North Carolina’s Role in the Safety Net System

1. North Carolina’s Role in the Safety Net System Building, Supporting, and Integrating Since 1973

2. The number of North Carolina residents younger than 65 who don’t have health insurance jumped 22.5 percent in a five-year stretch ending in 2010. About 1.6 million people, or almost one in five state residents, didn’t have health insurance, up from about 1.3 million. N.C. Institute of Medicine Source: NC Rural Economic Development Center, Inc.

3. Purpose Statement: The North Carolina Office of Rural Health and Community Care (ORHCC) assists underserved communities and populations to develop innovative strategies for equal access, quality, and cost-effectiveness of health care for all. • Principles: • Work with communities to meet the health needs of all underserved residents • Foster state and local partnerships with ownership vested in communities • Provide in-depth technical assistance on an ongoing basis • Assure clear and measurable accountability • Seek to eliminate health disparities

4. Building Rural Health Centers • Rural Health Centers (Total of 83 since 1973) • Non-Profit (501(c)3 corporations) • Community-owned with local board of directors • Capital funding (state to local match) • Work Force: From single mid-level practitioner to multiple physicians in multi-location networks • Infrastructure/Facilities • Technical Assistance: Provide comprehensive and targeted technical assistance in the development and operation of primary care practices serving underserved residents • Services include but are not limited to: market analysis, financial analysis, organizational analysis, practice development, practice management, clinical protocols, electronic health record implementation, and architectural design • Recently expanded beyond medical services to include dental and behavioral health services

5. Financially Supporting the Infrastructure • Safety Net System is comprised of community health centers (CHCs), rural health clinics and centers (RHCs), local health departments (LHDs), school-based/linked health clinics (SBHCs), free clinics (FCs), and critical access hospitals (CAH) • CHCs, RHCs and SBHCs receive federal resources • FCs in North Carolina receive significant support from Blue Cross Blue Shield • ORHCC receives federal funds to support CAHs • ORHCC providers support to 25 state-funded RHCs • In SFY 10, $1,802,838 used to fund primary care services to uninsured individuals under 200% of poverty and $809,799 for operational subsidy

6. Financially Supporting the Infrastructure • Operate a federally-funded migrant health voucher program that contracts with local safety net systems and accesses 340B prescriptions • Grantees provide outreach to farmworkers (case management and health education) and improves access to primary care services (after hours and mobile clinics) • ORHCC provides technical assistance and on-site monitoring • Leverages and builds on existing local primary care resources by partnering with 13 safety net sites including: RHCs, CHCs, LHDs, FCs, hospitals, and other community-based organizations

7. Supporting the Workforce • HPSA Designations: Began with medical designations and has been expanded over the years to include dental and mental health designations • Recruitment:Threefull-time recruiters: • Recruit primary medical, dental, and psychiatric providers for ANY safety net or private provider committed to serving vulnerable populations • Secure a candidate pool from in-state residencies, nationwide mailings, and national clinical meetings • Provide personal contact with providers and communities to assure quality matches • Provide travel assistance to sites for provider and spouse • Track provider placement and retention

8. Supporting the Workforce • Loan Repayment: • Makes optimal use of National Health Service Corps resources • Offers NC incentives to providers locating in areas of greatest need (loan repayment or high needs service bonus) • Requires provider to serve underserved populations

10. Documenting the Return On Investment (ROI) • Analysis of the benefit of ORHCC recruitment efforts on North Carolina’s economy: • The total value of revenue generated from the 129 primary medical, dental, and psychiatric placements in SFY 2011 is $47.8 million • The 129 placements resulted in approximately 382 jobs • In SFY 2011, the total cost of the recruitment program, including incentives, was $2,471,934 9, yielding a ROI of 19.3 to 1. If only the state appropriation is considered, the ROI is 22.8 to 1.

11. Supporting and Funding Key Resources • ORHCC Prescription Assistance Program provides prescription assistance software and technical assistance to community practices wanting to assist their low-income, uninsured residents in obtaining free prescription drugs. • ORHCC distributes and supports prescription assistance software, which accesses drug manufacturers’ free drug programs, in 120 safety net sites • Since 2003, ORHCC has secured approximately $694,604,154 in free medications through the Medication Assistance Program, which serves 160,000 low-income and uninsured patients • This total includes $180,681,291 in mental health drugs (antidepressants, antipsychotic, and other miscellaneous mental health medications) • In SFY 11, the ROI is approximately 44:1 • ORHCC contracts for prescription assistance coordinators in 59 sites • Provides technical assistance through training sessions, on-site visits, and software support

