Medicare for CHWS and Community Health Integration Services Webinar recap

The Institute for Public Health Innovation (IPHI) hosted a webinar on "Medicare for Community Health Workers (CHW) and Community Health Integration Services ." The conversation centered around addressing health-related social needs in healthcare, with a focus on the potential financial benefits and the connection between social needs and health outcomes. Timothy McNeill, RN, MPH from Freedmen’s Health , presented on the recent Centers for Medicare & Medicaid Services (CMS) rule establishing a direct payment for addressing social needs in Medicare beneficiaries. He also discussed the details for reimbursing community health workers.??

He highlighted the importance of emergency food assistance and health education for vulnerable populations. Importantly, he delved into the challenges and opportunities of scaling up community health worker (CHW) services, highlighting the complexity and potential of this task. Overall, the conversation emphasized the need for a comprehensive healthcare approach that addresses medical and social needs.?

New Medicare benefit for addressing health-related social needs.?

• CMS established a new payment policy for addressing health-related social needs in Medicare, providing a direct pathway for reimbursement for labor delivered by community health workers, health coaches, and others.?
• As of April 2024, there are a staggering 66.7 million people eligible for Medicare who have a benefit on the books to address their health-related social needs, and now have a direct pathway for reimbursement.?
• McNeill explained the three categories of codes for reimbursement: community health integration, principal illness navigation, and peer support.?
• Codes include billing codes and payment mechanisms for community health workers, health navigators, and peer support workers.?

CMS rule change for hospitals to screen for social needs, potential financial benefits.?

• CMS requires hospitals to screen for social needs, with penalties for non-compliance.?
• CMS recognizes homelessness as a complicating comorbidity, providing additional reimbursement for hospitals.?
• CMS demonstration shows addressing social needs reduces healthcare costs for non-white and Hispanic populations.?

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Medicare reimbursement for community health workers addressing social needs.?

• Provider billing for community health worker labor is time-based, with reimbursement rates varying based on time spent addressing social needs.?
• Time spent working on behalf of beneficiaries, not face-to-face time, counts towards reimbursement.?

Community health integration and social needs.?

• McNeill highlighted the importance of addressing social needs in healthcare.?
• Providers must document the connection between social needs and health outcomes for reimbursement.?
• CMS suggests providers contract with community-based organizations (CBOs) to address social needs.?
• Providers can use a payment mechanism to compensate CBOs for long-term sustainability.?

?Billing for social determinants of health interventions.?

• McNeill also highlighted the importance of person-centered assessments for reimbursement.?
• He highlighted the time-based billing with no cap or limit, emphasizing the importance of documented need and addressing high-risk conditions.?
• Principal illness navigation eligibility criteria include dementia, diabetes, heart disease, and cancer, with reimbursement possible for auxiliary personnel time spent supporting families.?
• McNeill discusses changes to principal illness navigation codes, including expanded eligibility and reimbursable activities (e.g., emotional support, social support).?
• Providers can now bill for time spent providing emotional support without limits on time spent, even outside of clinical settings.?

Case Study: Managing Complex Diabetes with Social Determinants of Health?

Patient: Gertrude, 62 years old, with diabetes and related complications.?

Challenges: In addition to managing her diabetes, Gertrude faces housing insecurity, transportation limitations, and mental health disorders. These social determinants of health make it difficult for her to adhere to her treatment plan.?

Intervention: A community health worker collaborates with Gertrude's primary care provider to implement a comprehensive care plan.?

Plan Components:?

• Improved diet: The health worker assists Gertrude with navigating resources like SNAP benefits to obtain healthy food options.?
• Medication adherence: Reminders and support are provided to ensure Gertrude takes her medications as prescribed.?
• Housing assistance: The care team explores resources to address Gertrude's housing insecurity, which can indirectly improve diabetes management.?

Outcomes: If followed, projects can profit $280,000 in annual revenue with a team of 10 community health workers at 60% production. Organizations could keep 10% of collections for administrative costs, passing 90% to community partners.?

This case highlights the importance of addressing social determinants of health for successful diabetes management. Community health workers are crucial in connecting patients with necessary resources and ensuring a holistic approach to care.?

For more information, visit: https://www.institutephi.org/2024/06/25/medicare-for-chws-and-community-health-integration-services-webinar-july-2-2024/