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Webinar Housekeeping• Register: https://attendee.gotowebinar.com/register/8302047649
417864706
• Join audio by calling in:1-888-398-2342Code: 3732275 (public line)*Member code on calendar invite*
• Public line is muted. Please don’t put the line on hold!• Send questions using the “Questions” box in the control pane• Public comment at 10:30. Please indicate in the “questions”
box if you would like to submit written comment.• Meeting/webinar is being recorded and will be posted online
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Meeting objectives• Regular business (e.g. approve minutes, review/approve
annual committee report)• Hear from an OHP member about their experience with
Medicaid• Understand the Accountable Health Communities project in
Oregon and how CCOs are engaged• Hear legislative recaps from OHA and DHS related to the
Medicaid program• Hear stakeholder input on MAC recommendations and
consider revisions• Discuss recommendations for implementation/use of MAC’s
recommendations
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AGENDATime Item Presenter Purpose9:00 Welcome and Introductions
• Adopt minutes• Review/approve 2017 committee report
Co-chairs Action
9:20 Why we are here: member story Brandy Charlan Informational
9:35 Oregon Accountable Health Communities presentation & discussion
Dr Bruce Goldberg Informational & Discussion
10:20 Break
10:30 Public Comment
10:40 Agency Medicaid update – legislative session focus
Dawn Jagger, OHAAngela Allbee, DHS
Informational
11:00 Review/revise MAC recommendations given stakeholder input• Staff review stakeholder input• Committee discuss revisions
Co-chairs & staff Discussion
11:30 Recommendations for implementation/next steps for OHA and stakeholders
Co-chairs Discussion
11:55 Closing Co-chairs
●During pregnancy - Emergency C-section with the 1st●Children - Broken bones, dental care, check-ups, tonsillectomy, etc.●Medicaid expansion
Personal Impact of Medicaid
● Mandatory enrollment
● Provider availability and wait times
■ Klamath Open Door
■ Cascades East
● Walk-In clinics
Some challenges to accessing health care services in Klamath Co
● Disabling stress
● The house is barely habitable
● Possibility of being homeless
● Exorbitant cost of rent in Kfalls
● Not an anomaly
● Largest demographic in Klamath County, the working poor.
● I’ve been dreaming of a solution though
How factors outside of health care impact my health -Housing
Cultural Climate around Medicaid Recipients in Klamath County
● Boot-strapablity - The ability to pull oneself up out of hard times through mental fortitude, persistence, and continuous effort
● Majority of us workers are forgotten
● Insecurity - Bosses tell us that we are replaceable in the same breath as asking us to do something unethical. Our landlords speak in undertones about ‘remodeling the house soon’ when we mention repairs. We’ll never be able to save enough for 1st, last and deposit.
● Failure - Telling your child ‘no’ to sports because you can’t afford the gear, even if you were awarded the meager scholarship from the Y. Not being able to afford to fix the used car that you just bought with your EIC that only lasted 2 mos. Serving Papa Murphy’s again this week because there is no time to shop and cook again, too busy working.
● Bargaining - Promising our kids a future reward for their forgiveness, ‘I know you're sad. Can imake it up to you later?’ Asking utility companies for payment plans and only ever being able to pay the past-due amount. With our bosses, making promises of great accomplishments in exchange for more hours while simultaneously begging for a couple hours out of the middle of the day to go to our kids’ X-mas program praying we don’t get fired for it. With ourselves, ‘Someday, I’ll do better’, as if the failure of the economy were ours.
There isn’t a bootstrap reliable enough to grab onto. There is nowhere to pull ourselves to. The dream of being rewarded for hard-work is dead.
● In recognizing that the economic climate is not designed for the working class to have upward mobility or assets, be a county that viciously confronts the challenges that workers face when trying to create housing stability for their families.
● Be a community that values the people that grew up here by protecting them from displacement. Population increase and gentrification are inevitable but the devastating impact of gentrification can be minimized with the foresight to prioritize the group most at risk, the working poor.
● Make good on the ideal that people who pull themselves up by their bootstraps who put in the time and effort will be rewarded with security.
