By Dr Laura Leone, DSW, MSSW, LMSW
Integrated Health Consultant for Practice Improvement, National Council for Behavioral Health

Suicide prevention can seem like a daunting undertaking for any health center, but as the number of deaths by suicide keep increasing, it becomes a necessary public health issue to be addressed within primary care. If your health center is overwhelmed with how to proceed, the following eight steps are a framework to give you the guidance on what to do.

  • Step 1: Identify Leadership, Champions and Task Force: It’s important to get many people involved in suicide-prevention efforts, supporting it both from the “bottom up” and from the “top-down.” It is most effective to find staff in several disciplines and roles that are not just from behavioral health, as well as to consider how to include the voice and choice of patients.

 

  • Step 2: Educate and Inspire Change: When people understand why change, new workflows or asking the hard questions is necessary, they are more likely to engage in doing it, and doing so well. Educate people on suicidality, including national and local statistics; on the various opportunities during work to ask people about suicide; and on ways to intervene when necessary.

 

  • Step 3: Gauge the Current Organizational Landscape: Understand the baseline metrics around suicide for your organization, such as when people are most “at risk,” how many deaths by suicide, how many suicide attempts, how many safety-planning interventions are used with patient expressing suicidality, etc.

 

  • Step 4: Practice Improvement: Take education a step further with understanding best practices around suicide inquiry, screening and evidence-based interventions. There are opportunities to assist clients in their outpatient setting rather than them visiting a hospital emergency department.

 

  • Step 5: Imbed Throughout Organization: Consider how to optimize your electronic health record around suicide-prevention efforts, including the use of decision supports, problem lists, and other features. Effectively communicating around patients who are “at risk” in real time could save a life. Likewise, find multiple ways to discuss suicide prevention efforts with staff, such as at staff meetings and during huddles; creating a continual feedback loop using the data collected.

 

  • Step 6: Ongoing Mining of Resources and Supports: There are constantly new resources, trainings and support around suicide prevention for both patients and staff. Take the time to periodically check in on what’s new, from organizations such as the National Council for Behavioral Health, Suicide Prevention Resource Center, Zero Suicide, Now Matters Now and more.

 

  • Step 7: Collaborate with Patients, Community, External Organizations, and Stakeholders: Consider how to best share information and support patients in the community around their suicidality, and to help create opportunities for wellness. Efforts and success will be greater and stronger when people and organizations collaborate, as well as share information and resources.

 

  • Step 8: Wash, Rinse, then Repeat! Don’t get comfortable in going through these steps once. Instead, run through them again and again to keep your continual quality improvement going for suicide prevention. Continue to use your metrics to gauge improvement opportunities and successes.

Remember that the Health Center Association of Nebraska and the National Council for Behavioral Health are available to provide support around building internal and external capacity for suicide prevention. You can make a difference by preventing deaths by suicides and the negative impact that every death has on the surviving 135+ lives that the person leaves behind.

