Regional Health Improvement Plan Council November 20, 2018 1 - - PowerPoint PPT Presentation

Regional Health Improvement Plan Council

November 20, 2018

1

Meeting Objectives

• General SWACH Updates
• Review Partner Placement Process and

Timeline

• Shared Learning

Review Meeting Minutes and Action Items

• Council Member Action:

– Approve Meeting Minutes – Decide on 2019 meeting schedule

SWACH Business

Our Vision

A healthy southwest Washington region where all people have equitable access to quality whole person care and live in connected and thriving communities without barriers to wellness

COMMUNITY HUB

Care Traffic Control

WHOLE PERSON CARE

Clinical Transformation

COMMUNITY CLINICAL LINKAGES

Integration of Social Determinants into Clinical Transformation

COLLABORATIVE IMPACT

Learning, Action, Equity, and Sustainability

Partnering to build a healthier future in Southwest Washington – for everyone

Operations Dashboard

Key Strategies Major Milestones Target Date Success Metric Status Staffing

• Opioid Coordinator
• Equity Manager

November 2018 Positions Filled Interviews underway

• Review organizational roles and potential staffing models that support

functions October 2018 Organizational structure to support 2019 Work Finalized; Board review 11.2018 Marketing & Communications

• Hired a Communications Director to develop a communications plan

August 2018 Position filled/Plan created Complete

• Communications Plan Launch and integration of Healthy Living

Collaborative Winter 2018/2019 Communications Plan Draft in review; SWACH brochure in review Underway Budget/Funds Flow

• Board approved operating budget.
• Board approved five-year Funds Flow Allocations
• Board approved 2018 Pathways/Hub budget.

Winter 2018/2019 Approved budget; Approved Funds Flow Funds Flow & 2018 Hub Budget approved

• New Opioid funding

September 2018 Grant approved Complete Internal Policies & Procedures

• Review operational policies and procedures for gaps; prepare and

implement policies and procedures Fall 2018 Full policies and procedures Underway Reporting & Accountability

• SARs 100%; Implementation Plan submitted Summer 2018

SARS 100% Complete Healthy Living Collaborative Integration

• Integrate Healthy Living Collaborative programs, staffing, and services

into SWACH regional plan

• CHW Neighborhood Pilot Transition

Winter 2018/9 CHW’s transitioned to new organizations In Progress

WHOLE PERSON CARE

Clinical Transformation

Partnering to build a healthier future in Southwest Washington – for everyone CLINICAL PARTNERS

• Clinical Improvement (Target Populations/issues)
• Clinical Integration (BH/PH)
• Participate in Targeted Learning Collaboratives
• Integrated Managed Care - Klickitat

STAKEHOLDER ENGAGEMENT SYSTEM: Clinical Transformation Workgroup; Clinical Community Opioid T.F.; Integrated Managed Care CORE (Klickitat); Pre-Managed Learning Collaborative: Tribal Partners SWACH ROLE

• Support for Value Based Payment, Workforce Development, Health

Information Exchange/Technology, Equity and quality improvements supports and evidenced based interventions towards integrated care for target populations (opioid, chronic disease, behavioral health)

• Technical assistance and learning collaboratives

Whole le Per Person Inte Integra rated Care are Das Dashboard

Key Strategies Major Milestones Target Date Success Metric Status Integrated Care Framework Development Co-Created Goals

• Integration of Physical and Behavioral Health
• Value Based Payment Goals Established
• Success Metrics Established
• Workforce Needs Established

October 2018 Implementation Plan Complete In Process Cohort of Providers for Clinical Transformation

• Clinical Partner Assessment
• Review Transformation Plan (TP)

July 2018 Transformation Plan Developed Complete

• Clinical Transformation Plan developed disseminated and returned

August 2018 Transformation Plan Completed Complete

• Clinical Transformation Plan review

October- early December 2018 Transformation Plan Mapping file In Process

• Established Cohort of Clinical Partners invited into a binding agreement to begin

workplan negotiations and Pay for Performance tied to transformation plans. January 2019 Binding Agreements Pending

• Provider contracts/MOU executed

January 2019 Binding Agreements Pending

• TA plan developed for each participating provider
• Capacity to deliver TA Secure

February 2019 Binding Agreements Pending Learning Collaborative(s)

