Conversation with Luella Penserga, Project Director of Collaborative Projects, Community

Conversation with Luella Penserga, Project Director of Collaborative Projects, Community Health Center Network (CHCN)/Alameda Health Consortium (AHC)

April 25, 2006

Alameda County is a small county (1.4 million people with 11% uninsured or about 173,000). Its community clinics are members of the Alameda Health Consortium (AHC), founded about 25-30 years ago, have a long history, political orientation and relationship of working together on issues of common interest.1 AHC’s eight member clinics are:

 West Oakland Health Council  La Clínica de La Raza  Tiburcio Vasquez Health Center  Axis Community Health  Asian Health Services  Tri-City Health Center  LifeLong Medical Care  Native American Health Center

In 1998, Kellogg selected Asian Health Services and La Clinica de la Raza along with AHC to be a Community Voices site. Under the leadership of Sherry Hirota (CEO of Asian Health Services), the Access to Care Collaborative (Collaborative) was formed as a body of safety net providers to come together to think strategically about expanding access and coverage to health care programs for low-income, uninsured populations, with AHC providing staff support and acting as a convener. The Collaborative’s members include:

 Alameda County Medical Center-Highland Hospital (public hospital)  Alameda Alliance for Health (Local Initiative, Ingrid Lamirault formerly of LACDHS Office of Ambulatory Care is now the CEO and Irene Ibarra was former CEO prior to joining LA Health Action and TCE)  Eight community clinics (listed above) – the Collaborative is clinic-heavy and its agenda has been clinic-driven  Alameda County Health Services Agency (Alameda County's health services program which includes the following program areas: Medical Care, Behavioral Care, Public Health, Agency Administration and Finance, and Alameda Alliance for Health)  Alameda County’s Social Services Agency (SSA) – equivalent of L.A. County DPSS

1 AHC is the Alameda County-equivalent of the Community Clinic Association of L.A. County (CCALAC), which has a shorter history (founded in 1994) having been initiated shortly before the approval of the Section 1115 L.A. Waiver and the founding of L.A. Care Health Plan, as well as a different relationship with LACDHS due to the initiation of the PPP program.

1 The Collaborative has worked together on several projects, with their main successes (and disappointments) being:  Family Care.2 While it had the potential of being the Collaborative’s greatest success, the state budget deficit coupled with the lack of movement on the Healthy Families statewide parental waiver resulted in the product being discontinued. This project came out with the recommendation that immigration status should not be used as a criteria for eligibility. The majority of Family Care’s members were immigrants (including the undocumented) and adults. The Collaborative played a key role in this project. The project was evaluated by University of Michigan for Community Voices.  No Wrong Door Project.3 With collaboration and leadership from SSA and the Health Care Services Agency, this project aimed to increase access and approval rates for its health insurance and other public assistance programs, improve efficiency of application processing and increase program retention. The project included Healthy Families and Medi-Cal as well as other county-only expansion programs such as Family Care and the County Medically Indigent Services Program. Regarded as a model for covering kids, the project is being studied and replicated in other counties and was awarded a National Achievement Award from the National Association of Counties. This project got people from county government to think across programs.  2000 County of Alameda Uninsured Survey. A copy of the report may be found at www.communityvoices.org/non_publication_pdfs/CAUS_Report.pdf. This survey was completed before CHIS data was available.

The Collaborative originally asked for the top two people from each member agency to be present at the meetings, which occurred on a roughly monthly basis. However, agencies starting sending junior staff and just going through project updates, losing momentum (especially due to the Family Care experience), and not doing any strategic thinking. As a result, the Collaborative has changed in the following ways:  Narrowing the number of people allowed to its meetings to the CEOs

2 A health coverage product offered to immigrant families through Alameda Alliance for Health (AAH) for families: 1) Ineligible for other public coverage programs, 2) Incomes up to 300% FPL; 3) Adults with at least one child who is a member of AAH; and 4) Regardless of immigration status. Family Care was financed through $15 million from AAH reserves, $2 million in funds from The California Endowment and California HealthCare Foundation, $3 million in county tobacco settlement funds and $20-120 member premiums depending on age. At the height of the program, 7,300 people were enrolled without a media campaign with a waiting list of more than 2,500. See Penserga L, Alliance Family Care: Health Coverage for Low-Income Immigrant Families (November 2003). Accessed at www.wkkf.org/Pubs/Health/APHA_03-Alliance_Family_Care_00250_03759.pdf. 3 This project fundamentally transformed the traditional role of SSA so that workers could help individuals and families complete health coverage applications, and could serve as links to other programs. Using a team approach, social services agency staff works together to streamline and expedite enrollment into Healthy Families and available county and local programs. The process allows the eligibility worker to arrive at a final decision sooner than traditionally possible since applications are complete and accurate, and do not require additional follow-up with families. Using this system, the pilot program eliminated processing delays and increased approvals in available programs from 50 percent to 70 percent. Among other support, The California Endowment awarded Alameda County a $1.5 million grant to implement the pilot program on a larger scale in 2003. See California HealthCare Foundation, How Policy Changes Impact Enrollment: A Look at Three County Efforts (May 2004) and The California Endowment, Public Policy and Advocacy, Alameda County ’s No Wrong Door Project: Counties lead way to improve health coverage for children. Accessed at www.calendow.org/policy/alamedacountynowrong.stm.

2  The Collaborative held retreats to develop operating principles but it does not have a formal mission (other than a slogan about expanding coverage and access that most of the group members probably couldn’t repeat)  Moving to a dinner meeting in a more casual format, which has created an “in-crowd” privileged feeling, forces people to sit at the same table to look at some of the deeper health care issues and has moved the dialogue to a higher level (the group meets on an approximately monthly basis)

Sherry Hirota of Asian Health Services is chairing the group this year. Ralph Silber (CEO for AHC/CHCN), Luella, Sherry and Jane (CEO for La Clinica de la Raza, community health center) all do a lot of the work of talking to people, setting agendas, etc. between meetings. The Collaborative does not have a formal decision-making process. It is kind of consensus, a lot is done informally by the “leadership group” but it is heavily clinic-driven. A lot of negotiation takes place. They have to balance many different agendas. Many groups (such as the clinics) get funding from the Alameda Alliance for Health, as well as everyone is funded by the Alameda County Health Services Agency, which creates dependencies in the relationships.

Strengths of the Collaborative include:  They are players all from one system, part of the health care network including SSA  The Collaborative has a chance to look at deeper health care issues given its early successes such as changing from a purely medical model to provide social support services, facilitate data sharing (short of legislation like SB 840 passing, Luella expressed that the Collaborative has done what they can to expand health coverage for primary care)

Negatives include:  Insular, could benefit from a broader group with respect to addressing mental health issues and racial and ethnic health disparities (how can the Collaborative play a role)

As of now, the Collaborative does not have any defined focus areas or strategic priorities.

While Luella expressed that the Collaborative may not want outside staff to sit in on its meetings due to the high-level discussions that take place (they have had speakers vs. observers), she said she would speak to Sherry Hirota and get back to us in a few days to let us know what learning opportunities exist.