Carlina Hansen, Senior Program Officer at California Health Care Foundation: Amplifying the Role of Community-Connected Health Workers

Van Ton-Quinlivan

Hello, I’m Van Ton-Quinlivan, CEO of Futuro Health, welcoming you to WorkforceRx, where I interview leaders and innovators for insights into creating a future-ready workforce.

Providing community-based providers is an important goal of California’s Medicaid program, known as Medi-Cal. To achieve this aim, policymakers started allowing non-traditional providers, such as doulas, to participate in the Medi-Cal program over the last several years.  A recent report from the California Health Care Foundation emphasized the role of Community Care Hubs in advancing this work, and we’re going to get the details on that and other aspects of this effort from Carlina Hansen, a senior program officer for CHCF’s Improving Access Team.

Thanks very much for joining us today, Carlina.

Carlina Hansen

Great to see you, Van. Thank you so much for having me.

Van

Well, let’s get started and have you just share with our listeners a little bit about the California Health Care Foundation in general and your work at the Foundation in particular.

Carlina

Yeah, sure thing. California Health Care Foundation is an independent philanthropy and we’re focused on improving how healthcare is delivered and financed in California. We center our work at the foundation on ensuring that Californians — and especially people with low incomes — have access to high quality affordable care. So, a lot of our work focuses on Medi-Cal, California’s Medicaid program. My role at the Foundation focuses on primary care equity, which is really about improving the quality and accessibility of primary care for all folks. Primary care is one of the most equitable ways to get access to care, and as it relates to the work we’re talking about today.

I’ve done a lot at the intersection of primary care and community, especially thinking about how we can amplify the role of community-based organizations and community-connected workforce — like community health workers in Medi-Cal — and I think you know a lot of these folks often act as trusted bridges between healthcare and our communities.

Van

Well, before I start diving into those respective topics, there’s many conversations happening right now about Medicaid in the federal context including possible cuts. I was wondering how that uncertainty is impacting the work that you’re doing and the work of the state?

Carlina

Great question, and an important question right now. Both the California Health Care Foundation, and of course our partners in state government, are closely monitoring the federal discussions about Medicaid funding. Any significant changes to Medicaid could impact the state’s ability to provide care to our Medi-Cal beneficiaries. Without getting too far into the weeds, there are things on the table like work requirements, cuts to federal funding for Medicaid, changes to subsidies for Covered California, just to name a few.

While we’re really committed to expanding and improving Medi-Cal services, there’s definitely a greater level of uncertainty than there was before. So, the Foundation and, again, state government are thinking about strategies to safeguard and sustain Medi-Cal programs to really make sure that a lot of the gains that we have made in California are not compromised.

Ultimately the biggest risk of cuts is that folks lose access to care, be they Democrat or Republican. So for that reason, defending Medicaid is really just of the utmost importance right now. We have to work with our advocate partners and state government to really make sure people understand how important Medicaid is to people and how much universal support of Medicaid there is.

Van

And would it be a true statement to say that we’re not alone as a state in our concerns about the uncertainties?

Carlina

Yes, absolutely. You know, the majority of our states have expanded Medicaid. We have the healthcare marketplace, and so there are a lot of people working together across the country to really amplify the message of how important Medicaid is. We have a lot of elected officials here in California and elsewhere that are really trying to protect Medicaid and again it’s a bipartisan issue. These are not just Democrats, they’re Republicans as well. Medicaid covers a huge portion of people in this country and is just really a critical lifeline for folks.

Van

So broadly speaking, I was wondering if you could do a little compare and contrast between the Medicaid program that is in California compared to the version that’s in other states and how does it measure up in terms of costs and healthcare outcomes?

Carlina

Well, I mean, I think one of the biggest things is that Medi-Cal is incredibly expansive and innovative. We, of course, have fabulously innovative partners in other states, but I think we’ve done a lot that we can really be proud of here in California. I think the first thing is the comprehensiveness of our coverage in California. We’ve really expanded over the past five years or so the number of people that are covered by Medi-Cal. We roughly provide health care services to over 13 million residents with a wide, wide range of benefits. We’ve just done incredible work increasing the availability of coverage so that people can stay healthy and get the care that they need. And ultimately, California is a large, populous state and so we have to have a Medi-Cal program that matches both the scale and the diversity of the people that live and work in California. That’s one of the things that’s just unusual, right? We are one of the most populous states in the nation, we’re the most diverse state in the nation and so that adds some unique elements and differences to our Medi-Cal program.

I think the other thing is the innovation that’s happened in Medi-Cal. I know we’re going to talk about it, but initiatives like CalAIM have been really watched by partners in other states. We are transforming care delivery in California to make sure that we’re focusing on whole person care, that we’re integrating physical health, behavioral health, and that we’re thinking about social needs and social services.

