While many organizations are just starting to deploy community health workers, the Care Transformation Collaborative of Rhode Island has been refining the community health team concept for almost a decade. In a recent interview, CTC-RI’s Linda Cabral, M.M., discussed research findings about the impact, some lessons learned and next steps.
Cabral is a senior program manager at Care Transformation Collaborative of Rhode Island, which was co-convened by the state Office of the Health Insurance Commissioner and its Medicaid authority about 10 years ago to support primary care practices in their their work toward designation as NCQA Patient-Centered Medical Homes (PCMHs). The organization provides practice facilitation to support team-based and whole-person care. “We have one of the highest percentages of patient-centered medical homes in the country,” Cabral said, “both on the adult side and the pediatric side. We continue to be in that space of supporting primary care practices in their transformation efforts, whether that be in their efforts to implement integrated behavioral health in their practice or work on a particular chronic disease management program.”
During the PCMH work, the practices identified a few key challenges. “One of the things that they kept raising was the need for a resource to work with their patients who were the most complex — medically, behaviorally and socially — to provide in-home and community-based resources to identify barriers to getting care,” Cabral said.
Modeling their work on similar efforts in Vermont, they created teams that would add a behavioral health resource and community health workers to help identify the resources in the local community, make those connections, help with the follow-up, and make sure patients have the transportation they need. With some grant funding, they began the work with two pilots in 2014.
“We had those models in operation and were incredibly successful,” Cabral said, “and as a result of that pilot of the two teams, we then expanded it to six teams across the state with some additional health plan funding and some additional CMS funding through our health systems transformation grant.”
Rhode Island ended up with two models of community health teams, Cabral explained. In the first model, the community health team partners with multiple small primary care practices. In the second model, some of the largest Federally Qualified Health Centers (FQHCs) in the state, with large patient populations, found it worthwhile to have their own dedicated community health teams.
Although it was a big lift, she said, CTC-RI recognized the need to demonstrate some positive outcomes from these interventions. One research project they worked on with the University of Rhode Island looked at both process measures as well as outcome measures. When patients first came on board to a community health team, there were some standard assessments — screening for depression, anxiety, substance use, health risk. “Those tools were administered either at discharge, or at 12 months later, so we were able to see changes in those anxiety and depression measures, substance use and health risk scores,” Cabral said.
Another study with Brown University compared a group of patients working with a community health team with a control group from the state’s all-payer claims database in terms of costs for those members over a 12-month period. The researchers found that the community health team cohort had lower overall total costs and lower emergency department costs. The annual savings per client was estimated at $4,627.
Still, there were some challenges around the financing and reimbursement with insurance in terms of making these community health team investments sustainable and scalable.
“The funding came from the health plans in a grant format to CTC-RI, which then dispersed it,” she said. That funding, which basically paid for the staff costs, ended about a year and a half ago. Most of the teams were able to sustain themselves, because things like behavioral health services are reimbursable now in Rhode Island. Community health worker services are also covered by Medicaid.
“What made this model so great and so attractive to primary care was that it was payer-blind and free to the practice and free to the patient,” Cabral said. “So, regardless of who the patients were, or their insurance status, if the provider felt they could benefit from it, they could receive it. Now, it's a little bit trickier where it’s only Medicaid people who can get community health worker services reimbursed, and then all of the collateral work that goes on for them.” Rhode Island does have Medicaid accountable care organizations (called accountable entities) that are invested in these types of teams because they see the value both financially and from a patient outcome perspective, Cabral said.
The community health teams now need to be thinking about this, not in a fee-for-service way, but they have to be thinking about it with a reimbursement model in their head, she explained. “I thought it was great when it was payer-blind and available to everybody. But the FQHCs certainly are not excluding people who are not on Medicaid from benefiting from the service. They make it work.”
She added that major payers such as Blue Cross Blue Shield of Rhode Island and United Healthcare are also making some significant investments in community health workers in the state. “But they're not funding what we modeled as community health teams,” Cabral added. “Where our community health team model is most successful and replicated almost perfectly is in the FQHC space.”
There also is an organization training and certifying new community health workers. The Community Health Workers Association of Rhode Island has developed a certification program for community health workers and a rigorous program that gives community health workers training on motivational interviewing and how to work to advance patient-centered goals. “In order to to be billable for Medicaid, you need to have that certification,” Cabral said.
Looking ahead, she said that one goal would be trying to leverage this resource for very small primary care practices with only one or two providers. “They have complex patients, but they certainly can't have a full-time community health worker,” she said. “How can we leverage geographically based teams to support primary care providers in a particular region? That's where accountable care organizations can have a centralized resource, a hub of community health workers that they can deploy to different practices as needed. I think that's the direction I see this moving towards is having this bandwidth of behavioral health clinicians and community health workers within those ACOs that they then deploy to their practices.”