MPH 6903-001 Internship Final Report...MPH 6903-001 Internship Final Report Outreach and Process...

MPH 6903-001 Internship Final Report

Outreach and Process Development of the

Affordable Care Act Enrollment Specialist Program at

Greene County Health Care, Inc.

Daniel Landon Allen, MBA, MPH(c)

Executive Director│The Grimesland Free Clinic

Doctor of Medicine│Master of Public Health│Class of 2016

Brody School of Medicine│East Carolina University

Contents

Executive Summary 1

Project Proposal 5

Final Report and Recommendations 13

Appendix I: Objective 1 Documentation 29

Enrollment Program Customer Survey 31

Enrollment Program Customer Survey Data Summary 35

Enrollment Program Customer Survey Results 43

Appendix II: Objective 2 Documentation 51

Enrollment Program Process Interview- CAC Staff 53

Enrollment Program Process Interview- Office Staff 57

Enrollment Program Process Interview- CAC Staff Raw Data 59

Enrollment Program Process Interview- Office Staff Raw Data 69

Enrollment Program Process Interview- CAC Staff Results 72

Enrollment Program Process Interview- Office Staff Results 78

CAC Appointment Tool 80

CAC Best Practices Document 82

Appendix III: Developed Marketing Material 85

Marketing Presentation 87

Marketing Card 91

Example Billboard 92

Appendix IV: Miscellaneous Documentation 93

Application Counselor Certification 95

Jean Mills Health Symposium 96

Allen MPH 6903-001 Internship Final Report

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Executive Summary


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Executive Summary

Introduction

This summary offers an overview of the material presented in the final report which

begins on page 13 of this document. It should not be used to implement recommendations or

replicate methods as significant caveats and limitations have been removed for brevity.

Objective 1 Overview

Develop and utilize an outreach program (with uniform outreach and marketing materials

as well as an outreach presentation for use at community meetings and events) to aid the ability

of enrollment specialists in making contacts and enrolling individuals in health insurance through

the marketplace during this and subsequent open enrollment periods.

Objective 1 Methods

A customer marketing survey was developed for use with those consumers who went

through the entire enrollment process. The survey focused on evaluating 1) the marketing

exposure sources and program materials, 2) their effectiveness, 3) how the program’s marketing

efforts could be improved, 4) consumers’ previous enrollment steps, and 5) the level of service

consumers received. Surveys were administered in both English and Spanish to customers after

enrolling in an insurance policy throughout the month of February. A database was created using

IBM SPSS statistical software (version 20) and subsequently analyzed to direct the creation of

marketing material and recommendations.

Objective 1 Recommendations

1. All future marketing material should emphasize the affordability of coverage, individual

mandate, available assistance, subsidy availability, and appointment flexibility and ease.

2. All future marketing materials should include the GCHC logo and the Health Insurance

Marketplace Logo.

3. The marketing presentation developed for the GCHC enrollment program should be

started by CACs on the patient education computers in waiting rooms each morning

during open enrollment and displayed on their laptops at outreach events.

4. Patient letters should not be used again in subsequent open enrollment periods and the

funds saved should be used to obtain high profile billboards near the GCHC centers.

5. CACs must emphasize heavily the need for consumers to refer family and friends during

encounters and should generously distribute the program’s informational cards to

consumers to aid this process.

6. All marketing materials used should be provided in both English and Spanish.

7. The enrolment program should continue to utilize available free documentation from the

US Centers for Medicare and Medicaid Services.

MPH 6903-001 Internship Final Report Allen

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Objective 2 Overview

Develop and implement an efficient plan for (a) enabling patients to navigate

GCHC’s infrastructure in order to reach enrollment specialists, and (b) making referrals

to enrollment specialists from within the GCHC system.

Objective 2 Methods

An in-depth interview tool was created for use with the CACs and focused on 1) the types

of outreach conducted, 2) setting up outreach events, 3) conducting outreach encounters, 4) the

content of initial encounters, and 5) enrollment appointment structure. A second interview was

developed and used to conduct brief group interviews with the office staff at each clinic and was

intended to identify 1) how referrals are handled by office staff, 2) the logistics of informing the

office staff of the CAC’s schedule, and 3) potential methods for developing a policy for internal

referrals at GCHC. Interviews were conducted over a two week period in late February and early

March. Responses were recorded and compiled into raw data documents which were analyzed

qualitatively using constant comparison methodology. The resultant themes identified from

within interview responses led to the recommendations proposed.

Objective 2 Recommendations

1. In order to improve internal referrals, GCHC should establish a corporate policy that all

new patients and all patients renewing their sliding scale fee be directly referred to a

CAC at that time in order to evaluate their insurance options.

2. GCHC should adopt a corporate policy that during the open enrollment period, all

patients visiting the clinic be asked about their “interest in meeting with a counselor to

determine if they are eligible for help paying for health insurance” at check-in.

3. Each CAC should establish a method to consistently inform office staff of whether they

are in or out of the office.

4. CACs should become familiar with and utilize the best practices included in the

document “CAC Best Practices” in Appendix II: Objective 2 Documentation.

5. The enrollment supervisor along with the appropriate CAC, should create and deliver a

15-20 minute presentation to deliver to office staff at each clinic at the start of each

enrollment period.

6. CACs should create and use a uniform packet of materials for all enrollment

appointments.

7. CACs should not profile consumers at outreach events.

8. CACs should not skip optional questions automatically.

9. As subsequent enrollment periods are entered into, the enrollment program supervisor’s

role will shift from one of establishing the program to one of initiating and conducting

outreach events.


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Project Proposal


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Project Proposal

Overview of Greene County Health Care, Inc.

