Today we hear an important conversation about the role of local government in population health and wellness. Scott LaVigne, Public Health Director of the Franklin County Health Department in North Carolina, talks with CHESS vice president, Josh Vire, about the broad scope of work his team is responsible for and how they are successfully tackling numerous initiatives, including managed Medicaid, to be a safety net provider for community health needs.

Scott LaVigne, welcome to the Move to Value podcast.

Oh, it's great to be here.

We're we're really excited and looking forward to the conversation. Scott, as a public health director, you're responsible for all aspects of the Franklin County Health department from the clinical to environmental services and you balance state mandated services. So for the audience that things like vaccines, basic health screenings, environmental services, and with the expectations of Franklin County government, all while dealing with the critical workforce shortages. Health departments are considered safety net providers in most of North Carolina's counties. Can you share how your team is addressing the specific healthcare needs of the Medicaid population in the county?

Sure. Well, after hearing all that, I'm, I'm getting tired. Yeah. That that is a we have a lot on our plate here at the health department and a lot of they're, they're not very often competing interests. But you know, I think what we look at when we talk about healthcare services in general and the overall health of the county, we don't break it up into per SE Medicaid population, although we do focus on that as part of the work that we do. But we, we have 2 broad missions and one is obviously population health and that it cuts across all payers and everyone in the community. And then the other role, which you correctly identified as we're a safety net provider. So in addition to putting out a lot of population health initiatives, we're also a provider and we're involved in a lot of the initiatives that all the providers in the community are involved in. So, you know, that gives us a unique position and we get to tailor some of our initiatives as a healthcare provider based on what we know the community health needs are. So it's, it's, I'm going to be honest, it's not very easy to do all of that. I would say we, as I said, we don't just focus on the Medicaid population, but we do have a lot of initiatives that cut across all of that.

Great. What are the specific issues that that I think you have a lot of experience in close to 30 years of behavioral health experience with much of that coming in New York. Can you describe the changes in public health that you see in your career and maybe also for the audience contrast the differences between the public health in New York and North Carolina. What are the differences you've seen?

Sure. Well, when I was in New York, I was a a mental hygiene director for a county and, and when I came to North Carolina, I became a public health director. But we were actually in the same building in New York with our public health programs and we had a very close relationship with that program. But there are some significant differences, but a lot of similarities. You know, the some of the big differences though relate to some of what we're talking about. Medicaid managed care being a big one in New York. Medicaid managed care started first with medical care and then they brought behavioral health and IDD into the picture. In North Carolina, they did it the exact opposite. And so that that was a, a big difference. When I came down here, we had a mental hygiene system that had already made the conversion and was and, and medical care, which is what I was now in, we had to make that shift. So, I would say that was a, a big difference. But in New York, most of the public health agencies had gotten out of providing their own home health care. They had the small county that I was in, we had stopped providing services. They were just providing the core services for public health, and that's it. And that's not uncommon in North Carolina as well. Some of the smaller health departments can't afford to deliver that care. So, yeah, I'd say the other big differences that we saw, especially when you look at the mental health and substance abuse is that New York was quite a bit ahead in terms of integration. They we were doing things like expert screening, brief intervention, referral for treatment for substance use and mental health. We were doing that in our health clinics in New York. They were doing motivational interviewing, trauma informed care, a lot of that good stuff. It was had already started. And I think the biggest crossover where we had a lot of synergy was in care management in the mental health side of things. We had a something called intensive case management and then there was advanced medical home and they were integrating those two and the state was trying to grapple with how they were going to approve people for, for those various levels of service. And it was pretty cumbersome and a lot, to give you an example, there was an 18-page assessment for delivering, for determining if somebody was eligible for intensive care management. So you know, it it people were mining Medicaid data in some of the bigger counties. They were looking at predictive analytics. They were trying to predict who was going to become a high user of service or someone that was in need of a high level of care in the future by looking at claims data and seeing what those claims data for the people that were currently high use what they looked like 10, five years earlier. And in terms of the claims data, when I got down here, we weren't doing that. And but what I realized is that we had something that was actually a really good predictor and in the form of ACE’s and the ACE’s evaluation. So trauma and adverse childhood experiences, a real strong predictor. So we've been able to kind of do stuff like that. Yeah. So I'd say overall, New York was quite a bit ahead still with the medical care side of it, but coming down midstream, that was that was a little bit of a shock on the medical side. Yeah

Sure. That's that's really interesting to hear about the differences and degree in, in terms of hearing where New York was versus North Carolina. And I think just goes to how lucky Franklin County Health is to have you with somebody with your experience background, you can have a lot of experience and help, help navigate that as it progresses here in North Carolina. So that's great. We started the podcast talking a little bit about all of the responsibilities that you oversee in Franklin County. And obviously Medicaid has its own sort of initiatives that require focus and effort and work. And I know you've talked about the larger population you guys serve. And I want to focus on Medicaid here for just a minute. How do you guys think about prioritizing Medicaid initiatives there and Franklin County Health Department?

