CDC’s 6|18 Initiative: Accelerating Evidence Into Action
29
August

By Adem Lewis / in , , , , , , , , , , /


Good afternoon, everyone. My name is Monica
Valdes Lupi and I’m the chief of health systems transformation here at the Association of
State and Territorial Health Officials. I’d like to welcome all of you to today’s interactive
webinar entitled CDC’s 618 Initiative: Accelerating Evidence Into Action. ASTHO with support from
the CDC is working to maximize the number of state health agencies that work with state
Medicaid agencies to implement activities aimed at increasing reimbursement for high
cost, high burden chronic conditions. We’re supporting the 618 initiative in person convening
next month, as well as additional technical assistance for states that are participating
in the initiative. Today’s webinar features one of the states
involved in the 681 initiative to talk about their work in Rhode Island in the collaborative
and the work that the state would like to accomplish and implement additional coverage,
utilization and reimbursement services. This webinar is supported by our colleagues at
the Health Resources and Services Administration, HRSA, who also support ASTHO’s work to maximize
the number of state health agencies that work with their Medicaid colleagues to implement
activities aimed at increasing reimbursement for these high cost, high burden chronic conditions. The objectives for today’s webinar include
to describe the 618 project, identify ways in which the state health agencies can support
the 618 initiative, describe Rhode Island’s interagency collaboration between state, Medicaid
and public health. And finally to demonstrate success to date in implementing the targeted
interventions with state Medicaid beneficiaries. We’re really pleased today to have an esteemed
panel of colleagues and experts that will be speaking with you. Following my introductions,
all the speakers will present their slides. If you have a question, you’re welcome to
post it onto the chat box that you’ll see on your screen at any time during the webinar.
These questions will be used during the Q&A at the end of the presentations. You’ll also
have the opportunity to chat any additional questions during the Q&A sessions. At the
end of today’s webinar, you’ll be directed to an evaluation survey. Please take a few
minutes to inform us about the challenges and barriers you’re experiencing in your space
in working with your public health and Medicaid colleagues to increase reimbursement for these
types of chronic conditions. Our speakers today are John Auerbach and Dr.
Nicole Alexander Scott, and I’ll just briefly introduce both of our speakers. John Auerbach
is the associate director for policy at the Centers for Disease Control and Prevention.
He oversees the office of the associate director for policy, which focuses on the promotion
of protocol health and prevention as components of health care and payment reform in health
systems transformation. Before being appointed at the CDC, he was a distinguished professor
of practice and health sciences and the director of the Institute on Urban Health Research
and Practice at Northeastern University. He also served as the commissioner of public
health for the Commonwealth of Massachusetts between 2007 and 2012. Under his leadership,
the health department developed new and innovative programs to address racial and ethic disparities,
to promote wellness, including the Mass in Motion campaign, and in combating chronic
disease and supporting the successful implementation of the state’s health care reform initiative.
He also served as the executive director and commissioner of the Boston Public Health Commission
for nine years, where he led work around health equity, emergency preparedness and tobacco
prevention, and also oversaw emergency medical services, homeless services and substance
abuse services for the city of Boston. He also worked at the state health department
as the chief of staff and also as an associate commissioner overseeing the HIV/AIDS bureau
during the early years of the epidemic. Following John’s presentation we’ll have Dr.
Nicole Alexander Scott on the webinar. Dr. Alexander Scott has been the director of the
Rhode Island Department of Health since May 2015. She brings a tremendous amount of experience
from her work as a specialist in infectious diseases for children and adults at hospital
in Rhode Island that have been affiliated with Brown, and at the Rhode Island Department
of Health. Her clinical and academic responsibilities were balanced with serving as consultant medical
director for the office of HIV/AIDS, viral hepatitis, STDs and TB in the division of
infectious diseased and epidemiology at the department of health. She’s also board certified
in pediatrics, internal medicine, pediatric infectious diseases and adult infectious diseases
and obtained her master’s degree in public health from Brown. She’s also an assistant
professor of pediatrics and medicine at the Warren Alpert Medical School at Brown University.
