Patient Activation Measure (PAM) for Uninsured

Project ID: 2.d.i

Project Name:

Patient Activation Measure (PAM) for Uninsured

Project Description:

Implementation of Patient Activation Activities to Engage, Educate and Integrate the uninsured and low/non-utilizing Medicaid populations into Community Based Care

Project Chairs:

John Migliore, Bassett Medical Center

Bonnie Post, Schoharie County Office of Community Services

Stephanie Lao. Catholic Charities Care Coordinator Services

Deanna Charles, Catholic Charities of Herkimer County

Objective:

This project will be focused on increasing patient activation related to health care paired with increased resources that can help the uninsured (UI) as well as non-utilizing (NU) and low utilizing (LU) populations gain access to and utilize the benefits associated with DSRIP PPS projects, particularly primary and preventative services.

(Note: While this project and Project 2.c.i both utilize community-based health navigators, the focus of the two projects is very different. This project is focused on persons not utilizing the health care system and working to engage and activate them to utilize the system to see primary and preventive care services. Project 2.c.i is focused on persons utilizing the system but doing it ineffectively or inappropriately. The navigation service in this case assists these person to access the system effectively and appropriately by providing bridge support until the patient has the self-confidence to manage his/her own health.)

Rationale and Relationship to Other Projects:

People have many reasons they do not interact with the health care system, including lack of knowledge of health issues, language, literacy and health literacy, lack of insurance or understanding coverage, cultural and religious barriers, embarrassment, fear and other life priorities, to name a few. Without targeted activities to address these issues, it will be difficult to engage these persons in managing their health and integrating them into the reformed health care system.

Significant efforts have been undertaken to increase access to health insurance and other financial resources to cover the cost of health care; however, without addressing the other aforementioned issues, there will still be a population that remains disenfranchised from the system until a serious/catastrophic event is sufficient to force them to seek care. Engagement with this population will not only require understanding their barriers, but also creating opportunities for this population to gain confidence in their ability to understand their health and how to manage it as well as how to understand and manage their interactions with the health care system.

There is a body of literature on patient activation and engagement, health literacy, and practices to reduce health care disparities that can all be used to develop a project that increases access to, and use of, the health care system by the UI, NU and LU populations. These resources include:

• Do Increases in Patient Activation Result in Improved Self-Management Behaviors?
• Patient And Family Engagement: A Framework For Understanding The Elements And Developing Interventions And Policies
• Health Literacy – US Department of Health and Human Services
• Health Literacy – American Medical Association (AMA)
• Culture, Language and Health Literacy
• Cultural Competency

Additionally, when individuals do not have health insurance, they face significant barriers not only accessing the services they need, but also in receiving those services in a timely manner. Cost becomes a significant barrier for those seeking the primary and preventive care they need. Self-pay costs, in most instances, are generally significantly higher than the discounted rates that the government and other insurers can negotiate. Personal barriers noted above may keep persons from self-negotiating for reduced fees or becoming aware of the availability of financial assistance or new options for coverage. The lack of connectivity to primary care and preventive services results in reliance on emergency departments for both minor urgent care and well as true emergent care that was potentially avoidable. Furthermore, health care facility providers are put in a precarious position when providing care to the uninsured, because, by law, providers must service this population when they seek emergency services, while knowing that they may not receive adequate financial compensation for services rendered.

Furthermore, in addition to the state’s uninsured population, there are also Medicaid members with very low to no PCP connectivity to the program. Currently, there are over one million Medicaid members that are enrolled in the program, but not using any services in a given year. Moreover, there is another group of Medicaid members that have minimal service utilization and little to no connectivity with their PCP or care manager. While these may represent generally healthy persons with limited needs for episodic health care, their lack of connectivity with primary and preventive services insures they will not have an adequate entry portal should they have urgent/emergent needs. This continues the cycle of being forced to use urgent/emergency services.
As part of the public comment period on the waiver and attachments, advocates strongly encouraged the state to include uninsured members in DSRIP, so that this population could utilize the benefits of a transformed health care system also. Also, concerns were raised about the NU and LU populations and the ability of PPS to affect their health.

This project will focus on these three populations and will require the PPS:

• to develop activities that promote community and patient activation and engagement with the above resources as a starting point,
• to provide community bridges that allow access to health coverage resources, and
• to build linkages to community based primary and preventive services and create community based health education to sustain and grow the community and patient activation in the region they serve.

The PPS will be required to undertake training to perform the Patient Activation Measure and will be required to assess their communities and individual patients on this measure before and at regular intervals during this project. This will provide the quality outcome metrics for this project.

In order to be eligible for this project, a PPS must already be pursing 10 projects and must demonstrate in its Project Plan application its network capacity to handle an 11th project and how the network is in a position to serve the UI, NU and LU populations. Any public hospital PPS in a specified region would have the first right of refusal in taking on this additional project and having the specified populations in their region attributed to their PPS. Only the uninsured as well as non-utilizing and low-utilizing Medicaid member populations will be attributed to this project.

