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SECTIONI:ACHLEVEL
ACH BetterHealthTogether
Name HadleyMorrow
PhoneNumber
509-954-0831
E-mail [email protected]
RegionalHealthNeedsInventory
RegionalHealthNeedsInventoryHowBetterHealthTogether(BHT)hasuseddatatoinformitsprojectselectionandplanningBHTACHhasuseddatato:assessneeds,resources,andinterestindifferentaspectsoftransformation;toengageprovidersandpotentialpartners;toinformstrategicdirectionandprioritizationdiscussions;andtoilluminateareaswheremoredataandanalysisareneededasprojectplanningcontinuesintoimplementationdesign.BHTACHhasexistedsince2013asaregionalorganizationdedicatedtoimprovinghealthandcommunitysystemsofcareforallresidents.Inthisrole,BHT’sstaff,LeadershipCouncil,andBoardreviewedavailabledataaboutcommunity-widehealthneedsandresourcesandhostednumerousconversationstobetterunderstandcommunities’perspectivesonbrightspotsandtoidentifyhealthdisparities(seeCommunityEngagementsection).Theseconversationsuncoveredseveralkeyconcernsincludingaccesstocare,chronicdisease,obesity,AdverseChildhoodExperiences,andinadequateaccesstoandcoordinationofcommunityresources,whichweresummarizedinfall2016andcanbeviewedinAppendix1.
SinceapprovaloftheMedicaidTransformationDemonstration(MTD)andpublicationoftheProjectToolkit,BHTACHhasusedarangeofdatatoconsidertheneedsofMedicaidbeneficiariesinparticularandtoassesscurrentperformanceandcapacityintheeightpotentialDemonstrationprojectareas,aswellasDomain1.ThegoalofthisstageofassessmenthasbeentoidentifyopportunitiesforrealimprovementandexploreareaswhereMTDworkcanhelpdrivecommunitypriorities.SeveraldatasourceshaveinformedBHTACH’siterativeprojectselectionandplanningprocess:
• BHTACHcollecteddatafrompartnersandcommunitymemberstoinformprojectselectionviaanopencallforLettersofInterest(LOIs)forcommunityprojectsinthesixoptionalMTDprojectareas.LOIswerereceivedfrom40differentorganizationsorpartnershipsacrossallsixofBHTACH’scounties.Whileallprojectareaswererepresented,overhalfoftheproposalsinvolvedcarecoordinationacrosssectors.
• NineteenoftheLOIparticipantswereselectedforacommunityshowcaseeventinAugust2017,whereorganizationsbrieflydescribedtheirprojectsandcommunitymembersparticipatedinavotingexercisetoindicatetheirinterestinandsupportfordifferentideas.Proposalsinvolvingcarecoordinationreceivedthelargestshareofvotesduringthecommunityfeedbackevent.Therewasinterestineachoftheremainingoptionalprojectareaaswell,butnoclearprioritizationamongthem.SeeAppendix2forsummariesofshowcasefeedback.
• Inthesummerof2017,BHTACHsurveyeditshealthsystemandcommunity-basedorganizationpartnersabouttheirinterest,capacity,andprioritiesforDemonstration-relatedwork(includingDomain1strategies).Thirty-nineorganizationssubmittedeitheraHealthSystemsInventoryorCareCoordinationInventory(HSIorCCI).Whiletherewasinterestacrossallprojectareas,responsesweremostconcreteforbi-directionalintegration(2A),carecoordination(2B),opioids(3A),andchronicdisease(3D).Inotherprojectareas,likelypartnershadlessexperienceorfewertangiblepriorities,ordidnotexpresssupportforthespecificevidence-basedstrategieshighlightedintheMTDToolkit.DatafromtheHSIandCCIalsohighlightedclientneedsaroundmentalhealth,substanceabuse,chronicdiseases,andsocialdeterminantsofhealth(e.g.insecurehousing).HSIandCCIresultsaredescribedinmoredetaillaterinthissection.
• AsdatasetsorreportsliketheRegionalHealthNeedsInventory‘starterset’files,HCAProviderreports,orpartnerpublicationssuchastheSpokaneUrbanIndianHealthProfilebecameavailable,BHTstaffandcontractorsreviewedthemtoinformprojectselectionandplanning.Reviewandanalysishaveencompassedissuesincludingbutnotlimitedto:
o Populationsizeanddiseaseburden(e.g.howmanyMedicaidmembersinBHTACHregionhavebothachronicdiseaseandmentalhealthorsubstanceabuseneed?);
o Disparitiesbasedondemographics,andgeography,andotherfactors;
o CurrentperformanceonMTDqualitymeasuresandpotentialforimpact(e.g.howdoesBHTACHcomparetostateandnationalaveragesforasthmamedicationmanagementbasedoncurrentpubliclyavailabledata?).
ManyoftheseexploratoryanalyseshavebeensharedwithBHTleadershipandpartnersasweconsideredprojectselectionandpriorities.Twoslidepresentations,fromaSeptemberBoardmeetingandOctobercommunitylearningwebinar,areattachedasexamples(Appendices3and4).
Projectplanningisofcourseongoing.AstheBHTACHandourpartnersmovedeeperintoprojectdesignandimplementationplanning,wewillcontinuetousedataformultiplepurposes,includingbutnotlimitedto:honinginontargetpopulationsandpartneringproviders(e.g.EDsseeingthelargestvolumeof‘highutilizers’withbehavioralhealthconditions);estimatingpotentialimpact(e.g.estimatingthenumberofreadmissionstobeavoidedinordertomeetimprovementtargets);orassessingthepotentialviabilityofproxymeasuresforperformanceimprovement(e.g.canunintendedpregnancyratesbereliablymeasuredataregionallevel?).Totheextentpossible,theBHTACHplanstoprovidetailoreddatatoeachofitsCommunityHealthTransformationCollaborativesfortheiruseinplanning,monitoring,andcontinuousimprovement.(TheCollaborativesarecomprisedofhealthsystemandsocialdeterminantofhealthpartnersservingastheactivationnetworkforimplementationoftheMTDprojects;seeTheoryofActionsectionformoredescription).TheBHTACHalsoplanstodisaggregatedata(byrace,ethnicity,geography,eligibilitygroup,andotherrelevantcategories)whereverpossibletoinformdecisionsabouttargetpopulationsandmonitortheimpactofprojectsacrossdiversegroups.TheBHTACHhasengagedwiththeProvidenceCenterforOutcomesResearchandEducation(CORE)tosupportourdataandanalyticneeds,includingaccessingandanalyzingdatatoinformprojectselectionanddevelopingplansformonitoringandcontinuousimprovementduringprojectimplementation.COREisanindependentresearchteamwithexpertiseindatascience,evaluation,andcollaborativeresearch.CORE’sstaffhaveextensiveexperienceinAccountableCommunityofHealthandMedicaidredesigninitiativesinOregon,California,andWashington. TheBHTACHalsoleveragesasharedlearningpartnershipwiththePierceCountyandSouthwestWashingtonACHsandconnectsregularlywithdataandanalyticresourcesintheregionincludingtheSpokaneRegionalHealthDistrictandEasternWashingtonUniversity’sInstituteforPublicPolicyandEconomicAnalysis.
DatasourcesTheBHTACHhasconsultedawiderangeofdatasourcestodate.ThesearesummarizedintheRHNIDataSources&UsesTable(Appendix5).Thesourcesinclude:
• HCAorDepartmentofSocialandHealthServices–ResearchandDataAnalysis(RDA)dataproductsproducedspecificallyforACHs(e.g.RDAmeasuredecompositionfiles,suppresseddatatablesforco-occurringdisorders,ProviderReport,etc.)
• StatedataforeithertheMedicaidorthegeneralpopulation(e.g.OpioidOverdoseDashboard;1WashingtonDOHregionalchronicdiseaseprofiles;2WashingtonStateOfficeofFinancialManagementreportonPotentiallyAvoidableHospitalizations3)
• ExistingdataorreportsfromBHTACH’sregion(e.g.TheNATIVEProject/SpokaneUrbanIndianHealthCenterCommunityProfile)
• PrimarydatacollectedbytheBHTACHfrompartneringproviders—includinghealthcareproviders,MedicaidManagedCareOrganizations,andCommunity-basedOrganizations—toinformprojectselectionandplanning.Thetwomostsignificantexamplesoforiginaldatacollectedfrompartneringorganizationsaredescribedbelow:BHTACH’sHealthSystemsandCareCoordinationInventories(brieflyreferencedabove)andtheBHTACH/SpokaneRegionalHealthDistrictCommunityLinkagesStudy.
TheHealthSystemandCareCoordinationInventories(HSIandCCI,seeAppendices6and7)collectedinformationonorganizations’Medicaidpatients/clientsandservicecharacteristics,includinghealthstatusandleadingdiagnoses.Theinventoriesalsoqueriedpartnersdirectlyabouttheirinterest,capacity,andprioritiesforMTD-relatedwork.TheBHTACHreceivedHSIresponsesfrom23organizationsintheregion,includingmajorhospitalnetworks,providersystems,andFQHCs.Twenty-six(26)CCIswerereturnedfromcommunity-basedorganizations.ThreeofthefiveMedicaidManagedCareOrganizationsalsocompletedCCIs;theseMCOsrepresent73%oftheMedicaid-enrolledpopulationinBHT’sregion.4SeeAppendix8forthelistofHSIandCCIrespondents(organizationsthatsubmittedprojectLettersofInterestarealsoincluded).TheBHTACHcomparedtheHSIrespondentswithHCA’sSeptember2017ProviderReport5andfoundthattheinventoryresponsesrepresentmorethan80%ofthehighest(top10)volumeMedicaidbillersineachmajorsetting(primarycare,mentalhealth/substanceabuse,inpatientandED.)ForseveralsettingsintheBHTACH’sfiveruralcounties,theHSIrespondentsrepresentalltheMedicaidbillerswithclaimsorbeneficiarycountsofmorethan10in2016.BHTstaffarefollowingupwithnon-representedprovidersthatseealargenumberofMedicaidclients,particularlysubstanceabusedisordertreatment,oralhealthandIndianHealthServicesproviders.
In2016,theSpokaneRegionalHealthDistrictconductedalargescaleCommunityLinkageMappingandsocialnetworkanalysis,6inwhich165individualsrepresenting112organizationsfromthehealth,socialservice,education,business,andpublicsectorscompletedaPopulationandSocialDeterminantsofHealthSystemsSurvey.Becauseparticipantswereabletodescribetheirlinkageswithorganizationsthatdidnotresponddirectly,thereportinfactrepresents564organizationsandisthemostcomprehensivepictureavailableofhealth-relevantcommunity-basedresourcesintheBHTACHregion.AfulllistofrepresentedorganizationsbygeographyandsectorcanbefoundinAppendix9.MedicaidBeneficiaryPopulationProfileBHTACHhasalargeserviceregion,whichcovers12,273squaremilesandispredominatelyrural.AnurbancoreexistsinSpokaneandthereisasurroundingsuburbancommutingarea.84%oftheregion’spopulationlivesinSpokaneCounty7andmanyareasinFerry,Lincoln,andAdamscountiesareclassifiedasisolated,asshowninthemapbelow.
Figure1:WashingtonState6-Tierruralcategorizationbycensustract(2010)8
BHTACHhasapproximately196,000Medicaidmembers,9whichrepresentsahigherproportionofthepopulationthanthestateasawhole(33%Medicaidcoveragevs.28%statewide).10AdamsCountyhasthehighestproportionalMedicaidpopulationinthestate,at52%.Following
thegeneralpopulationdistribution,mostofBHTACH’sMedicaidpopulationlivesinSpokaneCounty.Onthewhole,BHTACH’sMedicaidpopulationis:slightlyolderandmoremalethanthestateMedicaidpopulation;morelikelytobewhite(75%comparedto57.0%statewide);lesslikelytobeHispanic(11%comparedto21.0%statewide);andmorelikelytogiveEnglishastheirpreferredlanguage(94%vs.83%statewide).However,thereisrealvariationwithintheBHTACHregion.Forexample,AdamsCountyMedicaidbeneficiariesareyounger(68%under19),moreHispanic(78%),and46%identifySpanishastheirpreferredlanguage.11IndividualswhoidentifyasHispanicareagrowingproportionofthepopulationinallofBHTACH’scounties,astheyarestatewide.12InStevensandFerrycounties,whereSpokanetriballandsandpartoftheColvilleTriballandsarelocated,10%and27%ofMedicaidenrollees(respectively)identifyasAmericanIndianorAlaskaNative.13ThesenumbersaresignificantgivenongoingdisparitiesinhealthcareaccessandoutcomesamongNativegroups.BHTACH’snortherncountieshavesomeofthehighestunemploymentratesinthestate:FerryCountyleadsthestateat8.7%unemploymentasofSeptember2017andPendOreilleandStevensCountiesarebothcloseto6%.
Figure2:WashingtonStateUnemploymentRates,September201714
Similarly,thethreenortheastcountieshavehigher-thanaverageproportionsofchildreninpoverty(27%inStevens;31%forFerryandPendOreille).15InSpokaneCounty,morethanathirdoftheAmericanIndian/AlaskaNative(AI/AN)populationisbelowthepovertylineandunemploymentforAI/ANresidentsiscloseto20%.16Accordingtothe2015WashingtonStateHousingNeedsAssessment,allBHTACHcountieshavelownumbersofaffordablehousingunits,withSpokaneCountythelowestat12affordableandavailableunitsper100households.17BHTACH’sHealthSystemInventoryrespondentswithavailabledatareportedthatbetween3%and18%oftheirclientsliveinhousingthatiseithernotstableorisovercrowdedandthatasmanyas15%haveahistoryofincarceration.However,manynotedtheyhadnomechanismtotrackthistypeofinformation.
Table1:ClientneedestimatesfromBHT’sHealthSystemsInventory18
BHTACHHSIRespondentsontheirpatients/clients'needs Range%Childreninfostercare 0%-10%%Clientswithinsecureorinadequatehousing 3%-18%%Clientswithahistoryofincarceration 0%-15%
HistoricaldatafortheMedicaidTransformationDemonstrationperformancemeasures,whicharemorenarrowlydefinedtoMedicaidbeneficiariesandeventsinthelastyear,puttherateofhomelessnessamongBHTACHMedicaidenrolleesat3.8%(belowthestatewideaverage)andpast-yeararrestsat6.5%.19Medicaidbeneficiarypopulationhealthstatus
BehavioralHealthconditionsandtreatmentneedsarewidespread
Morethan44,000BHTACHMedicaidmembers(almost30%)havebeendiagnosedwithamentalillnessandapproximately20,000(12%)haveasubstanceabusetreatmentneed.About36,000(9%)haveamentalhealthorsubstanceabuseconditionand1ormorechronicdiseases.ThesefiguresrepresentalargersegmentoftheMedicaidpopulationforBHTACHthanthecorrespondingfiguresforWashingtonasawhole.
Figure3:PrevalenceofchronicconditionsamongBHTACHareaMedicaidbeneficiaries,FY2015-1620
Outsideofpregnancyandchildbirth,‘mentalandbehavioraldisorders’weretheleadingcauseofhospitalizationforBHTACHMedicaidbeneficiariesin2015,accountingfor17.5%ofallnon-birth-relatedhospitalizations.Substanceabusedisordersaccountedfor5.7%ofsuchhospitalizationsoverallbut8%amongnon-disabledadults.21BHTACH’sHealthSystemInventoryrespondentssuppliedinformationaboutthemostfrequentdiagnosesamongtheirpatients/clients.Mentalhealthconditionsrepresented23%oftop5diagnoses,andsubstanceabuseoradditionrepresented6%.22OpioiduseinhighamongBHTACH’sMedicaidpopulation.17.4%ofBHTACHMedicaidbeneficiariesarecurrentopioidusers(vs.13.5%statewide)and3.6%areheavyusers.
Table2:Medicaidbeneficiaryopioiduse,BHTvs.WashingtonState23
OpioidUsersas%ofMedicaidpopulation BHT WashingtonAll 17.4% 13.5%Userswithoutcancer 15.4% 11.9%HeavyUsers 3.6% 2.8%Usersfor>30days 3.9% 2.8%
InalmostallofBHTACH’scounties,opioidprescriptionsarewrittenandfilledatahigherratethanaverageforWashingtonstate.(AdamsCountyistheexception.)
8.8%
12.5%
29.5%
7.7%
11.2%
27.1%
0% 10% 20% 30% 40%
MIorSUDandCD
SUDtreatmentneed
Anymentalillness
Figure4:Opioidprescriptionswrittenandfilledper1,000residents,201424
BHTACHissubstantiallybelowthestateaverageforMedicaidopioidusersreceivingmedication-assistedtreatmentwithmethadone(11%vs.16%statewide)butisataboutthestatewideaverageforMATwithbuprenorphine(11%vs.10%statewide).25
BHTACHisalittlebelowthestateaverageformentalhealthtreatmentandsubstanceabusetreatmentpenetrationratesamongMedicaidbeneficiaries.However,ratesoffollow-upafterahospitalizationorEDvisitrelatedtomentalhealthorsubstanceusearehigherthantheaverageforWashingtonstate.2619Variationforchronicdisease
Overall,estimatedchronicdiseaseprevalenceamongtheMedicaidpopulationinBHTACHisclosetothestatewidefigures:approximately3%ofenrolleeshadaninpatientoroutpatientclaiminthelastyearthatincludedadiagnosisofdiabetes(vs.4%statewide),5%hadaclaimwithadiagnosisofasthma(vs.4%statewide)and11%receivedadiagnosisofdepression.27However,thesefiguresmasksomeregionalvariation:
• AsthmaishigherthanthestateaverageinStevensCounty(6%)andFerryandSpokaneCounties(both5%).
• Smokingisariskfactorforanumberofchronicdiseases.BHTACHhassomeofthehighest(StevensCountyat33%)andlowest(AdamsCountyat8%)smokingratesamongWashington’sMedicaidbeneficiaries.
Figure5:Smokingprevalencebycounty,2013-1527
• DepressiondiagnosesamongSpokaneandPendOreilleCountyMedicaidrecipientsare
higherthantheWashingtonaverageat12%butAdamsCountyhasthelowestrateinthestateat3%.
ChronicdiseasemanagementforBHTACH’sMedicaidpopulationalsovaries:28
• Between83%and87%ofdiabeticsreceiveregularbloodglucoseandkidneyfunctiontests,butonlyaboutathirdreceiveannualeyeexamsforretinopathy.
• About32%ofindividualswithpersistentasthmaareonappropriatemedicationand26%ofthosewithadvancedCVDreceiveastatinprescription.Theserelativelylownumbersareneverthelessabovethestateaverageperformance(28%forasthmamedicationmanagementand20%forstatintherapy).
ExistinghealthcareprovidersservingtheMedicaidpopulationTheBHTACHregionincludes:
• 14hospitals(notincludingmilitaryorV.A.facilities),8ofwhicharecriticalaccesshospitals
• EasternStatePsychiatricHospital
• 13RuralHealthClinics
• 6Federally-QualifiedHealthCenterswithatotalof28locationsintheregion
• 5TribalorUrbanIndianHealthProgramclinics,andanIndianHealthServiceClinicinWellpinitontheSpokanereservation
Inaddition,thereare34MentalHealthand/orSubstanceAbuseDisorderserviceproviderscontractedwiththeRegionalBehavioralHealthOrganization,manyofwhomhavemultiplecliniclocations.SeeAppendix10foralistofhealthcarefacilitiesintheregion.BHTACH’sMedicaidbeneficiariesareservedbyfiveMCOs:AmerigroupWashington,CommunityHealthPlanofWashington,CoordinatedCareWashington,MolinaHealthcareofWashington,andUnitedHealthcareCommunityPlan.Molinahasthelargestshareofmanagedcareenrolleesoverall(47%)butisnotthebiggestplanineverycounty.Between14%and36%ofMedicaidrecipientsinBHTACH’sregionarenotenrolledinamanagedcareplan,dependingonthecounty.FerryCounty,wheremorethanaquarterofMedicaidbeneficiariesidentifyasAmericanIndian/AlaskaNativeandmustoptintoMCOenrollment,hasthehighestproportionofbeneficiariesinfee-for-serviceat36%.29ThishighproportionofFFSclientscanmakeitchallengingtocoordinatecare.Informationaboutproviders’acceptanceofMedicaidclientsislimitedandoftennotcurrent.Surveysconductedwithinthelast5yearsaspartoftheHealthProfessionalShortageAreadesignationprocesssuggestthatthemajorityofprimarycareprovidersintheBHTACHregionserveatleastsomeMedicaidpatientsandthat65%-75%ofdentistsdoso.30Butanecdotally,BHTstaffhavereceivedreportsofmuchloweracceptanceratesfornewMedicaidpatientsamongdentalprovidersinparticular.Existingcommunity-basedresourcesavailabletotheMedicaidpopulationThefindingsofthe2016CommunityLinkagesStudy31describedearlierunderDataSourcesspeakdirectlytotheavailabilityofcommunity-basedresourcesforMedicaidbeneficiaries:
• BHTACH’scommunity-basedresourcesmostcommonlyaddresstheseneeds:communitysupport(sociallysupportivecareandpeergroupsthatfosteranindividual'ssenseofsupportandbelonging);education;food(access,affordability,nutrition);housing(access,affordability,andplacement);incomestability;andtransportation.
ThesekindsofresourcesareparticularlyrelevantforsupportingMedicaidclientswithawhole-personcareapproach.
• AstrongmajorityofrespondingorganizationsofferedservicesinSpokaneCounty,particularlyamongsocialsectorgroups.OrganizationsfromthesocialsectorwerecentraltothenetworkinSpokaneCounty(alongwiththepublichealthdepartment),whereashealthandeducatorsectorplayersweremorecentralinthenortheasttri-countyregionandinLincoln-Adamscounties.ThissuggeststhatadditionaltimeandeffortwillberequiredtolinksocialsupportsystemstohealthcareinBHTACH’sruralcounties.
• Mostofthereportedorganizationallinkagesinvolvedcollaboration(e.g.attendingmeetingstogether,sharingresources,completingjointprojects-56%)orreferral(30%).Dataexchange,education,andfinancialsupportweremuchlesscommon(lessthan6%oflinkagesforanyofthosecategories).BHTACHistakingthesefindingsintoconsiderationasitdevelopsplanstosupportvalue-basedpaymentandpopulationhealthdatasystemsintheregion.
• Thesocialsectorwasthebestlinkedtoothersectors(includinghealth)andhadthemostlinkagesoverall.Healthsectororganizationswerewelllinkedwitheachotherbutslightlymoresiloedwithintheirsector.
BHTACHwillexplorethefeasibilityofrepeatingthecommunitylinkagesstudyinsomeforminthefutureasameansofevaluatingtheimpactoftheACHandMTD-supportedactivitiesonsystemconnectionandintegrationacrosssectors.InadditiontotheCommunityLinkagesstudy,BHTACH’sCommunityCareCoordinationInventory(seedescriptionunderDataSources)providesdataoncommunity-basedresourcesfortheMedicaidpopulation.The27organizationalrespondents(includingthreeMCOs)describedsubstantialexistingeffortsandinvestmentsincarecoordinationandcasemanagement,suchasaruralElderDiabetesProjectofferedbyacommunity-basedorganizationusingStanfordChronicDiseaseSelf-Managementmodelcertifiededucators,oratransitionalrespitecareprograminSpokanethatprovidespost-hospitalhousing,care,andservicecoordinationtohomelessindividuals.32AstheoperatoroftheNavigatorNetworkofEasternWashington,BHThasdirectconnectionswithmorethan50organizationswhohostoremploynavigatorstohelppeoplesignupforcoveragethroughWashingtonHealthplanfinder.Thepartnersrepresentmanysectorsincluding:Communityhealthclinics,hospitals,publichealth,nonprofitorganizations,faithbasedcommunityorganizations,behavioralhealthproviders,thecriminaljusticesystem,agingandlong-termcare,affordablehousingagencies,libraries,earlylearning,K-12education,and
highereducation.BHTACHisleveragingtheseconnectionstoengagepartnersinMTDprojectplanningandimplementation.AccessandconnectiontocarefortheMedicaidbeneficiarypopulationAccesstoandutilizationofcareamongMedicaidbeneficiariesvariesconsiderablywithintheBHTACH’sregion.RatesofadultuseofambulatoryorpreventivecarearegenerallyatorabovethestateaverageinmostofBHT’scountiesbutStevensCountyisanexception.Amongchildren(1-19years),primarycarevisitsarebelowthestateaverageinallthreenortheasterncountiesbutsubstantiallyabovetheaverageinAdamsCounty,wherechildrenmakeup68%oftheMedicaidpopulation.33
Figure6:Ratesofaccesstoprimarycareamongadults(left)andchildren(right),2015-16
Disparitiesalsoexistbygenderandrace.Only69%ofadultmaleMedicaidbeneficiarieshadanambulatoryorpreventivecarevisitinthelastyear,vs.85%ofwomen.Amongdifferentracialgroups,ratesofambulatoryorpreventivevisitsbyadultsinthelastyearrangedfromalowof
72%amongNativeHawaiiansandPacificIslanderstoahighof80%amongAI/ANsandindividualswhoidentifiedasmulti-racial.34
QualisHealthreportsthatallMCOsinWashingtonstateshoweddecreasesinadultaccesstoambulatory/preventivehealthservicesfromthe2015to2016reportingyearsandthatthestaterateisnowmorethan5percentlowerthanthenationalaverageforMedicaidplans.35IntheBHTACHcounties,rateshavedeclinedmostnoticeablyinFerry,PendOreille,andStevensCounties.
Figure7:Medicaidadults(20+)whohadanambulatoryorpreventivecarevisitinthemeasurementyear(rolling12-monthperiods)36
Variationisalsothestoryforaccesstoandutilizationofparticularformsofcare:
• EDutilization(broadlydefined,includingvisitsrelatedtomentalhealthorsubstanceabuseissues)iscurrentlyat70visitsper1,000membermonthsfortheBHTregion,whichisslightlyabovethestateaverageof68visitsper1,000mm.ButtheaggregateBHTACHfigureisdrivenbythepopulationconcentrationinSpokaneCounty;adult
Medicaid-coveredresidentsofAdams,Lincoln,andFerrycountieshavesomeofthelowestMedicaidEDutilizationratesinthestate.37
• BHTACHisalittlebelowthestateaverageformentalhealthtreatmentandsubstanceabusetreatmentpenetrationratesamongMedicaidbeneficiaries.Ontheotherhand,ratesoffollow-upafterahospitalizationorEDvisitrelatedtomentalhealthorsubstanceusearehigherthantheaverageforWashingtonstateMedicaid.38
GapsbetweenMedicaidpopulationneedsandavailableservicesBHTACH’sregionisgeographicallyspacious,covering12,273squaremiles.TheareaincludesWashingtonState’shighest-elevation,pavedroadat5,574feet(ShermanPass)andonlyoneinterstatehighway,meaningthatStateRoutes,ruralroads,andferrycrossingsaretheprimaryroutesoftravel.Transportationshortcomings,geographicbarriers,andinclementweatherfrequentlylimitaccesstocare.MostofBHTACH’sregion,otherthantheSpokanemetroarea,hasmultiplehealthprofessionalshortagearea(HPSA)designations:39
• ThereisashortageofprimarycareprofessionalsforallresidentsofFerryCounty(greenshadinginthemapbelow),andforlow-incomeresidentsinmostotherareasofBHT(pinkshading)
Figure8:WashingtonPrimaryCareHealthProfessionalShortageAreas,Jan.2017
• AllBHTACHcountieshaveashortageofmentalhealthprovidersforanyresident,includingmostofSpokaneCounty(greenshading).ThemetroSpokaneregionisdesignatedasalow-incomementalhealthHPSA(pinkshading).
Figure9:WashingtonMentalHealthProfessionalShortageAreas,Jan.2017
• Finally,allBHTACHisdesignatedasadentalhealthcareprofessionalshortagearea.Thedesignationappliesmostlytolow-incomeresidentsbutappliestoallresidentsofFerryCounty(greenshadinginthemapbelow).
Figure10:WashingtonDentalHealthProfessionalShortageAreas,Jan.2017
TheUniversityofWashington’sCenterforHealthWorkforceStudiesreportsthatEasternWashingtonhasfewerphysiciansprovidingdirectpatientcarethantheWesternpartofthestate(185per100,000populationvs.242per100,000)andthatthephysicianworkforceisgrowingmoreslowlyintheeast.Theeast-westphysiciansupplydisparityisevenmorepronouncedforpsychiatrists:in2014therewere4.9psychiatristsper100,000incountieseastoftheCascadesvs.11.9per100,000inwesterncounties.Easterncountieslost2.5%oftheirpsychiatristworkforcebetween2014and2016,whereasWesternCountiessawa9%increase.40BHTACHareaparticipantsintheWashingtonStateHealthWorkforceSentinelNetworkreportrecentincreasesindemandforclinicalsocialworkersandmentalhealthcounselors.41
Statewidein2016,77%ofadultAppleHealthenrolleesreportedthattheywereusuallyoralwaysabletogetneededcareand78%reportedusuallyoralwaysgettingcarequickly.RegionalresultsarenotavailableandtherewaslittlevariationamongtheMCOs.42BHTACHhaslower-thanaverage(forWashingtonstate)ratesofpotentiallyavoidableEDvisitsamongMedicaidbeneficiaries43and,exceptfortheSpokanemetroarea,lowerthanaverageratesofpotentiallyavoidablehospitalizations(allpayers).44Intheinterestsofreducingaccessshortcomings,providerpartnersintheBHTACHregionhaveastronginterestinexpandingtelehealthcapacity.TelehealthprioritiesreportedbyrespondentstoBHTACH’sHealthSystemsInventoryincludedpsychiatry,neurology,andremotemonitoring.45ConversationswithproviderpartnershaveilluminatedafewbarrierstoexpansionoftelemedicineservicesthatBHTACHwillexplorefurtheraspartofMTDprojectplanning.Theseincludecertificationrequirementsthatrequirealargerencountervolumethansomeruralprovidershave,thecostoftechnologyandspacefortelehealth-enabledvisits,andstafftraining.
ACHTheoryofActionandAlignmentStrategy
ACHTheoryofActionandAlignmentStrategyBetterHealthTogetherVisionBetterHealthTogether’svisionisthateveryperson,regardlessofbackground,lifeexperienceorenvironment,willliveaproductive,highqualitylife,withaccesstostablehousing,nutritiousfood,transportation,education,meaningfulemploymentthatpaysthebillswithsomeleftoverforsavings,andsocialsupportnetworksthatfosteremotionalandpsychologicalwellbeing.PleaseseeAttachment1foranupdatedTheoryofActionlogicmodelgraphic.Thisisaloftyvisionandwillnotbeachievedbyanyoneorganization.BetterHealthTogether(BHT)willachievethisvisionbydevelopinganintegratedcommunityhealthsystem,accountabletoimprovinghealththroughdeliveringculturallycompetent,whole-personcaretoeachpersonwithintheregion.WhileBHTACH’svisionisaspirational,ourworkisgroundedintheneedsandconcernsvoicedbyourextensivearrayofpartneringprovidersaswellastheregionalhealthprioritiesidentifiedthroughourregionalhealthneedsinventory.Spanning12,273squaremiles,muchofourregionconsistsofisolated,ruralcommunitiesthataremilesawayfromconsistentlyavailablehealthservices.Providershortages,especiallyinbehavioralandoralhealth,furtherconstrictaccess,especiallyforruralhealthproviderswhostruggletofillpositions.Severedisparitiesexisteveninresource-heavyurbancenterSpokane,wherethelifeexpectancybetweenneighborhoodsvariesbyupto18years.46Ourjailandemergencysystemsareoverandinappropriatelyutilizedbybehavioralhealthpatientswithoutaccesstostablesocialandhealthsupports.YouthinSpokaneCountyenterfostercareatnearlydoublethestateaverage.47Aseverehousingshortagefurtherincreasestheriskofhomelessnessforvulnerablepeople.Thesesocialriskfactorsmaycontributetoourhighprevalenceratesofasthmaamongyouth(self-reportedat14-24%)48anddiabetesinadults(rangingfrom9-14%intheBHTACHcounties).49TheBHTACHconductedHealthSystemandCommunityCareCoordinationInventories,whichsurveyedpartnersfortheirvision,capacity,engagementofcliniciansandpatients,workforce,and data needs forMedicaid transformation. Based on information obtained through theseinventoriescoupledwithregionalhealthneeds,theBHTACHidentifiedthefollowingactionablegoals:
• Improvewholepersoncareinqualityandaccessthroughtheintegrationofbehavioral,physicalandoralhealthsystems
• Developstrongcommunitysystemsthatlinkhousing,foodsecurity,transportationandincomestability
• Decreaseobesityratesacrossallpopulationsthroughprevention
• Scalecommunity-basedcarecoordinationtoimprovehealth
Thesefourregionalprioritiesspeaktoacommunitydesiretoseestrongerlinkagesbetweenhealthandsocialdeterminantssystemstosupportwhole-person,community-basedcarewithafocusonprevention.BHTACH’sextensivecommunityconversations,alongwithprovidersurveysanddataassessments,alsoidentifiedprioritypopulationsfortheregion.Beneficiarieswithcomplexcareneeds,particularlythosewithaco-occurringbehavioralhealthdisorderandchronicdisease—suchasdiabetes,asthma,hypertension,andcardiovasculardisease—havebeenconsistentlyidentifiedashigh-prioritypopulationsfortheregion.TheneedsoftheseprioritypopulationswillbeemphasizedthroughouttheProjectPortfolioandthroughBHTACH’sadditionalinvestments,strategiesandpartnershipactivities.ByemphasizingtheneedsofthesepopulationsthroughtheProjectPortfolioandotheractivities,theBHTACHexpectstolowercostsandimprovehealthcaredeliveryandoutcomesfortheregion’smostvulnerablepopulationsaswellasimprovetheoverallhealthsystem.BHTbelievesthatatrulyeffectivecommunityhealthsystemnotonlycaresforthewholeperson,butisaccessibleandusedbyall.Weknowfromexperiencethatthebestsolutionsareledlocallyandhelpbuildastrongerbridgebetweenclinicalandcommunityproviders.AdailymantraforBHTstaffandpartneringprovidersis“successwillrequireEACHofustobeboldandengaged.”DespitethehighlevelofengagementofregionalprovidersintheBHTACHvisionandplans,changingpracticeandpaymentmodelswillbechallenging.TheMedicaidTransformationDemonstration(MTD)fundswillenabletheBHTACHtojump-starttheneededtransformations,provethesustainabilityofitsprojects,andsupportpracticechangesacrossprovidersettings.ProjectPortfolioTheBHTBoardofDirectors’decisionaboutprojectselectionwasbasedonrecommendationsfromourWaiverFinanceWorkgroupandBHTstaff,presentedattheNovember2nd,2017meeting.TheBoardapprovedaProjectPortfoliothatincludesfourprojects:
• Bi-DirectionalIntegrationofCare(required)
• Community-BasedCareCoordination
• AddressingtheOpioidsUseCrisis(required)
• ChronicDiseasePreventionandControl
TheBHTBoardselectedthesefourprojectsbecauseoftheirimportancetoMedicaidbeneficiariesintheregionaswellastheregionalhealthneedsofthebroaderpopulation.
AlthoughtheBoardhadpreviouslyconsideredaportfolioofsixprojects,therecentannouncementofareductioninavailablefundsforACHspromptedtheBoardtostrategicallyfocustheProjectPortfolioonthemostcriticalareasofneedforlong-termhealthsystemstransformation.ProjectSelectionProcessPriortotheportfolioselectioninearlyNovember,theBHTBoardundertookadeliberativeprocesstounderstandtheprojectsintheMTDToolkit,theirrequirements,includingtherequiredperformancemetricsandfundsflowweighting,alongwithcommunityinterestandregionalneeds.ThisworkbeganinearnestinJanuary2017attheannualBoardRetreat,duringwhichboardmemberslearnedfurtherdetailabouttheeightpotentialprojectsareasandheldearlydiscussionsontheprioritizationofprojectareasandtheappropriatesizeoftheProjectPortfolio.Althoughboardmembersexpressedsupportforallprojectareas,therewasconsensusthattheBHTACHProjectPortfolioshouldbealignedandfocusedonregionalneedsandprioritiesinordertomaximizeimpact.BoardmembersagreedthePortfolioshouldconsistofaminimumofsixprojects(theminimumnumberrequiredatthetimetobeeligiblefor100%oftheregion’spotentialfunding).Inthemonthsthatfollowed,theBHTACHundertookanextensivecommunityandstakeholderprocesstodevelopaProjectPortfolioinpartnershipwithprovidersandbasedonregionalprioritiesandneeds.CommunityconversationshavedriventhisworksincethebeginningthroughCommunityStrategyMapfocusgroups,ourLeadershipCouncil,andworkthroughfiveruralcountyhealthcoalitionsandSpokane-basedpartneringprovidersforexploringandguidingthebestlocalsolutionsandearlydevelopmentoftheBHTACHProjectPortfolio.InMarch2017,theBHTACHrequestedLettersofInterest(LOIs)tomoreformallygaugeinterestineachoftheeightpotentialprojectareasamongpartneringprovidersandcommunitystakeholders.Therewascross-sectorrepresentationintheprojectselectionprocess,includingcommunityhealthandbehavioralhealthcenters,managedcareplans,hospitals,communitypartners,consumerperspectivesandcommunity-basedorganizations.Thisinitialprocessidentifiedcommunityinterestinalleightareas.Furthercommunityconversationswithpartneringproviders(includingproviderfocusgroupsessions),meetingswiththeTribalPartnersLeadershipCouncil,andintheBHTACHLeadershipCouncilmeetingsresultedintheprioritizationofsixprojectareasfortheregion:community-basedcarecoordination,bi-directionalintegration,addressingtheopioidcrisis,chronicdisease,aswellastransitionsofcareanddiversions.Insummer2017,theBHTACHthenconductedHealthSystemsandCareCoordinationinventorieswithkeyagenciesacrossallsixcountiesintheregion.Thisprocessrevealedthatinterestandtangibleprioritiesweremostconcentratedin:
• Community-basedcarecoordination• Integrationofcare,includingbehavioralhealth,physicalhealthandoralhealth• Addressingtheopioidcrisis• ChronicDisease
Overwhelmingly,community-basedcarecoordinationwasidentifiedasthehighestpriorityintheregion.Asaresult,thePathwaysHubmodelforcommunity-basedcarecoordinationwillserveasananchorstrategyduetothecentrallyidentifiedneedto“coordinatethecoordinators,”whichhasbeenidentifiedoverandoveragainwhenengagingwithcommunitypartners.WiththecommunityprioritizationprocessandHealthSystemandCareCoordinationInventoriesinmind,alongwithhealthdatafromtheRegionalHealthNeedsInventoryandothersources,theBHTACHTechnicalCouncilsincludingtheWaiverFinanceWorkgroupandtheTribalPartnersLeadershipCouncil,aswellastheACHLeadershipCouncilandBoardofDirectorsmoredeeplyconsideredthemodelsinthetoolkitandtherequiredperformancemetrics.TheneedtoprioritizeandfocuswasagainreinforcedbytheBoard,withanemphasisonbuildinguponworkalreadyunderwayandcapitalizingontheprioritiesandinterestsoftheregion’shealthsystems.TheBoardconsideredthebalanceofpartneringproviders’interestinfocusingtheportfolio,particularlygiventhesignificantcutsintheDY2budgetannouncedinlateSeptember,withbroadercommunitystakeholderinterestinanexpandedportfolio.TheBHTACHmadeaconsciousdecisiontousetheProjectPortfolioasaprimaryleverforincreasingtheregion’sreadinessforValueBasedPayment(VBP).Ultimately,theBoarddeterminedthatthefourprojectareaswiththestrongestresponsesinthehealthinventoryweretherightProjectPortfoliofortheBHTACHregionandwouldbuildthebestfoundationforinvestinginVBPreadinessandincorporatingthesocialdeterminantsofhealth.However,becauseofthecommitmenttoalleightareasinthetoolkit,theBoardhasalsodirectedtheBHTACHtoincorporateoralhealth,transitionalcare,diversions,andreproductive,maternalandchildhealthintoACHactivitiesandstrategies.
ProjectSelectionCriteriaTheBHTACHusedthefollowingprinciplestoguideitsdecision-makingprocessaroundtheProjectPortfolio:
• RegionalNeed:Doesitconnecttoahighmagnitudeofdocumentedneed(withoutduplicationorintensecompetitionofexistingefforts)?
• Healthequity:Doesthestrategyreducehealthdisparitiesand/oradvancehealthequity?Doesitaddress/supportsocialdeterminants(underlyingcommunityconditions)?Doesitreducestigmaanddiscrimination?
• Impact&Sustainability:Can/doesitaffectalargenumberofMedicaid-coveredlivesandwillitprovideareturnoninvestmentwithin2-3years?
• Feasibility:Istherepartneringproviderinterest?Dothestrategiesoractivitiesbuildon(andnotduplicate)existingefforts?IsthereaclearrolefortheACH?DoesthestrategylinktoP4RandP4Pmeasuresinthetoolkit?
• VBPReadiness:WillitincreaseregionalreadinessforVBPbytheendofthedemonstration?
SharedInterventions,Resources,andInfrastructureAlloftheprojectsintheBHTACHProjectPortfoliomakeuseofthePathwaysHUBasasharedresource.Alongwithintegrationofcare,expandingcarecoordinationeffortswillbeananchorstrategyfortheBHTACHregioninconnectingdisparatesystems.TheBHTPathwaysHubwillsupportbestpracticecarecoordinationandinformationsharingacrosstheregion’scommunity-basedorganizationsandhealthsystems.ThePathwaystechnologyplatformprovidesreal-timedatatoidentifyresourcegapsandmonitorstheeffectivenessofbestpracticeinterventionsaswellasthequalityofthecarecoordinationagenciesimplementingthem.Thiswillbeapowerfultooltosupportadata-drivencaseforalignmentofcommunityinvestments,especiallyaroundmajorresourcegapsinsafeandaffordablehousing,jobsinruralcounties,andtransportationthroughouttheregion.TheBHTACHwillwithhold10%ofalldemonstrationdollarstoinvestinaCommunityResiliencyFund.ThefundwillalignwithACHcommunityprioritiestostrengthenthelinkagesbetweenthehealthcaresystemsandproviderswhofocusonsocialdeterminantsofhealth.ItistheintentoftheBHTACHtoleveragethesedollarstoinfluenceincreased,targetedinvestmentinpopulationandcommunityhealthimprovement,includingaligningnonprofithospitalcommunitybenefitdollars,philanthropicfunders,andsharedsavingsinvestmentmodelsbasedondatasupportedbyaBHTACHCommunityDashboard(explainedbelow).AllourprojectswillshareanemphasisondisruptingtheintergenerationalcycleofAdverseChildhoodExperiences(ACEs),acentralpartofwholepersoncareforourregion.ACEswillbeincorporatedintoeachproject’simplementationplans.Manyconcurrentregionalactivitiesareaddressingtheseriskfactors,includingmultisectororganizationssuchasPrioritySpokane,InvestHealth,theAWayHomeWashington100DayChallengearoundendingyouthhomelessness,andEmpireHealthFoundation’sregion-wideACEsinitiative.TheBHTACHhasactivelyengagedindesigneffortswiththesepartnerstoensureproactiveconnectiontoMTDprojectsand,specifically,carecoordinationefforts.Inaddition,theBHTACHisdevelopingasharedlearningandqualityimprovementinfrastructure.ThisinfrastructurewillincludetheBHTProvidersChampionCouncil.Thisrecentlyestablishedcouncilwillprovidegeneralclinicalandsubjectmatterexpertiseacrossthe
fourMTDprojectareas.ThecouncilwillmonitortrendsinclinicalperformanceacrosstheprojectstoassesswhethertheBHTACHisontracktoachieveexpectedoutcomesandwilladviseonproposedriskmitigationandcontinuousimprovementstrategies.TheBHTACH’sDirectorofClinicalIntegration,apositioncurrentlyinrecruitment,willstafftheProviderChampionsCouncilandhelpidentify,communicate,andaddresschallengestoclinicalintegrationandothertransformationstrategies.ToserveastheimplementationarmfortheMTDProjects,theBHTACHwillutilizeaCommunityHealthTransformationCollaborativemodel,withaSpokaneCountybasedCollaborativeandaRuralCollaborative,includingeachofourfiveruralcounties.CollaborativeswillbesupportedbyBHTstaff,whowillhavea“bird’seyeview”ofworkoccurringacrosstheregion.TheCollaborativeswillbecomprisedofkeypartnerswiththeexpertiseandexperiencerequiredtotransformourMedicaidDeliverySystemincludingclinics,FederallyQualifiedHealthCenters(FQHCs),hospitals,mentalhealthandsubstanceuseproviders,EMS,JailsandCountyCommissioners.EachCollaborativewillbeaccountabletodevelopacounty-basedsystemofcareprojectplantomeetboththeregionalACHobjectivesandtheMTDprojectrequirements.Inadditiontodevelopingacounty-basedplan,theCollaborativeswillbeaccountabletomonitorperformance,coursecorrectwhennecessary,andparticipateinsharedlearningopportunitieswithintheregion.BHTACHiscontractingwiththeProvidenceCenterforOutcomesResearchandEducation(CORE)toleadthemonitoringsystemdesignandoversight.ProvidenceCOREwillserveasasharedresourceacrossprojects,coordinatingwithBHTstaffandtheentitiesabovetoprovidetimelyinformation,datainterpretationexpertise,andbothtechnicalandstrategicsupportforpeerleaningandcontinuousimprovement.WeexpectCOREtodevelopacommunitydashboardtomonitorkeymetricsidentifiedintheMTDToolkitandourcommunitypriorities.Thiswillbeamulti-functionaldashboardextendingbeyondtheMTDtoallowongoingcommunitytrackingandprioritysetting. StatewidetransformationeffortsoutsideMedicaidwillalsoserveasasharedresourceandframeworkfortheBHTACHProjectPortfolio.Thereareanumberofstatewide,system-levelactivitiesinmotionwhicharedrivingeffortsfortransformation,includingtheshifttovalue-basedpayment(VBP)by2021,theshifttoFullyIntegratedManagedCare(FIMC)by2020,andeffortswhicharealigningMedicaidandMedicarepaymentstructures.Tobesuccessfulunderthistransformation,providersmustdevelopnewpracticesandworkflowsthatwillmeetspecifiedoutcomes.TheBHTACHviewswhole-personcareasafundamentalelementforsuccessinavalue-basedcaresystem.Ifthesystemisnotequippedtoseeandrespondtowhole-personneedsofpatients,truepopulationhealthimprovementwillneverbepossible.Aligningregionalenergyandinvestmentinactivitiesthatsupportwhole-personcarewillhelpprepareourregionforsuccess.
Concurrenttotheseactivities,MTDdollarscreateanopportunitytoacceleratesomeofthetransformativechanges,whiledemonstratingthevalueofwholepersoncareforpatientsandtheoverallefficiencyofthesystem.Overthenextfiveyears,theBHTACHwillcoordinatethefourintersectingprojectsthattargethigh-needsMedicaidpatientsandbuildoutmulti-sectorlinkagesbetweenprovidersthatsupportwholepersoncare(seelogicmodelinAttachment1).Eachoftheseprojectswillbetiedtospecificoutcomemeasuresthatwillincentproviderstodevelopnewprocessestodrivepatienthealthimprovement.TheBHTACHseekstomaximizeregionaleffortsbyaligningMTDprojectswithimplementationstrategiesdevelopedforupcomingMedicarechangesviaproviders’participationinanACOand/orMACRA/MIPSpreparation.Overthelastthreemonths,theBHTACHhasexploredwaystoleverageruralparticipationinanACOtocreatemoreopportunityforinvestmentandearningsforcountieswithhighratesofbothMedicaidandMedicare.Thesealignedeffortswillbuildcommunityinfrastructureandscaleupbestpracticethatsupportsresponsiveandsustainablesystemsimprovement.Withthesenewlinkagesandpracticesinplace,theBHTregionwillbepoisedforlargescaleimprovementofpopulationhealth.
Region-WideImprovementsTheBHTACHmadeastrategicdecisiontofocusitsProjectPortfolioonthefourcriticalareasnecessarytoimproveregion-widehealthoutcomesaswellasthequality,efficiencyandeffectivenessofthecaredeliverysystem.Overwhelmingly,providersandcommunitypartnersseeCommunity-BasedCareCoordinationasafoundationalinvestmentcriticaltohealthsystemstransformation.Increasedcarecoordination;whetherthroughCommunityHealthWorkers,CareCoordinators,orPeerSupportSpecialistswillcreatestrongerandbetterconnectionsandresourcingofsocialsupportsthatwillimproveoutcomesforMedicaidbeneficiariesandaccelerateadditionaldeliverysystemchangesthatwillultimatelybenefitallconsumers.Investmentsandactivitiestosupportintegrationofcare,includingphysical,behavioralandoralhealthcare,willimproveproviders’abilitytocoordinatecareforallpatientsandhelptobuildcapacitynecessaryfornewpaymentmodels.Additionally,ChronicDiseaseisasignificantcostdriverintheregion’shealthcaresystem,forMedicaidbeneficiariesandallconsumers.Strengtheningtheregion’sabilitytopreventchronicdiseaseandprovidebettermanagementforthoselivingwithchronicdiseasewillimproveoutcomesandlowercosts,freeingupmuchneededresourceswithinthehealthcaredeliverysystem.Andfinally,theOpioidcrisisimpactseverycommunityandeveryincomelevel.Itundermineseffortsunderwaytoimprovequalityofcareandlowercosts.Addressingthiscrisisthrougheducation,overdoseprevention,treatmentandsupportforrecovery,isnecessarytopreventtheissuefromcontinuingtoworsen.HealthEquityHealthequityisafoundationalgoaloftheBHTACHProjectPortfolio.Toensurethatindividualsfacingthegreatesthealthdisparitiesareservedbyourefforts,alloftheprojectswillengagein
extensiveassessmentoftargetpopulationsbyrace/ethnicityandlanguageaswellasgeographyduringtheplanningphase.Inordertoaddresshealthequity,thesystemneedstobesupportedbymechanismsandpracticeswhichallowproviderstorecognizetheholisticneedsofthepatient.Weseepositivemovementinthisdirectionwiththerecognitionofthedegreeofdisparitythatexistsinthecommunityandanever-growingacceptanceoftheimpactsofsocialdeterminantsonoverallhealthstatus.ItistheintentoftheBHTACHtocontinuetoworktoaddressenvironmentalandcommunitybarrierstoimprovingpopulationhealth.Atthecoreofhealthsystemtransformationeffectivelinksbetweenthehealthcaresystemandthesocialdeterminantofhealth.TheBHTACHhasdevisedafewkeyactivitiestoaccelerateourownequitywork,including:
• Disaggregatingdatabyrace/age/ethnicity/sex/zipcodewhereverpossiblebothtomakeinformeddecisionsabouttargetpopulationsandtomonitorimpactofprojectsacrossdiversegroups.TheBHTBoardhasidentifiedimpactedpopulationstotargetforMTDprojects.BHTwillsupplyCollaborativeswithregionaldatatoguideassessmentsofpartners,andexpecttodirectteamstodevelopTransformationplanstoaddresspopulationswithintheircountythatfaceahighlevelofdisparitiesand/orpresentashighlycomplexorhighrisk.
• LaunchingaCommunityVoicesCouncil,madeupofatleast50%Medicaidbeneficiariesorlow-incomecommunitymembers,aswellasCommunityAdvocatesandpeoplewithexperienceworkinginMedicaidservices.ThiscouncilwillbetaskedwithdevelopingHealthEquitymetricstowhichtheCollaborativeswillbeaccountableforhealthequitygoalsandstandards.ThisCouncilwillreviewtheCollaboratives’HealthEquityandTransformationprojectplansandprovidefeedbackoneffectivenesstoaddressingaccesstocareandequity.
• Developingan“EquityAcceleratorPayment”forprovidingpartnerswhoserveagreaterproportionofhighriskclients.ThismayincludeorganizationsthatservepredominatelyLatino/Hispanic,NativeorAfricanAmericanpopulations–allofwhomexperiencesignificanthealthdisparities–ororganizationsprovidingspecialtyservicestohighlycomplexpatientsthatrequiremoreintensivecare,suchassomesmallerMentalHealthandSUDproviderswhomightbeseeingfewerpatientsbecausetheonestheyservehavesuchintenseneeds.(WeexpectthemetricstiedtothesepaymentswillbeexploredbytheWaiverFinanceWorkgroup,vettedbyProviderChampionsCouncilandCommunityVoicesCouncil,andthenfinalizedforBHTBoardapproval.)
• Furthermore,thestrongemphasisonCommunity-BasedCareCoordinationasananchorstrategyservingallprojectsinthePortfoliowillalsoenabletheBHTACHtopromotehealthequity.ThePathwaysHubmodelwillexpandaccesstoCHWsandtheregion,providingculturallyandlinguisticallyresponsivecareacrossalloftheprojects.ThePathwaysHubcloselymonitorstheprogressofeachCareCoordinationAgency’s
CareCoordinatorsandclientstolookfortrends,strengths,andweaknessesamongproviders.ThisbothhelpstheHubtomaintainthequalityofcare,andoffertrainingswhenweaknessesareidentified,andhelpstheHubgrowourunderstandingofwhichagenciesmayofferthegreatestexpertiseorexperiencewithspecificpopulations.Additionally,thePathwaysmodelisoftenmostsuccessfulwhenimplementedwithcarecoordinatorswhohavelivedexperienceand/orcanrelatetopatientstheyareserving,providinganopportunityforworkforcedevelopmentandservicedelivery.