Dr. Nicole Alexander Scott is originally from Brooklyn, New York, where she attended Cornell
and subsequently graduated from medical school from CUNY Upstate Medical University in Syracuse. I’m going to now turn it over to John to begin
his overview of the 618 project. John? Thank you very much, Monica, and thanks also
to ASTHO for its support and input into the development of the 618 initiative. CDC wants
to assistant the state, territorial, tribal and local public health departments in building
partnerships with health care purchasers, payers and providers to improve health and
to control health care costs through an initiative called the 618 campaign. My presentation will
provide the background, current status and goals of this initiative and will provide
you with some important tools. Next slide, please. The 618 initiative is part of 1 of CDC’s 3
strategic directions, namely the strengthening of public health and health care collaboration
in the context of the rapidly transforming health care system. It’s important for those
of us in public health to strengthen this collaboration because of the unprecedented
opportunities to expand prevention and population health as components of health care and to
move in the direction of an integrated health system with more of an upstream focus rather
than a health care system that has its resources concentrated in the acute care sectors. Throughout the nation, there are meaningful
discussions that are taking place now that involve governors and other elected officials,
insurers and health care providers to redesign health systems. We’ve been saying for some
time now that public health needs to get to the table where these discussions are occurring
in order for us to be taken seriously and in order for us to have a voice. Next slide. But the question we’re focusing on today is
once you get to the table, what do you do? The purpose of 618 is to give you some of
the tools that will help answer that question. Next slide please. But before we dive into
618, let’s just step back for a moment and remind ourselves why being at the table matters
and let’s look at a person who’s been affected by some of the changes recently. Ms. Fran
Edwards has recently become insured and so she’s benefited from the health insurance
that’s available with health care reform. And she’s also benefited from the availability
of clinical interventions. So she now has medication to help to treat her asthma and
her high blood pressure, medications that she wasn�t taking before when money was
an issue, but she does still have a number of health issues and they include the fact
that she smokes, she’s overweight and doesn’t get much exercise, she has asthma and high
blood pressure. Next slide please. So while insurance and quality care help Ms.
Edwards and help her a good deal, they aren’t enough to guarantee that she’ll have good
health today or in the future. And this slide indicates some of the reasons for that. She
has a relatively low income, she’s in a neighborhood that’s not as safe as it could be, exercise
and access to healthy food are difficult for her, and she’s living in housing with mold
and ventilation problems that trigger and exacerbate her asthma. Next slide please. And this is a reminder that those of us working
in public health have to consider a wide variety of approaches in order to promote the public’s
health. And this can be confusing, particularly as we enter the discussions with other sectors,
health care included, whose understanding of the terms preventive care and population
health may be different than our own. To help to clarify this, we at CDC have conceptualized
the framework that is within – on this slide. It presents the notion of three buckets or
three components that link clinical care and public health. First bucket includes traditional
clinical preventive services, many of which are now covered benefits without cost sharing
under the ACA but utilization may still be lower than we wish it was. Bucket two involves innovative opportunities
to extend care outside of the clinical setting into the community or other – or into the
home, for example through the use of community health workers to assess asthma triggers in
the home. And bucket three includes community-wide interventions that reach the entire population,
for example through the passage of smoke-free policies that allow all communities to breathe
smoke-free air. We believe that it’s important for public
health to attend to each of these three buckets, but one or the other of them may be more appropriate,
depending on the setting that you’re in. Before moving off this slide, I will note that if
you want more information about the three buckets of prevention framework, there is
an article that’s being published in the next issue of the Journal of Public Health Management
and Practice if you get onto their website at www.JPHMP.com and click on the publish
ahead of print, it is available today. Next slide please. The 618 initiative focuses
on buckets 1 and 2, those buckets that have to do with clinical care to a patient, both
traditional and innovative, and those services that might be paid for by the health care
delivery system and the insurers. I’ll have more to say about bucket three later in the
presentation. Next slide. If we want credibility with the insurers and the providers, we need
to understand their priorities and their timeframes and often the relevant discussions that are
taking place with insurance and providers involve efforts to make the business case
or the return on investment for services that we’d like to see covered. In order to do that,
we need to show the – and prove that there will be a positive health and cost impact
in just a few years if the insurers pay for the interventions we’re proposing. CDC developed the 618 initiative to promote
the adoption of evidence-based interventions that we can demonstrate will improve health
and reduce cost in a relatively short period of time. The name 681 comes from the initial
focus on 6 high burden health conditions and 18 evidence-based interventions that can improve
health and save money. Next slide. This shows you what the six high burden, high cost health
conditions are. With each of these we looked for – we wanted to make sure that there was
a strong evidence base with interventions where we could summarize the information and
present it to the insurers in order to make a strong case. So six – these six health conditions
