Cascade Pacific Action Alliance

Domain 2 + Chronic Disease Workgroup

October 17, 2017

Agenda for Today

Review Work from Last Meeting/Overall Plan

Project Workplans

Domain 1 Investments

Logic models

Project Alignment & Telling our story

Next Steps

Section I (ACH) Project Update

Finance Committee has been meeting and made recommendations to the Council and Board about funding allocations

Last week Council and Board met- decided to move forward on 6 projects and approved funding flows.

Section II (Project Specific Workgroup Activities)

August/September

• Identified target populations

• Discussed engaged providers via RFQ and high-volume Medicaid providers

• Identified Domain 1 assets and challenges (for Section I)

• Developing proposals- HMA and CPAA

October:

• Workplans

• CPAA role for Domain 1

• Alignment

• Refining proposals

November: Review project proposals

Project Workplans

Project Workplans

Part of project application is a “high-level” workplan specific to each project, but similar milestones

CPAA earns dollars for completed milestones

• E.g. completed landscape analysis, contracts signed, # of providers trained

Three phases of work

• Planning (DY 2: 2018)

• Implementation (DY 3: 2019)

• Scale & Sustain (DY 4 &5: 2020-2021)

Workplan Example: Care Coordination

Project Stage Milestones

Deadli

ne

(DY,

Qtr) ACH Approach for Accomplishing Milestones

Stage 1: PlanningAssess current state capacity to effectively focus on

the need for regional community-based care

coordination

DY 2,

Q2

CPAA will implement a rigorous project planning and monitoring

approach to implementation of each project. The ACH will employ

project planning software and tools to lay out required deadlines,

key tasks, subordinate tasks, and milestones. Each project plan

will define critical paths and key dependencies. Failure to meet a

critical milestone will prompt a timely management response at

regular meetings that CPAA will convene with the staff and

providers responsible for implementation of each project.

CPAA Role

Domain 1 Challenges from last time

Workplans

What do you need from CPAA for the projects to move forward?

Domain 1 - Value-Based Purchasing

Assets: MCOs and providers are already moving toward VBP, with incentives and withholds

Challenges:

VBP approaches will require clean, accurate data that the ACH, payers and providers can timely access.

Patient Attribution: how to correctly attribute patients to providers?

Small providers and rural areas have too few patients to bear risk.

May need bridge funding to help providers transition to VBP

Assure VBP doesn’t penalize providers serving challenging clients

Potential CPAA Roles:

Convene and educate key stakeholders (health plans, providers, etc.)

Bring payers together to “harmonize” systems; identify where efforts cross and attempt to standardize processes across payers. Outcome: health plans work in concert with each other

Domain 1 - WorkforceChallenges:

Provider shortages (especially rural areas): create conditional scholarships or loan forgiveness for more professions. Recruiting rural providers requires recruiting the spouse

Patient engagement: effectively engaging complex patients is a major priority. Training, home visits and consistent engagement are key.

CHWs: training CHWs and Medical Asst’s to work with complex patients also a priority. Can we create local training programs (e.g. community colleges)?

Silos: Train BH and medical staff to work across silos

Time: costly for providers to go to training.

Potential Mitigation Strategies:

Telehealth to expand short resources

Tuition support (loan forgiveness & conditional scholarship)

Partner with colleges for internships

Expand use of family members as care givers

Engaging clients for MTD success

Survey what workforce trainings are needed; conduct onsite group instead of individual trainings

Use Qualis Health as training resource

Establish a learning collaborative of partnering providers

Domain 1 – Health Info Technology

Assets:

EDIE and Premanage are widely used and helpful

Avatar is widely used in BH agencies.

EPIC is used in ~40% of hospital systems

PRISM provides comprehensive picture of careChallenges:

Timely access to data: Need comprehensive, timely integrated picture of claims for patient registries, risk stratification and monitoring/reporting

EHRs: there are multiple platforms and versions making it impossible to aggregate data. EHRs don’t handle non-medical data (e.g., BH, dental, LTC)

Bi-directional: Sharing information between primary care and behavioral health

Cross-system data-sharing: Need ability for first responders, EDs, law enforcement, corrections, BH and PC to access data for shared clientsPotential CPAA Roles:

Develop inventory of EHRs partnering providers are using

Support multi-directional communication between parties: HCA providers, MCOs

Visually Displaying the Work

Application must include logic model that depicts the work and tells our story

Medicaid Demonstration is only Part of the CPAA Work

Medicaid Demo Project

All Other CPAAProjects

Maternal and Child Health & Reproductive Health 10 Recommendations to Improve

Women’s HealthHome Visiting Program

Bright Futures

Bi-Directional Integration of Care & Primary Care Transformation

Collaborative Care Model

Medicaid Projects & Strategies

Chronic Disease Prevention and Control Chronic Care Model

Addressing the Opioid Use Public Health Crisis

Prevention, Treatment, Overdose Prevention, Recovery

Transitional CareINTERACT 4.0

Transitional Care ModelThe Care Transitions Intervention

Community Based Care CoordinationPathways Community HUB

Target Pop (Medicaid Clts) Project Outcomes

↓ util. (ED, I/P, readmits)

↑ opioid care (hi-dosetherapy, MAT)

↑ BH care & follow-up (post ED, post I/P)

↓ homelessness

↑ access – pediatric care/screenings

↑ chronic disease screenings

(diabetes, depression, asthma)

↑ maternal & reproductive screenings and care

↑ diabetic care (eyes, HbA1C, nephropathy)