TheBHTACHalsointendstoconnectprojectwork,particularlyintheChronicDiseaseandCommunity-basedCareCoordinationproject,tolargersystemicworktoaffectACEs.HavingoneormoreACEsisassociatedwithhigherincidenceofchronicillness.50Ourfocusonapopulationwithdisproportionateimpactofchronicillnessisonewaytohelpdisproportionatelyaffectedpopulationsmoregenerally.BusinessModelandSustainabilityTheBHTACHisfocusedonmovingtheregiontoVBPandwholepersoncare.VBPisthecornerstoneofoursustainabilityplaninrecognitionoftheneedtotransitionhowwepayforcareandlinkingservicesthataddresssocialdeterminantsofhealth.Weareworkingtoaligndata,fundsflow,andmodeldevelopmenttomaximizetheopportunitytointegrateselectedprojectsintoavalue-basedmodelandweavetogetherlocalresourcesandinvestmenttoreachthisgoal.Forinstance,ourFundsFlowpolicywillincludedirectedinvestmentsforstartupcostsaswellasinfrastructureandtechnicalassistanceemphasizingDSRIPfundingfortransition,notanongoingpaymentstream.TheCommunityHealthTransformationCollaborativesaredesignedtosupporttheformationofthepartnershipsneededtosupportgeographicallybasedsystemsofcareinavalue-basedenvironment.ThelinkagescreatedtosupporttheMTDprojectswilltranslatetotherelationshipsnecessarytosucceedinavalue-basedmodelandimprovepopulationhealth.ThesupportfromtheACH,MTDdollars,andlocalinvestmentwillcreateanenvironmenttotestnewprocessesandimplementnewpracticestoensurereadinessforVBPandimprovedcaredelivery.EachofthefourMTDprojectsplayakeyroleininfrastructurechangeneededtosupportVBP.Increasedfocusandinvestmentinprevention,andscalingmoreefficientandconnectedinterventionstrategies,willleadtoamoreresponsivecommunityhealthsystem.TheBHTACHisalsoworkingtoalignitsstrategieswiththeACOdevelopmentsinMedicare,especiallyinruralcountieswiththemostrecentmeetingwithpartnersonNovember3rd,2017incollaborationwithGreaterColumbiaandNorthCentralACHs.TheCommunityResiliencyFundisanareathatmayextendbeyondtheMTDperiodaswebuildcommunityinvestmenttosupporteffectiveapproachestoaddressingsocial
determinantsofhealth.BHTwilldevelopacommunitydashboardthatmonitorskeysocialdeterminantandhealthindicatorsofourregionalhealthsystem’sviability.Byaligningregionalpartnersandinvestorsaroundtheseindicators,usingthedemonstrationasacatalyst,wecanidentifysynergiesandcreatealeveragedfundofflexibledollarsfortheregiontoaccessforstrategicinvestmentinovercominghealthdisparities.ImprovementssincePhaseIICertificationSincePhaseIICertification,theBHTACHhasdevelopedconcreteplansforsharedresourcesacrossprojectareas.TheBHTACHhascontinuedtorefineitsplansforsupportingtheworkoftheMTDProjects,aswellasthelong-termroleoftheACH.AstheregionalPathwaysHub,theACHwillmaintainanetworkofcommunity-basedreferralsandcarecoordinationresources,ensuringbest-fitcareattherighttime.TheACHwilltrackpopulationhealthacrossmultiplesystemstomeasuretheoveralleffectivenessofthecarenetworkinimprovingaccessandoutcomes.Baselinedatawilldefinethecurrentstatusandhelpidentifybrightspotinterventionstoscaleaswellasgapsorwideninghealthdisparities.Thisdatawillinformrecommendationsforpolicychange.CommittedtofurtheringourworkpastDSRIP,theBHTACHwillpositiontheuseofthePathwaysHubandaCommunityDashboardaslong-termcommunityinfrastructure.
GovernanceGovernanceBHT’sGovernanceStructureAlthoughtheBoardofDirectorsisultimatelyaccountableforBetterHealthTogetherACHdecisions,ourgovernancestructureismulti-tieredwithdistributeddecision-making,jointownershipandmutualaccountabilitythatdrivesinnovationandfostersco-investmentthatleadstoimpact.Thisstructureiscomprisedofthefollowingbodies(seealsotheGovernancestructurechartinAttachment2):
• BoardofDirectors:19-memberdecision-makingandoversightbodyforBHTACH.AccountableforTransformationProjectsandallworkoftheBetterHealthTogetherACH.TherearefourstandingoperatingcommitteesoftheBoardtoconductworkoftheBoardandpreparetheBoardfordecision-making.Theseare:
o ExecutiveCommittee:CommitteewiththeauthoritytomakedecisionsonbehalfoftheBoardasappropriateandconductotherBoardbusiness.
o GovernanceCommittee:RecommendsforapprovalBoardCandidates,Officers,CommitteeLeadershipandmembers.
o FinanceCommittee:ProvidesfinancialoversightforACHadministration,BHTbudgetdevelopment,andotherBHTfinancialoperations.
o AuditCommittee:AnnuallyreviewsAuditfindingsfromindependentauditors.
• LeadershipCouncil:Anadvisorybodycurrentlycomprisedof68organizations,whosebroadparticipationhelpssynthesizelocalprioritiesintoregionalstrategies.(SeeAppendix11forthemostrecentlistofLeadershipCouncilmembers).ItisexpectedthattheLeadershipCouncilwillbeconvenedonaquarterlybasisin2018.
• TribalPartnersLeadershipCouncil:TofostercollaborationandcommunicationwithregionalTribes,IndianHealthServicefacilities,TribalOrganizations,andUrbanIndianHealthPrograms,TheTribalPartnersLeadershipCouncilwascharteredandiscomprisedofrepresentativesfromtheKalispelTribeofIndians,ConfederatedTribesoftheColvilleReservation,SpokaneTribeofIndians,TheNATIVEProject,TheHealingLodgeoftheSevenNations,andtheAmericanIndianCommunityCenter.RecognizingtheuniqueandimportantrolethatAmericanIndian/AlaskaNative(AI/AN)populationshaveinourregion,theBHTBoarddevelopedthisgrouptoensurethatMedicaidTransformationDemonstration(MTD)projectswerealignedandculturallyappropriatetomeetthehealthneedsofNativeAmericans.ThisCouncilwillcontinuetoplayacriticalroleinimplementationplanningandmonitoringimpactofMTDprojectsonTribes,Urban
Indians,andIndianHealthServicesfacilities.TheTribalPartnersCouncilwilladviseonmetricstoevaluatehowwellprojectplansaddresshealthequityasitrelatestoAI/ANhealth.
• TechnicalAdvisoryCouncils:TheTechnicalAdvisoryCouncilsprovidetechnicalexpertiseandinputdirectlytotheBoardofDirectorsabouttheregion’sMTDprojectsandstrategies.TherearethreeTechnicalAdvisoryCouncils:
o ProviderChampionsCouncil(PCC):ThisrecentlyestablishedCouncilprovidesclinicalexpertiseandsubjectmattersupportinthedevelopmentofthe“TransformationCompact”(seeProgramManagement&StrategyDevelopmentbelow)acrosstheMTDProjectsareas.TheCouncilwillrecommendkeyclinicalelementsandperformancemeasuresacrossprojectstoassesswhetherCollaborativesareontracktoachieveexpectedoutcomes.ItisexpectedthatthisCouncilwillalsoplayaroleindevelopingclinically-focusedcontinuousimprovementstrategies.
o CommunityVoicesCouncil(CVC):TheCVCwilllaunchinDecember2017.Atleast50%ofmemberswillbeMedicaidbeneficiaries,withtheotherhalfmadeupofCommunityadvocateswithlivedexperiencehelpingcomplexpatientsaccessandnavigatecommunityservices.ThisgroupwillinformCollaborativeprojectplanningbyvalidatingimplementationplansagainsttheneedsandexpectationsofMedicaidpatients.TheCVCwilladviseonmetricstoevaluatehowwellprojectplansaddresshealthequity,andwillusethesemetricstomonitorandmakerecommendationsforcoursecorrectionasneeded.MemberswillreceiveastipendfromBHTfortheirparticipation.
o WaiverFinanceWorkGroup:ThisgroupdevelopsandrecommendstotheBHTBoardasetofpoliciestogoverntheMTDFundsandprovidesoversightofMTDfunddistributionasnecessary.ThisteamwillalsovalidatefinancialplansforapprovalbytheBHTBoard.ThisgroupmakesrecommendationsdirectlytotheBoard(nottotheBHTBoardFinanceCommittee)onallMTDfundsallocationsandbudget,CommunityResiliencefunds,andmid-adopterFIMCIncentives.
FortheMTDprojectstobesuccessful,BHTrecognizesthattheACHleadershipmustdevelopandmaintainstronglinesofcommunicationandcollaborationwithpartneringproviders.Inadditiontotheleadershipandadvisorycouncils,BHTisestablishingRegionalCommunityHealthTransformationCollaboratives:
• RuralCollaborative(includingFerry,Stevens,PendOreille,Lincoln,Adamscounties)
• SpokaneCollaborative(Spokanecounty)
ItistheintentoftheBHTACHtotakearegionalapproachtoMTDprojectdesignandimplementationtoallowlocalautonomywhilecreatingregionalaccountability.TheCollaborativeswillberesponsiblefordevelopingandleadingactionableMTDplansacrossBHT’sprojectportfolio,andensuringthattheprojectscoordinatewithanddonotduplicateexistingeffortsintheregion.TheCollaborativeswillbecomprisedofkeypartnerswiththeexpertiseandexperiencerequiredtotransformourMedicaidDeliverySystemincludingclinics,FederallyQualifiedHealthCenters(FQHCs),hospitals,mentalhealthandsubstanceuseproviders,Tribalhealthsystems,EMS,jailsandCountyCommissioners.TheCollaborativesandtheACHTechnicalCouncilswillworkinabi-directionalfeedbackpartnershiptofinalizepolicyandprojectplans.Bydesign,thereiscross-representationbetweenCollaborativesandTechnicalCouncilstoensurelocalbuy-inandregionalaccountability.Itwillbetheresponsibilityoftheseleaderstoprovidestrategicguidanceonissuescriticaltoimprovinghealthbasedonexperience,expertise,andperspective,usinganevidence-based,“healthinallpolicies”approachatbothlevels.Thisstructureisdesignedtopromotemeaningful,cross-sectorcollaborationanddeepengagementofpartners,aswellastopreventanysingleentity,sector,orpersonfromdominatingthedecision-makingoractivitiesoftheACH.TheLeadershipCouncilandtheTechnicalCouncilsprovidetheBoardwithinputandrecommendationsfromsubjectmatterexpertswhiletheRuralandSpokaneCommunityHealthTransformationCollaborativeswillprovidelocalcontrol,expertise,andimplementation,acriticalfunctionforBHTgivenourlargegeographicregion.BoardmembersparticipatethroughouttheTechnicalCouncilsandRegionalCollaborativesasvestedpartnersandtoensuretoensuretheBoardofDirectorshasadirectrelationshipandstronglinesofcommunication.
Thefollowingfiguredemonstratestheintegratedandinter-dependentgovernancestructurethatconnectstheBHTBoardandAccountableCommunityofHealthLeadershipCounciltoourengagementpartnersintheRegionalHealthTransformationCollaboratives.Thefigurealsoemphasizestheimportanceofacommonagenda,continuouscommunications,andmutuallyreinforcingactivities.WhiletheapprovaloftheACHactivitiesandpoliciesisultimatelytheresponsibilityoftheBHTBoardofDirectors,itistheexpectationthattheACHLeadershipCouncilandCommunityHealthTransformationCollaborativeswillplayasignificantroleininfluencingthedevelopmentofourregion’shealthtransformationplans.
Figure11:BHTACHGovernanceandEngagementStructure
Inadditiontothegroupsdescribedabove,BHThasestablishedaRegionalIntegrationTeamtosupportthestatemandated2020goalofIntegratedMedicaidManagedCare.ThisteamprovidesamultisectorforumforkeystakeholdersandpartnerstodevelopaplanandtimelinetomeetthestategoalandacceleratetransformationfortheMedicaidpopulation.
FinancialOversightTheBHTBoardFinanceCommitteeprovidesfinancialoversightforACHadministration,BHTbudgetdevelopment,andday-to-dayoperations.Decisionsaboutfundsallocationmethodology,projectbudgetdevelopment,andtheTransformationCompact(seeProgramManagement&StrategyDevelopmentbelow)aremadebytheWaiverFinanceWorkgroup,whichiscomprisedofcountycommissioners,leadersfromphysicalandbehavioralhealthorganizations,socialdeterminantofhealthproviders,Tribalhealthleaders,RuralPublicHospitalDistricts,MultiCare,Providence,andMCOs.(SeeAppendix12fortheWaiverFinanceWorkgroupCharter).ThisgroupmakesrecommendationsdirectlytotheBoard(nottheFinanceCommittee)onMTDProjectFunds,CommunityResilienceFunds,andMid-AdopterFullyIntegratedManagedCareIncentivefunding.ThefirstsetoffundingallocationdecisionsweremadeattheNovember2,2017Boardmeeting.
ClinicalOversightTheBHTACH’sclinicaloversightstrategyincludestheBHTProviderChampionsCouncillaunchedinNovember2017.Asdescribedearlierinthissection,thePCCprovidesclinicalexpertiseandsubjectmattersupportinthedevelopmentoftheTransformationCompact(seeProgramManagement&StrategyDevelopmentbelow)acrosstheMTDProjectsareas.ThePCCwillrecommendkeyclinicalelementsandadviseonclinicalperformancemeasuresacrossprojectstoassesswhetherCollaborativesareontracktoachieveexpectedoutcomes.Additionally,thePCCwilladviseonproposedriskmitigationandcontinuousimprovementstrategies.StrategiesformonitoringclinicaloutcomesandcaredeliveryredesignOurinitialassessmentofclinicalcapacitywasconductedthroughself-reportedinformationcollectedfrom23healthsystemsviaaHealthSystemsInventory,whichidentifiedcurrentandfuturecapacityneedsandplans.Thisscaninformedprojectselectionandfindingswillcontinuetobecross-referencedwithotherrelevantdatasourcesusinganalyticsupportfromProvidenceCORE.BHTACHiscontractingwithCOREtoleaddesignandoversightofourmonitoringsystem.COREwillserveasasharedresourceacrossMTDprojectsandCollaborativestoprovidetimelyinformation,datainterpretationexpertise,andbothtechnicalandstrategicsupportforpeerleaningandcontinuousimprovement.Additionally,theProviderChampionsCouncilwilldevelopaframeworktoaddressproviderneedsandadvocateforallocationofappropriateresources.TheWaiverFinanceWorkgroupwillalignproposedfinancialincentiveswithclinicalandprojectperformanceduringtheplanningphasein2018.ThePCCwillsupportsharedproblem-solvingandlearning,andprovidesupporttoproviderswhoarestrugglingwithimplementationorhavingdifficultyachievingmetricsorreportingtargets.StrategiesforincorporatingclinicalleadershipClinicalleadershipiswell-representedontheBHTBoard,LeadershipCouncilandTechnicalCouncils,particularlythePCCandintheRegionalCommunityHealthTransformationCollaboratives.TheHealthSystemsInventoriesalsoservedasaninitialstrategyforengagingclinicalproviders.Asameasureofoursuccesstodate,inventoriesreceivedcoveredallsixofourBHTACHcountiesandrepresentedmorethan80%ofthehighvolumeMedicaidbillersintheregion.Eightwerefromruralpartners;threewerefrompublichospitaldistrictsthatincluderuralclinics;threefromI/T/Upartners,andfourfromFQHCs.WealsoreceivedinventoriesfromallhighvolumeMedicaidbehavioralhealthprovidersintheruralcommunityandthelargestproviderinSpokaneCounty,aswellasbothProvidenceandRockwood/Multicare.The
BHTACHwillcontinuetoengagewithclinicalproviderstoensureparticipationintheCollaborativesandoversightofclinicaloutcomesandcaredeliveryredesign.WeexpecteachCollaborativetoengagewithcriticallocalpartnersneededtofulfilltheirprojectimplementationobjectives.Additionally,initsroleasthePathwaysHub,theACHwillserveasaconnectorbetweenCollaborativeprovidersandadditionalsocialservicesandcommunitypartnerswhocansupportconnectionstosocialdeterminantsofhealth.CommunityOversightAsBHT’sACHroleexpandedtoincludethatofregionalconvenerandbackbone,wefurtherdevelopedourgovernancestructuretoincludetheLeadershipCouncil.Thecombinationofstrategicalliancesandengagementstrategiesensuresfocusonthehealthstatusandprioritiesofthewholecommunitysothatnosingleentity,sectororpersondominatesthedecision-makingoractivitiesoftheACH.Additionally,asdescribedearlier,inDecember2017BHTwilllaunchTheCommunityVoicesCouncil,comprisedofatleast50%Medicaidbeneficiaries,withtheotherhalfmadeupofcommunityadvocateswithlivedexperiencehelpingcomplexpatientsaccessandnavigatecommunityservices.DataOversightBHTiscontractingwithProvidenceCOREtoleadthemonitoringsystemdesignandoversight.COREwillserveasasharedresourceacrossprojects,coordinatingwithBHTstaffandtheentitiesabovetoprovidetimelyinformation,datainterpretationexpertise,andbothtechnicalandstrategicsupportforpeerlearningandcontinuousimprovement.ProgrammanagementandstrategydevelopmentProjectswillbedevelopedandmanagedbytheRuralandSpokaneHealthTransformationCollaboratives.TheCollaborativeswillbeguidedbyaTransformationCompactdevelopedinpartbytheTechnicalAdvisoryCouncilsthatwillincludeastrategicrubricofrequiredelements,strategiesandmetrics,afundsflowframework,andassessmenttools.TheCollaborativeswillbesupportedthroughregionalinfrastructureincludingconsultantsandBHTstaffaswellassupportfromtheTechnicalAdvisoryCouncilsasneeded.BHTwillsupportregionalcoordination,crosssector/crossregioncommunication,andprojectmanagementoversight.BHTPositionsinclude:
• BHT’sExecutiveDirectorwillprovideleadershipandstrategysupportacrosstheregionwithaspecificemphasisonensuringregionalpolicyalignmentforFIMC,MTD,andACOdevelopment.Additionally,theExecutiveDirectorwillworktoincreaseinvestmentinTransformationeffortsbeyondMTDandincreasefundingfortheCommunityResiliencyFund.TheExecutiveDirectorstaffstheWaiverFinanceWorkGroup,RegionalIntegrationTeamandBHTBoardofDirectors.
• BHT’sDirectorofClinicalIntegration,apositioncurrentlyinrecruitment,willprovideCollaborative-andprovider-levelsupportonMTDclinicalintegrationefforts.TheDirectorstaffstheProviderChampionCouncil.
• BHT’sAssociateDirectorofHealthTransformationwillprovideoperationalandstrategyleadershiponCommunityCareCoordinationincludingdirectingthedevelopmentofthePathwaysHub.TheDirectoralsoprovidesleadershipandstrategysupporttostaffingtheTribalPartnerLeadershipCouncil.
• BHT’sAssociateDirectorofCommunityEngagementwillprovideoperationalstrategyleadershiponeffortstoengageMedicaidBeneficiariesinMTDplanningandimplementation,aswellascommunityengagementefforts,includingstaffingoftheACHLeadershipCouncilandtheCommunityVoicesCouncil.
BHTwillcontract,asneeded,withtechnicalconsultantsandsubjectmatterexpertstosupportthedevelopmentofassessmenttools,fundsflowarrangements,projectplans,dataandanalyticstrategy,andotherspecifictechnicalassistanceasneedsoftheCollaborativearesurfaced.ChangestoGovernanceStructuresincePhase2CertificationInadditiontothenewTechnicalCouncilsmentionedaboveandtheRuralandSpokaneCountyHealthTransformationCollaboratives,BHThasaddedfournewmemberstotheBoardofDirectors:acountycommissioner,aSpokaneTribeofIndiansrepresentative,theCEOofthelargestregionalFQHC,andtheChairmanoftheBoardoftheSpokaneCountyMedicalSociety(whoisalsoapracticingfamilyphysician).Inordertoincludetheseimportantregionalpartners,BHTincreasedthesizeoftheBoardfrom17to19membersinOctober2017,whentherewerepreviouslytwoBoardseatvacancies.BHTalsoadded6non-votingex-officioCountyCommissionerpositions. AreasIdentifiedasNeedingImprovementinPhase2Certification
Comment:“LackofclarityregardinghowBHTwillsupportboardmembersinestablishingregularcommunicationtoolstosupportongoingfeedbacktotheirsector.Themechanismsareunclear.”
TofurthersupporttheexpectationthatBoardmembersrepresenttheirsectorandtoimprovesectorcommunication,theBHTDirectorofCommunityEngagementdraftsasummaryaftereachBoardmeetingandpresentsittoBoardmemberstobeindividuallytailoredtotheirparticularsectorandsentwithinaweekofthemeeting.(AnexampleofthissummaryisprovidedinAppendix13).Thisprocessensuresthat,inadditiontogeneralBHTcommunication,thesectorsthatBoardmembersrepresenthavethemostup-to-dateinformationfromacolleagueintheirsector.Wehavereceivedpositivefeedbackonthisadditionalcommunicationeffortfromseveralpartners.
Comment:“WouldappreciateadditionaldiscussionregardingthepotentialCOIconcernsthatthepolicyisintendedtoaddress.”
ArevisedConflictofInterestpolicywasadoptedinJuly2017andisdesignedtoguideBoardMembersinavoidingandbeingtransparentaboutfinancialorotherpotentialconflictsofinterest.ThispolicyisintendedtoaddressanycircumstanceunderwhichaBoardmembermaybeinfluencedormayappeartobeinfluencedbyanypurposeormotiveotherthanthesuccess,bestinterest,andwell-beingofBetterHealthTogether.(SeeAppendix14fortheupdatedConflictofInterestpolicy).OurConflictofInterestpolicyhelpstoassuretransparencyinBoarddiscussionsanddecision-making,whichisimportantformaintainingthetrustofthecommunityandpartneringproviders.TheBoardChairopenseachmeetingbyaskingwhetheranymemberhasaconflict.TheChairalsohastherighttodeterminewhetheranotherBoardmemberhasaconflict.Boardmeetingsareopentothepublic.Describetheprocessforensuringoversightofpartneringproviderparticipationandperformance,includinghowtheACHwilladdresslow-performingpartneringprovidersorpartneringproviderswhoceasetoparticipatewiththeACH.
TheBoardhasultimateoversightoftheimplementationofMTDprojectsandoutcomes.TheRuralandSpokaneCountyCollaborativestructurewillmobilizelocaleffortstotransformtheMedicaiddeliverysystem.TheTechnicalCouncilssettherequirementsforsuccessoftheCollaborativesthroughthedevelopmentofaframeworkandmetricsofsuccessandbyidentifyingareasofimprovement.TheProviderChampionsCouncildevelopsrequiredclinicalchangeelements,andprovideoversightonclinicalintegrationprogress.TheWaiverFinanceWorkgroupdirectsfundsflowmodellingandprovidesfinancialoversight.TheCommunityVoicesCouncilandTribalPartnersLeadershipCouncilsetgoalsforbeneficiaryandNativeAmericanhealthintegrationandhealthequitygoals,andprovideoversightonprogressinthoseareas.ItisexpectedthatourFundsFlowmodelwillrewardparticipationandachievementofmetricsataProviderandCollaborativelevel.ThismodelallowsforustoensurebroadMedicaidproviderengagementthroughouttheregionandrewardperformance.BHTstaffandTechnicalAdvisoryCouncilswillengageexternalsubjectmatterexpertsasnecessaryinthedevelopmentofnecessarytechnicalassistanceandsharedlearningopportunitiestosupportproviders.BHTStaffwillalsofacilitatesharedlearningacrossprojectsandpartneringproviders.StartinginQ1of2018,Collaboratives/ProviderswillberequiredtosubmitmonthlyprogressreportstoBHTACHtotriggerparticipationpayments.ThisprogressreportwillallowBHTstafftomonitorprogressandprovidetechnicalassistancewherenecessary.Additionally,viaourTechnicalCouncils,BHTintendstoconvenecohortsofpartnerstolearnfromsuccessesandcollectivelyproblemsolvechallenges.In2019,BHTwillbegintoutilizeacommunitydashboarddevelopedbyCOREtomonitorkeymetricsrelatedtoMTDand
communitypriorities.AsweembarkontheCollaborativeplanningprocess,BHTACHiscommittedtoworkcloselywithpartnerstoassessthebestwaytosupportbothhighperformingandlow-performingandtodosofairlyandtransparently.
CommunityandStakeholderEngagementandInput
CommunityandStakeholderEngagementandInputTheBHTMeaningfulConsumerEngagementandMeaningfulProviderEngagementplanningprocessesinvolvedseveraltiersofactivitydesignedtosecureinputintotheselectionandplanningofMedicaidTransformationDemonstration(MTD)andtoyieldarecommendedpolicyandstrategyfortheBHTBoardtoconsideradoptingforongoingmeaningfulengagementofconsumersinfutureAccountableCommunityofHealth(ACH)andMTDactivities.TheengagementprocesseswerefacilitatedbyAppliedInsight.Tworeports,1)BHTMeaningfulConsumerEngagementand2)BHTMeaningfulProviderEngagement,detailfindings.(SeeAttachments3and4.)MeaningfulConsumerEngagement
Intotal,40consumersparticipatedinfocusgroupdiscussionstoinformtheselectionandplanningofMTDprojectsfortheBHTACHregionandtoprovideinsightandideasforestablishingalong-term,meaningfulconsumerengagementstrategyforongoingACHactivities.Thefollowinggroupswerecoordinatedinpartnershipwithavarietyofcommunityhostorganizations:
• YouthinFosterCareand/orRecentlyAgedOutoftheFosterSystem(inpartnershipwithEmbraceWashington,CareerPathServices,andSafetyNet)
• TribalMembersandUrbanIndianCommunityCenterVisitors(inpartnershipwiththeAmericanIndianCommunityCenterandEmpireHealthFoundation)
• RuralResidentsthroughoutNortheastWashington(inpartnershipwithRuralResources)
• RuralResidentsthroughoutLincolnCounty(inpartnershipwithLincolnCountyHealthDepartment)
• UrbanResidentsthroughoutSpokaneCounty(inpartnershipwithCommunityHealthAssociationofSpokane/CHAS)
Namesoffocusgroupparticipantsareconfidential,buthostorganizationsverifiedattendanceandgroupcompositionwasvalidatedfordiversitytoensurethefollowingcharacteristicswererepresentedbytheattendees:
• Geography(rural,urban,tribal)
• Raceandethnicity
• Gender
• Age
• Healthconditions
• SocialdeterminantneedsMeaningfulProviderEngagement
Intotal,21providersparticipatedinkeyinformantinterviewsand24providersparticipatedinthreeseparatefocusgroupstoinformtheselectionandplanningofMTDprojectsfortheBHTregionandtoprovidetheirinsightsandideasforestablishingalong-termmeaningfulproviderengagementstrategyfortheactivitiesoftheACH.Namesofintervieweesandhostorganizationsforfocusgroupsareincludedintheattachedreports.Intervieweesandfocusgroupparticipantsrepresentedadiversecross-sectionofprovidersaccordingtothefollowingcriteria:
• Geography(rural,urban,Tribal)
• Raceandethnicity
• Healthsystem/practicesizeandmodel(large,small,independent,university-affiliated,communitynon-profit,etc.)
• Sectorrepresentation(medical,behavioral,substanceabuse,oralhealth,publichealth,MCO,etc.)
• Practicetype/targetpopulationserved(pediatric,geriatric,familymedicine/primarycare,internalmedicine,tribal,homeless,psychiatric,etc.)
• Socialdeterminantsorganizations(housing,foodsecurity,socialservices)HealthSystemandCareCoordinationInventories
InlateAugust,BHTACHconducteditsHealthSystem(HSI)andCareCoordinationInventories(CCI),seekingpartneringproviderperspectivesontransformation(seeAppendices6and7).ThecomprehensiveinventorieshavebeenutilizedtoinformdecisionsabouthowtostructureourMTDplanningefforts.BHTACHofferedaPayforReportingincentivetoallpartnerswhocompletedtheinventories(excludingMCOs)of$5000fortheHSI,and$2000fortheCCI.TheHSIwasconsiderablylonger,andaskedformorepatientleveldata,whichaccountedforthehigherpayout.Intotal39uniquepartnerscompletedinventories,earning$181,000total.Thenumberofinventoryrespondents(HSIorCCI)bycountyisshowninfollowingchart;notethatseveralparticipatingorganizationsoperateinmorethanonecountyandarelistedunder‘multiple.’
Figure12:HealthSystemandCareCoordinationInventoryRespondentsbyCounty
EnsuringTransparencyandConsideringPublicInput
TheBHTACHinvestsheavilyinarobustwebsitewhichincludestheLeadershipCouncil(LC)andBoardmeetingschedulesforthewholeyear,aswellasnotes,documentsandrecordingsfrommeetings.Weregularlypostsynthesizedcontentonourbloginaneasy-to-digestformattosupportsharedknowledge.WeareespeciallyproudofourPathwaysvideos,whichwereincrediblywellreceivedbypartners.Additionally,allnewinformationissharedinweeklyACHeNewsupdatethroughMailChimp,whichhasincreasedfrom~200to~300subscriberssincewesubmittedourPhase1certification.WeareactiveTwitterusers,andattempttotweetabouteachmeetingordiscussionswithpartnerstoincreasetransparency.TheBHTBoardhostsapubliccommenthourandopenboardmeetingsonceamonth,generallyinSpokaneatthePhilanthropyCenter;accessisalsoavailablebywebinarcall-in.WealsohostaBoardmeetingannuallyinoneofourruralcounties.InMayof2017,wemetattheCamasPathCenterinPendOreilleCountyontheKalispelReservation.Thedates,locationandagendaforupcomingBoardmeetingsarepostedinadvanceonourwebsite.BHTstaffprovidesareportofanypubliccommentduringtheBoardmeetingandensurespubliccommentsarereflectedintheminutes.OnceapprovedbytheBoard,theminutesfromeachmeetingarepostedonourwebsite.
0 2 4 6 8 10 12 14 16 18 20
Adams
Ferry
Lincoln
Multiple
PendOreille
Spokane
ACHCapacityBuilding
SinceaddingthreemorestaffinMay2017,theBHTACHhasgreatlyincreaseditscapacitytoengageandseekfeedbackfromcommunitymembers.CentraltoourstrategyisofferingACHstafftimeforlocalcapacitybuilding,suchasstaffingRuralCountyHealthCoalitionsorfacilitatingprogramdesignacrosspartners.We’vewitnessedsuccessinourengagementstrategythroughregularparticipationfromahighnumberofdiversepartners,whoparticipatefreelyinconversationandcontributingtotheACH’sregion-widevisionandstrategy:
• Over75communitymembersparticipatedonaCommunityStrategyActionteam.
• Wereceivedlettersofinterest(LOI)representing90+differentprojectideasfromfortyuniqueorganizations
• 94communitymembersattendedourProjectShowcaseinSpokanetoprovidefeedbackinprojectideas,withrepresentationfromallsixcounties
Thislevelofparticipationsignalsasignificantlevelofcommitment,especiallywhencommunitymemberstraveledtogivefeedbackonprojectideas.Tosupportregionalparticipation,BHTACHofferstocompensatemileageandlodgingforruralpartners.Ourstaffarequicktoconductoutreachwithanyneworganizationsandcommunitymemberswhoexpressinterestorattendanyofourmeetings.OurLeadershipCouncilnowconsistsof68memberorganizations,with10newmembersaddedsinceSeptember2017.SincePhase2,theBHTACHhaslaunchedaweeklyCollaborativeLearningSessionwebinaronFridaymornings,coveringkeystrategiesandactivitiesoftheMTD.Thesesessionsareopentothepublicandallrecordedandpostedonourwebsite.
Table3:CollaborativeLearningSessionWebinars
ProvideexamplesofatleastthreekeyelementsoftheProjectPlanthatwereshapedbycommunityinput.TheBHTACHhasreliedoncommunityinputtoguideourprocess,withourregionalprioritiesgeneratedfromcommunityconversationsacrossallcountiesandunanimouslyagreedtobyourLeadershipCouncil.Weconductedover40meetingstobuildourCommunityActionStrategy
Date(2017) LearningSessionTopic
October6 RHNIOverview–howACHusesdata
October13 TransformationProjectSelection:4vs6vs8
October20 BehavioralHealthIntegration
October27 OverviewofCommunityLinkageMapping
November3 RegionalHealthWorkforceDevelopment
Maps,whichanchortheACHeffortstomemberswhoparticipatedintheseworkgroups,includingMedicaidbeneficiarieswhospoketotheirexperiences(seeAppendix1).Keyelement1:Participantsinthecommunityconversationsdescribedourregionashavingawealthofpassionatepeopleandeffectiveprograms,butaninabilitytomakelarge-scalepopulationimprovementsduetoalackofhigh-level,outcomes-basedcoordination.Participantsspecificallynotedtheneedtocoordinatethecoordinators.ThisfeedbackledustoexplorethePathwaysHUBModelforourSIMproject,andthemodelnowservesasafoundationalstrategyfortheBHTACH’sMTDefforts.Commentsandthemesgleanedfromtheproviderengagementfocusgroupsandkeyinformantinterviewsdescribedaboveledtothedevelopmentofotherkeyelements:Keyelement2:Providersidentified:significantchallengesincarecoordinationandcaretransitions;policyrestrictionsthatimpedetheabilitytocoordinatecareforcomplexpatients;inadequatetimewithpatients;andtheneedfortrainingandmodelsthatsupportthenewintegratedcareteamandrelatedsystemschangesbothwithinclinicalsettingsandbetweenclinicalandcommunityproviders.Additionally,mostofthehealthcareprovidersinterviewedpreferredacommunity-basedapproachtocarecoordinationthatseamlesslyandeffectivelyintegratesintotheclinicalsetting.Oneprovidernoted,“thisshouldbehousedoutsideofour,oranyone’s,systemandshouldfollow/servetheneedsoftheclient.”ThiscalloutfitswellwiththePathwayHUBModel.Keyelement3:ThroughtheprojectLettersofInterestandorganizationalHealthSystemsInventories,providersreflectedinterestinalleightprojectareas,butalsoaconcernaboutcapacitytoparticipateineightprojects.Additionally,manypartnersspoketohowinterconnectedeachoftheprojectsare.TheywarnedagainsttreatingtheMTDasseparateprojectsandinsteadadvisedapproachingitasoneopportunitywithmultiplealigningstrategies.ThisinformedourdecisiontoworkwithCollaborativestobuildcountybasedplansthataddressallfourselectedprojectsanddesiredelementsoftheotherfourprojectscollectively.DescribetheprocessestheACHwillusetocontinueengagingthepublicthroughouttheDemonstrationperiod.FeedbackfromourMeaningfulConsumerEngagementandMeaningfulProviderEngagementplanningprocessescontinuestovalidateanddeepentheconsumerandpartner-drivenprioritiesthatwereidentifiedinouroriginalstrategymapsessionsandcommunityshowcase.InourBoard’spubliccommenthour,keyinformantinterviewsandfocusgroups,andthroughLeadershipCouncilfeedbackactivities,weheardconcernsfromcommunitymembersthattherewasnoclearmechanismforcertainsectorstogiveinputtoprojectplanning.Whilepeopleseeoutreachhappening,bothprovidersandcommunitymembersfeltuncertaintheir
inputwasbeingincorporatedintoregionalplans.TheseconcernswerealsoreflectedincommentswereceivedbackfromourPhase2certification.Inresponse,theBHTACHhasaddedtwonewTechnicalCouncilstoourgovernancestructuresincePhase2certification.TheseCouncilswereapprovedbytheboardonOctober18thandwereannouncedtotheLeadershipCouncilonOctober25th.Wedistributednominationformsforco-chairsandparticipantsinthesemeetings,andalsorananonlinesurveyfornominations.EachCouncilwillbeco-chairedbyaBHTBoardmemberandLeadershipCouncilmember.TheCommunityVoicesCouncil(CVC)willlaunchinDecember.Ourintentistorecruitaninitialgroupofrepresentativesbasedofthefirstroundofcommunitynominations,andthentaskthemwithrecruitmentofadditionalmembersmeetingourmembershiprequirements.AdraftcharterfortheCVCcanbefoundinAppendix15,tobefinalizedoncethegroupislaunched.Membershipwillbeatleast50%Medicaidbeneficiaries,withtheotherhalfofthegroupmadeupofcommunityadvocateswithlivedexperiencehelpingcomplexpatientsaccessandnavigatecommunityservices.TheCVCwillhelpinformprojectplanningbyvalidatingimplementationplansagainsttheneedsandexpectationsofthebeneficiary.TheCVCwilladviseonmetricsforevaluatinghowwellprojectplansaddresshealthequity,andwillusethesemetricstomonitorandmakerecommendationsforcoursecorrectionasneeded.MemberswillreceiveastipendfromBHTfortheirparticipation,inrecognitionofthetimecommitmentrequired.Thisgroupwillalsohaveeveningand/orweekendmeetingastheCouncilseesfit,andtheBHTACHwillmakearrangementstoofferchildcaresupportformeetingswhenneeded.TheProviderChampionsCouncil(PCC)hostedtheirfirstmeetingonNovember13th,meetingintheeveningtoaccommodatetheschedulingneedsofproviderswhoaregenerallywithpatientsduringtheday.ThePCCcharterincludingmembershipcanbefoundinAppendix16.ThisCouncilprovidesclinicalexpertiseandsubjectmattersupportinthedevelopmentoftheCollaborativeCompact(anoperationalagreementfortransformationinmultiplesettingsofcare)acrosstheMTDProjectsareas.TheCouncilwillrecommendkeyclinicalelementsandadviseonanyneededclinicalperformancemeasuresacrossprojectstoassesswhetherCollaborativesareontracktoachieveexpectedoutcomes.Thisgroupwillmeetmonthly.DescribetheprocessestheACHused,andwillcontinuetouse,toengagelocalcountygovernment(s)throughouttheDemonstrationperiod.CountycommissionershaveregularlyparticipatedintheRuralCountyHealthCoalitionsinPendOreille,Stevens,FerryandLincolnCounties.BHTstaffhavebeenactivelyengagingthesecountycommissionersinthissetting.TheregionalBehavioralHealthOrganization(BHO)DirectorservedonBHTBoarduntilherretirementon10/31/17(theBHODirectoranswersdirectlytocountycommissioners).AndtheBHTExecutiveDirectorhasmadeseveralACHpresentationstocountycommissionersinvarioussettings(seeAppendix17foranexampleofapresentation).
BHTACHengagementwithcountygovernmentregardingfullyintegratedmanagementcare(FIMC)hasbeenproactive.WhenitbecameclearthattheBHOwasnotactivelyhostingcross-sectorconversationsregardingtheimpendingdecisiontobecomeamid-adopterofFIMC,theBHTACHconvenedtheRegionalIntegrationTeam(RIT)todeveloparegionalapproachtoaddressthestatemandateforFullyIntegratedManagedCareandensurealignmentwithMTDintegrationsefforts.MembershipfortheRITincludescountycommissionersfromeachcounty,theBHOdirector,behavioralhealthandphysicalproviders,andMCOs.ThisgroupacceleratedtheFIMCdiscussion,ultimatelyleadingtoallsixcountiesagreeingtobeamid-adopterforFullyIntegratedManagedCareonJanuary1,2019.TheACHplayedanimportantroleingettingunanimouscommitmentforFIMCmid-adoption.AslateasJune2016,therewaslittlecommissionerinterestinmovingtoFIMC.BHTstaffworkedtirelesslytounderstandconcerns,developstrategiestoalleviaterisk,anddemonstrateasharedrolefortheACHandcounties.Forexample,countycommissionersexpressedconcernabouttheACHbeinganotherlevelofbureaucracy.ToalleviateconcernsthattheBHTACHwouldtakevaluableservicedollars,theBHTBoardpassedapolicytowaivetheadministrativefeetoadministertheFIMCincentivessothatallfundswouldgotowardsintegrationefforts.Goingforward,eachBoardofCountyCommissionersintheBHTregionhasbeeninvitedtojointheWaiverFinanceWorkGroup.TheBHTBoardhasalsoaddedanexofficiomemberpolicy,allowingeachcountytosendaCommissionerRepresentative.Therehasbeenregular,in-personparticipationfromallcounties.InOctober2017,CommissionerMikeManusofPendOreilleCountywasappointedtotheBHTBoard.CountyCommissionerswillalsobeinvitedtoactivelyparticipateinimplementationplanningwiththeCollaboratives.Commissionerswillbekeyleadersinintegratingjaildiversionandtransitionstrategiesaswellasaligningprevention-relatedstrategiesthroughtheirmembershipintheirlocalcountyBoardofHealth.TheRegionalIntegrationTeamwillmeetinearlyDecember2017toresumetheworkofaligningFIMCandMTDefforts,andBHTexpectstohavecontinuedactiveengagementofcountycommissionersintheseefforts.DiscusshowtheACHaddressedareasofimprovement,asidentifiedinitsPhaseIICertification,relatedtomeaningfulcommunityengagement,partneringproviderengagement,ortransparencyandcommunications.Asnotedabove,theBHTACHhasaddedtwoadditionalTechnicalCouncilstothegovernancestructuresincePhaseIICertificationtoelevatethevoicesofconsumersandproviders:theConsumerVoicesCouncilandtheProviderChampionsCouncil.SincePhase2,BHThasalsolaunchedaweeklyCollaborativeLearningSessionwebinaronFridaymornings,coveringkeystrategiesandactivitiesofMTD.Thesesessionsareopentothepublicandallrecordedandpostedonourwebsite.WecompletedcollectionofourHealthSystemsandCareCoordinationInventoriestogatherfeedbackandinformationfromclinicalandcommunity-basedproviders.WehavealsomadeourBoardofDirectorsmeetingsopentothepublic.Lastly,theBHTACHhas
TribalEngagementandCollaborationTribalEngagementandCollaborationCommunicationandmeetingwithtribesInAugust2016,BetterHealthTogether(BHT)StaffandBoardmembersparticipatedinaNativeHealthSystemslearningsessionsponsoredbytheAmericanIndianHealthCommissionatTheNATIVEProject,includingafacilitatedconversationabouthowtoincreaseandsupportcollaborationbetweenIHS/Tribal/UrbanhealthfacilitiesandtheACH.TribalrepresentationonACHBoardTheBHTGovernanceCommittee,withsupportfromtheBHTBoard,prioritizedTribalrepresentationbyappointingtwooffouropenseatstoTribalrepresentatives.BHTACHacceptedopenapplicationsandusedacommunity-drivenprocessfornominations.WealsosentannouncementsofthenominationandapplicationprocessdirectlytorepresentativesofeachoftheTribesinourregionandTheNATIVEProject.Twomembers,representingtheKalispelTribeofIndiansandtheConfederatedTribesoftheColvilleReservation,wereelectedthroughthisprocess.TheBoardunanimouslyapprovedtheslateofnewofficers,andtheirtermsbeganJanuary2017.AthirdTribalpartnerwasaddedinOctober2017,representingtheSpokaneTribeofIndians.Withthisfinaladdition,hetheBHTBoardhasrepresentationfromallthreetribesintheregion.TribalLeadersPartnerCouncilAttherequestofTribalmembersontheBHTBoardandtosupportfurtheractiveengagement,theBHTBoardcreatedtheTribalPartnersLeadershipCouncil(TPLC)andappointedthetwoTribalBoardmembersastheco-chairsinMarch2017.TheBHTACHTPLCservesasaforumforcontinuedpartnership,education,andsharedlearningswithIHS/Tribal/UrbanhealthfacilitiesandTribalOrganizationsasACHworkdevelopswithaspecificfocusonprovidingimpactanalysisonprojectsandBoardpolicydecisions.BHTACHiscontinuingspecificeffortsfocusedonrelationship-buildingandcollaborationwithIndianHealthServiceproviders,TribalOrganizations,andUrbanIndianHealthCenters(I/T/U)inourregion.IdentifiedregionalTribalpartnersincludeTheConfederatedTribesoftheColvilleReservation,SpokaneTribeofIndians,KalispelTribeofIndians,TheHealingLodgeoftheSevenNations,TheNATIVEProject,TheAmericanIndianCommunityCenter,andLakeRooseveltCommunityHealthCenters.LeadersfromthesehealthsystemsareinviteddesigneesfortheTPLC.
ACHStaffingBetterHealthTogetherACHhiredanACHTribalSeniorProjectManagertoworkcollectivelyandindividuallywitheachofourTribalpartners.ThisstaffmemberisanenrolledmemberoftheYakamaNationandhasworkedfortheKalispelandYakamaTribalgovernments.MostrecentlysheservedastheCommunicationsManagerforTheNATIVEProject,andinrecentmonths,waspromotedtoAssociateDirectorofHealthSystemTransformation.Inthisrole,shecontinuestotravelfrequentlybetweenNativehealthleaderstosupportengagement,opencommunication,trust,andopportunitiesforcollaborationalongsideTribalcommunitiesaswedevelopourCommunityHealthTransformationCollaborativesandlookforalignmentandleveragewiththestatewideACHTribalefforts.IdentificationofTribalprioritiesAddressinghealthdisparitiesofAmericanIndianandAlaskaNative(AI/AN)peopleinourregionhasbeenidentifiedasapriorityissueforTribalrepresentatives.AttendeesatTPLCmeetingshaveidentifiedmentalhealthandsubstanceuseissues,includinglackofaccesstotreatmentandproviders,askeyareasofneed.TheCommunity-BasedCareCoordinationandOpioidsProjectswereidentifiedasthetwoprojectareasthatshouldbeprioritizedforcollaboration.ThisfeedbackwasincludedinallofourBoarddeliberationsaboutprojectselectionandcollaborativedevelopment.HowTribalprioritieshaveinformedprojectselectionandplanningBetterHealthTogetherACHconductedregion-wideHealthSystemsandCareCoordinationInventories,whicharebeingusedtofurtherrefineregionalprioritiesandassistinprojectdevelopmentandplanning.Recognizingtheneedtoincludeculturallycompetentevidencebasedcaremodels,weaskedaboutcurrentuseofspecificmodelsthattheI/T/Upartnersmayreferenceintheirhealthsystemtransformationefforts(e.g.theIndianHealthService’sImprovingPatientCareprogram,whichsupportsoutpatientteamstoachievepatient-centeredmedicalhomerecognition).BHTACHiscloselyfollowingtheTribalstatewideeffortsoftheIndianHealthCareProtocol(IHCP)andwouldliketoassistourTribalPartnerswherepossible.OnecomponentoftheIHCPisimprovementofbehavioralhealthforAI/ANMedicaidclients,adoptingatraumainformedapproach.ThisisinlinewithBHTACH’sBi-DirectionalIntegrationProjectPlan.IHCPinitiativesalsoincludeworkforcecapacityandHIE/HIT,andBHTACHiscommittedtoprovidingtechnicalandprojectsupporttoI/T/Upartnersasplanningandprojectimplementationcontinue.ExamplesofelementsoftheProjectPlanthatwereinformedbyTribalinputOnJune19,BHTACHhostedasix-hourworksessionfortheTPLC.Tribalpartnerssharedhealthsystemsupdatesandchallenges.Onecommonthemeidentifiedbetweenthehealthsystemsisoflackofworkforceavailableintheirruralareas,alongwithretentionandongoingproviderdevelopmentopportunities.BHTACHgaveaMedicaidTransformationDemonstration(MTD)fundingoverviewandprovidedanupdateonhealthsystemtransformationplanningactivities,
allofwhichworktoaddresstheissuesidentifiedbyourTribalpartners.Attendeesidentifiedaneedtoworktogethertoaddressmentalhealthandsubstanceuseissues.ThisinformedourpopulationfocusforourMTD-requiredBi-DirectionalIntegrationProject.TheJuly25BHTACHTPLCmeetingwasheldattheCamasCommunityCenterforWellnessinUsk,WA.ThegroupdiscussedtheMTDTribalProtocolfortheDSRIPProgram,andPhaseIandIICertificationprocesses.ThisincludedbriefingsandafeedbacksessiononallBHTBoardpoliciestobeadoptedattheJulyBoardmeeting.AttendeesconcludedthattheywouldliketofocusoncollaborationforsharedresourcesonCommunity-BasedCareCoordinationandtheOpioidProjects.Thisfeedbackwasincludedinourdecision-makingprocesstoselecttheCommunity-BasedCareCoordinationproject.AttherequestoftheTPLC,theBHTACHAssociateDirectorofHealthSystemTransformationispartofastatewideweeklycallwithTribalhealthprovidersandotherACHTribalengagementstafftodiscussacoordinatedstrategytoaddressopioids.ThisdiscussionledtoarecommendationtoincludeTheSixBuildingBlocksforSaferOpioidPrescribingasadesiredelementoftheclinicalstrategiesforOpioidsintheCollaborativeimplementationplans.ThroughoutourTPLCdiscussions,wehaveidentifiedaneedtoinvestinimprovinghealthinequities.ThesediscussionsspurredtheconversationwiththeMedicaidWaiverFinanceTeamtoincludeafundsusecategoryreferredtoastheEquityAcceleratorPayment,acknowledgingthelikelihoodthatmorecostsareincurredtoservepopulationswithhistoricaltrauma.IfTribes/IHCPsarenotinvolvedinACHprojectselectionanddesign,describehowtheACHisconsideringtheneedsofAmericanIndians/AlaskaNativesintheACHregionN/ADiscusshowtheACHaddressedareasofimprovementidentifiedinitPhaseIICertificationrelatedtoTribalengagementandcollaboration.EachoftheBHTACHTechnicalCouncilshaveappointeesfromtheTPLCtoensureappropriatelevelsoffeedbackandengagement.WecurrentlyhaveactiveparticipationfromTribalPartnersintheWaiverFinanceWorkGroup,RegionalIntegrationTeamandProviderChampionsCouncil.(SeeGovernancesectionforCouncilroles.)WeareactivelyrecruitingforTribalrepresentationonthesoon-to-belaunchedCommunityVoicesCouncil,ourmechanismfordirectcommunityandconsumerinput.Additionally,bothTheNATIVEProjectandLakeRooseveltCommunityHealthCenterscompletedBHTACH’sHealthSystemsInventory(HSI).WeareworkingwiththeotherTribalpartnerstocompletetheHSIinpreparationforthelaunchofourRuralandSpokaneCountyCollaboratives.WehavereceivedlettersofsupportfromtheKalispelTribeofIndians,TheConfederatedTribesoftheColvilleReservation,LakeRooseveltCommunityHealthCenters,andtheAmericanIndianCommunityCenter;thesecanbeviewedinAttachment5.We
continuetoactivelycommunicateandcollaboratewithourTribalPartnersandareexcitedabouttheadditionofarepresentativefromtheSpokaneTribeofIndianstotheBHTBoard.
FundsAllocationFundsAllocation
FundsFlowOversightOverthecourseoftheMedicaidTransformationDemonstration(MTD)period,theBetterHealthTogetherAccountableCommunityofHealth(BHTACH)willbuildregion-widecapacityforimprovingcommunityhealthandpreparingtheregionforvalue-basedcare.TheBHTACHwillleverageMTDinvestmentwithotherfundinginitiativestodrivestrategy,partnershipsandcapacitynecessarytostandupacritical,innovativeandsustainablesystemforlongtermimprovementstocommunityhealth.TheBHTACHispurposefullyconstructedtoensurebroadmulti-sector,geographical,andcross-organizationcollaboration.Tothisend,theBHTACHhasdevelopedatieredgovernanceandengagementstructurewithdistributeddecision-making,jointownership,andmutualaccountabilitythatdrivesinnovationandfostersco-investment.WhiletheBHTBoardofDirectorsretainsitsauthorityasthefinaldecision-makingbodyforMTDeffortsrelatedtoprojectselectionandfundsflowmanagement,itistheintenttoutilizemanymechanismsforpartners,providers,community,andstakeholderstoprovidefeedbackandinfluencefinaldecisions.Boardandtechnicalmembersareexpectedtodiscloseanyactualorperceivedconflictsofinterestastheyrelatetosector-affectingdecisionsand/ortheBHTACH.InJuly2017,theBHTBoardapprovedacomprehensivepersonalandorganizationalConflictofInterestpolicy(seeAppendix14).TheBHTACHLeadershipCouncil,whosebroadparticipationhelpsussynthesizelocalprioritiesintoregionalstrategies;andrepresentativesofourlocalhealthnetworkshaveinformedourregionalhealthprioritiesandinspiredthecreationoftheRuralandSpokaneCountyCollaborativestodevelopandimplementtheMTDprojects.Additionally,theBoardhasappointedTechnicalCouncilstoprovidedeeperfeedbackonthecomplexelementsrequiredtosuccessfullyimplementtheMTDefforts,suchas:
• TribalPartnersLeadershipCouncil(TPLC)
• ProviderChampionsCouncil
• CommunityVoicesCouncil
• MedicaidWaiverFinanceWorkgroup
• RegionalIntegrationTeam
ToalignwithACHvaluesforlocalcontrolandtobuildonthestrengthofgeographicbasedhealthcoalitions,theBHTACHwillutilizeaCommunityHealthTransformationCollaborative(Collaborative)modeltodevelopandimplementgeographicbasedsystemsofcareplansinthefourprojectareasBHTACHselected.TheCollaborativeswillbeguidedbyaCollaborativeCompact,whichincludesactivitiesandstrategiesneededtoimplementtherequiredMTDprojects,meetlocalcommunitypriorities,driveachievementofmetrics,andserveasthemechanismforproviderstoearnMTDdollars.TheWaiverFinanceWorkgroupischargedwithrecommendingtotheBHTBoardamethodologyfortheMTDfundsincluding:
• DevelopandrecommendtotheBHTBoardforapproval,asetofpoliciestogoverntheProjectandIntegratedManagedCareIncentivefundsincludingadetailedapproachforCollaborativesandpartneringproviderstoearnpayforreportingandpayforperformanceachievements.
• ReviewandrecommendtotheBHTBoardforapprovaleachCollaborativeDemonstrationfinancialplan;
• ProvideoversightofDemonstrationactivitiestoensurecompliancewithwaiverrequirements.
TheWaiverFinanceWorkGroupiscomprisedofaTPLCappointee,anFQHCappointee,CountyCommissioners,physicalandbehavioralhealthproviders,ProvidenceHealthSystem,MultiCareHealthSystem,publichospitalleadership,communitybasedorganizations,philanthropy,agingandlong-termcare,andBHOs/MCOs.(SeeAppendix12forthecharterandmembershiplist).TheWaiverFinanceWorkgrouprecommended,andtheboardapproved,thefollowingprinciplesasafoundationforthefundsflowdevelopment:
• Values:rewardsinnovation,supportscollaboration,recognizesat-riskandvulnerablepopulations,supportsdiversityofpartnersandapproachinthemarket,drivesmaximumimpacttonumberoflivesserved,maximizesfinancialresourcesfortheregion.
• Equity:EnsuresinvestmentaddressesdisparitiesandhealthinequitiesfortheMedicaidbeneficiary;ensuresafocusonincreasedaccesstoculturallyappropriatecare.
• Flexible:Abletochangemodelsandapproachesovertime(i.e.doesnotlockinfundingonlyoncertainapproaches),meetstheneedsoftheindividualcollaborativehub,mitigatesappropriateprovider risks,andrecognizesthevalueandcostof“sweatequity.”
• Fairness:Balances1)equitytoallpartnerswithintendedimpact,2)seedmoneywithsustainabilityandlonger-termimpact,and3)smaller,lessefficientproviders’needswiththoseofthelargerproviders.
