Accountable Health Communities
Accountable Health Communities (AHC): A CMS/CMMI Grant Opportunity Final Webinar
May 5, 2016
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www.hcgc.org
www.nationwidechildrens.org
Agenda
Topic
Presenter
Model & Partner Overview
Michelle Missler, LSW, Healthcare Collaborative of Greater Columbus
UpstreamColumbus
Deena Chisolm, PhD, Nationwide Children’s Hospital
Medicaid Partnership & MOUs
Morna Smith, PhD, Nationwide Children’s Hospital
Quality Improvement Process
Naomi Makni, MHA Nationwide Children’s Hospital
Questions of clarity
ALL
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www.hcgc.org
www.nationwidechildrens.org
Objectives
• Who are the partners on the Central Ohio Accountable Health Communities grant proposal?
• What are the key components of the Accountable Health Communities model grant? • What will UpstreamColumbus, Central Ohio’s unique Accountable Health Communities model grant proposal, look like in our community?
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www.hcgc.org
www.nationwidechildrens.org
Agenda
Model & Partner Overview
UpstreamColumbus
Medicaid & MOUs
Quality Improvement 4
www.hcgc.org
www.nationwidechildrens.org
AHC Model Goals
• 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
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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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www.hcgc.org
www.nationwidechildrens.org
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 7
www.hcgc.org
www.nationwidechildrens.org
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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www.hcgc.org
www.nationwidechildrens.org
Clinical Delivery Sites
Clinical Delivery Sites committed to collaborative grant application • • • • • • • • •
Columbus Area Health Integrated Services Central Ohio Primary Care Equitas Health (AIDS Resource Center) Lower Lights Christian Health Center Mount Carmel Health Partners Nationwide Children’s Hospital The Ohio State University Wexner Medical Center OhioHealth PrimaryOne Health
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www.hcgc.org
www.nationwidechildrens.org
Community Partners
Community Service Providers and Advisory Organizations committed to collaborative grant application • • • • • • • • • • • •
Alliance Healthcare Anthem Blue Cross and Blue Shield Asian American Community Services Central Ohio Area Agency on Aging Columbus Public Health Community Shelter Board Central Ohio Transit Authority Franklin County NAMI Franklin County Pathways Community HUB Franklin County Public Health HandsOn Central Ohio LifeCare Alliance
• • • • • •
Mid-Ohio Foodbank Molina National Church Residences Ohio Commission on Minority Health Ohio Health Information Partnership-CliniSync Ohio State University Center for Public Health Practice • Ripple Life Care Planning • United Way of Central Ohio
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www.hcgc.org
www.nationwidechildrens.org
Advisory Board Role
• Advisory Board – Made up of representatives from: • • • • • •
Bridge Organization Medicaid Each Clinical Delivery Site Each Community Service Provider Community & Government Agencies Payers
– HCGC will convene meetings utilizing the existing Medical Neighborhood Learning Group forum – Will utilize a Collective Impact Approach to analyze and address gaps and barriers to services in our community – Will create a safe space to engage meaningful work to improve the care for the community dwelling beneficiaries 11
www.hcgc.org
www.nationwidechildrens.org
Agenda
Model & Partner Overview
UpstreamColumbus
Medicaid & MOUs
Quality Improvement 12
www.hcgc.org
www.nationwidechildrens.org
Screening Tool
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
www.hcgc.org
Exits
Community Resource Summary
Medical Navigation Neighborhood Tracker Referral Tool Navigator Infrastructure Tool (CliniSync)
Tracked 13
www.nationwidechildrens.org
Screening Tool
Sample schematic of “UpstreamColumbus� proposal for AHC grant: Clinical Delivery Sites
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
www.hcgc.org
Exits
Community Resource Summary
Medical Navigation Neighborhood Tracker Referral Tool Navigator Infrastructure Tool (CliniSync)
Tracked 14
www.nationwidechildrens.org
Tailored Referral Summary
Sample schematic of “UpstreamColumbus� proposal for AHC grant:
Data
Data
Beneficiary Activity Management and Reporting System
Needs Screen
Eligibility Screen
www.hcgc.org
Ineligible
Clinical Delivery Site
Web-based Tool
Exits
Ohio Medicaid
Risk Level? Community Service Provider
Web-based Tool
Low
Community Resource Summary
Medical Navigation Neighborhood Tracker Franklin Referral Tool Navigator County Infrastructure Pathways Tool Community (CliniSync) Hub
HandsOn Central Ohio & 2-1-1
Tracked 15
www.nationwidechildrens.org
Navigation & Community Resource Inventory
Sample schematic of “UpstreamColumbus� proposal for AHC grant:
Data
Beneficiary Activity Management and Reporting System
Needs Screen
Eligibility Screen
www.hcgc.org
Ineligible
Clinical Delivery Site
Web-based Tool
Exits
Franklin County Pathways Data Community Hub Ohio Medicaid
Risk Level? Community Service Provider
Web-based Tool Low
Community Resource Summary
Medical Navigation Neighborhood Franklin Tracker Referral County Tool Navigator Infrastructure Pathways Tool Community (CliniSync) Hub
Tracked 16
www.nationwidechildrens.org
Collaborative Progress on AHC Application
Sample schematic of “UpstreamColumbus� proposal for AHC grant: Beneficiary Activity Management and Reporting System
Data
Data
Data Sharing
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
www.hcgc.org
Exits
Community Resource Summary
Medical Navigation Neighborhood Tracker Referral Tool Navigator Infrastructure Tool (CliniSync)
Tracked 17
www.nationwidechildrens.org
Target Zip Codes
Zip Codes • 43207 • 43224 • 43228 • 43219 • 43232 • 43211 • 43229 • 43204 • 43215 • 43222
• • • • • • • • • •
www.hcgc.org
43223 43123 43227 43206 43205 43068 43231 43213 43203 43212
www.nationwidechildrens.org
AHC Geographic Target Location
