DATE: January 24, 2023
TO: Board of Supervisors
SUBMITTED BY: David Luchini, RN, PHN, Director, Department of Public Health
SUBJECT: First Amendment to Agreement with Fresno Metropolitan Ministry
RECOMMENDED ACTION(S):
TITLE
Approve and authorize the Chairman to execute First Amendment to Agreement with Fresno Metropolitan Ministry to continue the work with Fresno Community Health Improvement Partnership to develop a Community Health Worker Network Hub, effective upon execution to extend the base term by twelve (12) months and continue with the option to extend for an additional two twelve (12) months for a full term of December 14, 2021 to July 31, 2026, and increase the total maximum compensation by $2,400,000 to a total of $9,612,976.
REPORT
There is no additional Net County Cost associated with the recommended action. The recommended action will allow Fresno Metropolitan Ministry (FMM) to continue their partnership with Fresno Community Health Improvement Partnership (FCHIP) and subcontracted agencies to continue providing essential services to Fresno County residents through the Community Health Worker (CHW) HUB by increasing FMM’s budget by $2,400,000, increasing the term of the agreement by a year, and updating the scope of work to reflect changes. All recommended actions are fully funded with existing grant funds. This item is countywide.
ALTERNATIVE ACTION(S):
Should your Board not approve the recommended action, FCHIP’s CHW HUB will be working with a limited time and resources to adequately carry out scope of work activities, which includes COVID-19 recovery interventions and providing substantial capacity building to the CHW network. The CHW HUB infrastructure would be limited to shorter outcomes, with limited time to focus on sustainable approaches that will have longer-lasting impacts beyond the contracted period.
FISCAL IMPACT:
There is no increase in Net County Cost associated with the recommended action. The maximum compensation of the agreement with FMM will increase by $2,400,000 to $9,612,976 for the term. The agreement is fully funded by federal grant revenue from The Center for Disease Control and Prevention’s Initiative to Address COVID-19 Related Health Disparities (Health Disparities), Epidemiology and Laboratory Capacity COVID-19 (ELC), and the Immunization Local Assistance program. Sufficient appropriations and estimated revenues are included in the Department’s Org 5620 FY 2022-23 Adopted Budget.
DISCUSSION:
On December 14, 2021, your board approved agreement No. 21-539 which allowed the County to partner with FMM to allow FMM to act as the fiscal sponsor for FCHIP. This agreement also allowed FCHIP to contract with community-based organizations (CBO) to continue critical COVID-19 response activities as well as develop a CHW Network HUB that would provide service delivery through a nationally recognized evidence-based model. This agreement builds off the successful foundation laid by the COVID Equity Project, where CBOs were contracted through a coalition structure to serve specific populations throughout the county that were disproportionately affected by COVID-19. Through COVID-19 county specific data, the Department was able to identify areas heavily impacted by COVID-19 to deploy community partners and resources to mitigate negative impacts in health burdened areas.
From December 14, 2021 through January of 2022, FCHIP was able to renegotiate contracts with twelve of the twenty-one original COVID Equity CBOs either through direct contracts or a coalition structure. These contracts ensured Fresno County residents were still able to receive critical services during the COVID-19 surge months and prevent a gap in services. In February of 2022, FCHIP launched the Fresno HOPE Pathways Community Hub (HOPE HUB) and released a request for applications for 18-month contracts. The contracted period was designed as a three-phase implementation process to allow for a structured timeline to carry out contracted activities, which includes COVID-19 mitigation efforts and provides capacity building to CBO partners. Culminating in a transition during phase three to a fiscally sustainable payment for outcome structure. The payment for outcome structure allows for organizations to be reimbursed based on successfully providing care-coordination services by leveraging the skills of community health workers. The seven subcontracted CBOs are:
• Centro La Familia Advocacy Services
• The Fresno Center
• Fresno Interdenominational Refugee Ministries (FIRM)
• Cultiva La Salud
• Exceptional Parents Unlimited (EPU)
• Fresno Economic Opportunities Commission (EOC), African American Campaign (AAC)
• Valley Center for the Blind (VCB)
This swift transition of the seven CBOs contracted under the HOPE HUB structure allowed organizations to continue providing direct services during the COVID-19 winter surge months. These services include isolation and quarantine support, vaccination and testing, COVID-19 education and outreach, community linkages and other wrap around services. At the launch of the HOPE HUB, there were some unexpected challenges that were met, which required modifications in order to continue to deliver services in the most impacted areas in the County. Some of these challenges included CBO contracts being fully executed at different intervals, delays with hiring new program HOPE HUB staff due to labor shortages and transitioning into a new evidence-based model. These initial challenges were coupled with an increase in isolation and quarantine support requests due to a surge of COVID-19 positive cases. During this time, the HOPE HUB was able to successfully adjust and continue to deliver these crucial services while actively working on establishing the infrastructure for a more sustainable CHW network approach. The HOPE HUB has been able to reach 25,451 community members through outreach, education, testing, and vaccines events since January 2022. The HUB has also provided wrap around services to over 300 families financially impacted by COVID-19, over 80% of which reside in the most health burdened areas of Fresno County.
