RHIP Council Meeting July 17, 2018
Meeting Objectives • Update on Charter and new member process • Introduction of Strategic Framework and Roadmap • General SWACH updates • Community Engagement, Policy and Equity updates • Findings of clinical partner assessment (continued) • Non-Clinical Partner Engagement
Charter Approval
SWACH Strategic Framework and Roadmap
Vision SWACH believes all people should have equitable access to quality whole-person care and ✓ live in connected and thriving communities without barriers to wellness ✓ SWACH is working with partners in our region to improve health, increase the quality of care and services, enhance employee satisfaction, increase employee retention and maintain a sustainable workforce We will invest in prevention, support wellness for our neighbors at every stage of life and help build strong families.
Strategy Our collective impact strategy is built on three Partnerships gears: A strong and diverse set • of cross-sector Community partnerships Engagement Authentic community • Data and Shared engagement Learning Environment Strong data and shared • learning infrastructure
Cornerstones
Care Settings
At the heart of everything we do…
Focus Areas 1. Use improvement methods to work in and across settings to implement key change ideas and standards of care for: I. Whole-Person Integrated Clinical Care II. Community-Clinical Linkages III. Sustainable Large Scale Impact 2. Use authentic community voices, provider inputs and data to identify priority populations and communities with the greatest needs and disparities.
Focus Areas Quality Improvement Technical Assistance • 3. Identify the settings of • Value-Based Payment Support care and providers people Workforce Development • Assistance Incorporating Authentic • rely most heavily upon for Community Voice care, and infuse resources • Tools and Technology for Population Health Management and supports to transform Address Inequities, Stigma, Trauma and • Institutional racism those settings. Community-Clinical Linkages/Partnership • Development
Focus Areas 4. Use data to optimize efforts and conduct robust evaluations on our priority initiatives. Spread effective approaches to other populations, settings, and providers throughout the region through a community-driven shared learning and action infrastructure. I. Shared Learning: Robust Monitoring and Evaluation II. Collective Systemic Change & Action: Scale, Spread, Innovate III. Sustainability
Updates • Semi Annual Report - Progress report • Communications – Feedback from newsletter and website • Clinical Transformation Plans – TA Support • Potential change in RHIP dates
Community Engagement, Policy, and Equity Updates • Community Engagement Coordinator Position – Need for local connection • Policy Updates – New members • Equity Framework updates – Finalized CTP – Continued learning from experts – Developing job description
Clinical Partner Assessment
Station 1: Foundations for Integration What lessons have physical health partners learned from integration that can be shared with behavioral health? How can behavioral health partners be encouraged to build more foundational support for integration? How should this inform how SWACH allocates its resources?
Has your organization completed any planning or assessment of readiness to deliver integrated care in the past 24 months? 3% 27%, NO 63% 40%, PLANNING & ASSESSMENT 13%, ASSESSMENT 16% 20%, PLANNING 19% Behavioral Health Organizations Physical Health Practices 18
Does your practice have any organizational support for practice transformation for delivering integrated care? FTE moving into operational 91% budget Medical Home technical Health plan staff assistance team support sites for accreditation and implementing new operating plans Health system provides behavioral health staff for clinic 9% 19 No Yes
Does your organization have a strategic plan or operational / implementation plan specific to delivering integrated care? Behavioral Health Organizations 47%, YES 53%, NO Physical Health Practices 91%, YES NO 20
Station 2: Technical Assistance Needs How should SWACH prioritize addressing these needs? How do needs differ between physical health and behavioral health partners? What are potential differences between large and small partner organizations?
Is there technical assistance or support that would help build your capacity to deliver integrated care? Help Funding to transitioning support to new EHR innovation in Interface between care delivery primary care EHR and own EHR Staff FTE for analytics / IT Help collaborating Funding to infrastructure with other small support staff mental health without revenue providers / clinics stream that want to work on integration 22
Is there any technical assistance Is there a population which you may need support to provide or support that would help your care coordination for? If so, organization build its capacity to what kind of support? deliver care coordination? Analytic / HIT Mental health, Financing ADHD, and autism support services for children Non- and adolescents Medicare Advantage Establishing patients Identifying a EHR primary care Funding for staff functionality partner time / space 23
Station 3: Interest in Chronic Disease Project Few behavioral health partners expressed interest in the chronic disease project. Consider what information they collect / services they provide; how can SWACH help address this gap and move toward whole person care?
Interest in Medicaid Transformation Projects, by project 87% Integration 84% 80% Care Coordination 84% 40% Opioids 69% 20% Chronic Disease 81% 13% Don't Know 3% No Response 16% Behavioral Health Organizations Physical Health Practices 25
Behavioral Health Organizations: Does your organization conduct Which of the following are collected and any of the following? documented for your clients? On routine basis Only for select clients No response / not collected 67% 53% 40% 40% 40% 60% 60% 67% 33% 40% 20% 27% 20% 27% 20% 20% 13% 13% Height, weight and/or Blood pressure Metabolic status (e.g. Infectious disease Chronic disease Screen clients on Screen clients with Screen clients with asthma BMI HbA1c) diagnoses (e.g. HIV, diagnoses (e.g. antipsychotics for diabetes for depression for anxiety disorders Hep C) diabetes) 26 metabolic disorders
Does your organization maintain a With the client record system your behavioral chronic disease registry? health organization has, how easy would it be to… Provide patients with clinical summaries for each visit 40% 13% List of all lab results for an individual patient (incl. those 20% 40% ordered by another doctor) 25%, NO List of all patients taking a particular medication 27% 20% List all medications taken by an individual patient (incl. those 33% 27% prescribed by another doctor) 87%, NO List patients who are due or overdue for tests or preventive 20% 47% 75%, YES care List patients by laboratory result 7% 40% 7%, YES List patients by diagnosis 53% 0% Behavioral Health Organizations Physical Health Practices Easy Somewhat difficult Difficult Cannot generate No response
Station 4: MAT Capacity What are some possible reasons that practices would have MAT-certified providers who are not currently providing MAT services? What are some possible reasons less than half of clinical partners refer to MAT providers? How can SWACH help increase MAT capacity and referrals with clinical partners?
Do you have providers in your organization certified to provide Medication Assisted Treatment (MAT)? behavioral health n = 5; physical health n = 31 According to HCA, in 2016, there were 39 MAT waivered prescribers (buprenorphine) with practices located within SWACH’s region 47%, NO 53%, NO 53%, YES 47%, YES Behavioral Health Organizations Physical Health Practices 29
Which types of MAT are your providers certified to provide? behavioral health n = 7; physical health n = 17 Only 65% of physical health practices with certified providers are currently providing 100% buprenorphine 71% 57% 47% 29% 14% 14% 0% 0% 0% Buprenorphine Methadone Naltrexone Other No response Behavioral Health Organizations Physical Health Practices 30
Does your organization refer clients to MAT providers? behavioral health n = 15; physical health n = 32 47%, NO RESPONSE 53%, NO RESPONSE 20%, NO 16%, NO 33%, YES 31%, YES Behavioral Health Organizations Physical Health Practices 31
Station 5: Naloxone What are some possible reasons that so few physical health partners dispense naloxone? What are some potential barriers to prescribing take-home naloxone for individuals with opioid prescriptions? How can SWACH help improve access to naloxone?
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