In Minnesota, a 2010 state law authorized the Department of Human Services to develop a Medicaid demonstration project to test alternative and innovative health care delivery systems, including Accountable Care Organizations. That year a state law also authorized Hennepin County to establish a pilot program to provide a health delivery network for adults without children whose incomes were at or below 75 percent of the federal poverty level. In 2011, a new state law, the Medical Assistance Reform Waiver Act, included the expansion of Medicaid eligibility for persons with incomes up to 75 percent of poverty and authorized the Department of Human Services to pursue waivers or changes in the state's Medicaid plan to reform the state's Medical Assistance program to achieve a variety of goals related to improving health outcomes and controlling costs.
In late 2011, the Department of Human Services began negotiations with Hennepin County to create a pilot ACO program for adults without children.
On January 1, 2012, the Department of Human Services contracted with Hennepin County to establish Hennepin Health, an integrated delivery network for adults without children with incomes up to 75 percent of poverty. Hennepin Health includes the county's public hospital, Hennepin County Medical Center, which provides inpatient, specialty, and outpatient clinic services, and the Northpoint Health and Wellness Center (outpatient clinic), as well as the county's Human Services and Public Health Department and Metropolitan Health Plan.
The vision of Hennepin Health includes a strong focus on integrating health, behavioral health, and social services to address social determinants of health, expecting to achieve savings by reducing avoidable hospitalizations and emergency department services and preventing duplication of care. This is how the county described the premise for Hennepin Health in its proposal submitted to the state in October 2011:
Treating a safety net patient's medical problems without addressing underlying social, behavioral, and human services barriers and needs produces costly, unsatisfactory results--both for the patient and the programs providing and paying for care. Conversely, addressing all of these issues and incorporating them into a coordinated patient and family-centered, comprehensive care plan should end the cycle of costly crisis care.88
Consistent with this premise, the Hennepin Health approach has been guided by an understanding that unmet social needs, including homelessness and hunger, have a significant impact on health status and the use and cost of health services for its members.
"We needed to build a system that first and foremost looks at the social determinants of health. What is wrong with my patient that I can't fix in this room but somebody else could?"
Mark Linzer, M.D., Director of General Internal Medicine at HCMC (Lowden 2012)
As Hennepin Health leaders describe their experience during the first year of implementation, they were "inventing as we go" and there was "no roadmap" for care coordination and for understanding and managing the total cost of care for these members across settings and providers. During the first year, they found that it was a bit of a challenge to "demand something different" for Hennepin Health members from the county hospital, clinics, and other programs, because the Hennepin Health members are only a subset of the low-income people served in these settings. Even at the county's Coordinated Care Clinic, which serves people with complex needs including many people experiencing homelessness, only about 30 percent of patients are Hennepin Health members.
The goals of Hennepin Health include increasing the level of engagement by the health care delivery system with patients and enrolled members, and facilitating stronger connections among health care and social services programs.
County-funded programs that serve low-income people are expected to be partners in delivering some of the services needed by Hennepin Health members. Hennepin County's planning efforts and work groups formed to support implementation of Hennepin Health have included representatives of county-funded programs serving people experiencing homelessness.
When Hennepin Health was first launched, some staff members and clinicians saw it as a standalone pilot or special population program rather than a strategy for transforming the way care is delivered for everyone who relies on the county's health care and social services systems. In the process of launching Hennepin Health and managing change within the health care system, it has been important to strike a balance between using the resources of Hennepin Health to make improvements for Hennepin Health members and pursuing opportunities to better coordinate and improve care for all of the low-income people who seek care from Hennepin County. One strategy for mitigating this challenge has been an ongoing effort by Hennepin Health leaders to identify improvements that can be made without additional funding, and to extend the learning and systems improvements of Hennepin Health to serve other people when possible.
7.3.1. Care Coordination and Housing Stabilization
Plans for Hennepin Health included an ambitious "tiering system" for matching people to the most appropriate types of clinical care at different levels, based on the complexity of their health and social needs. The program is designed to provide more-intensive services for members with high levels of need, including those with multiple emergency room visits for medical or mental health conditions or chemical dependency issues. Some staff members in public agencies, the county hospital, and clinics were assigned to new roles.