In terms of cost and health outcomes, California faces challenges similar to other states of our scale and size and diversity. We have a lot of initiatives that focus on improving quality,  — far too many to dive into today in the time that we have — but one thing I’ll highlight on the cost side is the launch of the Office of Healthcare Affordability, which is an example of how California is really proactively trying to address costs while not compromising quality or access. It includes things like encouraging systems to shift investments from more expensive care to preventive care by implementing things like a primary care spending benchmark and trying to shift money into the primary care system so that ultimately we’re in a place that’s both cost effective and effective from a human and health outcome perspective.

Van

Carlina, you had quickly mentioned the CalAIM (California Advancing and Innovating Medi-Cal) program. For our listeners’ sake, could you just explain CalAIM as juxtaposed to the Medi-Cal program?

Carlina

Yeah, I’ll talk a little bit about it. It’s of course, like many federally-governed things, a little bit complicated, so I’m not gonna get into the weeds, but I’ll share that CalAim has two sort of major components. One is called enhanced care management, and that provides intensive care coordination for people who have complex needs: folks that have a difficult time navigating our healthcare systems and have complex health and social factors going on in their lives; folks who may be homelessness, managing substance use disorder, et cetera.

The second part is called community supports and that’s a list of thirteen services that managed care plans in California can offer that include things like housing navigation, medically-tailored meals, and a variety of other interventions that address social determinants of health.

Van

That’s a great brief overview of the CalAIM program and that is a good transition. As I brought up in my introduction, your CHCF report highlighted the role of the Medi-Cal Community Care Hubs. Let us know, will you, what they are and how they’re supposed to help.

Carlina

You can think of Medi-Cal Community Care Hubs as sort of the connective tissue between health plans, providers, and communities. They are centralized entities that can help to coordinate services between providers, plans, and patients. So essentially it’s an entity that can help local providers, especially folks who are new to Medi-Cal, in contracting with managed care plans. They do things like manage contracts, process claims, facilitate data exchange, and reduce administrative burdens on providers. And then to the earlier conversation, they help people implement programs like enhanced care management and community supports, which address comprehensive health and social needs.

I think one of the important things to know about CalAIM is that it introduced a whole group of new types of providers and workforce into Medi-Cal and with that, there were a lot of new kinds of entities — local community-based organizations, for example — who had never participated in Medi-Cal before. It was new to them. There can be a high barrier to entry if you’re new to Medi-Cal. You have a lot of systems you have to set up, things that you need to do to be able to participate and hubs sort of hold the promise for some of those folks to make that easier and ultimately in doing so, to connect those community-based providers and their patients they see to Medi-Cal so that those folks have access to these important Medi-Cal services.

Van

Let’s dive a little deeper on that. These hubs lower the barrier to entry for community-based providers, or that’s the promise. What are some of these providers? think we mentioned doulas in the introduction.

Carlina

Exactly. So doulas, community health workers, behavioral health and peer support specialists are examples of the kinds of workers. And also community-based organizations who may be offering services like meals, et cetera, who may not have been in Medi-Cal before. There’s a whole variety of providers around the state who are trying to figure this out and trying to get into Medi-Cal so that their patients can benefit, but those are a few examples.

Van
So if I were a doula or a CHW or peer support specialist prior to these hubs, for example, what would be my experience trying to enter Medi-Cal and with the hubs in place and fully functional, how are you hoping it to manifest?

Carlina

Great question. So I think if someone was trying to get into Medi-Cal and it was their first time, they would have to go through a variety of different application processes with Medi-Cal to become a provider. In some cases, that involves various credentialing processes, etc. They would have to set up billing systems. They would have to manage things like claims denials and claims that didn’t go through. They would have to manage patient eligibility, care coordination with a variety of different agencies, data security and making sure that they can exchange their data in a compliant way with plans.

Those are just a few of the things that someone entering Medi-Cal for the first time might have to think about, and there’s a longer list than that. So the hope is that with the hubs, they can take on some of that burden. They can also support managed care contracting, which can be a complex and intimidating process for folks who haven’t done it before. So they can facilitate contracts and broker those relationships so that those providers don’t have to take all of those things on themselves.

It’s important to emphasize that hubs are all very different. You know, some do some things that others don’t. Some do more data exchange, some offer legal services and supports, but they really tailor what they do to the needs of the providers that they work with and the plans that they work with. So they’re both beneficial to the providers, the workforce, but also can be beneficial to the plans who are trying to contract with many of these entities.

Van

I can definitely see the value in these hubs because if I were trained to be a doula and I want to go out there and provide birthing support to my community, my goodness…I doubt I would be trained in data exchange, for example, or data security.  I can see how those could be barriers to even getting started with my business.

Carlina

Yeah, that’s right.

Van

I was wondering, is there an exemplar that you’d like to call out from all of the hubs that you’ve seen in action?

Carlina

Yeah, there is a national model called Pathways Community Hub that has evolved in a variety of different places in California, including San Joaquin. There is a model in San Diego called San Diego Wellness, and they have been doing phenomenal work in that region. And then there’s several for-profit, more tech-enabled hubs, notably Pear Team and Pear Suite. There is a long list and it’s in the publication that you mentioned earlier and I think we’ll provide a link to listeners so they can get to that.

