RHIP COUNCIL No November 17, 17, 2020 2020 Meeting Objectives - - PowerPoint PPT Presentation

RHIP COUNCIL

No November 17, 17, 2020 2020

Meeting Objectives

• Det

eter ermine n e next s steps eps f for r equ equity wo work rk

• He

Hear ar key ey upd pdates es r rel elated t to He Heal althConnect an and Trueblo lood

• d
• Provi

vide ad advi vice an e and f feed eedback

• Ap

Approv

• ve m

minutes fr from

• m Se

Septe tember 2020 r 2020 RHIP IP Cou

• uncil

l Meet eeting

• Revie

iew N New w RHIP P Counc uncil il M Member Applic ications

Approve Minutes and Review Applications

Equity Growth Next Steps

HealthConnect

HealthConnect Hub Evaluation

November 2020 RHIP Council

• Overall evaluation
• HealthConnect Hub evaluation activities
• Results

Overview

Overall Evaluation

Five interconnected activities:

• 1. HealthConnect Hub: Understanding how the Hub impacts client health and wellbeing
• 2. Community Connections: Understanding how individuals interact with different sectors

(housing, health care, education, criminal-legal system)

• 3. HHIP Evaluation: Understanding the impact of housing on health care utilization
• 4. Partner Evaluation: Understanding the experiences and viewpoints of SWACH’s partner
• rganizations
• 5. Workforce Evaluation: Understanding the experiences and viewpoints of frontline staff

in clinical and community based organizations in the region

HealthConnect Hub Evaluation

Activities for the evaluation presented in this report:

• 1. HealthConnect Hub: Collecting data from HUB, its programs, & its clients.
• 2. Partner Evaluation: Collecting data from the systems partners you are working with.
• 3. Workforce Evaluation: Collecting data from the people who work in your partner orgs.

Results

HealthConnect Hub: Enrollment

50 100 150 200 250 F M A M J J A S O N D J F M A M J J 2019 2020

Cumulative client enrollment per month

5 10 15 20 F M A M J J A S O N D J F M A M J J 2019 2020

Average CHW caseload per month over time

HealthConnect Hub: Demographics

36% 47% 12%

Missing 65+ 45-65 25-45 18 - 25

Age (years)

<5% <5%

47% 51%

Missing Transgender Male Female

Gender

<5% <5%

HealthConnect Hub: Demographics

13% 3%

3% 74% 4%

4%

Missing Other Multiracial White Black AI/AN

Race

28% 4%

68%

Missing Hispanic/ Latino Not Hispanic/ Latino

Ethnicity

HealthConnect Hub: Health

12% 8% 10% 12% 12% 12% 13% 13% 17% 19% 19% 20% 21% 22% 31% 35% 35% 44% 58% 58% Other Chronic Condition Movement impairment Hearing loss or impairment Hepatitis C Diabetes Type II Asthma Panic disorder Mood disorder Hypertension Arthritis Vision loss or impairment Bipolar disorder ADHD Alcohol abuse/Withdrawal Tobacco abuse Chronic Pain PTSD Addictions/Substance abuse Depression Anxiety disorder

Physical and Behavioral Health Conditions

Self-reported health:

• 40% in good health
• 80% multiple chronic

conditions

• 59% co-occurring physical &

behavioral health conditions

• 52% use tobacco
• 25% use alcohol
• 29% use other substances

• Only 20% had a medical home
• Nearly 20% reported the ED was their usual source of care
• Over 50% indicated needing a family doctor

HealthConnect Hub: Health Care

HealthConnect Hub: Health Care

13% 6% 25% 16% 41%

Missing 6+ 2-5 1

ED Visits in Prior Year

0% 9.5% 14.8% 64.8%

Missing 4+ 1-3

Hospital Visits in Prior Year

• 38% homeless
• 60% housing concern in prior year
• 65% family crisis in prior year
• 30% safety concern in the home

HealthConnect Hub: Housing

HealthConnect Hub: Social Needs

8% 18% 26% 38% 44% 46% 58% 59%

Childcare Utilities Medications Legal Clothing Food Transportation Housing

Top social needs identified

HealthConnect Hub: Complexity

Percent of clients with each need who also had:

Health condition ED visit in prior year Housing need 96% 51% Transportation need 97% 50% Food need 96% 52% Clothing need 97% 56% Legal need 99% 54% Medications need 97% 59% Utilities need 96% 54% Childcare need 97% 48%

