In January of 2019, the RFP was released to transition Medicaid's Patient 1st program to ACHN. Medicaid instituted ACHNs effective October 1, 2019 in an effort to transform the Medicaid delivery system and become more cost-efficient. The new single care coordination delivery system is designed to link patients, providers, and community resources in seven newly-defined ACHN regions. Delivery of medical services is not part of ACHN.

This new Medicaid program moved all case management (maternity, Plan First, and Patient 1st) under one entity in seven regions throughout the state. ADPH was the provider of the Medicaid Patient 1st and Plan First case management programs. Those programs are no longer under ADPH and resulted in a loss of $21.6 million for the department and significant layoff of ADPH social workers. Through negotiations with Medicaid, ADPH only provides case management services to those infants that did not pass the newborn screenings at the hospital and those children with an elevated lead level. FY 2019 ended with approximately 45 FTEs in the Patient 1st Program.

ACHN has a decreased emphasis on low risk family planning case management and does not support adherence to selected birth control methods. This model could potentially have a negative impact on the unintended pregnancy rate including the teenage pregnancy rate. The lack of family planning case management for low risk patients could potentially increase Alabama’s infant mortality rate. ADPH was the safety net provider for the citizens of Alabama, facilitating a centralized statewide referral system for all providers, including Children’s Hospital. In the past, ADPH was able to identify children that are non-compliant with prescribed treatment plans. That referral process was discontinued with the ACHN implementation.

Added to the changes at Medicaid are the federal and state budget cuts that most agencies have experienced in recent years. These cuts have greatly affected Alabama hospitals. Many hospitals face challenges with recruiting patients and sustaining the funds to provide the necessary services, especially when most are operating in the red. These challenges have resulted in a fragile health care system, particularly in the rural communities. A recent report by the Alabama Hospital Association(AHA) stated that since 2011, thirteen hospitals have closed in Alabama and seven of those hospitals were in rural areas. Patients must travel farther and farther to receive what some would consider a basic service, such as a safe place to deliver a healthy baby. Safe deliveries are especially important in Alabama where the infant mortality rate remains among the highest in the nation.

To combat some of these problems, FHS continues to aim to partner with Medicaid and AHA at every available opportunity. FHS routinely attends meetings with both agencies, sits on committees with common goals, and invites them to participate in all statewide MCH programs. FHS has several programs that collaborate closely with Medicaid. Title X Program works closely with MCH to ensure that contraception and other family planning needs are met. In 2019 ADPH and Medicaid developed new contracts to address billing for EPSDT clinical, EPSDT case management, the lead program, immunizations, and Plan First.

In 2012, the telemedicine service was established to address the lack of HIV care in rural areas of the state. ADPH bureau collaborations further expanded the reach of telemedicine in rural Alabama by funding start-up costs for the necessary equipment in select county health departments. ADPH actively began engaging medical partners who wanted to offer health care services utilizing telemedicine technology and health care providers, transmission of images, and remote monitoring of vital signs. Telemedicine services were first available in only four county health departments. The Telemedicine Program has grown exponentially in recent years. Sixty-five county health departments have telehealth carts and 15 healthcare agencies collaborate with the Telehealth Program. Telehealth equipment is also used for meetings and training.

The growth of ADPH’s telehealth capabilities and partnerships continues. Blue Cross Blue Shield of Alabama began reimbursing providers for all telehealth encounters with previously covered specialties in 2018. Governor Kay Ivey convened a workgroup to develop recommendations for proposed telehealth legislation by January 2019. A grant began in October 2018 with the Alabama Department of Mental Health and Children's of Alabama to allow adolescents to receive behavioral health services through telehealth. Additional MCH telehealth initiatives include the following:  1) Pediatric Neurology; objective is to empower pediatric neurologists to use telecommunications; 2) Maternal-Fetal Medicine with UAB and the University of South Alabama; two programs each with unique features; 3) Pediatric Nephrology; 4) Family Planning: EVAs for enhanced visualization and development of colposcopy services; 5) Developmental-Behavioral Health (Autism).

ADPH’s Office of Primary Care and Rural Health (OPCRH) facilitates and participates in activities to improve access to health care services for all rural Alabamians with special concern for children, the elderly, minorities and other medically underserved vulnerable populations. Fifty-five out of 67 of Alabama's counties are considered rural and 2,031,229 residents, or 43.6 percent of the entire Alabama population, live in rural areas. Currently, 63 of Alabama’s 67 counties have areas designated as medically underserved for primary care. Between 2018 and 2019, nine new rural health clinics were established, for a current total of 113. OPCRH works very closely with the Alabama Rural Health Association, AHA, the Alabama Primary Health Care Association, and departmental bureaus to address health issues affecting those living in rural areas. Some of the major programs employed by the OPCRH include the recruitment and retention of healthcare professionals and technical assistance to small rural hospitals, and health providers in transitioning to a new value-based healthcare system. Per the ADPH Annual Report, OPPCRH utilizes national programs to recruit health professionals into medically underserved areas. Currently, there are over 150 healthcare providers delivering medical care to rural and medically underserved Alabamians under these programs. The OPCRH also assists communities in establishing CMS certified rural health clinics.