• Learning Collaborative process and curriculum developed

January-March 2019 Collaboratives Developed Pending

WHOLE PERSON CARE

Clinical Transformation

COMMUNITY CLINICAL LINKAGES

Integration of Social Determinants into Clinical Transformation

Partnering to build a healthier future in Southwest Washington – for everyone INDIVIDUAL TRANSFORMATION PARTNER ROLE

• Complete a Community Serving Organization Request for Information

(RFI)

• Cross-sector regional opioid response plan
• Promote and support CHW neighborhood teams in Clark, Cowlitz and

Wahkiakum counties

• Address barriers to school attendance at McLoughlin Middle School

through the Education Community Health worker initiative STAKEHOLDER ENGAGEMENT SYSTEM: Community Health Advocates and Peer Supports Network CHAPS/HLC; Community Councils; Behavioral Health Advisory Board; Healthy Living Collaborative Committee SWACH Role

• Matchmaking of Community Serving Organizations to connect social

determinants into clinical transformation efforts

• Support prioritized initiatives with a target population of opioid,

chronic disease, and behavioral health

• Continue to support the HLC Community Health Worker Initiatives

Community Cli linical l Li Linkages Das Dashboard

Key Strategies Major Milestones Target Date Success Metric Status Engage Community Serving Organizations into Transformation

• Request for community serving organizations that support addressing the social

determinants of health to partner with clinical partners October 2018 RFI’s Received In process

• Establish review and matchmaking process and criteria

November 2018 Process Developed Pending

• Invite Community Serving Organizations into a transformation Cohort

February 2019 Cross-Setting collaboratives Planning Stage

• Current Project - SeaMar/CVAB Hep C CURES QI

Ongoing Improvement Cycle In Process

• Rapid Response MAT Clinic Collaborative QI Project

Ongoing Improvement Cycle In Process Healthy Living Collaborative Initiatives

• Promote and support CHW neighborhood teams in Clark, Cowlitz and Wahkiakum

counties; Select partner organizations for CHW teams. November 2018 Ongoing Ongoing MOUs completed Barriers identified In Process In Process In Process

• Address barriers to school attendance at McLoughlin Middle School through the

Education Community Health worker initiative

• Support growth of CHAPS network (namely Advocates, Community Health Workers,

Certified Peers and their organizations) serving Southwest Washington, to improve holistic health outcomes for the Community

COMMUNITY HUB

Care Traffic Control

WHOLE PERSON CARE

Clinical Transformation

COMMUNITY CLINICAL LINKAGES

Integration of Social Determinants into Clinical Transformation

PARTNER ROLE:

• Become a Care Coordination Agency or Referral Agency for a specific pilot population that uses the Pathways model

and technology for care coordination, Community Health Workers, and pay for performance. SWACH ROLE

• Provide a Care Traffic Control System by building a Community HUB that uses health exchange technology to support

community based care coordination with a pay for performance mechanism to connect individuals and families to community supports and care teams

• STAKEHOLDER ENGAGEMENT SYSTEM: Pathways Community HUB Advisory Committee; Care Coordination Agencies

Partnering to build a healthier future in Southwest Washington – for everyone

Community HUB UB Das Dashboard

Key Strategies Major Milestones Target Date Success Metric Status Community HUB

• Board adopts pathways

June 2018 Board Approval Complete

• CTPs identify Klickitat and Skamania interest in Pathways model (rural

engagement) September 2018 RFA released In progress

• Contract with CCS for HUB Technology and Technical Assistance
• Includes prelaunch support with Healthy Gen for CHW workforce development

September 2018 Contracts signed Complete

• Pathways HUB 2-Day Strategic Planning Meeting

September 2018 Implementation Tasks and Timeline developed Complete

• Recruiting Rural CCAs through RFA, Scoring Committee and Selection

November 2018 Rural CCAs announced In progress

• Implementation Team and HUB Advisory Committee formed

November 2018 First meetings scheduled Planning

• All CCAs Trained

February 2019 Training completed Planning

• Community HUB Go Live!

March 2019 First person enrolled Planning

WHOLE PERSON CARE

Clinical Transformation

COMMUNITY CLINICAL LINKAGES

Integration of Social Determinants into Clinical Transformation

COLLABORATIVE IMPACT

Learning, Action, Equity, and Sustainability

Partnering to build a healthier future in Southwest Washington – for everyone

PARTNER ROLE:

• Participate in regional shared learning; Identify policy barriers to whole person care.