Core Components:

PPSs undertaking this project will be required to complete the following activities which are grouped in three primary activities: patient activation, financially accessible health care resources, and engagement and linkage to primary and preventive care services.

1. Patient Engagement
   • Establish a team of appropriate staff who are formally trained in the Patient Activation Measure® (PAM®) and have expertise in developing patient activation and engagement activities to serve as “trainers” for the PPS. DSRIP applications that choose the 11th project must identify the relevant staff that will be designated for this team as part of its proposal.
   • Identify “hot spot” areas for UI, NU and LU within the PPS partner network (e.g., emergency rooms), while also working with partnering CBOs who are familiar with, and trusted by the community, to perform outreach in identified hot spots within the service region’s community.
   • Work with PPS partners to develop activities, including community forums, surveying the targeted population about health care in the PPS’ region.
   • PPS Providers located in “hot spot” areas should be trained by the above trainers in patient activation techniques, including shared decision making, measurements of health literacy, and cultural competency.
   • PPS is expected to partner with CBOs to assist in engagement efforts to the project’s targeted populations. PPSs must provide oversight and ensure that engagement is sufficient and appropriate.
   • To ensure continuity of care and the importance of an assigned PCP, MCOs will provide PPS with the PCPs assigned to NU and LU enrollees. The PPS must work with the member’s MCO and assigned PCP to help reconnect that beneficiary to their designated PCP (see outcome measurements below). This patient activation project is not to be used as a mechanism to inappropriately move members to different health plans and PCPs; but rather, shall be focused on establishing connectivity to resources already available to the member.
     • The PPS will work with the managed care plan and PCP to assure that there is proactive outreach to the beneficiary and that the beneficiary is provided information about insurance coverage, language resources and availability of primary and preventive services. The state must review and approve educational materials provided to beneficiaries that managed care plans or providers develop as part of this effort. Materials should comply with state marketing guidelines and federal regulations at 42 CFR §438.104.
   • PPS base line for each beneficiary cohort (a method will be developed by the state to appropriately identify this cohort) will be measured during first year of the project and at set intervals utilizing the PAM®. A baseline must be set for each cohort and intervals towards improvement must be set at the beginning of each performance period. The PPS will establish the intervals towards improvement that must be achieved at the beginning of each performance period.
   • PPS will include beneficiaries as part of a development team to promote preventative care
   • Measurement of PAM®
     • PPS will be responsible for screening patient status (UI, NU, LU) and for collecting the most recent contact information for the patient when they visit PPS designated facility or “hot spot” area for health service. If the beneficiary is UI, does not have a registered PCP or is attributed to a PCP in the PPS’ network, the PPS will be responsible for assessing patient, through PAM survey and designating a PAM score for baseline measure. Individual member score will then be averaged to calculate a baseline measure for that year’s cohort. The cohort will be followed for the remainder of DSRIP.
     • On an annual basis, the PPS will be responsible for assessing individual member and the overall cohort’s level of engagement, with the goal of moving the beneficiary to a higher level of activation.
     • If the beneficiary is deemed to be LU & NU, but has a designated PCP that is not part of the PPS’ network, the PPS will be responsible for counseling the beneficiary on how to better utilize their existing health care benefits, while also encouraging the beneficiary to reconnect with their designated PCP. The PPS will NOT be responsible for assessing the patient through PAM survey.
       • PPS will also be responsible for providing the most current contact information to the beneficiary’s MCO, so that MCO may help the assigned PCP reach out to the member.
     • PPS should provide member engagement lists to relevant insurance companies (for NU & LU populations) on a monthly basis and to DOH on a quarterly basis so that the state can track engagement and outreach efforts associated with the project.
2. Linkage to Financially Accessible Health Care Resources
   • Through engagement PPS will increase the volume of non-emergency (primary, behavioral, dental) care provided to uninsured persons and low utilizing Medicaid beneficiaries through its partner providers.
3. Linkage to Health Care Systems and PPSs
   • In collaboration with CBO, the PPS will develop a group of community Navigators who are trained in linkages to health care coverage, community health care resources including for primary and preventive services, and patient education. The PPS must keep record and report to the state, the number of Navigators that it employs. PPS must have a means for Medicaid recipients and project participants to report complaints and receive customer service.
   • Community Navigators will receive training in patient activation and education including use of the PAM® so they can appropriately assist project beneficiaries.
   • Navigators will be prominently available to the community at PPS “hot spots,” PPS partner CBOs, Emergency Departments and community events to ensure there is the ability to have direct hand-offs to the Navigator to educate on health insurance coverage (if applicable), educate on age-appropriate primary and preventive health care services, and to connect with primary and preventative care resources.
   • PPS will proactively inform and educate navigators about insurance options and health care resources available to populations in this project.
   • PPS will proactively ensure when Navigators call for primary and preventive services for a community member there is appropriate and timely access available.