CalAIM Six Month Check-Up Video–
Successes and Challenges of Enhanced Care Management and Community Supports Implementation
A Moderated Discussion Among Health Plan and CBO Leaders from Health Plan of San Mateo and Pacific Clinics.
As we are nearly six months into the launch of the CalAIM initiative, hear perspectives from health plan and CBO leaders on successes and failures of their ECM and CS implementations.
This panel discussion focuses on:
- Lessons learned around preparation, capacity planning, building new capabilities, and the go-live and operational impacts resulting from implementations.
- Insights on moving forward, including how CBO’s can best prepare for their roles in performing new functions such as revenue cycle management, encounter reporting, and what additional capabilities are yet to be built.
- Ideas for innovation beyond the initial implementation based on a proven framework for guiding effective implementation of evidence-based programs and other innovations in human service settings.
Hosted by Catalyst Solutions and InfoMC
- Moderated by: Mark Refowitz – Former Director, County of Orange Health Care Agency and Former Chairman of the Board of Directors, CalOptima.
- Guest Speaker: Eleanor Castillo-Sumi, PhD, BCBA-D, Pacific Clinics, Senior Vice President, Strategy, Innovation and Growth
- Guest Speaker: Chris Esquerra, MD, Health Plan of San Mateo, Chief Medical Officer
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SCOTT MARTIN: All right, thank you for thank you for attending. My name is Scott Martin, I am the president of Catalyst Solutions. On behalf of Catalyst Solutions and InfoMC we’d like to welcome you to our webinar today. CalAIM Six-Month Checkup: Successes and Challenges of Enhanced Care Management and Community Support and Implementation. Thank you for joining us. Thank you for taking time out of your busy day to listen to what we’re going to be talking about today.
As a matter of housekeeping, this webinar is being recorded and the recording will be shared. Questions can be submitted at any time using the Zoom Q & A buttons at the bottom of your screen. These questions will be addressed at the end of the presentation.
We are nearly six months into the launch of the CalAIM initiative and we’re welcoming you to hear the perspective from a health care plan and CBO leaders on the successes and failures of the ECM and CS implementations. This webinar will be a moderated discussion among healthcare plan and CBO leaders from the Health Plan of San Mateo and Pacific Clinics. These leaders will speak to the lessons learned around how CBO’s can best prepare for their goals and performing new functions such as revenue cycle management, counter reporting and ideas that go beyond the initial implementation such as using evidence-based programs and other innovations in the human services setting.
With that said it is my pleasure today to welcome the speakers first is Dr. Eleanor Castillo-Sumi, Senior Vice President of Strategy Innovations and Growth at Pacific Clinics. In this capacity, Dr. Castillo-Sumi’s responsible for developing new partnerships and programs to support the agency’s growth and commitment to communities across the state. Dr. Castillo-Sumi is a licensed psychologist and has published articles in the American Journal of Orthopsychiatry, among other publications. Additionally, she has spoken at various conferences including Open Minds and California Alliance for Children and Family Services. She is a member of the Research and Evaluation subcommittee for California’s Mental Health Services, Oversight, and Accountability commission. Dr. Castillo-Sumi is a board-certified behavioral analyst, doctoral, and has a Ph.D. in clinical psychology from Pacific Graduate school of Psychology at Palo Alto University where she was awarded dissertation of the year. We also have with us Today, Dr. Chris Esguerra, Chief Medical Officer at the Health Plan of San Mateo. Dr. Esguerra has led system transformation, program evolution, as well as public and private partnerships. These engagements have led to outcomes that meet the quadruple aim of improving health, cost-effectiveness enhancing patient experience, and supporting provider well-being. He has led significant efforts around the integration of care and services for a variety of populations. Holistically addressing social determinants of health, and healthcare delivery, and helping people remain engaged in the community with appropriate long-term services and support. Most recently, Dr. Esguerra served on the National Academy of Science Engineering and Medicine committee that published integrating social needs care into the delivery of health care to improve the nation’s health.
It’s also my pleasure to introduce today’s moderator Mark Refowitz, the former Director and former Chairman of the Board of Directors at the County of Orange Healthcare Agency and Cal Optima. Mark retired in April of 2017, but his career spanned more than 40 years in a variety of executive management and clinical leadership positions in the public sector in health care with the state and county government as well as the private sector. These roles included the Director of Behavioral Health in Orange County, Mental Health Director for the county of San Diego, Senior Vice President of Development for Health Inc in Costa Mesa California, Chief Clinical Officer with Community Care Behavioral Health organization in Pittsburgh Pennsylvania, Assistant Commissioner for Managed Care with Massachusetts, Department of Mental Health in Boston, Senior Administrator of the Department of Mental Health in the office of the Federal Receiver for the District of Columbia. Mark was a member of the Cal Optima Board of Directors and the Children and Families Commission First Five Commission of Orange County. With that said Mark, I’m going to pass it over to you.
