Meeting 2

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September 25, 2017

Welcome & Logistics

Chad Shearer, Vice President for Policy, United Hospital Fund

Raising a Hand via Webinar

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Chair´s Welcome

Nancy Zimpher, Co–Chair, First 1000 Days on Medicaid

Work Group Leadership

Chair:

Nancy Zimpher, Chancellor,
The State University of New York

Vice Chairs:

Kate Breslin, President & CEO,
Schuyler Center for Analysis and Advocacy

Jeff Kaczorowski, MD, Senior Advisor,
The Children´s Agenda

Commissioner:

MaryEllen Elia, New York State Education Department

Agenda and Goals

Chad Shearer, Vice President for Policy, United Hospital Fund

Reminder

  • ☒ The "First 1000 Days on Medicaid" initiative will be a collaborative effort, bringing together stakeholders to develop recommendations for a ten–point plan.
  • ☒ Builds off of the successful VBP Advisory Group on Children´s Health.
  • ☒ The group´s ten–point plan will focus on improving outcomes and access to services for children in their first 1000 days: the most crucial years of their development.

Meeting Agenda

Item # Agenda Items Time Duration
1. Welcome and Logistics 1:00pm 15 mins
2. Chair´s Welcome & Goals 1:15pm 10 mins
3. DOH and SED Updates 1:25pm 10 mins
4. Review of Process & Considerations for Today 1:35pm 10 mins
5. Presentation and Discussion of Ideas 1 – 7 1:45pm 75 mins
6. Break 3:00pm 15 mins
7. Presentation and Discussion of Ideas 8 – 14 3:15pm 65 mins
8. Big Picture Reflections 4:20pm 25 mins
9. Next Steps and Closing 4:45pm 15 mins

Goals for the Day

You´ve provided thoughtful input – and a lot of it. Thank you! Now we have to balance refining ideas while still exploring promising new approaches.>

Today´s goals are to:

  • Review a synthesis of your comments and ideas
  • Offer questions and refinements to the presented ideas
  • Identify important solutions that may have been omitted
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DOH Update

Jason Helgerson, Deputy Commissioner and Medicaid Director, NYSDOH

SED Update

Commissioner MaryEllen Elia, New York State Education Department

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Review of Process to Date

Kate Breslin, Vice–Chair, First 1000 Days on Medicaid

Where We´ve Been

  • Kick–off discussion on August 7th set the foundation for idea generation and led into an initial brainstorm
  • Initial brainstorm was organized and shared broadly
  • Workgroup members were invited to comment on initial brainstorm and add new ideas for consideration
  • In review, some solutions cross–pollinated against initially defined problem areas. Leadership team took this as an opportunity to look anew and re–categorize.
  • Synthesized into 14 ideas based on:
  • Evidence–base
  • # of comments
  • Path to recommendation that seemed feasible, non–duplicative, high impact
  • Cohesiveness as a set

Reminder: Pathway to Creating a Recommendation

  1. What is the problem we are trying to resolve? What are the barriers preventing Medicaid and partners from achieving our goals?
  2. What could work? What are the potential solutions to the identified issue?
  3. Which solutions can Medicaid effect? What Medicaid system levers could be used to implement the solutions(s)?
  4. What´s the measurable outcome that will be achieved if this solution is implemented? How does it fit into the framework?
  5. What´s the recommendation? How would a recommendation be framed given all of the above? What should Medicaid do?

Considerations for Today

Jeffrey Kaczorowski, Vice–Chair, First 1000 Days on Medicaid

Where We´re Headed

  • Today we are going to present 14 ideas
  • We need focused discussion of:
    • Opportunities to address issues in a cross–sector fashion, or more cross–sector ideas that have not been raised yet.
    • The details of operationalizing these ideas:
      • Degree of difficulty
      • Degree of investment
      • Degree of collaboration
    • Missing approaches/considerations for each idea
  • At the end, we´ll reflect as a whole: Any big missing issues?

Progress Grid

Each idea contains a grid at the bottom indicating where steps on the pathway are complete, incomplete, or has several options.

Problem, Idea, Lever, Outcome, Full Rec.