all are high cost and are of interest to insurers. Next slide please. And then within these 6, there are 18 evidence-based
interventions where we have gathered the evidence, we put it into a format that makes it easy
to present to insurers in language that they understand, it has – and we’ve got packets
that are available to you for each one of these. This page offers just a few of the
examples of those 18 interventions and it divides them for the purposes of illustrating
the examples into bucket 1 and bucket 2. Bucket one, as you can see, includes the elimination
of cost sharing for key services such as hypertension medication as well as coverage of comprehensive
tobacco cessation services and no barriers to long-acting, reversible contraception. Under bucket two, some of the examples from
the 18 include home visits for asthma care by community health workers. It includes self
monitoring of blood pressure by patients in their home, and it includes access to the
diabetes prevention program, a multisession approach often provided in YMCAs. Next slide
please. To give you some sense of the work that we’re
doing on the 618 initiative, there are four bullets on this page. The first involves the
fact that we are training the CDC’s employees to have a better understanding about how the
work we do relates to the insurance industry and health care delivery system. So we’ve
offered what you might call an insurance industry one-on-one course to many people in CDC, and
we can offer you materials if you’re interested in offering that kind of training to those
people in your own department. We – other examples of the kind of work we’ve
done is we’re – we’ve had the health economists at CDC study the methodologies that are used
by insurance company actuaries, so if we’re making the case, we’re doing it in the language
and using the methodologies the insurers use. Second bullet highlights that we have strong
connections with – in fact unprecedented connections with CMS. CMS is now a full partner in approaching
population health. They’re doing some innovative work, such as the state innovation model grants,
and their population health group has a number of other outstanding examples. We’ve also
worked increasingly with Medicaid programs. There’ve been some small summits that CMS
and CDC have recently convened and we’ve done a conference call where we’ve identified now
several states where the Medicaid director and the state public health director are interested
in focusing on 618 in some specific, concrete ways, and we’ll be working with them on a
one-on-one basis adapting the support we provide to the conditions in each state. The third bullet highlights that we’re working
with commercial payers and here we’ve invited the largest insurers in the country to spend
time at CDC where we’ve rolled up our sleeves and made proposals out of 618 for the kind
of initiatives that they can cover, and we’re in discussion now with a number of these large
insurers about developing pilots. And then finally that last bullet is the importance
of making sure that we’re providing information, tool kits, skill building to our partners
in public health and at the community level so that you feel comfortable about understanding
how this approach may be useful for the work in your state and community. Next. If you’re interested in obtaining some
of the materials that I was just referencing, you can get them through our newly developed
website, which is www.CDC.gov, slash, and then spell out the words 618. So that’s CDC.gov/sixeighteen.
On that website, you can get a brochure, you can get frequently asked questions that will
be answered about the initiative. You get individual evidence packages for the different
interventions. And we also, independently of the website, can – through ASTHO can get
you copies of slideshows and PowerPoints. Next slide please. Now, you might be asking yourself are there
other clinical steps that will go beyond the initial 618 interventions, the 6 conditions
and the interventions I’ve been referencing. And the answer is yes, we’ll continue to use
the word 618, but we’re working with other divisions at CDC so that we can develop the
evidence base for those interventions, as well, and expand the number of conditions
that are being addressed in this manner and the number of interventions, and over time
in the coming year, you may be hearing more about that. Independently of this work, you may want to
use the 618 approach in your own state or community. If you’ve already identified, for
example, a health condition that’s a priority for you that’s not included in 618, we encourage
you to use the same approach that we’ve adopted with 618, which means to gather more information
about the needs, processes and priorities of the payers and providers to whom you make
a proposal that there be increased coverage. To make sure to pay attention to the evidence
base and be prepared to make that business case, to find the table and get to it, and
then to make proposals, concrete and specific proposals about the way to expand population
health and prevention services with insurance coverage. Next slide. Now, I did want to say just another word or
two about bucket three. As a reminder, bucket three is our – it includes the more upstream,
community-wide population health approaches, those that are not patient focused, and those
are ones that public health has long taken the lead on and many of you do outstanding
work in this area already. But we’ve certainly heard from a number of individuals across
the country that it would be helpful if we also summarized the evidence base for a number
of these bucket three or population-wide initiatives and made the business case for those. Next slide. So to help, we’ve developed already
some tools that you might find useful. We have three websites that provide background
information that may be useful in making the case for bucket three, one focused on social
determinants of health, one on health and all policies, and one on the community health
improvement navigator. If you get onto the CDC website and just Google, and just search
for these, you can find these websites. And then coming soon we’re developing a kind
of 618-like approach to summarizing the evidence for those population-health-wide interventions
that we can demonstrate have a relatively short-term impact on cost and health outcomes.
Next slide. Now, going back to 618, the first 2 buckets,
this slide just gives some examples of what each sector can do in order to promote 618.
