AHC Online Work Session
Accountable Health Communities (AHC) Model Grant March 16, 2016
www.hcgc.org
www.nationwidechildrens.org
Today’s Agenda
• Review the AHC Model Overview • Review Collaborative Work That Has Already Taken Place • Explore AHC Key Driver Diagram • Explore subpopulations impacted by health disparities in the community • Next Steps
www.hcgc.org
www.nationwidechildrens.org
Model Background
The Accountable Health Communities (AHC) model addresses a critical gap between clinical care and community services in the current health care delivery system by testing whether systematically identifying and addressing the health-related social needs of beneficiaries’ impacts total health care costs, improves health, and quality of care.
www.hcgc.org
www.nationwidechildrens.org
Key Dates
• LOI Due (Optional & Non-Binding): February 8, 2016 • Proposal Due: May 18, 2016 • Grant Awarded: March 3, 2017 • Grant Period: April 1, 2017 – March 31, 2022
www.hcgc.org
www.nationwidechildrens.org
Model Background
What will it take to advance AHC in Greater Columbus?
State Medicaid Agency Social Service Agencies
Referral Infrastructur e
Bridge Organization
Providers -1 Hospital
www.hcgc.org
Evaluation
Care Coordinatio n
-1 PCP -1 Behavioral Health
Screening Tools
Fiscal Role
www.nationwidechildrens.org
What does the model fund?
Over a five-year performance period, CMS will implement and test a three-track model: • Track 1 – Awareness: Increase beneficiary awareness of available community services through information dissemination and referral • Track 2 – Assistance: Provide community service navigation services to assist high-risk beneficiaries with accessing services • Track 3 – Alignment: Encourage partner alignment to ensure that community services are available and responsive to the needs of beneficiaries www.hcgc.org
www.nationwidechildrens.org
Exploring the Funding Tracks
Track 3 - Alignment
www.hcgc.org
www.nationwidechildrens.org
Health-Related Social Needs
Core Needs (Required) Housing Instability Utility Needs Food Insecurity Interpersonal Violence Transportation
Grantees will be required to screen beneficiaries for all of the core health-related social needs.
Grantees can choose to screen for supplemental health-related social needs. Other needs can be identified by the community.
www.hcgc.org
Supplemental Needs Family & Social Supports Education Employment & Income Health Behaviors Others www.nationwidechildrens.org
Partner Roles
• State Medicaid Agency • Clinical Providers • At least 1 primary care provider • At least 1 hospital system • At least 1 behavioral health provider • Community Service Providers • Bridge Organization www.hcgc.org
www.nationwidechildrens.org
Goals of AHC Model Grant
• Address gap between clinical care and community services, improve collaboration • Identify and address health-related social needs • Reduce healthcare cost • Reduce inefficient use of healthcare services • Improve healthcare www.hcgc.org
www.nationwidechildrens.org
AHC Model Overview
Questions of Clarity?
www.hcgc.org
www.nationwidechildrens.org
AHC Model Grant
Review Collaborative Work That Has Already Taken Place
www.hcgc.org
www.nationwidechildrens.org
Exploratory Session Recap
What Geographic Area has the greatest opportunity to be impacted by the AHC Grant? Collaborative Agreement •
Implement screening process for all patients in Columbus/Franklin County
•
Start by providing patient navigation and measurement to beneficiaries in targeted zip codes. Targeted zip codes TBD
•
Spread navigation and measurement throughout the community over time.
www.hcgc.org
www.nationwidechildrens.org
Target Zip Codes
Proposed Zip Codes • 43207 • 43223 • 43224 • 43123 • 43228 • 43227 • 43219 • 43206 • 43232 • 43205 • 43211 • 43068 • 43229 • 43231 • 43204 • 43213 Additional Zip Codes Added
www.hcgc.org
www.nationwidechildrens.org
Exploratory Session Recap
What is a good place to start for health-related social needs? Collaborative Agreement •
Grant application will focus on core needs.
•
Patient navigators will address supplemental needs with patients on an individual basis.
•
Many supplemental needs will have to be addressed to impact core needs.
www.hcgc.org
www.nationwidechildrens.org
Exploratory Session Recap
What organizations have the interest and capacity to fill various project and grant writing roles? Collaborative Agreement •
Collaborative grant application led in partnership between Nationwide Children’s Hospital (NCH) & HCGC
•
NCH serving as the formal bridge
•
HCGC serving as neutral convener of community partners
www.hcgc.org
www.nationwidechildrens.org
Key Driver Diagram
• Key Driver Diagram (KDD): Quality improvement tool depicting a project’s aims/goals and cascading strategies for achievement.
