Greater Columbia Accountable Community of Health Yakima Valley Conference of Governments 10-19-16

Washington State vision for creating healthier communities and a more sustainable health care system by: Building healthier communities through a collaborative regional approach Ensuring health care focuses on the whole person - Executive branch support: Healthier Washington is the Governor’s vision; and state agency partners—including DOH and DSHS—are instrumental in this work. - Legislative support: They passed legislation moving the innovation plan forward, and bridge funding to start the work. - Federal support: A $65 million innovation grant to propel Healthier Washington from vision to reality. - 2015 is the year when the state innovation plan moves from a plan two years in the making to reality. Three Transformative Strategies: 1. Drive value-based purchasing across the community, starting with the State as “first mover.” 2. Improve health overall by building healthy communities and people by prioritizing prevention and early mitigation of disease throughout the life course. 3. Improve chronic illness care through better integration of care and social supports, particularly for individuals with physical and behavioral co-morbidities. Improving how we pay for services 2 Better Health, Better Care, Lower Costs

Healthier Washington recognizes that health is more than health care. - Health systems transformation is not just health care reform--this really is about all the systems that affect health, not just medical care. - The current system: - Separates the “head” from the “body” —no integration between services for physical health, mental health and chemical dependency. - Focuses on volume of services provided, not quality of outcomes. - Is expensive, and getting more so, without producing better results. Health is more than health care. HW is grounded in an understanding that health is more than health care – that 80% of the factors that affect a person’s health occur outside of the health care system. Improving people’s health outcomes (and lowering costs) will depend on addressing those factors and linking supports for them to the health care delivery system. - Health encompasses community (nutritious food, housing, public health), system supports (measurement, consumer engagement, workforce development) and health & recovery efforts (mental health, long-term care, oral health). Adapted from: Magnun et al. (2010). Achieving Accountability for Health and Health Care: A White Paper, State Quality Improvement Institute.. Minnesota. 3 Better Health, Better Care, Lower Costs

Healthier Washington is more than the State Innovation Models (SIM) grant… 2014 Legislation: House Bill 2572 Senate Bill 6312 Medicaid Transformation Potential demonstration project within Medicaid - In addition to WA state legislation and a grant from CMMI, Medicaid Transformation activities, such as the 1115 Global Medicaid Waiver, will support Healthier WA initiatives. - Implementation tools: - SIM grant: $65 million over 4 years - State budget: “Bridge” funding to move forward while awaiting word on SIM grant (July 2014-June 2015) - In-kind and philanthropic support - 2014 bills to support Healthier Washington: HB 2572: Performance measures, communities of health, all-payer claims database and SB 6312: Integration of physical and behavioral health SIM Grant: $65 million over 4 years from the federal government 7 Better Health, Better Care, Lower Costs

Accountable Communities of Health Healthier Washington is bringing together providers, social service organizations, health plans, hospitals, county governments, tribes, and others through nine regional Accountable Communities of Health (ACHs). ACHs will support communities in making informed decisions on health needs and priorities. - A foundational element of Washington state’s transformation strategy is the development of regionally based, voluntary collaborative called “Accountable Communities of Health” (ACHs) to drive integrated delivery of health and social services and improve population health. - ACHs will provide the forum, organizational support, and State-community partnership to achieve transformative results through collaboration. Within regions, and across the state, ACHs represent collaborative decision-making across multiple sectors and systems to align actions to achieve healthy communities and populations. ACHs are the accelerator/coordinator of regional best practices, lessons learned and shared challenges to drive health systems transformation focusing on population health, social determinants of health, clinical-community linkages and whole person care. Community and regional impact, including regional purchasing strategies, starting with Medicaid. - ACH infrastructure and governance grounded in the “collective impact” model - Collective Impact structure: common agenda, shared measurement, mutually reinforcing activities, continuous communication, and backbone support - Collective Impact is the commitment of a group of important actors from different sectors to a common agenda for solving a specific social problem. A Healthier WA will see engaged communities focused on community health and wellness, whole person care, and partnering with the state delivery system improvement, including value based purchasing. Timeline: Iterative development process over the entirety of the SIM grant. Goal for statewide designation for all ACHs by the end of 2015. We’re well into ACH design and implementation, but early in the four-year process. We still have a lot to learn in partnership with our communities. COH Planning (2572) in 2014 provided a very valuable learning opportunity for the state and for communities as they consider the newly established RSAs and future ACH development. COH planning regions informed the competitive selection of two pilot regions based on maturity and identification of regional pilot projects. Two Pilots were selected (2572) in 2015 and these two regions just recently achieved official ACH designation (North Sound and Cascade Pacific Action Alliance) Seven Design regions, of which SWWA is one, are working on the following: Governance and Organizational Structure Community Engagement and Multi-sector Representation Regional assessment and asset inventories 9 Better Health, Better Care, Lower Costs

