Brangan, Normandy

Martinez, Amanda Phillips

Patel, Tamanna

English

ScholarWorks @ Georgia State University

Georgia State University ScholarWorks @ Georgia State University GHPC Materials Georgia Health Policy Center 5-24-2017 Navigating the complexity of obtaining and utilizing health insurance: Taking a closer look at the impact of meaningful collaboration in rural communities Tamanna Patel Amanda Phillips Martinez Normandy Brangan Follow this and additional works at: https://scholarworks.gsu.edu/ghpc_materials Recommended Citation Patel, Tamanna; Martinez, Amanda Phillips; and Brangan, Normandy, "Navigating the complexity of obtaining and utilizing health insurance: Taking a closer look at the impact of meaningful collaboration in rural communities" (2017). GHPC Materials. 63. https://scholarworks.gsu.edu/ghpc_materials/63 This Article is brought to you for free and open access by the Georgia Health Policy Center at ScholarWorks @ Georgia State University. It has been accepted for inclusion in GHPC Materials by an authorized administrator of ScholarWorks @ Georgia State University. For more information, please contact scholarworks@gsu.edu. Analysis of the funded communities produced a typology of partnerships that describes the  targeted purpose, composition and scope of collaboration.A Typology Of Collaboration To Expand Access And  Utilization Of Coverage In Rural CommunitiesCase ExamplesDiscussion Outreach, education, and enrollment in rural communities is nascent and a clearer picture is  emerging of the factors that support and enhance these efforts, including:• One organization alone cannot accomplish this work. Partnerships are needed to assist  individuals new to health insurance and new to the healthcare system -both of which are  highly complex systems.• Partnerships can take several forms, include a range of community agencies and  organizations, and be used to expand efforts to a variety of populations.• Partnerships are an efficient way to build individual, agency, and local community capacity  and establish an integrated support system for the newly insured.Rural health organizations that build upon partnerships are better positioned to understand  and address the driving factors related to obtaining coverage and accessing care (e.g., local  system capacity, health insurance and financial literacy, and other barriers to continuity of  coverage), and create a local system to integrate the newly insured into care and utilize  resources beyond traditional healthcare partners and funding.Navigating the complexity of obtaining and utilizing health insurance:Taking a closer look at the impact of meaningful collaboration in rural communitiesTamanna Patel, MPH1, Amanda Phillips Martinez, MPH1, Normandy Brangan, MA2 1Georgia Health Policy Center, 2Federal Office of Rural Health Policy Rural areas face multiple barriers to accessing health care, including, but not limited to,  health insurance status, confidence in communicating with providers, and health literacy.  Between 2013 and 2016, the Federal Office of Rural Health Policy (FORHP) awarded grants  to encourage innovative and comprehensive approaches to improve health care coverage  and access to care in rural communities. Grantees developed formal and informal  partnerships to outreach to uninsured individuals; assisted with enrollment in Medicare,  Medicaid, the Children’s Health Insurance Program, and private health insurance; educated  newly insured about their benefits and how to use services; assisted with navigation of the  complex system of health care; and provided assistance to targeted populations, such as  seniors, veterans, farmers, and minorities. This study1. Examines how four FORHP grants helped rural and frontier communities expand access to  insurance coverage and2. Presents a typology of partnerships formed in this work, and describes the driving factors for collaboration, and how resources were leveraged to maximize efforts. 1 https://www.ruralhealthinfo.org/topics/healthcare-access#barriersBackgroundMethodology The authors reviewed program evaluation documents and program activities logs of ruralhealth organizations that conducted enrollment and benefits counseling work between 2013 and  2016 through the following FORHP grants: • Supplemental funding to Rural Health Care Services Outreach• Delta States Rural Development Network• Small Healthcare Provider Quality Improvement• the Rural Outreach and Benefits Counseling programFindingsAfter examining the experiences of 78 grantees, a typology of partnerships emerged.  Different approaches to partnerships were driven by timing, the education and support needs  of the newly insured, and grantees’ own place in the local health care system.Grantees developed partnerships that ensured outreach and education activities would build  awareness and maximize capacity and reach (i.e., staff trainings and certification for  enrollment, leveraging existing events, conducting outreach and enrollment on site at partner  facilities, etc.). As funding levels for rural outreach and enrollment became more stable,  grantees expanded their focus to include building capacity to support clients in enrolling and  maintaining continuous health coverage and in facilitating access to care. To address clients’  needs, grantees often worked with a range of traditional partners, including health  departments, clinics, and non-profits and nontraditional partners, such as Legal Aid offices,  insurance agencies, tax preparers, faith-based organizations, Community Action Agencies,  schools, and employers. The driving purpose behind collaboration differed based on the local context and focus of the  grantees’ efforts. Some partnerships were built to share in the expense and effort of staff  training and to develop local learning communities across agencies. In other communities,  partnerships were developed to build a “pipeline” into uninsured and hard to reach  populations. Partnerships were useful in developing support and education for clients to  assist them in maintaining continuity of coverage.Finally, grantees developed new processes, lines of communications and relationships within  their entities as a way to ensure that newly insured clients were connected to a source of  care.• Grantees with an initial and singular focus on outreach and enrollment formed  partnerships expand their work to ensure that clients better understand their benefits,  are able to maintain coverage, and access care.