MARK REFOWITZ: Thank you Scott and hello everyone, I just wanted to give you a snapshot of who has said they were going to attend today. As you can see we have about 150 participants. They represent health plans, FQHC’s, community-based organizations, county behavioral health, medical groups, hospital groups, consulting organizations and advocacy organizations. We have clinicians, administrators, I.T. people and data analytics folks, and advocates. Let’s get started let’s dive in with our first question. How would you, Chris and Eleanor, how would you describe the transition from whole-person care and the health home pilot programs to CalAIM enhanced care management and community supports, and what were some of the issues and challenges your organization faced during this phase?
CHRIS ESGUERRA, Ph.D.: Right well, Eleanor definitely will chime in. I think I’ll speak from the perspective of just overall and then based on sort of whether you were in a county that was whole-person care or actually had the health homes pilot. But the bottom line was that things were rushed and things were rough. Specifically, from the perspective of community-based organizations in the sense that whole-person care was a wholly different pilot and structure financially in terms of how it worked in the county setting. Whereas, Health Holmes actually did push and looked a little bit more like what we have with CalAIM. There was a little bit more practice there for those counties that did go live in health plans and community-based organizations with Health Homes and so there was just a little bit much more familiarity and it looked a little bit smoother. But the bottom line is that given the rush nature of how things played out with DHC Department of Health Care Services in providing the structure and the roadmap to going live and therefore the health plan’s actually having to submit things and get things approved and all of that, there really wasn’t that much time spent to be thinking about the implementation and thinking about it really from the community-based organization perspective. Just the amount of work it takes to actually bring these pieces up to speed, frankly. I turn it over to Eleanor to talk about that, but I also really just want to underline the implementation aspect.
ELEANOR CASTILLO-SUMI, PHD BCBA-D: Yes, Chris and I completely underscore, you know, the importance of implementation from the provider standpoint, you know, Pacific Clinics over two years ago I guess it was, you would consider it was an early adopter of Health Home programs. We saw this as an opportunity to, if you will, prepare ourselves for what was coming forward with CalAIM. There are a number of different CBOs like Pacific Clinics who currently contract primarily with counties that are currently in the exploration stage. If we’re talking about implementation science, there are a number of different phases, and within those phases, there are a number of different drivers to assist with implementation. Well, we knew that the change was coming, we adopted and therefore made an explicit decision to move forward with changing our infrastructure to be able to work within the space of the health plans so for CBOs this is huge. Pacific Clinics is an organization that’s over a 150 years old, so there’s a whole set of culture that’s associated with working with county mental health plans. That change and that’s changing for all these CBOs. The next stage after you explore and adopt is the program installation, what are the structures that need to change? What are the competencies that your staff needs to have to operate successfully in this new world? And for us, even though we had that opportunity to pilot those things through Health Homes, It was still a rough change for us. Our contracts ended 12/31. Contracts were supposed to be in place by 1/1/2022 and none of that, you know, that’s an example of something that wasn’t in place. We continue to serve those that were grandfathered into the enhanced care management program while we were still trying to build or if you will continue to do what we needed to do in the program installation stage to be ready for this initial installation. I would say we’re still there; we’re still trying to build all the things that we need to be successful in this new space.
CHRIS ESGUERRA, Ph.D.: Yeah, I definitely want to underline that Eleanor because I think you know what we saw at Health Plan of San Mateo was a heroic effort between our plan staff and our partners to get over the finish line of getting the contracts in place to get going and understanding the list from whole-person care to switch over to enhanced case management, and I think from the perspective then of an implementation science framework, is that ideally, implementations like this shouldn’t have to be heroic. There is a conscientious path that we set, what does that mean there, and we’ll get to this a little bit later, but that that there are implications to what happened on January first, it’s not the last implementation. We have other populations of focus to consider and actually, as plans, every six months we can choose to then include new community supports or, expanding what in whatever ways. There are opportunities there than to take what we have learned from the January first start of frankly, it’s going live and I think that that’s the other piece of making it wasn’t necessarily as clear as it could have been from a state perspective, but I think that’s the opportunity that can happen and be forged more locally of what are our expectations come a specific deadline date and I think making that clear as well I think also probably takes a lot of pressure off or at least makes it clear to the parties involved. One of the things I’m definitely mindful of, and we have been mindful of H.P.S.M. is really the power dynamics of all of a sudden now community-based organizations. Even county organizations with whom we partner may not necessarily have worked within a plans structure. With not necessarily just the contracting, but the payment models or/as well as the credentialing claims. All of those operational pieces and it’s this idea of how then do we help and support bringing that in. Thinking about it as you go forward, what are the structures then that could be useful to support. In a way sort of technical assistance now is a little too late. That would have been helpful before. I know some organizations, for example, California Food as Medicine Coalition did do technical assistance to the medically tailored meal organizations prior to all of this starting. However, that may not necessarily have been the case for other organizations. Understanding that for example for a small community-based organization, just the whole idea of getting up to speed with HIPPA and being able to bring up your security privacy levels could be what would blow your I.T. budget for the year for example. I think it’s just understanding that and what would be those pathways. Because from a planning perspective I think we needed to be, and I know we tried to be conscientious, in understanding that we cannot necessarily impose standards that we normally would impose say to a primary care office that wants to be in-network all of a sudden to a community-based organization that may not necessarily have worked with a health plan before.
