By Jessica Kendall and Jennifer Sullivan | September 2012
Starting in 2014, millions of Americans will become eligible for health coverage offered through health insurance exchanges and through Medicaid, which will dramatically alter the landscape for health centers. Health centers have long played a crucial role in providing affordable, high-quality, community-based care to vulnerable populations. Based on interviews with staff from health centers and primary care associations in four states (Arizona, Michigan, Texas, and Washington), this piece and its companion, “Health Centers’ Important Role in Outreach and Enrollment,” highlight the crucial role health centers play in outreach and enrollment and the best practices they can implement as health coverage opportunities are expanded.
From Innovations to Best Practices
Health centers and primary care associations around the country have been integral in efforts to reach and enroll uninsured children in health coverage, and they are hard at work identifying the outreach and enrollment strategies that will best position them to enroll as many people as possible when coverage is expanded more broadly in 2014. This piece discusses key practices that health centers and primary care associations can use to make their outreach and enrollment efforts even more effective in the coming years. We’ve grouped these best practices into the following five categories:
- Invest in Outreach Staff
- Make Technology Work for You (without Spending a Fortune)
- Recognize Everyone’s Role in Outreach
- Hold On to What You’ve Got
- Seek Resources to Ensure Sustainability
What Is Outreach?
The National Outreach Guidelines for Underserved Populations define
Source: Health Outreach Partners, National Outreach Guidelines for Underserved Populations (Oakland,
1. Invest in Outreach Staff
Every day, health centers see uninsured patients and provide them with quality services. By having outreach staff actively reach out to and engage uninsured individuals, enroll them in health coverage, and keep those who remain eligible covered, the centers benefit financially, and patients benefit from having continuous access to coverage and care. Each of the health centers and associations that we interviewed for this piece found that the investments they made in employing and training dedicated outreach staff more than paid for themselves. With the coverage expansions that are coming in 2014, a significant portion of the 49 million uninsured Americans under age 65 will be eligible for coverage, greatly increasing the potential return on investment for health centers that employ dedicated outreach staff.1
The Value of Providing Application Assistance
The Texas Association of Community Health Centers was awarded a cycle II outreach grant as part of the outreach funding that was made available through the federal Children’s Health Insurance Program Reauthorization Act (CHIPRA). As part of this project, health center staff provided families with information about Medicaid and the Children’s Health Insurance Program (CHIP) and helped them complete the application. Coupling application assistance with outstationed eligibility workers produced significant results, including the following:
- A 35 percent increase in the number of Medicaid applications submitted in the first six months of the project (compared to the previous year, when no application assistance was offered);
- Three-quarters of those applications led to enrollment in Medicaid or CHIP; and
- At least $1.6 million in additional Medicaid and CHIP reimbursement during the first year they offered both application assistance and outstationed eligibility workers.2
What Is an Outstationed Eligibility Worker?
Federal law requires that state Medicaid agencies outstation eligibility workers at federally qualified health centers and certain hospitals to accept and process Medicaid applications. States vary with respect to how many locations have outstationed eligibility workers and the frequency of workers’ visits.
Building Institutional Knowledge
Making upfront investments in outreach staff can also build institutional knowledge that will serve the organization in its future work. At Yakima Neighborhood Health Services in central Washington, outreach workers found that with each grant they received over the years to expand services or target a specific demographic, they developed valuable skills that they continued to share and implement after the grant ended. For example, the center at one point received funding to provide enrollment assistance to people who were eligible for Medicare savings programs. Even though that funding has ended, they continue to offer enrollment assistance and train new staff in how to enroll people in these programs, both because it benefits their patients and because it benefits the center by increasing the number of people who have some form of health coverage.
Many health centers already assist with Medicaid and CHIP enrollment. These efforts will serve as a good foundation as states develop their outreach and enrollment strategies, particularly as these strategies relate to navigators and other application assisters. However, these efforts must be bolstered in anticipation of the coverage expansions that are coming in 2014. Training materials for outreach staff and outreach and educational materials for consumers need to be developed to complement this work and make it possible to reach more people and enable staff to coordinate efforts internally while working with the community. The more innovative the tactics and streamlined the enrollment systems, the more efficient outreach staff can be.