Each column will use this shorthand:

  • Y = complete
  • N = incomplete
  • S = several options
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Presentation & Discussion 1 – 7

Nancy Zimpher, Chair, First 1000 Days on Medicaid
Chad Shearer, Vice President for Policy, United Hospital Fund
Suzanne Brundage, Program Director for Children´s Health Initiative, United Hospital Fund

Summary List

  1. Support connections to local preventative services for young children
  2. Support parents ability to meet developmental needs
  3. Build infrastructure for addressing social determinants of health
  4. Bolster prenatal care supports
  5. Aim for Kindergarten Readiness
  6. Improve training on early childhood mental health and development
  7. Create regulatory relief with a focus on services for children
  8. Support home visiting
  9. Track developmental screenings across sites
  10. Make improvements to Early Intervention
  11. Expand value–based payment to CHIP
  12. Encourage managed care plans to have a "Kids Agenda"
  13. Strengthen the early childhood workforce
  14. Insure all kids

Seeking Feedback in Three Areas

  • Opportunities to address issues in a cross–sector fashion, or more cross–sector ideas that have not been raised yet.
  • The details of operationalizing these ideas:
    • Degree of difficulty
    • Degree of investment
    • Degree of collaboration
  • Missing approaches/considerations for each idea

1. Support Connections to Local Preventative Services for Young Children

Support or develop local care coordination/ intake services that specialize in preventative connections for young children, including home visitation services, which providers and families can contact for information and for support in accessing programs.

Potential approaches:

  • Spread one intake approach, like Help Me Grow or GROW (Rochester), to other localities
  • Support and strengthen existing local intake/referral pilots
  • Expand and augment Growing Up Healthy Hotline/2–1–1
  • Examine and strengthen connection between local health care providers and education networks/resources to ensure increased opportunities to connect with parents/families of at–risk young children

How? Funding, 2–1–1 contract changes

Problem Idea Lever Outcome Full Rec.
Y S N N N

2. Support ability of parents to meet developmental needs

Meet parents where they are and develop opportunities in those locations to support them in meeting the developmental needs of their children.

Potential approaches:

  • Defining an Advanced Pediatric Primary Care model that proactively engages parents
  • Support incorporating a Healthy Steps practitioner into pediatric practices
  • Select 1 or more evidence–based parental support programs (Triple P, Video Interaction Project, etc.) to scale–up
  • Work cross–sector to establish promotional messaging around parenting, especially early literacy, that is reinforced in all settings

How? Convening power, managed care contracts, provider and community education, new SPA services

Problem Idea Lever Outcome Full Rec.
Y S S S N

3. Build infrastructure for addressing social determinants of health (SDH)

Support the capacity to screen for SDH, capture SDH needs during primary care visits through the medical record, and make successful referrals.

Consider:

  • Use of non–clinical providers
  • Bulk purchasing of an information technology tool and providing it to health care and social service providers with training
  • Building a non–personal health information ´tier´ to the Regional Health Information Exchanges to share information between health care providers and community organizations
  • Using z–codes (a type of medical reporting code) to create a database of social risks facing young children
  • Leveraging available data sources to assess housing instability for Medicaid population

How? Funding, provider education, regulatory changes, data collection

Problem Idea Lever Outcome Full Rec.
Y? S S S N

4. Bolster prenatal care supports

Help women have healthier pregnancies and better birth outcomes.

Potential approaches:

  • Support the expansion of Centering Pregnancy (a group–based model of prenatal care)
  • Work with managed care plans to ensure all high–risk pregnant women have an assigned care coordinator, who could be from the health plan or from a community organization.
  • Extend health insurance coverage for pregnant women up to 24 months to ensure continuity of coverage during the intrapartum years.
  • Create a Health Homes model (a care coordination model) for pregnancy/early childhood

How? Managed care contracts, quality improvement plans, Prenatal Care Assistance Program, financial incentives

Problem Idea Lever Outcome Full Rec.
Y S S S N

5. Aim for Kindergarten Readiness

Convene and co–lead an inter–agency process to create a standardized Kindergarten Readiness measure. Encourage the development of local collective impact strategies around Kindergarten Readiness with active Medicaid provider and plan participation.

