Scorecard Criteria Improved Access

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1 Final Pilot Closeouts Outcome Achievement Measurement Sufficiency Improved Health Outcomes MHL II MH,A&PCI BH_PCPCH PHN_HV UPS APM 1 PCPC LCSW in PCPCH CCCM PMH CPCB PHLI CVAIS Reduces Costs Scorecard Criteria Improved Access State Metrics Transformational Barriers Scalable Replicable Self-Sustaining # Reviews Rev 05/01/ of 31

2 Childhood Vaccine Attitudes and Information Sources Jessica Deas, Sandra Bean, Charlie Fautin Benton Co Health Dept Dates: 1/1/ /31/2016 Pilot Funds Used $ 10,000 Oregon experiences the highest nonmedical pediatric vaccine exemption rate of any state in the U.S., and the Linn, Benton, and Lincoln County region experiences some of the highest nonmedical exemption (NME) rates in the state. The proposed study will provide qualitative data on the underlying concerns and health beliefs of parents/guardians in the Linn, Benton & Lincoln counties concerning vaccination. We will also examine specific sources of these concerns and health beliefs (e.g., social and other media, alternative health care providers) so as to better frame future intervention messages around anti-vaccine arguments. Key Findings: 1. Even though parents reported their children as fully vaccinated, they very often delayed or spaced out those vaccines. Very few adhered to the recommended schedule. 2. Social networks are important for hesitant participants and provide a primary source of information whether accurate or not. 3. While parents do perceive that vaccines have risks, concerns for autism are diminishing. 4. Vaccine preventable diseases are not seen as large risk to parents. 5. Patients want doctors to listen to and understand them, not preach at them. Additional Information: 1. We need vaccine promotional interventions aimed at physicians and nurses, at parents, and addressing science education in elementary school children are a powerful force for change. 2. Pilot mentioned the potential to continue work on coming up with scripts for providers. Child Psychiatric Capacity Building Caroline Fisher, Samaritan Mental Health Dates: 9/1/2014 8/30/2016 Pilot Funds Used $ 321,350 Access to specialty mental health care for children and adolescents is very limited both nationally and locally. This leaves kids with complex psychiatric needs, both diagnostic and medical, with significantly limited access to care. Behavioral Health integration projects such as this pilot, take some of the workload off specialty mental health by shifting care for relatively straightforward cases to the primary care provider, allowing the specialty mental health psychiatrist to focus on the more complex cases. Services will be provided by Samaritan Mental Health Family Center. The specialty mental health provider will work with the primary care provider to offer on-going support and care coordination. Key Findings: 1. At 140 patients, the new model has almost twice the patient capacity as the old model greatly increasing capacity for psychiatric services in the area. 2. No show rate has plummeted. People come when they need help and appreciate not coming when they do not need help. 3. Burn out for Psychiatrist did not increase even though patient panel has shifted to high acuity patients. Model allows for lighter daily schedule. 4. Model could be adopted by other specialties. Additional Information: 1. New model uses Mental Health Specialist (MHS) trained to gather psychiatric data. Initial data gathered by MHS reducing MH time for initial visit from 90 minutes to 30 minutes. Follow up visits every 3 months instead of monthly, or as needed. MHS kept in touch by phone, usually 2-6 phone calls in between visits. Rev 05/01/ of 31

