Third Sector conducted a feasibility assessment that supported the Children and Families Commission of Orange County[1] (the Commission) in developing a value proposition for its home visiting services and identifying areas for improvement in managing its performance.
Sub-Recipient: Bridges Maternal Child Health Network
Home visiting is a voluntary, relationship-based intervention that includes regular visits by a trained professional to a family’s home when the parent is expecting and/or after they have given birth. Evidence from home visiting programs shows that when families receive this type of support, children are healthier and better prepared for school, parent-child bonds are stronger, and abuse and neglect are less likely.[2]
In Orange County, CA, home visiting services are supported by the Commission’s Bridges Maternal Child Health Network (Bridges Network). The countywide Network is unique in that it meets most parents at the hospital after they give birth. Mothers discuss the environment the baby will be experiencing with a Bridges Coordinator utilizing the validated Bridges Screening Tool. If home visiting services are appropriate, a referral is made to the Network provider whose service most align with the parent’s needs.
The Network has significant saturation in Orange County, it includes: ten hospitals, three community organizations (Children’s Bureau, MOMS Orange County, and Orange County Child Abuse Prevention Center), and Orange County Public Health Nursing. Collectively, the Bridges Network helps to ensure that children are born healthy and are raised in safe environments. Through this model of prevention and early intervention, the Commission aims to give Orange County’s children the healthiest start possible and to reduce the need for costlier remedial services in the future.[3] The Network provided over 65,000 screenings to children for health, behavior, and/or developmental milestones in FY14-15.[4]
Motivation for Exploring Pay for Success
The Bridges Network is the Commission’s largest annual funding commitment. Over the past decade, the Commission’s revenue from tobacco taxes has declined precipitously, resulting in a nearly 40% reduction in Bridges Network’s budget from 2010 to 2015[5]. As the Commission seeks to sustain the Network’s services for Orange County’s families, Pay for Success (PFS) has emerged as a promising opportunity.
Third Sector led a feasibility assessment, in partnership with the Commission, to explore the viability of using PFS to increase the financial sustainability of the Bridges Network. The engagement included the following key work streams: intervention assessment, data sources and gap analysis, target population analysis, end payer assessment, evaluation design and funder development. Third Sector served as overall project manager, leading all work streams and performing certain analyses while overseeing others that were performed by Partners (see below).
Findings and Insights
Through the feasibility assessment, Third Sector found that the Bridges Network has a strong value proposition given the outcomes it has achieved. The Network can continue to build on its success by investing in better performance management systems. Though there is not an end payer ready to engage in outcomes-based contracting with the Network now, the Commission’s commitment to continuous improvement will strengthen their ongoing conversations with CalOptima, Orange County’s Medicaid managed care plan[6].
The Feasibility Assessment enabled the Commission to:
- Demonstrate the efficacy of the Brides Network through a healthcare outcomes analysis. The analysis compared the healthcare outcomes of Bridges Network mothers and children to the outcomes of a control group by linking historical CalOptima data to Network data (Intervention Assessment)
- Understand the extent to which the Network’s current data collection and reporting processes provided:
- real-time access on mothers’ & families’ progression through the Bridges Network,
- appropriate metrics needed to evaluate program effectiveness, and
- on-going feedback to key network stakeholders (including Bridges’ hospitals and providers).
This work consisted of an in-depth process of interviews, documentation and research on potential solutions to fill identified gaps (Data Sources & Gap Analysis).
- Validate that the Network’s hospital screening process is working correctly and the highest need mothers are those that receive home visiting services. This was tested through an analysis of the pre-screen risk scores for the mothers that gave birth at Bridges hospitals (Target Population analysis).
- Advance conversations with CalOptima regarding the value proposition of the Bridges Network and potential for increased data sharing with the Commission (End Payer Assessment).
- Understand the considerations for rigorously evaluating the Bridges Network in a prospective evaluation (Evaluation Design).
The Feasibility Assessment also spurred the Commission to:
- Pursue a one-time Medicaid funding opportunity that could support components of the Bridges Network for several years[6]. While this funding is formula-based (i.e. not based on the outcomes) and may not occur again, it allows the Commission to stretch its limited funding across more years. During this time, they may be able to further engage a sustainable end payer.
- Further a culture at the Commission where funding decisions are based on data-driven approaches and consider programs with value propositions that can attract outcomes-based funding.
- Engage two experts to identify and implement changes needed to drive better service delivery across the Network through interviews and research. While this engagement was separate from the feasibility assessment, Third Sector provided input on how it related to the Network’s value proposition.
Partners
- Third Sector Capital Partners, Inc. led the feasibility assessment
- Abt Associates, Third Sector’s SIF Partner completed the Target Population Analysis and the Evaluation Design
- Health Management Associates performed the healthcare outcomes analysis (part of the Intervention Assessment)
- James Irvine Foundation and Non-profit Finance Fund funded the healthcare outcomes analysis
[1] The Commission was created as a result of Proposition 10, the California Children and Families Act of 1998, which added a 50-cent sales tax on tobacco products sold in California and required that funds raised be used to support education, health and child development programs for children from the prenatal stage through age five. Funds collected statewide are allocated to local county commissions based on each county’s birth rate. (http://occhildrenandfamilies.com/about-us/)
[2] http://homvee.acf.hhs.gov/outcomes.aspx
[3] 2014-15 Annual Report Supplement Appendices (Commission’s Healthy Children goal area), Appendix 1
[4] 2015 Annual Report for the Commission. (http://occhildrenandfamilies.com/wp-content/uploads/2015/12/CFCOC_AR15.pdf)
[5] CalOptima has more than 730,000 members (as of March 31, 2015). It is ranked the top Medi-Cal health plan in California by the National Committee for Quality Assurance (“NCQA”) due in large part to its performance on the Healthcare Effectiveness Data and Information Set (HEDIS) measures.
[6] This funding will flow to one Bridges Network provider, MOMS Orange County for uncompensated care for Medicaid-eligible families