Medicaid and Permanent Supportive Housing for Chronically Homeless Individuals: Emerging Practices From the Field. 7.4. Together4Health


T4H is an example of an Accountable Care Organization-like entity under development. It is an innovative care coordination model made possible by the Illinois Medicaid program's response to a requirement imposed by the Illinois state legislature to "move at least half of recipients eligible for comprehensive medical benefits…to a risk-based care coordination program by January 1, 2015."91 Having started in 2010 with a pilot program involving traditional Health Maintenance Organizations in the ring counties around Chicago, by the end of 2011 the state wanted to see what other structures might work to achieve the same ends.

In early 2012, the state issued a "Solicitation for Care Coordination Entities and Managed Care Community Networks for Seniors and Adults with Disabilities (Innovations Project/2013-24-002)." Participating state agencies included the Department of Healthcare and Family Services (which administers the state's Medicaid program); the Office of the Governor; the Department of Human Services, Divisions of Mental Health, Rehabilitation Services, and Developmental Disabilities; the Department on Aging; and the Department of Public Health. The solicitation's introduction states its purpose:

…to allow Providers to design and offer care coordination models other than traditional Health Maintenance Organizations (HMOs). The Department invites innovative Proposals to demonstrate that Providers can provide equal or better care coordination services, produce equal or better health outcomes and render equal or better savings than traditional HMOs (p. 1).

Although this Solicitation specifies minimum requirements for the composition of a collaboration, Bidders should understand that the State is looking for the most comprehensive models that take a holistic approach to individuals served and attempts to coordinate services for all of their needs. The State encourages models that attempt to coordinate social services beyond those covered by the Medicaid program (p.1).

In response to this solicitation, Heartland Health Outreach, a component of Heartland Alliance, took the lead in assembling potential partners and setting forth a vision of how the partners could collaborate to create a Care Coordination Entity that served the people the partners were already serving--seniors and persons with disabilities with the most complex and interacting needs, including those who had chronic patterns of homelessness. The selection of T4H and four other Care Coordination Entities was announced in mid-September 2012.

7.4.1. Governance Structure During Development and After Award

The 37 organizations involved in developing the T4H proposal came from all parts of Chicago and included Erie Family Health Center, AIDS Foundation of Chicago, Thresholds, Cook County Health and Hospital Systems, Northwestern Memorial Hospital, Lutheran Social Services, the Alliance of Chicago Community Health Services, Mercy Housing Lakefront, Heartland Human Care Services, and many more.

In addition to hospitals and hospital systems, Federally Qualified Health Centers, mental health, substance use, social service, and housing providers, advocacy organizations, and a pharmacy chain, the collaboration also included entities that provide training and technical assistance, data analytics, clinical decision support, and management of T4H's potential data warehouse.

Work groups for the proposal had substantive focuses, including Care Coordination, Finances, Information Technology, and a Leadership Advisory Board. Also meeting during proposal development were constituency groups based on provider type, including groups for hospitals, Health Centers, behavioral health, and social services.

Together4Health LLC

Staff of Heartland Health Outreach, along with potential partners, developed the structure by which the organization would be governed once the T4H proposal was accepted. This is a for-profit limited liability company through which each partner would own a share of the company and have the right to participate in guiding the company's development and direction. By mid-December 2012, 34 partner agencies had signed the operating agreement and paid their ownership share.

T4H LLC has a governing Board of Managers elected from among the members. Six Board committees oversee various aspects of the agency's operations--Executive; Finance; Care Coordination and Quality; Network Development and Provider Relations; Risk Policy; and Planning, Policy, and Evaluation. Working groups include Information Technology and Health Information, Marketing, Care Coordination Policy and Advocacy, Chicago Health and Social Innovation Research Group, and the Contract Negotiation Team. Constituency groups include hospitals, primary care providers, community behavioral health providers, social services providers, other member organizations (not direct services), and businesses. There are also plans to form a Consumer Advisory Board. T4H is run on a day-to-day basis by its management company, Heartland Health Outreach, which staffs the committees, working groups, and constituency groups and performs the many functions associated with each aspect of operations.

In addition to participating in the ownership structure, each partner agency has a service contract with T4H LLC. As of this study's final site visit, the Heartland Health Outreach team was developing the template for these contracts. Partner contracts will cover such things as commitments to the following:

  • Contribute patient data to the T4H database.

  • Serve a certain number of T4H clients, using funding from existing contracts or other reimbursement mechanisms, at least initially.

  • Make changes in their own organization so they can:

    • access the T4H data system;
    • work collaboratively with other T4H members in their local hub; and
    • have their service staff work with the T4H Care Coordination teams to move toward integrated care.