• Alignment:Ensuresalignmentbetweenfundsflowandintendedgoals(appropriatecareintheappropriateenvironment);healthcareasaneconomicdevelopmenttool.Encouragesandpromotesalignmentbetweenpartners,supportsintegrationamongtheproviders(bothruralandurban)topreparetheregionforvaluebasedpayments,alignseffortswithotherMedicaid,Medicareandlocalinitiatives,complieswithHCAcriteria,alignscontinuumofcarebetweenruralandurbanregions
Itisexpectedthatinearly2018,theBHTACHwillexecutememorandaofunderstanding(MOU)withitspartneringorganizationsthatwillstipulatethespecificrolesandresponsibilitiesofeachparty.ThisMOUwillserveasthefoundationforcontractswitheachprovidertodetailrequirementsforearningdollarsincluding(likely)monthlyreportingofpay-for-reportingandquarterlypay-for-performanceachievement.InconsiderationoftheexecutionoftheMOU,theWaiverFinanceWorkgroupwillrecommendtotheBHTBoardforapproval,amethodologyfordistributionofYear1Incentivefundsinthefirstquarterof2018.PriortosubmittingdistributiondirectiontotheFinancialExecutor,itisexpectedthatBHTleadershipwillpresent,forboardapproval,paymentstobemadebasedonachievementofagreeduponcontractualterms.Additionally,pleasenotethattheBHTBoardofDirectorshasaBoardFinanceCommitteechargedwithoversightofBHTfinances.ThissubcommitteereportsmonthlytotheBoardoncurrentstatusofBHT’sfinancesandperformancetoannuallyadoptedbudget.ThissubcommitteeprovidesfinancialoversightofMTDdollarsdistributedtotheACHfortheadministrationoftheDSRIPprogram,includingPhaseIandPhaseIICertificationdollars,andregionalinvestmentallocatedviatheWaiverFinanceWorkgroupforactivitiessuchastheestablishmentofthePathwaysHub.OneBHTBoardFinanceCommitteememberservesontheWaiverFinanceWorkgroup.Finally,BHTcontractswiththeEmpireHealthFoundationforbackofficeservicesincludingaccountingandfinancesupportservices.ThiscontractincludesCFOandfinancestaffcapacity.In2018,theBHTBoardwilladoptaformalizedsetofpoliciesandprocedurestoensurefederalandstatecompliancewithallcurrentcontracts.Additionally,BHTACHwillimplementanewaccountingplatform,NetSuite,thatwilleasilyallowfortrackingoftimeandexpensetofederalgrants.NetSuiteprovidesaccurate,real-timefinancialreportingofgrantcostsacrosstheorganizationsforgrantsrequiredtracking.NetSuitewillallowtrackingofexpensesagainstspecificrevenuesourcesdowntothetransactionallevel.ThisensuresadeeperleveloffinancialaccountabilityforMTDfunds.
DescribetheACHprocessforensuringstewardshipandtransparencyofDSRIPfundsoverthecourseoftheDemonstration.
TheWaiverFinanceWorkgroupCharterstipulatesexpectationofmembersto:
• ProvidestewardshipandmanagementofBHTACHWaiverFinancialresources;
• KeepthebestinterestoftheBHTACHandthecommunityattheforefrontofdiscussionanddecision-making.
BHTACHiscommittedtotransparencyandaccountabilityforhowMTDfundsarespentandtheimpactonmeetingMTDandregionalgoals.Usingtheboard-approvedfundsflowguidingprinciplesandusecategories,contractswillbedevelopedwithproviderstoensureaccountabilitybetweenfundsdistributedandachievementofpayforreportingandpayforperformancegoals.Tomitigateperformancerisks,BHTwilldevelopareviewprocesstoensurethatprovidersmeetreportingandperformancemetrics.Thisregularreportingprocesswillallowforcoursecorrectionviatechnicalassistanceandadependablemanneroffundingforpartners.TheBHTstaffwillensureallpaymentsarealignedwithgovernance,contractrequirementspriortoseekingapprovalfromtheBHTBoard,whoseapprovalwilldirectthefinancialexecutortoreleasepayments.ItistheexpectationthatfundsflowmethodologyandabilitytoearndollarswillbeclearlycommunicatedthroughseveralchannelsincludingweeklyBHTACHcommunication,OpenBoardmeeting,LeadershipCouncilmeetings,minutesfromWaiverFinanceWorkgroup,BHTwebsiteandcommunitypresentations.Itisexpectedthatfeedbackwillbeprovidedbytheothertechnicaladvisorygroupstoensureprogrammaticalignmentwithsuggestedfundsflowmethodology.Additionally,ataCollaborativelevel,allpartnerswillunderstandhowfundswillflowacrosspartnersandviatheRuralandSpokaneCountyCollaboratives.Ifapplicable,provideasummaryofanysignificantchangessincePhaseIICertificationinstateorfederalfundingorin-kindsupportprovidedtotheACHandhowthefundingalignswiththeDemonstrationactivities.
Therearenoothersignificantchangestoin-kindsupportoradditionalstateorfederalfundssincePhaseIICertification.However,theBHTACHhaslaunchedconversationswithlocalfunderstodevelopamatchinvestmenttoourCommunityResiliencyFund.Additionalexplorationofotherphilanthropiceffortstosupportclinicaltransformationeffortsformaternalandchildhealthandoralhealthisbuildingmomentum.TheBHTACHwillcontinuetoleverageinvestmentsfromSIMandtheEmpireHealthFoundation
tosupportourregion’shealthtransformationandcommunityefforts.WeareundercontractwiththeWashingtonHealthBenefitExchangetoadministerourregion’sNavigatorNetwork,toensurethatpeopleinourregionhaveaccesstohealthinsurance.AspartoftheCollaborativereportingprocess,theBHTACHwillrequirepartnerstotrackin-kindservicesandleveragedlocal,stateandfederalinvestments.Weexpecttodemonstratepartner’sinvestmentfordatasharing,clinicalproviderchampions,communitybenefit,meetingspaces,recruitment,anddonatedstafftimetosupportgovernance,strategicdevelopment,trainingandprogrammanagement.Ifapplicable,provideasummaryofanysignificantchangestotheACH’strackingmechanismtoaccountforvariousfundingstreamssincePhaseIICertification.
TherehavebeennosignificantchangestotheBHTACH’strackingmechanismtoaccountforvariousfundingstreamssincePhaseIICertification.In2018BHTACHwilllaunchanewaccountingsystemthatwillallowformorein-depthreportingandfederalgrantcompliance.ProjectDesignFundsDescribe,innarrativeform,howProjectDesignfundshavebeenusedthusfarandtheprojecteduseforremainingfundsthroughtherestoftheDemonstration.
Phase1and2projectdesigndollarsareallocatedbyBHTBoardpolicyandmanagedbytheBHTExecutiveDirectorandBHTBoardFinanceCommittee.InJuly,theBoardearmarkedfundsfordistributionin2017.InDecember2017,theBoardwillapprovethe2018budgetwithadditionalallocationsfromPhase1and2projectdesigndollars.TheBHTBoardFinanceCommitteemeetsmonthlytoreviewfinancialsincludingaprojectedyear-endspendingplan.InDecember,unspentandallocatedreservefundswillbeapportionedinthe2018Budget.TheBHTACHwillcontinuetoutilizeprojectdesignfundstobuildthecapacityofourinternalandcommunityteamstoprepareforprojectplanningand implementation.Year-to-date,wehaveexpendedapproximately$391,000ofthe$6millionreceivedsinceJune.Notably,$106,000has been distributed to partners for successful completion of Health System and CareCoordinationInventories.Additionalfundshavebeenexpendedfor:
• Central service administration, including BHT leadership and staff, shared serviceagreementsforfinance,HR,andcommunicationssupportandoperations;
• ContractedserviceswithKPMG,ProvidenceCORE,andUncommonSolutionstosupportfinancial,facilitation,data,andcollaborativeprojectdevelopment;
• Projectdevelopmentactivities,includingtravel;
• Communitymemberstipendsforparticipationinfocusgroups;and
• Websitedesign$870,000ofprojectdesignfundsarereservedfor:
• BHTACHadministration/projectmanagementduringtheremainderof2017and2018(balanceof$270,000)
• InvestmentintheCommunityResiliencyFundaimedatstrengtheningservicesthatsupportsocialdeterminantsofhealth($600,000)
SubjecttoBoardapproval,itisanticipatedremainingfundswillbeusedforcontinuedsupportof:
• BHTACHProjectPlan:Contractedservicestosupportfinancial,dataandcollaborativeprojectdevelopment.
• Engagement:Activitieswithbothconsumersandclinicians,includingfundingtosupportpartners for time and space provided, and to community member stipends forparticipationinthefocusgroups.
• ACH Administration Project Management: Central service administration, includingleadershipandstaff, sharedserviceagreements for finance,HR,andcommunicationssupportandoperations.
• Health Systems & Community Capacity Building: As needed to support regionalinfrastructureinvestmentssuchasthedevelopmentofthePathwaysHub.
• CollaborativeDevelopment:AsneedtosupportinvestmentinCollaboratives.
• Other:ReservesperBoardpolicytobespentbytheendofthedemonstrationperiod.BeginninginearlyCY2018,DesignFundswillbesupplementedbyanallocationof5%foradministrativedollarsfromprojectfunds,pertheBHTBoardapprovedfundsflow.FundsFlowDistributionDescribetheACH’santicipatedfundsflowdistribution.DescribehowProjectIncentivefundsareanticipatedtobeusedthroughouttheDemonstration.Provideanarrativedescriptionofhowfundsareanticipatedtobedistributedacrossusecategoriesandbyorganizationtype.
InNovember2017, theBHTBoardapproved4projects tomaximizeearningpotential for theregionandprovidemaximumlocalcontrolovertransformationeffortscustomizedtotheregion.TheBHTACHwillaligndata,fundsflowandmodeldevelopmenttomaximizetheopportunitytointegrateselectedprojects intoavaluebasedmodelandweavetogether local resourcesand
investments to reachthisgoal.Our funds flowplan includesdirected investments forstartupcosts, infrastructureandtechnicalassistanceemphasizingDSRIPfundingfortransition,notanongoingservicepaymentstream.
TheWaiver FinanceWorkgroup recommended, and the BHT Board approved, the followingprinciplesfocusedonmeetingthefundsflowneedsofourpartners:
• Values:BHTACHneedstoknowthattheorganizationandworkwillmakeadifferenceiffundsareaccepted.MoneyfromtheDSRIPeffortsshouldbeavailableacrossthecurrentsilos,supportlatitudetotrydifferentthings,incentivizecollaboration,betterflowofinformation,andcommunicationwithnewandexpandedpartners,supportinnovationsthatstimulatecostcurvebendingapproaches.
• BusinessPractices:Projectsneedtonotlosemoney(revenueandprofit)inthetransformation.TheBHTACHhelpsmitigatefinancialriskforpartners,butfundsshouldNOTberestrictiveandcomplicatedtotrack,andshouldsupportreorganizationofservicesinageographicallywidespreadareawithsiloedservice.Fundsareusedtodeveloparegion-widesharedsavingsmodelwithappropriateinvestmentinregional-levelinfrastructure,alignmenttoHCAtargets(MCOgoal)andBHTACHregiongoals,andgarnerthebroadsupportfromtheprovidercommunity.
• Operational: Funding should provide the ability to integratemedical and behavioralhealthrecords,andsupportinfrastructureneeds, e.g.,Behavioral healthlocatingtothecampuswhereprimarycarephysiciansandhospitalsare located.Effectivepatient flowbetween the various services that areprovided is a priority as is timely paymentmethodologyforhealthycashflow.Clarityisneededinthemethodtorequestandqualifyforfunds,andwhatdeliverables/commitmentsarerequiredinreturn.Fundsareexpectedtosupportsustainableeffortsthatspanbeyondthefive-yeardemonstrationperiod.FundsflowincentivesalignwiththeVBPeffortsandassociatedincentives(e.g.usingthesamemetrics).
The BHT Board adopted a high-level funds flow framework that consists of the followingelements:
• FundsusedbytheBHTACHforDSRIPprojectmanagementandACH-wideinvestmentsandsupportforthebenefitofallCollaboratives,subdividedintoprojectssuchasHIT/HIE,workforceandcommunityengagement.
• FixedfundstosupportCollaborativeswithDSRIPprojectmanagementandprojectcosts.
• Performance-basedfundstohelpalignCollaborativeincentiveswiththosetowhichtheACH is held accountable during the demonstration, such as engagement criteria,outcomes,andreportingrequirements.
TheWaiverFinanceWorkgrouprecommended,andtheBHTBoardapproved,fourinvestmentareasforfunding:ACHDSRIPManagement(5%),RegionalPartnerInvestments(30%),Collaboratives(55%),andCommunityResiliency(10%)Thefundsflowplanappliesfiveusecategoriesfordistribution:AdministrationandProjectManagement;ProjectEngagement,ParticipationandImplementation;ProviderPerformanceandQualityIncentivePayments;HealthSystemsandCommunityCapacityBuilding.TheBHTBoardapproved,aCommunityResiliencyFund.Theusecategorydistributionplanprovidesfor:
• AdministrativeoperatingexpensesoftheACH,including:financial,legal,administrativesalaries,facilitiesandequipment,B&Otaxes.
• Fixedpaymentforengagementandparticipation(signedpartneragreements,andmeaningfulleadershipandparticipationonworkgroupsandoperationalcommittees);implementationcostsforearlyinfrastructureandprocesschangesthatactivelymovethepartnerandpartnergrouptowardintegrationandcommunity-basedcare;
• Earnedpaymentsforreportingonprojectmilestones;performance-based,metric-drivenpayments;transitioningtonewpaymentmodels.Additionally,theWaiverFinanceWorkgroupisexploringtheabilitytofundanequityacceleratorpaymenttoreducehealthdisparities
• Regionalinvestmentsin:populationhealthmanagementsystems(EHRs,HIE/HIT,data);strategicimprovement/qualityimprovementactivities;workforcedevelopment;value-basedpaymenttechnicalassistance;revenuecyclemanagementandsupplychainmanagementsupport;PathwaysHUBoperations;trainingandeducationonpreventingproviderfatigue,andcommunityandproviderengagement;
• Regionalinvestmentsthatpromotelong-termtransformationandimpactissuesaffectingpopulationhealth,withafocusonprimarypreventionandsocialdeterminantsofhealth.
Usingtheboard-approvedfundsflowguidingprinciples,allocationsbyusecategoryanddistributionbyorganizationtypeswereestablished.BHTACHapproachedthefundsflowdistributionmethodologyforfourprojectswithconsiderationtowardtherecentHCAreductiontoYear1waiverrevenue,andtheuncertaintyaboutfundsavailabilityinsubsequentyears.UnderstandingourCollaborativeswillcustomizelocalsolutions,weconsideredanAveragePay-for-ReportingAchievementValueof100%acrossallfouryearsandAveragePay-for-PerformanceAchievementValueof75%vs90%acrossallthreeyears.
Table4:ALLOCATIONOFPROJECTFUNDSBYUSECATEGORYUseCategory 5-YearTotal
ProjectManagementandAdministration 5%
ProviderEngagement,ParticipationandImplementation
32%
ProviderPerformanceandQualityIncentivePayments 23%
HealthSystemsandCommunityCapacity 30%
CommunityResiliencyFund 10%
TheWaiverFinanceWorkgrouprecognizestheimportanceofdistributiontocommunity-partnersandproviderstospearheadregionalcommunity-ledinitiativesaimedatstrengtheningsocialdeterminantsinvestments.ProvisionswillbemadetodistributetheCommunityResiliencyFundtopartneringorganizationstosupportlinkinghealthcaresystemtosocialdeterminantsofhealth.TheBHTACHwillseektomatchMTDfundsintheCommunityResiliencyFundwithothercommunitybenefitdollarsfromfunderslikeEmpireHealthFoundation,communitybenefitinvestmentsfromProvidence,MultiCare,InlandNWCommunityFoundation,UnitedWay,andothers.Byaligningpartnersandinvestorsaroundtheseindicators,usingMTDfundsasanincubator,wecancreateaninvestmentfundofflexibledollarsfortheregiontocontinuetouseforstrategicinvestmentinovercominghealthdisparitiesandsocialdeterminantsofhealth.Weseethisfundasamechanismtonegotiatecrosssectorsharedsavingsmodeltoprovidealongertermfundingstrategy.PleasenoteitistheintentoftheBHTACHtoexpendallMTDCommunityResiliencyFunddollarsduringtheMTDperiod.ACollaborativestructurewillbeusedtoincentivizesharedaccountabilitytiedtooutcomesforpopulationhealth.TheCollaborativeswillbecomprisedofMedicaid,Non-MedicaidProvidersandTribalHealthSystemsdesignedtobuildontheruralCountyCoalitionsstructureandleveragethenaturalpartnershipsneededtosupportageographicallybasedsystemofcaresotheregioncansucceedinavaluebasedsystem.PartnershipswillsustainthemselvesasbusinessmodelsadapttovaluebasedcontractsanditisexpectedtheopportunitytoinvestinasharedsavingswillprovideadditionalcapitaltocontinueMTDefforts.ThesupportfromtheBHTACH,MTDfunds,andtheCollaborativepartnerswillfosteranenvironmentofinnovationandtransformation.
Table5:ALLOCATIONOFPROJECTFUNDSBYORGANIZATIONTYPE
DY1–2017
ACH 10%MedicaidProviders 70%Non-MedicaidProviders 10%I/T/U 10%Other* 0%
100.0%
Goingforward,guidedbytheprinciplesofcollaborationandaccountability,theallocationofMTDfundstopartneringorganizationswillcontemplatethevalueoftheproject,targetpopulation,levelofresourceandcommitmentbypartner,readinessandexpertise,financialresourcesandsuccessinachievingmilestonesandoutcomegoals.Attestations
• AttesttowhetherallcountiesinthecorrespondingRegionalServiceAreas(RSAs)havesubmittedabindingletterofintent(LOI)tointegratephysicalandbehavioralhealthmanagedcare
YES NOX
• AttesttowhethertheACHregionhasimplementedfullyintegratedmanagedcare.
YES NO
X
o IftheACHatteststohavingimplementedfullyintegratedmanagedcare,providedateofimplementation.
o IftheACHatteststonothavingimplementedfullyintegratedmanagedcare,providedateofprojectedimplementation.
January2019
DATE(month,year)
DATE(month,year)
HowIntegratedManagedCareIncentivefundswillbeusedorinvestedBHTACH views the transition to Fully IntegratedManagedCare (FIMC) as a requirement tosuccessfully transformthehealthandsocialdeterminantsofhealth systemsandsuccessfullyshiftingtoavaluebasedpaymentandcaremodel.TosupportregionaldecisionmakingonFIMCandalignmentonclinicalintegrationforphysicalandbehavioralhealth,theBHTACHformedaRegionalIntegrationPlanningTeam.TheteamiscomprisedofkeystakeholdersintheregionincludingCountyCommissionersfromAdams,Lincoln,Stevens,PendOreille,FerryandSpokaneCounty,MCOrepresentatives,ruralhealthleadership,Providence,MultiCare,PhysicalHealthandBehavioralhealthproviders,TribalPartnersLeadershipCouncilappointee,andtheSpokaneCountyBHODirector.AsnotedatameetinginlateJuly,“thisisthefirstconveningofkeypartnersinphysicalandbehavioralhealth,aswellascountyofficialsdiscussingtheneedsofourregion’shealthsystem.”Theinitialgoalofthistoteamwastoidentifyanapproachtomeetthestatemandated2020deadlineforFullyIntegratedManagedCare.TodemonstrategoodintentandreinforcetheACHbeliefthatFIMCiscriticaltotransformingthehealthsystem,theBoardpassedapolicyinAugust2017notingthatiftheregionwasaMid-Adopter,theBHTACHwouldnottakeanyadministrativeexpenseofFIMCincentivedollarsandwoulddirectallFIMCIncentivestosupporttheintegrationofphysicalandbehavioralhealthproviders.OnOctober16,2017,CountyCommissionerssubmittedabindingletterofintenttomovetoMid-AdopteronJanuary1,2019.TheBHOandHCAarestillfinalizingdetails,butitistheexpectationoftheregionwewillimplementFIMConJanuary1,2019.TheCommissionersfromaroundtheregioncontinuetodiscusstheroleoftheSpokaneCountyBHOtransitioningintoservingastheregion’sBehavioralHealthAdministrativeServicesOrganization.ThisdecisionisduetoHCAbyearlyJanuary2018.TheWaiverFinanceWorkgroupwilldevelopamethodologyfordistributionoffundsintwocategories:regionalinfrastructureandCollaborativeinvestment,inearly2018.Thismethodologywillalignwithourbi-directionalintegrationeffortsandwillseektomaximizethespenddownoftheBHOreservesSpokaneCountycurrentholds.
RequiredHealthSystemsandCommunityCapacity(Domain1)FocusAreasforallACHs
RequiredDomain1FocusAreasTheBHTACHRuralandSpokaneCollaborativeswillserveasthelocalexpertstoidentifyneedsanddevelopaplanforallselectedprojectsandactivities.BHTwillactastheaggregatoracrosstheCollaborativetoensurestandardization,coordination,collaborationandregionalaccountability.EachCollaborativewillcreateaninterconnectedplanacrossallprojectareasforeachDomain1elementusingasystemsapproach,withassistancefromtheBHTACHastheaggregatorandsystemfunder.BHTACHearningswillbeusedtoencourageadoptionofstandardpracticesandtoincentivizethecompletionoftheCollaborativeassessments.ConcretenextstepsforeachCollaborativeareasfollows:
• Q12018:EachCollaborativewillconductastandardizedneeds/gapassessmentforeachprojectareabasedontheCollaborativeCompact.
• Q12018:Basedonfindings,BHTACHwilldevelopacollectiveapproachforcollaborativeandsystem-widecapacitydevelopmentrelatedtoworkforce,VBPandpopulationhealthmanagement.
• Q12018:Implementationplanninganddevelopment(usingbaselinetargetsfromHCAandBHTACHregionalprioritygoals).
• Q32018:ImplementationPlansdue.
• Q42018:IncorporationofcollectiveapproachestodevelopandreinforcestatewidestrategiesandcapacitythroughaBHTACHAll-Collaborativeconvening.
FourBHTACHinvestmentcategorieshavebeenidentified:
• ACHDSRIPManagement,
• RegionalPartnerInvestments(includingHIE/HIT;PopulationHealthManagement;Training;WorkforceDevelopment;ProjectManagement;andPathwaysHub),
• Collaborative(fixedandearnedpaymentstomembersoftheCollaborative),and
• CommunityResiliencyFund.TheBHTACHwillserveasaconveneracrosstheregion,withtheRuralandSpokaneCollaborativesservingastheactivationnetworkforachievingACHandMedicaidTransformationDemonstration(MTD)goalsandoutcomes.TheBHTACHwillfacilitateanddrivealignmentacrosstheregiontoleverageadditionalresourcesandstrategiesamongpartners,providers,andfunders.Forexample,theCommunityResiliencyFundmayserveasa
mechanismtoalignneededsocialdeterminantinvestmentacrossphilanthropicpartners,allowingMTDresourcestohaveagreaterimpact.Asanotherexample,weareindiscussionswiththeEmpireHealthFoundationandUpstreamUSAtosupportincreasedregionaleffortstoreduceunintendedpregnanciesthroughtheutilizationoftheOneKeyQuestionmodel,andincreasingaccesstoLongActingReversibleContraception.ThispartnershipwillallowtheBHTACHtoleverageMTDfundstoaddadditionalelementstotheclinicaldeliverysystem.Thisalsomeetsourregion’sdesiretoreduceAdverseChildhoodExperiencesbyinvestinginpreventionefforts.ThistypeofalignmentandleveragingwillbeakeycomponentoftheCollaborativedevelopment.BHTValue-BasedPaymentStrategiesBHThasprovidedmultipleopportunitiesforpartnerstolearnaboutVBP,includingquarterlyupdatesattheACHLeadershipCouncilandtheBHTBoardmeetings.MarkWakaiofProvidenceHealthServices,whositsontheMVPteam,gaveapresentationontheVBPRoadmaptoourRegionalIntegrationTeamonSeptember12,2017andtoourLeadershipCouncilonSeptember28,2017.InOctober,theBHTACHhostedaLearningSessionconductedbyHCA’sChiefMedicalOfficer,Dr.DanLesslerthattouchedontheintersectionsbetweenBi-DirectionalIntegrationandVBP.Wehavereachedmorethan100organizationsviatheseefforts.BHThasconsistentlyprioritizedVBPeducationandstrategydevelopmentasakeyelementinachievingMTDgoals.DescribehowtheACHsupportedand/orpromotedthedistributionofthe2017ProviderVBPSurvey
BHTACHdistributedthe2017ProviderVBPSurveyfirstviaitsweeklypartneremail,whichwassentto291recipients.ThesurveylinkwasalsoplacedonthefrontpageofourBHT’swebsiteforthemonthsofJulyandAugust,duringwhichtimethepagehadatotalof1,811views.15organizationsrespondedtothe2017ProviderVBPSurvey.RespondentsrepresentMedicaid-criticalprovidersintheregion(e.g.CHAS;LakeRooseveltCHC;Providence;MultiCare;Ferry,Lincoln,andNewportHospitaldistricts).Providersrespondingrepresentagoodcrosssectionofpartners,includingTribalhealth,behavioralhealth,inpatient/outpatientfacilities,criticalaccesshospitals,hospitals,FederallyQualifiedHealthCenters(FQHCs),RuralHealthClinics(RHCs),multi-specialtypractices,andnot-for-profitorganizations.DescribethecurrentstateofVBPamongtheACH’sproviders
TheBHTACHhasworkedhardtoensurethatourhealthcareandSocialDeterminantofHealthpartnersareawareofthestate’sgoaltomove90%ofMedicaidpaymentstoaValueBasedmodelby2021.Increasingly,ourdiscussionsaremovingtospecificsaboutreadyingproviderstomeetthegoals.Weareencouragedbythefactthat6ofthe15respondentsintheHCAVBPSurveyreportedthattheycurrentlyhaveMedicaidContractsthatmeettheVBPtargetsintheLANcategories2C-4B.Additionally,theBHOinourregionhasbeenincludingValueBased
Paymentsintheirprovidercontractsoverthelastfewyears.Butevenwiththesedatapoints,weexpectthatthereisasignificantamountofworktobedonetomeetthe90%targetintheregion.TheBHTACHRuralandSpokaneCountyCollaborativeswilldevelopaprovider-by-providerplantopreparetheregionforVBPinpartnershipwiththeManagedCareOrganizationsandtheHealthCareAuthority.HastheACHobtainedadditionalinformationbeyondwhatthesurveyincluded?Ifso,werethesefindingsconsistentorinconsistentwiththesurveyresults?
TheACHhasinformallydiscussedVBPcontractswithMCOsandprovidersoverthelastfewmonthsandthesurveyfindingsareconsistent.ThereishighlevelknowledgefromregionalMedicaidprovidersaboutVBPgoals,theneedforinvestmentinclinicalandHIEtransformationtobereadyforrisk-basedVBPcontracts,andacceptancethatVBPoffersastrongvaluepropositiontoservepatientsbetter.However,thereisconcernofinadequateaccesstoservicesformentalhealth,substanceusetreatmentsandsocialdeterminantsofhealthfundingtoadequatelysupportwholepersoncare.ThismayresultinprovidersbeinglesslikelytoassumeriskbasedVBPcontracts.HowdoprovidersexpecttheirparticipationinVBPtochangeinthenext12months?
The15providersurveyrespondentsindicatedthat:• 1woulddecreaseVBPby10%• 3wouldstaythesame• 5wouldincreasebyupto10%• 3wouldincreaseby10-24%• 3wouldincreaseby25-50%
Foryourpartneringproviders,whatarethecurrentbarriersandenablerstoVBPadoptionthataredrivingchange?
AmongthosewithVBPexperience,responsesaboutwhathassupported(enabled)theirparticipationinVBPwerevaried.Themostfrequentlynotedparticipationenablersweretrustedpartnershipsandcollaborationwithpayers,andalignedincentivesandcontractrequirements.Dataissueswerethemostfrequentlymentionedbarrier-9or10organizationscitedtheseasobstacles:
• Lackofinteroperabledatasystems• Lackofaccesstocomprehensivedataonpatientpopulations(e.g.,demographics,
morbiditydata)• Lackofavailabilityoftimelypatient/populationcostdatatoassistwithfinancial
management
• Accesstomentalhealth,substanceusetreatment,housing,transportationservicesInourconversations,MCOshavereferencedalready-establishedVBPcontractsandaremovingtowardmeetingtheHealthierWA2017milestonethat30%ofMedicaidcontractsbeinVBParrangements.SeveralofBHTACH’skeyproviderpartnersarelikelytobeinapositiontomoveprogressivelyfrom50%-90%VBPwithintheHealthierWAestablishedtimeframes.TheCollaborativeswilldevelopaplantosupportthemajorityofMedicaidprovidersinmeetingthe90%VBPgoalbytheendoftheMTDperiod.BHTWorkforceStrategiesGrowingandmaintainingthesupplyofbehavioralhealthprofessionalsisapriorityfortheBHTACH,givenitsfocusacrossprojectareasonimprovingaccessandcareforindividualswithbehavioralhealthandco-occurringconditions.Similarly,establishingastrongnetworkofcarecoordinators(whetherthoseareCommunityHealthWorkers(CHWs),MedicalAssistants(MAs),orPeerCounselors)willsupportPathwaysandotherbi-directionalintegrationwork.Currently,mostoftheBHTACHregionisdesignatedasamentalhealthcareprofessionalshortagearea,51andBHTACHareaparticipantsintheWashingtonStateHealthWorkforceSentinelNetworkreportrecentincreasesindemandforclinicalsocialworkersandmentalhealthcounselors.52PartnerswhoparticipatedintheBHTACHHealthSystemsInventorynotedlong-standingchallengeswithworkforcerecruitmentandretentionacrossavarietyofroles.AmorefocusedworkforceassessmentlinkedtodevelopingMTDimplementationplanswillbeconductedinQ12018withCollaborativepartners.TheBHTACHwillpartnerwiththeCommunityCollegesofSpokaneandtheregionalWorkforceDevelopmentCounciltocompletetheassessment,withaspecialfocusonbuildingcapacityforthenextgenerationofhealthworkforcethatwillmeettheneedsofatransformedcommunityhealthsystem.Partnerdiscussionshaveenabledustodetermineinitialfocusareasforfurtherdevelopmentthroughtheassessment:
• Assesscarecoordinationutilizationandcapacityinclinicandcommunitybasedorganizations.
o ExplorecredentialingrequirementsforCareCoordinatorsincludeHealthCoaches,HealthHomesCareCoordinatorsandotherCommunityHealthworkers
o ExploreCommunityParamedicineopportunitiestoincreasetheuseofvolunteerEMSstafftoserveasabridgebetweenthepatientandcarecoordination.
o ExplorepotentialuseofMedicalAssistantsasmembersofintegratedprimarycareteams,anidentifiedgapareapriorityofourruralpartners.Astheruralpopulationagesandaccesstoservicescontinuestobeachallenge,theexplorationoftheadditionofMAsas“healthextenders”iswarranted.
• Assessmentalhealthandsubstanceuseworkforcegapso Exploreopportunitiestoincreasethepipelineformentalhealthandsubstance
useproviders.WorkwithMCOsinthetransitiontoFIMCtoensuretheworkforcecapacityofBHprovidersinintegratedsettings
o UtilizationofTeleHealthandTelePsychiatryinruralandprimarycaresettings
• AttheCollaborativelevel,assesstrainingneedstosupportproviderswhopracticeinanintegrated,value-basedsystem
HowBHTACHisconsideringandprioritizingstatewideworkforcecapacitydevelopment
AswedeveloparegionalworkforcestrategytomeetMTDprojectandCollaborativeneeds,wewillalignoureffortswithotherregionalstrategies.Theseinclude:increasingthenumberofPrimaryCareResidencyslotsforGraduateMedicalEducation;expandingtheruraltrackintheUWPrimaryCareResidencyprogram;developingaPsychiatryResidencyprogram,tofurtherintegrateawholepersonteamapproachatWSU’sMedicalSchool;andlaunchingtheProvidenceDentalResidencyClinic.WearealsopartneringonworkforceinnovationswiththeSpokaneAreaWorkforceDevelopmentCouncilandGreaterSpokaneIncorporated(GSI),thelargestregionalbusinessorganizationinthearea.GSIisfocusedoncreatinganenvironmentwhereemployerscansucceed,compete,andgrow.GSI’s“Vision2030”includesgrowingaHealthandLifeSciencesIndustryandincreasingeducationattainmentfrom40%to60%by2025.Finally,weareparticipatinginconversationswithotherACHs,HCA,DOH,WashingtonStateHospitalAssociation(WSHA),WashingtonStateMedicalAssociation(WSMA),andtheUniversityofWashingtonCenterforHealthWorkforceStudiestoalignourlocalstrategywithstatewideefforts.BHTPopulationHealthManagementSystemsThirty-nineuniqueorganizationsintheBHTACHregioncompletedaHealthSystemsInventory(HSI)orCareCoordinationInventory(CCI)tohelptheBHTACHlearnmoreabouttheorganizations’patientsandworkinareasrelevanttotheMTD.BasedonproviderresponsestotheHSI,weknowthatmultipledatasystemsareinuseacrossthecommunity.Itwillbenecessarytoconductaprovider/Collaborative-levelassessmentonHIE/HIT.WewillconductanHIE/HITsurveyinQ12018tobetterunderstandsystemsandtoolsinuse.Thiswillincludemappingassetsandcurrentpopulationhealthmanagementsystemscapabilities,capacityandgapsanddevelopaplanforcreatingthenecessaryinterconnectivityacrossproviders.
TheBHTACHwilldeveloparegionalimplementationplantoensureacoordinated,leveraged,andcost-effectivesolution.WeexpecttoexplorearobustpartnershipwithOneHealthPortandotherstateinitiatives.TheBHTACHhasdevelopedthefollowingstrategiestoexpand,use,support,andmaintainpopulationhealthmanagementsystemsacrossallprojects:
• UsetheCollaborativestructuretoincentsharedaccountabilitytiedtooutcomesforpopulationhealth.ItisexpectedthateachCollaborativewillbeeligibleforpaymentsbasedonperformanceonHIE/HITadoption.
• BHThassubcontractedwithProvidenceCOREtocreateacommunitydashboardthatwilla)provideabroaderviewofcommunityhealth;b)helpinformcommunityresiliencyinvesting(anothereligibleearnedincentivecategoryunderBHT’sapproach);andc)connectinformationaboutsocialdeterminantsandclinicalcare.
• UtilizeFIMCIncentivestosupportprovidersforconnectivityandupgradeEHRstomeetintegratedcarereportingandbillingneeds.EachCollaborativewillassessneeds/gapsthatwillinformtheWaiverFinanceWorkgrouprecommendationstotheBHTBoardonlevelsofinvestment.
• ExploreinformationsharingandstrategydevelopmentwiththeWashingtonStateHospitalAssociation(WSHA).BHT’sEDhasactivelyengagedwithWSHAaboutcapacityandpotentialutilizationofadaptingWSHA’scurrenthospitaldatareportingsystemtoincludepopulationhealthinformation.
Endnotes
1See:http://www.doh.wa.gov/Portals/1/Documents/2900/wa_ach_od_quarterly_2017Q1.zip2See:https://www.doh.wa.gov/DataandStatisticalReports/DiseasesandChronicConditions/ChronicDiseaseProfiles/AccountableCommunitiesofHealth
3WashingtonStateOfficeofFinancialManagement(2017).PotentiallyPreventableHospitalizationsbyLegislativeDistrict.ResearchBriefNo.85.Availableat:http://www.ofm.wa.gov/researchbriefs/2017/brief085.pdf
4CoordinatedCare,Molina,andUnitedsubmittedCCIs;these3MCOsrepresent73%oftheenrolledpopulationbasedonHCAMedicaidEnrollmentreports(PlanbyProgram)forSeptember2017.See:https://www.hca.wa.gov/about-hca/apple-health-medicaid-reports
5HCAACHToolkitProviderReportFilesupdated09.01.17,see:https://wahca.app.box.com/s/mxpg8euzbjpdkmyuftzb4ri5v41ia8v9/folder/30748038709.
6SpokaneRegionalHealthDistrictDataCenter(2017).CommunityLinkageMapping:GeneralReport.Anassessmentoftheregionalpopulationandsocialdeterminantsofhealthsystems.See:https://goo.gl/1WDBpo.Seealsotheinteractivemapavailableat:http://arcg.is/2pH9kuT
7CalculationsusingWashingtonStateOfficeofFinancialManagementOfficialPopulationEstimatesfor2016;see:http://www.ofm.wa.gov/pop/april1/
8Basedon2010censusdataandRUCAdesignationsbyWashingtonStateOfficeofRuralHealth;see:ftp://ftp.doh.wa.gov/geodata/layers/Scheme4_rurality_censustracts_WA.pdf
9HealthierWashingtonDataDashboard,CY2016data:https://www.hca.wa.gov/about-hca/healthier-washington/data-dashboard
10HealthierWashingtonDataDashboard(CY2016)andOfficeofFinancialManagementsmallareapopulationestimatesfor2016.
11HealthierWashingtonDataDashboard,Oct.2015–Sept.2016data12BasedonOfficeofFinancialManagementsmallareapopulationestimates,changeinHispanicpopulation2010-
2016.See:http://www.ofm.wa.gov/pop/asr/13HealthierWashingtonDataDashboard,CY2016data:https://www.hca.wa.gov/about-hca/healthier-
washington/data-dashboard14SpokaneAreaWorkforceDevelopmentCouncil,see:
http://www.betterhealthtogether.org/s/BetterHealthTogether_final.pdf15Basedon2015data,RWJFCountyHealthRankings:http://www.countyhealthrankings.org/16UrbanIndianHealthInstitute,SeattleIndianHealthBoard.(2017).CommunityHealthProfile:IndividualSite
Report,SpokaneUrbanIndianHealthProgramServiceArea.Seattle,WA:UrbanIndianHealthInstitute.Notethattheseestimatesarebasedon2010-14AmericanCommunitySurveydata,whiletheRWJFCountyHealthRankingsemploymentmeasureusestheCurrentEmploymentStatisticsSurvey.
17See:http://www.commerce.wa.gov/housing-needs-assessment.Affordable(meaningtheycostlessthan30%ofaveragehouseholdincome)&availableunitsper100householdsinBHTACHcountiesare:Adams22,Ferry26,Lincoln22,PendOreille26,SpokaneCo.12,Stevens26.Spokanemetroareahas14affordable&availablehousingunitsper100households.
18BHTACHHealthSystemsInventory(2017).19HCAACHToolkitHistoricalData:
https://wahca.app.box.com/s/mxpg8euzbjpdkmyuftzb4ri5v41ia8v9/folder/3695005203620HCACo-occurringdisordertables,see:https://wahca.app.box.com/s/mxpg8euzbjpdkmyuftzb4ri5v41ia8v9/folder/39866406519
21HCAhospitalizations_ach_rhni_tables:https://wahca.app.box.com/s/mxpg8euzbjpdkmyuftzb4ri5v41ia8v9/folder/23928005433.(Notethat1/3ofMedicaid-paidhospitalizationsinBHT’sregionthatwerenotrelatedtopregnancy/childbirthwereclassifiedasstemmingfrom“othercauses”intheavailabledata
22BHTACHHealthSystemsInventory(2017).
23HCARHNI“starterset”files,see:https://wahca.app.box.com/s/mxpg8euzbjpdkmyuftzb4ri5v41ia8v9/folder/23928005433
24WashingtonPrescriptionDrugMonitoringProgram,see:https://www.doh.wa.gov/ForPublicHealthandHealthcareProviders/HealthcareProfessionsandFacilities/PrescriptionMonitoringProgramPMP/CountyProfiles
25HCAACHToolkitHistoricalData:https://wahca.app.box.com/s/mxpg8euzbjpdkmyuftzb4ri5v41ia8v9/folder/36950052036
26HCAACHToolkitHistoricalData:https://wahca.app.box.com/s/mxpg8euzbjpdkmyuftzb4ri5v41ia8v9/folder/36950052036
27HealthierWashingtonDataDashboard,CY2016data:https://www.hca.wa.gov/about-hca/healthier-washington/data-dashboard
28HealthierWashingtonDataDashboard,Oct.2015–Sept.2016data29HCAMedicaidenrollmentreports;see:https://www.hca.wa.gov/about-hca/apple-health-medicaid-reports30Dataarefrom2012or2013andonlyavailableforAdams,Lincoln,Spokane,andStevenscounties.BasedonsurveysoflicensedprovidersconductedbytheWashingtonStateDepartmentofHealth,OfficeofRuralHealth,see:https://www.doh.wa.gov/ForPublicHealthandHealthcareProviders/RuralHealth/DataandOtherResources/HealthProfessionalShortageAreas/HealthcareAccessReports
31SpokaneRegionalHealthDistrictDataCenter(2017).CommunityLinkageMapping:GeneralReport.Anassessmentoftheregionalpopulationandsocialdeterminantsofhealthsystems.See:https://goo.gl/1WDBpo.Seealsotheinteractivemapavailableat:http://arcg.is/2pH9kuT
32ThetransitionalrespitecareprogramwasfeaturedinarecentRWJFcasestudy,availablehere:http://www.chcs.org/media/Respite-Program-Case-Study_101217.pdf
33HealthierWashingtonDataDashboard,Oct.2015–Sept.2016data34HealthierWashingtonDataDashboard,CY2016data:https://www.hca.wa.gov/about-hca/healthier-washington/data-dashboard
35QualisHealth(December2016).2016RegionalAnalysisReport,WashingtonAppleHealth,WashingtonHealthCareAuthority.Availableat:https://www.hca.wa.gov/assets/program/eqr-regional-analysis-report-2016.pdf
36HealthierWashingtonDataDashboard,CY2016data:https://www.hca.wa.gov/about-hca/healthier-washington/data-dashboard
37HealthierWashingtonDataDashboard,Oct.2015–Sept.2016data38HCAACHToolkitHistoricalData:https://wahca.app.box.com/s/mxpg8euzbjpdkmyuftzb4ri5v41ia8v9/folder/36950052036
39WashingtonStateDepartmentofHealth,OfficeofRuralHealth,see:https://www.doh.wa.gov/ForPublicHealthandHealthcareProviders/RuralHealth/DataandOtherResources/HealthProfessionalShortageAreas
40SkillmanSM,DahalA.(2017).WashingtonState’sPhysicianWorkforcein2016.Seattle,WA:CenterforHealthWorkforceStudies,UniversityofWashington.
41WashingtonStateHealthWorkforceSentinelNetworkdataforApril-May2017reportingperiod.13totalrespondentsfortheBHTACHregion,amongwhich4and3reporteddemandincreasesforsocialworkersandcounselors,respectively.See:http://www.wtb.wa.gov/HealthSentinel/
42QualisHealthandWashingtonStateHealthCareAuthority.(2016).AppleHealthManagedCareCAHPS©5.0HAdultMedicaidreport.See:https://www.hca.wa.gov/assets/program/ahmc-overall.pdf
43HCAACHToolkitHistoricalData:https://wahca.app.box.com/s/mxpg8euzbjpdkmyuftzb4ri5v41ia8v9/folder/36950052036
44WashingtonStateOfficeofFinancialManagement(2017).PotentiallyPreventableHospitalizationsbyLegislativeDistrict.ResearchBriefNo.85.Availableat:http://www.ofm.wa.gov/researchbriefs/2017/brief085.pdf
45BHTACHHealthSystemsInventory(2017).46WashingtonStateDepartmentofHealth,CenterforHealthStatistics,2009-2013.CalculationsandpresentationofdatabySpokaneRegionalHealthDistrict,DataCenter.
472013FosterPlacementrateper1000.SpokaneCounty=10.2,stateaverage=5.7.(http://datacenter.kidscount.org/data/)
482016WashingtonHealthyYouthSurveydataforBHTregion,grades6,8,and10(grade12responseratetoolow
toinclude).See:http://www.askhys.net/library/2016/ACH01MultiGr.pdf
49RWJFCountyHealthRankings,basedon3yearsofpooledBRFSSdata.See:http://www.countyhealthrankings.org/app/washington/2017/measure/outcomes/60/data
50FelittiV,etal.(1998).Relationshipofchildhoodabuseandhouseholddysfunctiontomanyoftheleadingcausesofdeathinadults.TheAdverseChildhoodExperiences(ACE)Study.AmJPrevMed.14(4):245–258
51WashingtonStateDepartmentofHealth,OfficeofRuralHealth,see:https://www.doh.wa.gov/ForPublicHealthandHealthcareProviders/RuralHealth/DataandOtherResources/HealthProfessionalShortageAreas
52WashingtonStateHealthWorkforceSentinelNetworkdataforApril-May2017reportingperiod.13totalrespondentsfortheBHTregion,amongwhich4and3reporteddemandincreasesforsocialworkersandcounselors,respectively.See:http://www.wtb.wa.gov/HealthSentinel/
SECTIONII:PROJECT-LEVEL
TransformationProjectDescription SelecttheprojectfromthemenubelowandcompletetheSectionIIquestionsforthatproject.
MenuofTransformationProjects
Domain2:CareDeliveryRedesign�� 2A:Bi-DirectionalIntegrationofPhysicalandBehavioralHealththroughCareTransformation
(required)
ProjectSelection&ExpectedOutcomes Thescopeoftheprojectmaybepreliminaryandsubjecttofurtherrefinement.InDemonstrationYear2,theACHwillberequiredtofinalizeselectionsoftargetpopulationandevidence-basedapproaches,andsecurecommitmentsfrompartneringproviders.
ACHResponse
ProjectDescriptionandJustificationIn2017,BHTlaunchedacross-sectordiscussionwithBehavioralHealth,PhysicalHealth,ManagedCareOrganizationsandCountyCommissionersaroundtheopportunitiestiedtofully-integratedmanagedcare(FIMC).Thisdiscussionchangedthetenorofthediscussionintheregionfrombehavioralhealthproviderconcernsabouttheunintendedconsequencesofchangetoaconsiderationofbroadsystemtransformationopportunitiesthroughnewinvestments,withthepossibilityofreducedcostsandimprovedpopulationhealth.Asaresult,ourcommunitycommittedtobi-directionalintegrationasacornerstoneofourcommunityhealthtransformationefforts.TheBHTACHbi-directionalintegrationprojectisdesignedtoimprovewhole-personcareandhealthoutcomesbyencouragingandfacilitatingevidence-basedmodelsofcareforhigh-needspopulations,whilealsobuildingonexistingphysicalandbehavioralhealthintegrationactivities.ConsistentwiththeMedicaidTransformationDemonstration(MTD)Projecttoolkitguidance,BHTwillsupportclinicsintheimplementationofevidence-basedmodelssuchastheBreeCollaborativeortheCollaborativeCareModel,andwillleverageHealthInformationTechnologyandcarecoordinationinfrastructuretolaunchourintegrationefforts.Furtheringintegrationofphysicalandbehavioralhealthcareisacriticalstepinaddressingthehealthneedsoftheregionalpopulation.Thisinitiativeholdspromisetoenhancecarecoordinationacrossthespectrumofphysicalandbehavioralhealthconditions,andofferpatientsmoretimelyaccesstoessentialservices.Morethan44,000BHTACHMedicaidmembershavebeendiagnosedwithamentalillness,andtheprevalenceofmentalillnessis29.5%intheBHTACHregion,higherthanthestatewidelevel.Approximately20,000clientsintheBHTACHregionhaveasubstanceabusetreatmentneed,equatingtoaprevalenceof11.2%.Finally,andperhapsmostconcerning:about36,000haveamentalhealthorsubstanceabuseconditionand1ormorechronicdisease,indicatingahighlevelofneedforbi-directionalcareintegrationtoprovidewholepersoncareandnavigatethemanyobstaclesthatariseforpatientssufferingfromtheseconditions.1Figure1belowprovidesdetailsontheprevalenceofconditionsintheBHTregion(orange)comparedtothestatewideprevalencerate(blue).
Figure1:ProportionofMedicaidPopulationwithKeyConditions
JustificationforselectingprojectandhowitaddressesregionalprioritiesTheprevalenceofbehavioralhealthdisordersandsubstanceusedisorders(SUD)constitutesamajorpublichealthissueintheBHTACHregion.Outsideofpregnancyandchildbirth,‘mentalandbehavioraldisorders’weretheleadingcauseofhospitalizationforBHTACHMedicaidbeneficiariesin2015,accountingfor17.5%ofallnon-birth-relatedhospitalizations.Substanceabusedisordersaccountedfor5.7%ofsuchhospitalizationsoverallbut8%amongnon-disabledadults.(Notethat1/3ofMedicaid-paidhospitalizationsintheBHTACHregionthatwerenotrelatedtopregnancy/childbirthwereclassifiedasstemmingfrom“othercauses”intheavailabledata.)2Moreover,opioiduseishighamongtheBHTACHMedicaidpopulation.17.4%ofBHTACHMedicaidbeneficiariesarecurrentopioidusers,vs.13.5%statewide,and3.6%areheavyusers.3InalmostalloftheBHTACHcounties,opioidprescriptionsarewrittenandfilledatahigherratethanaverageforWashingtonstate(AdamsCountyistheexception).4TheBHTACHexceedsthestateaverageforMedicaidusersreceivingmedication-assistedtreatmentwithbuprenorphine(11%vs.10%statewide)butissubstantiallybelowthestateaverageformethadoneMAT(11%vs.16%statewide).5TheBHTACHisalittlebelowthestateaverageformentalhealthtreatmentandsubstanceabusetreatmentpenetrationratesamongMedicaidbeneficiaries.Ontheotherhand,ratesoffollow-upafterahospitalizationorEDvisitrelatedtomentalhealthorsubstanceusearehigherthantheaverageforWashingtonState.5Overall,estimatedchronicdiseaseprevalenceamongtheMedicaidpopulationintheBHTACHregionisclosetothestatewidefigures:approximately3%hadaninpatientoroutpatientclaiminthelastyearthatincludedadiagnosisofdiabetes(vs.4%statewide)and5%hadaclaimwithadiagnosisofasthma(vs.4%statewide).However,thesefiguresmasksomeregionalvariation:
• AsthmaishigherthanthestateaverageinStevensCounty(6%)andFerryandSpokaneCounties(5%).
• SmokingisariskfactorforanumberofchronicdiseasesandBHThassomeofthehighest(StevensCountyat33%)andlowest(AdamsCountyat8%)smokingratesamongWashington’sMedicaidbeneficiaries.
8.8%
12.5%
29.5%
7.7%
11.2%
27.1%
0% 10% 20% 30% 40%
MIorSUDandCD
SUDtreatmentneed
Anymentalillness
BHTinorange Stateinblue
• DepressiondiagnosesamongSpokaneCountyMedicaidrecipientsis12%butAdamsCountyhasthelowestrateinthestateat3%.6
Finally,whiletheBHTACHregioncurrentlyperformsatorabovethestatelevelonseveralperformancemeasuresthatareconnectedtothe2Aproject,therearestillpromisingopportunitiestoenhanceintegratedcare,suchasincreasingfollow-upafterdischargefromtheEDforencounterstiedtoamentalhealthconditions.Theseopportunitiesforimprovedprocessesandpatientoutcomesprovideakeyrationaleforthisinvestment.
Figure2:BHTperformanceonselectintegrationperformancemeasures7
HowprojectwillsupportsustainablehealthsystemtransformationforthetargetpopulationTransformingthehealthcaresystemtobemoreresponsivetotheneedsofpeoplereceivingMedicaidservicesthroughtheprovisionofintegratedcare,whetherinaprimarycareorbehavioralhealthclinic,willimproveoutcomesnotonlyforthe2Atargetpopulation,butforMedicaidbeneficiariesoverall.WewillscaleuptofullimplementationoverthecourseoftheMTDperiod,startingwiththehigh-riskpopulationofMedicaidenrolleeswithco-morbidconditionsinordertobesuccessfulinachievingexpectedprojectoutcomes.Itistheexpectationthatbyincreasingintegratedcaretothistargetpopulations,therewillbegainstotheentirehealthcaredeliverysystem.Asprovidersbecomemorefluentincollaboratinginpatients’care,whole-personcare,expectedresultsincludeearlierdiagnosis,treatment,andopportunitiestomovecareupstreamandpreventconditionsfromexacerbatingandbecomingchronic.
Inadditiontostrongerintegrationofcarebetweenphysicalandbehavioralhealthproviders,collaborationwithsocialserviceprovidersthroughthePathwaysHubmodelimplementationwilllaythegroundworkforproviderstoeffectivelyaddresssocialdeterminantsofhealth,which,leftunaddressed,contributetopoorhealthoutcomes.Lastly,weareexploringtelehealthoptionstoincreaseaccesstocare.Ourprovidernetworkiscurrentlyreviewingpotentialtele-behavioralhealthservices,whichwouldbeavailableforemergencyconsultsintheED,formedicationmanagementandsupportoftheprimarycareteam,andforongoingcareofindividualswithchronicbehavioralhealthissues.Someexamples
22.0%
29.5%
63.8%
73.2%
76.8%
88.1%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Follow-upafterdischargefromEDforalcoholorotherdrugdependence - 7day
Follow-upafterdischargefromEDforalcoholorotherdrugdependence - 30day
Follow-upAfterDischargefromEDforMentalHealth- 7day
Follow-upAfterDischargefromEDforMentalHealth- 30day
Followupafterhospitalizationformentalillness- 7day
Followupafterhospitalizationformentalillness- 30day
alreadyexistthatcouldbetakentoscale:healthsystemsareworkingwithspecialistsinSpokanetohavefollow-upvisitsdoneviatelehealth;LincolnCountyhasusedatelehealth-basedhospitalistprogram;Newporthasdiabeteseducationclassesdeliveredviatelehealth;andthereisalsoaregularParkinson’sDiseasesupportgroupthatmeetsregularlyaroundtheregionviatelehealth.
HowBetterHealthTogetherwillensureprojectcoordinateswithanddoesn’tduplicateexistingeffortsBetterHealthTogetherissupportingthedevelopmentoftwoCommunityHealthTransformationCollaboratives:
1. RuralCollaborative(comprisedofFerry,PendOreille,Stevens,Lincoln,andAdamscounties)
2. SpokaneCollaborative(SpokaneCounty).
TheBHTACHistakingaregionalapproachtoprojectdesignandimplementationthatwillprovidelocalautonomyandregionalaccountability.TheCollaborativeswillberesponsiblefordevelopingandimplementingactionableMTDplansacrossBHT’sprojectportfolio,andensuringthattheprojectscoordinatewitheachotheranddonotduplicateexistingeffortsintheregion.TheCollaborativeswillbecomprisedofkeypartnerswiththeexpertiseandexperiencerequiredtotransformourMedicaidDeliverySystemincludingclinics,FederallyQualifiedHealthCenters(FQHCs),Hospitals,MentalhealthandSubstanceUseproviders,PublicHealth,TribalHealthsystems,EMS,JailsandCountyCommissioners.Thisrepresentationwillensureeffortsarecoordinatedacrosstheregionandresourcesareleveraged.
AnticipatedProjectScopeAnticipatedtargetpopulationTheMedicaidDemonstrationToolkitsuggestsanoveralltargetpopulationofalltheMedicaidenrolleesintheregion,approximately196,000individualsintheBHTregion.2A’sultimateprojectgoalforthedemonstrationisfullimplementationofintegratedcareforallMedicaidbeneficiaries.Weareproposingtoscaleuptofullimplementation,startingwithahigh-riskpopulationofMedicaidenrolleeswithco-morbidconditions,inordertobesuccessfulinachievingexpectedprojectoutcomes.