● Craft and hone a replicable workforce housing model – borrow from Housing First programs
Goal
End ProductHave Medicaid workers housing security program where:
● A medicaid recipient can buy a house without subsidies and without a cost of living increase
● Through use of investments from CCO and County● Non-profit manages program● 5yr lease option at fixed rate calculated by percentage of property value (addresses
gentrification)● Recipient required to participate in Credit Counseling program with Klamath Lake County
Action Services● Every “rent” payment is reported as good to credit agencies● Begin ownership transfer paperwork at year 4● At 4th year 60% of total rent payments are credited as a down payment● In 4th year, walk recipient through loan application process (also a service through
KCLAS)● By 5th year recipient is bank ready
TODAY
• Context for identifying and addressing social determinants of health
• Share work going on in Oregon through the Accountable Communities of Health Project
• Discuss future considerations
NATIONAL CONTEXT
• Health care costs growing faster than other economic indicators
• Outcomes are varied and inconsistent
• National health reform efforts – SIM, Medicare, PCMH, CPC+
• A plethora of state health reform efforts
• Growing evidence of importance of social investments, care coordination, primary care
Opportunity Costs!
• 1 ED Visit = 1 months rent
• 2 hospitalizations = 1 year of child care
• 20 MRIs = 1 social worker per year
• 60 echocardiograms = 1 public school teacher per year
SGIM Presidential Speech, Dr. Moran, 2015
STATE EFFORTS TO IMPROVE HEALTH &
INCREASE INVESTMENTS IN SOCIAL SPENDING
• Foster better value and efficiency in health delivery systems through payment reforms, value based purchasing and delivery system changes
• Invest some of those savings into social enterprises that improve health
• Increased partnerships across health and social service endeavors
• Creating coordinating/integrating organizations
Opportunity to create community-wide wrap-around care for high need residents by:
• Implementing screening for Medicaid and Medicare patients to identify health-related social needs: housing, food, utilities, transportation and violence
• Connecting patients to community services
• Developing a tailored referral and care plan for a subset of high risk patients
• Screening 75,000 Medicare and Medicaid beneficiaries per year using CMS tool for:• housing, food insecurity, transportation, utilities, interpersonal
violence
• Those with a social need get tailored referral summary/information on local community resources
• Navigation for 2,925 persons with 2 or more emergency department visits in the prior year plus 1 or more social needs
Oregon AHC Consortium
• Across 9 counties: Jackson, Josephine, Curry, Crook, Deschutes, Jefferson, Wasco, Hood River
• OHSU-ORPRN as bridge organization (CMS requirement)
• 6 CCO’s – AllCare, Primary Health, Pacific Source Columbia Gorge, Pacific Source Central Oregon, Pacific Source Hood River, Yamhill CCO, Jackson Care Connect
• IPAs, Hospitals, behavioral health organizations, public health, community service providers
• 2-1-1• Vistalogic
The Oregon Consortium
Help Answer the Primary Question
• Does screening for social needs plus tailored navigation to health and social services lead to improved outcomes and reduced costs of care?
Community Referral
• Tailored to address those items identified in positive screen
• Up to date information on resources available in local community
• Computer generated at time of screen
ScreeningSetting:
• Primary Care (Family Medicine, Internal Medicine, Pediatrics)
• Behavioral Health
• Hospital (including Emergency Department, Labor & Delivery, Inpatient Psych, specialty care)
• Public Health
• Dental Providers
• Organizations interested in partnering with clinical sites (CCO, IPA, social service agencies, 211info)
Method:
• In person
• Telephone before visit
• Computer kiosk/tablet in waiting room
• Financial reimbursement - Organizations will receive $10 per completed screen in the first year and $2 per completed screen every subsequent year. Organizations will also receive $100 for every completed navigation.
