1. 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

2. Acknowledgements
Funder: Maternal and Child Health Bureau, Health Services and Resources Administration, USDHHS, U45MC27709

3. Background

4. 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

5. 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 ( )
Awarded to state and local governments, tribal organizations, community groups, schools, etc.
*Available to states with Federally-Facilitated & State Partnership Marketplaces

6. Project Objective
Identify best-practices to increase access to and utilization of insurance enrollment & preventive visits among AYAs

7. Methods

8. Project Steps Identify top performing states Develop survey protocol
Recruit key stakeholders
Conduct Interviews
Analyze Data

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. Results: Outreach & Enrollment

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

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

18. 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.

19. 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.

20. 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, March 31, )
Source: Atkinson-Travis, 2014.

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

22. 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.

23. 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

24. 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

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

26. 3 States utilized innovative youth engagement strategies
Policy
Marketing
Outreach

27. 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

28. Source: Oregon Health Authority, 2011.

29. 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

30. Results: Preventive Care Visits

31. Major Themes: Preventive Care Visits
Commitment to Bright Futures Guidelines Focus on Medical Homes Capacity-Building

32. Major Themes: Preventive Care Visits
Commitment to Bright Futures Guidelines Focus on Medical Homes Capacity-Building

33. 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.

34. Major Themes: Preventive Care Visits
Commitment to Bright Futures Guidelines Focus on Medical Homes Capacity-Building

35. 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.

36. 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.

37. Major Themes: Preventive Care Visits
Commitment to Bright Futures Guidelines Focus on Medical Homes Capacity-Building

38. Capacity-Building Vermont
Youth Health Improvement Initiative
Started in 2001 to support pediatric and family practices to improve preventive services delivery for youth ages
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;_____________

39. 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.

40. 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

41. Influencing AYA Health Care: Where Can CoIINs Make a Difference?
Providers
Local Government
Agency Networks
State
Federal

42. 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

43. References
2014 Annual Report. START (Screening Tools and Referral Training): Oregon Pediatric Society. content/uploads/2015/07/Annual-Report-Year pdf. Accessed on September 10, About All Kids. ALL Kids: State of Illinois. Accessed on September 17, Askelson, N, Gikembiewski, E, Turchi, J, Elchert, D, Tegegne, M. Report on evaluation of Iowa’s CHIPRA II outreach and enrollment project Available at 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. Early and Periodic Screening, Diagnostic, and Treatment (EPSDT). Colorado Department of Healthcare Policy and Financing. Accessed on September 10, Fast Facts about the Colorado Medical Home Initiative. WONDERbabies, University of Colorado Denver. Accessed on September 10, Illinois. Patient-Centered Primary Care Collaborative. Accessed on September 10, Iowa Department of Human Services. Annual report of the hawk-i board to the governor, general assembly, and council on human services Available at 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): National Adolescent and Young Health Information Center, University of San Francisco. National Survey of Children’s Health [private data run] Centers for Disease Control and Prevention. Available at:

44. References, cont.
States & Communities. Bright Futures, American Academy of Pediatrics. communities/Pages/default.aspx#. Accessed on September 10, Youth Health Improvement Initiative (YHII). Vermont Child Health Improvement Program (VCHIP): The University of Vermont. Accessed on September 10, 2015.