This promising practice is shared by
Bluestem Health in Lincoln, NE
In July 2018, Bluestem Health applied for the Safety Net Solution In-Kind Dental Program Technical Assistance. This opportunity was first brought to our attention by Jenna Thomsen, Director of Training and Technical Assistance at HCAN. Bluestem Health’s dental clinic was one of ten programs selected to receive this technical assistance. The process included:
  1. Practice Analysis (practice management data survey, key practice data, site visit)
  2. Findings and Discussions (presentation, discussion, strategy)
  3. Improvement Plan (action steps, road map, timelines)
  4. Supported Implementation (coaching, guidance, motivation, accountability)
Beforehand, we were required to submit key practice data. The whole process was run very efficiently. Dr. Russell and Caroline from Dentaquest served as project managers. They came for a site visit and met with dental staff, billing staff, and the leadership team. Bluestem is currently in the ‘Improvement Plan’ stage, with some action steps completed and some in progress. This technical assistance will end February 15th, 2021. The advice that I would give other dental programs considering this process is to apply. We received helpful guidance from Dr. Russell and Caroline and gained access to resources such as templates, advice, reminders, and otherwise. Getting your dental program evaluated from an outside perspective is helpful and can result in a cascading effect of other positive outcomes similar to what Bluestem experienced, such as the HRSA grant and revenue cycle analysis technical assistance from HCAN.
Name something unique about the work completed:
Sometimes we do not think outside the box because we just keep on working and doing the same things over and over again. Bluestem Health Dental clinic was constantly looking to expand the dental program outside the main location thinking that we do not have space for expansion at the main clinic. Dr. Russell revealed to us during the site visit that we can indeed expand here by moving our dental front desk and dental waiting area to the large medical side lobby and build two dental operatories in that space. As soon as the HRSA Oral Health Infrastructure grant came along we were ready to act on this renovation project and were awarded the grant.
List lessons learned:
1. We were not collecting co-pays upfront for restorative visits for commercial insurance patients before the site visit. Now we are collecting all the co-pays upfront for restorative visits.
2. We were offering up to 3 dental appointments per patient which caused lot of back log in our scheduling and increased our no-shows. Per Dr. Russell’s recommendation we started giving only one appointment at a time and once the patient showed up for that appointment we give another one. This unclogged our scheduling and opened up lot of slots for other patients.
3. Staffing issues: We were short staffed at the dental front desk and sterilization. As per Dr. Russel’s recommendations we were able to add these two new positions for this year’s budget.
4. We were seeing too many new patients and were not able to complete their treatment plans in a timely manner. Now we are tracking the treatment plan completing rate.
5. Billing and Revenue cycle analysis weakness were identified at the site visit. We got TA assistance from HCAN to get Coding and Compliance Initiatives, Inc to do Revenue Cycle analysis and give us recommendations on improving our program.
Please list clinical outcomes/results from this project:
1. We got a HRSA grant to add two new dental operatories which was directly related to the recommendations from site visit.
2. Revenue cycle analysis was done from Coding and Compliance Initiative which came about because Jenna from HCAN was present during the final presentation of site visit and offered TA from HCAN.
3. We are tracking Treatment completion rate from the guidelines Dentaquest gave us.
4. We are focusing more on medical-dental integration and prioritizing children, pregnant patients, patients with diabetes, etc
Please list any future plans:
1. Follow Revenue cycle analysis site visit recommendations
2. Medical-dental integration
3. To increase treatment completion rate up to 80%
Submitted by:
Dr. Reddy
Bluestem Health

At this time of year, many of us are looking back at 2019 and looking forward to 2020.  As far as the 340B Program goes, although there was a lot of sabre rattling there were very few changes heading into 2020.

2019 Year in Review

Legislative Activity

Specific to FQHC’s, although 340B was mentioned in numerous pieces of legislation throughout the year no major 340B legislation materialized.  Because drug pricing is such a high priority, the program remains a talking point however the legislative focus has shifted from 340B to the PBM’s

Price compression

One of the biggest threats to 340B was not government related at all but rather the Pharmacy Benefit Industry (PBM) who has seen 340B as a threat to their rebate revenue stream. In late 2018, CVS Caremark, one of the country’s largest PBMs, sent notices to 340B providers and contract pharmacies notifying them of significant reductions in reimbursement rates. In essence they were attempting to recharacterize 340B pharmacy as non-retail pharmacies, which would allow CVS to reimburse these pharmacies at a much lower rate.  After a considerable outcry from a large number of 340B stakeholders and court rulings related to the reduce Medicare payments to 340B Hospitals, CVS Caremark backtracked and announced that it was reversing its decision.

Also, in late 2018, a federal district judge struck down HHS’ proposed cuts of almost 30% to Medicare Part B reimbursements for 340B providers stating CMS overreached its legal authority. This decision, however, was appealed and cuts remain in place.

A final hearing was held on November 8th with a decision expected soon. If the government prevails, we may see Caremark (and other PBM’s) attempt to lower reimbursement for 340B providers.

340B Drug Pricing Website

April 1st, HRSA finally launched its 340B Drug Pricing website, which provides additional transparency and assists safety-net providers in determining the maximum price manufacturers can charge under the program.  This implementation was driven by a 2010 law authorizing civil penalties for manufacturers who “knowingly and intentionally” overcharge covered entities. This should be accessible through the Covered Entity’s 340B PVP account.

On the audit front, HRSA suspended uploads of audit outcomes to its website during 2019.  The audits continued but between June 21st and October 10th no audit outcomes were posted on HRSA’s website.  HRSA states that it was reevaluating its level of authority and oversight of the program.

Looking Ahead to 2020

Focus of Attention

Drug pricing remains a focus of the Trump Administration as we enter the new year and most presidential candidates. This will keep a focus on the entire industry including 340B.

Rebates and Duplicate Discounts

The definition of “Medicaid” as it relates to 340B remains murky. At this time, HRSA only regulates Medicaid Fee-for-Service claims through the Medicaid Exclusion File located on the OPAIS. That said, it remains the covered entities responsibility to coordinate rebates/discounts with the state (which many states have not shown interest in doing).

Apexus provides a Medicaid profiles per State tool to assist entities in accurately billing Medicaid Fee-For-Service.  The tool can be found at https://www.340bpvp.com/resource-center/medicaid.

