RHIP Council Meeting July 17, 2018 Meeting Objectives Update on - - PowerPoint PPT Presentation

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.

Our collective impact strategy is built on three gears:

• A strong and diverse set
• f cross-sector

partnerships

• Authentic community

engagement

• Strong data and shared

learning infrastructure

Strategy

Data and Shared Learning Environment Community Engagement Partnerships

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.

• 3. Identify the settings of

care and providers people rely most heavily upon for care, and infuse resources and supports to transform those settings.

• Quality Improvement Technical Assistance
• Value-Based Payment Support
• Workforce Development
• Assistance Incorporating Authentic

Community Voice

• Tools and Technology for Population Health

Management

• Address Inequities, Stigma, Trauma and

Institutional racism

• Community-Clinical Linkages/Partnership

Development

Focus Areas

Focus Areas

• 4. Use data to optimize efforts and conduct robust evaluations on
• ur 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?

18

20%, PLANNING 19% 13%, ASSESSMENT 16% 40%, PLANNING & ASSESSMENT 63% 27%, NO 3% Behavioral Health Organizations Physical Health Practices

Has your organization completed any planning or assessment

• f readiness to deliver integrated care in the past 24 months?

19

91% 9% Yes No

Health plan staff support sites for accreditation and implementing new

• perating plans

Medical Home technical assistance team FTE moving into

• perational

budget Health system provides behavioral health staff for clinic

Does your practice have any organizational support for practice transformation for delivering integrated care?

20

47%, YES 91%, YES 53%, NO NO

Behavioral Health Organizations Physical Health Practices

Does your organization have a strategic plan or operational / implementation plan specific to delivering integrated care?

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?

22

Is there technical assistance or support that would help build your capacity to deliver integrated care?

Help transitioning to new EHR Interface between primary care EHR and own EHR Help collaborating with other small mental health providers / clinics that want to work on integration Funding to support innovation in care delivery Staff FTE for analytics / IT infrastructure Funding to support staff without revenue stream

23

Is there a population which you may need support to provide care coordination for? If so, what kind of support?

Funding for staff time / space Mental health, ADHD, and autism services for children and adolescents Non- Medicare Advantage patients

Is there any technical assistance

• r support that would help your
• rganization build its capacity to

deliver care coordination?

Analytic / HIT support Financing Identifying a primary care partner Establishing EHR functionality

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?

87% 80% 40% 20% 13% 84% 84% 69% 81% 3% 16%

Integration Care Coordination Opioids Chronic Disease Don't Know No Response

Interest in Medicaid Transformation Projects, by project

Behavioral Health Organizations Physical Health Practices

25

26 67% 53% 40% Screen clients on antipsychotics for metabolic disorders Screen clients with diabetes for depression Screen clients with asthma for anxiety disorders

Does your organization conduct any of the following?

27% 20% 20% 13% 13% 33% 40% 20% 20% 27% 40% 40% 60% 67% 60% Height, weight and/or BMI Blood pressure Metabolic status (e.g. HbA1c) Infectious disease diagnoses (e.g. HIV, Hep C) Chronic disease diagnoses (e.g. diabetes) On routine basis Only for select clients No response / not collected

Which of the following are collected and documented for your clients?

Behavioral Health Organizations:

7%, YES 75%, YES 87%, NO 25%, NO Behavioral Health Organizations Physical Health Practices

Does your organization maintain a chronic disease registry?

53% 7% 20% 33% 27% 20% 40% 0% 40% 47% 27% 20% 40% 13% List patients by diagnosis List patients by laboratory result List patients who are due or overdue for tests or preventive care List all medications taken by an individual patient (incl. those prescribed by another doctor) List of all patients taking a particular medication List of all lab results for an individual patient (incl. those

• rdered by another doctor)

Provide patients with clinical summaries for each visit

Easy Somewhat difficult Difficult Cannot generate No response

With the client record system your behavioral health organization has, how easy would it be to…

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?

29

behavioral health n = 5; physical health n = 31

Do you have providers in your organization certified to provide Medication Assisted Treatment (MAT)?

47%, YES 53%, YES

53%, NO 47%, NO Behavioral Health Organizations Physical Health Practices

According to HCA, in 2016, there were 39 MAT waivered prescribers (buprenorphine) with practices located within SWACH’s region

30

behavioral health n = 7; physical health n = 17

Which types of MAT are your providers certified to provide?

57% 29% 71% 14% 14% 100% 0% 47% 0% 0% Buprenorphine Methadone Naltrexone Other No response Behavioral Health Organizations Physical Health Practices

Only 65% of physical health practices with certified providers are currently providing buprenorphine

31

behavioral health n = 15; physical health n = 32

Does your organization refer clients to MAT providers?

33%, YES 31%, YES 20%, NO 16%, NO 47%, NO RESPONSE 53%, NO RESPONSE Behavioral Health Organizations Physical Health Practices

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?

33

behavioral health n = 15; physical health n = 32

Does your organization dispense naloxone?

behavioral health n = 15; physical health n = 32

Does your organization prescribe take-home naloxone for individuals with opioid Rx?

33%, YES 3%, YES

67%, NO 97%, NO Behavioral Health Organizations Physical Health Practices 27%, YES 28%, YES 73%, NO

72%, NO Behavioral Health Organizations Physical Health Practices

Station 6: Other

What other questions or comments do you have after reviewing part 2 of the assessment results?

Non-Clinical Partner Engagement Plan

Why engage non-clinical partners?

• Integration is not a cure for inadequate

access to resources

• To achieve whole-person health non-

traditional partners are essential

Process

• Request for Qualifications

– Identify areas where partners are needed – Look for interest and readiness

• Encourage partnerships between clinical and non-

clinical partners – Provide funding through binding agreements

Potential Focus Areas Clinical Assessment Results

– Top BH barriers

• 1) Housing; 2) Employment; 3) Transportation

– Top PH barriers

• 1) Housing; 2) Transportation

Potential Focus Areas BH Community Needs Assessment (Community Foundation-Not full region) – Housing – Transportation – Skilled workforce/Employment – CHW’s/Peers

Potential Focus Areas SWACH Staff potential additions

– Community paramedicine

• EMS Professionals that are trained to:

– Connect people to primary care – Post hospital follow-up care – Providing education and health promotion – Integrating with health systems

Feedback Needed

• Should these categories be included?

– Housing; Employment; Transportation; CHW’s/Peers; Community Paramedicine

• Should transportation be a category? What would

the work look like?

• What categories are missing?

Next Steps

• Moving to Action – Review action items

from agenda