Needs Assessment Committee Meeting July 16, 2020

Members Present: Marcy Thompson (co-chair), Amanda Lugg (co-chair), John Schoepp, David Klotz, Randall Bruce, Lisa Best, Rob Walker, Tim Frasca, Jennifer Irwin, Micah Domingo, Claire Simon, Billy Fields, Fay Barrett, Finn Schubert, Jamie Walkup, Jonathan Reveil, Karen McKinnon, Maiko Yomogido, Mytri Singh, Randall Bruce, Francine Cournos, Micheal Rifkin, Press Canady, Jonathan Reveil, Leo Ruiz

DOHMH, PHS, NYS and Other Staff: Cristina Rodriguez-Hart, Claire Simon, Graham Harriman, Kimbirly Mack, Bettina Carroll, Bryan Meisel, Perminder Khosa, Allison Baxter, Rachel Crowley

Welcome/Introductions/Moment of Silence/Public Comment/

Review of the Meeting Packet/Review of the Minutes:

Ms. Lawrence opened the meeting with introductions and an icebreaker.  Introductions with pronouns were conducted and a moment of silence was held. Mr. Bruce led the moment of silence. The July 16^th minutes were presented and accepted. 

Follow Up Part II: Persons with Serious Mental Illness Referred to Select Bureau of Mental Health Services and Matched to Persons with HIV

Ms.Khosa generated responses to questions that arose during the follow up presentation that the committee received in June. Clarifying questions and information indicate that people in the group matched with SMI are frequently diagnosed at a later stage of disease. Mortality among people with SMI is a complex issue that is difficult to parse with limited data.

Understanding RHIOs

Mr. Harriman introduced Kristen Wunder, public health consultant from Bannon Consulting, assisting with a wide variety of grant funding application.

What are RHIOs?

Regional Health Information Organizations (RHIOs) were set up by NYS, a total of 8 that serve different regions of NYS and they feed into the State Health Information of NY (SHINY). Organizations, hopsitals, labs associated with each RHIO are collected by the RHIO and sent up to the SHINY, and then that info can be fed back out to the RHIOs. In theory, there is seamless data sharing among organizations as long as a person has consented. 

There are 3 RHIOs in the  NYEMA – Healthix, which serves NYC and Long Island, Bronx RHIO for the Bronx and in the Hudson region is Healthtier. Healthix and Bronx RHIO are the most robust – largest served populations. Lots of potential uses and challenges. Mostly used for alerts around hospital admissions. A lot of agencies get so much info it isn’t useful. Alerts for admission, discharge to ER, admission to inpatient – Healthix working on how to make this data more useful.

Healthix uses subscriptions – a basic file on clients – can limit to specific populations – ie filter it to people with HIV and SMI – provides this to the RHIO and they would only provide info on this population. Can also specific info you wish to receive. Healthix is working to include claims data – to help provide context around the alerts.

A lot of current advocacy to have the state provide more timely pharmacy fill data to better know how quickly prescriptions are filled – useful for ARVs and psychotropics. 

Trying to refine data to look for risks and make it work for HIV. Connection fees for agencies to join – still a lot of challenges, especially around consent – client would currently have to sign a consent for each site. There is a community consent, but agencies have to share the full list of 1700 sites with the client. Ideas around an annual re-consent process. Some agencies, like SEIU, do consent through their health portal – have had great success with that.

Have you seen RHIOs in operation around SMI HIV and re-engagement in care?

No one has looked at SMI HIV, but have done work on uncontrolled diabetes. Created pilots with subscriptions on those clients – set up alerts. For those pilots have seen that it allows for more targeted outreach, especially around ER visits.

Is this new? Do people not know how to use it? How can this impact HIV treatment during hospitalization?

RHIOs have been around for 5-6 years (began with DSRIP). Taken a lot of work to get them where they are. Consent is a big barrier. A lot of challenges still present?

Are risk calculations public? 

Info is pulled from labs and public sources of data. Updated on a daily basis. 

Do all RHIOs speak to each other? How do you get access? At my agency we have access to one RHIO – do they share?

Healthix is predominant system in NYC – they have an up to date list of the agencies they serve. Map on SHINY site that illustrates which RHIO for each region. When an agency signs up, RHIO works with them to ensure the RHIO works with their data systems (EHR) data feeds into the RHIO then into the SHINY, then back down to the RHIO. Healthix is trying to become an integration partner – next step up from a Qualified Entity.

How well are agencies able to respond in a timely manner?