HealthConnect Hub: Pathways

Most commonly opened and closed complete pathways

Opened Pathways Closed Complete % Closed Complete Education 2233 1892 84.7% Social Service Referral 2149 678 31.5% Medical Referral 454 160 35.2% Tobacco Cessation 213 0.0% Medication Assessment 198 41 20.7% Medical Home 189 61 32.3% Behavioral Health 160 41 25.6% Housing 154 38 24.7% Employment 110 15 13.6% Health Insurance 65 13 20.0% Adult Learning 46 7 15.2% Family Planning 10 3 30.0% Medication Management 7 3 42.9% Developmental Referral 6 6 100.0% Pregnancy 4 1 25.0% Lead 1 0.0% Postpartum 1 0.0% Overall 6000 2959 49.3%

HealthConnect Workforce Focus Group

Being able to coordinate the care of the client and all be working on the same page to offer services would be amazing. Pathways is a good tool …. and I hope to see it rolled out to other agencies in Clark County. It could be a one stop hub for resources that everyone could access. My own sense of belonging to a more holistic care team has been empowering and invigorating.

Questions?

www.providenceoregon.org/CORE

Jane S e Smith th's 's S Story

Pathways Utilization, Expanding Programs

Launching in April 2019, HealthConnect HUB and Pathways has supported

• 356 P

356 Particip ipants

• 5383

5383 of 7736 7736 Pathwa ways c closed ( d (~70% 70%)

• Clie

ients-per-Pa Pathway u use 1. Social Service Referrals (99%) 2. Education (81%) 3. Smoking Cessation (65%) 4. Medical Referrals (60%) 5. Medical Home (55%) 6. Housing (44%) 7. Behavioral Health (40%) 8. Medication Assessment (38%) The he He Heal althC hConnect M Model continues t to a add dd partners a and d pr program ams tha hat c connect t thr hrough the H HUB UB:

• Community Paramedicine

(CCFR)

• Health Homes (AAADSW)
• Q&I Hotel (CCPH/DCS)
• CDSME (WSU-Extension)
• CarePort HUB (CPAA)
• Opioid Treatment Network

(PeaceHealth/ Lifeline Connections)

HealthConnect HUB Infrastructure "Care Traffic Control"

Stabilizing Crisis, Building Resilience, Supporting Health Equity: The HUB Makes it Happen

COVID CARE Equity Capacitation Effort: The COVID CARE opportunity supports equity focused workforce development funding - bringing on trusted CHW representatives of marginalized communities to connect Community Care Coordination and COVID Care. Studies underscore the enormous value of CHWs and PPs, an often overlooked, usually underutilized, yet highly versatile health workforce, as powerful health equity change agents.

https://www.familiesusa.org/wp-content/uploads/2019/11/HEV_PCORI-CHW-Report_11-04-19.pdf

Looking Ahead

Trueblood

• Compete

tenc ncy: M Menta ntal c capacit ity o

• f an indiv

ivid idua ual t to partic ticip ipate i in, an and b be e res espo ponsible f for, leg egal al pr proceed edings o

• r

r transactions.

• Compete

tenc ncy r restoratio tion: A process o

• f treatm

tment nt, e educatio tion, n, a and sup upport to to a assis ist th those f found inc incompetent to to sta tand tr tria ial ( (IST). Thi his p proce

• cesses i

is intended t to le

• lead t

d to t

• the

he i indi dividuals t to be

• be

adju djudicated com competent t to p

• proce
• ceed.

d.

• Forensic

ic: R Relati ting ng t to cour urts ts o

• f law or investig

tigatio tion a and establis ishment o nt of facts ts i in a cour urt o t of law.

• Clas

ass m mem embers rs: Those wh e who f fal all u under a r a group af affec ected ed b by a a cla class-actio ion l n lawsuit uit. Definition of Terms

• Tru

rueblood

• od et

t al.

• al. v
• v. Was

ashi hington

• n S

Sta tate D Depar artment of

• f

Soc Social al H Healt alth Se h Serv rvices (T (Tru rueblood

• od)
• Nam

amed af afte ter a attor torney C Cas assie Tru ruebl bloo

• od, ‘

‘next fri friend’

• f
• f A.

A.B.

