The Affordable Care Act of 2010 (ACA) unquestionably began a process that potentially could lead to a total transformation in the health and behavioral health care delivery system of the United States. The ACA is fundamentally a regulatory reform effort that is guided by the triple aim of expanding health insurance coverage; lowering the cost of health care; and improving the quality of the care provided as measured by improved health outcomes. The ACA does not provide a government sponsored public option for insurance coverage, but does require universal insurance coverage at affordable prices for everyone except those with undocumented status. It eliminates pre-existing condition exclusions, eliminates life time caps, and sets minimum standards for benefit packages.
Specifically, the ACA takes aim at lowering the costs of the existing healthcare system by reducing unnecessary acute and emergency medical care by promoting more accessible community-based care. This leads naturally to an emphasis on primary, as well as secondary and tertiary prevention efforts both on a systems as well as individual level. This law has also produced significant resources research and innovation to the field of prevention science, such as the Patient Centered Outcomes Research Institute (PCORI), as well the Center for Medicaid & Medicare Innovation (CMMI). These initiatives not only open new research opportunities but they also incentivize the development of innovative care which will demand new skills within the healthcare workforce.
Quality matters in relation to cost and both are related to the availability of preventive community-based health care. The extent to which individuals can receive continuity of care within a continuous healing relationship provided by a skilled multi-disciplinary team will determine quality improvements and cost outcomes. There are key facts that are important when one considers quality and cost. The United States outspends every other industrialized nation on health care, close to 16% of the country’s gross domestic product (GDP), but ranks 25th in the area of quality healthcare outcomes. Additionally, Medicaid expenditures, the National insurance program for the poor and disabled, which is in part supported by State contributions, is growing so rapidly in most States that these costs are imposing a crushing burden on State’s budgets. Further, existing evidence underscores the fact that people who are seriously mentally ill (SMI) live considerably shorter life spans than their non-disabled counterparts as a result of medical co-morbid conditions particularly substance abuse, diabetes, and cardio-vascular disorders that have been poorly managed. Over 50% of the people who have SMI also have at least one medical co-morbidity which increases the cost of care for them notwithstanding acute mental health related episodes they may experience. Finally, in NYS approximately 75% of Medicaid expenditures are spent on 20% of the Medicaid population most of whom have a primary disability and at least one medical co-morbid condition. Research has demonstrated that improving quality of care, especially to vulnerable populations with chronic co-morbid conditions by insuring continuity of care and coordination of specialty care will reduce costs and improve healthcare outcomes.
The ACA makes health insurance affordable and available in two ways. First, health insurance purchase subsidies are available through direct purchase options at the Federal and or State exchange sites. While initially mired in serious functional difficulties, the Federal website appears to be up and running. State based websites appear to also be functioning well. Second, States have the option to expand Medicaid coverage to people with low incomes by raising the federal poverty income level (FPL) which, in turn, sets Medicaid eligibility. However, based on a Supreme Court ruling, states are not required to do this, and some States have opted not to expand Medicaid eligibility.
Actuarially, the ACA is dependent upon young, healthy individuals purchasing insurance through the exchanges in order to balance out what might become disproportionate risk pools. Many of the formally uninsured people probably did not receive continuous medical care in the past. They are signing up for health care insurance and bring with them pre-existing and perhaps, undiagnosed medical conditions. The likelihood that many new to the insurance rolls will have co-morbid conditions requiring complex collaborative care within newly formed networks is considerable.
In an effort to manage this expansion, the ACA has made new delivery system elements available to the community-based system of care. Federally Qualified Health Center (FQHC) locations have been expanded, many of these intended to serve specialty underserved populations such as communities with a high proportion of ethnic minority residents, and special populations with multiple medical comorbidities. FQHC’s, by design, contain all the necessary specialty care elements to form multi-disciplinary systems of care with the capacity to engage in a “stepped care” and “treatment to target” methodology. Utilizing hi-tech electronic health records (EHR) many of these FQHC’s, as well as group practices, have formed medical homes certified by the National Committee on Quality Assurance (NCQA). Additionally, networks of community-based providers, including hospital systems, have formed Health Homes. HH’s are provider networks with the capacity to meet the complex needs of people with co-morbid conditions tied together with technology that permits communication across providers, thus, forming the basis for patient-centered medical care coordination. Regional Health Information Organizations (RHIOs) have emerged with the intention of connecting provider groups with important patient specific information. These are cloud based information systems providing the ability of medical centers to connect with community provider organizations enhancing hospital to community continuity and facilitating smooth community care transitions for people who do require hospitalization.