7.4.2. Care Coordination

T4H's care coordination structure is designed to assure that consumer needs are known and their interactions appreciated, a comprehensive plan is developed, needed services are delivered, outcomes are monitored and plans adjusted as needed, and unnecessary care in crisis or emergency settings is minimized. The structure directly provides, and the Illinois Medicaid program is expected to pay for, the care coordination that we so often found was not covered in the service structures described in earlier chapters.

Care will be coordinated through a central team and also in care coordination teams located in three hubs in different parts of the city to which nearby T4H member agencies will be attached. The team at each hub will have a nurse, a mental health expert, and community health workers. Care coordination staff will be employees of T4H LLC and will coordinate with case managers and similar staff in each agency from which a member needs service.

Links to housing and supportive services to help people maintain housing are built into the care coordination function. The graphic below depicts the central team (large gray circle at upper right) and a detailed schematic of one hub.

T4H staff, which includes team members from all the hubs, does intake, population management, data analysis to monitor care delivery and outcomes, and general oversight.

The hub-based care coordination teams will work with consumers, develop individual care plans, establish a coordination team for each consumer that links care delivery staff of each member organization involved in the consumer's care, and work to assure that the plan is carried out or modified as needed. The hub teams in their role as members of the central care coordination team also have the responsibility for making the overall system work, by identifying gaps and bottlenecks and bringing them to the attention of the Health Hubs and Care Coordination and Quality Committee for resolution. For individual care coordination, the Hub teams will connect to the clinicians, case managers, and other service providers in partner agencies, who are likely to remain somewhat siloed unless, as is true for some, they already do major care coordination work. They are expected to facilitate access to and coordination of all aspects of the care an individual needs and to assure that during its delivery the person is treated holistically and the effects of each type of care on other interventions is considered and accommodated.

EXHIBIT 7.1. T4H Hub Structure
See ALT TEXT at end of this exhibit.
ALT TEXT for EXHIBIT 7.1: This graphic shows the organizational structure of Together4Health. The graphic shows a large circle in the upper right representing the central team and its membership and functions. The text reads, "T4H Central Care Coordination Team. Program director oversees all CC teams. Central team includes members of teams from all hubs. Serves central intake functions; provides population management through oversight of outcomes, analysis of trends, and continual standardization of care."

An example of a care coordination team is represented by a mid-sized circle to the left, connected to the large circle by a line. The text in the mid-sized circle describes the membership and roles of the care coordination team. The text reads, "T4H Hub-based Care Coordination Team. RN, LCSW, CHW. Provide individual participant management across hub partners. Each participant has an assigned care coordinator."

Surrounding this mid-sized circle are 7 smaller circles, connected by lines to the mid-sized circle. These smaller circles represent partner providers to which the care coordination teams may refer. Text in these 7 circles reads, "RWCA, Case Management;" "CMHC;" "Substance use treatment provider;" "Supportive housing;" "Hospital;" "Other: Pharmacy, Refugee Resettlement, Long-term care," "Vocational;" "FQHC."

An unlabeled additional example of a care coordination team appears on the lower right of the graphic, represented by a small central circle representing a care coordination team and connected by lines to smaller circles representing partner providers. This represents the other hub-based care coordination teams associated with Together4Health.

Early on, the group realized that it needed an overarching value framework to drive the entire enterprise, covering assessment, engagement, staffing, and integrated service delivery. This framework has been critical to everything that followed, providing a constant frame of reference each time the details threatened to overwhelm the whole.

Starting with its early work on the T4H proposal, the Care Coordination Work Group has focused on how these teams will function and how the hubs and the actual care provider organizations will interact. Representatives of many partner agencies have attended this work group from the beginning. Initially they shared information about their own agencies (the services they offer, what their clients need, and what gets in their way). Quite a few improvements in communications evolved just from these meetings. The group recognized how big a challenge it would be to include hospitals in this open communication--something that had mostly not happened before.

The group also recognized that many individual member agencies do a lot of care coordination work already, and often with at least some other member agencies. But more would be needed, through more formalized structures, and tied to outcomes. Inevitably this would mean that agencies would need to modify some of their own established procedures to integrate their care with other agencies and the T4H care coordination teams. Further, once the proposal was accepted and the care coordination team realized it now had to make the plans work, it became clear that intra-organizational communication had to catch up. For the most part, executive directors were the agency staff working on the T4H conceptualization and proposal. With funding, clinical and casework staff, data system personnel, privacy officers, and all manner of employees had to be introduced to the T4H concept and convinced to cooperate. For most organizations, this meant that many people who did not participate in T4H's planning phase had to now understand the T4H vision and values and become engaged in the many start-up tasks required to make the plan operational.

Collaboration between two key members of T4H, the Cook County Health and Hospital System and Heartland Health Outreach, is evolving, with several emerging opportunities for working together to improve the delivery of health services for some of Cook County's most vulnerable people. In addition to CountyCare (see Chapter 3), which enrolls people who are currently uninsured, the Cook County Health and Hospital System and Heartland Health Outreach are also partners in Together4Health.

