Regional Health Needs Inventory - Washington State … · 2017-11-20 · Regional Health Needs...

SECTIONI:ACHLEVEL

ACH BetterHealthTogether

Name HadleyMorrow

PhoneNumber

509-954-0831

E-mail [email protected]

RegionalHealthNeedsInventory

RegionalHealthNeedsInventoryHowBetterHealthTogether(BHT)hasuseddatatoinformitsprojectselectionandplanningBHTACHhasuseddatato:assessneeds,resources,andinterestindifferentaspectsoftransformation;toengageprovidersandpotentialpartners;toinformstrategicdirectionandprioritizationdiscussions;andtoilluminateareaswheremoredataandanalysisareneededasprojectplanningcontinuesintoimplementationdesign.BHTACHhasexistedsince2013asaregionalorganizationdedicatedtoimprovinghealthandcommunitysystemsofcareforallresidents.Inthisrole,BHT’sstaff,LeadershipCouncil,andBoardreviewedavailabledataaboutcommunity-widehealthneedsandresourcesandhostednumerousconversationstobetterunderstandcommunities’perspectivesonbrightspotsandtoidentifyhealthdisparities(seeCommunityEngagementsection).Theseconversationsuncoveredseveralkeyconcernsincludingaccesstocare,chronicdisease,obesity,AdverseChildhoodExperiences,andinadequateaccesstoandcoordinationofcommunityresources,whichweresummarizedinfall2016andcanbeviewedinAppendix1.

SinceapprovaloftheMedicaidTransformationDemonstration(MTD)andpublicationoftheProjectToolkit,BHTACHhasusedarangeofdatatoconsidertheneedsofMedicaidbeneficiariesinparticularandtoassesscurrentperformanceandcapacityintheeightpotentialDemonstrationprojectareas,aswellasDomain1.ThegoalofthisstageofassessmenthasbeentoidentifyopportunitiesforrealimprovementandexploreareaswhereMTDworkcanhelpdrivecommunitypriorities.SeveraldatasourceshaveinformedBHTACH’siterativeprojectselectionandplanningprocess:

• BHTACHcollecteddatafrompartnersandcommunitymemberstoinformprojectselectionviaanopencallforLettersofInterest(LOIs)forcommunityprojectsinthesixoptionalMTDprojectareas.LOIswerereceivedfrom40differentorganizationsorpartnershipsacrossallsixofBHTACH’scounties.Whileallprojectareaswererepresented,overhalfoftheproposalsinvolvedcarecoordinationacrosssectors.

• NineteenoftheLOIparticipantswereselectedforacommunityshowcaseeventinAugust2017,whereorganizationsbrieflydescribedtheirprojectsandcommunitymembersparticipatedinavotingexercisetoindicatetheirinterestinandsupportfordifferentideas.Proposalsinvolvingcarecoordinationreceivedthelargestshareofvotesduringthecommunityfeedbackevent.Therewasinterestineachoftheremainingoptionalprojectareaaswell,butnoclearprioritizationamongthem.SeeAppendix2forsummariesofshowcasefeedback.

• Inthesummerof2017,BHTACHsurveyeditshealthsystemandcommunity-basedorganizationpartnersabouttheirinterest,capacity,andprioritiesforDemonstration-relatedwork(includingDomain1strategies).Thirty-nineorganizationssubmittedeitheraHealthSystemsInventoryorCareCoordinationInventory(HSIorCCI).Whiletherewasinterestacrossallprojectareas,responsesweremostconcreteforbi-directionalintegration(2A),carecoordination(2B),opioids(3A),andchronicdisease(3D).Inotherprojectareas,likelypartnershadlessexperienceorfewertangiblepriorities,ordidnotexpresssupportforthespecificevidence-basedstrategieshighlightedintheMTDToolkit.DatafromtheHSIandCCIalsohighlightedclientneedsaroundmentalhealth,substanceabuse,chronicdiseases,andsocialdeterminantsofhealth(e.g.insecurehousing).HSIandCCIresultsaredescribedinmoredetaillaterinthissection.

• AsdatasetsorreportsliketheRegionalHealthNeedsInventory‘starterset’files,HCAProviderreports,orpartnerpublicationssuchastheSpokaneUrbanIndianHealthProfilebecameavailable,BHTstaffandcontractorsreviewedthemtoinformprojectselectionandplanning.Reviewandanalysishaveencompassedissuesincludingbutnotlimitedto:

o Populationsizeanddiseaseburden(e.g.howmanyMedicaidmembersinBHTACHregionhavebothachronicdiseaseandmentalhealthorsubstanceabuseneed?);

o Disparitiesbasedondemographics,andgeography,andotherfactors;

o CurrentperformanceonMTDqualitymeasuresandpotentialforimpact(e.g.howdoesBHTACHcomparetostateandnationalaveragesforasthmamedicationmanagementbasedoncurrentpubliclyavailabledata?).

ManyoftheseexploratoryanalyseshavebeensharedwithBHTleadershipandpartnersasweconsideredprojectselectionandpriorities.Twoslidepresentations,fromaSeptemberBoardmeetingandOctobercommunitylearningwebinar,areattachedasexamples(Appendices3and4).

Projectplanningisofcourseongoing.AstheBHTACHandourpartnersmovedeeperintoprojectdesignandimplementationplanning,wewillcontinuetousedataformultiplepurposes,includingbutnotlimitedto:honinginontargetpopulationsandpartneringproviders(e.g.EDsseeingthelargestvolumeof‘highutilizers’withbehavioralhealthconditions);estimatingpotentialimpact(e.g.estimatingthenumberofreadmissionstobeavoidedinordertomeetimprovementtargets);orassessingthepotentialviabilityofproxymeasuresforperformanceimprovement(e.g.canunintendedpregnancyratesbereliablymeasuredataregionallevel?).Totheextentpossible,theBHTACHplanstoprovidetailoreddatatoeachofitsCommunityHealthTransformationCollaborativesfortheiruseinplanning,monitoring,andcontinuousimprovement.(TheCollaborativesarecomprisedofhealthsystemandsocialdeterminantofhealthpartnersservingastheactivationnetworkforimplementationoftheMTDprojects;seeTheoryofActionsectionformoredescription).TheBHTACHalsoplanstodisaggregatedata(byrace,ethnicity,geography,eligibilitygroup,andotherrelevantcategories)whereverpossibletoinformdecisionsabouttargetpopulationsandmonitortheimpactofprojectsacrossdiversegroups.TheBHTACHhasengagedwiththeProvidenceCenterforOutcomesResearchandEducation(CORE)tosupportourdataandanalyticneeds,includingaccessingandanalyzingdatatoinformprojectselectionanddevelopingplansformonitoringandcontinuousimprovementduringprojectimplementation.COREisanindependentresearchteamwithexpertiseindatascience,evaluation,andcollaborativeresearch.CORE’sstaffhaveextensiveexperienceinAccountableCommunityofHealthandMedicaidredesigninitiativesinOregon,California,andWashington. TheBHTACHalsoleveragesasharedlearningpartnershipwiththePierceCountyandSouthwestWashingtonACHsandconnectsregularlywithdataandanalyticresourcesintheregionincludingtheSpokaneRegionalHealthDistrictandEasternWashingtonUniversity’sInstituteforPublicPolicyandEconomicAnalysis.

DatasourcesTheBHTACHhasconsultedawiderangeofdatasourcestodate.ThesearesummarizedintheRHNIDataSources&UsesTable(Appendix5).Thesourcesinclude:

• HCAorDepartmentofSocialandHealthServices–ResearchandDataAnalysis(RDA)dataproductsproducedspecificallyforACHs(e.g.RDAmeasuredecompositionfiles,suppresseddatatablesforco-occurringdisorders,ProviderReport,etc.)

• StatedataforeithertheMedicaidorthegeneralpopulation(e.g.OpioidOverdoseDashboard;1WashingtonDOHregionalchronicdiseaseprofiles;2WashingtonStateOfficeofFinancialManagementreportonPotentiallyAvoidableHospitalizations3)

• ExistingdataorreportsfromBHTACH’sregion(e.g.TheNATIVEProject/SpokaneUrbanIndianHealthCenterCommunityProfile)

• PrimarydatacollectedbytheBHTACHfrompartneringproviders—includinghealthcareproviders,MedicaidManagedCareOrganizations,andCommunity-basedOrganizations—toinformprojectselectionandplanning.Thetwomostsignificantexamplesoforiginaldatacollectedfrompartneringorganizationsaredescribedbelow:BHTACH’sHealthSystemsandCareCoordinationInventories(brieflyreferencedabove)andtheBHTACH/SpokaneRegionalHealthDistrictCommunityLinkagesStudy.

TheHealthSystemandCareCoordinationInventories(HSIandCCI,seeAppendices6and7)collectedinformationonorganizations’Medicaidpatients/clientsandservicecharacteristics,includinghealthstatusandleadingdiagnoses.Theinventoriesalsoqueriedpartnersdirectlyabouttheirinterest,capacity,andprioritiesforMTD-relatedwork.TheBHTACHreceivedHSIresponsesfrom23organizationsintheregion,includingmajorhospitalnetworks,providersystems,andFQHCs.Twenty-six(26)CCIswerereturnedfromcommunity-basedorganizations.ThreeofthefiveMedicaidManagedCareOrganizationsalsocompletedCCIs;theseMCOsrepresent73%oftheMedicaid-enrolledpopulationinBHT’sregion.4SeeAppendix8forthelistofHSIandCCIrespondents(organizationsthatsubmittedprojectLettersofInterestarealsoincluded).TheBHTACHcomparedtheHSIrespondentswithHCA’sSeptember2017ProviderReport5andfoundthattheinventoryresponsesrepresentmorethan80%ofthehighest(top10)volumeMedicaidbillersineachmajorsetting(primarycare,mentalhealth/substanceabuse,inpatientandED.)ForseveralsettingsintheBHTACH’sfiveruralcounties,theHSIrespondentsrepresentalltheMedicaidbillerswithclaimsorbeneficiarycountsofmorethan10in2016.BHTstaffarefollowingupwithnon-representedprovidersthatseealargenumberofMedicaidclients,particularlysubstanceabusedisordertreatment,oralhealthandIndianHealthServicesproviders.

In2016,theSpokaneRegionalHealthDistrictconductedalargescaleCommunityLinkageMappingandsocialnetworkanalysis,6inwhich165individualsrepresenting112organizationsfromthehealth,socialservice,education,business,andpublicsectorscompletedaPopulationandSocialDeterminantsofHealthSystemsSurvey.Becauseparticipantswereabletodescribetheirlinkageswithorganizationsthatdidnotresponddirectly,thereportinfactrepresents564organizationsandisthemostcomprehensivepictureavailableofhealth-relevantcommunity-basedresourcesintheBHTACHregion.AfulllistofrepresentedorganizationsbygeographyandsectorcanbefoundinAppendix9.MedicaidBeneficiaryPopulationProfileBHTACHhasalargeserviceregion,whichcovers12,273squaremilesandispredominatelyrural.AnurbancoreexistsinSpokaneandthereisasurroundingsuburbancommutingarea.84%oftheregion’spopulationlivesinSpokaneCounty7andmanyareasinFerry,Lincoln,andAdamscountiesareclassifiedasisolated,asshowninthemapbelow.

Figure1:WashingtonState6-Tierruralcategorizationbycensustract(2010)8

BHTACHhasapproximately196,000Medicaidmembers,9whichrepresentsahigherproportionofthepopulationthanthestateasawhole(33%Medicaidcoveragevs.28%statewide).10AdamsCountyhasthehighestproportionalMedicaidpopulationinthestate,at52%.Following

thegeneralpopulationdistribution,mostofBHTACH’sMedicaidpopulationlivesinSpokaneCounty.Onthewhole,BHTACH’sMedicaidpopulationis:slightlyolderandmoremalethanthestateMedicaidpopulation;morelikelytobewhite(75%comparedto57.0%statewide);lesslikelytobeHispanic(11%comparedto21.0%statewide);andmorelikelytogiveEnglishastheirpreferredlanguage(94%vs.83%statewide).However,thereisrealvariationwithintheBHTACHregion.Forexample,AdamsCountyMedicaidbeneficiariesareyounger(68%under19),moreHispanic(78%),and46%identifySpanishastheirpreferredlanguage.11IndividualswhoidentifyasHispanicareagrowingproportionofthepopulationinallofBHTACH’scounties,astheyarestatewide.12InStevensandFerrycounties,whereSpokanetriballandsandpartoftheColvilleTriballandsarelocated,10%and27%ofMedicaidenrollees(respectively)identifyasAmericanIndianorAlaskaNative.13ThesenumbersaresignificantgivenongoingdisparitiesinhealthcareaccessandoutcomesamongNativegroups.BHTACH’snortherncountieshavesomeofthehighestunemploymentratesinthestate:FerryCountyleadsthestateat8.7%unemploymentasofSeptember2017andPendOreilleandStevensCountiesarebothcloseto6%.

Figure2:WashingtonStateUnemploymentRates,September201714

Similarly,thethreenortheastcountieshavehigher-thanaverageproportionsofchildreninpoverty(27%inStevens;31%forFerryandPendOreille).15InSpokaneCounty,morethanathirdoftheAmericanIndian/AlaskaNative(AI/AN)populationisbelowthepovertylineandunemploymentforAI/ANresidentsiscloseto20%.16Accordingtothe2015WashingtonStateHousingNeedsAssessment,allBHTACHcountieshavelownumbersofaffordablehousingunits,withSpokaneCountythelowestat12affordableandavailableunitsper100households.17BHTACH’sHealthSystemInventoryrespondentswithavailabledatareportedthatbetween3%and18%oftheirclientsliveinhousingthatiseithernotstableorisovercrowdedandthatasmanyas15%haveahistoryofincarceration.However,manynotedtheyhadnomechanismtotrackthistypeofinformation.

Table1:ClientneedestimatesfromBHT’sHealthSystemsInventory18

BHTACHHSIRespondentsontheirpatients/clients'needs Range%Childreninfostercare 0%-10%%Clientswithinsecureorinadequatehousing 3%-18%%Clientswithahistoryofincarceration 0%-15%

HistoricaldatafortheMedicaidTransformationDemonstrationperformancemeasures,whicharemorenarrowlydefinedtoMedicaidbeneficiariesandeventsinthelastyear,puttherateofhomelessnessamongBHTACHMedicaidenrolleesat3.8%(belowthestatewideaverage)andpast-yeararrestsat6.5%.19Medicaidbeneficiarypopulationhealthstatus

BehavioralHealthconditionsandtreatmentneedsarewidespread

Morethan44,000BHTACHMedicaidmembers(almost30%)havebeendiagnosedwithamentalillnessandapproximately20,000(12%)haveasubstanceabusetreatmentneed.About36,000(9%)haveamentalhealthorsubstanceabuseconditionand1ormorechronicdiseases.ThesefiguresrepresentalargersegmentoftheMedicaidpopulationforBHTACHthanthecorrespondingfiguresforWashingtonasawhole.

Figure3:PrevalenceofchronicconditionsamongBHTACHareaMedicaidbeneficiaries,FY2015-1620

Outsideofpregnancyandchildbirth,‘mentalandbehavioraldisorders’weretheleadingcauseofhospitalizationforBHTACHMedicaidbeneficiariesin2015,accountingfor17.5%ofallnon-birth-relatedhospitalizations.Substanceabusedisordersaccountedfor5.7%ofsuchhospitalizationsoverallbut8%amongnon-disabledadults.21BHTACH’sHealthSystemInventoryrespondentssuppliedinformationaboutthemostfrequentdiagnosesamongtheirpatients/clients.Mentalhealthconditionsrepresented23%oftop5diagnoses,andsubstanceabuseoradditionrepresented6%.22OpioiduseinhighamongBHTACH’sMedicaidpopulation.17.4%ofBHTACHMedicaidbeneficiariesarecurrentopioidusers(vs.13.5%statewide)and3.6%areheavyusers.

Table2:Medicaidbeneficiaryopioiduse,BHTvs.WashingtonState23

OpioidUsersas%ofMedicaidpopulation BHT WashingtonAll 17.4% 13.5%Userswithoutcancer 15.4% 11.9%HeavyUsers 3.6% 2.8%Usersfor>30days 3.9% 2.8%

InalmostallofBHTACH’scounties,opioidprescriptionsarewrittenandfilledatahigherratethanaverageforWashingtonstate.(AdamsCountyistheexception.)

8.8%

12.5%

29.5%

7.7%

11.2%

27.1%

0% 10% 20% 30% 40%

MIorSUDandCD

SUDtreatmentneed

Anymentalillness

Figure4:Opioidprescriptionswrittenandfilledper1,000residents,201424

BHTACHissubstantiallybelowthestateaverageforMedicaidopioidusersreceivingmedication-assistedtreatmentwithmethadone(11%vs.16%statewide)butisataboutthestatewideaverageforMATwithbuprenorphine(11%vs.10%statewide).25

BHTACHisalittlebelowthestateaverageformentalhealthtreatmentandsubstanceabusetreatmentpenetrationratesamongMedicaidbeneficiaries.However,ratesoffollow-upafterahospitalizationorEDvisitrelatedtomentalhealthorsubstanceusearehigherthantheaverageforWashingtonstate.2619Variationforchronicdisease

Overall,estimatedchronicdiseaseprevalenceamongtheMedicaidpopulationinBHTACHisclosetothestatewidefigures:approximately3%ofenrolleeshadaninpatientoroutpatientclaiminthelastyearthatincludedadiagnosisofdiabetes(vs.4%statewide),5%hadaclaimwithadiagnosisofasthma(vs.4%statewide)and11%receivedadiagnosisofdepression.27However,thesefiguresmasksomeregionalvariation:

• AsthmaishigherthanthestateaverageinStevensCounty(6%)andFerryandSpokaneCounties(both5%).

• Smokingisariskfactorforanumberofchronicdiseases.BHTACHhassomeofthehighest(StevensCountyat33%)andlowest(AdamsCountyat8%)smokingratesamongWashington’sMedicaidbeneficiaries.

Figure5:Smokingprevalencebycounty,2013-1527

• DepressiondiagnosesamongSpokaneandPendOreilleCountyMedicaidrecipientsare

higherthantheWashingtonaverageat12%butAdamsCountyhasthelowestrateinthestateat3%.

ChronicdiseasemanagementforBHTACH’sMedicaidpopulationalsovaries:28

• Between83%and87%ofdiabeticsreceiveregularbloodglucoseandkidneyfunctiontests,butonlyaboutathirdreceiveannualeyeexamsforretinopathy.

• About32%ofindividualswithpersistentasthmaareonappropriatemedicationand26%ofthosewithadvancedCVDreceiveastatinprescription.Theserelativelylownumbersareneverthelessabovethestateaverageperformance(28%forasthmamedicationmanagementand20%forstatintherapy).

ExistinghealthcareprovidersservingtheMedicaidpopulationTheBHTACHregionincludes:

• 14hospitals(notincludingmilitaryorV.A.facilities),8ofwhicharecriticalaccesshospitals

• EasternStatePsychiatricHospital

• 13RuralHealthClinics

• 6Federally-QualifiedHealthCenterswithatotalof28locationsintheregion

• 5TribalorUrbanIndianHealthProgramclinics,andanIndianHealthServiceClinicinWellpinitontheSpokanereservation

Inaddition,thereare34MentalHealthand/orSubstanceAbuseDisorderserviceproviderscontractedwiththeRegionalBehavioralHealthOrganization,manyofwhomhavemultiplecliniclocations.SeeAppendix10foralistofhealthcarefacilitiesintheregion.BHTACH’sMedicaidbeneficiariesareservedbyfiveMCOs:AmerigroupWashington,CommunityHealthPlanofWashington,CoordinatedCareWashington,MolinaHealthcareofWashington,andUnitedHealthcareCommunityPlan.Molinahasthelargestshareofmanagedcareenrolleesoverall(47%)butisnotthebiggestplanineverycounty.Between14%and36%ofMedicaidrecipientsinBHTACH’sregionarenotenrolledinamanagedcareplan,dependingonthecounty.FerryCounty,wheremorethanaquarterofMedicaidbeneficiariesidentifyasAmericanIndian/AlaskaNativeandmustoptintoMCOenrollment,hasthehighestproportionofbeneficiariesinfee-for-serviceat36%.29ThishighproportionofFFSclientscanmakeitchallengingtocoordinatecare.Informationaboutproviders’acceptanceofMedicaidclientsislimitedandoftennotcurrent.Surveysconductedwithinthelast5yearsaspartoftheHealthProfessionalShortageAreadesignationprocesssuggestthatthemajorityofprimarycareprovidersintheBHTACHregionserveatleastsomeMedicaidpatientsandthat65%-75%ofdentistsdoso.30Butanecdotally,BHTstaffhavereceivedreportsofmuchloweracceptanceratesfornewMedicaidpatientsamongdentalprovidersinparticular.Existingcommunity-basedresourcesavailabletotheMedicaidpopulationThefindingsofthe2016CommunityLinkagesStudy31describedearlierunderDataSourcesspeakdirectlytotheavailabilityofcommunity-basedresourcesforMedicaidbeneficiaries:

• BHTACH’scommunity-basedresourcesmostcommonlyaddresstheseneeds:communitysupport(sociallysupportivecareandpeergroupsthatfosteranindividual'ssenseofsupportandbelonging);education;food(access,affordability,nutrition);housing(access,affordability,andplacement);incomestability;andtransportation.

ThesekindsofresourcesareparticularlyrelevantforsupportingMedicaidclientswithawhole-personcareapproach.

• AstrongmajorityofrespondingorganizationsofferedservicesinSpokaneCounty,particularlyamongsocialsectorgroups.OrganizationsfromthesocialsectorwerecentraltothenetworkinSpokaneCounty(alongwiththepublichealthdepartment),whereashealthandeducatorsectorplayersweremorecentralinthenortheasttri-countyregionandinLincoln-Adamscounties.ThissuggeststhatadditionaltimeandeffortwillberequiredtolinksocialsupportsystemstohealthcareinBHTACH’sruralcounties.

• Mostofthereportedorganizationallinkagesinvolvedcollaboration(e.g.attendingmeetingstogether,sharingresources,completingjointprojects-56%)orreferral(30%).Dataexchange,education,andfinancialsupportweremuchlesscommon(lessthan6%oflinkagesforanyofthosecategories).BHTACHistakingthesefindingsintoconsiderationasitdevelopsplanstosupportvalue-basedpaymentandpopulationhealthdatasystemsintheregion.

• Thesocialsectorwasthebestlinkedtoothersectors(includinghealth)andhadthemostlinkagesoverall.Healthsectororganizationswerewelllinkedwitheachotherbutslightlymoresiloedwithintheirsector.

BHTACHwillexplorethefeasibilityofrepeatingthecommunitylinkagesstudyinsomeforminthefutureasameansofevaluatingtheimpactoftheACHandMTD-supportedactivitiesonsystemconnectionandintegrationacrosssectors.InadditiontotheCommunityLinkagesstudy,BHTACH’sCommunityCareCoordinationInventory(seedescriptionunderDataSources)providesdataoncommunity-basedresourcesfortheMedicaidpopulation.The27organizationalrespondents(includingthreeMCOs)describedsubstantialexistingeffortsandinvestmentsincarecoordinationandcasemanagement,suchasaruralElderDiabetesProjectofferedbyacommunity-basedorganizationusingStanfordChronicDiseaseSelf-Managementmodelcertifiededucators,oratransitionalrespitecareprograminSpokanethatprovidespost-hospitalhousing,care,andservicecoordinationtohomelessindividuals.32AstheoperatoroftheNavigatorNetworkofEasternWashington,BHThasdirectconnectionswithmorethan50organizationswhohostoremploynavigatorstohelppeoplesignupforcoveragethroughWashingtonHealthplanfinder.Thepartnersrepresentmanysectorsincluding:Communityhealthclinics,hospitals,publichealth,nonprofitorganizations,faithbasedcommunityorganizations,behavioralhealthproviders,thecriminaljusticesystem,agingandlong-termcare,affordablehousingagencies,libraries,earlylearning,K-12education,and

highereducation.BHTACHisleveragingtheseconnectionstoengagepartnersinMTDprojectplanningandimplementation.AccessandconnectiontocarefortheMedicaidbeneficiarypopulationAccesstoandutilizationofcareamongMedicaidbeneficiariesvariesconsiderablywithintheBHTACH’sregion.RatesofadultuseofambulatoryorpreventivecarearegenerallyatorabovethestateaverageinmostofBHT’scountiesbutStevensCountyisanexception.Amongchildren(1-19years),primarycarevisitsarebelowthestateaverageinallthreenortheasterncountiesbutsubstantiallyabovetheaverageinAdamsCounty,wherechildrenmakeup68%oftheMedicaidpopulation.33

Figure6:Ratesofaccesstoprimarycareamongadults(left)andchildren(right),2015-16

Disparitiesalsoexistbygenderandrace.Only69%ofadultmaleMedicaidbeneficiarieshadanambulatoryorpreventivecarevisitinthelastyear,vs.85%ofwomen.Amongdifferentracialgroups,ratesofambulatoryorpreventivevisitsbyadultsinthelastyearrangedfromalowof

72%amongNativeHawaiiansandPacificIslanderstoahighof80%amongAI/ANsandindividualswhoidentifiedasmulti-racial.34

QualisHealthreportsthatallMCOsinWashingtonstateshoweddecreasesinadultaccesstoambulatory/preventivehealthservicesfromthe2015to2016reportingyearsandthatthestaterateisnowmorethan5percentlowerthanthenationalaverageforMedicaidplans.35IntheBHTACHcounties,rateshavedeclinedmostnoticeablyinFerry,PendOreille,andStevensCounties.

Figure7:Medicaidadults(20+)whohadanambulatoryorpreventivecarevisitinthemeasurementyear(rolling12-monthperiods)36

Variationisalsothestoryforaccesstoandutilizationofparticularformsofcare:

• EDutilization(broadlydefined,includingvisitsrelatedtomentalhealthorsubstanceabuseissues)iscurrentlyat70visitsper1,000membermonthsfortheBHTregion,whichisslightlyabovethestateaverageof68visitsper1,000mm.ButtheaggregateBHTACHfigureisdrivenbythepopulationconcentrationinSpokaneCounty;adult

Medicaid-coveredresidentsofAdams,Lincoln,andFerrycountieshavesomeofthelowestMedicaidEDutilizationratesinthestate.37

• BHTACHisalittlebelowthestateaverageformentalhealthtreatmentandsubstanceabusetreatmentpenetrationratesamongMedicaidbeneficiaries.Ontheotherhand,ratesoffollow-upafterahospitalizationorEDvisitrelatedtomentalhealthorsubstanceusearehigherthantheaverageforWashingtonstateMedicaid.38

GapsbetweenMedicaidpopulationneedsandavailableservicesBHTACH’sregionisgeographicallyspacious,covering12,273squaremiles.TheareaincludesWashingtonState’shighest-elevation,pavedroadat5,574feet(ShermanPass)andonlyoneinterstatehighway,meaningthatStateRoutes,ruralroads,andferrycrossingsaretheprimaryroutesoftravel.Transportationshortcomings,geographicbarriers,andinclementweatherfrequentlylimitaccesstocare.MostofBHTACH’sregion,otherthantheSpokanemetroarea,hasmultiplehealthprofessionalshortagearea(HPSA)designations:39

• ThereisashortageofprimarycareprofessionalsforallresidentsofFerryCounty(greenshadinginthemapbelow),andforlow-incomeresidentsinmostotherareasofBHT(pinkshading)

Figure8:WashingtonPrimaryCareHealthProfessionalShortageAreas,Jan.2017

• AllBHTACHcountieshaveashortageofmentalhealthprovidersforanyresident,includingmostofSpokaneCounty(greenshading).ThemetroSpokaneregionisdesignatedasalow-incomementalhealthHPSA(pinkshading).

Figure9:WashingtonMentalHealthProfessionalShortageAreas,Jan.2017

• Finally,allBHTACHisdesignatedasadentalhealthcareprofessionalshortagearea.Thedesignationappliesmostlytolow-incomeresidentsbutappliestoallresidentsofFerryCounty(greenshadinginthemapbelow).

Figure10:WashingtonDentalHealthProfessionalShortageAreas,Jan.2017

TheUniversityofWashington’sCenterforHealthWorkforceStudiesreportsthatEasternWashingtonhasfewerphysiciansprovidingdirectpatientcarethantheWesternpartofthestate(185per100,000populationvs.242per100,000)andthatthephysicianworkforceisgrowingmoreslowlyintheeast.Theeast-westphysiciansupplydisparityisevenmorepronouncedforpsychiatrists:in2014therewere4.9psychiatristsper100,000incountieseastoftheCascadesvs.11.9per100,000inwesterncounties.Easterncountieslost2.5%oftheirpsychiatristworkforcebetween2014and2016,whereasWesternCountiessawa9%increase.40BHTACHareaparticipantsintheWashingtonStateHealthWorkforceSentinelNetworkreportrecentincreasesindemandforclinicalsocialworkersandmentalhealthcounselors.41

Statewidein2016,77%ofadultAppleHealthenrolleesreportedthattheywereusuallyoralwaysabletogetneededcareand78%reportedusuallyoralwaysgettingcarequickly.RegionalresultsarenotavailableandtherewaslittlevariationamongtheMCOs.42BHTACHhaslower-thanaverage(forWashingtonstate)ratesofpotentiallyavoidableEDvisitsamongMedicaidbeneficiaries43and,exceptfortheSpokanemetroarea,lowerthanaverageratesofpotentiallyavoidablehospitalizations(allpayers).44Intheinterestsofreducingaccessshortcomings,providerpartnersintheBHTACHregionhaveastronginterestinexpandingtelehealthcapacity.TelehealthprioritiesreportedbyrespondentstoBHTACH’sHealthSystemsInventoryincludedpsychiatry,neurology,andremotemonitoring.45ConversationswithproviderpartnershaveilluminatedafewbarrierstoexpansionoftelemedicineservicesthatBHTACHwillexplorefurtheraspartofMTDprojectplanning.Theseincludecertificationrequirementsthatrequirealargerencountervolumethansomeruralprovidershave,thecostoftechnologyandspacefortelehealth-enabledvisits,andstafftraining.

ACHTheoryofActionandAlignmentStrategy

ACHTheoryofActionandAlignmentStrategyBetterHealthTogetherVisionBetterHealthTogether’svisionisthateveryperson,regardlessofbackground,lifeexperienceorenvironment,willliveaproductive,highqualitylife,withaccesstostablehousing,nutritiousfood,transportation,education,meaningfulemploymentthatpaysthebillswithsomeleftoverforsavings,andsocialsupportnetworksthatfosteremotionalandpsychologicalwellbeing.PleaseseeAttachment1foranupdatedTheoryofActionlogicmodelgraphic.Thisisaloftyvisionandwillnotbeachievedbyanyoneorganization.BetterHealthTogether(BHT)willachievethisvisionbydevelopinganintegratedcommunityhealthsystem,accountabletoimprovinghealththroughdeliveringculturallycompetent,whole-personcaretoeachpersonwithintheregion.WhileBHTACH’svisionisaspirational,ourworkisgroundedintheneedsandconcernsvoicedbyourextensivearrayofpartneringprovidersaswellastheregionalhealthprioritiesidentifiedthroughourregionalhealthneedsinventory.Spanning12,273squaremiles,muchofourregionconsistsofisolated,ruralcommunitiesthataremilesawayfromconsistentlyavailablehealthservices.Providershortages,especiallyinbehavioralandoralhealth,furtherconstrictaccess,especiallyforruralhealthproviderswhostruggletofillpositions.Severedisparitiesexisteveninresource-heavyurbancenterSpokane,wherethelifeexpectancybetweenneighborhoodsvariesbyupto18years.46Ourjailandemergencysystemsareoverandinappropriatelyutilizedbybehavioralhealthpatientswithoutaccesstostablesocialandhealthsupports.YouthinSpokaneCountyenterfostercareatnearlydoublethestateaverage.47Aseverehousingshortagefurtherincreasestheriskofhomelessnessforvulnerablepeople.Thesesocialriskfactorsmaycontributetoourhighprevalenceratesofasthmaamongyouth(self-reportedat14-24%)48anddiabetesinadults(rangingfrom9-14%intheBHTACHcounties).49TheBHTACHconductedHealthSystemandCommunityCareCoordinationInventories,whichsurveyedpartnersfortheirvision,capacity,engagementofcliniciansandpatients,workforce,and data needs forMedicaid transformation. Based on information obtained through theseinventoriescoupledwithregionalhealthneeds,theBHTACHidentifiedthefollowingactionablegoals:

• Improvewholepersoncareinqualityandaccessthroughtheintegrationofbehavioral,physicalandoralhealthsystems

• Developstrongcommunitysystemsthatlinkhousing,foodsecurity,transportationandincomestability

• Decreaseobesityratesacrossallpopulationsthroughprevention

• Scalecommunity-basedcarecoordinationtoimprovehealth

Thesefourregionalprioritiesspeaktoacommunitydesiretoseestrongerlinkagesbetweenhealthandsocialdeterminantssystemstosupportwhole-person,community-basedcarewithafocusonprevention.BHTACH’sextensivecommunityconversations,alongwithprovidersurveysanddataassessments,alsoidentifiedprioritypopulationsfortheregion.Beneficiarieswithcomplexcareneeds,particularlythosewithaco-occurringbehavioralhealthdisorderandchronicdisease—suchasdiabetes,asthma,hypertension,andcardiovasculardisease—havebeenconsistentlyidentifiedashigh-prioritypopulationsfortheregion.TheneedsoftheseprioritypopulationswillbeemphasizedthroughouttheProjectPortfolioandthroughBHTACH’sadditionalinvestments,strategiesandpartnershipactivities.ByemphasizingtheneedsofthesepopulationsthroughtheProjectPortfolioandotheractivities,theBHTACHexpectstolowercostsandimprovehealthcaredeliveryandoutcomesfortheregion’smostvulnerablepopulationsaswellasimprovetheoverallhealthsystem.BHTbelievesthatatrulyeffectivecommunityhealthsystemnotonlycaresforthewholeperson,butisaccessibleandusedbyall.Weknowfromexperiencethatthebestsolutionsareledlocallyandhelpbuildastrongerbridgebetweenclinicalandcommunityproviders.AdailymantraforBHTstaffandpartneringprovidersis“successwillrequireEACHofustobeboldandengaged.”DespitethehighlevelofengagementofregionalprovidersintheBHTACHvisionandplans,changingpracticeandpaymentmodelswillbechallenging.TheMedicaidTransformationDemonstration(MTD)fundswillenabletheBHTACHtojump-starttheneededtransformations,provethesustainabilityofitsprojects,andsupportpracticechangesacrossprovidersettings.ProjectPortfolioTheBHTBoardofDirectors’decisionaboutprojectselectionwasbasedonrecommendationsfromourWaiverFinanceWorkgroupandBHTstaff,presentedattheNovember2nd,2017meeting.TheBoardapprovedaProjectPortfoliothatincludesfourprojects:

• Bi-DirectionalIntegrationofCare(required)

• Community-BasedCareCoordination

• AddressingtheOpioidsUseCrisis(required)

• ChronicDiseasePreventionandControl

TheBHTBoardselectedthesefourprojectsbecauseoftheirimportancetoMedicaidbeneficiariesintheregionaswellastheregionalhealthneedsofthebroaderpopulation.

AlthoughtheBoardhadpreviouslyconsideredaportfolioofsixprojects,therecentannouncementofareductioninavailablefundsforACHspromptedtheBoardtostrategicallyfocustheProjectPortfolioonthemostcriticalareasofneedforlong-termhealthsystemstransformation.ProjectSelectionProcessPriortotheportfolioselectioninearlyNovember,theBHTBoardundertookadeliberativeprocesstounderstandtheprojectsintheMTDToolkit,theirrequirements,includingtherequiredperformancemetricsandfundsflowweighting,alongwithcommunityinterestandregionalneeds.ThisworkbeganinearnestinJanuary2017attheannualBoardRetreat,duringwhichboardmemberslearnedfurtherdetailabouttheeightpotentialprojectsareasandheldearlydiscussionsontheprioritizationofprojectareasandtheappropriatesizeoftheProjectPortfolio.Althoughboardmembersexpressedsupportforallprojectareas,therewasconsensusthattheBHTACHProjectPortfolioshouldbealignedandfocusedonregionalneedsandprioritiesinordertomaximizeimpact.BoardmembersagreedthePortfolioshouldconsistofaminimumofsixprojects(theminimumnumberrequiredatthetimetobeeligiblefor100%oftheregion’spotentialfunding).Inthemonthsthatfollowed,theBHTACHundertookanextensivecommunityandstakeholderprocesstodevelopaProjectPortfolioinpartnershipwithprovidersandbasedonregionalprioritiesandneeds.CommunityconversationshavedriventhisworksincethebeginningthroughCommunityStrategyMapfocusgroups,ourLeadershipCouncil,andworkthroughfiveruralcountyhealthcoalitionsandSpokane-basedpartneringprovidersforexploringandguidingthebestlocalsolutionsandearlydevelopmentoftheBHTACHProjectPortfolio.InMarch2017,theBHTACHrequestedLettersofInterest(LOIs)tomoreformallygaugeinterestineachoftheeightpotentialprojectareasamongpartneringprovidersandcommunitystakeholders.Therewascross-sectorrepresentationintheprojectselectionprocess,includingcommunityhealthandbehavioralhealthcenters,managedcareplans,hospitals,communitypartners,consumerperspectivesandcommunity-basedorganizations.Thisinitialprocessidentifiedcommunityinterestinalleightareas.Furthercommunityconversationswithpartneringproviders(includingproviderfocusgroupsessions),meetingswiththeTribalPartnersLeadershipCouncil,andintheBHTACHLeadershipCouncilmeetingsresultedintheprioritizationofsixprojectareasfortheregion:community-basedcarecoordination,bi-directionalintegration,addressingtheopioidcrisis,chronicdisease,aswellastransitionsofcareanddiversions.Insummer2017,theBHTACHthenconductedHealthSystemsandCareCoordinationinventorieswithkeyagenciesacrossallsixcountiesintheregion.Thisprocessrevealedthatinterestandtangibleprioritiesweremostconcentratedin:

• Community-basedcarecoordination• Integrationofcare,includingbehavioralhealth,physicalhealthandoralhealth• Addressingtheopioidcrisis• ChronicDisease

Overwhelmingly,community-basedcarecoordinationwasidentifiedasthehighestpriorityintheregion.Asaresult,thePathwaysHubmodelforcommunity-basedcarecoordinationwillserveasananchorstrategyduetothecentrallyidentifiedneedto“coordinatethecoordinators,”whichhasbeenidentifiedoverandoveragainwhenengagingwithcommunitypartners.WiththecommunityprioritizationprocessandHealthSystemandCareCoordinationInventoriesinmind,alongwithhealthdatafromtheRegionalHealthNeedsInventoryandothersources,theBHTACHTechnicalCouncilsincludingtheWaiverFinanceWorkgroupandtheTribalPartnersLeadershipCouncil,aswellastheACHLeadershipCouncilandBoardofDirectorsmoredeeplyconsideredthemodelsinthetoolkitandtherequiredperformancemetrics.TheneedtoprioritizeandfocuswasagainreinforcedbytheBoard,withanemphasisonbuildinguponworkalreadyunderwayandcapitalizingontheprioritiesandinterestsoftheregion’shealthsystems.TheBoardconsideredthebalanceofpartneringproviders’interestinfocusingtheportfolio,particularlygiventhesignificantcutsintheDY2budgetannouncedinlateSeptember,withbroadercommunitystakeholderinterestinanexpandedportfolio.TheBHTACHmadeaconsciousdecisiontousetheProjectPortfolioasaprimaryleverforincreasingtheregion’sreadinessforValueBasedPayment(VBP).Ultimately,theBoarddeterminedthatthefourprojectareaswiththestrongestresponsesinthehealthinventoryweretherightProjectPortfoliofortheBHTACHregionandwouldbuildthebestfoundationforinvestinginVBPreadinessandincorporatingthesocialdeterminantsofhealth.However,becauseofthecommitmenttoalleightareasinthetoolkit,theBoardhasalsodirectedtheBHTACHtoincorporateoralhealth,transitionalcare,diversions,andreproductive,maternalandchildhealthintoACHactivitiesandstrategies.

ProjectSelectionCriteriaTheBHTACHusedthefollowingprinciplestoguideitsdecision-makingprocessaroundtheProjectPortfolio:

• RegionalNeed:Doesitconnecttoahighmagnitudeofdocumentedneed(withoutduplicationorintensecompetitionofexistingefforts)?

• Healthequity:Doesthestrategyreducehealthdisparitiesand/oradvancehealthequity?Doesitaddress/supportsocialdeterminants(underlyingcommunityconditions)?Doesitreducestigmaanddiscrimination?

• Impact&Sustainability:Can/doesitaffectalargenumberofMedicaid-coveredlivesandwillitprovideareturnoninvestmentwithin2-3years?

• Feasibility:Istherepartneringproviderinterest?Dothestrategiesoractivitiesbuildon(andnotduplicate)existingefforts?IsthereaclearrolefortheACH?DoesthestrategylinktoP4RandP4Pmeasuresinthetoolkit?

• VBPReadiness:WillitincreaseregionalreadinessforVBPbytheendofthedemonstration?

SharedInterventions,Resources,andInfrastructureAlloftheprojectsintheBHTACHProjectPortfoliomakeuseofthePathwaysHUBasasharedresource.Alongwithintegrationofcare,expandingcarecoordinationeffortswillbeananchorstrategyfortheBHTACHregioninconnectingdisparatesystems.TheBHTPathwaysHubwillsupportbestpracticecarecoordinationandinformationsharingacrosstheregion’scommunity-basedorganizationsandhealthsystems.ThePathwaystechnologyplatformprovidesreal-timedatatoidentifyresourcegapsandmonitorstheeffectivenessofbestpracticeinterventionsaswellasthequalityofthecarecoordinationagenciesimplementingthem.Thiswillbeapowerfultooltosupportadata-drivencaseforalignmentofcommunityinvestments,especiallyaroundmajorresourcegapsinsafeandaffordablehousing,jobsinruralcounties,andtransportationthroughouttheregion.TheBHTACHwillwithhold10%ofalldemonstrationdollarstoinvestinaCommunityResiliencyFund.ThefundwillalignwithACHcommunityprioritiestostrengthenthelinkagesbetweenthehealthcaresystemsandproviderswhofocusonsocialdeterminantsofhealth.ItistheintentoftheBHTACHtoleveragethesedollarstoinfluenceincreased,targetedinvestmentinpopulationandcommunityhealthimprovement,includingaligningnonprofithospitalcommunitybenefitdollars,philanthropicfunders,andsharedsavingsinvestmentmodelsbasedondatasupportedbyaBHTACHCommunityDashboard(explainedbelow).AllourprojectswillshareanemphasisondisruptingtheintergenerationalcycleofAdverseChildhoodExperiences(ACEs),acentralpartofwholepersoncareforourregion.ACEswillbeincorporatedintoeachproject’simplementationplans.Manyconcurrentregionalactivitiesareaddressingtheseriskfactors,includingmultisectororganizationssuchasPrioritySpokane,InvestHealth,theAWayHomeWashington100DayChallengearoundendingyouthhomelessness,andEmpireHealthFoundation’sregion-wideACEsinitiative.TheBHTACHhasactivelyengagedindesigneffortswiththesepartnerstoensureproactiveconnectiontoMTDprojectsand,specifically,carecoordinationefforts.Inaddition,theBHTACHisdevelopingasharedlearningandqualityimprovementinfrastructure.ThisinfrastructurewillincludetheBHTProvidersChampionCouncil.Thisrecentlyestablishedcouncilwillprovidegeneralclinicalandsubjectmatterexpertiseacrossthe

fourMTDprojectareas.ThecouncilwillmonitortrendsinclinicalperformanceacrosstheprojectstoassesswhethertheBHTACHisontracktoachieveexpectedoutcomesandwilladviseonproposedriskmitigationandcontinuousimprovementstrategies.TheBHTACH’sDirectorofClinicalIntegration,apositioncurrentlyinrecruitment,willstafftheProviderChampionsCouncilandhelpidentify,communicate,andaddresschallengestoclinicalintegrationandothertransformationstrategies.ToserveastheimplementationarmfortheMTDProjects,theBHTACHwillutilizeaCommunityHealthTransformationCollaborativemodel,withaSpokaneCountybasedCollaborativeandaRuralCollaborative,includingeachofourfiveruralcounties.CollaborativeswillbesupportedbyBHTstaff,whowillhavea“bird’seyeview”ofworkoccurringacrosstheregion.TheCollaborativeswillbecomprisedofkeypartnerswiththeexpertiseandexperiencerequiredtotransformourMedicaidDeliverySystemincludingclinics,FederallyQualifiedHealthCenters(FQHCs),hospitals,mentalhealthandsubstanceuseproviders,EMS,JailsandCountyCommissioners.EachCollaborativewillbeaccountabletodevelopacounty-basedsystemofcareprojectplantomeetboththeregionalACHobjectivesandtheMTDprojectrequirements.Inadditiontodevelopingacounty-basedplan,theCollaborativeswillbeaccountabletomonitorperformance,coursecorrectwhennecessary,andparticipateinsharedlearningopportunitieswithintheregion.BHTACHiscontractingwiththeProvidenceCenterforOutcomesResearchandEducation(CORE)toleadthemonitoringsystemdesignandoversight.ProvidenceCOREwillserveasasharedresourceacrossprojects,coordinatingwithBHTstaffandtheentitiesabovetoprovidetimelyinformation,datainterpretationexpertise,andbothtechnicalandstrategicsupportforpeerleaningandcontinuousimprovement.WeexpectCOREtodevelopacommunitydashboardtomonitorkeymetricsidentifiedintheMTDToolkitandourcommunitypriorities.Thiswillbeamulti-functionaldashboardextendingbeyondtheMTDtoallowongoingcommunitytrackingandprioritysetting. StatewidetransformationeffortsoutsideMedicaidwillalsoserveasasharedresourceandframeworkfortheBHTACHProjectPortfolio.Thereareanumberofstatewide,system-levelactivitiesinmotionwhicharedrivingeffortsfortransformation,includingtheshifttovalue-basedpayment(VBP)by2021,theshifttoFullyIntegratedManagedCare(FIMC)by2020,andeffortswhicharealigningMedicaidandMedicarepaymentstructures.Tobesuccessfulunderthistransformation,providersmustdevelopnewpracticesandworkflowsthatwillmeetspecifiedoutcomes.TheBHTACHviewswhole-personcareasafundamentalelementforsuccessinavalue-basedcaresystem.Ifthesystemisnotequippedtoseeandrespondtowhole-personneedsofpatients,truepopulationhealthimprovementwillneverbepossible.Aligningregionalenergyandinvestmentinactivitiesthatsupportwhole-personcarewillhelpprepareourregionforsuccess.

Concurrenttotheseactivities,MTDdollarscreateanopportunitytoacceleratesomeofthetransformativechanges,whiledemonstratingthevalueofwholepersoncareforpatientsandtheoverallefficiencyofthesystem.Overthenextfiveyears,theBHTACHwillcoordinatethefourintersectingprojectsthattargethigh-needsMedicaidpatientsandbuildoutmulti-sectorlinkagesbetweenprovidersthatsupportwholepersoncare(seelogicmodelinAttachment1).Eachoftheseprojectswillbetiedtospecificoutcomemeasuresthatwillincentproviderstodevelopnewprocessestodrivepatienthealthimprovement.TheBHTACHseekstomaximizeregionaleffortsbyaligningMTDprojectswithimplementationstrategiesdevelopedforupcomingMedicarechangesviaproviders’participationinanACOand/orMACRA/MIPSpreparation.Overthelastthreemonths,theBHTACHhasexploredwaystoleverageruralparticipationinanACOtocreatemoreopportunityforinvestmentandearningsforcountieswithhighratesofbothMedicaidandMedicare.Thesealignedeffortswillbuildcommunityinfrastructureandscaleupbestpracticethatsupportsresponsiveandsustainablesystemsimprovement.Withthesenewlinkagesandpracticesinplace,theBHTregionwillbepoisedforlargescaleimprovementofpopulationhealth.

Region-WideImprovementsTheBHTACHmadeastrategicdecisiontofocusitsProjectPortfolioonthefourcriticalareasnecessarytoimproveregion-widehealthoutcomesaswellasthequality,efficiencyandeffectivenessofthecaredeliverysystem.Overwhelmingly,providersandcommunitypartnersseeCommunity-BasedCareCoordinationasafoundationalinvestmentcriticaltohealthsystemstransformation.Increasedcarecoordination;whetherthroughCommunityHealthWorkers,CareCoordinators,orPeerSupportSpecialistswillcreatestrongerandbetterconnectionsandresourcingofsocialsupportsthatwillimproveoutcomesforMedicaidbeneficiariesandaccelerateadditionaldeliverysystemchangesthatwillultimatelybenefitallconsumers.Investmentsandactivitiestosupportintegrationofcare,includingphysical,behavioralandoralhealthcare,willimproveproviders’abilitytocoordinatecareforallpatientsandhelptobuildcapacitynecessaryfornewpaymentmodels.Additionally,ChronicDiseaseisasignificantcostdriverintheregion’shealthcaresystem,forMedicaidbeneficiariesandallconsumers.Strengtheningtheregion’sabilitytopreventchronicdiseaseandprovidebettermanagementforthoselivingwithchronicdiseasewillimproveoutcomesandlowercosts,freeingupmuchneededresourceswithinthehealthcaredeliverysystem.Andfinally,theOpioidcrisisimpactseverycommunityandeveryincomelevel.Itundermineseffortsunderwaytoimprovequalityofcareandlowercosts.Addressingthiscrisisthrougheducation,overdoseprevention,treatmentandsupportforrecovery,isnecessarytopreventtheissuefromcontinuingtoworsen.HealthEquityHealthequityisafoundationalgoaloftheBHTACHProjectPortfolio.Toensurethatindividualsfacingthegreatesthealthdisparitiesareservedbyourefforts,alloftheprojectswillengagein

extensiveassessmentoftargetpopulationsbyrace/ethnicityandlanguageaswellasgeographyduringtheplanningphase.Inordertoaddresshealthequity,thesystemneedstobesupportedbymechanismsandpracticeswhichallowproviderstorecognizetheholisticneedsofthepatient.Weseepositivemovementinthisdirectionwiththerecognitionofthedegreeofdisparitythatexistsinthecommunityandanever-growingacceptanceoftheimpactsofsocialdeterminantsonoverallhealthstatus.ItistheintentoftheBHTACHtocontinuetoworktoaddressenvironmentalandcommunitybarrierstoimprovingpopulationhealth.Atthecoreofhealthsystemtransformationeffectivelinksbetweenthehealthcaresystemandthesocialdeterminantofhealth.TheBHTACHhasdevisedafewkeyactivitiestoaccelerateourownequitywork,including:

• Disaggregatingdatabyrace/age/ethnicity/sex/zipcodewhereverpossiblebothtomakeinformeddecisionsabouttargetpopulationsandtomonitorimpactofprojectsacrossdiversegroups.TheBHTBoardhasidentifiedimpactedpopulationstotargetforMTDprojects.BHTwillsupplyCollaborativeswithregionaldatatoguideassessmentsofpartners,andexpecttodirectteamstodevelopTransformationplanstoaddresspopulationswithintheircountythatfaceahighlevelofdisparitiesand/orpresentashighlycomplexorhighrisk.

• LaunchingaCommunityVoicesCouncil,madeupofatleast50%Medicaidbeneficiariesorlow-incomecommunitymembers,aswellasCommunityAdvocatesandpeoplewithexperienceworkinginMedicaidservices.ThiscouncilwillbetaskedwithdevelopingHealthEquitymetricstowhichtheCollaborativeswillbeaccountableforhealthequitygoalsandstandards.ThisCouncilwillreviewtheCollaboratives’HealthEquityandTransformationprojectplansandprovidefeedbackoneffectivenesstoaddressingaccesstocareandequity.

• Developingan“EquityAcceleratorPayment”forprovidingpartnerswhoserveagreaterproportionofhighriskclients.ThismayincludeorganizationsthatservepredominatelyLatino/Hispanic,NativeorAfricanAmericanpopulations–allofwhomexperiencesignificanthealthdisparities–ororganizationsprovidingspecialtyservicestohighlycomplexpatientsthatrequiremoreintensivecare,suchassomesmallerMentalHealthandSUDproviderswhomightbeseeingfewerpatientsbecausetheonestheyservehavesuchintenseneeds.(WeexpectthemetricstiedtothesepaymentswillbeexploredbytheWaiverFinanceWorkgroup,vettedbyProviderChampionsCouncilandCommunityVoicesCouncil,andthenfinalizedforBHTBoardapproval.)

• Furthermore,thestrongemphasisonCommunity-BasedCareCoordinationasananchorstrategyservingallprojectsinthePortfoliowillalsoenabletheBHTACHtopromotehealthequity.ThePathwaysHubmodelwillexpandaccesstoCHWsandtheregion,providingculturallyandlinguisticallyresponsivecareacrossalloftheprojects.ThePathwaysHubcloselymonitorstheprogressofeachCareCoordinationAgency’s

CareCoordinatorsandclientstolookfortrends,strengths,andweaknessesamongproviders.ThisbothhelpstheHubtomaintainthequalityofcare,andoffertrainingswhenweaknessesareidentified,andhelpstheHubgrowourunderstandingofwhichagenciesmayofferthegreatestexpertiseorexperiencewithspecificpopulations.Additionally,thePathwaysmodelisoftenmostsuccessfulwhenimplementedwithcarecoordinatorswhohavelivedexperienceand/orcanrelatetopatientstheyareserving,providinganopportunityforworkforcedevelopmentandservicedelivery.