3 Final Report and Evaluation Pilot Community Paramedic Use the following format to provide a summary of your project. Please include: A. Amount of pilot funds used. Were additional funds used from other sources? If so, how much? The entire amount of the pilot funds were used to support this program. In addition, the City of Albany provided IT and legal services, office space, utilities, and equipment use. A specific amount for these services is not available. B. Final Measures and a brief narrative/summary of Goals, Activities, Measures, and Results. Goal Measure(s) Activities Results Acquire and equip a vehicle To be acquired within the first quarter Leased vehicle. Completed in first quarter. Hire and train Community Paramedic To be completed within the first quarter Paramedic was already on staff at AFD and was transferred into the Completed January Establish written protocols approved by Physician Adviser Establish forms for data collection in the field Establish computer software program for data collection and reporting Promote program within public and private healthcare systems and social service programs Establish protocol with healthcare providers and EMS providers to target IHN-CCO members for To be completed within the first quarter To be completed within the first quarter To be completed within the first quarter Provide the number of presentations and participants within the healthcare and social service provider networks Count number of referrals, specifically identifying IHN-CCO members position. Protocols written, reviewed, and approved. This has evolved over the course of the year as needs have been identified. Evaluated multiple methods for collecting data, unsuccessful in finding off-the-shelf product to meet program needs. Working with City staff to write an application for use in the field. Included presentations to community, healthcare, and social services organizations. Had preliminary meetings with a variety of Samaritan Health Services representatives, IHN, and other healthcare entities to Delay in receiving approval from physician, but completed in the third quarter. Completed in the first quarter, but will continue to improve as more details and program needs are identified. Used Excel for tracking data during the pilot program, but realize an application specific to meeting the program needs is required. We will continue to work toward completion of this goal. 27 presentations 413 participants (Numbers do not include all program promotion contacts.) This goal has not been accomplished and minimal progress has been made. This goal is 9 of 31

4 referral to Community Paramedic Identify and determine IHN-CCO patients with which to follow up Number of patients identified Number of patients followed up with help establish protocols. Referrals are primarily coming from AFD paramedics, word-ofmouth, and other sources, with limited referrals from external healthcare providers. All patients, including IHN-CCO patients, that have been referred to the program have received follow-up. reliant on commitment from key players in the Samaritan system and healthcare community. Progress is difficult to maintain and slow to develop due to the challenges in maintaining involvement from the outside players who are critical to its success. 100% Determine savings for IHN-CCO members Reduce medical transports to IHN-CCO members Reduce number of ambulance transports to the emergency department of IHN-CCO members by focusing on appropriate alternative care Reduce number of IHN- CCO members using system for overdose and seizures Reduce ambulance transports of IHN-CCO IHN-CCO members utilization rates of ED vs. primary care services Count of medical transports of IHN-CCO members compared to total transports Count number of referrals to alternate care that otherwise would have been ambulance transports of IHN-CCO members to an ED Referrals will be considered avoidance of ambulance transport to an ED IHN-CCO members currently comprise a higher percentage of overdose and seizure calls into AFD s response area compared to the general population of non-ihn-cco members Track referrals of IHN- CCO members to mental Tracked referrals to mental health Unable to quantify without more data. Prior to the pilot program 15.9% of transports were IHN members. The total for the year of the program was 14.6%, a reduction of 1.3%. Intended to develop a system for ambulance transport to alternative care, which we are unable to address during the pilot program period, and have determined is outside the scope of this program. Overall transports of IHN-CCO members related to overdose were 7.2% for the year. Overall transports of IHN-CCO members related to seizures were 11.4% for the year. Out of 16 referrals to mental health 10 of 31

