Making Connections How RHCs are supporting practice transformation and clinic-community linkages October 26, 2018

The project described was supported by Funding Opportunity Number CMS-1G1- 14-001 from the U.S. Department of Health and Human Services (HHS), Centers for Medicare & Medicaid Services (CMS), and by grant number 1R18HS023904-01 from the U.S. Department of Health and Human Services (HHS), Agency for Healthcare Research and Quality (AHRQ). The Colorado State Innovation Model (SIM), a four-year initiative, is funded by up to $65 million from CMS. EvidenceNOW Southwest (ENSW), a four-year initiative, is funded by up to $14.8 million from AHRQ. The content provided is solely the responsibility of the authors and does not necessarily represent the official views of HHS or any of its agencies.

It’s December – which means it’s time for two things: order new calendars and start thinking about new year’s resolutions. If you hate resolutions, raise your hand. If you made a resolution for 2018 or plan to make one for 2019, please raise your hand Please keep your hand raised if your resolution has something to do with your health Please keep your hand raised if your health-related resolution has something to do with your behavior – eating better, exercising more Thank you! You can put your hands down. Would anyone like to share their resolutions? We didn’t see very many hands go down. What does that tell us? Intuitively, we know that our behaviors influence our health. We also know that it’s hard to change our behaviors – hence the resolutions! And if you’re in this room, it’s probably because you know that both of those things are having a real impact on our health care system.

Resolutions for this Session Go outside the clinic to address the parts of our lives that determine our health Hear from Regional Health Connectors who are connecting clinics and communities Gather ideas for addressing community needs

Researchers have estimated how much of our health is determined by those answers and assigned a percentage of our health to each of these four categories. Does anyone want to guess what percentage of our health outcomes are determined by clinical care? Health behaviors? Physical environment? And that leaves 40% to socioeconomic factors. Estimates vary, but we know that most of what affects our health — as much as 80 percent — happens outside the doctor’s office. So addressing those non-clinical factors can make a huge difference in our health. This means that health care providers are increasingly looking outside their clinics to address these factors, often referred to as the social determinants of health. The research suggests that building clinical-community linkages holds promise for better care, better health and reduced health care spending over time.18, 19 But up front, they can be an expensive proposition. That’s because the cost savings for an insurer — like Medicaid or a private commercial plan — are tricky to calculate. But this is changing. With the movement toward value-based payments — or paying for health rather than for individual services — insurers are more likely to invest in those connections to support their patients outside of the clinic.

RHCs connect the existing work of different systems PF – Practice Facilitator CHITA – Clinical Health Information Technology Advisor

The RHC Roadmap Local relationships and priorities in each region will drive the work of each RHC, throughout the following steps: Review existing initiatives and data Align local priorities with statewide target areas Develop a roadmap for RHC work on local priorities Make connections and implement the roadmap

RHCs Connect Your Practice with Community What’s an example of a connection you’ve made for a practice? What upcoming community event do you want practices to know about? What is the resource you share most often, or find most valuable?

Southwestern Colorado Area Health Education Center Mary Dengler-Frey Southwestern Colorado Area Health Education Center What’s an example of a connection you’ve made for a practice? What upcoming community event do you want practices to know about? What is the resource you share most often, or find most valuable?

Alexis Klein Tri-County Health Network What’s an example of a connection you’ve made for a practice? What upcoming community event do you want practices to know about? What is the resource you share most often, or find most valuable?

Charity Weir Mesa County Public Health What’s an example of a connection you’ve made for a practice? What upcoming community event do you want practices to know about? What is the resource you share most often, or find most valuable?

West Mountain Regional Health Alliance Namrata Shrestha West Mountain Regional Health Alliance What’s an example of a connection you’ve made for a practice? What upcoming community event do you want practices to know about? What is the resource you share most often, or find most valuable?

Your Western Slope Regional Health Connectors Namrata Shrestha, Region 12, West Mountain Regional Health Alliance Charity Weir, Region 19, Mesa County Public Health Alexis Klein, Region 10, Tri-County Health Network Mary Dengler-Frey, Region 9, Southwestern Area Health Education Center Take questions from the audience

Resource Sharing BrainBloom

Take out a piece of paper and write down: Resources you currently share Gaps in resources

Want more information? Check out our Interactive Map! http://regionalhealthconnectors.org/

Read more about RHCs and Clinical-Community Linkages! North Colorado Health Alliance (NCHA) is offering a one year full scholarship to Regional Health Connectors to use the Thriving Colorado Dashboard, a community health data tracking tool Regional Health Connectors can use the Thriving Colorado Dashboard to: Track SMART goals and report on the progress made by partnerships Share data for patients, community members, and partners to view See what other RHCs and public health organizations are working on Identify evidence-based practices from around the state https://www.coloradohealthinstitute.org/blog/regional-health-connectors-make-clinical-community-links-happen

And, more success stories and RHC Profiles! Namrata coming soon! http://regionalhealthconnectors.org/

Thank you! RHConnectors@Coloradohealthinstitue.org @RHConnectors