I’ll highlight here what the public health sector can do, and that is, again, getting
to the table and being prepared with a toolkit of approaches to that you’re prepared to make
suggestions about the population and prevention services that should be covered by insurers
as the health system is under redesign. That may involve contacting and working with your
Medicaid program, we really encourage all public health agencies to strengthen their
relationship with their Medicaid programs, and to think about concrete and specific campaigns
that they can engage in together. We’re happy to offer some proposals and best examples
of where that’s already occurring. It’s – we also recommend taking a look at
what’s being funded now with public health funding within your agencies and consider
whether or not it’s possible to align those initiatives with the 618 approach or with
other approaches that are taking place as the insurers and the providers are thinking
about expanding population health and prevention. And finally, we think it’s important to consider
how to play a leadership role in gathering data that can demonstrate the impact of health
care and payment reform, and in particular those efforts that are focused on population
health and prevention, next page. So on this slide, I just want to go back again
to Mrs. Edwards and to summarize in a very concrete way how a 3-bucket approach with
a 618 lens to it can help an individual person. The payers and the providers can focus their
attention on a patient like Mrs. Edwards, on making sure that she has no co-pays for
her blood pressure and her asthma medication, because we know co-pays can result in some
patients not getting the medications when they need it. They also can pay for home visits to reduce
her asthma and reduce some of the triggers in her home. Hospitals, through their community
benefits, can pay for investments in healthy housing options in the community and support
for overall community policies, and then public health can be working in buckets one and two
at those tables we were describing within the states and communities, as well as doing
the traditional bucket three activity that focuses on various approaches, including regulatory,
legal and policy approaches that improve the health of all residents of the community. So finally with the last slide, please feel
free to go to the CDC website, we want to do as much as we can do be supportive of the
efforts that you’re involved in to strengthen the linkage between public health and clinical
care and to improve health within the country and reduce health care expenditures. And now
I’ll turn things over to Dr. Alexander Scott. Hello John and colleagues, thank you for that
excellent presentation. Can everyone hear me okay? Or can you, John? All right, good
[crosstalk]. Great, and thank you Monica, as well, for the introduction earlier. So
I’m the director of the department of health in Rhode Island and also want to acknowledge
my wonderful colleague, Anya Wallack, who is the director of our Medicaid program in
Rhode Island, and so I’m thrilled to have the opportunity to continue to partner with
her, as we’re both relatively new to our roles. And so the 618 framework provides an excellent
structure for us to build upon. Also, I’d like to take a moment to introduce
two of my colleagues who are joining me today from the Rhode Island Department of Health
as we look at applying 618 to Rhode Island and what it looks like. First is Julian Rodriguez-Drix,
who is the manager of our asthma control program, who you will hear from, and as well Erin Boles-Welsh,
who is the manager of our tobacco control program. They are both involved with doing
fantastic work in Rhode Island regarding the prevention efforts that are needed, and it
connects well with the fact that we’ve chosen asthma and tobacco to be our initial 618 charges
to focus on. So you’ll be able to hear from them firsthand, which will be good. So I’ll start with giving a general overview
of our approach on 618 and touch briefly on how it fits into the current climate in Rhode
Island. There is a strong interest from our state in all 6 areas of 618. It falls very
well within the strategies and priorities that we have set forth as a department. Our
three leading priorities of addressing social and environmental determinants of health first,
second eliminating disparities of health and promoting health equity, and third where this
applies very well is ensuring access to health services for all Rhode Islanders, including
our vulnerable populations. Those three leading priorities serve as the
framework for the population health goals that we have outlined. And the 6 areas of
618 fit within each of the components of those goals, and that’s why we’re able to go with
asthma and tobacco as our initial focus. So these 618 efforts will build off of the longstanding
work that’s been in these areas and help us strategically address barriers that we have
seen in the populations most affected by asthma and tobacco, by partnering with our Medicaid
colleagues. The 618 opportunity allows us to move forward
to advance the existing initiatives that we have in place to make sure that there is proper
alignment. So from a background standpoint, Rhode Island has been coordinating already
on a variety of related efforts that we hope to really maximize by taking on 618. We have
a focus on preventive health services and screenings and how we can make sure that they
apply best at the population health level. We have a number of evidence-based programs
and we’ve done a tremendous amount of work with community health workers in the state,
and I’ll get into how that can fit in a little bit more in a few minutes. From a Medicaid standpoint in Rhode Island,
we predominantly have a system that’s set up through managed care, that’s referred to
as Right Care. There are two managed care organizations, United Health Care Rhode Island
and Neighborhood Health Plan of Rhode Island. And recently or governor, Gina Raimondo, did
a fabulous job really charging the state with reinventing Medicaid. And so with her leadership
very early on in her tenure, a task force was convened to shift Rhode Island from a
value-based system to one that pays for better outcomes and value. And the goal for us as
a department and as a state has been to link that broad, necessary goal of shifting some
volume base to value base to the specific population health outcome and improvements
that we’re looking for, such as in asthma and tobacco. And so the challenge has been
to connect all of the moving parts that are going on within health care reform in Rhode
Island. So one of those moving parts is our state
innovation model grant, which we have, and we are fully engaged in the first step of
that grant, which is to develop a population health behavioral health statewide plan that