Anestimated36,000MedicaidbeneficiariesintheBHTregionhaveamentalhealthorsubstanceusedisorderandoneormorechronicdiseases.However,thereareafewsubpopulationswithinthebroaderBHTMedicaidpopulationthatareathigherriskofsufferingfromsubstanceusedisorder(SUD),mentalhealth(MH)conditions,andchronicdiseases,oracombinationthereof.AsshowninTable2,disabledclientsandnewlyeligible(Medicaidexpansion)adultsintheMedicaidpopulationhaveahigherrateofco-occurringdisordersthanthetraditionalMedicaidpopulation.RatesarealsohigherthanexpectedinPendOreilleandSpokanecounties.8IntheBHTACHregion,peoplewithanMHandSUDdiagnosisarealmost5timesaslikelytohave3+EDvisitsinayearasgeneralBHTACHareaMedicaidbeneficiaries.9
Table3:Co-occurringconditionsbyMedicaideligibilitygroupintheBHTACHregion8
Coveragegroup SUD MHcondition ChronicDisease SUDorMHandCD
Disabled 27.7% 60.6% 24.6% 58.8%
Newadults(MedicaidExpansion)
20.3% 32.1% 24.2% 29.4%
TraditionalMedicaid
5.5% 20.4% 27.2% 13.4%
Wewillworkinitiallywiththehighestvolumeprovidersineachcountytofurthertargetoureffortswithinthegroupof36,000individualswithco-occurringconditions.Forexample,wewilllookforopportunitiestoconnectbi-directionalintegrationstrategieswithourdiabetes-focusedchronicdiseaseeffortsfortheestimated4,850memberswhohavediabetesaswellasamentalhealthorsubstanceabusedisorder.InvolvementofPartneringProvidersTodeveloptheproposedproject,theBHTACHconvenedandmetone-on-onewithhighvolumeandengagedpartneringprovidersthroughouttheregionworkingonphysicalandbehavioralhealthintegration.Inaddition,theBHTACHengagedprovidersaHealthSystemsInventoryandaCareCoordinationInventory,toidentifyproviderinterestinMTDprojectareas.Draftinventorieswerefirstreleasedforpublicfeedback,andoncelaunched,wehosted3webinarstooverviewtheInventoryandansweranyquestionsfrompartners.BHTstaffhosted15hoursofOfficeHourssessionswherepartnerscoulddropinandtalkwithACHstaffabouttheirInventoriesorMTD,inadditiontonumerousoutreachmeetingstoindividualproviderorganizations.Throughtheseefforts,BHThasengagedabroadrangeofproviderscriticaltothesuccessofbi-directionalintegrationproject,includingphysicalandbehavioralhealthproviders,countyproviders,socialserviceagenciesandMCOs.39organizationsintheBHTACHregion,representingmostmajorhealthandsocialservicesystems,completedtheHealthSystemsInventory(HSI)and/orCareCoordinationInventory(CCI).TheseeffortsdirectlyinformedthedevelopmentoftheproposedBi-DirectionalIntegrationprojectprioritiesandtheBHTACHproposaltodevelopregionalCollaborativestoimplementMTDprojects.LevelofImpactIntegratingservicesforallMedicaidbeneficiariesacrosstheBHTACHregionwillresultinbettercareandpatientsatisfaction,aswellascostefficiencies.TheimpactoftheprojectwillreachbeyondtheMedicaidbeneficiariesintheregion,withsignificantinfrastructureimprovements:Virtualintegrationandco-locationmethods,e.g.
o Behavioralhealthconsultantswithwarmhandoff(co-location)o In-clinicBHproviders(master'slevel)withremotesupportfrompsychiatrist(virtual&in
person)• Inphysicalhealthsetting:In-clinicBHproviders(master'slevel)withremotesupportfrom
psychiatrist(virtual&inperson)• InBHsetting:Morechronicdiseasemanagementorself-managementsupport• Multidisciplinaryteams• Comprehensivesharedcareplans• BHandchronicdiseasescreenings
HowBetterHealthTogetherwillensurethathealthequityisaddressedintheprojectdesignTheBetterHealthTogetherAccountableCommunityofHealthisensuringthathealthequityisembeddedintheprojectdesignatmultiplelevels:
• RegionalHealthTransformationCollaboratives:WiththecreationofdistinctSpokaneCountyandRuralCollaboratives,BHTisensuringattentionandfocustoruralhealthissuesanddisparitiesin
ourregion.Inaddition,wearedesigningtheseCollaborativestoincludeorganizationsthatbringdiverseracialandculturalperspectivestokeyregionalhealthissues.
• CommunityVoicesCouncil:BHTACHislaunchingaCommunityVoicesCouncil,madeupofatleast50%Medicaidbeneficiariesorlow-incomecommunitymembers,toempowerandbringconsumervoicestoinformprojectdesignandimplementation.ThisCouncilwillbetaskedwithdevelopinghealthequitymetricsbywhichtoholdtheCollaborativesandprojectsaccountabletodefinedhealthequitygoalsandstandards.
• Targetpopulations:BHTisfocusingprojectsontargetpopulationsexperiencingthegreatesthealthdisparities.Weareapplyingan“equitylens”toallourworkbydisaggregatingdatabyrace/age/ethnicity/sex/zipcodewhereverpossible,bothtomakeinformeddecisionsabouttargetpopulationsandtomonitorimpactofprojectsacrossdiversegroups.TheBHTACHwillsupplyCollaborativeswithregionaldatatoguideearlyassessmentsofCollaborativepartners,andwilldirecttheseteamstoidentifypopulationswithintheircountythatfaceahighlevelofdisparitiesand/orpresentashighlycomplexorhighrisk.Initialdataexplorationindicatesthatindividualswithco-occurringmentalhealthandsubstanceabusedisorders—whorepresentpartoftheinitialfocuspopulationforourintegrationwork—experiencethefollowingdisparitiesinqualityofcare:10
o Higherratesofgeneralhospitalreadmissions(all-cause,30day)o Higherratesofreadmissiontoinpatientpsychiatriccare(30day)o LowerratesofannualHbA1ctesting
• Livedexperience:WiththeCommunity-basedCareCoordinationproject,BHTACHisadvancingthePathwaysmodelanduseofCommunityHealthWorkerswithlivedexperienceofhealthinequitiestofurtherourefforts.Carecoordinatorsarecriticaltodevelopingtrustandculturally-appropriatestrategiestomeettheneedsofourtargetpopulationsacrosstheMTDprojectareas.
• EquityAcceleratorPayment:Weanticipateimplementingthisincentivetosupportproviderswhoserveagreaterproportionofhigh-riskclients.ThemetricstiedtothesepaymentswillbedeterminedbytheWaiverFinanceWorkgroup,vettedbyProviderChampionsCouncilandCommunityVoicesCouncil,finalizedbyWaiverFinanceWorkgroup,andrecommendedtotheBHTBoard.
• PathwaysCommunityHubModel:HealthequityisbuiltintomanyelementsofourCommunity-basedCareCoordinationstrategyandthePathwaysmodel,throughindividualizedcareplans;standardsofcareandaccesstotheentirenetworkofcareagenciespartneringwiththeHub;culturally-informedcare;anddatainfrastructuretoolsthatcanbeusedtomonitorcarepractice,providerquality,andresourcegapsinthecommunity,toinformanaccuratepictureofourhealthsystem’scapacity.
Project’slastingimpactsandbenefittotheregion’soverallMedicaidpopulationShiftingtowhole-person,integratedcarewillimprovethequalityofcarepeoplereceiveandimproveoutcomesforthemostvulnerablepopulationsandallMedicaidbeneficiaries.Thisshiftwillalsoallowforamoreefficientuseofdollars,freeingupfundsforincreasedinvestmentsinupstreamhealth,includingpopulationhealth,preventionandaddressingsocialdeterminantsofhealth.Infrastructureinvestmentsandclinicalcareredesignwillbeamongthelastingimpactsfortheregion’soverallMedicaidpopulation,includinginvestmentsinHIE/HITandworkforcetosupportintegratedcare,establishedpathwaysforproviderstodevelopnewevidence-basedmodelsofcare/proofofevidence,implementationofclinicalscreeningtoolstonewpopulations,andfacilitated/sharedlearningacrosscollaborativeproviders.TheseinvestmentswillpavethewayforlastingchangeinhealthcaredeliveryandprepareprovidersintheBHTregionforvalue-basedpayment.
ImplementationApproachandTimingSeeSupplementalWorkbook
PartneringProvidersSeeSupplementalWorkbook
ACHResponse
HowBetterHealthTogetherhasincludedpartneringprovidersthatcollectivelyserveasignificantportionoftheMedicaidpopulationAsreferencedabove,theBHTACHsurveyedorganizationsintheregiontocompleteaHealthSystemsInventory(HSI)and/orCareCoordinationInventory(CCI)togatherproviderinformationaboutexistingworkintheregionrelatedtotheMTDprojectareas.BHTACHreceivedresponsesfrom39organizations,includinghospitalnetworks,providersystems,FQHCs,MCOs,andcarecoordinationagencies.
RespondingprovidersfortheHealthSystemsInventoryrepresentedmorethan80%ofthehighest(top10)volumeMedicaidbillersinprimarycare,mentalhealth/substanceabuse,inpatientandED.ForseveralsettingsintheBHTACH’sfiveruralcounties,theHSIrespondentsrepresentalltheMedicaidbillerswithclaimsorbeneficiarycountsofmorethan10in2016.
ProcessforensuringpartneringproviderscommittoservingtheMedicaidpopulation.In2018,theBHTACHwillformalizepartneringproviderparticipationinthebi-directionalprojectandotherMTDprojectareasthroughaTransformationCompactprocesstoensurecommitmenttoservingtheMedicaidpopulation.ThroughtheACHLeadershipCouncil,HealthSystemandCareInventory,BHTACHhasatrackrecordforengaginghighvolumeprovidersintheregionservingasignificantportionoftheMedicaidpopulation.TheBHTACHhasconfidencetheywillcommittoparticipationintheCollaborativeandwillformalizethiscommitmentthroughtheTransformationCompact.
Processforengagingpartneringprovidersthatarecriticaltotheproject’ssuccess,andensuringthatabroadspectrumofcareandrelatedsocialservicesisrepresentedBHThasidentifiedthatrepresentationfromthefollowingsectorsisrequiredforCollaborativestosuccessfullyimplementprojects:
• PhysicalHealthClinicalProvider(s)• HospitalSystem• BehavioralHealthClinicalProvider(s)• TribalHealthSystemProviders• EmergencyMedicalServices• CriminalJustice• SUDProvider(s)• Community-BasedChronicDiseasePrevention• CommunityBasedCareCoordinatingAgency• MCO(s)• CrisisManagementServices• Liaison:CommunityMember/Consumer
RegionalAssets,AnticipatedChallengesandProposedSolutions ACHResponse
Collaborativepartnershipswillbeexpandedasneeded.InitsroleasthePathwaysHub,theACHwillserveasaconnectorbetweenCollaborativeprovidersandsocialandcommunitypartners.BHTACHisalsolaunchingaProviderChampionsCounciltolendapracticingproviderperspectivetoourworkandtoinformandvalidateTransformationPlanslaidoutbyCollaboratives.HowBetterHealthTogetherisleveragingMCO’sexpertiseinprojectimplementation,andensuringthereisnoduplicationManagedCareOrganizationsareactivelyinvolvedinBHT’sgovernanceandleadershipgroups:
• TwoMCOrepresentatives,fromMolinaHealthCareofWashingtonandCoordinatedCareofWashington,areontheBoard
• AllfiveMCOsarevotingmembersofBHT’sLeadershipCouncilandMCOstaffparticipateinmeetingsandone-on-onesessionswiththeBHTteam
• MCOrepresentativesareontheBHTACHRegionalIntegrationPlanningTeam,WaiverFinanceWorkgroup,ProviderChampionsCouncilandCommunityVoicesCouncil
MCOswillcontinuetoparticipateinMTDprojectplanningviatheseTechnicalCouncilsandthroughtargetedcollaborationwithBHTACH’sCommunityHealthTransformationCollaboratives.
Inaddition,BHT,PierceCountyACH,andSouthwestACHhavecollaboratedonmeetingswithMCOpartnerstolearnaboutkeycrossoverareasbetweenACHsandMCOsunderMTD,toensurethattheBHTACHprojectstrategy,supportforproviders/Domain1strategies,andmonitoringandqualityimprovementeffortsalignwithexistingMCOactivitiesandgoals.Ourdiscussionscovered:
• Members/populationoverview• PCPassignment/empanelment• Providersupport,particularlyforvalue-basedpaymentandrelateddeliverysystemreform• Measurementandqualityimprovement• Memberengagement/education• Pathways
IntheBHTACHdiscussionswithMCOs,itwasemphasizedtheimportanceofconsideringtheneedsandutilizationpatternsofdifferentMedicaidpopulations(e.g.expansionadultsvs.traditionalMedicaid)anddesigningstrategiesthatcanintegrateadditionalgroups(e.g.dualspecialneedsclients)overtimetofullyengageMCOsandotherpartnersandsupportsustainability.Anothercommonpointwastheneedtoavoidoverwhelmingproviderswhoarereceivingassistanceandrequestsforpracticetransformationefforts.TheACHandtheCollaborativescanplayakeyroleincoordinatingTAsupportwithMCOs.WealsodiscussedwaystocoordinateondatasharingwithMCOs,HCA,theWashingtonHealthAlliance,OneHealthPortandeventuallytheWashingtonAllPayerClaimsDatabase.
ACHResponse
AssetsBetterHealthTogetherandregionalpartneringproviderswillbringtotheproject:TheBHTACHwillutilizearuralandSpokaneCountyCollaborativemodeltodevelopandimplementactionablebi-directionalintegrationplans.TheRuralCollaborative,covering35,173MedicaidlivesintheruralcountiesofAdams,Ferry,Lincoln,PendOreilleandStevens;andtheSpokaneCountyCollaborative,acountywith164,707coveredMedicaid.TheseCollaborativesareresponsiblefora
localsetofstrategiestomeettheMTDprojectgoals.TheCollaborativestructurewillalignwiththeproposedMTDfundsflowapproachbyallocatingearnedregionalfundstoeachcollaborativebasedonpayforreportingandpayforperformancegoalachievement.Fundsflowstrategiesincludeplansforfixedandearnedpaymentstobothurbanandruralproviderpartnerstocoverexpensessuchasprojectcosts,projectadministration,providerengagementandparticipation,workforcedevelopment,populationhealthmanagement,andothercosts.In2013,BHTdevelopedtheNavigatorNetwork,alargeandsuccessfulinitiativetoprovideIn-PersonAssisterstoenrollpeopleinAppleHealth(Medicaid)andQualifiedHealthPlansontheWashingtonHealthBenefitExchange.Throughtheseefforts,BHTsuccessfullyenrolledover125,000peoplewithhealthinsurance(manyofwhomhavebehavioralhealthdiagnoses)anddevelopedarobustnetworkofpartnersthroughouttheregion.AstheoperatoroftheNavigatorNetworkofEasternWashington,BHThasdirectconnectionswithmorethan50organizationswhohostoremploynavigators.ThisprovidescredibilityandimportantlocalconnectionstoprovidersneededtosuccessfullyimplementourMTDprojects.UtilizingSIMfunds,theBHTACHpilotedthePathwaysHubCareCoordinationmodeltoreducejailrecidivismratesinFerryCounty.Thisprojectdemonstratedthevalueofacommonreferralmechanismtoaddresssocialdeterminantsofhealthissues.Forbi-directionalintegration,thePathwaysHubwillprovideaddedsupporttoprovidersforreferringhighriskpatientsinneedofsocialdeterminantofhealthsupport.BHTandtheNWRuralHealthNetworkhaveworkedcollaborativelyoverthelast4yearstoestablishRuralCountyHealthCoalitions.Thishasjump-startedourplanningtodevelopacounty-basedCollaborativemodel.Ineachofour5ruralcounties,thereisanestablishedstructurethathasengagedkeystakeholders,includingphysicalhealthclinical,hospitalsystems,behavioralhealthclinical,SUD,Community-BasedChronicDisease,EmergencyMedicalServices,CriminalJustice,PublicHealthandCommunity-BasedCareCoordinatingAgencyproviders.InSpokaneCounty,throughourLeadershipCouncil,CommunityStrategymapworkgroups,andtheleveragingofadditionalnetworks,wehavealsoidentifiedkeypartnerstoserveasthefoundationoftheSpokaneCountyCollaborative.Otherassetstobeleveraged:BHTACHwillexploreapartnershipwithUpstreamUSA.UpstreamdeliversCME/CEU-eligibleon-sitetrainingandtechnicalassistancetohealthcenterssotheycanremovebarrierstosame-dayofferingofthefullrangeofcontraceptivemethods,includingLong-ActingReversibleContraceptives(LARC),toincreaseuseofLARCandreduceunintendedpregnancies.Upstream,inpartnershipwithalargelocalfunder,hasidentifiedWashingtonStateaspartoftheirexpansionstrategy.Investmentscouldrangefrom$1millionto$50millionstatewide.BHTwillexploreapartnershipwiththeARCORAFoundation,calledOralHealthConnections,toleverageinvestmentinseveraloralhealthstrategies.BasedontheSBIRTmodelforbehavioralhealthintegration,thismodelreinforcesadvancedprimarycare,emphasizingteambasedcare,EHRdrivendecisionsupport,andcoordinatedreferraltospecialtycare.OralHealthConnectionsisasystemofcarethatconnectsAppleHealth(Medicaid)patientswithdentalcareintheirlocalcommunities.In2017,theWashingtonStateLegislaturemandatedtheHealthCareAuthorityandARCORAFoundationtoworktogethertopilotOralHealthConnectionsinthreecommunities(Spokane,Thurston,andCowlitzCounties)withtwotargetpopulations–patientswithdiabetesandpregnantwomen.Dentistsservingthesepopulationswillreceiveenhancedreimbursementsfordoingso.Medicalsystemswill
identify,diagnose,andreferpatientstodentalcarethroughanonlinereferraltool,DentistLink,amongotherplaces.Medicalanddentalproviderswillshareinformationandtodevelopsharedplansofcare.Patientsinneedofadditionalserviceswillreceivecarecoordinationfromlocalagencies.Thisisakeystrategyforpatient-centeredintegrationofcare,managementofchronicdiseases,andoverallpopulationhealth.ThepilotisscheduledtolaunchonJanuary1,2019.
Challengestoimprovingoutcomesandloweringcostsfortargetpopulationandstrategytomitigaterisksandovercomebarriers:
Challengestoimprovingoutcomes Strategiestomitigaterisks/overcomebarriers• TrainingandTAforproviders,
includingexpectationsettingfordifferentgroupsandcommunicationacrossprofessionalcultures
• Actingasaconvener,BHTACHwillprovideresourcesforprovidertrainingandTAsupportthroughtheCollaborativestructure
• HarmonizingfinancialpaymenttoPCandBHsettings
• BHTwillworkwithHCA,MCOs,andtheBHTACHregiontosupporteducationandadoptionofVBP
• Clarityandtrainingaroundconsentrequirementsandpatientinformationsharing,incl.school-basedhealthcenters
• Actingasaconvener,BHTACHwillprovideresourcesforprovidertrainingandTAsupportthroughtheCollaborativestructure
• Workforcedevelopment,recruitment,andretentioncriticalforMH-psychiatryandruralhealth,inparticular.Bothchildandadultpractitionersareneeded.
• BHTACHwillcontinuetoworkonregionalworkforcestrategieswithourWDCandeducationpartners
• Lackoftelehealthinfrastructure(technology,space)andstafftrainingsupport
• Exploreregionalcontactingwithtelehealthtechnologyproviderstoovercomeissueswithruralvolume
• Increasingaccess,utilizationandattachmenttoPCP
• UseofCollaborativeinfrastructuretodevelopprovider-ledstrategiestoincreaseaccess,utilization,andattachmenttoPCP
• HITandHIEcapacityvariesbyorganization
• BHTACHwillcontinueEWAACHconversationwithprovidersandMCOsacrossmultipleACHstodrivetosharedapproachandinvestment,andwillcontinuetoworkwithHCAonstatewidealignment
MonitoringandContinuousImprovement
ACHResponse
ThegoalofBHTACH’smonitoringplanistousetimelydatatosupportprojectimplementation,peerlearning,andcontinuousimprovement.BHTACHwillworkwithitscontracteddatavendor,ProvidenceCenterforOutcomesResearch&Education(CORE),todesignandimplementamonitoringsystemthatwilltrackoperational,process,andoutcomemeasuresforeachprojectandCollaborative(seebelow)andfortheACHoverall.Thesystemwillbedesignedtocomplementexistingdataassets(suchastheHealthierWashingtonDataDashboards,anyFullyIntegratedManagedCareearlywarningsystem,andrelevantregionalreports)andwillrefreshanytimeaparticulardatafeedisupdated.Designwilltakeplacealongsideimplementationplandevelopmentinlate2017andearly2018,sothatthesystemisreadyasprojectsmoveintoimplementation.AvisualoverviewofBHTACH’splannedapproachtomonitoringandcontinuousimprovementisshownbelow.
MonitoringmetricswillincludeACHtoolkitpay-for-reportingandpay-for-performancemetrics,aswellasregionalaccountabilityandqualityimprovementplanmetricsthatspeaktotheeffectivenessofBHTACH’sstrategieswithinandacrossprojectareas.Fortheimplementationphase,manymetricswillbeprocessoroperationalinfocus(e.g.establishmentofcross-settingdatasharingagreementsamongCollaborativepartners.)Finalmetricswillbeidentifiedintheimplementationplan.
FortheBi-DirectionalIntegrationProject,theBHTACHwillbetracking,ataminimum,informationonthefollowingaccountabilitymeasures:
• Anti-depressionmedicationmanagement• ChildandAdolescents’AccesstoPrimaryCarePractitioners• ComprehensiveDiabetesCare:HbA1cTesting• ComprehensiveDiabetesCare:Medicalattentionfornephropathy• ComprehensiveDiabetesCare:EyeExam(retinal)performed• MedicationManagementforPeoplewithAsthma(5–64Years)• MentalHealthTreatmentPenetration(broad)• PlanAll-CauseReadmissionRate(30Days)
• SubstanceUseDisorderTreatmentPenetration• Follow-upAfterHospitalizationforMentalIllness• Follow-upAfterDischargefromEDforMentalHealth• Follow-upAfterDischargefromEDforAlcoholorOtherDrugDependence• InpatientHospitalUtilization• OutpatientEmergencyDepartmentVisitsper1000MemberMonths
Planformonitoringprojectimplementationprogress,includingaddressingdelaysinimplementationAsshowninthediagram,thesystemwillincorporateprocessmeasuresforprojectimplementation.ThoseprocessmeasureswillbeassociatedwithtimeframesandbenchmarksidentifiedbytheACHandtheCollaborativestoprovideimmediatefeedbackwhendelaysoccur.TheBHTACHwillworkwithCOREtodevelopacommunitydashboardtomonitorkeymetricsidentifiedinthetoolkitandourcommunitypriorities.Thiswillbeamulti-functionaldashboardextendingbeyondtheMTDtoallowongoingcommunitytrackingandprioritization.ResponsibilityforaddressingdelaysinimplementationwillliewiththeCollaboratives,BHTgovernancebodies,andselectBHTstaffpositionsasdescribedunder‘Planformonitoringcontinuousimprovement’below.Planformonitoringcontinuousimprovement,supportingpartneringprovidersanddeterminingwhetherornotBHTisontracktomeetexpectedoutcomesAmonitoringandcontinuousimprovementsystemismorethanjustdata;it’saboutthepeople,processes,andtoolsusedtoturnthatdataintoactionableinformationthatsupportssharedlearningandqualityimprovement.Inadditiontocreatingasystemtoaccessandanalyzedatafromdifferentsources,theBHTACHwillrelyonthefollowinggroupsandpositionstointerpretthedata,identifyperformanceshortcomingsorrisks,anddevelopsolutions:
• CommunityHealthTransformationCollaboratives.Asdescribedelsewhere,BHTislaunchingaSpokaneCountyCollaborativeandaRuralCollaborativetodevelopandimplementspecificregionalplansforhealthsystemtransformationinthefourprojectareasBHThasselected.Thecollaboratives’rolewillextendto:advisingondesignoftheself-monitoringsystem;regularlyreviewingthedatathatsystemprovides;collaboratingwiththeACHtomakecoursecorrectionsasneeded;andparticipatinginsharedlearningopportunitieswithinandacrossCollaborativesandACHregions.
• ProviderChampionCouncil(PCC).ThisrecentlyestablishedCouncilwillprovidegeneralclinicalexpertiseandsubjectmatterexpertiseindifferentMTDprojectareas.TheCouncilwillmonitortrendsinperformanceacrosstheCollaborativestoassesswhethertheBHTACHisontracktoachieveexpectedoutcomesandwilladviseontheCollaboratives’proposedriskmitigationandcontinuousimprovementstrategies.ThePCCwillalsomonitorindividualCollaborativepartnersandadviseontechnicalassistancenecessary.
• BHT’sDirectorofClinicalIntegration,apositioncurrentlyinrecruitment,willsupporttheclinicalstrategiesforBi-DirectionalIntegration,Opioids,ChronicDiseaseandCareCoordination.Additionally,willstafftheProviderChampionCouncilandidentify,communicate,andaddresschallengestoclinicalintegrationandothertransformationstrategies.
• JennySlagle,AssociateDirectorofHealthSystemTransformationwillserveasthePathwaysHUBDirectoroverseeingalloperationsoftheHubincludingtraining,qualityassuranceand
ProjectMetricsandReportingRequirements AttestthattheACHunderstandsandacceptstheresponsibilitiesandrequirementsforreportingonallmetricsforrequiredandselectedprojects.Theseresponsibilitiesandrequirementsconsistof:
• Reportingsemi-annuallyonprojectimplementationprogress.• Updatingproviderrostersinvolvedinprojectactivities.
YES NOX
RelationshipswithOtherInitiatives AttestthattheACHunderstandsandacceptstheresponsibilitiesandrequirementsofidentifyinginitiativesthatpartneringprovidersareparticipatinginthatarefundedbytheU.S.DepartmentofHealthandHumanServicesandotherrelevantdeliverysystemreforminitiatives,andensuringtheseinitiativesarenotduplicativeofDSRIPprojects.Theseresponsibilitiesandrequirementsconsistof:
• SecuringdescriptionsfrompartneringprovidersinDY2ofanyinitiativesthatarefundedbytheU.S.DepartmentofHealthandHumanServicesandanyotherrelevantdeliverysystemreforminitiativescurrentlyinplace.
• SecuringattestationsfrompartneringprovidersinDY2thatsubmittedDSRIPprojectsarenotduplicativeofotherfundedinitiatives,anddonotduplicatethedeliverablesrequiredbytheotherinitiatives.
• IftheDSRIPprojectisbuiltononeoftheseotherinitiatives,orrepresentsanenhancementofsuchaninitiative,explaininghowtheDSRIPprojectisnotduplicativeofactivitiesalreadysupportedwithotherfederalfunds.
YES NO
improvementandstrategicdirection.JennywillstaffthePathwaysCommunityCouncilthatwilllaunchin2018.ThispositionwillcloselymonitorthedataavailablefromtheHUBplatformandintervenewhenPathwaysareslowtocompleteorhaveencounteredroadblocks.
• Initsroleasmonitoringsystemlead,COREwillcoordinatewithBHTstaffandtheentitiesabovetoprovidetimelyinformation,datainterpretationexpertise,andbothtechnicalandstrategicsupportforpeerleaningandcontinuousimprovement.
• BHTBoardwillreceivemonthlydashboardsonkeymilestonesandplanstoaddressanyrisks
• BHTACH’sRegionalIntegrationTeamwillalsotrackkeymilestonesspecificallytiedtoFIMCandMTDprojectalignment
PlanforaddressingstrategiesthatarenotworkingornotachievingoutcomesIncombination,thepeopleandworkgroupsdescribedaboveandtimelydatafromthemonitoringsystemwillenabletheBHTACHtoidentifystrategiesthatarenotworkingandtothinkthroughsolutionsintimetoachieveprojectoutcomes.Ifnecessary,potentialadjustmentstoimplementationtimelineswillbetriagedthroughthemonitoringsystemtoassesstheirimpactondownstreamgoals.Iftimelinesstillcannotbemet,theBHTACHwillinformHCAaboutthereasonsanditsplanforadaptingthetimeline,andpreventing/riskmitigationstrategieswillbesharedtootherprogramswhereappropriate.
X
ProjectSustainability
1HCACo-occurringdisordertables,see:see:https://wahca.app.box.com/s/mxpg8euzbjpdkmyuftzb4ri5v41ia8v9/folder/39866406519
2HCAhospitalizations_ach_rhni_tables:https://wahca.app.box.com/s/mxpg8euzbjpdkmyuftzb4ri5v41ia8v9/folder/23928005433
3HCARHNI“starterset”files,see:https://wahca.app.box.com/s/mxpg8euzbjpdkmyuftzb4ri5v41ia8v9/folder/23928005433
4WashingtonPrescriptionDrugMonitoringProgram,see:https://www.doh.wa.gov/ForPublicHealthandHealthcareProviders/HealthcareProfessionsandFacilities/Pr
ACHResponse
BHT’sstrategyforlong-termprojectsustainability,anditsimpactonWashington’shealthsystemtransformationbeyondtheDemonstrationperiod:TheBHTACHunderstandsthatthebi-directionalcareintegrationproject,alongwiththeotherprojectplansandDomainIefforts,mustmovetheBHTACHregionforwardintermsofdevelopingalong-termclinicalinfrastructureandcommunitystructureabletoprovideseamlessaccesstoclinicalandcommunityservices,whereandwhenclientsneedthem.Toachievethis,theBHTACHhasdevelopedthe“scaleandsustain”targetpopulationmodelthatwillbeginwiththehighestneedpatientsandconditions,andthenrolloutbi-directionalcaretothebroaderMedicaidpopulationovertime.Doingsowillnotonlygiveproviderstimetodevelopandrefineevidence-basedbi-directionalcaremodels,butalsodevelopinsightsandevidenceabouthowbesttoimplementbi-directionalmodelsandwhatkindsofinterventionsandapproachesaremostsuccessful.WearedevelopingourCommunityHealthTransformationCollaborativeswithafocusonmovingtheregiontoValueBasedPurchasingandwholepersoncare.VBPisthecornerstoneofoursustainabilityplan,recognizingtheneedtotransitionhowwepayforcareandlinkingSocialDeterminantofHealthservices.Weareworkingtoaligndata,fundsflow,andmodeldevelopmenttomaximizetheopportunitytointegrateselectedprojectsintoavaluebasedmodelandweavetogetherlocalresourcesandinvestmenttoreachthisgoal.Forinstance,itisexpectedthattheBoard’sfundsflowpolicywillincludedirectedinvestmentsforstartupcosts,infrastructureandtechnicalassistanceemphasizingMTDfundingfortransition,notanongoingpaymentstream.Thebi-directionalintegrationprojectplaysakeyroleinsupportingthemovetoVBP.Increasedfocusandinvestmentinprevention,andscalingmoreefficientandconnectedinterventionstrategies,willleadtoamoreresponsivecommunityhealthsystem,bettersetuptosucceedinVPB.KeytothisprojectisthePathwaysHubModel,whichisasananchorstrategy–alongwithintegrationofcare-forallourMTDwork.PathwaysoffersanopportunitytobetterleverageanoutcomespaymentmodeltosustaincarecoordinationandcommunitycapacityforthetargetpopulationbeyondtheMTDperiod,todisruptthecycleoffragilefundingmanysocialdeterminantofhealthpartnersfaceasgovernmentandphilanthropicpartnersrotatethroughgrantperiods.WeexpectthatPathwayswillbefundedthroughMedicaidMCOsandotherinnovativepartnershipswithphilanthropicorganizationsandcityandcountygovernmentsthroughouttheregion.
escriptionMonitoringProgramPMP/CountyProfiles
5HCAACHToolkitHistoricalData:https://wahca.app.box.com/s/mxpg8euzbjpdkmyuftzb4ri5v41ia8v9/folder/36950052036
6HealthierWashingtonDataDashboard,CY2016data:https://www.hca.wa.gov/about-hca/healthier-washington/data-dashboard
7HCAACHToolkitHistoricalData:https://wahca.app.box.com/s/mxpg8euzbjpdkmyuftzb4ri5v41ia8v9/folder/36950052036
8HCACo-occurringdisordertables,see:see:https://wahca.app.box.com/s/mxpg8euzbjpdkmyuftzb4ri5v41ia8v9/folder/39866406519
9RDAMeasureDecompositionfilesreleased10-27-17.See:https://wahca.app.box.com/s/mxpg8euzbjpdkmyuftzb4ri5v41ia8v9/folder/41072598437
10RDAMeasureDecompositionfilesreleased10-27-17.See:https://wahca.app.box.com/s/mxpg8euzbjpdkmyuftzb4ri5v41ia8v9/folder/41072598437
SECTIONII:PROJECT-LEVEL
TransformationProjectDescription
MenuofTransformationProjects
Domain2:CareDeliveryRedesign�� 2B:Community-BasedCareCoordination
ACHResponseProjectDescriptionandJustificationBHTwillimplementtheCommunity-BasedCareCoordinationprojectasananchorstrategy(alongwithbi-directionalintegrationofcare)toconnecttheportfolioofprojectsintheMedicaidDemonstrationandtodevelopaccountablelinkagesbetweenclinically-basedhealthcareserviceswiththecommunity-basedservicesthatplayanintegralroleinimprovinghealthoutcomes.JustificationforselectingprojectandhowitaddressesregionalprioritiesResearchindicatesthat80%ofanindividual’shealthisdeterminedbywhathappensoutsideofthedoctor’soffice.1Toeffectivelyaddresspoorhealthoutcomes,itiscriticaltoemploymodelsofcarethatcomplementtheclinicalinterventionswitheffortstoaddresswhatarereferredtoassocialdeterminantsofhealth.Examplesoftheseincludeaccesstoaffordablehousing,education,transportation,andinvolvementwiththecriminaljusticesystem.IntheBHTregion,dataindicatetheneedtodeployastrategythatbetterconnectsclinicalcarewithcommunity-basedresourcestosupportimprovementsinhealth.Regionaldataindicatethepresenceofsignificantsocialdeterminantsofhealthwitharelationshiptopoorhealthoutcomes.WhiletheoverallemploymentrateacrosstheBHTregionisslightlyhigherthanthestatewideaverage(5.7%comparedwith5.0%),thenortherncountieshavesomeofthehighestunemploymentratesinthestate:PendOreilleandFerryarethetoptwocountiesat9.5%or10%unemploymentandStevensCountyisat8.8%.2Accordingtothe2015WashingtonStateHousingNeedsAssessment,allBHTcountieshavelownumbersofaffordablehousingunits,withSpokaneCountythelowestat12affordableandavailableunitsper100households.3ProvidersintheBHTregionreportthatbetween3%and18%oftheirclientsliveinhousingthatiseithernotstableorisovercrowdedandthatbetween5%and15%haveahistoryofincarceration.4Regionalhealthdataalsounderscorethesignificantneedforcarecoordination.EDutilizationintheBHTregion(55%)isslightlyhigherthanthestatewideaverage(54%)5.Morethan44,000BHTMedicaidmembers(almost30%)havebeendiagnosedwithamentalillnessandapproximately20,000(12%)haveasubstanceabusetreatmentneed.About36,000(9%)haveamentalhealthorsubstanceabuseconditionand1ormorechronicdiseases.ThesefiguresrepresentalargersegmentoftheMedicaidpopulationforBHTthanthe
correspondingfiguresforWashingtonasawhole.6Forthosewhohavereceivedabehavioralhealthdisorderdiagnosis(eithermentalillnessorsubstanceusedisorder)BHTisslightlybelowthestateaverageformentalhealthtreatmentandsubstanceabusetreatmentpenetrationratesamongMedicaidbeneficiaries,indicatingthat,accesstotreatmentandmanagementofthesedisordersremainsachallenge.
Outsideofpregnancyandchildbirth,‘mentalandbehavioraldisorders’weretheleadingcauseofhospitalizationforBHTMedicaidbeneficiariesin2015,accountingfor17.5%ofallnon-birth-relatedhospitalizations.Substanceusedisordersaccountedfor5.7%ofsuchhospitalizationsoverallbut8%amongnon-disabledadults.7ThePathwaysCommunityHubmodelofferstheBHTACHtheopportunitytobetterconnectthecommunity-basedsocialdeterminantofhealthsystemwiththeclinicaldeliverysystemtosupportatriskindividualstoaddresstherangeofclinicalandsocialfactorsimpactingtheirhealth.HowProjectwillsupportsustainablehealthsystemtransformationforthetargetpopulationAsignificantportionofwhatdeterminesandindividual’shealthhappensoutsideofaclinicalprovider’soffice.ThePathwaysCommunityHubmodelwilldemonstratethevalueofidentifyingandaddressingriskfactorsattheindividuallevelandcomprehensivelyapproachtreatmentofeachriskfactors.Additionally,theopportunitytoorganizecommunityresourcesinamoresystematicandmeasuredwaywilldemonstratethevalueofinvestinginsocialdeterminantsofhealthservices.HowBHTwillensureprojectcoordinateswithanddoesn’tduplicateexistingefforts�BetterHealthTogetherissupportingthedevelopmentoftwoCommunityHealthTransformationCollaboratives:1)RuralCollaborative(comprisedofFerry,Stevens,PendOreille,Lincoln,Adamscounties),and2)SpokaneCountyCollaborativeTheBHTACHistakingaregionalapproachtoprojectdesignandimplementationthatwillprovidelocalautonomyandregionalaccountability.TheCollaborativeswillberesponsiblefordevelopingandimplementingactionableMTDplansacrossBHT’sprojectportfolio,andensuringthattheprojectscoordinatewitheachotheranddonotduplicateexistingeffortsintheregion.TheCollaborativeswillbecomprisedofkeypartnerswiththeexpertiseandexperiencerequiredtotransformourMedicaidDeliverySystemincludingclinics,FederallyQualifiedHealthCenters(FQHCs),Hospitals,MentalhealthandSubstanceUseproviders,TribalHealthsystems,EMS,JailsandCountyCommissioners.Thisrepresentationwillensureeffortsarecoordinatedacrosstheregionandresourcesareleveraged.Inthesummer2017,BetterHealthTogether(BHT)surveyedorganizationsintheregiontocompleteaHealthSystemsInventory(HSI)and/orCareCoordinationInventory(CCI)tolearnmoreabouttheorganizations’clients(includingMedicaidcoverageandhealthstatus),and
gatherproviderinterest,capacity,priorities,andexistingeffortsrelatingtoMTDprojectareas.BHTreceivedHSIandCCIresponsesfrom39uniqueorganizationsthroughouttheregion,includinghospitalnetworks,behavioralandphysicalhealthproviders,PublicHealth,FQHCs,MCOs,andcommunity-basedorganizations.TheCCIinventoryidentifiesanddetailsexistingcarecoordinationeffortsacross29agenciesthroughouttheregion.TheRuralandSpokaneCountyCollaborativeswillbuildoninformationgatheredthroughtheseinventoriestocoordinateandleverageexistingcarecoordinationtoensurethatthePathwaysCommunityHubCareCoordinationprojectdoesnotduplicateexistingeffortsintheregion.BHTandtheCollaborativeswillalsoworkspecificallywiththeregion’sHeathHomestoassurethePathwaysCommunityHubreferralprocessfurthersupportidentificationofHealthHomeseligibleindividualsanddoesnotduplicatecarecoordinationforthispatientpopulation.WeexpectthePathwaysCommunityHubtocomplementtheHealthHomeseffortswithhighneedspatients.Inthelastmonth,SpokaneCountywasawardedanearly$1milliongrantfromtheDepartmentofJusticetoutilizethePathwaysCommunityHubastheanchorstrategyforalocalinitiativetoreformthelocalcriminaljusticesystem.InpartnershipwithBHT,theCountycriminaljustice,wewilllaunchthePathwaysCommunityHub.Thisfundingcameinadditiontoa$1.75milliongrantfromtheMacArthurFoundationinApril2016tohelpreducethejailpopulationby21%by2019.FundsfromtheMacArthurFoundationgrantisbeingusedtoimplementanewlydevelopedriskassessmenttoolinthecounty’sPre-TrialServicesDepartment,aswellasanewracialequitytoolkit.AnticipatedProjectScope&TargetPopulationTheBHTACHwillimplementthePathwaysCommunityHubwithaninitialfocusontwopopulations:HighRiskPregnantMomsandPeopletransitioningoutofjail.Thesetwohighriskpopulationswillindividuallybenefitfromtheinterventionandweexpecttodemonstratemutli-sectorsavings.TheBHTACHmayexpandtootherpopulationsinMTDYear4or5basedoncommunityneeds.TheMedicaidProjectToolkitsuggestsanumberofpotentialtargetpopulationsforthecommunitybasedcarecoordinationproject:Medicaidbeneficiaries(adultsandchildren)withoneormorechronicdiseaseorcondition(suchas,arthritis,cancer,chronicrespiratorydisease[asthma],diabetes,heartdisease,obesityandstroke),ormentalillness/depressivedisorders,ormoderatetoseveresubstanceusedisorderandatleastoneriskfactor(e.g.,unstablehousing,foodinsecurity,highEMSutilization).LookingcloselyatregionaldataandthroughourHSI,twokeypopulationsemergedasmostlikelytobenefitfromincreasedcommunity-basedcarecoordinationandwillbetheinitialtargetpopulationsforthisproject.
TargetPopulation PopulationEstimate
Peopletransitioningoutofjailwitheitheramentalhealthorsubstanceusedisordertreatmentneed
7,9138-11,2109
Pregnantwomen/Medicaidmoms 4,16010
InvolvementofPartneringProvidersTosupportthedevelopmentoftheMTDprojectplan,theBHTACHbuiltontheexperiencesoftheFerryCountyJailTransitionsPilotfundedbyStateInnovationModel(SIM)launchedinearly2017.ThepilotofferedseveralopportunitiestoworkwithprovidersfromtheCriminalJustice,Hospital,Clinic,andCommunityActionCHWtodevelopapowerfulmodeltosupportindividualsexitingjail.TheanticipatedpilotoutcomesaretoreducetherecidivismrateandhealthcarecostsoftheFerryCountyJail.Additionally,theBHTACHLOIprocessidentified22providerorganizationsinterestedinpursuingthePathwaysCommunityHubModel.Twenty-nineprovidersindicatedinterestinservingasapartneringproviderfortheCommunity-BasedCareCoordinationprojectaspartoftheHSIandCCI,thisincludesphysicalandbehavioralhealthproviders,housing,foodsecurity,socialservices,lawenforcement,justicesystem,publichealthandearlylearningproviders.Tofurthersupportdevelopment,theBHTACHconvenedandmetone-on-onewithhealthandsocialdeterminantprovidersthroughouttheregioncurrentlyworkingoncarecoordinationtoassessinterestandsupportforthePathwaysCommunityHubprocess.ThePathwaysCommunityHubmodelcontinuestogarnerdeepsupportformpartnerorganizations.LevelofImpactInselectingourinitialtargetpopulations,peopletransitioningoutofjailandhighriskpregnantmoms,wefocusedonpopulationswhotypicallyhavepoorhealthoutcomes,arehighutilizersofcommunityservicesandgeneratehighhealthcarecosts.Thistargetpopulationalsoprovidesanopportunitytocreatemultisectorsavingsandtopilotasharedsavingsmodel.HowBHTwillensurethathealthequityisaddressedintheprojectdesignHealthequityisbuiltintomanyelementsofourMTDstrategyincludingthePathwaysCommunityHubmodel.ThePathwaysCommunityHubprovidesanevidencedbasedmodelofcarethatfocusedonempoweringindividualstodevelopacareplanthatmeetstheirneeds,increasesaccesstoanetworkofculturally-informedcareagenciesandutilizesadatainfrastructuretoolthatcanbeusedtomonitorcare,providerquality,andresourcegapsinthecommunity. BetterHealthTogetherisensuringthathealthequityisembeddedintheMTDprojectdesignatmultiplelevels:
• APathwaysCommunityAdvisoryCouncil(PCAC)willbeformedinearly2018toconductaRFPforcarecoordinationagenciesandcompletetheenvironmentalscanwork.ThisCouncilwillincludeanappointeefromtheTribalPartnerLeadersCouncilandtheCommunityVoicesCouncil,MCOs,SocialDeterminantofHealthProvidersandHealthCareProviders
• CommunityHealthTransformationCollaboratives:UtilizingaRuralandSpokaneCountyCollaborativemodel,BHTisensuringattentionandfocusonlocalhealthdisparitiesinourregion.Inaddition,weexpectCollaborativestoincludeorganizationsthatbringdiverseracialandculturalperspectivestoMTDplanning.
ImplementationApproachandTiming
• CommunityVoicesCouncil:BHTislaunchingaCommunityVoicesCouncil,madeupof
atleast50%Medicaidbeneficiariesorlow-incomecommunitymembers,toempowerandbringconsumervoicestoinformprojectdesignandimplementation.ThiscouncilwillbetaskedwithdevelopinghealthequitymetricsbywhichtoholdtheCollaborativesandprojectsaccountabletodefinedhealthequitygoalsandstandards.
• Targetpopulations:BHTisfocusingprojectsontargetpopulationsexperiencingthegreatesthealthdisparities.Weareapplyingan“equitylens”toallourworkbydisaggregatingdatabyrace/age/ethnicity/sex/zipcodewhereverpossible,bothtomakeinformeddecisionsabouttargetpopulationsandtomonitorimpactofprojectsacrossdiversegroups.BHTwillsupplyCollaborativeswithregionaldatatoguideearlyassessmentsofpartners,andwilldirecttheseteamstoidentifypopulationswithintheircountythatfaceahighlevelofdisparitiesand/orpresentashighlycomplexorhighrisk.
• Livedexperience:WiththeCommunity-basedCareCoordinationproject,BHTisadvancingthePathwaysmodelanduseofCommunityHealthWorkerswithlivedexperienceofhealthinequities.CHWsarecriticaltodevelopingtrustandculturally-appropriatestrategiestomeettheneedsofourtargetpopulationsacrosstheDemonstrationprojectareas.
• EquityAcceleratorPayment:Weanticipateimplementingthisincentivetosupportproviderswhoserveagreaterproportionofhigh-riskclients.ThemetricstiedtothesepaymentswillbedeterminedbytheWaiverFinanceWorkgroup,vettedbyProviderChampionsCouncilandCommunityVoicesCouncil,andapprovedbytheboard.
Project’slastingimpactsandbenefittotheregion’soverallMedicaidpopulationThevalueofimplementingthePathwaysCommunityHubcarecoordinationprojectprovidesasolidframeworktobettermanageandorganizetheclinicalandcommunity-basedservicesneededtoimproveoutcomesforhighriskMedicaidenrollees.Weseetwokeybenefitsasthelastingimpactofthismodel:
• Abilitytocoordinatethecoordinators:High-riskpatientsoftenhavemany“carecoordinators”thatareunconnectedorunalignedoncareplansacrossdifferentneeds.
• Payforoutcomes:Wewillfocusoninitialtargetpopulationstoestablishastrongfoundationandproofofconceptforthemodelintheregion.Bydoingso,theprojectwillofferasustainablemodelthatcanbedeployedtootherMedicaidenrolleesinregiontobetterlinkthecommunity-basedresourcesthatareneededtostrengthenandbolstertheimprovedandtransformedclinicalsystem.Thiswillsupporttheregion’sshifttovalue-basedpaymentandprovideamoresustainablemodelforcarecoordinatingorganizationsthanthetraditionalmodelofhavingtorelyongrants.
SeeSupplementalWorkbook
PartneringProviders SeeSupplementalWorkbook
ACHResponseHowBHThasincludedpartneringprovidersthatcollectivelyserveasignificantportionoftheMedicaidpopulationBHTreceivedHealthSystemInventoryresponsesfrom23organizationsintheregion,includingmajorhospitalnetworks,providersystems,andFQHCs.Inaddition,BHTreceived29responsestotheCareCoordinationInventoryfromcommunity-basedorganizations.BHTcomparedtheHSIrespondentswithHCA’sSeptember2017ProviderReport11andfoundthattheinventoryresponsesrepresentmorethan80%ofthehighest(top10)volumeMedicaidbillersineachmajorsetting(primarycare,mentalhealth/substanceusedisorder,inpatientandED.)ForseveralsettingsininBHT’sfiveruralcounties,theHSIrespondentsrepresentalltheMedicaidbillerswithclaimsorbeneficiarycountsofmorethan10in2016.BHTstaffarefollowingupwithnon-representedprovidersthatseealargenumberofMedicaidclients,particularlysubstanceusedisordertreatmentproviders.ProcessforensuringpartneringproviderscommittoservingtheMedicaidpopulation.In2018,theBHTACHwillformalizepartneringproviderparticipationinthecarecoordinationprojectandotherMTDprojectareasthroughaTransformationCompactprocesstoensurecommitmenttoservingtheMedicaidpopulation.ThroughtheACHLeadershipCouncil,HealthSystemandCareInventories,BHTACHhasatrackrecordforengaginghighvolumeprovidersintheregionservingasignificantportionoftheMedicaidpopulation.TheBHTACHhasconfidencetheywillcommittoparticipationintheCollaborativeandwillformalizethiscommitmentthroughtheTransformationCompact.
Processforengagingpartneringprovidersthatarecriticaltotheproject’ssuccess,andensuringthatabroadspectrumofcareandrelatedsocialservicesisrepresentedBHThasbeenactivelyengagedwithcurrentCommunity-BasedCareCoordinationservicesintheregion.TheBHTCareCoordinationInventory(CCI)identifiedanddetailedexistingcarecoordinationeffortsacross29agenciesthroughouttheregion.TheCollaborativeswillbuildoninformationgatheredthroughthisinventorytoidentifyandengagepartnerscriticaltotheproject’ssuccess.BHThasalsoidentifiedthatrepresentationfromthefollowingsectorsisrequiredforCollaborativestosuccessfullyimplementallprojects.Eachofthesepartnersrepresentacriticalsettingforprojectimplementation:
Ø PhysicalHealthClinicalProvidersØ HospitalSystem(includingEmergencyDepartment)Ø BehavioralHealthClinicalProvidersØ TribalHealthSystems
Ø SUDProvider(s)Ø Community-BasedChronicDiseasePreventionandMitigationØ EmergencyMedicalServices(firstresponders)Ø CriminalJusticeØ CommunityBasedCareCoordinatingAgencyØ MCOsØ CrisisManagementServicesØ Liaison:CommunityMember/Consumer
Collaborativepartnershipswillbeexpandedasneeded.InitsroleasthePathwaysHub,theACHwillserveasaconnectorbetweenCollaborativeprovidersandsocialandcommunitypartners.BHTACHisalsolaunchingaProviderChampionsCounciltolendapracticingproviderperspectivetoourworkandtoinformandvalidateTransformationPlanslaidoutbyCollaboratives.HowBHTisleveragingMCO’sexpertiseinprojectimplementation,andensuringthereisnoduplicationManagedCareOrganizationsareactivelyinvolvedinBHT’sgovernanceandleadershipgroups:
• TwoMCOrepresentatives,fromMolinaHealthCareofWashingtonandCoordinatedCareofWashington,areontheBoard
• AllfiveMCOsarevotingmembersofBHT’sLeadershipCouncilandMCOstaffparticipateinmeetingsandone-on-onesessionswiththeBHTteam
• MCOrepresentativesareontheBHTACHRegionalIntegrationPlanningTeam,WaiverFinanceWorkgroup,ProviderChampionsCouncilandCommunityVoicesCouncil
MCOswillcontinuetoparticipateinMTDprojectplanningviatheseTechnicalCouncilsandthroughtargetedcollaborationwithBHTACH’sCommunityHealthTransformationCollaboratives.
Inaddition,BHT,PierceCountyACH,andSouthwestACHhavecollaboratedonmeetingswithMCOpartnerstolearnaboutkeycrossoverareasbetweenACHsandMCOsunderMTD,toensurethattheBHTACHprojectstrategy,supportforproviders/Domain1strategies,andmonitoringandqualityimprovementeffortsalignwithexistingMCOactivitiesandgoals.Ourdiscussionscovered:
• Members/populationoverview• PCPassignment/empanelment• Providersupport,particularlyforvalue-basedpaymentandrelateddeliverysystem
reform• Measurementandqualityimprovement• Memberengagement/education• PathwaysCommunityHub
IntheBHTACHdiscussionswithMCOs,itwasemphasizedtheimportanceofconsideringtheneedsandutilizationpatternsofdifferentMedicaidpopulations(e.g.expansionadultsvs.traditionalMedicaid)anddesigningstrategiesthatcanintegrateadditionalgroups(e.g.dual
RegionalAssets,AnticipatedChallengesandProposedSolutions ACHResponse
specialneedsclients)overtimetofullyengageMCOsandotherpartnersandsupportsustainability.
Additionally,theMCOsprovidedusefulinputaboutprojectfeasibilityandalignmentwithexistingcarecoordinationefforts.BHTwillworkwiththeMCOstoengageinplanningensurealignmentandsharedinvestmentinpreparingtheregionforbothfullyintegratedmanagedcareandvaluebasedpurchasing.MCOshavebeenactiveparticipantsintheformationoftheFerryCountyPathwaysPilotthroughourcommunitydesignsessionandwewillcontinuetoengageMCOSinplanningtoensurealignmentandsharedinvestment.Todate,wehavecompletedsecurityassessmentstocontractwithMCOsinFerryCountywithUnitedandMolinaandaremovingintoacontractingprocessinDecember.WeareinprocesswithCHPWtocontractforsecurityassessments.CoordinatedCarehasexpressedsupportforthePathwaysCommunityHubmodel.
