Accountable Health Communities Model

Agenda

1. Introductions

2. Quick Overview of the FOA

3. Why should we consider doing this?

4. Time for feelings and reflection

5. Rocky’s role and limits: ideas, resources, other.

6. Next Steps

Introductions • COMMUNITY PARTNERS

• STATEWIDE ORGS & OTHERS

Accountable Health Communities Model SUMMARY OVERVIEW AND CONSIDERATIONS

o AHCM is a new Center Medicare and Medicaid Innovation opportunity to conduct a 5 year test on whether identifying and attempting to address the health-related social needs through referral and community navigation can reduce healthcare costs and improve quality and delivery . All Models must address the “core” needs listed below. Applicants may also opt to address “supplemental” needs, not limited to, but including those listed below in the table.

o AHCM is authorized under section 1115A of the Social Security Act (added by section 3021) of the Affordable Care Act.

What is the Accountable Health Communities (AHCM)Model?

The model is intended to address community dwelling beneficiaries who have Medicare and/or Medicaid who receive care at a participating clinical site in a target geographic area.

Model Options

There are three levels of the ACHM defined in the table to the left. Total funding for each level: • Track 1: Up to $1 million to 12

awardees ($12 million total) • Track 2: Up to $2.57 million to 12

awardees ($30.84 million total) • Track 3: Up to 4.51 million to 20

awardees ($90.2 million total) Notes: Applicants can apply to multiple tracks but will only receive an award for one track. Only one award will be made in any given geographic area. Clinical delivery sites and community partners can support an unlimited number of applications. Applicants can request less than the full amount. .

The Bridge Entity & The Consortium The applying organization is called the Bridge Entity and is responsible for providing the infrastructure to convene and coordinate clinical and community resources. The Consortium must include Colorado Medicaid, clinical delivery sites (primary care, behavioral health, hospitals), community service providers who address the core social needs, local government and payers.

Step 1: Screening In the ACHM, each Bridge Entity is responsible for ensuring that 75,000 enrollees (accounting for more than 51% of Medicare and/or Medicaid enrollees in the geographic area) are screened for the five core needs using questions provided by CMS. Those screening are expected to happen in primary care clinics, behavioral health clinics, hospital ERs, labor & delivery and psychiatric units.

Step 2: Community Referral Summary Clients with an identified need will receive a tailored Community Referral Summary that includes contact information and hours of operation for the Community-Based Organization that will address their needs. Bridge Entities must retain records of these summaries.

Step 3: Community Navigation Clients with an identified need who have used the ER more than twice in the last year will be offered Community Service Navigation. Community Service Navigation is an in-depth personal interview, development of a person-centered action plan, follow up, and documentation of each encounter.

Step 4: Partner Alignment Track 3 requires partner alignment and quality improvement. This means Bridge Entities must perform an annual gap and resources analysis, convene an advisory board that can assess and prioritize needs, create and implement a quality improvement plan that improves systems efficiency between clinical care and community organizations.

A Few More Considerations Funding cannot be used for any service delivery.

Funding is tied to milestone completion -- as determined by CMS.

No more than 15% of the funding can be spent on Health Information Technology.

This is a Cooperative Agreement rather than a grant from CMS. That means that there will be significant oversight and involvement CMS.

Data collection: At its core, this opportunity is an attempt to prove that referrals to community organizations from clinical sites can reduce healthcare expenditure. There is a significant data collection and reporting components within the AHCM. All screenings, client assessments, referral summaries and community navigation summaries will need to be recorded and transmitted reliably to CMS.

Timelines

Concerns and Questions This is an excellent opportunity to learn, strengthen our community networks and shape future policy development in this area. However, there are some issues that we all need to take seriously:

High level issues:

• Focus: The hypothesis is that this work will improve health care outcomes and reduce costs. That may be true, but are the health care measures included in the FOA the right ones? Will the “needle move” in a short period of time on these measures? What about health and social outcome measures? Where are they in this enterprise?

•Funding: To the extent that AHCM won’t fit current workflows and resources, the funding may not be adequate for the effort required. Even if funding were no object, creating a new silo makes no sense.

•Prescriptive design: Several sections of the FOA describe a fairly inflexible approach. This may limit integration into current processes.

•Sound Assumptions? Some of the assumptions and program requirements in the FOA may be impractical or infeasible.

•Value proposition: What do people get out of this? What is the value proposition for organizations in the “Consortium” – individually and collectively?

Details and Devils • Wording and integration of AHCM screening questions into existing screenings, workflow, data sharing and reporting processes (e.g., MMP);

• Feasibility of initial screening in provider operations – as specified in FOA for primary care, mental health and hospital settings;

• Need to find the right balance between “face-to-face” encounters, compiled client information (e.g., LTSS, CMHC, RCCO), “asynchronous” and telephonic sources;

•Capacity for in-depth assessment and community service navigation for all “high-risk” (>2 ER visits in 12 months) individuals with an a social need;

•“Referrals”: How to close the loop – not just record and report them. What care planning and interventions follow when actual needs are identified?

•Technology resources and data collection processes; use of Essette, other applications and databases (e.g., “The Bus”….);

•MOUs and Consortium Stucture: How to leverage local leadership and decision-making with regional scale and performance requirements;

•Evaluation...unclear: Who, what, when, how....Balance between the beltway and outside world?

Pause for Feedback What’s missing, here?

Let’s channel our feelings….

- Are you definitely in? Or just maybe? - Are you definitely out (but haven’t hung up, yet)? - Do you want to do this on your own / in your own way? - Do you want to monitor but have other priorities? - Is this annoying? Will it mess up your plans in some way? - Should this be standardized – at the state, national, global or inter-

galactic level? - Do you think this is an “ACO” (Awesome Consulting Opportunity?)