will include strategies to help us shift from a volume-based system to one that pays for
better outcomes and value. We also have a strong patient-centered medical
home initiative in the state, the one for adults, the Care Transformation Collaborative,
has been I place for many years and we’re starting to see the population health outcomes
of that. And the second is also now following suite, the patient-centered medical home,
kids, which is the pediatric initiative that’s getting that started. And in combining those
two, what we are looking to do is establish or build on the structure of the patient-centered
medical home initiative to provide the strategies that _____ will need to bring us as a state
from volume based to value, with specific focus on some of these population health disease
outcome improvements, such as asthma and tobacco. Our third statewide initiative that we also
want to make sure is front and center and in place is the Rhode Island Department of
Health health equity zones initiative. And that’s where funding that we have typically
or previously received in silos is now being used to forge coordination and collaboration
to better address patient health outcomes at the population level in the communities
that most need it. So we’re partnering with community organizations on issues that will
help us address social and environmental determinants of health, community-clinical linkages and
community health teams. And so for the final part of our background
to set the stage before I pass it on to Julian, I will build a little bit more on the community
health teams model and how we’re fitting community health workers as a key profession within
that. As we look at our statewide reform and we know we need to use that to shift from
volume base to value base, we know that a big way to address these diseases such as
asthma and tobacco is to get into the community and overcome the barriers that folks in those
areas are seeing on a daily basis. So we’re using the patient-centered medical home structure
to develop community health teams and are talking about requiring or formalizing a way
to make sure that community health workers, the type of community health worker is included
in those teams, so that we know as we are addressing their health outcomes, we’re getting
out into their homes and into their communities where social and environmental factors truly
impact where health is determined. And we cannot do that unless we are partnering with
our insurers and with Medicaid, who can understand the needs for making sure these activities
are covered. So the community health workers model includes
what you’ll hear about with the asthma home visitors as well as the tobacco cessation
work that’s being done, and we’re considering the broad term of a community health worker
as being a front-line public health worker with close understanding of the communities
served who can improve the quality and cultural competency of the service delivered while
building individual and community capacity. So outreach, community education, counseling,
social support and advocacy can be implemented by engaging these community based professionals
who can get into the home and really help make a difference in the treatment and health
outcomes that we need for a population. So that’s to set the stage and we’ll go through
two examples of how we’re working on that with asthma first and the tobacco. Thank you, Dr. Alexander Scott. My name is
Julian Rodriguez-Drix, I’m the asthma program manager. I’ll be going through these slides
pretty quickly just to give a brief overview of what we have been doing in Rhode Island
around asthma and in partnership with our colleagues at CDC and the National Asthma
Control Program. What I will be summarizing here is the results
of a long-term foundation that we have been building for years and have been building
the evidence to put a business case forward and really see 618 as an incredible opportunity
to move that forward into action and implementation in partnership with Medicaid. So we started
with the CDC chronic disease cost calculator, the statistics that you see here, even in
a very small state such as Rhode Island with a small population, we still have significant
costs just in Medicaid related to asthma in terms of total costs and also specifically
looking, zeroing in on how can we reduce the costs of unnecessary asthma hospitalizations
and emergency department visits. Next slide. Within the 18 evidence-based initiatives that
are a part of 618 to begin with, we’re focusing on the 4th of the 4 asthma interventions listed,
and this one has to do with home visits. So expanding the access to home visits with both
a licensed health professional and qualified lay health worker is what we are doing here
in Rhode Island, and the curriculum, as you’ll see in a minute, includes both the soft management
education as well as reducing the home asthma triggers. The program that we have that fits in very
well with 618 is called HARP, the Home Asthma Response Program. The goal is to reduce these
preventable ED visits and hospitalizations, specifically among low income pediatric asthma
patients, through our home visiting model. Our model involves three home visits with
a certified asthma educator and a community health worker. It also includes environmental
supplies such as mattress covers, vacuums, food storage containers and some instruction
on how to use the supplies that the community health worker is instrumental with. This model was also includes as part of the
expansion on a region-wide basis. We had an initiative that was funded through a CMS innovation
award called NEAIC, the New England Asthma Innovation Collaborative, so we’re partnering
with this across New England, as well, while focusing our implementation within Rhode Island. The HARP program starts with the identification
of children who have more than one – one or more ED visit. We are restricting that slightly,
and I’ll get into that in a moment, based on the analysis we have for return on investment,
of really finding where it is most cost effective. There’s referral for home-based education,
the education is provided by the certified asthma educator and then a healthy home assessment
and follow up with the community health worker. The community health worker brings the – comes
to the two follow up visits and brings the supplies, the remediation of allergens and
triggers, does the referrals for appropriate services and supports, and links it back to
connect with primary care provider in order to coordinate around the asthma action plan
and any other items necessary to really build that bridge with primary care. Our – we have been doing various levels of
evaluation and most recently doing a return on investment analysis based on claims data.