TheBHTACHalsointendstoconnectprojectwork,particularlyintheChronicDiseaseandCommunity-basedCareCoordinationproject,tolargersystemicworktoaffectACEs.HavingoneormoreACEsisassociatedwithhigherincidenceofchronicillness.50Ourfocusonapopulationwithdisproportionateimpactofchronicillnessisonewaytohelpdisproportionatelyaffectedpopulationsmoregenerally.BusinessModelandSustainabilityTheBHTACHisfocusedonmovingtheregiontoVBPandwholepersoncare.VBPisthecornerstoneofoursustainabilityplaninrecognitionoftheneedtotransitionhowwepayforcareandlinkingservicesthataddresssocialdeterminantsofhealth.Weareworkingtoaligndata,fundsflow,andmodeldevelopmenttomaximizetheopportunitytointegrateselectedprojectsintoavalue-basedmodelandweavetogetherlocalresourcesandinvestmenttoreachthisgoal.Forinstance,ourFundsFlowpolicywillincludedirectedinvestmentsforstartupcostsaswellasinfrastructureandtechnicalassistanceemphasizingDSRIPfundingfortransition,notanongoingpaymentstream.TheCommunityHealthTransformationCollaborativesaredesignedtosupporttheformationofthepartnershipsneededtosupportgeographicallybasedsystemsofcareinavalue-basedenvironment.ThelinkagescreatedtosupporttheMTDprojectswilltranslatetotherelationshipsnecessarytosucceedinavalue-basedmodelandimprovepopulationhealth.ThesupportfromtheACH,MTDdollars,andlocalinvestmentwillcreateanenvironmenttotestnewprocessesandimplementnewpracticestoensurereadinessforVBPandimprovedcaredelivery.EachofthefourMTDprojectsplayakeyroleininfrastructurechangeneededtosupportVBP.Increasedfocusandinvestmentinprevention,andscalingmoreefficientandconnectedinterventionstrategies,willleadtoamoreresponsivecommunityhealthsystem.TheBHTACHisalsoworkingtoalignitsstrategieswiththeACOdevelopmentsinMedicare,especiallyinruralcountieswiththemostrecentmeetingwithpartnersonNovember3rd,2017incollaborationwithGreaterColumbiaandNorthCentralACHs.TheCommunityResiliencyFundisanareathatmayextendbeyondtheMTDperiodaswebuildcommunityinvestmenttosupporteffectiveapproachestoaddressingsocial

determinantsofhealth.BHTwilldevelopacommunitydashboardthatmonitorskeysocialdeterminantandhealthindicatorsofourregionalhealthsystem’sviability.Byaligningregionalpartnersandinvestorsaroundtheseindicators,usingthedemonstrationasacatalyst,wecanidentifysynergiesandcreatealeveragedfundofflexibledollarsfortheregiontoaccessforstrategicinvestmentinovercominghealthdisparities.ImprovementssincePhaseIICertificationSincePhaseIICertification,theBHTACHhasdevelopedconcreteplansforsharedresourcesacrossprojectareas.TheBHTACHhascontinuedtorefineitsplansforsupportingtheworkoftheMTDProjects,aswellasthelong-termroleoftheACH.AstheregionalPathwaysHub,theACHwillmaintainanetworkofcommunity-basedreferralsandcarecoordinationresources,ensuringbest-fitcareattherighttime.TheACHwilltrackpopulationhealthacrossmultiplesystemstomeasuretheoveralleffectivenessofthecarenetworkinimprovingaccessandoutcomes.Baselinedatawilldefinethecurrentstatusandhelpidentifybrightspotinterventionstoscaleaswellasgapsorwideninghealthdisparities.Thisdatawillinformrecommendationsforpolicychange.CommittedtofurtheringourworkpastDSRIP,theBHTACHwillpositiontheuseofthePathwaysHubandaCommunityDashboardaslong-termcommunityinfrastructure.

GovernanceGovernanceBHT’sGovernanceStructureAlthoughtheBoardofDirectorsisultimatelyaccountableforBetterHealthTogetherACHdecisions,ourgovernancestructureismulti-tieredwithdistributeddecision-making,jointownershipandmutualaccountabilitythatdrivesinnovationandfostersco-investmentthatleadstoimpact.Thisstructureiscomprisedofthefollowingbodies(seealsotheGovernancestructurechartinAttachment2):

• BoardofDirectors:19-memberdecision-makingandoversightbodyforBHTACH.AccountableforTransformationProjectsandallworkoftheBetterHealthTogetherACH.TherearefourstandingoperatingcommitteesoftheBoardtoconductworkoftheBoardandpreparetheBoardfordecision-making.Theseare:

o ExecutiveCommittee:CommitteewiththeauthoritytomakedecisionsonbehalfoftheBoardasappropriateandconductotherBoardbusiness.

o GovernanceCommittee:RecommendsforapprovalBoardCandidates,Officers,CommitteeLeadershipandmembers.

o FinanceCommittee:ProvidesfinancialoversightforACHadministration,BHTbudgetdevelopment,andotherBHTfinancialoperations.

o AuditCommittee:AnnuallyreviewsAuditfindingsfromindependentauditors.

• LeadershipCouncil:Anadvisorybodycurrentlycomprisedof68organizations,whosebroadparticipationhelpssynthesizelocalprioritiesintoregionalstrategies.(SeeAppendix11forthemostrecentlistofLeadershipCouncilmembers).ItisexpectedthattheLeadershipCouncilwillbeconvenedonaquarterlybasisin2018.

• TribalPartnersLeadershipCouncil:TofostercollaborationandcommunicationwithregionalTribes,IndianHealthServicefacilities,TribalOrganizations,andUrbanIndianHealthPrograms,TheTribalPartnersLeadershipCouncilwascharteredandiscomprisedofrepresentativesfromtheKalispelTribeofIndians,ConfederatedTribesoftheColvilleReservation,SpokaneTribeofIndians,TheNATIVEProject,TheHealingLodgeoftheSevenNations,andtheAmericanIndianCommunityCenter.RecognizingtheuniqueandimportantrolethatAmericanIndian/AlaskaNative(AI/AN)populationshaveinourregion,theBHTBoarddevelopedthisgrouptoensurethatMedicaidTransformationDemonstration(MTD)projectswerealignedandculturallyappropriatetomeetthehealthneedsofNativeAmericans.ThisCouncilwillcontinuetoplayacriticalroleinimplementationplanningandmonitoringimpactofMTDprojectsonTribes,Urban

Indians,andIndianHealthServicesfacilities.TheTribalPartnersCouncilwilladviseonmetricstoevaluatehowwellprojectplansaddresshealthequityasitrelatestoAI/ANhealth.

• TechnicalAdvisoryCouncils:TheTechnicalAdvisoryCouncilsprovidetechnicalexpertiseandinputdirectlytotheBoardofDirectorsabouttheregion’sMTDprojectsandstrategies.TherearethreeTechnicalAdvisoryCouncils:

o ProviderChampionsCouncil(PCC):ThisrecentlyestablishedCouncilprovidesclinicalexpertiseandsubjectmattersupportinthedevelopmentofthe“TransformationCompact”(seeProgramManagement&StrategyDevelopmentbelow)acrosstheMTDProjectsareas.TheCouncilwillrecommendkeyclinicalelementsandperformancemeasuresacrossprojectstoassesswhetherCollaborativesareontracktoachieveexpectedoutcomes.ItisexpectedthatthisCouncilwillalsoplayaroleindevelopingclinically-focusedcontinuousimprovementstrategies.

o CommunityVoicesCouncil(CVC):TheCVCwilllaunchinDecember2017.Atleast50%ofmemberswillbeMedicaidbeneficiaries,withtheotherhalfmadeupofCommunityadvocateswithlivedexperiencehelpingcomplexpatientsaccessandnavigatecommunityservices.ThisgroupwillinformCollaborativeprojectplanningbyvalidatingimplementationplansagainsttheneedsandexpectationsofMedicaidpatients.TheCVCwilladviseonmetricstoevaluatehowwellprojectplansaddresshealthequity,andwillusethesemetricstomonitorandmakerecommendationsforcoursecorrectionasneeded.MemberswillreceiveastipendfromBHTfortheirparticipation.

o WaiverFinanceWorkGroup:ThisgroupdevelopsandrecommendstotheBHTBoardasetofpoliciestogoverntheMTDFundsandprovidesoversightofMTDfunddistributionasnecessary.ThisteamwillalsovalidatefinancialplansforapprovalbytheBHTBoard.ThisgroupmakesrecommendationsdirectlytotheBoard(nottotheBHTBoardFinanceCommittee)onallMTDfundsallocationsandbudget,CommunityResiliencefunds,andmid-adopterFIMCIncentives.

FortheMTDprojectstobesuccessful,BHTrecognizesthattheACHleadershipmustdevelopandmaintainstronglinesofcommunicationandcollaborationwithpartneringproviders.Inadditiontotheleadershipandadvisorycouncils,BHTisestablishingRegionalCommunityHealthTransformationCollaboratives:

• RuralCollaborative(includingFerry,Stevens,PendOreille,Lincoln,Adamscounties)

• SpokaneCollaborative(Spokanecounty)

ItistheintentoftheBHTACHtotakearegionalapproachtoMTDprojectdesignandimplementationtoallowlocalautonomywhilecreatingregionalaccountability.TheCollaborativeswillberesponsiblefordevelopingandleadingactionableMTDplansacrossBHT’sprojectportfolio,andensuringthattheprojectscoordinatewithanddonotduplicateexistingeffortsintheregion.TheCollaborativeswillbecomprisedofkeypartnerswiththeexpertiseandexperiencerequiredtotransformourMedicaidDeliverySystemincludingclinics,FederallyQualifiedHealthCenters(FQHCs),hospitals,mentalhealthandsubstanceuseproviders,Tribalhealthsystems,EMS,jailsandCountyCommissioners.TheCollaborativesandtheACHTechnicalCouncilswillworkinabi-directionalfeedbackpartnershiptofinalizepolicyandprojectplans.Bydesign,thereiscross-representationbetweenCollaborativesandTechnicalCouncilstoensurelocalbuy-inandregionalaccountability.Itwillbetheresponsibilityoftheseleaderstoprovidestrategicguidanceonissuescriticaltoimprovinghealthbasedonexperience,expertise,andperspective,usinganevidence-based,“healthinallpolicies”approachatbothlevels.Thisstructureisdesignedtopromotemeaningful,cross-sectorcollaborationanddeepengagementofpartners,aswellastopreventanysingleentity,sector,orpersonfromdominatingthedecision-makingoractivitiesoftheACH.TheLeadershipCouncilandtheTechnicalCouncilsprovidetheBoardwithinputandrecommendationsfromsubjectmatterexpertswhiletheRuralandSpokaneCommunityHealthTransformationCollaborativeswillprovidelocalcontrol,expertise,andimplementation,acriticalfunctionforBHTgivenourlargegeographicregion.BoardmembersparticipatethroughouttheTechnicalCouncilsandRegionalCollaborativesasvestedpartnersandtoensuretoensuretheBoardofDirectorshasadirectrelationshipandstronglinesofcommunication.

Thefollowingfiguredemonstratestheintegratedandinter-dependentgovernancestructurethatconnectstheBHTBoardandAccountableCommunityofHealthLeadershipCounciltoourengagementpartnersintheRegionalHealthTransformationCollaboratives.Thefigurealsoemphasizestheimportanceofacommonagenda,continuouscommunications,andmutuallyreinforcingactivities.WhiletheapprovaloftheACHactivitiesandpoliciesisultimatelytheresponsibilityoftheBHTBoardofDirectors,itistheexpectationthattheACHLeadershipCouncilandCommunityHealthTransformationCollaborativeswillplayasignificantroleininfluencingthedevelopmentofourregion’shealthtransformationplans.

Figure11:BHTACHGovernanceandEngagementStructure

Inadditiontothegroupsdescribedabove,BHThasestablishedaRegionalIntegrationTeamtosupportthestatemandated2020goalofIntegratedMedicaidManagedCare.ThisteamprovidesamultisectorforumforkeystakeholdersandpartnerstodevelopaplanandtimelinetomeetthestategoalandacceleratetransformationfortheMedicaidpopulation.

FinancialOversightTheBHTBoardFinanceCommitteeprovidesfinancialoversightforACHadministration,BHTbudgetdevelopment,andday-to-dayoperations.Decisionsaboutfundsallocationmethodology,projectbudgetdevelopment,andtheTransformationCompact(seeProgramManagement&StrategyDevelopmentbelow)aremadebytheWaiverFinanceWorkgroup,whichiscomprisedofcountycommissioners,leadersfromphysicalandbehavioralhealthorganizations,socialdeterminantofhealthproviders,Tribalhealthleaders,RuralPublicHospitalDistricts,MultiCare,Providence,andMCOs.(SeeAppendix12fortheWaiverFinanceWorkgroupCharter).ThisgroupmakesrecommendationsdirectlytotheBoard(nottheFinanceCommittee)onMTDProjectFunds,CommunityResilienceFunds,andMid-AdopterFullyIntegratedManagedCareIncentivefunding.ThefirstsetoffundingallocationdecisionsweremadeattheNovember2,2017Boardmeeting.

ClinicalOversightTheBHTACH’sclinicaloversightstrategyincludestheBHTProviderChampionsCouncillaunchedinNovember2017.Asdescribedearlierinthissection,thePCCprovidesclinicalexpertiseandsubjectmattersupportinthedevelopmentoftheTransformationCompact(seeProgramManagement&StrategyDevelopmentbelow)acrosstheMTDProjectsareas.ThePCCwillrecommendkeyclinicalelementsandadviseonclinicalperformancemeasuresacrossprojectstoassesswhetherCollaborativesareontracktoachieveexpectedoutcomes.Additionally,thePCCwilladviseonproposedriskmitigationandcontinuousimprovementstrategies.StrategiesformonitoringclinicaloutcomesandcaredeliveryredesignOurinitialassessmentofclinicalcapacitywasconductedthroughself-reportedinformationcollectedfrom23healthsystemsviaaHealthSystemsInventory,whichidentifiedcurrentandfuturecapacityneedsandplans.Thisscaninformedprojectselectionandfindingswillcontinuetobecross-referencedwithotherrelevantdatasourcesusinganalyticsupportfromProvidenceCORE.BHTACHiscontractingwithCOREtoleaddesignandoversightofourmonitoringsystem.COREwillserveasasharedresourceacrossMTDprojectsandCollaborativestoprovidetimelyinformation,datainterpretationexpertise,andbothtechnicalandstrategicsupportforpeerleaningandcontinuousimprovement.Additionally,theProviderChampionsCouncilwilldevelopaframeworktoaddressproviderneedsandadvocateforallocationofappropriateresources.TheWaiverFinanceWorkgroupwillalignproposedfinancialincentiveswithclinicalandprojectperformanceduringtheplanningphasein2018.ThePCCwillsupportsharedproblem-solvingandlearning,andprovidesupporttoproviderswhoarestrugglingwithimplementationorhavingdifficultyachievingmetricsorreportingtargets.StrategiesforincorporatingclinicalleadershipClinicalleadershipiswell-representedontheBHTBoard,LeadershipCouncilandTechnicalCouncils,particularlythePCCandintheRegionalCommunityHealthTransformationCollaboratives.TheHealthSystemsInventoriesalsoservedasaninitialstrategyforengagingclinicalproviders.Asameasureofoursuccesstodate,inventoriesreceivedcoveredallsixofourBHTACHcountiesandrepresentedmorethan80%ofthehighvolumeMedicaidbillersintheregion.Eightwerefromruralpartners;threewerefrompublichospitaldistrictsthatincluderuralclinics;threefromI/T/Upartners,andfourfromFQHCs.WealsoreceivedinventoriesfromallhighvolumeMedicaidbehavioralhealthprovidersintheruralcommunityandthelargestproviderinSpokaneCounty,aswellasbothProvidenceandRockwood/Multicare.The

BHTACHwillcontinuetoengagewithclinicalproviderstoensureparticipationintheCollaborativesandoversightofclinicaloutcomesandcaredeliveryredesign.WeexpecteachCollaborativetoengagewithcriticallocalpartnersneededtofulfilltheirprojectimplementationobjectives.Additionally,initsroleasthePathwaysHub,theACHwillserveasaconnectorbetweenCollaborativeprovidersandadditionalsocialservicesandcommunitypartnerswhocansupportconnectionstosocialdeterminantsofhealth.CommunityOversightAsBHT’sACHroleexpandedtoincludethatofregionalconvenerandbackbone,wefurtherdevelopedourgovernancestructuretoincludetheLeadershipCouncil.Thecombinationofstrategicalliancesandengagementstrategiesensuresfocusonthehealthstatusandprioritiesofthewholecommunitysothatnosingleentity,sectororpersondominatesthedecision-makingoractivitiesoftheACH.Additionally,asdescribedearlier,inDecember2017BHTwilllaunchTheCommunityVoicesCouncil,comprisedofatleast50%Medicaidbeneficiaries,withtheotherhalfmadeupofcommunityadvocateswithlivedexperiencehelpingcomplexpatientsaccessandnavigatecommunityservices.DataOversightBHTiscontractingwithProvidenceCOREtoleadthemonitoringsystemdesignandoversight.COREwillserveasasharedresourceacrossprojects,coordinatingwithBHTstaffandtheentitiesabovetoprovidetimelyinformation,datainterpretationexpertise,andbothtechnicalandstrategicsupportforpeerlearningandcontinuousimprovement.ProgrammanagementandstrategydevelopmentProjectswillbedevelopedandmanagedbytheRuralandSpokaneHealthTransformationCollaboratives.TheCollaborativeswillbeguidedbyaTransformationCompactdevelopedinpartbytheTechnicalAdvisoryCouncilsthatwillincludeastrategicrubricofrequiredelements,strategiesandmetrics,afundsflowframework,andassessmenttools.TheCollaborativeswillbesupportedthroughregionalinfrastructureincludingconsultantsandBHTstaffaswellassupportfromtheTechnicalAdvisoryCouncilsasneeded.BHTwillsupportregionalcoordination,crosssector/crossregioncommunication,andprojectmanagementoversight.BHTPositionsinclude:

• BHT’sExecutiveDirectorwillprovideleadershipandstrategysupportacrosstheregionwithaspecificemphasisonensuringregionalpolicyalignmentforFIMC,MTD,andACOdevelopment.Additionally,theExecutiveDirectorwillworktoincreaseinvestmentinTransformationeffortsbeyondMTDandincreasefundingfortheCommunityResiliencyFund.TheExecutiveDirectorstaffstheWaiverFinanceWorkGroup,RegionalIntegrationTeamandBHTBoardofDirectors.

• BHT’sDirectorofClinicalIntegration,apositioncurrentlyinrecruitment,willprovideCollaborative-andprovider-levelsupportonMTDclinicalintegrationefforts.TheDirectorstaffstheProviderChampionCouncil.

• BHT’sAssociateDirectorofHealthTransformationwillprovideoperationalandstrategyleadershiponCommunityCareCoordinationincludingdirectingthedevelopmentofthePathwaysHub.TheDirectoralsoprovidesleadershipandstrategysupporttostaffingtheTribalPartnerLeadershipCouncil.

• BHT’sAssociateDirectorofCommunityEngagementwillprovideoperationalstrategyleadershiponeffortstoengageMedicaidBeneficiariesinMTDplanningandimplementation,aswellascommunityengagementefforts,includingstaffingoftheACHLeadershipCouncilandtheCommunityVoicesCouncil.

BHTwillcontract,asneeded,withtechnicalconsultantsandsubjectmatterexpertstosupportthedevelopmentofassessmenttools,fundsflowarrangements,projectplans,dataandanalyticstrategy,andotherspecifictechnicalassistanceasneedsoftheCollaborativearesurfaced.ChangestoGovernanceStructuresincePhase2CertificationInadditiontothenewTechnicalCouncilsmentionedaboveandtheRuralandSpokaneCountyHealthTransformationCollaboratives,BHThasaddedfournewmemberstotheBoardofDirectors:acountycommissioner,aSpokaneTribeofIndiansrepresentative,theCEOofthelargestregionalFQHC,andtheChairmanoftheBoardoftheSpokaneCountyMedicalSociety(whoisalsoapracticingfamilyphysician).Inordertoincludetheseimportantregionalpartners,BHTincreasedthesizeoftheBoardfrom17to19membersinOctober2017,whentherewerepreviouslytwoBoardseatvacancies.BHTalsoadded6non-votingex-officioCountyCommissionerpositions. AreasIdentifiedasNeedingImprovementinPhase2Certification

Comment:“LackofclarityregardinghowBHTwillsupportboardmembersinestablishingregularcommunicationtoolstosupportongoingfeedbacktotheirsector.Themechanismsareunclear.”

TofurthersupporttheexpectationthatBoardmembersrepresenttheirsectorandtoimprovesectorcommunication,theBHTDirectorofCommunityEngagementdraftsasummaryaftereachBoardmeetingandpresentsittoBoardmemberstobeindividuallytailoredtotheirparticularsectorandsentwithinaweekofthemeeting.(AnexampleofthissummaryisprovidedinAppendix13).Thisprocessensuresthat,inadditiontogeneralBHTcommunication,thesectorsthatBoardmembersrepresenthavethemostup-to-dateinformationfromacolleagueintheirsector.Wehavereceivedpositivefeedbackonthisadditionalcommunicationeffortfromseveralpartners.

Comment:“WouldappreciateadditionaldiscussionregardingthepotentialCOIconcernsthatthepolicyisintendedtoaddress.”

ArevisedConflictofInterestpolicywasadoptedinJuly2017andisdesignedtoguideBoardMembersinavoidingandbeingtransparentaboutfinancialorotherpotentialconflictsofinterest.ThispolicyisintendedtoaddressanycircumstanceunderwhichaBoardmembermaybeinfluencedormayappeartobeinfluencedbyanypurposeormotiveotherthanthesuccess,bestinterest,andwell-beingofBetterHealthTogether.(SeeAppendix14fortheupdatedConflictofInterestpolicy).OurConflictofInterestpolicyhelpstoassuretransparencyinBoarddiscussionsanddecision-making,whichisimportantformaintainingthetrustofthecommunityandpartneringproviders.TheBoardChairopenseachmeetingbyaskingwhetheranymemberhasaconflict.TheChairalsohastherighttodeterminewhetheranotherBoardmemberhasaconflict.Boardmeetingsareopentothepublic.Describetheprocessforensuringoversightofpartneringproviderparticipationandperformance,includinghowtheACHwilladdresslow-performingpartneringprovidersorpartneringproviderswhoceasetoparticipatewiththeACH.

TheBoardhasultimateoversightoftheimplementationofMTDprojectsandoutcomes.TheRuralandSpokaneCountyCollaborativestructurewillmobilizelocaleffortstotransformtheMedicaiddeliverysystem.TheTechnicalCouncilssettherequirementsforsuccessoftheCollaborativesthroughthedevelopmentofaframeworkandmetricsofsuccessandbyidentifyingareasofimprovement.TheProviderChampionsCouncildevelopsrequiredclinicalchangeelements,andprovideoversightonclinicalintegrationprogress.TheWaiverFinanceWorkgroupdirectsfundsflowmodellingandprovidesfinancialoversight.TheCommunityVoicesCouncilandTribalPartnersLeadershipCouncilsetgoalsforbeneficiaryandNativeAmericanhealthintegrationandhealthequitygoals,andprovideoversightonprogressinthoseareas.ItisexpectedthatourFundsFlowmodelwillrewardparticipationandachievementofmetricsataProviderandCollaborativelevel.ThismodelallowsforustoensurebroadMedicaidproviderengagementthroughouttheregionandrewardperformance.BHTstaffandTechnicalAdvisoryCouncilswillengageexternalsubjectmatterexpertsasnecessaryinthedevelopmentofnecessarytechnicalassistanceandsharedlearningopportunitiestosupportproviders.BHTStaffwillalsofacilitatesharedlearningacrossprojectsandpartneringproviders.StartinginQ1of2018,Collaboratives/ProviderswillberequiredtosubmitmonthlyprogressreportstoBHTACHtotriggerparticipationpayments.ThisprogressreportwillallowBHTstafftomonitorprogressandprovidetechnicalassistancewherenecessary.Additionally,viaourTechnicalCouncils,BHTintendstoconvenecohortsofpartnerstolearnfromsuccessesandcollectivelyproblemsolvechallenges.In2019,BHTwillbegintoutilizeacommunitydashboarddevelopedbyCOREtomonitorkeymetricsrelatedtoMTDand

communitypriorities.AsweembarkontheCollaborativeplanningprocess,BHTACHiscommittedtoworkcloselywithpartnerstoassessthebestwaytosupportbothhighperformingandlow-performingandtodosofairlyandtransparently.

CommunityandStakeholderEngagementandInput

CommunityandStakeholderEngagementandInputTheBHTMeaningfulConsumerEngagementandMeaningfulProviderEngagementplanningprocessesinvolvedseveraltiersofactivitydesignedtosecureinputintotheselectionandplanningofMedicaidTransformationDemonstration(MTD)andtoyieldarecommendedpolicyandstrategyfortheBHTBoardtoconsideradoptingforongoingmeaningfulengagementofconsumersinfutureAccountableCommunityofHealth(ACH)andMTDactivities.TheengagementprocesseswerefacilitatedbyAppliedInsight.Tworeports,1)BHTMeaningfulConsumerEngagementand2)BHTMeaningfulProviderEngagement,detailfindings.(SeeAttachments3and4.)MeaningfulConsumerEngagement

Intotal,40consumersparticipatedinfocusgroupdiscussionstoinformtheselectionandplanningofMTDprojectsfortheBHTACHregionandtoprovideinsightandideasforestablishingalong-term,meaningfulconsumerengagementstrategyforongoingACHactivities.Thefollowinggroupswerecoordinatedinpartnershipwithavarietyofcommunityhostorganizations:

• YouthinFosterCareand/orRecentlyAgedOutoftheFosterSystem(inpartnershipwithEmbraceWashington,CareerPathServices,andSafetyNet)

• TribalMembersandUrbanIndianCommunityCenterVisitors(inpartnershipwiththeAmericanIndianCommunityCenterandEmpireHealthFoundation)

• RuralResidentsthroughoutNortheastWashington(inpartnershipwithRuralResources)

• RuralResidentsthroughoutLincolnCounty(inpartnershipwithLincolnCountyHealthDepartment)

• UrbanResidentsthroughoutSpokaneCounty(inpartnershipwithCommunityHealthAssociationofSpokane/CHAS)

Namesoffocusgroupparticipantsareconfidential,buthostorganizationsverifiedattendanceandgroupcompositionwasvalidatedfordiversitytoensurethefollowingcharacteristicswererepresentedbytheattendees:

• Geography(rural,urban,tribal)

• Raceandethnicity

• Gender

• Age

• Healthconditions

• SocialdeterminantneedsMeaningfulProviderEngagement

Intotal,21providersparticipatedinkeyinformantinterviewsand24providersparticipatedinthreeseparatefocusgroupstoinformtheselectionandplanningofMTDprojectsfortheBHTregionandtoprovidetheirinsightsandideasforestablishingalong-termmeaningfulproviderengagementstrategyfortheactivitiesoftheACH.Namesofintervieweesandhostorganizationsforfocusgroupsareincludedintheattachedreports.Intervieweesandfocusgroupparticipantsrepresentedadiversecross-sectionofprovidersaccordingtothefollowingcriteria:

• Geography(rural,urban,Tribal)

• Raceandethnicity

• Healthsystem/practicesizeandmodel(large,small,independent,university-affiliated,communitynon-profit,etc.)

• Sectorrepresentation(medical,behavioral,substanceabuse,oralhealth,publichealth,MCO,etc.)

• Practicetype/targetpopulationserved(pediatric,geriatric,familymedicine/primarycare,internalmedicine,tribal,homeless,psychiatric,etc.)

• Socialdeterminantsorganizations(housing,foodsecurity,socialservices)HealthSystemandCareCoordinationInventories

InlateAugust,BHTACHconducteditsHealthSystem(HSI)andCareCoordinationInventories(CCI),seekingpartneringproviderperspectivesontransformation(seeAppendices6and7).ThecomprehensiveinventorieshavebeenutilizedtoinformdecisionsabouthowtostructureourMTDplanningefforts.BHTACHofferedaPayforReportingincentivetoallpartnerswhocompletedtheinventories(excludingMCOs)of$5000fortheHSI,and$2000fortheCCI.TheHSIwasconsiderablylonger,andaskedformorepatientleveldata,whichaccountedforthehigherpayout.Intotal39uniquepartnerscompletedinventories,earning$181,000total.Thenumberofinventoryrespondents(HSIorCCI)bycountyisshowninfollowingchart;notethatseveralparticipatingorganizationsoperateinmorethanonecountyandarelistedunder‘multiple.’

Figure12:HealthSystemandCareCoordinationInventoryRespondentsbyCounty

EnsuringTransparencyandConsideringPublicInput

TheBHTACHinvestsheavilyinarobustwebsitewhichincludestheLeadershipCouncil(LC)andBoardmeetingschedulesforthewholeyear,aswellasnotes,documentsandrecordingsfrommeetings.Weregularlypostsynthesizedcontentonourbloginaneasy-to-digestformattosupportsharedknowledge.WeareespeciallyproudofourPathwaysvideos,whichwereincrediblywellreceivedbypartners.Additionally,allnewinformationissharedinweeklyACHeNewsupdatethroughMailChimp,whichhasincreasedfrom~200to~300subscriberssincewesubmittedourPhase1certification.WeareactiveTwitterusers,andattempttotweetabouteachmeetingordiscussionswithpartnerstoincreasetransparency.TheBHTBoardhostsapubliccommenthourandopenboardmeetingsonceamonth,generallyinSpokaneatthePhilanthropyCenter;accessisalsoavailablebywebinarcall-in.WealsohostaBoardmeetingannuallyinoneofourruralcounties.InMayof2017,wemetattheCamasPathCenterinPendOreilleCountyontheKalispelReservation.Thedates,locationandagendaforupcomingBoardmeetingsarepostedinadvanceonourwebsite.BHTstaffprovidesareportofanypubliccommentduringtheBoardmeetingandensurespubliccommentsarereflectedintheminutes.OnceapprovedbytheBoard,theminutesfromeachmeetingarepostedonourwebsite.

0 2 4 6 8 10 12 14 16 18 20

Adams

Ferry

Lincoln

Multiple

PendOreille

Spokane

ACHCapacityBuilding

SinceaddingthreemorestaffinMay2017,theBHTACHhasgreatlyincreaseditscapacitytoengageandseekfeedbackfromcommunitymembers.CentraltoourstrategyisofferingACHstafftimeforlocalcapacitybuilding,suchasstaffingRuralCountyHealthCoalitionsorfacilitatingprogramdesignacrosspartners.We’vewitnessedsuccessinourengagementstrategythroughregularparticipationfromahighnumberofdiversepartners,whoparticipatefreelyinconversationandcontributingtotheACH’sregion-widevisionandstrategy:

• Over75communitymembersparticipatedonaCommunityStrategyActionteam.

• Wereceivedlettersofinterest(LOI)representing90+differentprojectideasfromfortyuniqueorganizations

• 94communitymembersattendedourProjectShowcaseinSpokanetoprovidefeedbackinprojectideas,withrepresentationfromallsixcounties

Thislevelofparticipationsignalsasignificantlevelofcommitment,especiallywhencommunitymemberstraveledtogivefeedbackonprojectideas.Tosupportregionalparticipation,BHTACHofferstocompensatemileageandlodgingforruralpartners.Ourstaffarequicktoconductoutreachwithanyneworganizationsandcommunitymemberswhoexpressinterestorattendanyofourmeetings.OurLeadershipCouncilnowconsistsof68memberorganizations,with10newmembersaddedsinceSeptember2017.SincePhase2,theBHTACHhaslaunchedaweeklyCollaborativeLearningSessionwebinaronFridaymornings,coveringkeystrategiesandactivitiesoftheMTD.Thesesessionsareopentothepublicandallrecordedandpostedonourwebsite.

Table3:CollaborativeLearningSessionWebinars

ProvideexamplesofatleastthreekeyelementsoftheProjectPlanthatwereshapedbycommunityinput.TheBHTACHhasreliedoncommunityinputtoguideourprocess,withourregionalprioritiesgeneratedfromcommunityconversationsacrossallcountiesandunanimouslyagreedtobyourLeadershipCouncil.Weconductedover40meetingstobuildourCommunityActionStrategy

Date(2017) LearningSessionTopic

October6 RHNIOverview–howACHusesdata

October13 TransformationProjectSelection:4vs6vs8

October20 BehavioralHealthIntegration

October27 OverviewofCommunityLinkageMapping

November3 RegionalHealthWorkforceDevelopment

Maps,whichanchortheACHeffortstomemberswhoparticipatedintheseworkgroups,includingMedicaidbeneficiarieswhospoketotheirexperiences(seeAppendix1).Keyelement1:Participantsinthecommunityconversationsdescribedourregionashavingawealthofpassionatepeopleandeffectiveprograms,butaninabilitytomakelarge-scalepopulationimprovementsduetoalackofhigh-level,outcomes-basedcoordination.Participantsspecificallynotedtheneedtocoordinatethecoordinators.ThisfeedbackledustoexplorethePathwaysHUBModelforourSIMproject,andthemodelnowservesasafoundationalstrategyfortheBHTACH’sMTDefforts.Commentsandthemesgleanedfromtheproviderengagementfocusgroupsandkeyinformantinterviewsdescribedaboveledtothedevelopmentofotherkeyelements:Keyelement2:Providersidentified:significantchallengesincarecoordinationandcaretransitions;policyrestrictionsthatimpedetheabilitytocoordinatecareforcomplexpatients;inadequatetimewithpatients;andtheneedfortrainingandmodelsthatsupportthenewintegratedcareteamandrelatedsystemschangesbothwithinclinicalsettingsandbetweenclinicalandcommunityproviders.Additionally,mostofthehealthcareprovidersinterviewedpreferredacommunity-basedapproachtocarecoordinationthatseamlesslyandeffectivelyintegratesintotheclinicalsetting.Oneprovidernoted,“thisshouldbehousedoutsideofour,oranyone’s,systemandshouldfollow/servetheneedsoftheclient.”ThiscalloutfitswellwiththePathwayHUBModel.Keyelement3:ThroughtheprojectLettersofInterestandorganizationalHealthSystemsInventories,providersreflectedinterestinalleightprojectareas,butalsoaconcernaboutcapacitytoparticipateineightprojects.Additionally,manypartnersspoketohowinterconnectedeachoftheprojectsare.TheywarnedagainsttreatingtheMTDasseparateprojectsandinsteadadvisedapproachingitasoneopportunitywithmultiplealigningstrategies.ThisinformedourdecisiontoworkwithCollaborativestobuildcountybasedplansthataddressallfourselectedprojectsanddesiredelementsoftheotherfourprojectscollectively.DescribetheprocessestheACHwillusetocontinueengagingthepublicthroughouttheDemonstrationperiod.FeedbackfromourMeaningfulConsumerEngagementandMeaningfulProviderEngagementplanningprocessescontinuestovalidateanddeepentheconsumerandpartner-drivenprioritiesthatwereidentifiedinouroriginalstrategymapsessionsandcommunityshowcase.InourBoard’spubliccommenthour,keyinformantinterviewsandfocusgroups,andthroughLeadershipCouncilfeedbackactivities,weheardconcernsfromcommunitymembersthattherewasnoclearmechanismforcertainsectorstogiveinputtoprojectplanning.Whilepeopleseeoutreachhappening,bothprovidersandcommunitymembersfeltuncertaintheir

inputwasbeingincorporatedintoregionalplans.TheseconcernswerealsoreflectedincommentswereceivedbackfromourPhase2certification.Inresponse,theBHTACHhasaddedtwonewTechnicalCouncilstoourgovernancestructuresincePhase2certification.TheseCouncilswereapprovedbytheboardonOctober18thandwereannouncedtotheLeadershipCouncilonOctober25th.Wedistributednominationformsforco-chairsandparticipantsinthesemeetings,andalsorananonlinesurveyfornominations.EachCouncilwillbeco-chairedbyaBHTBoardmemberandLeadershipCouncilmember.TheCommunityVoicesCouncil(CVC)willlaunchinDecember.Ourintentistorecruitaninitialgroupofrepresentativesbasedofthefirstroundofcommunitynominations,andthentaskthemwithrecruitmentofadditionalmembersmeetingourmembershiprequirements.AdraftcharterfortheCVCcanbefoundinAppendix15,tobefinalizedoncethegroupislaunched.Membershipwillbeatleast50%Medicaidbeneficiaries,withtheotherhalfofthegroupmadeupofcommunityadvocateswithlivedexperiencehelpingcomplexpatientsaccessandnavigatecommunityservices.TheCVCwillhelpinformprojectplanningbyvalidatingimplementationplansagainsttheneedsandexpectationsofthebeneficiary.TheCVCwilladviseonmetricsforevaluatinghowwellprojectplansaddresshealthequity,andwillusethesemetricstomonitorandmakerecommendationsforcoursecorrectionasneeded.MemberswillreceiveastipendfromBHTfortheirparticipation,inrecognitionofthetimecommitmentrequired.Thisgroupwillalsohaveeveningand/orweekendmeetingastheCouncilseesfit,andtheBHTACHwillmakearrangementstoofferchildcaresupportformeetingswhenneeded.TheProviderChampionsCouncil(PCC)hostedtheirfirstmeetingonNovember13th,meetingintheeveningtoaccommodatetheschedulingneedsofproviderswhoaregenerallywithpatientsduringtheday.ThePCCcharterincludingmembershipcanbefoundinAppendix16.ThisCouncilprovidesclinicalexpertiseandsubjectmattersupportinthedevelopmentoftheCollaborativeCompact(anoperationalagreementfortransformationinmultiplesettingsofcare)acrosstheMTDProjectsareas.TheCouncilwillrecommendkeyclinicalelementsandadviseonanyneededclinicalperformancemeasuresacrossprojectstoassesswhetherCollaborativesareontracktoachieveexpectedoutcomes.Thisgroupwillmeetmonthly.DescribetheprocessestheACHused,andwillcontinuetouse,toengagelocalcountygovernment(s)throughouttheDemonstrationperiod.CountycommissionershaveregularlyparticipatedintheRuralCountyHealthCoalitionsinPendOreille,Stevens,FerryandLincolnCounties.BHTstaffhavebeenactivelyengagingthesecountycommissionersinthissetting.TheregionalBehavioralHealthOrganization(BHO)DirectorservedonBHTBoarduntilherretirementon10/31/17(theBHODirectoranswersdirectlytocountycommissioners).AndtheBHTExecutiveDirectorhasmadeseveralACHpresentationstocountycommissionersinvarioussettings(seeAppendix17foranexampleofapresentation).

BHTACHengagementwithcountygovernmentregardingfullyintegratedmanagementcare(FIMC)hasbeenproactive.WhenitbecameclearthattheBHOwasnotactivelyhostingcross-sectorconversationsregardingtheimpendingdecisiontobecomeamid-adopterofFIMC,theBHTACHconvenedtheRegionalIntegrationTeam(RIT)todeveloparegionalapproachtoaddressthestatemandateforFullyIntegratedManagedCareandensurealignmentwithMTDintegrationsefforts.MembershipfortheRITincludescountycommissionersfromeachcounty,theBHOdirector,behavioralhealthandphysicalproviders,andMCOs.ThisgroupacceleratedtheFIMCdiscussion,ultimatelyleadingtoallsixcountiesagreeingtobeamid-adopterforFullyIntegratedManagedCareonJanuary1,2019.TheACHplayedanimportantroleingettingunanimouscommitmentforFIMCmid-adoption.AslateasJune2016,therewaslittlecommissionerinterestinmovingtoFIMC.BHTstaffworkedtirelesslytounderstandconcerns,developstrategiestoalleviaterisk,anddemonstrateasharedrolefortheACHandcounties.Forexample,countycommissionersexpressedconcernabouttheACHbeinganotherlevelofbureaucracy.ToalleviateconcernsthattheBHTACHwouldtakevaluableservicedollars,theBHTBoardpassedapolicytowaivetheadministrativefeetoadministertheFIMCincentivessothatallfundswouldgotowardsintegrationefforts.Goingforward,eachBoardofCountyCommissionersintheBHTregionhasbeeninvitedtojointheWaiverFinanceWorkGroup.TheBHTBoardhasalsoaddedanexofficiomemberpolicy,allowingeachcountytosendaCommissionerRepresentative.Therehasbeenregular,in-personparticipationfromallcounties.InOctober2017,CommissionerMikeManusofPendOreilleCountywasappointedtotheBHTBoard.CountyCommissionerswillalsobeinvitedtoactivelyparticipateinimplementationplanningwiththeCollaboratives.Commissionerswillbekeyleadersinintegratingjaildiversionandtransitionstrategiesaswellasaligningprevention-relatedstrategiesthroughtheirmembershipintheirlocalcountyBoardofHealth.TheRegionalIntegrationTeamwillmeetinearlyDecember2017toresumetheworkofaligningFIMCandMTDefforts,andBHTexpectstohavecontinuedactiveengagementofcountycommissionersintheseefforts.DiscusshowtheACHaddressedareasofimprovement,asidentifiedinitsPhaseIICertification,relatedtomeaningfulcommunityengagement,partneringproviderengagement,ortransparencyandcommunications.Asnotedabove,theBHTACHhasaddedtwoadditionalTechnicalCouncilstothegovernancestructuresincePhaseIICertificationtoelevatethevoicesofconsumersandproviders:theConsumerVoicesCouncilandtheProviderChampionsCouncil.SincePhase2,BHThasalsolaunchedaweeklyCollaborativeLearningSessionwebinaronFridaymornings,coveringkeystrategiesandactivitiesofMTD.Thesesessionsareopentothepublicandallrecordedandpostedonourwebsite.WecompletedcollectionofourHealthSystemsandCareCoordinationInventoriestogatherfeedbackandinformationfromclinicalandcommunity-basedproviders.WehavealsomadeourBoardofDirectorsmeetingsopentothepublic.Lastly,theBHTACHhas

madeimprovementsincommunicationstoolsforBoardmemberswhoaresectorrepresentatives.

TribalEngagementandCollaborationTribalEngagementandCollaborationCommunicationandmeetingwithtribesInAugust2016,BetterHealthTogether(BHT)StaffandBoardmembersparticipatedinaNativeHealthSystemslearningsessionsponsoredbytheAmericanIndianHealthCommissionatTheNATIVEProject,includingafacilitatedconversationabouthowtoincreaseandsupportcollaborationbetweenIHS/Tribal/UrbanhealthfacilitiesandtheACH.TribalrepresentationonACHBoardTheBHTGovernanceCommittee,withsupportfromtheBHTBoard,prioritizedTribalrepresentationbyappointingtwooffouropenseatstoTribalrepresentatives.BHTACHacceptedopenapplicationsandusedacommunity-drivenprocessfornominations.WealsosentannouncementsofthenominationandapplicationprocessdirectlytorepresentativesofeachoftheTribesinourregionandTheNATIVEProject.Twomembers,representingtheKalispelTribeofIndiansandtheConfederatedTribesoftheColvilleReservation,wereelectedthroughthisprocess.TheBoardunanimouslyapprovedtheslateofnewofficers,andtheirtermsbeganJanuary2017.AthirdTribalpartnerwasaddedinOctober2017,representingtheSpokaneTribeofIndians.Withthisfinaladdition,hetheBHTBoardhasrepresentationfromallthreetribesintheregion.TribalLeadersPartnerCouncilAttherequestofTribalmembersontheBHTBoardandtosupportfurtheractiveengagement,theBHTBoardcreatedtheTribalPartnersLeadershipCouncil(TPLC)andappointedthetwoTribalBoardmembersastheco-chairsinMarch2017.TheBHTACHTPLCservesasaforumforcontinuedpartnership,education,andsharedlearningswithIHS/Tribal/UrbanhealthfacilitiesandTribalOrganizationsasACHworkdevelopswithaspecificfocusonprovidingimpactanalysisonprojectsandBoardpolicydecisions.BHTACHiscontinuingspecificeffortsfocusedonrelationship-buildingandcollaborationwithIndianHealthServiceproviders,TribalOrganizations,andUrbanIndianHealthCenters(I/T/U)inourregion.IdentifiedregionalTribalpartnersincludeTheConfederatedTribesoftheColvilleReservation,SpokaneTribeofIndians,KalispelTribeofIndians,TheHealingLodgeoftheSevenNations,TheNATIVEProject,TheAmericanIndianCommunityCenter,andLakeRooseveltCommunityHealthCenters.LeadersfromthesehealthsystemsareinviteddesigneesfortheTPLC.

ACHStaffingBetterHealthTogetherACHhiredanACHTribalSeniorProjectManagertoworkcollectivelyandindividuallywitheachofourTribalpartners.ThisstaffmemberisanenrolledmemberoftheYakamaNationandhasworkedfortheKalispelandYakamaTribalgovernments.MostrecentlysheservedastheCommunicationsManagerforTheNATIVEProject,andinrecentmonths,waspromotedtoAssociateDirectorofHealthSystemTransformation.Inthisrole,shecontinuestotravelfrequentlybetweenNativehealthleaderstosupportengagement,opencommunication,trust,andopportunitiesforcollaborationalongsideTribalcommunitiesaswedevelopourCommunityHealthTransformationCollaborativesandlookforalignmentandleveragewiththestatewideACHTribalefforts.IdentificationofTribalprioritiesAddressinghealthdisparitiesofAmericanIndianandAlaskaNative(AI/AN)peopleinourregionhasbeenidentifiedasapriorityissueforTribalrepresentatives.AttendeesatTPLCmeetingshaveidentifiedmentalhealthandsubstanceuseissues,includinglackofaccesstotreatmentandproviders,askeyareasofneed.TheCommunity-BasedCareCoordinationandOpioidsProjectswereidentifiedasthetwoprojectareasthatshouldbeprioritizedforcollaboration.ThisfeedbackwasincludedinallofourBoarddeliberationsaboutprojectselectionandcollaborativedevelopment.HowTribalprioritieshaveinformedprojectselectionandplanningBetterHealthTogetherACHconductedregion-wideHealthSystemsandCareCoordinationInventories,whicharebeingusedtofurtherrefineregionalprioritiesandassistinprojectdevelopmentandplanning.Recognizingtheneedtoincludeculturallycompetentevidencebasedcaremodels,weaskedaboutcurrentuseofspecificmodelsthattheI/T/Upartnersmayreferenceintheirhealthsystemtransformationefforts(e.g.theIndianHealthService’sImprovingPatientCareprogram,whichsupportsoutpatientteamstoachievepatient-centeredmedicalhomerecognition).BHTACHiscloselyfollowingtheTribalstatewideeffortsoftheIndianHealthCareProtocol(IHCP)andwouldliketoassistourTribalPartnerswherepossible.OnecomponentoftheIHCPisimprovementofbehavioralhealthforAI/ANMedicaidclients,adoptingatraumainformedapproach.ThisisinlinewithBHTACH’sBi-DirectionalIntegrationProjectPlan.IHCPinitiativesalsoincludeworkforcecapacityandHIE/HIT,andBHTACHiscommittedtoprovidingtechnicalandprojectsupporttoI/T/Upartnersasplanningandprojectimplementationcontinue.ExamplesofelementsoftheProjectPlanthatwereinformedbyTribalinputOnJune19,BHTACHhostedasix-hourworksessionfortheTPLC.Tribalpartnerssharedhealthsystemsupdatesandchallenges.Onecommonthemeidentifiedbetweenthehealthsystemsisoflackofworkforceavailableintheirruralareas,alongwithretentionandongoingproviderdevelopmentopportunities.BHTACHgaveaMedicaidTransformationDemonstration(MTD)fundingoverviewandprovidedanupdateonhealthsystemtransformationplanningactivities,

allofwhichworktoaddresstheissuesidentifiedbyourTribalpartners.Attendeesidentifiedaneedtoworktogethertoaddressmentalhealthandsubstanceuseissues.ThisinformedourpopulationfocusforourMTD-requiredBi-DirectionalIntegrationProject.TheJuly25BHTACHTPLCmeetingwasheldattheCamasCommunityCenterforWellnessinUsk,WA.ThegroupdiscussedtheMTDTribalProtocolfortheDSRIPProgram,andPhaseIandIICertificationprocesses.ThisincludedbriefingsandafeedbacksessiononallBHTBoardpoliciestobeadoptedattheJulyBoardmeeting.AttendeesconcludedthattheywouldliketofocusoncollaborationforsharedresourcesonCommunity-BasedCareCoordinationandtheOpioidProjects.Thisfeedbackwasincludedinourdecision-makingprocesstoselecttheCommunity-BasedCareCoordinationproject.AttherequestoftheTPLC,theBHTACHAssociateDirectorofHealthSystemTransformationispartofastatewideweeklycallwithTribalhealthprovidersandotherACHTribalengagementstafftodiscussacoordinatedstrategytoaddressopioids.ThisdiscussionledtoarecommendationtoincludeTheSixBuildingBlocksforSaferOpioidPrescribingasadesiredelementoftheclinicalstrategiesforOpioidsintheCollaborativeimplementationplans.ThroughoutourTPLCdiscussions,wehaveidentifiedaneedtoinvestinimprovinghealthinequities.ThesediscussionsspurredtheconversationwiththeMedicaidWaiverFinanceTeamtoincludeafundsusecategoryreferredtoastheEquityAcceleratorPayment,acknowledgingthelikelihoodthatmorecostsareincurredtoservepopulationswithhistoricaltrauma.IfTribes/IHCPsarenotinvolvedinACHprojectselectionanddesign,describehowtheACHisconsideringtheneedsofAmericanIndians/AlaskaNativesintheACHregionN/ADiscusshowtheACHaddressedareasofimprovementidentifiedinitPhaseIICertificationrelatedtoTribalengagementandcollaboration.EachoftheBHTACHTechnicalCouncilshaveappointeesfromtheTPLCtoensureappropriatelevelsoffeedbackandengagement.WecurrentlyhaveactiveparticipationfromTribalPartnersintheWaiverFinanceWorkGroup,RegionalIntegrationTeamandProviderChampionsCouncil.(SeeGovernancesectionforCouncilroles.)WeareactivelyrecruitingforTribalrepresentationonthesoon-to-belaunchedCommunityVoicesCouncil,ourmechanismfordirectcommunityandconsumerinput.Additionally,bothTheNATIVEProjectandLakeRooseveltCommunityHealthCenterscompletedBHTACH’sHealthSystemsInventory(HSI).WeareworkingwiththeotherTribalpartnerstocompletetheHSIinpreparationforthelaunchofourRuralandSpokaneCountyCollaboratives.WehavereceivedlettersofsupportfromtheKalispelTribeofIndians,TheConfederatedTribesoftheColvilleReservation,LakeRooseveltCommunityHealthCenters,andtheAmericanIndianCommunityCenter;thesecanbeviewedinAttachment5.We

continuetoactivelycommunicateandcollaboratewithourTribalPartnersandareexcitedabouttheadditionofarepresentativefromtheSpokaneTribeofIndianstotheBHTBoard.

FundsAllocationFundsAllocation

FundsFlowOversightOverthecourseoftheMedicaidTransformationDemonstration(MTD)period,theBetterHealthTogetherAccountableCommunityofHealth(BHTACH)willbuildregion-widecapacityforimprovingcommunityhealthandpreparingtheregionforvalue-basedcare.TheBHTACHwillleverageMTDinvestmentwithotherfundinginitiativestodrivestrategy,partnershipsandcapacitynecessarytostandupacritical,innovativeandsustainablesystemforlongtermimprovementstocommunityhealth.TheBHTACHispurposefullyconstructedtoensurebroadmulti-sector,geographical,andcross-organizationcollaboration.Tothisend,theBHTACHhasdevelopedatieredgovernanceandengagementstructurewithdistributeddecision-making,jointownership,andmutualaccountabilitythatdrivesinnovationandfostersco-investment.WhiletheBHTBoardofDirectorsretainsitsauthorityasthefinaldecision-makingbodyforMTDeffortsrelatedtoprojectselectionandfundsflowmanagement,itistheintenttoutilizemanymechanismsforpartners,providers,community,andstakeholderstoprovidefeedbackandinfluencefinaldecisions.Boardandtechnicalmembersareexpectedtodiscloseanyactualorperceivedconflictsofinterestastheyrelatetosector-affectingdecisionsand/ortheBHTACH.InJuly2017,theBHTBoardapprovedacomprehensivepersonalandorganizationalConflictofInterestpolicy(seeAppendix14).TheBHTACHLeadershipCouncil,whosebroadparticipationhelpsussynthesizelocalprioritiesintoregionalstrategies;andrepresentativesofourlocalhealthnetworkshaveinformedourregionalhealthprioritiesandinspiredthecreationoftheRuralandSpokaneCountyCollaborativestodevelopandimplementtheMTDprojects.Additionally,theBoardhasappointedTechnicalCouncilstoprovidedeeperfeedbackonthecomplexelementsrequiredtosuccessfullyimplementtheMTDefforts,suchas:

• TribalPartnersLeadershipCouncil(TPLC)

• ProviderChampionsCouncil

• CommunityVoicesCouncil

• MedicaidWaiverFinanceWorkgroup

• RegionalIntegrationTeam

ToalignwithACHvaluesforlocalcontrolandtobuildonthestrengthofgeographicbasedhealthcoalitions,theBHTACHwillutilizeaCommunityHealthTransformationCollaborative(Collaborative)modeltodevelopandimplementgeographicbasedsystemsofcareplansinthefourprojectareasBHTACHselected.TheCollaborativeswillbeguidedbyaCollaborativeCompact,whichincludesactivitiesandstrategiesneededtoimplementtherequiredMTDprojects,meetlocalcommunitypriorities,driveachievementofmetrics,andserveasthemechanismforproviderstoearnMTDdollars.TheWaiverFinanceWorkgroupischargedwithrecommendingtotheBHTBoardamethodologyfortheMTDfundsincluding:

• DevelopandrecommendtotheBHTBoardforapproval,asetofpoliciestogoverntheProjectandIntegratedManagedCareIncentivefundsincludingadetailedapproachforCollaborativesandpartneringproviderstoearnpayforreportingandpayforperformanceachievements.

