INTEGRATED CLINICAL CARE ED ACUTE CARE (In-patient) Care Coordination (Pathways Hub Discharge Protocols Prescribing Guidelines INTEGRATED CLINICAL CARE Bi-directional Integration of Physical & Behavioral Health Care Coordination (Pathways HUB) Chronic Disease Care Standards (Prevention & Mitigation) Prescribing Guidelines Align with Value Based Payment ED Care Coordination (Pathways Hub) Discharge Protocols Prescribing Guidelines SUD Treatment Care Coordination (Pathways Hub) Prescribing Guidelines Enhance MAT & NARCAN Services EMERGENCY MEDICAL RESPONSE ACH supports Key EMS Strategy Needle Exchange Expansion COMMUNITY CARE COORDINATON BUILD - Community care coordination – Pathways HUB OPIOID RESPONSE PLAN CONVNE: Opioid task force to identify best practices and policy and systems changes for the region. JAIL ACH supports key Jail Diversion and Transitional Care Strategies ACH INFRASTRUCTURE SUPPORTS Cross Sector Partnerships & Governance & Structure Technical Assistance & Training Project Planning Coordination & Funds Flow Management Policy, Systems, Workforce Change Identification Data, Self Monitoring Evaluation & Shared Learning Community Resiliency Fund

Demonstration Collaborative Foundational Partners ACH Care Coordination Pathways HUB JAIL Diversion & Transitions Strategies EM Response Strategies Demonstration Collaborative Foundational Partners ACUTE CARE (In-patient) SUD TREATMENT Emergency Department Jails/Criminal Justice Primary Physical and Behavioral Health Care Community Based Organizations MCOs Emergency Services

COLLABORATIVE APPROACH Participate in the Pathways HUB – Care Coordination Community Paramedicine Crisis Management Interventions to reduce acute care transfers; Pain Management (Opioid Prescribing Guidelines) TeleHealth/Telepsychiatry Emergency Department Care Transitions into Mental Health, protocols for Overdose -Naloxone Chronic Disease Management Plan - exiting ED ACUTE CARE CLINICALLY INTEGRATED CARE DELIVERY Co-Located, Integrated Participate in the Pathways HUB – Care Coordination Support Value Based Payment Examples: Telehealth/Telepsychiatry *Chronic Care Standards Chronic Disease Clinical Care Standards Chronic Disease Prevention/Mitigation Community-Based Programs *Opioid Prescribing Guidelines (to include MAT) SUD Participate in the Pathways HUB – Care Coordination Care Transitions into Mental Health, protocols for Overdose -Naloxone Chronic Disease Management Plan - exiting ED Emergency Response Jail Diversion/Transitions Participate in the Pathways HUB – Care Coordination PH/BH Needs leaving incarceration MAT Service in the Jail setting PATHWAYS HUB SERVICE: Care Coordination Agencies (CCA) certified in 20 PATHWAYS• Adult Education •Employment • Health Insurance • Housing • Medical Home • Medical Referral • Medication Assessment • Medication Management • Smoking Cessation • Social Service Referral • Behavioral Referral • Developmental Screening • Developmental Referral • Education • Family Planning • Immunization Screening • Immunization Referral • Lead Screening • Pregnancy • Postpartum SOCIAL SERVICE REFERALL PATHWAYS: Child Assistance • Family • Assistance • Food Assistance / WIC • Housing Assistance • Insurance Assistance • Financial Assistance • Medication Assistance • Transportation Assistance • Job/Employment Assistance • Education Assistance • Medical Debt Assistance • Legal Assistance • Parent Education Assistance • Domestic Violence Assistance • Clothing Assistance • Utilities Assistance • Translation Assistance • Help Me Grow

Amounts represent maximum that can be earned ACH FUNDS DISBURSEMENT OVER 5 YEAR DEMONSTRATION 10% ACH Administration Funds $ 6.3M 10%- 25% Community Resiliency Fund $ 9.5M 60% - 35% System Capacity Building Funds Technology Investments, Training - Coaching, Pathways, TA $33.4 M 20% 20% 30% SAVE 30% 40% PAYMENT 1.75 Amounts represent maximum that can be earned End of Demonstration Outcome Payment Pool

ROLES & FUNCTIONS FUNCTION ACCOUNTABLE COMMUNITY OF HEALTH REGIONAL ROLE Collective of cross-sector partners COLLABORATIVE ROLE Collective of Key Partners for Transformation Implementation Cross Sector Partnerships Governance & Structure Board, RHIP Council, Community Voice System, Behavioral Health Advisory, Integration Panel, Data & Learning Team, Business Group Coordinate cross-sector stakeholders for collective action (Opioid T.F.) Ensure authentic community voice & engagement Pooled resources/funding Fund flow decisions Develop Collaborative membership Collaborative Partner Commitments Coordinate cross-sector partners for collective action Data & Evaluation Collect, analyze cross sector data Monitor regional performance and measure impact Identify efficiencies/savings Respond to Self Monitoring Requirements Course Correction As Needed Shared Learning Foster innovation through cross-sector dialogue and action Inform the community about regional health system transformation work and impact Share learnings in a meaningful way Participate in Shared Learning Opportunities Identify policy, systems, and community condition barriers Project Planning Support the development of a Regional Health Improvement Plan (RHIP) Coordinate MTD health transformation projects (which includes 1) reporting back to the state 2) communicating all project requirements to the collaborative along with providing TA where available and 3) support Pay for Performance and VBP alignment Identification of gaps, prioritize community needs Perform system analyses, focusing on big picture and system linkages Aggregate resources for transformation projects Advocate for policy and system changes Pool investment into prioritized community need Develop individual Collaborative project plan to include; Needs assessment, target populations, shared measures, identification of workforce issues, description of technology and health information exchange barriers and needs, assessment of VBP readiness and strategies to support attainment of VBP targets, identify technical assistance and training needs, data and analytic support gaps, and initial budget of anticipated costs (to include matching funds/resources). Care Coordination Create the Pathways HUB community-based care coordination service to the region that supports a wide variety of ACH goals. Develop out the Community care coordinators (CCCs)—community health workers, nurses, social workers, and others—who reach out to at-risk individuals through home visits and community-based work. Participate as Community care coordinators (CCCs)—community health workers, nurses, social workers, and others—who reach out to at-risk individuals through home visits and community-based work; and/or Participate as Referral Agencies within the Care Coordination HUB Jail Diversion Emergency Medical Response Partner with the Jail Systems Opioid Supporting the design of a best practices for the Demonstration transformation Collaboratives to address the opioid crisis in the SW ACH region. Use region wide list of best practices inform opioid strategy development and section. Use the Opioid T.F. to support any policy and systems barriers Project Plan Implementation Monitor and Support Project Plan Implementation IMPLEMENT THE PROJECT PLAN! How to handle partners, like county jail systems, needing to be at the table for each collaborative MCO role? Public health role? If you are working with a large system – which health system partners to you require to have at the table? Seems like it should be mostly Primary Care? Which primary care clinics – how to focus to set of clinics that will move the dial? Or is there a threshold that the ACH should set for % Medicaid served to be a Collaborative lead? How will regional differences impact the Collaborative model? (for example – should it be health-system centric or geographic?)