Individual states have recently begun to get explore various forms of 340B legislation. Some of these initiatives are advantageous to covered entities while others have the potential to be very detrimental.  Examples of these bills include:

  • Prohibition of discriminatory 340B reimbursements while others are considering the adoption of
  • Enhanced Medicaid billing procedures
  • Mandatory 340B reporting regulations

Changes to HRSA policy and areas of focus can affect a covered entity’s policies and procedures, contracts, and many other areas of program oversight.  RPh Innovations strives to keep up to date with what is happening with 340B, legislative and/or state involvement, HRSA changes, and other governmental and non-governmental organizations, to ensure covered entities are too. We suggest covered entities keep up to date on what is happening with proposed 340B legislation and sharing information gained with peers.

About RPHI

RPh Innovations offers many services to both its clients and to organizations such as HCAN and other state primary care associations such as:

  • 340B Program support
  • Independent, external audits
  • Contract pharmacy processing services
  • Consulting
  • Summit and other educational presentations

Please feel free to contact Myself, Lyn Mikesell at  lmikesell@rphinnovations.com or Anita Miller, RPHI’s Nebraska dedicated Account Manager at amiller@rphinnovations.com or call 630-963-0024.

This promising practice is shared by OneWorld Community Health Centers, in Omaha, NE

 

Please give an overview of your work completed:

HCAN offered a unique opportunity to work with a 340B consultant Judy Lapinski.  OneWorld’s Pharmacy Director and CEO met with Judy via phone and email several times in 2019.  HRSA offers best practice suggestions for entities to follow and one of them is having an external review of the program.  OneWorld decided this would be a great opportunity to work with Judy to perform this external review. During the initial meetings we identified areas we would like to focus on as an external 340B review  Those area’s included a review of:  policy and procedures, operational agreement for Contract Pharmacies, internal review procedures for both in-house and contract pharmacies and discussion around USP 800.

HRSA offers a check list that includes essential elements that should be discussed with in our policy and procedures.  Judy also provided us with 12 essential elements on monthly reviews.  We reviewed our audit procedures and audit templates with these elements to ensure we are looking at all compliance elements.

Name something unique about this work completed:

This was an excellent, unique opportunity to work with a knowledgeable consultant regarding 340B.  Valuable insight and feedback was given on the area’s we focused on.  Internal process changes were made based upon feedback given.  Our work is not completed as Judy will be making an on-site visit to our location in January.  This is also a unique and excellent opportunity to look at process and procedures at an in-depth level outside of an actual HRSA 340B audit.

Please list lessons learned/process improvements:

Working with Judy created an excellent opportunity to review operations of our 340B program.  This allowed us to collaborate on process improvement in numerous areas.  Policy and procedures:  when reviewing our policy and procedures and evaluating them against the HRSA check list we discovered there were several area’s that needed to be updated and redefined.  Material breach is an example of one of those areas.  We needed to provide a clear understanding of our limits on material breach and process regarding that if something were to happen.  Another area needing updated was to include statements with regards to patient freedom of choice.

Prescription capture rate was something we looked at as well.  We were able to create detailed reports from our EHR to determine our in-house pharmacy capture rate of prescriptions.  The results of our capture rate was lower than we anticipated.  There have been good conversations and collaboration around how to increase that number.  During these conversations challenges were also discussed regarding how to maximize capture rate, physical space, staffing, patient wait time, patient satisfaction and patient perception.  This will continue to be an area that we look at and follow in the upcoming year.

Please list clinical outcomes/results from project:

Clinical outcomes and results from this project are not complete.  We are looking forward to Judy’s on-site visit in January 2020.  At that time, we will be taking a closer look at maximizing prescription capture rates, maximizing workflow opportunities, patient wait time, staffing models, billing procedures, sliding fee schedules, reducing duplicate processing and review of the OPA database.  This has been a unique opportunity to collaborate with a 340B expert and come up with creative solutions and ideas for operational improvement and compliance.

USP 800 was an area that is still very vague and not a lot of guidance has been issued surrounding this topic.  USP800 enforcement body is still undetermined as this went into effect on December 1, 2019.  Ideas on how to create the policy and procedure and implementation was minimally discussed with Judy.  Due to vague national guidance this became an internal research project.  OneWorld pharmacy did create a policy and procedure, perform risk assessments on high risk medications listed on NIOSH list and implemented employee safety procedures.

Submitted by Coleen Schrage

Director of Pharmacy

OneWorld Community Health Centers, Inc.

 

Today, September 25th, we celebrate National Voter Registration Day. National Voter Registration Day is a day of action before state deadlines begin in October. Last year, millions of Americans didn’t vote because they missed a registration deadline or didn’t know how to register.

