DATE: July 9, 2024
TO: Board of Supervisors
SUBMITTED BY: David Luchini, RN, PHN, Director, Department of Public Health
SUBJECT: Second Amendment to Agreement with Fresno Metropolitan Ministry
RECOMMENDED ACTION(S):
TITLE
Approve and authorize the Chairman to execute a Second Amendment to Agreement with Fresno Metropolitan Ministry to continue the work with Fresno Community Health Improvement Partnership to provide health intervention activities for Fresno County’s Community Health Worker Network, effective upon execution, extending the term by twenty-two (22) months from August 1, 2024 to May 31, 2026, and increasing the maximum by $2,883,893 to a total of $12,496,869.
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 $2,883,893, increasing the term of the agreement by twenty-two months, and updating the budget and scope of work to reflect the changes. The recommended action will also allow for federal terms and conditions to be included in the agreement. 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 will have a limited duration to embed substantial capacity building into the CHW Network infrastructure. Within the current timeline, sustainability efforts will be limited to shorter outcomes than funding would allow. The intention of this recommended action is to maximize federal grant funding and assure sustainability of the CHW Network. Should it not be approved, FCHIP will have a limited time to focus on sustainable approaches that will provide a longer-lasting impact 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 $2,883,893 to $12,496,869 for the proposed increased term. This increase is in alignment with FMM’s current expenditure rate of $3.4M per year and will allow for the program to remain funded through the extended 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) and Epidemiology and Laboratory Capacity COVID-19 (ELC). Sufficient appropriations and estimated revenues will be included in the Department’s Org 5620 FY 2024-25 Recommended Budget and will be included in subsequent budget requests.
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. 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.
In February of 2022, FCHIP launched the Fresno HOPE Pathways Community Hub (HOPE HUB) and released a request for applications for contractors to provide wrap around services to community members negatively impacted by COVID-19. This transition of the CBOs contracted under the HOPE HUB structure allowed organizations to continue providing direct services during COVID-19 surges as well as additional services including isolation and quarantine support, vaccination and testing support, COVID-19 education and outreach, community linkages and other wrap around services. Implementation of the HOPE HUB infrastructure was also foundational for a more sustainable CHW intervention approach.
The contracted period was designed as a three-phase implementation process to allow for a structured timeline to carry out contracted activities and provide capacity building to CBO partners. The third and final phase of the contract period was designed to transition contracted agencies 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 and confirmed through measurable outcomes.
The HOPE HUB has been instrumental through each phase in providing guidance and technical assistance to build each contracted agency’s capacity and ensure success in becoming a fully outcome-based program. The HOPE HUB initially had seven contracted agencies providing services. Of the seven original agencies, six were able to adhere to the HOPE HUB’s compliance standards and have either transitioned or are on track to transition to the outcome-based payment structure. During phase transitions and ongoing quality improvement measures, one of the agencies was unable to maintain adherence with the evidence-based model despite on-going technical assistance and support, leading to the early termination of the contracted partnership. The current subcontracted CBOs include: Black Wellness and Prosperity Center, Centro La Familia Advocacy Services, Cultiva La Salud, Exceptional Parents Unlimited, The Fresno Center, and Valley Center for the Blind. These agencies administer unique approaches to serving specialized populations and offer services in 15 different languages.
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.
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 a social determinants of health (SDoH) screening. Once enrolled, clients begin an evidenced-based intervention (Pathways) to address their determined barriers to health. Under this model, each pathway is tied to an identified SDoH need expressed by the client. Since September 1, 2022, CHWs have completed 5,243 SDoH screening tools for community members. Also, during this time, a total of 10,354 pathways have been opened, of which, 7,476 were successfully completed, meaning 7,476 unique needs of community members were met. The community’s top identified needs were social services, learning, medical referral, health coverage, and food security. The top ten client zip codes serviced are: 93701, 93702, 93703, 93706, 93720, 93722, 93725, 93726, 93727, and 93630. All zip codes are within the Healthy Place Index Quartile 1 which are recognized as some of the most health burdened zip codes in California. Attachment A is the HOPE HUB’s annual impact summary for the period of September 1, 2022 through August 31, 2023.