ELEANOR CASTILLO-SUMI, Ph.D. BCBA-D: Yeah, underscoring again you know so organizations have to go through this you know transformation if you will. But that transformation is not just within the organization, right? And as Chris is I think describing here there’s a between the entities and the work that needs to happen between a CBO for example and the health plan or the county. We’re talking about program installation on multiple levels.
MARK REFOWITZ: Many waivered programs sometimes go through a readiness review. Did you have the opportunity to go through a readiness review with any of the health plans in the counties that you’re in? That you contracted with? And what was that experience like if you did?
ELEANOR CASTILLO-SUMI, Ph.D. BCBA-D: From the CBO perspective we did there wasn’t a formal readiness review. As an agency, there were several assessments from Open Minds that was available, is available, for CBOs to actually go through. Those different reviews that look at your workforce looks at your I.T. system from the EHR as well as from the revenue cycle management perspective. We made the choice to go through that assessment. But I would imagine if you didn’t know about those resources, then you wouldn’t know that that’s an option to you. But again that’s a choice that we made and I would say is a critical part of getting ready you know having that baseline knowing what targets need to have in place, identifying the areas for which you need to improve and targeting your efforts. I think those assessments would be really helpful.
CHRIS ESGUERRA, Ph.D.: Yes, I very much agree. I think you know part of the nature then in the roll-out thinking about this systematically from a statewide perspective is how, as a good part of a go forward, and clearly this gets to the deficiency of the implementation, is how do we actually make that as a standard because we’ll have other rollouts with populations of focus. Right. And how is it that there is a way to incentivize and provide that support technical assistance to actually go through that kind of assessment. Eleanor alluded to what is the transformation component? Well, I think one of the other transformation pieces is for example just for a CBO that perhaps had worked with contracts that were more of a cost basis perspective, right? The cost of which I’m doing, providing something and that’s how I’m going to get paid. For enhanced case management services, you are now paid on a per engaged member, per month. Completely different, the math works out very, very differently. You’re now having to think in a different way altogether. That’s a transformation in and of Itself and that’s just about one. Then we need to be thinking about data systems and the interaction with the health plans. What are the workflows and processes with the plans overall. I think whereas, I will say that certain plans, certain counties, we made it work given that those strong partnerships that we’ve had already. That’s not that’s not necessarily the case if you look at it more from a statewide perspective. Really when we think about it from that kind of inconsistency, there’s an opportunity then from that at the DHCS level to then be able to say these are the best practices that will be really helpful once we start thinking about going live. Going live is not that far for the next population of focus, which is July. For all of our other populations of focus, I think there’s a there’s a path there to be thinking about how do we address what has already happened and the challenges of what has already happened.
ELEANOR CASTILLO-SUMI, Ph.D. BCBA-D: You have, you know, again different CBOs in different places, right of implementation, you have those that are still just exploring all this. I think part of their exploration should be this assessment to say, can they go there. As opposed to going there and then figuring out, you know, this is just very difficult. As a large organization, we have the ability to be able to put in resources, but not all organizations are the same. The ones that are primarily that would be at risk without support are your ethnic specific CBOs. Who are critical in this, the whole system of care, but it might not have the resources to be able to go through this assessment phase if you will, to determine what they need to do to be able to operate in this new landscape.
CHRIS ESGUERRA, Ph.D.: I’ll say similarly on the plan side, there is a bit of readiness work. I think it was very easy to really focus on all of the ‘get the contracts in’ and ‘get your network in’ just to submit all of those things to DHCS to check the box because there’s the compliance component. Also, but then how is it that we’re now thinking of ‘well, okay, who is our population, how are we going to do referral workflows’, all of those pieces that other part of the process components of this implementation. I bring this up largely because I work with and support a number of other CBOs. One of the common themes I’m hearing is that for some in some other counties is that they’re not necessarily getting the referrals yet. Then this is in the world of community supports, let alone, thinking about enhanced care management, but just thinking community supports. I think then it’s back to that from a systematic perspective, how is it that there is a framework that every party that’s going to be coming together to accomplish this great thing, which is CalAIM, how is it that we start thinking about all of the pieces that we need to be doing in order to actually do this well.
ELEANOR CASTILLO-SUMI, Ph.D. BCBA-D: There’s huge consequences. For us, as a CBO we took our directive as to be ready to provide services on January first or January second, the day after new year’s. We hired, we hired for capacity reasons. We need to provide those capacity reports and we hired to be able to do that and its now May and we have staff in counties ready to provide services. But the referrals aren’t there. That would be a huge fiscal burden on a lot of organizations.
