Post on 13-Apr-2017
Date:
Presenter, Title
STRENGTHENING SYSTEMS
Social Determinants of Health
DateKristen West Fisher, VP of Programs
Our RegionEastern Washington
Our RegionEastern Washington
Our RegionSpokane County
86% White
Myanmar Marshall IslandsFormer Soviet Union
Source: U.S. Census Bureau
Several Refugee Populations
5% Latino
2.3% Asian1.7% AI/AN3.7% Two or more
races
0.4% Pacific Islander
1.7% Black or African American
Our Region
Life expectancy 10+ years
shorter in lower income areas
Spokane: Life Expectancy by Neighborhood
Sources: Spokane Regional Health District; City-Data.com, accessed 9/16/2015
West Central2013 Med. Income:
$26,194Avg. life expectancy:
74.49
Southgate2013 Med. Income:
$59,241Avg. Life Expectancy:
84.01
East Central2013 Med. Income:
$37,098Avg. Life Expectancy:
72.92
7.2 miles
4.6 miles
Our RegionRural Counties
Adams County• 61% Latino• 35% under
18 years old
Lincoln County• 22.9% over
65 years old
Ferry County• 21.4% over
65 years oldPend Oreille
County• 43% under
200% FPL
Source: U.S. Census Bureau
vs. 13.6%
statewide
vs. 13.6%
statewide
vs. 30% statewid
e
vs. 11.9%
statewidevs.
22.9% statewid
e
Our RegionRural Disparities
Adams County• 37% obesity
rate
Lincoln County• 12% diabetes
rate
Ferry County• 10% heart
disease ratePend Oreille
County• 45% high
cholesterol rate
Source: BHT Application, ACH Grant?
vs. 8% statewid
e
vs. 5% statewid
e
vs. 27% statewid
e
vs. 40% statewid
e
Healthcare Expenditures
Challenges and Opportunities
ValueNational Health Expenditures
30% Waste
Source: Dale Jarvis, Sustainability: Understanding the Healthcare Finance Landscape, presentation 2015.
ValueRegional Health Expenditures
$4 billion
is unnecessary
$900 million
• Overtreatment• Redundant
testing• Pricing failures
• Poor quality• Fragmented
care• Fraud
Source: DeLibero, Frank. Letting the Data Speak. www.lettingthedataspeak.com/county-health-care-costs-washington-state-example/
ValueNational Health Expenditures
~94M Covered Lives in Medicaid by 2024
~72M Covered Lives in Medicare
by 2024* *Medicare Part A Enrollment
Source: Sustainability: Robin Arnold Williams, Understanding the National Landscape, presentation 2015.
Medicaid is the single largest source of coverage
State Health ExpendituresThe Cost of Healthcare
Source: Washington State Health Care Authority. http://www.hca.wa.gov/medicaid/reports/Documents/enrollment_totals.pdf
1.8 million currently enrolled in WA
More Than HealthcareSocial Determinants of Health
Health Is More Than HealthcareHealthcare Providers see only the tip of the iceberg…
…but what’s under the
water has a profound effect on
the health outcomes
Health Is More Than HealthcareWhat Determines Health?
Environment and Behavior
60%
Healthcare10%
Genetics30%
• Quality, affordable housing
• Socioeconomic status• Early childhood
education and quality schools
• Family and social supports
• Neighborhood safety and accessibility
• Access to quality nutrition
• Education status
Health Is More Than HealthcareRole of Education
Housing Is HealthcareBreaking Down Silos
Housing in Our Region
• Affordable units per 100 extremely low-income households:
Affordable Housing Shortage
24 19 32 47
Spokane Whitman Adams, Ferry,
Lincoln, & Pend Oreille
Stevens
Source: Urban Institute. Mapping America’s Rental Housing Crisis. http://datatools.urban.org/features/rental-housing-crisis-map/
Current PrioritiesHousing & Health Investments SpokaneHousing
City and County of Spokane:
$6.65M in 2014
HealthMedicaid expenditures:
$464M annuallyCoordinated Assessment
3% Emergency Shelter
11%
Homeless Prevention
9%
Permanent Supportive
Housing28%
Rapid Rehousing34%
Transitional Housing
14%
Source: City of Spokane
Source: DeLibero, Frank. Letting the Data Speak. www.lettingthedataspeak.com/county-health-care-costs-washington-state-example/
A d u l t s I n d i v i d u a l s i n f a m i l i e s Y o u t h
519
366
16
115
16
1
Spokane County Point In Time Count 2015Sheltered Unsheltered
OpportunityHousing Demand
*PIT Count does not include chronically homeless individuals that are in permanent supportive housing at the time of the count.
Total count non-chronic:
1033Total count including
chronically homeless*:1231
Source: HUD Point In Time Count, 2015.