This upcoming Midterm elections are especially important for Nebraska. On November 6th, Nebraskans will be asked to vote on Initiative 427, which can expand Medicaid to an estimated 90,000 low-income Nebraskans and provide health coverage to those that desperately need it.

Medicaid Expansion will have a profound effect on thousands of hard-working Nebraskans who are working desperately to pull themselves out of poverty.  Patients with chronic disease such as diabetes are much more likely to have their conditions under control if they have health insurance.   Moreover, they are more likely to have serious diseases diagnosed earlier so treatment can begin sooner.  Expanding Medicaid will ensure families get access to preventative care, leading to overall improved well-being and avoiding costly trips to the emergency room.  A recent study of Medicaid Expansion in Ohio, conducted by The Ohio Department of Medicaid, found that emergency room utilization decreased 17%, 37% of smokers enrolled in the expansion program were able to quit, and 97% of those with an opioid addiction received treatment.

So, this National Voter Registration Day, I encourage you to get registered to vote. If you recently moved, turned 18, changed your name, or haven’t voted in recent elections, you need to update your voter registration!  All it takes is 30 seconds to register to vote online at  https://nationalvoterregistrationday.org/.

And when it comes time to vote on November 6th, I encourage you to vote FOR Initiative 427. Everyone deserves the peace of mind that comes with having access to health insurance.

 

By: Angela Lindstrom

Integrated Marketing Director

HCAN

The Envolve Vision Van stopped in Omaha and Lincoln, June 21st and 22nd, providing 108 Nebraskans with FREE vision screenings, and access to prescription and/or reading glasses. The “SeeMore” Vision Van, a collaboration between Envolve and the Association of Clinicians for the Underserved (ACU), visited six Nebraska Community Health Centers in the last nine months providing a total of:

  • 395 screenings
  • 294 prescription glasses
  • 92 reading glasses

 

This June, local Optometrists volunteered their time and expertise to screen patients at three Nebraska Community Health Centers. Health center staff organized on-site volunteers, translation services, and any additional support needed to ensure each event ran smoothly. The opportunity to assess patients’ sharpness of vision, need for corrective lenses, and screen for degenerative eye diseases (diabetic retinopathy, cataracts, glaucoma) showcased the enormous need for vision services within our communities.

 

HCAN is thankful for the Envolve Vision Van and their support of Nebraska Community Health Centers!

 

written by Jenna Thomsen, Director of Training and Technical Assistance

May is here, which means warmer weather is on its way, and school is almost out of session for summer break!  But it also marks the annual kickoff of a very important season of giving  – Nebraska’s Community Giving Days.  During specific days in the month, communities all around the state rally around hundreds of nonprofits to help raise money and awareness for their organizations.  The Giving Days is a 24-hour event where excitement and energy is generated around giving to local organizations.

However, choosing a nonprofit to give to can be intimidating.  Which one do you choose?  This year, we at HCAN would like for you to consider giving to any one of our Nebraska community health centers. In Nebraska, the community health centers served over 94,000 patients last year.  Nebraska’s community health centers ensure that all individuals have access to high-quality medical, dental, and behavioral health care, regardless of ability to pay.   Health centers are the safety net providers in the state, ensuring comprehensive, community-based, culturally appropriate healthcare in a compassionate and respectful environment.

Ninety percent of our patients are low income, and one out of every four uninsured individuals in our state receives care at a health center.  In fact, Nebraska has the second highest rate of uninsured patients across all health centers in the nation, with nearly 50% of our patients lacking health insurance.

When thinking of where you will be donating to this year, please consider giving a donation to any one of the community health centers in Nebraska.  Even the smallest gift can make a big difference to the patients we serve.  Your gift will directly help those vulnerable populations who would otherwise not have access to primary and preventative care.  For many patients, health centers may be the only source of health care services available in their community. You have a chance with your donation to make a powerful, yet critical difference in many lives.

During the month of May and the Giving Days to come, please take a moment to find your community’s Giving Day at http://www.nonprofitam.org/?page=GivingDays and choose one of Nebraska’ community health centers. Your donation is appreciated!

-Angela Lindstrom

Integrated Marketing Director

Health Center Association of Nebraska

The Certified Application Counselors (CACs) and other assisters throughout the state of Nebraska rocked Open Enrollment 5! The concert was executed smoothly with a nice balance of lights to complement the music.

How many consumers enrolled?

This year, 88,213 Nebraskans signed up for health insurance through the Health Insurance Marketplace. Why is this a big deal?  Take a look at the enrollment numbers for previous years and you can see why assisters are rejoicing.