Greene County Health Care (GCHC) was incorporated as a small rural health clinic in

1972 and has provided the local community with primary care services consistently since that

time. It has operated as a certified Federally Qualified Health Center (FQHC) since 1973. GCHC

currently operates a system of five medical centers, two dental offices, a school-based health

program, and a farmworker outreach program.1

As a Community Health Center (CHC), GCHC is operated as a nonprofit tax exempt

organization by a board of directors who are comprised of local community members, more than

half of whom are eligible for services within the clinics. The clinic also accepts cost based

Medicare and Medicaid reimbursement and uses a sliding scale fee based on patient income

while providing comprehensive primary and preventive services both in Medically Underserved

Areas (MUA) and with Medically Underserved Populations (MUP).1,2

In 2012, the GCHC system had 32,367 patients of record (8,838 of which were new) and

the 139 staff members performed 115,666 patient encounters (40,458 medical, 14,911 dental,

and 5,991 mental health). The patient population was primarily Hispanic (73%), with equal

portions of African-Americans and Caucasians (13% each). In addition, 99% fell below 100% of

the federal poverty level and 83% were uninsured. Therefore, during 2012, $5.6 million in

sliding fee discounts were given.1

Background

As is common knowledge among most public health workers, the Patient Protection and

Affordable Care Act of 2010 (PPACA) has created substantial changes in the healthcare

industry. Among the most important of these are: 1) the removal of annual spending caps, 2)

prohibited denial of coverage due to pre-existing conditions, 3) prohibited denial of payment due

to clerical mistakes, 4) regulation of the portion of premiums that must be used for healthcare by

insurance companies (the 80/20 rule), 5) requisite justification for insurance premium increases,

6) small business tax credits for providing health insurance to employees, 7) extending coverage

eligibility for children by their parent’s plan to age 26, 8) a set of minimum coverage standards

for all new health insurance plans, 9) free preventive care for a specific set of covered services,

and 10) a competitive marketplace for consumers to shop for and compare health insurance

policies as well as determine eligibility for income-based subsidies. In addition to these

provisions, the PPACA creates a mandate that, with some exceptions, requires all individuals to

maintain coverage in some capacity (through Medicare, Medicaid, employer-based coverage, or

private insurance for example).3 To facilitate the enrollment of uninsured Americans without

access to employer-based coverage into policies offered on the newly created exchanges, the

PPACA created a system of enrollment specialists trained in leading consumers through the

application process. Money to fund these positions was made available to entities interested in

helping consumers in this way through a series of grants from various federal agencies.


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For GCHC, such grant money was sought through the Health Resources and Services

Administration (HRSA) to hire one program coordinator and five enrollment specialists (in this

context, called certified application counselors). For other entities (like Community Care of

North Carolina), grant money was received directly from the Department of Health and Human

Services to hire patient navigators. These two categories of enrollment specialists (certified

application counselors and navigators) perform essentially the same function, but have different

funding sources, different limitations on who can serve in the various capacities, and various

flexibility over the extent to which states can regulate the certification of these individuals.4

In the initial GCHC grant application, goals were set regarding the number of individuals

that GCHC would attempt to enroll during the 2013-2014 open enrollment period (October 1st,

2013 – March 31st, 2014).3 As per the grant application:

“Greene County Health Care… will target… the 27,000 uninsured patients in

[its] patient population that are eligible for insurance, the 9,000 Medicaid

eligible individuals not currently enrolled in Greene, Pamlico, and Pitt counties,

as well as individuals referred by [its] existing farmworker outreach teams (that

cover 12 counties) and [its] front office and clinical staff… Almost all of

[GCHC’s] uninsured patients have income at or below 100% of the federal

poverty guideline [and] getting these individuals to enroll will be challenging.

Given this fact [GCHC] project[s] that it will be able to enroll 10% of the

contacts.”5

In addition, during the enrollment period, GCHC estimated that the enrollment specialists would

be able to help 160 individuals per worker per month for the ten months during and around the

open enrollment period (or 8,000 individuals total). Given the estimated 8,000 encounters and

the estimated 10% enrollment rate, GCHC felt that 800 individuals could reasonably be expected

to be enrolled in insurance (excluding Medicaid enrollments) via the help of the specialists

during the ten month period during which they would be working at GCHC.5 After the initial

grant application was made (but before the marketplace opened on October 1st), GCHC revised

its estimates and concluded that each enrollment specialist should be able to enroll 200

individuals during the 10 month period making the total number of individuals estimated to be

enrolled 1,000.

So far at the national level, the Department of Health and Human Services has reported

that during the first three months of the open enrollment period (October 1st through December

28th, 2014), 2,153,421 individuals selected a marketplace plan via either a state-based or

federally-facilitated marketplace.6 This represents 30.76% of the 7,000,000 individuals that are

expected to enroll in a plan by March 31st, 2014.7 At GCHC, during the same three month

period, an estimated 208 individuals were enrolled in a marketplace plan with the help of an

enrollment specialist.8 This represents 20.80% of the individuals expected to be enrolled by

GCHC.

While a 10% difference between GCHC and national enrollment rates is relatively small,

GCHC enrollment specialists have indicated that many of the internal contacts they possess have

been exhausted. As a result, the need for an effective outreach program will be paramount in the

months leading up to the end of the open enrollment period. In addition, a streamlined


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enrollment process plan is needed as there are significant inefficiencies in the current method of

guiding interested/qualified individuals through GCHC’s infrastructure to the enrollment

specialists. Addressing these two issues (outreach and enrollment process efficiency) will be

necessary to ensure that goals are met during the current and future enrollment periods.

Project Overview

“Outreach and Process Development of the Affordable Care Act Enrollment Specialist

Program at Greene County Health Care, Inc.” (hereafter, “the project”) was developed for this

internship through the collaboration of Doug Smith (GCHC CEO), Tom Irons, MD (GCHC

pediatrician; primary adviser), and Helen Hill (GCHC enrollment specialist supervisor;

secondary adviser) to meet the needs of the new enrollment specialist program. The project

consists of two aims (or objectives):

1. Develop and utilize an outreach program (with uniform outreach and

marketing materials as well as an outreach presentation for use at community

meetings and events) to aid the ability of enrollment specialists in making

contacts and enrolling individuals in health insurance through the marketplace

during this and subsequent open enrollment periods.

