Leveraging Policy to Promote Child and Family Well-Being and Address - - PowerPoint PPT Presentation

Leveraging Policy to Promote Child and Family Well-Being and Address Adverse Childhood Experiences

Academy Health National Health Policy Conference

Jeff Schiff, MD, MBA | Medical Director

Minnesota Department of Human Services February 6, 2018

mn.gov/dhs

Rationale: Match solutions with sources

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Sources of Health Genes and biology - 10% Social and economic - 40% Health behaviors - 30% Clinical care - 10% Physical environment - 10%

Minnesota Department of Human Services

• Medicaid enrollment and eligibility
• Health care
• Behavioral health
• Chemical health
• Disability services
• Senior services
• Child protection/welfare, SNAP,

economic assistance, foster care, adoption

• State operated direct care for

individuals committed to psychiatric care

• State sex offender program

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Minnesota children enrolled in DHS programs

Programs focus on different aspects of child/family well- being, but to a large extent serve the same children.

Why is this our American moment?

• Better understanding of the science of ACEs and SDoH
• Better integration of data to understand populations
• Better understanding of the economic cost of ACEs/SDoH
• Better integrated care delivery payment models in health care
• Better integration of services between sectors
• More authentic community engagement with diverse communities

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What do we need? Baseline data and analysis

• A clear taxonomy to discuss SDoH and ACEs
• The elevator speech
• Development of agreed-upon ways to collect the data across localities
• Integration of the community into the data structures
• Some ethics of data analysis and reporting
• Common economic modeling that includes downstream costs

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What do we need? Interventions

• A deep conversation with communities about SDoH/ ACEs and cultural trauma

that plans for interventions

• Modeling of interventions based on these conversations
• Recalibrating health care providers to see their role in addressing SDoH
• Recreating health care teams to have community members and other

professionals on the team and developing economic models to do this

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What do we need? Outcomes

• Useable structural, process and outcome measures for providers to share with

community/ social service providers (i.e. start with governance)

• Right amount of “accountability” for provider organizations to get this started
• Celebrate success, engage all levels, persist

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Priority Opportunities to Leverage Existing Policy-Driven Systems, Structures, and Innovation Platforms

Key Short-Term Opportunities and Actions

Prioritize early and periodic screening, diagnostic, and treatment (EPSDT) and prevention Focus hospital community benefit strategies Establish enabling

• rganization, payment,

and performance measurement policies (e.g. through CMMS, Title V, Head Start, etc.) Advance and test Medicaid policy implementation Inform and track legislation to accelerate translation into policy

Priority Opportunities to Leverage Existing and Evolving Practice Transformation Efforts

Key Short-Term Opportunities and Actions

Leverage medical/health home and social determinants of health “movement” Enable, activate, and support child, youth, and family engagement Build effective peer/family to peer/family support capacity Empower community- based services and resource brokers (e.g. early childhood, school health, youth, & after school programs) Leverage existing commitments and focus areas in child and family health

Leverage Existing Research and Data Platforms, Resources, and Opportunities

Key Short-Term Opportunities and Actions

Optimize existing federal surveys and data (including creation of follow- back surveys) Optimize state surveys Liberate available data (facilitate access and remove barriers to use) Build crowdsourcing, citizen science, and “N of 1” methods Integrate common- elements research modules for longitudinal studies Link to collaborative learning and research networks

Thank You!

Jeff Schiff, MD MBA

jeff.schiff@state.mn.us

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Purpose: Embed health equity at the source

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Risk factor categories

• Family structure (including family composition)
• Socio-economic indicators (income, neighborhood, homelessness)
• Parental functioning (mental health, substance use, child protection,

incarceration)

• Immigration status, ethnicity, language

DHS does not pay providers differently according to program participants’ racial or ethnic background

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Family structure risk factors

• Parent is unmarried

63%

• Four or more children on case

23%

• Child in home is medically complex

17%

• Parent is disabled/had very high medical expenses last year

8%

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Income and other tangible resources

• Family poverty

83%

• Neighborhood with concentrated poverty

32%

• Homelessness (5 years)

8%

• Family lacks vehicle worth at least $2,500

59%

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Parental functioning

• Parent with chemical dependency diagnosis (18 months)

10%

• Parent with serious mental illness (18 months)

13%

• Parent with serious, persistent mental illness

5%

• Child received child protection services

19% (FI, FA, or post-FI/FA services) (5 years)

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Language and Immigration

• Parent speaks language other than English most of the time

25%

• Child immigrated to U.S. (ever)

4%

• Parent immigrated to U.S. (ever)

28%

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Family risk factors by program participation

