pierce county ach community-based organization … · your medicaid transformation action plan. ......

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Pierce County ACH Community-Based Organization Assessment

Start of Block: CBO question copy Pierce County ACH – Community-Based Organization Assessment The purpose of this assessment is to:

- Assess the current state of community-based organizations in supporting whole person care and Medicaid Transformation

- Inform Pierce County ACH of regional health, community, and social services gaps - Identify areas where Pierce County ACH should make investments to reduce the gaps

and achieve the goals of Medicaid transformation - Introduce a framework for systems transformation within community-based organizations

for a continuum of whole person care - Support organizations that complete the assessment in developing an Action Plan for

potential participation in the Medicaid Transformation Project

Information you provide will be used to inform Pierce County ACH’s project implementation and regional investments, establish a baseline for state reporting requirements, and develop technical assistance and training resources for partnering providers. Organizations that are receiving this assessment have indicated their intent to partner with Pierce County ACH by submitting a letter of interest last fall and completing their registration in the Washington Financial Executor portal. To incentivize participation and offset the cost to the organization of participating in our planning efforts, your organization will receive $5,000 upon completion of the survey. This assessment is divided into five sections: Organizational Overview, Community – Clinical Linkages, Continuous Improvement, and Population Health Management, and Community-Based Care Coordination. Community – Clinical Linkages, Continuous Improvement, Population Health Management, and Community-Based Care Coordination are the Pierce County ACH’s engines of system change. Pierce County ACH is also embedding the following change concepts into all of our work: Engaged leadership Quality improvement strategies Building continuous relationships Evidence-based care and/or promising practice Authentic person/family engagement Reducing barriers to care Health equity. This is a current state assessment with no expectation of perfection. This assessment may

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illuminate areas of improvement for your organization and provide guidance as you develop your Medicaid Transformation Action Plan. This assessment will take approximately 60 minutes to complete. Please submit one response on behalf of your entire organization. We strongly encourage you to complete the assessment as a team or gather team input to inform your responses. The assessment is adaptive to your responses and will guide you through only the questions that pertain to your organization. To preview the questions, you may view a PDF version at [link]. Please note that the PDF version includes sections you might not need to answer depending on the organization you represent. Pierce County ACH may share assessment information with the Health Care Authority (HCA) and/or contractors as required/needed, but will only share aggregate or de-identified information for work groups, partners, and public reports. Partners can receive their own assessment results. Please complete the assessment by Friday June 15th, 2018. Page Break

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About your organization Organization Name:

________________________________________________________________ Who is completing this survey?

o Your Name: ________________________________________________

o Role or Title: ________________________________________________

o Email Address: ________________________________________________

o Phone Number: ________________________________________________ What is your organizational vision and mission?

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________ Page Break

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Which of the following best describes your organization?

▢ Basic needs (e.g., housing, food, financial assistance, etc.)

▢ Community Center or Neighborhood Organization

▢ Educational Institution

▢ EMS/ Fire & Rescue

▢ Information and referral

▢ Jail or Criminal Justice

▢ Public Health Organization

▢ Social services

▢ Other (please specify) ________________________________________________ Page Break

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Which of the following types of services does your organization provide? Check all that apply.

▢ Care coordination (e.g., a set of services designed to provide accurate information and referrals to individuals, family members and caregivers to ensure that the appropriate services are accessed and coordinated)

▢ Case management (e.g., a set of services designed to improve an individual’s health including health assessment and on-going reassessments, development of a care plan, monitoring progress, utilization of evidence-based practices in screening and intervention, coordination of care across the continuum of medical, behavioral, oral health, and long-term care services and supports, crisis intervention and case conferencing)

▢ Advocacy

▢ Clothing

▢ Community/Individual education and training

▢ Counseling

▢ Education (e.g., primary, secondary or post-secondary)

▢ Housing or housing assistance

▢ Emergency Medical Services

▢ Transportation

▢ Employment, vocational, or job training supports

▢ Food assistance

▢ Financial Assistance

▢ Immigrant supports

▢ Reentry services for people returning from jail, hospitalization, rehabilitation, nursing homes, etc.

▢ Legal support

▢ Syringe exchange or other harm reduction services for opioid users

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▢ Utility assistance

▢ Programs or interventions provided in clients homes

▢ Other (please specify) ________________________________________________ Page Break Does your organization provide direct, ongoing services to individuals or families?

o Yes

o No Does your organization have a documented process for involving clients and families in decision-making and collaborating with patients/families in developing the care plan?

o Yes

o No Page Break

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Please focus on your organization's work within Pierce County as you answer the following questions:Text boxes expand as you type. What populations does your organization serve?

________________________________________________________________

How many sites does your organization operate in Pierce County?