• A.B. i

is ab abbrevi eviation f for r repr epres esen ented pl plai aintiff

• Class M

Members in in this is c case are ind indiv ivid iduals d detained in city ty an and c d cou

• unty

ty jai jails ls aw awai aiting c com

• mpete

tency serv rvices

• The

he cas ase challe hallenged u uncon

• nsti

titution

• nal de

l dela lays i in com

• mpete

tency e evalu aluation

• n an

and r d restor toration

• n

Overview of the Trueblood Case

References: Various HCA Publications, Trueblood Court Documents, and https://www.dshs.wa.gov/bha/trueblood-et-al-v-washington-state-dshs

• Phas

ase O e One (2019-2021): S Southwes west, S Spo pokane, an and P Pier erce Regio ions f focus used i implement ntatio tion

• At reg

egional i impl plem ementation, t the f e followi wing el elem emen ents wi will b be e ad addres essed ed:

• Compete

tenc ncy E Evalua uatio tion

• Compete

tenc ncy R Resto toratio tion

• Cri

risis Tri riag age an e and D Divers version S Supp pports ( (ups pstream s supp pport)

• Educatio

tion n and T Training ining

• Work

rkforce D e Devel evelopment Phased Implementation

• Compete

tenc ncy E Eval alua uati tion

• Co

Compet eten ency R Restoration

• Outp

tpati tient C nt Compete tenc ncy R Resto toration P n Program

• Resident

ntial al S Supports ts a as clini nical ally a appropri riate

• Forens

nsic H HARPS PS

• Forens

nsic N Navigators rs

• Additiona

nal F l Forensic Bed C Capacity ty (Weste tern n and E Eastern S State te H Hospitals ls)

• Crisi

sis s Triage a and D Diversi sion S Supports ( s (upst stream s support)

• Enhancin

ing Crisis is Tria iage a and C Crisis is S Stabil iliz izatio ion

• Mobile C

Crisi sis s Response se

• Forens

nsic P PATH TH

• Educ

ucation n and T Trai aining ng

• Jail T

Techni nical l Assista tance Pro rogram

• Crisis I

Interv rvent ntion n Trai aini ning ng ( (CIT) T) f for l law e aw enforcement nt a and corr rrections ns o

• fficers

rs

• Criminal C

l Courts rts Techni nical l Assista tanc nce ( (upon re request) t): e eligibili lity, c conditi tions, a and u use of Residential s supports

• Workf

kforce D Development

• Enhan

anced P Peer S Support S t Special alists ts

Programs of Trueblood

References: Various HCA Publications, Trueblood Court Documents, and https://www.dshs.wa.gov/bha/trueblood-et-al-v-washington-state-dshs

• Whol
• le P

Person

• n C

Car are (No

• wron
• ng door

door)

• Bid

Bidir irectio ional Int ntegration o n of Be Behavioral H Health & & Ph Physic ical Health

• CHW/P

/Peer eer Workforce Devel elopmen ent

• Ov

Overall C Communit unity Sy Systems I Int ntegratio ion (D (De-sil iloing)

• Stakeholder s

sup upport a and nd eng ngagement nt (r (rig ight efforts w wit ith the rig ight stakeholders)

• Advancing

ing e equit uity

• Creating

ing, a amplifyin ing, a and nd int integratin ing a alternativ ives t to inc incarceration

• Inc

ncreasing ing access to care and nd treatment pene netration n for those wit ith the most sever vere b e beha havi vioral hea l health lth issues es i in our community ty.

• Potent

ntia ial F Fut utur ure P Project I Int ntegratio ion

• Op

Opio ioid id C Cris isis R Response

• Hea

ealthC lthConnec ect H t Hub

• Communit

unity Eng Engagement

• Pol
• licy A

y Adv dvoc

• cac

acy

How does Trueblood support other efforts?

• Wh

When en d det eterm rmined t to need eed f foren ensic s servi ervices es b by court o

• rder

er, a a foren ensic eval evaluation i is need eeded

• Wor
• rking t

to i

• incr

crease ca capacity a and de d decr crease de dela lay t time of

• f

Forensic E c Evalu luation

• ns i

in each r h region

• n

Forensic Competency Evaluations

References: Various HCA Publications, Trueblood Court Documents, and https://www.dshs.wa.gov/bha/trueblood-et-al-v-washington-state-dshs

• Regio

ional C Contr ntracte ted Agency: L Lifelin ine C Conne nnectio ions ns

• Work

rks wi with par participants t to ac achieve eve t the ab e ability t to par participate i e in thei eir o

• wn

wn def efen ense i e in a a community-based s sett tting ng.

