Using NCACH Project Metrics to determine our Collective Impact Chelan-Douglas CHI May 9, 2018

NCACH has selected 6 Medicaid Transformation Projects to implement across Chelan, Douglas, Grant, and Okanogan counties These projects are all held accountable by metrics issued by the HCA NCACH, its partnering providers, and members of the community all have a role to play in achieving these metrics All projects and funding are aimed at supporting Medicaid beneficiaries, with the assumption that by improving quality of care and access to services for low-income and underserved populations will in turn improve quality of care and access to services for all through a strengthened system

Project Objective Bi-Directional Integration of Care Through a whole-person approach to care, address physical and behavioral health needs in one system through an integrated network of providers Community-Based Care Coordination (aka Pathways Community HUB) Promote care coordination across the continuum of health for Medicaid beneficiaries, ensuring those with complex health needs are connected to the interventions and services needed to improve their health Transitional Care Improve transitional care services to reduce avoidable hospital utilization and ensure beneficiaries are getting the right care in the right place Diversion Intervention Implement diversion strategies to promote more appropriate use of emergency care services and person-centered care through increased access to primary care and social services, especially for medically underserved populations Addressing the Opioid Use Public Health Crisis Support the achievement of the state’s goals to reduce opioid-related morbidity and mortality through strategies that target prevention, treatment, and recovery supports Chronic Disease (e.g. cardiovascular, respiratory, diabetes, obesity, stroke, arthritis, etc) Prevention and Control Integrate health system and community approaches to improve chronic disease management and control

HCA Performance Metrics 2A: Integration 2B: Pathways 2C: Transitional 2D: Diversion 3A: Opioid 3D: Chronic Total Outpatient Emergency Department Visits per 1000 Member Months 1 6 Inpatient Hospital Utilization   5 Follow-up After Discharge from ED for Mental Health 3 Follow-up After Discharge from ED for Alcohol or Other Drug Dependence Follow-up After Hospitalization for Mental Illness Percent Homeless (Narrow Definition) Plan All-Cause Readmission Rate (30 Days) Substance Use Disorder Treatment Penetration 2 Mental Health Treatment Penetration (Broad Version) Child and Adolescents' Access to Primary Care Practitioners Comprehensive Diabetes Care: Eye Exam (Retinal) Performed Comprehensive Diabetes Care: Hemoglobin A1c Testing Comprehensive Diabetes Care: Medical Attention for Nephropathy Medication Management for People with Asthma (5-64 years) Substance Use Disorder Treatment Penetration (Opioid) Antidepressant Medication Management Patients on high-dose chronic opioid therapy by varying thresholds Patients with concurrent sedatives prescriptions Percent Arrested Statin Therapy for Patients with Cardiovascular Disease (Prescribed)

HCA Performance Metrics - Unpacked 2A: Integration 2B: Pathways 2C: Transitional 2D: Diversion 3A: Opioid 3D: Chronic TotalR Reduce Outpatient Emergency Department Visits incl. visits for mental health & chemical dependency 1 6 Reduce Inpatient Hospital Utilization   5 Reduce number of follow-up visits/hospitalization within 30-days by beneficiaries who had were hospitalized 3 “^” After Discharge from ED for Alcohol or Other Drug Dependence “^” Follow-up After Hospitalization for Mental Illness Reduce rate of beneficiaries who experience homelessness ≥ 1 month (excludes “homeless with housing”) Reduce readmission (within 30 days) rates to hospital to those who have been discharged Ensure that those who need SUD services and treatment get them 2 Ensure that those who need mental health services get them Ensure that children and adolescents receive annual visits with a primary care provider Ensure that clients with diabetes are receive a retinal/dilated eye exam by eye care professional Reduce number of clients with diabetes whose last A1c Hemoglobin test was recorded > 9% (poor control) Ensure that clients with diabetes are screened for nephropathy (kidney function test) Ensure that clients with asthma are dispensed and have access to appropriate medications and treatment Ensure that clients identified with a SUD for opioids receive SUD treatment and support Ensure that clients with a diagnosis of major depression and were newly treated with depression meds stay on them Monitor and reduce number of Patients on high-dose chronic opioid therapy by varying thresholds Monitor and reduce number of Patients with concurrent sedatives prescriptions Reduce Percentage of Medicaid enrollees Arrested Ensure that clients with ACSVD (heart disease) are dispensed appropriate medications and treatment

Unpacking the Metrics Symptoms of the problem PROBLEM Root Causes

Unpacking the Metrics Medication Management for People with Asthma ages 5 - 64 More hospital (ED) visits for asthma related issues (e.g. attacks) Lower population health Increased financial burden on families managing asthma Lower life expectancy Poor academic or job performance from absences, etc More use of EMS (e.g. ambulance called for asthma attack) ASTHMA MEDICATION MANAGEMENT Links between agricultural operations and chronic respiratory illnesses Socioeconomic status = living conditions +/- likely to experience asthma Lack of health literacy around individual asthma management Transportation may create barriers to accessing care or pharmacy Costs of medications may cause barriers or hardship Employment may make it hard to get to regularly scheduled appointments Limited non-clinical support to help with disease education and management Overburdened medical system – hard to get in with PCP or in some cases find one

Prevention Strategies 5 Levels of Prevention for Health Issues or Conditions: Primordial – Addressing known factors that are a threat to population health (e.g. banning cigarettes or seatbelt laws) Primary – Level of prevention at which health promotion measures are taken before clinical intervention (e.g. receiving vaccinations, eating nutritious meals, exercise, reproductive health education & services) Secondary – Taken after one is exposed to illness (e.g. screening tests for common risks, like colonoscopies, blood pressure, or mammograms; BH services for those who may be at risk of suicide); used to detect at early stage to avoid more costly measures Tertiary – Lifestyle of person after developing disease – maximize longevity or quality of life (e.g. insulin for diabetes management; SUD services and support) Quaternary – Keeping people from at risk from over-medication or unnecessary or excessive intervention from health system (e.g. protecting homeless or elderly from over-diagnosis or being excessively medicated; palliative care; support services for those with life-long disabilities)

+ Medicaid Project Objectives Small group exercise: NCACH Project Metrics + Medicaid Project Objectives + Chelan-Douglas Goals Identified in March X Prevention Strategies = Our Collective Impact

ROOT CAUSE AND SYSTEMIC EVALUATION PREVENTATIVE STRATEGIES & PARTNERSHIP OPPORTUNITIES FOR: (WRITE METRIC BELOW) ROOT CAUSE AND SYSTEMIC EVALUATION What sequence of events lead to the problem? What conditions allow the problem to occur? What other problems surround the occurrence of the central problem?   PREVENTION PRIMORDIAL & PRIMARY PREVENTION STRATEGIES (How do we stop this problem from occurring in the first place?) SECONDARY PREVENTION (What do we do now that this problem exists?) TERTIARY & QUATERNARY PREVENTION (What long term responses can we take to mitigate and manage this problem and its affects?) What can your client do? What can CBOs and other non-clinical partners do? What can clinical partners do? Opportunities for Partnership or Collaboration? What outside funding opportunities exist to support these strategies? Which of the goals identified during the March 2018 meeting align with these strategies?

Resources: HCA Healthier Washington Dashboard - https://www.hca.wa.gov/about-hca/healthier-washington/data- dashboards HCA Medicaid Transformation Project Metrics - https://www.hca.wa.gov/assets/program/mtp-measurement- guide.pdf