So we are doing a one year pre compared to one year post analysis of HARP. Although there
have been over 350 families that have gone through the HARP intervention so far, the
initial analysis is with the early participants who have had – go back one. Who – and 84 children
were available within that initial analysis. Of those, only 49 were able to be analyzed
with claims data based on having a full set of claims data continual from 1 year pre to
1 year post intervention. Within that, ED visits reduced from 80 – just over – under
82 percent to 16 percent. Hospitalizations reduced from 12 percent to 0 percent. Next
slide. There had – was a reduction in both overall
asthma costs and a much greater reduction in the specific ED and hospital costs. So
52 percent overall reduction, which is around just over $1,000 per patient, when we look
at just the ED and hospital costs, it was a 92 percent reduction in costs, of $1,175
per patient. When we zeroed this in and looked at the higher utilizers, which we defined
as participants who had initially more than one ED visit and/or an asthma hospitalization,
we saw an 80 percent reduction in the overall asthma costs, which was saving just over $2,500
per patient, and a 92.6 percent reduction in the ED and hospital asthma costs, with
a reduction of $2,257. In the first set, the intervention was cost
effective, in the second set of the high utilizers, it – this does show a strong return on investment
in which the initial investment was – the savings were more than double the initial
investment. So where we are now, we’ve been bringing this data, we’re in communication
with Medicaid statewide and previously we’ve been talking with the individual managed care
organizations. And what 618 will hopefully be making possible for us is to get some additional
technical assistance on analytics, the economic analysis and helping us take all these pieces
we have and combine them together to make a robust business case that can look at the
Rhode Island Medicaid asthma data and build some really robust projections for realistic
cost savings, which can then be used in decision making around how to incorporate this logistically
into the managed care environment, while looking at capitation rates in the contracts and implementing
it on a statewide level. So basically taking the evidence we’ve built over years of doing
grant-funded work and moving it forward to a statewide reimbursable model. And with that I’ll turn it over to Erin Boles-Welsh
to talk about tobacco. Great, thanks. Rhode Island, we’re very fortunate
that we’re able to work on two initiatives within 618. On the issue of tobacco control,
I should start by saying that in Rhode Island, we’re in a really great position. We have
a fantastic tobacco cessation foundation to work from. We do have access to all seven
medications that are FDA approved for smoking cessation, and that is inclusive of over-the-counter
as well as prescription. Also, our Medicaid recipients have access
to individual, group and telephone counseling, so we have this great foundation of policy.
