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?