• Has

s comp mponents su such a as: s:

• Symptom
• m managem

ement, socia ial skills t s train inin ing, underst standin ing t the l e legal syst stem em and courtroom

• om proc
• cess,

ess, r refer erral to beha havior ioral hea ealth t h trea eatmen ent, hou housing and p pee eer su support

• HC

HCA wi will c continue t e to s supp pport OC OCRP c contracted ed ag agen encies es f for r tec echnical as assistance an e and f foren ensic n navi avigators rs Outpatient Competency Restoration Program (OCRP)

References: Various HCA Publications, Trueblood Court Documents, and https://www.dshs.wa.gov/bha/trueblood-et-al-v-washington-state-dshs

• Regio

iona nal Cont ntracted Agenc ncy: C Colum umbia R Riv iver Ment ntal H Health Se Servic ices

• HARPS:

PS: H Hous using ing a and nd Recovery throug ugh P Peer Se Servic ices

• At least f

four ur t teams w wil ill b be s set up up in W in WA

• HARPS

PS teams wil ill f focus us o

• n

n hous using ing t throug ugh

• Ad

Addressing b barriers

• Find

ind a and nd maint intain h in hous using ing

• Sub

Subsid idizing ng c costs (s (suc uch as applic icatio ion n fees, secur urity d deposit its, init initia ial r rent nt c costs)

• El

Elig igibilit ity p pathways

• rdered t

to out utpatie ient nt c competenc ncy restoratio ion program

• On

On the Research a and nd Data A Ana nalysis is r referral lis ist

• Referred by

by a a for

• rensic n

nav avigator

• r
• Meet c

cris isis tria iage/stabilizatio ion crit iteria for access (p (prio ior f forensic ic s systems c cont ntact)

Forensic HARPS

References: Various HCA Publications, Trueblood Court Documents, and https://www.dshs.wa.gov/bha/trueblood-et-al-v-washington-state-dshs

• Region
• nal

l Contract cted A Agenci cies: :

• Coordina

inatio tion: B Beacon H n Health th

• Servi

ervice P Provi vider ers:

• Communit

ity S Servic ices es Northw hwest st, S Sea ea Mar

• Comprehen

ehensi sive C e Community Hea ealth C Centers: s: Mobil ile e Crisis sis/DCR

• Skamani

nia C Count unty y Communi unity Health

• Incr

crease ca capacity of

• f mobi
• bile cr

crisis r respon

• nse i

in each ch cou county i in the he r region

• In

Increase awar awaren enes ess o

• f mobile c

cri risis r res espo ponse s e servi ervices es an and h how t w to requ eques est t them em. Mobile Crisis Response

References: Various HCA Publications, Trueblood Court Documents, and https://www.dshs.wa.gov/bha/trueblood-et-al-v-washington-state-dshs

• Regio

iona nal C Cont ntracted Agenc ncy: Communit unity Se Servic ices No Northwest, Se Sea M Mar

• Conne

nnect those a at hig igh r ris isk o

• f referral f

for competenc ncy r restoratio ion (h (hig igh ut util iliz izers) t ) to services

• Determine

ned b by:

• Inpati

tient p t psych treatm tment e t episod

• des
• Criminal j

justi tice s systems invol

• lvement
• Homele

lessn sness ss

• Wil

ill us use t the Projects f for Assistance in in Transit ition n from Homelessness (P (PATH) m ) model

• Meets s

settlement nt r requi uirement nt for “int “intens nsive c case mana nagement”

• Prog
• gram

am de design

• Teams wil

ill inc includ ude e enh nhanc nced c certifie ied peer c couns unselors

• Init

nitia ial p partic icip ipatio ion n period w wil ill b be s six ix m mont nths

• Wil

ill offer help g getting ing and nd keepin ing h hous using ing, t trans nsportation n assistance, h help a accessing ng health s servic ices, training ining o

• n

n ind independent nt l liv ivin ing skil ills

Forensic PATH

References: Various HCA Publications, Trueblood Court Documents, and https://www.dshs.wa.gov/bha/trueblood-et-al-v-washington-state-dshs

• To divert f

forensica cally lly-involv

• lved c

d criminal d l defenda dants

• Assigned

ed a a navi avigator wh r when en a a competency eval evaluation i is order ered ed b by a a cou court

• If

If suitable, c courts m may ay el elec ect t to g gran ant c conditional al r rel eleas ase t e to r rec ecei eive ve services i includ udin ing o

• utp

tpatie tient c nt compete tenc ncy r restoratio ion

• Foren

ensic N Navi avigators rs wi will s serve erve to s supp pport c clas ass m mem embers rs an and c coordinate car are e throughout t the pr e proces ess. Forensic Navigators