Community health workers were hired or reassigned to deliver enhanced services to Hennepin Health members, including conducting outreach, helping patients follow through on treatment recommendations, helping them make changes to harmful or risky behaviors, providing the personal attention and coaching to encourage members to stop smoking or achieve and maintain sobriety, and identifying patients with unmet needs for housing or other social supports and services. Hennepin County has provided extensive training to help workers acquire new skills, gain familiarity with resources available across health care and social services systems, and move into new roles that include increasing engagement with members outside of clinic settings.
During the first year of implementation, Hennepin Health launched several program initiatives to improve and better coordinate care for the most vulnerable and costly members, while achieving savings. Some examples are described below:
The program identified a large number of emergency room visits associated with dental pain and made arrangements for same-day dental care for patients who could be diverted from the hospital emergency department, where they could only get pain medications, to get them the right care to meet their needs.
The program determined that homeless patients often lacked transportation to visit a pharmacy to get prescribed medications, so it implemented a system for delivering medications to shelters, reducing the need to provide transportation vouchers and increasing timely prescription refills and medication compliance.
The program recognized the consequences of fragmentation across health care and behavioral health services, and worked on strategies to co-locate care, embedding behavioral health clinicians in primary care clinics and developing primary care services that can be delivered in behavioral health clinics. The program has worked to create a process for "warm handoffs" and more seamless transitions among programs.
Housing navigators play an important role in serving Hennepin Health members whose homelessness or residential instability has a significant impact on health-related vulnerabilities and service use. The housing navigators are employed by the county's Human Services and Public Health Department. They play a broker role--they do not work directly with clients but instead work with the social workers and community health workers who are part of the teams based in clinics or the county hospital. Clinical teams and the housing navigators use the Hennepin Health "tiering system" to target assistance to the most vulnerable patients who are homeless or unable to return to a safe and stable living situation and at (or close to) tier 3, meaning the person has had multiple emergency department visits or detox stays, or two or more hospital admissions for medical conditions, mental health, or substance use disorders in the past year, or acute medical needs. The goal is to focus on those whose lack of housing is contributing to escalating medical costs, prioritizing housing for those for whom it is likely to have the greatest impact not only on quality of life but also on cost reductions, providing a return on investment that can help make the case for funding the necessary supports.
About 75 percent of the people referred to the housing navigators are currently unsheltered or staying in homeless shelters, and many have been experiencing long-term homelessness. Through the referral process, the housing navigators, community health workers, social workers, and clinical team members are developing a shared understanding about how to identify and describe housing status and needs, including the definition of homelessness and eligibility criteria for housing programs, as well as what housing options are available to offer patients. Housing options include both emergency or short-term options as well as permanent supportive housing. Housing navigators know about all of the housing options in the county, and they know which programs use a housing-first approach and which have rules about sobriety.
The community health workers and social workers who make referrals gather information about patients and then work with the housing navigators to identify options that offer the best fit for each individual in terms of eligibility, needs, and preferences. The housing navigators track information about housing program characteristics, including application procedures and vacancies, and then offer up to three options for the community health workers or social workers to discuss with their clients. The community health workers or social workers are responsible for helping clients follow through to complete applications and get into housing. If the client is rejected by a suggested housing provider, the housing navigators keep trying to find other options. The housing navigators also provide information that community health workers can use to follow up on their own to assist other patients who have lower levels of need.
Hennepin Health community health workers, social workers, and housing navigators have helped to achieve significant improvements in the well-being of members who were experiencing chronic homelessness, and they can point to success stories like the person with diabetes who was able to manage meals and diet after getting into housing, reducing the need for hospital care. Another Hennepin Health member who was experiencing homelessness frequently visited the emergency room for pain management, but had been unable to get needed surgery without a home in which to recover. With help to get housing, the person was able to have surgery and recover at home, reducing costs for avoidable emergency room visits and providing a significant improvement in quality of life.