What we’re – what we’ll be focusing on with this initiative is removing barriers to accessing
these interventions. So we have – what we hear from the ground is that Medicaid recipients
often find barriers in accessing this, specifically around being requested to seek prior authorization
for tobacco cessation treatments, and this is not a prerequisite, according to the policy. Often what we hear is that a recipient is
interested in tobacco cessation, is told that they need to enroll in counseling before they
receive medications such as the patch. That is not a prerequisite. Or that they’re told
by the MCO, by the managed care organization, that they can’t go straight to using a nicotine
replacement therapy gum, that for instance, maybe they need to start with a Chantix or
a patch first. That is not the case. Or that there are limits on the duration of the treatment
or limits on the number of quit attempts they can make a year. So what we’re looking to improve by working
with Medicaid on 618 is really the communication of these policies to the MCOs, make sure that
the health care providers understand what these policies are, what they can give their
patients access, to, and make sure that recipients know exactly what they’re entitled to, as
well. So we’ll be looking to, again, strengthen this strong foundation that we have working
with Medicaid to help them communicate and reinforce support for comprehensive tobacco
cessation coverage that will remove barriers to accessing tobacco cessation treatment,
and in helping to support our governor, Governor Raimondo’s task force that will shift Medicaid
to the outcomes and value-based system. We hope that participation in this initiative
will increase utilization of tobacco cessation benefits. In Rhode Island we’re so appreciative
of the opportunity to participate in 618 and really applaud the CDC for helping to put
this together, and we look forward to working with our state Medicaid office to move this
forward. We’re done. Great, well thank you very much for both of
those presentations from our colleagues at CDC and the state health department in Rhode
Island. Again, this is Monica Valdes Lupi from ASTHO and I want to thank everyone for
putting your questions in the chat box. What I’m going to do now is read through the questions
that we’ve received. If we don�t get through all of these questions, what Courtney and
I will do is include it, along with a copy of the webinar and the slide decks that we
showed you today. So we’ll do our best to go through each of the questions that we’ve
received. So the first question comes from Sherilee
Sherry, who was curious as to why community health workers were called out and not others
such as health education specialists, and perhaps, John, that question is best directed
to you. Sure. Well, I – when we – as I mentioned,
when we were developing 618, what we looked at was the already existing evidence base.
And so we looked for research studies with strong methodology that had demonstrated it
was possible to improve health and reduce or have an – positive impact on cost in a
relatively short period of time. That involved identifying a number of studies that specifically
spoke to community health workers as those who had been studied. That said, there may well be other research
that has been done that we can refer to, as well, and so if the person asking the call
would want to refer us to particular studies we may have overlooked that addressed the
positive contributions of others, we’re happy to take a look at those and to consider whether
or not they should be added to the evidence base. And I can also add very quickly, Monica, this
is Nicole Alexander Scott, Rhode Island, in case that question was towards us, as well,
we’re looking at a community health worker profession as a very broad term that includes
a variety of specializations such as the home visiting asthma role and some of the tobacco
cessation and even the education component that you mentioned. So what we’re doing as
a state is establishing a bare minimum certification for community health workers so that there
is a standardization that we’re all familiar with, and then above and beyond that, there
can be people who are specialized with specific skill sets regarding education on a particular
topic or home visiting specific to a particular area. I just wanted to throw that in Thanks. Thanks for explaining how it looks
like on the ground in terms of that umbrella category, in terms of the CHW workforce. The
next question is from Beth, and I apologize if I’m mispronouncing the last name here,
Beth Pallo. She thanks both of you for your presentations and I think this one goes to
you, John. Can you please explain the differences and similarities between the 618 initiative
and CDC’s winnable battles? Sure, there is overlap in terms of looking
at the high burden conditions. You’ll see that many of the winnable battles are reflected
in the 618 initiative. 618, they were developed with different goals in mind. But the – both
goals had to do with looking at high burden, high cost conditions and both involved looking
at what – whether we – there is a strong evidence base for prevention. With 618, though, we
had a very specific lens, which is we were looking for studies that had a strong methodology
in terms of both cost and health outcome, with a relatively short timeframe, so that
we could make a focused argument with insurers about insurance coverage. The winnable battles approach includes some
of those short-term interventions as part of the action steps, but it also includes
a variety of other approaches that can be taken, including some of those total population
initiatives I was mentioning under bucket three. Great, thanks John. Next question is from
Dwayne Stansberry who asks have you considered adding mental and – or behavioral health to
your six high burden health conditions? This is an area that we have difficulty finding
adequate coverage and reimbursements. We are – we share your interest in paying
a good deal of attention to behavioral health conditions, and we have an interest in looking
at the evidence base for those, as well. So we will be paying attention to that and seeing
if there is a strong enough evidence base to make the case for particular types of intervention
that aren’t routinely covered by insurers, and we’re happy to hear of suggested areas
where you think we – there are interventions we should be examining to see whether the
evidence base is strong enough. Thanks, and I think this is another one for
you, John. This is from our colleague, Jeff Engle, at CSTE. Does CDC have initiatives
in workforce development for 618, particularly interprofessional education as is being developed
in C cells, DSEPD or population – or the population health branch. We have – we are in the process of investigating
those and considering how to make sure that as 618 continues to develop, there is attention
being paid to workforce issues, and we’d love to work with CSTE on that because of your
knowledge and expertise. But we are having some internal discussions, as well. So please
give us your thoughts about where we should be paying attention on that. And I think this question goes to the Rhode
Island team, it’s from Amkofum Abdel Moges. Would you elaborate about how patient-centered
home visits can help in tobacco control activities? Hi, this is Erin from tobacco control in Rhode
Island. We – our program is not designed for specifically home visitors to be providing
tobacco cessation counseling. We do have a program where tobacco cessation counselors
are embedded in the community, specifically through community health centers that provide
group face-to-face counseling, but we don�t have that happening in the home. So and I’ll add the patient-centered medical
home provides a structured model that looks through the lens of how can we connect this
person here in the clinic to the needs they have in their community, because we know that’s
what’s actually determining their health, those social and environmental factors. And
we want to tailor that to the system or the mechanism that will work best. So Erin’s example
shows how that patient-centered medical home model within the community health center allows
us to connect the tobacco cessation work with programs and opportunities available in the
community that will best suit the needs of the patient and improve our population health
outcomes. We’ll take two more questions here, the next
on is from Sarah Wright and this is for you, John. Are there current grant opportunities
for other states to implement the 618 initiative? There aren’t current grant opportunities.