A Forum for regional collaborative decision making

Community Empowerment & Accountability Accountable Communities of Health (ACHs) will: Provide a multi-sector voice for delivery system reform, shared health improvement goals and regional purchasing strategies. Serve as a forum for regional collaborative decision-making to accelerate health system transformation, focusing on social determinants of health, clinical-community linkages, and whole person care. Accelerate physical and behavioral health care integration through financing and delivery system adjustments, starting with Medicaid.

Medicaid Transformation Those of you who read the concept paper and draft application are familiar with the story of John. John was a recent Apple Health enrollee, a young adult with a bipolar disorder and diabetes. As described in the concept paper, he has a number of challenges in managing his health. Most of these stem from the fact that his two diagnoses are being treated by different people in different systems that are not connected; sometimes they don’t even have critical information about the other medications he’s been prescribed. The fragmented care, particularly during times when he has transitioned out of acute care settings, has also had an impact in how engaged John is in his own recovery. And this is in a system where every person involved in John’s care – physicians, counselors, and case managers – are all committed and doing their best to help John get healthy. In our current system, you could multiply John’s situation thousands of times over to people in all sorts of situations – people you’ve heard giving testimony or met back at home in your districts. The people who use our system most heavily, who suffer from non-medical issues as well, like homelessness, and those who are more reflective of the average…from a mother with asthma who has difficulty getting to her medical appointments to a retired person with mobility issues who is struggling to stay in her home. 10 Better Health, Better Care, Lower Costs

Current System Transformed System Medicaid Transformation Current System Transformed System Fragmented clinical and financial approaches to care delivery Integrated systems that deliver whole person care Disjointed care and transitions Coordinated care and transitions Disengaged clients Activated clients Capacity limits in critical service areas Optimal access to appropriate services Individuals impoverish themselves to access long term services and supports (LTSS) Timely supports delay or divert need for Medicaid LTSS Inconsistent measurement of delivery system performance Standardized performance measurement with accountability for improved health outcomes Volume-based payment Value-based payment The changes in recent years – and the years to come that make transformation as a road to sustainability essential. With ACA, Medicaid enrollment has grown by more than 50 percent. Washington is a leader and has cut the state’s uninsured rate in half. But this also means our current system is serving more people – in particular, the 550,000 new adult enrollees that it was not previously serving, individuals with different care needs than the children and people with disabilities it was serving before. The potential 1115 Global Medicaid Waiver demonstration in WA state is an opportunity to bring the Healthier Washington vision to scale for Apple Health, giving us the flexibility to use Medicaid funds to pay for what works. 12 Better Health, Better Care, Lower Costs

Washington’s Medicaid Transformation Goals Achieving the Triple Aim Reduce avoidable use of intensive services and settings Improve population health Accelerate the transition to value-based payment Ensure that Medicaid per-capita cost growth is below national trends Better Health, Better Care, Lower Costs 10

