1. Public Health 3.0 and Medicaid Transformation
Nursing leadership in a changing public health environment
October 25th, 2018
Beth Lovette, Acting Director, NC DPH

2. Objectives Define Public Health 3.0 Medicaid Transformation
Provide examples of opportunities in a 3.0 world at LHDs
Consider strategies for prioritization of limited resources and services
Medicaid Transformation
Understand risk and opportunities
Understand the public health “win” for Care Management
Understand and identify strategies to the challenges of the public health care management programs
Identify strategies to determine your LHDs future in:
Advanced Medical Home
Fee for Service
Prenatal Clinical Services

3. 2016 North Carolina ranked 32nd
2016 Challenges
High percentage of children living in poverty (43rd) (35th 2017)
High prevalence of low birth weight (41st) (still 41st 2017)
High infant mortality rate (41st)
2015 North Carolina ranked 31st
But first – a reality check of North Carolina’s overall Health ranking* *America’s Health Rankings United Health Foundation
2016 North Carolina ranked 32nd
2017 North Carolina ranked 33rd
2017 Challenges
High infant mortality rate (42nd)
High percentage of uninsured population (41st)
High incidence of chlamydia (48th)

5. NACCHO Public Health 3.0 Issue Brief
What 3.0 says we ought to do:
Chief (Community) Health Strategist
Shift from access to health care, to universal access to health
Shift public health responsibilities upstream, through the lens of health equity and social determinants of health
Flexible funding streams with less emphasis on health outcomes to encourage resources directed toward SDOH
Cross-jurisdictional sharing to improve capacity of smaller health departments (under 50,000 population)
Accreditation (PHAB)
Challenges for LHDs:
Getting influential partners to the table can be hard – hospitals, schools, business
Closing the coverage gap hasn’t happened
How do LHDs actually push upstream?
Housing, food, transportation, ACES
Few flexible funding streams, many strings attached to siloed funding
County leaders may struggle to value regional services
resources/NACCHO-PH-3.0-Issue-Brief-2016.pdf

6. PH 3.0 Resources
Community Toolkit
SDOH Resource and Referral Platform
SDOH Mapping

7. Medicaid Transformation Source of Truth!
Bookmark this and visit often:
Training notices
Tools
FAQs
NC TRACKS messaging

8. 3

9. LHD Care Management WIN!! Why did public health win on this?
2 – 3 years without competition
Funded access to Virtual Health – data, analytics, performance measures (real time!)
Why did public health win on this?
Population care management is unique to public health in the managed care transformation today

10. LHD Care Management
Public health care management (OBCM and CC4C) – identifies individuals at risk for a variety of medical, social, economic, behavioral health issues and works to prevent problems to keep people healthy
Helps to prevent high (health care) costs from becoming an issue
Opportunity: population health care management is a challenge for Medicaid prepaid health plans or MCOs to implement. LHDs are uniquely positioned to work toward improvement of the whole county population

11. Care Management Concerns for LHDs
Recruitment and retention of care management staff (RNs, BSWs)
Travel in rural communities to work with clients at home or at OB office
Proving value in the managed care space where the prepaid health plans are managing their bottom line fiscal responsibilities
Regional approach may work better for lower population counties, but how to sell that approach to county stakeholders

12. LHD Care Management vs AMH Care Management
Public Health
AMH
Builds on current CC4C and OBCM
RN or BSW credentialing required
Dollars will flow from Division of Health Benefits (DHB) to Prepaid Health Plans (PHP) to LHDs
Predict less budget oversight
LHDs will have opportunities to enhance and lead
Builds on current CCNC Network approach
Chronic care management
Disease specific
Triggered by diagnoses or Medicaid expenses for healthcare interventions
Medication reconciliation, linked to hospital inpatient and ED visits
Requires LCSW or RN

13. Transition to Medicaid managed care
Enrollment
Credentialing
Contracting
Payments
AMH Requirements
Changing how Medicaid
benefits are delivered
From predominantly fee-for-service program to Medicaid managed care
model

14. Provider enrollment and credentialing
Provider Participation
Providers must be enrolled as a Medicaid or NC Health Choice provider to be paid for services to a Medicaid beneficiary
Credentialing is a central part of the federally regulated screening and enrollment process
2016 Medicaid Managed Care Final Rule 21st Century Cures Act
Enrollment process similar to today
Centralized credentialing and recredentialing policies uniformly applied
Nationally recognized, third- party credentials verification organization (CVO)
NC Medicaid Transformation website:

15. Network adequacy
PHPs must maintain sufficient provider networks for adequate access to covered services
The Department will develop network adequacy standards; e.g., time/distance, “realized access”
Law requires PHPs to contract with all
“essential providers”
Building provider networks is a standard business operation for health plans

