Insurance issues as a barrier to HIV care: using a newsletter to raise awareness

By Kathleen Xu, MPH & Ranjani Paradise, PhD 

“Take the test. Take control.” – National HIV Testing Day slogan

In honor of National HIV Testing Day, we are sharing our experience working with Cambridge Health Alliance’s (CHA) two HIV clinics, The Zinberg Clinic and Somerville Hospital Primary Care, on a Continuous Quality Improvement (CQI) Team. Our team consists of a nurse manager, a social work manager, a nurse practitioner, a community health worker, a program support director, and three Institute for Community Health (ICH) staff members. We meet regularly to track quality measures and strategize how to help the HIV clinics sustain high quality services. One of the issues we have been tracking is the relationship between health insurance coverage and access to care for HIV patients. Insurance policy changes and gaps in coverage impact patients’ ability to maintain ongoing HIV treatment, which is extremely important for reducing HIV viral load and minimizing HIV drug resistance. With 63% of CHA’s HIV patients on public insurance, and a large proportion of them affected by unstable housing and employment situations, their insurance coverage often fluctuates. Therefore, the CQI team has made an effort to better understand the main insurance issues and ongoing policy changes that most affect these patients, so that CHA providers can better support patients through the process.

Over the past few months, our CQI team gathered information and feedback from the two clinics’ case managers about challenges they have experienced with insurance policy changes when trying to maintain coverage for their patients. We learned that as a result of many policy changes over the last 4 years, including those that resulted from the Massachusetts health care reform, the time it took case managers to ensure each patient received adequate coverage quadrupled.  Much of the added time was attributed to extra paperwork and delays in insurers’ response time.

One particular challenge case managers and patients have faced in recent years is stricter proof of residency requirements. Since many of CHA’s HIV patients are of low socioeconomic status and have unstable living situations, they often do not have the documents required to prove MA residency (e.g., mortgage papers, utility bills, leases). As a result of this policy change, patients experience unexpected coverage termination and coverage gaps. Case managers must continuously monitor patients’ social and living statuses on a month-to-month basis, as any income, dependency, address or job status changes could disqualify patients for some insurance policies. In such cases, case managers must help patients identify and apply for a new insurance policy depending on the status change and also help them determine which pharmacies accept the new insurance.

Overall, obtaining insurance has become a time-consuming and complicated process for patients and case managers. CHA is fortunate to have dedicated case managers to help patients navigate the complex insurance system, as well as providers who also work hard to keep patients in care and adhering to their medication regimens, even when faced with these insurance barriers.

In order to support our case managers, providers, and patients, the CQI team focused the April 2013 issue of our newsletter, Facts for Action, on insurance and HIV. This newsletter was disseminated to all staff and patients in order to raise awareness about the effects of insurance issues on HIV care.

The first page displays a timeline and comprehensive list of insurance issues that case managers have been working hard to overcome, while the second page includes a list of recommendations for providers and patients about how they can work together with their case managers to avoid insurance issues. Especially in the multidisciplinary setting of CHA’s HIV clinics, the newsletter served as an important reminder for all staff to collaborate as a team and communicate with each other and their patients to provide the best care for their patients.

National HIV Testing Day is an important annual event promoting HIV testing and encouraging all people to learn their HIV status. Getting tested is only the first step to managing HIV. As we reflect on our work with the CQI team, we are reminded that in addition to encouraging testing, we must ensure that those tested positive have access to the medical care that they need.

Special thanks to the HIV Continuous Quality Improvement (CQI) team and the CHA HIV clinics' case management staff for their help in compiling the Facts For Action newsletter!

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The views expressed on the Institute for Community Health blog page are solely those of the blog post author(s), and do not necessarily reflect the views of ICH, the author’s employer or other organizations with which the author is associated.

Making Data Useful, Making Data Meaningful: Participatory Evaluation in the Youth First initiative

By Jeff Desmarais, MA, Maeve Conlin, MPH, Nazmim Bhuiya, MPH

May was teen pregnancy prevention month, which is a chance to highlight the Institute for Community Health’s (ICH) partnership focusing on teen pregnancy prevention. Massachusetts has made great strides in reducing the teen birth rate in the past decade, as evidenced by 2010 community-level teen birth rate data recently released by the Massachusetts Department of Public Health. In 2010, Massachusetts teen birth rate was 17.1 per 1,000 adolescent females aged 15-19, the lowest birthrate on record, continuing the state’s downward trend. While progress has been made, strong racial and geographic disparities in teen birth rates persist among Massachusetts’ communities. These disparities must be addressed through collaborative, multilevel efforts, such as Youth First, an initiative that aims to reduce the teen birth rate in Springfield and Holyoke, two communities with some of the highest teen birth rates in Massachusetts. In 2010, Holyoke had the highest teen birth rate in the state and Springfield had the third highest.

