A Primer on Managed Care: Multiple Chronic Conditions

cerns. In Washington State’s Medicaid Trans- formation Project Demonstration, nine ACHs are working to “address local health priori- ties, transform the Medicaid delivery system, improve population health, and reduce health care disparities” by addressing community sys- tems capacity, as well as the healthcare delivery system (Spencer, 2018). All nine ACHs have cho- sen to focus in part on chronic disease preven- tion and control. Under Washington’s Medicaid One culturally specific feature of Healthy Fit was the use of fotonovelas as education tools. managed care contract (called Apple Health), CHWs can be part of a comprehensive care team and are allowed to provide services that facili- tate the work of a care coordinator. In line with the Washington State Health- care Authority’s “Healthier Washington” guide- lines, all nine ACHs have included CHWs in order to achieve their project goals, including CHW roles in chronic disease−specific inter- ventions. Six elected to work with the Founda- tion for Healthy Generations (Healthy Gen) on a CHW care coordination model called Pathways/ Community Hub ( This approach was taken in part to address a lack of experience with CHWs among a number of the ACHs; replication of an existing, fully developed model was preferred to starting from scratch. Parallel to the ACH initiative, the Washing- ton State Health Care Authority and the Wash- ington State Department of Health charged the Community Health Worker Task Force in 2015 with developing policy and system change recommendations to align with the Health- ier Washington initiative. The task force’s work was viewed as key to the long-term sus- tainability of programs such as the ACH ini- tiative; Healthy Gen also played a pivotal role in the task force’s work. In February 2016, the task force released a set of recommenda-

tions, which included defining CHW roles, skill requirements, training standards, and financial sustainability. It did not, however, produce con- crete recommendations related to state-level certification of CHWs. Due to the pace of the task force work and the prominence of Healthy Gen and the ACHs in its deliberations, a number of stakeholder groups, notably in rural areas, expressed reser- vations about the task force process and its con- clusions; for a variety of reasons, the task force process suffered a major loss of momentum after release of the recommendations. In January 2018, building off the task force recommendations, the state legislature passed a bill to support refining earlier task force recom- mendations and producing a plan of action (per telephone interviews with Scott Carlson, Wash- ington State Department of Health, Kathy Bur- goyne, Foundation for Healthy Generations, and Seth Doyle, Northwest Regional Primary Care Association, for the Association of State and Ter- ritorial Health Officials, May–August 2018). Healthy Fit Initiative, El Paso, Texas The Healthy Fit initiative was a pilot project developed as a partnership between the local health department and the University of Texas School of Public Health (El Paso campus), with funding from a Medicaid Section 1115 waiver and additional support from a National Cancer Institute Community Networks Program grant (Brown et al., 2018). The purpose of 1115 waiv- ers is to demonstrate innovations in care deliv- ery, which can be implemented more widely to improve outcomes and control costs under Med- icaid. A number of states have included CHW interventions as part of 1115 waivers. Although the Healthy Fit study was not spe- cifically focused on older adults, the percent- age of the study sample who were eligible for colorectal cancer screening (39 percent) and-or breast cancer screening (38 percent of women) suggests that the project reached a substantial number of adults ages 50 and older.

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