SWACH ROLE

• Assess community needs and map assets
• Collaborative Impact: Neutral convener of diverse partners (stakeholder and community engagement system to include Tribal partners)
• Sustainability & Equity: Community Resiliency Fund to invest in Social Determination of Health
• Policy & Action: Prioritized regional policy issues that respond to community needs
• Equity & Inclusion planning (organizational and regionwide)
• Shared Learning & Sustainability:
• Regional Training & Skills Building and Knowledge on key regional topics (I.e. Equity, HLC Quarterly Convenings)
• Monitoring & Evaluation (Transformation Dashboards)
• Community Connections (Cross Sector Data Sharing)
• STAKEHOLDER ENGAGEMENT SYSTEM: RHIP Council; Policy Committee (HLC); Data Workgroup; Healthy Living Collaborative Stakeholders

Colla llabora rative Im Impact t Das Dashboard

Strategy Key Milestones Target Date Success Metric Status Cross Sector Shared Learning

• Monthly Stakeholder Meetings Held
• Opioid Learning Sessions: Successful events for providers “The Uses of Suboxone in a

Practical Clinical Setting”; Events in Clark and Skamania Counties 9/2018 Minimum attendance

• f 40 Providers

Complete Community Engagement System

• Conduct an internal assessment of SWACH’s community engagement efforts, collate

community engagement knowledge, and refine and communicate community engagement strategy 1/2019 Assessment completed In progress

• Form local and regional community councils

3/2019 Councils formed On progress

• Host community engagement sessions

Ongoing Quarterly community engagement sessions

• Create a culture of community engagement within SWACH as an organization and within the

work groups and learning collaboratives it supports Ongoing

Colla llabora rative Impact t Das Dashboard Cont. t.

Strategy Key Milestones Target Date Success Metric Status Equity Planning

• Hire Equity Manager and Equity Consultant team

12/18

• Developed Equity Shared Learning Cohort and Curriculum

3/19 4/19 12/19

• ngoing

Curriculum developed Partners complete assessment and plans SWACH completes assessment and plan Trainings completed quarterly

• Support partners to equity assessment and plans
• Complete an internal assessment and plan
• Support equity, stigma reduction and trauma informed training and capacity building across

the region Platform for Policy and System Changes

• Conduct policy watch and analysis at the local regional, state and federal levels.

Ongoing

• Maintain a high functioning Policy committee

Ongoing

• Develop a policy agenda that is community led and supported

Ongoing

• Support advocacy at local, state, and federal levels, to include letter writing, direct outreach

to decision makers, and public testimony Ongoing

• Develop a process for bridging SWACH and HLC policy agenda
• Connect to organizational/system policy change and identify opportunities to influence by

bringing an equity, health and community lens Evaluation

• Developing 3rd evaluation plan in partnership with CORE

Community Resiliency Funding

Clinical Transformation Plan Summary

About

Clinical Transformation Plans (CTPs) allowed clinical organizations in the SWACH region to capture their high-level plans for Medicaid Transformation. SWACH provided compensation for submitting a successful plan. As of October 15th, 21 partners had successfully submitted a CTP

• Child & Adolescent Clinic
• Children’s Center
• Children’s Home Society
• Columbia River Mental Health
• Community Services NW
• Comprehensive Healthcare
• Daybreak Youth Services
• Family Solutions
• Kaiser
• Klickitat Valley Health
• Legacy
• Lifeline
• Lutheran Community Services NW
• NAMI SW Washington
• North Shore Medical Group
• PeaceHealth
• Planned Parenthood
• Providence
• Sea Mar
• Skamania County Community Health
• Skyline Primary Care

Urban, 15 Rural, 6

Where are partners located?

Vancouver Portland Seattle Brush Prairie Goldendale Stevenson White Salmon Yakima

What projects did partners select?

21 21 21 12 18 Bi-Directional Integration Care Coordination Opioids Chronic Disease Systems Change

Only 57% of partners selected chronic disease

N=21

Opportunity?

What tactics did partners select?

What assistance did partners request?

