Regional Health Improvement Plan Council September 17, 2019 1 - PowerPoint PPT Presentation

Regional Health Improvement Plan Council September 17, 2019 1

Meeting Objectives • SWACH updates • Receive key information • Advise on committee idea • Advise on partner funding plan for Years 3 and 4

Review Meeting Minutes and Action Items • Council member action: – Approve meeting minutes – Approve new committee members

SWACH Updates • Introduce new staff • Need to knows • Board Retreat

HealthConnect Continuum

HealthConnect Continuum Community Care Multi-Disciplinary Resource & Referral Referral & Results Coordination Care Team Community care Healthbridge.care Risk assessment & Whole-person care coordination driven partnered with 211 for high complexity connection by a CHW/peer clients workforce Pathways HealthConnect Referral and support for Multi-disciplinary clinical Provides the region with a CHW/peers connect with community members in community teams find, go-to online resource & community members & need of programs, services meet & treat people referral system embedded close physical, behavioral & care coordination, with where they are & provide in the HealthConnect Hub health and social service documented follow up a warm handoff within the infrastructure. pathways based on risk and service engagement. care continuum. assessment.

Resource & Referral: Healthbridge.care Partnered with 211 Free and open community access Community sourced and 211 supported • Available on the cloud • Easy to use app interface • Free technical assistance • Available community-wide No bi-lateral patient health information exchanged Current and updated resource library HealthConnect Continuum : Supported by HealthConnect Hub Infrastructure

Referral & Results: Risk Assessment & Connection Free and accessible to Health- Feedback loop Connect directly system related to partners client status and specific service • Free technical assistance referrals  Webinars  Shared learning portal  Direct human to human Potential support outcome payment for • Available for HealthConnect client referral and system partners engagement Data collection for identification of resource and care gaps HealthConnect Continuum : Supported by HealthConnect Hub Infrastructure

Community Care Coordination: Pathways HealthConnect Driven by Bi-lateral CHW/Peer patient health support and information coordination exchanged • Pathways HealthConnect program training • HealthConnect Hub IT training Social Determinant • Common principles and practices and Clinical of CHW/peers and DOH training Pathways for CHWs • State certification opportunity for peer supporters Data collection for • Trainings specific to focus identification population care needs (TI, crisis of resource and care gaps response, homeless, SUD, etc.) • Available for Pathways Outcome- HealthConnect partners based payment HealthConnect Continuum : Supported by HealthConnect Hub Infrastructure

Multi-Disciplinary Care Team: Whole-Person Care for High Complexity Clients Driven by multi- disciplinary Bi-lateral care teams patient health including information CHW/Peer • HealthConnect Hub IT exchanged supporters training • Common principles and practices of CHW/peers and Specialized DOH training for CHWs access to care • State certification opportunity for peer supporters • Trainings specific to focus population care needs (TI, Social determinant, crisis response, homeless, SUD, clinical and etc.) care transition pathways • Available for SWACH multi- Data disciplinary health team collection for partners identification Outcome- of resource based and care gaps payment HealthConnect Continuum : Supported by HealthConnect Hub Infrastructure

Current Clients in Pathways HealthConnect Contract Coordination Agency Pathways HealthConnect enrollment over time 140 Community Voices are Born 35 120 120 100 Sea Mar Community Health 34 92 82 80 66 Skamania County Community Health 33 60 56 40 Washington Gorge Action Program 37 25 20 0 Total 139 March April May June July August

Clients by Area

Top Ten Chronic Conditions by Number of Clients Depression 98 Anxiety disorder 92 PTSD 60 Addictions/Substance abuse 59 Chronic Pain (leg, foot, back, hip, shoulder, etc.) 56 Tobacco abuse 50 Vision loss or impairment 39 Attention Deficit Hyperactivity Disorder 32 Hypertension (high blood pressure) 31 Arthritis 27

Clients with Opioid Use Disorder Complex Health Needs Only (including non Opioid SUD) 111 OUD and in MAT 7 OUD not in MAT 0 Individual in Opioid Affected Household 6

Pathways Initiated by Contracted Coordination Agency WGAP Skamania Sea Mar CVAB 0 100 200 300 400 500 600 700 800 900 Pathways Initiated Total Pathways Initiated- 2033

Pathways Initiated by Standard Pathway 800 700 600 500 400 300 200 100 0 Initiated Completed