• ReviewandrecommendtotheBHTBoardforapprovaleachCollaborativeDemonstrationfinancialplan;

• ProvideoversightofDemonstrationactivitiestoensurecompliancewithwaiverrequirements.

TheWaiverFinanceWorkGroupiscomprisedofaTPLCappointee,anFQHCappointee,CountyCommissioners,physicalandbehavioralhealthproviders,ProvidenceHealthSystem,MultiCareHealthSystem,publichospitalleadership,communitybasedorganizations,philanthropy,agingandlong-termcare,andBHOs/MCOs.(SeeAppendix12forthecharterandmembershiplist).TheWaiverFinanceWorkgrouprecommended,andtheboardapproved,thefollowingprinciplesasafoundationforthefundsflowdevelopment:

• Values:rewardsinnovation,supportscollaboration,recognizesat-riskandvulnerablepopulations,supportsdiversityofpartnersandapproachinthemarket,drivesmaximumimpacttonumberoflivesserved,maximizesfinancialresourcesfortheregion.

• Equity:EnsuresinvestmentaddressesdisparitiesandhealthinequitiesfortheMedicaidbeneficiary;ensuresafocusonincreasedaccesstoculturallyappropriatecare.

• Flexible:Abletochangemodelsandapproachesovertime(i.e.doesnotlockinfundingonlyoncertainapproaches),meetstheneedsoftheindividualcollaborativehub,mitigatesappropriateprovider risks,andrecognizesthevalueandcostof“sweatequity.”

• Fairness:Balances1)equitytoallpartnerswithintendedimpact,2)seedmoneywithsustainabilityandlonger-termimpact,and3)smaller,lessefficientproviders’needswiththoseofthelargerproviders.

• Alignment:Ensuresalignmentbetweenfundsflowandintendedgoals(appropriatecareintheappropriateenvironment);healthcareasaneconomicdevelopmenttool.Encouragesandpromotesalignmentbetweenpartners,supportsintegrationamongtheproviders(bothruralandurban)topreparetheregionforvaluebasedpayments,alignseffortswithotherMedicaid,Medicareandlocalinitiatives,complieswithHCAcriteria,alignscontinuumofcarebetweenruralandurbanregions

Itisexpectedthatinearly2018,theBHTACHwillexecutememorandaofunderstanding(MOU)withitspartneringorganizationsthatwillstipulatethespecificrolesandresponsibilitiesofeachparty.ThisMOUwillserveasthefoundationforcontractswitheachprovidertodetailrequirementsforearningdollarsincluding(likely)monthlyreportingofpay-for-reportingandquarterlypay-for-performanceachievement.InconsiderationoftheexecutionoftheMOU,theWaiverFinanceWorkgroupwillrecommendtotheBHTBoardforapproval,amethodologyfordistributionofYear1Incentivefundsinthefirstquarterof2018.PriortosubmittingdistributiondirectiontotheFinancialExecutor,itisexpectedthatBHTleadershipwillpresent,forboardapproval,paymentstobemadebasedonachievementofagreeduponcontractualterms.Additionally,pleasenotethattheBHTBoardofDirectorshasaBoardFinanceCommitteechargedwithoversightofBHTfinances.ThissubcommitteereportsmonthlytotheBoardoncurrentstatusofBHT’sfinancesandperformancetoannuallyadoptedbudget.ThissubcommitteeprovidesfinancialoversightofMTDdollarsdistributedtotheACHfortheadministrationoftheDSRIPprogram,includingPhaseIandPhaseIICertificationdollars,andregionalinvestmentallocatedviatheWaiverFinanceWorkgroupforactivitiessuchastheestablishmentofthePathwaysHub.OneBHTBoardFinanceCommitteememberservesontheWaiverFinanceWorkgroup.Finally,BHTcontractswiththeEmpireHealthFoundationforbackofficeservicesincludingaccountingandfinancesupportservices.ThiscontractincludesCFOandfinancestaffcapacity.In2018,theBHTBoardwilladoptaformalizedsetofpoliciesandprocedurestoensurefederalandstatecompliancewithallcurrentcontracts.Additionally,BHTACHwillimplementanewaccountingplatform,NetSuite,thatwilleasilyallowfortrackingoftimeandexpensetofederalgrants.NetSuiteprovidesaccurate,real-timefinancialreportingofgrantcostsacrosstheorganizationsforgrantsrequiredtracking.NetSuitewillallowtrackingofexpensesagainstspecificrevenuesourcesdowntothetransactionallevel.ThisensuresadeeperleveloffinancialaccountabilityforMTDfunds.

DescribetheACHprocessforensuringstewardshipandtransparencyofDSRIPfundsoverthecourseoftheDemonstration.

TheWaiverFinanceWorkgroupCharterstipulatesexpectationofmembersto:

• ProvidestewardshipandmanagementofBHTACHWaiverFinancialresources;

• KeepthebestinterestoftheBHTACHandthecommunityattheforefrontofdiscussionanddecision-making.

BHTACHiscommittedtotransparencyandaccountabilityforhowMTDfundsarespentandtheimpactonmeetingMTDandregionalgoals.Usingtheboard-approvedfundsflowguidingprinciplesandusecategories,contractswillbedevelopedwithproviderstoensureaccountabilitybetweenfundsdistributedandachievementofpayforreportingandpayforperformancegoals.Tomitigateperformancerisks,BHTwilldevelopareviewprocesstoensurethatprovidersmeetreportingandperformancemetrics.Thisregularreportingprocesswillallowforcoursecorrectionviatechnicalassistanceandadependablemanneroffundingforpartners.TheBHTstaffwillensureallpaymentsarealignedwithgovernance,contractrequirementspriortoseekingapprovalfromtheBHTBoard,whoseapprovalwilldirectthefinancialexecutortoreleasepayments.ItistheexpectationthatfundsflowmethodologyandabilitytoearndollarswillbeclearlycommunicatedthroughseveralchannelsincludingweeklyBHTACHcommunication,OpenBoardmeeting,LeadershipCouncilmeetings,minutesfromWaiverFinanceWorkgroup,BHTwebsiteandcommunitypresentations.Itisexpectedthatfeedbackwillbeprovidedbytheothertechnicaladvisorygroupstoensureprogrammaticalignmentwithsuggestedfundsflowmethodology.Additionally,ataCollaborativelevel,allpartnerswillunderstandhowfundswillflowacrosspartnersandviatheRuralandSpokaneCountyCollaboratives.Ifapplicable,provideasummaryofanysignificantchangessincePhaseIICertificationinstateorfederalfundingorin-kindsupportprovidedtotheACHandhowthefundingalignswiththeDemonstrationactivities.

Therearenoothersignificantchangestoin-kindsupportoradditionalstateorfederalfundssincePhaseIICertification.However,theBHTACHhaslaunchedconversationswithlocalfunderstodevelopamatchinvestmenttoourCommunityResiliencyFund.Additionalexplorationofotherphilanthropiceffortstosupportclinicaltransformationeffortsformaternalandchildhealthandoralhealthisbuildingmomentum.TheBHTACHwillcontinuetoleverageinvestmentsfromSIMandtheEmpireHealthFoundation

tosupportourregion’shealthtransformationandcommunityefforts.WeareundercontractwiththeWashingtonHealthBenefitExchangetoadministerourregion’sNavigatorNetwork,toensurethatpeopleinourregionhaveaccesstohealthinsurance.AspartoftheCollaborativereportingprocess,theBHTACHwillrequirepartnerstotrackin-kindservicesandleveragedlocal,stateandfederalinvestments.Weexpecttodemonstratepartner’sinvestmentfordatasharing,clinicalproviderchampions,communitybenefit,meetingspaces,recruitment,anddonatedstafftimetosupportgovernance,strategicdevelopment,trainingandprogrammanagement.Ifapplicable,provideasummaryofanysignificantchangestotheACH’strackingmechanismtoaccountforvariousfundingstreamssincePhaseIICertification.

TherehavebeennosignificantchangestotheBHTACH’strackingmechanismtoaccountforvariousfundingstreamssincePhaseIICertification.In2018BHTACHwilllaunchanewaccountingsystemthatwillallowformorein-depthreportingandfederalgrantcompliance.ProjectDesignFundsDescribe,innarrativeform,howProjectDesignfundshavebeenusedthusfarandtheprojecteduseforremainingfundsthroughtherestoftheDemonstration.

Phase1and2projectdesigndollarsareallocatedbyBHTBoardpolicyandmanagedbytheBHTExecutiveDirectorandBHTBoardFinanceCommittee.InJuly,theBoardearmarkedfundsfordistributionin2017.InDecember2017,theBoardwillapprovethe2018budgetwithadditionalallocationsfromPhase1and2projectdesigndollars.TheBHTBoardFinanceCommitteemeetsmonthlytoreviewfinancialsincludingaprojectedyear-endspendingplan.InDecember,unspentandallocatedreservefundswillbeapportionedinthe2018Budget.TheBHTACHwillcontinuetoutilizeprojectdesignfundstobuildthecapacityofourinternalandcommunityteamstoprepareforprojectplanningand implementation.Year-to-date,wehaveexpendedapproximately$391,000ofthe$6millionreceivedsinceJune.Notably,$106,000has been distributed to partners for successful completion of Health System and CareCoordinationInventories.Additionalfundshavebeenexpendedfor:

• Central service administration, including BHT leadership and staff, shared serviceagreementsforfinance,HR,andcommunicationssupportandoperations;

• ContractedserviceswithKPMG,ProvidenceCORE,andUncommonSolutionstosupportfinancial,facilitation,data,andcollaborativeprojectdevelopment;

• Projectdevelopmentactivities,includingtravel;

• Communitymemberstipendsforparticipationinfocusgroups;and

• Websitedesign$870,000ofprojectdesignfundsarereservedfor:

• BHTACHadministration/projectmanagementduringtheremainderof2017and2018(balanceof$270,000)

• InvestmentintheCommunityResiliencyFundaimedatstrengtheningservicesthatsupportsocialdeterminantsofhealth($600,000)

SubjecttoBoardapproval,itisanticipatedremainingfundswillbeusedforcontinuedsupportof:

• BHTACHProjectPlan:Contractedservicestosupportfinancial,dataandcollaborativeprojectdevelopment.

• Engagement:Activitieswithbothconsumersandclinicians,includingfundingtosupportpartners for time and space provided, and to community member stipends forparticipationinthefocusgroups.

• ACH Administration Project Management: Central service administration, includingleadershipandstaff, sharedserviceagreements for finance,HR,andcommunicationssupportandoperations.

• Health Systems & Community Capacity Building: As needed to support regionalinfrastructureinvestmentssuchasthedevelopmentofthePathwaysHub.

• CollaborativeDevelopment:AsneedtosupportinvestmentinCollaboratives.

• Other:ReservesperBoardpolicytobespentbytheendofthedemonstrationperiod.BeginninginearlyCY2018,DesignFundswillbesupplementedbyanallocationof5%foradministrativedollarsfromprojectfunds,pertheBHTBoardapprovedfundsflow.FundsFlowDistributionDescribetheACH’santicipatedfundsflowdistribution.DescribehowProjectIncentivefundsareanticipatedtobeusedthroughouttheDemonstration.Provideanarrativedescriptionofhowfundsareanticipatedtobedistributedacrossusecategoriesandbyorganizationtype.

InNovember2017, theBHTBoardapproved4projects tomaximizeearningpotential for theregionandprovidemaximumlocalcontrolovertransformationeffortscustomizedtotheregion.TheBHTACHwillaligndata,fundsflowandmodeldevelopmenttomaximizetheopportunitytointegrateselectedprojects intoavaluebasedmodelandweavetogether local resourcesand

investments to reachthisgoal.Our funds flowplan includesdirected investments forstartupcosts, infrastructureandtechnicalassistanceemphasizingDSRIPfundingfortransition,notanongoingservicepaymentstream.

TheWaiver FinanceWorkgroup recommended, and the BHT Board approved, the followingprinciplesfocusedonmeetingthefundsflowneedsofourpartners:

• Values:BHTACHneedstoknowthattheorganizationandworkwillmakeadifferenceiffundsareaccepted.MoneyfromtheDSRIPeffortsshouldbeavailableacrossthecurrentsilos,supportlatitudetotrydifferentthings,incentivizecollaboration,betterflowofinformation,andcommunicationwithnewandexpandedpartners,supportinnovationsthatstimulatecostcurvebendingapproaches.

• BusinessPractices:Projectsneedtonotlosemoney(revenueandprofit)inthetransformation.TheBHTACHhelpsmitigatefinancialriskforpartners,butfundsshouldNOTberestrictiveandcomplicatedtotrack,andshouldsupportreorganizationofservicesinageographicallywidespreadareawithsiloedservice.Fundsareusedtodeveloparegion-widesharedsavingsmodelwithappropriateinvestmentinregional-levelinfrastructure,alignmenttoHCAtargets(MCOgoal)andBHTACHregiongoals,andgarnerthebroadsupportfromtheprovidercommunity.

• Operational: Funding should provide the ability to integratemedical and behavioralhealthrecords,andsupportinfrastructureneeds, e.g.,Behavioral healthlocatingtothecampuswhereprimarycarephysiciansandhospitalsare located.Effectivepatient flowbetween the various services that areprovided is a priority as is timely paymentmethodologyforhealthycashflow.Clarityisneededinthemethodtorequestandqualifyforfunds,andwhatdeliverables/commitmentsarerequiredinreturn.Fundsareexpectedtosupportsustainableeffortsthatspanbeyondthefive-yeardemonstrationperiod.FundsflowincentivesalignwiththeVBPeffortsandassociatedincentives(e.g.usingthesamemetrics).

The BHT Board adopted a high-level funds flow framework that consists of the followingelements:

• FundsusedbytheBHTACHforDSRIPprojectmanagementandACH-wideinvestmentsandsupportforthebenefitofallCollaboratives,subdividedintoprojectssuchasHIT/HIE,workforceandcommunityengagement.

• FixedfundstosupportCollaborativeswithDSRIPprojectmanagementandprojectcosts.

• Performance-basedfundstohelpalignCollaborativeincentiveswiththosetowhichtheACH is held accountable during the demonstration, such as engagement criteria,outcomes,andreportingrequirements.

TheWaiverFinanceWorkgrouprecommended,andtheBHTBoardapproved,fourinvestmentareasforfunding:ACHDSRIPManagement(5%),RegionalPartnerInvestments(30%),Collaboratives(55%),andCommunityResiliency(10%)Thefundsflowplanappliesfiveusecategoriesfordistribution:AdministrationandProjectManagement;ProjectEngagement,ParticipationandImplementation;ProviderPerformanceandQualityIncentivePayments;HealthSystemsandCommunityCapacityBuilding.TheBHTBoardapproved,aCommunityResiliencyFund.Theusecategorydistributionplanprovidesfor:

• AdministrativeoperatingexpensesoftheACH,including:financial,legal,administrativesalaries,facilitiesandequipment,B&Otaxes.

• Fixedpaymentforengagementandparticipation(signedpartneragreements,andmeaningfulleadershipandparticipationonworkgroupsandoperationalcommittees);implementationcostsforearlyinfrastructureandprocesschangesthatactivelymovethepartnerandpartnergrouptowardintegrationandcommunity-basedcare;

• Earnedpaymentsforreportingonprojectmilestones;performance-based,metric-drivenpayments;transitioningtonewpaymentmodels.Additionally,theWaiverFinanceWorkgroupisexploringtheabilitytofundanequityacceleratorpaymenttoreducehealthdisparities

• Regionalinvestmentsin:populationhealthmanagementsystems(EHRs,HIE/HIT,data);strategicimprovement/qualityimprovementactivities;workforcedevelopment;value-basedpaymenttechnicalassistance;revenuecyclemanagementandsupplychainmanagementsupport;PathwaysHUBoperations;trainingandeducationonpreventingproviderfatigue,andcommunityandproviderengagement;

• Regionalinvestmentsthatpromotelong-termtransformationandimpactissuesaffectingpopulationhealth,withafocusonprimarypreventionandsocialdeterminantsofhealth.

Usingtheboard-approvedfundsflowguidingprinciples,allocationsbyusecategoryanddistributionbyorganizationtypeswereestablished.BHTACHapproachedthefundsflowdistributionmethodologyforfourprojectswithconsiderationtowardtherecentHCAreductiontoYear1waiverrevenue,andtheuncertaintyaboutfundsavailabilityinsubsequentyears.UnderstandingourCollaborativeswillcustomizelocalsolutions,weconsideredanAveragePay-for-ReportingAchievementValueof100%acrossallfouryearsandAveragePay-for-PerformanceAchievementValueof75%vs90%acrossallthreeyears.

Table4:ALLOCATIONOFPROJECTFUNDSBYUSECATEGORYUseCategory 5-YearTotal

ProjectManagementandAdministration 5%

ProviderEngagement,ParticipationandImplementation

32%

ProviderPerformanceandQualityIncentivePayments 23%

HealthSystemsandCommunityCapacity 30%

CommunityResiliencyFund 10%

TheWaiverFinanceWorkgrouprecognizestheimportanceofdistributiontocommunity-partnersandproviderstospearheadregionalcommunity-ledinitiativesaimedatstrengtheningsocialdeterminantsinvestments.ProvisionswillbemadetodistributetheCommunityResiliencyFundtopartneringorganizationstosupportlinkinghealthcaresystemtosocialdeterminantsofhealth.TheBHTACHwillseektomatchMTDfundsintheCommunityResiliencyFundwithothercommunitybenefitdollarsfromfunderslikeEmpireHealthFoundation,communitybenefitinvestmentsfromProvidence,MultiCare,InlandNWCommunityFoundation,UnitedWay,andothers.Byaligningpartnersandinvestorsaroundtheseindicators,usingMTDfundsasanincubator,wecancreateaninvestmentfundofflexibledollarsfortheregiontocontinuetouseforstrategicinvestmentinovercominghealthdisparitiesandsocialdeterminantsofhealth.Weseethisfundasamechanismtonegotiatecrosssectorsharedsavingsmodeltoprovidealongertermfundingstrategy.PleasenoteitistheintentoftheBHTACHtoexpendallMTDCommunityResiliencyFunddollarsduringtheMTDperiod.ACollaborativestructurewillbeusedtoincentivizesharedaccountabilitytiedtooutcomesforpopulationhealth.TheCollaborativeswillbecomprisedofMedicaid,Non-MedicaidProvidersandTribalHealthSystemsdesignedtobuildontheruralCountyCoalitionsstructureandleveragethenaturalpartnershipsneededtosupportageographicallybasedsystemofcaresotheregioncansucceedinavaluebasedsystem.PartnershipswillsustainthemselvesasbusinessmodelsadapttovaluebasedcontractsanditisexpectedtheopportunitytoinvestinasharedsavingswillprovideadditionalcapitaltocontinueMTDefforts.ThesupportfromtheBHTACH,MTDfunds,andtheCollaborativepartnerswillfosteranenvironmentofinnovationandtransformation.

Table5:ALLOCATIONOFPROJECTFUNDSBYORGANIZATIONTYPE

DY1–2017

ACH 10%MedicaidProviders 70%Non-MedicaidProviders 10%I/T/U 10%Other* 0%

100.0%

Goingforward,guidedbytheprinciplesofcollaborationandaccountability,theallocationofMTDfundstopartneringorganizationswillcontemplatethevalueoftheproject,targetpopulation,levelofresourceandcommitmentbypartner,readinessandexpertise,financialresourcesandsuccessinachievingmilestonesandoutcomegoals.Attestations

• AttesttowhetherallcountiesinthecorrespondingRegionalServiceAreas(RSAs)havesubmittedabindingletterofintent(LOI)tointegratephysicalandbehavioralhealthmanagedcare

YES NOX

• AttesttowhethertheACHregionhasimplementedfullyintegratedmanagedcare.

YES NO

X

o IftheACHatteststohavingimplementedfullyintegratedmanagedcare,providedateofimplementation.

o IftheACHatteststonothavingimplementedfullyintegratedmanagedcare,providedateofprojectedimplementation.

January2019

DATE(month,year)

DATE(month,year)

HowIntegratedManagedCareIncentivefundswillbeusedorinvestedBHTACH views the transition to Fully IntegratedManagedCare (FIMC) as a requirement tosuccessfully transformthehealthandsocialdeterminantsofhealth systemsandsuccessfullyshiftingtoavaluebasedpaymentandcaremodel.TosupportregionaldecisionmakingonFIMCandalignmentonclinicalintegrationforphysicalandbehavioralhealth,theBHTACHformedaRegionalIntegrationPlanningTeam.TheteamiscomprisedofkeystakeholdersintheregionincludingCountyCommissionersfromAdams,Lincoln,Stevens,PendOreille,FerryandSpokaneCounty,MCOrepresentatives,ruralhealthleadership,Providence,MultiCare,PhysicalHealthandBehavioralhealthproviders,TribalPartnersLeadershipCouncilappointee,andtheSpokaneCountyBHODirector.AsnotedatameetinginlateJuly,“thisisthefirstconveningofkeypartnersinphysicalandbehavioralhealth,aswellascountyofficialsdiscussingtheneedsofourregion’shealthsystem.”Theinitialgoalofthistoteamwastoidentifyanapproachtomeetthestatemandated2020deadlineforFullyIntegratedManagedCare.TodemonstrategoodintentandreinforcetheACHbeliefthatFIMCiscriticaltotransformingthehealthsystem,theBoardpassedapolicyinAugust2017notingthatiftheregionwasaMid-Adopter,theBHTACHwouldnottakeanyadministrativeexpenseofFIMCincentivedollarsandwoulddirectallFIMCIncentivestosupporttheintegrationofphysicalandbehavioralhealthproviders.OnOctober16,2017,CountyCommissionerssubmittedabindingletterofintenttomovetoMid-AdopteronJanuary1,2019.TheBHOandHCAarestillfinalizingdetails,butitistheexpectationoftheregionwewillimplementFIMConJanuary1,2019.TheCommissionersfromaroundtheregioncontinuetodiscusstheroleoftheSpokaneCountyBHOtransitioningintoservingastheregion’sBehavioralHealthAdministrativeServicesOrganization.ThisdecisionisduetoHCAbyearlyJanuary2018.TheWaiverFinanceWorkgroupwilldevelopamethodologyfordistributionoffundsintwocategories:regionalinfrastructureandCollaborativeinvestment,inearly2018.Thismethodologywillalignwithourbi-directionalintegrationeffortsandwillseektomaximizethespenddownoftheBHOreservesSpokaneCountycurrentholds.

RequiredHealthSystemsandCommunityCapacity(Domain1)FocusAreasforallACHs

RequiredDomain1FocusAreasTheBHTACHRuralandSpokaneCollaborativeswillserveasthelocalexpertstoidentifyneedsanddevelopaplanforallselectedprojectsandactivities.BHTwillactastheaggregatoracrosstheCollaborativetoensurestandardization,coordination,collaborationandregionalaccountability.EachCollaborativewillcreateaninterconnectedplanacrossallprojectareasforeachDomain1elementusingasystemsapproach,withassistancefromtheBHTACHastheaggregatorandsystemfunder.BHTACHearningswillbeusedtoencourageadoptionofstandardpracticesandtoincentivizethecompletionoftheCollaborativeassessments.ConcretenextstepsforeachCollaborativeareasfollows:

• Q12018:EachCollaborativewillconductastandardizedneeds/gapassessmentforeachprojectareabasedontheCollaborativeCompact.

• Q12018:Basedonfindings,BHTACHwilldevelopacollectiveapproachforcollaborativeandsystem-widecapacitydevelopmentrelatedtoworkforce,VBPandpopulationhealthmanagement.

• Q12018:Implementationplanninganddevelopment(usingbaselinetargetsfromHCAandBHTACHregionalprioritygoals).

• Q32018:ImplementationPlansdue.

• Q42018:IncorporationofcollectiveapproachestodevelopandreinforcestatewidestrategiesandcapacitythroughaBHTACHAll-Collaborativeconvening.

FourBHTACHinvestmentcategorieshavebeenidentified:

• ACHDSRIPManagement,

• RegionalPartnerInvestments(includingHIE/HIT;PopulationHealthManagement;Training;WorkforceDevelopment;ProjectManagement;andPathwaysHub),

• Collaborative(fixedandearnedpaymentstomembersoftheCollaborative),and

• CommunityResiliencyFund.TheBHTACHwillserveasaconveneracrosstheregion,withtheRuralandSpokaneCollaborativesservingastheactivationnetworkforachievingACHandMedicaidTransformationDemonstration(MTD)goalsandoutcomes.TheBHTACHwillfacilitateanddrivealignmentacrosstheregiontoleverageadditionalresourcesandstrategiesamongpartners,providers,andfunders.Forexample,theCommunityResiliencyFundmayserveasa

mechanismtoalignneededsocialdeterminantinvestmentacrossphilanthropicpartners,allowingMTDresourcestohaveagreaterimpact.Asanotherexample,weareindiscussionswiththeEmpireHealthFoundationandUpstreamUSAtosupportincreasedregionaleffortstoreduceunintendedpregnanciesthroughtheutilizationoftheOneKeyQuestionmodel,andincreasingaccesstoLongActingReversibleContraception.ThispartnershipwillallowtheBHTACHtoleverageMTDfundstoaddadditionalelementstotheclinicaldeliverysystem.Thisalsomeetsourregion’sdesiretoreduceAdverseChildhoodExperiencesbyinvestinginpreventionefforts.ThistypeofalignmentandleveragingwillbeakeycomponentoftheCollaborativedevelopment.BHTValue-BasedPaymentStrategiesBHThasprovidedmultipleopportunitiesforpartnerstolearnaboutVBP,includingquarterlyupdatesattheACHLeadershipCouncilandtheBHTBoardmeetings.MarkWakaiofProvidenceHealthServices,whositsontheMVPteam,gaveapresentationontheVBPRoadmaptoourRegionalIntegrationTeamonSeptember12,2017andtoourLeadershipCouncilonSeptember28,2017.InOctober,theBHTACHhostedaLearningSessionconductedbyHCA’sChiefMedicalOfficer,Dr.DanLesslerthattouchedontheintersectionsbetweenBi-DirectionalIntegrationandVBP.Wehavereachedmorethan100organizationsviatheseefforts.BHThasconsistentlyprioritizedVBPeducationandstrategydevelopmentasakeyelementinachievingMTDgoals.DescribehowtheACHsupportedand/orpromotedthedistributionofthe2017ProviderVBPSurvey

BHTACHdistributedthe2017ProviderVBPSurveyfirstviaitsweeklypartneremail,whichwassentto291recipients.ThesurveylinkwasalsoplacedonthefrontpageofourBHT’swebsiteforthemonthsofJulyandAugust,duringwhichtimethepagehadatotalof1,811views.15organizationsrespondedtothe2017ProviderVBPSurvey.RespondentsrepresentMedicaid-criticalprovidersintheregion(e.g.CHAS;LakeRooseveltCHC;Providence;MultiCare;Ferry,Lincoln,andNewportHospitaldistricts).Providersrespondingrepresentagoodcrosssectionofpartners,includingTribalhealth,behavioralhealth,inpatient/outpatientfacilities,criticalaccesshospitals,hospitals,FederallyQualifiedHealthCenters(FQHCs),RuralHealthClinics(RHCs),multi-specialtypractices,andnot-for-profitorganizations.DescribethecurrentstateofVBPamongtheACH’sproviders

TheBHTACHhasworkedhardtoensurethatourhealthcareandSocialDeterminantofHealthpartnersareawareofthestate’sgoaltomove90%ofMedicaidpaymentstoaValueBasedmodelby2021.Increasingly,ourdiscussionsaremovingtospecificsaboutreadyingproviderstomeetthegoals.Weareencouragedbythefactthat6ofthe15respondentsintheHCAVBPSurveyreportedthattheycurrentlyhaveMedicaidContractsthatmeettheVBPtargetsintheLANcategories2C-4B.Additionally,theBHOinourregionhasbeenincludingValueBased

Paymentsintheirprovidercontractsoverthelastfewyears.Butevenwiththesedatapoints,weexpectthatthereisasignificantamountofworktobedonetomeetthe90%targetintheregion.TheBHTACHRuralandSpokaneCountyCollaborativeswilldevelopaprovider-by-providerplantopreparetheregionforVBPinpartnershipwiththeManagedCareOrganizationsandtheHealthCareAuthority.HastheACHobtainedadditionalinformationbeyondwhatthesurveyincluded?Ifso,werethesefindingsconsistentorinconsistentwiththesurveyresults?

TheACHhasinformallydiscussedVBPcontractswithMCOsandprovidersoverthelastfewmonthsandthesurveyfindingsareconsistent.ThereishighlevelknowledgefromregionalMedicaidprovidersaboutVBPgoals,theneedforinvestmentinclinicalandHIEtransformationtobereadyforrisk-basedVBPcontracts,andacceptancethatVBPoffersastrongvaluepropositiontoservepatientsbetter.However,thereisconcernofinadequateaccesstoservicesformentalhealth,substanceusetreatmentsandsocialdeterminantsofhealthfundingtoadequatelysupportwholepersoncare.ThismayresultinprovidersbeinglesslikelytoassumeriskbasedVBPcontracts.HowdoprovidersexpecttheirparticipationinVBPtochangeinthenext12months?

The15providersurveyrespondentsindicatedthat:• 1woulddecreaseVBPby10%• 3wouldstaythesame• 5wouldincreasebyupto10%• 3wouldincreaseby10-24%• 3wouldincreaseby25-50%

Foryourpartneringproviders,whatarethecurrentbarriersandenablerstoVBPadoptionthataredrivingchange?

AmongthosewithVBPexperience,responsesaboutwhathassupported(enabled)theirparticipationinVBPwerevaried.Themostfrequentlynotedparticipationenablersweretrustedpartnershipsandcollaborationwithpayers,andalignedincentivesandcontractrequirements.Dataissueswerethemostfrequentlymentionedbarrier-9or10organizationscitedtheseasobstacles:

• Lackofinteroperabledatasystems• Lackofaccesstocomprehensivedataonpatientpopulations(e.g.,demographics,

morbiditydata)• Lackofavailabilityoftimelypatient/populationcostdatatoassistwithfinancial

management

• Accesstomentalhealth,substanceusetreatment,housing,transportationservicesInourconversations,MCOshavereferencedalready-establishedVBPcontractsandaremovingtowardmeetingtheHealthierWA2017milestonethat30%ofMedicaidcontractsbeinVBParrangements.SeveralofBHTACH’skeyproviderpartnersarelikelytobeinapositiontomoveprogressivelyfrom50%-90%VBPwithintheHealthierWAestablishedtimeframes.TheCollaborativeswilldevelopaplantosupportthemajorityofMedicaidprovidersinmeetingthe90%VBPgoalbytheendoftheMTDperiod.BHTWorkforceStrategiesGrowingandmaintainingthesupplyofbehavioralhealthprofessionalsisapriorityfortheBHTACH,givenitsfocusacrossprojectareasonimprovingaccessandcareforindividualswithbehavioralhealthandco-occurringconditions.Similarly,establishingastrongnetworkofcarecoordinators(whetherthoseareCommunityHealthWorkers(CHWs),MedicalAssistants(MAs),orPeerCounselors)willsupportPathwaysandotherbi-directionalintegrationwork.Currently,mostoftheBHTACHregionisdesignatedasamentalhealthcareprofessionalshortagearea,51andBHTACHareaparticipantsintheWashingtonStateHealthWorkforceSentinelNetworkreportrecentincreasesindemandforclinicalsocialworkersandmentalhealthcounselors.52PartnerswhoparticipatedintheBHTACHHealthSystemsInventorynotedlong-standingchallengeswithworkforcerecruitmentandretentionacrossavarietyofroles.AmorefocusedworkforceassessmentlinkedtodevelopingMTDimplementationplanswillbeconductedinQ12018withCollaborativepartners.TheBHTACHwillpartnerwiththeCommunityCollegesofSpokaneandtheregionalWorkforceDevelopmentCounciltocompletetheassessment,withaspecialfocusonbuildingcapacityforthenextgenerationofhealthworkforcethatwillmeettheneedsofatransformedcommunityhealthsystem.Partnerdiscussionshaveenabledustodetermineinitialfocusareasforfurtherdevelopmentthroughtheassessment:

• Assesscarecoordinationutilizationandcapacityinclinicandcommunitybasedorganizations.

o ExplorecredentialingrequirementsforCareCoordinatorsincludeHealthCoaches,HealthHomesCareCoordinatorsandotherCommunityHealthworkers

o ExploreCommunityParamedicineopportunitiestoincreasetheuseofvolunteerEMSstafftoserveasabridgebetweenthepatientandcarecoordination.

o ExplorepotentialuseofMedicalAssistantsasmembersofintegratedprimarycareteams,anidentifiedgapareapriorityofourruralpartners.Astheruralpopulationagesandaccesstoservicescontinuestobeachallenge,theexplorationoftheadditionofMAsas“healthextenders”iswarranted.

• Assessmentalhealthandsubstanceuseworkforcegapso Exploreopportunitiestoincreasethepipelineformentalhealthandsubstance

useproviders.WorkwithMCOsinthetransitiontoFIMCtoensuretheworkforcecapacityofBHprovidersinintegratedsettings

o UtilizationofTeleHealthandTelePsychiatryinruralandprimarycaresettings

• AttheCollaborativelevel,assesstrainingneedstosupportproviderswhopracticeinanintegrated,value-basedsystem

HowBHTACHisconsideringandprioritizingstatewideworkforcecapacitydevelopment

AswedeveloparegionalworkforcestrategytomeetMTDprojectandCollaborativeneeds,wewillalignoureffortswithotherregionalstrategies.Theseinclude:increasingthenumberofPrimaryCareResidencyslotsforGraduateMedicalEducation;expandingtheruraltrackintheUWPrimaryCareResidencyprogram;developingaPsychiatryResidencyprogram,tofurtherintegrateawholepersonteamapproachatWSU’sMedicalSchool;andlaunchingtheProvidenceDentalResidencyClinic.WearealsopartneringonworkforceinnovationswiththeSpokaneAreaWorkforceDevelopmentCouncilandGreaterSpokaneIncorporated(GSI),thelargestregionalbusinessorganizationinthearea.GSIisfocusedoncreatinganenvironmentwhereemployerscansucceed,compete,andgrow.GSI’s“Vision2030”includesgrowingaHealthandLifeSciencesIndustryandincreasingeducationattainmentfrom40%to60%by2025.Finally,weareparticipatinginconversationswithotherACHs,HCA,DOH,WashingtonStateHospitalAssociation(WSHA),WashingtonStateMedicalAssociation(WSMA),andtheUniversityofWashingtonCenterforHealthWorkforceStudiestoalignourlocalstrategywithstatewideefforts.BHTPopulationHealthManagementSystemsThirty-nineuniqueorganizationsintheBHTACHregioncompletedaHealthSystemsInventory(HSI)orCareCoordinationInventory(CCI)tohelptheBHTACHlearnmoreabouttheorganizations’patientsandworkinareasrelevanttotheMTD.BasedonproviderresponsestotheHSI,weknowthatmultipledatasystemsareinuseacrossthecommunity.Itwillbenecessarytoconductaprovider/Collaborative-levelassessmentonHIE/HIT.WewillconductanHIE/HITsurveyinQ12018tobetterunderstandsystemsandtoolsinuse.Thiswillincludemappingassetsandcurrentpopulationhealthmanagementsystemscapabilities,capacityandgapsanddevelopaplanforcreatingthenecessaryinterconnectivityacrossproviders.

TheBHTACHwilldeveloparegionalimplementationplantoensureacoordinated,leveraged,andcost-effectivesolution.WeexpecttoexplorearobustpartnershipwithOneHealthPortandotherstateinitiatives.TheBHTACHhasdevelopedthefollowingstrategiestoexpand,use,support,andmaintainpopulationhealthmanagementsystemsacrossallprojects:

• UsetheCollaborativestructuretoincentsharedaccountabilitytiedtooutcomesforpopulationhealth.ItisexpectedthateachCollaborativewillbeeligibleforpaymentsbasedonperformanceonHIE/HITadoption.

• BHThassubcontractedwithProvidenceCOREtocreateacommunitydashboardthatwilla)provideabroaderviewofcommunityhealth;b)helpinformcommunityresiliencyinvesting(anothereligibleearnedincentivecategoryunderBHT’sapproach);andc)connectinformationaboutsocialdeterminantsandclinicalcare.

• UtilizeFIMCIncentivestosupportprovidersforconnectivityandupgradeEHRstomeetintegratedcarereportingandbillingneeds.EachCollaborativewillassessneeds/gapsthatwillinformtheWaiverFinanceWorkgrouprecommendationstotheBHTBoardonlevelsofinvestment.

• ExploreinformationsharingandstrategydevelopmentwiththeWashingtonStateHospitalAssociation(WSHA).BHT’sEDhasactivelyengagedwithWSHAaboutcapacityandpotentialutilizationofadaptingWSHA’scurrenthospitaldatareportingsystemtoincludepopulationhealthinformation.

Endnotes

1See:http://www.doh.wa.gov/Portals/1/Documents/2900/wa_ach_od_quarterly_2017Q1.zip2See:https://www.doh.wa.gov/DataandStatisticalReports/DiseasesandChronicConditions/ChronicDiseaseProfiles/AccountableCommunitiesofHealth

3WashingtonStateOfficeofFinancialManagement(2017).PotentiallyPreventableHospitalizationsbyLegislativeDistrict.ResearchBriefNo.85.Availableat:http://www.ofm.wa.gov/researchbriefs/2017/brief085.pdf

4CoordinatedCare,Molina,andUnitedsubmittedCCIs;these3MCOsrepresent73%oftheenrolledpopulationbasedonHCAMedicaidEnrollmentreports(PlanbyProgram)forSeptember2017.See:https://www.hca.wa.gov/about-hca/apple-health-medicaid-reports

5HCAACHToolkitProviderReportFilesupdated09.01.17,see:https://wahca.app.box.com/s/mxpg8euzbjpdkmyuftzb4ri5v41ia8v9/folder/30748038709.

6SpokaneRegionalHealthDistrictDataCenter(2017).CommunityLinkageMapping:GeneralReport.Anassessmentoftheregionalpopulationandsocialdeterminantsofhealthsystems.See:https://goo.gl/1WDBpo.Seealsotheinteractivemapavailableat:http://arcg.is/2pH9kuT

7CalculationsusingWashingtonStateOfficeofFinancialManagementOfficialPopulationEstimatesfor2016;see:http://www.ofm.wa.gov/pop/april1/

8Basedon2010censusdataandRUCAdesignationsbyWashingtonStateOfficeofRuralHealth;see:ftp://ftp.doh.wa.gov/geodata/layers/Scheme4_rurality_censustracts_WA.pdf

9HealthierWashingtonDataDashboard,CY2016data:https://www.hca.wa.gov/about-hca/healthier-washington/data-dashboard

10HealthierWashingtonDataDashboard(CY2016)andOfficeofFinancialManagementsmallareapopulationestimatesfor2016.

11HealthierWashingtonDataDashboard,Oct.2015–Sept.2016data12BasedonOfficeofFinancialManagementsmallareapopulationestimates,changeinHispanicpopulation2010-

2016.See:http://www.ofm.wa.gov/pop/asr/13HealthierWashingtonDataDashboard,CY2016data:https://www.hca.wa.gov/about-hca/healthier-

washington/data-dashboard14SpokaneAreaWorkforceDevelopmentCouncil,see:

http://www.betterhealthtogether.org/s/BetterHealthTogether_final.pdf15Basedon2015data,RWJFCountyHealthRankings:http://www.countyhealthrankings.org/16UrbanIndianHealthInstitute,SeattleIndianHealthBoard.(2017).CommunityHealthProfile:IndividualSite

Report,SpokaneUrbanIndianHealthProgramServiceArea.Seattle,WA:UrbanIndianHealthInstitute.Notethattheseestimatesarebasedon2010-14AmericanCommunitySurveydata,whiletheRWJFCountyHealthRankingsemploymentmeasureusestheCurrentEmploymentStatisticsSurvey.

17See:http://www.commerce.wa.gov/housing-needs-assessment.Affordable(meaningtheycostlessthan30%ofaveragehouseholdincome)&availableunitsper100householdsinBHTACHcountiesare:Adams22,Ferry26,Lincoln22,PendOreille26,SpokaneCo.12,Stevens26.Spokanemetroareahas14affordable&availablehousingunitsper100households.

18BHTACHHealthSystemsInventory(2017).19HCAACHToolkitHistoricalData:

https://wahca.app.box.com/s/mxpg8euzbjpdkmyuftzb4ri5v41ia8v9/folder/3695005203620HCACo-occurringdisordertables,see:https://wahca.app.box.com/s/mxpg8euzbjpdkmyuftzb4ri5v41ia8v9/folder/39866406519

21HCAhospitalizations_ach_rhni_tables:https://wahca.app.box.com/s/mxpg8euzbjpdkmyuftzb4ri5v41ia8v9/folder/23928005433.(Notethat1/3ofMedicaid-paidhospitalizationsinBHT’sregionthatwerenotrelatedtopregnancy/childbirthwereclassifiedasstemmingfrom“othercauses”intheavailabledata

22BHTACHHealthSystemsInventory(2017).

23HCARHNI“starterset”files,see:https://wahca.app.box.com/s/mxpg8euzbjpdkmyuftzb4ri5v41ia8v9/folder/23928005433

24WashingtonPrescriptionDrugMonitoringProgram,see:https://www.doh.wa.gov/ForPublicHealthandHealthcareProviders/HealthcareProfessionsandFacilities/PrescriptionMonitoringProgramPMP/CountyProfiles

25HCAACHToolkitHistoricalData:https://wahca.app.box.com/s/mxpg8euzbjpdkmyuftzb4ri5v41ia8v9/folder/36950052036



28HealthierWashingtonDataDashboard,Oct.2015–Sept.2016data29HCAMedicaidenrollmentreports;see:https://www.hca.wa.gov/about-hca/apple-health-medicaid-reports30Dataarefrom2012or2013andonlyavailableforAdams,Lincoln,Spokane,andStevenscounties.BasedonsurveysoflicensedprovidersconductedbytheWashingtonStateDepartmentofHealth,OfficeofRuralHealth,see:https://www.doh.wa.gov/ForPublicHealthandHealthcareProviders/RuralHealth/DataandOtherResources/HealthProfessionalShortageAreas/HealthcareAccessReports

31SpokaneRegionalHealthDistrictDataCenter(2017).CommunityLinkageMapping:GeneralReport.Anassessmentoftheregionalpopulationandsocialdeterminantsofhealthsystems.See:https://goo.gl/1WDBpo.Seealsotheinteractivemapavailableat:http://arcg.is/2pH9kuT

32ThetransitionalrespitecareprogramwasfeaturedinarecentRWJFcasestudy,availablehere:http://www.chcs.org/media/Respite-Program-Case-Study_101217.pdf

33HealthierWashingtonDataDashboard,Oct.2015–Sept.2016data34HealthierWashingtonDataDashboard,CY2016data:https://www.hca.wa.gov/about-hca/healthier-washington/data-dashboard

35QualisHealth(December2016).2016RegionalAnalysisReport,WashingtonAppleHealth,WashingtonHealthCareAuthority.Availableat:https://www.hca.wa.gov/assets/program/eqr-regional-analysis-report-2016.pdf


37HealthierWashingtonDataDashboard,Oct.2015–Sept.2016data38HCAACHToolkitHistoricalData:https://wahca.app.box.com/s/mxpg8euzbjpdkmyuftzb4ri5v41ia8v9/folder/36950052036

39WashingtonStateDepartmentofHealth,OfficeofRuralHealth,see:https://www.doh.wa.gov/ForPublicHealthandHealthcareProviders/RuralHealth/DataandOtherResources/HealthProfessionalShortageAreas

40SkillmanSM,DahalA.(2017).WashingtonState’sPhysicianWorkforcein2016.Seattle,WA:CenterforHealthWorkforceStudies,UniversityofWashington.

41WashingtonStateHealthWorkforceSentinelNetworkdataforApril-May2017reportingperiod.13totalrespondentsfortheBHTACHregion,amongwhich4and3reporteddemandincreasesforsocialworkersandcounselors,respectively.See:http://www.wtb.wa.gov/HealthSentinel/

42QualisHealthandWashingtonStateHealthCareAuthority.(2016).AppleHealthManagedCareCAHPS©5.0HAdultMedicaidreport.See:https://www.hca.wa.gov/assets/program/ahmc-overall.pdf


44WashingtonStateOfficeofFinancialManagement(2017).PotentiallyPreventableHospitalizationsbyLegislativeDistrict.ResearchBriefNo.85.Availableat:http://www.ofm.wa.gov/researchbriefs/2017/brief085.pdf

45BHTACHHealthSystemsInventory(2017).46WashingtonStateDepartmentofHealth,CenterforHealthStatistics,2009-2013.CalculationsandpresentationofdatabySpokaneRegionalHealthDistrict,DataCenter.

472013FosterPlacementrateper1000.SpokaneCounty=10.2,stateaverage=5.7.(http://datacenter.kidscount.org/data/)

482016WashingtonHealthyYouthSurveydataforBHTregion,grades6,8,and10(grade12responseratetoolow

toinclude).See:http://www.askhys.net/library/2016/ACH01MultiGr.pdf

49RWJFCountyHealthRankings,basedon3yearsofpooledBRFSSdata.See:http://www.countyhealthrankings.org/app/washington/2017/measure/outcomes/60/data

50FelittiV,etal.(1998).Relationshipofchildhoodabuseandhouseholddysfunctiontomanyoftheleadingcausesofdeathinadults.TheAdverseChildhoodExperiences(ACE)Study.AmJPrevMed.14(4):245–258

51WashingtonStateDepartmentofHealth,OfficeofRuralHealth,see:https://www.doh.wa.gov/ForPublicHealthandHealthcareProviders/RuralHealth/DataandOtherResources/HealthProfessionalShortageAreas

52WashingtonStateHealthWorkforceSentinelNetworkdataforApril-May2017reportingperiod.13totalrespondentsfortheBHTregion,amongwhich4and3reporteddemandincreasesforsocialworkersandcounselors,respectively.See:http://www.wtb.wa.gov/HealthSentinel/

SECTIONII:PROJECT-LEVEL

TransformationProjectDescription SelecttheprojectfromthemenubelowandcompletetheSectionIIquestionsforthatproject.

MenuofTransformationProjects

Domain2:CareDeliveryRedesign�� 2A:Bi-DirectionalIntegrationofPhysicalandBehavioralHealththroughCareTransformation

(required)

ProjectSelection&ExpectedOutcomes Thescopeoftheprojectmaybepreliminaryandsubjecttofurtherrefinement.InDemonstrationYear2,theACHwillberequiredtofinalizeselectionsoftargetpopulationandevidence-basedapproaches,andsecurecommitmentsfrompartneringproviders.

ACHResponse

ProjectDescriptionandJustificationIn2017,BHTlaunchedacross-sectordiscussionwithBehavioralHealth,PhysicalHealth,ManagedCareOrganizationsandCountyCommissionersaroundtheopportunitiestiedtofully-integratedmanagedcare(FIMC).Thisdiscussionchangedthetenorofthediscussionintheregionfrombehavioralhealthproviderconcernsabouttheunintendedconsequencesofchangetoaconsiderationofbroadsystemtransformationopportunitiesthroughnewinvestments,withthepossibilityofreducedcostsandimprovedpopulationhealth.Asaresult,ourcommunitycommittedtobi-directionalintegrationasacornerstoneofourcommunityhealthtransformationefforts.TheBHTACHbi-directionalintegrationprojectisdesignedtoimprovewhole-personcareandhealthoutcomesbyencouragingandfacilitatingevidence-basedmodelsofcareforhigh-needspopulations,whilealsobuildingonexistingphysicalandbehavioralhealthintegrationactivities.ConsistentwiththeMedicaidTransformationDemonstration(MTD)Projecttoolkitguidance,BHTwillsupportclinicsintheimplementationofevidence-basedmodelssuchastheBreeCollaborativeortheCollaborativeCareModel,andwillleverageHealthInformationTechnologyandcarecoordinationinfrastructuretolaunchourintegrationefforts.Furtheringintegrationofphysicalandbehavioralhealthcareisacriticalstepinaddressingthehealthneedsoftheregionalpopulation.Thisinitiativeholdspromisetoenhancecarecoordinationacrossthespectrumofphysicalandbehavioralhealthconditions,andofferpatientsmoretimelyaccesstoessentialservices.Morethan44,000BHTACHMedicaidmembershavebeendiagnosedwithamentalillness,andtheprevalenceofmentalillnessis29.5%intheBHTACHregion,higherthanthestatewidelevel.Approximately20,000clientsintheBHTACHregionhaveasubstanceabusetreatmentneed,equatingtoaprevalenceof11.2%.Finally,andperhapsmostconcerning:about36,000haveamentalhealthorsubstanceabuseconditionand1ormorechronicdisease,indicatingahighlevelofneedforbi-directionalcareintegrationtoprovidewholepersoncareandnavigatethemanyobstaclesthatariseforpatientssufferingfromtheseconditions.1Figure1belowprovidesdetailsontheprevalenceofconditionsintheBHTregion(orange)comparedtothestatewideprevalencerate(blue).

Figure1:ProportionofMedicaidPopulationwithKeyConditions

JustificationforselectingprojectandhowitaddressesregionalprioritiesTheprevalenceofbehavioralhealthdisordersandsubstanceusedisorders(SUD)constitutesamajorpublichealthissueintheBHTACHregion.Outsideofpregnancyandchildbirth,‘mentalandbehavioraldisorders’weretheleadingcauseofhospitalizationforBHTACHMedicaidbeneficiariesin2015,accountingfor17.5%ofallnon-birth-relatedhospitalizations.Substanceabusedisordersaccountedfor5.7%ofsuchhospitalizationsoverallbut8%amongnon-disabledadults.(Notethat1/3ofMedicaid-paidhospitalizationsintheBHTACHregionthatwerenotrelatedtopregnancy/childbirthwereclassifiedasstemmingfrom“othercauses”intheavailabledata.)2Moreover,opioiduseishighamongtheBHTACHMedicaidpopulation.17.4%ofBHTACHMedicaidbeneficiariesarecurrentopioidusers,vs.13.5%statewide,and3.6%areheavyusers.3InalmostalloftheBHTACHcounties,opioidprescriptionsarewrittenandfilledatahigherratethanaverageforWashingtonstate(AdamsCountyistheexception).4TheBHTACHexceedsthestateaverageforMedicaidusersreceivingmedication-assistedtreatmentwithbuprenorphine(11%vs.10%statewide)butissubstantiallybelowthestateaverageformethadoneMAT(11%vs.16%statewide).5TheBHTACHisalittlebelowthestateaverageformentalhealthtreatmentandsubstanceabusetreatmentpenetrationratesamongMedicaidbeneficiaries.Ontheotherhand,ratesoffollow-upafterahospitalizationorEDvisitrelatedtomentalhealthorsubstanceusearehigherthantheaverageforWashingtonState.5Overall,estimatedchronicdiseaseprevalenceamongtheMedicaidpopulationintheBHTACHregionisclosetothestatewidefigures:approximately3%hadaninpatientoroutpatientclaiminthelastyearthatincludedadiagnosisofdiabetes(vs.4%statewide)and5%hadaclaimwithadiagnosisofasthma(vs.4%statewide).However,thesefiguresmasksomeregionalvariation:

• AsthmaishigherthanthestateaverageinStevensCounty(6%)andFerryandSpokaneCounties(5%).

• SmokingisariskfactorforanumberofchronicdiseasesandBHThassomeofthehighest(StevensCountyat33%)andlowest(AdamsCountyat8%)smokingratesamongWashington’sMedicaidbeneficiaries.

8.8%

12.5%

29.5%

7.7%

11.2%

27.1%

0% 10% 20% 30% 40%

MIorSUDandCD

SUDtreatmentneed

Anymentalillness

BHTinorange Stateinblue

• DepressiondiagnosesamongSpokaneCountyMedicaidrecipientsis12%butAdamsCountyhasthelowestrateinthestateat3%.6

Finally,whiletheBHTACHregioncurrentlyperformsatorabovethestatelevelonseveralperformancemeasuresthatareconnectedtothe2Aproject,therearestillpromisingopportunitiestoenhanceintegratedcare,suchasincreasingfollow-upafterdischargefromtheEDforencounterstiedtoamentalhealthconditions.Theseopportunitiesforimprovedprocessesandpatientoutcomesprovideakeyrationaleforthisinvestment.

Figure2:BHTperformanceonselectintegrationperformancemeasures7

HowprojectwillsupportsustainablehealthsystemtransformationforthetargetpopulationTransformingthehealthcaresystemtobemoreresponsivetotheneedsofpeoplereceivingMedicaidservicesthroughtheprovisionofintegratedcare,whetherinaprimarycareorbehavioralhealthclinic,willimproveoutcomesnotonlyforthe2Atargetpopulation,butforMedicaidbeneficiariesoverall.WewillscaleuptofullimplementationoverthecourseoftheMTDperiod,startingwiththehigh-riskpopulationofMedicaidenrolleeswithco-morbidconditionsinordertobesuccessfulinachievingexpectedprojectoutcomes.Itistheexpectationthatbyincreasingintegratedcaretothistargetpopulations,therewillbegainstotheentirehealthcaredeliverysystem.Asprovidersbecomemorefluentincollaboratinginpatients’care,whole-personcare,expectedresultsincludeearlierdiagnosis,treatment,andopportunitiestomovecareupstreamandpreventconditionsfromexacerbatingandbecomingchronic.