2. Make Technology Work for You (without Spending a Fortune)
Health centers use a wide variety of computer and data collection systems to keep track of patient demographics, medical records, and financial information. These tools help keep the centers’ doors open, but they are not necessarily the only tools for providing outreach and enrollment assistance. Luckily, it doesn’t cost a fortune to arm outreach staff with the right tools. First, as budgets allow, provide all outreach staff with basic supplies such as the following:
- a program manual,
- access to materials needed for outreach events,
- a computer or tablet with a wireless card,
- a cell phone, and
- a printer/scanner. The Michigan Primary Care Association has put these basic supplies to use and found that they have helped their outreach team succeed. Other primary care associations and health centers may want to consider using these tools as well.
Map Your Progress
The Michigan Primary Care Association uses mapping to determine where uninsured people live in the state and where Medicaid and CHIP enrollees are concentrated. Staff can shade specific areas to work in, pinpoint areas where outreach is already successful, and plan their work based on what they find. For example, as part of Michigan’s work to get children covered, staff concentrated their outreach efforts in the counties with the highest percentage of uninsured children and chose to pursue outreach efforts in enrollment “hot spots”—neighborhoods where mapping found geographic concentrations of recent enrollments.
Free, online mapping tools like Google Maps can be very helpful in developing a community- or state-wide sense of where work is being done, where progress is being made, and where there are gaps that need to be addressed. These tools can be shared by multiple users and updated in “the cloud” so that workers can pull down and update data from any location. Mapping can be simple (for example, plotting the locations of health centers, eligibility offices, and outreach events), or it can be more sophisticated (for example, mapping concentrations of uninsured people by primary language spoken, or mapping concentrations of children enrolled in Medicaid or CHIP, whose parents may be eligible for coverage starting in 2014).
Make It Easy to Communicate on the Go
For outreach staff to be successful, they need to be out in the community, not at a desk. But this can make it harder for consumers to reach them when they have questions or need assistance. With the rise of internet-based phone service, it has become easier to integrate staff phone numbers, voicemail systems, and text messages so that this information is available in one place, anytime, anywhere. Services like Google Voice and Skype allow users to have a single phone number that connects to all of their devices (cell phone, office phone, etc.). Even if the user’s device or location changes, that phone number is still a direct line to the user. The user can also set his or her preferences so that the phone number connects to the right devices on the right days.
These services also capture voicemails and texts and save them until the user deletes them, instead of deleting them after an arbitrary number of days as many systems do. These messages can be downloaded, replayed, annotated, and emailed to others, making it easier to stay connected, keep referrals moving, and be highly responsive to the population being served.
Put Your Data to Work
When starting an outreach program, staff can use their current internal data system to help them identify uninsured patients and offer them assistance with applying for coverage. For example, health centers already collect information about existing coverage when they screen their patients for Medicaid and CHIP. Use these data to design an outreach campaign that targets those who are already coming to your health center. For instance, many patients who are paying on a sliding scale will likely be eligible for Medicaid or qualify for a tax credit through the exchange. Developing a targeted campaign that educates these patients to make sure they know about the new coverage options that are coming next fall and that provides enrollment services to help them apply could translate into more insured patients at the health center and a substantially stronger payer mix.
3. Recognize Everyone’s Role in Outreach
Outreach can be divided into two categories: internal and external. Internal or “in-reach” focuses on contacting and enrolling people who are already getting services at the health center and streamlining administrative processes to build outreach into staff’s daily work. External outreach focuses on actively seeking out uninsured people in the community, helping them find health coverage, and connecting them to care at the health center. Both kinds of outreach are important, even for non-outreach staff, regardless of whether they are part of the leadership team at a health center or primary care association, provide other services within the center, or are community partners.
Most health centers are working hard to achieve recognition as Patient Centered Medical Homes.3 One way that centers can become even more patient-centered is to ask patients at every point of entry to the center what other services they may need, even if the center does not directly provide all of those services. At Yakima Neighborhood Health Services, all patients are asked whether they need help with food, health coverage, housing, and other basic needs as part of the patient registration process. The group has even included a measurement in its quality assurance program to evaluate how well it is assisting clients that receive one service and assessing whether they need or receive other services that the group provides.
The Importance of Health Center Leadership
Primary care associations often provide training and technical assistance to health centers at the state and local levels in order to encourage development of staff that have the knowledge and skills necessary to conduct outreach and enrollment. Once these skills are cultivated, an organizational leader who is an internal champion can prioritize outreach and enrollment assistance in an organization’s work plan, building in opportunities for front-line staff to refer patients to outreach workers or application specialists. For example, both the Michigan Primary Care Association and the Texas Association of Community Health Centers provide a considerable amount of technical support to health centers in their states. The Texas Association of Community Health Centers provides application and outreach training, eligibility screening tools, promotional materials, and policy-related information to health centers.
