Lessons Learned From StatesIncreasing Coverage & Preventive Visits for

Adolescents and Young Adults (AYAs)

Claire D. Brindis, DrPHCo-Project Director, AYAH-NRC

Lauren Twietmeyer, MPHResearch Associate, AYAH-NRC

University of California, San Francisco

September 23, 2015

Acknowledgements

• Funder: Maternal and Child Health Bureau, Health Services and Resources Administration, USDHHS, U45MC27709

Background

The Promise of the Affordable Care Act

• Insurance Expansion- Medicaid- Marketplace/“State Exchanges”- Dependent coverage to age 26

• Access to Preventive Services- Provided by plans without cost-sharing to members- Requirements established by:

US preventive Services Task Force “A” and “B” recommendations Bright Futures Guidelines for Children and Adolescents ACIP Immunization RecommendationsHRSA-supported IOM recommendations for women’s health

ACA: Opportunities• Medicaid Expansion- 31 States including D.C. have expanded as of Sept 2015

• CMS Navigator Grants* (2013-present)- Awards to hospitals, universities, Indian tribes, and

patient advocacy groups, etc.

• CHIPRA Outreach and Enrollment Grants (2009-2013)- Awarded to state and local governments, tribal

organizations, community groups, schools, etc.

*Available to states with Federally-Facilitated & State Partnership Marketplaces

Project Objective

• Identify best-practices to increase access to and utilization of insurance enrollment & preventive visits among AYAs

Methods

Project Steps

1. Identify top performing states

2. Develop survey protocol

3. Recruit key stakeholders

4. Conduct Interviews

5. Analyze Data

1. Calculated Insurance and Preventive Visit Rates- Data Sources: National Survey of Children’s Health & Behavioral

Risk Factors Surveillance System

Pre- and post- ACA rates of insurance coverage Pre- and post- ACA rates of preventive visits Pre- and post- ACA change rates

2. State-Level Medicaid Data

3. Final Selection- Preliminary list of top-performers refined to ensure

broad geographic and demographic representation

Step 1: State Selection

Step 1: Identify States

Seven states: CA, CO, IL, IA*, OR, TX*, and VT*

*AYAH-NRC CoIIN State Texas only finalist state that did not expand Medicaid

Step 2: Guided Questions for Selected States

• Specific strategies to enroll:- Eligible populations? - AYAs?- Vulnerable groups?

• Previous efforts to increase enrollment

• Barriers

Outreach and Enrollment Preventive Care Visits

• How were high rates accomplished?

• Initiatives to encourage annual preventive visits

• Strategies to help AYAs access care

• Barriers

Step 3: Recruit Stakeholders

• Targeted outreach based on:- Internal knowledge of AYA state-level leadership- Recommendations from Adolescent Health Coordinators- Research of state-level youth advocacy organizations

Step 4: Conduct Interviews

Title V MCH Directors

Adolescent Health Coordinators

Youth Advocacy Organizations

State & County Health Employees

3

6

4

12

Twenty-five respondents were interviewed between May and July 2015

Step 5: Qualitative Analysis of Interviews

• Conducted interview analysis to identify promising practices to increase enrollment and preventive visits among AYAs in top-performing states

Results:Outreach & Enrollment

Major Themes: Outreach & Enrollment

Use of Community Agencies and Networks

Focus on Special Populations

Youth Engagement

Major Themes: Outreach & Enrollment

Use of Community Agencies and Networks

Focus on Special Populations

Youth Engagement

• In 2006, Department of Public Health & Department of Human Services collaborated to increase enrollment and retention in Medicaid and hawk-i. - Contract with 22 local Title V MCH agencies to serve all

99 counties

- Outreach focused on adolescents (ages 13-19) and parents through activities: youth athletics, after-school programs, and youth employment agencies.

• Results: In 2014, 36,000 kids were enrolled in hawk-i (69% increase since 2006)

Community AgenciesIOWA

Source: Iowa Department of Human Services, 2014; Askelson et al., 2013.

Community AgenciesILLINOIS• In 2005, Healthcare and Family Services utilized All

Kids Application Agents (AKAAs) to enroll uninsured children

- Community-based organizations (e.g., faith-based, day care centers, and school districts) enrolled as AKAAs

• In 2006, AKAAs conducted over 275 enrollment events in supermarkets, malls, schools, etc.