Inadditiontostrongerintegrationofcarebetweenphysicalandbehavioralhealthproviders,collaborationwithsocialserviceprovidersthroughthePathwaysHubmodelimplementationwilllaythegroundworkforproviderstoeffectivelyaddresssocialdeterminantsofhealth,which,leftunaddressed,contributetopoorhealthoutcomes.Lastly,weareexploringtelehealthoptionstoincreaseaccesstocare.Ourprovidernetworkiscurrentlyreviewingpotentialtele-behavioralhealthservices,whichwouldbeavailableforemergencyconsultsintheED,formedicationmanagementandsupportoftheprimarycareteam,andforongoingcareofindividualswithchronicbehavioralhealthissues.Someexamples

22.0%

29.5%

63.8%

73.2%

76.8%

88.1%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Follow-upafterdischargefromEDforalcoholorotherdrugdependence - 7day

Follow-upafterdischargefromEDforalcoholorotherdrugdependence - 30day

Follow-upAfterDischargefromEDforMentalHealth- 7day

Follow-upAfterDischargefromEDforMentalHealth- 30day

Followupafterhospitalizationformentalillness- 7day

Followupafterhospitalizationformentalillness- 30day

alreadyexistthatcouldbetakentoscale:healthsystemsareworkingwithspecialistsinSpokanetohavefollow-upvisitsdoneviatelehealth;LincolnCountyhasusedatelehealth-basedhospitalistprogram;Newporthasdiabeteseducationclassesdeliveredviatelehealth;andthereisalsoaregularParkinson’sDiseasesupportgroupthatmeetsregularlyaroundtheregionviatelehealth.

HowBetterHealthTogetherwillensureprojectcoordinateswithanddoesn’tduplicateexistingeffortsBetterHealthTogetherissupportingthedevelopmentoftwoCommunityHealthTransformationCollaboratives:

1. RuralCollaborative(comprisedofFerry,PendOreille,Stevens,Lincoln,andAdamscounties)

2. SpokaneCollaborative(SpokaneCounty).

TheBHTACHistakingaregionalapproachtoprojectdesignandimplementationthatwillprovidelocalautonomyandregionalaccountability.TheCollaborativeswillberesponsiblefordevelopingandimplementingactionableMTDplansacrossBHT’sprojectportfolio,andensuringthattheprojectscoordinatewitheachotheranddonotduplicateexistingeffortsintheregion.TheCollaborativeswillbecomprisedofkeypartnerswiththeexpertiseandexperiencerequiredtotransformourMedicaidDeliverySystemincludingclinics,FederallyQualifiedHealthCenters(FQHCs),Hospitals,MentalhealthandSubstanceUseproviders,PublicHealth,TribalHealthsystems,EMS,JailsandCountyCommissioners.Thisrepresentationwillensureeffortsarecoordinatedacrosstheregionandresourcesareleveraged.

AnticipatedProjectScopeAnticipatedtargetpopulationTheMedicaidDemonstrationToolkitsuggestsanoveralltargetpopulationofalltheMedicaidenrolleesintheregion,approximately196,000individualsintheBHTregion.2A’sultimateprojectgoalforthedemonstrationisfullimplementationofintegratedcareforallMedicaidbeneficiaries.Weareproposingtoscaleuptofullimplementation,startingwithahigh-riskpopulationofMedicaidenrolleeswithco-morbidconditions,inordertobesuccessfulinachievingexpectedprojectoutcomes.

Anestimated36,000MedicaidbeneficiariesintheBHTregionhaveamentalhealthorsubstanceusedisorderandoneormorechronicdiseases.However,thereareafewsubpopulationswithinthebroaderBHTMedicaidpopulationthatareathigherriskofsufferingfromsubstanceusedisorder(SUD),mentalhealth(MH)conditions,andchronicdiseases,oracombinationthereof.AsshowninTable2,disabledclientsandnewlyeligible(Medicaidexpansion)adultsintheMedicaidpopulationhaveahigherrateofco-occurringdisordersthanthetraditionalMedicaidpopulation.RatesarealsohigherthanexpectedinPendOreilleandSpokanecounties.8IntheBHTACHregion,peoplewithanMHandSUDdiagnosisarealmost5timesaslikelytohave3+EDvisitsinayearasgeneralBHTACHareaMedicaidbeneficiaries.9

Table3:Co-occurringconditionsbyMedicaideligibilitygroupintheBHTACHregion8

Coveragegroup SUD MHcondition ChronicDisease SUDorMHandCD

Disabled 27.7% 60.6% 24.6% 58.8%

Newadults(MedicaidExpansion)

20.3% 32.1% 24.2% 29.4%

TraditionalMedicaid

5.5% 20.4% 27.2% 13.4%

Wewillworkinitiallywiththehighestvolumeprovidersineachcountytofurthertargetoureffortswithinthegroupof36,000individualswithco-occurringconditions.Forexample,wewilllookforopportunitiestoconnectbi-directionalintegrationstrategieswithourdiabetes-focusedchronicdiseaseeffortsfortheestimated4,850memberswhohavediabetesaswellasamentalhealthorsubstanceabusedisorder.InvolvementofPartneringProvidersTodeveloptheproposedproject,theBHTACHconvenedandmetone-on-onewithhighvolumeandengagedpartneringprovidersthroughouttheregionworkingonphysicalandbehavioralhealthintegration.Inaddition,theBHTACHengagedprovidersaHealthSystemsInventoryandaCareCoordinationInventory,toidentifyproviderinterestinMTDprojectareas.Draftinventorieswerefirstreleasedforpublicfeedback,andoncelaunched,wehosted3webinarstooverviewtheInventoryandansweranyquestionsfrompartners.BHTstaffhosted15hoursofOfficeHourssessionswherepartnerscoulddropinandtalkwithACHstaffabouttheirInventoriesorMTD,inadditiontonumerousoutreachmeetingstoindividualproviderorganizations.Throughtheseefforts,BHThasengagedabroadrangeofproviderscriticaltothesuccessofbi-directionalintegrationproject,includingphysicalandbehavioralhealthproviders,countyproviders,socialserviceagenciesandMCOs.39organizationsintheBHTACHregion,representingmostmajorhealthandsocialservicesystems,completedtheHealthSystemsInventory(HSI)and/orCareCoordinationInventory(CCI).TheseeffortsdirectlyinformedthedevelopmentoftheproposedBi-DirectionalIntegrationprojectprioritiesandtheBHTACHproposaltodevelopregionalCollaborativestoimplementMTDprojects.LevelofImpactIntegratingservicesforallMedicaidbeneficiariesacrosstheBHTACHregionwillresultinbettercareandpatientsatisfaction,aswellascostefficiencies.TheimpactoftheprojectwillreachbeyondtheMedicaidbeneficiariesintheregion,withsignificantinfrastructureimprovements:Virtualintegrationandco-locationmethods,e.g.

o Behavioralhealthconsultantswithwarmhandoff(co-location)o In-clinicBHproviders(master'slevel)withremotesupportfrompsychiatrist(virtual&in

person)• Inphysicalhealthsetting:In-clinicBHproviders(master'slevel)withremotesupportfrom

psychiatrist(virtual&inperson)• InBHsetting:Morechronicdiseasemanagementorself-managementsupport• Multidisciplinaryteams• Comprehensivesharedcareplans• BHandchronicdiseasescreenings

HowBetterHealthTogetherwillensurethathealthequityisaddressedintheprojectdesignTheBetterHealthTogetherAccountableCommunityofHealthisensuringthathealthequityisembeddedintheprojectdesignatmultiplelevels:

• RegionalHealthTransformationCollaboratives:WiththecreationofdistinctSpokaneCountyandRuralCollaboratives,BHTisensuringattentionandfocustoruralhealthissuesanddisparitiesin

ourregion.Inaddition,wearedesigningtheseCollaborativestoincludeorganizationsthatbringdiverseracialandculturalperspectivestokeyregionalhealthissues.

• CommunityVoicesCouncil:BHTACHislaunchingaCommunityVoicesCouncil,madeupofatleast50%Medicaidbeneficiariesorlow-incomecommunitymembers,toempowerandbringconsumervoicestoinformprojectdesignandimplementation.ThisCouncilwillbetaskedwithdevelopinghealthequitymetricsbywhichtoholdtheCollaborativesandprojectsaccountabletodefinedhealthequitygoalsandstandards.

• Targetpopulations:BHTisfocusingprojectsontargetpopulationsexperiencingthegreatesthealthdisparities.Weareapplyingan“equitylens”toallourworkbydisaggregatingdatabyrace/age/ethnicity/sex/zipcodewhereverpossible,bothtomakeinformeddecisionsabouttargetpopulationsandtomonitorimpactofprojectsacrossdiversegroups.TheBHTACHwillsupplyCollaborativeswithregionaldatatoguideearlyassessmentsofCollaborativepartners,andwilldirecttheseteamstoidentifypopulationswithintheircountythatfaceahighlevelofdisparitiesand/orpresentashighlycomplexorhighrisk.Initialdataexplorationindicatesthatindividualswithco-occurringmentalhealthandsubstanceabusedisorders—whorepresentpartoftheinitialfocuspopulationforourintegrationwork—experiencethefollowingdisparitiesinqualityofcare:10

o Higherratesofgeneralhospitalreadmissions(all-cause,30day)o Higherratesofreadmissiontoinpatientpsychiatriccare(30day)o LowerratesofannualHbA1ctesting

• Livedexperience:WiththeCommunity-basedCareCoordinationproject,BHTACHisadvancingthePathwaysmodelanduseofCommunityHealthWorkerswithlivedexperienceofhealthinequitiestofurtherourefforts.Carecoordinatorsarecriticaltodevelopingtrustandculturally-appropriatestrategiestomeettheneedsofourtargetpopulationsacrosstheMTDprojectareas.

• EquityAcceleratorPayment:Weanticipateimplementingthisincentivetosupportproviderswhoserveagreaterproportionofhigh-riskclients.ThemetricstiedtothesepaymentswillbedeterminedbytheWaiverFinanceWorkgroup,vettedbyProviderChampionsCouncilandCommunityVoicesCouncil,finalizedbyWaiverFinanceWorkgroup,andrecommendedtotheBHTBoard.

• PathwaysCommunityHubModel:HealthequityisbuiltintomanyelementsofourCommunity-basedCareCoordinationstrategyandthePathwaysmodel,throughindividualizedcareplans;standardsofcareandaccesstotheentirenetworkofcareagenciespartneringwiththeHub;culturally-informedcare;anddatainfrastructuretoolsthatcanbeusedtomonitorcarepractice,providerquality,andresourcegapsinthecommunity,toinformanaccuratepictureofourhealthsystem’scapacity.

Project’slastingimpactsandbenefittotheregion’soverallMedicaidpopulationShiftingtowhole-person,integratedcarewillimprovethequalityofcarepeoplereceiveandimproveoutcomesforthemostvulnerablepopulationsandallMedicaidbeneficiaries.Thisshiftwillalsoallowforamoreefficientuseofdollars,freeingupfundsforincreasedinvestmentsinupstreamhealth,includingpopulationhealth,preventionandaddressingsocialdeterminantsofhealth.Infrastructureinvestmentsandclinicalcareredesignwillbeamongthelastingimpactsfortheregion’soverallMedicaidpopulation,includinginvestmentsinHIE/HITandworkforcetosupportintegratedcare,establishedpathwaysforproviderstodevelopnewevidence-basedmodelsofcare/proofofevidence,implementationofclinicalscreeningtoolstonewpopulations,andfacilitated/sharedlearningacrosscollaborativeproviders.TheseinvestmentswillpavethewayforlastingchangeinhealthcaredeliveryandprepareprovidersintheBHTregionforvalue-basedpayment.

ImplementationApproachandTimingSeeSupplementalWorkbook

PartneringProvidersSeeSupplementalWorkbook

ACHResponse

HowBetterHealthTogetherhasincludedpartneringprovidersthatcollectivelyserveasignificantportionoftheMedicaidpopulationAsreferencedabove,theBHTACHsurveyedorganizationsintheregiontocompleteaHealthSystemsInventory(HSI)and/orCareCoordinationInventory(CCI)togatherproviderinformationaboutexistingworkintheregionrelatedtotheMTDprojectareas.BHTACHreceivedresponsesfrom39organizations,includinghospitalnetworks,providersystems,FQHCs,MCOs,andcarecoordinationagencies.

RespondingprovidersfortheHealthSystemsInventoryrepresentedmorethan80%ofthehighest(top10)volumeMedicaidbillersinprimarycare,mentalhealth/substanceabuse,inpatientandED.ForseveralsettingsintheBHTACH’sfiveruralcounties,theHSIrespondentsrepresentalltheMedicaidbillerswithclaimsorbeneficiarycountsofmorethan10in2016.

ProcessforensuringpartneringproviderscommittoservingtheMedicaidpopulation.In2018,theBHTACHwillformalizepartneringproviderparticipationinthebi-directionalprojectandotherMTDprojectareasthroughaTransformationCompactprocesstoensurecommitmenttoservingtheMedicaidpopulation.ThroughtheACHLeadershipCouncil,HealthSystemandCareInventory,BHTACHhasatrackrecordforengaginghighvolumeprovidersintheregionservingasignificantportionoftheMedicaidpopulation.TheBHTACHhasconfidencetheywillcommittoparticipationintheCollaborativeandwillformalizethiscommitmentthroughtheTransformationCompact.

Processforengagingpartneringprovidersthatarecriticaltotheproject’ssuccess,andensuringthatabroadspectrumofcareandrelatedsocialservicesisrepresentedBHThasidentifiedthatrepresentationfromthefollowingsectorsisrequiredforCollaborativestosuccessfullyimplementprojects:

• PhysicalHealthClinicalProvider(s)• HospitalSystem• BehavioralHealthClinicalProvider(s)• TribalHealthSystemProviders• EmergencyMedicalServices• CriminalJustice• SUDProvider(s)• Community-BasedChronicDiseasePrevention• CommunityBasedCareCoordinatingAgency• MCO(s)• CrisisManagementServices• Liaison:CommunityMember/Consumer

RegionalAssets,AnticipatedChallengesandProposedSolutions ACHResponse

Collaborativepartnershipswillbeexpandedasneeded.InitsroleasthePathwaysHub,theACHwillserveasaconnectorbetweenCollaborativeprovidersandsocialandcommunitypartners.BHTACHisalsolaunchingaProviderChampionsCounciltolendapracticingproviderperspectivetoourworkandtoinformandvalidateTransformationPlanslaidoutbyCollaboratives.HowBetterHealthTogetherisleveragingMCO’sexpertiseinprojectimplementation,andensuringthereisnoduplicationManagedCareOrganizationsareactivelyinvolvedinBHT’sgovernanceandleadershipgroups:

• TwoMCOrepresentatives,fromMolinaHealthCareofWashingtonandCoordinatedCareofWashington,areontheBoard

• AllfiveMCOsarevotingmembersofBHT’sLeadershipCouncilandMCOstaffparticipateinmeetingsandone-on-onesessionswiththeBHTteam

• MCOrepresentativesareontheBHTACHRegionalIntegrationPlanningTeam,WaiverFinanceWorkgroup,ProviderChampionsCouncilandCommunityVoicesCouncil

MCOswillcontinuetoparticipateinMTDprojectplanningviatheseTechnicalCouncilsandthroughtargetedcollaborationwithBHTACH’sCommunityHealthTransformationCollaboratives.

Inaddition,BHT,PierceCountyACH,andSouthwestACHhavecollaboratedonmeetingswithMCOpartnerstolearnaboutkeycrossoverareasbetweenACHsandMCOsunderMTD,toensurethattheBHTACHprojectstrategy,supportforproviders/Domain1strategies,andmonitoringandqualityimprovementeffortsalignwithexistingMCOactivitiesandgoals.Ourdiscussionscovered:

• Members/populationoverview• PCPassignment/empanelment• Providersupport,particularlyforvalue-basedpaymentandrelateddeliverysystemreform• Measurementandqualityimprovement• Memberengagement/education• Pathways

IntheBHTACHdiscussionswithMCOs,itwasemphasizedtheimportanceofconsideringtheneedsandutilizationpatternsofdifferentMedicaidpopulations(e.g.expansionadultsvs.traditionalMedicaid)anddesigningstrategiesthatcanintegrateadditionalgroups(e.g.dualspecialneedsclients)overtimetofullyengageMCOsandotherpartnersandsupportsustainability.Anothercommonpointwastheneedtoavoidoverwhelmingproviderswhoarereceivingassistanceandrequestsforpracticetransformationefforts.TheACHandtheCollaborativescanplayakeyroleincoordinatingTAsupportwithMCOs.WealsodiscussedwaystocoordinateondatasharingwithMCOs,HCA,theWashingtonHealthAlliance,OneHealthPortandeventuallytheWashingtonAllPayerClaimsDatabase.

ACHResponse

AssetsBetterHealthTogetherandregionalpartneringproviderswillbringtotheproject:TheBHTACHwillutilizearuralandSpokaneCountyCollaborativemodeltodevelopandimplementactionablebi-directionalintegrationplans.TheRuralCollaborative,covering35,173MedicaidlivesintheruralcountiesofAdams,Ferry,Lincoln,PendOreilleandStevens;andtheSpokaneCountyCollaborative,acountywith164,707coveredMedicaid.TheseCollaborativesareresponsiblefora

localsetofstrategiestomeettheMTDprojectgoals.TheCollaborativestructurewillalignwiththeproposedMTDfundsflowapproachbyallocatingearnedregionalfundstoeachcollaborativebasedonpayforreportingandpayforperformancegoalachievement.Fundsflowstrategiesincludeplansforfixedandearnedpaymentstobothurbanandruralproviderpartnerstocoverexpensessuchasprojectcosts,projectadministration,providerengagementandparticipation,workforcedevelopment,populationhealthmanagement,andothercosts.In2013,BHTdevelopedtheNavigatorNetwork,alargeandsuccessfulinitiativetoprovideIn-PersonAssisterstoenrollpeopleinAppleHealth(Medicaid)andQualifiedHealthPlansontheWashingtonHealthBenefitExchange.Throughtheseefforts,BHTsuccessfullyenrolledover125,000peoplewithhealthinsurance(manyofwhomhavebehavioralhealthdiagnoses)anddevelopedarobustnetworkofpartnersthroughouttheregion.AstheoperatoroftheNavigatorNetworkofEasternWashington,BHThasdirectconnectionswithmorethan50organizationswhohostoremploynavigators.ThisprovidescredibilityandimportantlocalconnectionstoprovidersneededtosuccessfullyimplementourMTDprojects.UtilizingSIMfunds,theBHTACHpilotedthePathwaysHubCareCoordinationmodeltoreducejailrecidivismratesinFerryCounty.Thisprojectdemonstratedthevalueofacommonreferralmechanismtoaddresssocialdeterminantsofhealthissues.Forbi-directionalintegration,thePathwaysHubwillprovideaddedsupporttoprovidersforreferringhighriskpatientsinneedofsocialdeterminantofhealthsupport.BHTandtheNWRuralHealthNetworkhaveworkedcollaborativelyoverthelast4yearstoestablishRuralCountyHealthCoalitions.Thishasjump-startedourplanningtodevelopacounty-basedCollaborativemodel.Ineachofour5ruralcounties,thereisanestablishedstructurethathasengagedkeystakeholders,includingphysicalhealthclinical,hospitalsystems,behavioralhealthclinical,SUD,Community-BasedChronicDisease,EmergencyMedicalServices,CriminalJustice,PublicHealthandCommunity-BasedCareCoordinatingAgencyproviders.InSpokaneCounty,throughourLeadershipCouncil,CommunityStrategymapworkgroups,andtheleveragingofadditionalnetworks,wehavealsoidentifiedkeypartnerstoserveasthefoundationoftheSpokaneCountyCollaborative.Otherassetstobeleveraged:BHTACHwillexploreapartnershipwithUpstreamUSA.UpstreamdeliversCME/CEU-eligibleon-sitetrainingandtechnicalassistancetohealthcenterssotheycanremovebarrierstosame-dayofferingofthefullrangeofcontraceptivemethods,includingLong-ActingReversibleContraceptives(LARC),toincreaseuseofLARCandreduceunintendedpregnancies.Upstream,inpartnershipwithalargelocalfunder,hasidentifiedWashingtonStateaspartoftheirexpansionstrategy.Investmentscouldrangefrom$1millionto$50millionstatewide.BHTwillexploreapartnershipwiththeARCORAFoundation,calledOralHealthConnections,toleverageinvestmentinseveraloralhealthstrategies.BasedontheSBIRTmodelforbehavioralhealthintegration,thismodelreinforcesadvancedprimarycare,emphasizingteambasedcare,EHRdrivendecisionsupport,andcoordinatedreferraltospecialtycare.OralHealthConnectionsisasystemofcarethatconnectsAppleHealth(Medicaid)patientswithdentalcareintheirlocalcommunities.In2017,theWashingtonStateLegislaturemandatedtheHealthCareAuthorityandARCORAFoundationtoworktogethertopilotOralHealthConnectionsinthreecommunities(Spokane,Thurston,andCowlitzCounties)withtwotargetpopulations–patientswithdiabetesandpregnantwomen.Dentistsservingthesepopulationswillreceiveenhancedreimbursementsfordoingso.Medicalsystemswill

identify,diagnose,andreferpatientstodentalcarethroughanonlinereferraltool,DentistLink,amongotherplaces.Medicalanddentalproviderswillshareinformationandtodevelopsharedplansofcare.Patientsinneedofadditionalserviceswillreceivecarecoordinationfromlocalagencies.Thisisakeystrategyforpatient-centeredintegrationofcare,managementofchronicdiseases,andoverallpopulationhealth.ThepilotisscheduledtolaunchonJanuary1,2019.

Challengestoimprovingoutcomesandloweringcostsfortargetpopulationandstrategytomitigaterisksandovercomebarriers:

Challengestoimprovingoutcomes Strategiestomitigaterisks/overcomebarriers• TrainingandTAforproviders,

includingexpectationsettingfordifferentgroupsandcommunicationacrossprofessionalcultures

• Actingasaconvener,BHTACHwillprovideresourcesforprovidertrainingandTAsupportthroughtheCollaborativestructure

• HarmonizingfinancialpaymenttoPCandBHsettings

• BHTwillworkwithHCA,MCOs,andtheBHTACHregiontosupporteducationandadoptionofVBP

• Clarityandtrainingaroundconsentrequirementsandpatientinformationsharing,incl.school-basedhealthcenters

• Actingasaconvener,BHTACHwillprovideresourcesforprovidertrainingandTAsupportthroughtheCollaborativestructure

• Workforcedevelopment,recruitment,andretentioncriticalforMH-psychiatryandruralhealth,inparticular.Bothchildandadultpractitionersareneeded.

• BHTACHwillcontinuetoworkonregionalworkforcestrategieswithourWDCandeducationpartners

• Lackoftelehealthinfrastructure(technology,space)andstafftrainingsupport

• Exploreregionalcontactingwithtelehealthtechnologyproviderstoovercomeissueswithruralvolume

• Increasingaccess,utilizationandattachmenttoPCP

• UseofCollaborativeinfrastructuretodevelopprovider-ledstrategiestoincreaseaccess,utilization,andattachmenttoPCP

• HITandHIEcapacityvariesbyorganization

• BHTACHwillcontinueEWAACHconversationwithprovidersandMCOsacrossmultipleACHstodrivetosharedapproachandinvestment,andwillcontinuetoworkwithHCAonstatewidealignment

MonitoringandContinuousImprovement

ACHResponse

ThegoalofBHTACH’smonitoringplanistousetimelydatatosupportprojectimplementation,peerlearning,andcontinuousimprovement.BHTACHwillworkwithitscontracteddatavendor,ProvidenceCenterforOutcomesResearch&Education(CORE),todesignandimplementamonitoringsystemthatwilltrackoperational,process,andoutcomemeasuresforeachprojectandCollaborative(seebelow)andfortheACHoverall.Thesystemwillbedesignedtocomplementexistingdataassets(suchastheHealthierWashingtonDataDashboards,anyFullyIntegratedManagedCareearlywarningsystem,andrelevantregionalreports)andwillrefreshanytimeaparticulardatafeedisupdated.Designwilltakeplacealongsideimplementationplandevelopmentinlate2017andearly2018,sothatthesystemisreadyasprojectsmoveintoimplementation.AvisualoverviewofBHTACH’splannedapproachtomonitoringandcontinuousimprovementisshownbelow.

MonitoringmetricswillincludeACHtoolkitpay-for-reportingandpay-for-performancemetrics,aswellasregionalaccountabilityandqualityimprovementplanmetricsthatspeaktotheeffectivenessofBHTACH’sstrategieswithinandacrossprojectareas.Fortheimplementationphase,manymetricswillbeprocessoroperationalinfocus(e.g.establishmentofcross-settingdatasharingagreementsamongCollaborativepartners.)Finalmetricswillbeidentifiedintheimplementationplan.

FortheBi-DirectionalIntegrationProject,theBHTACHwillbetracking,ataminimum,informationonthefollowingaccountabilitymeasures:

• Anti-depressionmedicationmanagement• ChildandAdolescents’AccesstoPrimaryCarePractitioners• ComprehensiveDiabetesCare:HbA1cTesting• ComprehensiveDiabetesCare:Medicalattentionfornephropathy• ComprehensiveDiabetesCare:EyeExam(retinal)performed• MedicationManagementforPeoplewithAsthma(5–64Years)• MentalHealthTreatmentPenetration(broad)• PlanAll-CauseReadmissionRate(30Days)

• SubstanceUseDisorderTreatmentPenetration• Follow-upAfterHospitalizationforMentalIllness• Follow-upAfterDischargefromEDforMentalHealth• Follow-upAfterDischargefromEDforAlcoholorOtherDrugDependence• InpatientHospitalUtilization• OutpatientEmergencyDepartmentVisitsper1000MemberMonths

Planformonitoringprojectimplementationprogress,includingaddressingdelaysinimplementationAsshowninthediagram,thesystemwillincorporateprocessmeasuresforprojectimplementation.ThoseprocessmeasureswillbeassociatedwithtimeframesandbenchmarksidentifiedbytheACHandtheCollaborativestoprovideimmediatefeedbackwhendelaysoccur.TheBHTACHwillworkwithCOREtodevelopacommunitydashboardtomonitorkeymetricsidentifiedinthetoolkitandourcommunitypriorities.Thiswillbeamulti-functionaldashboardextendingbeyondtheMTDtoallowongoingcommunitytrackingandprioritization.ResponsibilityforaddressingdelaysinimplementationwillliewiththeCollaboratives,BHTgovernancebodies,andselectBHTstaffpositionsasdescribedunder‘Planformonitoringcontinuousimprovement’below.Planformonitoringcontinuousimprovement,supportingpartneringprovidersanddeterminingwhetherornotBHTisontracktomeetexpectedoutcomesAmonitoringandcontinuousimprovementsystemismorethanjustdata;it’saboutthepeople,processes,andtoolsusedtoturnthatdataintoactionableinformationthatsupportssharedlearningandqualityimprovement.Inadditiontocreatingasystemtoaccessandanalyzedatafromdifferentsources,theBHTACHwillrelyonthefollowinggroupsandpositionstointerpretthedata,identifyperformanceshortcomingsorrisks,anddevelopsolutions:

• CommunityHealthTransformationCollaboratives.Asdescribedelsewhere,BHTislaunchingaSpokaneCountyCollaborativeandaRuralCollaborativetodevelopandimplementspecificregionalplansforhealthsystemtransformationinthefourprojectareasBHThasselected.Thecollaboratives’rolewillextendto:advisingondesignoftheself-monitoringsystem;regularlyreviewingthedatathatsystemprovides;collaboratingwiththeACHtomakecoursecorrectionsasneeded;andparticipatinginsharedlearningopportunitieswithinandacrossCollaborativesandACHregions.

• ProviderChampionCouncil(PCC).ThisrecentlyestablishedCouncilwillprovidegeneralclinicalexpertiseandsubjectmatterexpertiseindifferentMTDprojectareas.TheCouncilwillmonitortrendsinperformanceacrosstheCollaborativestoassesswhethertheBHTACHisontracktoachieveexpectedoutcomesandwilladviseontheCollaboratives’proposedriskmitigationandcontinuousimprovementstrategies.ThePCCwillalsomonitorindividualCollaborativepartnersandadviseontechnicalassistancenecessary.

• BHT’sDirectorofClinicalIntegration,apositioncurrentlyinrecruitment,willsupporttheclinicalstrategiesforBi-DirectionalIntegration,Opioids,ChronicDiseaseandCareCoordination.Additionally,willstafftheProviderChampionCouncilandidentify,communicate,andaddresschallengestoclinicalintegrationandothertransformationstrategies.

• JennySlagle,AssociateDirectorofHealthSystemTransformationwillserveasthePathwaysHUBDirectoroverseeingalloperationsoftheHubincludingtraining,qualityassuranceand

ProjectMetricsandReportingRequirements AttestthattheACHunderstandsandacceptstheresponsibilitiesandrequirementsforreportingonallmetricsforrequiredandselectedprojects.Theseresponsibilitiesandrequirementsconsistof:

• Reportingsemi-annuallyonprojectimplementationprogress.• Updatingproviderrostersinvolvedinprojectactivities.

YES NOX

RelationshipswithOtherInitiatives AttestthattheACHunderstandsandacceptstheresponsibilitiesandrequirementsofidentifyinginitiativesthatpartneringprovidersareparticipatinginthatarefundedbytheU.S.DepartmentofHealthandHumanServicesandotherrelevantdeliverysystemreforminitiatives,andensuringtheseinitiativesarenotduplicativeofDSRIPprojects.Theseresponsibilitiesandrequirementsconsistof:

• SecuringdescriptionsfrompartneringprovidersinDY2ofanyinitiativesthatarefundedbytheU.S.DepartmentofHealthandHumanServicesandanyotherrelevantdeliverysystemreforminitiativescurrentlyinplace.

• SecuringattestationsfrompartneringprovidersinDY2thatsubmittedDSRIPprojectsarenotduplicativeofotherfundedinitiatives,anddonotduplicatethedeliverablesrequiredbytheotherinitiatives.

• IftheDSRIPprojectisbuiltononeoftheseotherinitiatives,orrepresentsanenhancementofsuchaninitiative,explaininghowtheDSRIPprojectisnotduplicativeofactivitiesalreadysupportedwithotherfederalfunds.

YES NO

improvementandstrategicdirection.JennywillstaffthePathwaysCommunityCouncilthatwilllaunchin2018.ThispositionwillcloselymonitorthedataavailablefromtheHUBplatformandintervenewhenPathwaysareslowtocompleteorhaveencounteredroadblocks.

• Initsroleasmonitoringsystemlead,COREwillcoordinatewithBHTstaffandtheentitiesabovetoprovidetimelyinformation,datainterpretationexpertise,andbothtechnicalandstrategicsupportforpeerleaningandcontinuousimprovement.

• BHTBoardwillreceivemonthlydashboardsonkeymilestonesandplanstoaddressanyrisks

• BHTACH’sRegionalIntegrationTeamwillalsotrackkeymilestonesspecificallytiedtoFIMCandMTDprojectalignment

PlanforaddressingstrategiesthatarenotworkingornotachievingoutcomesIncombination,thepeopleandworkgroupsdescribedaboveandtimelydatafromthemonitoringsystemwillenabletheBHTACHtoidentifystrategiesthatarenotworkingandtothinkthroughsolutionsintimetoachieveprojectoutcomes.Ifnecessary,potentialadjustmentstoimplementationtimelineswillbetriagedthroughthemonitoringsystemtoassesstheirimpactondownstreamgoals.Iftimelinesstillcannotbemet,theBHTACHwillinformHCAaboutthereasonsanditsplanforadaptingthetimeline,andpreventing/riskmitigationstrategieswillbesharedtootherprogramswhereappropriate.

X

ProjectSustainability

1HCACo-occurringdisordertables,see:see:https://wahca.app.box.com/s/mxpg8euzbjpdkmyuftzb4ri5v41ia8v9/folder/39866406519

2HCAhospitalizations_ach_rhni_tables:https://wahca.app.box.com/s/mxpg8euzbjpdkmyuftzb4ri5v41ia8v9/folder/23928005433

3HCARHNI“starterset”files,see:https://wahca.app.box.com/s/mxpg8euzbjpdkmyuftzb4ri5v41ia8v9/folder/23928005433

4WashingtonPrescriptionDrugMonitoringProgram,see:https://www.doh.wa.gov/ForPublicHealthandHealthcareProviders/HealthcareProfessionsandFacilities/Pr

ACHResponse

BHT’sstrategyforlong-termprojectsustainability,anditsimpactonWashington’shealthsystemtransformationbeyondtheDemonstrationperiod:TheBHTACHunderstandsthatthebi-directionalcareintegrationproject,alongwiththeotherprojectplansandDomainIefforts,mustmovetheBHTACHregionforwardintermsofdevelopingalong-termclinicalinfrastructureandcommunitystructureabletoprovideseamlessaccesstoclinicalandcommunityservices,whereandwhenclientsneedthem.Toachievethis,theBHTACHhasdevelopedthe“scaleandsustain”targetpopulationmodelthatwillbeginwiththehighestneedpatientsandconditions,andthenrolloutbi-directionalcaretothebroaderMedicaidpopulationovertime.Doingsowillnotonlygiveproviderstimetodevelopandrefineevidence-basedbi-directionalcaremodels,butalsodevelopinsightsandevidenceabouthowbesttoimplementbi-directionalmodelsandwhatkindsofinterventionsandapproachesaremostsuccessful.WearedevelopingourCommunityHealthTransformationCollaborativeswithafocusonmovingtheregiontoValueBasedPurchasingandwholepersoncare.VBPisthecornerstoneofoursustainabilityplan,recognizingtheneedtotransitionhowwepayforcareandlinkingSocialDeterminantofHealthservices.Weareworkingtoaligndata,fundsflow,andmodeldevelopmenttomaximizetheopportunitytointegrateselectedprojectsintoavaluebasedmodelandweavetogetherlocalresourcesandinvestmenttoreachthisgoal.Forinstance,itisexpectedthattheBoard’sfundsflowpolicywillincludedirectedinvestmentsforstartupcosts,infrastructureandtechnicalassistanceemphasizingMTDfundingfortransition,notanongoingpaymentstream.Thebi-directionalintegrationprojectplaysakeyroleinsupportingthemovetoVBP.Increasedfocusandinvestmentinprevention,andscalingmoreefficientandconnectedinterventionstrategies,willleadtoamoreresponsivecommunityhealthsystem,bettersetuptosucceedinVPB.KeytothisprojectisthePathwaysHubModel,whichisasananchorstrategy–alongwithintegrationofcare-forallourMTDwork.PathwaysoffersanopportunitytobetterleverageanoutcomespaymentmodeltosustaincarecoordinationandcommunitycapacityforthetargetpopulationbeyondtheMTDperiod,todisruptthecycleoffragilefundingmanysocialdeterminantofhealthpartnersfaceasgovernmentandphilanthropicpartnersrotatethroughgrantperiods.WeexpectthatPathwayswillbefundedthroughMedicaidMCOsandotherinnovativepartnershipswithphilanthropicorganizationsandcityandcountygovernmentsthroughouttheregion.

escriptionMonitoringProgramPMP/CountyProfiles




8HCACo-occurringdisordertables,see:see:https://wahca.app.box.com/s/mxpg8euzbjpdkmyuftzb4ri5v41ia8v9/folder/39866406519

9RDAMeasureDecompositionfilesreleased10-27-17.See:https://wahca.app.box.com/s/mxpg8euzbjpdkmyuftzb4ri5v41ia8v9/folder/41072598437

10RDAMeasureDecompositionfilesreleased10-27-17.See:https://wahca.app.box.com/s/mxpg8euzbjpdkmyuftzb4ri5v41ia8v9/folder/41072598437


TransformationProjectDescription


Domain2:CareDeliveryRedesign�� 2B:Community-BasedCareCoordination

ACHResponseProjectDescriptionandJustificationBHTwillimplementtheCommunity-BasedCareCoordinationprojectasananchorstrategy(alongwithbi-directionalintegrationofcare)toconnecttheportfolioofprojectsintheMedicaidDemonstrationandtodevelopaccountablelinkagesbetweenclinically-basedhealthcareserviceswiththecommunity-basedservicesthatplayanintegralroleinimprovinghealthoutcomes.JustificationforselectingprojectandhowitaddressesregionalprioritiesResearchindicatesthat80%ofanindividual’shealthisdeterminedbywhathappensoutsideofthedoctor’soffice.1Toeffectivelyaddresspoorhealthoutcomes,itiscriticaltoemploymodelsofcarethatcomplementtheclinicalinterventionswitheffortstoaddresswhatarereferredtoassocialdeterminantsofhealth.Examplesoftheseincludeaccesstoaffordablehousing,education,transportation,andinvolvementwiththecriminaljusticesystem.IntheBHTregion,dataindicatetheneedtodeployastrategythatbetterconnectsclinicalcarewithcommunity-basedresourcestosupportimprovementsinhealth.Regionaldataindicatethepresenceofsignificantsocialdeterminantsofhealthwitharelationshiptopoorhealthoutcomes.WhiletheoverallemploymentrateacrosstheBHTregionisslightlyhigherthanthestatewideaverage(5.7%comparedwith5.0%),thenortherncountieshavesomeofthehighestunemploymentratesinthestate:PendOreilleandFerryarethetoptwocountiesat9.5%or10%unemploymentandStevensCountyisat8.8%.2Accordingtothe2015WashingtonStateHousingNeedsAssessment,allBHTcountieshavelownumbersofaffordablehousingunits,withSpokaneCountythelowestat12affordableandavailableunitsper100households.3ProvidersintheBHTregionreportthatbetween3%and18%oftheirclientsliveinhousingthatiseithernotstableorisovercrowdedandthatbetween5%and15%haveahistoryofincarceration.4Regionalhealthdataalsounderscorethesignificantneedforcarecoordination.EDutilizationintheBHTregion(55%)isslightlyhigherthanthestatewideaverage(54%)5.Morethan44,000BHTMedicaidmembers(almost30%)havebeendiagnosedwithamentalillnessandapproximately20,000(12%)haveasubstanceabusetreatmentneed.About36,000(9%)haveamentalhealthorsubstanceabuseconditionand1ormorechronicdiseases.ThesefiguresrepresentalargersegmentoftheMedicaidpopulationforBHTthanthe

correspondingfiguresforWashingtonasawhole.6Forthosewhohavereceivedabehavioralhealthdisorderdiagnosis(eithermentalillnessorsubstanceusedisorder)BHTisslightlybelowthestateaverageformentalhealthtreatmentandsubstanceabusetreatmentpenetrationratesamongMedicaidbeneficiaries,indicatingthat,accesstotreatmentandmanagementofthesedisordersremainsachallenge.

Outsideofpregnancyandchildbirth,‘mentalandbehavioraldisorders’weretheleadingcauseofhospitalizationforBHTMedicaidbeneficiariesin2015,accountingfor17.5%ofallnon-birth-relatedhospitalizations.Substanceusedisordersaccountedfor5.7%ofsuchhospitalizationsoverallbut8%amongnon-disabledadults.7ThePathwaysCommunityHubmodelofferstheBHTACHtheopportunitytobetterconnectthecommunity-basedsocialdeterminantofhealthsystemwiththeclinicaldeliverysystemtosupportatriskindividualstoaddresstherangeofclinicalandsocialfactorsimpactingtheirhealth.HowProjectwillsupportsustainablehealthsystemtransformationforthetargetpopulationAsignificantportionofwhatdeterminesandindividual’shealthhappensoutsideofaclinicalprovider’soffice.ThePathwaysCommunityHubmodelwilldemonstratethevalueofidentifyingandaddressingriskfactorsattheindividuallevelandcomprehensivelyapproachtreatmentofeachriskfactors.Additionally,theopportunitytoorganizecommunityresourcesinamoresystematicandmeasuredwaywilldemonstratethevalueofinvestinginsocialdeterminantsofhealthservices.HowBHTwillensureprojectcoordinateswithanddoesn’tduplicateexistingefforts�BetterHealthTogetherissupportingthedevelopmentoftwoCommunityHealthTransformationCollaboratives:1)RuralCollaborative(comprisedofFerry,Stevens,PendOreille,Lincoln,Adamscounties),and2)SpokaneCountyCollaborativeTheBHTACHistakingaregionalapproachtoprojectdesignandimplementationthatwillprovidelocalautonomyandregionalaccountability.TheCollaborativeswillberesponsiblefordevelopingandimplementingactionableMTDplansacrossBHT’sprojectportfolio,andensuringthattheprojectscoordinatewitheachotheranddonotduplicateexistingeffortsintheregion.TheCollaborativeswillbecomprisedofkeypartnerswiththeexpertiseandexperiencerequiredtotransformourMedicaidDeliverySystemincludingclinics,FederallyQualifiedHealthCenters(FQHCs),Hospitals,MentalhealthandSubstanceUseproviders,TribalHealthsystems,EMS,JailsandCountyCommissioners.Thisrepresentationwillensureeffortsarecoordinatedacrosstheregionandresourcesareleveraged.Inthesummer2017,BetterHealthTogether(BHT)surveyedorganizationsintheregiontocompleteaHealthSystemsInventory(HSI)and/orCareCoordinationInventory(CCI)tolearnmoreabouttheorganizations’clients(includingMedicaidcoverageandhealthstatus),and

gatherproviderinterest,capacity,priorities,andexistingeffortsrelatingtoMTDprojectareas.BHTreceivedHSIandCCIresponsesfrom39uniqueorganizationsthroughouttheregion,includinghospitalnetworks,behavioralandphysicalhealthproviders,PublicHealth,FQHCs,MCOs,andcommunity-basedorganizations.TheCCIinventoryidentifiesanddetailsexistingcarecoordinationeffortsacross29agenciesthroughouttheregion.TheRuralandSpokaneCountyCollaborativeswillbuildoninformationgatheredthroughtheseinventoriestocoordinateandleverageexistingcarecoordinationtoensurethatthePathwaysCommunityHubCareCoordinationprojectdoesnotduplicateexistingeffortsintheregion.BHTandtheCollaborativeswillalsoworkspecificallywiththeregion’sHeathHomestoassurethePathwaysCommunityHubreferralprocessfurthersupportidentificationofHealthHomeseligibleindividualsanddoesnotduplicatecarecoordinationforthispatientpopulation.WeexpectthePathwaysCommunityHubtocomplementtheHealthHomeseffortswithhighneedspatients.Inthelastmonth,SpokaneCountywasawardedanearly$1milliongrantfromtheDepartmentofJusticetoutilizethePathwaysCommunityHubastheanchorstrategyforalocalinitiativetoreformthelocalcriminaljusticesystem.InpartnershipwithBHT,theCountycriminaljustice,wewilllaunchthePathwaysCommunityHub.Thisfundingcameinadditiontoa$1.75milliongrantfromtheMacArthurFoundationinApril2016tohelpreducethejailpopulationby21%by2019.FundsfromtheMacArthurFoundationgrantisbeingusedtoimplementanewlydevelopedriskassessmenttoolinthecounty’sPre-TrialServicesDepartment,aswellasanewracialequitytoolkit.AnticipatedProjectScope&TargetPopulationTheBHTACHwillimplementthePathwaysCommunityHubwithaninitialfocusontwopopulations:HighRiskPregnantMomsandPeopletransitioningoutofjail.Thesetwohighriskpopulationswillindividuallybenefitfromtheinterventionandweexpecttodemonstratemutli-sectorsavings.TheBHTACHmayexpandtootherpopulationsinMTDYear4or5basedoncommunityneeds.TheMedicaidProjectToolkitsuggestsanumberofpotentialtargetpopulationsforthecommunitybasedcarecoordinationproject:Medicaidbeneficiaries(adultsandchildren)withoneormorechronicdiseaseorcondition(suchas,arthritis,cancer,chronicrespiratorydisease[asthma],diabetes,heartdisease,obesityandstroke),ormentalillness/depressivedisorders,ormoderatetoseveresubstanceusedisorderandatleastoneriskfactor(e.g.,unstablehousing,foodinsecurity,highEMSutilization).LookingcloselyatregionaldataandthroughourHSI,twokeypopulationsemergedasmostlikelytobenefitfromincreasedcommunity-basedcarecoordinationandwillbetheinitialtargetpopulationsforthisproject.

TargetPopulation PopulationEstimate

Peopletransitioningoutofjailwitheitheramentalhealthorsubstanceusedisordertreatmentneed

7,9138-11,2109

Pregnantwomen/Medicaidmoms 4,16010

InvolvementofPartneringProvidersTosupportthedevelopmentoftheMTDprojectplan,theBHTACHbuiltontheexperiencesoftheFerryCountyJailTransitionsPilotfundedbyStateInnovationModel(SIM)launchedinearly2017.ThepilotofferedseveralopportunitiestoworkwithprovidersfromtheCriminalJustice,Hospital,Clinic,andCommunityActionCHWtodevelopapowerfulmodeltosupportindividualsexitingjail.TheanticipatedpilotoutcomesaretoreducetherecidivismrateandhealthcarecostsoftheFerryCountyJail.Additionally,theBHTACHLOIprocessidentified22providerorganizationsinterestedinpursuingthePathwaysCommunityHubModel.Twenty-nineprovidersindicatedinterestinservingasapartneringproviderfortheCommunity-BasedCareCoordinationprojectaspartoftheHSIandCCI,thisincludesphysicalandbehavioralhealthproviders,housing,foodsecurity,socialservices,lawenforcement,justicesystem,publichealthandearlylearningproviders.Tofurthersupportdevelopment,theBHTACHconvenedandmetone-on-onewithhealthandsocialdeterminantprovidersthroughouttheregioncurrentlyworkingoncarecoordinationtoassessinterestandsupportforthePathwaysCommunityHubprocess.ThePathwaysCommunityHubmodelcontinuestogarnerdeepsupportformpartnerorganizations.LevelofImpactInselectingourinitialtargetpopulations,peopletransitioningoutofjailandhighriskpregnantmoms,wefocusedonpopulationswhotypicallyhavepoorhealthoutcomes,arehighutilizersofcommunityservicesandgeneratehighhealthcarecosts.Thistargetpopulationalsoprovidesanopportunitytocreatemultisectorsavingsandtopilotasharedsavingsmodel.HowBHTwillensurethathealthequityisaddressedintheprojectdesignHealthequityisbuiltintomanyelementsofourMTDstrategyincludingthePathwaysCommunityHubmodel.ThePathwaysCommunityHubprovidesanevidencedbasedmodelofcarethatfocusedonempoweringindividualstodevelopacareplanthatmeetstheirneeds,increasesaccesstoanetworkofculturally-informedcareagenciesandutilizesadatainfrastructuretoolthatcanbeusedtomonitorcare,providerquality,andresourcegapsinthecommunity. BetterHealthTogetherisensuringthathealthequityisembeddedintheMTDprojectdesignatmultiplelevels:

• APathwaysCommunityAdvisoryCouncil(PCAC)willbeformedinearly2018toconductaRFPforcarecoordinationagenciesandcompletetheenvironmentalscanwork.ThisCouncilwillincludeanappointeefromtheTribalPartnerLeadersCouncilandtheCommunityVoicesCouncil,MCOs,SocialDeterminantofHealthProvidersandHealthCareProviders

• CommunityHealthTransformationCollaboratives:UtilizingaRuralandSpokaneCountyCollaborativemodel,BHTisensuringattentionandfocusonlocalhealthdisparitiesinourregion.Inaddition,weexpectCollaborativestoincludeorganizationsthatbringdiverseracialandculturalperspectivestoMTDplanning.

ImplementationApproachandTiming

• CommunityVoicesCouncil:BHTislaunchingaCommunityVoicesCouncil,madeupof

atleast50%Medicaidbeneficiariesorlow-incomecommunitymembers,toempowerandbringconsumervoicestoinformprojectdesignandimplementation.ThiscouncilwillbetaskedwithdevelopinghealthequitymetricsbywhichtoholdtheCollaborativesandprojectsaccountabletodefinedhealthequitygoalsandstandards.

• Targetpopulations:BHTisfocusingprojectsontargetpopulationsexperiencingthegreatesthealthdisparities.Weareapplyingan“equitylens”toallourworkbydisaggregatingdatabyrace/age/ethnicity/sex/zipcodewhereverpossible,bothtomakeinformeddecisionsabouttargetpopulationsandtomonitorimpactofprojectsacrossdiversegroups.BHTwillsupplyCollaborativeswithregionaldatatoguideearlyassessmentsofpartners,andwilldirecttheseteamstoidentifypopulationswithintheircountythatfaceahighlevelofdisparitiesand/orpresentashighlycomplexorhighrisk.

• Livedexperience:WiththeCommunity-basedCareCoordinationproject,BHTisadvancingthePathwaysmodelanduseofCommunityHealthWorkerswithlivedexperienceofhealthinequities.CHWsarecriticaltodevelopingtrustandculturally-appropriatestrategiestomeettheneedsofourtargetpopulationsacrosstheDemonstrationprojectareas.

• EquityAcceleratorPayment:Weanticipateimplementingthisincentivetosupportproviderswhoserveagreaterproportionofhigh-riskclients.ThemetricstiedtothesepaymentswillbedeterminedbytheWaiverFinanceWorkgroup,vettedbyProviderChampionsCouncilandCommunityVoicesCouncil,andapprovedbytheboard.

Project’slastingimpactsandbenefittotheregion’soverallMedicaidpopulationThevalueofimplementingthePathwaysCommunityHubcarecoordinationprojectprovidesasolidframeworktobettermanageandorganizetheclinicalandcommunity-basedservicesneededtoimproveoutcomesforhighriskMedicaidenrollees.Weseetwokeybenefitsasthelastingimpactofthismodel:

• Abilitytocoordinatethecoordinators:High-riskpatientsoftenhavemany“carecoordinators”thatareunconnectedorunalignedoncareplansacrossdifferentneeds.

• Payforoutcomes:Wewillfocusoninitialtargetpopulationstoestablishastrongfoundationandproofofconceptforthemodelintheregion.Bydoingso,theprojectwillofferasustainablemodelthatcanbedeployedtootherMedicaidenrolleesinregiontobetterlinkthecommunity-basedresourcesthatareneededtostrengthenandbolstertheimprovedandtransformedclinicalsystem.Thiswillsupporttheregion’sshifttovalue-basedpaymentandprovideamoresustainablemodelforcarecoordinatingorganizationsthanthetraditionalmodelofhavingtorelyongrants.

SeeSupplementalWorkbook

PartneringProviders SeeSupplementalWorkbook

ACHResponseHowBHThasincludedpartneringprovidersthatcollectivelyserveasignificantportionoftheMedicaidpopulationBHTreceivedHealthSystemInventoryresponsesfrom23organizationsintheregion,includingmajorhospitalnetworks,providersystems,andFQHCs.Inaddition,BHTreceived29responsestotheCareCoordinationInventoryfromcommunity-basedorganizations.BHTcomparedtheHSIrespondentswithHCA’sSeptember2017ProviderReport11andfoundthattheinventoryresponsesrepresentmorethan80%ofthehighest(top10)volumeMedicaidbillersineachmajorsetting(primarycare,mentalhealth/substanceusedisorder,inpatientandED.)ForseveralsettingsininBHT’sfiveruralcounties,theHSIrespondentsrepresentalltheMedicaidbillerswithclaimsorbeneficiarycountsofmorethan10in2016.BHTstaffarefollowingupwithnon-representedprovidersthatseealargenumberofMedicaidclients,particularlysubstanceusedisordertreatmentproviders.ProcessforensuringpartneringproviderscommittoservingtheMedicaidpopulation.In2018,theBHTACHwillformalizepartneringproviderparticipationinthecarecoordinationprojectandotherMTDprojectareasthroughaTransformationCompactprocesstoensurecommitmenttoservingtheMedicaidpopulation.ThroughtheACHLeadershipCouncil,HealthSystemandCareInventories,BHTACHhasatrackrecordforengaginghighvolumeprovidersintheregionservingasignificantportionoftheMedicaidpopulation.TheBHTACHhasconfidencetheywillcommittoparticipationintheCollaborativeandwillformalizethiscommitmentthroughtheTransformationCompact.

Processforengagingpartneringprovidersthatarecriticaltotheproject’ssuccess,andensuringthatabroadspectrumofcareandrelatedsocialservicesisrepresentedBHThasbeenactivelyengagedwithcurrentCommunity-BasedCareCoordinationservicesintheregion.TheBHTCareCoordinationInventory(CCI)identifiedanddetailedexistingcarecoordinationeffortsacross29agenciesthroughouttheregion.TheCollaborativeswillbuildoninformationgatheredthroughthisinventorytoidentifyandengagepartnerscriticaltotheproject’ssuccess.BHThasalsoidentifiedthatrepresentationfromthefollowingsectorsisrequiredforCollaborativestosuccessfullyimplementallprojects.Eachofthesepartnersrepresentacriticalsettingforprojectimplementation:

Ø PhysicalHealthClinicalProvidersØ HospitalSystem(includingEmergencyDepartment)Ø BehavioralHealthClinicalProvidersØ TribalHealthSystems

Ø SUDProvider(s)Ø Community-BasedChronicDiseasePreventionandMitigationØ EmergencyMedicalServices(firstresponders)Ø CriminalJusticeØ CommunityBasedCareCoordinatingAgencyØ MCOsØ CrisisManagementServicesØ Liaison:CommunityMember/Consumer

Collaborativepartnershipswillbeexpandedasneeded.InitsroleasthePathwaysHub,theACHwillserveasaconnectorbetweenCollaborativeprovidersandsocialandcommunitypartners.BHTACHisalsolaunchingaProviderChampionsCounciltolendapracticingproviderperspectivetoourworkandtoinformandvalidateTransformationPlanslaidoutbyCollaboratives.HowBHTisleveragingMCO’sexpertiseinprojectimplementation,andensuringthereisnoduplicationManagedCareOrganizationsareactivelyinvolvedinBHT’sgovernanceandleadershipgroups:

• TwoMCOrepresentatives,fromMolinaHealthCareofWashingtonandCoordinatedCareofWashington,areontheBoard


• MCOrepresentativesareontheBHTACHRegionalIntegrationPlanningTeam,WaiverFinanceWorkgroup,ProviderChampionsCouncilandCommunityVoicesCouncil

MCOswillcontinuetoparticipateinMTDprojectplanningviatheseTechnicalCouncilsandthroughtargetedcollaborationwithBHTACH’sCommunityHealthTransformationCollaboratives.

