By Janna Wilson, Senior External Relations Officer, Public Health — Seattle & King County
Nationally and in Seattle and King County, health care reform is accelerating the work to better deliver both clinical services and population-based prevention, and there is much talk about the integration of public health and the health care delivery system. As we do this, however, we need to concurrently build out the third leg of this stool—the integration of human services—to more effectively tackle the underlying causes of poor health.
In King County, some 79,000 additional people are expected to enter the Medicaid program in 2014, and another 117,000 people with low and moderate incomes will be eligible for tax credits and cost sharing assistance to encourage coverage under plans sold in the Exchange marketplace, Washington Healthplanfinder. While they are a varied group, their profile includes those who are expected to experience challenging social circumstances such as unemployment, housing problems, abusive relationships, substance abuse, or food instability — circumstances which in turn affect their health.
Today, many of these uninsured low-income adults in King County connect with health and human service systems on an intermittent basis. They engage during times of need and crisis, and then may “drop out” when the issues stabilize — too often only to find that those issues resurface later because the underlying conditions were not addressed. With health care reform, low-income residents are expected to have health care coverage that allows for on-going attachment to a “medical home,” replacing what had been intermittent contact with a more stable, on-going connection. We’re working to leverage this system change into a platform for providing more efficient, stable connections to human services. As local government — and a major funder of these services — we’re in a good position to make a difference.
As part of our pathway to accomplish this, we convened and continue to work with the King County Health Reform Planning Team, a group of representatives from across the health, behavioral health and human services fields, that emerged following the 2011 kick-off dialogue. They work with us to identify tactics that will drive more linkage and coordination between human services and the health care systems.
We recently worked with our King County Executive and the King County Council on successful legislation that calls for the development of “a plan for an accountable and integrated system of health, human services and community-based prevention in King County… in collaboration with the departments of public health and community and human services, and a community stakeholder panel informed by local and national expertise.” The plan must include recommendations on investment strategies and financing options, a positive sign that local elected officials are engaged and recognize the larger benefits to our community’s well-being that could be realized.
Our efforts extend as well into the depths of the Medicaid program, where we are actively influencing Medicaid transformations being rolled out at the state level. When Washington State began its design of a managed care demonstration to integrate care for people dually eligible for Medicaid and Medicare—our poorest, most vulnerable residents with extensive human service needs and involvement—county human service leaders advocated for a state legislative provision that assured the demonstration could only go forward in a geographic area with county government approved terms and conditions of participation.
Because we share responsibility for the well-being of this population, the alignment between the state, the managed care organizations and local entities was important to us.
In our County, we’ve chosen to place ourselves right in the middle of this complex project. Quite simply, for the demonstration project to achieve its goals, local human services expertise and relationships must be involved. In the latter half of 2012, King County’s Department of Community and Human Services, Public Health-Seattle & King County, and our Area Agency on Aging worked with state Medicaid program staff to design the terms of our county’s participation in the demonstration, with one of the critical provisions being a commitment to work together in an implementation team to share information, monitor impacts and make course corrections.
We are also engaged with state Medicaid program partners and managed care plans in shaping the design and standards for “health home” services, a provision under section 2703 of the Affordable Care Act that provides enhanced federal match levels for care management of Medicaid beneficiaries with chronic health conditions.
Linkage to social services and health promotion are among the required services, and we believe it’s here at the local level where we can best arrange for a systematic approach to making these connections, and negotiate with the payers who stand to benefit financially from the benefits of those services.
Like many states, Washington is increasingly turning to managed care in the Medicaid program to advance integration as well as better manage costs. As managed care works to serve its growing volume of members with more complex social issues, our health department is already initiating contracts with them in our relevant areas of expertise, such as case management of children with highly complex health issues, and a post-hospital recuperation program for homeless adults. Through these activities, we are intersecting with the health care system and payers around what’s most on their minds today — controlling costs while improving health—to shape their roles in supporting that critical third leg of the stool, a robust and much-needed integration with human services.
Building community and political will for an integrated system of health, human services, and community-based prevention in King County, Washington
In 2011, at a community center in a suburb south of Seattle, over 120 representatives from the region’s medical, behavioral health, public health, human services and local government systems kicked off a dialogue about how to use the opportunities of health care reform to build a healthier King County. The gathering was co-convened by Public Health- Seattle & King County and our fellow county agency the Department of Community and Human Services, with the support of the King County Executive.
As the group settled, a manager of an affordable housing agency whispered to organizers, “I’m here but I’m not sure why —what do I have to do with health care reform?” We talked through the many ways that her program supported people’s health: first and foremost, they helped people get and stay in housing. They reminded tenants about appointments.
They hosted job fairs and healthy cooking classes. And they were going smokefree. “Your tenants are the health care systems’ patients,” we explained, “and you are doing far more to impact health and health care costs than you realize. You have everything to do with health care reform.” She stayed.
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