Aligning Workforce Skills with System Transformation: Where the Rubber Meets the Road
There have been multiple articles written about workforce re-design rising up to meet the new demands of a transformed healthcare delivery systems since the signing of the ACA into law. Many of these focus upon workforce shortages in specialty and primary care in the face of the market expansion and expected increases in demand as the number of people with access to insurance grows.
The enactment of the ACA and the concomitant revamped healthcare system that emerges will undoubtedly have an impact on the health care workforce demanding new skills regardless of specialization.
The major specializations within the healthcare work force consist of nurses, social workers, physicians, pharmacists, and psychologists. Most of these professionals have been trained within a solo practitioner model often using intervention strategies that were not empirically validated on specific categories of diagnostic groups or populations. Further, this initial training occurred within a system that created incentives for volume of care, rather than outcome as a measure of health improvement. This may be one of the reasons why healthcare has been so slow to adopt evidenced based treatment systems although the pace of innovation diffusion has picked up considerably pushed by new payment methodologies, the ever-increasing use of managed care, and a prevention rather than medically necessary focus of care.
Additionally, the ACA has placed emphasis on the utilization of para-professional and peer supported interventions, such as family support, and care navigation. Some research points to the efficacy of peer support for people in recovery using evidence-based treatments, such as motivational interviewing. This element of the workforce can greatly assist in lowering cost and improving quality, but will need training and supervision in new healthcare delivery strategies as well.
So, the existing health care workforce, as well as new graduates, find themselves entering a work environment with a host of challenges. New clinical skills are necessary to align with evidenced based models; group and multi-disciplinary skills that form the basis of collaborative case management need to be developed, and an understanding of new models of care must be assimilated, all against the backdrop of understanding new methods of health insurance accessibility, eligibility, and standard benefit packages.
The Role of Graduate Education and Certificate Training
The NYU Silver School of Social work has been very proactive in addressing the workforce needs in the new emerging healthcare system. This has been reflected in the Schools graduate program equipping its new MSW graduates to play an informed and competency-based role within the new system. The School offers training in evidenced based treatment as well as integrated health. The School has also launched a special program that integrates advanced social policy in healthcare and behavioral healthcare to better equip students joining the new emerging healthcare system.
In September of 2011, the Dean of the Silver School commissioned a collaborative working group focused on integrated primary and behavioral healthcare. The committee consisted of prominent local experts to examine the possibility of developing an advanced certificate program in integrated health care as a continuing education program under the joint auspices of the McSilver Institute and the Office of Global & Life Long Learning. The Committee has been meeting on a quarterly basis and developed a recommendation to design a six-module advanced certificate in healthcare reform program consisting of a total of approximately 100 continuing education units [hours] or CEU’s. From among the menu of modules identified by the committee one was selected to fully develop and use as a beta test. This module, Leadership: Managing during Times of Change consisted of 22 contact hours. The curriculum focused on:
- Managing During Times of Change
- The Role of Leadership (Quality Improvement & Implementation Science)
- Collaborative Care Models
- Clinical Best Practices
- Technology/Hi Tech Coordination
- Sustaining Change: Supervision and Continuous Quality Improvement
- Performance Metrics: Outcome Evaluation
The committee focused on assessing the viability of the certificate program as well designing the optimal instructional model. These included:
- Ability to recruit a diverse group of middle to upper level managers who would attend early evening classes as measured by registration and attendance rates over a 20-week period
- Ability to successfully employ a mixed distanced learning (WebEx) and face to face instructional model as measured by engagement and satisfaction in each
- Ability to successfully pair field-based health and behavioral experts with faculty to form a team-teaching model that maintained a quality instructional environment and promoted by-in from provider groups as measured by participant satisfaction, and self- report of learning
- Ability to translate instructional material into field-based changes as measured by final project design and implementation.
