Notes for a proposal for community-based CHIP/Medicaid Outreach
The experience of other states suggests that this is not going to be a walk in the park. There are a few bright spots nationally, but results are not encouraging. A gols should not be to enroll all potentially eligible children: more realistic might be 60 percent of them in 3-5 years.
We will need to make extra effort with regard to trust issues (trusting the government, especially around immigration). This will require additional materials and media efforts, but it will mostly be achieved by face-to-face communication.
Community and migrant health centers (CHCs/MHCs) are central players and could serve as the lead agency (agencies) for this proposal. However, they can’t do the job alone. Families who are already bringing their kids to the centers must be helped and must be part of the strategy. But the families who are not bringing their kids to any provider are most prone to waiting until an illness or injury is very acute before seeking care, and they are probably also the hardest to reach. Many channels must be used to reach them.
Schools will be central. The Federal government is pushing approaches coordinated with application for school lunch programs; the State has specifically emphasized tie-ins with school-based heath services, and school nurses are well-positioned to identify uninsured kids.
The dollars most States offer to provide are not enough to do the outreach exclusively (or even primarily) by hiring "outreach workers." For example, if we have a budget of $400,000 with $250,000 in the first year, for a county with almost 100,000 potential eligibles, we could hire and supervise at most about 10 full time workers (leaving no funding for evaluation, reporting etc.). If they were doing direct outreach themselves (as opposed to recruiting and training "partners"), it is doubtful they could penetrate much of the potential population.
We suggest that staffing be concentrated on skilled and energetic organizers and trainers rather than directly hiring outreach workers. Other resources can be leveraged such as VISTA/Americorps, and other funding should be sought to supplement State funds for the first two to three years.
I would also hope the same CHIP coalition or a subgroup could sponsor such a proposal to the State and other funders to show the benefits of good follow-through in assuring access, quality care and improved health outcomes by making sure these families develop good primary care relationships.
Project objectives should include numbers of families and children identified, numbers of applications initiated, numbers of kids actually enrolled. A fairly sophisticated (yet clear and simple) information system will be required to track these results to meet reporting and QA requirements, consistent with sound confidentiality practice. For example, how do we avoid double-counting families with uninsured kids if they show up at a health fair, are identified by school health officials and also show up at a CHC?
Proposed strategy (in broad strokes):
 | Use project staff to recruit and train partner organizations and to make sure the many activities are coordinated with one another. Get partners to do things that they can continue to do without outside support after this contract is ended. Home visits where needed should be done by volunteers, for the following reason: |
With limited funds, a paid home visitor (including training and supervision) may cost $25-30,000 per FTE. Each actual home visit, including missed appointments, travel time etc. can require (in the ballpark of) an hour. Experience with existing promotora programs (under contracts with HRSA) suggests that most families need more than one visit to complete the process (including help after an application is submitted), and even then only about half finally qualify; the rest either do not follow through and complete the process or are found ineligible.
This means that a successful full time worker doing only home visits might actually be able to work with only 1,000 families over the course of a year, although they will knock on many more doors. With a final success rate of about 50% and a typical average of two kids per family applying, this means 1,000 enrollments per worker. That’s actually pretty good, but the TDH funds would only cover at most ten workers, for about 10,000 enrollments a year (out of a target of 80,000+). And this strategy would not allow for staff resources to support and coordinate partner organization activities.
| Expand the local CHIP coalition by enlisting as many as possible of the following: |
School districts and PTAs
Church organizations
Child care providers, Head Start and related programs
Pharmacies
Service clubs and volunteer groups
Existing promotora and other health outreach programs
| Conduct two pushes per year in school districts, built around report card pickups (where used), application for lunch programs, immunization programs etc. |
| Conduct 3-4 concentrated canvassing "pushes" each year in the top 4-5 ZIP codes, intending to reach (ballpark) 20,000 households each time. In addition to directly identifying families, this push would provide families with info on other health programs as well as insurance, and (b) encourage families contacted to speak with their neighbors. These pushes should be orchestrated with neighborhood associations, merchants’ associations etc. |
| Organize a church-based awareness campaign with coordinated pulpit messages, bulletin notices and availability of application assistance in selected locations. |
| Establish a comprehensive calendar of health fairs and other health related events and arrange to have partner organizations staff them with both awareness materials and application assistance. |
| Organize employers through chambers of commerce and human resources associations, to promote kids’ coverage to their employees. Provide videos and printed materials to use in employee orientations. |
| Mount an aggressive campaign among immigration lawyers, notaries and others who advise immigrants in status-change applications, to get the word out about the facts on policy, especially "public charge." |
| Monitor all partner activity for reporting purposes, and provide technical assistance and problem-solving support to partners as needed. |