Rocky’s Thoughts ALIGNMENT, STRATEGY, RESOURCES AND POTENTIAL ROLES

Why is RMHP interested in this? •Strategy: This Opportunity is in strategic alignment with RMHP’s Community Integration initiatives: coordinated assessment and care planning, support for advanced primary care, investing in technology, sharing data and contracting with local agencies to “wrap around” services that address the needs of a whole person.

•Better process: Addressing social determinants, over an extended period of time, requires a community-wide strategy across health, behavioral and social services providers. We need to share information, improve coordination, hand offs and loop closure. We need to create a value proposition for providers and agencies to participate – but work largely within existing resources. We need to reduce duplication and a mal-distribution of care coordination resources across the community.

•Better measures: We need better alignment of health, social and health care measures. Several initiatives, such as SIM, are focused upon better multi-sector coordination in this area.

• Impetus: ACHM will provide impetus for the hard work, constructive failure and shared learning. AHCM represents an opportunity to accelerate this process.

• Policy Leadership: The Western Colorado community is well positioned to provide policy direction to federal and state policy leaders in this area.

What RMHP will and will not do •RMHP will provide the administrative and technical support to assist our community partners in this process. This includes aligning our functions as a payer to support this process.

•RMHP will fulfill this role with full transparency – all financial, operational and decision-making process will be open.

•RMHP will share all data within our possession that is necessary for the purpose of achieving the goals of this initiative.

•RMHP will support local, community alliances and leadership structures, and empower them to set their own priorities and direction.

•RMHP will not participate where there is no clear role for us play or way to add value.

•RMHP will not compete or interfere with local leadership or individual organizational efforts to move forward with community integration.

Scale and Scope

RCCO Prime Rocky Medicare Total RCCO Prime

Rocky Medicare Total

Northwest Colorado West Mountain

Jackson 218 0 7 225 Pitkin 288 764 40 1,092 Grand 1,606 2 107 1,715 Garfield 7,088 5,419 676 13,183 Routt 3,088 3 49 3,140 Eagle 5,144 145 214 5,503

Moffat 3,048 8 115 3,171 19,778

Rio Blanco 520 502 231 1,253 Summit

9,504 Summit 3,366 3 37 3,406

West Central 3,406

Delta 7,912 144 1228 9,284 Southwest Colorado

Montrose 5,411 5,249 1460 12,120 Dolores 460 2 46 508 San Miguel 1,084 30 23 1,137 La Plata 8,903 5 775 9,683 Hinsdale 120 5 12 137 Archuleta 2,763 3 233 2,999 Gunnison 1,039 1,699 76 2,814 San Juan 136 0 80 216

Ouray 597 11 110 718 Montezuma 6,696 3 577 7,276

26,210 20,682 Grand Junction

Mesa 17,430 21,381 8230 47,041 Grand Total 126,621

Next Steps 1. Identify a community lead who can be a liaison and has some capacity to work on proposal development

2. Identify Possible Consortium Members

Example: Northwest Colorado Possible Clinical Consortium Members

Hospital Middle Park Medical Center Primary Care

Steamboat Springs Family Medicine - Steamboat Springs

Hospital Yampa Valley Medical Center Primary Care Yampa Valley Medical Associates

Hospital The Memorial Hospital Primary Care

Northwest Colorado Community Health Center - Steamboat Springs

Hospital Pioneers Medical Center Primary Care Pediatrics of Steamboat Springs

Hospital Rangley District Hospital Primary Care Moffat Family Clinic

Primary Care North Park Medical Center Primary Care

Northwest Colorado Community Health Center

Primary Care

Clinic at Middle Park Medical Center - Primary Care

Rangely Family Medicine

Primary Care South Routt Medical Center Primary Care Meeker Family Health Center

Primary Care Sleeping Bear Pediatrics, PC Behavioral Health Mind Springs

Primary Care

Steamboat Medical Group - Steamboat Springs

Example: Northwest Colorado Possible Community Service Consortium Members

Housing Yampa Valley Housing Authority Interpersonal

Violence Advocates for a Violence Free Community

Food Commodity Supplemental Food program, Food Bank of the Rockies

Interpersonal Violence Advocates Crisis Support

Food Mountain View Baptist Church Food Bank Interpersonal

Violence Rangely Victim Services

Food Nurse Family Partnership-Northwest Colorado

Interpersonal Violence Safehouse, Inc

Food Routt County Human Services Transportation Alpine Taxi-Eveline Bacon

Utilities Lift-Up of Routt County Transportation Steamboat Springs Transit

Utilities Community Budget Center Transportation Meeker Streaker

Interpersonal Violence Advocates Building Peaceful Communities

Next Steps 1. Identify a community lead who can be a liaison and has some capacity to work on proposal development.

2. Identify Possible Consortium Members

3. Collaborate with Rocky on the development of the AHCM Proposal Components for Western CO

Key Components of the Proposal Decide whether to address additional/supplemental social needs and identify any special populations in the region;

Develop a plan for screening beneficiaries in clinical sites and transmitting the data to CMS;

Design and tailor community referral summary and logistics of preparing and distributing the summaries;

Develop or identify tools to be used for Navigation services and process for providing navigation services;

Develop Advisory Board role, structure and composition;

Develop a process for quality improvement within the model;

Develop a data strategy and plan to track the results of all community interventions.

Next Steps 1. Identify a community lead who can be a liaison and has some capacity to work on proposal development

2. Identify Possible Consortium Members

3. Collaborate with Rocky on the development of the AHCM for Western CO

4. Complete MOUs for Application Submission (due in March)