The two initiatives will serve different target populations, at least initially, while the two provider networks include some of the same organizations. At the time of our final site visit, the Cook County Health and Hospital System and Heartland Health Outreach were negotiating an agreement to place Heartland Health Outreach staff in the emergency department at Stroger Hospital to engage people who are homeless and connect them to more appropriate care. Over the coming months and years, the organizations will likely have a complex and evolving set of relationships, sharing responsibility for coordinating care for many people experiencing homelessness and PSH tenants.

7.4.3. How the Finances Are Expected to Work

T4H's goal is to operate as a Care Coordination Entity for three years and then transition in the fourth year to operating as a Managed Care Community Network. These networks are essentially ACOs or ACO-like entities with risk-based managed care financing. T4H will use this financing to pay other providers for all covered services.

As a Care Coordination Entity, T4H receives a Care Coordination fee from the state's Medicaid program. During the first three years as T4H operates as a Care Coordination Entity, all health and behavioral health care and other services received by T4H consumers, other than the activities of the care coordination teams, will be paid for in the same way they would have been paid for before T4H. This could be Medicaid reimbursements paid on a fee-for-service basis; federal, state, or county grants and contracts; housing subsidies for supportive housing providers; and other payment mechanisms. Initially, the contract between the state and T4H LLC pays for Heartland Health Outreach's management functions and for staff of the care coordination teams. T4H has budgeted a small portion of its income from Care Coordination fees to pilot services that are expected to have an impact on client outcomes. The hope and expectation is that as care through T4H results in savings in the costs of Medicaid-covered health care and behavioral health services over the first 2-3 years of the initiative, and the state shares those savings with T4H as one component of a pay-for-performance mechanism, these revenues will be used to improve T4H's infrastructure and also ultimately to contract with its members to fill gaps in services that are not covered by Medicaid reimbursements.

But for the organizations that deliver services in permanent supportive housing and to other people with chronic patterns of homelessness, T4H will not provide an immediate solution for the gaps they experience in financing the services they deliver. While this reality caused some tensions and debate during the planning process, the partner organizations that provide services to people with chronic patterns of homelessness recognize that they need to participate as co-owners of T4H as it develops; they need to have a seat at the table and work within the organization to figure out how services in PSH will be financed as new ways of delivering and paying for health care emerge over the next few years.

While this case study was underway, the state was expecting to amend its state Medicaid plan to use the health home option, available under the Affordable Care Act, to provide Medicaid reimbursement for the Care Coordination fees it pays to Care Coordination Entities, including T4H, to cover management functions and care coordination. As of early 2014, the state had not yet submitted a state plan amendment to CMS to add a health home benefit, and was considering other Medicaid financing approaches to cover these costs. Existing Medicaid benefits will still pay for other covered services in the usual way, including hospitalizations, nursing home stays, and community mental health services, outside the Care Coordination Entity framework.

The state expects to realize savings when care coordination leads to fewer or shorter hospitalizations and nursing home stays and lower related costs. The expectation is that savings in hospitalizations and other health care costs will be comparable to (or greater than) those the state achieves through other types of managed care arrangements, with appropriate risk-adjustment to reflect differences in the characteristics of people enrolled in each Care Coordination Entity. Ultimately, subject to CMS approval, the state expects to return a portion of those savings to T4H as part of a pay-for-performance mechanism that will also incorporate quality measures. T4H may use the funds to expand infrastructure, purchase types of care that would otherwise be unavailable, distribute some funds to members, including incentive payments for achieving targets for volume and quality of services and outcomes, and so on, as the Board of Managers decides.

T4H financing is based on the organization receiving a per-consumer monthly care coordination fee from the Department of Healthcare and Family Services for all enrolled members, regardless of the specific services the consumer actually receives. A great deal of the work leading up to the T4H proposal involved analyses to determine whether T4H could afford to do what it wanted to do--it had to develop a defensible expectation of how much that fee needed to be.

With foundation support, Heartland Health Outreach was able to hire an actuarial firm to help analyze the state Medicaid claims data to develop a realistic fee proposal. The analysis required the firm to take everyone in the Medicaid data living within a certain geographical area who was a high user of covered services, look for top diagnoses, top expenses, and similar information, and map these against the types of people that T4H was expected to target. The firm looked at service use patterns, diagnostic codes, age, and various social determinants of health such as poverty and neighborhood.

Four target groups emerged from this analysis for purposes of setting rates for care coordination fees: (1) Medicaid-only with serious mental illness; (2) Medicaid-only without serious mental illness; (3) dualeligibles (Medicaid and Medicare) with serious mental illness; and (4) dual-eligibles without serious mental illness. Initially, the state has allowed T4H to enroll only people in the two Medicaid-only groups, and T4H has not been permitted to enroll people who are dual-eligible for both Medicaid and Medicare.