2. Develop and implement an efficient plan for (a) enabling patients to navigate

GCHC’s infrastructure in order to reach enrollment specialists, and (b)

making referrals to enrollment specialists from within the GCHC system.

In order to accomplish these objectives, a critical analysis of the current functioning of

the GCHC enrollment specialist program is needed. Once this analysis has been done (through

marketing questionnaires and in-depth interviews of employees; see Weekly Activity Plan on

next page for more details), attempts to formalize the program’s functions can be taken.

Throughout the course of the internship, I will attempt to:

1. Solidify my understanding of the PPACA provisions and the marketplace

enrollment process.

2. Learn, understand, and analyze the current processes regarding marketing,

outreach, customer referral, and individual enrollment appointments at

GCHC.

3. Develop an outreach program (with uniform marketing and outreach materials

as well as an outreach presentation) to use at community meetings and events.

4. Develop and implement a formalized procedure for navigating patients

through GCHC’s infrastructure to enrollment specialists as well as identifying

mechanisms through which GCHC can make efficient internal referrals to

enrollment specialists.


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With the abovementioned goals in mind, a more detailed schedule of tasks and

responsibilities can be developed which indicate the ways in which they are to be addressed. This

schedule (the Weekly Activities Plan) is shown on the next page. In addition to the tasks listed,

weekly meetings with the primary adviser will be held and additional public health related

educational opportunities may be added at the discretion of the primary adviser.

Weekly Activities Plan

Week Activities Time

1

1) GCHC employee screenings

2) GCHC orientation/training

3) Project development

16

2 1) Project Development

2) PPACA Certified Application Counselor Training 16

3 1) Learn/master the enrollment process through marketplace by acting as an

enrollment specialist at the four GCHC enrollment sites

2) Informally learn the referral process in the various clinics 48 4

5

6 1) Develop and distribute marketing questionnaire for enrolled individuals to

analyze referral patterns 16

7 1) Develop and conduct in-depth interviews of enrollment specialists to

analyze referral and enrollment process protocols at GCHC 32

8

9

1) Analyze process information from marketing questionnaires and interviews

2) Develop a formal procedure for GCHC to use to (a) enable patients to

navigate GCHC’s infrastructure to reach enrollment specialists, and (b)

make internal referrals to enrollment specialists

40

10

1) Identify and review previously used marketing materials and outreach

strategies as well as those used by other community health center

enrollment programs

16

11 1) Develop an outreach program (with uniform marketing and outreach

materials as well as an outreach presentation) to use at community

meetings and events

32 12

13 1) Create final report for GCHC board of directors regarding collected data,

conclusions, and the developed outreach program and procedural plan

2) Present plan to board of directors

3) Implement outreach program and procedural plan

32 14

Total Hours: 248

Core Competencies Addressed

1. Describe a public health problem in terms of magnitude, person, time, and place.

Much literature exists regarding the insurance coverage rates throughout the country and

in eastern North Carolina. Using this information and internal GCHC statistics, I will

characterize the magnitude of this problem in the local population.


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2. Describe the role of social and community factors in both the onset and solution of public

health problems.

Developing an effective outreach program will require an understanding of the current

climate in the target market. An analysis of the social and community factors affecting

enrollment will be included in the marketing questionnaires and enrollment specialist

interviews conducted when analyzing the current program.

3. Identify the basic theories, concepts, and models from a range of social and behavioral

disciplines that are used in public health research and practice.

An analysis of current techniques being utilized by other enrollment specialist programs

as they relate to theories and models used in public health will be conducted during the

development of the outreach program.

4. Develop cogent and persuasive written materials regarding public health topics.

A final report of the current enrollment process and outreach materials, the gathered data

from my analysis, and the process and outreach plan will be compiled.

5. Deliver oral presentations using recognized criteria for effective information

dissemination.

A brief final presentation to the board of directors as well as a full length presentation to

internship personnel will be given.

6. Identify the main components and issues of the organization, financing and delivery of

health services in the US.

An analysis of the internal operations of GCHC as they relate to the enrollment process

will be undertaken during questionnaires and in-depth interviews and addressed in the

formal procedural plan that will be developed.

7. Use the principles of program planning, development, budgeting, management, and

evaluation in organizational and community initiatives.

The components of the enrollment specialist program will be analyzed during in-depth

interviews and formalized/created in the outreach plan to be developed.

Personal Objectives

During this internship, I hope to develop a better sense of how to engage in project

analysis, development, and implementation. Given GCHC’s specific difficulties regarding the

portion of patients eligible/able to enroll in health insurance via the marketplace, this program is

likely to present me with unique challenges and thus offer significant opportunity for developing

problem solving skills. In addition, I hope to broaden and solidify my understanding of the


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PPACA as it relates to patient care in a CHC as I intend to work in such a setting in the future.

Understanding the internal operations of GCHC and the enrollment specialist program will be of

substantial benefit later in my career. Learning how to address public health problems in a

culturally competent manner will also enable me to excel as a medical student and future

provider.

References

1. Smith, Doug. 2013 Community Impact Report. Snow Hill, NC: Greene County Health

Care, 2013. Print.

2. Lefkowitz, Bonnie. Community Health Centers: A Movement and the People Who Made

It Happen. New Brunswick, NJ: Rutgers UP, 2007. Print.

3. "Key Features of the Affordable Care Act." United States Department of Health and

Human Services. Web. 16 Jan. 2014.

<http://www.hhs.gov/healthcare/facts/timeline/index.html>.

4. “Assistance Roles to Help Consumers Apply and Enroll in Health Coverage Through the

Marketplace." Health Insurance Marketplace Resources. United States Department of

Health and Human Services. Web. 16 Jan. 2014.

<http://www.cms.gov/CCIIO/Resources/Files/Downloads/marketplace-ways-to-

help.pdf>.