• New partnerships with insurance brokers and local, regional, and state entities focus  on health insurance literacy with clients and building grantee staff capacity. • Grantees developed partnerships with nontraditional entities like transportation services, financial education and planning organizations, and community action  agencies. They provide direct financial and/or information and referral assistance to  the newly enrolled help enrollees maintain coverage in the face of financial and other  challenges. • “Wraparound” partnerships that support consumers in understanding and more  effectively utilizing their benefits, as well as supportive services that aid consumers in  balancing competing financial demands, are needed to ensure continuity of coverage  and access to care.• Grantees and consortia focused on outreach and education on health insurance options  and health insurance literacy often built new partnerships to extend their reach beyond  the populations they typically serve into populations likely to be under and uninsured.• By partnering with organizations that had existing entrée and relationships with these  populations, grantee organizations were able to more easily establish trust and leverage  the resources made available to them by these partnerships (e.g., space for meetings,  existing events with targeted audiences, outreach and marketing support, culturally and  linguistically appropriate resources, etc.). • Grantees described the formation of these partnerships as “a treasure hunt” or as “tactical” in nature –as a flexible and agile strategy to connect with, or “plug into” a  community to provide education and enrollment assistance.• Training navigators and building staff capacity became a key driver for the  development of partnerships in order to meet federal and state training and  certification requirements, including annual certification and continuing education.• Grantees turned to formal and informal learning communities to share challenges  and lessons learned and build staff capacity through “grand rounds” around  particularly challenging cases. These learning collaboratives often included other  agencies employing navigators, social service agencies, patient care coordinators  and community health workers. • Partnerships were also formed to support state and federal training and certification  requirements. Grantees formed training networks and offered shared training and  CEUs to navigators as well as supplementary training focused on more effective  consumer support around health insurance literacy, continuity of coverage andaccess to care.• For rural and frontier communities that are health systems, hospitals, or clinics,  engaging in insurance coverage and access to care work involved a reorganization of  relationships across departments within their entities. They established new referral  processes and warm hand-off protocols to “close the loop” between enrollment and  access to care. • In these cases, internal process changes were driven by interest in connecting  uninsured patients to a source of coverage and addressing patient/consumer health  seeking behavior by encouraging utilization of preventive/wellness benefits in a primary care setting rather than through the emergency department.Plug-In Partnerships WrapAroundPartnerships Capacity-BuildingPartnerships Closed-Loop Partnerships Plug-In Partnerships• A hospital in Missouri placed their navigator in the financial counseling department to discuss  eligibility options with uninsured that come in to the hospital and the local rural health clinics.  The clinics are connected with the hospital, so her access to the scheduling system allowed her  to assist those newly enrolled in scheduling an appointment.• A clinic in rural Indiana embedded their navigator into the clinic setting and operations so she is  part of the patient visit whenever possible. An uninsured patient will have back-to-back visits  with the provider and the navigator.• A critical access hospital in Maine created a “pipeline” for enrollment which included triage and  different subject matter experts within the hospital to educate and enroll individuals based on  where they were at.• A grantee in Oregon partners with parole and probation departments to assist the incarcerated,  soon-to-be-released population enroll in coverage within thirty days of their release. They also  partner with insurance brokers to refer those eligible for private insurance.• A grantee in eastern Maryland established relationships with “gatekeepers” among their “hard-to-reach” population of employees within the fishing industry (e.g., Watermen Association and other associations in the fishing industry).• A grantee in rural Georgia developed relationships with farmworker employers, the farms, and  schools to reach their seasonal agricultural worker population.Wrap Around Partnerships• A Federally Qualified Health Center in Maryland recognized that some newly insured struggled  to integrate premium payments in their monthly budgets. They partnered with their Community  Action Agency to help consumers access to energy and food assistance. They also partnered  with a university to develop relevant trainings for staff and navigators to address patient  financial and health insurance literacy.• The newly insured struggled to understand their benefits and access a local source of care. A  rural hospital in Wisconsin engaged the state health literacy council to build their staff capacity  to help develop materials to support their health insurance literacy efforts.Capacity-Building Partnerships• A provider network in Indiana convened a learning community of navigators and community  health workers across the state to work on enrollment and benefits counseling. They hold  regular calls and meetings to discuss cases and share tips to support their clients. In addition,  they developed a series of e-learning courses for engaging with specific populations, including  veterans and criminal justice-involved population.• A grantee in Arizona developed a joint educator training program with local social service  agencies, such as the housing authority, food bank, community development corporation, and  the hospital. They met regularly to hold “grand rounds” on enrollment cases to trouble shoot and  to share information about their enrollment efforts.Closed-Loop Partnerships

