1. 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

2. 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

3. 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

4. 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

5. 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?)