• Results: 1.6 million children are enrolled in All Kids (33% increase since 2005)

Source: All Kids Preliminary Report, 2008; About All Kids, 2015.

Community AgenciesTEXAS - Enroll Gulf Coast• Began in 2013 to coordinate, network and streamline

efforts to efficiently and effectively engage eligible population of Greater Harris County

• Comprised of 21 organizations (e.g., Change Happens, Children’s Defense Fund, and Young Invincibles)

- Internal committees include: Intelligence, operations, and logistics

• Results: 190,000 Houstonians were enrolled in the first open enrollment period (Oct. 1, 2013 - March 31, 2014)

Source: Atkinson-Travis, 2014.

Major Themes: Outreach & Enrollment

Use of Community Agencies and Networks

Focus on Special Populations

Youth Engagement

• Categorization of adolescent sub-populations

- Demographically-defined

Racial/ethnic groups Immigrant

- Legally-definedFoster care Incarcerated

- Other Youth PopulationsHomeless

Special Populations

Source: Knopf et al., 2007.

• Six states focused on Hispanic/Latino, mixed-status, and undocumented youth- Oregon Health Authority designated state employees to

directly oversee and coordinate outreach events (e.g., 3-day soccer tournament)

- Texas’ Enroll Gulf Coast partnered with Univision to hold enrollment telethon

- Boulder County (CO) co-located Health Coverage Guides every two weeks at a Spanish family resource center

Special PopulationsRacial/Ethnic

• Children Now, a California non-profit, spearheaded CoveredTil26 campaign- Informational flyers- Social media campaigns- Direct outreach- County contact list of individuals who would help

navigate enrollment in Medicaid (Medi-Cal)- Toolkit with sample language and resources for outreach

to Former Foster Youth

Special PopulationsFormer Foster Youth

Major Themes: Outreach & Enrollment

Use of Community Agencies and Networks

Focus on Special Populations

Youth Engagement

Youth Engagement3 States utilized innovative youth engagement

strategies

Policy

Marketing

Outreach

Youth Engagement• State-level Policy:- Youth Partnership for Health (CO): Public health

department employs youth to provide feedback and recommendations on programs, practices, and policies

• State-level Media:- Oregon Health Authority: Youth advisory group created

“one of the most successful” teen-friendly flyers

• Local-level Outreach:- Beacon Therapeutic (IL): Peer advocates that lived in

homeless shelters and assisted in recruiting homeless AYAs

Source: Oregon Health Authority, 2011.

Outreach & Enrollment: Lessons Learned

Approaches in top-performing states:

Use of multiple, concurrent, and reinforcing strategies

Focus on families: “All boats will rise” - Two generational effect

Results:Preventive Care Visits

Major Themes: Preventive Care Visits

Commitment to Bright Futures Guidelines

Focus on Medical Homes

Capacity-Building

Major Themes: Preventive Care Visits

Commitment to Bright Futures Guidelines

Focus on Medical Homes

Capacity-Building

Commitment to Bright Futures Guidelines

• Vermont, 2008:State’s Medicaid program adopted Bright Futures as

standard of care

AAP Chapter organized ‘roadshows’ to educate providers about Bright Futures

• Illinois, 2011:State’s Medicaid program adopted Bright Futures as

standard of care

• Colorado, 2014:

Adopted Bright Futures as state’s EPSDT Periodicity Schedule

Source: States & Communities, 2015; EPSDT, 2015.

Major Themes: Preventive Care Visits

Commitment to Bright Futures Guidelines

Focus on Medical Homes

Capacity-Building

Focus on Medical HomesColorado• Medical Home Initiative, 2011

- Goal to ensure all children receive care within a medical home

- Brings together over 40 representatives from government agencies, health providers, NGOs, and policy-makers

• Legislation in 2007 established medical homes for children in Medicaid

• Results: By 2012, 45% of children in Medicaid/CHIP had a medical home compared to 41% in 2007

Source: Fast Facts, 2015; National Survey of Children’s Health, 2015.

Focus on Medical HomesIllinois• Primary Care Case Management Program, 2006- Founded on the medical home concept called Illinois

Health Connect

• SMART Act, 2012- Required 50% of Medicaid recipients be enrolled in care

coordination by 2015

• Results: By 2012, 29% of children in Medicaid/CHIP had a medical home compared to 20% in 2007

Source: Illinois, 2015; National Survey of Children’s Health, 2015.