12. Integrating Rural Hospitals and EMS • To develop new networks and financial arrangements that can improve quality of services and financial sustainability • Provide technical assistance and funding to 23 certified CAHs and 33 small, rural hospitals in the state • Annual Southeastern CAH meeting (NC, SC, GA, FL) • NC Consortium for Medication Safety in 33 hospitals • Project for Critical Access for Pediatric Emergencies (CAPE) in 5 hospitals • Regional Health Information Technology development • Lean implementation with remarkable results in rural hospitals • Redesign of systems of care for all time-sensitive illness and injury • Statewide access to EMS group purchasing (500+ providers) • Community Paramedics pilot in Montgomery County • EMS Voluntary Event Notification Tool (EVENT) was launched to allow those involved with emergency care to anonymously report if a medical error occurred

13. Funding Collaborative Activities • Legislatively-mandated Community Health Grants are available to safety net providers, including: CHCs, FCs, RHCs, SBHCs, LHDs, and CAHs. These providers along with other key stakeholders form the Safety Net Advisory Council (SNAC), which has a significant role in RFA design and selection of grantees. • Historically, these grants were funded by non-recurring funds and primarily funded individual safety net capital projects • Advocates secured recurring funding and focus shifted to expanding scope to clinical services. Awards moved to a three-year cycle to allow for sustainability. • Most recent new awards focused on safety nets’ ability to share data via an established mechanism with the NC Health Information Exchange (NC HIE).  This data sharing capability allows many safety net providers to qualify for the incentives offered through the Center for Medicare & Medicaid Services (CMS) for Electronic Health Records (EHR) meaningful use (and avoid the financial penalties in later years for noncompliance). 

14. Funding Collaborative Activities • The Community Health Grant HIE Initiative will allow the safety net system to address a shared need and moves the entire system forward in an organized manner. • Provides funding to essential primary medical care safety net providers (CHCs, RHCs, SBHCs, FCs, and LHDs) through their established non-profit foundation or association • Funding will support equipment (hardware and/or software) and connection costs required for a qualified safety net provider to link to the NC HIE. 

16. Map is available at:http://batchgeo.com/map/2c0e698a6095baac51335da8823164d7

18. Integrating the Safety Net System for Medicaid • In 1998, ORHCC and Medicaid began linking the safety net system, private primary care practices, hospitals, departments of social services, and public health departments through regional networks called Community Care of North Carolina (CCNC). The providers received a per member per month payment (pm/pm) to be the medical home in addition to their fee for service. • Networks receive a pm/pm payment for: disease management, care coordination, clinical directors, pharmacists, psychiatrists/behavioral health, quality improvement, and Informatics/Data/Software. This allows the partners to join together to provide high quality care, reduce utilization, and improve outcomes for a shared population. • Networks and practices, which include safety net providers, receive performance data on their assigned populations. This model of Medicaid managed care is considered an enhanced primary care coordination model.

20. Leveraging the Integrated System for the Uninsured • ORHCC’s HealthNet program funds CCNC Networks that utilize the infrastructure Medicaid built to organize a system of care for the uninsured within the community. Most of the providers in safety net system serves the Medicaid population and therefore, they are already members of CCNC. HealthNet brings free clinics and school-based health clinics to table. • HealthNet funds are used to fill in the gaps identified for the safety net community: • Enrolls patients who are up to 200% of poverty for donated care • Organizes a system of donated primary and specialty care • Funds care managers for uninsured (approximately 50) • Allows for local needs and flexibility • Funds some direct services (dental/behavioral health/FNP) • Addressed high-risk /high cost individuals

22. Documenting the ROI • Fee for service payments – Uninsured networks offer the unique opportunity to design a system of care that is built around patient need vs. patient payment • A local community in western NC targeted patients “with complex behavioral health and medical problems [that have a disproportionate impact on emergency departments].” • Emergency department use dropped from a rate of 0.58 per patient per month to 0.23 (P < .001) • Hospital charges dropped from $1,167 per patient per month to $230 (P < .001) • Employment status increased from 4 to 14 among the 36 patients enrolled • Total annualized cost of the program - $66,000 • JABFM article: http://www.jabfm.org/content/25/2/184.full.pdf+html

23. Key Principles • Focus on supporting the work of the local communities and improving the system of care for underserved populations • Be a neutral convener and a good partner • Collaborate, coordinate, align ,and integrate with any willing partner: • Academic Centers • Associations • Corporations • Foundations • Non-profits • Providers • State and Federal Partners • Provide some flexible funding

24. State government cannot merely issue edicts or dangle money; it has to engage in meaningful partnerships, be prepared to make long-term investments in communities, and nurture the leadership needed to deliver the desired improvements. Jim Bernstein

25. Chris Collins, MSW, Deputy Director NC Office of Rural Health and Community Care 2009 Mail Service Center Raleigh, NC 27699-2009 Telephone: (919) 733-2040 Email: chris.collins@dhhs.nc.gov Website: www.ncdhhs.gov/orhcc/