KATCH-ing the Uninsured: Lessons from Kansas’ Out-stationed Eligibility Workers

To increase their capacity to reach uninsured individuals, many states utilize out-stationed eligibility workers to help enroll individuals into Medicaid. “Out-stationed” at community-based organizations (e.g. health centers, clinics, hospitals, schools, community centers), these workers enable individuals to apply for public assistance benefits at locations other than the typical Medicaid or social services offices; optimally in locations that are more geographically accessible to potential consumers than state or county offices might be.

Through support from the SHAP grant, the Kansas Access to Comprehensive Health Project (KATCH) hired, trained, and placed 12 out-stationed eligibility workers in communities throughout the state (target populations include Hispanics, Native Americans, and pregnant women).  Often tasked with a breadth of responsibilities, workers primarily assist individuals and families determine eligibility and enroll in Medicaid coverage options.  These workers often split their time between 2-3 offices at various community hubs while also spending time throughout their designated community to spread information and awareness at local events, such as health fairs, and to build relationships with key leaders at local elementary and high schools. When necessary, some workers also conduct home visits for hard to reach, often elderly, individuals.

Kansas’ out-stationed eligibility workers have largely been successful in the enrollment of eligible populations, processing approximately 5,000 applications to enroll nearly 7,000 individuals since the program began.  One key success of the program has been the ability of workers to conduct outreach efforts while also establishing connections with community stakeholders. Clinics and health centers have been especially receptive to this program, as workers have served to not only connect patients with coverage, but also to develop relationships, build education, and improve health care access among patients.  For instance, in the case of one tribe served by an eligibility worker, it was discovered that most health care needs of the tribal members were absorbed by the tribal health center, prompting many members to only apply for coverage when they needed specialty care outside of the tribal center. After placement of the eligibility worker in that health center, staff noted the positive impact of having someone available to build trust and share information with tribal members so that, in turn, tribal members would be more likely to apply for available programs before they were in need of specialty services. (Click here,  here, or here for some additional resources detailing enrollment strategies across states.)

Kansas continues to evolve the work of its out-stationed program, leveraging lessons from a recent audience analysis to enhance outreach practices, as well as researching better ways to track enrollment and disenrollment information through the eligibility process. Kansas has also learned many valuable lessons from the project about the unique needs and challenges of various populations in navigating current state eligibility processes. For example, the hiring of bilingual out-stationed workers greatly benefited one region of the state with a large concentration of Mexican-Americans.  For communities with large Native American populations, cultural competency was a huge barrier to enrollment, and workers who had an understanding of the traditions and unique needs of local tribes were most successful. Such lessons will be used to enhance the capacity of the state’s new eligibility enforcement system—which will provide consumers with self-service options to inquire about potential eligibility for social service programs—to work for diverse populations within the state.

Thanks to Jenifer Telshaw and Russell Nittler from the Kansas Department of Health and Environment for their input on this blog. For more information about the work of Kansas or any other SHAP state to increase enrollment, please be sure to check out some of our previous blogs, or you can contact a member of our SHAP team directly.

There’s this one cool thing…. : Nevada Rural Mental Health Pilot Project

As SHAP states work to expand health insurance coverage to new populations, one of the areas that they are also addressing is provider capacity. One particular area that suffers from provider shortages is mental health, especially in rural areas. However, one SHAP state is taking a cutting-edge approach to addressing its mental health capacity issues through the use of telepsychiatry.

In 2008, the state of Nevada published “Nevada’s Mental Health Needs Assessment,” which revealed problematic areas in the state’s mental health system. Although Nevada operates rural services mental health centers in 14 communities around the state, the assessment suggested that the state needed more mental health providers to meet growing needs in rural areas in the state, which have been historically underserved. In order to improve their mental health infrastructure, Nevada created a rural mental health community-building plan, which is intended to enhance and expand access to mental health care in rural areas of the state.

Over the last year, the state used a portion of its SHAP funding to develop and implement a pilot program to improve mental health care to rural populations. The program is coordinated through a collaboration among the Division of Mental Health and Developmental Services, the University of Nevada School of Medicine, and Access to Healthcare Network (AHN), which provides uninsured Nevadans with access to care through a network of providers, and the Office of Rural Health. The state estimated that 90 percent of the state’s mental health needs could be accommodated through the existing delivery system, so it decided to build on its existing AHN network. The pilot is intended to increase access to mental health services, divert patients from hospital care, provide an initial assessment and linkages to services, and provide follow-up programs and support.

Earlier this year, the Rural Mental Health Partnership enabled three rural hospitals to upgrade their telepsychiatry systems. Currently, the pilot program has recruited a total of 27 providers, including 22 mental health counselors and 5 psychiatrists. Once participants in the pilot provide telemedicine consent, they are able to receive an evaluation through telepsychiatry and prescription medication if needed. Staff in the rural services clinics are also available on stand-by to provide support for the recommendations from the psychiatrist.

In July 2011, the three rural hospitals began seeing patients via telepsychiatry. Typically, a patient will arrive in an emergency room and then will be screened for triage, which includes a risk assessment. If a psychiatrist is unavailable, a telepsychiatry appointment is scheduled and the patient is transported to a rural services office where the appointment takes place. The hospital faxes the patient’s referral and information to the rural services office in advance of the appointment. During the pilot program, it usually took, on average, an hour and 15 minutes between the time the referral form was faxed by the hospital and when the patient received a telepsychiatry appointment.

Since then, wait times have been reduced in rural mental health clinics by approximately 56 percent and over 98 telepsychiatry appointments have been conducted. While the state plans to conduct a full evaluation, initial results from the program suggest that the telepsychiatry approach is increasing access to mental health services and easing the burden on rural clinics. The state also found that building communications with the hospitals was an important factor during implementation. Other states that experience access issues for mental health services in rural areas may want to consider taking Nevada’s approach.

A Look at What’s Ahead for ACA Implementation in 2012

It’s been a busy year for states that are implementing various provisions of the Affordable Care Act and getting ready for enrollment expansions and other health system changes that are coming in 2014. In 2012, states are sure to be busy with continuing implementation activities geared toward establishing insurance exchanges and preparing for Medicaid expansions, among others.

In addition, several new ACA requirements and options go into effect in 2012, many aimed at payment reforms and quality improvements in the healthcare delivery system. Within the Medicare program, big developments in 2012 include accountable care organizations (ACOs), bonus payments for high-performing Medicare Advantage plans, hospital value-based purchasing, and reduced payments for preventable hospital readmissions. Similarly, Medicaid will institute new fraud and abuse prevention measures, and fund demonstration projects on bundled payments and pediatric ACOs. And new reporting requirements to reduce health disparities also go into effect.

As we head into 2012, the health wonk blogosphere is beginning to speculate on what the year may hold. Here is a sampling to peruse as you count down to a happy new year!

• The Center for Children and Families projects a positive outlook for 2012 with state budgets growing and Medicaid enrollment increases slowing.

• PWC lists the top health industry issues for the year. How do they compare to your state’s priorities?

• The New England Journal of Medicine takes a look into the political crystal ball to speculate on possible 2012 election scenarios and their effects on ACA implementation.

All of us on the NASHP SHAP team wish all of you a very happy 2012 and look forward to continuing to work with you into the spring.