16. Centralized credentialing-full implementation

17. Management for High-need Enrollees
Population health: care management
PHPs will be responsible for care management of enrollees
Care
Care Needs
Screening
Risk Scoring &
Stratification
Comprehensive
Assessment
Management for High-need Enrollees
Under AMH, PHPs delegate primary responsibility to practices, when practices certify into
higher AMH tiers

18. Transition plan for Carolina ACCESS practices
ELIGIBILITY FOR AMH PROGRAM
NOT AMH ELIGIBLE
AMH TIER 1
CERTIFIED
(will phase out after 2 years)
AMH TIER 2*
AMH TIER 3
CAROLINA ACCESS STATUS
NOT PARTICIPATING IN CA
Default placement
Not permitted
If successfully attests to
Tier 2
requirements
If successfully attests to
Tier 3 requirements
CA I
Choose:
Not to contract as an AMH, OR
Notify DHHS to be removed from master list
Notify DHHS to be placed into Tier 2
CA II
*Tier 2 requirements are same as Carolina ACCESS requirements
**CAI providers are already meet Carolina ACCESS requirements

19. Tier 3 AMH oversight roles/responsibilities
DHHS
Place CM requirements in contract
Conduct oversight/monitoring of PHPs
Develop attestation; require PHPs to have selected terms/conditions in PHP/AMH contract
Certify AMH practices
DHHS
Contract
Establish specific terms/conditions in PHP/AMH contract
PHPs
PHP
Contract
Attest to requirements
Contract with PHPs and, if applicable, CIN
AMHs
AMHs
AMHs
AMH
Contract
Support Tier 3 AMHs in meeting requirements
Contract with AMHs
CLINICALLY INTEGRATED NETWORK (CIN)
The Department does not place direct requirements on CINs or have an attestation/certification process for CINs

20. Core Public Health Clinical Services vs Advanced Medical Home
AMH in LHD
Fee-for-service in FP, CH, MH, IMM, CD, other
Provides clinical services that are not in a medical home model
Pts may need a medical home for f/u
Pts may have a medical home to connect with
Pts may want confidential services
Some federal/state funding
Cost settlement (carved out services or populations)/kick-payments
24/7 after hours line may be for PH emergencies rather than one-on-one patient follow-up
Doing what we’ve always done, but better connection with AMH will be essential
Patient medical home – provides preventive and sick care
No federal/state funding except in child health, special grants, FQHC
24/7 access to nurse or provider on call, ideally with access to health record
Relationship with hospital for inpatient and ED visits as needed, including f/u
Still have Cost settlement (carved out services or populations)/kick-payments
Moving toward outcomes based payment based on clinical reporting
Care management provided directly or via contracting with a Clinically Integrated Network (CIN)

21. What to do next?
If your business and community health planning reflects more emphasis in moving toward PH 3.0, i.e. continued fee-for-service model
Connect with patient’s AMH, when appropriate
Carefully consider clinic staffing needs vs care management opportunities and other community health work when budgeting
Regular clinic service reporting is essential
Capacity (next available appointment)
Customer satisfaction (really, in all we do)
Trends in volume of unduplicated patients and in encounter level visits

22. What to do next? Decision time for AMH.
If your business and community health planning reflects a need for your LHD to continue in primary care for adults and/or children
Access training
Evaluate capacity
Consider a Clinically Integrated Network
Validate sustainability with current payer mix
Connect with your patients to assure their connection to you for Medicaid, medical home, preventive health services

23. What next:
Consider gap analysis for clinical services – include other safety net providers, clients and hospital system, if applicable.
Consider budget – analyze dollars to compare PH funding toward clinical services compared to population health. What should that ratio actually be?
Know your clinical services trends, challenges, costs
Board involvement is essential.
External stakeholder relationships are essential
Communication, communication, communication

24. What’s next for DPH? Facing the same challenges!
Evaluation of agreement addenda deliverables
Siloed funding is a limiting factor
Data analytics, statewide (LHD Health Services Analysis and Aid-to-County reporting system (WIRM)

25. References
Auerbach, J. (2016). The 3 buckets of prevention. Journal of Public Health Management and Practice 22(3), 215– 218.
DeSalvo, K. B., O'Carroll, P. W., Koo, D., Auerbach, J. M., & Monroe, J. A. (2016). Public health 3.0: Time for an upgrade. American Journal of Public Health, 106(4), doi: /AJPH
National Association of City and County Health Officials. (2016) NACCHO Public Health 3.0 Issue Brief.

26. Questions, discussion, hopes, dreams…..
Beth Lovette –
Phyllis Rocco –
Dennis Williams –