For people experiencing homelessness who are hard to engage, the county's Health Care for the Homeless program and a nonprofit partner, St. Stephens Human Services, do street outreach and collaborate with Hennepin Health housing navigators. Hennepin Health also has a social services navigator who is out in the field and can help to locate vulnerable Hennepin Health members. This person coordinates with Health Care for the Homeless and local shelters to find people when they come in for service, to let them know they need to follow up on a housing option the housing navigators have found for them.
During the time frame for this study, Hennepin Health had not been able to allocate new resources directly for PSH. But by providing supports and working to coordinate care for its members, Hennepin Health helps to supplement the services in PSH and to help some very vulnerable people who were experiencing homelessness to succeed in housing. In addition, the county already provides funding and administers state and federal funding for a wide range of housing and residential programs. Housing providers that receive funding through the county are encouraged to give priority to people who are referred by Hennepin Health housing navigators, and the county is trying to find ways to create incentives for housing providers to prioritize members when there are openings. For example, when the county issued a request for proposals for new housing development, the project selection criteria awarded extra points for providers that agreed to prioritize housing applicants referred by Hennepin Health.
Some housing providers are calling the housing navigators when they have vacancies. Although Hennepin Health does not fund PSH services, the housing providers recognize that Hennepin Health members come with a connection to health care and other services, and these connections and supports can help a homeless person be a more successful tenant. The county also has some leverage to advocate for changes in the tenant selection criteria used by housing providers who receive funding through the county. The process of using the housing navigators to facilitate housing placements for Hennepin Health members has provided an opportunity to focus on some housing providers who have been highly selective, sometimes offering housing only to people already participating in their programs and screening out many people experiencing homelessness. When these barriers are identified, the program manager for the county's Housing and Homelessness Initiatives can advocate for changes to improve access to housing for those with the greatest needs and barriers.
During the first year of Hennepin Health implementation, the housing navigators expected to facilitate about 100 housing placements. Already they have been seeing some good outcomes in terms of reducing use of the most costly inpatient and crisis health services and improving health outcomes. The housing navigators reported that they sometimes hear from social workers who say that the clinical teams are recognizing the health impacts of housing solutions.
7.3.2. How the Finances Work
Hennepin Health receives Medicaid funding on a capitated basis, meaning a fixed payment per-member per-month for the total cost of care including all Medicaid-covered health services with the exception of long-term care. Social services are funded through other existing sources and are not included in the capitation rate.
Hennepin County had hoped to receive a risk-adjusted capitated rate for a package of covered health, mental health, and chemical dependency services. "We already have the highest risk patients," say county staff, who had hoped the rate would reflect this high level of risk and need. The rates negotiated with the state were not risk-adjusted, but instead were the same as the rates the state negotiated with insurance companies to cover newly eligible people. They included only four rate cells with different rates based on gender and age (21-40 and 41-64). Rates may be renegotiated in future years.
Hennepin County's health plan, the Metropolitan Health Plan, provides administrative services for Hennepin Health, including payments to providers at contracted rates for covered services. The County is tracking revenues and claims data, as well as other data in electronic health records, to evaluate the total cost and quality of care. A shared savings pool is funded from savings that result from a more efficient care model that reduces expensive and avoidable hospital admissions, re-admissions, and health complications.
At the end of its first year, Hennepin Health leaders reported that they had achieved savings "all over the place," including a 29 percent reduction in inpatient hospitalizations and a 24 percent reduction in emergency department visits, and they had adopted a re-investment strategy for 2013. The goal of this strategy was to further reduce costs by continuing to reduce inpatient and emergency department utilization while increasing primary care engagement and improving health outcomes. Priorities for reinvestment in 2013 included funding start-up costs and motivational interviewing training for a new 30-bed sobering center to divert chronic inebriates from the emergency room; developing interim housing units through a partnership with the Minneapolis Housing Authority to provide placement alternatives with wraparound services for persons "stuck" at Hennepin County Medical Center or other institutional facilities at county cost; expanding the capacity of the Coordinated Care Clinic; and creating a new program of community support and linkage for the most frequent users of hospital emergency room care.