5. Smith, Doug. Enrollment Specialist Grant Application. UDS# 041020. Snow Hill, NC:

Greene County Health Care, Inc., 2013. Print.

6. Jacobson, Murrey. "HealthCare.gov Enrolls 110,000 in November, but Falls Short of

Goals."PBS. PBS, 11 Dec. 2013. Web. 21 Jan. 2014.

<http://www.pbs.org/newshour/rundown/2013/12/healthcaregov-enrollment-hits-110000-

in-november-but-falls-short-of-goals.html>.

7. United States of America. Department of Health and Human Services. Office of the

Assistant Secretary for Planning and Evaluation. Health Insurance Marketplace: January

Enrollment Report. ASPE Issue Brief, 13 Jan. 2014. Web. 21 Jan. 2014.

<http://aspe.hhs.gov/health/reports/2013/MarketPlaceEnrollment/Dec2013/ib_2013dec_e

nrollment.pdf>.

8. Smith, Doug. Health Center Outreach and Enrollment Quarterly Progress Report. UDS#

041020. Snow Hill, NC: Greene County Health Care, Inc., 2013. Print.


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Final Report and Recommendations


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Final Report and Recommendations

Introduction

As indicated in the original internship proposal, this project had two objectives which

have been repeated below.

1. Develop and utilize an outreach program (with uniform outreach and

marketing materials as well as an outreach presentation for use at community

meetings and events) to aid the ability of enrollment specialists in making

contacts and enrolling individuals in health insurance through the marketplace

during this and subsequent open enrollment periods.

2. Develop and implement an efficient plan for (a) enabling patients to navigate

GCHC’s infrastructure in order to reach enrollment specialists, and (b)

making referrals to enrollment specialists from within the GCHC system.

Though not initially included in the project proposal, it was evident early in the internship

that the program suffered from inconsistent and inadequate outreach methods among staff. An

analysis of these methods and a recapping of best practices for enrollment specialists was

therefore included with objective 2.

These objectives were met using the general techniques indicated in the proposal.

However, a more detailed methodology for the steps taken with regard to each objective is

shown in the sections below. These sections also contain an overview of the results and the final

recommendations for each goal.

Objective 1

Methodology

In order to fully evaluate the effectiveness of current outreach and marketing strategies of

the enrollment program at GCHC, a customer marketing survey was developed for use with

those consumers who went through the entire enrollment process. The survey, shown in

Appendix I: Objective 1 Documentation and titled “Enrollment Program Customer Survey,”

focused on evaluating 1) the marketing exposure sources and program materials, 2) their

effectiveness, 3) how the program’s marketing efforts could be improved, 4) consumers’

previous enrollment steps, and 5) the level of service consumers received.

Surveys were administered in both English and Spanish (also shown in Appendix I) to

customers after enrolling in an insurance policy. The surveys were collected throughout the

month of February. A database was then created using IBM SPSS statistical software (version

20). The raw data used in the database is shown in Appendix I: Objective 1 Documentation and

titled “Enrollment Program Customer Survey Data Summary.” Analysis of this data was then

conducted using SPSS and the results are described in the following section and are also shown


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in the document “Enrollment Program Customer Survey Results” in Appendix I: Objective 1

Documentation. The surveys continue to be administered to customers following their enrollment

into insurance policies as a means for internal GCHC enrollment specialist performance review.

Following the data analysis, marketing materials were designed for the enrollment

program and are described in further detail in the recommendation section.

Results

The results of the customer marketing survey as they relate to the five survey goals are

shown below as well as in the Appendix I results document. Recommendations regarding these

findings are presented in the following section. As only 35 surveys were completed during the

referenced time period, data may not be robust enough to make all marketing decisions; it does,

however, offer insight into some trends which should be considered in future open enrollment

periods.

1. The marketing exposure sources and program materials.

The most respondents indicated that they were referred to GCHC’s enrollment program

through friends and family members (31.4%). 20.0% received referrals from within

GCHC when there for an appointment. As 68.6% of respondents indicated that they were

already patients of GCHC, it is evident that substantial opportunity exists for increasing

enrollment through internal referrals. 20.0% also indicated that they received referrals

from sources not listed in the survey, but a textual analysis of these responses indicated

that all of these fell into one of the above categories. Together, internal referrals and

those from family and friends accounted for 61.0% of the exposure methods reported. In

addition, 11.4% of respondents reported receiving a letter and the same amount received

a phone-call. 5.7% each were exposed to news reports, newspaper ads, and information

from their church. 2.9% each were exposed to information at community events or

through flyers. With regards to the published informational materials that individuals

encountered either prior to or during their enrollment, 32.1% encountered flyers, 28.6%

encountered letters, and 3.6% encountered brochures. 39.3% reported seeing other

materials, but after textual analysis of these responses, it was observed that all were

incorrectly categorized and were actually referral sources.

2. Their effectiveness.

97.1% of respondents indicated that the exposure methods reported above were

appropriate for their family. 95.2% indicated that the printed resources distributed in the

program were useful and effective and did not need improvement. In both cases,

respondents did not choose to leave feedback regarding ways of improving the

effectiveness of either the exposure/marketing sources or the materials used by the

program. The high number of positive responses is likely a byproduct of social

desirability bias and should be interpreted with caution.1


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3. How the program’s marketing efforts could be improved.

When asked directly about the types of marketing emphasis that should be used in future

campaigns that would have led to them coming in sooner, 50.0% of respondents indicated

that greater focus needed to be placed on the affordability of available options. 22.6%

indicated that the individual mandate should be emphasized, and 19.4% indicated that

nothing should be changed about the marketing messages. 12.9% stated that other steps

should be taken not listed as options with write-in responses ranging from an explanation

of the assistance provided and the ease of the application process to utilizing more

advertisements in Spanish. 9.7% reported there should be more focus on subsidy

availability and 6.5% reported a need for focus on appointment flexibility.