5 mental health patients to ED by referring these patients to mental health providers Provide in-home evaluation and services to reduce patient entrance into the health care system Conduct a cost effectiveness analysis health professionals Track services provided to IHN-CCO members by Community Paramedic Services, i.e. EKG, blood sugar levels, fall prevention, home safety evaluations, medication reconciliation, etc. Pilot cost, minus infrastructure cost, divided by unique member. Pilot cost, minus infrastructure cost divided by encounter. professional during each quarter. professionals, one was an IHN-CCO member. Out of 137 in-home evaluations, 9 were IHN- CCO members. The count of IHN-CCO members only reflects the last three quarters. IHN-CCO members were not being tracked for this in the first quarter. $1, per unique member $1, per encounter Results Narrative: C. What were the most important outcomes of your Pilot? The Community Paramedic Program successfully provided an innovative and transformational model for providing healthcare in our community that reduced the use of traditional emergency services. The Fire Department saw a 1.3% reduction in emergency transports of IHN-CCO members. The program allowed access into at-risk patient homes to assess their living situation and outside conditions to provide a proactive approach to their healthcare, and prevent unnecessary entry into the emergency medical care system. The Community Paramedic is able to take a more intimate look at the situation and coordinate with outside healthcare and social service resources to better meet the needs of the client at a lower cost than entry through the system and hospital emergency room. The program has provided for better healthcare integration by building relationships and understanding of each other s roles between the Fire Department, social service agencies, and healthcare providers to reduce duplication and best utilize the resources of each organization. D. How has your Pilot contributed to Triple Aim of improving health; increasing quality, reliability, and availability of care; and lowering or containing the cost of care? The program has reduced the demand on the system and hospital emergency room admissions through a proactive approach to healthcare. Access into patients homes provides a perspective not available to physicians that can aid in determining the root of a patient s complications and allow immediate remedies to issues not otherwise known to the healthcare provider that can improve the patient s health and wellbeing. The program directs patients to medical care, e.g. mental health, home health, or other human service agency, that best meets their needs more timely and at a lower cost of care, and reduces the frequency of access into the healthcare system through E. What has been most successful? 11 of 31

6 The positive impact of the Community Paramedic program on people s lives as described in the success stories documented in our quarterly reports. Also, the referrals into the program have come primarily from Fire Department paramedics. The program has provided a valuable resource to paramedics to refer recurring patients that require care beyond emergency transport. This has helped address the basic needs of the patient and lessen the frequency of emergency care and transport for these patients. This is evident by the reduced number of transports of IHN patients by 1.3%. F. Were there barriers to success? How were they addressed? Yes, the primary barrier was in establishing referral procedures with outside healthcare providers, targeting IHN- CCO members for referral, and establishing an APM. We had a number of conversations with several different representatives of Samaritan Health Services. These would result in interest and excitement about the program, but would not lead to anything further or concrete in forming referral procedures or APM. We believe this is because the concept of a Community Paramedic Program is new, and more education is needed to understand how the program can be used and the positive impact it can have on the individual practitioners as well as the healthcare system in general. G. How readily would the pilot be scalable or replicable? Describe cautions and considerations when considering scaling, or replicating the Pilot. (i.e. Success dependent on personality/skills set, or activities appropriate under certain conditions like size, target population, etc.) The program is easily scalable and replicable. The Lebanon Fire District has already sought out information and funding to start a Community Paramedic program based on Albany s model. The cautions and considerations are being able to develop an APM and formal referral procedures necessary to sustain the program long term. Although we were not successful in getting referral to the program from a PCP or Samaritan Health, the number of referrals from agencies outside of the Albany Fire Department increased by the end of the pilot program. We believe this was primarily due to the relationships developed by the Community Paramedic during the program with social service and other agencies. H. Will the activities and their impact continue? If not, why? It is our intent to continue the program through temporary funding while we take an alternative approach to developing APM and a formal referral program. The current funding availability through the City is limited, and the services of the program will be reduced until permanent funding can be obtained. The Fire Department sees great value in this program and understands the necessity in dedicating more resources in order for it to be successful. The Community Paramedic s primary role is to deliver patient care, and Fire Department administration is unable to provide the time and effort required to coordinate with the diverse number of stakeholders, maintain continuity, and adequately promote the program to get the needed results. It has become apparent over the course of the pilot program year that we need to seek additional outside funding to sustain the program while we also direct resources to hire a staff person whose sole responsibility is to develop APM and a system-wide referral program for long-term sustainability. 12 of 31