MARK REFOWITZ: I think it’d be fair to say that our friends and partners at DHCS understand the landscape of California. There’s a saying in California to see one county, we’ve seen one county. In this 58 plus the city of Berkeley and tri-cities that all have to figure this out and move forward. I also believe that from their perspective, it was going to start slow, even though they had bold aspirations of getting out of the gate and that people who were going to build on the previous pilots; whole-person care, and the Home Help pilot at the very beginning. Hopefully, as we’ve talked about implementation science, the lessons learned as Chris said, we have many more populations to bring on, that things will improve. I do know that many of the health plans have posted lots of material on their websites about how to do community engagement and explaining CalAIM in CalAIM names, goals, and aspirations. There was material there. I appreciate your perspectives on the, on this very first question. I think it’d be fair to say that CalAIM really is a very bold partnership between the state of California, federal government, CMS, the communities of California, the counties of California, and really is an opportunity to invest in results and to really solve these very difficult issues, rather than just trying to manage them. With that I think we should move on to the second question which is what outcomes have you seen so far? And successes with challenges?
CHRIS ESGUERRA, Ph.D.: I’ll speak to one. We went live. We got started. That’s good. We also got started we were able to continue some of the work that was already occurring, and speaking to San Mateo in particular, and transition and from whole-person care to you know enhanced case management. For some of the specific community supports that we were already doing. And you know Health Plan Mateo has a history of doing community supports, housing, navigation, transitions from nursing, all these things for years. We just put it in our admin budget, now it’s actually just being recognized. And so that’s great. To be able then to actually continue that knowing that we can enhance it and really move it. Which is great. But if I look at some of the newer community supports, not much utilization just yet and that’s going to be the how do we continue to start to emphasize these pieces? But at the same time there’s still such this focus of theirs ‘that continuation, can we get TCM going?’ Now understanding that’s how it’s worked so far given the intensity of the work and partnerships that we had to do prior to getting started. Now, I understand too and Eleanor will definitely expand on this. There are some other counties where contracts haven’t been done yet or processes haven’t been figured out just yet. I think if anything, initially the thought was okay, well maybe we would be able to get things in order by the first quarter. It’s May now and I think there’s still a bit of a struggle and I think part of that means then what, what is the support needed or do we need to be thinking about to actually get this going in an equitable way throughout the state so that it’s not so dependent on which county can make it work versus other counties, where it struggles.
ELEANOR CASTILLO-SUMI, Ph.D. BCBA-D: I would definitely say, I agree Chris, I mean we went live for good or for bad, or worst, right? We now have conversations with different partners that we never had prior to Health Homes and prior to CalAIM. I think there’s a different level of appreciation for what this means for community-based organizations. But again, I just want to underscore Pacific Clinics is a large behavioral health organization that has the resources to be able to do this. It’s more risky for organizations that do not have that kind of resources and so we feel like it’s our responsibility as a large organization to also help be a partner in trying to figure this out for the system. We talked about an assessment for CBOs, but I think there also needs to be assessments for the counties, and the relationships within the county’s because that definitely trickles down. We are in multiple counties, and I can underscore our experiences and each county is very different. The county in which we started Health Home is far more advanced because of the previous relationship that we’ve had. But it’s, again not every organization and not every county has gone through that. I think going back to that assessment if you will and monitoring progress so, you know, just a process of implementation I think is a needed part in the system. I think we all have a very different perspective of how well the implementation has gone so far. But I would say from the CBOs perspective this health pay, this payment reform is a huge concern. Because there’s not a whole lot of conversation, or at least on the CBO’s perspective, about what this will mean and the implications to the CBOs who have been operating under a certain framework and payment structure for decades. This is right in front of us and again if we were to talk about implementation science, this program installation stage to really having an adequate program installation phase to really prepare and minimize the unintended consequences of this change is really critical.
CHRIS ESGUERRA, Ph.D.: Well, I mean Eleanor I’ll have a question for you, but I wanted to really underline the payment model change in that piece. One of the interesting things, you know, if I’m going to compare and contrast that North Carolina also did a huge transformation to its Medicaid program. Recognizing that we are just as a country, we are not going to be spending any extra money on social services compared to other developed nations. That’s just who we are here in the US but instead, we are going to invest healthcare dollars hopefully to more social services that will improve the health of people in the US. Great. One of the things though that did occur in North Carolina is there was quite a long stakeholder process and thoughtfulness on just even the payment models for the social services and development of the fee schedule. One of the resounding themes around that, the whole discussion was to be thinking about, if not value-based now, what is the path to something that’s value-based? Understanding that by using that term, that payment is really more about creativity and getting the outcomes. That was quite a process was so fortunate to be able to help and participate in that whole piece. I don’t recall seeing that necessarily as a discussion here and I know one of my concerns has been that we don’t necessarily repeat the challenges and unfortunate things that happened in primary care in the health plan world that we’ve done in just the fee-for-service model. Now, it’s great that with enhanced case management that’s you know, per member per month. But you know, some of the community supports are more of a fee-for-service in nature. I’ve definitely seen that in some interesting contracts where it’s like, whereas the guidance is much more of a value-based or a bundle or something like that, that it actually went more to a fee-for-service. But that’s still a change. And so I think Eleanor, I’m wondering what would be helpful as a go-forward to really support and be thinking about, well, in terms of a revenue perspective for CBOs, how to adapt to these different payment models?