Phase one of implementation, which concluded in August 2022, served as a capacity building period for the HOPE HUB and contracted partners. The innovative nature of the HUB required organizations to complete extensive training in a standardized and linguistically appropriate manner. CHWs and supervisors completed 300 hours of evidence-based training through the nationally recognized Pathways Community Hub Institute (PCHI). The HOPE HUB and contracted partners also received training in the Care Coordination Systems (CCS) which serves as the integrated data management system that standardizes data tracking and provides invoicing capabilities. Additionally, CBOs were crucial in processing isolation and quarantine support requests for community members by utilizing their expertise and unique approaches when serving specialized populations and offering services in 15 different languages. Other capacity building efforts include the successful launch of a multi-part disability training developed in partnership with Valley Center for the Blind, which is a training focused on disability inclusivity and competencies around person-centered care. This multi-part training will also be offered to non-contracted agencies, at a cost, and will support in generating revenue as a sustainable approach. It also enhances the HOPE HUB’s capacity to provide technical assistance to other CHW led efforts beyond the contracted period.
In September of 2022, the HOPE HUB began phase two of the implementation process. During phase two, CHWs recruit clients through an in-depth enrollment process that includes the completion of a social determinants of health (SDOH) screening tool. Once enrolled, clients begin evidenced based interventions (Pathways) to address their previously determined barriers to health. Pathway completion times vary, depending on individualized needs of the client, and other identified barriers. From September 1, 2022 through December 31, 2022 the HOPE HUB has enrolled 395 clients, conducted 267 SDOH screenings, hosted 190 outreach events, opened 508 pathways, and successfully completed 189 pathways (Attachment A). Also, during phase two, CBOs have been submitting data to support the evidence-based model into CCS, and thus allowing a CBO to observe what level of reimbursement they can earn based on the outcome-based structure. Upon approval and term extension, phase two will also be extended and further evaluated to establish best practices and ensure an uninterrupted transition to phase three. During phase three, the new outcome-based reimbursement will be fully implemented and carried out for the remainder of term of the Agreement. Phase three will also allow for blended funding through outside sources, providing sustainable revenue for the HOPE HUB past the lifetime of the agreement.
In addition to providing resources to underserved residents of the County, the HOPE HUB has created job opportunities for over 35 new positions, many of which were filled by individuals that live in the same communities they are serving. The HOPE HUB is also invested in capacity building for local organizations through its offering of a nationally certified CHW certification training, which has already been completed by all CHWs currently employed by the HOPE HUB. Cross sector partnerships have been created through various taskforces and advisory councils including the Community Advisory Council, which has memberships from local hospitals, managed care programs, community foundations, mental health care providers, government agencies, as well as CBOs. To remain sustainable, the HOPE HUB has begun assessing funding opportunities including The California Department of Health Care Services’ CHW Benefit, CalAIM, Kaiser Permanente, Substance Abuse and Mental Health Services Administration, and other local managed care programs or community investment opportunities. Securing additional funding will be pivotal in the HOPE HUB’s sustainability after initial federal and state funded grants have expired in 2024.
Approval of the recommend action will allow the County to continue to partner with FMM and FCHIP to continue to provide critical services to residents of Fresno County through the HOPE HUB during the COVID-19 recovery phase. With the extension of the ELC and Health Disparities grant funds, the County has an opportunity to continue to support FCHIP in their transition to a fiscally sustainable model by contracting and leveraging with other payors that will provide reimbursement for these services beyond the contracted period. The extension and supplementation of funds will also allow the HOPE HUB to strengthen their infrastructure to serve as a provider of capacity building and technical assistance for the CHW network, extending their reach beyond their contracted partners for a more equitable service delivery to our Fresno County residents. With an extended term, the HOPE HUB will have more time to implement lessons learned, continue with quality improvement in ensuring adherence to the evidence-based model, and address gaps in service delivery, from previous phases that may not be as easily identified and corrected during a shorter term. One example of changes already taking place is the HOPE HUB’s review and corrective process to ensure that contracted partners are expending budgeted funds at an appropriate rate. This approach has also served as a capacity building opportunity for CBOs to enhance their fiscal capabilities. Since this practice was implemented, invoices have been more consistent with initial expectations and projections of additional funding. If approved, the recommended action would allow FMM’s agreement to be extended for an additional year, increase their budget by $2,400,000, and allow for a reallocation of funds in Personnel, Operating Costs, and Other Costs budget categories. This recommended action will also allow the scope of work to be updated to specify activity descriptions in Exhibit A of the agreement.
REFERENCE MATERIAL:
BAI #68, December 14, 2021
ATTACHMENTS INCLUDED AND/OR ON FILE:
On file with Clerk - Attachment A Phase Two Data
On file with Clerk - First Amendment to Agreement with Fresno Metropolitan Ministries
CAO ANALYST:
Ron Alexander