Delivery System Reform Waiver Initiatives Initiative 1 Initiative 2 Initiative 3 Transformation through Accountable Communities of Health Enable Older Adults to Stay at Home; Delay or Avoid the Need for More Intensive Care Targeted Foundational Community Supports Delivery System Reform Benefit: Medicaid Alternative Care (MAC) Benefit: Supportive Housing Community based option for Medicaid clients and their families Services to support unpaid family caregivers Individualized, critical services and supports that will assist Medicaid clients to obtain and maintain housing. The housing-related services do not include Medicaid payment for room and board. Each region, through its Accountable Community of Health, will be able to pursue projects that will transform the Medicaid delivery system to serve the whole person and use resources more wisely. Benefit: Tailored Supports for Older Adults (TSOA) Benefit: Supported Employment For individuals “at risk” of future Medicaid LTSS not currently meeting Medicaid financial eligibility criteria Primarily services to support unpaid family caregivers Services such as individualized job coaching and training, employer relations, and assistance with job placement. Transformation Projects Medicaid Benefits/Services

Domains Transformation Framework The framework is a high-level overview of the strategies necessary to achieve the desired outcomes under each domain. Domain 1: Health Systems Capacity Building* Workforce and non-conventional service sites Primary care models Data collection and analytic capacity * All Domain 1 projects must demonstrate a direct connection to Domains 2 or 3 Domains Domain 2: Care Delivery Redesign Bi-directional integration of care Care coordination Care transitions Domain 3: Prevention and Health Promotion Chronic disease prevention and/or management Maternal and child health 12

Medicaid Population: Greater Columbia ACH SUMMARY GROUP NAME Statewide Total GCACH ADULTS CHILDREN TOTAL 2016   County Population OFM April 1, 2016 AEM Expansion Adults 298 64 Asotin 22,150 Apple Health For Kids 797,098 524 131,598 132,122 Benton 190,500 *18% Elderly persons 73,717 7,447 Columbia 4,050 *1% Family (TANF) Medical 33 4 1 5 Franklin 88,670 Family Planning 11,754 1,737 86 1,823 Garfield 2,200 Former Foster Care Adults 2,134 248 34 282 Kittitas 43,710 Foster Care 29,375 35 3,272 3,307 Klickitat 21,270 *.45% Medicaid CN Caretaker Adults 137,374 18,088 Walla Walla 60,730 *2.5% Medicaid CN Expansion Adults 596,958 70,133 Whitman 47,940 *10% Other Federal Programs 21 Yakima 250,900 Partial Duals 60,123 6,849 Total GCACH Pop  732,120   *.9% Persons with disabilities 149,983 14,017 3,497 17,514 Total GCACH Pop Medicaid  260,535  *1.9% *.5% Pregnant Womens Coverage 17,242 2,901 *.4% Total WA State 2016 1,876,110 122,047 138,488 260,535 26.5% *17% *18.9% *35%

Greater Columbia Governance Structure

Accountable Community of Health (ACH) History Basic Idea: Everyone moving into the same direction at the same time to impact some of our seemingly intractable health issues. A regional health improvement coalition of independent organizations An Accountable Community of Health is a group of leaders from a variety of sectors in a given geographic area with a common interest in improving health. Participating, among others, are health and long-term care providers, health insurance companies, public health agencies, school districts, criminal justice agencies, non-profit social service agencies, legal services organizations, tribes, and philanthropic agencies. With support from the state, they are voluntarily organizing to coordinate activities, jointly implement health-related projects, and advise state agencies on how to best address health needs with in their area. They are not intended to duplicate or replace existing services. Mission: The mission of the Greater Columbia Accountable Community of Health is to advance the health of our population by decreasing health disparities, improving efficiency of health care delivery, and empowering individuals and communities through collaboration, innovation, and community engagement. Accountable Community of Health (ACH) History 7/2014 – Launch of “Communities of Health” (COH) 1/13/2016 - State Designation Achieved “Accountable Community of Health” 7/29/16 – Submitted Regional Health Improvement Plan 8/8/16 – SIM Project Approved