ELEANOR CASTILLO-SUMI, Ph.D. BCBA-D: You know, basic things, it’s not so basic because if you don’t have the right technology to do this, then, it might sound easy, but just knowing your cost. Knowing your cost is not just your staffing costs; it’s all the associated supports, quality assurance, credentialing, to be successful in this in this business right or the way we’re changing to do business. Things like, again, just knowing your costs, do you have the right technology to even, the organization and cultural change that needs to happen. Being cognizant of utilization and understanding what utilization means. Being able to stratify your population. I mean, just understanding that within your organization, it’s huge. I think again, technical assistance oftentimes CBOs are left out there. I mean there are tools, and you know, it’s on you to go figure it out. But having the coaching and the technical assistance to really look at that, I think would be important.
MARK REFOWITZ: Did either of you have any particular insights into working, for example with, you know, one of the priority populations working with the correctional settings to help ease the transition back of those future members of the health plans and potential members of the CalAIM you see on the initiative.
CHRIS ESGUERRA, Ph.D.: Ah, yeah. So, let’s talk about the transition from incarceration back to the community and that is, you know, for criminal justice involved individuals as a population of focus. I think the thing to remember or recognize when we’re talking about supporting that population, especially in that transition period, it’s not just the plans and the CBOs. One of the key pieces that we all have to remember is that in California if you’re incarcerated you go to jail, you lose Medi-Cal automatically bottom line. And that when you’re released and when you’re, when someone is released, you’re released at midnight the day you’re supposed to be released, when everything’s closed, you don’t have Medi-Cal and you’re left to essentially try to figure out how to do that and how does one get back on Medi-Cal. It’s not necessarily through the health plans. It’s not necessary through the CBOs, it’s through the county human services agencies or, the equivalent, to do that. That’s another partner that needs to be involved. How do we start thinking about that process that kind of in-reach? So that we are prepared because again, from just that the criminal justice system perspective, they’re not going to and you know, there’s a rights component. They’re not going to hold that person to the morning when business hours are available, they’re going to release them at midnight. So, there’s all these implications. Way back when I used to be a covering psychiatrist at the local county jail. I mean, we had issues of “What pharmacy is open at midnight?” for our folks that are being released that need to be having medication. So, we would give a supply, but what’s an appropriate supply? These are going to be, the challenge is to think through, even before you start thinking about what the services are.
MARK REFOWITZ: Chris, I raised that question just because it was a specific example, I know that many of the listeners want to know what’s worked well, and not worked well with engagement and outreach etcetera. But it’s time for us, I think we should transition to the next question, and I think that this will give you and Eleanor a wide swath to enter into here. If you had a magic wand and three wishes, and it’s hard to limit sometimes to just three wishes, what would they be for your program?
CHRIS ESGUERRA, Ph.D.: I think we’re both resounding yes, on the attention to the need for implementation pathways, of which, you know, implementation science, it’s there, I mean we can all google it and figure out all the steps and lay it out. That’s a whole webinar in and of itself. However, I think making sure that there’s time and therefore stakeholder discussions to actually do that because we have a lot of other populations of focus to go live so that’s one. I think the other piece is a technical assistance arm. Eleanor, I’m not, I mean I’m not fully aware of any statewide version of that necessarily but I think that would be very, very helpful on really helping the CBOs. Also helping the plans on some of the operational pieces as I’m sure the CBOs can definitely give that feedback to say, where, where is it that we’re not doing so well and what is it that we need to improve. So, I’ll definitely start there.
ELEANOR CASTILLO-SUMI, Ph.D. BCBA-D: No, I completely agree Chris just being mindful of implementation, science, and implementation drivers and really applying that in the implementation of future population or for organizations who have not yet started with CalAIM but are considering it. I think you know that is really important and then when we say technical assistance it’s more than just training so this is not a here’s a webinar on this, go forth, good luck, we hope and pray you do well. But technical assistance on getting into the baseline measure of where we are and where we need to be. We being an organization, we being the system, the partnership within the county and the partnership with the state and what is it that we need to be able to be successful. This cannot be left to just CBOs or other organizations to figure this out because it’s, it’s a lot and for organizations, they’re still doing business as usual. So, to learn to have the resources again that can focus on just transition is again another layer of resources, another layer of skill sets that’s needed to help an organization transform. I definitely agree with the technical assistance and perhaps even using some of the incentive payment plan monies to help organizations along this way it would be a good use. I mean it’s interesting to put together a plan and apply. Quite honestly my organization has been doing this for the last two years, we’ve got and we’ve had in the EHR since 2000, so that’s not new for us. But it’s still figuring out, I mean, you have CBOs trying to figure out what technology, what does the data infrastructure need to look like, because I mean, for us, again, we went through this. So, we have a picture of that, but for an organization that has never done this, they don’t know what to ask for on that IBP application. So again, you know, technical systems on multiple fronts and multiple levels is really important.