________________________________________________________________ What geographic locations within Pierce County do you serve?

________________________________________________________________

How many of your staff work in Pierce County?

________________________________________________________________

How many people volunteer in your Pierce County programs?

________________________________________________________________ Page Break

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How many clients does your organization currently serve in Pierce County?

________________________________________________________________

What percent of Pierce County clients are low-income and/or Medicaid eligible?

________________________________________________________________ How long is your waiting list for services in Pierce County?

o Weeks ________________________________________________

o Months ________________________________________________

o Years ________________________________________________ Page Break

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Do you provide services in any other ACH region?

o Yes. If so, which region(s)? ________________________________________________

o No Does your agency have a staffing diversity plan that addresses recruitment and retention of staff, contractors, and/or partnership members who reflect the diversity of your clients?

o Yes

o No Does your organization regularly assess training needs of the staff?

o Yes

o No

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How frequently are staff required to complete the following trainings?

At least once during

employment

At least annually

Less frequent than annually

Offered, but not required

Not offered or required

Cultural and language diversity o o o o o Cultural humility o o o o o Stigma

reduction o o o o o Motivational Interviewing o o o o o

Trauma-Informed

Care o o o o o Social and

environmental conditions that affect health and well-being

o o o o o Page Break

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Community – Clinical Linkages: A key component of improving people’s health is the connection between the community and clinical health systems. Strong links between community and clinical systems support people’s ability to avoid unnecessary, institutional care; effectively transition from one care setting (e.g., hospital, jail) to another (e.g., primary care); and receive high quality, culturally- and linguistically-appropriate, evidence-based education and care.

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With which, if any, of the following health systems do you have a close working relationship?

▢ CHI Franciscan

▢ Community Health Care

▢ Comprehensive Life Resources

▢ Crisis Clinic

▢ Children’s Home Society

▢ Greater Lakes Mental Health

▢ HopeSparks

▢ Metropolitan Development Council

▢ Multicare

▢ Northwest Integrated Health

▢ Northwest Physician’s Network

▢ Optum

▢ Pediatrics Northwest

▢ Pioneer Human Services

▢ Planned Parenthood

▢ Prosperity Wellness

▢ SeaMar

▢ Tacoma-Pierce County Health Department

▢ Other (please specify) ________________________________________________

▢ None of the above

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Page Break Which of the following strengths enhance your organization’s ability to develop and maintain a strong link with clinical health systems? Check all that apply

▢ Linking with clinical systems is a part of our mission

▢ Leadership is committed to engaging with clinical systems

▢ Staff commitment to partnering with clinical systems

▢ Deep person/family engagement in directing their care

▢ A commitment to reducing the barriers to care

▢ Formal written agreement

▢ Collection of client-level data

▢ An ability to share data with partners


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Ideally, who would you like to partner with to form stronger community – clinical linkages that support better health outcomes? Check all that apply

▢ CHI Franciscan

▢ Community Health Care

▢ Comprehensive Life Resources

▢ Crisis Clinic

▢ Children’s Home Society

▢ Greater Lakes Mental Health

▢ HopeSparks

▢ Metropolitan Development Council

▢ Multicare

▢ Northwest Integrated Health

▢ Northwest Physician’s Network

▢ Optum

▢ Pediatrics Northwest

▢ Pioneer Human Services

▢ Planned Parenthood

▢ Prosperity Wellness

▢ SeaMar

▢ Tacoma-Pierce County Health Department


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▢ None of the above Page Break Which, if any, describes the type of partnership your organization would like to have with these organizations? Check all that apply

▢ Coordination to identify and shape joint efforts

▢ Coordination to share information and/or coordinate activities

▢ Collaboration with common goals and priorities identified and agreed to by stakeholders

▢ Collaboration with shared project governance

▢ Partnership with a project(s) being jointly controlled, funded and operated by partners

▢ Partnership with pooled resources and formal authority to govern the project(s)


▢ None Page Break

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Which, if any, of the following barriers or challenges limit your ability to partner with clinical health systems?Check all that apply

▢ Board buy-in

▢ Leadership buy-in

▢ Staff interest/ buy-in

▢ Lack of relationships with willing health system providers

▢ Workforce availability

▢ Scope of practice

▢ Requirements from clinical systems such as HIPPA compliance

▢ HIE/HIT systems

▢ Shared communication platforms

▢ Cultural and language differences between our organization and clinical systems

▢ Payment or financing mechanisms (categorical funding restrictions)

▢ Staffing constraints (e.g., do not have necessary skill sets, etc.)