Inaddition,BHT,PierceCountyACH,andSouthwestACHhavecollaboratedonmeetingswithMCOpartnerstolearnaboutkeycrossoverareasbetweenACHsandMCOsunderMTD,toensurethattheBHTACHprojectstrategy,supportforproviders/Domain1strategies,andmonitoringandqualityimprovementeffortsalignwithexistingMCOactivitiesandgoals.Ourdiscussionscovered:

• Members/populationoverview• PCPassignment/empanelment• Providersupport,particularlyforvalue-basedpaymentandrelateddeliverysystem

reform• Measurementandqualityimprovement• Memberengagement/education• PathwaysCommunityHub

IntheBHTACHdiscussionswithMCOs,itwasemphasizedtheimportanceofconsideringtheneedsandutilizationpatternsofdifferentMedicaidpopulations(e.g.expansionadultsvs.traditionalMedicaid)anddesigningstrategiesthatcanintegrateadditionalgroups(e.g.dual


specialneedsclients)overtimetofullyengageMCOsandotherpartnersandsupportsustainability.

Additionally,theMCOsprovidedusefulinputaboutprojectfeasibilityandalignmentwithexistingcarecoordinationefforts.BHTwillworkwiththeMCOstoengageinplanningensurealignmentandsharedinvestmentinpreparingtheregionforbothfullyintegratedmanagedcareandvaluebasedpurchasing.MCOshavebeenactiveparticipantsintheformationoftheFerryCountyPathwaysPilotthroughourcommunitydesignsessionandwewillcontinuetoengageMCOSinplanningtoensurealignmentandsharedinvestment.Todate,wehavecompletedsecurityassessmentstocontractwithMCOsinFerryCountywithUnitedandMolinaandaremovingintoacontractingprocessinDecember.WeareinprocesswithCHPWtocontractforsecurityassessments.CoordinatedCarehasexpressedsupportforthePathwaysCommunityHubmodel.

ACHResponseAssetstheACHandregionalpartnersproviderswillbringtotheprojectInventories:BHThascompletedanextensiveinventoryprocessthroughoutthelasttwoyearsofplanninginorderto“map”existingprojects,pilots,andassetsthroughouttheregion.Thishasgivenusacomprehensive“currentstate”landscapeassessmentfromwhichtobaseourinitialprojectselection.TheseeffortsincludeourCommunityLinkageMap,CommunityStrategyMaps,HealthSystemsInventory,andCareCoordinationInventory.CommunityLinkageMap:In2016,theSpokaneRegionalHealthDistrictconductedalarge-scaleCommunityLinkageMappingandsocialnetworkanalysis,12inwhich165individualsrepresenting112organizationsfromthehealth,socialservice,education,business,andpublicsectorscompletedaPopulationandSocialDeterminantsofHealthSystemsSurvey.Becauseparticipantswereabletodescribetheirlinkageswithorganizationsthatdidnotresponddirectly,thereportinfactrepresents564organizationsintheBHTregion.Afulllistofparticipatingorganizationsbygeographyandsector,whichisthemostcomprehensivepictureofhealth-relevantcommunity-basedresourcesintheBHTregion,canbefoundasanAppendixtotheRHNIsectionofthissubmission.In2013,BHTdevelopedtheNavigatorNetwork,asuccessfulinitiativetoprovideIn-PersonAssisterstoenrollpeopleinAppleHealth(Medicaid)andQualifiedHealthPlansontheWashingtonHealthBenefitExchange.Throughtheseefforts,BHTsuccessfullyenrolledover125,000peopleinhealthinsurance,manyofwhomhavebehavioralhealthdiagnoses,anddevelopedarobustnetworkofpartnersthroughouttheregion.AstheoperatoroftheNavigatorNetworkofEasternWashington,BHThasdirectconnectionswithmorethan50organizationswhohostoremploynavigators.ThisprovidescredibilityandimportantlocalconnectionstoprovidersneededtosuccessfullyimplementourMTDprojects.RecentlySpokaneCountywasawardedaDepartmentofJusticeSmartReentryGrantformatchingfundsupto$1milliondollars.ThisgrantwillsupporttheSpokaneCountyJailTransitionPathwaysPilot,includingfundingforcarecoordinatingagencypersonnel,training,

technologyandorganizationinfrastructureneedsoftheCountyandPathwaysCommunityHub.Anticipatedoutcomesaretoincreasecommunication,coordination,andcollaborationforreentrypopulation,increaseuseofevidence-basedpractices,andimproveaccesstoresourcesinthecommunityforreentrysupport.ThispilotwillsupporttheSpokaneCountyCollaborativeandallowaleverageofMTDresources.Recognizingtheneedtosupportmutualregionalstrategicgoalsandmakemeasurableimprovementsinhealthofruralcommunities,theEmpireHealthFoundationinvested$25,000inRuralResourcesCommunityActiontobeacarecoordinatingagencyfortheFerryCountyPathwaysPilot.Thisallowedthepilottobeginassmallandmanageable,allowingforgrowthasresultsandsuccessfuloutcomeswereobtained.BHTisexploringapartnershipwiththeCityofSpokanetoinvestintheHousingPathwaysOutcomepayment.ThiswouldofferanopportunityforlocaljurisdictionstoleverageotherresourcestomeetsharedgoalsandreducethefinancialpressureonMCOstopayforeverypathway.PleasenotethatlackofhousingintheBHTACHregionisthebiggestsocialdeterminantsofhealthbarrier.BHTisalsoexploringapartnershipwiththeARCORAFoundationtoensureoralhealthaccessandservicesareavailableforat-riskpatients.In2017,theWashingtonStateLegislaturemandatedtheHealthCareAuthorityandARCORAFoundationtoworktogethertodevelopapilot,OralHealthConnections,inthreecommunities(includingSpokane,County)withtwotargetpopulations–patientswithdiabetesandpregnantwomen.Dentistsservingthesepopulationswillreceiveenhancedreimbursementsfordoingso.ChallengestoimprovingoutcomesandloweringcostsfortargetpopulationandstrategytomitigaterisksandovercomebarriersBHThasidentifiedseveralkeychallengestosuccessfulimplementationofthePathwaysCommunityHubmodel.Theseinclude:

• HIT/HIEcapacity:BasedonproviderHSIresponses,HITandHIEcapacityseemstovarystronglyamongdifferentorganizations.Withafewexceptions,capacityaroundinformationexchangeislimited(e.g.systemcansendsummariesoutbutnotacceptdatain,orthereisadatasharingrelationshipwithspecificpartnersonly,likeanFQHCandtheBHO).WhilethePathwaysCommunityHubplatformoffersaflexibletechnologytheabilitytoconnectwithexistingsystemswillneedtobeexplored.

• Workforceneeds:BasedonproviderHSIresponses,workforceneedsareasignificantconcern.Recruiting,trainingandprovidingCommunityHealthWorkerswithalivingwagemaybeasignificantchallengefortheregion.

• Resources:Limitationsinregional/localbehavioralhealthprovidersandsocialdeterminantofhealthresourcesmaydirectlyimpactsuccessfulcompletionofPathways.

Strategiesforovercomingbarriers

• HIT/HIEcapacity:wewillworkwithorganizationstobetterlinkcommunitybasedcarecoordinationeffortsusingtheCareCoordinationSystemsplatformbybuilding


applicationprograminterfacesbetweenCCSandorganizationshealthrecordmanagementsystems.ThiswillallowallPathwaysCommunityHubpartnersreal-timeinformationtoservetheirclientsinamoreeffectivemanner.ManyBHTACHpartnershavecitedtheCCSplatformflexibilityandinteroperabilitypotentialasamajorreasonforfutureadoption.

• Workforceneeds:many,ifnotall,potentialcarecoordinatingagenciesintheBHTACHregionalreadyemploycarecoordinators,rangingfromcommunitybasedorganizations,healthclinics,hospitals,andbehavioralhealthproviders.AspartoftheMTDCareCoordinationprojectplanwewillsupporttransitioningcurrentcarecoordinatorstothePathwaysCommunityHubmodel.Inearly2017,sixteenparticipantsweretrainedinthePathwaysCommunityHubmodelandCCSplatform.OrganizationsrangedfromruralandurbanCHWS,CommunityOrganizations,HealthHomes,andMCOstaff.TheSpokaneRegionalHealthDistrictconductsallregionalCHWtrainingonbehalfoftheWAStateDepartmentofHealthandfacilitatestheEasternWashingtonCommunityHealthWorkerNetwork.TheBHTACHisanactiveparticipantandmemberoftheleadershipteamofthislocalcoalitionofCHWsthatmeetmonthlyforinformationsharingandcapacitybuilding.InOctober2017,theBHTDirectorofCommunityEngagementpresentedontheongoingACHworktoover40CHWstofurtherimproveCHWworkforcebuy-inandfeedback.ThePathwaysCommunityHubcarecoordinatorswillberequiredtocompletetheCHWtrainingofferedviatheWashingtonStateDepartmentofHealthandparticipateinlocalandregionallearningopportunitiesthatsupportthedevelopmentofarobustcarecoordinationcommunity.TheBHTACHPathwaysHubwillprovidetrainingonthePathwaysHubmodel,CCStechnologyplatformandcoordinateinformationandeducationopportunitiesthroughwebinars,calls,newsletters,etc.BHTACHwillhostregularin-personlearningeventsthataddresscommonchallengesofcarecoordinatorsandagencies.

• Resources:TheBHTACHwillfosterconnectionsbetweenregionalpartnerstoensureinvestmentresourcesandinfrastructuretoclosegapsinourregion.ThroughthereportingcapabilityoftheCCSplatform,we’llbeabletoquantifygapsinresourceavailabilityandadvocateformorelocalandstateinvestment.Additionally,theBHTACHstaffworkcloselywiththelocalWashingtonInformationNetwork211toensurethatcommunityresourcedatabasesareup-to-dateandreadyforlargerscaleusebycarecoordinators.

ACHResponseThegoalofBHT’smonitoringplanistousetimelydatatosupportprojectimplementation,peerlearning,andcontinuousimprovement.BHTwillworkwithitscontracteddatavendor,

ProvidenceCenterforOutcomesResearch&Education(CORE),todesignandimplementamonitoringsystemthatwilltrackoperational,process,andoutcomemeasuresforeachprojectandCollaborative(seebelow)andfortheACHoverall.Thesystemwillbedesignedtocomplementexistingdataassets(suchastheHealthierWashingtonDataDashboardsand—particularlyforCommunityCareCoordination,theHUBdataplatform)andwillrefreshanytimeaparticulardatafeedisupdated.Fortheimplementationphase,manymetricswillbeprocessoroperationalinfocus(e.g.developingguidelines,policiesandprotocolstoimplementthePathways).Finalmetricswillbeidentifiedintheimplementationplan.Designwilltakeplacealongsideimplementationplandevelopmentinlate2017andearly2018,sothatthesystemisreadyasprojectsmoveintoimplementation.AvisualoverviewofBHT’splannedapproachtomonitoringandcontinuousimprovementisshownbelow.

Planformonitoringprojectimplementationprogress,includingaddressingdelaysinimplementationAsshowninthediagram,thesystemwillincorporateprocessmeasuresforprojectimplementation.ThoseprocessmeasureswillbeassociatedwithtimeframesandbenchmarksidentifiedbytheBHTACHanditsCollaborativestoprovideimmediatefeedbackwhendelaysoccur(forexample,anypotentialchallengesinhiringstafftooperatethePathwaysCommunityHub).WeplantoworkwithCOREtodevelopacommunitydashboardtomonitorkeymetricsidentifiedinthewaiverandourcommunitypriorities.Thiswillbeamulti-functionaldashboardextendingbeyondthewaivertoallowongoingcommunitytrackingandprioritization.ResponsibilityforaddressingdelaysinimplementationwillliewiththeCollaboratives,BHTgovernancebodies,andselectBHTstaffpositionsasdescribedunder‘Planformonitoringcontinuousimprovement’below.

Planformonitoringcontinuousimprovement,supportingpartneringprovidersanddeterminingwhetherornotBHTisontracktomeetexpectedoutcomesAmonitoringandcontinuousimprovementsystemismorethanjustdata;it’saboutthepeople,processes,andtoolsusedtoturnthatdataintoactionableinformationthatsupportssharedlearningandqualityimprovement.Inadditiontocreatingasystemtoaccessandanalyzedatafromdifferentsources,theBHTACHwillrelyonthefollowinggroupsandpositionstointerpretthedata,identifyperformanceshortcomingsorrisks,anddevelopsolutions:

• CommunityHealthTransformationCollaboratives.Asdescribedelsewhere,BHTislaunchingaRuralandSpokaneCountyCollaborativestodevelopandimplementspecificregionalplansforhealthsystemtransformationinthefourprojectareasBHThasselected.TheCollaboratives’rolewillextendto:advisingondesignoftheself-monitoringsystem;regularlyreviewingthedatathatsystemprovides;collaboratingwiththeACHtomakecoursecorrectionsasneeded;andparticipatinginsharedlearningopportunitieswithinandacrossCollaborativesandACHregions.

• BHTProviderChampionsCouncil.ThisrecentlyestablishedCouncilwillprovidegeneralclinicalexpertiseandsubjectmatterexpertiseindifferentMTDprojectareas.TheCouncilwillmonitortrendsinperformanceacrosstheCollaborativestoassesswhetherBHTisontracktoachieveexpectedoutcomesandwilladviseontheCollaboratives’proposedriskmitigationandcontinuousimprovementstrategies.ThePCCwillalsomonitorindividualcollaborativepartnersandadviseontechnicalassistancenecessary.

• JennySlagle,AssociateDirectorforHealthSystemTransformationwillserveasthePathwaysCommunityHubDirectoroverseeingalloperationsofthehubincludingtraining,qualityassuranceandimprovementandstrategicdirection.JennywillstaffthePathwaysCommunityAdvisoryCouncilthatwilllaunchin2018.ThispositionwillcloselymonitorthedataavailablefromtheHUBplatformandintervenewhenPathwaysareslowtocompleteorhaveencounteredroadblocks.

• BHT’sDirectorofClinicalIntegration,apositioncurrentlyinrecruitment,willstafftheProviderChampionCouncilandhelpidentify,communicate,andaddresschallengestoclinicalintegrationandothertransformationstrategies.


• BHT’sboardwillreceivemonthlydashboardsonkeymilestonesandplanstoaddressanyrisks

• BHT’sRegionalIntegrationteamwillalsotrackkeymilestonesspecificallytiedtoFIMCandMTDprojectalignment



YESX

NOX





YES NOX

PlanforaddressingstrategiesthatarenotworkingornotachievingoutcomesIncombination,thepeopleandworkgroupsdescribedaboveandtimelydatafromthemonitoringsystemwillenabletheBHTACHanditspartneringproviderstoidentifystrategiesthatarenotworkingandtothinkthroughsolutionsintimetoachieveprojectoutcomes.Ifnecessary,potentialadjustmentstoimplementationtimelineswillbetriagedthroughthemonitoringsystemtoassesstheirimpactondownstreamgoals.Iftimelinesstillcannotbemet,BHTwillinformthestateaboutthereasonsanditsplanforadaptingthetimeline,andpreventing/riskmitigationstrategieswillbesharedtootherprogramswhereappropriate.BHTwillcontinuetoreceivetechnicalassistancefromDr.SarahReddingwiththePathwaysCommunityHubCertificationProgram,andCareCoordinationSystemsprojectmanagementteamontheimplementationofthePathwaysCommunityHubinourregion.


ACHResponseBHTstrategyforlong-termprojectsustainabilityBetterHealthTogetherisdevelopingourCommunityHealthTransformationCollaborativeswithafocusonmovingtheregiontovaluebasedpurchasingandwholepersoncare.VBPisthecornerstoneofoursustainabilityplanrecognizingtheneedtotransitionhowwepayforcareandlinkingsocialdeterminantofhealthservicestohealthcareservices.Weareworkingtoaligndata,fundsflow,andmodeldevelopmenttomaximizetheopportunitytointegrateselectedprojectsintoavaluebasedmodelandweavetogetherlocalresourcesandinvestmenttoreachthisgoal.Forinstance,itisexpectedthattheBHTBoard’sfundsflowpolicywillincludedirectedinvestmentsforstartupcosts,infrastructureandtechnicalassistanceemphasizingDSRIPfundingfortransition,notanongoingpaymentstream.CommunityHealthTransformationCollaborativesaredesignedtosupporttheearlyformationofthenaturalpartnershipsneededtosupportageographicallybasedhealthsystem’ssuccessinavaluebasedsystem.Thelinkagescreatedtosupporttheseprojectswilltranslatetotherelationshipsneedtosucceedinavalue-basedmodelandimprovepopulationhealth.Thesepartnershipswillsustainthemselvesassharedsavingsarere-investedinCollaborativeefforts.ThesupportfromtheACH,MTDfunds,andCollaborativepartners,willcreateanenvironmenttotestnewprocessesandimplementnewprojects.ThePathwaysCommunityHubwilldevelopcontractswithMCOSandotherfundersforoutcomebasedpaymentstiedtosuccessfulcompletionofPathways.Thisoffersasustainablefundingmodelforcarecoordinationandsharedsavings.Finally,theCommunityResiliencyfundisanareaoftheMTDprojectsweexpecttobesustainedpasttheMTDperiod.BHTwilldevelopacommunitydashboardthatmonitorskeysocialdeterminantandhealthindicatorsofourregionalhealthsystem’sviability.Byaligningregionalpartnersandinvestorsaroundtheseindicators,usingdemonstrationasanincubator,wecancreateaninvestmentfundofflexibledollarsfortheregiontocontinuetouseforstrategicinvestmentinovercominghealthdisparities.Project’simpactonWashington’shealthsystemtransformationbeyondtheDemonstrationperiodThePathwaysCommunityHubmodeliscentraltoourMTDeffortsandtheregion’seffortstomovetoValueBasedcare.ThePathwaysCommunityHubmodeloffersascalableopportunitytolinkcarecoordinationandtoimprovehealthoutcomesthroughasustainablemodelofcarebeyondtypicalphilanthropic/governmentcontracts.ByimplementingthePathwaysCommunityHub,wewilldemonstratethevalueofbetterlinkingeffortstoaddresssocialdeterminantswithclinicaleffortstoimprovehealthoutcomes.OtherstateshaveimplementedthePathwaysCommunityHubandfoundsuccessindevelopinglongtermcontractswithfunders(notlimitedtoMCOs).ThiswillresultinimprovedcommunitycapacitytolinkhealthsocialdeterminantofhealthsupportwithatriskpatientsthatwilllastbeyondtheMTDperiod.

(500words)

1WHO(WorldHealthOrganization).2012.Whatarethesocialdeterminantsofhealth?http://www.who.int/social_determinants/sdh_definition/en/2Basedon2015data,RWJFCountyHealthRankings:http://www.countyhealthrankings.org/3See:http://www.commerce.wa.gov/housing-needs-assessment.Affordable(meaningtheycostlessthan30%ofaveragehouseholdincome)&availableunitsper100householdsinBHTcountiesare:Adams22,Ferry26,Lincoln22,PendOreille26,SpokaneCo.12,Stevens26.Spokanemetroareahas14affordable&availablehousingunitsper100households.4BHTHealthSystemsInventory(2017).5HCAACHToolkitHistoricalData:https://wahca.app.box.com/s/mxpg8euzbjpdkmyuftzb4ri5v41ia8v9/folder/369500520366HCACo-occurringdisordertables,see:https://wahca.app.box.com/s/mxpg8euzbjpdkmyuftzb4ri5v41ia8v9/folder/398664065197HCAhospitalizations_ach_rhni_tables:https://wahca.app.box.com/s/mxpg8euzbjpdkmyuftzb4ri5v41ia8v9/folder/23928005433.(Notethat1/3ofMedicaid-paidhospitalizationsinBHT’sregionthatwerenotrelatedtopregnancy/childbirthwereclassifiedasstemmingfrom“othercauses”intheavailabledata8Thisisanupper-boundestimatebasedonfindingfrom2013analysisestimatingthat60%ofWAjailinmateswhowereenrolledinMedicaidin2012or2013hadamentalhealthneedandassumingthatthesameproportionappliestoinmateswithoutarecenthistoryofMedicaidenrollment.See:http://sac.ofm.wa.gov/sites/all/themes/wasac/assets/docs/research-11-226a.pdf

9Thisisanupper-boundestimatebasedonuncitedfigurefromSpokaneCountyCorrectionsthat85%ofinmateshaveabehavioralhealthneed.

10WashingtonDOHVitalStatisticsMedicaid-paidbirths,2015data.See:https://www.doh.wa.gov/DataandStatisticalReports/HealthStatistics/Birth/BirthTablesbyYear

11HCAACHToolkitProviderReportFilesupdated09.01.17,see:https://wahca.app.box.com/s/mxpg8euzbjpdkmyuftzb4ri5v41ia8v9/folder/30748038709.12SpokaneRegionalHealthDistrictDataCenter(2017).CommunityLinkageMapping:GeneralReport.Anassessmentoftheregionalpopulationandsocialdeterminantsofhealthsystems.https://goo.gl/1WDBpo.Seealsotheinteractivemapavailableat:http://arcg.is/2pH9kuT


TransformationProjectDescription


Domain3:PreventionandHealthPromotion�� 3A:AddressingtheOpioidUsePublicHealthCrisis(required)

ACHResponseTheOpioidsProjectwillsupportWashingtonState’sgoalsofreducingopioid-relatedmorbidityandmortality.BetterHealthTogetherAccountableCommunityofHealth(BHTACH)willaligncommunityeffortstopromoteprevention,accesstotreatment,overdoseprevention,andrecoveryforarearesidents,focusingspecificallyonadultsandyouthenrolledinMedicaidviaourRuralandSpokaneCountyCollaboratives.JustificationforselectingprojectandhowitaddressesregionalprioritiesTheopioidcrisishasskyrocketedinWashingtonandtheBHTACHregion,anditisaffectingtheMedicaidpopulation.AccordingtotheUniversityofWashingtonAlcoholandDrugAbuseInstitute,threecountiesintheBHTACH(Ferry,LincolnandPendOreille)eachhadarateofpubliclyfundedadmissionsforopioidsofbetween90and180per1,000residentsbetween2011and2013.SpokaneandStevensCountieseachhad180-360admissionsper1,000residentsinthissameperiod.1Opioidrelatedtreatmentanddeathsincreasedacrossthestateoverthepastdecade,mirroringagrowingproblemnationally.AcrosstheBHTACHregion,17.4percentofMedicaidenrolleesareopioidusers.ThisrateishighcomparedtotheoverallWashingtonrateof13.5percentofallMedicaidenrollees,andallcountiesintheregionexceptAdamshaveahigherrateofopioidusethanthestateasawhole.Whilenotallopioidusersaredependent,over7,000people(3.6percentofMedicaidenrollees)meettheCDCdefinitionofheavyopioidusers,and3.9percentofthepopulationhasusedopioidsforover30days.Oversixthousandpeople(3.2percentofMedicaidenrolleesintheregion)areopioiddependentorabusing,basedonICD9andICD10codesoveratwo-yearclaimsperiod.2

Table1:OpioiduseamongMedicaidbeneficiaries,BHTandWAstate

MedicaidOpioidUseData BHT WashingtonOpioidUsersas%ofMedicaidpopulationAll 17.4% 13.5%Userswithoutcancer 15.4% 11.9%HeavyUsers 3.6% 2.8%Usersfor>30days 3.9% 2.8%

Diagnosishistoryofopioidabuseordependence

All 3.2% 2.7%Males 3.2% 2.8%Females 3.2% 2.6%

BetterHealthTogetherhashigherratesofopioidoverdoseeventsthanthestateaverageand,in2016,hadthehighestratesamongallACHsforopioidoverdose-relatedhospitalizationsandEDvisits.ThedatainthetablebelowcomefromtheWashingtonDepartmentofHealth’sOpioidOverdoseDashboard.

Table2:Opioid-relatedevents,BHTregionandWAstate3

Opioid-relatedevents,2016 BHT WashingtonAllnumbersaregeneralpopulationratesper100,000Opioidoverdosedeaths 11.1 10.7Opioidoverdosehospitalizations 27.6 21.6OpioidoverdoseEDvisits 94.1 48.2

Note:Hospitalizationsarebasedonpatient’scountyofresidence,whereasdeathsandEDvisitsarebasedoncountyofoccurrenceandfacilitylocation,respectively.

DatasuppressionmakesitdifficulttoestimatethenumberofactiveopioidprescribersfortheMedicaidpopulationinBHT’sregion.However,informationfromthePrescriptionDrugMonitoringProgramsuggeststhatopioidprescriptionsarewrittenandfilledatelevatedratesinmostofBHT’scounties,ascomparedtothestate.

Figure1:Opioidprescriptionswrittenandfilledper1,000residents,20144

Theregionhashostedseveraldiscussionsandeffortsoverthelastfewyears,thoughnoneoftheseeffortshavesustainednorcreatedsignificantchange.TheBHTACHwillaligntoolkitrequirementsintoourclinicalsettingeffortsviaourCollaborativestoimplementbestpracticesandevidence-basedstrategies.Additionally,viaourACHLeadershipCouncil,ProviderChampionsCouncil,CommunityVoiceCouncilandTribalPartnerLeadersCouncilefforts,wewillalignothercommunityeffortsrelatedtoopioidprevention,suchasARCORA’sefforttosupportanoralhealthlocalimpactnetworkwithafocusonreducingopioidusedisorder.Thisstrategywillassistusinbuildingarobustnetworkofdentalpracticeswhoareakeysourceofopioidprescribing,andinvolvementandleadershipfromthedentalcommunitywhichwillbeakeysuccessfactorforestablishingamorecoordinatedresponsetoopioid-addictionpreventionandtreatmentactivities.HowProjectwillsupportsustainablehealthsystemtransformationforthetarget

populationThisprojectwillsupportsustainablehealthsystemtransformationforthetargetpopulationbyfosteringcross-sectorpartnershipsthatleverageourlocalresourcestoreversetheopioidepidemicinourregion.Theprojectwillfosterdeliverysystemchangesthatsupportcoordinationandcollaborationacrossproviders,promoteappropriateprescribing,patient-centeredtreatmentandrecovery-orientedcare,andValueBasedPayment(VBP)modelsthatincentivizeandsustainthesesystemchanges.HowBetterHealthTogetherwillensureprojectcoordinateswithanddoesn’tduplicate

existingeffortsBetterHealthTogetherissupportingthedevelopmentoftwoCommunityHealthTransformationCollaboratives:

1. RuralCollaborative(comprisedofFerry,Stevens,PendOreille,Lincoln,andAdamsCounties)

2. SpokaneCountyCollaborative

TheBHTACHistakingaregionalapproachtoprojectdesignandimplementationthatwillprovidelocalautonomyandregionalaccountability.TheCollaborativeswillberesponsiblefordevelopingandimplementingactionableMTDplansacrossBHT’sprojectportfolio,andensuringthattheprojectscoordinatewitheachotheranddonotduplicateexistingeffortsintheregion.TheCollaborativeswillbecomprisedofkeypartnerswiththeexpertiseandexperiencerequiredtotransformourMedicaidDeliverySystemincludingclinics,FederallyQualifiedHealthCenters(FQHCs),Hospitals,MentalhealthandSubstanceUseproviders,PublicHealth,TribalHealthsystems,EMS,JailsandCountyCommissioners.Thisrepresentationwillensureeffortsarecoordinatedacrosstheregionandresourcesareleveraged.

IntheSummer2017,BHTACHalsosurveyedorganizationsintheregiontocompleteaHealthSystemsInventory(HSI)orCareCoordinationInventory(CCI)togatherproviderinterest,capacity,prioritiesandinformationaboutexistingworkintheregionrelatingtotheMTD

projectareas.BasedonproviderHSIresponses,akeyareawhereweseetheopportunityforcoordinationisintheuseofTheSixBuildingBlocksforPainManagementandSafeOpioidTherapy.BHTACHisworkingwithatleasttworuralprovidersengagedwiththiseffort,andfurtherexploringtheextenttowhichotherprovidersintheregionarealsoparticipating.TheHSIindicatesthatfewpartnersdonotorarenotabletoofferMedicationAssistedTherapybecauseoflackofprovidersorresources.AnticipatedProjectScopeBHTACHproposestoaddressopioidsintheregionthroughfourinterconnectedinitiativesfocusedonprovidersandMedicaidconsumers.TheseeffortsalignwiththeWashingtonStateOpioidResponsePlan.Initiative1:Prevention–ImproveProviderPrescribingPractices

• Strategy1:ViaourTransformationCollaboratives,provideadditionalsupporttoprovidersregardingprescribingpractices,accessingpatientinformationandhistory,andincreasingnon-opioidpainmanagementstrategies.

o AspartoftheCollaborativeassessment,identifyproviderunderstandingofprescribingguidelinesandtargettrainingandcoachingtoproviderswithmostneed

o AspartoftheCollaborativetechnicalassistanceplan,promotebestpracticesforprescribingopioidsforacuteandchronicpain,includingincreasingtheuseofthePrescriptionDrugMonitoringProgram(PDMP)bymoreproviders.

§ DistributeWashingtonStateMedicalAssociation/WashingtonStateHospitalAssociation/HealthCareAuthorityopioidprescribingvariancereportsthatincludefeedbackandcomparisonmetrics,sothatprescriberscanevaluatetheirprescribingpracticesrelativetoothersinthestate.

§ ProvidetrainingandinformationonWashingtonStateAgencyMedicaidDirector’s(AMDG)prescribingguidelines.PromoteadoptionoftheSixBuildingBlocksforopioidpainmanagementbyprimarycareprovidersandpromoteaccesstotheteamofSixBuildingBlocksexpertsandpracticecoachesforindividualconsultationandassistancewithimplementationwithprimarycarepractices.

• Increaseleadershipandconsensusaroundsafeprescribing.• Usearegistrytoproactivelymanagepatients.• Revisepoliciesandstandardworktosupportsafeprescribing.• Increasepatient-centeredcare.• Providecareforcomplexpatients• Measuresuccess

o ItisexpectedthatCollaborativeswillmeasureincreasedphysicians’useofthe

PrescriptionDrugMonitoringProgram(PDMP):§ FacilitateintegrationofthePDMPwithelectronichealthrecords

systems.

§ OffsetadministrativecostsassociatedwithmanuallycheckingthePDMP(forprovidersunabletointegrate).

o Increasetheuseoftelehealthtoimprovecapacityinruralareas.o Promotetheuseofnon-opioidpainmanagement.

• Strategy2:Workwithpartnerstoincreaseunderstandingofadverseeffectsofopioiduse

o AspartoftheCollaborativeassessmentprocess,eachCollaborativegroupwillassesstheavailabilityandqualityofeducationalmaterialsforconsumers.

o Promoteaccurateandconsistentmessagingaboutopioidsafetyandtoaddressthestigmaofaddiction.

o Utilizecommunitycarecoordinatorsandothercommunitymemberstoconductpeeroutreachandeducation.

o Promotenationalsocialmarketingcampaignsonthepotentialharmsofprescriptionmedicationmisuseandabuseandsecurehomestorage.

• AnticipatedOutcomes,theMedicaidWaiverFinanceGroupwillexploretyingincentivepaymentstotheseoutcomes.

o Improvebaselineunderstandingofproviderknowledgeandtrainingneedso Increaseprovider,consumerandcommunitylevelunderstandingofimpactsof

opioiduse,alternativestoopioidsforpainrelief.§ Increasenumberofprescribersawareoftheirprescribingpatternsand

trainedonAMDGguidelines.§ IncreasenumberofprescribersregisteredforandusingthePDMP.

o Reducehigh-doseprescriptionopioidtherapyforchronicuse.o Reducenumberofconcurrentsedativeprescriptions.o Reduceopioidrelatedinpatientstaysandemergencydepartmentvisits.

Initiative2:Treatment–SupportProviders,IncreaseAccesstoServices

• Strategy1:Educateproviderstoidentifypotentialopioidmisuse,OpioidUseDisorder(OUD),andontheavailabletreatmentoptions.

o AspartofourOpioidstrategyandourPathwaysCommunityHubregionalassessment,identifyexistingcommunity-leveltreatmentresources

o AspartofourworkthroughRegionalHealthTransformationCollaborativeandtechnicalassistanceandtrainingprovision:

§ EducateprovidersonhowtorecognizesignsofopioidmisuseandOUDamongpatientsandhowtouseappropriatetoolstoidentifyOUD.

§ Increaseproviderabilitytohavesupportivepatientconversationsaboutproblematicopioiduseandtreatmentoptions.

o Providepharmacistswithtoolstopromotereferralsforopioidprescriptionmisuse.

• Strategy2:Increaseaccesstoanduseofcommunity-levelOUD.o IncreasethenumberoflocalproviderscertifiedtoprescribeOUDmedications.o WorkwiththeHealthCareAuthoritytoidentifypolicychangesthatcould

improveavailabilityanduseoftreatmentoptions.

o Utilizecommunityresources(CHWs,PathwaysCommunityhubpartners,socialserviceorganizationsand211)tosupportpeerlearningandsupportforOUDtreatment.

o Supportefforttoincreaseaccesstobuprenorphine.o Improvecommunicationbetweenphysiciansandpsychosocialproviders.

• Strategy3:Targethigh-impactpatientsforspecializedinterventionandeducation(pregnantandparentingwomen)

o AspartofourCollaborativeTechnicalAssistance§ Increaseproviders’awarenessanduseofSubstanceAbuseduring

Pregnancy:GuidelinesforScreeningandManagement,theWashingtonStateHospitalAssociationSafeDeliveriesRoadmapstandards.

§ EducatepediatricandfamilymedicineproviderstorecognizeandappropriatelymanagenewbornswithNAS.

o WorkwithMCOsandHCAtoincreasethenumberofobstetricandmaternalhealthcareproviderspermittedtodispenseandprescribeMATthroughtheapplicationandreceiptofDEAapprovedwaivers.

o Workwithclinicalandsocialservicesproviderstoimproveaccesstotherangeofservicesthataddressphysical,mentalandsubstanceusedisordertreatmentneedsduring,throughandafterpregnancy.

• AnticipatedOutcomes:TheMedicaidWaiverFinanceGroupwillexploretyingincentivepaymentstotheseoutcomes.

o Increaseaccesstotreatment(includingMAT)forMedicaidbeneficiarieso Increaseaccesstothefullrangeofservicestotreatthewholepersonand

supporttreatmentsuccessInitiative3:OverdosePrevention

• Strategy1:Increaseavailabilityanduseofnaloxone.o Establishstandingordersinallcountiesandallopioidtreatmentprogramsto

authorizecommunity-basednaloxonedistributionandlayadministration.o Encourageproviderstoprescribenaloxoneforpainpatients.

• Strategy2:Educatetargetedconsumers(opioidsandheroinusersandprovidersandotherswhointeractwithusers)abouthowtorecognizeandrespondtoanoverdose.

o Educatefirstresponders,chemicaldependencycounselors,andlawenforcementonopioidoverdoseresponsetrainingandnaloxoneprograms.

o Helpemergencyprovidersdevelopandimplementoverdoseeducationprotocols,encouragethemtosendhomenaloxonewithpatientsseenforopioidoverdose.

• Strategy3:IncreasegeneralunderstandingaboutWashingtonState’sGoodSamaritanLaw.

o WorkwiththeCenterforOpioidSafetyEducationtoeducatelawenforcement,prosecutorsandthepublicabouttheGoodSamaritanResponseLaw.

• AnticipatedOutcomes:

o Increaseaccesstonaloxoneforindividualsusingheroinandopioids,andforclinicalandlayresponders.

o Reduceopioidoverdosedeaths.Initiative4:Recovery

• Strategy1:Improveaccesstorecoverysupportsandlong-termstabilization.o Buildonexistingcommunityeffortstosupportaregionalapproachtocreatea

recoverycultureincludingthescalingoftheRecoveryCare,PathwaysHubandcarecoordinators,alongwithCHWstoincreaseuseofpeerandotherrecoverysupportservicesdesignedtoimprovetreatmentaccessandretentionandsupportlong-termrecovery.

o Supportaccesstoharm-reductiontechniques.o ConnectSUDproviderswithphysicalandbehavioralhealthproviderssocial

servicesorganizationsandpeersupportstoaddressaccess,referralandfollowupforservices.

• AnticipatedOutcomes:TheMedicaidWaiverFinanceGroupwillexploretyingincentivepaymentstotheseoutcomes.

o IncreasenumberofMedicaidenrolleeswithOUDwhoaccesscarecoordinationthroughthePathwaysHub.Increasereferralsandfollowuptreatment,includingtorecoverysupportsandharmreductionservices.

AnticipatedTargetPopulationThetargetpopulationisadultandyouthMedicaidbeneficiarieswhouse,misuse,orabuseprescriptionopioidsorheroin.Thistargetpopulationwillincludeapproximately7,688individualsintheBHTACHregionwhohaveusedopioidsformorethan30days.5Asindicatedinthestrategies,providingspecialassistancetopopulationsforwhomopioidmisusehasimmediateandsystemicimpacts(e.g.pregnantwomen)willbeapriority.AmongMedicaidbeneficiariesintheregionandstate,womenaresomewhatmorelikelytobeheavyopioidusersthanaremen(intheBHTACHcatchmentarea,womenmakeup58percentofheavyopioidusersdespitebeingonly51percentofoverallenrollment)5InvolvementofPartneringProvidersTodeveloptheproposedproject,BHTACHhasconvenedandmetone-on-onewithpartneringprovidersthroughouttheregionworkingonopioid-relatedefforts.Inaddition,BHTACHengagedprovidersinanLOIprocesstoidentifyproviderinterestinMTDprojectareas.TheseeffortshavedirectlyinformedthedevelopmentoftheproposedOpioidprojectprioritiesandBHT’sproposaltodevelopregionalCollaborativestofurtherdevelopMTDprojectsin2018.ThefollowingprovidersandorganizationsexpressedinterestinOpioidprojectimplementationand/orpartnership.

Provider/PartneringOrganization LOIforProjectImplementation

LOIforProject

PartnershipAgingandLong-TermCareofEasternWashington

X X

CatholicCharitiesSpokane XCHASHealth X CommunitiesinSchools XConsistentCareServices,SPC,PS X CommunityHealthPlanofWashington XEastAdamsRuralHealthcare X FerryCountyPublicHospitalDistrict X XEmpireHealthFoundation X FrontierBehavioralHealth X GreaterSpokaneCountyMealsonWheels XInlandNorthwestHealthServices X KalispelTribeofIndians X LakeRooseveltCommunityHealthCenters XLincolnCountyHealthDepartment X MeritDisability XNationalAllianceonMentalIllness XNHHS/PendOreilleHealthCoalition XNortheastTriCountyHealthDistrict X XOdessaMemorialHealthcareCenter X OperationHealthyFamily X XOralHealthcareLLC X OthelloCommunityHospital X PendOreilleHealthCoalition X PioneerHumanServices X XPlannedParenthood XProvidenceHealthCare X XRuralResourcesCommunityAction X XSNAP XSpokaneNeighborhoodActionPartners X SpokaneRegionalHealthDistrict X XVirginiaMatheny X WashingtonDentalServiceFoundation X XYMCA XYWCA X

LevelofImpact

BetterHealthTogetherisidentifyingtargetpopulationsbasedonexaminationofregionaldatademonstratingkeyhealthdisparities.Asnotedabove,providingspecialassistanceto

populationsforwhomopioidmisusehasimmediateandsystemicimpacts(e.g.pregnantwomen)willbeapriority.Whileopioiduseandusedisorderisanissueacrosstheregion,someareasappeartobemoreimpactedthanothers.Forexample,PrescriptionDrugMonitoringProgramdatashowelevatedratesofopioidprescribinginLincoln,PendOreille,andStevensCounties6(seemapearlierinthissection)andPendOreilleCountyhadthesecondhighestrateofopioidoverdosefatalitiesinthestatebetween2011and2015,7althoughsmallnumbersmakethatratesubjecttofluctuation.AsweworktoconnectouropioidprojectworktolargersystemiceffortstoreduceAdverseChildhoodEvents(ACEs),itisclearthatreducingopioidaddictionanddeathsbenefitsnotonlytheindividualswithOUD,buttheirfamiliesandcommunities.Thisisparticularlyanissueforchildrenofopioidusers.HavingoneormoreACESisassociatedwithhigherincidenceofchronicillness.Consideringthecross-projectimpactsofACHactivities,reducingchronicillnessisanadditionalequitybenefitofsuccessreducingopioidsusedisorderanddeath.

HowBetterHealthTogetherwillensurethathealthequityisaddressedintheproject

design

BetterHealthTogetherisensuringthathealthequityisembeddedintheprojectdesignatmultiplelevels:

• RegionalHealthTransformationCollaboratives:WiththecreationofdistinctSpokaneCountyandRuralCollaboratives,BHTisensuringattentionandfocustoruralhealthissuesanddisparitiesinourregion.Inaddition,wearedesigningtheseCollaborativestoincludeorganizationsthatbringdiverseracialandculturalperspectivestokeyregionalhealthissues.

• CommunityVoicesCouncil:BHTACHislaunchingaCommunityVoicesCouncil,madeupofatleast50%Medicaidbeneficiariesorlow-incomecommunitymembers,toempowerandbringconsumervoicestoinformprojectdesignandimplementation.ThisCouncilwillbetaskedwithdevelopinghealthequitymetricsbywhichtoholdtheCollaborativesandprojectsaccountabletodefinedhealthequitygoalsandstandards

• Targetpopulations:BHTACHisfocusingprojectsontargetpopulationsexperiencingthegreatesthealthdisparities.Weareapplyingan“equitylens”toallourworkbydisaggregatingdatabyrace/age/ethnicity/sex/zipcodewhereverpossible,bothtomakeinformeddecisionsabouttargetpopulationsandtomonitorimpactofprojectsacrossdiversegroups.BHTACHwillsupplyCollaborativeswithregionaldatatoguideearlyassessmentsofCollaborativepartners,andwilldirecttheseteamstoidentifypopulationswithintheircountythatfaceahighlevelofdisparitiesand/orpresentashighlycomplexorhighrisk.

• Livedexperience:WiththeCommunity-basedCareCoordinationproject,BHTACHisadvancingthePathwaysmodelanduseofCommunityHealthWorkerswithlivedexperienceofhealthinequitiestofurtherourefforts.Carecoordinatorsarecriticaltodevelopingtrustandculturally-appropriatestrategiestomeettheneedsofourtargetpopulationsacrosstheMTDprojectareas.

• EquityAcceleratorPayment:Weanticipateimplementingthisincentivetosupportproviderswhoserveagreaterproportionofhigh-riskclients.Themetricstiedtothese

ImplementationApproachandTiming SeeSupplementalWorkbook


paymentswillbedeterminedbytheWaiverFinanceWorkgroup,vettedbyProviderChampionsCouncilandCommunityVoicesCouncil,finalizedbyWaiverFinanceWorkgroup,andrecommendedtotheBHTBoard.

• PathwaysModel:HealthequityisbuiltintomanyelementsofourCareCoordinationstrategyandthePathwaysmodel,throughindividualizedcareplans;standardsofcareandaccesstotheentirenetworkofcareagenciespartneringwiththeHub;culturally-informedcare;anddatainfrastructuretoolsthatcanbeusedtomonitorcarepractice,providerquality,andresource.

Project’slastingimpactsandbenefittotheregion’soverallMedicaidpopulationOpioiduseisapublichealthcrisisacrossthestateandinourregion.Addressingthiscrisisthroughincreasedprevention,treatment,overdosepreventionandlong-termrecoveryisvitaltotransformationthehealthcaredeliverysystemandusinglimiteddollarsmoreeffectively.BHTACHwillsupportcaretransformationandpaymentredesignthroughitsCollaboratives.TheCollaboratives’diversepartnersandcommunityvoiceswillspurregionaleffortstotransformclinicalcaredelivery,transitionanddivertindividualsoutofemergencydepartmentsandjails,andcoordinatecare.Theactivitiesintheopioidprojectareakeyelementofthisoverallstrategy,witheffortstosupportclinicalcare,addictiontreatmentandotherservicesforindividualswithopioidaddiction.

ACHResponse

HowBetterHealthTogetherhasincludedpartneringprovidersthatcollectivelyservea

significantportionoftheMedicaidpopulation

Asreferencedabove,BHTACHsurveyedorganizationsintheregiontocompleteaHealthSystemsInventory(HSI)orCareCoordinationInventory(CCI)togatherproviderinformationaboutexistingworkintheregionrelatedtotheMTDprojectareas.BHTACHreceivedresponsesfrom42organizations,includingmajorhospitalnetworks,providersystems,FQHCs,MCOs,andcarecoordinationagencies.RespondingprovidersfortheHealthSystemsInventory(HSI)representedmorethan80percentofthehighest(top10)volumeMedicaidbillersinprimarycare,mentalhealth/substanceusedisorder,inpatientandED.ForseveralsettingsinBHT’sfiverural

counties,theHSIrespondentsrepresentalltheMedicaidbillerswithclaimsorbeneficiarycountsofmorethan10in2016.BetterHealthTogetherstaffarefollowingupwithnon-representedprovidersservingasignificantnumberofMedicaidclients,particularlysubstanceusedisordertreatmentproviders.

ProcessforensuringpartneringproviderscommittoservingtheMedicaidpopulation.

In2018,BHTACHwillformalizepartneringproviderparticipationinthecommunity-basedcarecoordinationprojectandotherMTDprojectareasthroughaTransformationCompactprocesstoensurecommitmenttoservingtheMedicaidpopulation.BHTACHhasalreadyengagedprovidersintheregionservingasignificantportionoftheMedicaidpopulationandhasconfidenceintheircontinuedcommitment,buttheTransformationCompactwillformalizethatexpectation.

Processforengagingpartneringprovidersthatarecriticaltotheproject’ssuccess,and

ensuringthatabroadspectrumofcareandrelatedsocialservicesisrepresented

BetterHealthTogetherhasidentifiedthatrepresentationfromthefollowingsectorsisrequiredforCollaborativestosuccessfullyimplementprojects.Eachofthesepartnersrepresentacriticalsettingforprojectimplementation:

• PhysicalHealthClinicalProvider(s)• HospitalSystem(toincludeanEDDoctor)• BehavioralHealthClinicalProvider(s)• TribalHealthSystems• EmergencyMedicalServices(firstresponders)• CriminalJustice• SUDProvider(s)• Community-BasedChronicDiseasePreventionandMitigationOrganization• CommunityBasedCareCoordinatingAgency• MCO(s)• CrisisManagementServices• Liaison:CommunityMember/Consumer

TheCollaborativeswillidentifyadditionalcriticalpartnersneededtodevelopandimplementtheirprojects,andCollaborativepartnershipsmaybeexpandedasneeded.InitsroleasthePathwaysHub,theBHTACHwillserveasaconnectorbetweencollaborativeprovidersandadditionalsocialandcommunitypartnersthatcanhelpimprovecommunityhealth.

HowBetterHealthTogetherisleveragingMCO’sexpertiseinprojectimplementation,and

ensuringthereisnoduplication

ManagedCareOrganizations(MCOs)areactivelyinvolvedinBHT’sgovernanceandleadershipgroups:

• TwoMCOrepresentatives,fromMolinaHealthCareofWashingtonandCoordinatedCareofWashington,areontheBoard.

• AllfiveMCOsarevotingmembersofBHT’sLeadershipCouncilandMCOstaffparticipateinmeetingsandone-on-onesessionswiththeBHTACHteam.


• BHT’sRegionalIntegrationPlanningTeam,supportingFIMC

MCOswillcontinuetoparticipateinMTDprojectplanningviatheseleadershipgroupsandthroughtargetedcollaborationwithBHT’sHealthTransformationCollaboratives.

Inaddition,BHTACH,PierceCountyACH,andSouthwestACHhavecollaboratedonmeetingswithMCOpartnerstolearnaboutkeycrossoverareasbetweenACHsandMCOundertheMTD,toensurethatBHT’sprojectstrategy,supportforproviders/Domain1strategies,andmonitoringandqualityimprovementeffortsalignwithexistingMCOactivitiesandgoals.Ourdiscussionscovered:

• Members/populationoverview• PCPassignment/empanelment• Providersupport,particularlyforvalue-basedpaymentandrelateddeliverysystem

reform• Measurementandqualityimprovement• Memberengagement/education• PathwaysCommunityHub

MCOsemphasizedtheimportanceofconsideringtheneedsandutilizationpatternsofdifferentMedicaidpopulations(e.g.expansionadultsvs.traditionalMedicaid)anddesigningstrategiesthatcanintegrateadditionalgroups(e.g.dualspecialneedsclients)overtimetofullyengageMCOsandotherpartnersandsupportsustainability.Anothercommonpointwastheneedtoavoidoverwhelmingproviderswhoarereceivingassistanceandrequestsforpracticechangesacrosspayersandpaymentmodels.TheBHTACHandtheCollaborativescanplayakeyroleincoordinatingTAsupportwithMCOs.WealsodiscussedwaystocoordinateondatasharingwithMCOs,HCA,theWashingtonHealthAlliance,OneHealthPortandeventuallytheWashingtonAllPayerClaimsDatabase.

ACHResponseAssetstheACHandregionalpartnersproviderswillbringtotheproject

• Engagedpartners:TheclinicalandotherpartnersontheCollaborativesandsub-committeesarehighlyengagedinunderstandingkeyregionalhealthneedsandunderstandinghowgapscanberesolvedthroughcollaborativeaction.Inaddition,theWashingtonDentalServicesFoundationhasexpressedconcernandinterestintheopioidsissue,recognizingthatdentalprovidersarealargesourceofopioidprescriptions.TheFoundation’sefforttoestablishataskforcearebeingconnectedtotheCollaborativeeffortsinordertoensurethatknowledgeandresourcesarecombinedratherthanduplicated.

• FinancialAssets.EmpireHealthFoundationpledged$240,000toACHeffortsin2017.Theregionhastwolargenon-profithospitalsthathavehistoriesofgenerouscommunitybenefitgiving.InJuly2017,BHTACHrenewedits5-yearcontractwiththe

WashingtonStateHealthBenefitExchangetoadministertheregionalNavigatorNetwork.

• DataAssets.SpokaneRegionalHealthDistricthasgivenstafftimetobuildtheCommunityLinkageMap.Ithasalsoofferedadditionalin-kinddataandanalyticssupportforCommunityStrategyMaps.IntheirresponsestotheHSI,themajorityofpotentialpartnersexpressedwillingnesstosharedataforplanningandevaluation.

• ARCORAeffortstodevelopanOralHealthLocalImpactNetworkthatincludesanOpioidTaskForcechairedbySRHDAdministratorandBHTBoardmember,TorneySmith,tosupportalignmentacrossoralhealth,physical,substanceuseproviders.

Challengesandbarrierstoachievingoutcomesandstrategiesformitigatingrisks

ThechallengesintheBHTACHregioninclude:Challenge/Barrier Strategy

ProviderShortage/Serviceshortageespeciallyinruralareas

ChangestothefundingstructurefromBHOtomanagedIntegratedcarewilldramaticallyassistincreatingamorecoordinatedapproachformanagingcareanditisexpectedwillassistincreatingmoreavenuesforcareasmoreintegratedpracticeswillbeabletoofferbothmentalhealthandsubstanceuseservicesundertheirMCOcontract.Additionally,workingwiththeWorkforceDevelopmentCouncil,CommunityCollegeandEasternWASchoolofSocialtoexpandthecredentialprofessionalsavailable.Exploreinnovativewaystoprovidemoresupporttogetprovidersintrainingcertifiedquicker.

Lifestylebarriers,unsafeneighborhoods,lackoffamilywagejobs

WorkwithlocalpartnerstoalignhealthofthecommunitywithEconomicDevelopmentplansfordiversifyingeconomicopportunities(PendOreilleCountyrecruitmentofHiTesttoprovide100familywagejobs),ParksandRecreationeffortstoprovidemorecommunityopportunities(FerryCountyHealthCoalitionhasasummeractivitiesscheduleforteensand20stokeepengaged)andothercommunity

Stigmaaroundmedicationuseandaskingforhelpinsmallercommunities

Seekeducationalresourcestoaddresspublicperceptionofmentalhealthtreatmentandmedicationmanagementtoalleviatestigma.

ConcentrationofresourcesinSpokane,whichmeansSpokanepartnerscouldbeoverwhelmed

Throughthedevelopmentofruralcounty-basedcollaborative,buildstrongerreferralnetworkswith


byasksfromruralpartners–howtoscaleintoruralareas

Spokaneservicesandfurtherexploreexpansionofappropriatelevelofservices.

BetterHealthTogetherisexplicitlyfocusingonlocalneedsandresources.ThisallowsBHTACHtopromotesolutionsfromthegroundup.Collaborativeswillidentifycommunity-levelsocialdeterminantsofhealththatareproblematic.Educationofproviders,consumersandcommunitymemberswillhelpincreaseunderstandingaboutthecausesofopioidmisuse,alternativesforpaintreatmentandopportunitiestoreceivetreatmentandrecoveryassistance.Tacklingstigmaisakeypartofovercomingtheotherbarriersfacingourregion.WewillsupportCollaborativeeffortstoexpandculturallycompetentandinformedcare.CHWsarealargepartofthisstrategy.Peersupportscanprovideinformationandatrustedsource.Weprioritizebestfitcarecoordinatorswhowillensureculturallycompetentcare.

ACHResponseThegoalofBHT’smonitoringplanistousetimelydatatosupportprojectimplementation,peerlearning,andcontinuousimprovement.BHTACHwillworkwithitscontracteddatavendor,ProvidenceCenterforOutcomesResearch&Education(CORE),todesignandimplementamonitoringsystemthatwilltrackoperational,process,andoutcomemeasuresforeachprojectandCollaborative(seebelow)andfortheACHoverall.Thesystemwillbedesignedtocomplementexistingdataassets(suchastheHealthierWashingtonDataDashboards,anyFIMCearlywarningsystem,andrelevantregionalreports)andwillrefreshanytimeaparticulardatafeedisupdated.Designwilltakeplacealongsideimplementationplandevelopmentinlate2017andearly2018,sothatthesystemisreadyasprojectsmoveintoimplementation.AvisualoverviewofBHT’splannedapproachtomonitoringandcontinuousimprovementisshownbelow.

