1. Benton Franklin Board of Health December 16, 2015
Greater Columbia COH: ACHs and Health Systems Transformation in Washington State
Benton Franklin Board of Health
December 16, 2015

2. 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.
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

3. 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

4. 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
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

5. 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

6. 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.

7. A Forum for regional collaborative decision making

8. 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

9. 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

10. Medicaid Population:Greater Columbia ACH
Medicaid Population as of Nov 1, 2015
Adult Medicaid (19 & over)
Youth Medicaid (under 19)
Total
Asotin
3,965
2,724
6,689
Benton
26,585
29,060
55,645
Columbia
747
463
1,210
Franklin
12,636
22,249
34,885
Garfield
339
290
629
Kittitas
5,808
4,031
9,839
Klickitat
3,631
2,816
6,447
Walla Walla
8,840
8,168
17,008
Whitman
4,823
2,994
7,817
Yakima
50,840
62,924
113,764
118,214
135,719
253,933
Washington State
1,835,360

11. Washington Health Alliance Performance Measures released 12-8-15

12. Section 1115 Global Medicaid Waiver
ACHs will be the Coordinating Entity
Provide ACHs the flexibility to fund projects/programs that promote the objectives of Medicaid programs
Address underlying health care delivery gaps through implementation of meaningful reforms
Take advantage of work done to date & increase access to community based options
Enable administrative simplification & standard performance measurement across systems

13. Medicaid Goals
Reduce avoidable use of intensive services and settings, such as acute care hospitals, nursing facilities, psychiatric hospitals, jails, and traditional long-term services and supports.
Improve population health, with a focus on the prevention and management of diabetes, cardiovascular disease, oral health, pediatric obesity, smoking, mental illness, and substance use disorders; care should be coordinated and whole-person centered.
Accelerate the transition to value-based payment, while ensuring that access to specialty and community services outside the Indian health system are maintained for Washington's tribal members.
Ensure that Medicaid per capita cost growth is two percentage points lower than national trend.

14. Greater Columbia Governance Structure

15. Backbone Organization
BFCHA
Carol Moser
Aisling Fernandez
PMH Medical Center
Blake Rose
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
Kadlec Regional Medical Center
Lane Savitch
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
Yakima
Commissioner
Kevin Bouchey
Education
Philanthropy
Managed Care
Housing
Business
Tribes
Public Safety
Consumer
Transportation
ESD 123
Les Stahlnecker
Three Rivers Community Foundation
Carrie Green
Coordinated Care
Caitlin Safford
Yakima Neighborhood Health
Rhonda Hauff
WA State Growers Association
Mike Gempler
Yakama Nation
Frank Mesplie
Kittitas Fire
John Sinclair
TBD
People for People
Madelyn Carlson

16. Greater Columbia ACH Collective Impact Structure
Governing
Board
Execution
&
Evaluation
Working Groups & Committees
Benton Franklin Community Health Alliance
Backbone Organization
Care
Coordination
Obesity/
Diabetes
Behavioral
Health
Healthy Youth/Equitable Communities
Action
Planning
Partners/Sectors
Public Health
Hospital
FQHC
Healthcare Provider
Mental Health Provider
CBO/FBO
Social Services
Local Government
Education
Philanthropy
Managed Care
Housing
Business
Tribes
Public Safety
Consumer
Transportation
Prioritization
Community Members
Public Will

17. GC ACH Designation Deliverables
Governance Structure and Administrative Capacity
Health Improvement and Measurement Planning
Health and Delivery System Transformation
Develop and Refine Governing Body and Backbone Capacity
Develop Regional Health Improvement Plan (RHIP)
Implement initial health improvement plan based on interventions, strategies and board approved criteria
Develop Structure for Funding Pass Through in Partnership with the State
Serve a coordinating role between ACH Membership and State for Analytics, ACH Measure Set and alignment of regional priorities with State measures
Assist State in Development of Regional Linkage with the Practice Transformation Hub
Implement Communication Plan for Transparency and Awareness
Coordinate with Regional and State Entities for integration of physical and behavioral health
Explore Sustainability Planning – including savings and reinvestment strategy

18. For more information, contact: Carol Moser cmoser@bfcha
For more information, contact: Carol Moser Website:
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