7 IHN-CCO DST Limited Pilot Proposal Extension or Expansion Amendment Please use the following format to provide a summary of your project: A. Pilot Title: Albany Fire Department Community Paramedic Program Original Pilot Funding Amount: $290,400 Short summary: Requesting a one-year extension and expansion of the Community Paramedic Program pilot that started in January The achievements and needs of the program are evident and are also being recognized by neighboring jurisdictions. The Lebanon Fire District has requested expansion of the program into their community, which would require adding additional Community Paramedics. A more comprehensive referral system and sustainable funding sources are required in order to sustain this program long term. Development of the referral system and Alternative Payment Methodologies (APM) is underway, but IHN funding is needed to continue the current program in Albany and expand into portions of East Linn County where community paramedic services can impact the transformation of healthcare into more areas of Linn County. The total program costs are estimated to be $514,800, and we are requesting $378,000. The difference will be supported by the two fire agencies operating budgets. B. Request (check all that apply): Additional Funds Extended Timeframe (Attach new budget and New Start Date: outcomes) 5/1/2017 New End Date: $378,000 5/1/2018 Shift of Focus C. What is the rationale for the requested change? A Community Paramedic Program relies on referrals from outside healthcare and social service agencies for patients to enter the program. Initially these referrals were primarily coming from paramedics within our organization. In the first three quarters of the pilot, only 24 percent of patient referrals were from outside agencies and the remaining 76 percent came from within our organization. However, as the program continued and more connections were made between the healthcare delivery system and our community, referrals from outside agencies expanded significantly. In the fourth quarter, 63 percent of referrals were from outside agencies. Other healthcare provider and physician referrals are essential to accessing the IHN-CCO patient community in need of Community Paramedic Program services. Continued funding of the Community Paramedic Program will allow for more time for connections to be made and appropriate awareness of how the Community Paramedic can transform healthcare in the midvalley. Toward that end, we have been meeting with Samaritan Health representatives from various departments throughout their system. We are on the cusp of establishing a referral process with 13 of 31

8 Samaritan and expect to have an integrated referral program within the next six months. We would also like to establish a referral process and APM with IHN. Extension and expansion of the Community Paramedic Program will provide the time needed to further develop a sustainable referral program and APM for a permanent, successful program. At the time of last year s application 15.9 percent of patients transported to the hospital by Albany Fire Department were IHN-CCO members. Throughout the 12 months of the pilot study we realized a decrease to 14.6 percent. We attribute this success to the ability to proactively address the medical needs of these patients, preventing further decline in their health and the need for emergency healthcare services. The program s impact has been recognized by the Lebanon Fire District, resulting in their request to expand the program into their district. We currently have a partnership with Lebanon and Tangent Fire Districts that provides a hospital transfer unit during peak activity hours. Expansion of the Community Paramedic Program into Lebanon s district will further enhance the cooperative relationship between our agencies, thereby increasing the benefits to both programs within both communities. Community Paramedic Program expansion would allow services to a greater IHN-CCO population and reduce admissions and readmissions to multiple area hospitals. After an initial successful pilot year, and an anticipated expansion year into further areas of East Linn County, we believe continued expansion and sustainability can eventually spread throughout the three-county region of Linn, Benton, and Lincoln Counties. Community Paramedic programs are becoming more established throughout the state. There is potential legislation to further establish and expand community paramedic services as a transformational form of healthcare for the future. D. If this request is not granted, will any activities or outcomes from the original proposal not be possible? The Fire Department is funded by limited property tax revenue which provides for maintaining fire engines, medic units, and staffing for emergency fire, rescue, and medical services. Although there has been limited short-term funding to continue the program to date, there is not funding to support long-term continuity to adequately implement the necessary referral process and APM. In order to adequately fund the current program, notwithstanding any expansion, this program or other Fire Department programs could suffer or be in jeopardy in the future. Expansion of the program will not be possible without continued IHN-CCO funding. E. If this request is granted, are there new activities or outcomes that will be possible? If this request is granted, the Community Paramedic Program will expand into portions of East Linn County that are serviced by the Lebanon Fire District, more dramatically increasing the IHN- CCO population served. The outcomes of the program will remain the same or similar as during the first year of the pilot program, in addition to establishing APMs and solidifying the referral process. 14 of 31