MonitoringmetricswillincludeACHtoolkitpay-for-reportingandpay-for-performancemetrics,aswellasregionalaccountabilityandqualityimprovementplanmetricsthatspeaktotheeffectivenessofBHT’sstrategieswithinandacrossprojectareas.Fortheimplementationphase,manymetricswillbeprocessoroperationalinfocus(e.g.establishmentofcross-settingdatasharingagreementsamongCollaborativepartners.)Finalmetricswillbeidentifiedintheimplementationplan.FortheOpioidsProject,BHTACHwillbetracking,ataminimum,informationonthefollowingaccountabilitymeasures:

• OutpatientEmergencyDepartmentVisitsper1,000MemberMonths• InpatientHospitalUtilization• Patientsonhigh-dosechronicopioidtherapybyvaryingthresholds• Patientswithconcurrentsedativesprescriptions• SubstanceUseDisorderTreatmentPenetration(Opioid)

TheBHTACHhassetambitiousstretchgoalsofincreasingby10percentoverfiveyearstheproportionofMedicaidmemberswhosementalhealthorsubstanceusedisordertreatmentneedsaremet.Planformonitoringprojectimplementationprogress,includingaddressingdelaysin

implementation

ThoseprocessmeasureswillbeassociatedwithtimeframesandbenchmarksidentifiedbytheACHanditsCollaborativestoprovideimmediatefeedbackwhendelaysoccur.TheBHTACHplanstoworkwithCOREtodevelopacommunitydashboardtomonitorkeymetricsidentifiedintheMTDandourcommunitypriorities.Thiswillbeamulti-functionaldashboardextendingbeyondtheMTDtoallowongoingcommunitytrackingandprioritization.ResponsibilityforaddressingdelaysinimplementationwillliewiththeCollaboratives,BHTgovernancebodies,andselectBHTACHstaffpositionsasdescribedunder‘Planformonitoringcontinuousimprovement’below.

Planformonitoringcontinuousimprovement,supportingpartneringprovidersand

determiningwhetherornotBHTisontracktomeetexpectedoutcomes

Amonitoringandcontinuousimprovementsystemismorethanjustdata;it’saboutthepeople,processes,andtoolsusedtoturnthatdataintoactionableinformationthatsupportssharedlearningandqualityimprovement.Inadditiontocreatingasystemtoaccessandanalyzedatafromdifferentsources,BHTACHwillrelyonthefollowinggroupsandpositionstointerpretthedata,identifyperformanceshortcomingsorrisks,anddevelopsolutions:

• CommunityHealthTransformationCollaboratives.Asdescribedelsewhere,BHTislaunchingaSpokaneCountyCollaborativeandaRuralCollaborativetodevelopandimplementspecificregionalplansforhealthsystemtransformationinthefourprojectareasBHThasselected.TheCollaboratives’rolewillextendto:advisingondesignoftheself-monitoringsystem;regularlyreviewingthedatathatsystemprovides;collaboratingwiththeACHtomakecoursecorrectionsasneeded;andparticipatinginsharedlearningopportunitieswithinandacrossCollaborativesandACHregions.



• JennySlagle,AssociateDirectorforHealthSystemTransformationwillserveasthePathwaysHubDirectoroverseeingalloperationsofthehubincludingtraining,qualityassuranceandimprovementandstrategicdirection.JennywillstaffthePathwaysCommunityCouncilthatwilllaunchin2018.ThispositionwillcloselymonitorthedataavailablefromtheHubplatformandintervenewhenPathwaysareslowtocompleteorhaveencounteredroadblocks.

• Initsroleasmonitoringsystemlead,COREwillcoordinatewithBHTACHstaffandtheentitiesabovetoprovidetimelyinformation,datainterpretationexpertise,andbothtechnicalandstrategicsupportforpeerleaningandcontinuousimprovement.

• BHT’sBoardwillreceivemonthlydashboardsonkeymilestonesandplanstoaddressanyrisks



YESX

NOX





YES NOX


PlanforaddressingstrategiesthatarenotworkingornotachievingoutcomesIncombination,thepeopleandworkgroupsdescribedaboveandtimelydatafromthemonitoringsystemwillenableBHTACHanditspartneringproviderstoidentifystrategiesthatarenotworkingandtothinkthroughsolutionsintimetoachieveprojectoutcomes.Ifnecessary,potentialadjustmentstoimplementationtimelineswillbetriagedthroughthemonitoringsystemtoassesstheirimpactondownstreamgoals.Iftimelinesstillcannotbemet,BHTACHwillinformthestateaboutthereasonsanditsplanforadaptingthetimeline,andpreventing/riskmitigationstrategieswillbesharedtootherprogramswhereappropriate.

ProjectSustainability (

500words)

1UniversityofWashingtonAlcohol&DrugAbuseInstitute(April2015).OpioidTrendsAcrossWashingtonState.See:http://adai.uw.edu/pubs/infobriefs/ADAI-IB-2015-01.pdf.NotethatAdamsCounty’sratewasnotcalculatedasthetotalcasesin2015werefewerthan5.2Source:HCARHNIstarterkit,see:https://wahca.app.box.com/s/mxpg8euzbjpdkmyuftzb4ri5v41ia8v9/folder/23928005433

3Source:WADrugOverdoseDashboard,see:http://www.doh.wa.gov/Portals/1/Documents/2900/wa_ach_od_quarterly_2017Q1.zip.NexthighestACHfor2016

ACHResponseBetterHealthTogether’sstrategyforlong-termprojectsustainabilityBetterHealthTogetherisdevelopingourSpokaneCountyandRuralCommunityHealthTransformationCollaborativesasacorestrategytoestablishlong-term,cross-sectorpartnershipsthatadvancehealthdeliverysystemtransformationandvalue-basedpaymentmodelsthatsupportlong-termchange.BHTACHisworkingtoaligndata,fundsflow,andmodeldevelopmenttomaximizetheopportunitytointegrateselectedprojectsintoavalue-basedmodelandweavetogetherlocalresourcesandinvestmenttoreachthisgoal.Project’simpactonWashington’shealthsystemtransformationbeyondtheDemonstrationperiodWeenvisionthatcollectivelydevelopinglocally-administeredprojectswillhavelong-term,sustainablebenefitforMedicaidrecipientsandotherresidentsofourregion.Improvingproviders,consumersandcommunitymembers’understandingoftheimpactsofopioiduse,potentialforharmandalternativesfortreatmentofpainwillreduceopioidrelianceandOUD.Thischangewillimpacthealthcarecostsandfreeupclinicalresourcesforotherserviceneeds.Additionally,reducedopioiddependenceandusedisorderwillpositivelyimpactsocialfactors,reducingACEsandmakingcommunitiessaferforallresidents.BetterHealthTogetherissupportingbroad-reaching,system-widetransformationinordertohavelastingimpactsandbenefittheregion’soverallpopulation,regardlessofchosentargetpopulation(s)orselectedapproaches/strategies.ImprovingaccesstobothSUDservicesandthelonger-termclinicalandsupportiveservicesthatwillkeepaffectedMedicaidmembershealthyandlesslikelytomustbetiedtoapaymentstructuretiedtohealthoutcomesandkeepingpopulationshealthieroverall.Thecombinationofimprovingcareforparticipantsandincreasingculturallyresponsiveaccessthatbringspeopletoneededserviceswillimpactcosts.Reducedclinicalcoststiedtoreimbursementforoutcomeswillbeamodelthatcanbereplicatedintheregionandstatewithoutregardtopayer.Provideracceptanceofnewpaymentmodelscanbecapitalizedtoexpandtothecommercialindividualandsmallgroupmarkets.

opioidoverdosehospitalizationswasSWACHat23.1eventsper100,000andnexthighestfor2016opioidoverdoseEDvisitswasCPAAat80eventsper100,000.

4WashingtonPrescriptionDrugMonitoringProgram,see:https://www.doh.wa.gov/ForPublicHealthandHealthcareProviders/HealthcareProfessionsandFacilities/PrescriptionMonitoringProgramPMP/CountyProfiles

5HCARHNI"starterkit,"see:https://wahca.app.box.com/s/mxpg8euzbjpdkmyuftzb4ri5v41ia8v9/folder/239280054336WashingtonPrescriptionDrugMonitoringProgram,see:https://www.doh.wa.gov/ForPublicHealthandHealthcareProviders/HealthcareProfessionsandFacilities/PrescriptionMonitoringProgramPMP/CountyProfiles

7WashingtonTrackingNetwork(WTN),see:https://www.doh.wa.gov/DataandStatisticalReports/EnvironmentalHealth/WashingtonTrackingNetworkWTN


TransformationProjectDescription SelecttheprojectfromthemenubelowandcompletetheSectionIIquestionsforthatproject.


Domain3:PreventionandHealthPromotion�� 3D:ChronicDiseasePreventionandControl

ProjectSelection&ExpectedOutcomes

ACHResponse

ProjectDescriptionandJustificationSincetheinceptionoftheBetterHealthTogetherAccountableCommunityofHealth,preventionhasbeenacornerstoneofeffortstoimprovecommunityhealth.TheBHTACHselectedtheChronicDiseasePreventionandControlMedicaidTransformationDemonstration(MTD)projecttoaccelerateoureffortstoimprovehealth,withaninitialfocusoncontrolandpreventionofType2diabetes.Theprojectstrategiesinclude:increasingaccesstocare;educatingconsumersandtheirfamilies;identifyingriskearlier,increasingcoordinationofservicesthatlinkclinicalprovidersandservicestosocialsupportsandotherserviceneeds;andworkingwiththestatetosupporthealthychoicesforWashingtonresidents.TheBHTACHisalsoexploringthepossibilityoffocusedeffortsaroundpreventionandmanagementofasthmaamongyouthandwillmakefinaldecisionsaboutprojectactivitiesandtargetpopulationsinconsultationwithitsCollaborativesandTechnicalCouncils.

TheCommunityHealthTransformationCollaborativeswillberequiredtodevelopaMTDimplementationplanforchronicdiseasecarepreventionandmitigationstrategiesinthePrimaryCare,PediatricandFamilyMedicinesettingsandpotentiallyaBehavioralHealthsetting.TheprojectswillutilizetheChronicCareModel.EachCollaborativewillalignofthemodelwiththeirProviders,Medicaidpopulationandotherfactorsinfluencingcareinthearea.Thisalignmentincludes,butisnotlimitedto,theCommunityGuide,StanfordChronicDiseaseSelf-ManagementProgram,andCDC-recognizedNationalDiabetesPreventionProgramsaswellassupportingwherepossible,implementationofdiabetesprogramsspecifictoTribalHealthProviders.WeexpectthateachCollaborativewillalsodeveloparegionalapproachtoCommunityParamedicine,astheselocallydesigned,community-basedsolutionscouldextendthereachofchronicdiseasemanagementthroughtheutilizationoftheskillsofparamedicsandemergencymedicalservices(EMS)systemstoaddressgapsthatareidentifiedthroughcommunitylevelneedsassessment.

Mosteffortstotacklechronicdiseaseareaimedatrespondingtothesymptomsandnegativeconsequencesofthosediseases.TheBHTACHseekstoworkupstream,tohelppeopleavoid

chronicdiseases.TheMTDprojectwillincludeafocusonearlydetectionandinterventionforindividualsatriskfordiabetes,andonreinforcinghealthylifestylehabitsearlyinlife.Thiswillincludeeffortsto:

• Educatepeopleaboutopportunitiestoincludephysicalactivityindailylife,howtochooseandpreparehealthy,freshfoods.

• Increasetheinvolvementofschoolsandworkplaces,helpingtheseinstitutionstoimplementpracticesthatencouragehealthylifestyle,andreinforcehealthynorms.

• Supportingprogramsandincentivesthatpromotehealthychoices.

Thisprojectwillalsoaligneffortswiththebi-directionalintegrationeffortstointegratehealthsystemandcommunityapproachestoimprovechronicdiseasemanagementandcontrolforhighprioritypopulations.Projectswereselectedtosupportdeliverysystemtransformationeffortsaimedatdevelopingasustainablebusinessmodelforinvestmentinprevention,managementandlinkingofhealthcaretosocialdeterminantsofhealth.TheMTDprojectforChronicDiseasewillpreparetheregiontothriveinaValueBasedPaymentenvironmentandsupportlongtermsustainabilityforpreventionefforts.

Type2DiabeteswasselectedasapriorityconditionfortheChronicDiseaseprojectbecauseofthephysicalandfinancialburdenitrepresentsforindividualsandthehealthcaresystem.StakeholdersintheBHT/ACHregionhighlightedobesityanddiabetesinearlycommunityconversationsandhealthsystempartnerscommonlycitedType2Diabetesasaconditionwhereimprovedintegrationandcoordinationofcarecouldleadtobetterhealthandfinancialoutcomes.

Diabetesisthe7thleadingcauseofdeathinWashingtonState.1Whilethegrowthindiagnosescasesofdiabeteshasslowedsince2011,anestimated2millionadultsarepre-diabeticandasmanyas30%ofthemwilldevelopType2diabeteswithin5years.2TheCentersforDiseaseControlandPreventionestimatethatdiabetescoststhenationalabout$245billioneachyearduetomedicalcare,disability,andprematuredeath.3TheBHTACHregionhashigherthanaverageratesofseveralriskfactorsfordiabetesandrelatedchronicconditions,asshowninthetablebelow:Table1:ChronicDiseaseRiskFactors

Chronicdiseaseriskfactors BHT WashingtonPoornutrition 12% 10%Insufficientphysicalactivity 41% 38%Smoking 18% 15%Usee-cigarettes 7% 6%Obesity 30% 27%

Similarly,theBHTregion’srateofhospitalizationsrelatedtoDiabetesishigherthanthestateaverage(1,200per100,00vs.1,096per100,000statewide).AmongACHregions,theBHT

ACHhadthethird-highestage-adjustedrateofdiabetesrelateddeathsin2015(77per100,000,whichissubstantiallyhigherthanthestateaverageof71.6per100,000).4PendOreilleandStevensCountyratesarehigher,andtheAdamsCountyratefor2015wasastaggering203per100,000.5

HowProjectwillsupportsustainablehealthsystemtransformationforthetargetpopulationStrengtheningtheregion’sabilitytopreventandmanagechronicdisease,particularlyDiabeteswillresultinhigherqualitycare,improvedhealthoutcomesandcostsavingsforthetargetpopulation.ByinvestinginthecapacityofproviderstobetteridentifyandmanageDiabetes,weexpecttobeabletoreducelong-termcostsandimprovepopulationhealth.Wewilllaunchoureffortsbyensuringthatprovidersintheprimarycaresettinghaveadequateprocess,toolsandcapacityinplacetosupportidentificationandmanagement.Wewillexpandoureffortstoalsoworkwithbehavioralhealth,EMSandothercommunityproviderstoensureregularlytrackingofkeyhealthindications(A1Clevels,etc.)andensuresupportservicestoensureaccesstohealthyfoodsandregularphysicalactivities.Additionally,weexpecttoleveragetheCommunityHealthWorkersNetworkofEasternWashingtonaswellasourCommunityVoicesCounciltobuildacommunitylevelmovementtoencouragehealthybehaviors.

HowBetterHealthTogetherwillensureprojectcoordinateswithanddoesn’tduplicateexistingeffortsBetterHealthTogetherissupportingthedevelopmentoftwoCommunityHealthTransformationCollaboratives:

1. RuralCollaborative(comprisedofFerry,Stevens,PendOreille,Lincoln,Adamscounties)

2. SpokaneCountyCollaborative

TheBHTACHistakingaregionalapproachtoprojectdesignandimplementationthatwillprovidelocalautonomyandregionalaccountability.TheCollaborativeswillberesponsiblefordevelopingandimplementingactionableMTDplansacrossBHT’sprojectportfolio,andensuringthattheprojectscoordinatewitheachotheranddonotduplicateexistingeffortsintheregion.TheCollaborativeswillbecomprisedofkeypartnerswiththeexpertiseandexperiencerequiredtotransformourMedicaidDeliverySystemincludingclinics,FederallyQualifiedHealthCenters(FQHCs),Hospitals,MentalhealthandSubstanceUseproviders,PublicHealth,TribalHealthsystems,EMS,JailsandCountyCommissioners.Thisrepresentationwillensureeffortsarecoordinatedacrosstheregionandresourcesareleveraged.AnticipatedProjectScopeTargetPopulation.IndividualswithType2diabetesaretheinitialtargetpopulationforthechronicdiseasepreventionandcontrolproject,thisgroupprovidesapromisingfocustobuildsystemstoimproveaccess,care,andoutcomesforallindividualswithchronicdiseaseintheregion.EachCollaborativewilldevelopanintegratedplantoaddressthetargetpopulation

basedondatafromindividualcounties.Weanticipateanadditionalemphasisonindividualswithco-morbidityofbehavioralhealthandDiabetes.Weseeanadditionalopportunityforengagementwithindividualswithbehavioralhealthneedsforthepopulationtargetedinthebi-directionalintegrationMTDproject.Toproceedwiththisdeepenedfocus,wewillanalyzedatatoassesstheoverlapbetweendiabetesanddepressionamongBHT’sMedicaidpopulation.Potentialeffortsmayincludeflaggingindividualsatappointmentstoensurethattheyareassessedandtreatedforunmanageddiabetesandpresentingbehavioralhealthsymptoms.

TheCenterforOutcomesandResearchandEvaluation(CORE)estimatesthatbetween5,800and7,500Medicaid-coveredadultsintheregionhaveDiabetes.Thelow-endestimateisbasedonindividualswith24monthsofcontinuouseligibility,whichisprobablyanundercountgiventhenumberofpeoplewhocycleonandoffMedicaidoveratwo-yearperiod.6TheestimatedprevalencerateofdiabetesamongBHTareaMedicaidbeneficiariesoverallis3%butvariesslightlybetween3%and4%amongBHT’scountiesandamongdifferentraceandethnicitygroups.IndividualswhoidentifytheirpreferredlanguageasRussianhaveaslightlyhigherrateof5%.(Notethatthenumeratorinclusioncriteriaforalloftheseestimatesrequireatleastoneinpatientortwooutpatientclaimswithadiagnosisofdiabetesinthelastyear,sodiabeticswhoarenotincarearenotcaptured.)7

Asnotedearlier,theBHTACHisalsoconsideringasuiteofchronicdiseasepreventionandcontrolactivitiesrelatedtochildhoodasthmaandwillfinalizethisdecisioninconsultationwithpartnersinthecomingmonths.ThreepercentofMedicaidenrolleesundertheageof19haveadiagnosisofasthmainBHT’sregion;thistranslatesintoapproximately2600children.RatesareelevatedinSpokaneandStevenscounties,andamongAmericanIndian/Alaskanativeindividuals.7

Strategies.WhiletheCollaborativeswilladoptstrategiesthatworkbestfortheircommunities,theBHTACHissupportinganumberofkeystrategiestopromotememberhealthandmovetowardasustainable,transformedsystem,including:

• Self-ManagementSupport,includingstrategiesandresourcestoprovidetargetedmemberstheresourcestheyneedtobettermanagetheirhealthandhealthcare.ExamplesoftheseeffortsincludeDiabetesSelf-ManagementEducationandtheStanfordChronicDiseaseManagementProgram.SeveralStanford-modelprogramsexistintheregionnow,supportinghome-basedbloodpressuremonitoring;providemotivationalinterviewing;ensureculturalandlinguisticappropriateness.Inaddition,EmpireHealthFoundationhasamedicationmanagementprogramthatwewillextendtheMTDeffortandinvestment.

• DeliverySystemDesignstrategiessupporteffective,efficientcarebyimplementingandsupportingteam-basedcarestrategies,increasingthepresenceandclinicalroleofnon-physicianmembersonthecareteam,increasingfrequencyandimprovingprocessesofplannedcarevisitsandfollow-up,andestablishingorimprovingreferralprocessestocaremanagementandspecialtycare.WewillutilizePathwaysCommunityHubcarecoordinationmodeltoreduceriskfactorsandsupportincreasedengagement,followup,andreductionofbarriers.

• ClinicalInformationSystemsstrategieswillorganizepatientandpopulationdatatofacilitateefficientandeffectivecare,suchas:utilizationofpatientregistries;automatedappointmentremindersystems;bi-directionaldatasharingandencounteralertsystems;providerperformancereporting.

• Community-basedResourcesandPolicystrategieswillactivatethecommunity,increasecommunity-basedsupportsfordiseasemanagementandprevention,andsupportdevelopmentoflocalcollaborationstoaddressstructuralbarrierstocare.Wewilldevelopdiabetes-specificMOUswithcommunitybasedorganizationstosupportpeopledischargedfromthehospitalfordiabetesrelatedservices,offerpre-diabetesscreeningstoincreasehelpforpeoplewithearlyneed,andconnectMedicaidenrolleestolocalresources.Inadditiontothepreviouslydiscussedfoodbankclasses,wewillconnectwithothereducationbasedservicesandsupportssuchastheEmpireHealthFoundationsponsoredfitnessclassforelders,withagoalofincreasingwellness,fitness,exerciseandeducation.

• HealthInsuranceAccess:In2013,BHTdevelopedtheNavigatorNetwork,alargeandsuccessfulinitiativetoprovideIn-PersonAssisterstoenrollpeopleinAppleHealth(Medicaid)andQualifiedHealthPlansontheWashingtonHealthBenefitExchange.Throughtheseefforts,BHTsuccessfullyenrolledover125,000peopleinhealthinsurance,manyofwhomhavebehavioralhealthdiagnoses,anddevelopedarobustnetworkofpartnersthroughouttheregion.TheBHT/ACHwillworktomaximizeenrollmentcoverageforthecommunity.

InvolvementofPartneringProvidersWelaunchedtheMTDprojectdevelopmentprocessbyrequestingstakeholderssubmitanoptionalletterofinteresttoidentifypotentialpartnersandwheretheyarelocated.WereceivedresponsesfromprovidersineachCountyindicatinginterestinalltheoptionalprojects.WealsouseddatafromHealthSystemInventories(HSI)tounderstandthelevelofneedandresourcesatthelocallevel.Thefollowingprovidersandcommunityorganizationsrespondedtothecallforlettersofinterest(LOI)withanLOIforProjectImplementationorProjectPartnership:

AgingandLong-TermCareofEasternWashington

NortheastTriCountyHealthDistrict

CatholicCharitiesSpokane OdessaMemorialHealthcareCenterCHASHealth OperationHealthyFamilyCommunitiesinSchools OralHealthcareLLCConsistentCareServices,SPC,PS OthelloCommunityHospitalCommunityHealthPlanofWashington PendOreilleHealthCoalitionEastAdamsRuralHealthcare PioneerHumanServicesFerryCountyPublicHospitalDistrict PlannedParenthoodEmpireHealthFoundation ProvidenceHealthCareFrontierBehavioralHealth RuralResourcesCommunityActionGreaterSpokaneCountyMealsonWheels SNAPInlandNorthwestHealthServices SpokaneNeighborhoodActionPartners

KalispelTribeofIndians SpokaneRegionalHealthDistrictLakeRooseveltCommunityHealthCenters VirginiaMathenyLincolnCountyHealthDepartment WashingtonDentalServiceFoundationMeritDisability YMCANationalAllianceonMentalIllness YWCANHHS/PendOreilleHealthCoalition TodeveloptheproposedChronicDiseaseMTDproject,theBHTACHconvenedandmetone-on-onewithhighvolumeandengagedpartneringprovidersthroughouttheregionworkingonchronicdisease.Inaddition,theBHTACHengagedprovidersaHealthSystemsInventory(HSI)andaCareCoordinationInventory(CCI),toidentifyproviderinterestinthechronicMTDprojectareas.Draftinventorieswerefirstreleasedforpublicfeedback,andoncelaunched,wehosted3webinarstooverviewtheInventoryandansweranyquestionsfrompartners.BHTstaffhosted15hoursofOfficeHourssessionswhereproviderscoulddropinandtalkwithACHstaffabouttheirInventoriesorMTD,inadditiontonumerousoutreachmeetingstoindividualproviderorganizations.39organizationsintheBHTACHregion,representingmostmajorhealthandsocialservicesystems,completedtheHealthSystemsInventory(HSI)and/orCareCoordinationInventory(CCI).TheseeffortsdirectlyinformedthedevelopmentoftheproposedChronicDiseaseprojectprioritiesandtheBHTACHproposaltodevelopregionalCollaborativestoimplementMTDprojects. LevelofImpactWeenvisionthatbycollectivelydevelopingsustainableprojectsatthelocallevel,Medicaidrecipientsandotherresidentswillbenefitlong-termwithimprovedhealthoutcomeswhilebendingthecostcurve.Diabetespreventionandcontrolisanexpensiveissuethatpresentsabigopportunityforsavingsandtodemonstratethebenefitofclinical-socialservicesconnections.Diabetesimpactsoverallhealth,andisimpactedbyavarietyofsocialandenvironmentalfactors.Reducingdiabetesincidencewillgreatlyreducehealthcareneedsandcosts.Atthesametimeeffortstoimpactdiabeteswillalsoimpactotherhealthandsocialriskfactors.

Approximately58,000peopleinBHT’sserviceareahavediabetes.8ByfocusingonimprovingaccesstocareandservicesforMedicaidmembers,wecanchangehowclinicalandsocialservicesproviderssupportalldiabeticsintheregion.BHTCollaborativeswillfocusinitiallyonimprovingdiabetesmanagementprocessesasprioritizedbytheMTDperformancemeasures–increasingtheproportionofdiabeticswhoreceiveannualbloodglucosetests,kidneyfunctiontests,andeyeexamsforretinopathy–aswellasonimprovingaccesstoandcoordinationofcare.Thereissubstantialroomtoimproveontheannualeyeexammeasure,wherebothBHTandstatewideperformanceforMedicaidarewellbelownationalbenchmarks.Weestimatethatwewillneedtoensurethatatleast175additionalMedicaidmemberswithdiabetesintheBHTregionreceiveannualeyeexamsinordertomeetdemonstrationperformancetargets.

HowBetterHealthTogetherwillensurethathealthequityisaddressedintheprojectdesignCurrentdatadoesnotsuggestanysignificantracial/ethnic,geographic,orgenderdisparitiesindiabetesprevalenceamongMedicaidbeneficiariesinBHT’sregion.However,disparitiesdoexistindiabetesmanagement.Thetablebelowshows2016performanceonthreediabetescarequalitymeasuresbycounty,race,andethnicity.Yellowshadingindicatesthattheperformanceismorethan1%belowtheBHTregionaverage.BHTwillassistitsCollaborativestoreviewlocaldataanddevelopstrategiesforimprovingequityindiabetesmanagementintheirareas.

Table2:DiabetesQualityofCareMeasuresforMedicaid,20169

HbA1ctestingDiabeticEye

ExamDiabetesKidney

testCounty Adams 87% 47% 90%Ferry 92% 24% 94%Lincoln 84% 37% 88%PendOreille 83% 21% 77%Spokane 82% 28% 87%Stevens 82% 23% 84%

Ethnicity Hispanic 83% 34% 87%NotHispanic 82% 28% 86%Unknown 86% 29% 88%

Race AI/AN 79% 36% 88%Asian 82% 41% 83%Black 71% 31% 89%NH/PI 75% 35% 86%White 83% 27% 86%Multiracial 82% 39% 82%Other 83% 35% 85%Unknown 89% 32% 89%

BHToverall 83% 29% 86%State 84% 30% 86%

BetterHealthTogetherACHisensuringthathealthequityisembeddedintheprojectdesignatmultiplelevels:

• RegionalHealthTransformationCollaboratives:WiththecreationofdistinctSpokane

CountyandRuralCollaboratives,BHTisensuringattentionandfocustoruralhealthissuesanddisparitiesinourregion.Inaddition,wearedesigningtheseCollaborativestoincludeorganizationsthatbringdiverseracialandculturalperspectivestokeyregionalhealthissues.

• CommunityVoicesCouncil:BHTACHislaunchingaCommunityVoicesCouncil,madeupofatleast50%Medicaidbeneficiariesorlow-incomecommunitymembers,toempowerandbringconsumervoicestoinformprojectdesignandimplementation.ThisCouncilwillbetaskedwithdevelopinghealthequitymetricsbywhichtoholdtheCollaborativesandprojectsaccountabletodefinedhealthequitygoalsandstandards.

• Targetpopulations:BHTisfocusingprojectsontargetpopulationsexperiencingthegreatesthealthdisparities.Weareapplyingan“equitylens”toallourworkbydisaggregatingdatabyrace/age/ethnicity/sex/zipcodewhereverpossible,bothtomakeinformeddecisionsabouttargetpopulationsandtomonitorimpactofprojectsacrossdiversegroups.BHTwillsupplyCollaborativeswithregionaldatatoguideearlyassessmentsofCollaborativepartners,andwilldirecttheseteamstoidentifypopulationswithintheircountythatfaceahighlevelofdisparityand/orpresentashighlycomplexorhighrisk.

• Livedexperience:WiththeCommunity-basedCareCoordinationproject,theBHTACHisadvancingthePathwaysmodelanduseofcommunitycarecoordinatorswithlivedexperienceofhealthinequitiestoimprovecare.Carecoordinatorsarecriticaltodevelopingtrustandculturally-appropriatestrategiestomeettheneedsofourtargetpopulationsacrosstheMTDprojectareas.

• EquityAcceleratorPayment:Weanticipateimplementingthisincentivetosupportproviderswhoserveagreaterproportionofhigh-riskclients.ThemetricstiedtothesepaymentswillbedeterminedbytheWaiverFinanceWorkgroup,vettedbyProviderChampionsCouncilandCommunityVoicesCouncil,finalizedbyWaiverFinanceWorkgroup,andrecommendedtotheBHTBoard.

• WewillalsoseektoconnectourchronicdiseaseprojectworktolargersystemicworktoaffectAdverseChildhoodEvents(ACEs).HavingoneormoreACESisassociatedwithhigherincidenceofchronicillnessesincludingobesity,cardiovasculardisease,hypertension,andhighcholesterol.10Ourfocusonapopulationwithdisproportionateimpactofchronicillnessisonewaytohelpdisproportionatelyaffectedpopulations.TheBHTACHalsoseesanopportunitytosupportintergenerationalknowledgetransfer.Asindividualswithdiabetesimprovetheirchronicdiseaseself-managementthrougheducationonhealthyfoodpreparation,theysharethisknowledgeandexperiencewiththeirfamilies.Promotinghealthychoicesthrougheducationandtrustedsourcesofinformationcanimpactmorethanthechronicallyillindividualsthemselves,butcanspreadtotheirfamiliesandcommunities,extendingtheimpactofinterventionsandsupports.

Project’slastingimpactsandbenefittotheregion’soverallMedicaidpopulationOurgoalistofacilitatehealthsystemtransformationthroughtheadoptionofValueBasedPaymentsandgreaterintegrationofcommunitysupportsintoclinicalcare.TheincreaseduseofcommunitycarecoordinatorsandsocialservicesproviderswillimproveaccesstochronicdiseasecareforMedicaidconsumersfacingaccessbarriers.Theprojectsdevelopedbythe

ImplementationApproachandTiming SeeSupplementalWorkbook


Collaborativeswillincreasetheuseofcost-effectiveservicesandimprovehealthoutcomes.ClinicalproviderswillseetheimpactofpartneringwithsocialdeterminantofhealthprovidersandbothtypesofproviderswillreceiveVBPreimbursementthatfurtherpromoteintegrationofcommunitysupports.

ACHResponse

HowBetterHealthTogetherhasincludedpartneringprovidersthatcollectivelyserveasignificantportionoftheMedicaidpopulationIntheSpringof2017,providersandstakeholderswereinformedabouttheopportunitytoimprovepopulationhealthfortheMedicaidpopulation.InterestedorganizationssubmittedanLOIindicatingtheirlevelandtypeofinterest(projectimplementation,projectpartnership)inMTD.ThefollowingprovidersandorganizationsexpressedinterestinChronicDiseaseMTDprojectimplementation(toserveasapartneringproviderandimplementtheproject)and/orpartnership(toserveasasupportivepartner).

Provider/PartneringOrganization LOIforProjectImplementation

LOIforProject

PartnershipAgingandLong-TermCareofEasternWashington

X X

CatholicCharitiesSpokane XCHASHealth X CommunitiesinSchools XConsistentCareServices,SPC,PS X CommunityHealthPlanofWashington XEastAdamsRuralHealthcare X FerryCountyPublicHospitalDistrict X XEmpireHealthFoundation X FrontierBehavioralHealth X GreaterSpokaneCountyMealsonWheels XInlandNorthwestHealthServices X KalispelTribeofIndians X LakeRooseveltCommunityHealthCenters(ColvilleTribeofIndians)

X

LincolnCountyHealthDepartment X

MeritDisability XNationalAllianceonMentalIllness XNHHS/PendOreilleHealthCoalition XNortheastTriCountyHealthDistrict X XOdessaMemorialHealthcareCenter X OperationHealthyFamily X XOralHealthcareLLC X OthelloCommunityHospital X PendOreilleHealthCoalition X PioneerHumanServices X XPlannedParenthood XProvidenceHealthCare X XRuralResourcesCommunityAction X XSNAP XSpokaneNeighborhoodActionPartners X SpokaneRegionalHealthDistrict X XVirginiaMatheny X WashingtonDentalServiceFoundation X XYMCA XYWCA X

Additionally,theBHTACHsurveyedorganizationsintheregiontocompleteaHealthSystemsInventory(HSI)orCareCoordinationInventory(CCI)togatherproviderinformationaboutexistingworkintheregionrelatedtotheChronicDiseaseMTDprojectarea.TheBHTACHreceivedresponsesfrom42organizations,includingmajorhospitalsystems,socialserviceproviders,FQHCs,MCOs,andcarecoordinationagencies.TheBHTACHcomparedtheHSIrespondentswithHCA’sSeptember2017ProviderReportandfoundthattheinventoryresponsesrepresentmorethan80%ofthehighest(top10)volumeMedicaidbillersineachmajorsetting(primarycare,mentalhealth/substanceabuse,inpatientandED.)ForseveralsettingsintheBHTACH’sfiveruralcounties,theHSIrespondentsrepresentalltheMedicaidbillerswithclaimsorbeneficiarycountsofmorethan10in2016.BHTstaffarefollowingupwithnon-representedprovidersthatseealargenumberofMedicaidclients,particularlysubstanceabusedisordertreatmentandTribalhealthproviders.ProcessforensuringpartneringproviderscommittoservingtheMedicaidpopulation.In2018,theBHTACHwillformalizepartneringproviderparticipationinthecommunity-basedcarecoordinationprojectandotherMTDprojectareasthroughaTransformationCompactprocesstoensurecommitmenttoservingtheMedicaidpopulation.BHThasalreadyengagedprovidersintheregionservingasignificantportionoftheMedicaidpopulationandhasconfidenceintheircontinuedcommitment,buttheTransformationCompactwillformalizethatexpectation.

Processforengagingpartneringprovidersthatarecriticaltotheproject’ssuccess,andensuringthatabroadspectrumofcareandrelatedsocialservicesisrepresentedTheBHTACHhasidentifiedthatrepresentationfromthefollowingsectorsisrequiredforCollaborativestosuccessfullyimplementprojects.Eachofthesepartnersrepresentacriticalsettingforprojectimplementation:

• PhysicalHealthClinicalProvider(s)• HospitalSystem(toincludeanEDDoctor• BehavioralHealthClinicalProvider(s)• IndianHealthSystems• PublicHealth• EmergencyMedicalServices(firstresponders)• CriminalJustice• SUDProvider(s)• Community-BasedChronicDiseasePreventionandMitigationOrganization• CommunityBasedCareCoordinatingAgency• MCO(s)• CrisisManagementServices• Liaison:CommunityMember/Consumer

Collaborativepartnershipswillbeexpandedasneeded.InitsroleasthePathwaysHub,theACHwillserveasaconnectorbetweenCollaborativeprovidersandsocialandcommunitypartners.BHTisalsolaunchingaProviderChampionsCounciltolendapracticingproviderperspectivetoourworkandtoinformandvalidateMTDPlanslaidoutbyCollaboratives.HowBetterHealthTogetherisleveragingMCO’sexpertiseinprojectimplementation,andensuringthereisnoduplicationManagedCareOrganizationsareactivelyinvolvedinBHT’sgovernanceandleadershipgroups:

• TwoMCOrepresentatives,fromMolinaHealthCareofWashingtonandCoordinatedCareofWashington,areontheBHTBoard


• TwoMCOrepresentativesareontheBHT’sRegionalIntegrationPlanningTeam,supportingFIMC

MCOswillcontinuetoparticipateinDemonstrationprojectplanningviatheseleadershipgroupsandthroughtargetedcollaborationwithBHT’sHealthTransformationCollaboratives.

Inaddition,BHTACH,PierceCountyACH,andSouthwestACHhavecollaboratedonmeetingswithMCOpartnerstolearnaboutkeycrossoverareasbetweenACHsandMCOsundertheMTD,toensurethatBHT’sprojectstrategy,supportforproviders/Domain1strategies,andmonitoringandqualityimprovementeffortsalignwithexistingMCOactivitiesandgoals.Ourdiscussionscovered:

• Members/populationoverview• PCPassignment/empanelment


• Providersupport,particularlyforvalue-basedpaymentandrelateddeliverysystemreform

• Measurementandqualityimprovement• Memberengagement/education• PathwaysCommunityHub

MCOsemphasizedtheimportanceofconsideringtheneedsandutilizationpatternsofdifferentMedicaidpopulations(e.g.expansionadultsvs.traditionalMedicaid)anddesigningstrategiesthatcanintegrateadditionalgroups(e.g.dualspecialneedsclients)overtimetofullyengageMCOsandotherpartnersandsupportsustainability.Anothercommonpointwastheneedtoavoidoverwhelmingproviderswhoarereceivingassistanceandrequestsforclinicalpracticechangesacrosspayersandpaymentmodels.TheACHandtheCollaborativescanplayakeyroleincoordinatingTAsupportwithMCOs.WealsodiscussedwaystocoordinateondatasharingwithMCOs,HCA,theWashingtonHealthAlliance,OneHealthPortandeventuallytheWashingtonAllPayerClaimsDatabase.

ACHResponse

RegionalAssets,AnticipatedChallengesandProposedSolutionsAssetstheACHandregionalpartnersproviderswillbringtotheprojectTheBHTACHwillutilizeaRuralandSpokaneCountyCollaborativemodeltodevelopandimplementactionablechronicdiseaseplans.TheRuralCollaborative,covering35,173MedicaidlivesintheruralcountiesofAdams,Ferry,Lincoln,PendOreilleandStevens;andtheSpokaneCountyCollaborative,acountywith164,707coveredMedicaidlives.TheseCollaborativesareresponsiblefordevelopingalocalsetofstrategiestomeettheMTDprojectgoals.TheCollaborativestructurewillalignwiththeproposedMTDfundsflowapproachbyallocatingearnedregionalfundstoeachCollaborativebasedonpayforreportingandpayforperformancegoalachievement.Fundsflowstrategiesincludeplansforfixedandearnedpaymentstobothurbanandruralproviderpartnerstocoverexpensessuchasprojectcosts,projectadministration,providerengagementandparticipation,workforcedevelopment,populationhealthmanagement,andothercosts.LocalPartnerAssets.ThereareanumberoflocaleffortsthatwillserveasresourcesandmodelstobuildonforourChronicDiseaseMTDproject.WeexpecttheseorganizationstobeactiveinlocalplanningandimplementationattheCollaborativelevel.YMCAoftheInlandNorthwest(Spokane)andRuralResourcesCommunityAction(PendOreille,StevensandFerryCounties)areoperatingprogramsusingtheStanfordChronicDiseasemodel.INHSisimplementingapilotprojectintwoclinicsimplementPre-DiabetesRiskTestwithPatientsandprovideadirectreferraltoDiabetesPreventionProgram(DPP).TheDPPprogramsareofferedmonthlyandfullwith15-18peopleeachtime.

EmpireHealthFoundationandSpokaneTribeofIndiansisoperatingmultipleChronicDiseaseprojectsintheregion.Theirlongestrunningprogram,inpartnershipwiththeSpokaneTribeHealthandHumanservices,EHFhascreatedtheproprietary“CoachingforActivation”tool(providedthroughthePatientActivationMeasurelicensethroughInsigniaHealth)whichidentifiesdiseasestatesandlevelsofactivationtoindividuallytailorprogramsforSpokaneTribalElders.Thepilotusesin-personhealthcoachingfocusedongoal-settingandactionplanningwhichcanincludechronicdiseasemanagementinadditiontootherpersonalhealthgoalsthattheelderwantstoaccomplish.EmpireHealthFoundationandlocalruralPharmacistsarepilotingasetofMedicationManagementprojectsintendedtoexploreaddingcarecoordinationcapacityvialocalpharmacistinruralsettings.Thepilotpopulationincludespeoplewithco-occurringconditionsincludingdiabetes.SecondHarvestandlocalfoodbanks:Inadditiontoofferinghealthyfoodtolowincomeresidentsintheregion,areaFoodBanksprovideeducation,cookingclassesandresourcesforindividualswithdiabetes.Thisisavaluableresourcethatcanpositivelyimpactthelivesofindividualswithchronicillnessandlimitedresourcestosupportlifestylechangesneededtomanagediabetes.InSpokane,residentscangetwalkedthroughthefoodbanktogetthefoodsthatmeettheirhealthneeds,andreceivecoachingonmealplanningandhealthymealpreparation.Wewillworktoscaleupcommunityeducationactivitiessuchastheavailabilityofcookingclassesanddiabetesfriendlymeals.

SpokaneRegionalHealthDistrict1422:OverthepastthreeyearstheSpokaneregionhasparticipatedinthe1422DepartmentofHealthgrantfromtheCDCtoreduceDiabetes,Stroke,HeartDiseaseandHypertension.ThisworkincludespowerfulpartnershipstobeleveragedinourcollaborativedevelopmentwithWSUSchoolofPharmacy,INHSDiabeteseffortsandtheStatewideDiabetesNetworkhttps://diabetes.doh.wa.gov/.WewillberequiringeachcollaborativetoaligneffortswithstatewiderecommendedpracticesfromthestatewideDiabetesnetworkandencouragingalignmentwitheffortsbeingdevelopedviaINHSDiabetesPreventionandManagementProgram,YMCADiabetesPreventioneffortsandthe211programforDiabetes

DataAssets.SpokaneRegionalHealthDistrictin-kindsupportincludedstafftimetobuildtheCommunityLinkageMap.Ithasalsoofferedadditionalin-kinddataandanalyticssupportforCommunityStrategyMaps.IntheirresponsestotheHealthSystemInventory(HSI),themajorityofpotentialpartnersexpressedwillingnesstosharedataforplanningandevaluation.

Clinical.SixclinicalprovidersincludedintheHSIhaveclinicalproviderchampionswillingtodonatetimeandexpertisetoprojectplanningCollaboratives.Mostpotentialcarecoordinationagenciesindicatedtheywoulddonatestafftimetotrainingnewworkflowsandmodelstomeetrequirements.

In-kind.EmpireHealthFoundationandSpokaneRegionalHealthDistrictprovidesconveningspaceforpartnermeetingsandACHeffortsFormeetingsoutsideofSpokane,ourruralpartnershavedonatedmeetingspaceandcoordinationsupport.Weanticipatecontinuedin-kindsupportfor


meetingspace,recruitmentandvolunteering.Partnershaveexpressedwillingnesstodonatestaffandleadershiptimeandexpertisetosupportstrategydevelopment.ChallengestoimprovingoutcomesandloweringcostsfortargetpopulationandstrategytomitigaterisksandovercomebarriersThechallengesintheBHTACHregioninclude:

• Providershortagesandchallengeofincreasingaccess,utilizationandattachmenttoPCPs.• Servicesshortage,especiallysupportiveservicesinruralcounties• Lifestylebarriers,suchashealthyfoodoptionswhereitisdifficultorexpensivetogetfresh

vegetables• Unsafeneighborhoodswithlackofaccesstosafeplacestoexercise• ConcentrationofresourcesinSpokane,whichmeansSpokanepartnerscouldbe

overwhelmedbyasksfromruralpartners–howtoscaleintoruralareas• HITandHIEcapacityvariesbyorganization

BetterHealthTogether’sStrategyformitigatingtheidentifiedrisksandovercomingbarriersBHTACHisexplicitlyfocusingonlocalneedsandresources.ThisallowsBHTtopromotesolutionsfromthegroundup.Collaborativeswillidentifycommunity-levelsocialdeterminantsofhealthissuesthatareproblematic.Forexample,FerryCountyrequiresatransportationresourcetogetlowincomeresidentstoagrocerystore.Innovativecommunityeffortswillbeneededtotackletheselocalissues.WewillsupportCollaborativeeffortstoexpandculturallycompetentcare,suchastargetingdiabetesandwellnessprogramsfortheAmericanIndian/AlaskaNativepopulationstoaddressrelevantculturalmotivatorsandneeds.Communitycarecoordinatorsarealargepartofthisstrategy,becausehavingapersonwithasharedlivedexperiencewillengageandmotivatewithindividualstoovercomebarriers.Wewillprioritizebestfitcarecoordinatorstoensureculturallycompetentcare.

ACHResponse

ThegoalofBHTACH’smonitoringplanistousetimelydatatosupportprojectimplementation,peerlearning,andcontinuousimprovement.BHTACHwillworkwithitscontracteddatavendor,ProvidenceCenterforOutcomesResearch&Education(CORE),todesignandimplementamonitoringsystemthatwilltrackoperational,process,andoutcomemeasuresforeachprojectandCollaborative(seebelow)andfortheACHoverall.Thesystemwillbedesignedtocomplementexistingdataassets(suchastheHealthierWashingtonDataDashboards,anyFullyIntegratedManagedCareearlywarningsystem,andrelevantregionalreports)andwillrefreshanytimeaparticulardatafeedisupdated.Designwilltakeplacealongsideimplementationplandevelopmentinlate2017andearly2018,sothatthesystemisreadyasprojectsmoveintoimplementation.AvisualoverviewofBHTACH’splannedapproachtomonitoringandcontinuousimprovementisshownbelow.

MonitoringmetricswillincludeACHtoolkitpay-for-reportingandpay-for-performancemetrics,aswellasregionalaccountabilityandqualityimprovementplanmetricsthatspeaktotheeffectivenessofBHTACH’sstrategieswithinandacrossprojectareas.Fortheimplementationphase,manymetricswillbeprocessoroperationalinfocus(e.g.establishmentofcross-settingdatasharingagreementsamongCollaborativepartners.)Finalmetricswillbeidentifiedintheimplementationplan.FortheBi-DirectionalIntegrationProject,theBHTACHwillbetracking,ataminimum,informationonthefollowingaccountabilitymeasures:

• Anti-depressionmedicationmanagement• ChildandAdolescents’AccesstoPrimaryCarePractitioners• ComprehensiveDiabetesCare:HbA1cTesting• ComprehensiveDiabetesCare:Medicalattentionfornephropathy• ComprehensiveDiabetesCare:EyeExam(retinal)performed• MedicationManagementforPeoplewithAsthma(5–64Years)• MentalHealthTreatmentPenetration(broad)• PlanAll-CauseReadmissionRate(30Days)• SubstanceUseDisorderTreatmentPenetration• Follow-upAfterHospitalizationforMentalIllness• Follow-upAfterDischargefromEDforMentalHealth• Follow-upAfterDischargefromEDforAlcoholorOtherDrugDependence• InpatientHospitalUtilization• OutpatientEmergencyDepartmentVisitsper1000MemberMonths

Planformonitoringprojectimplementationprogress,includingaddressingdelaysinimplementationAsshowninthediagram,thesystemwillincorporateprocessmeasuresforprojectimplementation.Thoseprocessmeasureswillbeassociatedwithtimeframesandbenchmarks

identifiedbytheACHandtheCollaborativestoprovideimmediatefeedbackwhendelaysoccur.TheBHTACHwillworkwithCOREtodevelopacommunitydashboardtomonitorkeymetricsidentifiedinthetoolkitandourcommunitypriorities.Thiswillbeamulti-functionaldashboardextendingbeyondtheMTDtoallowongoingcommunitytrackingandprioritization.ResponsibilityforaddressingdelaysinimplementationwillliewiththeCollaboratives,BHTgovernancebodies,andselectBHTstaffpositionsasdescribedunder‘Planformonitoringcontinuousimprovement’below.Planformonitoringcontinuousimprovement,supportingpartneringprovidersanddeterminingwhetherornotBHTisontracktomeetexpectedoutcomesAmonitoringandcontinuousimprovementsystemismorethanjustdata;it’saboutthepeople,processes,andtoolsusedtoturnthatdataintoactionableinformationthatsupportssharedlearningandqualityimprovement.Inadditiontocreatingasystemtoaccessandanalyzedatafromdifferentsources,theBHTACHwillrelyonthefollowinggroupsandpositionstointerpretthedata,identifyperformanceshortcomingsorrisks,anddevelopsolutions:

• CommunityHealthTransformationCollaboratives.Asdescribedelsewhere,BHTislaunchingaSpokaneCountyCollaborativeandaRuralCollaborativetodevelopandimplementspecificregionalplansforhealthsystemtransformationinthefourprojectareasBHThasselected.TheCollaboratives’rolewillextendto:advisingondesignoftheself-monitoringsystem;regularlyreviewingthedatathatsystemprovides;collaboratingwiththeACHtomakecoursecorrectionsasneeded;andparticipatinginsharedlearningopportunitieswithinandacrossCollaborativesandACHregions.



• JennySlagle,AssociateDirectorforHealthSystemTransformationwillserveasthePathwaysHUBDirectoroverseeingalloperationsofthehubincludingtraining,qualityassuranceandimprovementandstrategicdirection.JennywillstaffthePathwaysCommunityCouncilthatwilllaunchin2018.Thispositionwillcloselymonitorthedata



YES NOX





availablefromtheHUBplatformandintervenewhenPathwaysareslowtocompleteorhaveencounteredroadblocks.


• TheBHTBoardwillreceivemonthlydashboardsonkeymilestonesandsuggestedplanstoaddressanyrisks


PlanforaddressingstrategiesthatarenotworkingornotachievingoutcomesIncombination,thepeopleandworkgroupsdescribedaboveandtimelydatafromthemonitoringsystemwillenabletheBHTACHtoidentifystrategiesthatarenotworkingandtothinkthroughsolutionsintimetoachieveprojectoutcomes.Ifnecessary,potentialadjustmentstoimplementationtimelineswillbetriagedthroughthemonitoringsystemtoassesstheirimpactondownstreamgoals.Iftimelinesstillcannotbemet,BHTwillinformthestateaboutthereasonsanditsplanforadaptingthetimeline,andpreventing/riskmitigationstrategieswillbesharedtootherprogramswhereappropriate.

YES NOX


(

1WashingtonDOH,see:https://www.doh.wa.gov/DataandStatisticalReports/HealthStatistics/Death/DeathTablesbyTopic2WashingtonStateDiabetesEpidemicandActionReport,2017.See:https://www.doh.wa.gov/Portals/1/Documents/Pubs/345-349-DiabetesEpidemicActionReport.pdf3CentersforDiseaseControlandPrevention.NationalDiabetesStatisticsReport:EstimatesofDiabetesandItsBurden

ACHResponse

BetterHealthTogether’sstrategyforlong-termprojectsustainabilityBHTACHisworkingtointegratehealthsystemandcommunityapproachestoimprovechronicdiseasemanagementandcontrol.WorkingwiththeCollaborativestodevelopprojectsthatsupporttransformativechange,wearebuildingamodelthatmatchesfundingtothechangesincaredelivery.Wewillalignmissionandbusinessbysupportinglong-termsustainablefundingforservicesandactivitiesthatimproveandsupporthealth.WeconsideredregionalhealthneedsandcommunitymomentuminselectingchronicdiseasepreventionandcontrolasanMTDProject.

WearedevelopingourCollaborativeswithafocusonmovingtheregiontoValueBasedPurchasingandwholepersoncare.VBPisthecornerstoneofoursustainabilityplan,recognizingtheneedtotransitionhowwepayforcareandlinkingsocialdeterminantofhealthservices.Weareworkingtoaligndata,fundsflow,andmodeldevelopmenttomaximizetheopportunitytointegrateselectedprojectsintoavaluebasedmodelandweavetogetherlocalresourcesandinvestmenttoreachthisgoal.Forinstance,itisexpectedthattheBoard’sfundsflowpolicywillincludedirectedinvestmentsforstartupcosts,infrastructureandtechnicalassistanceemphasizingDSRIPfundingfortransition,notanongoingpaymentstream.Project’simpactonWashington’shealthsystemtransformationbeyondtheDemonstrationperiodTheBHTACHissupportingbroad-reaching,system-widetransformationinordertohavelastingimpactsandbenefittheregion’soverallpopulation,regardlessofchosentargetpopulation(s)orselectedapproaches/strategies.ChanginghowservicesaredeliveredforpopulationssuchasindividualswithType2diabeteswillpromotepaymenttiedtohealthoutcomesandkeepingpopulationshealthieroverall.Thecombinationofimprovingcareforparticipantsandincreasingculturallyresponsiveaccessthatbringspeopletoneededserviceswillimpactcosts.Reducedclinicalcoststiedtoreimbursementforoutcomeswillbeamodelthatcanbereplicatedintheregionandstatewithoutregardtopayer.Provideracceptanceofnewpaymentmodelscanbecapitalizedtoexpandtothecommercialindividualandsmallgroupmarkets.

intheUnitedStates,2014.Atlanta,GA:USDepartmentofHealthandHumanServices;2014.Availablefrom:http://www.cdc.gov/diabetes/data/statistics/2014StatisticsReport.html.4WashingtonTrackingNetwork,see:https://www.doh.wa.gov/DataandStatisticalReports/EnvironmentalHealth/WashingtonTrackingNetworkWTN.Allratesincludebothmenandwomenandareage-adjusted.5Samesourceasabove.SmallnumbersinAdamsCountymeanthattheconfidenceintervalaroundthisestimateiswide,butthelowerboundofthe95%CIisstill132diabetes-relateddeathsper100,000.6VaryingestimatesbasedonHCABehavioralHealthandChronicConditionsfiles9-29-17(https://wahca.app.box.com/s/mxpg8euzbjpdkmyuftzb4ri5v41ia8v9/folder/39866406519)andHealthierWashingtonDataDashboard,whichusedifferentcontinuousenrollmentcriteria.

