Access to Care Program 

State: OH Type: Promising Practice Year: 2018

Columbus Public Health (CPH) department is charged with assuring conditions in which people can be healthy. CPH is made up of a range of programs, with an annual budget of approximately $46 million and more than 400 employees. Columbus is the state capital and the 14th-most populous city in the U.S., with a population of over 860,000. Franklin County, where Columbus is located, has been a hot spot for new Americans, and is home to the second largest Somali community and the largest Bhutanese-Nepali community in the U.S. The passage of the Affordable Care Act and expanded Medicaid have significantly benefited Columbus residents, providing more health insurance options and access to care. In 2014, CPH introduced the Access to Care program to take a systems level approach addressing discrepancies in obtaining health insurance and navigating local healthcare options. Since 2015, the program has managed enrollment services at CPH, partnering with several local agencies through memorandums of understanding to provide in-person assistance for Medicaid and Marketplace enrollment. Through this program, outreach workers have served more than 3,100 clients since 2015. In 2017, the Access to Care program obtained Qualified Entity status for CPH through the Ohio Department of Medicaid. The designation provides health department staff the option to enroll clients into Presumptive Eligibility, a temporary Medicaid coverage while a clients permanent application is processing. In 2017, the Access to Care program trained 18 public health staff on Medicaid and Presumptive eligibility enrollment. While CPH continues to operate as an in-person enrollment center, Columbus continues to face challenging health care disparities. According to the most recent data released by the Ohio Medicaid Assessment Survey, nearly 50,000 low-income (under 200% of FPL) Columbus residents remain uninsured. This is significant among minority populations, as 28% of foreign-born residents in Franklin County, regardless of citizenship or income, remain uninsured. In order to better understand the current community scope, CPH partnered with an independent research firm to conduct a landscape analysis on the availability of primary care for residents living under 200% of the federal poverty level. Researchers collected qualitative and quantitative data through reports, surveys, focus groups and stakeholder interviews. Data collection reinforced the assumption that low-income residents face significant health challenges associated with social determinants of health and lack of access to primary care. Data collection showed an overwhelming response that not having health insurance is the number one barrier to accessing primary care. In the midst of this assessment, the federal government ruled in favor of drastic funding cuts to outreach and enrollment services for the ACA. As a result, Ohio lost 70% of navigator funding, leaving residents with fewer options for in-person assistance. The culmination of issues solidified the need for CPH to organize efforts to increase health literacy. In 2017, The Columbus Health Literacy Committee was formed, bringing together agencies with shared interests of improving navigation of the local healthcare system. Since meeting, the committee has expanded its membership to more than fifteen local organizations. The committee drafted a mission statement, and developed a goal that each member complete health literacy training by December 2018. Also during this time, CPH began to evaluate internal policies and procedures by completing an organizational health literacy assessment. The goal was to identify opportunities to improve patient navigation and provider communication. This process was completed using, The 10 Attributes of a Health Literate Health Care Organization,” from the Institute of Medicine, and The Health Literacy Environment of Hospitals and Health Centers,” assessment from the T.H. Chan School of Public Health at Harvard University. The assessments examined the following environmental factors: building navigation, print communication, oral exchange, technology, and policies and protocols. The assessment was designed to help consider a broad range of issues and identify existing strengths, as well as potential barriers. Major takeaways from include the need to address inconsistencies with the departments phone system; assess reading levels on print communication; and provide ongoing training to staff on topics such as teach-back, plain language and universal precautions. Internal changes, as well as community collaboration, allow residents to have greater access to public health care. Not only will the work of the Access to Care program directly impact vulnerable Columbus residents, but implemented strategies will have a positive impact on the departments ability to meet PHAB, CLAS and Healthy People 2020 goals. Addressing health literacy directly impacts the department's strategic priorities, one of which focuses on improving access to public health care.
According to the National Assessment of Adult Literacy, only 12% of U.S. adults have proficient health literacy. Nearly 77 million people struggle with everyday health tasks, such as reading and understanding a prescription, or obtaining the right immunizations or health screenings. Low health literacy can result in lapse of coverage, medication errors and unnecessary ER visits. Resident surveys completed through our 2017 landscape analysis showed that one in three low-income residents most often go to a hospital for primary health care, with many respondents referring to emergency rooms as one-stop shops. Through our focus groups, we learned that residents are often confused about their health insurance status. Many participants noted that, at one point or another, their coverage had lapsed without their knowledge. CPH uses Healthy People 2020 as a framework for maximizing access to care both internally and throughout the community. CPH looks to address the three steps listed in Healthy People 2020's objective, Access to Health Services.” These steps include, gaining entry into the healthcare system (usually through insurance coverage,) accessing a location where needed health care services are provided (geographic availability) and finding a healthcare provider whom the patient trusts and can communicate with. Our program focuses on systems level changes, and we look to engage providers to become liaisons for our community. We believe that it's our job as a public health department to improve health literacy for our community. It's also understood that, in order to do so, our community of partners must also be health literate. The framework for our health literacy plan and recommendations are based around the Institute of Medicine's 10 Attributes of a Health Literate Health Care Organization,” which are a set of evidence-based guidelines geared toward healthcare organizations that seek to improve health literacy.
