RHIP Council Meeting September 18, 2018 Meeting Objectives General - PowerPoint PPT Presentation

RHIP Council Meeting September 18, 2018

Meeting Objectives • General SWACH updates • Introduction of new staff • 2019 Policy agenda ideas • Pathways Overview • Amerigroup as a third-party administrator

New Sta Staff ff • Barbe West – Executive Director • Susan Crandall – Finance Director • Jack Coleman – Communications Director • Jamie Smeland – Community Engagement Manager

Ge Genera ral SW SWACH Up Updates • Semi Annual Report – Completed • Clinical Transformation Plans – Updates • Implementation Plan – Update • Community Based Organizations Request for Information – Updates

Pol olicy Ide Ideas Brainstorm ideas for 2019 Policy agenda bring concrete ideas to the October meeting

Care Coordination & Pathways Hub Overview

Our Vision for Care Coordination A stronger and more seamless system of care coordination in Southwest Washington.

Our Approach Improving Coordination with Technology Care coordination is nearly impossible without shared technology. The Pathways Hub (HUB) is a nationally recognized solution. SWACH is partnering with regional and state-wide partners to pioneer the Pathways Community HUB model. Enhancing Access to Support and Resources Health is influenced by all sorts of factors. For example, housing, food and social support. SWACH’s vision is a care coordination workforce with real time access to a wide range of knowledge and resources to help their clients get and stay healthy. We’re exploring a variety of tools and partnerships that support this vision. Engaging Underserved Communities Access to care coordination and resources varies widely depending on where you live. Rural areas often lack care coordinators and other services. SWACH is working with local voices, healthcare providers and other partners to understand the gaps and identify solutions to serve our underserved communities.

Implementation Strategy SWACH CTPs identify Pathways 2- ALL CCAs Board Pathways Klickitat and Day Strategic Trained Rural CCAs Approved Lead engage GO LIVE! Skamania Planning to be January & CCS Software Rural interest in March 2019 Identified September February Partners Pathways June 2018 26 & 27 2019 model August 2018

Pathways 101 Video

Pathways Community Hub Video

Community Based Care Coordination Delivered in the home or other community setting Meet all possible client needs Find | Treat | Measure

20 Standardized Pathways Adult Education Behavioral Referral • • Employment Developmental Screening • • Health Insurance Developmental Referral • • Housing Education • • Medical Home Family Planning • • Medical Referral Immunization Screening • • Medication Assessment Immunization Referral • • Medication Management Lead Screening • • Smoking Cessation Pregnancy • • Social Service Referral Postpartum • •

Systems Transformation Standardized Secure Health Financial Model & Information Equity Sustainability Services Coordination Analysis

Pathways Advantages Clients CCAs Payers • One coordinator • Platform & • Purchase client per-person or partnerships outcomes, not FTE family • Built-in quality • Community led • Well trained & assurance & delivery system supported improvement coordinators

Pathways Community HUB Model Shared Platform, Records & Planning Target Population: • Behavioral Health Payers CCAs • Chronic Disease HUB • Additional Risk Factors SWACH Staff Advisory CCAs Serve: board Clark County • of all partners Klickitat County • Local Referral Skamania County Partners •

HUB: Processes Payments • Health & Human Services • Clinics • Medicare/ • State Agencies • Private Health Plans • Housing • FQHCs • Medicaid • County Departments • Foundations • Area Agency on Aging • Hospitals • Managed Care • Physicians HUB CCA CCA CCA

HUB Processes: Payments • Medicare/Medicaid • State Agencies • Hospitals • Private Health Plans • Managed Care • County Departments • Foundations HUB CCA CCA CCA

SWACH Implementation Approach Pilot model to Use early results to establish roots across bring payers into the Rapidly scale-up the SWACH region outcome marketplace Integrate with other Determine total client care delivery systems capacity & & transformation sustainable funding projects by 2022