7HealthierWashingtonDataDashboard,CY2016data.See:https://www.hca.wa.gov/about-hca/healthier-washington/data-dashboard

8Estimatecalculatedbyapplying10%self-reportedprevalenceratefromWADept.ofHealthACHChronicDiseaseProfilesto2016regionalpopulationestimatesfromWAOfficeofFinancialManagement.

9Source:HealthierWashingtonDataDashboard,CY2016data.See:https://www.hca.wa.gov/about-hca/healthier-washington/data-dashboard

107.FelittiV,etal.(1998).Relationshipofchildhoodabuseandhouseholddysfunctiontomanyoftheleadingcausesofdeathinadults.TheAdverseChildhoodExperiences(ACE)Study.AmJPrevMed.14(4):245–258

Theory of Action

Statewide Drivers of Systems Transformation

Strengthen the Foundationalign energy and investment around regional strategies needed to support Whole Person Care, and success in Value Based care.

Improve Population Health transformation activities build community infrastructure and scale best practice to support responsive, sustainable, systems improvement.

OUR VISION:An integrated community health system, accountable to improving health through delivering culturally competent, whole person care to all community members

• Healthier Washington Initiative

• Shift to 90% Value Based Contracts by 2021

• Shift to Integrated Managed Care by 2020

• Upcoming changes to Medicare via MACRA/MIPS

• Align with regional and statewide workforce development activities to increase capacity of the region’s health workforce

• Effectively link health care transformation efforts with community services to support whole person care

• Integrate behavioral health and physical health payments through Integrated Managed Care

• Link and leverage data to monitor improvement and guide activities with a focus on health equity

• Retain less than a 5% uninsured rate, to ensure access to Whole Person Care

• Develop a Community Dashboard to monitor key population health priorities regionally across multiple payers, providers and measurements.

• Align ACO efforts throughout the region to leverage investment in Medicaid Transformation efforts and MACRA/MIPS reporting

• Align regional funders around a Community Resiliency Fund to address social determinants

• Reinvest shared savings with a focus on upstream prevention

• Connect siloed services into a continuum of care with “no wrong door” for patients

• Boost culturally competent and trauma informed care practices

DESIRED REGIONAL IMPROVEMENTS þ 90% of Medicaid contracts are Value Based in 2021

þ Implement regional plan to be ready for Integrated Managed Care by 2019

þ Reduce Medicaid emergency department utilization by 6%

þ Reduce hospital readmission rates for Medicaid by 2%

þ Increase % of Medicaid residents who have their mental health treatment needs met by 10%

þ Increase % of Medicaid residents who have substance use disorder needs met by 10%

þ Train 25 Care Coordinators to the Pathways Hub model by December 2019

þ Reduce # preventable hospital admissions for diabetes and asthma by 10%

þ Increase % effective contraceptive use among Medicaid women by 50%

þ Increase health workforce to meet health care demands

þ Decrease jail recidivism by 20%

þ All children in foster care will have at least one annual primary care visit

þ 10% of Medicaid children receive fluoride varnish in a primary care setting

þ Develop data sharing agreements amongst 90% of Collaborative members

PROJECT IMPACT POPULATIONSBi-Directional Integration of Behavioral and Physical Health

• Medicaid patients with both a Behavioral Health issue and chronic disease

Community Based Care Coordination

• People transitioning of jail• Pregnant women on Medicaid• Foster youth & youth exiting or aging out of foster care

Opioid Responses • Medicaid beneficiaries who use, misuse, or abuse prescription opioids and/or heroin

Chronic Disease Management • Medicaid adults with diabetes• Medicaid children with asthma • Medicaid beneficiaries with chronic

behavioral health issues

COLLABORATIVE ACTIVITIES: • Build and scale linkages between physical, oral,

behavioral, and social determinant of health providers

• Prepare providers for value based payments

• Support population health management through proactive use of data to track progress and identify areas for improvement among partners

• Implement Care Coordination strategies to help complex patients overcome risks

• Align disparate community strategies into community based plans to improve population health outcomes around regional priorities

Medicaid Transformation ProjectsDemonstrate the Value of Whole Person Care

Transformation Project Plan Governance

Comprised of Health System and Social Determinant partners serving as the activation network for Transformation Projects

SPOKANE COLLABORATIVERURAL COLLABORATIVE

Ferry | Stevens | Pend Oreille | Lincoln | Adams

Provider Champions

Council

Community Voices

Council

Waiver Finance

Workgroup

Regional Integration

TeamLEADERSHIP COUNCIL

Technical Councils

Each Technical council is co-chaired by a Board and Leadership Council memberReceives feedback from Collaboratives on proposed policy

COMMUNITY HEALTH TRANSFORMATION COLLABORATIVES

Tribal Partner

Leadership Council

BHT BOARDFinal decision maker for Medicaid Transformation Projects

Receives policy recommendations from Leadership Council and Technical Councils

BetterHealthTogether(BHT)MeaningfulConsumerEngagementSummaryReportASummaryofConsumerInputUsedtoInformMedicaidTransformationDemonstration(MTD)ProjectSelectionandPlanning,andtoDesignBHT’sLong-termMeaningfulConsumerEngagementPolicyandStrategy

OverviewTheBHTMeaningfulConsumerEngagementplanningprocessinvolvedseveraltiersofactivitydesignedtosecureinputintotheselectionandplanningofMTDprojectsandtoyieldarecommendedpolicyandstrategyfortheBHTBoardtoconsideradoptingforongoingmeaningfulengagementofconsumersinfutureAccountableCommunityofHealth(ACH)andMTDactivities.Thisreportdetailsfindingsfromthefirstphaseofactivity:consumerfocusgroups.

Methodology:ConsumerFocusGroups

Intotal,40consumersparticipatedinfocusgroupdiscussionstoinformtheselectionandplanningofMTDprojectsfortheBHTregionandtoprovideopinionsandideasforestablishingalong-termmeaningfulconsumerengagementstrategyfortheactivitiesoftheACH.Thefollowinggroupswerecoordinatedinpartnershipwithavarietyofcommunityhostorganizations:

• YouthinFosterCareand/orRecentlyAgedOutoftheFosterSystem(inpartnershipwithEmbraceWashington,CareerPathServices,andSafetyNet)

• TribalMembersandUrbanIndianCommunityCenterVisitors(inpartnershipwiththeAmericanIndianCommunityCenterandEmpireHealthFoundation)

• RuralResidentsthroughoutNorthEastWashington(inpartnershipwithRuralResources)• RuralResidentsthroughoutLincolnCounty(inpartnershipwithLincolnCountyHealth

Department)• UrbanResidentsthroughoutSpokaneCounty(inpartnershipwithCommunityHealth

AssociationofSpokane/CHAS)

Namesoffocusgroupparticipantsareheldconfidential,buthostorganizationsverifiedattendanceandgroupcompositionhasbeenvalidatedfordiversitytorepresentthefollowingcharacteristicsofattendees:

• Geography(rural,urban,tribal)• Raceandethnicity• Gender• Age• Healthconditions• Socialdeterminantneeds

ConsumerInputRegardingMedicaidTransformationDemonstration

ConsumersDefine“GoodHealth”Inanefforttolearnbaselinehealthknowledgeandself-determinedhealthpriorities,attendeeswereaskedtheopen-endedquestions,“whatdoesgoodhealthmeantoyou/howdoyoudefinegoodhealth?”Thefollowingthemesemerged:• PERSONALHEALTHBEHAVIORSANDCAPACITIES:

o Allfocusgroupsidentifiedhealthydietandexerciseaskeycontributor/indicatorofhealth.

o Allgroupstouchedonhealthyrelationships(family,friends,marriages)asimportantpredictorsofhealth,andmanyparticipantsreferencedlifepurposeand/orspiritualityaskeydriversofwellbeing.

o Manyparticipantsreferencedtheabilitytodowhatyouwant/needtodoinlifeandtotakecareofyourfamily’sneeds.

o Mostreferencedadvocatingforyourhealth(askingquestions,researching,learninghowtonavigatehealthcare).

o Afewdiscussedprevention(startingtocareforyourhealthyoung,notwaitinguntilyouaresick)andafewindicatedthat“notneedingtogotothedoctortoomuch”isamarkerofgoodhealth.

o Afewindicatedthatfreedomfromdiseaseorchronichealthconditionsisafactorofhealth.

• BASICNEEDSANDSOCIALDETERMINANTS

o Allfocusgroupsidentifiedaccesstosafe,affordable,healthyhousingasacriticalfactorforhealth,andanumberdiscussedhomelessnessspecificallyasadeterrenttohealth.

o Allgroupsdiscussedfoodsecurityandhealthyfoodasakeyfactor,withthemostprominentobservationsummarizedbyoneparticipantas,“youcan’tbehealthywithouthealthyfood,butyoucan’taffordtobuyhealthyfoodandeventhefoodbanksprovidesomeofthemostunhealthyfoodaroundlikeunhealthycarbsandemptycalories.”

o Transportationwascitedasakeyfactorcontributingtohealth,particularlyamongrural,tribal,andfostersystemparticipants,notingthatyoucan’taccesshealthyfood,medicalappointments,orsafelygetaroundwithoutgoodtransportationanditisakeyfactorinreducedhealth.

o Rural,tribal,andfostersystemparticipantsalldiscussedtheneedforsufficientfinancialresourcestomeetyourbasicneedsandtoaccesshealthyfoodsandhealthservices.

• ACCESSTOAPPROPRIATEHEALTHCAREo Allgroupsnotedthataccesstohealthcarewasimportant,particularlyciting“regular

checkups,immunizations,andpreventivecarelikemammograms,”asimportanttohealth.

o Allgroupsreferencedaccesstonecessaryprescriptionmedications,particularlyforchronicconditions(suchasdiabetes),andthedifficultygettingtherightmedicationsintherightamountsattherighttimeasachallenge.PrescriptionswereheavilydiscussedintheTribalgroup.

o Severalgroupshadrobustdiscussionsaboutknowinghow/when/wheretogetappropriatecare,andknowinghowtouseyourcoverage(indicatingthatitrequireslotsoftime,work,andself-advocacytoutilizeMedicaidbenefits).

o Allgroupsnotedthatoralhealthwasimportant,thoughtheyfocusedmoreonaccesstodentaltreatment,restoration,andthechallengeinfindingproviderswhowouldtakeMedicaidandaffordingservicesthatMedicaidwon’tpayfor(dentures,crowns)asasignificantbarriertohealth.

• BEHAVIORALHEALTHANDSUBSTANCEUSE,STRESS,EMOTIONALWELLBEING

o Behavioralhealthwasadominanttopicofconversationineverygroup,withparticipantssuggestingthat:

• Peopledon’ttalkaboutitenoughand/orthereisstigmaregardingmentalhealthandaddiction.

• Thereareinsufficientresourcestomeettheneeds(insurancecoverageforvariousservices,lackoftrustedserviceprovidersparticularlyinruralandtribalareas.

• Familytraumaandhistoricaltraumacreatesignificanthealthchallengesparticularlyforyouthinfostercare/agingoutandamongTribalpopulations.

o Accesstosubstanceabusetreatmentiswhollyinadequateacrosstheboard(lackofimmediateaccess,lackofcoverage,lackofculturally-appropriateoptions).

• Theopioidepidemichashadaprofoundandpersonalimpactonmostattendees(eitherpersonallyorfamilyandfriends).

• Theresponsetothisepidemiciscausingstigmainruralcommunities(e.g.,communitymembersfeelingjudgedandlabeledasdrugseekerswhentheyhavedocumentedissues).

• Thelackofproviderchoice,treatmentdelays,andcoverageissuesmakesuccessfultreatmentdifficult.

• SIMILARITIESANDDIFFERENCESAMONGGROUPS:

o RuralresidentsandTribalpopulationsfocusedfarmorethantheirurbancounterpartson:§ Basicneedsandsocialdeterminantsissues(housing,transportation,foodsecurity,

healthyfoodaccess).§ Lackofhealthcareproviderchoice,theimportanceof(andlackof)trustedhealth

carerelationships,andtheneedformoreaccesstoimmediate,tailored(culturally,individually)behavioralhealthandsubstanceabusetreatment.

o YouthinFosterCare/AgingOutandTribalpopulationsfocusedonbehavioralhealthchallenges,addiction,andotherissuesrelatedtofamilyandhistoricaltrauma.

o Ruralresidentsfocusedmoreheavilyonutilizingtrustedrelationships(family,friends,neighbors)tohelpanswerhealthquestions,connectoneanothertocommunitysupports.

o Urbanresidentsfocusedmoreheavilyonself-advocacytoaskprovidersquestions,seekoutcoverageandcareoptionsthroughtheirMCOs,andresearchhealthandhealthcareoptionsthroughvariousresourcesonline.

o Allfocusgroupsdemonstratedanimmediateandrobusttendencytocollectivelyproblem-solvehealthorhealthcarechallenges,andtoshareresourceswithandcoachoneanotherwhenamembernotedahealthorhealthcareproblem(e.g.,problemsgettingaccesstodentalcare,challengeswithprescriptionmedicationsandcoverages,difficultywithbehavioralhealthoraddictiontreatmentaccess).

ConsumersExploreHealthCare,HealthCareChallenges,andHealthCareSystemIdeasOnceparticipantsweregroundedintheiropen-endedthoughtsonhealthandhealth-care,theywereaskedthefollowingopen-endedquestions:

• “WhatdoesgoodhealthCAREmeantoyou?”• “Whatgetsinthewayofgettingthehealthcareyouneed?”• “Whathealthorhealthcareaccesssupportsdoyouwishyouhadforyouoryourfamily?”• “Ifyouhadamagicwandtomakeanychangeyouwantedinthehealthcaresystem,what

wouldyouchangetomakehealthcareeasiertogetandhealtheasiertokeep?”Theseconversationsyieldedthefollowingthemes:

• PRESCRIPTIONACCESS:

o Participantscitedchallengesgettingprescriptionmedicationsneededforchronicconditions(diabetes,Parkinson’s),withdelays,multipletripstothepharmacy,uncovereditems,havingtogetprescriptionsfrompharmaciesoutsideoftheirneighborhoodsbecauseofinsurancecoverage,andgoingdayswithoutneededprescriptionsduetoMCOapprovalprocesses.Manyparticipantssharedsomeversionofthiscomment,“Itissohardtogetapprovalfortherightmedications,evenifyouhavesomethinglikediabetes.”

o Theirprimaryconcernsdealtwiththeapprovalprocess,changesinformularies,andcostofmedicationsandsupplies(e.g.,syringes,diabetestestingsupplies).Oneparticipantsharedthatfamilymembersandfriendssoughtout“donations”ofprescriptionsandsuppliesforherfromothercommunitymembersorgavehermedicationsandsuppliesleftwhenanotherindividualpassedaway,astheyknewshedidn’thaveaccesstowhatsheneededonaregularbasis.

• DENTALHEALTHACCESS:

o Dentalhealthwasraisedinallfocusgroups,withconcernsregardingfindingdentistswhotakeMedicaid,gettingcareforuncovereddentalneeds(dentures,oralsurgery,crowns),andtheneedforruralresidentstodrivetourbancenterstofindproviderswhowilltakeMedicaid.

o Participantsnotedthattheywere“waitingforteethtofallout”or“walkingaroundinconstantpain”becauseoforalhealthissues.

o Attendeesfrequentlystated,“I’vecalleddentistafterdentisttryingtofindsomeonewhowouldseeme.”

o Onlyonegroupfocusedaverybriefdiscussiononpreventivedentalhealthororalhygiene,yetallgroupsfocusedprimarilyontheneedfor/lackofaccesstotreatmentforseveredentalissuesresultingfromlackofappropriatepreventivecare.

• VISIONCARE:

o Visioncare,particularlyglasses,werediscussedateveryfocusgroup.Participantsexpressedfrustrationwithdifficultyaccessingadequatecareandhardware,andrelayedthattheyexperiencedchallengeswithwhattheyperceivedwerevisioncoveragechanges.

o Numerousattendeesindicatedtheyhadonlybeenabletosecureglassesbecausecharitableorclinicspecialprogramshelpedthemdoso.

• TIMELY,TAILORED,ANDAPPROPRIATEBEHAVIORALHEALTHANDADDICTIONTREATMENT

o Behavioralhealthneedswerediscussedacrossallgroups,focusingonarangeofbehavioralhealthissues,includingstress,depression,anxiety,maritalandparentingissues,trauma,mentalillness,andsubstanceabuse.

o Destigmatizingbehavioralhealthdiagnoseswasreferencedrepeatedly,withparticipantsshowingaclearawarenessthat“mentalhealthisasimportantasphysicalhealth,butnoonereallytalksaboutitandnoonereallytreatsit.”Fearofrepercussionscanalsokeeppeoplefromseekinghelp,asexpressedbyoneindividualwhostated,“Ihadpostpartumdepressionbutdidn’tgogethelpbecauseIwasafraidCPSwouldtakemybabyaway.”

o Lackofbehavioralhealthproviders,lackofintegrationbetweenprimarycareandbehavioralhealth,andlackofappropriatecoverageforbehavioralhealthservicesorneedswererepeatedlycitedthroughoutallgroups.

o Addictionandsubstanceabusetreatmentwasdiscussedatlengthinallgroups,withahighpercentageofindividualsself-disclosingaddictionsthemselvesoramonglovedones.Oneofthemostsignificantconcernsinallgroupswasthelackoftimelyandcomprehensiveaccesstosubstanceabusetreatment,withcommentssuchas:

§ “Stateinsurancepaysforyoutotakeallthedrugsbutwon’tpaytohelpyougetoffofthem.”

§ “Gettingthedrugsiseasy.Gettinghelptogetoffofthemisn’t.”§ “Ifsomeoneisreadyfortreatmentthereshouldbeanoptionfortreatment

becauseiftheydon’tgonowtheywon’tgoin2monthswhenthereisanopening.”

§ “Treatmentneedstobelongerandinvolvemoresupportsandcounseling”o Ruralresidentsindicatedtheyfeltstigmatized,judged,orlabeledasdrugseekersin

theircommunitieseventhoughtheyhavegenuinechronicconditionsthatrequireoptionsforpaincontrol,andthattheyfeeltheyhavenorealoptionsforhelpwithchronicpain.

• ACALLFORTRUEWHOLE-PERSONCARE

o Allgroupsindicatedtheneedfortruewhole-personcarethatfocusesonphysical,mental,dental,vision,prescription,andsocialsupports(housing,transportation,food,carecoordination)thathelppeoplegetandstayhealthy.Onegroupsummeditupwiththefollowingstatement,“Makethemedicalhomeareality.”

o Severalgroupsfocusedoncomplementary,alternative,andothermedicaltreatments(nutritionists,massage,acupuncture,chiropractic)thatwouldhelpthemstayhealthyfromapreventivestandpointand/orinlieuofmedications,yettheseservicesareeithernotcoveredornotavailableincertainareas(e.g.,rural).Oneparticipantsummedthisupstating,“giveusotheroptionsthanjusttheprescriptionortheknife.”

• COVERAGECHALLENGES:

o Manyattendeesexpressedchallengesunderstandingtheircoverageandhowandwheretoaccesscare.Oneparticipantnoted,“whyaretheresomanyinsurancecompaniesandwhyismycoveragechangingallthetime?AlloftheinsurancecompanieshavedifferentwaysofdoingthingsanditmakesithardtogetthecareIneed.”

o Ruralparticipantsexpressedfrustrationtryingtoaccessthecaretheyneedacrosscountylines,wheredifferentMCOsmighthavedifferentproviderpanels.MorethanoneindividualindicatedhavingtoenrollinadifferentMCOtoaccessneededcareforachronicissueortoseektreatmentinadifferentcounty,andthenre-enrolledinthepreviousMCOwhentheyreturnedtoresideintheirowncounty.

o RuralparticipantsexpressedfrustrationwithMCOs“whodon’tunderstandwhatit’slikeintheruralcounties…theydon’tknowwhatwehaveordon’thavehere,orwhatit’sliketotrytogetcarehere.They’rejustreadingfromascript.”

o Respondentsfrommostfocusgroupsindicatedthattheyregularlyhaveto“jumpthroughsomanyhoops”toworkwiththeirinsurancecompaniesandgetthecaretheyneed,andthattheyspend“hoursonthephone”tryingtogetanswers,referrals,coverageinformation,authorizations,andprovidernames.Oneruralparticipantnoted,“bythetimeyougettheauthorizationyouaremuchmoresickthanyouwouldhavebeenifyoucouldhavejustgoneinwhenthedoctorsuggestedthetreatment.”

o Thereweredividedresponsesamongfocusgroupparticipantsregardingwhethertheyfelttheyreceivedgoodcareand/orlessercarebecausetheywereonAppleHealth:

§ Participantsconnectedtolargerhealthsystemprovidersreportedeasieraccessandbettersatisfaction(intheirwords“betterqualitycare”)thanthoseinwithsmallersystemsorseeingindividualproviders.

§ Participantsseekingphysicalhealthcareservicesreportedeasieraccessandbettersatisfaction(again,intheirwords,“betterqualitycare”)thanthoseseekingdentalormentalhealthservices,withoneattendeenoting,“sometypesofprovidersthatacceptAppleHealtharen’tasgood…itseemsliketheyarelowerendprovidersorsomeonewhoisjustlearning.”

§ Participantsinruralareasreportedaperceptionofmorestigma,judgement,ordisrespecttowardthosecoveredbyMedicaid.

• LACKOFPROVIDERS/IMPORTANCEOFTRUSTINGRELATIONSHIPSWITHPROVIDERS

o Tribalparticipantsnotedlackofculturally-sensitivetreatmentoptionsasabarriertogoodcare,particularlyregardingbehavioralhealthandaddiction/recoveryneedsforadults,butalsonotingthattheyneedmoretrustedproviderswhotreatthemholisticallyandinculturally-appropriate,community-andfamily-centeredways.

o Ruralresidentsindicatedlackofproviderswasasignificantbarriertogoodhealthcareforthem,citinglackoflocalaccesstoproviderssuchaspediatrics,obstetrics,cardiac,behavioralhealth,anddentalproviders.

o Participantsoftencitedtheneedtoestablishtrustingrelationshipswithprovidersinordertohavegoodhealthandhealthcareexperiences.Thisisparticularlydifficultinruralcommunities,withwhattheydescribedasan“exodos”ofprovidersandan“ongoingchallengeto”drawspecialists,behavioralhealth,andevenprimarycareproviderstoruralcommunities.Oneparticipantnoted,“whenyouonlyhaveoneoptionforcounselinginyourtownandyoudon’ttrustthem,youronlyoptionistonotgetthecareyouneed.”Ruralresidentsrepeatedlyreporteddriving60to100milestoseeadifferentproviderthattheytrusted.

o Attendeesindicatedtheyprefertohaveahealthcareteamthatknowsthem,suchasthesamenurseormedicalassistantwhotalkstothemeverytime,andthesameproviderwhoknowstheirhistory.Onepersonstated,“itmakesmefeellikeamemberofmyownhealthcareteam.”Mostgroupsnotedthatthisisoftennotthecase,though,withstaffturnoverandchangesinhealthcaredeliverymodels.

• DELAYSINACCESSTOCARE/INABILITYTOBETREATEDFORMORETHANONEISSUEo Participantsacrossallfocusgroupsindicatedchallengesduetodelayedaccesstocare,

evenwhenprimarycarerelationshipsexist.Oneattendeeshared,“EventhoughIhaveaprimarycareproviderIlikeandwhoisreallygood,itcantakemonthstogetintoseethem.”

o Attendeesinallgroupsexpressedfrustrationatbeingtreatedforonlyoneissueatavisit,necessitatingadditionalvisitsforotherconditionsorconcerns.Thisbecomesatremendousburdenfortime,finances,childcare,transportation,andhealthissueexacerbation.Oneparticipantnoted,“whenIgoinformyarm,theycan’tseemeforsomethingelseandthenit’sanothermonthbeforetheycanseemeagainandwehavetopayfor2visitsinsteadofone.”Anothernoted,“it’sallrelated,it’sallinthesamebodybuttheyareonlyallowedtotreatonebodypartorissueatatimebecauseoftimeandmoney.”

o Groupsnotedthatgettingreferralstoandappointmentswithspecialistsisexceptionallychallenging.Oneparticipantnoted,“Ittookme7weekstogetintoseesomeoneformyneck,andthatwasaftermydoctorknewthatsomethingwasdefinitelywrong.”

o Participantsindicatedfrustrationwiththelimitedamountoftimetheyseeproviders,andthat“administrationmakesthemseeacertainnumberofpeopleperdaysotheycan’treallyfocusonmeandwhatIneed.”

• TRANSPORTATIONCHALLENGES:

o Ruralparticipantsreportedtransportationchallengesasahugeissuetoaccessingcare,includingdistancetravelledtogetcare,lackofspecialmobilitysupportsforthosewith

chronicissues,andfeelingtheywerejudgedbyothersforusingpublicorspecialclinicorsocialservicesupporttransportation.

o Fosteryouthandtribalmembersalsoreferencedtransportationchallengesasbarrierstohealthandaccesstohealthcare.

• CARECOORDINATIONANDACCESSSUPPORT

o Allfocusgroupsdiscussedthechallengesinsecuringthecaretheyneeded,rangingfromfindingproviders,tocoordinatingreferrals,tounderstandingtheirbenefits,todealingwithmultiplesocialdeterminantsneeds.Attendeesshared,

§ “It’shardtoknowwheretostart…whodoyougotogetguidance?”§ “Patientsdon’talwaysspeakorunderstandthemedicallingoanddoctorsdon’t

alwaysconveyitwell,”suggestingthathavinganadvocateasa“translator”wouldbehelpful.

§ “Weneedsomeonetohelpuscommunicatewithourproviders,tohelpthemunderstandusandtohelpusunderstandthem.”

o Severalgroupshadlengthydiscussionsonhowhelpfulitwouldbetohavea“hub”ora“resourcecenter”whereyoucouldgotoaskquestions,getinformation,findreferrals,orgetsupportforneededservices.

o Gettingreferralsandauthorizationswasachallengeformany,describing“jumpingthroughsomanyhoops”andlengthydelaystogetcare.Someparticipantsnotedhavinghelpwiththis(severalruralparticipantshadsupportfromareferralspecialist),butmostindicatedthisisachallengingprocessthatsimplyrequiresthemtostayonthephoneorresearchonlineforhours.

o Acrossallgroupsattendeesindicatedasignificantneedtohaveaccesstocarecoordinatorsorcommunityhealthworkerswhocouldhelpthemunderstandtheircoverage,accesscare,andgainreferralsandapprovalsforservicesandmedications.

o Ahighpercentageofparticipantswantedhelpknowingwhichproviderstooktheirinsuranceandhowtogetintoseethem.

• FINANCIALBURDENSDELAYINGACCESSTOCAREORRESULTINGFROMCARE

o Severalpeoplenotedthattheydidn’tseekcaretheyneededbecausetheywereafraidofthecostand/ordidn’tknowiftheirinsurancewouldcoverit.

o Othersweresurprisedbywhattheydescribedas“balancebills”forservicestheyhadreceivedthattheythoughtwerecoveredbutweren’t,orininstanceswheretheyhadsoughtcareandonlypartofitwascovered(e.g.,anEDvisitwherethehospitalbillwaspaidbutthephysicianbillwasn’tbecausethephysicianwasnotcontractedwiththeMCO).Theynotedthesesituationsdestabilizetheirbasicneedsandmakethemlesslikelytoseekcareinthefuture.

o Onesuggested(andothersagreed)thatthisisanotherissuethatcouldbeaddressedthroughcarecoordinationoradvocateswhocouldhelpcoachpatientsonhowtoaskquestionsabouttheircoverage,bills,andhowtonavigatecharitycareandrequestedwrite-offs.

• AREQUESTFORMOREHEALTHSERVICES,COACHING,ANDSUPPORTFORYOUTHINFOSTERCARE/AGINGOUT

o Youthinthefostersystemsharedseveralspecificneeds,including:§ Moreandbetterbehavioralhealthsupportsfortrauma,depression,anxiety,

familydysfunction,becauseinthewordsofoneattendee,“weareemotionalwrecksduetothereasonsweareinfostercare.”Severalagreedwiththenotionthattheirhealth(mentalandphysical)hasbeencompromisedbecause“wehavebeenletdownbythesystemsomanytimes.”

• Allparticipantsaroundthetableagreedwiththisandallofferedconcernsaboutthequalityofbehavioralhealthcareservices,withonenoting,“Ifeltlikealabrat,”anotherstating,“IliedtothembecausetheyIknewwhattheywantedmetosayandtheytreatedmelikeanumber…peopledon’task‘whydidyoustealthatcar?’theyjustcheckthingsoffalistanddon’tgettoknowyou…everyoneisuniqueandshouldbetreatedthatway,”andanothersuggestingthat,“IhadtodrivetoLibertyLaketogetagoodcounselor…whatifIdidn’thavetransportation?”

• Severalsuggestedthatpeersupportswouldbebeneficial,aswell,formentorship,coaching,andsharingresourcesbypeoplewhoknowwhatyou’vegonethrough.Oneattendeestated,“Ittakesonetoknowone.”

§ Bettertrainingandmoresupportsforfosterparentsandsocialworkerstocreatehealthyenvironmentsandhelpkids/youngadultsbehealthyandlearnhowtobehealthyonourown.

§ Helplearningabouttheircoverageandcarewhentheytransitionoutofthefostersystem,withoneparticipantstating,“InsteadofahugepacketofinformationIdon’tunderstand,helpmetransitiontounderstandhowtousemyhealthcoverageandgetthecareIneed.”Otherssharedthefollowingrequests:

• “Weneeddoctorswhodon’tusebigwordsandwhoexplainthingsinrealterms”

• “Ineedsomeonewhocanhelpmeunderstandcoverageandaccess”• “Youneedsomeonewhocangrabyourhandandhelpyou.”

• AREQUESTFORMORECULTURALLY-APPROPRIATE,HOLISTICCAREFORTRIBALMEMBERS

o TheTribalfocusgroupwasveryclearthatthehealthcaresystemisnoteffectiveforthem.

o Oneparticipantsummedthisupwiththefollowingstatement:“Weareinasystemthatwasn'tmadeforus…we'renotallthesame.Wearecountedinthecensusbutwearenottreatedappropriatelyespeciallyforthingslikediabetesandheartissuesthattheyknowwearemorelikelytohave.Weneedmorenativecaseworkers,moreaccesstoservicesforphysicalandmentalhealth.Diabetes,drugs,depression,suicide,hopelessness…allofthesethingsarekillingus.”

o Therestofthegroupaffirmedtheaboveandagreedthathealthcarefortribalmembersmustbeholistic,attendtothefamily/communityandspiritualaspectsoftheculture,andaddresshistoricaltraumathatiscontributingtohealthissues.

ConsumerInputRegardingLong-termMeaningfulConsumerEngagementStrategy

ConsumerswereguidedthroughavarietyofquestionstoassesshowtheythoughtBHTcouldmostmeaningfullyengagewiththemregardingtheMTDandthelong-termactivitiesoftheACH.Thefollowingthemesemerged.

§ Themostcommonfeedbackwereceivedwasgratitudeforaskingfortheirinput.Thegroupsuniversallysharedthattheconversationsweremeaningfulandagooduseoftheirtime.Theysharedcommentssuchas,

o “Thankyouforcomingtousratherthanmakinguscomeyou.Itwasnicethatsomeonebotheredtocomeouttotheruralcommunitiestohavetheseconversations.”

o “Thanksforaskingaboutwhatmatterstousandwhatmakesadifferenceforus.”o “Thisdiscussionmakesusfeellikewematterandthatwe’renotinthisalone.”o “Iactuallyfeellistenedto,whichdoesn’talwayshappeninthemedicalsystem.”

§ Focusgroupparticipantsacrossallgroupsindicatedthatbyfarthebestwaytoengagethemto

gettheirideasandfeedbackwasthroughthesetypesofgroupdiscussionsintheirowncommunities.Afewclarificationsincluded:

o “Wewanttotalktoandwithrealpeople…thiskindofdialoguereallymatters.”o “Wewanttotalktoahumanbeing,nottoacomputer.”o “Wewanttobeapersonandnotanumberoradollarsign.”

§ Whileingeneralmostgroupsindicatedthattheypreferin-personopportunitiestoprovide

input,andsomeindicated“ifwegetphonecallsorsurveys,weignorethem,”furtherdiscussionindicatedthat“iftheyactuallyaskedifthiswasaconvenienttime,”or“ifweactuallysawthatourphoneconversationsorsurveysactuallychangedsomething,”thattheywouldbemorelikelytoparticipate.

§ Regardingpreferredmethodsofcommunicatingtheiropinionsandideas,theysharedthefollowingfeedback:

o Thattheywanttoknowtheirtimeandinputmakesadifference—theywantfeedbackonchangesmadeinsystemsorimpactsmadeinhealth.

o Theywant“plainspeak”communicationonwhatthingsmean—“don’tdumbitdownforme,buthelpmeunderstanditinclearlanguage,”

o Theywanttomakesurethattheirinputischanneledupthechaintoadministrationanddecision-makers.Specifically,oneattendeenoted,“Oftenadministrationissofarremovedfromtherealexperienceofthepatient…thegapisn'talwaysbridged…therearetoomanypoliciesthatlimitthedoctorsfromprovidinggoodcare,andtheyneedtoknowthis.”

o Theysuggestedthatsomehowcoordinatinginputthroughhealthcoachesorthepreviously-referencedcarecoordination/informationresource“hub”wouldhelpthembetterarticulatewhattheywereneeding,andhelpthembetterunderstandwhatprovidersareasking.Thusindicatingthatcarecoordination,communityhealthworker,orsocialservicepartnerorganizationscouldbetappedtobeaconduitformeaningfulengagement.

o Tribalparticipantsstronglyadvocatedconversationswithtribalelders,bothbecause“theycan’tcometogroupslikethese”andbecause“theyaretheoneswhowillreallytalk.”Theyalsosuggestedconveninglargercommunityconversationsatthecommunitycenter,school,orlonghousesontriballand,noting,“it’snottoodifficulttogetabuzzgoingontheres,especiallyaboutsomethingthisimportant.”

o Ruralcommunitiesrecommendedboththesesmaller,conversationalgatherings“whereyoucanbuildtrustandbounceideasoffothers,”butalsosuggestedthatlargergroupdiscussionswithmorecommunitymembers(andfood!)couldgetmorepeopleinvolvedandtalking,“thoughyou’dreallyneedtopromoteit.”Liketribalmembers,ruralcommunitymembersspecificallyflaggedtheneedtoreachouttoeldersandtothedisabledinotherways(e.g.,intheirhomes),because“theycan’tmakeittoeventslikethese.”

o Youthinfostercarewanttohavemeaningful,focusedconversationslikethese,buttobringmorepeopleintothemix.Andtheysuggestedworkingwitheventslike“MakeitHappen”andorganizationstheytrust(liketheoneswhoreferredthemtothisconversationtobeginwith)tosecureinputandvoice.

§ Regardingreceivinginformationabouthealthandhealthsystemchanges,responseswere

varied:o Manynotedthatthey’dliketohaveaccesstoa“centralofficetogotoorcallwhere

theyadvocateforyou,aresourcecentertogiveandgetinformationandtogetthehelpandsupportyouneed.”(Theseweresuggestedinconversationsdealingwithcarecoordination,healthadvocates/coaches,support“hubs”inthecommunity).

o Someindicatedthattheywanttoreceiveinformationfromtheirphysicianortheirproviderteam(thoughothersindicatedthiswouldonlybepossibleifyoucouldactuallygetintoseethem).

o Therewerewildlyvaryingreportsregardingattendees’desiretoreceiveinformationfromtheirinsurancecompanies,withmostparticipantsindicatingthat“Ican’tevengetthroughtothemtoaskquestionsorgetmycards,muchlessreceiveorshareimportantinformation”andafewindicating,“Ireceivereallyvaluablehealthremindersandresourcesfrommine.”

o RuralandtribalparticipantsindicatedpreferencesforreceivinginformationandinvitationsviaUSPostalServicemailorthroughlocalnewspapersandtribalpublications.Theyagainrequestedshort,simplecommunicationsand“nobigfatbooklets”or“sevencopiesofthesamething,whichalwayshappenswithmyMedicaidcoverage.”

o Tribalattendeesspecificallyrequestedthatinformationbedisseminatedto“dispelmisinformationthatisconstantlyoutthere.”

o Urbanandtribalparticipantssuggestedthatelectroniccommunications(socialmedia,text,email,web)wouldbegoodavenuestoshareinformationbecause“everyonehasaphonethesedays.”Ruralattendeesdidnotsharethispreference.

ProviderInputRegardingLong-termMeaningfulConsumerEngagementStrategy

OverviewInadditiontoconsumerfocusgroups,representativesof14organizationswereinterviewedtogathertheirideasforestablishingalong-termmeaningfulconsumerengagementstrategytoinformtheMTDandthebroaderactivitiesoftheACH.Theseorganizationsdemonstratedthefollowingdiversity:

• Geography(rural,urban,tribal)• Raceandethnicity• Healthsystemsizeandmodel(large,small,independent,university-affiliated,communitynon-

profit)• Typeofpractitioner/provider(medical,behavioral,substanceabuse,oralhealth,publichealth)• Socialdeterminantsorganizations(housing,foodsecurity,socialservices)• Professionalassociations• ManagedCareOrganizations• Associations• Community-basedInitiatives

NamesofintervieweesareincludedinAppendixA.

IdeasforConsumerEngagement

Whenaskedtheirideason“whichengagementstrategieswouldbemosteffectiveinreachingconsumersfortheirinputandideasintotheMDTandthelong-termgoalsoftheACH?”,thefollowingthemesemerged:

§ Thetoprecommendationwastoreachouttoconsumersthroughtheconduitoftrustedproviders,advocates,andorganizationswithwhomconsumersalreadyhavetrustingrelationships.

o “IfBHTisreachingouttoconsumers,dosothroughthetrustedorganizationsorconsumersmightgetconfusedandfrustrated.”

o “Meetthemwheretheyarethroughtheircoreconnections.”

o “WorkthroughNavigatorsandCHWinitiatives,becausetheyreallyhavetheirpulseontheconsumerneedsandthetrustoftheirclients.”

o “Reachoutthroughruralcoalitionsandhealthchampions,whoreallyknowtheirpeople.”

o “BuildonexistingeventsandfairsthatMCOstakepartin—partnerwiththemastheyconnectwithconsumers.MCOscouldbeambassadorsforspecificengagingquestions/actionsintheirinterfacewithconsumers.”

o “OutreachthroughHealthHomescarecoordinatorsorothercarecoordinationprograms,orinterviewclientsinwaitingroomsatFQHCs,NativeClinic,ortheTeachingHealthClinic.Gettingone-on-oneinputinthesesettingswouldrichlyinformourwork.”

o “Hostoutreacheventssuchasminitownhallsinvariouscommunities,withinvitationscomingfromtrustedpartners.”

o “Don’tjustsay,we’reheretohelpyou.Breakbreakwithpeople.Buildrelationships.Invitethemtopartner.”

o “Dovetailconsumerengagementactivitieswithotherestablishedorganizationmeetingsorevents(e.g.,homelesscoalition,ruralcoalitions,healthfairs)”

§ Respondentsindicatedthattheresultofthatoutreachtroughtrustedorganizationsandadvocatesshouldyieldthefollowingformal,structured,long-termengagementopportunities:

o ImplementanAdvisoryCommitteethatinformsstaff,board,andleadershipcouncilregularly

§ Peopleselectedbasedontheirrepresentation,expertise,andwillingnesstoprovidevoiceovertime

§ Peopleconnectedtootheradvisoryboardsortrustedorganizationssoyouarechannelingamuchbroaderaudiencevoice

§ “Ittakesalotofexpertise,time,andenergytomanagethesetypesofgroupstoreallygetwhatyouneedfromit”andanotherrespondentsaid,“it’snotjustaboutmeetingOURneeds,it’saboutmakingsuretheparticipants’timeandexpertisearehonored”

§ Learnfromotherentitiesthatdothiswellandreplicatehowtheyhavemadeiteffective,withoneexampleasProvidenceSaintPeterinOlympia

§ Capitalizingonexistingconsumerpanelsandadvisoryboardswiththecaveatthat,“thesearethepeoplewhohavebeenshowingupfor20years…weneedtohearfromnewvoices.”

o IntegrateConsumersintotheLeadershipCouncilmeetingsandhavesupportivepeopletheretohelpthemusetheirvoice…callthemoutasconsumerrepresentatives(notprofessionalsservinganorganization)andpaythemfortheirtimejustaseveryoneelseintheroomispaidtobethere.E.g.,perhapshaveorganizationrepresentativesbringaconsumerrepresentativetohelpsupportthem.

§ HearconsumerstoriesmonthlyatLeadershipCouncilandboardmeetings.Fromtheconsumersdirectly.

§ “Havingconsumersrandomlyattendmeetingsisn’teffective.Thereneedstobeaspecificstructureandsupportstomakethemcomfortableandtomaketheirattendancecount.”

§ WeneedmoreadvisoryorLeadershipCouncilrepresentationfromfront-lineprovidersworkingdirectlywithclients.

o Ensureconsumervoiceontheboard(likeFQHCshave)

§ Oneintervieweeoffered“animportantcaveat;oneconsumercannotrepresentallconsumers.Oneconsumer’sexperienceisexactlythat…oneconsumer’sexperience.”

§ “ChangingboardandLeadershipCouncilcompositionmaytakealongtime,soweneedtostartnow.”

§ Onerespondentsuggested,“ensuretheboardandLeadershipCouncilaretrulydiversebecausethatwillhelpmakealloftheactivitiesoftheACHmorediverse.”

§ Respondentssuggestedthatthemostappropriateshort-termstrategiesforsecuringinputinto

projectplanningandspecificimplementationactivitiescouldinclude:o Focusgroupswithparticularpopulations,hostedby/recruitedbyorganizationsthey

knowandtrust,besuretocompensate/incentivizeparticipation§ Earlymethodofgettingmeaningfulinputnowwhileyouaresettingthestage

foramorecomprehensiveplanlong-term§ Optionforspecificfocusareas,e.g.,exploringbidirectionalintegrationofcare,

opiods,etc.withaspecificpopulationweighinginonaspecifictopico Carefullydesignedsurveys,particularlyforthoselesscomfortableingroupsettingsor

withlimitationsinmobility,transportation,etc.§ Oneintervieweestated,“laserinonkeyissuesthatmeetconsumerswherethey

areatsotheydon’tgetlostintheglobalpartsofsystemdesignbuthaveavoiceinthethingsthatreallymattertothem”

§ Anothersuggestedatieredsurveyprocesssimilar§ OnesuggestedusingaplatformsuchasThoughtExchange,whichisusedin

someschoolsystemsettings§ Severalnotedthatitwouldbeimportanttoprovideincentivesforsurvey

participationtogetbetterresponserates

§ Regardingtheabove-listedoptionsforengagingconsumers,respondentswereveryclearabouttheconsiderationsthatwouldmakeconsumersmorelikelytoparticipate:

o Structuremeetingsandeventswiththefollowingconsiderations§ Scheduleat“nontraditionaltimes”§ Providefoodandchildcare§ Providefinancialstipendsandtransportation

§ Engagesupportandcoachingfromtrustedadvocatestohelpthemfeelmorecomfortable

o Onerespondentnoted,“Everyoneelsegetspaidfortheircontributiontothisplanningeffort.Consumersshouldbesimilarlycompensatedbecausearguablytheirvoiceisthemostimportant.”

§ Othersuggestionsincluded:

o Socialmedia.“Gettheyoungervoiceandengagementthroughsocialmedia.”o Earnedmediaandlocalpublications(tribal,rural,Inlander).“Peoplerelyonthese

resourcesandtheycanbeagooddooropener.”o Continueasking,“whoelseshouldbeatthetable…orwhosevoiceshouldwesecure

fromelsewheretobringtothetable?Ifwekeepaskingthisquestionitwillidentifywherethegapsareinourstrategy.”

o ReduceMedicaidstigmatoinvitemoreopeninput.“Doacommunitycampaignthatde-stigmatizesMedicaid—itissomeofthebestcoverageyoucanget.Helpprovidersandconsumersunderstanditisagoodthingandhowtomaximizehealthwithit.Treatconsumersliketheyhaveaninsuranceplan—whichtheydo—it’snotwelfare.Theywillbemorelikelytosharetheirideas.”

o LookatthecertificationrequirementsforPatientCenteredCareandmodelconsumerengagementstrategiesafterthat.

o PulltheactualbillingcodesforMedicaidandlookatwhoisusingthoseservicesthemost…startthereandaskthemfortheirinputonhowtoshapethepatientexperienceandoutcomes.

o “EngagethepeoplewhohaveeffectivelytransitionedoffMedicaid,thosewhohavesuccessfullybetteredtheirlife,tolearnmoreaboutwhathelpedthemdothat.Allowthattoinformhowweprovidesupportsnow.”

o LearnfromotherstateswhohavegonethroughMTDactivities…whatdidtheyfindworked(anddidn’twork)?

§ Onlytworespondentsindicatedthatcomprehensiveconsumerengagementmightnotbe

desirableatthispoint,indicating,o “Unlesstherearegoingtobetargeted/focusedchangesthatwillimpactthem,it'sa

wasteoftime/energy/moneyandwillonlycreatemoreconfusion.Theywanttoknow…’doIstillhavebenefits,willIstillbeabletoseemyprovider?’Thisindividualnotedthatthebetterapproachwouldbetohavetheseconversationswiththeadvocateswhoworkwithconsumers“dayinanddayout,astheyknowtheirstrugglesandneedsandwouldbeabletospeakonbehalfofthebroaderpopulationwithoutconfusingorfrustratingthem.”Thisrespondentfearedthataskingconsumersforinputonsocialdeterminantsissues(transporation,housing,etc.)wouldonlyconfuseandirritatethembecause“Medicaidclientsarehereandnow…tryingtomeettheirneedstoday…ifwebringupthingsthatwon’tchangefor4-5years(ifthen)we’llmakethemmad.”

o “Ifweputtoomuchoutthererightnowwithoutanswersandspecificchanges,itwillcreatefear.Changeishardforthispopulation.Manyarelivingdaytoday.”

o Oneotherrespondentprovidedthefollowingrecommendation:“AskconsumersandprovidersquestionsaboutthingswecanactuallyDOsomethingabout,otherwiseit’sarecipeforfrustration.”

HowSuccessWillBeMeasured

Whenasked,“howwillyouknowthatBHThadbeensuccessfulinmeaningfullyengagingconsumers?”thefollowingthemesemerged:

§ “Iwillseethemandhearthematmeetingsandevents,andtheirvoicewillbeincludedinminutesandinplans.Theywillbeatthetableandtheirvoicetrulyinformswhatwedo.”

§ Iwillseelong-termattendanceandengagementattheLeadershipCouncil,morediversity,morelegislativeandelectedofficialsattendingfocusingonpolicyfortheirconstituentsbecausetheirconstituentsareaskingforit

§ “Youwouldseeitinthestoriesthatpeoplearesharing—theirstoriesinformchangeandtheirnewstoriesreflectchange”

§ “Weareseeingtheevolutionofprojectsandsolutionsbasedonfeedbackfromthepeopleimpactedbythem”

§ “TheprescriptivenessoftheMTDToolkitwillbecustomizedbythevoiceofthepeopleitisintendedtoserve”

§ “Consumerhealthhasimproved.”§ “Consumersatisfactionwiththeircare,theirhealth,andtheirvoiceinhealthsystem

transformationhasappreciablyincreased.”§ “ConsumerswouldknowwhoBHTisandtrustthemandindicatethattheyareatrusted

organizationtogotoforadvocacy,help,partnership.”

WhichConsumerPopulationsShouldBeInformingtheWorkoftheACH?

Respondentsareseekingnewvoices:

§ “SpecificallywedoNOTneedtobereachingtheaverageconsumerwhooftenhasavoice(definedasapersoninaprofessionalcapacityadvisingontheseissues).Thesearenottheconsumerswewanttohearfrom.”

§ “Wetendtohaveasmallgroupofvocalpeoplewhomayormaynotberepresentativeofthelargergroup.Thatcanendupyieldingtokenconsumerinput.”

§ “Wetendtogetthehighestfunctioningandmostvocalpeoplewhohavebeenprovidinginputforalongtime.Weneednewvoices.”

§ “Weasserviceprovidersaredesigningprogramsforpeoplewhoaren’tintheroom.Thishastostop.Weneedtoheardirectlyfromthepeopleweareserving.”

RespondentssuggestedthatBHTshouldoutreachtovulnerablepopulationswhohaven’thadasayinthepast,suchas:

§ Behavioralhealth,substanceabuse,anddualdiagnosisclients(weneedthisvoicebutwanttomakesureweareengagingthemintherightway)

§ Thosewithchronicconditionsandmultiplecomplexhealthissues§ Individualsacrosstheagerange,particularlycallingoutseniors§ Disabled§ Ruralandurbanresidents

o “Ruralsgetforgottenandwearenotreachedouttobecausemostoftheproviders(andallofthebigones)areinSpokane.”

o “Peopledon’tcometous…theyexpectustocometothem.”§ Fosteryouthandthoseagingoutoffostercare§ Homelessorinsufficientlyhoused§ Medicaidclientsandtheuninsured,those“stuckinthemiddle”betweenMedicaidand

insurance(theymaketoomuchforMedicaidbutnotenoughtopurchasetheirownanddon’thaveaccesstocommercialinsurance)

§ ThosewiththehighestMedicaid/healthcarecosts§ Lowincome§ Children/parentsofchildren§ Communitiesofcoloranddiverseculturalgroups(AfricanAmerican,NativeAmerican/Alaska

Native,Immigrants,Refugees),especiallywomenofcolor§ Populationswithspecificdisparities(lookattheSRHDdataondisparitiesandseekoutthese

populations)§ Specificgeographicareasoftheregionwhohaveverylowincome,highrisk,significanthealth

issues

WhichOrganizationsMightHelpEngagetheConsumerVoiceEffectively?

Specificsuggestionsincluded:

§ NationalAssociationofMentallyIll§ BHOConsumerPanel§ FQHCConsumerPanels§ HomelessCoalition§ CommunityActionNetworks§ WashingtonStateCommunityActionPartnership§ SpokaneAlliance§ InPersonAssisterNetwork§ WorldRelief§ HealthPlans§ VOA§ MCOs§ CatholicCharities§ SNAP

InWhatOtherWaysCanBHTContinuetoImproveConsumerEngagementOverTime?§ AlmostuniversallyrespondentsindicatedthatBHTcouldimproveitsmeaningful

consumerengagementprocessbycreatingaformal,structured,consistentmeaningfulengagementpolicyand/orstrategy.

o WhilemanyrespondentsindicatedthatBHThaddoneagreatjobbringingpartnersandprofessionalsintotheroomandcreatingstrongmomentumaroundthisplatform,mostindicatedthatthe“true,authentic,in-personconsumervoicehadnotbeeneffectivelysolicited”untilthisprocessbegan.

o RespondentsreportedbeingpleasedthatBHTistakingsuchacomprehensiveapproachtoplanningitsmeaningfulengagementstrategy.

§ Themostcommonsuggestionofferedtohelpimproveengagementwasa

communicationstrategythatprovidesmoreregular,clear,specific,“plain-speak”communicationthatis“notjustonaby-requestbasis.”

o “Don’tusewaiver-speak!”o “Helpconsumersunderstandhowallofthisimpactsthemandbenefitsthem,

andtheywillbemorelikelytowanttoengage.”o “Communicationneedstobeimprovedforbothprovidersandconsumers.

Providersdon’tunderstandwhatitallmeans,sohowcantheyhelpconsumersunderstand?”

o “Thereisn’tenoughdisseminationoftheinformationdownthroughorganizations,either.There’sabottleneckwhereadministratorsknowtheinformationandthemid-levelandfront-linestaffdon’tgetthedetails,buttheyaretheonesinteractingwiththeconsumers.Providersarethecoaches,soifyouwantgoodcommunityengagement,educatethemwell.”

§ Specificcommunicationrequestsincluded:

o Transparencyabout“here’swhatweknow,here’swhatwedon’tknow.”o Clear,concisemappingoftheprocess.o Pushnotifications(toalertofchanges).o Dynamicandconcisewebcontent(toclearlyoutlinetheprocessandprogress).

Makesurewebsiteisupdatedandthatit’snavigableandfocusedonwhatpeoplemostneedtoknow.Basic,clearinformationthatisseparatedbasedonaudience(consumers,providers,policymakers),clearlyarticulatingthevaluepropositionandactionitemsforeach.“Wedon’thaveaplacetodirectconsumersorproviderswheretheycanlearnmoreandfindwhattheyneedeasily.”

o Closethecommunicationloop…makesurepeopleknowthattheirvoicemadeadifference.Informandshowthatchangehasbeenmade.

o Consumersandprovidersalikeneedtoseetheseprojectsas“relevantandaccessibletothem,”sothecommunicationandoutreachhastoconveythis.Provide“predictablyfrequentcommunications—consistentandsustained,forums,andotherwaystoreachpeopleandengagethem.”