Goals of health literacy for CPH are to engage community partners in local health literacy initiatives, while examining internal health literacy practices and making the necessary changes toward becoming a health literate health care organization. In 2017, we completed a landscape analysis examining the availability of primary care. We partnered with an independent research firm to conduct data collection and propose recommendations, and the contract amounted to approximately one year of work and $98,000. The analysis looked at the availability, accessibility and affordability of primary care services in Columbus. The firm utilized existing data sources, including the Behavioral Risk Factor Surveillance System, Ohio Medicaid Assessment Survey, Census data and the American Community Survey. This information was combined with over 400 resident surveys, focus groups and stakeholder interviews. We learned where Columbus residents most commonly sought care and why. We learned that beyond increased insurance coverage and increased number of community-based provider organizations, the Columbus community has also changed over the years, becoming increasingly diverse in background, health beliefs, race, ethnicity, and geography of origin as well as geography of residence in Columbus and Franklin County. These factors created an opportunity for CPH to reassess its strategic investments and partnerships to assure access to quality primary medical care for Columbus residents who live at or below 200% of poverty. Strategies and specific recommendations that maximize the number of uninsured persons served and receiving quality primary medical care services are critical to improving the health and wellbeing of residents, as well as continued strategic, cost-effective city investment. Two strategic planning meetings were completed, inviting the participating stakeholders to share feedback on their ideal local healthcare system. By reconnecting with stakeholders, we had the opportunity to continue the conversation and planning into 2018. This landscape analysis reconnects CPH to partner agencies and redefines shared goals, as well as plan for future collaboration. CPH has decided to utilize a local collaborative to start a coalition dedicated to expanding access to care for Columbus residents. CPH will make a conscious effort to redefine community collaboration through shared partnership and goal setting. While research partners were conducting the landscape analysis, Access to Care program completed an internal assessment to identify strengths and opportunities for institutionalizing health literacy. The Access to Care program recruited two undergraduate public health interns to conduct staff interviews, collect print materials and complete building and service navigation evaluations. Despite health literacy being traditionally viewed as the ability to obtain process and act on health information, there is a growing acknowledgement that organizations must take an active role in promoting health literacy. Embracing national tools and a culture of health literacy are the first steps to creating a healthcare organization that can help individual's access optimal care and improve the quality, safety and health outcomes of populations served. The CDC recommends assessing organizational health literacy as the initial step to addressing health literacy opportunities and barriers. This work was also influenced by the National Action Plan to Improve Health Literacy and Healthy People 2020. A health literacy intervention combines assessments, planning and evaluation. Topics evaluated in the assessment can have an impact on the way in which people access, understand and apply health information and services. We hoped to understand the current environment and improve the communication and understanding of information. Measurement is a key aspect of system wide efforts to address health literacy, as organizations need to be able to assess their current status for accountability purposes, to drive changes and track progress. The tool selected to conduct the assessment was the Health Literacy Environment of Hospitals and Health Centers Survey and Checklist through the Harvard T.H. Chan School of Public Health.This 164 page guide helps health systems address health literacy throughout their organization. The guide includes instructions for reviewing one's organization for health literacy issues and includes measures related to navigation, print communication, oral exchange, technologies and policies and protocols. CPH aims to achieve each of the 10 Attributes of a Health Literate Health Care Organization, using these tools as guides to inform and improve. In using these documents, we identified the presence or absence of characteristics of each attribute within the organization; documents notes and planned for future action. Findings, planning and recommendations have been shared with department leadership.
Health literacy goals for CPH are to engage partners in local initiatives; examining internal practices and making necessary changes to becoming a health literate organization. To conduct the landscape analysis, researchers utilized existing data sources, including the Behavioral Risk Factor Surveillance System, Ohio Medicaid Assessment Survey, Census data and the American Community Survey. This data was combined with over 400 resident surveys, five focus groups and 30 stakeholder interviews. Recommendations were finalized after the conclusion of two strategic planning meetings with the 30 stakeholders and city leadership, including city and county Health Commissioners, City Council and the Mayor's office. The landscape analysis led to a citywide reinvestment in access to care in the community. This will be demonstrated though the current Health Literacy Committee, as well as the development of a new Access to Care Coalition in 2018. In the midst of federal funding cuts that reduced the availability of insurance navigators across the state by 70%, CPH acknowledged the need to continue promoting the availability of enrollment services. In 2017, the Access to Care program trained 18 CPH staff on Medicaid and Presumptive Eligibility, cutting down on referrals and shifting capacity. Following the health literacy assessment, recommendations were made, including training opportunities. In October 2017, CPH hosted two training's titled, Health Literacy: Using the Right Words for Better Health”, and Bridging the Gap: New Americans and Cultural Considerations in the Language We Use,” drawing over 100 attendees. Over 70% of attendees reported increased health literacy. Through the Health Literacy Committee member on-boarding, more than 15 partner agencies will receive Health Literacy training in 2018. Internally, we have infused health literacy into the 2018-2020 CPH Health Equity plan, which includes establishing a plain language policy, to be developed in 2018.
One of the biggest lessons we've learned thus far in tackling health literacy is that many organizations do not have this issue on their radar. We'd like to hope that we are pioneering an issue that will create a domino effect for partners, but that will require lasting engagement, outreach and education. However, we have also learned through this work that there are key partners currently engaging in work around health literacy. This gives CPH the opportunity to leverage those existing partnerships to promote the importance of integrating health literacy into your organizational goals and objectives. To our benefit, the Access to Care program is not a grant funded initiative, which gives the program flexibility to plan ahead and sustain the health literacy committee as the acting chair. In Columbus, CPH is the third organization to conduct a health literacy assessment. Through the Health Literacy Committee, each organization will share their findings and outcomes as an opportunity to promote additional agencies participation in completing their own assessments. While we have not done an official cost/benefit analysis on health literacy initiatives, we did examine the costs/benefits of staff training for Medicaid and Presumptive Eligibility enrollment. The opportunity to bill for services provided at CPH by enrolling a client into same-day coverage through the Presumptive eligibility program could generate reimbursement funds for the department. This process is also eligible to reimburse staff time, up to 50%, through Medicaid Administrative Claiming (MAC.) While official numbers have not been produced, we understand that there is an opportunity to generate reimbursement through providing greater access to health insurance and public health care for clients.
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