Ex)
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www.nationwidechildrens.org
Key Driver Diagram
• Definitions: –“Global Aim”: Vision, ideal or overarching purpose –“Aim Statement”: Specific, Measureable, Achievable, Realistic, Time-bound (SMART) goal(s) for the project –“Primary Drivers”: Forces that directly impact the achievement of your Aim Statement –“Interventions”): Action steps and/or strategies for impacting the Primary Drivers to the desired effect.
www.hcgc.org
www.nationwidechildrens.org
Key Driver Diagram
• Types of Measures on a KDD: –Outcome: Measures the health, finance or clinical outcome of a targeted population or system. • Ex) readmissions, quality of life, total cost of care
–Process: Represents the effectiveness of a process which was implemented to affect an outcome measure. • Ex) waitlisted patients, days between referrals, turnaround time.
www.hcgc.org
www.nationwidechildrens.org
Key Driver Diagram
• Benefits to using a KDD:
–Reinforces desired project outcome (aim) –Defines the key leverage points, or system “drivers” –Links specific project activities and changes (the “hows”) to key components in the system –Ensures project progress and results are measured and monitored –Facilitates stakeholder buy-in and commitment by providing transparency around changes required for project success
www.hcgc.org
www.nationwidechildrens.org
Global Key Driver Diagram O: % navigated HRCDBs w/ unmet needs
Aim Statement •
•
P: #/% of CDB screened/year
Every year, connect at least 3,000 high-risk community-dwelling beneficiaries (HRCDB) with unmet health-related social needs (HRSN) to a community-based navigator, with a goal of >75% of HRCDBs completing referrals from 4/1/2018 O: % decrease in navigated to 9/30/2021 NRCDB’s TCOC Reduce service gaps in each of the 5 core HRSN domains through the implementation of a sustained, collaborative quality improvement project series beginning 7/1/2018.
O: % increase in navigated HRCDB’s QOL
P: #/% of HRCDB navigated/yr
P: #/% of HRCDB referred/year
Primary Drivers Established Navigation System across Clinical Service Delivery Sites
Inventory local community service providers responsive to community needs assessment Develop and implement front-end HRSN screening tool for CBDs seen at clinical sites
Community Resource Partner Alignment through Quality Improvement
Design and disseminate referral and navigation policies & procedures including training plan Establish Advisory Board to oversee availability of community services and support data sharing
Data-Driven Infrastructure, Monitoring and DecisionMaking
Develop targeted action plans for the equity subpopulations including pre/post-intervention Complete gap analysis and quality improvement goals with community service provider network Recruit and/or contract, and train navigation services staff for high-risk beneficiaries
Capacity & Efficiency of Community Service Providers
Reduce inefficient use of inpatient and outpatient health care services through resolution of unmet health-related social needs (HRSN) O: % increase in CDB literacy
P: # updates to CRI/year
Secure subcontracts, consultant agreements, IRB approval, and collaborative reporting structure
P: % referred on waiting list
Global Aim (Vision)
Interventions
Design and implement data monitoring and analysis system for back-end reporting to CMMI Recruit or secure staff member at Ohio Dept. of Medicaid to assist with data collection
Resource Awareness and Health Literacy of CDBs
Establish mechanism for monitoring and reducing duplication of program services P: # QI projects completed/yr
P: % trained w/i 30 days
Key Driver Diagram
Questions of Clarity?
www.hcgc.org
www.nationwidechildrens.org
Key Driver Diagram
What reflections can you share about this Key Driver Diagram?
www.hcgc.org
www.nationwidechildrens.org
Health Equity Definition
–Study and causes of differences in the quality of health and healthcare across different populations (race, ethnicity, gender, disability status, language, and/or geographic area)
–Equal opportunity to attain their highest level of health –Achieved by addressing social determinants –Inequities exist when barriers prevent individuals from reaching their full potential
www.hcgc.org
www.nationwidechildrens.org
AHC Health Resource Equity Statement (HRES) Purpose
–Identify and target minority and underserved populations –Assess the geographic target area in relation to targeted subpopulation –Evaluate the inclusion of subpopulations in the AHC interventions –Track progress on outcomes and engagement of these subpopulations
www.hcgc.org
www.nationwidechildrens.org
AHC Health Resource Equity Statement (HRES)
Questions of Clarity?
www.hcgc.org
www.nationwidechildrens.org
HRES Proposed Subpopulations
What subpopulations are a good place to start? – AHC Grant must focus on 3-5 subpopulations – Proposed subpopulations 1. Women of childbearing age 2. Children with medical complexity (ABD) 3. African Immigrants 4. Dually eligible individuals with mental health issues www.hcgc.org
www.nationwidechildrens.org
HRES Proposed Subpopulations
What reflections can you share about the proposed subpopulations?
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www.nationwidechildrens.org
HRES Proposed Subpopulations
• Are there additional subpopulations that should be considered for the AHC? • Should any of the proposed subpopulations be removed?
www.hcgc.org
www.nationwidechildrens.org
Next Steps
•
HCGC and Nationwide Children’s will use feedback to continue shaping the AHC Grant Application
•
Michelle and Deena will be following up with individual organizations to secure their commitment to participate
•
May 5 Final Pass Webinar
www.hcgc.org
www.nationwidechildrens.org