Youth First, a 5-year CDC-funded initiative, seeks to address teen birth rate disparities through a community-wide collaborative approach to enhance access to quality sexual health education and reproductive health services. This collaboration involves the lead organizations, Massachusetts Alliance on Teen Pregnancy (MATP) and the Youth Empowerment and Adolescent Health (YEAH!) Network, as well as a host of Springfield and Holyoke-based clinical and community partners. These partners aim to mobilize the community, empower youth through engagement and enhance the quality of clinical and health education services for sexual and reproductive health.

Working in partnership as the evaluator for this initiative, ICH’s role is to facilitate data collection and help our partners utilize this data to drive program improvements and decisions. Since ICH utilizes a participatory research approach to guide the evaluation process, we are simultaneously building our partners’ capacity to collect, analyze, and interpret data for their current and future work. This data allows our partners to think about their programs’ impact—to see how their hard work is making a difference in the lives of the youth they serve and the community more broadly—and informs their services in the future.

As we reflect on this important partnership and the value it brings to the health of populations, we have several critical lessons to share as evaluators:

First, in order for data to be useful for our community partners, it must be meaningful to them. As an evaluator, you can’t assume that all partners will have an understanding of how to interpret and use data to improve their communities. Building an understanding of what data actually tells us and how it can be used to inform programs’ strengths, gaps, needs, and target populations is an important step in any partnership. Having these conversations early on in the collaboration will help you identify which capacities must be improved so that data can be collected and used effectively.

Additionally, as evaluators we must help build communities’ data collection infrastructure to enable partners to collect and use data independently, so that teen pregnancy prevention efforts can be continuously improved and sustained even after grant funding ends. With a strong data collection system in place, the partners can better understand and improve their programs and in turn, their communities.

The Youth First initiative’s multifaceted approach to teen pregnancy prevention is what makes the program distinctive. Our work as evaluators is a small but very important piece of the initiative. Erica Fletcher, Prevention Director at MATP, describes our strong partnership as a unique project element and states that ICH has been instrumental to the initiative’s planning, implementation, and ongoing quality improvement efforts. Given that May was teen pregnancy prevention month, it is an opportune time to highlight strategies and share tips with other evaluators aiming to reduce teen pregnancy.  Strong partnerships with the community and a participatory evaluation approach are key steps towards recognizing opportunities to address social, behavioral and environmental factors that impact teen pregnancy.

Special thanks to Shalini Tendulkar, ScD, ScM, and Jessica Waggett, MPH at ICH and Erica Fletcher, Ed.M. Prevention Director at the Massachusetts Alliance on Teen Pregnancy for their support and guidance. 

 

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The views expressed on the Institute for Community Health blog page are solely those of the blog post author(s), and do not necessarily reflect the views of ICH, the author’s employer or other organizations with which the author is associated.

Reflections on Real World Public Health Day 2013

By Kelly Washburn, MPH, ICH Research Associate II

 

On April 3^rd 2013, The Institute for Community Health (ICH), in collaboration with the Cambridge Public Health Department (CPHD), hosted its 10th annual Real World Public Health (RWPH) Day. This free, half-day seminar aims to provide public health graduate students with insight into “a day in the life” of a local public health department. The event features breakout workshops, a career panel, and a keynote speaker from the field – this year Patrick Wardell, CEO of the Cambridge Health Alliance delivered the keynote.

Over the past few months, I’ve worked closely with CPHD staff to plan and implement this year’s RWPH Day. As a former MPH student, I remember seeking out real-life examples of the information my professors discussed in class. One of the major benefits of Real World Public Health Day – the workshops in particular – is that the event provides students with a great opportunity to learn about a variety of public health issues that public health departments and the field in general currently confront.

Workshop foci change each year and typically feature the current “hot topics” in public health. This year, the workshops highlighted climate change and emergency preparedness; fatherhood as a social determinant of health; and policy development for workforce domestic violence. By depicting partnerships across different sectors, the workshops provide students with examples of the opportunities and challenges that exist when multiple stakeholders work together. The workshops are intended to be very interactive, and students are encouraged to generate discussion questions. In many workshops, students also have the opportunity to offer programmatic recommendations to presenters.