ACHResponseAssetstheACHandregionalpartnersproviderswillbringtotheprojectInventories:BHThascompletedanextensiveinventoryprocessthroughoutthelasttwoyearsofplanninginorderto“map”existingprojects,pilots,andassetsthroughouttheregion.Thishasgivenusacomprehensive“currentstate”landscapeassessmentfromwhichtobaseourinitialprojectselection.TheseeffortsincludeourCommunityLinkageMap,CommunityStrategyMaps,HealthSystemsInventory,andCareCoordinationInventory.CommunityLinkageMap:In2016,theSpokaneRegionalHealthDistrictconductedalarge-scaleCommunityLinkageMappingandsocialnetworkanalysis,12inwhich165individualsrepresenting112organizationsfromthehealth,socialservice,education,business,andpublicsectorscompletedaPopulationandSocialDeterminantsofHealthSystemsSurvey.Becauseparticipantswereabletodescribetheirlinkageswithorganizationsthatdidnotresponddirectly,thereportinfactrepresents564organizationsintheBHTregion.Afulllistofparticipatingorganizationsbygeographyandsector,whichisthemostcomprehensivepictureofhealth-relevantcommunity-basedresourcesintheBHTregion,canbefoundasanAppendixtotheRHNIsectionofthissubmission.In2013,BHTdevelopedtheNavigatorNetwork,asuccessfulinitiativetoprovideIn-PersonAssisterstoenrollpeopleinAppleHealth(Medicaid)andQualifiedHealthPlansontheWashingtonHealthBenefitExchange.Throughtheseefforts,BHTsuccessfullyenrolledover125,000peopleinhealthinsurance,manyofwhomhavebehavioralhealthdiagnoses,anddevelopedarobustnetworkofpartnersthroughouttheregion.AstheoperatoroftheNavigatorNetworkofEasternWashington,BHThasdirectconnectionswithmorethan50organizationswhohostoremploynavigators.ThisprovidescredibilityandimportantlocalconnectionstoprovidersneededtosuccessfullyimplementourMTDprojects.RecentlySpokaneCountywasawardedaDepartmentofJusticeSmartReentryGrantformatchingfundsupto$1milliondollars.ThisgrantwillsupporttheSpokaneCountyJailTransitionPathwaysPilot,includingfundingforcarecoordinatingagencypersonnel,training,
technologyandorganizationinfrastructureneedsoftheCountyandPathwaysCommunityHub.Anticipatedoutcomesaretoincreasecommunication,coordination,andcollaborationforreentrypopulation,increaseuseofevidence-basedpractices,andimproveaccesstoresourcesinthecommunityforreentrysupport.ThispilotwillsupporttheSpokaneCountyCollaborativeandallowaleverageofMTDresources.Recognizingtheneedtosupportmutualregionalstrategicgoalsandmakemeasurableimprovementsinhealthofruralcommunities,theEmpireHealthFoundationinvested$25,000inRuralResourcesCommunityActiontobeacarecoordinatingagencyfortheFerryCountyPathwaysPilot.Thisallowedthepilottobeginassmallandmanageable,allowingforgrowthasresultsandsuccessfuloutcomeswereobtained.BHTisexploringapartnershipwiththeCityofSpokanetoinvestintheHousingPathwaysOutcomepayment.ThiswouldofferanopportunityforlocaljurisdictionstoleverageotherresourcestomeetsharedgoalsandreducethefinancialpressureonMCOstopayforeverypathway.PleasenotethatlackofhousingintheBHTACHregionisthebiggestsocialdeterminantsofhealthbarrier.BHTisalsoexploringapartnershipwiththeARCORAFoundationtoensureoralhealthaccessandservicesareavailableforat-riskpatients.In2017,theWashingtonStateLegislaturemandatedtheHealthCareAuthorityandARCORAFoundationtoworktogethertodevelopapilot,OralHealthConnections,inthreecommunities(includingSpokane,County)withtwotargetpopulations–patientswithdiabetesandpregnantwomen.Dentistsservingthesepopulationswillreceiveenhancedreimbursementsfordoingso.ChallengestoimprovingoutcomesandloweringcostsfortargetpopulationandstrategytomitigaterisksandovercomebarriersBHThasidentifiedseveralkeychallengestosuccessfulimplementationofthePathwaysCommunityHubmodel.Theseinclude:
• HIT/HIEcapacity:BasedonproviderHSIresponses,HITandHIEcapacityseemstovarystronglyamongdifferentorganizations.Withafewexceptions,capacityaroundinformationexchangeislimited(e.g.systemcansendsummariesoutbutnotacceptdatain,orthereisadatasharingrelationshipwithspecificpartnersonly,likeanFQHCandtheBHO).WhilethePathwaysCommunityHubplatformoffersaflexibletechnologytheabilitytoconnectwithexistingsystemswillneedtobeexplored.
• Workforceneeds:BasedonproviderHSIresponses,workforceneedsareasignificantconcern.Recruiting,trainingandprovidingCommunityHealthWorkerswithalivingwagemaybeasignificantchallengefortheregion.
• Resources:Limitationsinregional/localbehavioralhealthprovidersandsocialdeterminantofhealthresourcesmaydirectlyimpactsuccessfulcompletionofPathways.
Strategiesforovercomingbarriers
• HIT/HIEcapacity:wewillworkwithorganizationstobetterlinkcommunitybasedcarecoordinationeffortsusingtheCareCoordinationSystemsplatformbybuilding
MonitoringandContinuousImprovement
applicationprograminterfacesbetweenCCSandorganizationshealthrecordmanagementsystems.ThiswillallowallPathwaysCommunityHubpartnersreal-timeinformationtoservetheirclientsinamoreeffectivemanner.ManyBHTACHpartnershavecitedtheCCSplatformflexibilityandinteroperabilitypotentialasamajorreasonforfutureadoption.
• Workforceneeds:many,ifnotall,potentialcarecoordinatingagenciesintheBHTACHregionalreadyemploycarecoordinators,rangingfromcommunitybasedorganizations,healthclinics,hospitals,andbehavioralhealthproviders.AspartoftheMTDCareCoordinationprojectplanwewillsupporttransitioningcurrentcarecoordinatorstothePathwaysCommunityHubmodel.Inearly2017,sixteenparticipantsweretrainedinthePathwaysCommunityHubmodelandCCSplatform.OrganizationsrangedfromruralandurbanCHWS,CommunityOrganizations,HealthHomes,andMCOstaff.TheSpokaneRegionalHealthDistrictconductsallregionalCHWtrainingonbehalfoftheWAStateDepartmentofHealthandfacilitatestheEasternWashingtonCommunityHealthWorkerNetwork.TheBHTACHisanactiveparticipantandmemberoftheleadershipteamofthislocalcoalitionofCHWsthatmeetmonthlyforinformationsharingandcapacitybuilding.InOctober2017,theBHTDirectorofCommunityEngagementpresentedontheongoingACHworktoover40CHWstofurtherimproveCHWworkforcebuy-inandfeedback.ThePathwaysCommunityHubcarecoordinatorswillberequiredtocompletetheCHWtrainingofferedviatheWashingtonStateDepartmentofHealthandparticipateinlocalandregionallearningopportunitiesthatsupportthedevelopmentofarobustcarecoordinationcommunity.TheBHTACHPathwaysHubwillprovidetrainingonthePathwaysHubmodel,CCStechnologyplatformandcoordinateinformationandeducationopportunitiesthroughwebinars,calls,newsletters,etc.BHTACHwillhostregularin-personlearningeventsthataddresscommonchallengesofcarecoordinatorsandagencies.
• Resources:TheBHTACHwillfosterconnectionsbetweenregionalpartnerstoensureinvestmentresourcesandinfrastructuretoclosegapsinourregion.ThroughthereportingcapabilityoftheCCSplatform,we’llbeabletoquantifygapsinresourceavailabilityandadvocateformorelocalandstateinvestment.Additionally,theBHTACHstaffworkcloselywiththelocalWashingtonInformationNetwork211toensurethatcommunityresourcedatabasesareup-to-dateandreadyforlargerscaleusebycarecoordinators.
ACHResponseThegoalofBHT’smonitoringplanistousetimelydatatosupportprojectimplementation,peerlearning,andcontinuousimprovement.BHTwillworkwithitscontracteddatavendor,
ProvidenceCenterforOutcomesResearch&Education(CORE),todesignandimplementamonitoringsystemthatwilltrackoperational,process,andoutcomemeasuresforeachprojectandCollaborative(seebelow)andfortheACHoverall.Thesystemwillbedesignedtocomplementexistingdataassets(suchastheHealthierWashingtonDataDashboardsand—particularlyforCommunityCareCoordination,theHUBdataplatform)andwillrefreshanytimeaparticulardatafeedisupdated.Fortheimplementationphase,manymetricswillbeprocessoroperationalinfocus(e.g.developingguidelines,policiesandprotocolstoimplementthePathways).Finalmetricswillbeidentifiedintheimplementationplan.Designwilltakeplacealongsideimplementationplandevelopmentinlate2017andearly2018,sothatthesystemisreadyasprojectsmoveintoimplementation.AvisualoverviewofBHT’splannedapproachtomonitoringandcontinuousimprovementisshownbelow.
Planformonitoringprojectimplementationprogress,includingaddressingdelaysinimplementationAsshowninthediagram,thesystemwillincorporateprocessmeasuresforprojectimplementation.ThoseprocessmeasureswillbeassociatedwithtimeframesandbenchmarksidentifiedbytheBHTACHanditsCollaborativestoprovideimmediatefeedbackwhendelaysoccur(forexample,anypotentialchallengesinhiringstafftooperatethePathwaysCommunityHub).WeplantoworkwithCOREtodevelopacommunitydashboardtomonitorkeymetricsidentifiedinthewaiverandourcommunitypriorities.Thiswillbeamulti-functionaldashboardextendingbeyondthewaivertoallowongoingcommunitytrackingandprioritization.ResponsibilityforaddressingdelaysinimplementationwillliewiththeCollaboratives,BHTgovernancebodies,andselectBHTstaffpositionsasdescribedunder‘Planformonitoringcontinuousimprovement’below.
Planformonitoringcontinuousimprovement,supportingpartneringprovidersanddeterminingwhetherornotBHTisontracktomeetexpectedoutcomesAmonitoringandcontinuousimprovementsystemismorethanjustdata;it’saboutthepeople,processes,andtoolsusedtoturnthatdataintoactionableinformationthatsupportssharedlearningandqualityimprovement.Inadditiontocreatingasystemtoaccessandanalyzedatafromdifferentsources,theBHTACHwillrelyonthefollowinggroupsandpositionstointerpretthedata,identifyperformanceshortcomingsorrisks,anddevelopsolutions:
• CommunityHealthTransformationCollaboratives.Asdescribedelsewhere,BHTislaunchingaRuralandSpokaneCountyCollaborativestodevelopandimplementspecificregionalplansforhealthsystemtransformationinthefourprojectareasBHThasselected.TheCollaboratives’rolewillextendto:advisingondesignoftheself-monitoringsystem;regularlyreviewingthedatathatsystemprovides;collaboratingwiththeACHtomakecoursecorrectionsasneeded;andparticipatinginsharedlearningopportunitieswithinandacrossCollaborativesandACHregions.
• BHTProviderChampionsCouncil.ThisrecentlyestablishedCouncilwillprovidegeneralclinicalexpertiseandsubjectmatterexpertiseindifferentMTDprojectareas.TheCouncilwillmonitortrendsinperformanceacrosstheCollaborativestoassesswhetherBHTisontracktoachieveexpectedoutcomesandwilladviseontheCollaboratives’proposedriskmitigationandcontinuousimprovementstrategies.ThePCCwillalsomonitorindividualcollaborativepartnersandadviseontechnicalassistancenecessary.
• JennySlagle,AssociateDirectorforHealthSystemTransformationwillserveasthePathwaysCommunityHubDirectoroverseeingalloperationsofthehubincludingtraining,qualityassuranceandimprovementandstrategicdirection.JennywillstaffthePathwaysCommunityAdvisoryCouncilthatwilllaunchin2018.ThispositionwillcloselymonitorthedataavailablefromtheHUBplatformandintervenewhenPathwaysareslowtocompleteorhaveencounteredroadblocks.
• BHT’sDirectorofClinicalIntegration,apositioncurrentlyinrecruitment,willstafftheProviderChampionCouncilandhelpidentify,communicate,andaddresschallengestoclinicalintegrationandothertransformationstrategies.
• Initsroleasmonitoringsystemlead,COREwillcoordinatewithBHTstaffandtheentitiesabovetoprovidetimelyinformation,datainterpretationexpertise,andbothtechnicalandstrategicsupportforpeerleaningandcontinuousimprovement.
• BHT’sboardwillreceivemonthlydashboardsonkeymilestonesandplanstoaddressanyrisks
• BHT’sRegionalIntegrationteamwillalsotrackkeymilestonesspecificallytiedtoFIMCandMTDprojectalignment
ProjectMetricsandReportingRequirements AttestthattheACHunderstandsandacceptstheresponsibilitiesandrequirementsforreportingonallmetricsforrequiredandselectedprojects.Theseresponsibilitiesandrequirementsconsistof:
• Reportingsemi-annuallyonprojectimplementationprogress.• Updatingproviderrostersinvolvedinprojectactivities.
YESX
NOX
RelationshipswithOtherInitiatives AttestthattheACHunderstandsandacceptstheresponsibilitiesandrequirementsofidentifyinginitiativesthatpartneringprovidersareparticipatinginthatarefundedbytheU.S.DepartmentofHealthandHumanServicesandotherrelevantdeliverysystemreforminitiatives,andensuringtheseinitiativesarenotduplicativeofDSRIPprojects.Theseresponsibilitiesandrequirementsconsistof:
• SecuringdescriptionsfrompartneringprovidersinDY2ofanyinitiativesthatarefundedbytheU.S.DepartmentofHealthandHumanServicesandanyotherrelevantdeliverysystemreforminitiativescurrentlyinplace.
• SecuringattestationsfrompartneringprovidersinDY2thatsubmittedDSRIPprojectsarenotduplicativeofotherfundedinitiatives,anddonotduplicatethedeliverablesrequiredbytheotherinitiatives.
• IftheDSRIPprojectisbuiltononeoftheseotherinitiatives,orrepresentsanenhancementofsuchaninitiative,explaininghowtheDSRIPprojectisnotduplicativeofactivitiesalreadysupportedwithotherfederalfunds.
YES NOX
PlanforaddressingstrategiesthatarenotworkingornotachievingoutcomesIncombination,thepeopleandworkgroupsdescribedaboveandtimelydatafromthemonitoringsystemwillenabletheBHTACHanditspartneringproviderstoidentifystrategiesthatarenotworkingandtothinkthroughsolutionsintimetoachieveprojectoutcomes.Ifnecessary,potentialadjustmentstoimplementationtimelineswillbetriagedthroughthemonitoringsystemtoassesstheirimpactondownstreamgoals.Iftimelinesstillcannotbemet,BHTwillinformthestateaboutthereasonsanditsplanforadaptingthetimeline,andpreventing/riskmitigationstrategieswillbesharedtootherprogramswhereappropriate.BHTwillcontinuetoreceivetechnicalassistancefromDr.SarahReddingwiththePathwaysCommunityHubCertificationProgram,andCareCoordinationSystemsprojectmanagementteamontheimplementationofthePathwaysCommunityHubinourregion.
ProjectSustainability
ACHResponseBHTstrategyforlong-termprojectsustainabilityBetterHealthTogetherisdevelopingourCommunityHealthTransformationCollaborativeswithafocusonmovingtheregiontovaluebasedpurchasingandwholepersoncare.VBPisthecornerstoneofoursustainabilityplanrecognizingtheneedtotransitionhowwepayforcareandlinkingsocialdeterminantofhealthservicestohealthcareservices.Weareworkingtoaligndata,fundsflow,andmodeldevelopmenttomaximizetheopportunitytointegrateselectedprojectsintoavaluebasedmodelandweavetogetherlocalresourcesandinvestmenttoreachthisgoal.Forinstance,itisexpectedthattheBHTBoard’sfundsflowpolicywillincludedirectedinvestmentsforstartupcosts,infrastructureandtechnicalassistanceemphasizingDSRIPfundingfortransition,notanongoingpaymentstream.CommunityHealthTransformationCollaborativesaredesignedtosupporttheearlyformationofthenaturalpartnershipsneededtosupportageographicallybasedhealthsystem’ssuccessinavaluebasedsystem.Thelinkagescreatedtosupporttheseprojectswilltranslatetotherelationshipsneedtosucceedinavalue-basedmodelandimprovepopulationhealth.Thesepartnershipswillsustainthemselvesassharedsavingsarere-investedinCollaborativeefforts.ThesupportfromtheACH,MTDfunds,andCollaborativepartners,willcreateanenvironmenttotestnewprocessesandimplementnewprojects.ThePathwaysCommunityHubwilldevelopcontractswithMCOSandotherfundersforoutcomebasedpaymentstiedtosuccessfulcompletionofPathways.Thisoffersasustainablefundingmodelforcarecoordinationandsharedsavings.Finally,theCommunityResiliencyfundisanareaoftheMTDprojectsweexpecttobesustainedpasttheMTDperiod.BHTwilldevelopacommunitydashboardthatmonitorskeysocialdeterminantandhealthindicatorsofourregionalhealthsystem’sviability.Byaligningregionalpartnersandinvestorsaroundtheseindicators,usingdemonstrationasanincubator,wecancreateaninvestmentfundofflexibledollarsfortheregiontocontinuetouseforstrategicinvestmentinovercominghealthdisparities.Project’simpactonWashington’shealthsystemtransformationbeyondtheDemonstrationperiodThePathwaysCommunityHubmodeliscentraltoourMTDeffortsandtheregion’seffortstomovetoValueBasedcare.ThePathwaysCommunityHubmodeloffersascalableopportunitytolinkcarecoordinationandtoimprovehealthoutcomesthroughasustainablemodelofcarebeyondtypicalphilanthropic/governmentcontracts.ByimplementingthePathwaysCommunityHub,wewilldemonstratethevalueofbetterlinkingeffortstoaddresssocialdeterminantswithclinicaleffortstoimprovehealthoutcomes.OtherstateshaveimplementedthePathwaysCommunityHubandfoundsuccessindevelopinglongtermcontractswithfunders(notlimitedtoMCOs).ThiswillresultinimprovedcommunitycapacitytolinkhealthsocialdeterminantofhealthsupportwithatriskpatientsthatwilllastbeyondtheMTDperiod.
(500words)
1WHO(WorldHealthOrganization).2012.Whatarethesocialdeterminantsofhealth?http://www.who.int/social_determinants/sdh_definition/en/2Basedon2015data,RWJFCountyHealthRankings:http://www.countyhealthrankings.org/3See:http://www.commerce.wa.gov/housing-needs-assessment.Affordable(meaningtheycostlessthan30%ofaveragehouseholdincome)&availableunitsper100householdsinBHTcountiesare:Adams22,Ferry26,Lincoln22,PendOreille26,SpokaneCo.12,Stevens26.Spokanemetroareahas14affordable&availablehousingunitsper100households.4BHTHealthSystemsInventory(2017).5HCAACHToolkitHistoricalData:https://wahca.app.box.com/s/mxpg8euzbjpdkmyuftzb4ri5v41ia8v9/folder/369500520366HCACo-occurringdisordertables,see:https://wahca.app.box.com/s/mxpg8euzbjpdkmyuftzb4ri5v41ia8v9/folder/398664065197HCAhospitalizations_ach_rhni_tables:https://wahca.app.box.com/s/mxpg8euzbjpdkmyuftzb4ri5v41ia8v9/folder/23928005433.(Notethat1/3ofMedicaid-paidhospitalizationsinBHT’sregionthatwerenotrelatedtopregnancy/childbirthwereclassifiedasstemmingfrom“othercauses”intheavailabledata8Thisisanupper-boundestimatebasedonfindingfrom2013analysisestimatingthat60%ofWAjailinmateswhowereenrolledinMedicaidin2012or2013hadamentalhealthneedandassumingthatthesameproportionappliestoinmateswithoutarecenthistoryofMedicaidenrollment.See:http://sac.ofm.wa.gov/sites/all/themes/wasac/assets/docs/research-11-226a.pdf
9Thisisanupper-boundestimatebasedonuncitedfigurefromSpokaneCountyCorrectionsthat85%ofinmateshaveabehavioralhealthneed.
10WashingtonDOHVitalStatisticsMedicaid-paidbirths,2015data.See:https://www.doh.wa.gov/DataandStatisticalReports/HealthStatistics/Birth/BirthTablesbyYear
11HCAACHToolkitProviderReportFilesupdated09.01.17,see:https://wahca.app.box.com/s/mxpg8euzbjpdkmyuftzb4ri5v41ia8v9/folder/30748038709.12SpokaneRegionalHealthDistrictDataCenter(2017).CommunityLinkageMapping:GeneralReport.Anassessmentoftheregionalpopulationandsocialdeterminantsofhealthsystems.https://goo.gl/1WDBpo.Seealsotheinteractivemapavailableat:http://arcg.is/2pH9kuT
SECTIONII:PROJECT-LEVEL
TransformationProjectDescription
MenuofTransformationProjects
Domain3:PreventionandHealthPromotion�� 3A:AddressingtheOpioidUsePublicHealthCrisis(required)
ACHResponseTheOpioidsProjectwillsupportWashingtonState’sgoalsofreducingopioid-relatedmorbidityandmortality.BetterHealthTogetherAccountableCommunityofHealth(BHTACH)willaligncommunityeffortstopromoteprevention,accesstotreatment,overdoseprevention,andrecoveryforarearesidents,focusingspecificallyonadultsandyouthenrolledinMedicaidviaourRuralandSpokaneCountyCollaboratives.JustificationforselectingprojectandhowitaddressesregionalprioritiesTheopioidcrisishasskyrocketedinWashingtonandtheBHTACHregion,anditisaffectingtheMedicaidpopulation.AccordingtotheUniversityofWashingtonAlcoholandDrugAbuseInstitute,threecountiesintheBHTACH(Ferry,LincolnandPendOreille)eachhadarateofpubliclyfundedadmissionsforopioidsofbetween90and180per1,000residentsbetween2011and2013.SpokaneandStevensCountieseachhad180-360admissionsper1,000residentsinthissameperiod.1Opioidrelatedtreatmentanddeathsincreasedacrossthestateoverthepastdecade,mirroringagrowingproblemnationally.AcrosstheBHTACHregion,17.4percentofMedicaidenrolleesareopioidusers.ThisrateishighcomparedtotheoverallWashingtonrateof13.5percentofallMedicaidenrollees,andallcountiesintheregionexceptAdamshaveahigherrateofopioidusethanthestateasawhole.Whilenotallopioidusersaredependent,over7,000people(3.6percentofMedicaidenrollees)meettheCDCdefinitionofheavyopioidusers,and3.9percentofthepopulationhasusedopioidsforover30days.Oversixthousandpeople(3.2percentofMedicaidenrolleesintheregion)areopioiddependentorabusing,basedonICD9andICD10codesoveratwo-yearclaimsperiod.2
Table1:OpioiduseamongMedicaidbeneficiaries,BHTandWAstate
MedicaidOpioidUseData BHT WashingtonOpioidUsersas%ofMedicaidpopulationAll 17.4% 13.5%Userswithoutcancer 15.4% 11.9%HeavyUsers 3.6% 2.8%Usersfor>30days 3.9% 2.8%
Diagnosishistoryofopioidabuseordependence
All 3.2% 2.7%Males 3.2% 2.8%Females 3.2% 2.6%
BetterHealthTogetherhashigherratesofopioidoverdoseeventsthanthestateaverageand,in2016,hadthehighestratesamongallACHsforopioidoverdose-relatedhospitalizationsandEDvisits.ThedatainthetablebelowcomefromtheWashingtonDepartmentofHealth’sOpioidOverdoseDashboard.
Table2:Opioid-relatedevents,BHTregionandWAstate3
Opioid-relatedevents,2016 BHT WashingtonAllnumbersaregeneralpopulationratesper100,000Opioidoverdosedeaths 11.1 10.7Opioidoverdosehospitalizations 27.6 21.6OpioidoverdoseEDvisits 94.1 48.2
Note:Hospitalizationsarebasedonpatient’scountyofresidence,whereasdeathsandEDvisitsarebasedoncountyofoccurrenceandfacilitylocation,respectively.
DatasuppressionmakesitdifficulttoestimatethenumberofactiveopioidprescribersfortheMedicaidpopulationinBHT’sregion.However,informationfromthePrescriptionDrugMonitoringProgramsuggeststhatopioidprescriptionsarewrittenandfilledatelevatedratesinmostofBHT’scounties,ascomparedtothestate.
Figure1:Opioidprescriptionswrittenandfilledper1,000residents,20144
Theregionhashostedseveraldiscussionsandeffortsoverthelastfewyears,thoughnoneoftheseeffortshavesustainednorcreatedsignificantchange.TheBHTACHwillaligntoolkitrequirementsintoourclinicalsettingeffortsviaourCollaborativestoimplementbestpracticesandevidence-basedstrategies.Additionally,viaourACHLeadershipCouncil,ProviderChampionsCouncil,CommunityVoiceCouncilandTribalPartnerLeadersCouncilefforts,wewillalignothercommunityeffortsrelatedtoopioidprevention,suchasARCORA’sefforttosupportanoralhealthlocalimpactnetworkwithafocusonreducingopioidusedisorder.Thisstrategywillassistusinbuildingarobustnetworkofdentalpracticeswhoareakeysourceofopioidprescribing,andinvolvementandleadershipfromthedentalcommunitywhichwillbeakeysuccessfactorforestablishingamorecoordinatedresponsetoopioid-addictionpreventionandtreatmentactivities.HowProjectwillsupportsustainablehealthsystemtransformationforthetarget
populationThisprojectwillsupportsustainablehealthsystemtransformationforthetargetpopulationbyfosteringcross-sectorpartnershipsthatleverageourlocalresourcestoreversetheopioidepidemicinourregion.Theprojectwillfosterdeliverysystemchangesthatsupportcoordinationandcollaborationacrossproviders,promoteappropriateprescribing,patient-centeredtreatmentandrecovery-orientedcare,andValueBasedPayment(VBP)modelsthatincentivizeandsustainthesesystemchanges.HowBetterHealthTogetherwillensureprojectcoordinateswithanddoesn’tduplicate
existingeffortsBetterHealthTogetherissupportingthedevelopmentoftwoCommunityHealthTransformationCollaboratives:
1. RuralCollaborative(comprisedofFerry,Stevens,PendOreille,Lincoln,andAdamsCounties)
2. SpokaneCountyCollaborative
TheBHTACHistakingaregionalapproachtoprojectdesignandimplementationthatwillprovidelocalautonomyandregionalaccountability.TheCollaborativeswillberesponsiblefordevelopingandimplementingactionableMTDplansacrossBHT’sprojectportfolio,andensuringthattheprojectscoordinatewitheachotheranddonotduplicateexistingeffortsintheregion.TheCollaborativeswillbecomprisedofkeypartnerswiththeexpertiseandexperiencerequiredtotransformourMedicaidDeliverySystemincludingclinics,FederallyQualifiedHealthCenters(FQHCs),Hospitals,MentalhealthandSubstanceUseproviders,PublicHealth,TribalHealthsystems,EMS,JailsandCountyCommissioners.Thisrepresentationwillensureeffortsarecoordinatedacrosstheregionandresourcesareleveraged.
IntheSummer2017,BHTACHalsosurveyedorganizationsintheregiontocompleteaHealthSystemsInventory(HSI)orCareCoordinationInventory(CCI)togatherproviderinterest,capacity,prioritiesandinformationaboutexistingworkintheregionrelatingtotheMTD
projectareas.BasedonproviderHSIresponses,akeyareawhereweseetheopportunityforcoordinationisintheuseofTheSixBuildingBlocksforPainManagementandSafeOpioidTherapy.BHTACHisworkingwithatleasttworuralprovidersengagedwiththiseffort,andfurtherexploringtheextenttowhichotherprovidersintheregionarealsoparticipating.TheHSIindicatesthatfewpartnersdonotorarenotabletoofferMedicationAssistedTherapybecauseoflackofprovidersorresources.AnticipatedProjectScopeBHTACHproposestoaddressopioidsintheregionthroughfourinterconnectedinitiativesfocusedonprovidersandMedicaidconsumers.TheseeffortsalignwiththeWashingtonStateOpioidResponsePlan.Initiative1:Prevention–ImproveProviderPrescribingPractices
• Strategy1:ViaourTransformationCollaboratives,provideadditionalsupporttoprovidersregardingprescribingpractices,accessingpatientinformationandhistory,andincreasingnon-opioidpainmanagementstrategies.
o AspartoftheCollaborativeassessment,identifyproviderunderstandingofprescribingguidelinesandtargettrainingandcoachingtoproviderswithmostneed
o AspartoftheCollaborativetechnicalassistanceplan,promotebestpracticesforprescribingopioidsforacuteandchronicpain,includingincreasingtheuseofthePrescriptionDrugMonitoringProgram(PDMP)bymoreproviders.
§ DistributeWashingtonStateMedicalAssociation/WashingtonStateHospitalAssociation/HealthCareAuthorityopioidprescribingvariancereportsthatincludefeedbackandcomparisonmetrics,sothatprescriberscanevaluatetheirprescribingpracticesrelativetoothersinthestate.
§ ProvidetrainingandinformationonWashingtonStateAgencyMedicaidDirector’s(AMDG)prescribingguidelines.PromoteadoptionoftheSixBuildingBlocksforopioidpainmanagementbyprimarycareprovidersandpromoteaccesstotheteamofSixBuildingBlocksexpertsandpracticecoachesforindividualconsultationandassistancewithimplementationwithprimarycarepractices.
• Increaseleadershipandconsensusaroundsafeprescribing.• Usearegistrytoproactivelymanagepatients.• Revisepoliciesandstandardworktosupportsafeprescribing.• Increasepatient-centeredcare.• Providecareforcomplexpatients• Measuresuccess
o ItisexpectedthatCollaborativeswillmeasureincreasedphysicians’useofthe
PrescriptionDrugMonitoringProgram(PDMP):§ FacilitateintegrationofthePDMPwithelectronichealthrecords
systems.
§ OffsetadministrativecostsassociatedwithmanuallycheckingthePDMP(forprovidersunabletointegrate).
o Increasetheuseoftelehealthtoimprovecapacityinruralareas.o Promotetheuseofnon-opioidpainmanagement.
• Strategy2:Workwithpartnerstoincreaseunderstandingofadverseeffectsofopioiduse
o AspartoftheCollaborativeassessmentprocess,eachCollaborativegroupwillassesstheavailabilityandqualityofeducationalmaterialsforconsumers.
o Promoteaccurateandconsistentmessagingaboutopioidsafetyandtoaddressthestigmaofaddiction.
o Utilizecommunitycarecoordinatorsandothercommunitymemberstoconductpeeroutreachandeducation.
o Promotenationalsocialmarketingcampaignsonthepotentialharmsofprescriptionmedicationmisuseandabuseandsecurehomestorage.
• AnticipatedOutcomes,theMedicaidWaiverFinanceGroupwillexploretyingincentivepaymentstotheseoutcomes.
o Improvebaselineunderstandingofproviderknowledgeandtrainingneedso Increaseprovider,consumerandcommunitylevelunderstandingofimpactsof
opioiduse,alternativestoopioidsforpainrelief.§ Increasenumberofprescribersawareoftheirprescribingpatternsand
trainedonAMDGguidelines.§ IncreasenumberofprescribersregisteredforandusingthePDMP.
o Reducehigh-doseprescriptionopioidtherapyforchronicuse.o Reducenumberofconcurrentsedativeprescriptions.o Reduceopioidrelatedinpatientstaysandemergencydepartmentvisits.
Initiative2:Treatment–SupportProviders,IncreaseAccesstoServices
• Strategy1:Educateproviderstoidentifypotentialopioidmisuse,OpioidUseDisorder(OUD),andontheavailabletreatmentoptions.
o AspartofourOpioidstrategyandourPathwaysCommunityHubregionalassessment,identifyexistingcommunity-leveltreatmentresources
o AspartofourworkthroughRegionalHealthTransformationCollaborativeandtechnicalassistanceandtrainingprovision:
§ EducateprovidersonhowtorecognizesignsofopioidmisuseandOUDamongpatientsandhowtouseappropriatetoolstoidentifyOUD.
§ Increaseproviderabilitytohavesupportivepatientconversationsaboutproblematicopioiduseandtreatmentoptions.
o Providepharmacistswithtoolstopromotereferralsforopioidprescriptionmisuse.
• Strategy2:Increaseaccesstoanduseofcommunity-levelOUD.o IncreasethenumberoflocalproviderscertifiedtoprescribeOUDmedications.o WorkwiththeHealthCareAuthoritytoidentifypolicychangesthatcould
improveavailabilityanduseoftreatmentoptions.
o Utilizecommunityresources(CHWs,PathwaysCommunityhubpartners,socialserviceorganizationsand211)tosupportpeerlearningandsupportforOUDtreatment.
o Supportefforttoincreaseaccesstobuprenorphine.o Improvecommunicationbetweenphysiciansandpsychosocialproviders.
• Strategy3:Targethigh-impactpatientsforspecializedinterventionandeducation(pregnantandparentingwomen)
o AspartofourCollaborativeTechnicalAssistance§ Increaseproviders’awarenessanduseofSubstanceAbuseduring
Pregnancy:GuidelinesforScreeningandManagement,theWashingtonStateHospitalAssociationSafeDeliveriesRoadmapstandards.
§ EducatepediatricandfamilymedicineproviderstorecognizeandappropriatelymanagenewbornswithNAS.
o WorkwithMCOsandHCAtoincreasethenumberofobstetricandmaternalhealthcareproviderspermittedtodispenseandprescribeMATthroughtheapplicationandreceiptofDEAapprovedwaivers.
o Workwithclinicalandsocialservicesproviderstoimproveaccesstotherangeofservicesthataddressphysical,mentalandsubstanceusedisordertreatmentneedsduring,throughandafterpregnancy.
• AnticipatedOutcomes:TheMedicaidWaiverFinanceGroupwillexploretyingincentivepaymentstotheseoutcomes.
o Increaseaccesstotreatment(includingMAT)forMedicaidbeneficiarieso Increaseaccesstothefullrangeofservicestotreatthewholepersonand
supporttreatmentsuccessInitiative3:OverdosePrevention
• Strategy1:Increaseavailabilityanduseofnaloxone.o Establishstandingordersinallcountiesandallopioidtreatmentprogramsto
authorizecommunity-basednaloxonedistributionandlayadministration.o Encourageproviderstoprescribenaloxoneforpainpatients.
• Strategy2:Educatetargetedconsumers(opioidsandheroinusersandprovidersandotherswhointeractwithusers)abouthowtorecognizeandrespondtoanoverdose.
o Educatefirstresponders,chemicaldependencycounselors,andlawenforcementonopioidoverdoseresponsetrainingandnaloxoneprograms.
o Helpemergencyprovidersdevelopandimplementoverdoseeducationprotocols,encouragethemtosendhomenaloxonewithpatientsseenforopioidoverdose.
• Strategy3:IncreasegeneralunderstandingaboutWashingtonState’sGoodSamaritanLaw.
o WorkwiththeCenterforOpioidSafetyEducationtoeducatelawenforcement,prosecutorsandthepublicabouttheGoodSamaritanResponseLaw.
• AnticipatedOutcomes:
o Increaseaccesstonaloxoneforindividualsusingheroinandopioids,andforclinicalandlayresponders.
o Reduceopioidoverdosedeaths.Initiative4:Recovery
• Strategy1:Improveaccesstorecoverysupportsandlong-termstabilization.o Buildonexistingcommunityeffortstosupportaregionalapproachtocreatea
recoverycultureincludingthescalingoftheRecoveryCare,PathwaysHubandcarecoordinators,alongwithCHWstoincreaseuseofpeerandotherrecoverysupportservicesdesignedtoimprovetreatmentaccessandretentionandsupportlong-termrecovery.
o Supportaccesstoharm-reductiontechniques.o ConnectSUDproviderswithphysicalandbehavioralhealthproviderssocial
servicesorganizationsandpeersupportstoaddressaccess,referralandfollowupforservices.
• AnticipatedOutcomes:TheMedicaidWaiverFinanceGroupwillexploretyingincentivepaymentstotheseoutcomes.
o IncreasenumberofMedicaidenrolleeswithOUDwhoaccesscarecoordinationthroughthePathwaysHub.Increasereferralsandfollowuptreatment,includingtorecoverysupportsandharmreductionservices.
AnticipatedTargetPopulationThetargetpopulationisadultandyouthMedicaidbeneficiarieswhouse,misuse,orabuseprescriptionopioidsorheroin.Thistargetpopulationwillincludeapproximately7,688individualsintheBHTACHregionwhohaveusedopioidsformorethan30days.5Asindicatedinthestrategies,providingspecialassistancetopopulationsforwhomopioidmisusehasimmediateandsystemicimpacts(e.g.pregnantwomen)willbeapriority.AmongMedicaidbeneficiariesintheregionandstate,womenaresomewhatmorelikelytobeheavyopioidusersthanaremen(intheBHTACHcatchmentarea,womenmakeup58percentofheavyopioidusersdespitebeingonly51percentofoverallenrollment)5InvolvementofPartneringProvidersTodeveloptheproposedproject,BHTACHhasconvenedandmetone-on-onewithpartneringprovidersthroughouttheregionworkingonopioid-relatedefforts.Inaddition,BHTACHengagedprovidersinanLOIprocesstoidentifyproviderinterestinMTDprojectareas.TheseeffortshavedirectlyinformedthedevelopmentoftheproposedOpioidprojectprioritiesandBHT’sproposaltodevelopregionalCollaborativestofurtherdevelopMTDprojectsin2018.ThefollowingprovidersandorganizationsexpressedinterestinOpioidprojectimplementationand/orpartnership.
Provider/PartneringOrganization LOIforProjectImplementation
LOIforProject
PartnershipAgingandLong-TermCareofEasternWashington
X X
CatholicCharitiesSpokane XCHASHealth X CommunitiesinSchools XConsistentCareServices,SPC,PS X CommunityHealthPlanofWashington XEastAdamsRuralHealthcare X FerryCountyPublicHospitalDistrict X XEmpireHealthFoundation X FrontierBehavioralHealth X GreaterSpokaneCountyMealsonWheels XInlandNorthwestHealthServices X KalispelTribeofIndians X LakeRooseveltCommunityHealthCenters XLincolnCountyHealthDepartment X MeritDisability XNationalAllianceonMentalIllness XNHHS/PendOreilleHealthCoalition XNortheastTriCountyHealthDistrict X XOdessaMemorialHealthcareCenter X OperationHealthyFamily X XOralHealthcareLLC X OthelloCommunityHospital X PendOreilleHealthCoalition X PioneerHumanServices X XPlannedParenthood XProvidenceHealthCare X XRuralResourcesCommunityAction X XSNAP XSpokaneNeighborhoodActionPartners X SpokaneRegionalHealthDistrict X XVirginiaMatheny X WashingtonDentalServiceFoundation X XYMCA XYWCA X
LevelofImpact
BetterHealthTogetherisidentifyingtargetpopulationsbasedonexaminationofregionaldatademonstratingkeyhealthdisparities.Asnotedabove,providingspecialassistanceto
populationsforwhomopioidmisusehasimmediateandsystemicimpacts(e.g.pregnantwomen)willbeapriority.Whileopioiduseandusedisorderisanissueacrosstheregion,someareasappeartobemoreimpactedthanothers.Forexample,PrescriptionDrugMonitoringProgramdatashowelevatedratesofopioidprescribinginLincoln,PendOreille,andStevensCounties6(seemapearlierinthissection)andPendOreilleCountyhadthesecondhighestrateofopioidoverdosefatalitiesinthestatebetween2011and2015,7althoughsmallnumbersmakethatratesubjecttofluctuation.AsweworktoconnectouropioidprojectworktolargersystemiceffortstoreduceAdverseChildhoodEvents(ACEs),itisclearthatreducingopioidaddictionanddeathsbenefitsnotonlytheindividualswithOUD,buttheirfamiliesandcommunities.Thisisparticularlyanissueforchildrenofopioidusers.HavingoneormoreACESisassociatedwithhigherincidenceofchronicillness.Consideringthecross-projectimpactsofACHactivities,reducingchronicillnessisanadditionalequitybenefitofsuccessreducingopioidsusedisorderanddeath.
HowBetterHealthTogetherwillensurethathealthequityisaddressedintheproject
design
BetterHealthTogetherisensuringthathealthequityisembeddedintheprojectdesignatmultiplelevels:
• RegionalHealthTransformationCollaboratives:WiththecreationofdistinctSpokaneCountyandRuralCollaboratives,BHTisensuringattentionandfocustoruralhealthissuesanddisparitiesinourregion.Inaddition,wearedesigningtheseCollaborativestoincludeorganizationsthatbringdiverseracialandculturalperspectivestokeyregionalhealthissues.
• CommunityVoicesCouncil:BHTACHislaunchingaCommunityVoicesCouncil,madeupofatleast50%Medicaidbeneficiariesorlow-incomecommunitymembers,toempowerandbringconsumervoicestoinformprojectdesignandimplementation.ThisCouncilwillbetaskedwithdevelopinghealthequitymetricsbywhichtoholdtheCollaborativesandprojectsaccountabletodefinedhealthequitygoalsandstandards
• Targetpopulations:BHTACHisfocusingprojectsontargetpopulationsexperiencingthegreatesthealthdisparities.Weareapplyingan“equitylens”toallourworkbydisaggregatingdatabyrace/age/ethnicity/sex/zipcodewhereverpossible,bothtomakeinformeddecisionsabouttargetpopulationsandtomonitorimpactofprojectsacrossdiversegroups.BHTACHwillsupplyCollaborativeswithregionaldatatoguideearlyassessmentsofCollaborativepartners,andwilldirecttheseteamstoidentifypopulationswithintheircountythatfaceahighlevelofdisparitiesand/orpresentashighlycomplexorhighrisk.
• Livedexperience:WiththeCommunity-basedCareCoordinationproject,BHTACHisadvancingthePathwaysmodelanduseofCommunityHealthWorkerswithlivedexperienceofhealthinequitiestofurtherourefforts.Carecoordinatorsarecriticaltodevelopingtrustandculturally-appropriatestrategiestomeettheneedsofourtargetpopulationsacrosstheMTDprojectareas.
• EquityAcceleratorPayment:Weanticipateimplementingthisincentivetosupportproviderswhoserveagreaterproportionofhigh-riskclients.Themetricstiedtothese
ImplementationApproachandTiming SeeSupplementalWorkbook
PartneringProviders SeeSupplementalWorkbook
paymentswillbedeterminedbytheWaiverFinanceWorkgroup,vettedbyProviderChampionsCouncilandCommunityVoicesCouncil,finalizedbyWaiverFinanceWorkgroup,andrecommendedtotheBHTBoard.
• PathwaysModel:HealthequityisbuiltintomanyelementsofourCareCoordinationstrategyandthePathwaysmodel,throughindividualizedcareplans;standardsofcareandaccesstotheentirenetworkofcareagenciespartneringwiththeHub;culturally-informedcare;anddatainfrastructuretoolsthatcanbeusedtomonitorcarepractice,providerquality,andresource.
Project’slastingimpactsandbenefittotheregion’soverallMedicaidpopulationOpioiduseisapublichealthcrisisacrossthestateandinourregion.Addressingthiscrisisthroughincreasedprevention,treatment,overdosepreventionandlong-termrecoveryisvitaltotransformationthehealthcaredeliverysystemandusinglimiteddollarsmoreeffectively.BHTACHwillsupportcaretransformationandpaymentredesignthroughitsCollaboratives.TheCollaboratives’diversepartnersandcommunityvoiceswillspurregionaleffortstotransformclinicalcaredelivery,transitionanddivertindividualsoutofemergencydepartmentsandjails,andcoordinatecare.Theactivitiesintheopioidprojectareakeyelementofthisoverallstrategy,witheffortstosupportclinicalcare,addictiontreatmentandotherservicesforindividualswithopioidaddiction.
ACHResponse
HowBetterHealthTogetherhasincludedpartneringprovidersthatcollectivelyservea
significantportionoftheMedicaidpopulation
Asreferencedabove,BHTACHsurveyedorganizationsintheregiontocompleteaHealthSystemsInventory(HSI)orCareCoordinationInventory(CCI)togatherproviderinformationaboutexistingworkintheregionrelatedtotheMTDprojectareas.BHTACHreceivedresponsesfrom42organizations,includingmajorhospitalnetworks,providersystems,FQHCs,MCOs,andcarecoordinationagencies.RespondingprovidersfortheHealthSystemsInventory(HSI)representedmorethan80percentofthehighest(top10)volumeMedicaidbillersinprimarycare,mentalhealth/substanceusedisorder,inpatientandED.ForseveralsettingsinBHT’sfiverural
counties,theHSIrespondentsrepresentalltheMedicaidbillerswithclaimsorbeneficiarycountsofmorethan10in2016.BetterHealthTogetherstaffarefollowingupwithnon-representedprovidersservingasignificantnumberofMedicaidclients,particularlysubstanceusedisordertreatmentproviders.
ProcessforensuringpartneringproviderscommittoservingtheMedicaidpopulation.
In2018,BHTACHwillformalizepartneringproviderparticipationinthecommunity-basedcarecoordinationprojectandotherMTDprojectareasthroughaTransformationCompactprocesstoensurecommitmenttoservingtheMedicaidpopulation.BHTACHhasalreadyengagedprovidersintheregionservingasignificantportionoftheMedicaidpopulationandhasconfidenceintheircontinuedcommitment,buttheTransformationCompactwillformalizethatexpectation.
Processforengagingpartneringprovidersthatarecriticaltotheproject’ssuccess,and
ensuringthatabroadspectrumofcareandrelatedsocialservicesisrepresented
BetterHealthTogetherhasidentifiedthatrepresentationfromthefollowingsectorsisrequiredforCollaborativestosuccessfullyimplementprojects.Eachofthesepartnersrepresentacriticalsettingforprojectimplementation:
• PhysicalHealthClinicalProvider(s)• HospitalSystem(toincludeanEDDoctor)• BehavioralHealthClinicalProvider(s)• TribalHealthSystems• EmergencyMedicalServices(firstresponders)• CriminalJustice• SUDProvider(s)• Community-BasedChronicDiseasePreventionandMitigationOrganization• CommunityBasedCareCoordinatingAgency• MCO(s)• CrisisManagementServices• Liaison:CommunityMember/Consumer
TheCollaborativeswillidentifyadditionalcriticalpartnersneededtodevelopandimplementtheirprojects,andCollaborativepartnershipsmaybeexpandedasneeded.InitsroleasthePathwaysHub,theBHTACHwillserveasaconnectorbetweencollaborativeprovidersandadditionalsocialandcommunitypartnersthatcanhelpimprovecommunityhealth.
HowBetterHealthTogetherisleveragingMCO’sexpertiseinprojectimplementation,and
ensuringthereisnoduplication
ManagedCareOrganizations(MCOs)areactivelyinvolvedinBHT’sgovernanceandleadershipgroups:
• TwoMCOrepresentatives,fromMolinaHealthCareofWashingtonandCoordinatedCareofWashington,areontheBoard.
• AllfiveMCOsarevotingmembersofBHT’sLeadershipCouncilandMCOstaffparticipateinmeetingsandone-on-onesessionswiththeBHTACHteam.
RegionalAssets,AnticipatedChallengesandProposedSolutions ACHResponse
• BHT’sRegionalIntegrationPlanningTeam,supportingFIMC
MCOswillcontinuetoparticipateinMTDprojectplanningviatheseleadershipgroupsandthroughtargetedcollaborationwithBHT’sHealthTransformationCollaboratives.
Inaddition,BHTACH,PierceCountyACH,andSouthwestACHhavecollaboratedonmeetingswithMCOpartnerstolearnaboutkeycrossoverareasbetweenACHsandMCOundertheMTD,toensurethatBHT’sprojectstrategy,supportforproviders/Domain1strategies,andmonitoringandqualityimprovementeffortsalignwithexistingMCOactivitiesandgoals.Ourdiscussionscovered:
• Members/populationoverview• PCPassignment/empanelment• Providersupport,particularlyforvalue-basedpaymentandrelateddeliverysystem
reform• Measurementandqualityimprovement• Memberengagement/education• PathwaysCommunityHub
MCOsemphasizedtheimportanceofconsideringtheneedsandutilizationpatternsofdifferentMedicaidpopulations(e.g.expansionadultsvs.traditionalMedicaid)anddesigningstrategiesthatcanintegrateadditionalgroups(e.g.dualspecialneedsclients)overtimetofullyengageMCOsandotherpartnersandsupportsustainability.Anothercommonpointwastheneedtoavoidoverwhelmingproviderswhoarereceivingassistanceandrequestsforpracticechangesacrosspayersandpaymentmodels.TheBHTACHandtheCollaborativescanplayakeyroleincoordinatingTAsupportwithMCOs.WealsodiscussedwaystocoordinateondatasharingwithMCOs,HCA,theWashingtonHealthAlliance,OneHealthPortandeventuallytheWashingtonAllPayerClaimsDatabase.
ACHResponseAssetstheACHandregionalpartnersproviderswillbringtotheproject
• Engagedpartners:TheclinicalandotherpartnersontheCollaborativesandsub-committeesarehighlyengagedinunderstandingkeyregionalhealthneedsandunderstandinghowgapscanberesolvedthroughcollaborativeaction.Inaddition,theWashingtonDentalServicesFoundationhasexpressedconcernandinterestintheopioidsissue,recognizingthatdentalprovidersarealargesourceofopioidprescriptions.TheFoundation’sefforttoestablishataskforcearebeingconnectedtotheCollaborativeeffortsinordertoensurethatknowledgeandresourcesarecombinedratherthanduplicated.
• FinancialAssets.EmpireHealthFoundationpledged$240,000toACHeffortsin2017.Theregionhastwolargenon-profithospitalsthathavehistoriesofgenerouscommunitybenefitgiving.InJuly2017,BHTACHrenewedits5-yearcontractwiththe
WashingtonStateHealthBenefitExchangetoadministertheregionalNavigatorNetwork.
• DataAssets.SpokaneRegionalHealthDistricthasgivenstafftimetobuildtheCommunityLinkageMap.Ithasalsoofferedadditionalin-kinddataandanalyticssupportforCommunityStrategyMaps.IntheirresponsestotheHSI,themajorityofpotentialpartnersexpressedwillingnesstosharedataforplanningandevaluation.
• ARCORAeffortstodevelopanOralHealthLocalImpactNetworkthatincludesanOpioidTaskForcechairedbySRHDAdministratorandBHTBoardmember,TorneySmith,tosupportalignmentacrossoralhealth,physical,substanceuseproviders.
Challengesandbarrierstoachievingoutcomesandstrategiesformitigatingrisks
ThechallengesintheBHTACHregioninclude:Challenge/Barrier Strategy
ProviderShortage/Serviceshortageespeciallyinruralareas
ChangestothefundingstructurefromBHOtomanagedIntegratedcarewilldramaticallyassistincreatingamorecoordinatedapproachformanagingcareanditisexpectedwillassistincreatingmoreavenuesforcareasmoreintegratedpracticeswillbeabletoofferbothmentalhealthandsubstanceuseservicesundertheirMCOcontract.Additionally,workingwiththeWorkforceDevelopmentCouncil,CommunityCollegeandEasternWASchoolofSocialtoexpandthecredentialprofessionalsavailable.Exploreinnovativewaystoprovidemoresupporttogetprovidersintrainingcertifiedquicker.
Lifestylebarriers,unsafeneighborhoods,lackoffamilywagejobs
WorkwithlocalpartnerstoalignhealthofthecommunitywithEconomicDevelopmentplansfordiversifyingeconomicopportunities(PendOreilleCountyrecruitmentofHiTesttoprovide100familywagejobs),ParksandRecreationeffortstoprovidemorecommunityopportunities(FerryCountyHealthCoalitionhasasummeractivitiesscheduleforteensand20stokeepengaged)andothercommunity
Stigmaaroundmedicationuseandaskingforhelpinsmallercommunities
Seekeducationalresourcestoaddresspublicperceptionofmentalhealthtreatmentandmedicationmanagementtoalleviatestigma.
ConcentrationofresourcesinSpokane,whichmeansSpokanepartnerscouldbeoverwhelmed
Throughthedevelopmentofruralcounty-basedcollaborative,buildstrongerreferralnetworkswith
MonitoringandContinuousImprovement
byasksfromruralpartners–howtoscaleintoruralareas
Spokaneservicesandfurtherexploreexpansionofappropriatelevelofservices.
BetterHealthTogetherisexplicitlyfocusingonlocalneedsandresources.ThisallowsBHTACHtopromotesolutionsfromthegroundup.Collaborativeswillidentifycommunity-levelsocialdeterminantsofhealththatareproblematic.Educationofproviders,consumersandcommunitymemberswillhelpincreaseunderstandingaboutthecausesofopioidmisuse,alternativesforpaintreatmentandopportunitiestoreceivetreatmentandrecoveryassistance.Tacklingstigmaisakeypartofovercomingtheotherbarriersfacingourregion.WewillsupportCollaborativeeffortstoexpandculturallycompetentandinformedcare.CHWsarealargepartofthisstrategy.Peersupportscanprovideinformationandatrustedsource.Weprioritizebestfitcarecoordinatorswhowillensureculturallycompetentcare.
ACHResponseThegoalofBHT’smonitoringplanistousetimelydatatosupportprojectimplementation,peerlearning,andcontinuousimprovement.BHTACHwillworkwithitscontracteddatavendor,ProvidenceCenterforOutcomesResearch&Education(CORE),todesignandimplementamonitoringsystemthatwilltrackoperational,process,andoutcomemeasuresforeachprojectandCollaborative(seebelow)andfortheACHoverall.Thesystemwillbedesignedtocomplementexistingdataassets(suchastheHealthierWashingtonDataDashboards,anyFIMCearlywarningsystem,andrelevantregionalreports)andwillrefreshanytimeaparticulardatafeedisupdated.Designwilltakeplacealongsideimplementationplandevelopmentinlate2017andearly2018,sothatthesystemisreadyasprojectsmoveintoimplementation.AvisualoverviewofBHT’splannedapproachtomonitoringandcontinuousimprovementisshownbelow.
MonitoringmetricswillincludeACHtoolkitpay-for-reportingandpay-for-performancemetrics,aswellasregionalaccountabilityandqualityimprovementplanmetricsthatspeaktotheeffectivenessofBHT’sstrategieswithinandacrossprojectareas.Fortheimplementationphase,manymetricswillbeprocessoroperationalinfocus(e.g.establishmentofcross-settingdatasharingagreementsamongCollaborativepartners.)Finalmetricswillbeidentifiedintheimplementationplan.FortheOpioidsProject,BHTACHwillbetracking,ataminimum,informationonthefollowingaccountabilitymeasures:
• OutpatientEmergencyDepartmentVisitsper1,000MemberMonths• InpatientHospitalUtilization• Patientsonhigh-dosechronicopioidtherapybyvaryingthresholds• Patientswithconcurrentsedativesprescriptions• SubstanceUseDisorderTreatmentPenetration(Opioid)
TheBHTACHhassetambitiousstretchgoalsofincreasingby10percentoverfiveyearstheproportionofMedicaidmemberswhosementalhealthorsubstanceusedisordertreatmentneedsaremet.Planformonitoringprojectimplementationprogress,includingaddressingdelaysin
implementation
ThoseprocessmeasureswillbeassociatedwithtimeframesandbenchmarksidentifiedbytheACHanditsCollaborativestoprovideimmediatefeedbackwhendelaysoccur.TheBHTACHplanstoworkwithCOREtodevelopacommunitydashboardtomonitorkeymetricsidentifiedintheMTDandourcommunitypriorities.Thiswillbeamulti-functionaldashboardextendingbeyondtheMTDtoallowongoingcommunitytrackingandprioritization.ResponsibilityforaddressingdelaysinimplementationwillliewiththeCollaboratives,BHTgovernancebodies,andselectBHTACHstaffpositionsasdescribedunder‘Planformonitoringcontinuousimprovement’below.