Without these tools and leadership, front-line health center staff would not have the time, training, or capacity needed to help people apply for coverage. Leaders who are outreach champions can greatly influence day-to-day operations, including whether there are dedicated, well-supported outreach staff; whether referrals are made to these outreach staff; and the degree to which systems are streamlined to capture data that lead to easier, quicker enrollment.
Other Health Center Services
All health centers provide enabling services, such as transportation and translation services, and they may provide additional services depending on the needs of the community. For example, Yakima Neighborhood Health Services provides a full array of support services, including housing assistance, family unification services, addiction treatment services, and more. Each department is connected to the outreach staff, who are available to provide patients with application assistance.
Health centers will be best served if they build eligibility outreach and screening into all aspects of their operations, from patient care to health education programs to billing, translation, and transportation services.
Health centers are inherently connected to the communities in which they work. However, it is still important to make sure that outreach staff are well-connected to local resources. One effective way to help outreach staff build connections with their community is to require them to research the community they will be serving before they go out in the field. This process should examine what kinds of organizations exist and all of the services these organizations provide. It is important to build relationships with organizations that may provide referrals of uninsured people to the outreach staff, for staff to know what services are available in the community to provide better assistance to patients, and to prevent duplication of efforts.
Developing and implementing an outreach plan that has both internal and external components will help streamline processes and broaden an organization’s reach. The Michigan Primary Care Association updates its outreach plan every six months and has found that having clear goals and priorities makes it easier for individual outreach staff to measure success and identify and maintain partnerships. (See the Appendix on page 13 for a sample individual outreach plan.) The association also has ongoing conversations internally and with partners to build profiles of the communities they are working in to make sure they complement existing programs, focus their work on reaching populations that are not yet being served, and identify any gaps in services.
Practical Outreach Tips For Health Centers, Primary Care Associations, and Community Partners that Work with Health Centers
Note: These tips are based on Health Outreach Partners, National Outreach Guidelines for Underserved Populations (Oakland, CA: Health Outreach Partners, 2012), available online at http://www.outreach-partners.org/resources/nationaloutreachguidelines.
4. Hold On to What You’ve Got
By 2014, states will have to simplify both their application processes and their renewal processes for Medicaid and CHIP compared to current Medicaid processes (even in states that do not expand Medicaid). However, health centers will still have an important role to play in making sure that people who get enrolled stay enrolled, both now and in the future. Maintaining continuous coverage helps patients get and stay healthier.
If a patient fails to renew coverage on time and becomes uninsured, a health center can continue to treat the patient. However, the patient may face higher out-of-pocket costs and limited access to services that are outside the scope of what the health center can provide (e.g., specialty and hospital services).4 Research has found that having to pay even minimal out-of-pocket costs can cause low-income patients to delay or forgo necessary health services, seeking care only in emergency situations.5 Health centers play an integral role in ensuring that eligible people do not lose coverage and that they receive the care they need when they need it.
Experience with public coverage programs has also demonstrated the importance of building renewal strategies into outreach, especially in states that have cumbersome application processes. Below we list a few simple ways that health centers can connect their outreach staff to patients to help them renew.
- Add a “tickler” or alert to each patient’s medical record that staff can see when patients come in for care, reminding patients to renew their benefits. This could also be added electronically using a center’s practice management system.
- Automatically send patients a postcard close to renewal time that includes consumer assistance contact information. Centers can also send out text message reminders to patients who are able to receive them. Centers can partner with companies that send out mass text messages at low cost, which will further reduce the expense.
- Place “apply and renew” messages in public waiting spaces with information that can help connect patients to outreach and eligibility workers.
- Call patients and remind them to renew, offering application assistance.
Arizona: After the state closed CHIP to new enrollees, health centers played a big part in making sure that the children they served kept their coverage. This was particularly important because, if parents failed to renew their children’s coverage on time, they could not re-apply for coverage until the program reopened. The Arizona Association of Community Health Centers, working with health centers and other organizations, created a “Don’t Get Dropped” campaign to spread the message across the state about the importance of maintaining coverage.6
Texas: To reduce gaps in coverage, the Texas Association of Community Health Centers created the Texas Migrant Care Network, which allows enrolled families to use their Texas Medicaid coverage while they are temporarily out of state for employment purposes. The program targets migrant workers, but any Texas Medicaid recipient can participate. Providing consumers with the ability to carry their coverage with them makes them less likely to experience gaps in coverage as they change addresses.