▢ Time constraints: demands of running our organization require all of our effort

▢ Budget constraints

▢ Regulations or policies (federal, state, other)


▢ None Page Break

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Continuous Process Improvement: A key component of improving people’s health is the way in which your organization systematically goes about improving your services. In this section, we explore how your organization answers three questions: What are we trying to accomplish? How do we know that what we did helped? What changes will we make as a result of what we have learned? Page Break Tell us about your organizational strengths in developing and maintaining a process improvement system. Which of the following apply to your organization? Check all that apply.

▢ Our organization has a designated quality improvement team and/or infrastructure to support staff

▢ Our organization involves clients and families in the selection of quality improvement projects

▢ Our organization regularly reviews the cultural and language diversity of our client population and makes changes to improve the client experience

▢ Our organization routinely collects client satisfaction data

▢ As a part of new program or project development our organization incorporates evaluation into the initial design

▢ Other strengths in quality improvement strategies and tools (please specify) ________________________________________________

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Ideally, how would you strengthen your organization’s improvement system? Check all that apply.

▢ Purchase a data collection tool

▢ Hire or contract with a quality improvement expert to help us design and implement a process improvement plan

▢ Leverage ACH resources such as staff training and/or Improvement Advisor 1:1 support

▢ Train staff in process improvement

▢ Identify and develop quality improvement methodology to be used organization-wide for project planning and operational process improvement

▢ Other (please specify) ________________________________________________ Page Break

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Which, if any, of the following barriers interfere with your ability to develop and maintain a process improvement system? Check all that apply.

▢ Board buy-in


▢ Staff interest/buy-in

▢ Time constraints, the demands of running our organization require all of our effort

▢ Workforce availability with the necessary skill sets

▢ Information technology capacity

▢ Data availability


▢ Budget constraints, it costs more than we can afford

▢ Cultural and language differences between our organization and traditional process improvement systems

▢ Cultural and language differences between the clients we serve and what is traditionally measured in process improvement and evaluation



▢ None Page Break

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Population Health Management: A key component of improving people’s health is the way your organization understands its impact on the population you serve. The information you collect on your clients can help you better target services, uncover disparities, and inform you of the difference your organizations makes with the various populations it serves. Which of the following demographic data do you track for clients your organization serves?

▢ Race

▢ Ethnicity

▢ Primary language spoken at home

▢ Gender

▢ Date of birth

▢ Gender identity

▢ Disability status

▢ Household income

▢ Sexual orientation

▢ Immigrant

▢ Refugee

▢ Other, please specify ________________________________________________

▢ None Page Break

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Does your organization screen clients for any of the following?

▢ Physical illness

▢ Substance use disorder

▢ Behavioral health disorder

▢ Oral health

▢ Homelessness

▢ Housing status

▢ Intimate partner violence

▢ Food security

▢ Employment, vocational, or job training

▢ Education

▢ Developmental (children thru age 5 ½)

▢ Trauma or adverse life events

▢ Transportation needs

▢ Assets, resources, or sources of support

▢ Other, Please specify ________________________________________________

▢ None Page Break

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In your agency’s data systems, can client demographic information (such as race/ethnicity and language) be linked with other data (such as client satisfaction, grievances/complaints, and dis-enrollment)?

o Yes

o No In your agency’s data systems, can client screening information (such as health status, housing status) be linked with other data (such as client satisfaction, grievances/complaints, and dis-enrollment)?

o Yes

o No Please specify any other strengths of your agency's data system for population health management.

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

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Ideally, what kind of information would your organization like to collect to understand your organization’s impact on the various populations of people you serve? Check all that apply

o Disaggregated demographic data

o Person/family satisfaction

o Outcome data

o Linked data to identify disparities

o Linked data to show the relationship between outcomes and social determinants

o Other, please specify ________________________________________________

o None

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Which, if any, of the following barriers interfere with your ability to develop and maintain a population health management system? Check all that apply

▢ Board buy-in




▢ Workforce with the necessary skill sets

▢ Workforce availability: staff are currently stretched to capacity




▢ Budget constraints. It costs more than we can afford

▢ Cultural and language differences between our organization and data systems



▢ None Page Break

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Community Based Care Coordination: A key component of improving people’s health is how individuals and families are connected to the services they need to be healthy. Pierce County ACH has adopted the Pathways Community-HUB Model. There are two components of the model. First, is care coordination services which are provided in the community, often in people’s homes, and follow an evidence-based protocol. Second is the HUB itself. The Pathways HUB is the administrative center. It receives referrals, assigns people to Care Coordination Agencies for services, maintain the data system, provides training, etc. There are three ways your organization could partner with Pathways including: Be a Care Coordination Agency that provides Pathways Community Care Coordination Services Refer clients who are eligible for services to the Pathways HUB Partner with Pierce County ACH to link existing programs to the Pathways Community-Based Care Coordination System, leveraging Pathways to increase service delivery in Pierce County Page Break Does your organization serve any of the following populations? Select all that apply.