Planformonitoringcontinuousimprovement,supportingpartneringprovidersand
determiningwhetherornotBHTisontracktomeetexpectedoutcomes
Amonitoringandcontinuousimprovementsystemismorethanjustdata;it’saboutthepeople,processes,andtoolsusedtoturnthatdataintoactionableinformationthatsupportssharedlearningandqualityimprovement.Inadditiontocreatingasystemtoaccessandanalyzedatafromdifferentsources,BHTACHwillrelyonthefollowinggroupsandpositionstointerpretthedata,identifyperformanceshortcomingsorrisks,anddevelopsolutions:
• CommunityHealthTransformationCollaboratives.Asdescribedelsewhere,BHTislaunchingaSpokaneCountyCollaborativeandaRuralCollaborativetodevelopandimplementspecificregionalplansforhealthsystemtransformationinthefourprojectareasBHThasselected.TheCollaboratives’rolewillextendto:advisingondesignoftheself-monitoringsystem;regularlyreviewingthedatathatsystemprovides;collaboratingwiththeACHtomakecoursecorrectionsasneeded;andparticipatinginsharedlearningopportunitieswithinandacrossCollaborativesandACHregions.
• ProviderChampionCouncil(PCC).ThisrecentlyestablishedCouncilwillprovidegeneralclinicalexpertiseandsubjectmatterexpertiseindifferentMTDprojectareas.TheCouncilwillmonitortrendsinperformanceacrosstheCollaborativestoassesswhethertheBHTACHisontracktoachieveexpectedoutcomesandwilladviseontheCollaboratives’proposedriskmitigationandcontinuousimprovementstrategies.ThePCCwillalsomonitorindividualCollaborativepartnersandadviseontechnicalassistancenecessary.
• BHT’sDirectorofClinicalIntegration,apositioncurrentlyinrecruitment,willsupporttheclinicalstrategiesforBi-DirectionalIntegration,Opioids,ChronicDiseaseandCareCoordination.Additionally,willstafftheProviderChampionCouncilandidentify,communicate,andaddresschallengestoclinicalintegrationandothertransformationstrategies.
• JennySlagle,AssociateDirectorforHealthSystemTransformationwillserveasthePathwaysHubDirectoroverseeingalloperationsofthehubincludingtraining,qualityassuranceandimprovementandstrategicdirection.JennywillstaffthePathwaysCommunityCouncilthatwilllaunchin2018.ThispositionwillcloselymonitorthedataavailablefromtheHubplatformandintervenewhenPathwaysareslowtocompleteorhaveencounteredroadblocks.
• Initsroleasmonitoringsystemlead,COREwillcoordinatewithBHTACHstaffandtheentitiesabovetoprovidetimelyinformation,datainterpretationexpertise,andbothtechnicalandstrategicsupportforpeerleaningandcontinuousimprovement.
• BHT’sBoardwillreceivemonthlydashboardsonkeymilestonesandplanstoaddressanyrisks
ProjectMetricsandReportingRequirements AttestthattheACHunderstandsandacceptstheresponsibilitiesandrequirementsforreportingonallmetricsforrequiredandselectedprojects.Theseresponsibilitiesandrequirementsconsistof:
• Reportingsemi-annuallyonprojectimplementationprogress.• Updatingproviderrostersinvolvedinprojectactivities.
YESX
NOX
RelationshipswithOtherInitiatives AttestthattheACHunderstandsandacceptstheresponsibilitiesandrequirementsofidentifyinginitiativesthatpartneringprovidersareparticipatinginthatarefundedbytheU.S.DepartmentofHealthandHumanServicesandotherrelevantdeliverysystemreforminitiatives,andensuringtheseinitiativesarenotduplicativeofDSRIPprojects.Theseresponsibilitiesandrequirementsconsistof:
• SecuringdescriptionsfrompartneringprovidersinDY2ofanyinitiativesthatarefundedbytheU.S.DepartmentofHealthandHumanServicesandanyotherrelevantdeliverysystemreforminitiativescurrentlyinplace.
• SecuringattestationsfrompartneringprovidersinDY2thatsubmittedDSRIPprojectsarenotduplicativeofotherfundedinitiatives,anddonotduplicatethedeliverablesrequiredbytheotherinitiatives.
• IftheDSRIPprojectisbuiltononeoftheseotherinitiatives,orrepresentsanenhancementofsuchaninitiative,explaininghowtheDSRIPprojectisnotduplicativeofactivitiesalreadysupportedwithotherfederalfunds.
YES NOX
• BHT’sRegionalIntegrationteamwillalsotrackkeymilestonesspecificallytiedtoFIMCandMTDprojectalignment
PlanforaddressingstrategiesthatarenotworkingornotachievingoutcomesIncombination,thepeopleandworkgroupsdescribedaboveandtimelydatafromthemonitoringsystemwillenableBHTACHanditspartneringproviderstoidentifystrategiesthatarenotworkingandtothinkthroughsolutionsintimetoachieveprojectoutcomes.Ifnecessary,potentialadjustmentstoimplementationtimelineswillbetriagedthroughthemonitoringsystemtoassesstheirimpactondownstreamgoals.Iftimelinesstillcannotbemet,BHTACHwillinformthestateaboutthereasonsanditsplanforadaptingthetimeline,andpreventing/riskmitigationstrategieswillbesharedtootherprogramswhereappropriate.
ProjectSustainability (
500words)
1UniversityofWashingtonAlcohol&DrugAbuseInstitute(April2015).OpioidTrendsAcrossWashingtonState.See:http://adai.uw.edu/pubs/infobriefs/ADAI-IB-2015-01.pdf.NotethatAdamsCounty’sratewasnotcalculatedasthetotalcasesin2015werefewerthan5.2Source:HCARHNIstarterkit,see:https://wahca.app.box.com/s/mxpg8euzbjpdkmyuftzb4ri5v41ia8v9/folder/23928005433
3Source:WADrugOverdoseDashboard,see:http://www.doh.wa.gov/Portals/1/Documents/2900/wa_ach_od_quarterly_2017Q1.zip.NexthighestACHfor2016
ACHResponseBetterHealthTogether’sstrategyforlong-termprojectsustainabilityBetterHealthTogetherisdevelopingourSpokaneCountyandRuralCommunityHealthTransformationCollaborativesasacorestrategytoestablishlong-term,cross-sectorpartnershipsthatadvancehealthdeliverysystemtransformationandvalue-basedpaymentmodelsthatsupportlong-termchange.BHTACHisworkingtoaligndata,fundsflow,andmodeldevelopmenttomaximizetheopportunitytointegrateselectedprojectsintoavalue-basedmodelandweavetogetherlocalresourcesandinvestmenttoreachthisgoal.Project’simpactonWashington’shealthsystemtransformationbeyondtheDemonstrationperiodWeenvisionthatcollectivelydevelopinglocally-administeredprojectswillhavelong-term,sustainablebenefitforMedicaidrecipientsandotherresidentsofourregion.Improvingproviders,consumersandcommunitymembers’understandingoftheimpactsofopioiduse,potentialforharmandalternativesfortreatmentofpainwillreduceopioidrelianceandOUD.Thischangewillimpacthealthcarecostsandfreeupclinicalresourcesforotherserviceneeds.Additionally,reducedopioiddependenceandusedisorderwillpositivelyimpactsocialfactors,reducingACEsandmakingcommunitiessaferforallresidents.BetterHealthTogetherissupportingbroad-reaching,system-widetransformationinordertohavelastingimpactsandbenefittheregion’soverallpopulation,regardlessofchosentargetpopulation(s)orselectedapproaches/strategies.ImprovingaccesstobothSUDservicesandthelonger-termclinicalandsupportiveservicesthatwillkeepaffectedMedicaidmembershealthyandlesslikelytomustbetiedtoapaymentstructuretiedtohealthoutcomesandkeepingpopulationshealthieroverall.Thecombinationofimprovingcareforparticipantsandincreasingculturallyresponsiveaccessthatbringspeopletoneededserviceswillimpactcosts.Reducedclinicalcoststiedtoreimbursementforoutcomeswillbeamodelthatcanbereplicatedintheregionandstatewithoutregardtopayer.Provideracceptanceofnewpaymentmodelscanbecapitalizedtoexpandtothecommercialindividualandsmallgroupmarkets.
opioidoverdosehospitalizationswasSWACHat23.1eventsper100,000andnexthighestfor2016opioidoverdoseEDvisitswasCPAAat80eventsper100,000.
4WashingtonPrescriptionDrugMonitoringProgram,see:https://www.doh.wa.gov/ForPublicHealthandHealthcareProviders/HealthcareProfessionsandFacilities/PrescriptionMonitoringProgramPMP/CountyProfiles
5HCARHNI"starterkit,"see:https://wahca.app.box.com/s/mxpg8euzbjpdkmyuftzb4ri5v41ia8v9/folder/239280054336WashingtonPrescriptionDrugMonitoringProgram,see:https://www.doh.wa.gov/ForPublicHealthandHealthcareProviders/HealthcareProfessionsandFacilities/PrescriptionMonitoringProgramPMP/CountyProfiles
7WashingtonTrackingNetwork(WTN),see:https://www.doh.wa.gov/DataandStatisticalReports/EnvironmentalHealth/WashingtonTrackingNetworkWTN
SECTIONII:PROJECT-LEVEL
TransformationProjectDescription SelecttheprojectfromthemenubelowandcompletetheSectionIIquestionsforthatproject.
MenuofTransformationProjects
Domain3:PreventionandHealthPromotion�� 3D:ChronicDiseasePreventionandControl
ProjectSelection&ExpectedOutcomes
ACHResponse
ProjectDescriptionandJustificationSincetheinceptionoftheBetterHealthTogetherAccountableCommunityofHealth,preventionhasbeenacornerstoneofeffortstoimprovecommunityhealth.TheBHTACHselectedtheChronicDiseasePreventionandControlMedicaidTransformationDemonstration(MTD)projecttoaccelerateoureffortstoimprovehealth,withaninitialfocusoncontrolandpreventionofType2diabetes.Theprojectstrategiesinclude:increasingaccesstocare;educatingconsumersandtheirfamilies;identifyingriskearlier,increasingcoordinationofservicesthatlinkclinicalprovidersandservicestosocialsupportsandotherserviceneeds;andworkingwiththestatetosupporthealthychoicesforWashingtonresidents.TheBHTACHisalsoexploringthepossibilityoffocusedeffortsaroundpreventionandmanagementofasthmaamongyouthandwillmakefinaldecisionsaboutprojectactivitiesandtargetpopulationsinconsultationwithitsCollaborativesandTechnicalCouncils.
TheCommunityHealthTransformationCollaborativeswillberequiredtodevelopaMTDimplementationplanforchronicdiseasecarepreventionandmitigationstrategiesinthePrimaryCare,PediatricandFamilyMedicinesettingsandpotentiallyaBehavioralHealthsetting.TheprojectswillutilizetheChronicCareModel.EachCollaborativewillalignofthemodelwiththeirProviders,Medicaidpopulationandotherfactorsinfluencingcareinthearea.Thisalignmentincludes,butisnotlimitedto,theCommunityGuide,StanfordChronicDiseaseSelf-ManagementProgram,andCDC-recognizedNationalDiabetesPreventionProgramsaswellassupportingwherepossible,implementationofdiabetesprogramsspecifictoTribalHealthProviders.WeexpectthateachCollaborativewillalsodeveloparegionalapproachtoCommunityParamedicine,astheselocallydesigned,community-basedsolutionscouldextendthereachofchronicdiseasemanagementthroughtheutilizationoftheskillsofparamedicsandemergencymedicalservices(EMS)systemstoaddressgapsthatareidentifiedthroughcommunitylevelneedsassessment.
Mosteffortstotacklechronicdiseaseareaimedatrespondingtothesymptomsandnegativeconsequencesofthosediseases.TheBHTACHseekstoworkupstream,tohelppeopleavoid
chronicdiseases.TheMTDprojectwillincludeafocusonearlydetectionandinterventionforindividualsatriskfordiabetes,andonreinforcinghealthylifestylehabitsearlyinlife.Thiswillincludeeffortsto:
• Educatepeopleaboutopportunitiestoincludephysicalactivityindailylife,howtochooseandpreparehealthy,freshfoods.
• Increasetheinvolvementofschoolsandworkplaces,helpingtheseinstitutionstoimplementpracticesthatencouragehealthylifestyle,andreinforcehealthynorms.
• Supportingprogramsandincentivesthatpromotehealthychoices.
Thisprojectwillalsoaligneffortswiththebi-directionalintegrationeffortstointegratehealthsystemandcommunityapproachestoimprovechronicdiseasemanagementandcontrolforhighprioritypopulations.Projectswereselectedtosupportdeliverysystemtransformationeffortsaimedatdevelopingasustainablebusinessmodelforinvestmentinprevention,managementandlinkingofhealthcaretosocialdeterminantsofhealth.TheMTDprojectforChronicDiseasewillpreparetheregiontothriveinaValueBasedPaymentenvironmentandsupportlongtermsustainabilityforpreventionefforts.
Type2DiabeteswasselectedasapriorityconditionfortheChronicDiseaseprojectbecauseofthephysicalandfinancialburdenitrepresentsforindividualsandthehealthcaresystem.StakeholdersintheBHT/ACHregionhighlightedobesityanddiabetesinearlycommunityconversationsandhealthsystempartnerscommonlycitedType2Diabetesasaconditionwhereimprovedintegrationandcoordinationofcarecouldleadtobetterhealthandfinancialoutcomes.
Diabetesisthe7thleadingcauseofdeathinWashingtonState.1Whilethegrowthindiagnosescasesofdiabeteshasslowedsince2011,anestimated2millionadultsarepre-diabeticandasmanyas30%ofthemwilldevelopType2diabeteswithin5years.2TheCentersforDiseaseControlandPreventionestimatethatdiabetescoststhenationalabout$245billioneachyearduetomedicalcare,disability,andprematuredeath.3TheBHTACHregionhashigherthanaverageratesofseveralriskfactorsfordiabetesandrelatedchronicconditions,asshowninthetablebelow:Table1:ChronicDiseaseRiskFactors
Chronicdiseaseriskfactors BHT WashingtonPoornutrition 12% 10%Insufficientphysicalactivity 41% 38%Smoking 18% 15%Usee-cigarettes 7% 6%Obesity 30% 27%
Similarly,theBHTregion’srateofhospitalizationsrelatedtoDiabetesishigherthanthestateaverage(1,200per100,00vs.1,096per100,000statewide).AmongACHregions,theBHT
ACHhadthethird-highestage-adjustedrateofdiabetesrelateddeathsin2015(77per100,000,whichissubstantiallyhigherthanthestateaverageof71.6per100,000).4PendOreilleandStevensCountyratesarehigher,andtheAdamsCountyratefor2015wasastaggering203per100,000.5
HowProjectwillsupportsustainablehealthsystemtransformationforthetargetpopulationStrengtheningtheregion’sabilitytopreventandmanagechronicdisease,particularlyDiabeteswillresultinhigherqualitycare,improvedhealthoutcomesandcostsavingsforthetargetpopulation.ByinvestinginthecapacityofproviderstobetteridentifyandmanageDiabetes,weexpecttobeabletoreducelong-termcostsandimprovepopulationhealth.Wewilllaunchoureffortsbyensuringthatprovidersintheprimarycaresettinghaveadequateprocess,toolsandcapacityinplacetosupportidentificationandmanagement.Wewillexpandoureffortstoalsoworkwithbehavioralhealth,EMSandothercommunityproviderstoensureregularlytrackingofkeyhealthindications(A1Clevels,etc.)andensuresupportservicestoensureaccesstohealthyfoodsandregularphysicalactivities.Additionally,weexpecttoleveragetheCommunityHealthWorkersNetworkofEasternWashingtonaswellasourCommunityVoicesCounciltobuildacommunitylevelmovementtoencouragehealthybehaviors.
HowBetterHealthTogetherwillensureprojectcoordinateswithanddoesn’tduplicateexistingeffortsBetterHealthTogetherissupportingthedevelopmentoftwoCommunityHealthTransformationCollaboratives:
1. RuralCollaborative(comprisedofFerry,Stevens,PendOreille,Lincoln,Adamscounties)
2. SpokaneCountyCollaborative
TheBHTACHistakingaregionalapproachtoprojectdesignandimplementationthatwillprovidelocalautonomyandregionalaccountability.TheCollaborativeswillberesponsiblefordevelopingandimplementingactionableMTDplansacrossBHT’sprojectportfolio,andensuringthattheprojectscoordinatewitheachotheranddonotduplicateexistingeffortsintheregion.TheCollaborativeswillbecomprisedofkeypartnerswiththeexpertiseandexperiencerequiredtotransformourMedicaidDeliverySystemincludingclinics,FederallyQualifiedHealthCenters(FQHCs),Hospitals,MentalhealthandSubstanceUseproviders,PublicHealth,TribalHealthsystems,EMS,JailsandCountyCommissioners.Thisrepresentationwillensureeffortsarecoordinatedacrosstheregionandresourcesareleveraged.AnticipatedProjectScopeTargetPopulation.IndividualswithType2diabetesaretheinitialtargetpopulationforthechronicdiseasepreventionandcontrolproject,thisgroupprovidesapromisingfocustobuildsystemstoimproveaccess,care,andoutcomesforallindividualswithchronicdiseaseintheregion.EachCollaborativewilldevelopanintegratedplantoaddressthetargetpopulation
basedondatafromindividualcounties.Weanticipateanadditionalemphasisonindividualswithco-morbidityofbehavioralhealthandDiabetes.Weseeanadditionalopportunityforengagementwithindividualswithbehavioralhealthneedsforthepopulationtargetedinthebi-directionalintegrationMTDproject.Toproceedwiththisdeepenedfocus,wewillanalyzedatatoassesstheoverlapbetweendiabetesanddepressionamongBHT’sMedicaidpopulation.Potentialeffortsmayincludeflaggingindividualsatappointmentstoensurethattheyareassessedandtreatedforunmanageddiabetesandpresentingbehavioralhealthsymptoms.
TheCenterforOutcomesandResearchandEvaluation(CORE)estimatesthatbetween5,800and7,500Medicaid-coveredadultsintheregionhaveDiabetes.Thelow-endestimateisbasedonindividualswith24monthsofcontinuouseligibility,whichisprobablyanundercountgiventhenumberofpeoplewhocycleonandoffMedicaidoveratwo-yearperiod.6TheestimatedprevalencerateofdiabetesamongBHTareaMedicaidbeneficiariesoverallis3%butvariesslightlybetween3%and4%amongBHT’scountiesandamongdifferentraceandethnicitygroups.IndividualswhoidentifytheirpreferredlanguageasRussianhaveaslightlyhigherrateof5%.(Notethatthenumeratorinclusioncriteriaforalloftheseestimatesrequireatleastoneinpatientortwooutpatientclaimswithadiagnosisofdiabetesinthelastyear,sodiabeticswhoarenotincarearenotcaptured.)7
Asnotedearlier,theBHTACHisalsoconsideringasuiteofchronicdiseasepreventionandcontrolactivitiesrelatedtochildhoodasthmaandwillfinalizethisdecisioninconsultationwithpartnersinthecomingmonths.ThreepercentofMedicaidenrolleesundertheageof19haveadiagnosisofasthmainBHT’sregion;thistranslatesintoapproximately2600children.RatesareelevatedinSpokaneandStevenscounties,andamongAmericanIndian/Alaskanativeindividuals.7
Strategies.WhiletheCollaborativeswilladoptstrategiesthatworkbestfortheircommunities,theBHTACHissupportinganumberofkeystrategiestopromotememberhealthandmovetowardasustainable,transformedsystem,including:
• Self-ManagementSupport,includingstrategiesandresourcestoprovidetargetedmemberstheresourcestheyneedtobettermanagetheirhealthandhealthcare.ExamplesoftheseeffortsincludeDiabetesSelf-ManagementEducationandtheStanfordChronicDiseaseManagementProgram.SeveralStanford-modelprogramsexistintheregionnow,supportinghome-basedbloodpressuremonitoring;providemotivationalinterviewing;ensureculturalandlinguisticappropriateness.Inaddition,EmpireHealthFoundationhasamedicationmanagementprogramthatwewillextendtheMTDeffortandinvestment.
• DeliverySystemDesignstrategiessupporteffective,efficientcarebyimplementingandsupportingteam-basedcarestrategies,increasingthepresenceandclinicalroleofnon-physicianmembersonthecareteam,increasingfrequencyandimprovingprocessesofplannedcarevisitsandfollow-up,andestablishingorimprovingreferralprocessestocaremanagementandspecialtycare.WewillutilizePathwaysCommunityHubcarecoordinationmodeltoreduceriskfactorsandsupportincreasedengagement,followup,andreductionofbarriers.
• ClinicalInformationSystemsstrategieswillorganizepatientandpopulationdatatofacilitateefficientandeffectivecare,suchas:utilizationofpatientregistries;automatedappointmentremindersystems;bi-directionaldatasharingandencounteralertsystems;providerperformancereporting.
• Community-basedResourcesandPolicystrategieswillactivatethecommunity,increasecommunity-basedsupportsfordiseasemanagementandprevention,andsupportdevelopmentoflocalcollaborationstoaddressstructuralbarrierstocare.Wewilldevelopdiabetes-specificMOUswithcommunitybasedorganizationstosupportpeopledischargedfromthehospitalfordiabetesrelatedservices,offerpre-diabetesscreeningstoincreasehelpforpeoplewithearlyneed,andconnectMedicaidenrolleestolocalresources.Inadditiontothepreviouslydiscussedfoodbankclasses,wewillconnectwithothereducationbasedservicesandsupportssuchastheEmpireHealthFoundationsponsoredfitnessclassforelders,withagoalofincreasingwellness,fitness,exerciseandeducation.
• HealthInsuranceAccess:In2013,BHTdevelopedtheNavigatorNetwork,alargeandsuccessfulinitiativetoprovideIn-PersonAssisterstoenrollpeopleinAppleHealth(Medicaid)andQualifiedHealthPlansontheWashingtonHealthBenefitExchange.Throughtheseefforts,BHTsuccessfullyenrolledover125,000peopleinhealthinsurance,manyofwhomhavebehavioralhealthdiagnoses,anddevelopedarobustnetworkofpartnersthroughouttheregion.TheBHT/ACHwillworktomaximizeenrollmentcoverageforthecommunity.
InvolvementofPartneringProvidersWelaunchedtheMTDprojectdevelopmentprocessbyrequestingstakeholderssubmitanoptionalletterofinteresttoidentifypotentialpartnersandwheretheyarelocated.WereceivedresponsesfromprovidersineachCountyindicatinginterestinalltheoptionalprojects.WealsouseddatafromHealthSystemInventories(HSI)tounderstandthelevelofneedandresourcesatthelocallevel.Thefollowingprovidersandcommunityorganizationsrespondedtothecallforlettersofinterest(LOI)withanLOIforProjectImplementationorProjectPartnership:
AgingandLong-TermCareofEasternWashington
NortheastTriCountyHealthDistrict
CatholicCharitiesSpokane OdessaMemorialHealthcareCenterCHASHealth OperationHealthyFamilyCommunitiesinSchools OralHealthcareLLCConsistentCareServices,SPC,PS OthelloCommunityHospitalCommunityHealthPlanofWashington PendOreilleHealthCoalitionEastAdamsRuralHealthcare PioneerHumanServicesFerryCountyPublicHospitalDistrict PlannedParenthoodEmpireHealthFoundation ProvidenceHealthCareFrontierBehavioralHealth RuralResourcesCommunityActionGreaterSpokaneCountyMealsonWheels SNAPInlandNorthwestHealthServices SpokaneNeighborhoodActionPartners
KalispelTribeofIndians SpokaneRegionalHealthDistrictLakeRooseveltCommunityHealthCenters VirginiaMathenyLincolnCountyHealthDepartment WashingtonDentalServiceFoundationMeritDisability YMCANationalAllianceonMentalIllness YWCANHHS/PendOreilleHealthCoalition TodeveloptheproposedChronicDiseaseMTDproject,theBHTACHconvenedandmetone-on-onewithhighvolumeandengagedpartneringprovidersthroughouttheregionworkingonchronicdisease.Inaddition,theBHTACHengagedprovidersaHealthSystemsInventory(HSI)andaCareCoordinationInventory(CCI),toidentifyproviderinterestinthechronicMTDprojectareas.Draftinventorieswerefirstreleasedforpublicfeedback,andoncelaunched,wehosted3webinarstooverviewtheInventoryandansweranyquestionsfrompartners.BHTstaffhosted15hoursofOfficeHourssessionswhereproviderscoulddropinandtalkwithACHstaffabouttheirInventoriesorMTD,inadditiontonumerousoutreachmeetingstoindividualproviderorganizations.39organizationsintheBHTACHregion,representingmostmajorhealthandsocialservicesystems,completedtheHealthSystemsInventory(HSI)and/orCareCoordinationInventory(CCI).TheseeffortsdirectlyinformedthedevelopmentoftheproposedChronicDiseaseprojectprioritiesandtheBHTACHproposaltodevelopregionalCollaborativestoimplementMTDprojects. LevelofImpactWeenvisionthatbycollectivelydevelopingsustainableprojectsatthelocallevel,Medicaidrecipientsandotherresidentswillbenefitlong-termwithimprovedhealthoutcomeswhilebendingthecostcurve.Diabetespreventionandcontrolisanexpensiveissuethatpresentsabigopportunityforsavingsandtodemonstratethebenefitofclinical-socialservicesconnections.Diabetesimpactsoverallhealth,andisimpactedbyavarietyofsocialandenvironmentalfactors.Reducingdiabetesincidencewillgreatlyreducehealthcareneedsandcosts.Atthesametimeeffortstoimpactdiabeteswillalsoimpactotherhealthandsocialriskfactors.
Approximately58,000peopleinBHT’sserviceareahavediabetes.8ByfocusingonimprovingaccesstocareandservicesforMedicaidmembers,wecanchangehowclinicalandsocialservicesproviderssupportalldiabeticsintheregion.BHTCollaborativeswillfocusinitiallyonimprovingdiabetesmanagementprocessesasprioritizedbytheMTDperformancemeasures–increasingtheproportionofdiabeticswhoreceiveannualbloodglucosetests,kidneyfunctiontests,andeyeexamsforretinopathy–aswellasonimprovingaccesstoandcoordinationofcare.Thereissubstantialroomtoimproveontheannualeyeexammeasure,wherebothBHTandstatewideperformanceforMedicaidarewellbelownationalbenchmarks.Weestimatethatwewillneedtoensurethatatleast175additionalMedicaidmemberswithdiabetesintheBHTregionreceiveannualeyeexamsinordertomeetdemonstrationperformancetargets.
HowBetterHealthTogetherwillensurethathealthequityisaddressedintheprojectdesignCurrentdatadoesnotsuggestanysignificantracial/ethnic,geographic,orgenderdisparitiesindiabetesprevalenceamongMedicaidbeneficiariesinBHT’sregion.However,disparitiesdoexistindiabetesmanagement.Thetablebelowshows2016performanceonthreediabetescarequalitymeasuresbycounty,race,andethnicity.Yellowshadingindicatesthattheperformanceismorethan1%belowtheBHTregionaverage.BHTwillassistitsCollaborativestoreviewlocaldataanddevelopstrategiesforimprovingequityindiabetesmanagementintheirareas.
Table2:DiabetesQualityofCareMeasuresforMedicaid,20169
HbA1ctestingDiabeticEye
ExamDiabetesKidney
testCounty Adams 87% 47% 90%Ferry 92% 24% 94%Lincoln 84% 37% 88%PendOreille 83% 21% 77%Spokane 82% 28% 87%Stevens 82% 23% 84%
Ethnicity Hispanic 83% 34% 87%NotHispanic 82% 28% 86%Unknown 86% 29% 88%
Race AI/AN 79% 36% 88%Asian 82% 41% 83%Black 71% 31% 89%NH/PI 75% 35% 86%White 83% 27% 86%Multiracial 82% 39% 82%Other 83% 35% 85%Unknown 89% 32% 89%
BHToverall 83% 29% 86%State 84% 30% 86%
BetterHealthTogetherACHisensuringthathealthequityisembeddedintheprojectdesignatmultiplelevels:
• RegionalHealthTransformationCollaboratives:WiththecreationofdistinctSpokane
CountyandRuralCollaboratives,BHTisensuringattentionandfocustoruralhealthissuesanddisparitiesinourregion.Inaddition,wearedesigningtheseCollaborativestoincludeorganizationsthatbringdiverseracialandculturalperspectivestokeyregionalhealthissues.
• CommunityVoicesCouncil:BHTACHislaunchingaCommunityVoicesCouncil,madeupofatleast50%Medicaidbeneficiariesorlow-incomecommunitymembers,toempowerandbringconsumervoicestoinformprojectdesignandimplementation.ThisCouncilwillbetaskedwithdevelopinghealthequitymetricsbywhichtoholdtheCollaborativesandprojectsaccountabletodefinedhealthequitygoalsandstandards.
• Targetpopulations:BHTisfocusingprojectsontargetpopulationsexperiencingthegreatesthealthdisparities.Weareapplyingan“equitylens”toallourworkbydisaggregatingdatabyrace/age/ethnicity/sex/zipcodewhereverpossible,bothtomakeinformeddecisionsabouttargetpopulationsandtomonitorimpactofprojectsacrossdiversegroups.BHTwillsupplyCollaborativeswithregionaldatatoguideearlyassessmentsofCollaborativepartners,andwilldirecttheseteamstoidentifypopulationswithintheircountythatfaceahighlevelofdisparityand/orpresentashighlycomplexorhighrisk.
• Livedexperience:WiththeCommunity-basedCareCoordinationproject,theBHTACHisadvancingthePathwaysmodelanduseofcommunitycarecoordinatorswithlivedexperienceofhealthinequitiestoimprovecare.Carecoordinatorsarecriticaltodevelopingtrustandculturally-appropriatestrategiestomeettheneedsofourtargetpopulationsacrosstheMTDprojectareas.
• EquityAcceleratorPayment:Weanticipateimplementingthisincentivetosupportproviderswhoserveagreaterproportionofhigh-riskclients.ThemetricstiedtothesepaymentswillbedeterminedbytheWaiverFinanceWorkgroup,vettedbyProviderChampionsCouncilandCommunityVoicesCouncil,finalizedbyWaiverFinanceWorkgroup,andrecommendedtotheBHTBoard.
• WewillalsoseektoconnectourchronicdiseaseprojectworktolargersystemicworktoaffectAdverseChildhoodEvents(ACEs).HavingoneormoreACESisassociatedwithhigherincidenceofchronicillnessesincludingobesity,cardiovasculardisease,hypertension,andhighcholesterol.10Ourfocusonapopulationwithdisproportionateimpactofchronicillnessisonewaytohelpdisproportionatelyaffectedpopulations.TheBHTACHalsoseesanopportunitytosupportintergenerationalknowledgetransfer.Asindividualswithdiabetesimprovetheirchronicdiseaseself-managementthrougheducationonhealthyfoodpreparation,theysharethisknowledgeandexperiencewiththeirfamilies.Promotinghealthychoicesthrougheducationandtrustedsourcesofinformationcanimpactmorethanthechronicallyillindividualsthemselves,butcanspreadtotheirfamiliesandcommunities,extendingtheimpactofinterventionsandsupports.
Project’slastingimpactsandbenefittotheregion’soverallMedicaidpopulationOurgoalistofacilitatehealthsystemtransformationthroughtheadoptionofValueBasedPaymentsandgreaterintegrationofcommunitysupportsintoclinicalcare.TheincreaseduseofcommunitycarecoordinatorsandsocialservicesproviderswillimproveaccesstochronicdiseasecareforMedicaidconsumersfacingaccessbarriers.Theprojectsdevelopedbythe
ImplementationApproachandTiming SeeSupplementalWorkbook
PartneringProviders SeeSupplementalWorkbook
Collaborativeswillincreasetheuseofcost-effectiveservicesandimprovehealthoutcomes.ClinicalproviderswillseetheimpactofpartneringwithsocialdeterminantofhealthprovidersandbothtypesofproviderswillreceiveVBPreimbursementthatfurtherpromoteintegrationofcommunitysupports.
ACHResponse
HowBetterHealthTogetherhasincludedpartneringprovidersthatcollectivelyserveasignificantportionoftheMedicaidpopulationIntheSpringof2017,providersandstakeholderswereinformedabouttheopportunitytoimprovepopulationhealthfortheMedicaidpopulation.InterestedorganizationssubmittedanLOIindicatingtheirlevelandtypeofinterest(projectimplementation,projectpartnership)inMTD.ThefollowingprovidersandorganizationsexpressedinterestinChronicDiseaseMTDprojectimplementation(toserveasapartneringproviderandimplementtheproject)and/orpartnership(toserveasasupportivepartner).
Provider/PartneringOrganization LOIforProjectImplementation
LOIforProject
PartnershipAgingandLong-TermCareofEasternWashington
X X
CatholicCharitiesSpokane XCHASHealth X CommunitiesinSchools XConsistentCareServices,SPC,PS X CommunityHealthPlanofWashington XEastAdamsRuralHealthcare X FerryCountyPublicHospitalDistrict X XEmpireHealthFoundation X FrontierBehavioralHealth X GreaterSpokaneCountyMealsonWheels XInlandNorthwestHealthServices X KalispelTribeofIndians X LakeRooseveltCommunityHealthCenters(ColvilleTribeofIndians)
X
LincolnCountyHealthDepartment X
MeritDisability XNationalAllianceonMentalIllness XNHHS/PendOreilleHealthCoalition XNortheastTriCountyHealthDistrict X XOdessaMemorialHealthcareCenter X OperationHealthyFamily X XOralHealthcareLLC X OthelloCommunityHospital X PendOreilleHealthCoalition X PioneerHumanServices X XPlannedParenthood XProvidenceHealthCare X XRuralResourcesCommunityAction X XSNAP XSpokaneNeighborhoodActionPartners X SpokaneRegionalHealthDistrict X XVirginiaMatheny X WashingtonDentalServiceFoundation X XYMCA XYWCA X
Additionally,theBHTACHsurveyedorganizationsintheregiontocompleteaHealthSystemsInventory(HSI)orCareCoordinationInventory(CCI)togatherproviderinformationaboutexistingworkintheregionrelatedtotheChronicDiseaseMTDprojectarea.TheBHTACHreceivedresponsesfrom42organizations,includingmajorhospitalsystems,socialserviceproviders,FQHCs,MCOs,andcarecoordinationagencies.TheBHTACHcomparedtheHSIrespondentswithHCA’sSeptember2017ProviderReportandfoundthattheinventoryresponsesrepresentmorethan80%ofthehighest(top10)volumeMedicaidbillersineachmajorsetting(primarycare,mentalhealth/substanceabuse,inpatientandED.)ForseveralsettingsintheBHTACH’sfiveruralcounties,theHSIrespondentsrepresentalltheMedicaidbillerswithclaimsorbeneficiarycountsofmorethan10in2016.BHTstaffarefollowingupwithnon-representedprovidersthatseealargenumberofMedicaidclients,particularlysubstanceabusedisordertreatmentandTribalhealthproviders.ProcessforensuringpartneringproviderscommittoservingtheMedicaidpopulation.In2018,theBHTACHwillformalizepartneringproviderparticipationinthecommunity-basedcarecoordinationprojectandotherMTDprojectareasthroughaTransformationCompactprocesstoensurecommitmenttoservingtheMedicaidpopulation.BHThasalreadyengagedprovidersintheregionservingasignificantportionoftheMedicaidpopulationandhasconfidenceintheircontinuedcommitment,buttheTransformationCompactwillformalizethatexpectation.
Processforengagingpartneringprovidersthatarecriticaltotheproject’ssuccess,andensuringthatabroadspectrumofcareandrelatedsocialservicesisrepresentedTheBHTACHhasidentifiedthatrepresentationfromthefollowingsectorsisrequiredforCollaborativestosuccessfullyimplementprojects.Eachofthesepartnersrepresentacriticalsettingforprojectimplementation:
• PhysicalHealthClinicalProvider(s)• HospitalSystem(toincludeanEDDoctor• BehavioralHealthClinicalProvider(s)• IndianHealthSystems• PublicHealth• EmergencyMedicalServices(firstresponders)• CriminalJustice• SUDProvider(s)• Community-BasedChronicDiseasePreventionandMitigationOrganization• CommunityBasedCareCoordinatingAgency• MCO(s)• CrisisManagementServices• Liaison:CommunityMember/Consumer
Collaborativepartnershipswillbeexpandedasneeded.InitsroleasthePathwaysHub,theACHwillserveasaconnectorbetweenCollaborativeprovidersandsocialandcommunitypartners.BHTisalsolaunchingaProviderChampionsCounciltolendapracticingproviderperspectivetoourworkandtoinformandvalidateMTDPlanslaidoutbyCollaboratives.HowBetterHealthTogetherisleveragingMCO’sexpertiseinprojectimplementation,andensuringthereisnoduplicationManagedCareOrganizationsareactivelyinvolvedinBHT’sgovernanceandleadershipgroups:
• TwoMCOrepresentatives,fromMolinaHealthCareofWashingtonandCoordinatedCareofWashington,areontheBHTBoard
• AllfiveMCOsarevotingmembersofBHT’sLeadershipCouncilandMCOstaffparticipateinmeetingsandone-on-onesessionswiththeBHTteam
• TwoMCOrepresentativesareontheBHT’sRegionalIntegrationPlanningTeam,supportingFIMC
MCOswillcontinuetoparticipateinDemonstrationprojectplanningviatheseleadershipgroupsandthroughtargetedcollaborationwithBHT’sHealthTransformationCollaboratives.
Inaddition,BHTACH,PierceCountyACH,andSouthwestACHhavecollaboratedonmeetingswithMCOpartnerstolearnaboutkeycrossoverareasbetweenACHsandMCOsundertheMTD,toensurethatBHT’sprojectstrategy,supportforproviders/Domain1strategies,andmonitoringandqualityimprovementeffortsalignwithexistingMCOactivitiesandgoals.Ourdiscussionscovered:
• Members/populationoverview• PCPassignment/empanelment
RegionalAssets,AnticipatedChallengesandProposedSolutions ACHResponse
• Providersupport,particularlyforvalue-basedpaymentandrelateddeliverysystemreform
• Measurementandqualityimprovement• Memberengagement/education• PathwaysCommunityHub
MCOsemphasizedtheimportanceofconsideringtheneedsandutilizationpatternsofdifferentMedicaidpopulations(e.g.expansionadultsvs.traditionalMedicaid)anddesigningstrategiesthatcanintegrateadditionalgroups(e.g.dualspecialneedsclients)overtimetofullyengageMCOsandotherpartnersandsupportsustainability.Anothercommonpointwastheneedtoavoidoverwhelmingproviderswhoarereceivingassistanceandrequestsforclinicalpracticechangesacrosspayersandpaymentmodels.TheACHandtheCollaborativescanplayakeyroleincoordinatingTAsupportwithMCOs.WealsodiscussedwaystocoordinateondatasharingwithMCOs,HCA,theWashingtonHealthAlliance,OneHealthPortandeventuallytheWashingtonAllPayerClaimsDatabase.
ACHResponse
RegionalAssets,AnticipatedChallengesandProposedSolutionsAssetstheACHandregionalpartnersproviderswillbringtotheprojectTheBHTACHwillutilizeaRuralandSpokaneCountyCollaborativemodeltodevelopandimplementactionablechronicdiseaseplans.TheRuralCollaborative,covering35,173MedicaidlivesintheruralcountiesofAdams,Ferry,Lincoln,PendOreilleandStevens;andtheSpokaneCountyCollaborative,acountywith164,707coveredMedicaidlives.TheseCollaborativesareresponsiblefordevelopingalocalsetofstrategiestomeettheMTDprojectgoals.TheCollaborativestructurewillalignwiththeproposedMTDfundsflowapproachbyallocatingearnedregionalfundstoeachCollaborativebasedonpayforreportingandpayforperformancegoalachievement.Fundsflowstrategiesincludeplansforfixedandearnedpaymentstobothurbanandruralproviderpartnerstocoverexpensessuchasprojectcosts,projectadministration,providerengagementandparticipation,workforcedevelopment,populationhealthmanagement,andothercosts.LocalPartnerAssets.ThereareanumberoflocaleffortsthatwillserveasresourcesandmodelstobuildonforourChronicDiseaseMTDproject.WeexpecttheseorganizationstobeactiveinlocalplanningandimplementationattheCollaborativelevel.YMCAoftheInlandNorthwest(Spokane)andRuralResourcesCommunityAction(PendOreille,StevensandFerryCounties)areoperatingprogramsusingtheStanfordChronicDiseasemodel.INHSisimplementingapilotprojectintwoclinicsimplementPre-DiabetesRiskTestwithPatientsandprovideadirectreferraltoDiabetesPreventionProgram(DPP).TheDPPprogramsareofferedmonthlyandfullwith15-18peopleeachtime.
EmpireHealthFoundationandSpokaneTribeofIndiansisoperatingmultipleChronicDiseaseprojectsintheregion.Theirlongestrunningprogram,inpartnershipwiththeSpokaneTribeHealthandHumanservices,EHFhascreatedtheproprietary“CoachingforActivation”tool(providedthroughthePatientActivationMeasurelicensethroughInsigniaHealth)whichidentifiesdiseasestatesandlevelsofactivationtoindividuallytailorprogramsforSpokaneTribalElders.Thepilotusesin-personhealthcoachingfocusedongoal-settingandactionplanningwhichcanincludechronicdiseasemanagementinadditiontootherpersonalhealthgoalsthattheelderwantstoaccomplish.EmpireHealthFoundationandlocalruralPharmacistsarepilotingasetofMedicationManagementprojectsintendedtoexploreaddingcarecoordinationcapacityvialocalpharmacistinruralsettings.Thepilotpopulationincludespeoplewithco-occurringconditionsincludingdiabetes.SecondHarvestandlocalfoodbanks:Inadditiontoofferinghealthyfoodtolowincomeresidentsintheregion,areaFoodBanksprovideeducation,cookingclassesandresourcesforindividualswithdiabetes.Thisisavaluableresourcethatcanpositivelyimpactthelivesofindividualswithchronicillnessandlimitedresourcestosupportlifestylechangesneededtomanagediabetes.InSpokane,residentscangetwalkedthroughthefoodbanktogetthefoodsthatmeettheirhealthneeds,andreceivecoachingonmealplanningandhealthymealpreparation.Wewillworktoscaleupcommunityeducationactivitiessuchastheavailabilityofcookingclassesanddiabetesfriendlymeals.
SpokaneRegionalHealthDistrict1422:OverthepastthreeyearstheSpokaneregionhasparticipatedinthe1422DepartmentofHealthgrantfromtheCDCtoreduceDiabetes,Stroke,HeartDiseaseandHypertension.ThisworkincludespowerfulpartnershipstobeleveragedinourcollaborativedevelopmentwithWSUSchoolofPharmacy,INHSDiabeteseffortsandtheStatewideDiabetesNetworkhttps://diabetes.doh.wa.gov/.WewillberequiringeachcollaborativetoaligneffortswithstatewiderecommendedpracticesfromthestatewideDiabetesnetworkandencouragingalignmentwitheffortsbeingdevelopedviaINHSDiabetesPreventionandManagementProgram,YMCADiabetesPreventioneffortsandthe211programforDiabetes
DataAssets.SpokaneRegionalHealthDistrictin-kindsupportincludedstafftimetobuildtheCommunityLinkageMap.Ithasalsoofferedadditionalin-kinddataandanalyticssupportforCommunityStrategyMaps.IntheirresponsestotheHealthSystemInventory(HSI),themajorityofpotentialpartnersexpressedwillingnesstosharedataforplanningandevaluation.
Clinical.SixclinicalprovidersincludedintheHSIhaveclinicalproviderchampionswillingtodonatetimeandexpertisetoprojectplanningCollaboratives.Mostpotentialcarecoordinationagenciesindicatedtheywoulddonatestafftimetotrainingnewworkflowsandmodelstomeetrequirements.
In-kind.EmpireHealthFoundationandSpokaneRegionalHealthDistrictprovidesconveningspaceforpartnermeetingsandACHeffortsFormeetingsoutsideofSpokane,ourruralpartnershavedonatedmeetingspaceandcoordinationsupport.Weanticipatecontinuedin-kindsupportfor
MonitoringandContinuousImprovement
meetingspace,recruitmentandvolunteering.Partnershaveexpressedwillingnesstodonatestaffandleadershiptimeandexpertisetosupportstrategydevelopment.ChallengestoimprovingoutcomesandloweringcostsfortargetpopulationandstrategytomitigaterisksandovercomebarriersThechallengesintheBHTACHregioninclude:
• Providershortagesandchallengeofincreasingaccess,utilizationandattachmenttoPCPs.• Servicesshortage,especiallysupportiveservicesinruralcounties• Lifestylebarriers,suchashealthyfoodoptionswhereitisdifficultorexpensivetogetfresh
vegetables• Unsafeneighborhoodswithlackofaccesstosafeplacestoexercise• ConcentrationofresourcesinSpokane,whichmeansSpokanepartnerscouldbe
overwhelmedbyasksfromruralpartners–howtoscaleintoruralareas• HITandHIEcapacityvariesbyorganization
BetterHealthTogether’sStrategyformitigatingtheidentifiedrisksandovercomingbarriersBHTACHisexplicitlyfocusingonlocalneedsandresources.ThisallowsBHTtopromotesolutionsfromthegroundup.Collaborativeswillidentifycommunity-levelsocialdeterminantsofhealthissuesthatareproblematic.Forexample,FerryCountyrequiresatransportationresourcetogetlowincomeresidentstoagrocerystore.Innovativecommunityeffortswillbeneededtotackletheselocalissues.WewillsupportCollaborativeeffortstoexpandculturallycompetentcare,suchastargetingdiabetesandwellnessprogramsfortheAmericanIndian/AlaskaNativepopulationstoaddressrelevantculturalmotivatorsandneeds.Communitycarecoordinatorsarealargepartofthisstrategy,becausehavingapersonwithasharedlivedexperiencewillengageandmotivatewithindividualstoovercomebarriers.Wewillprioritizebestfitcarecoordinatorstoensureculturallycompetentcare.
ACHResponse
ThegoalofBHTACH’smonitoringplanistousetimelydatatosupportprojectimplementation,peerlearning,andcontinuousimprovement.BHTACHwillworkwithitscontracteddatavendor,ProvidenceCenterforOutcomesResearch&Education(CORE),todesignandimplementamonitoringsystemthatwilltrackoperational,process,andoutcomemeasuresforeachprojectandCollaborative(seebelow)andfortheACHoverall.Thesystemwillbedesignedtocomplementexistingdataassets(suchastheHealthierWashingtonDataDashboards,anyFullyIntegratedManagedCareearlywarningsystem,andrelevantregionalreports)andwillrefreshanytimeaparticulardatafeedisupdated.Designwilltakeplacealongsideimplementationplandevelopmentinlate2017andearly2018,sothatthesystemisreadyasprojectsmoveintoimplementation.AvisualoverviewofBHTACH’splannedapproachtomonitoringandcontinuousimprovementisshownbelow.
MonitoringmetricswillincludeACHtoolkitpay-for-reportingandpay-for-performancemetrics,aswellasregionalaccountabilityandqualityimprovementplanmetricsthatspeaktotheeffectivenessofBHTACH’sstrategieswithinandacrossprojectareas.Fortheimplementationphase,manymetricswillbeprocessoroperationalinfocus(e.g.establishmentofcross-settingdatasharingagreementsamongCollaborativepartners.)Finalmetricswillbeidentifiedintheimplementationplan.FortheBi-DirectionalIntegrationProject,theBHTACHwillbetracking,ataminimum,informationonthefollowingaccountabilitymeasures:
• Anti-depressionmedicationmanagement• ChildandAdolescents’AccesstoPrimaryCarePractitioners• ComprehensiveDiabetesCare:HbA1cTesting• ComprehensiveDiabetesCare:Medicalattentionfornephropathy• ComprehensiveDiabetesCare:EyeExam(retinal)performed• MedicationManagementforPeoplewithAsthma(5–64Years)• MentalHealthTreatmentPenetration(broad)• PlanAll-CauseReadmissionRate(30Days)• SubstanceUseDisorderTreatmentPenetration• Follow-upAfterHospitalizationforMentalIllness• Follow-upAfterDischargefromEDforMentalHealth• Follow-upAfterDischargefromEDforAlcoholorOtherDrugDependence• InpatientHospitalUtilization• OutpatientEmergencyDepartmentVisitsper1000MemberMonths
Planformonitoringprojectimplementationprogress,includingaddressingdelaysinimplementationAsshowninthediagram,thesystemwillincorporateprocessmeasuresforprojectimplementation.Thoseprocessmeasureswillbeassociatedwithtimeframesandbenchmarks
identifiedbytheACHandtheCollaborativestoprovideimmediatefeedbackwhendelaysoccur.TheBHTACHwillworkwithCOREtodevelopacommunitydashboardtomonitorkeymetricsidentifiedinthetoolkitandourcommunitypriorities.Thiswillbeamulti-functionaldashboardextendingbeyondtheMTDtoallowongoingcommunitytrackingandprioritization.ResponsibilityforaddressingdelaysinimplementationwillliewiththeCollaboratives,BHTgovernancebodies,andselectBHTstaffpositionsasdescribedunder‘Planformonitoringcontinuousimprovement’below.Planformonitoringcontinuousimprovement,supportingpartneringprovidersanddeterminingwhetherornotBHTisontracktomeetexpectedoutcomesAmonitoringandcontinuousimprovementsystemismorethanjustdata;it’saboutthepeople,processes,andtoolsusedtoturnthatdataintoactionableinformationthatsupportssharedlearningandqualityimprovement.Inadditiontocreatingasystemtoaccessandanalyzedatafromdifferentsources,theBHTACHwillrelyonthefollowinggroupsandpositionstointerpretthedata,identifyperformanceshortcomingsorrisks,anddevelopsolutions:
• CommunityHealthTransformationCollaboratives.Asdescribedelsewhere,BHTislaunchingaSpokaneCountyCollaborativeandaRuralCollaborativetodevelopandimplementspecificregionalplansforhealthsystemtransformationinthefourprojectareasBHThasselected.TheCollaboratives’rolewillextendto:advisingondesignoftheself-monitoringsystem;regularlyreviewingthedatathatsystemprovides;collaboratingwiththeACHtomakecoursecorrectionsasneeded;andparticipatinginsharedlearningopportunitieswithinandacrossCollaborativesandACHregions.
• ProviderChampionCouncil(PCC).ThisrecentlyestablishedCouncilwillprovidegeneralclinicalexpertiseandsubjectmatterexpertiseindifferentMTDprojectareas.TheCouncilwillmonitortrendsinperformanceacrosstheCollaborativestoassesswhethertheBHTACHisontracktoachieveexpectedoutcomesandwilladviseontheCollaboratives’proposedriskmitigationandcontinuousimprovementstrategies.ThePCCwillalsomonitorindividualCollaborativepartnersandadviseontechnicalassistancenecessary.
• BHT’sDirectorofClinicalIntegration,apositioncurrentlyinrecruitment,willsupporttheclinicalstrategiesforBi-DirectionalIntegration,Opioids,ChronicDiseaseandCareCoordination.Additionally,willstafftheProviderChampionCouncilandidentify,communicate,andaddresschallengestoclinicalintegrationandothertransformationstrategies.
• JennySlagle,AssociateDirectorforHealthSystemTransformationwillserveasthePathwaysHUBDirectoroverseeingalloperationsofthehubincludingtraining,qualityassuranceandimprovementandstrategicdirection.JennywillstaffthePathwaysCommunityCouncilthatwilllaunchin2018.Thispositionwillcloselymonitorthedata
ProjectMetricsandReportingRequirements AttestthattheACHunderstandsandacceptstheresponsibilitiesandrequirementsforreportingonallmetricsforrequiredandselectedprojects.Theseresponsibilitiesandrequirementsconsistof:
• Reportingsemi-annuallyonprojectimplementationprogress.• Updatingproviderrostersinvolvedinprojectactivities.
YES NOX
RelationshipswithOtherInitiatives AttestthattheACHunderstandsandacceptstheresponsibilitiesandrequirementsofidentifyinginitiativesthatpartneringprovidersareparticipatinginthatarefundedbytheU.S.DepartmentofHealthandHumanServicesandotherrelevantdeliverysystemreforminitiatives,andensuringtheseinitiativesarenotduplicativeofDSRIPprojects.Theseresponsibilitiesandrequirementsconsistof:
• SecuringdescriptionsfrompartneringprovidersinDY2ofanyinitiativesthatarefundedbytheU.S.DepartmentofHealthandHumanServicesandanyotherrelevantdeliverysystemreforminitiativescurrentlyinplace.
• SecuringattestationsfrompartneringprovidersinDY2thatsubmittedDSRIPprojectsarenotduplicativeofotherfundedinitiatives,anddonotduplicatethedeliverablesrequiredbytheotherinitiatives.
• IftheDSRIPprojectisbuiltononeoftheseotherinitiatives,orrepresentsanenhancementofsuchaninitiative,explaininghowtheDSRIPprojectisnotduplicativeofactivitiesalreadysupportedwithotherfederalfunds.
availablefromtheHUBplatformandintervenewhenPathwaysareslowtocompleteorhaveencounteredroadblocks.
• Initsroleasmonitoringsystemlead,COREwillcoordinatewithBHTstaffandtheentitiesabovetoprovidetimelyinformation,datainterpretationexpertise,andbothtechnicalandstrategicsupportforpeerleaningandcontinuousimprovement.
• TheBHTBoardwillreceivemonthlydashboardsonkeymilestonesandsuggestedplanstoaddressanyrisks
• BHT’sRegionalIntegrationteamwillalsotrackkeymilestonesspecificallytiedtoFIMCandMTDprojectalignment
PlanforaddressingstrategiesthatarenotworkingornotachievingoutcomesIncombination,thepeopleandworkgroupsdescribedaboveandtimelydatafromthemonitoringsystemwillenabletheBHTACHtoidentifystrategiesthatarenotworkingandtothinkthroughsolutionsintimetoachieveprojectoutcomes.Ifnecessary,potentialadjustmentstoimplementationtimelineswillbetriagedthroughthemonitoringsystemtoassesstheirimpactondownstreamgoals.Iftimelinesstillcannotbemet,BHTwillinformthestateaboutthereasonsanditsplanforadaptingthetimeline,andpreventing/riskmitigationstrategieswillbesharedtootherprogramswhereappropriate.
YES NOX
ProjectSustainability
(
1WashingtonDOH,see:https://www.doh.wa.gov/DataandStatisticalReports/HealthStatistics/Death/DeathTablesbyTopic2WashingtonStateDiabetesEpidemicandActionReport,2017.See:https://www.doh.wa.gov/Portals/1/Documents/Pubs/345-349-DiabetesEpidemicActionReport.pdf3CentersforDiseaseControlandPrevention.NationalDiabetesStatisticsReport:EstimatesofDiabetesandItsBurden
ACHResponse
BetterHealthTogether’sstrategyforlong-termprojectsustainabilityBHTACHisworkingtointegratehealthsystemandcommunityapproachestoimprovechronicdiseasemanagementandcontrol.WorkingwiththeCollaborativestodevelopprojectsthatsupporttransformativechange,wearebuildingamodelthatmatchesfundingtothechangesincaredelivery.Wewillalignmissionandbusinessbysupportinglong-termsustainablefundingforservicesandactivitiesthatimproveandsupporthealth.WeconsideredregionalhealthneedsandcommunitymomentuminselectingchronicdiseasepreventionandcontrolasanMTDProject.