On January 24, 2023, your Board approved agreement No. 23-047 which amended agreement No. 21-539 to allow the agreement to be extended through July 31, 2024, and increased the total maximum compensation of the agreement by $2,400,000. This amendment also allowed phase two to be extended for further evaluation to establish best practices, which ensured an uninterrupted transition to phase three.
Phase three of implementation began August 1, 2023. During phase three, organizations have begun transitioning to the outcome-based reimbursement structure for the remainder of term of the Agreement. Two of the seven organizations are fully reimbursed through the outcome-based structure, while the remaining five are in a 50/50 transitionary period while the HOPE HUB continues to build their capacity with the intent to move all agencies to a fully outcome-based payment structure.
To remain sustainable, phase three leverages outside sources that creates a blended funding structure. In addition to County resources, the HOPE HUB has successfully secured additional funding opportunities from other organizations including: The California Department of Health Care Services’ CHW Benefit, CalAIM, Kaiser Permanente, Substance Abuse and Mental Health Services Administration, Parlier Unified School District, CalViva/Healthnet, and continues to assess other local managed care programs, such as, a partnership with Anthem Blue Cross and other regional community funding opportunities. Fresno HOPE HUB currently has the highest utilization for the CHW Benefit across active CalViva Health and Health Net counties. Securing additional funding will be pivotal in providing the HOPE HUB sustainable revenue past the lifetime of the agreement and after initial federal and state funded grants have expired.
As the County has moved into a post pandemic era, the HOPE HUB has transitioned from being primarily a COVID-19 response program, to a care coordination agency with an emphasis on the health disparities exacerbated by COVID-19. The project’s primary focus is to enroll clients into the program and provide services to address underlying health issues identified through SDoH screeners. Since the inception of the HOPE HUB, this model has been able to successfully enroll 2,439 total unique participants who have received individualized intervention services. Cross sector partnerships have been created through various taskforces, 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. In alignment with initial plans for this funding, The Department is also strategizing with the other County Departments, including the Department of Social Services and the Department of Behavioral Health, on how to maximize the HOPE HUB’s model and structure within existing County programs who have agreements for similar services and/or are contracted with the same CBOs. This approach aims at avoiding duplication of services and maximizing reach in a standardized way where outcomes are being tracked through a multi-agency collaboration.
The success of the HOPE HUB has led to receiving national acknowledgment by various Federal and State entities. On March 26, 2024, Department staff were selected to present at the Centers for Disease Control and Prevention, COVID-19 Health Disparities Grant (OT21-2103) Convening to share information about the CHW Network on a national level. Additionally, at the request of the Public Health Alliance of Southern California, Department of Public Health and HOPE HUB staff were given the opportunity to present on the program’s infrastructure, lessons learned, and best practices. Through this partnership and funding opportunity, the HOPE HUB infrastructure and model has become nationally certified and evolved into the largest PCHI evidence-based CHW Hub in California.
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 Fresno County residents. In addition, fiscal sustainability has always been a priority for the Department, the recommended action will allow the County to capitalize on remaining ELC funding to assure that other County Departments have the access to leverage the benefits of the HOPE HUB and the services in alignment with this program’s outcome-based model.
If approved, the recommended action would allow FMM’s agreement to be extended for an additional two years, increase the budget by $2,883,893, and allow for a reallocation of funds in Personnel, Operating Costs, and Other Costs budget categories. This recommended action will also allow the agreement to be updated to reflect a more accurate scope of work and include federal terms and conditions of the agreement’s funding sources.
REFERENCE MATERIAL:
BAI #39, January 24, 2023
BAI #68, December 14, 2021
ATTACHMENTS INCLUDED AND/OR ON FILE:
On file with Clerk - Attachment A Annual Impact Summary
On file with Clerk - Second Amendment to Agreement with FMM
CAO ANALYST:
Ron Alexander