4. Consumers’ previous enrollment steps.

65.7% of respondents stated that they had not taken any other actions to enroll in an

insurance policy prior to seeing one of the CACs. 17.1% indicated they had gone to

healthcare.gov, 8.6% had gone to another agency, 5.7% each had called the healthcare

hotline or done something else. Of those that had sought help elsewhere, 52.6% stated

that they came to a CAC at GCHC because they needed help understanding their options,

47.4% needed help completing their application, 21.1% had questions they could not find

answers to, and 5.3% stated the other agency had inconvenient or no appointments

available.

5. The level of service consumers received.

In general, respondents rated the level of service they received extremely highly.

Parameters measured included 1) ease of setting up appointments, 2) locating CAC

offices, 3) contacting CAC, 4) CAC’s answers to questions, 5) CAC’s instructions on

documentation needed for appointments, 6) CAC overall service, 7) healthcare.gov

functionality, 8) GCHC’s community reputation, and 9) the overall experience. Each

factor was measured on a five level scale of “poor,” “fair,” “OK,” “good,” and “great.”

Of the 287 individual responses received from the 35 respondents regarding these

parameters, 93.4% were at the “good” or “great” levels. Of those responses at lower

levels, 42.1% referred to the government website and the remaining 57.9% referenced

one particular CAC. As with the previously discussed marketing effectiveness data, the

satisfaction data described here was also likely affected by social desirability bias

significantly.1

Recommendations

Recommendations for the process component of this internship are listed below in order

of their perceived importance in improving consumer marketing and outreach. These have been

derived using the results above and reference example materials included in Appendix III:

Developed Marketing Material.


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1. All future marketing material should emphasize the affordability of coverage,

individual mandate, available assistance, subsidy availability, and appointment

flexibility and ease. This is exemplified in the “Marketing Card” in Appendix III:

Developed Marketing Material. These factors were most heavily emphasized by

consumers completing the “Enrollment Program Customer Survey” as key to improving

the likelihood that they would utilize GCHC enrollment program services. These factors

should also be emphasized during initial encounters with consumers or those in charge of

outreach venues.

2. All future marketing materials should include the GCHC logo and the Health

Insurance Marketplace Logo. The former will help create a consistent image for GCHC

and the latter is in accordance with requirements made by the US Centers for Medicare

and Medicaid Services. These images have been incorporated into the developed

marketing materials seen in Appendix III and are also shown below.2,3

3. The marketing presentation developed for the GCHC enrollment program should

be started by CACs on the patient education computers in waiting rooms each

morning during open enrollment and displayed on their laptops at outreach events. The slides used in the presentation are shown in the document “Marketing Presentation”

in Appendix III: Developed Marketing Material. The presentation is designed to

automatically advance and loop and incorporates several highly educational videos from

the Kaiser Family Foundation (shown as blank screens in the previously referenced

document).4 Two files, an editable PowerPoint (.pptx format) and a non-editable

PowerPoint slideshow (.ppsx format), will be left with the enrollment program

supervisor. The latter should be saved to the patient education computers and initiated

each morning during the open enrollment period. The IT department may be needed in

setting up the computers and turning off any screensavers.

4. Patient letters should not be used again in subsequent open enrollment periods and

the funds saved should be used to obtain high profile billboards near the GCHC

centers. Letter receipt was only reported by 11.4% of consumers and it is likely that with

the adoption of the process improvements proposed under Objective 2 below

(recommendations 1 and 2), the letters would become redundant. In addition, these

process improvements will ensure that all GCHC patients eligible for ACA subsidies are

captured and thus, the majority of marketing efforts will need to target those outside the

GCHC system. An example billboard is shown in the document “Example Billboard” in

Appendix III: Developed Marketing Material.


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5. CACs must emphasize heavily the need for consumers to refer family and friends

during encounters and should generously distribute the program’s informational

cards to consumers to aid this process. As the largest portion of new consumer

appointments came from referrals from previous consumers (31.4%), it is imperative that

CACs emphasize the need for these referrals. Multiple copies of the “Marketing Card” (in

Appendix III: Developed Marketing Material) should be given to each consumer as

described in Objective 2, recommendation 6 below.

6. All marketing materials used should be provided in both English and Spanish. Some

consumers complained that the marketing they were exposed to was not in Spanish and

thus, they could not understand it. By ensuring that all materials are provided in separate

documents for each language or in one bilingual document, the program will better

capture everyone who stands to benefit from the enrollment program. For the previously

referenced marketing cards, this would likely best be done by having one side printed in

English and the other in Spanish, but costs should be evaluated before using this strategy.

7. The enrolment program should continue to utilize available free documentation

from the US Centers for Medicare and Medicaid Services. These materials, like the

posters and pamphlets GCHC has used in the past, are well reviewed, strategically

marketed, highly informative for consumers, and a valuable free resource for GCHC.

Objective 2

Methodology

In order to fully evaluate the current status of the enrollment process at GCHC, an in-

depth interview tool was created for use with the certified application counselors (CACs). This

tool (titled “Enrollment Program Process Interview- CAC Staff”) can be seen in Appendix II:

Objective 2 Documentation below. The interview focused on 1) the types of outreach conducted,

2) setting up outreach events, 3) conducting outreach encounters, 4) the content of initial

encounters, and 5) enrollment appointment structure. By focusing on these areas and reporting

best practices, the enrollment program staff will better understand the techniques they should use

to help with outreach. They will also be more prepared to follow a standardized process for the

encounters they have with consumers.

A second interview instrument (titled “Enrollment Program Process Interview- Office

Staff”) was also developed and is shown in Appendix II as well. This tool was used to conduct

brief group interviews with the office staff at each clinic and was intended to identify 1) how

referrals are handled by office staff, 2) the logistics of informing the office staff of the CAC’s

schedule, and 3) potential methods for developing a policy for internal referrals at GCHC.