WearedevelopingourCollaborativeswithafocusonmovingtheregiontoValueBasedPurchasingandwholepersoncare.VBPisthecornerstoneofoursustainabilityplan,recognizingtheneedtotransitionhowwepayforcareandlinkingsocialdeterminantofhealthservices.Weareworkingtoaligndata,fundsflow,andmodeldevelopmenttomaximizetheopportunitytointegrateselectedprojectsintoavaluebasedmodelandweavetogetherlocalresourcesandinvestmenttoreachthisgoal.Forinstance,itisexpectedthattheBoard’sfundsflowpolicywillincludedirectedinvestmentsforstartupcosts,infrastructureandtechnicalassistanceemphasizingDSRIPfundingfortransition,notanongoingpaymentstream.Project’simpactonWashington’shealthsystemtransformationbeyondtheDemonstrationperiodTheBHTACHissupportingbroad-reaching,system-widetransformationinordertohavelastingimpactsandbenefittheregion’soverallpopulation,regardlessofchosentargetpopulation(s)orselectedapproaches/strategies.ChanginghowservicesaredeliveredforpopulationssuchasindividualswithType2diabeteswillpromotepaymenttiedtohealthoutcomesandkeepingpopulationshealthieroverall.Thecombinationofimprovingcareforparticipantsandincreasingculturallyresponsiveaccessthatbringspeopletoneededserviceswillimpactcosts.Reducedclinicalcoststiedtoreimbursementforoutcomeswillbeamodelthatcanbereplicatedintheregionandstatewithoutregardtopayer.Provideracceptanceofnewpaymentmodelscanbecapitalizedtoexpandtothecommercialindividualandsmallgroupmarkets.
intheUnitedStates,2014.Atlanta,GA:USDepartmentofHealthandHumanServices;2014.Availablefrom:http://www.cdc.gov/diabetes/data/statistics/2014StatisticsReport.html.4WashingtonTrackingNetwork,see:https://www.doh.wa.gov/DataandStatisticalReports/EnvironmentalHealth/WashingtonTrackingNetworkWTN.Allratesincludebothmenandwomenandareage-adjusted.5Samesourceasabove.SmallnumbersinAdamsCountymeanthattheconfidenceintervalaroundthisestimateiswide,butthelowerboundofthe95%CIisstill132diabetes-relateddeathsper100,000.6VaryingestimatesbasedonHCABehavioralHealthandChronicConditionsfiles9-29-17(https://wahca.app.box.com/s/mxpg8euzbjpdkmyuftzb4ri5v41ia8v9/folder/39866406519)andHealthierWashingtonDataDashboard,whichusedifferentcontinuousenrollmentcriteria.
7HealthierWashingtonDataDashboard,CY2016data.See:https://www.hca.wa.gov/about-hca/healthier-washington/data-dashboard
8Estimatecalculatedbyapplying10%self-reportedprevalenceratefromWADept.ofHealthACHChronicDiseaseProfilesto2016regionalpopulationestimatesfromWAOfficeofFinancialManagement.
9Source:HealthierWashingtonDataDashboard,CY2016data.See:https://www.hca.wa.gov/about-hca/healthier-washington/data-dashboard
107.FelittiV,etal.(1998).Relationshipofchildhoodabuseandhouseholddysfunctiontomanyoftheleadingcausesofdeathinadults.TheAdverseChildhoodExperiences(ACE)Study.AmJPrevMed.14(4):245–258
Theory of Action
Statewide Drivers of Systems Transformation
Strengthen the Foundationalign energy and investment around regional strategies needed to support Whole Person Care, and success in Value Based care.
Improve Population Health transformation activities build community infrastructure and scale best practice to support responsive, sustainable, systems improvement.
OUR VISION:An integrated community health system, accountable to improving health through delivering culturally competent, whole person care to all community members
• Healthier Washington Initiative
• Shift to 90% Value Based Contracts by 2021
• Shift to Integrated Managed Care by 2020
• Upcoming changes to Medicare via MACRA/MIPS
• Align with regional and statewide workforce development activities to increase capacity of the region’s health workforce
• Effectively link health care transformation efforts with community services to support whole person care
• Integrate behavioral health and physical health payments through Integrated Managed Care
• Link and leverage data to monitor improvement and guide activities with a focus on health equity
• Retain less than a 5% uninsured rate, to ensure access to Whole Person Care
• Develop a Community Dashboard to monitor key population health priorities regionally across multiple payers, providers and measurements.
• Align ACO efforts throughout the region to leverage investment in Medicaid Transformation efforts and MACRA/MIPS reporting
• Align regional funders around a Community Resiliency Fund to address social determinants
• Reinvest shared savings with a focus on upstream prevention
• Connect siloed services into a continuum of care with “no wrong door” for patients
• Boost culturally competent and trauma informed care practices
DESIRED REGIONAL IMPROVEMENTS þ 90% of Medicaid contracts are Value Based in 2021
þ Implement regional plan to be ready for Integrated Managed Care by 2019
þ Reduce Medicaid emergency department utilization by 6%
þ Reduce hospital readmission rates for Medicaid by 2%
þ Increase % of Medicaid residents who have their mental health treatment needs met by 10%
þ Increase % of Medicaid residents who have substance use disorder needs met by 10%
þ Train 25 Care Coordinators to the Pathways Hub model by December 2019
þ Reduce # preventable hospital admissions for diabetes and asthma by 10%
þ Increase % effective contraceptive use among Medicaid women by 50%
þ Increase health workforce to meet health care demands
þ Decrease jail recidivism by 20%
þ All children in foster care will have at least one annual primary care visit
þ 10% of Medicaid children receive fluoride varnish in a primary care setting
þ Develop data sharing agreements amongst 90% of Collaborative members
PROJECT IMPACT POPULATIONSBi-Directional Integration of Behavioral and Physical Health
• Medicaid patients with both a Behavioral Health issue and chronic disease
Community Based Care Coordination
• People transitioning of jail• Pregnant women on Medicaid• Foster youth & youth exiting or aging out of foster care
Opioid Responses • Medicaid beneficiaries who use, misuse, or abuse prescription opioids and/or heroin
Chronic Disease Management • Medicaid adults with diabetes• Medicaid children with asthma • Medicaid beneficiaries with chronic
behavioral health issues
COLLABORATIVE ACTIVITIES: • Build and scale linkages between physical, oral,
behavioral, and social determinant of health providers
• Prepare providers for value based payments
• Support population health management through proactive use of data to track progress and identify areas for improvement among partners
• Implement Care Coordination strategies to help complex patients overcome risks
• Align disparate community strategies into community based plans to improve population health outcomes around regional priorities
Medicaid Transformation ProjectsDemonstrate the Value of Whole Person Care
Transformation Project Plan Governance
Comprised of Health System and Social Determinant partners serving as the activation network for Transformation Projects
SPOKANE COLLABORATIVERURAL COLLABORATIVE
Ferry | Stevens | Pend Oreille | Lincoln | Adams
Provider Champions
Council
Community Voices
Council
Waiver Finance
Workgroup
Regional Integration
TeamLEADERSHIP COUNCIL
Technical Councils
Each Technical council is co-chaired by a Board and Leadership Council memberReceives feedback from Collaboratives on proposed policy
COMMUNITY HEALTH TRANSFORMATION COLLABORATIVES
Tribal Partner
Leadership Council
BHT BOARDFinal decision maker for Medicaid Transformation Projects
Receives policy recommendations from Leadership Council and Technical Councils
BetterHealthTogether(BHT)MeaningfulConsumerEngagementSummaryReportASummaryofConsumerInputUsedtoInformMedicaidTransformationDemonstration(MTD)ProjectSelectionandPlanning,andtoDesignBHT’sLong-termMeaningfulConsumerEngagementPolicyandStrategy
OverviewTheBHTMeaningfulConsumerEngagementplanningprocessinvolvedseveraltiersofactivitydesignedtosecureinputintotheselectionandplanningofMTDprojectsandtoyieldarecommendedpolicyandstrategyfortheBHTBoardtoconsideradoptingforongoingmeaningfulengagementofconsumersinfutureAccountableCommunityofHealth(ACH)andMTDactivities.Thisreportdetailsfindingsfromthefirstphaseofactivity:consumerfocusgroups.
Methodology:ConsumerFocusGroups
Intotal,40consumersparticipatedinfocusgroupdiscussionstoinformtheselectionandplanningofMTDprojectsfortheBHTregionandtoprovideopinionsandideasforestablishingalong-termmeaningfulconsumerengagementstrategyfortheactivitiesoftheACH.Thefollowinggroupswerecoordinatedinpartnershipwithavarietyofcommunityhostorganizations:
• YouthinFosterCareand/orRecentlyAgedOutoftheFosterSystem(inpartnershipwithEmbraceWashington,CareerPathServices,andSafetyNet)
• TribalMembersandUrbanIndianCommunityCenterVisitors(inpartnershipwiththeAmericanIndianCommunityCenterandEmpireHealthFoundation)
• RuralResidentsthroughoutNorthEastWashington(inpartnershipwithRuralResources)• RuralResidentsthroughoutLincolnCounty(inpartnershipwithLincolnCountyHealth
Department)• UrbanResidentsthroughoutSpokaneCounty(inpartnershipwithCommunityHealth
AssociationofSpokane/CHAS)
Namesoffocusgroupparticipantsareheldconfidential,buthostorganizationsverifiedattendanceandgroupcompositionhasbeenvalidatedfordiversitytorepresentthefollowingcharacteristicsofattendees:
• Geography(rural,urban,tribal)• Raceandethnicity• Gender• Age• Healthconditions• Socialdeterminantneeds
ConsumerInputRegardingMedicaidTransformationDemonstration
ConsumersDefine“GoodHealth”Inanefforttolearnbaselinehealthknowledgeandself-determinedhealthpriorities,attendeeswereaskedtheopen-endedquestions,“whatdoesgoodhealthmeantoyou/howdoyoudefinegoodhealth?”Thefollowingthemesemerged:• PERSONALHEALTHBEHAVIORSANDCAPACITIES:
o Allfocusgroupsidentifiedhealthydietandexerciseaskeycontributor/indicatorofhealth.
o Allgroupstouchedonhealthyrelationships(family,friends,marriages)asimportantpredictorsofhealth,andmanyparticipantsreferencedlifepurposeand/orspiritualityaskeydriversofwellbeing.
o Manyparticipantsreferencedtheabilitytodowhatyouwant/needtodoinlifeandtotakecareofyourfamily’sneeds.
o Mostreferencedadvocatingforyourhealth(askingquestions,researching,learninghowtonavigatehealthcare).
o Afewdiscussedprevention(startingtocareforyourhealthyoung,notwaitinguntilyouaresick)andafewindicatedthat“notneedingtogotothedoctortoomuch”isamarkerofgoodhealth.
o Afewindicatedthatfreedomfromdiseaseorchronichealthconditionsisafactorofhealth.
• BASICNEEDSANDSOCIALDETERMINANTS
o Allfocusgroupsidentifiedaccesstosafe,affordable,healthyhousingasacriticalfactorforhealth,andanumberdiscussedhomelessnessspecificallyasadeterrenttohealth.
o Allgroupsdiscussedfoodsecurityandhealthyfoodasakeyfactor,withthemostprominentobservationsummarizedbyoneparticipantas,“youcan’tbehealthywithouthealthyfood,butyoucan’taffordtobuyhealthyfoodandeventhefoodbanksprovidesomeofthemostunhealthyfoodaroundlikeunhealthycarbsandemptycalories.”
o Transportationwascitedasakeyfactorcontributingtohealth,particularlyamongrural,tribal,andfostersystemparticipants,notingthatyoucan’taccesshealthyfood,medicalappointments,orsafelygetaroundwithoutgoodtransportationanditisakeyfactorinreducedhealth.
o Rural,tribal,andfostersystemparticipantsalldiscussedtheneedforsufficientfinancialresourcestomeetyourbasicneedsandtoaccesshealthyfoodsandhealthservices.
• ACCESSTOAPPROPRIATEHEALTHCAREo Allgroupsnotedthataccesstohealthcarewasimportant,particularlyciting“regular
checkups,immunizations,andpreventivecarelikemammograms,”asimportanttohealth.
o Allgroupsreferencedaccesstonecessaryprescriptionmedications,particularlyforchronicconditions(suchasdiabetes),andthedifficultygettingtherightmedicationsintherightamountsattherighttimeasachallenge.PrescriptionswereheavilydiscussedintheTribalgroup.
o Severalgroupshadrobustdiscussionsaboutknowinghow/when/wheretogetappropriatecare,andknowinghowtouseyourcoverage(indicatingthatitrequireslotsoftime,work,andself-advocacytoutilizeMedicaidbenefits).
o Allgroupsnotedthatoralhealthwasimportant,thoughtheyfocusedmoreonaccesstodentaltreatment,restoration,andthechallengeinfindingproviderswhowouldtakeMedicaidandaffordingservicesthatMedicaidwon’tpayfor(dentures,crowns)asasignificantbarriertohealth.
• BEHAVIORALHEALTHANDSUBSTANCEUSE,STRESS,EMOTIONALWELLBEING
o Behavioralhealthwasadominanttopicofconversationineverygroup,withparticipantssuggestingthat:
• Peopledon’ttalkaboutitenoughand/orthereisstigmaregardingmentalhealthandaddiction.
• Thereareinsufficientresourcestomeettheneeds(insurancecoverageforvariousservices,lackoftrustedserviceprovidersparticularlyinruralandtribalareas.
• Familytraumaandhistoricaltraumacreatesignificanthealthchallengesparticularlyforyouthinfostercare/agingoutandamongTribalpopulations.
o Accesstosubstanceabusetreatmentiswhollyinadequateacrosstheboard(lackofimmediateaccess,lackofcoverage,lackofculturally-appropriateoptions).
• Theopioidepidemichashadaprofoundandpersonalimpactonmostattendees(eitherpersonallyorfamilyandfriends).
• Theresponsetothisepidemiciscausingstigmainruralcommunities(e.g.,communitymembersfeelingjudgedandlabeledasdrugseekerswhentheyhavedocumentedissues).
• Thelackofproviderchoice,treatmentdelays,andcoverageissuesmakesuccessfultreatmentdifficult.
• SIMILARITIESANDDIFFERENCESAMONGGROUPS:
o RuralresidentsandTribalpopulationsfocusedfarmorethantheirurbancounterpartson:§ Basicneedsandsocialdeterminantsissues(housing,transportation,foodsecurity,
healthyfoodaccess).§ Lackofhealthcareproviderchoice,theimportanceof(andlackof)trustedhealth
carerelationships,andtheneedformoreaccesstoimmediate,tailored(culturally,individually)behavioralhealthandsubstanceabusetreatment.
o YouthinFosterCare/AgingOutandTribalpopulationsfocusedonbehavioralhealthchallenges,addiction,andotherissuesrelatedtofamilyandhistoricaltrauma.
o Ruralresidentsfocusedmoreheavilyonutilizingtrustedrelationships(family,friends,neighbors)tohelpanswerhealthquestions,connectoneanothertocommunitysupports.
o Urbanresidentsfocusedmoreheavilyonself-advocacytoaskprovidersquestions,seekoutcoverageandcareoptionsthroughtheirMCOs,andresearchhealthandhealthcareoptionsthroughvariousresourcesonline.
o Allfocusgroupsdemonstratedanimmediateandrobusttendencytocollectivelyproblem-solvehealthorhealthcarechallenges,andtoshareresourceswithandcoachoneanotherwhenamembernotedahealthorhealthcareproblem(e.g.,problemsgettingaccesstodentalcare,challengeswithprescriptionmedicationsandcoverages,difficultywithbehavioralhealthoraddictiontreatmentaccess).
ConsumersExploreHealthCare,HealthCareChallenges,andHealthCareSystemIdeasOnceparticipantsweregroundedintheiropen-endedthoughtsonhealthandhealth-care,theywereaskedthefollowingopen-endedquestions:
• “WhatdoesgoodhealthCAREmeantoyou?”• “Whatgetsinthewayofgettingthehealthcareyouneed?”• “Whathealthorhealthcareaccesssupportsdoyouwishyouhadforyouoryourfamily?”• “Ifyouhadamagicwandtomakeanychangeyouwantedinthehealthcaresystem,what
wouldyouchangetomakehealthcareeasiertogetandhealtheasiertokeep?”Theseconversationsyieldedthefollowingthemes:
• PRESCRIPTIONACCESS:
o Participantscitedchallengesgettingprescriptionmedicationsneededforchronicconditions(diabetes,Parkinson’s),withdelays,multipletripstothepharmacy,uncovereditems,havingtogetprescriptionsfrompharmaciesoutsideoftheirneighborhoodsbecauseofinsurancecoverage,andgoingdayswithoutneededprescriptionsduetoMCOapprovalprocesses.Manyparticipantssharedsomeversionofthiscomment,“Itissohardtogetapprovalfortherightmedications,evenifyouhavesomethinglikediabetes.”
o Theirprimaryconcernsdealtwiththeapprovalprocess,changesinformularies,andcostofmedicationsandsupplies(e.g.,syringes,diabetestestingsupplies).Oneparticipantsharedthatfamilymembersandfriendssoughtout“donations”ofprescriptionsandsuppliesforherfromothercommunitymembersorgavehermedicationsandsuppliesleftwhenanotherindividualpassedaway,astheyknewshedidn’thaveaccesstowhatsheneededonaregularbasis.
• DENTALHEALTHACCESS:
o Dentalhealthwasraisedinallfocusgroups,withconcernsregardingfindingdentistswhotakeMedicaid,gettingcareforuncovereddentalneeds(dentures,oralsurgery,crowns),andtheneedforruralresidentstodrivetourbancenterstofindproviderswhowilltakeMedicaid.
o Participantsnotedthattheywere“waitingforteethtofallout”or“walkingaroundinconstantpain”becauseoforalhealthissues.
o Attendeesfrequentlystated,“I’vecalleddentistafterdentisttryingtofindsomeonewhowouldseeme.”
o Onlyonegroupfocusedaverybriefdiscussiononpreventivedentalhealthororalhygiene,yetallgroupsfocusedprimarilyontheneedfor/lackofaccesstotreatmentforseveredentalissuesresultingfromlackofappropriatepreventivecare.
• VISIONCARE:
o Visioncare,particularlyglasses,werediscussedateveryfocusgroup.Participantsexpressedfrustrationwithdifficultyaccessingadequatecareandhardware,andrelayedthattheyexperiencedchallengeswithwhattheyperceivedwerevisioncoveragechanges.
o Numerousattendeesindicatedtheyhadonlybeenabletosecureglassesbecausecharitableorclinicspecialprogramshelpedthemdoso.
• TIMELY,TAILORED,ANDAPPROPRIATEBEHAVIORALHEALTHANDADDICTIONTREATMENT
o Behavioralhealthneedswerediscussedacrossallgroups,focusingonarangeofbehavioralhealthissues,includingstress,depression,anxiety,maritalandparentingissues,trauma,mentalillness,andsubstanceabuse.
o Destigmatizingbehavioralhealthdiagnoseswasreferencedrepeatedly,withparticipantsshowingaclearawarenessthat“mentalhealthisasimportantasphysicalhealth,butnoonereallytalksaboutitandnoonereallytreatsit.”Fearofrepercussionscanalsokeeppeoplefromseekinghelp,asexpressedbyoneindividualwhostated,“Ihadpostpartumdepressionbutdidn’tgogethelpbecauseIwasafraidCPSwouldtakemybabyaway.”
o Lackofbehavioralhealthproviders,lackofintegrationbetweenprimarycareandbehavioralhealth,andlackofappropriatecoverageforbehavioralhealthservicesorneedswererepeatedlycitedthroughoutallgroups.
o Addictionandsubstanceabusetreatmentwasdiscussedatlengthinallgroups,withahighpercentageofindividualsself-disclosingaddictionsthemselvesoramonglovedones.Oneofthemostsignificantconcernsinallgroupswasthelackoftimelyandcomprehensiveaccesstosubstanceabusetreatment,withcommentssuchas:
§ “Stateinsurancepaysforyoutotakeallthedrugsbutwon’tpaytohelpyougetoffofthem.”
§ “Gettingthedrugsiseasy.Gettinghelptogetoffofthemisn’t.”§ “Ifsomeoneisreadyfortreatmentthereshouldbeanoptionfortreatment
becauseiftheydon’tgonowtheywon’tgoin2monthswhenthereisanopening.”
§ “Treatmentneedstobelongerandinvolvemoresupportsandcounseling”o Ruralresidentsindicatedtheyfeltstigmatized,judged,orlabeledasdrugseekersin
theircommunitieseventhoughtheyhavegenuinechronicconditionsthatrequireoptionsforpaincontrol,andthattheyfeeltheyhavenorealoptionsforhelpwithchronicpain.
• ACALLFORTRUEWHOLE-PERSONCARE
o Allgroupsindicatedtheneedfortruewhole-personcarethatfocusesonphysical,mental,dental,vision,prescription,andsocialsupports(housing,transportation,food,carecoordination)thathelppeoplegetandstayhealthy.Onegroupsummeditupwiththefollowingstatement,“Makethemedicalhomeareality.”
o Severalgroupsfocusedoncomplementary,alternative,andothermedicaltreatments(nutritionists,massage,acupuncture,chiropractic)thatwouldhelpthemstayhealthyfromapreventivestandpointand/orinlieuofmedications,yettheseservicesareeithernotcoveredornotavailableincertainareas(e.g.,rural).Oneparticipantsummedthisupstating,“giveusotheroptionsthanjusttheprescriptionortheknife.”
• COVERAGECHALLENGES:
o Manyattendeesexpressedchallengesunderstandingtheircoverageandhowandwheretoaccesscare.Oneparticipantnoted,“whyaretheresomanyinsurancecompaniesandwhyismycoveragechangingallthetime?AlloftheinsurancecompanieshavedifferentwaysofdoingthingsanditmakesithardtogetthecareIneed.”
o Ruralparticipantsexpressedfrustrationtryingtoaccessthecaretheyneedacrosscountylines,wheredifferentMCOsmighthavedifferentproviderpanels.MorethanoneindividualindicatedhavingtoenrollinadifferentMCOtoaccessneededcareforachronicissueortoseektreatmentinadifferentcounty,andthenre-enrolledinthepreviousMCOwhentheyreturnedtoresideintheirowncounty.
o RuralparticipantsexpressedfrustrationwithMCOs“whodon’tunderstandwhatit’slikeintheruralcounties…theydon’tknowwhatwehaveordon’thavehere,orwhatit’sliketotrytogetcarehere.They’rejustreadingfromascript.”
o Respondentsfrommostfocusgroupsindicatedthattheyregularlyhaveto“jumpthroughsomanyhoops”toworkwiththeirinsurancecompaniesandgetthecaretheyneed,andthattheyspend“hoursonthephone”tryingtogetanswers,referrals,coverageinformation,authorizations,andprovidernames.Oneruralparticipantnoted,“bythetimeyougettheauthorizationyouaremuchmoresickthanyouwouldhavebeenifyoucouldhavejustgoneinwhenthedoctorsuggestedthetreatment.”
o Thereweredividedresponsesamongfocusgroupparticipantsregardingwhethertheyfelttheyreceivedgoodcareand/orlessercarebecausetheywereonAppleHealth:
§ Participantsconnectedtolargerhealthsystemprovidersreportedeasieraccessandbettersatisfaction(intheirwords“betterqualitycare”)thanthoseinwithsmallersystemsorseeingindividualproviders.
§ Participantsseekingphysicalhealthcareservicesreportedeasieraccessandbettersatisfaction(again,intheirwords,“betterqualitycare”)thanthoseseekingdentalormentalhealthservices,withoneattendeenoting,“sometypesofprovidersthatacceptAppleHealtharen’tasgood…itseemsliketheyarelowerendprovidersorsomeonewhoisjustlearning.”
§ Participantsinruralareasreportedaperceptionofmorestigma,judgement,ordisrespecttowardthosecoveredbyMedicaid.
• LACKOFPROVIDERS/IMPORTANCEOFTRUSTINGRELATIONSHIPSWITHPROVIDERS
o Tribalparticipantsnotedlackofculturally-sensitivetreatmentoptionsasabarriertogoodcare,particularlyregardingbehavioralhealthandaddiction/recoveryneedsforadults,butalsonotingthattheyneedmoretrustedproviderswhotreatthemholisticallyandinculturally-appropriate,community-andfamily-centeredways.
o Ruralresidentsindicatedlackofproviderswasasignificantbarriertogoodhealthcareforthem,citinglackoflocalaccesstoproviderssuchaspediatrics,obstetrics,cardiac,behavioralhealth,anddentalproviders.
o Participantsoftencitedtheneedtoestablishtrustingrelationshipswithprovidersinordertohavegoodhealthandhealthcareexperiences.Thisisparticularlydifficultinruralcommunities,withwhattheydescribedasan“exodos”ofprovidersandan“ongoingchallengeto”drawspecialists,behavioralhealth,andevenprimarycareproviderstoruralcommunities.Oneparticipantnoted,“whenyouonlyhaveoneoptionforcounselinginyourtownandyoudon’ttrustthem,youronlyoptionistonotgetthecareyouneed.”Ruralresidentsrepeatedlyreporteddriving60to100milestoseeadifferentproviderthattheytrusted.
o Attendeesindicatedtheyprefertohaveahealthcareteamthatknowsthem,suchasthesamenurseormedicalassistantwhotalkstothemeverytime,andthesameproviderwhoknowstheirhistory.Onepersonstated,“itmakesmefeellikeamemberofmyownhealthcareteam.”Mostgroupsnotedthatthisisoftennotthecase,though,withstaffturnoverandchangesinhealthcaredeliverymodels.
• DELAYSINACCESSTOCARE/INABILITYTOBETREATEDFORMORETHANONEISSUEo Participantsacrossallfocusgroupsindicatedchallengesduetodelayedaccesstocare,
evenwhenprimarycarerelationshipsexist.Oneattendeeshared,“EventhoughIhaveaprimarycareproviderIlikeandwhoisreallygood,itcantakemonthstogetintoseethem.”
o Attendeesinallgroupsexpressedfrustrationatbeingtreatedforonlyoneissueatavisit,necessitatingadditionalvisitsforotherconditionsorconcerns.Thisbecomesatremendousburdenfortime,finances,childcare,transportation,andhealthissueexacerbation.Oneparticipantnoted,“whenIgoinformyarm,theycan’tseemeforsomethingelseandthenit’sanothermonthbeforetheycanseemeagainandwehavetopayfor2visitsinsteadofone.”Anothernoted,“it’sallrelated,it’sallinthesamebodybuttheyareonlyallowedtotreatonebodypartorissueatatimebecauseoftimeandmoney.”
o Groupsnotedthatgettingreferralstoandappointmentswithspecialistsisexceptionallychallenging.Oneparticipantnoted,“Ittookme7weekstogetintoseesomeoneformyneck,andthatwasaftermydoctorknewthatsomethingwasdefinitelywrong.”
o Participantsindicatedfrustrationwiththelimitedamountoftimetheyseeproviders,andthat“administrationmakesthemseeacertainnumberofpeopleperdaysotheycan’treallyfocusonmeandwhatIneed.”
• TRANSPORTATIONCHALLENGES:
o Ruralparticipantsreportedtransportationchallengesasahugeissuetoaccessingcare,includingdistancetravelledtogetcare,lackofspecialmobilitysupportsforthosewith
chronicissues,andfeelingtheywerejudgedbyothersforusingpublicorspecialclinicorsocialservicesupporttransportation.
o Fosteryouthandtribalmembersalsoreferencedtransportationchallengesasbarrierstohealthandaccesstohealthcare.
• CARECOORDINATIONANDACCESSSUPPORT
o Allfocusgroupsdiscussedthechallengesinsecuringthecaretheyneeded,rangingfromfindingproviders,tocoordinatingreferrals,tounderstandingtheirbenefits,todealingwithmultiplesocialdeterminantsneeds.Attendeesshared,
§ “It’shardtoknowwheretostart…whodoyougotogetguidance?”§ “Patientsdon’talwaysspeakorunderstandthemedicallingoanddoctorsdon’t
alwaysconveyitwell,”suggestingthathavinganadvocateasa“translator”wouldbehelpful.
§ “Weneedsomeonetohelpuscommunicatewithourproviders,tohelpthemunderstandusandtohelpusunderstandthem.”
o Severalgroupshadlengthydiscussionsonhowhelpfulitwouldbetohavea“hub”ora“resourcecenter”whereyoucouldgotoaskquestions,getinformation,findreferrals,orgetsupportforneededservices.
o Gettingreferralsandauthorizationswasachallengeformany,describing“jumpingthroughsomanyhoops”andlengthydelaystogetcare.Someparticipantsnotedhavinghelpwiththis(severalruralparticipantshadsupportfromareferralspecialist),butmostindicatedthisisachallengingprocessthatsimplyrequiresthemtostayonthephoneorresearchonlineforhours.
o Acrossallgroupsattendeesindicatedasignificantneedtohaveaccesstocarecoordinatorsorcommunityhealthworkerswhocouldhelpthemunderstandtheircoverage,accesscare,andgainreferralsandapprovalsforservicesandmedications.
o Ahighpercentageofparticipantswantedhelpknowingwhichproviderstooktheirinsuranceandhowtogetintoseethem.
• FINANCIALBURDENSDELAYINGACCESSTOCAREORRESULTINGFROMCARE
o Severalpeoplenotedthattheydidn’tseekcaretheyneededbecausetheywereafraidofthecostand/ordidn’tknowiftheirinsurancewouldcoverit.
o Othersweresurprisedbywhattheydescribedas“balancebills”forservicestheyhadreceivedthattheythoughtwerecoveredbutweren’t,orininstanceswheretheyhadsoughtcareandonlypartofitwascovered(e.g.,anEDvisitwherethehospitalbillwaspaidbutthephysicianbillwasn’tbecausethephysicianwasnotcontractedwiththeMCO).Theynotedthesesituationsdestabilizetheirbasicneedsandmakethemlesslikelytoseekcareinthefuture.
o Onesuggested(andothersagreed)thatthisisanotherissuethatcouldbeaddressedthroughcarecoordinationoradvocateswhocouldhelpcoachpatientsonhowtoaskquestionsabouttheircoverage,bills,andhowtonavigatecharitycareandrequestedwrite-offs.
• AREQUESTFORMOREHEALTHSERVICES,COACHING,ANDSUPPORTFORYOUTHINFOSTERCARE/AGINGOUT
o Youthinthefostersystemsharedseveralspecificneeds,including:§ Moreandbetterbehavioralhealthsupportsfortrauma,depression,anxiety,
familydysfunction,becauseinthewordsofoneattendee,“weareemotionalwrecksduetothereasonsweareinfostercare.”Severalagreedwiththenotionthattheirhealth(mentalandphysical)hasbeencompromisedbecause“wehavebeenletdownbythesystemsomanytimes.”
• Allparticipantsaroundthetableagreedwiththisandallofferedconcernsaboutthequalityofbehavioralhealthcareservices,withonenoting,“Ifeltlikealabrat,”anotherstating,“IliedtothembecausetheyIknewwhattheywantedmetosayandtheytreatedmelikeanumber…peopledon’task‘whydidyoustealthatcar?’theyjustcheckthingsoffalistanddon’tgettoknowyou…everyoneisuniqueandshouldbetreatedthatway,”andanothersuggestingthat,“IhadtodrivetoLibertyLaketogetagoodcounselor…whatifIdidn’thavetransportation?”
• Severalsuggestedthatpeersupportswouldbebeneficial,aswell,formentorship,coaching,andsharingresourcesbypeoplewhoknowwhatyou’vegonethrough.Oneattendeestated,“Ittakesonetoknowone.”
§ Bettertrainingandmoresupportsforfosterparentsandsocialworkerstocreatehealthyenvironmentsandhelpkids/youngadultsbehealthyandlearnhowtobehealthyonourown.
§ Helplearningabouttheircoverageandcarewhentheytransitionoutofthefostersystem,withoneparticipantstating,“InsteadofahugepacketofinformationIdon’tunderstand,helpmetransitiontounderstandhowtousemyhealthcoverageandgetthecareIneed.”Otherssharedthefollowingrequests:
• “Weneeddoctorswhodon’tusebigwordsandwhoexplainthingsinrealterms”
• “Ineedsomeonewhocanhelpmeunderstandcoverageandaccess”• “Youneedsomeonewhocangrabyourhandandhelpyou.”
• AREQUESTFORMORECULTURALLY-APPROPRIATE,HOLISTICCAREFORTRIBALMEMBERS
o TheTribalfocusgroupwasveryclearthatthehealthcaresystemisnoteffectiveforthem.
o Oneparticipantsummedthisupwiththefollowingstatement:“Weareinasystemthatwasn'tmadeforus…we'renotallthesame.Wearecountedinthecensusbutwearenottreatedappropriatelyespeciallyforthingslikediabetesandheartissuesthattheyknowwearemorelikelytohave.Weneedmorenativecaseworkers,moreaccesstoservicesforphysicalandmentalhealth.Diabetes,drugs,depression,suicide,hopelessness…allofthesethingsarekillingus.”
o Therestofthegroupaffirmedtheaboveandagreedthathealthcarefortribalmembersmustbeholistic,attendtothefamily/communityandspiritualaspectsoftheculture,andaddresshistoricaltraumathatiscontributingtohealthissues.
ConsumerInputRegardingLong-termMeaningfulConsumerEngagementStrategy
ConsumerswereguidedthroughavarietyofquestionstoassesshowtheythoughtBHTcouldmostmeaningfullyengagewiththemregardingtheMTDandthelong-termactivitiesoftheACH.Thefollowingthemesemerged.
§ Themostcommonfeedbackwereceivedwasgratitudeforaskingfortheirinput.Thegroupsuniversallysharedthattheconversationsweremeaningfulandagooduseoftheirtime.Theysharedcommentssuchas,
o “Thankyouforcomingtousratherthanmakinguscomeyou.Itwasnicethatsomeonebotheredtocomeouttotheruralcommunitiestohavetheseconversations.”
o “Thanksforaskingaboutwhatmatterstousandwhatmakesadifferenceforus.”o “Thisdiscussionmakesusfeellikewematterandthatwe’renotinthisalone.”o “Iactuallyfeellistenedto,whichdoesn’talwayshappeninthemedicalsystem.”
§ Focusgroupparticipantsacrossallgroupsindicatedthatbyfarthebestwaytoengagethemto
gettheirideasandfeedbackwasthroughthesetypesofgroupdiscussionsintheirowncommunities.Afewclarificationsincluded:
o “Wewanttotalktoandwithrealpeople…thiskindofdialoguereallymatters.”o “Wewanttotalktoahumanbeing,nottoacomputer.”o “Wewanttobeapersonandnotanumberoradollarsign.”
§ Whileingeneralmostgroupsindicatedthattheypreferin-personopportunitiestoprovide
input,andsomeindicated“ifwegetphonecallsorsurveys,weignorethem,”furtherdiscussionindicatedthat“iftheyactuallyaskedifthiswasaconvenienttime,”or“ifweactuallysawthatourphoneconversationsorsurveysactuallychangedsomething,”thattheywouldbemorelikelytoparticipate.
§ Regardingpreferredmethodsofcommunicatingtheiropinionsandideas,theysharedthefollowingfeedback:
o Thattheywanttoknowtheirtimeandinputmakesadifference—theywantfeedbackonchangesmadeinsystemsorimpactsmadeinhealth.
o Theywant“plainspeak”communicationonwhatthingsmean—“don’tdumbitdownforme,buthelpmeunderstanditinclearlanguage,”
o Theywanttomakesurethattheirinputischanneledupthechaintoadministrationanddecision-makers.Specifically,oneattendeenoted,“Oftenadministrationissofarremovedfromtherealexperienceofthepatient…thegapisn'talwaysbridged…therearetoomanypoliciesthatlimitthedoctorsfromprovidinggoodcare,andtheyneedtoknowthis.”
o Theysuggestedthatsomehowcoordinatinginputthroughhealthcoachesorthepreviously-referencedcarecoordination/informationresource“hub”wouldhelpthembetterarticulatewhattheywereneeding,andhelpthembetterunderstandwhatprovidersareasking.Thusindicatingthatcarecoordination,communityhealthworker,orsocialservicepartnerorganizationscouldbetappedtobeaconduitformeaningfulengagement.
o Tribalparticipantsstronglyadvocatedconversationswithtribalelders,bothbecause“theycan’tcometogroupslikethese”andbecause“theyaretheoneswhowillreallytalk.”Theyalsosuggestedconveninglargercommunityconversationsatthecommunitycenter,school,orlonghousesontriballand,noting,“it’snottoodifficulttogetabuzzgoingontheres,especiallyaboutsomethingthisimportant.”
o Ruralcommunitiesrecommendedboththesesmaller,conversationalgatherings“whereyoucanbuildtrustandbounceideasoffothers,”butalsosuggestedthatlargergroupdiscussionswithmorecommunitymembers(andfood!)couldgetmorepeopleinvolvedandtalking,“thoughyou’dreallyneedtopromoteit.”Liketribalmembers,ruralcommunitymembersspecificallyflaggedtheneedtoreachouttoeldersandtothedisabledinotherways(e.g.,intheirhomes),because“theycan’tmakeittoeventslikethese.”
o Youthinfostercarewanttohavemeaningful,focusedconversationslikethese,buttobringmorepeopleintothemix.Andtheysuggestedworkingwitheventslike“MakeitHappen”andorganizationstheytrust(liketheoneswhoreferredthemtothisconversationtobeginwith)tosecureinputandvoice.
§ Regardingreceivinginformationabouthealthandhealthsystemchanges,responseswere
varied:o Manynotedthatthey’dliketohaveaccesstoa“centralofficetogotoorcallwhere
theyadvocateforyou,aresourcecentertogiveandgetinformationandtogetthehelpandsupportyouneed.”(Theseweresuggestedinconversationsdealingwithcarecoordination,healthadvocates/coaches,support“hubs”inthecommunity).
o Someindicatedthattheywanttoreceiveinformationfromtheirphysicianortheirproviderteam(thoughothersindicatedthiswouldonlybepossibleifyoucouldactuallygetintoseethem).
o Therewerewildlyvaryingreportsregardingattendees’desiretoreceiveinformationfromtheirinsurancecompanies,withmostparticipantsindicatingthat“Ican’tevengetthroughtothemtoaskquestionsorgetmycards,muchlessreceiveorshareimportantinformation”andafewindicating,“Ireceivereallyvaluablehealthremindersandresourcesfrommine.”
o RuralandtribalparticipantsindicatedpreferencesforreceivinginformationandinvitationsviaUSPostalServicemailorthroughlocalnewspapersandtribalpublications.Theyagainrequestedshort,simplecommunicationsand“nobigfatbooklets”or“sevencopiesofthesamething,whichalwayshappenswithmyMedicaidcoverage.”
o Tribalattendeesspecificallyrequestedthatinformationbedisseminatedto“dispelmisinformationthatisconstantlyoutthere.”
o Urbanandtribalparticipantssuggestedthatelectroniccommunications(socialmedia,text,email,web)wouldbegoodavenuestoshareinformationbecause“everyonehasaphonethesedays.”Ruralattendeesdidnotsharethispreference.
ProviderInputRegardingLong-termMeaningfulConsumerEngagementStrategy
OverviewInadditiontoconsumerfocusgroups,representativesof14organizationswereinterviewedtogathertheirideasforestablishingalong-termmeaningfulconsumerengagementstrategytoinformtheMTDandthebroaderactivitiesoftheACH.Theseorganizationsdemonstratedthefollowingdiversity:
• Geography(rural,urban,tribal)• Raceandethnicity• Healthsystemsizeandmodel(large,small,independent,university-affiliated,communitynon-
profit)• Typeofpractitioner/provider(medical,behavioral,substanceabuse,oralhealth,publichealth)• Socialdeterminantsorganizations(housing,foodsecurity,socialservices)• Professionalassociations• ManagedCareOrganizations• Associations• Community-basedInitiatives
NamesofintervieweesareincludedinAppendixA.
IdeasforConsumerEngagement
Whenaskedtheirideason“whichengagementstrategieswouldbemosteffectiveinreachingconsumersfortheirinputandideasintotheMDTandthelong-termgoalsoftheACH?”,thefollowingthemesemerged:
§ Thetoprecommendationwastoreachouttoconsumersthroughtheconduitoftrustedproviders,advocates,andorganizationswithwhomconsumersalreadyhavetrustingrelationships.
o “IfBHTisreachingouttoconsumers,dosothroughthetrustedorganizationsorconsumersmightgetconfusedandfrustrated.”
o “Meetthemwheretheyarethroughtheircoreconnections.”
o “WorkthroughNavigatorsandCHWinitiatives,becausetheyreallyhavetheirpulseontheconsumerneedsandthetrustoftheirclients.”
o “Reachoutthroughruralcoalitionsandhealthchampions,whoreallyknowtheirpeople.”
o “BuildonexistingeventsandfairsthatMCOstakepartin—partnerwiththemastheyconnectwithconsumers.MCOscouldbeambassadorsforspecificengagingquestions/actionsintheirinterfacewithconsumers.”
o “OutreachthroughHealthHomescarecoordinatorsorothercarecoordinationprograms,orinterviewclientsinwaitingroomsatFQHCs,NativeClinic,ortheTeachingHealthClinic.Gettingone-on-oneinputinthesesettingswouldrichlyinformourwork.”
o “Hostoutreacheventssuchasminitownhallsinvariouscommunities,withinvitationscomingfromtrustedpartners.”
o “Don’tjustsay,we’reheretohelpyou.Breakbreakwithpeople.Buildrelationships.Invitethemtopartner.”
o “Dovetailconsumerengagementactivitieswithotherestablishedorganizationmeetingsorevents(e.g.,homelesscoalition,ruralcoalitions,healthfairs)”
§ Respondentsindicatedthattheresultofthatoutreachtroughtrustedorganizationsandadvocatesshouldyieldthefollowingformal,structured,long-termengagementopportunities:
o ImplementanAdvisoryCommitteethatinformsstaff,board,andleadershipcouncilregularly
§ Peopleselectedbasedontheirrepresentation,expertise,andwillingnesstoprovidevoiceovertime
§ Peopleconnectedtootheradvisoryboardsortrustedorganizationssoyouarechannelingamuchbroaderaudiencevoice
§ “Ittakesalotofexpertise,time,andenergytomanagethesetypesofgroupstoreallygetwhatyouneedfromit”andanotherrespondentsaid,“it’snotjustaboutmeetingOURneeds,it’saboutmakingsuretheparticipants’timeandexpertisearehonored”
§ Learnfromotherentitiesthatdothiswellandreplicatehowtheyhavemadeiteffective,withoneexampleasProvidenceSaintPeterinOlympia
§ Capitalizingonexistingconsumerpanelsandadvisoryboardswiththecaveatthat,“thesearethepeoplewhohavebeenshowingupfor20years…weneedtohearfromnewvoices.”
o IntegrateConsumersintotheLeadershipCouncilmeetingsandhavesupportivepeopletheretohelpthemusetheirvoice…callthemoutasconsumerrepresentatives(notprofessionalsservinganorganization)andpaythemfortheirtimejustaseveryoneelseintheroomispaidtobethere.E.g.,perhapshaveorganizationrepresentativesbringaconsumerrepresentativetohelpsupportthem.
§ HearconsumerstoriesmonthlyatLeadershipCouncilandboardmeetings.Fromtheconsumersdirectly.
§ “Havingconsumersrandomlyattendmeetingsisn’teffective.Thereneedstobeaspecificstructureandsupportstomakethemcomfortableandtomaketheirattendancecount.”
§ WeneedmoreadvisoryorLeadershipCouncilrepresentationfromfront-lineprovidersworkingdirectlywithclients.
o Ensureconsumervoiceontheboard(likeFQHCshave)
§ Oneintervieweeoffered“animportantcaveat;oneconsumercannotrepresentallconsumers.Oneconsumer’sexperienceisexactlythat…oneconsumer’sexperience.”
§ “ChangingboardandLeadershipCouncilcompositionmaytakealongtime,soweneedtostartnow.”
§ Onerespondentsuggested,“ensuretheboardandLeadershipCouncilaretrulydiversebecausethatwillhelpmakealloftheactivitiesoftheACHmorediverse.”
§ Respondentssuggestedthatthemostappropriateshort-termstrategiesforsecuringinputinto
projectplanningandspecificimplementationactivitiescouldinclude:o Focusgroupswithparticularpopulations,hostedby/recruitedbyorganizationsthey
knowandtrust,besuretocompensate/incentivizeparticipation§ Earlymethodofgettingmeaningfulinputnowwhileyouaresettingthestage
foramorecomprehensiveplanlong-term§ Optionforspecificfocusareas,e.g.,exploringbidirectionalintegrationofcare,
opiods,etc.withaspecificpopulationweighinginonaspecifictopico Carefullydesignedsurveys,particularlyforthoselesscomfortableingroupsettingsor
withlimitationsinmobility,transportation,etc.§ Oneintervieweestated,“laserinonkeyissuesthatmeetconsumerswherethey
areatsotheydon’tgetlostintheglobalpartsofsystemdesignbuthaveavoiceinthethingsthatreallymattertothem”
§ Anothersuggestedatieredsurveyprocesssimilar§ OnesuggestedusingaplatformsuchasThoughtExchange,whichisusedin
someschoolsystemsettings§ Severalnotedthatitwouldbeimportanttoprovideincentivesforsurvey
participationtogetbetterresponserates
§ Regardingtheabove-listedoptionsforengagingconsumers,respondentswereveryclearabouttheconsiderationsthatwouldmakeconsumersmorelikelytoparticipate:
o Structuremeetingsandeventswiththefollowingconsiderations§ Scheduleat“nontraditionaltimes”§ Providefoodandchildcare§ Providefinancialstipendsandtransportation
§ Engagesupportandcoachingfromtrustedadvocatestohelpthemfeelmorecomfortable
o Onerespondentnoted,“Everyoneelsegetspaidfortheircontributiontothisplanningeffort.Consumersshouldbesimilarlycompensatedbecausearguablytheirvoiceisthemostimportant.”
§ Othersuggestionsincluded:
o Socialmedia.“Gettheyoungervoiceandengagementthroughsocialmedia.”o Earnedmediaandlocalpublications(tribal,rural,Inlander).“Peoplerelyonthese
resourcesandtheycanbeagooddooropener.”o Continueasking,“whoelseshouldbeatthetable…orwhosevoiceshouldwesecure
fromelsewheretobringtothetable?Ifwekeepaskingthisquestionitwillidentifywherethegapsareinourstrategy.”
o ReduceMedicaidstigmatoinvitemoreopeninput.“Doacommunitycampaignthatde-stigmatizesMedicaid—itissomeofthebestcoverageyoucanget.Helpprovidersandconsumersunderstanditisagoodthingandhowtomaximizehealthwithit.Treatconsumersliketheyhaveaninsuranceplan—whichtheydo—it’snotwelfare.Theywillbemorelikelytosharetheirideas.”
o LookatthecertificationrequirementsforPatientCenteredCareandmodelconsumerengagementstrategiesafterthat.
o PulltheactualbillingcodesforMedicaidandlookatwhoisusingthoseservicesthemost…startthereandaskthemfortheirinputonhowtoshapethepatientexperienceandoutcomes.
o “EngagethepeoplewhohaveeffectivelytransitionedoffMedicaid,thosewhohavesuccessfullybetteredtheirlife,tolearnmoreaboutwhathelpedthemdothat.Allowthattoinformhowweprovidesupportsnow.”
o LearnfromotherstateswhohavegonethroughMTDactivities…whatdidtheyfindworked(anddidn’twork)?
§ Onlytworespondentsindicatedthatcomprehensiveconsumerengagementmightnotbe
desirableatthispoint,indicating,o “Unlesstherearegoingtobetargeted/focusedchangesthatwillimpactthem,it'sa
wasteoftime/energy/moneyandwillonlycreatemoreconfusion.Theywanttoknow…’doIstillhavebenefits,willIstillbeabletoseemyprovider?’Thisindividualnotedthatthebetterapproachwouldbetohavetheseconversationswiththeadvocateswhoworkwithconsumers“dayinanddayout,astheyknowtheirstrugglesandneedsandwouldbeabletospeakonbehalfofthebroaderpopulationwithoutconfusingorfrustratingthem.”Thisrespondentfearedthataskingconsumersforinputonsocialdeterminantsissues(transporation,housing,etc.)wouldonlyconfuseandirritatethembecause“Medicaidclientsarehereandnow…tryingtomeettheirneedstoday…ifwebringupthingsthatwon’tchangefor4-5years(ifthen)we’llmakethemmad.”
o “Ifweputtoomuchoutthererightnowwithoutanswersandspecificchanges,itwillcreatefear.Changeishardforthispopulation.Manyarelivingdaytoday.”
o Oneotherrespondentprovidedthefollowingrecommendation:“AskconsumersandprovidersquestionsaboutthingswecanactuallyDOsomethingabout,otherwiseit’sarecipeforfrustration.”
HowSuccessWillBeMeasured
Whenasked,“howwillyouknowthatBHThadbeensuccessfulinmeaningfullyengagingconsumers?”thefollowingthemesemerged:
§ “Iwillseethemandhearthematmeetingsandevents,andtheirvoicewillbeincludedinminutesandinplans.Theywillbeatthetableandtheirvoicetrulyinformswhatwedo.”
§ Iwillseelong-termattendanceandengagementattheLeadershipCouncil,morediversity,morelegislativeandelectedofficialsattendingfocusingonpolicyfortheirconstituentsbecausetheirconstituentsareaskingforit
§ “Youwouldseeitinthestoriesthatpeoplearesharing—theirstoriesinformchangeandtheirnewstoriesreflectchange”
§ “Weareseeingtheevolutionofprojectsandsolutionsbasedonfeedbackfromthepeopleimpactedbythem”
§ “TheprescriptivenessoftheMTDToolkitwillbecustomizedbythevoiceofthepeopleitisintendedtoserve”
§ “Consumerhealthhasimproved.”§ “Consumersatisfactionwiththeircare,theirhealth,andtheirvoiceinhealthsystem
transformationhasappreciablyincreased.”§ “ConsumerswouldknowwhoBHTisandtrustthemandindicatethattheyareatrusted
organizationtogotoforadvocacy,help,partnership.”
WhichConsumerPopulationsShouldBeInformingtheWorkoftheACH?
Respondentsareseekingnewvoices:
§ “SpecificallywedoNOTneedtobereachingtheaverageconsumerwhooftenhasavoice(definedasapersoninaprofessionalcapacityadvisingontheseissues).Thesearenottheconsumerswewanttohearfrom.”
§ “Wetendtohaveasmallgroupofvocalpeoplewhomayormaynotberepresentativeofthelargergroup.Thatcanendupyieldingtokenconsumerinput.”
§ “Wetendtogetthehighestfunctioningandmostvocalpeoplewhohavebeenprovidinginputforalongtime.Weneednewvoices.”
§ “Weasserviceprovidersaredesigningprogramsforpeoplewhoaren’tintheroom.Thishastostop.Weneedtoheardirectlyfromthepeopleweareserving.”
RespondentssuggestedthatBHTshouldoutreachtovulnerablepopulationswhohaven’thadasayinthepast,suchas:
§ Behavioralhealth,substanceabuse,anddualdiagnosisclients(weneedthisvoicebutwanttomakesureweareengagingthemintherightway)
§ Thosewithchronicconditionsandmultiplecomplexhealthissues§ Individualsacrosstheagerange,particularlycallingoutseniors§ Disabled§ Ruralandurbanresidents
o “Ruralsgetforgottenandwearenotreachedouttobecausemostoftheproviders(andallofthebigones)areinSpokane.”
o “Peopledon’tcometous…theyexpectustocometothem.”§ Fosteryouthandthoseagingoutoffostercare§ Homelessorinsufficientlyhoused§ Medicaidclientsandtheuninsured,those“stuckinthemiddle”betweenMedicaidand
insurance(theymaketoomuchforMedicaidbutnotenoughtopurchasetheirownanddon’thaveaccesstocommercialinsurance)
§ ThosewiththehighestMedicaid/healthcarecosts§ Lowincome§ Children/parentsofchildren§ Communitiesofcoloranddiverseculturalgroups(AfricanAmerican,NativeAmerican/Alaska
Native,Immigrants,Refugees),especiallywomenofcolor§ Populationswithspecificdisparities(lookattheSRHDdataondisparitiesandseekoutthese
populations)§ Specificgeographicareasoftheregionwhohaveverylowincome,highrisk,significanthealth
issues
WhichOrganizationsMightHelpEngagetheConsumerVoiceEffectively?
Specificsuggestionsincluded:
§ NationalAssociationofMentallyIll§ BHOConsumerPanel§ FQHCConsumerPanels§ HomelessCoalition§ CommunityActionNetworks§ WashingtonStateCommunityActionPartnership§ SpokaneAlliance§ InPersonAssisterNetwork§ WorldRelief§ HealthPlans§ VOA§ MCOs§ CatholicCharities§ SNAP
InWhatOtherWaysCanBHTContinuetoImproveConsumerEngagementOverTime?§ AlmostuniversallyrespondentsindicatedthatBHTcouldimproveitsmeaningful
consumerengagementprocessbycreatingaformal,structured,consistentmeaningfulengagementpolicyand/orstrategy.
o WhilemanyrespondentsindicatedthatBHThaddoneagreatjobbringingpartnersandprofessionalsintotheroomandcreatingstrongmomentumaroundthisplatform,mostindicatedthatthe“true,authentic,in-personconsumervoicehadnotbeeneffectivelysolicited”untilthisprocessbegan.
o RespondentsreportedbeingpleasedthatBHTistakingsuchacomprehensiveapproachtoplanningitsmeaningfulengagementstrategy.
§ Themostcommonsuggestionofferedtohelpimproveengagementwasa
communicationstrategythatprovidesmoreregular,clear,specific,“plain-speak”communicationthatis“notjustonaby-requestbasis.”
o “Don’tusewaiver-speak!”o “Helpconsumersunderstandhowallofthisimpactsthemandbenefitsthem,
andtheywillbemorelikelytowanttoengage.”o “Communicationneedstobeimprovedforbothprovidersandconsumers.
Providersdon’tunderstandwhatitallmeans,sohowcantheyhelpconsumersunderstand?”
o “Thereisn’tenoughdisseminationoftheinformationdownthroughorganizations,either.There’sabottleneckwhereadministratorsknowtheinformationandthemid-levelandfront-linestaffdon’tgetthedetails,buttheyaretheonesinteractingwiththeconsumers.Providersarethecoaches,soifyouwantgoodcommunityengagement,educatethemwell.”