• Access to a web-based software program that provides tailored referral summaries for connecting patients to community resources
• Better connections to community service providers with plans to develop closed loop referrals in the future
• Opportunity to better understand population/community needs
• Training and technical assistance to develop screening and navigation protocols
Participating Screening Sites
• Screen 75K and better understand social need• Understand if screening health care settings and
connection to resources can improve health and reduce health care costs
• Better understand social need/unmet social need • Gain experience and knowledge in how and where
to screen• Improve connection between health and social
service providers and learn what is needed and can work
• Get experience in data and information sharing between health and social service agencies
Short Term Goals
• Ability for information sharing between health and social service organizations
• Closed loop referrals between health and social service organizations
• Real time information on need and services available across a community
• Better understand where and how to screen and address social determinants
Longer Term Goals
June-Sept 2017
Oct Nov Dec Jan 2018 Feb March April May June
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PHASE 1: Recommendations for Addressing SDOH in Oregon CCOs
PHASE 2: Health-related services and Housing guide
Committee background and work plan
HRS guide drafted
SDoHdefinition drafted
Final definition and recommendations approved (Phase 1)
Mar 12 consultation with CCOs at QHOC
• Housing identified as priority area for health-related services guide
• Approved draft recommendations for stakeholder feedback
SDoH CCO stakeholder survey fielded
Milestone 1
Milestone 2
Milestone 3
Milestone 4
Milestone 5
MAC SDOH Timeline & Critical Milestones
Feb 1: consultation with HITOC
Milestone 6
HRS guide final (Phase 2)
Milestone 7
MAC selects SDOH at 2017 retreat
March 22 consultations with Allies for a Healthier Oregon and HITAG; Health Equity Committee survey
CCO and Stakeholder Presentations to MAC
Stakeholder feedback: Six recommendations• Connect to community health needs assessment and
community health improvement plan (HEC, AHO)• What are the MAC’s thoughts about how CCOs will pay
for/justify spending on work in SDOH? (QHOC)• Suggest removing the term “equity lens” and talking
about equity as a foundational tool for addressing SDOH (HEC)
• There needs to be more transparency of investments in SDOH (e.g. HRS) for communities (AHO)
• Much of the work to address SDOH is done at the provider level (AHO)
• Is there a way to emphasize consumer engagement in care more? (QHOC)44
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Six recommendations to OHA on CCO roles to address SDOH (DRAFT 3/26)
1. CCOs select SDOH role(s) based on the needs and resources in a given community. This includes:
a) Relying on regional plans such as Community Health Assessments and Community Health Improvement.
b) Working directly with Community Advisory Councils (CACs), providers, and other community partners already engaged in addressing the SDOH.
2. CCOs support & leverage existing internal, community, and provider efforts to address SDOH, in order to increase the effectiveness of these existing efforts.
3. CCOs build from their roles as the main Medicaid payer in a community, and use the unique tools provided by the CCO model to spend funds on SDOH, including:
a) Health-related services
b) Value-based payment strategies that incent providers to address SDOH
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Six recommendations to OHA on CCO roles to address SDOH, Cont. (DRAFT 3/26)
4. CCOs support providers and community partners in working together with patients to identify and address the SDOH challenges patients face and would like help to resolve. This includes:
a) Addressing provider needs and infrastructure to impact SDOH (e.g. need for data systems or technology to track and address SDOH)
b) Ensuring providers have the necessary SDOH data to deliver both SDOH-informed and SDOH-targeted healthcare
5. CCOs consider equity and the SDOH as the foundation in all policies and programs they develop. This includes being conscious of the critical infrastructure needed – such as culturally competent providers – to address SDOH in a way that also addresses the social determinants of equity.
6. CCOs address SDOH in a way that promotes person and family-centered care, including tailoring SDOH efforts around member needs and desires.
a) For example, member-based efforts (e.g. flexible services) consider a patient’s desires and priorities when it comes to addressing their SDOH barriers. Population-based SDOH initiatives should be tailored to the needs and priorities identified through community health assessments.
Stakeholder feedback: Definition
• Positive feedback about the definition – no changes (QHOC)• Caution against framing health equity as a “lens” in the
recommendations – recommend framing as a foundation to the work in the definition and in the recommendations (HEC)
• Appreciate that SDOH and social determinants of equity are both included (HEC)
• The definition is slightly long – look for ways to condense if possible (HEC & AHO)
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Definition: Social Determinants of Health & Equity (DRAFT 3/26)
Health begins where we live, work, learn, and play. The social determinants of health are the social, economic, political, and environmental conditions in which people are born, grow, work, live, and age. These conditions significantly impact length and quality of life and contribute to health inequities.
The social determinants of health are not fairly distributed in communities, but are shaped by structural factors, like racism. These structural factors are called the social determinants of equity, and they are evident in social norms, policies, and political systems, both historical and current.
