Grass-roots community health initiatives meet local needs
While politicians, analysts, and policy-makers discuss and debate big-picture solutions to the nation's health care problems, locally crafted community health initiatives have been steadfast in their efforts to connect uninsured and medically indigent people to health care services and health insurance.
A Commonwealth Fund report by Karen Minyard, executive director of Georgia State University's Georgia Health Policy Center in Atlanta, says the community programs assist in outreach, coordinate and integrate care, and help clients use resources efficiently.
In her report she presents case studies from five local community health initiatives that seek to improve access and coverage for low-income, nonelderly adults. Included are Community Health Works, Forsyth, GA; General Assistance Medical Program, Milwaukee; Choice Regional Health Network, Olympia, WA; Community HealthLink's Health Care Access Program, Ratcliff, AR; and Project Access, Wichita, KS (see related story below).
Five community initiatives profiled A Commonwealth Fund research team headed by Georgia State University professor Karen Minyard developed case studies of five community health initiatives that seek to improve access and coverage for low-income, nonelderly adults. Highlights from the five case studies include:
|
Ms. Minyard says it is clear that merely referring people with complex medical and social needs to care is often insufficient. Thus, these successful initiatives assist in outreach, coordinate and integrate care, and help clients use limited resources efficiently.
Study findings fall into three areas—1) the critical importance of state context; 2) the need for community health initiatives and the difficulty of sustaining them; and 3) the challenges of replication.
Across the five case studies, Ms. Minyard says, it is apparent that state political, economic, and social context matters. Local programs can support or complement state public and private insurance programs, but they are unlikely to thrive independently. The researchers found that community initiatives that don't capitalize on state policies and resources struggle against greater barriers.
Several measures of state context, she says, seem especially useful in differentiating whether a community initiative can survive and succeed, including supportive public programs or a strong private insurance base, state-level vision and supportive programs and policies, and community and provider culture.
Despite their value to individuals and the community as a whole, local initiatives are difficult to sustain. Community leaders interviewed for the research identified several organizational attributes as necessary for sustainability, including dedicated leadership; funding sources, including provider volunteerism, Medicaid partnerships, and federal grants; and data to evaluate and demonstrate initiatives' successes. Strong leaders were able to create programs that were solidly grounded in the needs of the target population. They flexibly adapted to the changing environment and engaged in a continuous blending of programs to shape a complete portfolio connecting their clients to care.
Face-to-face communication
Diffusion of innovation among community health initiatives is more likely, Ms. Minyard says, when there is extensive face-to-face communication between individuals in the original and replication sites, and when there are contextual and organizational factors common to both sites. She says research indicates that important contextual factors include strong leadership, high levels of knowledge among interconnected parties, and a state environment with opinion leaders and change agents who value local innovation.
Even though the initiatives are local, Ms. Minyard says, they have state and federal policy implications because they ultimately are derived from state and federal policies, and changes in policy would cause the initiatives to adapt and change.
She says policy change in the current environment would not eliminate local initiatives' goal of serving low-income residents at the edges of both public programs and private coverage. "Some proposals at the national level—in particular, block grants to finance Medicaid—could greatly increase the need for community initiative if states were forced to respond by narrowing program eligibility," she says. "Without greater resources for community initiatives, however, the volunteerism they rely on would be strained and could fray."
Other national proposals offering new opportunities for financing coverage could help support local initiatives if care were taken to define qualified coverage to include programs offered through community initiatives. Ms. Minyard says the initiatives then could leverage and amplify the funds' value. Thus, refundable tax credits could be used to buy coverage offered through the networks and their providers. Community initiatives might also be allowed to qualify as association health plans that could enroll any small group that includes a threshold proportion of low-wage workers. Small employers might offer the programs as an option available to low-wage workers or to their entire group.
Researchers spent 18 months visiting each of the five study groups that were selected to represent a range of geographic areas and operational models. All five groups want to improve access and coverage for those most likely to be uninsured—low-income, nonelderly adults. The programs that offer coverage typically provide comprehensive benefits for a limited time, often for individuals who seek care after contracting an illness. Other programs manage care for clients with complex needs, chaperoning them through systems they characteristically have trouble navigating.
Appropriate care is cost-effective
Local leaders in each of the communities studied said that providing more appropriate care is cost-effective for both providers and the community. The initiatives reportedly use various strategies to control cost, including cost-sharing in the form of modest copayments, administrative fees, or membership dues, and health care providers bearing significant risk through discounted rates or capitated reimbursement.
Community initiatives generally can't or don't make the necessary investment to develop strong evidence of cost-effectiveness, but some in the case studies were able to demonstrate cost-effectiveness on selected measures or a positive return on investment. Thus, Community Health Works estimates its clients use 40% less hospital care and 18% less emergency department care than a synthetic control group developed from national data. And the longer a client remains in the program, the less likely it is that he or she will have an inpatient stay.
Choice Regional Health Network has claimed success in enrolling and retaining eligible adults in the Washington Basic Health Plan. And GAMP says it has raised an additional dollar for every local dollar used to pay for the care of individuals enrolled in the program, offering a 100% rate of return to local funds, without even considering potential gains from improvements in population health and efficient use of care.
Ms. Minyard tells State Health Watch that local initiatives often have difficulty demonstrating their successes because there is a lot they are trying to do with limited resources and it is in their nature to just get into the work and do it, rather than thinking about long-term sustainability. "It's not usually in their area of expertise to do cost-effectiveness analysis and evaluation," she says.
The original Commonwealth Fund proposal had been to develop an evaluation template that communities could plug into, she says, and there still is a need for such a template that could look at evaluation with common measures.
Such evaluation is important, she says, because it can help lead to long-term sustainability and that can be important because community initiatives are an important component of how the nation deals with access to care and health status improvement. She says community initiatives can be sustainable if they focus not only on what they are doing but also on the issue of sustainability past the initial funding.
"There are a lot of local resources on the table," she says. "Some people think of national solutions without bringing those local resources into the mix. State and national leaders must recognize that there are important resources left on the table if they don't work with local communities to build return on investment."
Download the report at www.commonwealthfund.org/publications/publications_show.htm?doc_id=515749. Contact Ms. Minyard at (404) 413-0301.
While politicians, analysts, and policy-makers discuss and debate big-picture solutions to the nation's health care problems, locally crafted community health initiatives have been steadfast in their efforts to connect uninsured and medically indigent people to health care services and health insurance.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content