April 2016 AHC Model Break Out

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Accountable Health Communities

Accountable Health Communities (AHC): A CMS/CMMI Grant Opportunity

HCGC Regional Learning Session

April 8, 2016

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Today’s Agenda

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Define and Explore Existing Accountable Health Communities

Models

Introduce the Accountable Health Communities (AHC)

CMMI Grant Opportunity

Review Collaborative

Progress on AHC Application Strategy

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Define and Explore AHC Models

Accountable Health Communities: What Do they Do?

• Address gaps between clinical care and community services,

improve collaboration

• Identify and address health-related social needs

• Reduce inefficient use of healthcare services and overall cost

• Improve health status

• Reduce health disparities


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Case Study #1: Washington

Accountable Communities of Health

• Funded by 12% of SIM award to HCA’s “Healthier Washington”

• Created 9 ACH regions in 2015

– Matches Medicaid’s regional service areas

– Regional, cross-sector governance

– Regional Health Improvement Plans

• Alignment with concurrent HW efforts

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Regions range from 1-10 counties

• King & Pierce = 2.8M (40% of WA)

– 23% Medicaid enrollees

Types of “Backbone” organizations:

• Local public health

• Community-based orgs

• Nonprofits (dual)

Regional Health Improvement Plans

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Case Study #2: Minnesota

Accountable Communities for Health

• Funded by 14% of SIM award to DHS and MDH’s “Accountable Health Model”

• Created 3 AHCs in 2013, 12 in 2015

– Multi-sector care coordination

– ACO provider contracts

– Multi-payer alignment

• Builds on infrastructure from 2013 Medicaid demonstration (IHP)

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• Eligible organization types:

“…tribes, community or consumer organizations, public health boards, health plans, counties, health care providers, or any other non-profit or for profit entity located in the State of Minnesota.”

• $185K/year/ACH for 2 years

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• ACH essentials:

– Target population

– Advancing health equity strategies

– Community engagement

– Community partnerships

– Quality infrastructure and measurement

– Accountable Care Organization partnership

– Health reform history

• Within 24 months, must create:

– Leadership team

– Community based care coordination system/team

– Population based prevention

– Sustainability plan

– Measurement plan

– Learning Collaborative

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Today’s Agenda



Models





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CMMI AHC Grant Opportunity


In January 2016, CMS/CMMI announced the Accountable Health Communities collaborative grant opportunity.

Application Timelines

• Letter of Intent Due (Optional & Non-Binding): February 8, 2016

• Grant Applications Due: May 18, 2016

• Grant Awarded: March 3, 2017

• Grant Period: April 1, 2017 – March 31, 2022

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CMMI AHC Grant Opportunity

CMMI’s describes an Accountable Health Community as a regional partnership managing the total health of public beneficiaries.

Partners include:• State Medicaid Agency• Bridge Organization• Clinical Providers

• At least 1 primary care provider• At least 1 hospital system• At least 1 behavioral health provider

• Community Service Providers• Advisory Board


Beneficiary

Payer

ProviderCommunity

Services

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Health-Related Social Needs

Core Needs (Required)

Housing Instability

Utility Needs

Food Insecurity

Interpersonal Violence

TransportationSupplemental Needs

Family & Social Supports

Education

Employment & Income

Health Behaviors

Others

1. Grantees will be required to screen beneficiaries for all of the core health-related social needs.

2. Grantees can choose to screen for supplemental health-related social needs. Other needs can be identified by the community.


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Key Grant Components

Bridge Organization

Evaluation

Referral Infrastructure

Screening Tools

Care Coordination

Fiscal Role

Providers

• 1 PCP

• 1 Hospital

• 1 Behavioral Health

State Medicaid Agency

Social Service Agencies


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Today’s Agenda



Models





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Collaborative Progress on AHC Application

Formal Bridge Organization• Grants management and

reporting functions• Interfacing with Ohio Medicaid• Coordinate evaluation• Engage provider community

on the screening and referral

Co-Lead Convener Role • Engaging community service

partners• Coordinating/developing the

navigator approach and linkages


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Clinical Delivery Sites committed to collaborative grant application

• Affirmative Counseling Associates• Columbus Area Health Integrated Services• Central Ohio Primary Care• Heart of Ohio Family Health Center• Lower Lights Christian Health Center• The Medical Group of Ohio• Mount Carmel• Nationwide Children’s Hospital• The Ohio State University Wexner Medical Center• OhioHealth• PrimaryOne Health• Southeast, Inc.• Syntero


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Community Service Providers and Advisory Organizations committed to collaborative grant application


• AbbVie• Affirmative Counseling Associates• AIDS Resource Center Ohio• Alliance Healthcare Partners• American Cancer Society• Anthem• Asian American Community Services• AST• Battelle• CBIZ• Charitable Pharmacy• Central Ohio Area Agency on Aging• Columbus Public Health• Community Shelter Board

• Central Ohio Transit Authority• Duet Health• Evi-Base Community Care• Findley Davies, Inc.• Franklin County Pathways Community HUB• Franklin County Public Health• Franklin International• HandsOn Central Ohio• Helper Holdings, LLC dba Caliber Patient Care• InHealth Mutual• InXite Health

• Lifecare Alliance

• Medical Mutual

• Mercer Health

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• Mid-Ohio Foodbank

• Molina

• National Church Residences

• Ohio Association of Area Agencies on Aging

• Ohio Association of Free Clinics

• Ohio Commission on Minority Health

• Ohio Department of Health-Help Me Grow

• Ohio Health Information Partnership

• Ohio Public Employees Retirement System

• Ohio State University

• Ohio State University College of Pharmacy

• Ohio State University College of Public Health

• Ohio University College of Health Sciences and

Professions

• Pataskala Medical Center

• Pfizer

• Ripple Life Care Planning

• Summit Orthopaedic Home Care

• Syntero, Inc.