 

For 2018 coverage:   88,213   5th open enrollment   November 1, 2017 – December 15, 2017

For 2017 coverage:   84,371   4th open enrollment    November 1, 2016 – January 31, 2017

For 2016 coverage:   87,835   3rd open enrollment    November 1, 2015 – January 31, 2016

For 2015 coverage:   74,152   2nd open enrollment   November 15. 2014 – February 15, 2015

For 2014 coverage:   63,776   1st open enrollment    October 1, 2013 – March 31, 2014

Note: CMS started to report state-level plan selection figures after January 9, 2015.

 

All hands were on deck to help spread the word about open enrollment. I probably annoyed many people by using my personal social media platforms to educate those I know. What was enlightening to me were the stories shared by individuals who were able to find affordable health insurance.

On Healthcare.gov, there was a tool that allowed consumers to explore the plans offered in their state. While many of the prices listed were high, many consumers were surprised by how affordable a plan was for them once they completed an application and were able to see what tax credits and/or cost sharing reductions they received.

In fact, many consumers were able to receive free health insurance. That’s right – many qualified for free plans based upon their income.

So, as I stated before, the assisters in Nebraska rocked hard. Fans at the concert enjoyed the performance, especially the epic encore.

To everyone that helped ensure a successful concert…..Great work! We did it.

 

 

 

 

-Keshia Bradford, Director of Strategic Initiatives, Health Center Association of Nebraska

 

 

*https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-12-28.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=descending

Get Ready for a Performance of a Lifetime!

The crowd is ready…

The performers take the stage…

The curtain goes up…

The performers play and the crowd goes wild!!!

 

 

 

 

 

 

That’s how I think about the outreach and enrollment staff at the health centers. They practice (train) for the Open Enrollment and once it begins, all that practice (training) begins to take hold.

How is Open Enrollment going?

Rockin’! Open enrollment is going very well. Signing up has been going well for many consumers and Certified Application Counselors (CACs) at the health centers. Despite the lack of advertising funding used to promote Healthcare.gov and reduced number of trained assisters, more consumers are signing up for health insurance plans than expected. Each week, we are seeing enrollment numbers climbing higher. In fact, enrollment numbers this year are higher than in years past based upon the same number of days into Open Enrollment. In Nebraska we have enrolled 32,759 from November 1st to November 25th.

Counselors from the health centers have reported that many consumers have been shocked by how affordable their health insurance has been. For many, qualifying for the tax credits has helped tremendously lower their monthly payments.

There have even been a few consumers remark how nervous they were about how much their insurance was going to be until they were able to see for themselves how affordable their plan was.

Health center CACs are seeing their schedules bustling with appointments and walk-ins. We still have a couple weeks before Open Enrollment ends (December 15th). We are anxiously awaiting the final enrollment numbers.

In other words, the performers are in the middle of their set. The crowd is enthusiastically reacting to the music.

Will there be an encore after the final set? Stay tuned.

 

-Keshia Bradford, Director of Strategic Initiatives, Health Center Association of Nebraska

 

 

 

 

 

What does rock have to do with enrollments? Everything. Yes, everything. Hear me out.

Background

Here at HCAN, I have been rocking out to new information at the federal level and providing updates to the Certified Application Counselors (CACs) in a timely manner. Back in September, there was a 1½ day rock concert (training) filled with a variety of sessions that complemented the required federal CAC training. Since the concert, weekly updates have become more important as new information becomes available.

New information

Examples of information that has been shared:
• 2018 Open Enrollment begins November 1st and ends December 15th 2017- only 45 days long.
• Affordable Care Act (ACA) is still the law.
• Tax penalties still exist. Depending on income, you can be subject to a fine of $695 or 2.5% of your income, whichever is greater.
• Medica is the only insurance company in Nebraska offering plans on the Health Insurance Marketplace.
• Eligibility for premium tax credits and Cost Sharing Reductions (CSRs) to lower out of pocket costs hasn’t changed. Even if the administration stops making CSR payments to insurance companies, consumers will still receive these reductions.

Rock and Enrollments do go together

As I mentioned earlier, there has been a lot of rocking going on in preparation of Open Enrollment. So much rocking took place, that enrolling time is almost here. CACs across the state of Nebraska will rock enrollments in the coming weeks.

Need more proof? Here is proof that rock enrollments go together: Nebraska coalition video.

If you know of anyone that needs health insurance, have them visit healthcare.gov or contact a Nebraska health center today. Help us rock enrollments!

-Keshia Bradford, Director of Strategic Initiatives, Health Center Association of Nebraska