BetterHealthTogether(BHT)MeaningfulProviderEngagementSummaryReportASummaryofProviderInputUsedtoInformMedicaidTransformationDemonstration(MTD)ProjectSelectionandPlanning,andtoDesignBHT’sLong-termMeaningfulProviderEngagementPolicyandStrategy

OverviewTheBHTMeaningfulProviderEngagementplanningprocessinvolvedseveraltiersofactivitydesignedtosecureinputintotheselectionandplanningofMTDprojectsandtoyieldarecommendedpolicyandstrategyfortheBHTBoardtoconsideradoptingforongoingmeaningfulengagementofprovidersinfutureAccountableCommunityofHealth(ACH)andMTDactivities.Thisreportdetailsfindingsfromthefirstphaseofactivity:providerkeyinformantinterviewsandfocusgroups.

Methodology:ProviderKeyInformantInterviewsandFocusGroups

Intotal,21providersparticipatedinkeyinformantinterviewsand24providersparticipatedinthreeseparatefocusgroupstoinformtheselectionandplanningofMTDprojectsfortheBHTregionandtoprovideopinionsandideasforestablishingalong-termmeaningfulproviderengagementstrategyfortheactivitiesoftheACH.NamesofintervieweesandhostorganizationsforfocusgroupsareincludedinAppendixA.Intervieweesandfocusgroupparticipantsrepresentedadiverscross-sectionofprovidersaccordingtothefollowingcriteria:

• Geography(rural,urban,tribal)• Raceandethnicity• Healthsystem/practicesizeandmodel(large,small,independent,university-affiliated,

communitynon-profit,etc.)• Sectorrepresentation(medical,behavioral,substanceabuse,oralhealth,publichealth,MCO,

etc.)• Practicetype/targetpopulationserved(pediatric,geriatric,familymedicine/primarycare,

internalmedicine,tribal,homeless,psychiatric,etc.)• Socialdeterminantsorganizations(housing,foodsecurity,socialservices)

ProviderInputRegardingMedicaidTransformationDemonstration

Whenaskedtheopen-endedquestions“whatarethebiggestchallengesfacingprovidersnow,”“whatarethebiggestbarrierstoprovidingwhole-personcarethatimproveshealth,”and“whatwouldmakeiteasier/moreefficientforproviderstoprovidewholepersoncarethatimproveshealth,”thefollowingthemesemerged:• TIMEANDADEQUATEREIMBURSEMENT:Themostcommontheme,citedinoneformoranother

byallprovidersinthisresearchprocess,was“lackoftimeandreimbursementtotreatpatientsholistically.”

o Time.Providersfeeltheylacksufficienttimetotreat:thewholeperson;morethanoneissueatatime;complexmedicalconditions;relatedsocialneeds;orevenasinglemedicalissueadequately.Theyindicatedthatthe“productivitymodel”isstillthestandard,andthateventhoughthereisatrendtowardqualityandvalue,theyarestillpaidonafee-for-servicebasis,whichconstrainsthemfromeffectivelyandefficientlymeetingthecomprehensiveneedsoftheirpatients.Commentsincluded:

§ “Youcan’tdoanythingmeaningfuloreffectivein15-20minutes,muchlesstreattheholisticneedsofpatientswithmultiple,complexconditions.”

§ “MybarberspendsmoretimecuttingmyhaireachtimeIseehim(30minutes)thanIamgiventotreatapatientwithdiabetesandothercomplexhealthissuesandmultiplesocialneeds.”

o Reimbursement:Providerscited“piecemeal”reimbursementasadetrimenttopatienthealth.Oneprovidersuggestedthattheyareexpectedtodealwithonlyone“problem”atatimeforapatient,andarereimbursedinthisway,whenthereare“6interrelatedproblems—3acuteand3chronic—nottomentionsocialneeds,andwehave15minutestoworksomekindofamiracle.”

• INFORMATIONEXCHANGE:Allprovidersindicatedthatinformationexchangeamongstthe

variousproviders(clinicalandcommunity)wasasignificantbarriertotheirabilitytoprovidequalitycarethatmakesadifference.Challengescitedincluded:

o LackofInfrastructureandInteroperabilityforHealthInformationExchangechallenges,includingnonexistent,insufficient,orinefficientconnectionsbetweenoramong:hospitalsandprimarycare;behavioralhealthandprimarycare;primarycareandcommunitysupports;primarycareandspecialtycare.TheynotedtheinabilityofElectronicHealthRecordstoeffectivelyinterfacewithoneanother,andthelackofreal-timeaccesstodiagnosisandtreatmentinformationatcaretransitions(particularlyfrominpatientdischargesorEmergencyDepartmentvisits)asbarrierstoeffectivewhole-personcare.Evenwhenproviderssendreferralsandpatientinformationtospecialists,theydonotreceivereturninformationondiagnosesortreatment.

o Commentsincluded,§ “Wearedoingourbestasprovidersbutwe’redrivingblindalotofthetime.”§ “Weareaskedtocollaborateonbehalfofourpatientsbutdon’thavethetools

todosooutofourownsystems.”§ “Ineedreal-timeabilitytotalktootherproviders,exchangeinformation,and

treatthewholepersonatthetimetheyneedtobetreated…whentheyareinmyoffice.”

• ADMINISTRATIVEBURDENS:Providersuniversallyreportedadministrativeburdensasoneofthe

greatestchallengestotheirabilitytoprovideexcellentcareandtomeettheneedsoftheirpatients.Theycited:

o Toomuchdocumentationandadministrativeroadblockstoprovidinggoodcare.Manyprovidersnotedtheconstantneedtoprovidedouble,triple,orevenquadrupledataentryanddocumentation,notingthat“italltakesawayfromourabilitytotreatthepatients…andthedatatheyareaskingforisn’tactuallymakingadifference”

o Theconstantneedtofindworkaroundsfordatasystems,variousMCOcoveragerequirements

o Oneprovidersaid,“Ispendmoreofmytimetypingratherthantreatingpatients”(thissentimentreceivedsignificantaffirmativefeedback).

o Anotherprovidersuggested,“Eachtimetheyaskustotrackonemorething,theysay,‘it’sjustonemoreboxtocheck,’buttheydon’trealizethatifyou’reonlycheckingboxes,youcan’ttreatthepatient”

o Finally,onephysiciannoted,“ifyouwanttoseechangehappen,payfortherightactivitiesthatproducetherightresultsandifyoucan’tdothat,atleastunburdentheproviderwhowillbedoingthework.”

• CARECOORDINATIONANDCLINICAL/COMMUNITYLINKAGES:Providersacrossallpractice

settingsanddisciplinescitedsignificantchallengesduetothelackofresourcesforcarecoordination,caretransitions,andsocialdeterminantservicesthatsupportoptimalpatientoutcomes.Mostinterviewsandfocusgroupssharedsomeversionofoneprovider’scommentthat“wespendmoreofourtimebeingasocialworkerthanaphysician.”Providerscitedspecificchallenges,including:

o ProviderTimeConstraintsforEffectiveInformationExchange,particularlyinadequatetimetoconsultwithotherprovidersbothwithinsystemsandacrosssystemstomeetthediverseneedsofpatients,andinsufficienttimetoconsultwithfamilymembersonbehalfofcertainpopulations(children,elders,andat-riskpopulationssuchasthosewithchronicbehavioralhealthissues).Oneprovidernoted,“evenwhenIdogetdetailedpatientinformation,Ispend20minutesreadingwhatIneedtoinordertotreatthepatientandthat'showlongI'mallottedforapatientvisit.”

o ResourceBarriersforInformationExchange,includingthelackofreimbursementprovidertoproviderconsultation,carecoordination,andfamilyconsults.Providersuniversallycitedtheinabilitytoeffectivelycoordinatecareamongthefullcareteamandthevariouscommunityprovidersandfamilymembersnecessarytoprovidewholepersoncare.

o Challengeofeffectivelyintegratingadditionalcarecoordinationintoexistingclinicmedicalteams(e.g.,notenoughstafftodothework,notenoughfundingtopaythestaff,notenoughtrainingtorevisepatientandteamflows,lackofspacetoprovidetheseservices).

o Theneedforimmediate/real-timeandco-locatedservices,particularlyforbehavioralhealthclientsandthehomeless(oftenpatientsfallintobothcategories),inthewordsofoneprovider:“inordertokeepthemfromtherevolvingdoorofEmergencyDepartmentvisits,inpatienthospitalizations,orincarceration.”Co-locatedphysical,behavioral,addiction,dental,andsupportserviceswouldvastlyimprovepatientoutcomes.Providersnotedthattheseindividualsneedfarmoresupportforsocialneedssuchastransportation,supportiveservices,housing,employment,foodsecurity,andtimely

addictiontreatment.Asoneproviderstated,“areferraltwoblocksawayisoftenthesameasareferralacrosstown,andanappointmentintwoweeksisasgoodasnoappointmentatall.”

o Consistentlystaffedandfundedteamsprovidingsocialdeterminantservicesandclinicalsupports(housing,foodsecurity,transportation),aswellaspreventiveeducationandsupport(dietitian,physicalactivity,healthcoaching)inordertoadvancehealthgoals,but,asoneprovidernoted,“thiscostsmoneyandnoonepaysforit.”Anotherproviderstated,“ouremphasisnowisdxandrx,notwholehealth…weneedanexpandedcareteam,thespacetoprovidetheseresources,coverageforthingsthatmakeadifference(likecarecoordination,dietitians,physicalactivity,socialsupports),andsupportgettingtheprocessesandintegrationsetupintheclinicalsetting.”Whenaskedwherethisfunctionshouldreside,mostproviderspreferredacommunity-basedapproachtocarecoordinationthatseamlesslyandeffectivelyintegratesintotheclinicalsetting.Oneprovidernoted,“thisshouldbehousedoutsideofouroranyone'ssystemandshouldfollow/servetheclient.”

o Consistentassessmentofneedsthatimpactclinicaloutcomesbeforepatientsseetheirproviders.Clinicalsettingscouldbenefitfromacarecoordinatororcommunityhealthworkerwhocanperformfullassessmentsofpatientsastheywalkinthedoor,toidentifyifthereareissuesoutsideoftheclinicthatwillpreventpatientsfrombeingcompliantandsuccessfulwithtreatmentrecommendations.Asoneprovidersuggested,“weneedtoaddresstheirhierarchyofneeds,becauseifItellthemtogotothegymandtheycan’taffordrentthismonth,nothinggetssolved.”Andanothernoted,“noamountoftreatmentfordiabeteswillhelpifthepatientishomelessanddoesn’thavesocksandshoesthatkeeptheirfeetdry.”Anotherprovidersnotedthat“patients’numberonecomplaintis‘theprovidersaren’tlisteningtome,’whenpartoftheproblemisthepatientcan’tclearlyarticulatewhattheywantorneed…theyneedsomeonehelpingthemdothissotheprovidercanfullyunderstandthoseneedsandaddressthem.”

o Additionstothecareteam.Themostcommonlycitedprovidersthatneedtobeaddedtothecareteamtoprovidewhole-personcarewere:behavioralhealthproviders,communityhealthworkers,carecoordinators,anddietitians.

• POLICYBARRIERS:Providersrepeatedlyreferencedpolicybarriersthatinhibitwhole-personcare

orpreventprovidersfromeffectivelycoordinatingcareonbehalfoftheirpatients.Examplesofpolicybarriersincluded:

o Pronouncedrestrictionsinprovidercoordinationwithbehavioralhealthandsubstanceabusetreatmentandtheircoordinationwiththemedicalcaresystem.Thiswasthemostuniversalconcernexpressedbyprovidersfromallpracticesettingsanddisciplines.Oneprovidernoted,“wearehandcuffedbylegislationthatactuallypreventsusfromeffectiveintegration.”

o Inabilitytoprovidesimpleresolutionofissueswithoutadditionalbillinganddocumentation.Examplesincludednotbeingabletoprovideanuncoveredservicethatcouldresolveasimpleneed(e.g.,providingabandaidorgauzetoapatient),ortherequirementthatyoumustattempttocollectco-paysforfederally-fundedprogramswhenitcoststheprovidersmoretotrytocollectthanitdoestosimplywriteoffacopay.

o Requiredspenddownsforbehavioralhealthclients.Suchpracticesprofoundlyinterruptcareandresultinunnecessaryhospitalizations.Behavioralhealthclientscould

bebetterservediftherewerefundsavailabletodrawonduringthattimetomaintaincontinuityofcare.Oneprovidernoted,“thispracticeiscontrarytorecovery"

o Transitioningclientsoutofsupportserviceswhentheymakeadvancesintheirhealthandlifegoals.Iftheygetjobsormakecertainincomestheylosesupportstheyneedtostayhealthyandstable,soadvancingtowardhealthandlifegoals“oftenpushesthemoutofservicesandputsthembackonthestreetsorlandstheminthehospital.,onlytostartthecycleagain.”

• CLINICAL,COVERAGE,ANDACCESSCONSTRAINTS:Providersnotethatthereareavarietyof

clinicalandcoveragerestraintsthatinhibittheirpracticeofwhole-personcare.Examplesinclude:

o Formulariesaretoorestrictive,particularlyforspecificissues(e.g.Suboxonetreatment),andtheyaredifferentfromplantoplan,resultinginproviderssayingtheyhaveto“bobandweaveallthetimeandconstantlyresearchalternativeoptionsforprescribingratherthantreatingthepatient”(andagaintheycitetheyarenotreimbursedtoresearchalternativemedications)

o Medicaiddoesn’tcoveradditionaltreatmentsforpreventiveandchronichealthconditionmanagement(e.g.,dietitians,physicalactivity,painmanagementmodalitiesotherthanprescriptions)thatcommercialplanswillpayfor.Oneprovidersuggestedthatthisis“discriminatorymedicine”

o Manyprovidersindicatedlackofaccesstodrugaddictiontreatment(orlongdelaystoentertreatment)asamajorproblem,asitcausesusto“missthewindowofintervention”whenthepatientisactuallyreadytoentertreatment.

o PatienttransitionsacrossthevariousMCOscreatesignificanthardshipbecauseprovidersoftenhavetocreatenewtreatmentplansbecausethepreviousonedoesn’tmeetthenewMCO’srequirements.

o AccesstocareandmedicationsisachallengebasedonMCOpanels—particularlywhenpatientschangeMCOs,theyaretoldwhotheycansee(mostoftenNOTalong-termprovidertheytrustandwhoknowstheirhistory)andwheretheycangettheirmedications(whichoftenisNOTintheirownneighborhood,causingmorebarrierstocompliance).

o Insufficientnumberorwell-trainedproviders• Respondentsindicatedthatthere“arenotenoughproviderswhoarewell

trained;advancedcareprovidershavehelped,butit’snotenough.TherearesomanythingsIdothatsomeoneelsecoulddo.”

• Providerrecruitmentandretentionisamajorchallenge,particularlyinruralareasandinbehavioralhealth.Respondentsreported“poaching”ofexistingclinicalstafffromruralandsafetynetproviderstogoworkforlargerhealthsystemsandMCOs(betterpay,betterbenefits,betterqualityoflife),andanexodousofprovidersfromruralandbehavioralhealthsafetynetentitiesduetoproviderburnoutandthechallengeoftryingtodopatient-andmission-centeredworkamidstever-growingcaseloadsandadministrativeburdens.

o Avarietyofprovidersindicatedfearthatprogresstowardbetterintegratedcareteamswouldbethwartedbylackofaccesstonewtypesofproviders(e.g.,communityhealthworkers)oradministrativeorpolicychallengestoallowingvariouscareteammemberstoworkatthetopoftheircertification/licensuretobettermeetpatientneeds.Oneprovidernoted,“weneedtohaveallofuspracticingatthetopofourlicensessothephysician/providercanhelpfacilitatewholepersoncare.”

o Anumberofprovidersalsocitedthecriticalnatureofculturally-sensitivecare,particularlycitingtheneedformoreeffectivepartnershipswithTribesandrefugeepopulationstodefineculturally-appropriatecare.Anumberofrespondentsalsocalledouttheneedforculturally-appropriatementalhealthandsubstanceabusetreatmentservices,indicatingtherearefewresourcesthateffectivelytreatthewholepersonwiththistypeofsensitivity.

• ADDITIONALCONCERNS:Providerssurfacedavarietyofotherchallengestoprovidingwhole-

personcare:o Changefatigueandburnoutwascitedbymanyrespondents,withcommentssuchas

• “Burnoutcloudsourabilitytotreatthewholepatient,”and“adaptingtotheseconstantchangesisalmostimpossiblewithallwe’reaskedtodo.”

• “Burnoutishigh,thetreadmillisrunningfasterthanIhaveeverdealtwithbefore.Beingadochaschangedtoajobmorethanavocation.”

• “Ifyou’regoingtoaddsomething,takesomethingaway.Wecan’tjustkeepaddingtowhatneedstobedone.Providersarealreadytoobusy.”

• “Yes,changefatigueisaproblem.Weneedtorallythetroopstomakesystem-widechangepossible.Itcan’tjustrestontheshouldersofproviders.Wehavetohaveastrong,mission-drivenculturethatenergizes.”

o “Wewanttobeabletojustcommunicationwithourpatients…therearetoomanylawyersandadministrativelayersthatkeepusfromsimplytreatingthem,”and“createwaysofworkingwithpatientsthatworkforpatients.”

o Ruralareasfaceuniqueandcostlychallengesforthingslikeintegrationofbehavioralhealthintoclinicalsettings.Oneprovidernoted,“publichospitalsaren'treimbursedsufficientlyforthis—theyaredoingsomuchontheirowndime,andtheycanonlydothatforsolong."

Oncetheopen-endedquestionspresentedtheabove-articulatedthemes,intervieweesandfocusgroupparticipantswereaskedspecificquestionsaboutseveralfocusareasintheMedicaidTransformationDemonstration,sharingthefollowingfeedback:

• VALUEBASEDPURCHASING:Whenaskedabouttheextenttowhichprovidershavetheknowledge,skills,andreadinesstomovetowardValueBasedPurchasing,thefollowingthemesemerged:

o ThemostcommonfirstresponsetothequestionaboutVBPwasalwayssomeversionof,“cansomeonepleasetelluswhatthismeans?”

o RespondentsfeltthatlargesystemsandFQHCsarewellpoisedtomeetthenewrequirementsunderVBPbecausetheformerhavesignificantadministrativelayerstosupportitandthelatterhavebeenworkinginpatient-centeredandvalue-basedmodelslong-term.

o Participantsfeltthatindividualprovidersandsmallerclinics/practicesandindependentprovidersprobablyhavenoideawhatitmeansand/orhowitwillactuallyimpactthemortheirpatientsortheirpracticeofmedicine,andtheywouldnothavetheresourcestomanagethedataandthesystemsrequiredforVBP.Therewereconcernsthatsmallerpracticesandruralproviderswouldeithersimplycloseupshoporjoinoneofthelargersystemsunderduress,creatingmoredysfunctioninthesystem.

o Providersindicatedthattheybelievetheyaremeasuredontoomanymetricsalready(manyofwhicharenotalignedwithwhatisreallyimportant),andthatmorearebeingadded,creatingmoreadministrativeburdenandmovingusfurtherawayfromtreatingpatientsholistically.

o Anumberofproviderswereespeciallyconcernedaboutbehavioralhealthmetrics--theyaren’tconvincedthatthereare“reallygoodoutcomemeasures”forbehavioralhealth,yetintegrationisahuge(andcritical)partoftheDemonstration.Andthattheadministrativeandtimeburdenoftrackingmetricswouldcontinuetodecreasetimeandfocusforgoodpatientcare.

o Otherswereconcernedthatprovidersarebeing“graded”onoutcomesthattheydon’thavecontrolover,inparticularthesocialdeterminantsfactorsthatimpactpatientcompliancewithtreatmentrecommendationsandmedications(thiswasparticularlycitedwithregardtobehavioralhealthclients).Thisconcernwasexpressedacrosshealthsystemsandproviderdisciplines.

• INTEGRATEDCAREMODELS:Whenaskedtheextenttowhichprovidershavetheknowledge,

skills,andreadinesstomovetowardintegratedcaremodels,thefollowingthemesemerged:

o Providersunderstandtheintegratedcaremodel,theyareconstrainedbymanyofthepreviously-listedissues(healthinformationexchange,space,trainingonnewcaredeliverymodels,workforce).

o Again,providersnotedthatlargesystemsarebetterpoisedtointegratebehavioralhealthandphysicalhealthneeds(asopposedtosmallerclinicsorindependentproviders),butnooneispoisedtosupportthesocialdeterminantneedsthatmakeintegratedcarereallywork.Onerespondentsaid,“healthcaresystemsarethinkingabouthealthcaredeliveryonly,butsocialdeterminantsisreallywherewecanmakeadifference.Providersaren'treadybecausetheydon'tknowhowtohelpwithfoodinsecurity,housing,andthingslikethat.”

o Therewerespecificconcernsabouteffectivetreatmentforco-occurringmentalillnessandsubstanceabuse,withsomerespondentsnotingthatprovidersareill-equippedtodealwiththispopulationandfinancing,policy,andsystemissuescreate“almostinsurmountablebarriers”totreatingthispopulationeffectively.Oneprovidersummarizedconcernsexpressedbyseveralothersabout“thelackofscientificevidenceofsomeofwhatisdoneinthebehavioralworld.”

• REDUCINGEMERGENCYDEPARTMENTVISITSFORNON-EMERGENTREASONS:WhenaskedwhattheythoughtwouldhelpreduceEDVISITSfornon-emergentreasons,providersofferedthefollowingfeedback:o Co-locatedservicesortransportationtoservices,andsame-dayaccesstocare(particularly

forhigh-riskbehavioralhealthandchronicconditionpatients)o Real-timehealthinformationexchangeandproviderconsultabilityforthoseathighestrisk.o Bettermedicationeducationandreconciliationatdischargewithappropriatefollow-up

afterdischargetoensurepatientcomplianceandaccesstomedicationso Incentivesforprimarycareproviderstocontinuepracticinginprimarycareandincentives

forseeingMedicaidpatients.Same-dayaccesstoprimarycareandreductionsinwaittimestosecure/seeprimarycareproviders.Oneprovidernoted,“thereisincredibledemandandverylimitedresourcesforeffectiveprimarycare.”

o Betteraccesstosame-daybehavioralhealthservices.Asoneprovidernoted,“ifapatienthastoschedule3weeksouttobetreatedforanxiety,theEDistheirnaturalnextstep.”

o Moreeffectiveandcomprehensivecarecoordinationforhighutilizers(primarilybehavioralhealthandsignificantchronicconditions),focusingonsocialdeterminantsofhealthandbuildingatrustedrelationshipthatcanhelpcoachthemtoutilizeresourcesmoreeffectivelyandefficientlyfortheirhealthneedsandlifegoals.

o DiversionstrategiesthatpairmentalhealthprofessionalswithEMSprovidersandpoliceofficerstoavoidEDvisitsfornon-emergentreasonsandroutepatientsintointegratedcare(primarycare/behavioralhealthmodels)withrobustcarecoordinationforsocialsupports.(Oneprovidernotedthatpolicyandreimbursementchangeswouldbeneededtoimplementsuchstrategies.Thisindividualalsonoted“diversionisn’tthegoal…appropriate,holistic,patient-centeredcareisthegoal!”)

o Extendedhoursforprimarycare,moreurgentcareaccess,24-hourphonecare,and“behavioralhealthurgentcare”models.

• THEOPIODCRISIS:Whenaskedwhattheythoughtwouldmakethebiggestdifferencein

addressingtheopioidcrisis,providerssharedthefollowingcomments:o Providersacrossalltypesofsystemsandpracticeareasindicatedthatweneedmore

treatmentmodalities(options,coveragefor,providers)totreatpainwithoutprescribingopioids,includingpainmanagementspecialists,massagetherapy,physicaltherapy,acupuncture,etc..Asoneprovidernoted,“theywantustostopprescribingandthesepatientswithrealpainissuesdon’thavealternativemodalitiesthatarecovered.”Anotherstated,“TheHealthCareAuthority’sapproachtotheopioidcrisisiscausingmoreproblemsforcaringforthewholepatientbecausewedon'thaveothermodalitiestotreatthem.”

o Providersneedtoseethedataaboutprescribingpracticesandhowtheymeasureuptoothers,alongwithcoachingonothertreatmentoptionswhereoutliersexist.

o “Weneedreal-timeaccesstothePDMPsystemthroughEHRs.Accessafterthefactdoesn’thelp.”

o Acrosshealthsystemsandareasofpractice,providersnotedthatforthoseaddicted,weneedmorereadyaccesstotreatment,includingbetterpoliciesandcoverageforMATandbetterabilitytoprescribeSuboxone.

o Oneprovider(totheagreementofothersintheroom)stated“Wemustde-stigmatizethediagnosisandtreatmentofaddiction.Wedon’tstigmatizediabetesorhighbloodpressureasadiagnosis…addictionshouldbesimilarlyde-stigmatized.”

o Patientswhoarereadytoentertreatmentneedimmediateaccesstosubstanceabusetreatmentoptionsandmorecomprehensivefundedaddictioncounselingandsupport.

o Providersinallfocusgroupsindicatedthattreatingpainasavitalsigncreatedthisdynamicand,asoneparticipantnoted,“thependulumneedstoswingintheotherdirection…weneedtofacetheproblemwehavecreated.”Theycalledforprovidereducationoneffectivepaintreatmentsandaccesstoappropriateservicesandsupportsforpatients,balancedbypatienteducationandsupportandsocialdeterminantssupportstohelptreatunderlyingcausesandavoidaddiction.

ProviderInputRegardingLong-termMeaningfulProviderEngagementStrategy

IdeasforProviderEngagement

GeneralEngagementandCommunicationStrategies

Whenaskedtheirideason“whichengagementstrategieswouldbemosteffectiveinreachingprovidersfortheirinputandideasintotheMDTandthelong-termgoalsoftheACH?”,thefollowingthemesemerged:

• COMMUNICATECLEARLY,CONCISELY,ANDCONSISTENTLY:ThevastmajorityofrespondentsindicatedthatBHTwillneedtoplacestrongemphasisoncommunicatingmoreeffectivelyandmethodicallywithproviders.Asonerespondentsuggested,“Createasolidcommunicationstrategicplanthatwilldrivethemtoengage.”Themesincluded:

o Buildoncurrentstrengths§ BHTwascommendedbymanyrespondentsfortheirdemonstrated

commitmenttogooutintocommunitiesandconnectwithpartners(e.g.,travelingtoruralcommunitiesandhavingoneononemeetingswithpartnersthroughouttheregion).

§ TherewererepeatedreferencesthatBHThasmadeimportantprogressinrecentmonthsfocusingonTribalrelationships.

§ Oneparticipantsuggested,“it’scriticaltocontinuethisfocusonruralandTribalpartners.Don’ttreatruralcommunitiesandTribesasafterthoughtsinthisprocess.”

o Buildname,mission,andtrustrecognitionamongproviders:§ “Whilethereisgood“brandidentity”ingeneral,especiallyamongcurrent

partnersandadministrators,front-lineproviders(especiallymedical,dental,andmentalhealthproviders,asopposedtosocialdeterminantsproviders)don’tknowwhoBHTisorwhytheyshouldcare.

o “MedicalprovidershavenoideawhatBHTis.There'sabsolutelackofrecognitionofwhattheACHorthewaiverisdoing,sothere’snoplatformtobuildengagementon.Thosewhoareseeingpatientsdon'thaveanunderstandingofwhyit'simportantandwhytheyshouldpayattention.”

o “It’sallstillprettyfuzzytomost,ifnotall,providersifthey’renotactivelyleadinganarmofthiswork.”

o “BHTdoesagreatjobofcommunicatingwiththeadministrators,butwhatweneedisclearcommunicationswithprovidersabouthowthisimpactstheirpatients,theirpractice,andtheirpaycheck.”

o “Providersneedtobeeducatedonwhatthewaiverisandisnot(e.g.,itisnotagrantmakingopportunity),andtheyneedclear,consistent

communicationwithopportunitiestoaskquestionsanddetermine‘what’sinitforthemandfortheirpatients.’”

§ Ofnote.Severalrespondentsindicatedthatsomeofthecurrentcommunications“canfeellikemarketingratherthanengaging.Wewantpeoplewantingtoleanin,notfeeling‘sold’onsomething.”

o Focusontheuniquevaluepropositionforeachaudienceorindividual§ “Alwaysfocuscommunicationandmeetingsonthe‘whyshouldIbehereor

care’game—peopleneedtoknowwhythey’rebeingaskedtodosomethingandhowitwillaffectthem/theirpractice.Thisneedstobestandardforallcommunicationsandmeetings—highlightingthevaluepropositionandmakinggooduseofpeople’stimeandexpertise.”

§ “Keepthevaluestatementupfrontinallcommunicationsandkeepremindingpeopleinclearlanguageofexactlywhatyouaremakingadecisiononandwhyit’simportanttothem.”

§ “Sellthebenefit.Tellmethevaluepropositionformypatients,formeasanindividualpractitioner,andasapractice/organization.Thisiswheretheengagementwillhappen.”

o Sharewhatyoudoknowwhenyouknowit§ MostacknowledgedthatBHTisinachallengingrole,disseminatinginformation

thatisconstantlychangingorslowlyemergingatthestateandfederallevels.§ Still,providerssuggested,“eveniftheHCAisn'tdefinitiveonsomething,say

‘here'swhatweDOknow,here’swhatwe'rethinking,thetimelinewe'reanticipating,andthenextdecisionswewillbemakingbasedonwhatweknownow.”

o Usetherightlanguagefortheaudienceandpurposeofcommunication§ Themostcommonlycitedsuggestionforimprovingcommunicationwas

summedupbythisprovider:“Sharekeyinformationin‘plainspeak’forallaudiences.”Manyrespondentssharedsimilarcomments—keepcommunicationshort,simple,andtailored.

§ Severalparticipantssuggestedthe“threebulletrule,”withprovidersthemselvessuggestingtheydon’thavethetime(orwon’ttakethetimeamidsttheirotherpriorities)toreadmorethanthatunlesstheyfeeldrawninbyatopic.The3bulletsshouldintroducethekeyinformationandprovidelinkstowherepeoplecangetequallyconcisebutmoredetailedinformationoneachtopic.(Ofnote:severalrespondentsspecificallysuggestedNOTdirectingpeopletothetoolkitorotherstateresources,astheyaretooconvoluted).

§ “Askphysicians,PAs,ARNPs,etc.,whatkindoflanguagewouldmakeitmorelikelythattheirrespectivegroupswouldlisten,andthenuseit.”

§ “RememberthatBHThastheconversationeverydayeveryweek.Itiseasytoforgetwhatyouhavesharedwithdifferentaudiences…findawaytomakesurethateveryonegetsthekeyinformation.”

o Respectandrelyonorganizationsandproviderswhodothisworkandhavedoneitlong-term

§ Relyonproviderswhohavebeendoingthisworkandwhoaretheexpertsintheirrespectivefieldstohelpinformtherightcommunicationandengagementapproaches.

§ “BHTisthenewbieinthislandscape.Consultthepeoplewhohavebeenholdingtheriskandcontendingwiththechallengesfor25years.Respecttheexpertiseofestablishedinstitutionsandpartnerwiththemtoinnovate.”

§ Onepersonsharedacontraryopiniontotheabove,stating,“Weneedtomineeverycornerforchangemakers,interestingideas,andenergy.Don'tasktheoldpeoplewhohavebeendoingthisfor20or30or40yearsandneverchangedathinginthattime.”Severalotherssuggestedsimilarrequeststo“hearnewvoices”and“seekoutthosewhohaven’tbeenaskedfortheiropinions.”

o Listenbothtothesupportersandtothedissenters§ “Reallylistentotheconcernsofprovidersandbalancethehopeinherentin

innovationwiththerealchallengesandfearsthattheyhave.Thereissomefeelingthatifyou’reaskingtoughquestionsorposingcounterpoints,you’llbedisregardedasanaysayer.Butweneedtoexamineallsidesoftheseissues,notjustthepositiveones.”

§ “Becarefultolisten,notjusttell.”§ “Havehonest,boldconversationswiththosewhoaren’tatthetable,asking

them,‘whatwillittaketogetyouthere?’”§ Otherproviderssuggestedbeingresponsivetowhatyouhearbydispelling

mythsinrespectfulwaysandusingconversationsaboutfearstoinformthoughtfulprojectresearchandplanning.

o Bespecific,brief,andchoosethebesttimetoengage§ “Beveryclearabouttellingproviders,‘hereiswhatweareaskingyoutodo.’

Theyareconfusedbecausethemessaginghasn’tbeenclear.”§ “Providersneedtobetoldwhatisbeingaskedofthemsotheycantestit

againsttheirbusinessmodel,staffingmodel,andwhatitwouldtaketobesuccessfuloperationally.Thisisn’thappening.Ornotwell.”

§ Takeintoconsiderationprovidertimeconstraintsandinvitethemintotheplanningandtheprocess“whentheycanactuallymakeadifference”

o “Don’thaveopen-ended,blankslateconversations.Giveussomethingtorespondtobasedonourexperienceandourpatient’sneeds.”

o “The‘sowhatdoYOUthinkweshoulddo’conversationwon’twork.It’sawasteoftheirtimeandyouruntheriskoflosingtheirengagementlong-term.Bringideasandsuggestionsthatproviderscanrespondto.”

o Gotothem§ Asoneindividualsuggested,“findplacestointersectwithproviderswherethey

alreadyare.Wheredotheymeet?Gotothem.”§ Ideasincludedmedicalstaffmeetings,grandrounds,conferencesormeetings

likethePrimaryCareUpdateandCMEevents.o Consistencyandtransparencyarebothimportant

§ “BHThasanear-impossibletasktotrytokeepcommunicationandtransparencyupwiththeever-changinglandscapeatthestate.Theydoagreatjobwithwhatthey’vebeengiven.ANDitwillbehelpfulforthemtokeeprefiningtheircommunicationapproachtobemoremethodical,consistent,andtransparent.”

§ “Weneedmoreconsistentcommunication,overviews,andclearpicturesofhowdecisionswillbemadeandprojectswillmoveforward.Forexample,onaweeklybasis,saying,“hereisourunderstandingofthelatestandgreatest.”

o Electroniccommunicationimprovements

§ NumerousrespondentsindicatedthattheBHTwebsiteneedstohavesimple-to-findandeasy-to-understandinformationforeachaudiencebasedontheirneeds(front-lineproviders,administrators,consumers,communitypartners,etc.).

§ Providersandpartnersarealsoaskingfor“push”notificationsofkeydecisions,timelines,opportunities,oroutcomesincarefullyconstructedandveryconciseemailorwebalerts.(Recallthe“3bullet”rulereferencedabove).Note:giventhatBHTsendsoutregularupdates,perhapsthisrequestcouldbebesthonoredwithaprovider-focusedtemplateandmailinglistand/orsentoutthroughtrustedmessengersthroughtheirchannels(e.g.,SCMSandotherassociations).

§ Providersarerequestingconsistentreportingongoals,timelines,benchmarks,andsuccesses.“Knowingprogresshasbeenmadewillmakethebiggestdifferenceinlong-termproviderengagement.”

o Learnfromcommunicationerrorsandbeopentoguidanceonhowtodobetter§ Oneexamplecitedbymanyrespondentswasthemethodusedtocommunicate

theLOIprocessforprojectideas,inparticularhowthisprocesswouldbeusedtoinformprojectselection,whatmethodologywouldbe/wasusedfor“scoring,”andwhatthenextstepswouldbe.Ingeneral,communitypartnersfelteitherconfusedordissatisfiedwiththecommunicationaboutthisprocess,whichledtoquestionsabouttransparency(oranacknowledgementthatotherscouldhavequestionedtransparencyeveniftheindividualrespondentdidn’tfeelthisway).Thiswascitedasa“learninglesson”regardinghowtoapproachcommunicationmorecarefullyadmethodicallyforfutureACHactivities.

§ Anotherexamplecitedwastheinvitationtoproviderstojointheintegratedcareteam,whereoneprovidernoted,“IreceivedanemailthatpresumedthatIwouldtakepart,butthiswasthefirstIhadheardofit.EventhoughI’minterestedandwouldlikelywanttobeinvolved,thewordingoftheemailwasoff-puttingtome.Anditseemedtocomeoutofnowhere.”

• CAPITALIZEONTRUSTEDMESSENGERSANDESTABLISHEDCOMMUNICATIONCHANNELS:

Mostrespondentsnotedthattrustedmessengershelpgetpeopletothetable:“IcometothetablewhensomeoneItrustsaystobethere.

o SuggestedtrustedorganizationsincludedtheSpokaneCountyMedicalSociety(citedbyalargepercentageofrespondents),WashingtonStateMedicalAssociation,WashingtonAcademyofFamilyPhysicians,andvariousspecialtygroupsliketheregionalmeetingofpharmacists.

§ “I’dpayattentiontosomekindoftailored,specialnotificationfromSCMS.”§ Otherscitedturningtotheirprofessionaljournalsorassociationnewslettersfor

specialtyareasofpractice.o Whenaskedforideasofotherorganizationsthatwouldbehelpfulinengaging

providers,thefollowingweresuggested:§ MedicalteachingfacilitiesinSpokane

o “Leveragethesepartnershipstoinformhowweengageprovidersnowandhowwetrainnewproviderstoengageinthefuture.”

o “WeneedtobuildontheconnectionsourUniversitypartnershavewithestablishedandemergingproviders.”

§ WashingtonStateCommunityActionPartnership§ TheHomelessCoalition§ WashingtonStateDentalSociety§ RuralHealthCoalitions§ CommunityActionCouncils§ FederallyQualifiedHealthCenters§ RuralHealthSystems§ SpecialtyPractices,withseveralrespondentsnoting,“theyaren’taroundthe

tableandhealthsystemreformwon’tworkwithoutthem.”§ PracticesseeingthemostMedicaidclients,withoneprovidersuggesting,“Look

atthedataontheprovidersthatareseeingthebiggestpercentageofMedicaidlivesandstarttalkingwiththemdirectly.”

o Severalrespondentsmentionedindividualthoughtleadersthattheywouldbelikelytorespondtoifinvitationsorcommunicationscamefromthem,includingJayFathi,MD;JohnMcCarthy,MD;TomMartin,andTomWilbur.Oneparticipantnotedthattheseprofessionalsshouldbelookedtoas“activedisseminators”duetotheirtrustedstatusintheprofessionalcommunity.

• BUILDONANDEXPANDTHEIMPACTOFTHELEADERSHIPCOUNCILANDTHEBHTBOARD:

OneofthemostcommonsstrengthscitedbyrespondentswasthebreadthanddepthofexpertiseontheBHTLeadershipCouncilandBoard,andtheprogressmadeoverthepastyeartoexpandrepresentation.o “Tapintothewealthofexpertiseatthetablealready(boardandLeadershipCouncil)

andletthemguidethenextstepsforproviderengagement.”o Respondentscalledforcontinueddevelopmentoftheseleadershipbodiestorepresent

thediversityandprofessionalcapacitiesneededtotransformthehealthsystem.o Avarietyofparticipantsspoketotheexpansionofdiversityandbuilding“atrueequity

lens,”intheworkoftheACH,includingthefollowingcomments:§ “Weneedatrulydiverseboardwithanequitylensandastrongfocuson

culturalcompetencewouldmakethebiggestdifferenceinattractingprovidersandservingtheneedsofourcommunity.”

§ “Theleadershiptable/execlevelthatcometotheboardandmeetingtablestendtobealotofwhitepeople.Weneedthevoiceofdiverseprovidersbothprovidersthemselvesandthecommunitiestheyserve.”

WhichProviderPopulationsShouldBeInformingtheWorkoftheACH?

• Respondentsnotedthat,“overallwehaveagoodcross-ectionof“theusualsuspects,”andcouldbenefitfromengagingthefollowingproviders

o FrontLineMedicalProviders§ Primarycareproviders§ HospitalistsandERPhysicians§ Pharmacyandmedmanagement§ Specialtycare§ BehavioralHealth

§ OralHealth§ Long-termCare§ Commentsincluded:

o “Wehavealotofformerprovidersintheroom,andalotofadministrators.Wereallyneedthecurrentfront-lineprovidersorMedicalDirectorswhoaretheconduittothefront-lineproviders,buttheyneedtobeaskedintotheconversationwhentheycanreallymakeadifferenceorwe’lllosethem.Wereallyneedprimarycare,dentists,ERdocsintheroomtoinformfromthereal-worldexperienceofwhat’shappening,notfromtheadministrativelens.”

o “Reachdowntothegrassrootsproviders.I'veneverseenasmallsingleowneddentistorsmallgrouppracticeorindependentmentalhealthprofessionalsattheLeadershipCouncil.”

o SocialDeterminants/SupportOrganizations§ Transportationproviders,“wehavealotofthetraditionalmedicaland

communityorganizations,butwereallyneedcreativesolutionsforhowwe’regoingtogetpeopletoappointments.”

§ Refugeeandotherminoritypopulations• Respondentsalsonotedtheneedtoensuremorediversityinproviderrepresentation,including:

o SmallerProviders§ “Aswithanybusiness,whenyoubringinthetoptieredentitiesinthe

professiontheirvoicesareusuallyconsolidatedaroundincomevs.impact.Wealsoneedtohearthevoicesofthesmallerproviderswhoaredeterminedtomakeimpactevenattheexpenseofincome.”

§ “Smallerproviders.You’regoingtogetthebigonesanyway.Someofthesmallerprovidershaveinnovativeprogramswithexcellentresults.Weshouldbelearningaboutandbuildingonthese….theyareeffectivebecausetheyarenimbleandinnovative.”

o DiverseofProviders§ “Expandourrange:rural/urban,communitiesofcolor,drugaddictionand

recovery,thoseservingtheworkingpoor,seniors,youngmothers,etc.”.§ “Weneedengagementacrossthespectrumofprovidersizesandtypes,butthe

problemisalwaysthatyoucan’ttakesmall/midandindependentpractitionersawayfromtheirpracticesorpatientsdon’thavecareandproviderscan’tgetpaid.Weneedtoaddressthis.”

o ProvidersWhoSeetheMostMedicaidClients§ “WorkmoredeeplywiththeFQHCs,ruralhealthcenters,andNativehealth

centers,whohavebeendoingmanyoftheseinnovativethingsforalongtime.Learnfromtheirexperienceandexpertise.Thesearealsotheentitiesthatareservingthehighestpercentageofthoseimpactedbythewaiver.”

§ “Smallruralhealthsystems…noteverythingcanbedefinedanddesignedbylargehealthsystemsorFQHCs.Innovationinruralcommunitiesneedstocomefromruralproviders.It'seasytofocusonurbanandbigplayerstogetthe

outcomesattheexpenseoftheareasthatdon'thavealotofaccessandmayneedthemosthelp.”

§ “Thelargerhealthsystemsthatservehugenumbersofpeople(Providence,Rockwood,etc.).That’swhoseesthelargestnumberofMedicaidlivesandsomebigopportunitiesforimpact.”

ProjectPlanningandImplementation,TransitioningintoLonger-termEngagement

§ SHORT-TERMSTRATEGIESFORPROJECTPLANNINGANDIMPLEMENTATION:Respondents

suggestedthatthemostappropriateshort-termstrategiesforsecuringinputintoprojectplanningandspecificimplementationactivitiesshouldinclude:

o “Morevoicesandmoreinnovativedialoguerightnow.”o NumerousrespondentssuggestedthatBHTrelyon“focusgroupsandforumsearlyon

tostartthewaveofcommunicationandengagement,”butthatthesemethodologieswouldnotsufficelong-termforongoingengagement.

o Asplansarecomingtogether,identifyanygapsandanyproviders,gettheminanduptospeedrightawaytoprovidetheirinsights.

o Getpeopletogetherbyprojectareaearlyandconsistentlysodecision-makingisn’tlast-minute,which“createsmoreriskoffailureandpartnerdistrust.”

o “Youwillgetthemostmeaningfulengagementifpeopleknowwhatmoneyisavailableandhowtheymighthaveareasonablechanceofaccessingsomeofittomakeadifference.”

o Seekmuchmoreproviderinvolvementearlyon“tobalancethefactthatthetoolkitissoprescriptive—theirexpertisewillhelpshapeinterventionsinmeaningfulways.”

o ManyrespondentssuggestedthatBHTshouldcultivatestructuredconversationsthatallowproviderstorespondtoprojectmodelsandideas,includingcommentssuchas:

§ “Offerideasnotina‘pre-decided’waybutinawaytheycanrespondtosomething…notjusttalkinginamorphous,open-endedways.[Providers]arefrustratedwhenit'snotagooduseoftheirtime—givethema‘strawmanproposal’torespondto.”

§ “Beginwiththeendinmind:hereiswhatasuccessfulprojectwouldlooklike,andworkbackwardfromtherewiththemtoseewhatproviderswouldneedtodotomakethathappen.Havethoseveryspecific,detailedconversationswiththemaboutthe‘how’.”

§ “Ontheportfolio…onceyouhaveit,makeaspecificplantoengagethepeoplewhoaregoingtoimpactmostorbemostimpactedbytheprioritiesandactivitiesthatareselected.Whatistheplanforsharingandexpandingthoseportfolioprocessesacrosstheregionsoitwillbeatransformedsystem?Butyoudon'twanttogotoobroad….focusondepthofinvolvementratherthaneveryoneatsuperficiallevel.

§ “Considerwhatareyougoingtodotoengageproviderswhoarecutoutoftheprojectsorwhowon'tbereceivingfunds.Haveaplanforthe‘fallout’.”

o Inputregardingcombinedandseparateplanningaudiencesandprocesses:§ Severalrespondentswantedtomakesurethatpeoplefromdifferenttypesof

systems(rural/urban,FQHC/largehealthsystem/independentproviders,primarycare/behavioralhealth,etc.)comeTOGETHERforplanninginordertomakesenseoftheglobalneedsandopportunitiesinoursystems,e.g.,“don’thaveruralandurbansystemsplanningseparately…weneedthefullcontinuumofcareandcareacrosscaretype,geography,andlifespanintheroomtocreatearationalhealthsystem.”

§ Otherrespondentsnotedthatdifferenttypesofsystemsandvariouspracticedisciplines“havedifferentlanguages,cultures,priorities,andwaysofdoingthings,soitisimportanttoletthemmeetontheirowntoworkthingsout.”Forinstance,thewayoftransforminganFQHCwouldbedifferentfromalargehealthsystemoraruralhealthsystem.“Weneedtoworktogetheronavisionandweneedtoworkindependentlyonhowthatvisiongetsenactedinourownhealthcareworld.”

§ LONG-TERMSTRATEGIESFORPROJECTIMPLEMENTATIONANDTHEBROADERVISIONOFTHE

ACH:Manyofthestrategiesforcommunicationandshort-termengagement(alldetailedpreviously)werecitedaslong-termstrategies,aswell.Additionalsuggestionsincluded:

o ManyrespondentsrepeatedlysuggestedcreatingaprovideradvisorygroupthathasrepresentationfromdiverserepresentativesfromdifferentsectorstoguidetheACHovertime.

§ Participantsrepeatedlyreferenceculturalcompetenceandrepresentationacrossthevariouspracticesofmedicine/specialties,theagespectrum,andsizesofpractices

§ “Weneedtohearmorefromprovidersthatnotonlyhavetheharddesireforthisworkbuthavelotsofeducationaboutculturalcompetence.”

§ “Wehaveagreatsystemthatproducesgoodcliniciansbutwouldlovetoseegreaterretentionofthosepeoplehere,notfleeingtoothermarkets.Wewanttoinvolveproviderswhowantimpactvs.income.Thosewhowanttostayhere,giveback,helpimprovethehealthhere.”

o Providersalsocautionedagainstrelyingexclusivelyonanadvisoryboard,because,“oneprovider’sexperienceandopinionisoneprovider’sexperienceandopinion.”Assuch,theysuggested:

§ Whendealingwithlargerorganizationsorsystems,“Usetheinternalprocessestheyhave(MedicalDirectors,providerleadershipmeetings)toincorporateknowledgefromtheirproviders,since“100providerswouldgive100answers.”Askthemtodistillwhattheyknowfromthemoreglobalproviderfeedback.”

§ “Referencethepreviously-detailedsuggestionsregardinggeneralcommunicationandengagement,suchas“gotowheretheyare”(e.g.,existingmeetingsandevents),“usetrustedadvisors”(e.g.,SCMS,specialtyassociations),and“communicatewithbetterclarityandfrequency”(e.g.,electronicdisseminationimprovements).

o Regardingalloftheabove-listedoptionsforengagingproviders,respondentssuggested:§ Schedulemeetingsandplanningattimesthatproviderscanactuallyengage

(e.g.,earlymorningorevening).§ Providealternativewaysforthemtotakepart(e.g.,videoconferencing,etc.).

§ Provideresourcesforsmallerorganizationsandpracticestoparticipate,as,“theydon’thavetheresourcesoradministrativesupportthatlargesystemshave,sotheyneedextrasupporttobeinvolved.”

HowSuccessWillBeMeasured

Whenasked,“howwillyouknowthatBHThadbeensuccessfulinmeaningfullyengagingproviders?”thefollowingthemesemerged:

• PROVIDERKNOWLEDGE,TRUST,ANDONGOINGINVOLVEMENTo “PrimaryCareProviderswouldknowwhatBHTstandsfor,andwouldknowwhat

financialimplicationsandqualityofcareimplicationswerebeingworkedon.”o “IfstrategiesthattheACHisadvancingareconsistentwithandreflectiveofinputgiven

byproviders.”o “Therightpeoplearestillatthetableandthere’senoughdepthofproviderstodothe

heavyliftforsomeoftheseprojects.”o Providersunderstandclearlyarticulatedgoals,projects,andmethodsofevaluating

them.”o “Consistentattendanceatleadershipcouncilmeetingsfromacrossthespectrumof

providers.”o “Noglaringgapsbetweenwhoisatthetableandwhoshouldbeatthetabletomake

theseinterventionssuccessful.”o “Providerskeepshowingupandaretremendouslysupportivebecausetheyseevalue

andimpact.Thiswouldmeantheyhavebeentreatedfairly,therehasbeengoodcommunication,andthereareperformancemeasuresinplaceshowingimpact.”

o “Everyorganizationthatneedstobeatthetableisthereandeverypopulationthatneedstobeatthetablesays,‘yes,thisworksformypopulation.’”

o “TheLeadershipCouncilhasexpandedtoincludeallofthegapsthatcurrentlyexist(smallpractices,independentproviders,specialty,etc.).”

o “Youwouldknowinyourgutbasedontherelationshipsandtrustthatwasbuiltthroughthisprocess.”

• COMMUNITYANDSYSTEMMETRICS

o “Wearemovingthemetricsandimprovinghealth.”o “Ifpeoplearedoingtherightthingattherighttimeintherightplaceintherightwayto

improvehealthandhealthcare.(e.g.,EmergencyRoomsareforEmergencies).”o “Trulyintegratedsystems,whereprimarycareandbehavioralhealth,hospitalsandlong

termcare,andcommunitysystemsareallsupportingbetterhealth,bettercare,betterquality,andwearereplicating(orscalingandspreading)innovativeprogramsthatreallywork,notjusttalkingaboutit.”

o "Organizationswhodidn'thistoricallytalktooneanotherareinteractinginawaythatpatientoutcomeshaveimprovedorthatpatientsaren'tfallingthroughthecracks."

o “Ifservicesforvulnerableindividuals,organizations,workforcesaren'tdestabilizedintheprocess.”

o “Successfuloutcomesontheoutcomemetrics.Theprojectsaresustainable.Ifyoudon'thearuproarfromproviders,thereisseamlessadoption,andprovidersarebeingpaidastheyshould.”

o “Asenseoftrustandawarenessthatwe'vemadeimprovementsandchanges,andweareeffectivegettingwherewewanttobe(reachingourgoals.”

o Evidenceofchange§ “Weneedtotellthestoriesoftheimpactwe’vehad…onpeople,communities,

practices.That’swhatkeepspeoplecomingback.”§ “Makesurethedataandmetricsarepairedwithstories,sothatwehavethe

numbersandthevoicesandfacessharingthesamemessage.”

• PATIENTHEALTH,SATISFACTION,ANDENGAGEMENTo “Patientsarehealthierandaretakingmoreofaproactiveroleintheirhealth.”o “Clientsarebeingpolledandtheirsatisfactionishigh.”o “Clientsaretellingustheyaregettinggoodqualityservices.

InWhatOtherWaysCanBHTContinuetoImproveProviderEngagementOverTime?

Respondentsprovidedavarietyofothercomments,requests,orcautionsregardingengagementthatdidn’treadilyfitintoothercategoriesbutmeritedinclusionhere:

• “Bemindfulofnotinadvertentlymisleadingorganizationsorbuildingexpectationsthataren'tgoingtobefulfilled.”

• “Don'tmakethingsworsebydestabilizingsystems,causingstafftoleave,makingchangesthatmakeitharderforclientstogetcare.Disruptforthebetteranddisruptforthelonghaul.Don'tpolarizeintheprocess.”

• “Worktobetterunderstandproviderorganizations’businessmodels.PartofthedifficultyisthatI'mnotsureBHThasthepracticalknowledgeinmanyoftheseareasaboutwhattheprovidersactuallydoandhowtheydoit.BHTcancomeacrossasstronginmarketingbutshallowintermsofpracticalknowledgeofthesystem,sotheyhavetocountontheproviders(andconsumers)todefineandshapethenewpriorities.ThereshouldbemoredepthofknowledgeandexpertisethatactuallyresidesatBHTitself.”

• “WeneedtomakesurewehavegoodresearchthatwillinformusappropriatelyabouthowDSRIPmodelshaveworkedelsewhereandhowtheyapplytoWashingtonstate,understandfundsflowandwhetherwehaveanequitablearrangementinplace,andlookatworkforceandclinicaldataflow--whatkindofanalyticsandhowcantheybeuseddownstream?”

• “AttendcarefullytotheviabilityofruralandTribalhealthsystems.Manyofthesechangescouldradicallydestabilizeorcausethefailureofwholesystemsthatservetheircommunities.Thenwhathavewedone?”

Regional Health Needs Inventory - Washington State … · 2017-11-20 · Regional Health Needs...

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