OpportunityHousing Supply
Spokane has made strides in meeting this need…
Emerg ency Ot her Perma nent H ousing
Perma nent Suppor ti ve
H ousing
R a pid R ehousing Tr a nsitiona l
Spoka ne
267
77
152
41
438
401
0
53
184
166
37
0 0 0 00 0
200
0
46
0 0
205
0 0
Spokane County Housing Stock, 2014 HUD Inventory
Sum of FamiliesSum of AdultsSum of YouthSum of VeteranSum of Chronic
1562 non-emergency beds
total687 permanent
875 non-permanent
Housing Types
• Emergency Shelter– 90 days or less emergency shelter
• Rapid Re-Housing– Vouchers and rent assistance for housing as
quickly as possible• Transitional Housing– Up to 24 months interim housing
• Permanent Supportive Housing– Housing First concurrent w/ treatment
Varying Requirements and Timeframes
Opportunity
• 63 unsheltered and 135 sheltered chronically homeless individuals (2015)– Does not include chronically homeless individuals
already in Permanent Supportive Housing (481*)• Permanent Supportive Housing stock: 610
beds• Not enough beds left for the 198 chronically
homeless individuals
Chronic Homeless and Supportive Housing
*Source: City of Spokane
Systems ApproachSeeing and Filling Gaps in the Housing Stock
Father Bach Haven II
The MarileeOn Track
15 unitsFamily housingAvail. July 2016
51 UnitsPSH/Housing
FirstAvail. 2016
51 UnitsPSH/Housing
FirstAvail. 2016
Spokane Housing
• Housing type poorly matched to client needs• Lack of sustainable funding for supportive
services• Need to strengthen relationships with landlords
of potential rapid rehousing units• Limited funding focuses on high risk instead of on
prevention• Homeless Prevention rental assistance hasn’t
been effective in Spokane County
Opportunities for improvement
Service Delivery Networks
Integrating Systems
Transforming SystemsOur Approach• Public-private co-investment and co-design– Health, Housing, & Homelessness– Better Health Together– Family Impact Network
• Networked approach to service delivery– Network hub administrator– Network service delivery– Show wins for multiple “bottom lines”– East and West side intermediaries
• Performance driven payments
Systems Approach
• Utilize Accountable Communities of Health– Tailored menu of care options
• Housing and community-based service integration– Increased capacity for supportive housing– Increase access to long-term supports and
services• Opportunity for local savings reinvestment
Medicaid Section 1115 Waiver
Systems Approach
• Highly skilled, flexibly deployed• Specialty areas include:– Outreach, Enrollment, and Connectors– Culturally Connected CHWs– Peer Model CHWs– Behaviorally and/or Socially Complex– Medically Complex/Chronic Disease Management
Community Health Workers**Nomenclature varies: Community Connector, Patient Navigator, Resource Specialist, et al
Integrating SystemsH3/Hotspotters Programs
Community Care Programs
3-year outcomes, 2015-2018
2015 Program Measurements
Key Activities
Reduce ER visits for BHT clients by 50%
Serve 2500 complex clients by 12/31/2015
Develop an integrated Community Care Program to serve highest utilizers of ED, EMS, & Medicaid by 4/30/15
Develop integrated process for referrals, intake, client tracking, & management
Develop adequate data sharing agreements
Reduce EMS usage for BHT clients by 50%
Build a financially sustainable model
Deliver high quality programs & services to complex clients
Dental Emergencies Needing Treatment
Reduce per capita Medicaid enrollee expenditures in the region by 15%
Family Assessment Response
Health, Housing, & Homelessness
Hot Spotters
Service Model Integration
Community Care ProgramsService Model Integration
3-Year Outcomes, 2015-2018
Reduction in ER visits for BHT clients
Reduction in EMS usage for
BHT clients
Reduction in regional per capita Medicaid enrollee
expenditures
H3Community Care Programs
Problem: Perverse Policies
• Policies drive low-income people to access high-cost health care.
Opportunities: Cost Savings
• Medicaid/Medicare• Emergency Room• Criminal Justice System• Child Welfare
Approach: Integrated Service Delivery
• Co-investment• Network hub
administrator• Rapidly adaptive
Connecting Housing & Health
Current State:• Early positive results• Networks developing, still
incompleteChallenges:• Creating a new way of
doing business– Fitting people into program
silos– Accessing funding to operate
network– Capturing savings
• Lack of specialized housing
Current State & Challenges
For more information
• http://www.betterhealthtogether.org
• http://www.empirehealthfoundation.org
Who We Are
• Private health conversion foundation formed in 2008
• $80 million in assets; $18 million annual grants• Focus Areas:
Improving Health Outcomes
Growing Physician Supply
Strengthening Health Systems
Building Nonprofit Capacity
Empire Health Foundation
Discussion
• What opportunities do you see to improve on this work?
• How can we better leverage work that is already being done?