The specific goal of the career panel is to introduce students to a variety of career paths within public health, with each panelist speaking about his or her job responsibilities and the skill sets required. Along with the workshops, the career panel provides students with the opportunity to learn about the breadth of career options available to public health graduates and encourages students to explore different opportunities to work in public health. This year’s panel featured a research associate, a registered nurse, an emergency preparedness coordinator, and a health promotion and marketing coordinator who was actually a student in the audience a couple of years ago! She shared that attending Real World Public Health Day greatly influenced her career decision to go into health promotion and marketing.

The overall feedback from this year’s students was very positive; many stated they enjoyed hearing about the complexity of public health programs, how their coursework can be applied in real life, and the various career paths open to them. Hearing and seeing the students’ enthusiasm certainly validates the importance of continuing to offer this event in years to come!

Kelly Washburn, MPH is a Research Associate II at the Institute for Community Health.

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The views expressed on the Institute for Community Health blog page are solely those of the blog post author(s), and do not necessarily reflect the views of ICH, the author’s employer or other organizations with which the author is associated.

 

 

National Public Health Week 2013 Perspective: Population Health and Return on Investment

 

By: Karen Hacker, MD, MPH, ICH Executive Director

Today, as part of health care reform, new strategies such as Accountable Care Organizations (ACOs) and Patient-Centered Medical Homes (PCMHs) are being developed to enhance quality, efficiency and control costs. Achieving these goals necessarily requires managing a “population” of patients, and shifting the focus of care from illness to wellness. The Triple Aim initiative of the Institute for HealthCare Improvement provides a roadmap for transformation, emphasizing the importance of improving: 1) the patient experience of care, 2) population health, and 3) reducing the cost of healthcare. While the aims of cost and patient experience are self-explanatory, the population health aim still remains unclear.

So what is population health?

Today, the phrase “population health” has many meanings. For some health care providers, it is simply about the panel of patients they serve. For larger integrated systems and health care insurers, it’s often their entire enrolled population. While both of these definitions move us from the individual patient to a group perspective, they don’t include larger geographic populations. Thus, controversy about the precise definition of population health continues. And that definition matters – especially considering how it impacts the ways in which systems allocate resources for and measure changes in broader health. To improve overall health, the definition of population health must extend beyond the delivery system to consider the many social determinants of health that fall outside of the medical system’s purview.

However, expanding this definition comes with challenges. Is it realistic to expect the health delivery system to influence the health of the geographic community that it serves? If so, how will this new direction be paid for? In a recent issue of the Journal of the American Medical Association, Drs. Noble and Casalino commented on this by asking “should ACOs be given incentives to improve the health of the population in their geographic area?” Further, how can the delivery system leverage community benefits to support the public health system – both governmental and community-based?

The Affordable Care Act offers enormous opportunity for collaboration across sectors to achieve overall population health. Both the delivery system and the public health system are important players in this endeavor and can improve health and reduce costs if they work together. In order to achieve a return on investment for future health and more immediate cost savings, these partnerships must utilize evidence-based preventive strategies which span policy and clinical strategies and range from screening and vaccinations, to no-smoking policies and access to fresh fruits and vegetables.

But how do we get there from here? As delivery systems identify their populations and the opportunities for improvement, so too public health systems are trying to understand how their historic work intersects with today’s focus on care delivery. These two areas tend to think very differently, but we need them to start thinking together. We also need to ensure that the focus on care delivery doesn’t sacrifice our public health system but rather builds the appropriate bridges to create a continuum of care for communities. In the face of the massive delivery system transformation that is occurring nationwide, this is a challenge. As these two systems begin to clearly articulate their roles and responsibilities, one jurisdiction at a time, and as new models emerge and are tested, we should hopefully see whether collaboration creates the efficiency and improvement that is needed. There is much to do in population health, and the opportunity is now.

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For more information on ACOs and population health see Drs. Hacker & Walker's forthcoming article in the American Journal of Public Health: Hacker K, Klein-Walker D. Achieving Population Health in Accountable Care Organizations, In Press, American Journal of Public Health 2013

To Shame or Not to Shame—NYC’s New Teen Pregnancy Prevention Campaign

By Nazmim Bhuiya, MPH

Doleful, doe-eyed babies plastered throughout subways and bus stops reading “I’m as twice as likely not to graduate high school because you had me as a teen”, “Dad, you’ll be paying to support me for the next 20 years”, “Honestly Mom…chances are he won’t stay with you. What happens to me?”

