Western Colorado Accountable Health Community Model (AHC Model)
Funding & Disclaimer The project described in these slides is supported by Funding Opportunity Number 1P1CMS331575-01-00 from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies. 2
The Mission We seek your partnership in creating a more effective network to support the social, emotional and physical health of Western Coloradoans. By supporting and empowering our entire community, especially those members who may have additional resource needs, we are able to improve the health of the entire community. We are here to make a real difference for real people. 3
Values We, individuals and communities, have a right to We have an opportunity and responsibility to achieve our greatest potential of health . foster more leaders in our communities. There is room for improvement in the systems We value funding the social determinants that that support health. We have a responsibility impact individual and community positive and an opportunity to improve those systems. health outcomes and well-being. We seek continuous learning and improvement. Healthcare and systems of health are local . Collaboration is built on trust and trust is built We work to identify the value proposition of on relationships. We will be intentional and our efforts; to be transparent in discussing and patient with the time-consuming process of communicating those tangible/non-tangible relationship-building. short-term/long-term benefits. Achieving needed change will require risk taking, being nimble, adaptable, and bold. 4
Why now? • Increasing recognition % OF LIFE EXPECTANCY AND HEALTH STATUS ATTRIBUTABLE TO of importance of social determinants of health • Shift towards value based purchasing • Accountable Health Communities Model 5
The Accountable Health Communities Model Community Convening – Plan to address gaps Social Needs Screening Community Navigation 6
Jackson Moffat Routt Grand Rio Blanco Geographic Target Area Garfield Summit Eagle Western Colorado Pitkin Accountable Health Communities Model Mesa Delta Gunnison Montrose COLOR KEY: Ouray Northwest Colorado Community Health Partnership Hinsdale San Miguel West Mountain Regional Health Alliance San Dolores Juan Mesa County Public Health Tri-County Health Network Southwest Area Health Education Center Montezuma La Plata Archuleta San Juan Basin Health Department 7
Community Convening Goals: Review available data on gaps in community resources with clinical and community based partners. Prioritize gaps in resources. Develop a quality improvement plan for prioritized gaps. Leverage existing forums and existing needs assessments (public health and community hospitals) 8
Social Needs Screening Clinical Sites: Hospitals Primary Care Behavioral Health ER | Psychiatric Units | Labor & Delivery Screen For: Social Interpersonal Transportation Housing Food Utilities Isolation Violence Medicaid Medicaid-Medicare Medicare Enrollees Enrollees Enrollees IT Platform: The Referrals Based on 2-1-1: Community Resource Network (a QHN platform) 9
Clinical Partners who signed MOUs • A Kidz Clinic • Peak Family Medicine • Axis Health System • Pediatric Associates of Durango • Castle Valley Children’s Clinic • Pediatric Associates • Delta County Memorial • Pediatric Partners of the SW • Ebert Family Clinic • Pioneer Medical Center-DBA Meeker Family Health Center • Foresight Family Physicians • Primary Care Partners, Inc • Grand River Health • Rangely District Hospital • Gunnison Valley Health • River Valley Family Health • Juniper Valley Family Medicine • Roaring Fork Family Practice • Marillac Clinic • Southwest Medical Group • Memorial Hospital-Craig • St. Mary’s Family Practice • Mid Valley Family Practice • St. Mary’s Hospital • Midwestern Colorado Mental Heath Center, Inc • Summit Community Care Clinic • Mindsprings, Inc • Surface Creek • Moffat Family Clinic • Telluride Medical Center • Montrose Memorial Hospital • Uncompahgre Medical center • Mountain Family Health Centers • Valley View Hospital • New Castle Family Health • Whole Health • Northwest Colorado Health • Yampa Valley Hospital • Peach Valley Family Medical Center 10
Community Based Organizations • 71 Across Western Colorado signed MOUs • If they submit data, RMHP will send the organization monthly population-level data about the impact their interventions have on healthcare costs and outcomes for the patient 11
Community Navigation A Community Navigator is someone who can help clients identify and access community services such as food banks. Community navigation typically involves meeting clients in the community rather than at a doctors office. For the AHC Model, we will both provide training and support to current community navigators Navigation Process: Initial visit within 48 hrs Follow-up minimum Graduate & celebrate (in home or community) to monthly, up to daily for successes. assess and develop a client three to twelve months centered action plan. Community based navigators - region-wide network Supported by a Region-wide Navigation Program Manager 12
Screened Population Measures Social Health Cost/Utilization Client Engagement Quality Prevalence of Increase screening BMI ER visits, hospital Patient social need, for clinical ( Clinical data, admissions, Activation prevalence of depression and QHN) skilled nursing Measure (PAM, social need ensure follow up facility RMHP) with no referral plan admissions, total Navigation pop. (clinical data, cost, discharge to only: resolution QHN) home rather than of social need a nursing facility (social needs (claims) screening data) 13
Community Health Measures Food Rate of % of adults % of high Rates of child % of adults environment population that report a school and elder and children index with BMI > 30% students who adult who state that inadequate or seriously maltreatment their general unstable considered health was fair housing attempting or poor suicide in the last 12 months Comprehensive CDC Diabetes Health Kids Colorado Health USDA Food Colorado Housing Interactive Atlas Colorado Survey Indicators Environment Atlas, Behavioral Risk Affordability Map the Meal Gap Factor Surveillance Strategy data 14
Timeline May - September March- June July 2018 - April 2022 Develop Policies and Screen ~100,000 people Begin piloting screening Procedures annually and referrals and navigation Conduct community gap assessments, prioritization and improvement plan 15
Governance Regional Consortium Community Leadership, Screening / Community Data / IT Gap Analysis Clinical Navigation Infrastructure and Quality Improvement 5 Community Level Advisory Boards 16
Consortium Responsibilities Program Performance Gap Analysis & Quality Improvement Report to State & Federal Partners Review the Advisory Board Gap Analysis Provide progress assessment, Review quarterly program performance performance assessments, strategic and Quality Improvement Plans for each reports such as rates of screening, clinical feedback w/state & federal partners as visits and completed community region necessary to address state & federal policy navigation assessments Identify areas of alignment and issues that impact the Western Slope opportunities for partnership between the Identify issues in program operations Document successes, failures & regions improvement strategies & share meeting Develop plans to address those issues summaries & minutes publicly Provide the regional Advisory Boards with feedback & support Information Technology, Data Program Communications Annual Summit Program Operations & Measurement Activities Annually review the Provide guidance on project Identify collaborative learning Provide guidance on AHCM information technology, data communication to ensure that & program direction objectives policies and procedures & measurement infrastructure community engagement for the annual AHCM Summit of the program remains strong, & that state & federal leaders understand & Where possible, provide support AHCM objectives guidance to align the AHCM model w/other state initiatives 17
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