Van

That would be terrific. And what is the business model that would allow for a sustained approach to these hubs?

Carlina

I think it’s still evolving and really varies from hub to hub and from region to region. But you know, some of the things that we’re seeing are the importance of diversified funding streams – so, not relying just on one thing like Medi-Cal reimbursement — but also thinking about local grants, philanthropic investments in some cases, and then sort of one-time Medi-Cal grant programs that are available, like PATH CITED. And plans also have had funds available to invest in local infrastructure called IPP, so there’s a variety of different ways that folks can access funding.

Secondly, thinking about economies of scale, the more folks you have in your hub, sometimes scaling can get easier and it can kind of be simpler in some ways to sustain your infrastructure. If you have fifty organizations, that’s different than just having two organizations. So I think growth and scale can be important in addition to thinking about the value to the managed care plan partners. I think if the plans can see the impact in terms of access and quality for their members, then I think they are more likely to be able to invest and really think about how they contract with these hubs to continue to make sure that they add value. But I think, it depends both on payment streams and supportive policies. It’s not money alone.

So I think hubs are really watching the federal policy shifts to understand how it could impact their work and they’re also looking for what the state will do around hubs so that folks have more clarity and understanding about the state’s perspective.

Van

I want to shift a little bit and take advantage of your expansive view of the state and the healthcare landscape and just get your advice because as you know, I chair the Health Workforce Education and Training Council and so we want to get advice from experts on where is the puck heading with regards to the healthcare workforce and evolving skills.  I know that your emphasis is in the primary care workforce, so I would love to hear any thoughts or any asks that you would have in terms of evolving the healthcare workforce towards those goals.

Carlina

Well, Van, thank you very much for your service on the Council.  It’s an important role. You have seen firsthand some of the information that’s been shared about the acute shortages in workforce that we face in the state of California and that is all the more acute when it comes to primary care workforce. That’s driven by some of the things that folks might expect: unfortunately, wages are lower for primary care physicians than they are in other specialties; additionally, some of the training pipelines and residency slots are constraining and so we just don’t have enough folks coming into our primary care workforce. At the California Health Care Foundation we’re really thinking about those things and trying to enhance and improve those pipelines as are folks like HWET and our Department of Health Care Access and Information, HCAI.

But I think one of the other things we need to think about is just the role of the interprofessional team. We are in a time both with regards to the breadth of what health workers have to address and the shortages that we see that our healthcare can no longer fall to one person. We also need to think about our behavioral health workforce and the shortages we also have there, which are quite acute. I know folks are thinking about the role of Medi-Cal assistants, nurses, nurse practitioners, and of course where lay workers like community health workers and others can really augment the team so that people are being seen as a whole person and receiving care as a whole person.

So I think those kinds of interprofessional approaches to care really hold promise both in helping us when we think about our healthcare workforce shortages, but also in terms of addressing the whole needs of the patient. We know that patients come in the door with a whole host of concerns that are not just about their healthcare, they’re about their housing, food insecurity, and other things. There’s no hope that a physician could address that in a fifteen-minute visit, which is why we have people who are equipped to go out into the community who are working with patients between visits — social workers and other types of providers — to make sure that they can stay healthy and get the care that they need.

Van

For the listeners that want to track and follow this body of work on evolving towards the team-based approach of primary care or the interprofessional approach to care, where should they start?

Carlina

Well, I’ll do a shameless plug, Van. Go to our website, chcf.org, follow us on social media and sign up for our mailing list. I promise you will not be disappointed. We put out a lot of really fantastic information about our healthcare ecosystem in California. And then some of the publications that I mentioned, exploring Medi-Cal Community Care Hubs…and we have a new publication that just came out about community connected workforce and looking at doulas, behavioral health peers, support specialists, and community health workers and the role that they play in Medi-Cal. So those are just a few things.

Van

Fantastic. I receive those newsletters and you’re right, our listeners will not be disappointed. There’s a lot of goodies that come out in those newsletters. So, why don’t we close with giving you an opportunity to share what makes you optimistic about the future of care.

Carlina

What makes me optimistic about the future of care — and I’m not just saying this because you invited me on the podcast, Van —  is leaders like yourselves and the peers that I get to work with in California who are so incredibly thoughtful about the ways that we can improve our healthcare system. I think listeners should have faith that we have a lot of smart, committed people in California who in this moment in time are working hard to defend Medicaid and to think about strategies still to improve Medi-Cal for the people in the state of California. I think I just feel fortunate to be here in this beautiful state and to learn from some of our other states who are just doing incredible work themselves. But as a proud Californian, I have to speak for our wonderful Golden State here.

Van

Well, Carlina, thank you so much for your leadership and your firepower in terms of being able to think through some very complex issues on behalf of the citizens of California. Thank you for being with us today.

Carlina

Thank you so much for having me, Van. Great speaking with you.

Van

Likewise. I’m Van Ton-Quinlivan with Futuro Health. Thanks for checking out this episode of WorkforceRx. I hope you will join us again as we continue to explore how to create a future- focused workforce in America.