We haven’t had a specific line item in our budget that has focused on that. Instead what
we are offering is technical assistance, access to educational materials, opportunities to
participate in some learning collaboratives. And we are, however, working with our CDC
colleagues in the different centers and divisions, and as I’ve mentioned earlier, we’re paying
a lot of attention to internal training at CDC. And so it may be possible to include
within the work plans for certain categorical funds that you get now activities that are
618 focused. But in order to determine that, you’d have to have the discussions of that
with the project officers for those grants. And the final question that we’ll be able
to take on the call is from Artis Davis, and this one is for you, Dr. Alexander Scott,
and your team. Artis asks this, Rhode Island’s high-level decision at the governor’s level
to shift Medicaid from volume based to value-based reimbursement seems to be a really critical
background piece to your ability to achieving success in Rhode Island in relation to 618
today. Are there lessons learned from the Rhode Island experience on how this high level
of impact might be generalizable to other states? That’s a great question. So the biggest lessons
learned that I think we all continue to be reminded of is to make sure that elements
on those high levels are communicating as actively and as consistently as possible.
Because there is such great work going on, given that the governor has done a good job
really setting the bar high and charging us, we have to catch ourselves from going too
far down a particular path in that great work, be it the reinventing Medicaid or the working
group for health care innovation that the governor started or our health equity zone
work. To make sure, at some point, how are we each connecting, where is there leverage
and where can we make sure that consistency is kept in our messaging. So the best example
is we’ve put a lot of effort into making sure that when we talk about the population health,
behavioral health plan, that our _____ effort is charged with doing, that that can be the
same plan that the working group for health care innovation says that they want to write,
and then that also becomes the same plan that our legislature’s required us to do from a
health care capacity standpoint. And we’re there, but it takes active engagement
to say oh, it’s the same plan, let’s keep it all the same. And then that helps us better
develop structures such as the patient-centered medical home and the community health team
and what we’re talking about getting, a variety of types of community health workers to be
a part of that, getting those structures to advance and move forward with consistent communication
where we and the Medicaid program with Anya’s great leadership can partner and actually
make stuff happen. So I would say that’s the active part of the lessons learned is to make
sure we continually connect the dots that are moving. It’s great that things are moving,
we’ve just got to make sure that they’re moving simultaneously and all communicating. Thank you so much. And I want to wrap up by
thanking all of the participants on the webinar this afternoon. I wanted to also remind you
from earlier that at the end of the slide deck and this webinar you’ll be directed to
an evaluation of the webinar. It’s really helpful for us to gather your feedback and
it helps inform the types of webinars and speakers that we line up for our members.
I’d also like to thank HRSA for sponsoring this webinar and a special thank you to our
speakers, John Auerbach, Nicole Alexander Scott, Julian Rodriguez-Drix and Erin Boles-Welsh
from Rhode Island. The presentations and the responses to the
questions that we weren’t able to get through from today’s webinar will be available on
our website in the next few weeks and the web address is on your screen now. Please
be on the lookout for our newsletters and the links for more information regarding upcoming
webinars. If you’d like to subscribe to ASTHO’s primary care and prevention network newsletter
if you have any follow up questions, please feel free to contact Courtney Bartlett, and
her e-mail should be up there on your screen. We hope that all of you will be able to use
what you’ve learned in this webinar as a resource and we’ll share all the materials with everyone
once they become available. Thank you very much again and hope you all enjoy
the rest of your day. Thank you. This concludes today’s call, you may now disconnect. [End of Audio]


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