▢ Individuals or families experiencing homeless, being unhoused or at-risk of being homeless

▢ Individuals or families who are frequently seen in hospital emergency departments

▢ Individuals who have serious chronic illnesses like diabetes, heart failure, COPD, asthma etc.

▢ Individuals with serious behavioral or emotional health conditions like major depression, anxiety, schizophrenia, etc.

▢ Individuals with addiction or harmful substance use including the harmful use of alcohol, opioids, marijuana, etc.

▢ Pregnant women


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Describe your organization’s strength in serving your population. Select all that apply

▢ Authentic partnerships with clients

▢ Staff with deep content specific, expertise and commitment

▢ Staff who share cultural and linguistic backgrounds with the clients

▢ Flexibility to provide services clients need

▢ An approach that achieves measurable outcomes

▢ Convener – Share data and facilitate discussions to build strategic direction and objectives among groups doing similar work with similar populations

▢ Other, please specify ________________________________________________ Page Break Does your organization currently provide care coordination services that allow you to connect individuals to other resources they need?

o Yes

o No If yes, does your organization provide connect/refer to other divisions or services within your organization (e.g., you refer clients to an energy assistance program your organization provides)?

o Yes

o No

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Does your organization provide care coordination services to programs and services outside of your organization (e.g., a set of services designed to provide accurate information and referrals to individuals, family members and caregivers to ensure that the appropriate services are accessed and coordinated)?

o Yes

o No Does your organization have a systematic process for referring individuals/families to other organizations?

o Yes

o No Does your organization currently provide intensive case management services (e.g., a set of services designed to improve an individual’s health including health assessment and on-going reassessments, development of a care plan, monitoring progress, utilization of evidence-based practices in screening and intervention, coordination of care across the continuum of medical, behavioral, oral health, and long-term care services and supports, crisis intervention and case conferencing)?

o Yes

o No

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What/which population(s) do you provide case management services for? Check all that apply

▢ Homeless or unhoused individuals and/or families

▢ People who are frequently seen in hospital emergency department

▢ People who have serious chronic illnesses like diabetes, heart failure, COPD, asthma etc.

▢ People with serious behavioral or emotional problems health condition like major depression, anxiety, schizophrenia, etc.

▢ People with addiction or substance abuse misuse problems such as problems with alcohol, opioids, marijuana, etc.

▢ Pregnant and post-partum women

▢ People with over a 1.5 PRISM score

▢ People with serious communicable diseases like tuberculosis

▢ Children with special health care needs

▢ Other, please describe ________________________________________________ Page Break

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Which, if any, of the following barriers interfere with your ability to be a Care Coordination Agency for Pathways? Check all that apply

▢ Board buy-in



▢ Cultural and language differences between our organization and Pathways

▢ Lack of a community health worker workforce

▢ Lack of knowledge about how to most effectively use community health workers


▢ Following the program, the way it was designed (fidelity to the model)

▢ Payment or financing mechanisms. (outcome-based payments)

▢ Serving people who are not clients of our organization

▢ Providing home-based services

▢ Commitment of time from supervisors

▢ Not in our scope of service

▢ Pathways is limited to Medicaid population


▢ None Page Break

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Which, if any, of the following barriers interfere with your ability to be a referral partner for Pathways? Check all that apply

▢ Information technology capacity to send and receive referrals electronically

▢ Knowing who to refer to the Pathways HUB (e.g., Pathways administrative center)

▢ Confusion over who to refer to which programs



▢ None Page Break

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Which, if any, of the following barriers interfere with your ability to partner with the Pathways Community Care Coordination System, including the Pathways HUB, to integrate Pathways Community Based Care Coordination with your existing care coordination or case management program(s)? Check all that apply

▢ Board buy-in




▢ Workforce with the necessary skill sets

▢ Workforce availability: staff are currently stretched to capacity

▢ Information technology capacity.


▢ Payment or financing mechanisms. (categorical funding restrictions)

▢ Budget constraints. It costs more than we can afford

▢ Cultural and language differences between our organization and data systems




▢ None Page Break

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If you or your organization have other concerns, strengths, issues outside of what was addressed in this survey that you think are important for Pierce County ACH to consider, please describe them here.

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________ Thank you for your commitment to providing quality services and to helping Pierce County to be healthier. You've reached the end of the survey. If you are satisfied with your answers, clicking 'next' below will submit your answers to Pierce County ACH and you can download a PDF of your responses on the next screen. If you'd like to review or edit your responses, your answers have been saved to the Qualtrics server with your IP address, and you can close this window and return to your unsubmitted survey on this browser at a later time. Thank you!

End of Block: CBO question copy

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