MARK REFOWITZ: Again, this is your magic wand. I’m surprised that no one jumped in and basically talked about the problem with affordable housing in California. If you think back to Malcolm Gladwell published the article about billion-dollar Murray back in 2006 about Murray, who lived in Nevada housing was a significant issue and it was also a focus for, you know, people in the whole-person care. So, it’s kind of interesting that nobody used the/took a wish you know, I wanted to talk a little bit about affordable housing.
CHRIS ESGUERRA, Ph.D.: Well, that’s because I think we all know how complicated that issue is. And it’s not just something in health care, it’s not just something that happens with CBOs. There’s a whole policy piece and I’m sure we can detract from that. One other actually sort of nice to have wish that would be really cool to see, curious on your thoughts on this Eleanor too, is a forum wherein plans and the CBOs interact to really start addressing what will be the common things of what do we do when. So Christopher Zubiate pointed out like you know what out of county placements when someone loses their Medi-Cal for whatever reason, what do we do when and frankly that applies statewide and that becomes operational pieces so you know, instead of us saying like ‘yay we went live’ but then there are all these other pieces from a process perspective that just will happen. Now from the planned perspective, yeah, we deal with that pretty regularly. But from the CBO perspective, you’ll see it as a disjointed effort around case management, or all of a sudden you’re not getting paid but yet you’re actually still working with that client or something to that effect. So how is it that we surface these things, and essentially create that kind of partnership and working together as a forum, but with this as an initial focus, I’m sure some other things productive can come out of that.
ELEANOR CASTILLO-SUMI, Ph.D. BCBA-D: Yes, I mean, again, from the CBO perspective, we’ve been asking where can we give feedback? Because we certainly participate in many different webinars, you know, many different forms to receive information, but the ability to give feedback and not just give feedback, but really see that the feedback is taken into consideration. I haven’t found, and there might be a forum out there for that, but I haven’t found such a forum, and we are on as many stakeholder mailing lists as possible.
MARK REFOWITZ: So, from both of your perspectives, what are the kinds of things that, again might be needed to, so when each and every potential member of that, and they start, member choice is still very important. What can be done that when people are contacting them and trying to engage them either at FQHC or another community-based organization or out on the streets, that somehow, they feel that you’re their angel and you’re giving them some hope – hope and aspiration that, you know, things will improve for them.
ELEANOR CASTILLO-SUMI, Ph.D. BCBA-D: I’m sorry, Mark, were you asking from the member’s perspective?
MARK REFOWITZ: The member’s perspective, how do we give them hope, but that, you know, their hopes and aspirations will be reachable.
ELEANOR CASTILLO-SUMI, Ph.D. BCBA-D From the provider standpoint, you know, we have service principles that guide us around there, and one of them is to do whatever it takes. And CBOs will do whatever it takes, no matter how difficult it is, they will try to figure it out. They will go down whatever path they need to know of use whatever resources they have with other sister organizations to figure things out. But I think inspiring hope is number one, and we hire staff that agree to, or share the same service principles.
CHRIS ESGUERRA, Ph.D.: Yep, totally agree. And I think where from a structural perspective, the plans come in and how we support that, two major areas. One, the way in which we pay supports that kind of creativity. We know that engagement for just engaging clients/members, in general, is a tough process. And that you have to be creative, it’s not going to be just phone calls like ad nauseum, right? You’re going to have to find ways to get through in the community. And it’s not going to be just one meeting, it’s going to be multiple discussions over time, because frankly, even if I took that that perspective of the member, it’s really ‘who are you stranger and why are you talking to me?’ So, it is an imposition and how is it that you build that trust over time in order then to see that you know to work towards change. That’s the motivational interviewing framework, that’s an engagement framework altogether. The other aspect is really as plans is then how is it that we are able to share the data that we have knowing at least the healthcare identifiable signals and behaviors that we have in our systems whether it’s you know information that oh they did, they were able to see their primary care, their primary care is this person or their pharmacy is this and they’ve actually last filled medications at this time or they were last seen in an emergency room here, or whatever other information that we have that are then able to support that so that the CBO is not necessarily going in blind. Because we have that information and so how do we make sure that is going through what are the other technologies that we may have as a plan that we can share? So, for example you know we have the notifications from you know when someone pops up in an emergency room, we have that as sort of real-time notifications. How do we share that again with the CBOs and again it’s thinking about it from that perspective to really then empower our partners to be successful but also knowing that success isn’t going to be, you know, you talk to that member once and all of a sudden it’s going to happen now. We know that we know that success takes time and that could be as many it could be multiple conversations, multiple engagements, especially for more challenging populations.