CRS Health Care Delivery System

CRS is involved in several collaborative efforts with other federal, state, and non-governmental partners to ensure access to quality health care and needed services for the CSHCN population. CRS, in conjunction with Children’s Hospital of Alabama (COA) and Medicaid, held the first in a series of Pediatric Care Coordination Curriculum trainings. The trainings are funded by a grant from the Alabama Department of Early Childhood Education. CRS is also an active member of ACHIA which is the state improvement partnership program working with the AL Chapter of the AAP and pediatric practices across the state. The CRS Assistant Commissioner and SPC are members of the ACHIA steering committee. The SPC serves on the Continuous Quality Improvement Committee, which is charged with reviewing possible topics for future learning collaboratives coordinated by ACHIA. Other members of ACHIA include Medicaid, CHIP, Title V, and COA. CRS is also the lead agency for the Alabama CMC CoIIN, which is a collaboration of several entities including Medicaid, University of South Alabama Pediatric Complex Care Clinic, and COA. Through the placement of a care coordinator at the USAPCCC the CoIIN project has created a multidisciplinary group dedicated to providing comprehensive, well-coordinated care for Children with Medical Complexity and their families at the University of South Alabama Pediatric Complex Care Clinic.

CRS Medicaid Partnership

CRS partners with Medicaid in various ways. Although EPSDT services are the responsibility of the primary care provider for all children under Medicaid managed care arrangements, CRS coordinates services with the medical home to ensure access to specialty care and related services through Medicaid funding for all CYSHCN served by the program. CRS continues its inter-agency agreement with Medicaid to provide Children’s Specialty Clinic Services throughout the State, which enhances access to services for Medicaid recipients. In order to ensure consistent quality, statewide standards of care, and access to community-based clinical services, Medicaid and CRS have negotiated a list of approved multidisciplinary clinics. CRS and Medicaid have negotiated a clinic encounter rate that Medicaid pays per specialty medical clinic visit of a Medicaid enrolled child. In addition to covering the cost of the clinic visit it also helps fund wrap around services to the client.

Medicaid implemented a consolidated Care Coordination system through a Section 1915 (b) Waiver effective October 1, 2019. This resulted in the formation of ACHN. CRS care coordinators have developed a close partnership and collaboration with the care coordination staff at the ACHN regional offices. CRS and Medicaid state staff also collaborate to hold statewide joint meetings regarding collaboration and service delivery. ACHN staff participated in the previously mentioned Pediatric Care Coordination Curriculum training and will continue to participate in future trainings.

Medicaid has a wide variety of Home and Community-Based Waiver programs for which CYSHCN may be eligible. CRS care coordinators and Parent Consultants educate families about the various waiver programs and assist families with the referral and application processes.

CRS serves as the reviewer of all requests for Medicaid funding for augmentative communication devices and houses all Medicaid PA requests for ACDs. CRS is the only provider of medically necessary orthodontia for Medicaid recipients. CRS works closely with Medicaid’s Dental Director regarding payment for orthodontia services.

CRS serves in an advisory role to Medicaid for program and policy decisions likely to affect CYSHCN and its sub-group, CMC, and serves as a voice for this population. Medicaid staff members are assigned to work with CRS. Meetings between Medicaid and CRS are held quarterly to discuss any issues or concerns regarding providing services to Medicaid recipients with CSHCN. If issues arise outside the quarterly meetings, the CRS Medicaid liaison will contact Medicaid to discuss. In addition, CRS staff including SPC participate on advisory committees and work groups associated with various Medicaid initiatives.

CRS staff are trained on Medicaid and CHIP program eligibility and diligently work to ensure that all coverage options have been explored for any uninsured child. If a client is found to be uninsured the CRS care coordinator will assist the parent/guardian in submitting a joint application for Medicaid, CHIP and the Federally Facilitated Marketplace. The joint eligibility system will make a determination for which program the child is eligible. Alabama has a low uninsured rate for children, which is due to the focus on education and outreach to all uninsured children. CRS also works with private insurers to ensure coverage for services for CYSHCN.

CRS continues to work towards joining Alabama’s One Health Record. The One Health Record® system was created as Alabama’s health information exchange (HIE) through a federal grant awarded to the state in 2009. Under the guidance of the Alabama Health Information Commission, One Health Record® has emerged as an interoperable, two-way data exchange system between providers, hospitals and others within Alabama and in other states. Participating providers can query the interoperable, two-way data exchange from within their electronic health record system to access patient health data from other providers.  Interfacing CRS’s current EMR to One Health Record® will save CRS time and money. CRS will be able to provide an electronic copy of the medical portion of a child’s clinic report of visit (ROV) to each physician involved in their care. CRS program physicians will have the capability to send and receive laboratory and x-ray orders electronically and it will provide the ability to send electronic prescriptions.