Backbone Organization BFCHA Carol Moser Aisling Fernandez Eastern WA University Dr. Patrick Jones Board of Directors Public Health Hospital FQHC Healthcare Provider Mental Health Provider CBO/FBO Social Services Local Government Columbia County Martha Lanman Yakima Memorial Hospital Eddie Miles Tri-Cities Community Health Martin Valadez Sunnyside Community Hospital Brian Gibbons Comprehensive Mental Health Ed Thornbrugh Catholic Family and Child Services Darlene Darnell SE WA Aging and Long Term Care Lori Brown GCBH Executive Director Ken Roughton Education Philanthropy Managed Care Housing Business Tribes Public Safety Consumer Transportation ESD 123 Les Stahlnecker Three Rivers Community Foundation Carrie Green Coordinated Care Andrea Tull Yakima Neighborhood Health Rhonda Hauff TBD Yakama Nation Frank Mesplie Kittitas Fire John Sinclair Northwest Justice Project Jefferson Coulter People for People Madelyn Carlson

Greater Columbia Accountable Community of Health Collective Impact Model Committees Backbone Organization for Greater Columbia Accountable Community of Health Board of Directors Care Coordination Partners/Sectors Community Members Public Health Hospital FQHC Healthcare Provider Mental Health Provider CBO/FBO Social Services Managed Care Philanthropy Education Local Government Public Safety Tribes Business Housing Consumer Transportation Other Leadership Council Behavioral Health Oral Health Healthy Youth & Equitable Communities Diabetes & Obesity Assessment & Planning Committee Executive Committee Nominating Committee Finance Committee By-Laws Committee Communications Committee Strategic Issues Committee Data Com Priority Workgroups and Committees

Guiding Principles Promote a culture of health and health equity 7 local community forums (county-based) that interact with a regional coordinating council 4 core values (operating principles) Guiding Principles Promote a culture of health and health equity Facilitate a regional population health approach Engage the community Focus on prevention and early intervention Ensure strategies are data-informed, aligned, culturally competent, and sustainable

Overarching Strategies in RHIP

Access to exercise opportunities: Lower than the State! Increased physical activity is associated with lower risks of type 2 diabetes, cancer, stroke, hypertension, cardiovascular disease, and premature mortality, independent of obesity. The role of the built environment is important for encouraging physical activity. Individuals who live closer to sidewalks, parks, and gyms are more likely to exercise.

Dental Workforce Shortages Untreated dental disease can lead to serious health effects including pain, infection, and tooth loss. Although lack of sufficient providers is only one barrier to accessing oral health care, much of the country suffers from shortages.

Median Household Income, 2016 Median household income is a well-recognized indicator of income and poverty and is strongly correlated with children in poverty. Poverty can result in an increased risk of mortality, prevalence of medical conditions and disease incidence, depression, intimate partner violence, and poor health behaviors. Note: YIN = Yakama Indian Nation

Shortage of Mental Health Providers Thirty percent of the U.S. population lives in a county designated as a Mental Health Professional Shortage Area. As the mental health parity aspects of the Affordable Care Act create increased coverage for mental health services, many anticipate increased workforce shortages.i

State Innovation Model (SIM) Project Care Transitions: Coordinating the medical and social services needed to improve patients' likelihood of readmitting to the hospital within 30 days of their last hospital stay. Working with Consistent Care Services, the Pilot will identify 40 patients (25 Kadlec, 15 Trios) and transition their care into their home with follow-up visits from WSU Nursing students.

For more information, contact: Carol Moser cmoser@greatercolumbiaach For more information, contact: Carol Moser cmoser@greatercolumbiaach.org Website: www.greatercolumbiaach.org Thank you for the opportunity to discuss Healthier WA with you today, and we look forward to a continued partnership as Healthier WA further develops throughout the state. Thank you!