CPAA Medicaid Demo Project Logic Model - Option 1

Having or at-risk for behavioral health conditions

In transition from intensive settings of care or institutional settings

Having or at risk for, arthritis, cancer, chronic respiratory disease, diabetes, heart disease, obesity and stroke

Women of reproductive age, pregnant women, mothers

Youth and adults who use, misuse, or abuse, prescription opioids and/or heroin

One or more chronic disease or condition and at least one risk factor

↑ MH or SUD screenings

↑ Rx management (anti-depressant, asthma, statin)

Medicaid Demonstration ProjectLogic Model – Option 2

Maternal and Child Health & Reproductive Health 10 Recommendations to Improve

Women’s HealthHome Visiting Program

Bright Futures

Bi-Directional Integration of Care & Primary Care Transformation

Collaborative Care Model

Medicaid Projects & Strategies

Chronic Disease Prevention and Control Chronic Care Model

Addressing the Opioid Use Public Health Crisis

Prevention, Treatment, Overdose Prevention, Recovery

Transitional CareINTERACT 4.0

Transitional Care ModelThe Care Transitions Intervention

Community Based Care CoordinationPathways Community HUB

Hospitals

PCPs

BHOs Social Services

Target Pop 1 Target Pop 2

Target Pop 3Target Pop 4

Long-Term Outcomes

↓ util. (ED, I/P, readmits)

↑ opioid care (hi-dosetherapy, MAT)

↑ BH care & follow-up (post ED, post I/P)

↓ homelessness

↑ access – pediatric care/screenings

↑ chronic disease screenings (diabetes, depression, asthma)

↑ maternal & reproductive screenings and care

↑ diabetic care (eyes, HbA1C, nephropathy)

↓ concurrent sedatives

↑ MH or SUD screenings

↓ arrests

↑ Rx management (anti-depressant, asthma, statin)

Long Term Outcomes

(2021+)

Intermediate Outcomes(2019-2021)

Short Term Outcomes

(2018)

Resources/Strategy

Shared vision for the community

Multi-Sector engagement

Greater Columbia ACH

Medicaid Transformation Project Funding

Collective understanding of community needs

EXAMPLE OF ANOTHER ACH LOGIC MODEL (Greater Columbia)A vibrant, healthy community in which all individuals, regardless of their

circumstances, have the ability to achieve their highest potential.

Project Portfolio Implemented to:

Achieve project implementation milestones (e.g. # of providers trained, implementing models)

Achieve project process and system metrics (e.g. # of screenings, reduced ED).

Generate resources for community investments

Project Portfolio Planned to:

Improve overall health outcomes

Reduce disparities

Make strategic health system capacity investments that support projects and sustain change

Project Portfolio Scaled to:

Achieve project scale and sustain milestones (e.g. # of providers using models)

Achieve systemwide outcome metrics (e.g. reduced ED, inpatient hospitalizations)

Invest in the community to sustain the vision

Decreased health disparities

Improved and efficient health care delivery system

Empowered, engaged individuals and communities collaborating and innovating to address community problems

Other Examples

Prepared by the Center for Community Health and Evaluation www.cche.org

Accountable Communities of Health | Conceptual Model

Regional multi‐sector community organizations:

- Develop vision & role

- Build functional capacity

- Collaboratively implement health improvement projects & activities

- Contribute to system‐level capacity building

Health improvement is

measurable, scaled & spread

System, practice & policy changes

support & sustain

transformation

Collaboration model is effective, integral &

sustainable

Healthier communities & transformed health system:

- Improved health care cost, quality & access

- Improved wellbeing & health equity

Approved ACH Logic ModelAccountable Communities of Health | Logic Model

Short-term (2017-18) Intermediate (2019-20) Long-term (2021+)

Achieve MTD scale & sustain project outcomes

Upstream/broader community improvement efforts implemented

Demonstrated synergy between MTD & broader community efforts to amplify health systems change (leveraging MTD investments, etc.)

Well-functioning community organizations

Shared understanding of regional priorities/needs

MTD projects planned, implemented effectively & achieving initial process / implementation outcomes

Upstream/broad community improvement efforts planned

Articulated synergy: MTD & broader community efforts

ACH multi-sector members & partners

Existing community collaboration

Community resources & programs

SIM funding & resources

Healthier WA initiative

MTD funding, structure, & resources

Healthier WA’s ability to influence Medicaid / health system

Outcomes Activities Inputs

Implement collaborative health improvement projects & policy/practice changes to transform the health system (Whole community & MTD)

Meet VBP targets

Increased workforce capacity & effective HIE to better meet needs

Fully integrated managed care implemented

Meet VBP targets

Incorporate workforce & pop health (data) management in projects

Fully integrated managed care plan developed

Contribute to HWA coordinated statewide health system capacity building efforts

Demonstrated ACH value- add to regional health system & communities

Evolving ACH role

Development of policy/ business model to support it

ACH is an effective, integral sustainable part of a transformed system

Enacted policy/business model to support role

Demonstrated value-add beyond MTD projects

Develop & implement shared vision for a regional collaborative model, including the ACHs long term role in region

2014-2016: ACH foundational development through SIM

Well- functioning, high capacity, transformed health care system

Healthier communities

Improved health care cost, quality, access & workforce

Improved health & well-being

Improved SDOH & health equity

Build strong, functional community organizations with capacity to coordinate regional health improvement activities (Whole community & MTD)

Discussion

What do you like about this?

What is missing?

What don’t you like?

How do we convey the alignment between multiple projects targeted to multiple target populations and multiple outccomes?

Next Steps

HMA and CPAA Staff working on Project Drafts

Posted in November for Review/Comment

Final Project Application to Council & Board for approval