7.3.3. Information Technology and Data Sharing
Hennepin Health was launched with ambitious plans to create for all enrollees "a single, comprehensive electronic record that is inclusive of many facets of their treatment, tells their story, tracks their goals, includes the care plan and outcomes data, and evaluates their responses to interventions across a continuum of care."89 The county uses the Epic electronic health record for most of the care system and is working to enhance that system to provide the capacity to link primary care, specialty care, behavioral health care, and social services into one seamless system that can provide real-time data for clinical teams to support the delivery and coordination of care.
The Hennepin Health partners have worked to allow Metropolitan Health Plan to have direct access to the patient's electronic health record for inputting critical health plan information into the chart for provider action, including data about member calls, hospital alerts, and referrals. This shared information helps to support care planning. It also reduces duplication of assessments, referrals, and some interventions, and provides real-time alerts to primary care providers about hospitalizations. Hennepin Health also provided access to the county health care system's patient record system (with client consent) to allow community behavioral health care providers to have more timely information to support hospital discharges and prevent re-admissions.
An analysis of pharmacy data allowed Hennepin Health to identify the highest users of the plan's pharmacy benefit, including some members who were seeing and getting prescriptions from more than ten providers and filling prescriptions with seven or more pharmacies.90 Through outreach to these members and other interventions, Hennepin Health helped to facilitate connections to health care homes, reducing medications costs significantly as well as reducing health risks associated with medication side effects and complications.
For busy health care professionals, more data from multiple providers and systems can be a mixed blessing, and providers have limited time to review other records to find the information they need to make good decisions about care. Hennepin Health created provider dashboards to make it easier for providers to find critical data.
Progress toward data sharing across systems of care has been challenging. Hennepin Health has encountered some barriers in provisions of state law that govern the privacy of health care and social services, but do not include provisions for information sharing across systems to facilitate collaborative care. Hennepin County has advocated for the state to enact legislation to allow providers working within an accountable care system to share data among partners, specifically to share data across health care and welfare entities. Hennepin Health would like to obtain consent for systematic data sharing as part of the process of enrolling members in these public programs.
While the implementation of Hennepin Health has been challenging, there were very significant accomplishments in improving and coordinating care for its members during its first year. Housing navigators have worked to facilitate access to housing for the most vulnerable homeless members, and the services provided by Hennepin Health have promoted housing stability and recovery for some PSH tenants. This has not yet translated into a way to finance the services that are part of PSH, which are still funded by a variety of federal, state, and county programs. Hennepin Health is not paying for PSH at this time, but can provide or facilitate linkages to some additional services such as nursing or home health workers to enhance the capacity of supportive housing providers to house Hennepin Health members who have more significant health needs. Hennepin Health leaders expressed an interest in using Medicaid financing to cover services within PSH for medically fragile persons experiencing homelessness. They anticipate that the return on this investment would be reductions in other health care costs, but they are uncertain about what types of PSH services could be covered using capitated Medicaid funding.
As noted in an earlier chapter, one of the biggest challenges facing Hennepin Health during its first two years was the significant monthly turnover in enrollees, as an average of 15 percent of its members became disenrolled each month primarily because they failed to complete recertification paperwork. For many of Hennepin Health's members, who had been uninsured and living with incomes significantly below poverty before the expansion of Medicaid eligibility, staying enrolled in a health plan had not been either possible or a priority. Maintaining enrollment in Hennepin Health was particularly challenging for members with incomes far below the federal poverty level who were experiencing homelessness and ongoing crises. Recertification notices failed to reach as many as half of Hennepin Health's members because they lacked a stable address at which to receive mail. As a result, members did not know they were no longer enrolled until they sought care and discovered that there was a lag time for processing applications to renew or restore coverage.
Hennepin Health does not receive monthly capitation payments for the months during which a member is not enrolled. The problems Hennepin Health experienced with churning enrollment not only jeopardize the financial viability of an ACO model because the gaps in coverage reduce payments to the plan, but they also make it difficult for the plan to deliver continuity of care and to achieve and track outcomes for its members. Hennepin Health leaders were hopeful that some of these problems could be reduced when Affordable Care Act provisions for streamlined and automated Medicaid eligibility determinations and redeterminations are fully implemented starting in 2014.