Actuaries combined the Medicaid claims data with data from years of Heartland Health Outreach records for the types of clients T4H would be targeting. The analysis was also informed by publications by the Corporation for Supportive Housing that summarized research findings of cost reductions in crisis and emergency health services once people experiencing homelessness are stably housed. The actuaries used the data to stratify the likely T4H population into risk categories and attach likely savings from care coordination. Also, using Heartland Health Outreach data, they looked at service, cost, and use patterns for each of the T4H target groups and projected them by quarter for all 12 quarters of T4H's first three years, during which T4H is expected to function as a Care Coordination Entity. These actuarial analyses were used to justify the T4H cost proposal to the state.

Costs that T4H has identified to start up and operate as a care coordination entity, and considered in developing its cost proposal to the state include the following:

  • The Care Coordination Teams.

  • Information technology--the data supports, infrastructure, software, and staffing to run T4H's integrated data system (being developed).

  • Running T4H--management through Heartland Health Outreach, which contracts with Heartland Alliance for some services.

  • Ongoing actuarial analyses for many purposes.

The budget covering these activities is for running the company, not for development costs and not for any of the costs to transition to operating as a full-risk Managed Care Community Network entity or Accountable Care Organization.

T4H has already benefited from substantial foundation support to pay for start-up costs, including work with consultants (such as the actuarial firm that did the cost analysis) to help it develop its design and strategy. In addition T4H received valuable pro bono legal assistance to create the LLC and its governance structure, including operating agreements.

T4H will be trying to gain access to other resources, aiming at state-only funds designated for serving Medicaid populations. Currently, funds are technically available but restricted, and some programs pay for services that might be more effective if better integrated and aligned with other benefits. T4H member agencies will advocate for redirecting some funds that are currently administered by state agencies and allocated to T4H member organizations to be used by T4H with fewer restrictions on who can receive care using these dollars. Potentially some of the state funding can be used for federal funding match for services that could be covered through Medicaid. Foundation grants and commitments from social investment funds are other funding options T4H is pursuing to augment available resources to invest in infrastructure.

7.4.4. Information Technology and Data Sharing

One of the greatest challenges any care coordination or integration effort faces is assuring that patient information can be shared easily and accurately, while also fully respecting data privacy and confidentiality. Performance monitoring and outcome measurement is a second, hugely important use for good information, without which individual agencies and the system as a whole cannot document the benefits of coordination and integration. With these imperatives in mind, the T4H partners established a Health Information and Information Technology Work Group.

As would be true for any group of agencies, the T4H members use a variety of data systems, none of which were interoperable before T4H began. These include Centricity (a GE product), Epic, ClientTrack, and Service Point (HMIS). In addition, Illinois state agencies are in the process of developing the Illinois Health Information Exchange to comply with Affordable Care Act requirements. The Illinois Health Information Exchange will be: (1) a central repository containing a master patient index of anyone who gets care anywhere in the state; and (2) a conduit through which information can move among health care providers. It will not, however, be a data warehouse. T4H will have access to this state data structure once it is up and running. Current plans for the Illinois Health Information Exchange do not include providers of behavioral health care services, although the state may be using SAMHSA grant funding to add some capacity for shared data, including a core data set and information about behavioral health care that could be important in planning care transitions. Illinois state law contains some data privacy provisions that create barriers to sharing some behavioral health information, and efforts are under way to modify some provisions that are more restrictive than required by federal law or regulations.

T4H is working to establish a centralized data warehouse system where multiple types of data will reside and be available to partners. T4H has purchased a care coordination software and data analytics package that will be integrated with claims data. Eventually the warehouse will have the capacity to pull clinical data from electronic health records maintained by T4H member organizations. The T4H central data system will take both clinical and financial data, and will have the capacity to send routine reports to member organizations and also to respond to specific requests.

T4H has put in place an integrated tool and process for care coordination assessments. The assessments done by T4H care coordination teams do not duplicate information gathered by T4H providers, but rather focus on care coordination needs. These assessments will be electronic and available through the data system. T4H members will thus be able to share information across partners, with the appropriate broad consents and releases.

T4H has ambitious goals for its data system, hoping that eventually it will support care coordination, avoiding duplication and simplifying the client's life by consolidating care in fewer places (e.g., if it turns out that a client gets care from agencies in two different hubs, seeing if the client wants to switch to have everything come through one hub, which would be geographically more concentrated and easier to access).

The Health Information and Information Technology Work Group has a huge amount of work to do, but it has a coherent strategy and the envisioned system will provide major advantages to all T4H members. The devil will, as always, be in the details.

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