Major Themes: Preventive Care Visits

Commitment to Bright Futures Guidelines

Focus on Medical Homes

Capacity-Building

Capacity-BuildingVermont• Youth Health Improvement Initiative

- Started in 2001 to support pediatric and family practices to improve preventive services delivery for youth ages 8-18

- Results: 69 practices have been assisted in improving the quality of health care they provide

• Child Health Advances Measured in Practice- Started in 2012 to increase the efficiency, economy, and

quality of care provided to Medicaid-eligible children and families

- Results: 40 practices (95% pediatric) have participated in annual QI projects

Source: YHII, 2015;_____________

Capacity-BuildingOregon Pediatric Society• Adolescent Health Project

- Purpose: Increase universal screening, brief interventions, and referral to treatment for depression and substance use within the context of an adolescent well-visit

- Trained 173 PCPs and clinic staff between March and November 2014

- Results: By October 2014, enrolled practices reported improvements on a number of systems related to confidentiality, privacy, screening and QI capacity

Source: 2014 Annual Report.

Preventive Care Visits: Lessons Learned

Features of top-performing states:

Built on experiences to expand access to AYAs

Committed to providing comprehensive, coordinated care to all children

Leveraged state-private partnerships to build capacity and train providers

Influencing AYA Health Care:Where Can CoIINs Make a Difference?

Providers Local Government

Agency Networks

State Federal

Stayed Tuned

• Brief outlining ‘Lessons Learned’ from ACCESS interviews

• Compendium of best practices that promote increased access to and utilization of preventive visits among AYAs

References2014 Annual Report. START (Screening Tools and Referral Training): Oregon Pediatric Society. http://oregonstart.org/wp-content/uploads/2015/07/Annual-Report-Year-6-2014.pdf. Accessed on September 10, 2015.

About All Kids. ALL Kids: State of Illinois. http://www.allkids.com/hfs8269.html. Accessed on September 17, 2015.

Askelson, N, Gikembiewski, E, Turchi, J, Elchert, D, Tegegne, M. Report on evaluation of Iowa’s CHIPRA II outreach and enrollment project. 2013. Available at http://ppc.uiowa.edu/publications/report-evaluation-iowas-chipra-ii-outreach-and-enrollment-project.

Atkinson-Travis D. Gulf coast health insurance marketplace collaborative leading the way!Presented at: Gulf Coast of Texas African American Family Support Conference; November 7, 2014; Houston, TX.http://gcaafsc.net/wr/wp-content/uploads/2014-conference-prog-book.pdf.

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT). Colorado Department of Healthcare Policy and Financing. https://www.colorado.gov/pacific/hcpf/early-and-periodic-screening-diagnostic-and-treatment-epsdt. Accessed on September 10, 2015.

Fast Facts about the Colorado Medical Home Initiative. WONDERbabies, University of Colorado Denver.www.wonderbabiesco.org/UserFiles/Media/MHFactSheet.doc. Accessed on September 10, 2015.

Illinois. Patient-Centered Primary Care Collaborative.https://www.pcpcc.org/initiatives/Illinois. Accessed on September 10, 2015.

Iowa Department of Human Services. Annual report of the hawk-i board to the governor, general assembly, and council on human services. 2014.Available at http://dhs.iowa.gov/sites/default/files/2014_hawk-i_Board_Annual_Report.pdf.

Knopf D, Park MJ, Brindis CD, Mulye TP, Irwin CE. What gets measures gets done: assessing data availability for adolescent populations. Matern Child Health J. 2007; 11(4): 335-345.

National Adolescent and Young Health Information Center, University of San Francisco. National Survey of Children’s Health [private data run] 2015. Centers for Disease Control and Prevention. Available at: http://childhealthdata.org/.

References, cont.States & Communities. Bright Futures, American Academy of Pediatrics. https://brightfutures.aap.org/states-and-communities/Pages/default.aspx#. Accessed on September 10, 2015.

Youth Health Improvement Initiative (YHII). Vermont Child Health Improvement Program (VCHIP): The University of Vermont.https://www.uvm.edu/medicine/vchip/?Page=VTYHI.html. Accessed on September 10, 2015.