References: Various HCA Publications, Trueblood Court Documents, and https://www.dshs.wa.gov/bha/trueblood-et-al-v-washington-state-dshs

• Assessing

ing c capacity ity i in many r regions ns i including ing S South thwest t Washing ington

• Coordina

inatio tion a and e enrollment w nt with c commun unity ity b behavio ioral h health th s support t ag agen encies es an and Appl pple He e Heal alth ( (Med Medicai aid)

• In

Increasing r rates es f for r licen ensed ed c community b beh ehav avioral h heal alth ag agen encies es t that

• perate

te c crisis is t triage a and s stabil iliz izatio tion f n facil iliti ities

• In

Increase c capac apacity t to ac accep ept i indivi viduals b brought i in by po police f e for r 6-12 2 hou hour hol hold f for

• r assessment
• In

Increase c coordination wi with c cri risis r res espo ponders rs an and f foren ensic n navi avigators

• Shor

hort-term rm h housing vo vouchers ers pr provi vided ed as as need eeded ed Enhancing Crisis Triage and Crisis Stabilization

References: Various HCA Publications, Trueblood Court Documents, and https://www.dshs.wa.gov/bha/trueblood-et-al-v-washington-state-dshs

• TA focus ar

areas as:

• Pr

Pre- an and po post-booking ing o

• ptio

tions ns

• Screening

ning a and a access t to t treatm tment nt

• Guideline

ines f for adminis inistr tratio tion o n of involunta ntary m medicatio tion

• Continui

ntinuity ty o

• f care
• Us

Use e of s seg egreg egation

• Release p

planning nning, c crisis is d de-esca cala lation

• n
• An

And mo more Jail Technical Assistance Program

References: Various HCA Publications, Trueblood Court Documents, and https://www.dshs.wa.gov/bha/trueblood-et-al-v-washington-state-dshs

• Offic

fice o

• f Foren

ensi sic M Mental H Hea ealth S h Servic ices es (OFMHS) has s a workfor force d e devel elop

• pmen

ent program to address c ess capacit ity issu sues es related ed to:

• Compet

eten ency E Evaluation

• n
• Compet

eten ency R Rest stor

• ration
• n
• Foren

ensi sic r risk assessm sessmen ent

• Not Guil

ilty by Rea eason son of Insa sanity ( (NGRI) trea eatmen ent

• This

is will be enha hanced ed t to include d e devel elop

• pmen

ent r rela lated ed to:

• Communit

ity Workfor force i including crisis isis respon

• nse

se, h homel elessn essness, ss, a and in-hom home, e, resid iden ential, and c clin inic ic-based sed s servic ices es

• In-pati

tient t care

• Law enfor
• rcem

emen ent and c correc ection

• ns,

s, including j jail ils and prison isons

Workforce Development

References: Various HCA Publications, Trueblood Court Documents, and https://www.dshs.wa.gov/bha/trueblood-et-al-v-washington-state-dshs

• Assist i

t indiv ivid idua uals i in navig igating ting t throug ugh t the c crimin inal c cour urt s t syste tem, setting r recov covery g goa

• als, con

connecting t to com

• community r

resou

• urces, a

and d buildi lding r relation

• nshi

hips

• Developin

ing a a contin ntinuin uing e educatio ion t n traini ining ng f for certif tifie ied p peer cou counselors i in the he cr criminal cou court s system

• In

Integ egrate en enhanced peer s peer suppo pport i into o

• ther

er Tru rueb eblood ef efforts s such as as:

• Forensic

ic P PATH, O Outpatie tient C nt Compete tenc ncy R Resto toratio tion P n Program, Foren ensic Ho Housing, TA for r Jai ails, an and R Rec ecover very t through P Peer S eer Servi ervices es pr program am. Enhanced Peer Support Specialists

References: Various HCA Publications, Trueblood Court Documents, and https://www.dshs.wa.gov/bha/trueblood-et-al-v-washington-state-dshs

Any Questions?

If y you

• u h

have ave f fol

• llow-up q

question ions or

• r com

comments, pleas ase f feel f free t to

• con

contact act m me. Ji Jim Je Jensen, MA MAC, CADC ADCII

jim.jen jensen en@south thwes esta tach.org (360) 4 409-3056 3056

• MTP c

contr ntracts

• Board

rd re retre reat

• Susta

taina inabil ility ity w workgroup up

• HC

HCA (wai waiver e ver extension) SWACH Updates

THANK YOU!

Next Meeting January 19, 2021