Medicaid Transformation Demonstration - Snapshot Required Tactics Imbedded Into Each Initiative ✓ Value-Based Payment Assessment & Transition Plan ✓ Workforce Development Plan ✓ System for Population Health Management: The expansion, evolution and integration of health information systems and technology This includes linkages to community-based care models. Health data and analytics capacity will need to be improved to support system transformation efforts, including combining clinical and claims data to advance VBP models Care Delivery Redesign Prevention & Health Promotion ✓ Behavioral/PA Health Integration ✓ Addressing Opioid Use Comprehensive Regional Health Needs Inventory (RHNI) Comprehensive Regional Health Needs Inventory (RHNI) • • Community Voice Community Voice • • VBP Contract Assessment & Development VBP Contract Assessment & Development • 1 • 2 System for Population Health Management System for Population Health Management • • Bi-directional Workforce Development Bi-directional Workforce Development • • ONE REQUIRED FROM BELOW: ONE REQUIRED FROM BELOW: Community Care Coordination: (Pathways Model or Similar Evidenced Based Chronic Disease Prevention & Control • • Approach ) Oral Health • Transitional Care Maternal Child & Health • • Diversion Interventions Comprehensive Regional Health Needs Inventory (RHNI) • • Community Voice • Comprehensive Regional Health Needs Inventory (RHNI) • VBP Contract Assessment & Development • Community Voice • 3 System for Population Health Management • VBP Contract Assessment & Development • 4 Bi-directional Workforce Development • System for Population Health Management • Bi-directional Workforce Development •

Endorsers of the Pathways Community HUB Model The CMS Innovation Center

Muskegon Michigan: Year One - Chronic disease

Medicaid Transformation Demonstration - Snapshot Required Tactics Imbedded Into Each Initiative ✓ Value-Based Payment Assessment & Transition Plan ✓ Workforce Development Plan ✓ System for Population Health Management: The expansion, evolution and integration of health information systems and technology This includes linkages to community-based care models. Health data and analytics capacity will need to be improved to support system transformation efforts, including combining clinical and claims data to advance VBP models Care Delivery Redesign Prevention & Health Promotion ✓ Behavioral/PA Health Integration ✓ Addressing Opioid Use Comprehensive Regional Health Needs Inventory (RHNI) Comprehensive Regional Health Needs Inventory (RHNI) • • Community Voice Community Voice • • VBP Contract Assessment & Development VBP Contract Assessment & Development • 1 • 2 System for Population Health Management System for Population Health Management • • Bi-directional Workforce Development Bi-directional Workforce Development • • ONE REQUIRED FROM BELOW: ONE REQUIRED FROM BELOW: Community Care Coordination: (Pathways Model or Similar Evidenced Based Chronic Disease Prevention & Control • • Approach ) Oral Health • Transitional Care Maternal Child & Health • • Diversion Interventions Comprehensive Regional Health Needs Inventory (RHNI) • • Community Voice • Comprehensive Regional Health Needs Inventory (RHNI) • VBP Contract Assessment & Development • Community Voice • 3 System for Population Health Management • VBP Contract Assessment & Development • 4 Bi-directional Workforce Development • System for Population Health Management • Bi-directional Workforce Development •

ACH Adopters of Pathways • Better Health Together • Cascade Pacific Action Alliance • North Central ACH • North Sound ACH • Pierce County ACH • Southwest ACH

Measure: Track Risk Reduction Track and Measure Progress with Pathways By Community Care Coordinator Name Medical Pregnancy Social Service • Care Coordinator Home • Agency CHW A 5 2 10 CHW B 1 3 4 • HUB CHW C 9 15 18 • Community By Agency • Region Site Medical Pregnancy Social Home Service • State Agency A 50 25 22 Agency B 64 17 35 Agency C 40 32 19

Community HUB Example

Amerigroup as Third-Party Administrator

Amerigroup Washington Foundational Community Supports Third Party Administrator

What is Foundational Community Supports It isn’t… It is… • Subsidy for wages or room & • Medicaid benefits for help board finding housing and jobs : • For all Medicaid-eligible • Supportive Housing to find people a home or stay in your home • Supported Employment to find the right job, right now 30