Accountable Health Communities
Accountable Health Communities (AHC): A CMS/CMMI Grant Opportunity HCGC Regional Learning Session April 8, 2016 1
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Today’s Agenda
Define and Explore Existing Accountable Health Communities Models
Introduce the Accountable Health Communities (AHC) CMMI Grant Opportunity
Review Collaborative Progress on AHC Application Strategy
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Define and Explore AHC Models
Accountable Health Communities: What Do they Do? • Address gaps between clinical care and community services, improve collaboration
• Identify and address health-related social needs • Reduce inefficient use of healthcare services and overall cost • Improve health status • Reduce health disparities 3
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Define and Explore AHC Models
Case Study #1: Washington Accountable Communities of Health • Funded by 12% of SIM award to HCA’s “Healthier Washington” • Created 9 ACH regions in 2015 – Matches Medicaid’s regional service areas – Regional, cross-sector governance – Regional Health Improvement Plans
• Alignment with concurrent HW efforts
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Define and Explore AHC Models
Regions range from 1-10 counties • King & Pierce = 2.8M (40% of WA)
Regional Health Improvement Plans
– 23% Medicaid enrollees
Types of “Backbone” organizations: • Local public health • Community-based orgs • Nonprofits (dual)
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Define and Explore AHC Models
Case Study #2: Minnesota Accountable Communities for Health • Funded by 14% of SIM award to DHS and MDH’s “Accountable Health Model” • Created 3 AHCs in 2013, 12 in 2015 – Multi-sector care coordination – ACO provider contracts – Multi-payer alignment
• Builds on infrastructure from 2013 Medicaid demonstration (IHP)
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Define and Explore AHC Models
• Eligible organization types: “…tribes, community or consumer organizations, public health boards, health plans, counties, health care providers, or any other non-profit or for profit entity located in the State of Minnesota.” • $185K/year/ACH for 2 years
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Define and Explore AHC Models
• ACH essentials: – Target population – Advancing health equity strategies – Community engagement – Community partnerships – Quality infrastructure and measurement – Accountable Care Organization partnership – Health reform history
• Within 24 months, must create: – Leadership team – Community based care coordination system/team – Population based prevention – Sustainability plan – Measurement plan – Learning Collaborative
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www.hcgc.org
www.nationwidechildrens.org
Today’s Agenda
Define and Explore Existing Accountable Health Communities Models
Introduce the Accountable Health Communities (AHC) CMMI Grant Opportunity
Review Collaborative Progress on AHC Application Strategy
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www.hcgc.org
www.nationwidechildrens.org
CMMI AHC Grant Opportunity
In January 2016, CMS/CMMI announced the Accountable Health Communities collaborative grant opportunity. Application Timelines • Letter of Intent Due (Optional & Non-Binding): February 8, 2016 • Grant Applications Due: May 18, 2016 • Grant Awarded: March 3, 2017 • Grant Period: April 1, 2017 – March 31, 2022
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CMMI AHC Grant Opportunity
CMMI’s describes an Accountable Health Community as a regional partnership managing the total health of public beneficiaries. Partners include: • State Medicaid Agency • Bridge Organization • Clinical Providers • At least 1 primary care provider • At least 1 hospital system • At least 1 behavioral health provider • Community Service Providers • Advisory Board
Payer
Beneficiary Community Services
Provider
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Health-Related Social Needs
Core Needs (Required) Housing Instability Utility Needs Food Insecurity Interpersonal Violence Transportation 2. Grantees can choose to screen for supplemental health-related social needs. Other needs can be identified by the community.
