SOBRA Outreach Program

1. SOBRA Outreach Program Chapter 20, HSSG January 22, 2008 Presentation

2. Introduction The Sixth Omnibus Budget Reconciliation Act (SOBRA) Outreach Program is a component of the Medipass Section 1915(b)(1) Waiver created June 7, 2001. Waiver builds on public and private partnership to bring services to the community level. The Waiver specifies that HS Coalitions are the most appropriate vehicle for implementing this program.

3. SOBRA Process Program for all newly enrolled Medicaid women in SOBRA (MMP) and PEPW (MU) categories. AHCA sends letter to all newly enrolled in the above 2 categories. AHCA transfers list of names to Healthy Start Coalitions via SIS weekly.

4. SOBRA Process (Continued) The SOBRA Outreach Program can either be retained at the Coalition or contracted out to local provider. Maternity Care Advisor (MCA) is the staff person employed by the Coalition, or its subcontracted provider, to perform the duties stated in the standards and criteria.

5. Changes from Previous HSSG Chapter 20 Some of the definitions have been fine-tuned (auto-assign; enrollee; follow-up; HMS; medical guidance; and PEPW); New definition for post-enrollment added; Additional changes are underlined in red in this PowerPoint

6. Useful Definitions for This Presentation SIS (SOBRA Information System) � the web-based information system, owned by the Florida Association of Healthy Start Coalitions, by which SOBRA enrollees are tracked. Attempt to Contact - Work efforts related to verbally contacting an enrollee either face-to-face or by phone. Does not include letters, except for those enrollees who provide only a post office box as an address; does include phone calls or visits to enrollee�s home, workplace, WIC clinic, Department of Children and Family Services, County Health Departments, or health care provider in attempts to locate the enrollee.

7. Useful Definitions for This Presentation Attempt to Communicate � Additional interaction attempt to auto-assigned recipients that may be by letter, telephone call or face-to-face encounter. NOTE: Difference between an attempt to communicate and attempt to contact is that an attempt to contact does not include sending a letter, where an attempt to communicate does.

8. Standard 20.1 and Criteria The MCA shall be responsible for attempting to contact by telephone all SOBRA eligible women identified on the weekly Medicaid fiscal agent list within five (5) working days to discuss the below list of items:

9. Standard 20.1 Criteria (Continued) Explain program and benefits; Present a list of Prenatal Care (PNC) providers to enrollees who have not chosen a prenatal care provider; Assist enrollees with their choice of PNC providers; Register choice in SIS; Facilitate initial or next appointment; Determine if the enrollee has completed a Healthy Start screen and, if not, facilitate the completion; Facilitate enrollment in WIC

10. Standard 20.2 and Criteria Within 30 days of notification from the fiscal agent, the MCA shall register the enrollee with her selected PNC provider and facilitate the completion of the Healthy Start screen. The MCA shall make at least three (3) attempts to contact within the first 30 days of notification of eligibility by the fiscal agent.

11. Standard 20.2 Criterion MCA Has 5 working days to make the first ATC to explain the program and facilitate the completion of the screen; Of those enrollees that the MCA is unable to reach by phone within the 30-day period, at least 25% will receive an attempted face-to-face contact with priority given to enrollees who have no phone but have a street address for this attempted face-to-face contact.

12. Standard 20.3 and Criteria If the enrollee has not made a decision within 30 days, the MCA shall assign a PNC provider by selecting from providers within a 30-minute drive radius from the enrollee�s residence. Coalitions with more than one PNC provider who meet this requirement shall assign a PNC provider�

13. Standard 20.3 Criteria (Continued) � to the enrollee based upon a locally established unbiased protocol. The selection process shall be weighted for those group practices with more than one PNC provider.

14. Standard 20.4 and Criteria The MCA shall inform the recipient that her PNC provider can be changed for up to 60 days from provider enrollment. However, after 60 days, it is recommended that the recipient would only change providers for the following reasons:

15. Standard 20.4 Criteria (Continued) Change of recipient�s county of residence; Cause, such as recipient�s inability to schedule appointments in a timely manner, or patient/provider conflict; PNC provider termination from Medicaid or relocation; Recommendation of the provider based on complications of the recipient�s pregnancy such as to a Regional Perinatal Intensive Care Center provider.

16. Standard 20.5 and Criteria For all recipients that have been auto-assigned (not verbally contacted but their provider choice registered either from auto-assignment or information received from the screen) the MCA shall provide one additional attempt to communicate.

17. Standard 20.5 Criteria Communication with the recipient can be by letter, telephone call, or a face to face encounter. The MCA will make this one additional attempt to communicate to women who have been auto-assigned or not verbally contacted between day 31 and the end of month 5.

18. Standard 20.6 and Criteria The MCA shall provide follow-up services as needed to recipients. These follow-up services can include, but are not limited to, the following criteria:

19. Standard 20.6 Criteria (Continued) Ensuring that the Coalition�s prenatal care counselors work closely with prenatal care providers for notification of no-shows or problems; Contacting the recipient to determine the reasons for reported no shows and facilitating rescheduling; Assisting the recipient in accessing recommended prenatal care services and resolving problems in receipt of care; Facilitating continuity of prenatal care in case of provider termination, loss of Medicaid coverage, or other problem; Ensuring that the Coalition�s prenatal care counselors facilitate making appointments for recipients for other health services if needed; Conducting periodic surveys with samples of recipients concerning their access to all services covered in this contract.

20. Standard 20.7 and Criteria After enrollment between the sixth and ninth month of pregnancy, the MCA shall provide these mandatory post-enrollment services to recipients, including recipients that are auto assigned: Facilitate accessing family planning services; Facilitate accessing health care coverage for the infant; and, Facilitate choosing a pediatric care provider for the infant.

21. Standard 20.8 and Criteria The Coalition shall work with PNC providers to provide them with information on the Healthy Start Program available to recipients. This will help to increase screening rates and referrals to the program.

22. Standard 20.9 and Criteria The Coalition shall encourage PNC providers to refer recipients into Healthy Start in the Coalition�s service delivery area for reasons other than score, such as knowledge or suspicion of the following criteria:

23. Standard 20.9 Criteria (Continued) Domestic violence; Sexual abuse; Other threatened violence, including child abuse; Substance abuse; Untreated mental illness including severe depression and suicidal tendencies; Known history of abuse and neglect in family/household; Pregnancy complication, such as maternal obesity, gestational diabetes and hypertension; Infant whose mother received late or no PNC; An infant whose mother is at risk for a shortened interpregnancy interval; HIV positive; Hepatitis B positive; Lack of basic needs such as housing and food; Insufficient prenatal or pediatric care; and Inappropriate growth and development of the baby/fetus.

24. Standard 20.10 and Criteria The Coalition, or its subcontracted provider, shall compile information about language skills of prenatal care providers and their office staff and provide recipients with this information when requested. The Coalition, or its subcontracted provider must identify what language skills the PNC providers or staff possess and have this information available for enrollees during their PNC provider decision-making process.