Results: Data Speaks Louder than Words
The leadership module consisted of a series of 13 class meetings intermixed between 2-hour face to face seminars and one-hour WebEx presentations. The webinar series utilized power point presentations but also permitted viewers to view presenters and allowed for questions and answers through a chat box feature. There were a total of 20 hours of class presentations and a formal syllabus that contained readings geared to each topic area. Most topic areas had at least one web-ex presentation and one face to face presentation. WebEx technology, adapted from the Clinic Technical Assistance Collaborative (CTAC), was utilized to attempt to minimize the negative impact of traveling upon participants always associated with organized training activities. Marketing of the endeavor occurred through broad based out-reach to a diverse group including providers, managed care organizations (MCOs) and health homes (HHs).
Sixteen mid to upper level managers were recruited from twelve discrete organizations within NYC spanning a broad array of interest and experience. All were graduate trained with considerable field-based experience. The cadre of team-based faculty consisted of mostly graduate trained individuals who were professionals, peer educators and a doctoral student from the field. These were paired with University faculty members who were well known in the health and mental health fields and had years of both practice and teaching experience. The Dean of the Silver School taught the inaugural class session on the need for new skills to align with the transforming healthcare system. In addition, during the class, at the suggestion of one of the field-based presenters, an opportunity arose to add an additional WebEx on “managed care in NYS” presented by a senior State regulator. The WebEx was added to the regular syllabus and was opened to a much broader audience. Over 200 individuals registered for this event which was coordinated between Albany and NYC. Class participants were exclusively accorded panelist status by permitting them to interact with the presenter through the chat box function.
Attendance at all sessions hovered at about an 85% average with 100% notification if personal circumstance did not permit attendance. All participants were asked to submit an anonymous semester- end survey to gain feedback. On quality measures most students rated the instructional quality as good to exceptional.
- 85% agreed that the sessions provided new and valuable information about the ACA
- Material presented was rated as significantly improving students work capacity
- Students indicated that they would recommend attendance to colleagues
- 60% of the class felt that WebEx presentations were as engaging as in class sessions
Interestingly, and perhaps mindful of the need for transformative change, strong endorsement of organizational change dynamics was seen.
Final projects were designed and implemented within the participating organizations Participants were encouraged to form working groups for the purpose of project design encouraging collaborative behavior and cross communication. These projects included:
- Incorporating peer engagement support in ambulatory care settings
- Incorporating collaborative care focused on medical co-morbidity
- Developing an in-depth partnership with an FQHC to integrate behavioral and medical integration
- Developing a partnership between the MCO and HH to broaden the base of referrals across systems
- Developing medical access models for veterans not eligible for VA services due to discharge status
Clearly, these projects reflect the ACA goals toward integration and innovation of care. While it is premature to contemplate how sustainable these projects will be over time, it is likely that as new emerging payment models take hold forward transformative systems movement will “follow the money” and be seen as essential to survival.
Lessons Learned: Future Directions
There is a growing understanding among agencies and seasoned professionals that the transformative process launched by the ACA will require new skills and an understanding of new technologies to be effectively implemented. A mixed instructional model utilizing team teaching consisting of faculty and field-based professionals is effective, can be crafted to maintain instructional quality, and will promote buy-in. A final project model can be helpful in implementing actual change at the agency level resulting from educational processes.
The curriculum, as it responds to participant feedback, should incorporate presentations from medical professionals on integrative principals and sections on organizational change should be expanded. As a final note, during a meeting of MCO leaders hosted by the Silver School and the McSilver Institute, the MCO leadership noted two other important areas that they are focused upon as managed care takes the reins of Medicaid based healthcare. These are the need for more inclusive partnerships among providers to facilitate specialty care and support service to their members who have diverse and complicated needs, as well as the need for providers to develop medical literacy regarding medical co-morbidities among their staff at all levels.