Initial feedback about how much info was coming in – not useful – need to manage the information – resulted in a variety of pilots to focus messages. One person is usually responsible for triaging the info – some agencies have it entered into EHR – feedback currently says it seems to be working, but pilots are much smaller than capacity of system. RHIOs have been working closely with agencies to try and make data useful.

Does RHIO work with PYSCHES?

Not sure – PYSCHES work with claim data, and RHIO is looking to work with claims data – but would have to go back and find out. EngageWell is doing this work.

Some in-patient stays do not support HIV treatment, can you talk about who monitors this info? Who are the people who are allowed to view personal health data?

Usually restricted to certain people – but this would be on an agency by agency basis.

In hospitals, clients must advocate to get HIV meds?

Invitation Letter to NYS DOH, NYS OMH

Edits to the draft invitation were recommended. Appropriate data was discusses and will be correctly cited. All parts of Ryan White must adhere to payor of last resort restrictions.

Discussing HIV & SMI with Doug Wirth, CEO of AmidaCare

Doug Wirth is the President and CEO of Amida Care, a not-for-profit Medicaid special needs health plan (SNP) that specializes in providing comprehensive health coverage and coordinated care to New Yorkers with chronic conditions, including HIV and behavioral health disorders, and who are experiencing homelessness (regardless of HIV status).

Mr. Wirth served as senior faculty on The Hope Project, a mental health program that worked to train professionals who work with people with SMI and HIV.

AmidaCare is one of 3 special needs plans – the largest with over 8,000 members. About 29,000 people in NYC are living with HIV and have straight Medicaid. About half of this number have joined an SNP

1. How does Amida Care define serious mental illness?

Use the OMH definition as included in the 2014 RFQ – a diagnosable mental disorder experienced by an adult that is sufficiently severe and enduring to cause functional impairment in one or more areas in life and a recurrent need for mental health (MH) services. 

• Does Amida Care collect data on health outcomes/engagement for PWH with SMI, and would you be comfortable with informally sharing that with the committee?

Use claims/utilization data and additional care coordination data collected from providers to identify persons with SMI.

• What percent of clients are SMI – and how many of this group need additional services?

About 45% of members accessed MH services last year – number has been as high as 60%. About 33% of members carry a co-occurring SMI diagnosis. About 29% of members are also in the HARP (Health and Recovery Portion of Medicaid Benefits) – about 4-5% of people with SMI are eligible for HARP but not enrolled – choose not to access higher level of care and services.

• Does the state release diagnoses/specific data to Amida Care to facilitate this process? How does Amida Care determine internally that a client is SMI?

Generally get this information from our claims, but receive coding from HARP members – that tells us they are HARP eligible – but does not come with complete diagnostic info. But they know from roster based on state’s data – who has SMI. Plans get that from the roster. HARP cohort – about 2600 members – know they are eligible and have said yes to additional care coordination services. These members are PWH with SMI- have an ongoing need for services. 

• What strategies have you put in place to identify and determine additional services to provide support?

Colocation of AmidaCare and Beacon – including integrated teams – allow for real time communication. Team works in an integrated way – including finding outpatient providers that a patient already has a relationship with – or does that work need to happen from scratch. Weekly co-facilitated rounds are held every week, where behavioral health, medical, psycho-social and social determinant of health issues are addressed. Use a risk score system – allows prediction around future utilization/costs – higher risk scores – higher focus by team. High risk scores can mean they are missing medication refills, or services. Often referred for services but clients do not go – very poor rates of effectively connecting people to outpatient services.

Underdiagnosed or undertreated trauma issues are a key factor in lack of adherence. All plans need to do a better job of engaging members with Harm Reduction – High level of co-occurrence between SMI and substance use. About 90% of members report hard drug use history – with 20-30% reporting active hard drug use. Substance use to facilitate navigating trauma – self medicating.

Started an initiative – working with Cicatelli on a trauma informed care pilot – this was implemented in New Jersey. Most plans refer people to outpatient article 31 MH programs and article 32 licensed substance use programs – not everyone is ready to give up use. Abstinence is not a meaningful place. Outpatient BH services are not right for everyone. In the initiative using psycho-educational tools to help clients manage triggers – to vote with their feet by leaving care – often people are triggered during care visits – primary or BH – working to transform the provider delivery system – comprehensive experience from front desk to provider.

Also have field-based staff: health navigators, community health outreach workers, etc. Staff focus on people who have dropped out of services/programs – or if person isn’t filling HIV medication prescriptions – rather then wait for people to re-enter the system through the hospital, outreach workers go to the clients. Most outreach plans make phone calls or send letters – this is not effective, which is why we go into the community and find out what happened and find a new provider if needed.