5. Seek Resources that Ensure Sustainability
Health centers and primary care associations have been well represented in national efforts to enroll uninsured children and teens in coverage, such as the federal outreach grants that were provided as part of the Children’s Health Insurance Program Reauthorization Act, and the philanthropically funded Covering Kids and Covering Kids and Families campaigns. Looking ahead, the ability of primary care associations and health centers to effectively conduct outreach begins with having leaders who are dedicated to trying new approaches, streamlining systems, and seeking out funding.
The Michigan Primary Care Association sought out large grant opportunities, such as the outreach grants that were available through the Children’s Health Insurance Program Reauthorization Act, as well as numerous smaller grant and contract opportunities, to augment its efforts in specific areas. For example:
- The association vigorously seeks out corporate partners that offer discounts and deals. It has successfully negotiated lower hotel rates for traveling outreach staff, and it has gotten event registration participation fees waived in exchange for donating giveaways and prizes. For example, some events charge hundreds of dollars in exhibitor fees while also offering prizes and giveaways to attendees. The association donates prizes, like a back-to school backpack filled with school supplies, in exchange for having their exhibitor fee waived.
- They were also awarded a relatively small ($2,000) sub-contract to provide training to locally based organizations on the state’s new online eligibility platform. This funding has bolstered the association’s ability to offer nearly a dozen training opportunities for health centers throughout the state.
Just as outreach and enrollment activities are ongoing, efforts to secure funding to support this work must be, too. Enrolling uninsured people in coverage through Medicaid or health insurance exchanges will generate additional revenue that health centers can reinvest in outreach and enrollment efforts, but grants (large and small), corporate partnerships, in-kind donations, and volunteers are all also part of the sustainability equation.
National, state, and local public education and outreach efforts will be essential to getting the millions of uninsured people enrolled as coverage is expanded in the coming years. Health centers are one of the few places that already have direct connections with uninsured people who are seeking health care, and more people are likely to seek care at health centers once coverage is expanded. These connections should be maximized to ensure that, beginning with open enrollment on October 1, 2013, no uninsured patient that is seen by a health center leaves without learning about new coverage options and the enrollment assistance that is also available.
This piece was written by Jessica Kendall, Director of Outreach, and Jennifer Sullivan, Director of the Best Practices Institute. Assistance was provided by Rachel Klein, Executive Director, Enroll America.
The authors wish to thank the following individuals for their input and guidance:
- Tara McCollum, Plese Arizona Association of Community Health Centers
- Phillip Bergquist and Natasha Robinson, Michigan Primary Care Association
- Dawn McKinney, Robert Kidney, and DaShawn Groves, National Association of Community Health Centers
- Jana Blasi, Texas Association of Community Health Ceners
- Rhonda Hauff and Annette Rodriguez, Yakima Valley Neighborhood Health Services
Enroll America thanks Families USA for their editorial and design support in the production of this brief.
1 Carmen DeNavas-Walt, Bernadette D. Proctor, and Jessica C. Smith, U.S. Census Bureau, Current Population Reports, P60-239, Income, Poverty, and Health Insurance Coverage in the United States: 2010 (Washington: Government Printing Office, 2011), available online at http://www.census.gov/prod/2011pubs/p60-239.pdf.
2 For these estimates, the Texas Association of Community Health Centers examined the average utilization rate of medical and dental visits per year and multiplied this by the average prospective payment system rate.
3 The Agency for Healthcare Research and Quality defines a medical home as a primary care delivery model that is organized around five core functions or attributes: comprehensive care, patient-centeredness, coordinated care, accessible services, and quality and safety. See the Patient Centered Medical Homes Resource Center, “Defining the PCMH,” available online at http://pcmh.ahrq.gov/portal/server.pt/community/pcmh__home/1483/PCMH_Defining%20the%20 PCMH_v2, accessed on August 23, 2012.
4 Nakela L. Cook, LeRoi S. Hicks, A. James O’Malley, Thomas Keegan, Edward Guadagnoli, and Bruce E. Landon, “Access to Specialty Care and Medical Services in Community Health Centers,” Health Affairs 26, no. 5 (2007): 1,459-1,468.
5 Rachel Gold, Jennifer E. DeVoe, Patti J. McIntire, Jon E. Puro, Susan L. Chauvie, and Amit R. Shah, “Receipt of Diabetes Preventive Care among Safety Net Patients Associated with Differing Levels of Insurance Coverage,” Journal of the American Board of Family Medicine 25, no. 1 (2012): 42-49.
6 See “Don’t Get Dropped AZ!,” available online at http://dontgetdroppedaz.org/, accessed on July 26, 2012.