ELEANOR CASTILLO-SUMI, Ph.D. BCBA-D: It would be great to be finance for creativity. You mean, we have a drop-in center, that’s really based on motivational interviewing and recovery supports principles. And the idea there is it’s this open center for TA youth, transitional age youth, they can drop in, they have resources there, they can use that opportunity to start building relationships. But, you know what, we don’t get paid for that, we don’t get paid. Health plans don’t pay us to create an environment where people feel welcome, and they can build trust. When they build trust and when they start to, you know, pre-contemplate/contemplate and then get ready to take action, they know we’re there. So, that’s what we’re investing in, is here, come into this open space, build a relationship. Meanwhile, you know, there’s some washer and dryers here if you want to clean your clothes. There’s some showers here. We have a small kitchen where you can cook a little bit of something, throw something the microwave and do some employment search while you’re waiting for your dryers. You know you’re close to get dried and your meal to be done in the microwave.
MARK REFOWITZ: I’m being very mindful of the time, this seems to be a good stopping point. I just want to do a very, very short recap of what I heard what I’ve heard and then turn it back over to Scott because we’re going to try to get to some of the questions. This is a bold initiative. It was in Chris’s words, it was a little rough and rushed at the beginning. I like to say it’s somewhat like building the airplane while you’re flying it. And we need to learn as we go. I mean that was that was really clear from both of you and from both of you also take this as an opportunity to build a learning community and work with all the communities within under the purview or in the service area of a health plan. And so with that quick recap I’m going to turn it back over to Scott.
SCOTT MARTIN: Mark, thank you very much. So, we have a number of questions that popped up over the course of the discussions. Some of them are things that we’ve touched on. But I want to actually take the question and forward it back to you to kind of hit on the specifics. So, number one what is working in terms of outreach and getting individuals from the W. P. C. Pilot engaged with the service providers. And there’s a part two. What is resonating with the clients that are, and are the strategies varying community by community?
CHRIS ESGUERRA, Ph.D.: Eleanor, I’ll let you take this one to start.
ELEANOR CASTILLO-SUMI, Ph.D. BCBA-D: Yes. So, what is working in terms of outreach and getting individuals? You know Mark, I mean you brought up the in the point of hope and I think that’s a really critical thing and you know when you get that first contact with people whether it’s by phone or going to their homes or you know meeting them somewhere where they feel safe in the community. Inspiring hope with that first visit is really critical. And that is you know that’s something that’s universal between communities or across counties/across communities. But there are different strategies. And I would say with a different, even with different age groups, the different strategies there. So, it’s not just with ethnic groups, but age, rural versus suburban. But working with people who really understand those communities and having them as part of our team is really important. Again, that’s a selection piece when you think about an implementation driver and have the competency that you need. The selection of your staff is pretty critical.
CHRIS ESGUERRA, Ph.D.: And where the plans really help is, as we are assigning those members to the CBOs for enhanced case management services. We have the analytics tools to be able to say hey here are the characteristics of those members that we’re sending over to you. To help you plan for this to be able to think about your staffing patterns. We have that data from a demographic perspective from the utilization of services or lack of perspective and I think then, or even internally, where have we tried to reach out from a case management perspective? Have we been successful? Have we not been successful? What has worked before? And so those are things that we readily can provide to varying degrees and I think that’s the key of how then do we think about that? Standardizing it from a statewide perspective because from a planning perspective this is our population health management effort and how we think about our membership overall and that we’re already working to stratify our population in some way or another, and we have that information. So that’s where we can become partners to then help and really fuel that creativity by way of the data.
ELEANOR CASTILLO-SUMI, Ph.D. BCBA-D: And that is that would be amazing again from the CBO perspective. We would love to have that data and from the CBO perspective we know our experience has been in the last two years that we can convert from 25% to 40% of members. And actually, there’s some differences between health plans with our experience. For us and then about 25% of the data, the information that we get, you know wrong numbers, numbers that don’t work, that’s about 25, that’s pretty consistent, about 25% of our data. We know that we have to work hard to getting the right information, but for us we’re more interested in the not only who converts but who doesn’t and why? And is there a certain profile, because then we can strategize more specifically to reach out to those people and we hope that we can get there at some point and that’s part of again the data infrastructure that providers need to develop.