• Children in child protective programs had greatest prevalence of risk factors
• Children in cash/food programs (but not child protection program) had next

greatest prevalence of risk factors

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Dramatic differences in risk by the child’s ethnicity

• White children have lowest rates by far
• Black children
• 16% homeless in past 5 years
• 20% children on the same case who is medically complex
• 45% have an immigrant parent
• Hispanic children
• 2 in 3 have immigration and language risk factors
• Low rates of homelessness

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Why is it important to consider ethnicity

• f program participants?
• Ethnic background impacts a person’s exposure to social risk factors
• Historical trauma and other experiences impact well-being of current and

future generations

• The results are changes to:
• Access to family and community supports
• Access to financial and other resources
• Background and culture also impact the service models that are effective for

each population

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Why is it so difficult to make progress on health disparities among people with social risk factors?

• Goals
• Fund providers who serve our most vulnerable participants fairly
• Evaluate vulnerable participants’ outcomes fairly, which might mean adjusting for higher

level of need without

• Accepting lower quality care for vulnerable participants
• Disguising or overlooking poor outcomes for vulnerable participants
• Finding funds for health care services is easier than funding more upstream

resources that could prevent medical conditions.

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Why is it so difficult to make progress on health disparities among people with social risk factors? (continued)

• Addressing children’s needs requires a two-generation (or more) approach

that considers the ACES literature.

• Some child welfare and mental health programs reflect this
• Need more community-integrated solutions
• Many funding barriers
• Ethnic background is associated with health outcomes through many,
• verlapping pathways.

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How can DHS address health disparities among program participants of different ethnic backgrounds?

• Getting better at designing, offering, and supporting services for diverse

ethnic groups (e.g. finding more culturally appropriate substance use treatment models than 12-step Christian models for American Indians)

• Examples:
• Integrated Care for High Risk Pregnancies (ICHiRP)
• American Indian partners
• African American partners
• Native doula program

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Who is included in this analysis?

• A total of 397,306 kids
• Enrolled in Medicaid or MN Care at least 3 months in 2013
• Lived with a parent sometime in 2013, relationship identified in MAXIS
• 23,000 excluded because they did not meet this criteria; most lived with

someone other than a parent, some enrolled in MN Care and not a MAXIS- based program

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Translate the science of ACEs, resilience, and nurturing relationships Fuel “launch and learn” research, innovation, and implementation efforts

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Priorities to Address ACEs and Promote Child Well-Being

Cultivate the conditions for cross-sector collaboration to incentivize action and address structural inequalities Restore and reward safe and nurturing relationships and self-, family-, and community-led prevention and healing

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Specify and test family- and youth-centered methods to assess and discuss ACEs and foster essential self-care, resilience, and relationship skills in clinical and other settings. Clinical Protocols Define and cultivate provider, health care system, and community-based core competencies related to ACEs, and the training, payment, and accountability models that will be effective in establishing these competencies. Capacity Building and Accountability

Priority Areas for Innovation and Research

Evaluate the effects of alternative clinical and self-care interventions, including effects on health outcomes, utilization, and health care costs. Outcomes and Costs Promote and examine the effects of provider self-care related to ACEs, resilience, and relationship skills on quality of care and other

• utcomes.

Provider Self-Care

The 7C’s of Policy and Practice Translation

Cover age & Codin g Costs and Payme nt Contr acting & Accou ntabili ty Capaci ty & Traini ng Crede ntialin g & Integr ation Coordi nation Withi n and Across Commu nication Within and Across Partners and Patients

Priority Opportunities to Leverage Existing Policy-Driven Systems, Structures, and Innovation Platforms

Key Short-Term Opportunities and Actions

Prioritize early and periodic screening, diagnostic, and treatment (EPSDT) and prevention Focus hospital community benefit strategies Establish enabling

• rganization, payment,

and performance measurement policies (e.g. through CMMS, Title V, Head Start, etc.) Advance and test Medicaid policy implementation Inform and track legislation to accelerate translation into policy

Priority Opportunities to Leverage Existing and Evolving Practice Transformation Efforts

Key Short-Term Opportunities and Actions

Leverage medical/health home and social determinants of health “movement” Enable, activate, and support child, youth, and family engagement Build effective peer/family to peer/family support capacity Empower community- based services and resource brokers (e.g. early childhood, school health, youth, & after school programs) Leverage existing commitments and focus areas in child and family health

Leverage Existing Research and Data Platforms, Resources, and Opportunities

Key Short-Term Opportunities and Actions

Optimize existing federal surveys and data (including creation of follow- back surveys) Optimize state surveys Liberate available data (facilitate access and remove barriers to use) Build crowdsourcing, citizen science, and “N of 1” methods Integrate common- elements research modules for longitudinal studies Link to collaborative learning and research networks