Top Ten Pathways Medical Referrals Social Service Referrals 120 100 80 60 40 20 0 Open Complete Unsuccessful

Pathways by Sector Social Services Medical Behavioral Health

Pathways HealthConnect Outcome Based Payment Schedule of Service: Adult Member - Normal Risk Number of Outcome Based Units Outcome Based Payment (OBU’s x $15 per OBU) (OBP) Checklists Initial Adult Checklist Completed one time at enrollment 9 (x$15) $135.00 Adult Checklist Completed at each face-to-face encounter 3 (x$15) $45.00 Tools PHQ-9 Depression Screen 3 (x$15) $45.00 PAM Patient Activation Measure 3 (x$15) $45.00 Pathways Adult Learning Confirm that client successfully completes stated education goal 4 (x$15) $60.00 Behavioral Health Kept three scheduled behavioral health appointments 4 (x$15) $60.00 Education All required education components are completed and documented 1 (x$15) $15.00 Employment Consistent source of steady income and is employed more than 30 days from 4 (x$15) $60.00 date of hire Family Planning Tubal ligation, vasectomy, IUD, implant, shot or other form of long-acting 5 (x$15) $75.00 reversible contraceptive (LARC) is obtained Family Planning Method other than a permanent method or LARC chosen & client has 4 (x$15) $60.00 successfully used the method for more than 30 days from the start date Health Insurance Received health insurance – document plan and insurance number 5 (x$15) $75.00 Housing Moved into and maintained a suitable and affordable housing unit for more than 9 (x$15) $135.00 30 days from the move-in date Medical Home Confirmed appointment with medical home 5 (x$15) $75.00 Medical Referral Confirmed appointment for health services 2 (x$15) $30.00 Medication Assessment Provider receives Medication Assessment Tool 4 (x$15) $60.00 Medication Management Provider or pharmacist confirms client is taking medications as prescribed 9 (x$15) $135.00 Social Service Referral Confirmed appointment for social services 2 (x$15) $30.00 Tobacco Cessation Stopped using tobacco products for one month 4 (x$15) $60.00 This schedule is evolutionary and may be subject to modification based on improvement processes and stakeholder input including, but not limited to, input from Pathways HealthConnect Advisory Committees.

Pathways HealthConnect Outcome Based Payment Schedule of Service: Adult Member - High Risk Number of Outcome Based Units Outcome Based Payment (OBU’s x $15 per OBU) (OBP) Checklists Initial Adult Checklist Completed one time at enrollment 9 (x$15) $135.00 Adult Checklist Completed at each face-to-face encounter 4 (x$15) $60.00 Tools PHQ-9 Depression Screen 3 (x$15) $45.00 PAM Patient Activation Measure 3 (x$15) $45.00 Pathways Adult Learning Confirm that client successfully completes stated education goal 5 (x$15) $75.00 Behavioral Health Kept three scheduled behavioral health appointments 5 (x$15) $75.00 Education All required education components are completed and documented 1 (x$15) $15.00 Employment Consistent source of steady income and is employed more than 30 days from 5 (x$15) $75.00 date of hire Family Planning Tubal ligation, vasectomy, IUD, implant, shot or other form of long-acting 6 (x$15) $90.00 reversible contraceptive (LARC) is obtained Family Planning Method other than a permanent method or LARC chosen & client has 5 (x$15) $75.00 successfully used the method for more than 30 days from the start date Health Insurance Received health insurance – document plan and insurance number 6 (x$15) $90.00 Housing Moved into and maintained a suitable and affordable housing unit for more than 10 (x$15) $150.00 30 days from the move-in date Medical Home Confirmed appointment with medical home 6 (x$15) $90.00 Medical Referral Confirmed appointment for health services 3 (x$15) $45.00 Medication Assessment Provider receives Medication Assessment Tool 5 (x$15) $75.00 Medication Management Provider or pharmacist confirms client is taking medications as prescribed 10 (x$15) $150.00 Social Service Referral Confirmed appointment for social services 3 (x$15) $45.00 Tobacco Cessation Stopped using tobacco products for one month 6 (x$15) $90.00 This schedule is evolutionary and may be subject to modification based on improvement processes and stakeholder input including, but not limited to, input from Pathways HealthConnect Advisory Committees.

Next Steps • Save the dates recap • Email/call Jamie with suggestions for November meeting agenda

Thank you!