Navigating the complexity of obtaining and utilizing health insurance: Taking a closer look at the impact of meaningful collaboration in rural communities

Georgia State University

Georgia State University 
ScholarWorks @ Georgia State University 
GHPC Materials Georgia Health Policy Center 
5-24-2017 
Navigating the complexity of obtaining and utilizing health 
insurance: Taking a closer look at the impact of meaningful 
collaboration in rural communities 
Tamanna Patel 
Amanda Phillips Martinez 
Normandy Brangan 
Follow this and additional works at: https://scholarworks.gsu.edu/ghpc_materials 
Recommended Citation 
Patel, Tamanna; Martinez, Amanda Phillips; and Brangan, Normandy, "Navigating the complexity of 
obtaining and utilizing health insurance: Taking a closer look at the impact of meaningful collaboration in 
rural communities" (2017). GHPC Materials. 63. 
https://scholarworks.gsu.edu/ghpc_materials/63 
This Article is brought to you for free and open access by the Georgia Health Policy Center at ScholarWorks @ 
Georgia State University. It has been accepted for inclusion in GHPC Materials by an authorized administrator of 
ScholarWorks @ Georgia State University. For more information, please contact scholarworks@gsu.edu. 
Analysis of the funded communities produced a typology of partnerships that describes the  
targeted purpose, composition and scope of collaboration.
A Typology Of Collaboration To Expand Access And  
Utilization Of Coverage In Rural Communities
Case Examples
Discussion 
Outreach, education, and enrollment in rural communities is nascent and a clearer picture is  
emerging of the factors that support and enhance these efforts, including:
• One organization alone cannot accomplish this work. Partnerships are needed to assist  
individuals new to health insurance and new to the healthcare system -both of which are  
highly complex systems.
• Partnerships can take several forms, include a range of community agencies and  
organizations, and be used to expand efforts to a variety of populations.
• Partnerships are an efficient way to build individual, agency, and local community capacity  
and establish an integrated support system for the newly insured.
Rural health organizations that build upon partnerships are better positioned to understand  
and address the driving factors related to obtaining coverage and accessing care (e.g., local  
system capacity, health insurance and financial literacy, and other barriers to continuity of  
coverage), and create a local system to integrate the newly insured into care and utilize  
resources beyond traditional healthcare partners and funding.
Navigating the complexity of obtaining and utilizing health insurance:
Taking a closer look at the impact of meaningful collaboration in rural communities
Tamanna Patel, MPH1, Amanda Phillips Martinez, MPH1, Normandy Brangan, MA2 
1Georgia Health Policy Center, 2Federal Office of Rural Health Policy 
Rural areas face multiple barriers to accessing health care, including, but not limited to,  
health insurance status, confidence in communicating with providers, and health literacy.  
Between 2013 and 2016, the Federal Office of Rural Health Policy (FORHP) awarded grants  
to encourage innovative and comprehensive approaches to improve health care coverage  
and access to care in rural communities. Grantees developed formal and informal  
partnerships to outreach to uninsured individuals; assisted with enrollment in Medicare,  
Medicaid, the Children’s Health Insurance Program, and private health insurance; educated  
newly insured about their benefits and how to use services; assisted with navigation of the  
complex system of health care; and provided assistance to targeted populations, such as  
seniors, veterans, farmers, and minorities. 
This study
1. Examines how four FORHP grants helped rural and frontier communities expand access to  
insurance coverage and
2. Presents a typology of partnerships formed in this work, and describes the driving 
factors for collaboration, and how resources were leveraged to maximize efforts. 
1 https://www.ruralhealthinfo.org/topics/healthcare-access#barriers
Background
Methodology 
The authors reviewed program evaluation documents and program activities logs of rural
health organizations that conducted enrollment and benefits counseling work between 2013 and  
2016 through the following FORHP grants: 
• Supplemental funding to Rural Health Care Services Outreach