These are the descriptions of New York City’s (NYC's) recently launched ad campaign targeting teen pregnacy—a campaign that has sparked much discussion and controversy. The situations highlighted in the ads depict the imminent consequences of teen pregnancy “through the lens of the children.” In a city that is requiring schools to provide comprehensive sexual health education and is increasing access to birth control, I was disheartened to see that a shaming message focusing solely on the negative consequences of teen parenthood was used as an educational tool for adolescents. Teen mothers have also been dismayed by these messages. NPR recently interviewed Gloria Malone, a former teen mom who now runs the blog Teen Mom NYC. Gloria said these ads “brought back all of the insults and stereotypes and stigmas that I had to fight against in high school and everywhere else . . . And the shame and the stigma is what kept me in unhealthy situations.” Shameful, fear-inducing, negative messaging is not an effective strategy in changing behavior, and moreover, this strategy may inadvertently have adverse effects, as research on anti-smoking/anti-drinking ads for teens has illustrated.

Having worked in teen pregnancy prevention for several years now, I have seen the many layers and complexities of this public health issue. Factors contributing to particular behaviors (e.g. early sexual initiation) that may lead to teen pregnancy are multi-faceted and go beyond the individual level to the socio-ecological determinants of health. Many young people who become teen parents grow up in surroundings entrenched in poverty, violence, and a myriad of other risk factors. Some view pregnancy as the only path they are destined to take because they do not see any hope for a promising road ahead. For others, pregnancy is a way of having a family of their own and being loved— something they may not have experienced.

                                                                                      

Shameful messaging may help to avert some pregnancies, but it still does not respond to the larger issues at play. Efforts need to focus on creating a supportive environment for young people. Systems need to be in place to ensure they have the resources they need whether they decide to have a child or not. Young people need to be provided with tools to make healthy decisions and with opportunities that will empower them, cultivate their development, and reinforce their hopes. There needs to be a shift in our overall approach in addressing teen pregnancy to truly mitigate this issue.

Nazmim Bhuiya, MPH is a Research Associate II at the Institute for Community Health.

References:

1) Agrawal N, Duhachek, A. Emotional Compatibility and the Effectiveness of Antidrinking Messages: A Defensive Processing Perspective on Shame and Guilt. Journal of Marketing Research. 2010; 47(2):263-273.

2) Henriksen L, Dauphinee AL, Wang Y, Fortmann SP. Industry sponsored anti-smoking ads and adolescent reactance: test of a boomerang effect. Tob Control. 2006;15(1):13-8.

3) Snyder, LB, Blood, DJ. Caution: Alcohol advertising and the Surgeon General's alcohol warnings may have adverse effects on young adults. Journal of Applied Communication Research 1992; 20(1): 37-53.

4) Wolburg, JM. The need for new anti-smoking advertising strategies that do not provoke smoker defiance. Journal of Consumer Marketing. 2004; 21(3): 173-174.

5) New York Ads Resurrect Stereotypes For Former Teen Mom [transcript]. Weekend Edition Sunday. National Public Radio. March 24, 2013.

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The views expressed on the Institute for Community Health blog page are solely those of the blog post author(s), and do not necessarily reflect the views of ICH, the author’s employer or other organizations with which the author is associated.

Language Services Quality Improvement at the Cambridge Health Alliance

 By Ranjani Paradise, PhD

Here at ICH, we work in close partnership with the Cambridge Health Alliance (CHA) on a number of research, quality improvement, and evaluation projects. CHA serves an extremely ethnically and linguistically diverse patient population. For example, last year, one in three of CHA’s outpatients, and one in four of inpatients, spoke a language other than English at home!

Because of this incredible linguistic diversity, CHA has long been working to ensure that limited English proficient (LEP) patients can communicate with their doctors in safe and effective ways. To support communication with LEP patients, the Multicultural Affairs and Patient Services (MAPS) Department offers professional interpreter services in three modalities: face-to-face, telephone, and videoconference. In addition, MAPS offers language testing for multilingual providers who wish to speak directly to their LEP patients.

For one of my ICH projects, I work with MAPS on language services quality improvement. Over the last several months, a major focus of our work has been to reduce the use of patients’ family members and friends as interpreters, as this practice can compromise the quality of communication in a number of ways.

When you think about potential risks related to using family/friends as interpreters, what comes to mind?

