (CMS) and a state Medicaid program Under the state plan, a Medicaid program receives federal matching funds for strictly defined categories of services No state has successfully amended the Medicaid state plan under a 2013 regulatory change deemed promising to open the Medicaid preventive services category to payment for CHWs [42 CFR 440.130(c)] 24

25. Fee-for-service example: Minnesota Medicaid Diagnosis-related patient education Services provided under medical supervision and billed by supervisor Approved Medicaid state plan As of July 2015, less than 100 claims annually 25

26. Medicaid Managed Care Delivery Model 26 19 Medicaid managed care organizations (MCOs) Goal to deliver quality, cost-effective care through medical home State pays MCOs a capitated rate for each member enrolled, rather than paying for each unit of service MCOs must offer services required by Texas Medicaid MCOs may offer value-added services (e.g., sports/ community membership, pest control, respite care, etc.) Certain MCO costs must be classified as administrative due to federal requirements – includes CHW services

27. 27

28. February 2016 Texas Medicaid MCO Survey: Use of CHWs 5 MCOs are aware of physician practices in their networks using CHWs 15 MCOs use CHWs directly: o 1 contracts with a CHW network but does not directly employ CHWs o 14 directly employ CHWs (3 among these also contract for CHW services) 28

29. CHW Services Delivered by Texas Medicaid MCOs ServiceMCO Count Health education/promotion15 Information and referral14 System navigation/service access12 Ask members about their health and needs11 Individual and community advocacy10 Informal counseling and social support9 Cultural liaison/mediation7 Ask about medication and other treatments6 29

30. Grant-funding example: South Carolina Medicaid CHWs part of care team improving patient compliance with screenings, office visits, and medications Nineteen primary care practices participating in a grant-funded pilot program that bills under physician education codes already authorized under the Medicaid state plan Billing by the clinical supervisor State not successful in implementing a preventive services state plan amendment with CMS 30

31. Texas Medicaid 1115 Demonstration Waiver Federal law allows states to apply to CMS for permission to deviate from certain Medicaid program requirements through waivers 1115 waivers are designed specifically to test new service delivery and management models Texas currently has approval for an 1115 waiver with a Delivery System Reform Incentive Payment (DSRIP) component DSRIP is an incentive program to transform delivery systems through infrastructure development and testing innovative care models 31

32. Texas Medicaid 1115 Demonstration Waiver CHW Delivery System Reform Incentive Payment (DSRIP) projects include: o CHW integration in care teams, such as for behavioral health services o Patient navigation, particularly to divert nonemergent ED visits o Disease-specific prevention and education, such as for asthma and diabetes o Compliance with appointments and following care regimens, such as prenatal care 32

33. Questions?

34. Integrating CHWs into Your Health Care Team: 5 Lessons Learned Rosalia Guerrero-Luera, Program Manager Texas Public Health Training Center Community Health Worker Training Program University of Texas School of Public Health

35. Background University of Texas School of Public Health – CHW training center Partner: UT Physicians Project: 1115 Waiver DSRIP project to train and integrate CHWs in clinical settings Types of Clinical Settings: Medical Homes, Specialty Clinics, Hospital, Behavioral Health, other DSRIP projects 35

36. Lesson 1 – Start at the End Understand how CHWs will help you meet organizational goals Increase patient satisfaction Reduce no-shows Patient education Your decision to integrate CHWs should be strategic, not emotional 36

37. Lesson 2 – CHWs are Unique Job description not determined by certification Flexibility – double-edged sword Can carry out several roles; not at the same time CHWs – neither clinical nor clerical Focused on health literacy and social determinants, not medical knowledge They change the relationship with patient population and community 37

38. Lesson 3 – CHW is a Model, Not a Person Impacts several aspects of organization Communication is key Rest of staff needs to understand roles and competencies of CHW CHWs augment and leverage existing staff activities; does not replace them Can be tied to continual quality improvement activities 38

39. Lesson 4 – Beyond CEUs Continuing education is integral to CHW work Training is source of resources and referrals Leads to specialties CHWs learn from other CHWs CHWs learn from the community CHWs as teachers 39

40. Lesson 5 – Management Matters CHW projects fail due to poor management Can get lost in a team Need for one supervisor, mentor, teacher Specific work plan and measures important 40

41. Questions?

42. Contact Carisa Magee, Special Advisor Medicaid/CHIP Division Texas Health and Human Services Commission E-mail: Carisa.Magee@hhsc.state.tx.us Phone: 512-707-6106 Rosalia Guerrero-Luera, Program Manager Texas Public Health Training Center Community Health Worker Training Program University of Texas School of Public Health E-mail: Rosalia.Guerrero@uth.tmc.edu Phone: 713-500-9395 Beatrice Smith, Program Coordinator CHW Training and Certification Program Texas Department of State Health Services E-mail: Beatrice.Smith@dshs.state.tx.us Phone: 512-776-2208