Interviews were conducted by the student over a two week period in late February and

early March. Responses were recorded by the student and then compiled into two raw data

documents shown in Appendix II (titled “Enrollment Program Process Interview- CAC Staff

Raw Data” and “Enrollment Program Process Interview- Office Staff Raw Data”). The data in

the documents was colored with each color representing a different CAC or office group. A code

to these colors was not kept so as to ensure anonymity of the respondents.


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The information in the two raw data documents was then analyzed qualitatively using

constant comparison methodology which is “the iterative and sequential process used when

analyzing qualitative data that involves refinement of categories and interpretations based on

increasing depth of understanding.”5 This analysis was conducted until the point of theoretical

saturation was reached; that is, “the point at which the analyst or analysts agree that new data no

longer adds new meaning; the analysis is then saturated in the sense that it is complete and

sufficient.”5 This type of thematic analysis has been widely used for interview data in a variety

of fields.6 The resultant themes identified from within interview responses are shown in

Appendix II in the documents “Enrollment Program Process Interview- CAC Staff Results” and

“Enrollment Program Process Interview- Office Staff Results.” These are further discussed in the

following section.

Results

The thematic outcomes from the interviews with CACs (as shown in the abovementioned

document “Enrollment Program Process Interview- CAC Staff Results” in Appendix II) will be

summarized along the five goals of the interviews indicated in the previous section. Additional

information regarding practices that were not pervasive in the program will also be cited from

the raw data document as dependent on their importance.

1. The types of outreach conducted.

CACs had engaged in multiple types of outreach at the time the interviews were

conducted. Many of these focused on locations where target populations were expected to

be such as church meetings, certain community businesses, and community events. Some

CACs engaged in fewer outreach activities than others and thus the program had excess

capacity that was not being utilized. Some GCHC clinic populations were underutilized

as sources for contacts. Most CACs needed better follow-up with the outreach venues

they contacted. A novel approach by one CAC using GCHC community outreach

workers as partners during outreach events was highly effective.

2. Setting up outreach events.

Most CACs set up outreach events face-to-face with community organizations.

Introductions to the program were most likely to lead to an event when the CAC

emphasized the role of GCHC in the community, its services, and then the help that the

enrollment program could offer in finding healthcare for employees. Engaging in these

conversations and then moving into a request for setting up an event at the venue were

most likely to be received favorably. The most effective CACs followed up frequently

with the organization to provide additional outreach materials and obtain referrals for

both additional venues and consumers.


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3. Conducting outreach encounters.

Most CACs conducted outreach encounters in a similar manner consisting of first

introducing themselves, inquiring about ACA familiarity, filling in knowledge gaps,

answering specific questions, emphasizing available subsidies, the individual mandate,

and time deadlines, and then referring for or setting up an appointment. Some CACs

offered unrequested, specific guidance regarding legal eligibility requirements to Latino

individuals (and not other groups). Most approached all individuals, but some chose not

to ask all population groups (e.g. the elderly as they were assumed to have Medicare, and

Latinos as they were assumed not to speak English). In general, CACs tried not to screen

patients during these initial encounters, but in cases where it was evident that the

consumer did not qualify, this information was relayed; all consumers were offered

appointments to further evaluate their eligibility status however.

4. The content of initial encounters.

The initial contact CACs had with consumers tended to be on the phone or from walk-ins

to their clinic site. These encounters were very similar in nature to the encounters

discussed above in an outreach setting with the exception that they tended to be more

tailored to the consumer’s situation. The CACs again first introducing themselves;

inquired about ACA familiarity; filled in knowledge gaps; answered specific questions;

emphasized available subsidies, the individual mandate, and time deadlines; and then set

up an appointment. As many of these conversations were done in greater detail, with

more emphasis on individual circumstances than the outreach encounters, some of these

information categories were left out depending on the specific needs of the consumer. In

general, this component of the enrollment program seemed to be in the least need of

improvement. Estimates of the referral patterns for these initial conversations were

obtained from the CACs and is shown below.

Referral Source for Initial Contact Percentage (Average of CAC Responses)

Previous Contacts at Outreach Events 23%

Walk-ins Asking for Information 27%

Referrals from Office Staff 9%

Follow-up from Mailed Flyers 6%

Cold Calls made by CAC 6%

Cold Calls from Consumers 29%

5. Enrollment appointment structure

CACs all did a fairly consistent job with the enrollment appointments. A standardization

of procedures relating to particular parts of this process will be presented in the

recommendations section along with best practices for this CAC function. In general

though, problems arose during the analysis regarding the types and degree of education

being provided to consumers, the skipping of optional questions without the consent of

consumers, and the ability to organize, in a standard way, the materials used throughout

the encounters.


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Similarly, the outcomes from the interviews with office staff (as shown in the

abovementioned document “Enrollment Program Process Interview- Office Staff Results” in

Appendix II) will be summarized along the three goals of the interviews indicated in the previous

section. Additional information regarding practices that were not pervasive in the program will

also be cited from the raw data document as dependent on their importance.

1. How referrals are handled by office staff.

Most office staff do not attempt to directly engage customers about insurance status or

wanting to see a CAC. Those that do use various, non-standardized measures to screen

patients before engaging them. For walk-ins and telephone calls, office staff tend to call

or transfer to the CAC directly. When the CAC is not in, they tend to either give the

consumer the CAC’s information or request that they call back the next day.

2. The logistics of informing the office staff of the CAC’s schedule.

Office staff are not consistently aware of when the CAC is in or out of the office at all

locations. When they receive a walk-in or phone call, they tend to call the CAC’s office

to see if they’re available. More consistently informing the office staff of the CAC’s

whereabouts would greatly improve the process of making internal referrals. The method

for accomplishing this does not need to be consistent throughout all locations, but should

be developed and adhered to by each CAC in their office.