Perhaps the most obvious risk is that family members and friends are often not familiar with medical terminology, and may make errors or omissions during interpretation that could compromise patient safety. If an interpretation error or omission results in harm to the patient, this can have severe legal and financial consequences for the hospital. In one well known case, misinterpretation of a single word resulted in a $71 million lawsuit against a hospital after the patient ended up with quadriplegia (paralysis of both the arms and legs). This illustrates the fact that interpretation errors can present truly serious patient safety concerns as well as liability issues.

Another problem with using family members and friends to interpret is that they have a personal connection with the patient. Because of this:

·        Family members and friends may choose to withhold bad news or insert personal opinions into the conversation, which can compromise communication accuracy.

·        The patient, as well as the family member or friend, may be uncomfortable discussing sensitive information, such as sexual or mental health. This can create a situation where important information is not disclosed to the doctor. Imagine having to discuss the sexual history of a parent, and I’m sure you’ll understand why this can be a problem!

Communicating through a family member or friend may prevent a patient from being able to tell you about domestic violence or other abuse. In fact, a physician friend of mine (not at CHA) experienced this firsthand – a patient came to the hospital and she didn’t speak English, but her husband did. The hospital was not able to bring in a professional interpreter right away, so the patient’s husband interpreted. When the professional interpreter was later brought in, my friend had a chance to talk with the patient while the husband was out of the room. The patient stated that her husband had been abusing her and that she did not trust him to interpret for her. Patients should feel safe sharing this kind of information with their doctors, and using a family member or friend to interpret can compromise this.

As part of our quality improvement work, we monitor data each month to track how often family and friends are being used to interpret at CHA sites. We have also surveyed providers to understand reasons behind this practice. We got some terrific information from the survey: many providers were candid in sharing the challenges they face in caring for LEP patients, which really helped us understand their perspectives on this issue. We’re currently working on using the survey findings to identify resources that we can provide to help providers communicate with their LEP patients in the safest and most effective ways possible.

I’m glad to be a part of the team and look forward to supporting MAPS in their efforts to keep improving LEP patient care at CHA!

Ranjani Paradise, PhD is a Research Associate II at the Institute for Community Health.

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The views expressed on the Institute for Community Health blog page are solely those of the blog post author(s), and do not necessarily reflect the views of ICH, the author’s employer or other organizations with which the author is associated.

Engaging Youth through PhotoVoice: ICH Intern Perspective II

By Alice Chan, ICH Intern

What a wonderful way to start off the New Year with the third session of our Youth Photovoice project, funded through the Saffron Circle, in Malden! After a successful last session, Shalini and I were ready to move forward with the next (and exciting) step of the project – the Photography Workshop! The objective of this session was to train the youth with a basic tutorial in using digital cameras, generously loaned to us by Yolanda Ortiz from Wayside Youth, before giving the youth the cameras to capture trial run photos.

It was important to review the principles and importance of the ethics involved in taking photos and so I led a team building exercise to refresh the youth’s memory on these ethical principles developed at a prior session. Everyone proved to be very knowledgeable about the “dos and don’ts” with their soon-to-be-assigned cameras. Following this brief review came the photography tutorial part of our session. Who better to lead this photography workshop than our fellow Cambridge Health Alliance colleague Dr. Freeman Changamire, MD, ScD, an expert and enthusiast in all things photography? Dr. Changamire led an outstanding demonstration of the cameras’ functions and settings. Thanks to his guidance, I am confident that the youth are well-prepared to spend the next month taking pictures that capture their attention and convey personal meanings in relation to mental health.

Now that the youth have finally received their digital cameras, they have an opportunity to capture their thoughts and ideas on the topic of mental health and wellness via photos. The goal from now until the next session is for the youth to experiment and be creative as they are exploring their community for those fascinating and noteworthy photo opportunities.

As the cliché goes: a picture is worth a thousand words. At the next session, that is exactly what we will be proving (that is, we will be putting, or “analyzing,” the images with words). Stay tuned for more updates!

Alice Chan is an intern at ICH working with Shalini Tendulkar, ScD, ScM on the Youth Photovoice project through the ICH Education Program. Ms. Chan is a sophomore in the Department of Psychology at Tufts University.

For more information on internship opportunities like this one at ICH, please click here!

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The views expressed on the Institute for Community Health blog page are solely those of the blog post author(s), and do not necessarily reflect the views of ICH, the author’s employer or other organizations with which the author is associated.