§ Specificcommunicationrequestsincluded:
o Transparencyabout“here’swhatweknow,here’swhatwedon’tknow.”o Clear,concisemappingoftheprocess.o Pushnotifications(toalertofchanges).o Dynamicandconcisewebcontent(toclearlyoutlinetheprocessandprogress).
Makesurewebsiteisupdatedandthatit’snavigableandfocusedonwhatpeoplemostneedtoknow.Basic,clearinformationthatisseparatedbasedonaudience(consumers,providers,policymakers),clearlyarticulatingthevaluepropositionandactionitemsforeach.“Wedon’thaveaplacetodirectconsumersorproviderswheretheycanlearnmoreandfindwhattheyneedeasily.”
o Closethecommunicationloop…makesurepeopleknowthattheirvoicemadeadifference.Informandshowthatchangehasbeenmade.
o Consumersandprovidersalikeneedtoseetheseprojectsas“relevantandaccessibletothem,”sothecommunicationandoutreachhastoconveythis.Provide“predictablyfrequentcommunications—consistentandsustained,forums,andotherwaystoreachpeopleandengagethem.”
BetterHealthTogether(BHT)MeaningfulProviderEngagementSummaryReportASummaryofProviderInputUsedtoInformMedicaidTransformationDemonstration(MTD)ProjectSelectionandPlanning,andtoDesignBHT’sLong-termMeaningfulProviderEngagementPolicyandStrategy
OverviewTheBHTMeaningfulProviderEngagementplanningprocessinvolvedseveraltiersofactivitydesignedtosecureinputintotheselectionandplanningofMTDprojectsandtoyieldarecommendedpolicyandstrategyfortheBHTBoardtoconsideradoptingforongoingmeaningfulengagementofprovidersinfutureAccountableCommunityofHealth(ACH)andMTDactivities.Thisreportdetailsfindingsfromthefirstphaseofactivity:providerkeyinformantinterviewsandfocusgroups.
Methodology:ProviderKeyInformantInterviewsandFocusGroups
Intotal,21providersparticipatedinkeyinformantinterviewsand24providersparticipatedinthreeseparatefocusgroupstoinformtheselectionandplanningofMTDprojectsfortheBHTregionandtoprovideopinionsandideasforestablishingalong-termmeaningfulproviderengagementstrategyfortheactivitiesoftheACH.NamesofintervieweesandhostorganizationsforfocusgroupsareincludedinAppendixA.Intervieweesandfocusgroupparticipantsrepresentedadiverscross-sectionofprovidersaccordingtothefollowingcriteria:
• Geography(rural,urban,tribal)• Raceandethnicity• Healthsystem/practicesizeandmodel(large,small,independent,university-affiliated,
communitynon-profit,etc.)• Sectorrepresentation(medical,behavioral,substanceabuse,oralhealth,publichealth,MCO,
etc.)• Practicetype/targetpopulationserved(pediatric,geriatric,familymedicine/primarycare,
internalmedicine,tribal,homeless,psychiatric,etc.)• Socialdeterminantsorganizations(housing,foodsecurity,socialservices)
ProviderInputRegardingMedicaidTransformationDemonstration
Whenaskedtheopen-endedquestions“whatarethebiggestchallengesfacingprovidersnow,”“whatarethebiggestbarrierstoprovidingwhole-personcarethatimproveshealth,”and“whatwouldmakeiteasier/moreefficientforproviderstoprovidewholepersoncarethatimproveshealth,”thefollowingthemesemerged:• TIMEANDADEQUATEREIMBURSEMENT:Themostcommontheme,citedinoneformoranother
byallprovidersinthisresearchprocess,was“lackoftimeandreimbursementtotreatpatientsholistically.”
o Time.Providersfeeltheylacksufficienttimetotreat:thewholeperson;morethanoneissueatatime;complexmedicalconditions;relatedsocialneeds;orevenasinglemedicalissueadequately.Theyindicatedthatthe“productivitymodel”isstillthestandard,andthateventhoughthereisatrendtowardqualityandvalue,theyarestillpaidonafee-for-servicebasis,whichconstrainsthemfromeffectivelyandefficientlymeetingthecomprehensiveneedsoftheirpatients.Commentsincluded:
§ “Youcan’tdoanythingmeaningfuloreffectivein15-20minutes,muchlesstreattheholisticneedsofpatientswithmultiple,complexconditions.”
§ “MybarberspendsmoretimecuttingmyhaireachtimeIseehim(30minutes)thanIamgiventotreatapatientwithdiabetesandothercomplexhealthissuesandmultiplesocialneeds.”
o Reimbursement:Providerscited“piecemeal”reimbursementasadetrimenttopatienthealth.Oneprovidersuggestedthattheyareexpectedtodealwithonlyone“problem”atatimeforapatient,andarereimbursedinthisway,whenthereare“6interrelatedproblems—3acuteand3chronic—nottomentionsocialneeds,andwehave15minutestoworksomekindofamiracle.”
• INFORMATIONEXCHANGE:Allprovidersindicatedthatinformationexchangeamongstthe
variousproviders(clinicalandcommunity)wasasignificantbarriertotheirabilitytoprovidequalitycarethatmakesadifference.Challengescitedincluded:
o LackofInfrastructureandInteroperabilityforHealthInformationExchangechallenges,includingnonexistent,insufficient,orinefficientconnectionsbetweenoramong:hospitalsandprimarycare;behavioralhealthandprimarycare;primarycareandcommunitysupports;primarycareandspecialtycare.TheynotedtheinabilityofElectronicHealthRecordstoeffectivelyinterfacewithoneanother,andthelackofreal-timeaccesstodiagnosisandtreatmentinformationatcaretransitions(particularlyfrominpatientdischargesorEmergencyDepartmentvisits)asbarrierstoeffectivewhole-personcare.Evenwhenproviderssendreferralsandpatientinformationtospecialists,theydonotreceivereturninformationondiagnosesortreatment.
o Commentsincluded,§ “Wearedoingourbestasprovidersbutwe’redrivingblindalotofthetime.”§ “Weareaskedtocollaborateonbehalfofourpatientsbutdon’thavethetools
todosooutofourownsystems.”§ “Ineedreal-timeabilitytotalktootherproviders,exchangeinformation,and
treatthewholepersonatthetimetheyneedtobetreated…whentheyareinmyoffice.”
• ADMINISTRATIVEBURDENS:Providersuniversallyreportedadministrativeburdensasoneofthe
greatestchallengestotheirabilitytoprovideexcellentcareandtomeettheneedsoftheirpatients.Theycited:
o Toomuchdocumentationandadministrativeroadblockstoprovidinggoodcare.Manyprovidersnotedtheconstantneedtoprovidedouble,triple,orevenquadrupledataentryanddocumentation,notingthat“italltakesawayfromourabilitytotreatthepatients…andthedatatheyareaskingforisn’tactuallymakingadifference”
o Theconstantneedtofindworkaroundsfordatasystems,variousMCOcoveragerequirements
o Oneprovidersaid,“Ispendmoreofmytimetypingratherthantreatingpatients”(thissentimentreceivedsignificantaffirmativefeedback).
o Anotherprovidersuggested,“Eachtimetheyaskustotrackonemorething,theysay,‘it’sjustonemoreboxtocheck,’buttheydon’trealizethatifyou’reonlycheckingboxes,youcan’ttreatthepatient”
o Finally,onephysiciannoted,“ifyouwanttoseechangehappen,payfortherightactivitiesthatproducetherightresultsandifyoucan’tdothat,atleastunburdentheproviderwhowillbedoingthework.”
• CARECOORDINATIONANDCLINICAL/COMMUNITYLINKAGES:Providersacrossallpractice
settingsanddisciplinescitedsignificantchallengesduetothelackofresourcesforcarecoordination,caretransitions,andsocialdeterminantservicesthatsupportoptimalpatientoutcomes.Mostinterviewsandfocusgroupssharedsomeversionofoneprovider’scommentthat“wespendmoreofourtimebeingasocialworkerthanaphysician.”Providerscitedspecificchallenges,including:
o ProviderTimeConstraintsforEffectiveInformationExchange,particularlyinadequatetimetoconsultwithotherprovidersbothwithinsystemsandacrosssystemstomeetthediverseneedsofpatients,andinsufficienttimetoconsultwithfamilymembersonbehalfofcertainpopulations(children,elders,andat-riskpopulationssuchasthosewithchronicbehavioralhealthissues).Oneprovidernoted,“evenwhenIdogetdetailedpatientinformation,Ispend20minutesreadingwhatIneedtoinordertotreatthepatientandthat'showlongI'mallottedforapatientvisit.”
o ResourceBarriersforInformationExchange,includingthelackofreimbursementprovidertoproviderconsultation,carecoordination,andfamilyconsults.Providersuniversallycitedtheinabilitytoeffectivelycoordinatecareamongthefullcareteamandthevariouscommunityprovidersandfamilymembersnecessarytoprovidewholepersoncare.
o Challengeofeffectivelyintegratingadditionalcarecoordinationintoexistingclinicmedicalteams(e.g.,notenoughstafftodothework,notenoughfundingtopaythestaff,notenoughtrainingtorevisepatientandteamflows,lackofspacetoprovidetheseservices).
o Theneedforimmediate/real-timeandco-locatedservices,particularlyforbehavioralhealthclientsandthehomeless(oftenpatientsfallintobothcategories),inthewordsofoneprovider:“inordertokeepthemfromtherevolvingdoorofEmergencyDepartmentvisits,inpatienthospitalizations,orincarceration.”Co-locatedphysical,behavioral,addiction,dental,andsupportserviceswouldvastlyimprovepatientoutcomes.Providersnotedthattheseindividualsneedfarmoresupportforsocialneedssuchastransportation,supportiveservices,housing,employment,foodsecurity,andtimely
addictiontreatment.Asoneproviderstated,“areferraltwoblocksawayisoftenthesameasareferralacrosstown,andanappointmentintwoweeksisasgoodasnoappointmentatall.”
o Consistentlystaffedandfundedteamsprovidingsocialdeterminantservicesandclinicalsupports(housing,foodsecurity,transportation),aswellaspreventiveeducationandsupport(dietitian,physicalactivity,healthcoaching)inordertoadvancehealthgoals,but,asoneprovidernoted,“thiscostsmoneyandnoonepaysforit.”Anotherproviderstated,“ouremphasisnowisdxandrx,notwholehealth…weneedanexpandedcareteam,thespacetoprovidetheseresources,coverageforthingsthatmakeadifference(likecarecoordination,dietitians,physicalactivity,socialsupports),andsupportgettingtheprocessesandintegrationsetupintheclinicalsetting.”Whenaskedwherethisfunctionshouldreside,mostproviderspreferredacommunity-basedapproachtocarecoordinationthatseamlesslyandeffectivelyintegratesintotheclinicalsetting.Oneprovidernoted,“thisshouldbehousedoutsideofouroranyone'ssystemandshouldfollow/servetheclient.”
o Consistentassessmentofneedsthatimpactclinicaloutcomesbeforepatientsseetheirproviders.Clinicalsettingscouldbenefitfromacarecoordinatororcommunityhealthworkerwhocanperformfullassessmentsofpatientsastheywalkinthedoor,toidentifyifthereareissuesoutsideoftheclinicthatwillpreventpatientsfrombeingcompliantandsuccessfulwithtreatmentrecommendations.Asoneprovidersuggested,“weneedtoaddresstheirhierarchyofneeds,becauseifItellthemtogotothegymandtheycan’taffordrentthismonth,nothinggetssolved.”Andanothernoted,“noamountoftreatmentfordiabeteswillhelpifthepatientishomelessanddoesn’thavesocksandshoesthatkeeptheirfeetdry.”Anotherprovidersnotedthat“patients’numberonecomplaintis‘theprovidersaren’tlisteningtome,’whenpartoftheproblemisthepatientcan’tclearlyarticulatewhattheywantorneed…theyneedsomeonehelpingthemdothissotheprovidercanfullyunderstandthoseneedsandaddressthem.”
o Additionstothecareteam.Themostcommonlycitedprovidersthatneedtobeaddedtothecareteamtoprovidewhole-personcarewere:behavioralhealthproviders,communityhealthworkers,carecoordinators,anddietitians.
• POLICYBARRIERS:Providersrepeatedlyreferencedpolicybarriersthatinhibitwhole-personcare
orpreventprovidersfromeffectivelycoordinatingcareonbehalfoftheirpatients.Examplesofpolicybarriersincluded:
o Pronouncedrestrictionsinprovidercoordinationwithbehavioralhealthandsubstanceabusetreatmentandtheircoordinationwiththemedicalcaresystem.Thiswasthemostuniversalconcernexpressedbyprovidersfromallpracticesettingsanddisciplines.Oneprovidernoted,“wearehandcuffedbylegislationthatactuallypreventsusfromeffectiveintegration.”
o Inabilitytoprovidesimpleresolutionofissueswithoutadditionalbillinganddocumentation.Examplesincludednotbeingabletoprovideanuncoveredservicethatcouldresolveasimpleneed(e.g.,providingabandaidorgauzetoapatient),ortherequirementthatyoumustattempttocollectco-paysforfederally-fundedprogramswhenitcoststheprovidersmoretotrytocollectthanitdoestosimplywriteoffacopay.
o Requiredspenddownsforbehavioralhealthclients.Suchpracticesprofoundlyinterruptcareandresultinunnecessaryhospitalizations.Behavioralhealthclientscould
bebetterservediftherewerefundsavailabletodrawonduringthattimetomaintaincontinuityofcare.Oneprovidernoted,“thispracticeiscontrarytorecovery"
o Transitioningclientsoutofsupportserviceswhentheymakeadvancesintheirhealthandlifegoals.Iftheygetjobsormakecertainincomestheylosesupportstheyneedtostayhealthyandstable,soadvancingtowardhealthandlifegoals“oftenpushesthemoutofservicesandputsthembackonthestreetsorlandstheminthehospital.,onlytostartthecycleagain.”
• CLINICAL,COVERAGE,ANDACCESSCONSTRAINTS:Providersnotethatthereareavarietyof
clinicalandcoveragerestraintsthatinhibittheirpracticeofwhole-personcare.Examplesinclude:
o Formulariesaretoorestrictive,particularlyforspecificissues(e.g.Suboxonetreatment),andtheyaredifferentfromplantoplan,resultinginproviderssayingtheyhaveto“bobandweaveallthetimeandconstantlyresearchalternativeoptionsforprescribingratherthantreatingthepatient”(andagaintheycitetheyarenotreimbursedtoresearchalternativemedications)
o Medicaiddoesn’tcoveradditionaltreatmentsforpreventiveandchronichealthconditionmanagement(e.g.,dietitians,physicalactivity,painmanagementmodalitiesotherthanprescriptions)thatcommercialplanswillpayfor.Oneprovidersuggestedthatthisis“discriminatorymedicine”
o Manyprovidersindicatedlackofaccesstodrugaddictiontreatment(orlongdelaystoentertreatment)asamajorproblem,asitcausesusto“missthewindowofintervention”whenthepatientisactuallyreadytoentertreatment.
o PatienttransitionsacrossthevariousMCOscreatesignificanthardshipbecauseprovidersoftenhavetocreatenewtreatmentplansbecausethepreviousonedoesn’tmeetthenewMCO’srequirements.
o AccesstocareandmedicationsisachallengebasedonMCOpanels—particularlywhenpatientschangeMCOs,theyaretoldwhotheycansee(mostoftenNOTalong-termprovidertheytrustandwhoknowstheirhistory)andwheretheycangettheirmedications(whichoftenisNOTintheirownneighborhood,causingmorebarrierstocompliance).
o Insufficientnumberorwell-trainedproviders• Respondentsindicatedthatthere“arenotenoughproviderswhoarewell
trained;advancedcareprovidershavehelped,butit’snotenough.TherearesomanythingsIdothatsomeoneelsecoulddo.”
• Providerrecruitmentandretentionisamajorchallenge,particularlyinruralareasandinbehavioralhealth.Respondentsreported“poaching”ofexistingclinicalstafffromruralandsafetynetproviderstogoworkforlargerhealthsystemsandMCOs(betterpay,betterbenefits,betterqualityoflife),andanexodousofprovidersfromruralandbehavioralhealthsafetynetentitiesduetoproviderburnoutandthechallengeoftryingtodopatient-andmission-centeredworkamidstever-growingcaseloadsandadministrativeburdens.
o Avarietyofprovidersindicatedfearthatprogresstowardbetterintegratedcareteamswouldbethwartedbylackofaccesstonewtypesofproviders(e.g.,communityhealthworkers)oradministrativeorpolicychallengestoallowingvariouscareteammemberstoworkatthetopoftheircertification/licensuretobettermeetpatientneeds.Oneprovidernoted,“weneedtohaveallofuspracticingatthetopofourlicensessothephysician/providercanhelpfacilitatewholepersoncare.”
o Anumberofprovidersalsocitedthecriticalnatureofculturally-sensitivecare,particularlycitingtheneedformoreeffectivepartnershipswithTribesandrefugeepopulationstodefineculturally-appropriatecare.Anumberofrespondentsalsocalledouttheneedforculturally-appropriatementalhealthandsubstanceabusetreatmentservices,indicatingtherearefewresourcesthateffectivelytreatthewholepersonwiththistypeofsensitivity.
• ADDITIONALCONCERNS:Providerssurfacedavarietyofotherchallengestoprovidingwhole-
personcare:o Changefatigueandburnoutwascitedbymanyrespondents,withcommentssuchas
• “Burnoutcloudsourabilitytotreatthewholepatient,”and“adaptingtotheseconstantchangesisalmostimpossiblewithallwe’reaskedtodo.”
• “Burnoutishigh,thetreadmillisrunningfasterthanIhaveeverdealtwithbefore.Beingadochaschangedtoajobmorethanavocation.”
• “Ifyou’regoingtoaddsomething,takesomethingaway.Wecan’tjustkeepaddingtowhatneedstobedone.Providersarealreadytoobusy.”
• “Yes,changefatigueisaproblem.Weneedtorallythetroopstomakesystem-widechangepossible.Itcan’tjustrestontheshouldersofproviders.Wehavetohaveastrong,mission-drivenculturethatenergizes.”
o “Wewanttobeabletojustcommunicationwithourpatients…therearetoomanylawyersandadministrativelayersthatkeepusfromsimplytreatingthem,”and“createwaysofworkingwithpatientsthatworkforpatients.”
o Ruralareasfaceuniqueandcostlychallengesforthingslikeintegrationofbehavioralhealthintoclinicalsettings.Oneprovidernoted,“publichospitalsaren'treimbursedsufficientlyforthis—theyaredoingsomuchontheirowndime,andtheycanonlydothatforsolong."
Oncetheopen-endedquestionspresentedtheabove-articulatedthemes,intervieweesandfocusgroupparticipantswereaskedspecificquestionsaboutseveralfocusareasintheMedicaidTransformationDemonstration,sharingthefollowingfeedback:
• VALUEBASEDPURCHASING:Whenaskedabouttheextenttowhichprovidershavetheknowledge,skills,andreadinesstomovetowardValueBasedPurchasing,thefollowingthemesemerged:
o ThemostcommonfirstresponsetothequestionaboutVBPwasalwayssomeversionof,“cansomeonepleasetelluswhatthismeans?”
o RespondentsfeltthatlargesystemsandFQHCsarewellpoisedtomeetthenewrequirementsunderVBPbecausetheformerhavesignificantadministrativelayerstosupportitandthelatterhavebeenworkinginpatient-centeredandvalue-basedmodelslong-term.
o Participantsfeltthatindividualprovidersandsmallerclinics/practicesandindependentprovidersprobablyhavenoideawhatitmeansand/orhowitwillactuallyimpactthemortheirpatientsortheirpracticeofmedicine,andtheywouldnothavetheresourcestomanagethedataandthesystemsrequiredforVBP.Therewereconcernsthatsmallerpracticesandruralproviderswouldeithersimplycloseupshoporjoinoneofthelargersystemsunderduress,creatingmoredysfunctioninthesystem.
o Providersindicatedthattheybelievetheyaremeasuredontoomanymetricsalready(manyofwhicharenotalignedwithwhatisreallyimportant),andthatmorearebeingadded,creatingmoreadministrativeburdenandmovingusfurtherawayfromtreatingpatientsholistically.
o Anumberofproviderswereespeciallyconcernedaboutbehavioralhealthmetrics--theyaren’tconvincedthatthereare“reallygoodoutcomemeasures”forbehavioralhealth,yetintegrationisahuge(andcritical)partoftheDemonstration.Andthattheadministrativeandtimeburdenoftrackingmetricswouldcontinuetodecreasetimeandfocusforgoodpatientcare.
o Otherswereconcernedthatprovidersarebeing“graded”onoutcomesthattheydon’thavecontrolover,inparticularthesocialdeterminantsfactorsthatimpactpatientcompliancewithtreatmentrecommendationsandmedications(thiswasparticularlycitedwithregardtobehavioralhealthclients).Thisconcernwasexpressedacrosshealthsystemsandproviderdisciplines.
• INTEGRATEDCAREMODELS:Whenaskedtheextenttowhichprovidershavetheknowledge,
skills,andreadinesstomovetowardintegratedcaremodels,thefollowingthemesemerged:
o Providersunderstandtheintegratedcaremodel,theyareconstrainedbymanyofthepreviously-listedissues(healthinformationexchange,space,trainingonnewcaredeliverymodels,workforce).
o Again,providersnotedthatlargesystemsarebetterpoisedtointegratebehavioralhealthandphysicalhealthneeds(asopposedtosmallerclinicsorindependentproviders),butnooneispoisedtosupportthesocialdeterminantneedsthatmakeintegratedcarereallywork.Onerespondentsaid,“healthcaresystemsarethinkingabouthealthcaredeliveryonly,butsocialdeterminantsisreallywherewecanmakeadifference.Providersaren'treadybecausetheydon'tknowhowtohelpwithfoodinsecurity,housing,andthingslikethat.”
o Therewerespecificconcernsabouteffectivetreatmentforco-occurringmentalillnessandsubstanceabuse,withsomerespondentsnotingthatprovidersareill-equippedtodealwiththispopulationandfinancing,policy,andsystemissuescreate“almostinsurmountablebarriers”totreatingthispopulationeffectively.Oneprovidersummarizedconcernsexpressedbyseveralothersabout“thelackofscientificevidenceofsomeofwhatisdoneinthebehavioralworld.”
• REDUCINGEMERGENCYDEPARTMENTVISITSFORNON-EMERGENTREASONS:WhenaskedwhattheythoughtwouldhelpreduceEDVISITSfornon-emergentreasons,providersofferedthefollowingfeedback:o Co-locatedservicesortransportationtoservices,andsame-dayaccesstocare(particularly
forhigh-riskbehavioralhealthandchronicconditionpatients)o Real-timehealthinformationexchangeandproviderconsultabilityforthoseathighestrisk.o Bettermedicationeducationandreconciliationatdischargewithappropriatefollow-up
afterdischargetoensurepatientcomplianceandaccesstomedicationso Incentivesforprimarycareproviderstocontinuepracticinginprimarycareandincentives
forseeingMedicaidpatients.Same-dayaccesstoprimarycareandreductionsinwaittimestosecure/seeprimarycareproviders.Oneprovidernoted,“thereisincredibledemandandverylimitedresourcesforeffectiveprimarycare.”
o Betteraccesstosame-daybehavioralhealthservices.Asoneprovidernoted,“ifapatienthastoschedule3weeksouttobetreatedforanxiety,theEDistheirnaturalnextstep.”
o Moreeffectiveandcomprehensivecarecoordinationforhighutilizers(primarilybehavioralhealthandsignificantchronicconditions),focusingonsocialdeterminantsofhealthandbuildingatrustedrelationshipthatcanhelpcoachthemtoutilizeresourcesmoreeffectivelyandefficientlyfortheirhealthneedsandlifegoals.
o DiversionstrategiesthatpairmentalhealthprofessionalswithEMSprovidersandpoliceofficerstoavoidEDvisitsfornon-emergentreasonsandroutepatientsintointegratedcare(primarycare/behavioralhealthmodels)withrobustcarecoordinationforsocialsupports.(Oneprovidernotedthatpolicyandreimbursementchangeswouldbeneededtoimplementsuchstrategies.Thisindividualalsonoted“diversionisn’tthegoal…appropriate,holistic,patient-centeredcareisthegoal!”)
o Extendedhoursforprimarycare,moreurgentcareaccess,24-hourphonecare,and“behavioralhealthurgentcare”models.
• THEOPIODCRISIS:Whenaskedwhattheythoughtwouldmakethebiggestdifferencein
addressingtheopioidcrisis,providerssharedthefollowingcomments:o Providersacrossalltypesofsystemsandpracticeareasindicatedthatweneedmore
treatmentmodalities(options,coveragefor,providers)totreatpainwithoutprescribingopioids,includingpainmanagementspecialists,massagetherapy,physicaltherapy,acupuncture,etc..Asoneprovidernoted,“theywantustostopprescribingandthesepatientswithrealpainissuesdon’thavealternativemodalitiesthatarecovered.”Anotherstated,“TheHealthCareAuthority’sapproachtotheopioidcrisisiscausingmoreproblemsforcaringforthewholepatientbecausewedon'thaveothermodalitiestotreatthem.”
o Providersneedtoseethedataaboutprescribingpracticesandhowtheymeasureuptoothers,alongwithcoachingonothertreatmentoptionswhereoutliersexist.
o “Weneedreal-timeaccesstothePDMPsystemthroughEHRs.Accessafterthefactdoesn’thelp.”
o Acrosshealthsystemsandareasofpractice,providersnotedthatforthoseaddicted,weneedmorereadyaccesstotreatment,includingbetterpoliciesandcoverageforMATandbetterabilitytoprescribeSuboxone.
o Oneprovider(totheagreementofothersintheroom)stated“Wemustde-stigmatizethediagnosisandtreatmentofaddiction.Wedon’tstigmatizediabetesorhighbloodpressureasadiagnosis…addictionshouldbesimilarlyde-stigmatized.”
o Patientswhoarereadytoentertreatmentneedimmediateaccesstosubstanceabusetreatmentoptionsandmorecomprehensivefundedaddictioncounselingandsupport.
o Providersinallfocusgroupsindicatedthattreatingpainasavitalsigncreatedthisdynamicand,asoneparticipantnoted,“thependulumneedstoswingintheotherdirection…weneedtofacetheproblemwehavecreated.”Theycalledforprovidereducationoneffectivepaintreatmentsandaccesstoappropriateservicesandsupportsforpatients,balancedbypatienteducationandsupportandsocialdeterminantssupportstohelptreatunderlyingcausesandavoidaddiction.
ProviderInputRegardingLong-termMeaningfulProviderEngagementStrategy
IdeasforProviderEngagement
GeneralEngagementandCommunicationStrategies
Whenaskedtheirideason“whichengagementstrategieswouldbemosteffectiveinreachingprovidersfortheirinputandideasintotheMDTandthelong-termgoalsoftheACH?”,thefollowingthemesemerged:
• COMMUNICATECLEARLY,CONCISELY,ANDCONSISTENTLY:ThevastmajorityofrespondentsindicatedthatBHTwillneedtoplacestrongemphasisoncommunicatingmoreeffectivelyandmethodicallywithproviders.Asonerespondentsuggested,“Createasolidcommunicationstrategicplanthatwilldrivethemtoengage.”Themesincluded:
o Buildoncurrentstrengths§ BHTwascommendedbymanyrespondentsfortheirdemonstrated
commitmenttogooutintocommunitiesandconnectwithpartners(e.g.,travelingtoruralcommunitiesandhavingoneononemeetingswithpartnersthroughouttheregion).
§ TherewererepeatedreferencesthatBHThasmadeimportantprogressinrecentmonthsfocusingonTribalrelationships.
§ Oneparticipantsuggested,“it’scriticaltocontinuethisfocusonruralandTribalpartners.Don’ttreatruralcommunitiesandTribesasafterthoughtsinthisprocess.”
o Buildname,mission,andtrustrecognitionamongproviders:§ “Whilethereisgood“brandidentity”ingeneral,especiallyamongcurrent
partnersandadministrators,front-lineproviders(especiallymedical,dental,andmentalhealthproviders,asopposedtosocialdeterminantsproviders)don’tknowwhoBHTisorwhytheyshouldcare.
o “MedicalprovidershavenoideawhatBHTis.There'sabsolutelackofrecognitionofwhattheACHorthewaiverisdoing,sothere’snoplatformtobuildengagementon.Thosewhoareseeingpatientsdon'thaveanunderstandingofwhyit'simportantandwhytheyshouldpayattention.”
o “It’sallstillprettyfuzzytomost,ifnotall,providersifthey’renotactivelyleadinganarmofthiswork.”
o “BHTdoesagreatjobofcommunicatingwiththeadministrators,butwhatweneedisclearcommunicationswithprovidersabouthowthisimpactstheirpatients,theirpractice,andtheirpaycheck.”
o “Providersneedtobeeducatedonwhatthewaiverisandisnot(e.g.,itisnotagrantmakingopportunity),andtheyneedclear,consistent
communicationwithopportunitiestoaskquestionsanddetermine‘what’sinitforthemandfortheirpatients.’”
§ Ofnote.Severalrespondentsindicatedthatsomeofthecurrentcommunications“canfeellikemarketingratherthanengaging.Wewantpeoplewantingtoleanin,notfeeling‘sold’onsomething.”
o Focusontheuniquevaluepropositionforeachaudienceorindividual§ “Alwaysfocuscommunicationandmeetingsonthe‘whyshouldIbehereor
care’game—peopleneedtoknowwhythey’rebeingaskedtodosomethingandhowitwillaffectthem/theirpractice.Thisneedstobestandardforallcommunicationsandmeetings—highlightingthevaluepropositionandmakinggooduseofpeople’stimeandexpertise.”
§ “Keepthevaluestatementupfrontinallcommunicationsandkeepremindingpeopleinclearlanguageofexactlywhatyouaremakingadecisiononandwhyit’simportanttothem.”
§ “Sellthebenefit.Tellmethevaluepropositionformypatients,formeasanindividualpractitioner,andasapractice/organization.Thisiswheretheengagementwillhappen.”
o Sharewhatyoudoknowwhenyouknowit§ MostacknowledgedthatBHTisinachallengingrole,disseminatinginformation
thatisconstantlychangingorslowlyemergingatthestateandfederallevels.§ Still,providerssuggested,“eveniftheHCAisn'tdefinitiveonsomething,say
‘here'swhatweDOknow,here’swhatwe'rethinking,thetimelinewe'reanticipating,andthenextdecisionswewillbemakingbasedonwhatweknownow.”
o Usetherightlanguagefortheaudienceandpurposeofcommunication§ Themostcommonlycitedsuggestionforimprovingcommunicationwas
summedupbythisprovider:“Sharekeyinformationin‘plainspeak’forallaudiences.”Manyrespondentssharedsimilarcomments—keepcommunicationshort,simple,andtailored.
§ Severalparticipantssuggestedthe“threebulletrule,”withprovidersthemselvessuggestingtheydon’thavethetime(orwon’ttakethetimeamidsttheirotherpriorities)toreadmorethanthatunlesstheyfeeldrawninbyatopic.The3bulletsshouldintroducethekeyinformationandprovidelinkstowherepeoplecangetequallyconcisebutmoredetailedinformationoneachtopic.(Ofnote:severalrespondentsspecificallysuggestedNOTdirectingpeopletothetoolkitorotherstateresources,astheyaretooconvoluted).
§ “Askphysicians,PAs,ARNPs,etc.,whatkindoflanguagewouldmakeitmorelikelythattheirrespectivegroupswouldlisten,andthenuseit.”
§ “RememberthatBHThastheconversationeverydayeveryweek.Itiseasytoforgetwhatyouhavesharedwithdifferentaudiences…findawaytomakesurethateveryonegetsthekeyinformation.”
o Respectandrelyonorganizationsandproviderswhodothisworkandhavedoneitlong-term
§ Relyonproviderswhohavebeendoingthisworkandwhoaretheexpertsintheirrespectivefieldstohelpinformtherightcommunicationandengagementapproaches.
§ “BHTisthenewbieinthislandscape.Consultthepeoplewhohavebeenholdingtheriskandcontendingwiththechallengesfor25years.Respecttheexpertiseofestablishedinstitutionsandpartnerwiththemtoinnovate.”
§ Onepersonsharedacontraryopiniontotheabove,stating,“Weneedtomineeverycornerforchangemakers,interestingideas,andenergy.Don'tasktheoldpeoplewhohavebeendoingthisfor20or30or40yearsandneverchangedathinginthattime.”Severalotherssuggestedsimilarrequeststo“hearnewvoices”and“seekoutthosewhohaven’tbeenaskedfortheiropinions.”
o Listenbothtothesupportersandtothedissenters§ “Reallylistentotheconcernsofprovidersandbalancethehopeinherentin
innovationwiththerealchallengesandfearsthattheyhave.Thereissomefeelingthatifyou’reaskingtoughquestionsorposingcounterpoints,you’llbedisregardedasanaysayer.Butweneedtoexamineallsidesoftheseissues,notjustthepositiveones.”
§ “Becarefultolisten,notjusttell.”§ “Havehonest,boldconversationswiththosewhoaren’tatthetable,asking
them,‘whatwillittaketogetyouthere?’”§ Otherproviderssuggestedbeingresponsivetowhatyouhearbydispelling
mythsinrespectfulwaysandusingconversationsaboutfearstoinformthoughtfulprojectresearchandplanning.
o Bespecific,brief,andchoosethebesttimetoengage§ “Beveryclearabouttellingproviders,‘hereiswhatweareaskingyoutodo.’
Theyareconfusedbecausethemessaginghasn’tbeenclear.”§ “Providersneedtobetoldwhatisbeingaskedofthemsotheycantestit
againsttheirbusinessmodel,staffingmodel,andwhatitwouldtaketobesuccessfuloperationally.Thisisn’thappening.Ornotwell.”
§ Takeintoconsiderationprovidertimeconstraintsandinvitethemintotheplanningandtheprocess“whentheycanactuallymakeadifference”
o “Don’thaveopen-ended,blankslateconversations.Giveussomethingtorespondtobasedonourexperienceandourpatient’sneeds.”
o “The‘sowhatdoYOUthinkweshoulddo’conversationwon’twork.It’sawasteoftheirtimeandyouruntheriskoflosingtheirengagementlong-term.Bringideasandsuggestionsthatproviderscanrespondto.”
o Gotothem§ Asoneindividualsuggested,“findplacestointersectwithproviderswherethey
alreadyare.Wheredotheymeet?Gotothem.Ӥ Ideasincludedmedicalstaffmeetings,grandrounds,conferencesormeetings
likethePrimaryCareUpdateandCMEevents.o Consistencyandtransparencyarebothimportant
§ “BHThasanear-impossibletasktotrytokeepcommunicationandtransparencyupwiththeever-changinglandscapeatthestate.Theydoagreatjobwithwhatthey’vebeengiven.ANDitwillbehelpfulforthemtokeeprefiningtheircommunicationapproachtobemoremethodical,consistent,andtransparent.”
§ “Weneedmoreconsistentcommunication,overviews,andclearpicturesofhowdecisionswillbemadeandprojectswillmoveforward.Forexample,onaweeklybasis,saying,“hereisourunderstandingofthelatestandgreatest.”
o Electroniccommunicationimprovements
§ NumerousrespondentsindicatedthattheBHTwebsiteneedstohavesimple-to-findandeasy-to-understandinformationforeachaudiencebasedontheirneeds(front-lineproviders,administrators,consumers,communitypartners,etc.).
§ Providersandpartnersarealsoaskingfor“push”notificationsofkeydecisions,timelines,opportunities,oroutcomesincarefullyconstructedandveryconciseemailorwebalerts.(Recallthe“3bullet”rulereferencedabove).Note:giventhatBHTsendsoutregularupdates,perhapsthisrequestcouldbebesthonoredwithaprovider-focusedtemplateandmailinglistand/orsentoutthroughtrustedmessengersthroughtheirchannels(e.g.,SCMSandotherassociations).
§ Providersarerequestingconsistentreportingongoals,timelines,benchmarks,andsuccesses.“Knowingprogresshasbeenmadewillmakethebiggestdifferenceinlong-termproviderengagement.”
o Learnfromcommunicationerrorsandbeopentoguidanceonhowtodobetter§ Oneexamplecitedbymanyrespondentswasthemethodusedtocommunicate
theLOIprocessforprojectideas,inparticularhowthisprocesswouldbeusedtoinformprojectselection,whatmethodologywouldbe/wasusedfor“scoring,”andwhatthenextstepswouldbe.Ingeneral,communitypartnersfelteitherconfusedordissatisfiedwiththecommunicationaboutthisprocess,whichledtoquestionsabouttransparency(oranacknowledgementthatotherscouldhavequestionedtransparencyeveniftheindividualrespondentdidn’tfeelthisway).Thiswascitedasa“learninglesson”regardinghowtoapproachcommunicationmorecarefullyadmethodicallyforfutureACHactivities.
§ Anotherexamplecitedwastheinvitationtoproviderstojointheintegratedcareteam,whereoneprovidernoted,“IreceivedanemailthatpresumedthatIwouldtakepart,butthiswasthefirstIhadheardofit.EventhoughI’minterestedandwouldlikelywanttobeinvolved,thewordingoftheemailwasoff-puttingtome.Anditseemedtocomeoutofnowhere.”
• CAPITALIZEONTRUSTEDMESSENGERSANDESTABLISHEDCOMMUNICATIONCHANNELS:
Mostrespondentsnotedthattrustedmessengershelpgetpeopletothetable:“IcometothetablewhensomeoneItrustsaystobethere.
o SuggestedtrustedorganizationsincludedtheSpokaneCountyMedicalSociety(citedbyalargepercentageofrespondents),WashingtonStateMedicalAssociation,WashingtonAcademyofFamilyPhysicians,andvariousspecialtygroupsliketheregionalmeetingofpharmacists.
§ “I’dpayattentiontosomekindoftailored,specialnotificationfromSCMS.”§ Otherscitedturningtotheirprofessionaljournalsorassociationnewslettersfor
specialtyareasofpractice.o Whenaskedforideasofotherorganizationsthatwouldbehelpfulinengaging
providers,thefollowingweresuggested:§ MedicalteachingfacilitiesinSpokane
o “Leveragethesepartnershipstoinformhowweengageprovidersnowandhowwetrainnewproviderstoengageinthefuture.”
o “WeneedtobuildontheconnectionsourUniversitypartnershavewithestablishedandemergingproviders.”
§ WashingtonStateCommunityActionPartnership§ TheHomelessCoalition§ WashingtonStateDentalSociety§ RuralHealthCoalitions§ CommunityActionCouncils§ FederallyQualifiedHealthCenters§ RuralHealthSystems§ SpecialtyPractices,withseveralrespondentsnoting,“theyaren’taroundthe
tableandhealthsystemreformwon’tworkwithoutthem.”§ PracticesseeingthemostMedicaidclients,withoneprovidersuggesting,“Look
atthedataontheprovidersthatareseeingthebiggestpercentageofMedicaidlivesandstarttalkingwiththemdirectly.”
o Severalrespondentsmentionedindividualthoughtleadersthattheywouldbelikelytorespondtoifinvitationsorcommunicationscamefromthem,includingJayFathi,MD;JohnMcCarthy,MD;TomMartin,andTomWilbur.Oneparticipantnotedthattheseprofessionalsshouldbelookedtoas“activedisseminators”duetotheirtrustedstatusintheprofessionalcommunity.
• BUILDONANDEXPANDTHEIMPACTOFTHELEADERSHIPCOUNCILANDTHEBHTBOARD:
OneofthemostcommonsstrengthscitedbyrespondentswasthebreadthanddepthofexpertiseontheBHTLeadershipCouncilandBoard,andtheprogressmadeoverthepastyeartoexpandrepresentation.o “Tapintothewealthofexpertiseatthetablealready(boardandLeadershipCouncil)
andletthemguidethenextstepsforproviderengagement.”o Respondentscalledforcontinueddevelopmentoftheseleadershipbodiestorepresent
thediversityandprofessionalcapacitiesneededtotransformthehealthsystem.o Avarietyofparticipantsspoketotheexpansionofdiversityandbuilding“atrueequity
lens,”intheworkoftheACH,includingthefollowingcomments:§ “Weneedatrulydiverseboardwithanequitylensandastrongfocuson
culturalcompetencewouldmakethebiggestdifferenceinattractingprovidersandservingtheneedsofourcommunity.”
§ “Theleadershiptable/execlevelthatcometotheboardandmeetingtablestendtobealotofwhitepeople.Weneedthevoiceofdiverseprovidersbothprovidersthemselvesandthecommunitiestheyserve.”
WhichProviderPopulationsShouldBeInformingtheWorkoftheACH?
• Respondentsnotedthat,“overallwehaveagoodcross-ectionof“theusualsuspects,”andcouldbenefitfromengagingthefollowingproviders
o FrontLineMedicalProviders§ Primarycareproviders§ HospitalistsandERPhysicians§ Pharmacyandmedmanagement§ Specialtycare§ BehavioralHealth
§ OralHealth§ Long-termCare§ Commentsincluded:
o “Wehavealotofformerprovidersintheroom,andalotofadministrators.Wereallyneedthecurrentfront-lineprovidersorMedicalDirectorswhoaretheconduittothefront-lineproviders,buttheyneedtobeaskedintotheconversationwhentheycanreallymakeadifferenceorwe’lllosethem.Wereallyneedprimarycare,dentists,ERdocsintheroomtoinformfromthereal-worldexperienceofwhat’shappening,notfromtheadministrativelens.”
o “Reachdowntothegrassrootsproviders.I'veneverseenasmallsingleowneddentistorsmallgrouppracticeorindependentmentalhealthprofessionalsattheLeadershipCouncil.”
o SocialDeterminants/SupportOrganizations§ Transportationproviders,“wehavealotofthetraditionalmedicaland
communityorganizations,butwereallyneedcreativesolutionsforhowwe’regoingtogetpeopletoappointments.”
§ Refugeeandotherminoritypopulations• Respondentsalsonotedtheneedtoensuremorediversityinproviderrepresentation,including:
o SmallerProviders§ “Aswithanybusiness,whenyoubringinthetoptieredentitiesinthe
professiontheirvoicesareusuallyconsolidatedaroundincomevs.impact.Wealsoneedtohearthevoicesofthesmallerproviderswhoaredeterminedtomakeimpactevenattheexpenseofincome.”
§ “Smallerproviders.You’regoingtogetthebigonesanyway.Someofthesmallerprovidershaveinnovativeprogramswithexcellentresults.Weshouldbelearningaboutandbuildingonthese….theyareeffectivebecausetheyarenimbleandinnovative.”
o DiverseofProviders§ “Expandourrange:rural/urban,communitiesofcolor,drugaddictionand
recovery,thoseservingtheworkingpoor,seniors,youngmothers,etc.”.§ “Weneedengagementacrossthespectrumofprovidersizesandtypes,butthe
problemisalwaysthatyoucan’ttakesmall/midandindependentpractitionersawayfromtheirpracticesorpatientsdon’thavecareandproviderscan’tgetpaid.Weneedtoaddressthis.”
o ProvidersWhoSeetheMostMedicaidClients§ “WorkmoredeeplywiththeFQHCs,ruralhealthcenters,andNativehealth
centers,whohavebeendoingmanyoftheseinnovativethingsforalongtime.Learnfromtheirexperienceandexpertise.Thesearealsotheentitiesthatareservingthehighestpercentageofthoseimpactedbythewaiver.”
§ “Smallruralhealthsystems…noteverythingcanbedefinedanddesignedbylargehealthsystemsorFQHCs.Innovationinruralcommunitiesneedstocomefromruralproviders.It'seasytofocusonurbanandbigplayerstogetthe
outcomesattheexpenseoftheareasthatdon'thavealotofaccessandmayneedthemosthelp.”
§ “Thelargerhealthsystemsthatservehugenumbersofpeople(Providence,Rockwood,etc.).That’swhoseesthelargestnumberofMedicaidlivesandsomebigopportunitiesforimpact.”
ProjectPlanningandImplementation,TransitioningintoLonger-termEngagement
§ SHORT-TERMSTRATEGIESFORPROJECTPLANNINGANDIMPLEMENTATION:Respondents
suggestedthatthemostappropriateshort-termstrategiesforsecuringinputintoprojectplanningandspecificimplementationactivitiesshouldinclude:
o “Morevoicesandmoreinnovativedialoguerightnow.”o NumerousrespondentssuggestedthatBHTrelyon“focusgroupsandforumsearlyon
tostartthewaveofcommunicationandengagement,”butthatthesemethodologieswouldnotsufficelong-termforongoingengagement.
o Asplansarecomingtogether,identifyanygapsandanyproviders,gettheminanduptospeedrightawaytoprovidetheirinsights.
o Getpeopletogetherbyprojectareaearlyandconsistentlysodecision-makingisn’tlast-minute,which“createsmoreriskoffailureandpartnerdistrust.”
o “Youwillgetthemostmeaningfulengagementifpeopleknowwhatmoneyisavailableandhowtheymighthaveareasonablechanceofaccessingsomeofittomakeadifference.”
o Seekmuchmoreproviderinvolvementearlyon“tobalancethefactthatthetoolkitissoprescriptive—theirexpertisewillhelpshapeinterventionsinmeaningfulways.”
o ManyrespondentssuggestedthatBHTshouldcultivatestructuredconversationsthatallowproviderstorespondtoprojectmodelsandideas,includingcommentssuchas:
§ “Offerideasnotina‘pre-decided’waybutinawaytheycanrespondtosomething…notjusttalkinginamorphous,open-endedways.[Providers]arefrustratedwhenit'snotagooduseoftheirtime—givethema‘strawmanproposal’torespondto.”
§ “Beginwiththeendinmind:hereiswhatasuccessfulprojectwouldlooklike,andworkbackwardfromtherewiththemtoseewhatproviderswouldneedtodotomakethathappen.Havethoseveryspecific,detailedconversationswiththemaboutthe‘how’.”
§ “Ontheportfolio…onceyouhaveit,makeaspecificplantoengagethepeoplewhoaregoingtoimpactmostorbemostimpactedbytheprioritiesandactivitiesthatareselected.Whatistheplanforsharingandexpandingthoseportfolioprocessesacrosstheregionsoitwillbeatransformedsystem?Butyoudon'twanttogotoobroad….focusondepthofinvolvementratherthaneveryoneatsuperficiallevel.
§ “Considerwhatareyougoingtodotoengageproviderswhoarecutoutoftheprojectsorwhowon'tbereceivingfunds.Haveaplanforthe‘fallout’.”
o Inputregardingcombinedandseparateplanningaudiencesandprocesses:§ Severalrespondentswantedtomakesurethatpeoplefromdifferenttypesof
systems(rural/urban,FQHC/largehealthsystem/independentproviders,primarycare/behavioralhealth,etc.)comeTOGETHERforplanninginordertomakesenseoftheglobalneedsandopportunitiesinoursystems,e.g.,“don’thaveruralandurbansystemsplanningseparately…weneedthefullcontinuumofcareandcareacrosscaretype,geography,andlifespanintheroomtocreatearationalhealthsystem.”
§ Otherrespondentsnotedthatdifferenttypesofsystemsandvariouspracticedisciplines“havedifferentlanguages,cultures,priorities,andwaysofdoingthings,soitisimportanttoletthemmeetontheirowntoworkthingsout.”Forinstance,thewayoftransforminganFQHCwouldbedifferentfromalargehealthsystemoraruralhealthsystem.“Weneedtoworktogetheronavisionandweneedtoworkindependentlyonhowthatvisiongetsenactedinourownhealthcareworld.”
§ LONG-TERMSTRATEGIESFORPROJECTIMPLEMENTATIONANDTHEBROADERVISIONOFTHE
ACH:Manyofthestrategiesforcommunicationandshort-termengagement(alldetailedpreviously)werecitedaslong-termstrategies,aswell.Additionalsuggestionsincluded:
o ManyrespondentsrepeatedlysuggestedcreatingaprovideradvisorygroupthathasrepresentationfromdiverserepresentativesfromdifferentsectorstoguidetheACHovertime.
§ Participantsrepeatedlyreferenceculturalcompetenceandrepresentationacrossthevariouspracticesofmedicine/specialties,theagespectrum,andsizesofpractices
§ “Weneedtohearmorefromprovidersthatnotonlyhavetheharddesireforthisworkbuthavelotsofeducationaboutculturalcompetence.”
§ “Wehaveagreatsystemthatproducesgoodcliniciansbutwouldlovetoseegreaterretentionofthosepeoplehere,notfleeingtoothermarkets.Wewanttoinvolveproviderswhowantimpactvs.income.Thosewhowanttostayhere,giveback,helpimprovethehealthhere.”
o Providersalsocautionedagainstrelyingexclusivelyonanadvisoryboard,because,“oneprovider’sexperienceandopinionisoneprovider’sexperienceandopinion.”Assuch,theysuggested:
§ Whendealingwithlargerorganizationsorsystems,“Usetheinternalprocessestheyhave(MedicalDirectors,providerleadershipmeetings)toincorporateknowledgefromtheirproviders,since“100providerswouldgive100answers.”Askthemtodistillwhattheyknowfromthemoreglobalproviderfeedback.”
§ “Referencethepreviously-detailedsuggestionsregardinggeneralcommunicationandengagement,suchas“gotowheretheyare”(e.g.,existingmeetingsandevents),“usetrustedadvisors”(e.g.,SCMS,specialtyassociations),and“communicatewithbetterclarityandfrequency”(e.g.,electronicdisseminationimprovements).
o Regardingalloftheabove-listedoptionsforengagingproviders,respondentssuggested:§ Schedulemeetingsandplanningattimesthatproviderscanactuallyengage
(e.g.,earlymorningorevening).§ Providealternativewaysforthemtotakepart(e.g.,videoconferencing,etc.).
§ Provideresourcesforsmallerorganizationsandpracticestoparticipate,as,“theydon’thavetheresourcesoradministrativesupportthatlargesystemshave,sotheyneedextrasupporttobeinvolved.”
HowSuccessWillBeMeasured
Whenasked,“howwillyouknowthatBHThadbeensuccessfulinmeaningfullyengagingproviders?”thefollowingthemesemerged:
• PROVIDERKNOWLEDGE,TRUST,ANDONGOINGINVOLVEMENTo “PrimaryCareProviderswouldknowwhatBHTstandsfor,andwouldknowwhat
financialimplicationsandqualityofcareimplicationswerebeingworkedon.”o “IfstrategiesthattheACHisadvancingareconsistentwithandreflectiveofinputgiven
byproviders.”o “Therightpeoplearestillatthetableandthere’senoughdepthofproviderstodothe
heavyliftforsomeoftheseprojects.”o Providersunderstandclearlyarticulatedgoals,projects,andmethodsofevaluating
them.”o “Consistentattendanceatleadershipcouncilmeetingsfromacrossthespectrumof
providers.”o “Noglaringgapsbetweenwhoisatthetableandwhoshouldbeatthetabletomake
theseinterventionssuccessful.”o “Providerskeepshowingupandaretremendouslysupportivebecausetheyseevalue
andimpact.Thiswouldmeantheyhavebeentreatedfairly,therehasbeengoodcommunication,andthereareperformancemeasuresinplaceshowingimpact.”
o “Everyorganizationthatneedstobeatthetableisthereandeverypopulationthatneedstobeatthetablesays,‘yes,thisworksformypopulation.’”
o “TheLeadershipCouncilhasexpandedtoincludeallofthegapsthatcurrentlyexist(smallpractices,independentproviders,specialty,etc.).”
o “Youwouldknowinyourgutbasedontherelationshipsandtrustthatwasbuiltthroughthisprocess.”
• COMMUNITYANDSYSTEMMETRICS
o “Wearemovingthemetricsandimprovinghealth.”o “Ifpeoplearedoingtherightthingattherighttimeintherightplaceintherightwayto
improvehealthandhealthcare.(e.g.,EmergencyRoomsareforEmergencies).”o “Trulyintegratedsystems,whereprimarycareandbehavioralhealth,hospitalsandlong
termcare,andcommunitysystemsareallsupportingbetterhealth,bettercare,betterquality,andwearereplicating(orscalingandspreading)innovativeprogramsthatreallywork,notjusttalkingaboutit.”
o "Organizationswhodidn'thistoricallytalktooneanotherareinteractinginawaythatpatientoutcomeshaveimprovedorthatpatientsaren'tfallingthroughthecracks."
o “Ifservicesforvulnerableindividuals,organizations,workforcesaren'tdestabilizedintheprocess.”
o “Successfuloutcomesontheoutcomemetrics.Theprojectsaresustainable.Ifyoudon'thearuproarfromproviders,thereisseamlessadoption,andprovidersarebeingpaidastheyshould.”
o “Asenseoftrustandawarenessthatwe'vemadeimprovementsandchanges,andweareeffectivegettingwherewewanttobe(reachingourgoals.”
o Evidenceofchange§ “Weneedtotellthestoriesoftheimpactwe’vehad…onpeople,communities,
practices.That’swhatkeepspeoplecomingback.”§ “Makesurethedataandmetricsarepairedwithstories,sothatwehavethe
numbersandthevoicesandfacessharingthesamemessage.”
• PATIENTHEALTH,SATISFACTION,ANDENGAGEMENTo “Patientsarehealthierandaretakingmoreofaproactiveroleintheirhealth.”o “Clientsarebeingpolledandtheirsatisfactionishigh.”o “Clientsaretellingustheyaregettinggoodqualityservices.
InWhatOtherWaysCanBHTContinuetoImproveProviderEngagementOverTime?
Respondentsprovidedavarietyofothercomments,requests,orcautionsregardingengagementthatdidn’treadilyfitintoothercategoriesbutmeritedinclusionhere:
• “Bemindfulofnotinadvertentlymisleadingorganizationsorbuildingexpectationsthataren'tgoingtobefulfilled.”
• “Don'tmakethingsworsebydestabilizingsystems,causingstafftoleave,makingchangesthatmakeitharderforclientstogetcare.Disruptforthebetteranddisruptforthelonghaul.Don'tpolarizeintheprocess.”
• “Worktobetterunderstandproviderorganizations’businessmodels.PartofthedifficultyisthatI'mnotsureBHThasthepracticalknowledgeinmanyoftheseareasaboutwhattheprovidersactuallydoandhowtheydoit.BHTcancomeacrossasstronginmarketingbutshallowintermsofpracticalknowledgeofthesystem,sotheyhavetocountontheproviders(andconsumers)todefineandshapethenewpriorities.ThereshouldbemoredepthofknowledgeandexpertisethatactuallyresidesatBHTitself.”
• “WeneedtomakesurewehavegoodresearchthatwillinformusappropriatelyabouthowDSRIPmodelshaveworkedelsewhereandhowtheyapplytoWashingtonstate,understandfundsflowandwhetherwehaveanequitablearrangementinplace,andlookatworkforceandclinicaldataflow--whatkindofanalyticsandhowcantheybeuseddownstream?”
• “AttendcarefullytotheviabilityofruralandTribalhealthsystems.Manyofthesechangescouldradicallydestabilizeorcausethefailureofwholesystemsthatservetheircommunities.Thenwhathavewedone?”