3. Potential methods for developing a policy for internal referrals at GCHC.

While some office staff did not want the responsibility of engaging patients regarding

their insurance status, most seemed open to the idea. The general consensus was that the

best time to engage patients would be during the initial check-in. Staff also felt that it

would be beneficial to direct all new patients to a CAC directly after their initial

enrollment and at the annual sliding-scale fee adjustment. Staff also felt that a short

presentation at the start of each open enrollment period to discuss the program, its effects

on the overall company, and the specific plan for making internal referrals, would be

helpful to them.

Recommendations

Recommendations for the process component of this internship are listed below in order

of their perceived importance in improving referrals, CAC functionality, outreach initiatives, and

customer experience. These have been derived using the results above and many, especially

those related to outreach and customer encounters, can be found in the two Appendix II:

Objective 2 Documentation documents “CAC Appointment Tool” and “CAC Best Practices.”


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1. In order to improve internal referrals, GCHC should establish a corporate policy

that all new patients and all patients renewing their sliding scale fee be directly

referred to a CAC at that time in order to evaluate their insurance options. Completion of this referral should be made mandatory for patients. As criteria for sliding

scale fee category and subsidy categorization are different, these patients should not be

screened for CAC referral, but automatically referred. During open-enrollment periods,

those patients who fall in the coverage gap should be kept on their sliding scale fee and

those who qualify for insurance subsidies should be encouraged to utilize this option but

remain on their sliding scale fee if they decline. Outside open-enrollment periods, all

referred patients will be screened for changes in insurance status which may qualify them

for subsidies. If they do qualify for subsidies, the instructions above regarding steps

during open-enrollment should be followed. If they do not qualify as having a change in

insurance status, CACs should evaluate income sources and determine if the patient is

likely to qualify for subsidies during the next enrollment period. If so, the sliding scale

fee should be temporarily renewed until the next open enrollment period at which time

the CAC should contact the patient for further evaluation. If they are not likely to qualify,

the sliding scale fee should be renewed as normal. During this evaluation, CACs should

err on the side of reevaluation during the next open enrollment period for borderline

cases. Instituting this policy will enable patients to obtain more robust healthcare access

and stands to improve the payer profile of GCHC. The investment required for CACs to

conduct these screenings would likely amount to less than an hour per day and these

interactions could be potentially done via phone when CACs are not in the office or are

unavailable and need to follow-up at a later time. In addition, as indicated in the results

regarding Objective 1, 68.6% of consumer survey respondents indicated that they were

already patients of GCHC. It is evident that substantial opportunity exists for increasing

enrollment through internal referrals and instituting this policy will significantly improve

this.

2. GCHC should adopt a corporate policy that during the open enrollment period, all

patients visiting the clinic be asked about their “interest in meeting with a counselor

to determine if they are eligible for help paying for health insurance” at check-in. Those who agree can be referred to the CAC directly while no action will be needed for

those who decline. Taking this step will increase the catchment of internal referrals in a

manner similar to recommendation 1 above. Using the above phraseology, specifically

the term “counselor” and phrase “help paying for health insurance,” will ensure that

patients do not decline due to misunderstanding. While some redundancies are likely to

occur between this recommendation and the one above, patients will likely indicate that

they have already recently met with the CAC if this is the case. In addition, because the

question is short and the office staff will not be responsible for providing any additional

information, the burden on the check-in process will be minimal.


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3. Each CAC should establish a method to consistently inform office staff of whether

they are in or out of the office. Though many CACs reported telling office staff their

location, most office staff reported inadequacies with this method. Recommendations

include a sign to flip in the front office that indicates if the CAC is in or out of the

building. Because there are multiple office staff, each of whom is continually busy, this

type of visual mechanism is likely to be most successful, though it is ultimately the

responsibility of CACs to establish a protocol that works for their location. Better

communication in this area will lead to better referrals and more consistent follow-

through with recommendation 1 and 2 above (if implemented).

4. CACs should become familiar with and utilize the best practices included in the

document “CAC Best Practices” in Appendix II: Objective 2 Documentation. This

document reflects those CAC actions which have significant potential to improve 1) the

types of outreach conducted, 2) setting up outreach events, 3) conducting outreach

encounters, 4) the content of initial encounters, and 5) the enrollment appointment

structure. Taking these steps will ensure GCHC is able to reach as many individuals in

the community as possible by improving outreach. They will also ensure consistent

appointment structures are utilized so that consumers receive the same level of help from

each CAC.

5. The enrollment supervisor along with the appropriate CAC, should create and

deliver a 15-20 minute presentation to deliver to office staff at each clinic at the start

of each enrollment period. This presentation should 1) explain the CACs’ role, 2)

emphasizes the referral protocols in recommendations 1 and 2 above (if implemented),

and 3) end with the impact of changing our payer profile to include more patients with

insurance on GCHC’s financial position (i.e. higher profitability, more robust outreach,

broader services, and potentially more incentive pay and raises).

6. CACs should create and use a uniform packet of materials for all enrollment

appointments. These packets should consist of: 1) CAC Authorization form, 2) 3-5

GCHC Enrollment program information cards (see “Marketing Card” in Appendix III:

Developed Marketing Material), 3) the “CAC Appointment Tool” shown in Appendix II:

Objective 2 Documentation, and 4) the “Enrollment Program Customer Survey” shown in

Appendix I: Objective 1 Documentation. At the conclusion of the appointment, the CAC

should retain the authorization form and survey, which will be used for internal CAC

evaluations. They should also print and include 1) an application summary and 2) the

eligibility document. The latter should have any requirements for mailing in verifying

documentation highlighted for the customer. The packet should be given in a folder, file,

or envelope so that the customer is likely to retain the information in one location for

future encounters or for when they need to update their income information during the

year. The CAC should emphasize heavily the need for the consumer to distribute the

marketing material to those they know in the community as 31.4% of our encounters

came from such referrals. Indeed, I recommend having this material placed in the front of

the packet and imploring consumers to make such referrals after reminding them that

CAC services are free and the only way we will be able to maintain the program and help

them in the future is by having customers make their own referrals.