Collaborative community development initiatives currently underway in the target area: –Celebrate One –Healthy Neighborhoods/Healthy Families –Partners Achieving Community Transformation –The Weinland Park Collaborative –Franklin County Pathways Community HUB –Medical Neighborhood Referral Infrastructure Project www.hcgc.org
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www.nationwidechildrens.org
AHC Geographic Target Location
Health equity populations of focus: • Women of childbearing age – AHC will support the city’s goal of reducing infant mortality by facilitating access to new mothers, pregnant women, and women who may become pregnant
• Children with medical complexity – As this is the highest cost pediatric population, addressing health related social needs could have a noteworthy influence on cost
• African immigrants – Columbus is home to the second largest Somali immigrant population in the nation – African-born immigrants make up 23% of Columbus’ foreign born population
www.hcgc.org
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www.nationwidechildrens.org
Agenda
Model & Partner Overview
UpstreamColumbus
Medicaid & MOUs
Quality Improvement 21
www.hcgc.org
www.nationwidechildrens.org
Medicaid Partnership
• State of Ohio Medicaid – Utilization of T-MSIS system – Medicaid data responsibility – Annual duplicative services review – Advisory Board participation – Ensure alignment with existing policy – Waiver and State Plan Amendments to achieve scalability and sustainability if the model is successful – Annual verification of community dwelling beneficiaries ED utilization – Participate in annual gap analysis – Assist in Quality Improvement project work
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www.hcgc.org
www.nationwidechildrens.org
Memorandum of Understanding
• Clinical Delivery Site MOU – Goals of the AHC model – Outlines project clinical setting-Hospital, Behavioral Health, Primary Care – Description of population served at the clinical delivery site in the previous 12 months – Number of community dwelling beneficiaries who utilized the ED in the previous 12 months – Screening process protocols – Clinical delivery site data responsibility – Advisory Board participation – Participate in annual gap analysis – Assist in Quality Improvement project work
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www.hcgc.org
www.nationwidechildrens.org
Memorandum of Understanding
• Community Service Provider MOU – Goals of the AHC model – Referral and intervention tracking and reporting – Resource and outcome tracking and reporting – Advisory Board participation – Participate in annual gap analysis – Assist in Quality Improvement project work
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www.hcgc.org
www.nationwidechildrens.org
Letters of Commitment
• Advisory Board Letter of Commitment – Goals of the AHC model – Organization type that Advisory Board Participant is representing – Data sharing awareness – Participate in annual gap analysis – Assist in Quality Improvement project work
• Letter of Commitment – Indicates organizational support to the community project – Expresses understanding of goals and expectations of the project 25
Agenda
Model & Partner Overview
UpstreamColumbus
Medicaid & MOUs
Quality Improvement 26
www.hcgc.org
www.nationwidechildrens.org
Quality Improvement
Quality Improvement Plan • Will be informed by Advisory Board’s annual Gap Analysis • Goals – Capacity for meeting health related social needs across providers – Data sharing across providers – Outcome of impact made to the health & well-being of target population
• Utilize Plan-Do-Study-Act model – Teams will be created to work on QI action items identified by Advisory Board • • • •
Planning a response (Plan) Implementing a response (Do) Evaluate results (Study) Decide on next steps (Act)
– Team will be lead by content Champion and convened by UpstreamColumbus facilitator • Will provide updates at each Advisory Board meeting 27
www.hcgc.org
www.nationwidechildrens.org
Global Key Driver Diagram O: % navigated HRCDBs w/ unmet needs
Aim Statement •
•
P: #/% of HRCDB navigated/yr
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 to 9/30/2021 Identify and resolve service gaps in each of the 5 core HRSN domains through the implementation of a continuous county-wide population health improvement plan to begin in 7/1/2018
P: # updates to CRI/year P: #/% of HRCDB referred/year
Primary Drivers
Interventions Secure subcontracts, consultant agreements, IRB approval, and collaborative reporting structure
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 Design and disseminate referral and navigation policies & procedures including training plan
Aligned Population Health Planning and Implementation
Establish Advisory Board to oversee availability of community services and support data sharing
O: % decrease in navigated NRCDB’s TCOC
Integrate gap analysis and QI plans into local community health implementation strategies
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
O: % increase in navigated HRCDB’s QOL
P: % referred on waiting list
Capacity & Efficiency of Community Service Providers
Recruit and/or contract, and train navigation services staff for high-risk beneficiaries
Global Aim (Vision)
Design and implement data monitoring and analysis system for back-end reporting to CMMI
Reduce and resolve unmet health-related social needs (HRSN) to reduce inefficient use of inpatient and outpatient healthcare services O: % increase in CDB literacy
Recruit or secure staff member at Ohio Dept. of Medicaid to assist with data management
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
Next Steps
• Grant submitted by May 18
• Will know if we received the grant by March, 2017 • AHC grant partners will be invited to join the Medical Neighborhood Learning Group • HCGC will work to incorporate the work of the grant into that Learning Group to continue the momentum 29
www.hcgc.org
www.nationwidechildrens.org
Exploratory Time
Questions of clarity?
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www.hcgc.org
www.nationwidechildrens.org