• Delta States Rural Development Network
• Small Healthcare Provider Quality Improvement
• the Rural Outreach and Benefits Counseling program
Findings
After examining the experiences of 78 grantees, a typology of partnerships emerged.  Different 
approaches to partnerships were driven by timing, the education and support needs  of the 
newly insured, and grantees’ own place in the local health care system.
Grantees developed partnerships that ensured outreach and education activities would build  
awareness and maximize capacity and reach (i.e., staff trainings and certification for  
enrollment, leveraging existing events, conducting outreach and enrollment on site at partner  
facilities, etc.). As funding levels for rural outreach and enrollment became more stable,  
grantees expanded their focus to include building capacity to support clients in enrolling and  
maintaining continuous health coverage and in facilitating access to care. To address clients’  
needs, grantees often worked with a range of traditional partners, including health  
departments, clinics, and non-profits and nontraditional partners, such as Legal Aid offices,  
insurance agencies, tax preparers, faith-based organizations, Community Action Agencies,  
schools, and employers. 
The driving purpose behind collaboration differed based on the local context and focus of the  
grantees’ efforts. Some partnerships were built to share in the expense and effort of staff  
training and to develop local learning communities across agencies. In other communities,  
partnerships were developed to build a “pipeline” into uninsured and hard to reach  
populations. Partnerships were useful in developing support and education for clients to  
assist them in maintaining continuity of coverage.
Finally, grantees developed new processes, lines of communications and relationships within  
their entities as a way to ensure that newly insured clients were connected to a source of  
care.
• Grantees with an initial and singular focus on outreach and enrollment formed  
partnerships expand their work to ensure that clients better understand their benefits,  
are able to maintain coverage, and access care.
• New partnerships with insurance brokers and local, regional, and state entities focus  
on health insurance literacy with clients and building grantee staff capacity. 
• Grantees developed partnerships with nontraditional entities like transportation 
services, financial education and planning organizations, and community action  
agencies. They provide direct financial and/or information and referral assistance to  
the newly enrolled help enrollees maintain coverage in the face of financial and other  
challenges. 
• “Wraparound” partnerships that support consumers in understanding and more  
effectively utilizing their benefits, as well as supportive services that aid consumers in  
balancing competing financial demands, are needed to ensure continuity of coverage  
and access to care.
• Grantees and consortia focused on outreach and education on health insurance 
options  and health insurance literacy often built new partnerships to extend their 
reach beyond  the populations they typically serve into populations likely to be under 
and uninsured.
• By partnering with organizations that had existing entrée and relationships with these  
populations, grantee organizations were able to more easily establish trust and 
leverage  the resources made available to them by these partnerships (e.g., space for 
meetings,  existing events with targeted audiences, outreach and marketing support, 
culturally and  linguistically appropriate resources, etc.). 
• Grantees described the formation of these partnerships as “a treasure hunt” or as 
“tactical” in nature –as a flexible and agile strategy to connect with, or “plug into” a  
community to provide education and enrollment assistance.
• Training navigators and building staff capacity became a key driver for the  
development of partnerships in order to meet federal and state training and  
certification requirements, including annual certification and continuing education.
• Grantees turned to formal and informal learning communities to share challenges  
and lessons learned and build staff capacity through “grand rounds” around  
particularly challenging cases. These learning collaboratives often included other  
agencies employing navigators, social service agencies, patient care coordinators  