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7. CACs should not profile consumers at outreach events. It should not be assumed that

older appearing adults are on Medicare or that Latinos do not speak English. In the case

that individuals are on Medicare, they may transmit program information to people whom

they know. If a Latino individual does not speak English (and the CAC does not speak

Spanish), Spanish marketing material can still be distributed.

8. CACs should not skip optional questions automatically. The choice of completing

such questions should be left to the consumer. This type of information is vital for

PPACA evaluation and the CAC role is only to assist in completing an application and

not to make decisions on how an application is completed.

9. As subsequent enrollment periods are entered into, the enrollment program

supervisor’s role will shift from one of establishing the program to one of initiating

and conducting outreach events. While such outreach will not consume all of the

supervisor’s time, organizing such events through personal and GCHC contacts will aide

CACs in obtaining consumer referrals.

Core Competencies Addressed (Revised)

1. Describe a public health problem in terms of magnitude, person, time, and place.

As part of the proposal development, a significant investigation of the insurance coverage

rates within GCHC was conducted. This information was utilized in developing targeted

approaches to engage those patients who remain uninsured from within the GCHC

system using internal processes and marketing.

2. Describe the role of social and community factors in both the onset and solution of public

health problems.

Developing an effective outreach program requires an understanding of the current

climate in the target market. An analysis of the social and community factors affecting

enrollment was conducted using surveys and enrollment specialist interviews. The most

important hindrances to public engagement were addressed through more focused

marketing strategies and tailored advice for conducting outreach encounters.

3. Identify the basic theories, concepts, and models from a range of social and behavioral

disciplines that are used in public health research and practice.

Theoretically based research techniques were utilized when developing and analyzing the

surveys and interviews. When interpreting results, biases and limitations were noted that

conformed to social science research techniques.1,5,6

4. Develop cogent and persuasive written materials regarding public health topics.

A final report of the current enrollment process and outreach materials, the gathered data

from the analysis, and the process and marketing plan recommendations were compiled.


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5. Deliver oral presentations using recognized criteria for effective information

dissemination.

A final presentation to the internship personnel will be given. In addition, the final report

will be sent to the NC Community Health Center Association and organizers at Enroll

America as a tool for program improvement among other community health centers.

6. Identify the main components and issues of the organization, financing and delivery of

health services in the US.

An analysis of the internal operations of GCHC as they relate to the enrollment process

was undertaken during questionnaires and in-depth interviews and addressed in the

formal procedural plan that was developed.

7. Use the principles of program planning, development, budgeting, management, and

evaluation in organizational and community initiatives.

The components of the enrollment specialist program were analyzed during in-depth

interviews and formalized/created in the outreach plan developed.

Personal Reflections

This internship has taken me through the evaluation and improvement of a public health

initiative that is fraught with contention and misunderstanding in the community. The political

environment surrounding the PPACA makes conducting outreach and consumer education

difficult. I believe that identifying and implementing culturally competent strategies that still

accomplish these functions, but do so in a way that handles such difficulties, has made me a

stronger public health professional. My goals of learning the detailed nuances of obtaining

coverage with the help of the online marketplaces was accomplished and will allow me to better

advise patients regarding their options in the future when it becomes evident that access and

financial constraints are inhibiting their ability to obtain the care they need. I have also enjoyed

the multiple levels at which this project operated; it was a public health project that had medical

implications and business-related constraints, and thus provided the perfect opportunity to rely

on my skills and interest in public health, medicine, and business. I also appreciate the fact that

this project will result in meaningful improvements in the enrollment program at GCHC and

other community health centers and stands to provide a means through which to substantially

improve the payer profile of the corporation, making the institution more profitable and capable

of engaging the community. Finally, the success of this project would not have been possible

without the consumers willing to participate in surveys, the honest input of CACs and office staff

with whom interviews were conducted, the day-to-day instructional support of Helen Hill, and

the guidance of Dr. Tom Irons. To these individuals, I say thank you for your assistance in

making this project into something meaningful.


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References

1. Norwood F, Lusk J. Social Desirability Bias in Real, Hypothetical, and Inferred

Valuation Experiments. American Journal of Agricultural Economics. 2011;93(2):528-

534.

2. "Greene County Health Care - Community Partners HealthNet." Greene County Health

Care. Community Partners HealthNet. Web. 08 Apr. 2014.

<http://www.cphealthnet.org/gchc.htm>.

3. "Health Insurance Marketplace." HealthCare.gov. US Centers for Medicare and

Medicaid Services. Web. 06 Apr. 2014. <https://www.healthcare.gov/>.

4. "Understanding Health Reform." Consumer Resources. The Henry J. Kaiser Family

Foundation. Web. 08 Apr. 2014. <http://kff.org/aca-consumer-resources/>.

5. Trochim, William MK, and James P. Donnelly. "Chapter 13: Qualitative and Mixed

Methods Analysis." The Research Methods Knowledge Base. 3rd ed. Mason, OH:

Cengage Learning, 2008. 283-92. Print.

6. Bailey, Eric J. "Chapter 6: Strategies for Applied Medical Anthropology Health Care

Research." Medical Anthropology and African American Health. Westport, CT: Bergin &

Garvey, 2002. 109-31. Print.


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Appendix I: Objective 1 Documentation


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Enrollment Program Customer Survey


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Enrollment Program Customer Survey Data Summary


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Enrollment Program Customer Survey Results


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Appendix II: Objective 2 Documentation


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Enrollment Program Process Interview- CAC Staff


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Enrollment Program Process Interview- Office Staff


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Enrollment Program Process Interview- CAC Staff Raw Data


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Enrollment Program Process Interview- Office Staff Raw Data


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Enrollment Program Process Interview- CAC Staff Results


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Enrollment Program Process Interview- Office Staff Results


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CAC Appointment Tool


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CAC Best Practices


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Appendix III: Developed Marketing Material


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Marketing Presentation


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Marketing Card


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Example Billboard


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Appendix IV: Miscellaneous Documentation


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Application Counselor Certification


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