How? Convening power, provider and plan guidance, funding

Problem Idea Lever Outcome Full Rec.
Y Y S Y N

6. Improve training on early childhood mental health and development

Create Early Childhood ´Boot Camps´ to train providers and managed care staff in core concepts related to early childhood development, including risks and protective factors, infant and early childhood mental health, ACEs, and trauma–informed care that is responsive to culture, race, ethnicity, and language.

Consider:

  • Leveraging cross–sector expertise and leadership to develop training
  • Developing at least one module on the opioid epidemic´s impact on children and families

How? Provider training

Problem Idea Lever Outcome Full Rec.
Y Y Y N N

7. Review regulations and policies with a focus on services for children

Convene a Regulatory Modernization Task Force on issues related to early childhood health and development, potentially focusing on issues most relevant to infant and early childhood mental health (remote consults, billing for dyadic therapies, etc.).

How? Convening power, review of existing statutes, regulations, billing and reimbursement policies.

Problem Idea Lever Outcome Full Rec.
Y Y Y N N
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Break

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Presentation and Discussion of Ideas 8 – 14

Nancy Zimpher, Chair, First 1000 Days on Medicaid
Chad Shearer, Vice President for Policy, United Hospital Fund
Suzanne Brundage, Program Director for Children´s Health Initiative, United Hospital Fund

8. Support home visiting

Potential approaches:

  • Support the development of a common home visiting training that all home visiting staff would benefit from, regardless of which program model they work for. Support a staff person to organize and deliver training.
  • Conduct a study on the barriers to enrollment in home visiting services, and develop a plan in partnership with Maternal, Infant, Early Childhood Home Visiting colleagues to decrease unused home visiting slots.
  • Provide payment for evidence–based home visiting programs and promote their use in partnership with Maternal, Infant, Early Childhood Home Visiting colleagues

How? convening, funding, 1115 or 1915(b) waiver

Problem Idea Lever Outcome Full Rec.
S S S S N

9. Track developmental screenings across sites

Initiate a Developmental Registry Project that uses immunization registries as a model or infrastructure for a statewide developmental screening registry.

Consider:

  • Limiting use to one (or a few) standardized allowable developmental screening tool(s)
  • Enabling screening to be done in multiple clinical and community locations, with results accessible by health care providers, agencies working with families, and early care and education providers.

How? Convening, provider guidance, funding

Problem Idea Lever Outcome Full Rec.
Y Y N Y N

10. Make Improvements to Early Intervention

Take a multi–faceted approach to reduce wait–times and other barriers to enrollment and service receipt in Early Intervention (EI), and improve transitions to Committees on Preschool Special Education (CPSE).

Consider:

  • Carving EI services into Medicaid managed care
  • Network requirements to ensure adequate provider supply
  • Provider education to encourage referral to open EI slots, especially in areas with racial or ethnic disparities in access
  • ´Presumptive eligibility´ for children just below, but likely to soon exceed, the EI screening threshold
  • Service coordination to assist parents with the transition/referral process from EI to CPSE
  • Strengthen the availability and sharing of interagency data to better predict the program/provider needs for children transitioning from EI to CPSE
  • Strengthen communication between EI and CPSE service providers to ensure effective collaboration throughout the transition process from EI to CPSE

How? Administrative changes, managed care network requirements, provider education, data sharing

Problem Idea Lever Outcome Full Rec.
Y S N N N

11. Expand value–based payment to Child Health Plus

Extend the opportunity for Child Health Plus (a type of insurance coverage) plans and providers to participate in value–based payment arrangements that might encourage more effective pediatric primary care for young children by allowing them to enter into pediatric primary care capitation arrangements consistent with Medicaid value–based payment.

