Lessons Learned From States Increasing Coverage & Preventive Visits for Adolescents and Young Adults (AYAs) Claire D. Brindis, DrPH Co-Project Director, AYAH-NRC Lauren Twietmeyer, MPH Research 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 Recommendations HRSA-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 Identify top performing states Develop survey protocol Recruit key stakeholders Conduct Interviews Analyze Data

Step 1: State Selection 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 State-Level Medicaid Data Final Selection Preliminary list of top-performers refined to ensure broad geographic and demographic representation

Seven states: CA, CO, IL, IA*, OR, TX*, and VT* 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 Outreach and Enrollment Preventive Care Visits Specific strategies to enroll: Eligible populations? AYAs? Vulnerable groups? Previous efforts to increase enrollment Barriers 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 Twenty-five respondents were interviewed between May and July 2015 Title V MCH Directors Adolescent Health Coordinators Youth Advocacy Organizations State & County Health Employees 3 6 4 12

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

Community Agencies IOWA 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) Source: Iowa Department of Human Services, 2014; Askelson et al., 2013.

Community Agencies ILLINOIS 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 Agencies TEXAS - 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

Special Populations Categorization of adolescent sub-populations Demographically-defined Racial/ethnic groups Immigrant Legally-defined Foster care Incarcerated Other Youth Populations Homeless Source: Knopf et al., 2007.

Special Populations Racial/Ethnic 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 Populations Former Foster Youth 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

Major Themes: Outreach & Enrollment Use of Community Agencies and Networks Focus on Special Populations Youth Engagement

3 States utilized innovative youth engagement strategies Policy Marketing Outreach

Youth Engagement State-level Policy: State-level Media: 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: 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 Homes Colorado 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 Homes Illinois 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-Building Vermont 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-Building Oregon 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

References 2014 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.