Social Determinants of Health & Equity Factors (DRAFT 3/26)
Social Determinants
of Health
Neighborhood and Built
Environment
Health and health care
Social and Community
Health
Education
Economic Stability
Social integration Civic participation/community engagement Meaningful social role (e.g. meaningful work) Discrimination (e.g. race, ethnicity, culture,
gender, disability) Citizenship/immigration status Incarceration/Corrections Trauma (e.g. adverse childhood experiences)
Early childhood education and development
Language and literacy High school graduation Enrollment in higher
education
Poverty Employment Food insecurity Diaper insecurity Access to quality childcare Housing instability,
including homelessness Access to banking/credit
SOCIAL DETERMINANTS OF EQUITY
SOCIAL DETERMINANTS OF EQUITY
Access to healthy foods/protection from food “swamps”
Access to transportation (non-medical) Quality, availability, and affordability of housing Crime and violence (including domestic
violence) Environmental conditions Access to the outdoors/parks
racism sexism
ableism Homophobia & transphobiaageism
Access to health care Culturally and linguistically
appropriate care Health literacy
Stakeholder feedback: 10 possible roles• It’s helpful for CCOs to have a menu of possible roles to play
in addressing SDOH (HITAG)• Appreciate that the MAC called out the importance of
partnership in communities (QHOC)• Foundational role: include engaging with the communities
that a CCO serves (HEC)• Direct investment role: concern about sustainability if the
focus is on grants. What about calling out the CCO’s role in direct investment to develop community infrastructure to support SDOH work? (HEC)
• Data/analytics support role: A big barrier in clinic-level SDOH work is technology (AHO/HEC). Maybe include a reference to Health Information Exchanges? (HEC)
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Ten possible roles for CCOs to address SDOH (DRAFT 3/26)CCO Role Description ExampleFoundational role: Internal infrastructure changes
Hiring, training, retention, recruitment, and community engagement strategies necessary toensure entity is well set up to address SDOH
CCO employs staff to meet the social, racial, and cultural needs of the community
Direct Investment Grants or more permanent funding to build infrastructure in communities to addressing SDOH, often by providing funding providers and community-based organizations.
CCO partners with local farmers’ market organization to establish a farmers’ market in a food desert/food swamp (area with limited access to healthy food)
Health-related Services Form of direct investment. Health-related services are non-state plan, non-covered services (HRS) intended to improve care delivery and member health. HRS include flexible services (member-specific services) and community benefit initiatives.
CCO funds non-medical transportation for members to go to parenting classes, food bank, job interview
Alternative Payment Models (APM)/Value-Based Payment (VBP)
Payment models designed to pay for value (i.e. outcomes) rather than volume (i.e. services). Payment can be designed to incentivize SDOH activities, allow flexibility address holistic medical/social needs to improve health.
CCO provides incentive payments to providers to support SDOH work, e.g. incentives for SDOH screenings, for PCPCHs to adopt optional program standard for tracking community/social service referrals
Workforce Contracting with or otherwise funding healthcare workers to address social determinants of health (e.g. community health workers)
CCO contracts with community health worker to provide social service referrals to high utilizers or operates a care coordination hub, such as the Pathways model
Convener Bringing together diverse, multi-sectoral partners to identify common priorities and work toward addressing SDOH
CCO engages social service and other community partners to integrate social determinants of health into its community health assessment and community health improvement plan; facilitate identification of common SDOH priorities for community
Data/analytics support Providing health care data or data resources (e.g. Health IT, supporting development of Health Information Exchange) to partners, such as social service entities
CCO supports building a social determinant of health screening instrument into EHR for provider use
General alignment/collaboration
Aligning CCO SDOH priorities with community-selected goals or strategies
CCO adopts common metrics with local early learning hub
Policy/government relations
Advocating for policies that address SDOH in communities
CCO advocates for improved transportation options for residents in service area
Social needs/resource clearinghouse
Compiling and distributing social needs/resource data to providers and other partners
CCO assembles social needs data on members and shares risk scores with providers to inform care51
Questions for discussion:
• What does the MAC recommend OHA do to implement its recommendations? (e.g. how does the MAC recommend the agency use its definition?)
• What other work is needed to support the MAC’s recommendations? For example, how can OHA aid CCOs to address SDOH in ways that align with the MAC’s recommendations?
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Starting list for discussion: Recommendations to OHA• Provide SDOH learning and information sharing opportunities for CCOs to
promote replication and scaling up of SDOH efforts• Increase tracking of CCO SDOH initiatives and data, and share information
publicly to identify best practices and areas for improvement• From increased tracking and data, establish clear goals and metrics to
assess CCO spending and work on SDOH• Strengthen requirements for Community Health Improvement Plans (CHP)
to ensure CCOs work with appropriate community partners and include SDOH strategies in their CHPs
• Increase transparency of CCO spending and policies/procedures related to SDOH
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