and community health workers. 
• Partnerships were also formed to support state and federal training and certification  
requirements. Grantees formed training networks and offered shared training and  
CEUs to navigators as well as supplementary training focused on more effective  
consumer support around health insurance literacy, continuity of coverage and
access to care.
• For rural and frontier communities that are health systems, hospitals, or clinics,  
engaging in insurance coverage and access to care work involved a reorganization of  
relationships across departments within their entities. They established new referral  
processes and warm hand-off protocols to “close the loop” between enrollment and  
access to care. 
• In these cases, internal process changes were driven by interest in connecting  
uninsured patients to a source of coverage and addressing patient/consumer health  
seeking behavior by encouraging utilization of preventive/wellness benefits in a 
primary care setting rather than through the emergency department.
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Plug-In Partnerships
• A hospital in Missouri placed their navigator in the financial counseling department to discuss  
eligibility options with uninsured that come in to the hospital and the local rural health clinics.  The 
clinics are connected with the hospital, so her access to the scheduling system allowed her  to 
assist those newly enrolled in scheduling an appointment.
• A clinic in rural Indiana embedded their navigator into the clinic setting and operations so she is  
part of the patient visit whenever possible. An uninsured patient will have back-to-back visits  
with the provider and the navigator.
• A critical access hospital in Maine created a “pipeline” for enrollment which included triage and  
different subject matter experts within the hospital to educate and enroll individuals based on  
where they were at.
• A grantee in Oregon partners with parole and probation departments to assist the incarcerated,  
soon-to-be-released population enroll in coverage within thirty days of their release. They also  
partner with insurance brokers to refer those eligible for private insurance.
• A grantee in eastern Maryland established relationships with “gatekeepers” among their “hard-
to-reach” population of employees within the fishing industry (e.g., Watermen Association and other 
associations in the fishing industry).
• A grantee in rural Georgia developed relationships with farmworker employers, the farms, and  
schools to reach their seasonal agricultural worker population.
Wrap Around Partnerships
• A Federally Qualified Health Center in Maryland recognized that some newly insured struggled  
to integrate premium payments in their monthly budgets. They partnered with their Community  
Action Agency to help consumers access to energy and food assistance. They also partnered  
with a university to develop relevant trainings for staff and navigators to address patient  
financial and health insurance literacy.
• The newly insured struggled to understand their benefits and access a local source of care. A  
rural hospital in Wisconsin engaged the state health literacy council to build their staff capacity  
to help develop materials to support their health insurance literacy efforts.
Capacity-Building Partnerships
• A provider network in Indiana convened a learning community of navigators and community  
health workers across the state to work on enrollment and benefits counseling. They hold  
regular calls and meetings to discuss cases and share tips to support their clients. In addition,  
they developed a series of e-learning courses for engaging with specific populations, including  
veterans and criminal justice-involved population.
• A grantee in Arizona developed a joint educator training program with local social service  
agencies, such as the housing authority, food bank, community development corporation, and  
the hospital. They met regularly to hold “grand rounds” on enrollment cases to trouble shoot and  
to share information about their enrollment efforts.
Closed-Loop Partnerships


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Navigating the complexity of obtaining and utilizing health insurance: Taking a closer look at the impact of meaningful collaboration in rural communities

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