1. Grantees will be required to screen beneficiaries for all of the core health-related social needs.
Supplemental Needs Family & Social Supports Education Employment & Income Health Behaviors Others 13
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Key Grant Components
Referral Infrastructure
State Medicaid Agency
Social Service Agencies
Screening Tools
Bridge Organization
Evaluation
Providers • 1 PCP • 1 Hospital • 1 Behavioral Health
Care Coordination Fiscal Role
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www.hcgc.org
www.nationwidechildrens.org
Today’s Agenda
Define and Explore Existing Accountable Health Communities Models
Introduce the Accountable Health Communities (AHC) CMMI Grant Opportunity
Review Collaborative Progress on AHC Application Strategy
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Collaborative Progress on AHC Application
Formal Bridge Organization • Grants management and reporting functions • Interfacing with Ohio Medicaid • Coordinate evaluation • Engage provider community on the screening and referral
Co-Lead Convener Role • Engaging community service partners • Coordinating/developing the navigator approach and linkages
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Collaborative Progress on AHC Application
Clinical Delivery Sites committed to collaborative grant application • • • • • • • • • • • • •
Affirmative Counseling Associates Columbus Area Health Integrated Services Central Ohio Primary Care Heart of Ohio Family Health Center Lower Lights Christian Health Center The Medical Group of Ohio Mount Carmel Nationwide Children’s Hospital The Ohio State University Wexner Medical Center OhioHealth PrimaryOne Health Southeast, Inc. Syntero 17
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Collaborative Progress on AHC Application
Community Service Providers and Advisory Organizations committed to collaborative grant application • • • • • • • • • • • • • •
AbbVie Affirmative Counseling Associates AIDS Resource Center Ohio Alliance Healthcare Partners American Cancer Society Anthem Asian American Community Services AST Battelle CBIZ Charitable Pharmacy Central Ohio Area Agency on Aging Columbus Public Health Community Shelter Board
• • • • • • • • • • • • • •
Central Ohio Transit Authority Duet Health Evi-Base Community Care Findley Davies, Inc. Franklin County Pathways Community HUB Franklin County Public Health Franklin International HandsOn Central Ohio Helper Holdings, LLC dba Caliber Patient Care InHealth Mutual InXite Health Lifecare Alliance Medical Mutual Mercer Health 18
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Collaborative Progress on AHC Application
Community Service Providers and Advisory Organizations committed to collaborative grant application • • • • • • • • • • • • •
Mid-Ohio Foodbank Molina National Church Residences Ohio Association of Area Agencies on Aging Ohio Association of Free Clinics Ohio Commission on Minority Health Ohio Department of Health-Help Me Grow Ohio Health Information Partnership Ohio Public Employees Retirement System Ohio State University Ohio State University College of Pharmacy Ohio State University College of Public Health Ohio University College of Health Sciences and
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• • • • • • • • • • •
Professions Pataskala Medical Center Pfizer Ripple Life Care Planning Summit Orthopaedic Home Care Syntero, Inc. Total Wellness Concepts, LLC UHCAN United Way of Central Ohio UnitedHealthcare UnitedHealthcare Community Plan of Ohio YMCA
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Collaborative Progress on AHC Application
Proposed Target Zip Codes • 43207 • 43223 • 43224 • 43123 • 43228 • 43227 • 43219 • 43206 • 43232 • 43205 • 43211 • 43068 • 43229 • 43231 • 43204 • 43213 Additional Zip Codes Added
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Collaborative Progress on AHC Application
Track 3 - Alignment
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Collaborative Progress on AHC Application
Sample schematic of “UpstreamColumbus� proposal for AHC grant: Beneficiary Activity Management and Reporting System
Data
Data
Needs Screen
Eligibility Screen Ineligible
Clinical Delivery Site
Web-based Tool
Ohio Medicaid
Risk Level? Community Service Provider
Web-based Tool
Low Franklin County Pathways Community Hub
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Exits
Community Resource Summary
Medical Navigation Neighborhood Tracker Referral Tool Navigator Infrastructure Tool (CliniSync)
Tracked 22
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Collaborative Progress on AHC Application
• Key Driver Diagram (KDD): Quality improvement tool depicting a project’s aims/goals and cascading strategies for achievement.
Ex)
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Collaborative Progress on AHC Application
• Definitions: –“Global Aim”: Vision, ideal or overarching purpose –“Aim Statement”: Specific, Measureable, Achievable, Realistic, Timebound (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.
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Collaborative Progress on AHC Application
• 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.
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Collaborative Progress on AHC Application
• 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
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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
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Exploratory Time
Questions of Clarity
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Contact Information
Naomi Makni (Naomi.Makni@NationwideChildrens.org) Michelle Missler (michelle@hcgc.org)
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