Well, our focus is on what our county residents and our patients need. So, you know, that's pretty much what guides us in everything that we do from the community health needs assessment right on down to an individual patient's particular needs. There have been a lot of Medicaid initiatives and we've tried to participate in as many of them as we possibly can, but we're going to do it if we can do it well. And, and one of the things that one of the reasons that we really wanted to pursue advanced medical home in particular was my experience with intensive case management in New York and how that I saw that play out in a rural county, Franklin County, For those who know, don't know North Carolina, it's right next to Raleigh in terms of a county and that's Wake County. But it's also it, it's classified now as an urban county in which makes very little sense to me because when you drive through it, you would consider it rural. And there's about close to 80,000 people in the county. And you know, when you, when you look at the makeup of our population and you look at the, the different health initiatives that are coming out, one of the things that that I discovered was in, in the county, I was in New York, which was 35,000 people when it came to care management. Initially we had boots on the ground care managers that were right there in in our facility seeing our patients and when they came in for appointments and you know, trying to have home visits with them and all that great stuff. And that was in the beginning. But the county I was in was positioned across two different counties that were huge and these care management entities had responsibilities in those as well as mine. And so what we saw as a gradual reduction in the amount of effort they were able to put in to my county and my county's patients. Now it when I when I came with that in experience down here and I looked at Franklin County, I said, you know what, we do not want to replicate that. So, we initially started doing our own intensive case management for advanced medical home. We were doing Tier 3 care management services. And the rationale for that was that I did not believe, based on my prior experience, that telephonically managing would work. Well, a funny thing happened between that time period. Fast forward seven years and a lifetime, and most people prefer to be on the phone or to do text messages today. They really aren't looking for that level of engagement. And so that was a big about face. And so given that that was off the table, that kind of got us shifting how we wanted to prioritize this initiative in terms of how we wanted to address it But I would say that definitely wanting the Tier 3 advanced medical home because we're an adult health provider and a child health provider. And then also definitely wanting to be able to give that service in a way that our patients were not going to run away from it.

That's great. I love the focus on that needs based or contextualized care that that you talked about. And I want to dig a little bit more into the advanced medical home and an issue that in North Carolina and is a is on top of minds a lot, which is access to care. So one thing that our listeners may not know is only about half of the health departments in North Carolina have primary care services mean that while all must provide those mandate mandated services that I mentioned earlier, only a little over 40 have clinics that qualify them to participate in Medicaid, managed cares, advanced medical home. Do you feel that nearly three years of experience with AMH has increased access to clinical services for the population in Franklin County?

I would say for the general population and for the Medicaid population in particular. Absolutely. We've had two things happen here in North Carolina. One was this initiative and the other was finally Medicaid expansion. And, and those two things together have definitely opened up a lot of doors. But you know, my, my background is in planning, especially mental health and, and substance abuse and developmental disability planning. And we always said it's, it's about access, capacity, utilization, and outcomes and access. Yeah, we've, we have, we've got fairly good systems to get people in the front door capacity. We've got excess capacity in a lot of respects when it comes to this level of service, primarily because we haven't done a really good job of engaging with patients like we should. I went back and looked at some of the process improvements that the clinics had done 10 years ago and it read more like operations management and business, You know, where you were trying to move as many people through a process as you could. And certainly, you want to make sure that people receive timely care, but it didn't, I didn't get the feeling that patient experience was really factored into that. So, you know, looking at it today, I would say our current patients, they've had the same level of access to services within the community. Medicaid expansion has definitely increased that advanced medical home has definitely helped. And this is a big distinction. There used to be Medicaid patients in our county who we had no knowledge of. They weren't our patients. And one of the benefits of this program has been because they're assigned to prepaid health plans, we now have a list of people that have been assigned to us and we're responsible for, even if they aren't our patients, and they come with contact information that we're now able to reach out to them and begin to engage. And that's where I really think the process has been a benefit because most of the people that are in that group of, yeah, they're they've got Medicaid, but no, the system is agnostic to them because they don't have a lot of claims data because they're not getting help. That population in particular has been very helpful to be able to reach out to. It's one that we never would have been able to reach out to otherwise.