• Total Wellness Concepts, LLC

• UHCAN

• United Way of Central Ohio

• UnitedHealthcare

• UnitedHealthcare Community Plan of Ohio

• YMCA

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Community Service Providers and Advisory Organizations committed to collaborative grant application

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Proposed Target Zip Codes• 43207 • 43224 • 43228 • 43219 • 43232 • 43211 • 43229• 43204

Additional Zip Codes Added

• 43223 • 43123 • 43227 • 43206 • 43205 • 43068 • 43231• 43213


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Track 3 - Alignment


Beneficiary Activity Management and Reporting System

Eligibility Screen

Needs Screen

Risk Level?

Community Resource Summary

Franklin County

Pathways Community

Hub

Medical Neighborhood

Referral Infrastructure

Tool (CliniSync)

Navigation Tracker

Tool

Clinical Delivery Site

Low

Navigator

Community Service ProviderWeb-based Tool

Web-based Tool


www.hcgc.org www.nationwidechildrens.org22Exits

Dat

a

Ineligib

le

Ohio Medicaid

Data

Tracked

Sample schematic of “UpstreamColumbus” proposal for AHC grant:

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• Key Driver Diagram (KDD): Quality improvement tool depicting a project’s aims/goals and cascading strategies for achievement.

Ex)


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• Definitions:

–“Global Aim”: Vision, ideal or overarching purpose

–“Aim Statement”: Specific, Measureable, Achievable, Realistic, Time-bound (SMART) goal(s) for the project

–“Primary Drivers”: Forces that directly impact the achievement of your Aim Statement

–“Interventions”): Action steps and/or strategies for impacting the Primary Drivers to the desired effect.


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• Types of Measures on a KDD:

–Outcome: Measures the health, finance or clinical outcome of a targeted population or system.

• Ex) readmissions, quality of life, total cost of care

–Process: Represents the effectiveness of a process which was implemented to affect an outcome measure.

• Ex) waitlisted patients, days between referrals, turnaround time.


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• Benefits to using a KDD:

–Reinforces desired project outcome (aim)

–Defines the key leverage points, or system “drivers”

–Links specific project activities and changes (the “hows”) to key components in the system

–Ensures project progress and results are measured and monitored

–Facilitates stakeholder buy-in and commitment by providing transparency around changes required for project success


Global Key Driver Diagram

Primary DriversAim Statement

Interventions

• Every year, connect at least 3,000

high-risk community-dwelling

beneficiaries (HRCDB) with unmet

health-related social needs (HRSN)

to a community-based navigator,

with a goal of >75% of HRCDBs

completing referrals from 4/1/2018

to 9/30/2021

• Reduce service gaps in each of the 5

core HRSN domains through the

implementation of a sustained,

collaborative quality improvement

project series beginning 7/1/2018.

Global Aim (Vision) Capacity & Efficiency of

Community Service Providers

Secure subcontracts, consultant agreements, IRB

approval, and collaborative reporting structureEstablished Navigation

System across Clinical Service

Delivery Sites

Data-Driven Infrastructure,

Monitoring and Decision-

Making

Resource Awareness and

Health Literacy of CDBs

Community Resource Partner

Alignment through Quality

Improvement

Develop and implement front-end HRSN

screening tool for CBDs seen at clinical sites

Design and disseminate referral and navigation

policies & procedures including training plan

Establish Advisory Board to oversee availability

of community services and support data sharing

Complete gap analysis and quality improvement

goals with community service provider network

Recruit and/or contract, and train navigation

services staff for high-risk beneficiaries

Design and implement data monitoring and

analysis system for back-end reporting to CMMI

Recruit or secure staff member at Ohio Dept. of

Medicaid to assist with data collection

Establish mechanism for monitoring and

reducing duplication of program services

Reduce inefficient use of

inpatient and outpatient health

care services through resolution

of unmet health-related

social needs (HRSN)

P: #/% of HRCDB navigated/yrP: #/% of CDB

screened/year

P: % referred on waiting list

O: % increase in navigated

HRCDB’s QOL

Inventory local community service providers

responsive to community needs assessment

P: # updates to CRI/year

O: % increase in CDB literacy

P: # QI projects completed/yr

P: % trained w/i 30 days

O: % navigated HRCDBs w/

unmet needs

O: % decrease in navigated

NRCDB’s TCOC

Develop targeted action plans for the equity

subpopulations including pre/post-intervention

P: #/% of HRCDB referred/year

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Exploratory Time

Questions of Clarity


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Contact Information


Naomi Makni

([email protected])

Michelle Missler

([email protected])

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mailto:[email protected]

mailto:[email protected]

Documents

April 2016 AHC Model Break Out