Total count of assistance requests by project

79 60 65 20 47 35 14 47 122 84 96 23 69 26 37 25 29 23 30 26 11 6 6 Integration Care Coordination Opioids Chronic Disease Systems Change Technical Assistance Training Funding Partnership Other

Next steps for Clinical Transformation Plans

Partner Clinical Transformation Process & Timeline

November 9th Finalized Criteria Categories and Tool(s) – Based on Stakeholder Feedback 20th 26th 28th Internal Team Transformation Plan Evaluation Meeting with CHW’s to review process and address questions Develop Tool for Contract Negotiations with CORE 29th Executive Director to Finalize Transformation Plan Recommendations December 7th External Partners Team Review of Recommendations 13th Board Review 17th Partners Invited into a Binding Agreement Negotiations January 1st Partner Statement of Work Co-Creation Begins 20th Partner Binding Agreements Completed

Clinical Transformation Plan Evaluation Criteria

Volume - Medicaid Lives Served (Primary Care) Low = Serves less than 500 Medicaid lives Medium = Serves between 501-1500 Medicaid lives High = Serves more than 1500 Medicaid lives Volume - Medicaid Lives Served (Behavioral Health) Low = Serves up to 3000 Medicaid lives Medium = Serves between 3,001 and 10,000 Medicaid lives Large = Serves more than 10,000 Medicaid lives Strategic Alignment: Whole-Person Care CTP response demonstrates how the clinical partners will achieve whole-person care. Strategic Alignment: Community-Clinical Linkages CTP response demonstrates how the clinical partners will achieve community-clinical linkages. Strategic Alignment: Large Scale, Sustainable impact CTP response demonstrates how the clinical partners will achieve large scale, sustainable impact. Transformational Impact CTP response includes innovative tactics that show how intervention(s) will systemically transform the way care is delivered.

Clinical Transformation Plan Evaluation Criteria (continued)

Strategic Commitment to Transformation Organization/partnership has demonstrated commitment to the goals of SWACH. Commitment of Funding and Capacity to Achieve Transformation Organization/partnership has demonstrated commitment to the goals of SWACH and CTP response scope is commensurate with size of the organization. Equity Equity-oriented improvement efforts are embedded into overall strategic plan and throughout the CTP. Sustainability of Transformational program Proposal demonstrates the ability to scale and spread. Note: Supplant vs supplement: Described tactics must be new or in addition to what would be supplied or carried out through other dollars (federal/state/local funds). Waiver funds are not permitted to be used to supplant existing programs. Value-Based Payment Proposal demonstrates a vision for (or is aligned with) value-based contracting expectations. Measurable CTP outcomes can be reasonably determined and measurable. Readiness CTP demonstrates the readiness to begin implementation in 2019 and to complete goals.

COMMUNITY HUB

Care Traffic Control

WHOLE PERSON CARE

Clinical Transformation

COMMUNITY CLINICAL LINKAGES

Integration of Social Determinants into Clinical Transformation

COLLABORATIVE IMPACT

Learning, Action, Equity, and Sustainability

Partnering to build a healthier future in Southwest Washington – for everyone

Partner Placements Possibilities

Category A

Clinical Transformation Partner

Category B

Community Serving Organization Partner

Category C

SWACH Regional Service

Category D

Partner for Shared Learning and Regional Impact Whole Person Care-Clinical Integration Based on decision making criteria, partners are invited into a negotiation process to result in a two- year binding agreement accountable to supporting the achievement of SWACH goals. (Community-Clinical Linkages: Integration

• f Social Determinants into Clinical

Transformation) Partners who are essential to addressing prevention and social determinants of health. Based on decision making criteria used to evaluate the RFI, partners are invited into a negotiation process to result in a one-year binding agreement accountable to supporting the achievement of SWACH goals. Community HUB (Care Traffic Control) Care Coordinating Agencies that will be piloting the Community HUB Care Coordination for target populations to sustain and scale across the care continuum. Collaborative Impact All Partners are Eligible for Regional learning, Capacity Building, and improvement.

Category C: SWACH Regional Services Community HUB Care Traffic Control COMMUNITY HUB

Care Traffic Control

Category A: Clinical Transformation (Whole Person Care-Clinical Integration) Category B: Community Serving Organizations (Community-Clinical Linkages: Integration of Social Determinants into Clinical Transformation) COLLABORATIVE IMPACT

Learning, Action, Equity, and Sustainability

Partnering to build a healthier future in Southwest Washington – for everyone Category D: SWACH Regional Services/Collaborative Impact

Washington Portal Demonstration

Portal Demonstration

What is the WA Portal?

WA Portal - Features

Shared Learning: Breakout Groups

Shared Learning Development

• Please review the Shared Learning Matrix in your packet.
• SWACH is looking for guidance from the RHIP Council for

the following three items: 1) Is there anything missing from the shared learning list? 2) What is the priority level of each of the major categories? 3) Do you have recommendations on who might be a good partner to train, present, or provide technical assistance for any of the topics?

THANK YOU!