CHRIS ESGUERRA, Ph.D.: Yeah. I recall, I was with a different plan when we implemented the help homes program, and the state the HCS was targeting an initial engagement of a pretty high rate. It was in the double digits definitely. When you looked at other states that had implemented health homes, the first-year engagement rate was pretty much if not one percent then low single digits and the reality is because this was just new and people had to be creative and then people had to then figure out the data component, what was needed. Now, what was interesting in part of the rolling out was the financial model that we decided to take that kind of gets to Eleanor’s point of financing the creativity. So typically, you know, the payment model for r Health Homes was once you have someone enrolled you get paid. We actually chose a different route of saying, okay sure, we’ll pay that. We’ll take some of that though, and actually for the entire list that we’re going to give you, we’re going to give you what essentially is called the engagement fee. Because we know you’re going to do a lot of work for free and so we’re going to need to fund that. And that that actually got people to be much more creative, but it’s again being mindful of the payment model itself and what exactly is being paid versus what isn’t. I think it’s helpful however, from the planned perspective, we won’t necessarily know that unless we get feedback and it gets back to what Eleanor is saying is let’s you know, how do we build that feedback mechanism so, and to have those discussions to be able to acknowledge the work.
SCOTT MARTIN: Okay, we have time, I think for a couple more questions, so I’m gonna throw one more out there and see how we’re doing for time. And Eleanor, this one looks like it’s going towards you. So, given that Pacific Clinics is in multiple counties, are you finding that the implementation experience differs from one county to the next?
ELEANOR CASTILLO-SUMI, Ph.D. BCBA-D: Absolutely. I mean, again, because the relationship between health plans and counties vary, across the state. And there are counties that did the whole person care did H. H. P. And so those counties tend to be a little bit more advanced, if you will, with implementation. And there are counties that didn’t, and are still trying to figure this out and the providers are, you know, are at the end of the county is trying to figure this out. And when I say, the county’s, its relationship between the health plan and a county.
SCOTT MARTIN: Okay, awesome. I’m going to ask another question based on populations of interest, how should the implementation be thought of for future rollouts? And there’s an example here, what should it look like for the incarcerated population who are returning to the community? And I know we touched on this, but I’d like to get some specific thoughts here.
CHRIS ESGUERRA, Ph.D.: So I think part of it really is, there’s pre-work that has will be done. You can’t just say, all right, we’re going to go live, and magically we’re live. And part of the pre-work is understanding these populations of focus. You heard me on my little rant of like here are the things we need to pay attention to for those who are criminal justice involved. But that’s the same thing for every other population of focus. You know, when we’re talking about foster youth, same thing. There’s a whole different system of care or supports that we need to then be thinking about. So, I think that pre-work to then start thinking well, who else is involved? How do we get them involved? And how do we think about the design of this? Because as we think about all these pieces, very, very great goals to start really thinking about these populations that are very challenging. We need to understand though, that there is a system that already exists that in some way or another supports, somewhat support/may not support that population. And so how is it that we start engaging sooner rather than later because it might be something as basic as when I say case management, that might mean different things to staff in Eleanor’s clinics, versus when I say it to my teams, versus when I say it to probation, versus when I say it to housing coordinator. Right. So just even in the way we use terms and learning each other’s languages that I think is part of the pre-work.
ELEANOR CASTILLO-SUMI, Ph.D. BCBA-D: Absolutely. I mean, it goes back to implementation science. I mean, that’s program installation and having adequate time for that and having this forum where CBOs are a part of it, you know? I cannot underscore enough just that program installation phase that can take months.
SCOTT MARTIN: All right. Thank you, we’ll make this the last question, and just so you know, we will answer all the questions via email because it looks like we’re going to get close to time here. How are the CBOs managing payment slash invoicing back to the health plans? And what is the biggest challenge in this process?
ELEANOR CASTILLO-SUMI, Ph.D. BCBA-D: I guess that that’s for me. We, again as an organization that primarily had contracts with the counties, with county health plans. We built our infrastructure for payments around doing that business. This is a different skill set to build. Health plans is a different skill set. It’s a different process, and we tried, building this on the backs of our staff that built the counties, the counties for the services. And we learned this is where again, organizations need to be willing to try something fail fast and change. But we quickly learned that we couldn’t do this. This was something we couldn’t build. This is something where we needed to partner with organizations. A third-party biller, and not just, you know, have a third-party billing, but really interview that third-party biller to see if they would be partners with us. If they would be a right partner with us, and you know, coming with the payment structure for their services and while there are lots of building organizations out there, it’s finding the right one. And so we do it. We have a 3rd party biller.
SCOTT MARTIN: Perfect. Thank you. So, we are just about at time. I want to thank everyone who attended the webinar. We are very grateful for the time you’ve taken to spend with us this afternoon or this morning, depending on where you’re located. As you can see the bullet points up here any of the questions that you submitted and there’s still a number that we didn’t have a chance to get to just on the basis of time. We will respond to all of those questions. On behalf of Info M.C. and from Catalyst Solutions if there are any questions feel free to visit our websites. And if you have any specific questions for either Chris or Eleanor, we have provided their email contact information. Feel free to send them a note with that said I am going to wrap up the webinar so everyone, thank you so much for your time. Have a wonderful day. Thank you