How? Medicaid management of the Child Health Plus program

Problem Idea Lever Outcome Full Rec.
Y Y Y Y Y

Draft Recommendation text (11)

Few providers and managed care plans currently operate in a system that incentivizes and provides adequate flexibility for effective pediatric primary care that promotes healthy development, especially for children ages zero to three. The state should extend the opportunity for Child Health Plus plans and providers to enter into pediatric primary care capitation (PPCC) arrangements, consistent with recommendations of the Medicaid Value– Based Payment Workgroup. The state should formalize the availability of this option in CHP plan contracts, and include CHP plans and providers in PPCC educational initiatives. The success of this recommendation should be measured by the percent of children in Child Health Plus that are attributed to a PPCC model.

12. Encourage managed care plans to have a "Kids Agenda"

Encourage managed care plans to focus on young children by requiring that MCOs focus on at least one state–defined early childhood health and development outcome as part of their quality improvement plans.

Consider:

  • Additional incentive for quality improvement plans that engage non–health sectors

How? Quality improvement plans, managed care contracts

Problem Idea Lever Outcome Full Rec.
Y Y Y S Y

Draft Recommendation text (12)

Given the average low cost of the child population in Medicaid, managed care plans do not have sufficient incentive to focus on children, particularly those between ages zero and three. The Office of Health Insurance Programs should utilize the processes available under the Medicaid Managed Care Model Contract (Sections 18.5–x and 16.1–b) to identify a small subset of early childhood health and development outcomes that need to be improved, and encourage managed care organizations to work with the external quality review organization on internal performance improvement projects consistent with the model contract language. The success of this recommendation should be measured by the percent change improvement in the selected outcomes.

13. Strengthen the early childhood workforce

Examine workforce issues and concerns specific to early childhood services and create interagency and cross–sector partnerships - working with universities, offering loan repayment, etc. - to strengthen the early childhood workforce pipeline.

Consider:

  • Options for expanding early childhood specialists
  • Options for developing roles for frontline public health workers such as Early Childhood Community Health Workers
  • Options for reducing shortages in pediatric primary care professionals

How? Partnerships, Primary Care Service Corps Loan Repayment Program?

Problem Idea Lever Outcome Full Rec.
Y S N N N

14. Insure all kids

Create an "Insure All Kids" Taskforce charged with identifying ways to insure the remaining children in New York that do not have health insurance and therefore achieve a 0% uninsured rate for children in New York. The task force would partner with stakeholders, identify all uninsured kids, identify ways to address barriers, and get kids into coverage.

How? Convening; provider, managed care plan and community outreach; potential administrative changes

Problem Idea Lever Outcome Full Rec.
Y Y Y Y Y

Draft Recommendation text (14)

In 2016 an estimated 101,066 New York children did not have health insurance. The State should set a goal of achieving a 0% uninsured rate for children and establish an "Insure All Kids" Taskforce to identify all uninsured kids, pinpoint ways to address barriers to them accessing coverage, and work with partners to get all kids into coverage. The success of this recommendation should be measured by the reduction in the number of uninsured children.

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Big Picture Reflections

Kate Breslin, Vice–Chair, First 1000 Days on Medicaid
Jeffrey Kaczorowski, Vice–Chair, First 1000 Days on Medicaid

Big Picture Feedback

Keeping in mind that we are looking for a well–balanced, cohesive set of 10 recommendations (and that we are proceeding forward with refining and exploring the above 14)...

What "doable and high impact" ideas are missing?
Have we sufficiently addressed cross–sector opportunities?

Reflections

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Next Steps & Closing

Nancy Zimpher, Chair, First 1000 Days on Medicaid

Meeting Dates

  • October 11, 11am – 3pm (webinar)
  • November 1, 11am – 3pm (in–person, Albany)

Next Steps

  • Leadership team will process today´s feedback
  • Please send us:
    • Ideas for additional approaches, and specific levers, outcomes, and recommendation formulation for 1 – 14
    • New ideas – especially cross–sector ideas we may have missed

Contact Information

Chad Shearer
Vice President for Policy Director, Medicaid Institute
cshearer@uhfnyc.org (212) 494–0793
@chadeshearer

Suzanne Brundage
Program Director, Children´s Health Initiative
sbrundage@uhfnyc.org (212) 494 – 0729@suzbrundage

Join the conversation on twitter: #First1KDaysNY @NewYorkMRT

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