Work closely with Beacon to facilitate referrals to health home (HH) case management – about 30% of members are regularly in that level of care mgmt. services. HH came after the COBRA model – make sure we engage members – especially HARP population. HH are not required to share any information with insurance plan about whats going on with their members – our care coordination teams are trying to support the members – but don’t know about those community based relationships. Creates a gap in knowing what’s going on with members. So developed MOUs and now pay HH to ensure providers are sharing the info and can support the member’s relationships alongside the HH. Much more personal experience for member.

There is a gap between members accessing MH services and those in a HH. About 30% of PWH have significant MH and substance use challenges.

In 2006, VLS (viral load suppression) was around 60% – today around 80%. Routinely looking at VLS because a rise in VL means issues with adherence to HIV meds – and likely to BH meds as well. Members most challenged with VLS are most likely to have BH challenges. See significant co-occurrence of MH and substance use (s/u) – indicating a strong need for harm reduction.

• Has Amida Care had success in navigating HARPs?

See above

• Have HARPs worked to stabilize clients and improve outcomes?

Our experience and experience of our Beacon vendor that there are too many barriers for clients to access home and community-based services (HCBS). A lot of red tape. Given high rates of un and underemployment – people are able to access employment support programs. 

• What strategies/interventions/services have had the most success, from low hanging fruit (low costs) to more complex (expensive) interventions?

Have integrated care teams of nurses, SWs, outreach workers, care coordinators. Also have behavioral health experts onsite. Those specialists are a part of our team and sit side by side the integrated care team to support providing access to a higher level of services.

• When thinking about the healthcare landscape in NYC/State, what are some key policies that you would like to see put in place with regard to Medicaid? Coordinated care? Integrated care?

42CFR limits the level of info sharing that happens -if a BH provider is isolated in their picture of a client – primary care does not know – challenges in coordinating care and facilitating open communication. 

Supportive of maintaining the increased flexibility to offer services through telehealth. Transportation is frequently a barrier to accessing care. Benefit of home assessment that becomes possible when doing telehealth. 

Also interested in improving housing stability. PWH who qualify for Medicaid should qualify for HASA. But the quality of housing and ease of falling behind on rent is a big challenge – places where people with s/u are housed can undermine stability and harm reduction. 

Harm Reduction providers say it is easier to get grant funding, and count services against funding from OASAS or AIDS Institute, but to deliver Medicaid services – big lift to implement and must wait to get paid. State could put requirements on timely billing. Otherwise, will not see an uptick in harm reduction. Could mean grant funds, especially in this economy, dry up, and HR providers are not ready for Medicaid billing.

A risk score is like a light on a member to get a better idea of what is going on with a client. Have a total cost of care report that we share with providers – gives utilization and medication data – helps paint a bigger picture – doesn’t include a lot about BH due to 42 CFR. Run VLS based on providers and facilities. 

HIV is associated with poverty, racism, transphobia, homophobia, stigma – biggest thing I worry about is people not accessing services. We work to start a conversation with clients about why they aren’t attending appointments – some people need a metrocard to get to the appointment. 

Regarding the trauma initiative – first year involved a lot of training of staff – not only clients with trauma histories, but often the staff. No data yet on health outcomes – first year was about helping clients manage triggers and self-modulate. Second year engages more health center sites – launching short education programs designed for consumer- building self-management capacity. The idea is that with that level of support more people will access traditional outpatient services. Hoping to show that the trauma informed work will facilitate people being able to get the services they deserve. 

As an insurance company – someone is paying us to ensure people get care – we have an obligation to get people care. So we knock on doors – which is too much for some people – but we have said, yes, we have to engage you – which has caused some people to leave the plan. But if people aren’t getting care and services – that’s a problem. Have had over 1200 members cured of Hepatitis C. Fought with NYS to ensure that people have access to Hep C treatment – unacceptable to wait until stage 3 liver disease to be able to access treatment. To date have no record of re-infection. Our job is to coordinate care, most especially when people are not getting services.

How does the spenddown work with a SNP?

Medicaid is a state program – modifications and changes that the state needs to advance – why not have the state and health plans figure out the payment piece around HH and take that off of the client – this should be figured out by Medicaid, the plan and the HH – not the consumer.

With TIC – AIDS Institute has funded this project in partnership with Cicatelli – creating ways for people to get certifications to do the work but not creating the jobs for them to fill. Having people with lived experience on how to navigate the care system and get needs met – that’s the best advocate. There must be a living wage and technical assistance should be provided to truly integrate that worker into the team as well as ensure the peer worker is supported. Must include more consumer workers in the service delivery system to ensure respect and dignity for all consumers. 

Public Comment

None.