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

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

HealthConnect Continuum

Free and open community access Community sourced and 211 supported No bi-lateral patient health information exchanged Current and updated resource library

• Available on the cloud
• Easy to use app interface
• Free technical assistance
• Available community-wide

HealthConnect Continuum: Supported by HealthConnect Hub Infrastructure

Resource & Referral: Healthbridge.care Partnered with 211

• Free technical assistance

 Webinars  Shared learning portal  Direct human to human support

• Available for HealthConnect

system partners

HealthConnect Continuum: Supported by HealthConnect Hub Infrastructure

Free and accessible to Health- Connect system partners Feedback loop directly related to client status and specific service referrals Potential

• utcome

payment for client referral and engagement Data collection for identification

• f resource

and care gaps

Referral & Results: Risk Assessment & Connection

Driven by CHW/Peer support and coordination Bi-lateral patient health information exchanged Social Determinant and Clinical Pathways Data collection for identification

• f resource

and care gaps Outcome- based payment

• Pathways HealthConnect

program training

• HealthConnect Hub IT training
• Common principles and practices
• f CHW/peers and DOH training

for CHWs

• State certification opportunity for

peer supporters

• Trainings specific to focus

population care needs (TI, crisis response, homeless, SUD, etc.)

• Available for Pathways

HealthConnect partners

Community Care Coordination: Pathways HealthConnect

HealthConnect Continuum: Supported by HealthConnect Hub Infrastructure

• HealthConnect Hub IT

training

• Common principles and

practices of CHW/peers and DOH training for CHWs

• State certification opportunity

for peer supporters

• Trainings specific to focus

population care needs (TI, crisis response, homeless, SUD, etc.)

• Available for SWACH multi-

disciplinary health team partners

Driven by multi- disciplinary care teams including CHW/Peer supporters Bi-lateral patient health information exchanged Specialized access to care Social determinant, clinical and care transition pathways Data collection for identification

• f resource

and care gaps Outcome- based payment

Multi-Disciplinary Care Team: Whole-Person Care for High Complexity Clients

HealthConnect Continuum: Supported by HealthConnect Hub Infrastructure

Current Clients in Pathways HealthConnect

Contract Coordination Agency Community Voices are Born 35 Sea Mar Community Health 34 Skamania County Community Health 33 Washington Gorge Action Program 37

Total 139

25 56 66 82 92 120 20 40 60 80 100 120 140 March April May June July August

Pathways HealthConnect enrollment over time

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 Individual in Opioid Affected Household 6

Pathways Initiated by Contracted Coordination Agency

100 200 300 400 500 600 700 800 900 CVAB Sea Mar Skamania WGAP Pathways Initiated

Total Pathways Initiated- 2033

Pathways Initiated by Standard Pathway

100 200 300 400 500 600 700 800 Initiated Completed

Top Ten Pathways

20 40 60 80 100 120

Social Service Referrals

Open Complete Unsuccessful

Medical Referrals

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 (OBU’s x $15 per OBU) Outcome Based Payment (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 date of hire 4 (x$15) $60.00 Family Planning Tubal ligation, vasectomy, IUD, implant, shot or other form of long-acting reversible contraceptive (LARC) is obtained 5 (x$15) $75.00 Family Planning Method other than a permanent method or LARC chosen & client has successfully used the method for more than 30 days from the start date 4 (x$15) $60.00 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 30 days from the move-in date 9 (x$15) $135.00 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 (OBU’s x $15 per OBU) Outcome Based Payment (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 date of hire 5 (x$15) $75.00 Family Planning Tubal ligation, vasectomy, IUD, implant, shot or other form of long-acting reversible contraceptive (LARC) is obtained 6 (x$15) $90.00 Family Planning Method other than a permanent method or LARC chosen & client has successfully used the method for more than 30 days from the start date 5 (x$15) $75.00 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 30 days from the move-in date 10 (x$15) $150.00 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!