accountable health communities final webinar

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Accountable Health Communities

Accountable Health Communities (AHC): A CMS/CMMI Grant Opportunity

Final Webinar

May 5, 2016

www.nationwidechildrens.org1

www.hcgc.org www.nationwidechildrens.org2

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

Agenda

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Objectives

www.nationwidechildrens.org

• 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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Agenda


Model & Partner Overview

UpstreamColumbus

Medicaid & MOUsQuality

Improvement

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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


www.hcgc.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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Health-Related Social Needs

Core Needs (Required)

Housing Instability

Utility Needs

Food Insecurity

Interpersonal Violence

TransportationSupplemental Needs

Family & Social Supports

Education

Employment & Income

Health Behaviors

Others

1. Grantees will be required to screen beneficiaries for all of the core health-related social needs.

2. Grantees can choose to screen for supplemental health-related social needs. Other needs can be identified by the community.


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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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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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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

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• 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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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

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www.hcgc.org

Agenda



UpstreamColumbus


Improvement

Beneficiary Activity Management and Reporting System

Eligibility Screen

Needs Screen

Risk Level?

Community Resource Summary

Franklin County

Pathways Community

Hub

Medical Neighborhood

Referral Infrastructure

Tool (CliniSync)

Navigation Tracker

Tool

Clinical Delivery Site

Low

Navigator

Community Service ProviderWeb-based Tool

Web-based Tool

Screening Tool

www.hcgc.org www.nationwidechildrens.org13Exits

Dat

a

Ineligib

le

Ohio Medicaid

Data

Tracked

Sample schematic of “UpstreamColumbus” proposal for AHC grant:


Eligibility Screen

Needs Screen

Risk Level?


Franklin County

Pathways Community

Hub



Tool (CliniSync)

Navigation Tracker

Tool


Low

Navigator


Web-based Tool

Screening Tool


Dat

a

Ineligib

le

Ohio Medicaid

Data

Tracked


Clinical Delivery Sites


Eligibility Screen

Needs Screen

Risk Level?


Franklin County

Pathways Community

Hub



Tool (CliniSync)

Navigation Tracker

Tool


Low

Navigator


Web-based Tool

Tailored Referral Summary


Dat

a

Ineligib

le

Ohio Medicaid

Data

Tracked


HandsOn Central Ohio & 2-1-1


Eligibility Screen

Needs Screen

Risk Level?


Franklin County

Pathways Community

Hub



Tool (CliniSync)

Navigation Tracker

Tool


Low

Navigator


Web-based Tool

Navigation & Community Resource Inventory


Dat

a

Ineligib

le

Ohio Medicaid

Data

Tracked


Franklin County Pathways

Community Hub


Eligibility Screen

Needs Screen

Risk Level?


Franklin County

Pathways Community

Hub



Tool (CliniSync)

Navigation Tracker

Tool


Low

Navigator


Web-based Tool

Collaborative Progress on AHC Application


Dat

a

Ineligib

le

Ohio Medicaid

Data

Tracked


Data Sharing

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Target Zip Codes

Zip Codes• 43207 • 43224 • 43228 • 43219 • 43232 • 43211 • 43229• 43204• 43215 • 43222

• 43223 • 43123 • 43227 • 43206 • 43205 • 43068 • 43231• 43213• 43203• 43212


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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

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www.hcgc.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

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Agenda



UpstreamColumbus


Improvement

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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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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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Memorandum of Understanding


• Community Service Provider MOU


–Referral and intervention tracking and reporting

–Resource and outcome tracking and reporting

–Advisory Board participation



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• Advisory Board Letter of Commitment


–Organization type that Advisory Board Participant is representing

–Data sharing awareness



• Letter of Commitment– Indicates organizational support to the community project

– Expresses understanding of goals and expectations of the project

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Letters of Commitment

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Agenda



UpstreamColumbus


Improvement

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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

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Global Key Driver Diagram

Primary DriversAim Statement

Interventions

• 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

Global Aim (Vision)

Capacity & Efficiency of

Community Service Providers

Secure subcontracts, consultant agreements, IRB

approval, and collaborative reporting structure

Established Navigation

System across Clinical Service

Delivery Sites

Data-Driven Infrastructure,

Monitoring and Decision-

Making

Resource Awareness and

Health Literacy of CDBs

Aligned Population Health

Planning and Implementation

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

Establish Advisory Board to oversee availability of

community services and support data sharing

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

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 management

Establish mechanism for monitoring and reducing

duplication of program services

Reduce and resolve unmet

health-related social needs (HRSN) to

reduce inefficient use of inpatient

and outpatient healthcare

services

P: #/% of HRCDB navigated/yr

P: #/% of CDB screened/year

P: % referred on waiting list

O: % increase in navigated

HRCDB’s QOL

Inventory local community service providers

responsive to community needs assessment

P: # updates to CRI/year

O: % increase in CDB literacy

P: # QI projects completed/yr

P: % trained w/i 30 days

O: % navigated HRCDBs w/

unmet needs

O: % decrease in navigated

NRCDB’s TCOC

Develop targeted action plans for the equity

subpopulations including pre/post-intervention

P: #/% of HRCDB referred/year

Integrate gap analysis and QI plans into local

community health implementation strategies

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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

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Exploratory Time

Questions of clarity?


accountable health communities final webinar

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