9 IHN-CCO DST Pilot Measures and Evaluation Template Pilot: Community Paramedic Program (CPP) A. Use the format below to identify the key Measures that will be collected and analyzed to know that the Pilot has accomplished these goals. Goal Measure(s) How it will be collected Acquire and equip a vehicle in Lebanon Hire and train Community Paramedic in Lebanon Establish referral criteria and process with healthcare providers that also targets IHN-CCO members Establish patient status communication system between healthcare providers and CPP Promote program with private healthcare and social service providers Target areas within Linn County where IHN-CCO members have a higher rate of requests for healthcare services Reduce number of ambulance transports to the emergency department of IHN- CCO members To be acquired within the first quarter. To be completed within the first quarter. To be completed within the first six months To be completed within the first six months. Provide the number of presentations and participations within the healthcare and social service provider networks. Identify targeted geographic areas and track incidents where IHN-CCO members have a higher rate of requests for healthcare services Count number of referrals to alternate care that otherwise would have been ambulance transports of IHN members to an ED. N/A N/A Utilize data collection from Samaritan Epic system and the Albany Fire and Lebanon Fire records management systems Utilize and link Samaritan Epic with Albany Fire and Lebanon Fire records management systems Count number of meetings and presentations. GIS assistance with mapping and Community Paramedic Program database Electronic data collection program specific to the CPP. 15 of 31 How often it will be collected Within the first quarter. Within the first quarter. At the end of the first and second quarters Quarterly Quarterly Quarterly Quarterly Definition of success Vehicle is purchased and equipped for response. Community Paramedic is hired and response ready. Receiving regular patient referrals from established partners Successful two way communication and information sharing between involved agencies Program is recognized and being utilized by local healthcare providers and other human service providers Target areas show a decrease in demand for service tracked over a period of time Reduce number of ED transports for IHN members by 2.0%.

10 Referrals will be considered avoidance of ambulance transport to an ED. Identify/track issues that cause IHN-CCO members to call and develop resolutions to reduce the most common issues Determine why IHN- CCO patients are accessing 9-1-1; quantify total number of patients; focus on common solutions to reduce continued reoccurrence Aggregate data from CPP initial patient intake form Quarterly Results of data over 6 and 12 months; Identify target areas; a reduction in activations by IHN- CCO members Reduce ambulance transports of IHN- CCO mental health patients to ED by referring these patients to mental health providers Increase number of referrals from Community Paramedic to Mental Health Providers Medical services transport records Quarterly Decrease ambulance transports and emergency room visits to mental health patients in target areas Provide in-home evaluation and services to reduce repeat patient entrance into the healthcare system Track services provided to IHN members by community paramedic. Services, i.e. EKG, blood sugar levels, fall prevention, home safety evaluations, medication reconciliation, etc. Electronic data collection program specific to the CPP. Quarterly Reduce referrals into the healthcare system through preventative inhome evaluation and services. Conduct a cost effectiveness analysis Program costs, minus infrastructure cost, divided by unique member. Operating budget, unique members, and number of encounters Semi-annually Determined by funding provider Program costs, minus infrastructure cost, divided by encounter 16 of 31

11 IHN-CCO DST Pilot Budget Template Pilot: Community Paramedic Program Project Start Date: 05/01/2017 Project End Date: 05/01/2018 General and Contracted Services Costs Resource Total Cost Amount Requested* Administrative, Supervision, Data Collection, and Delivery of Goals $ 412,200 $ 301,400 Physician Advisor Services $ 2,400 $ 2,400 Program Advertising/Promotion $ 2,000 $ 0 $ $ Subtotal Resource costs $ 416,600 $ 303,800 Materials & Supplies Client Services Safety Equipment & Supplies $ 10,300 $ 10,300 Program Materials, Supplies, and Equipment $ 39,900 $ 39,900 Subtotal Materials & Supplies $ 50,200 $ 50,200 Travel Expenses Vehicle Leasing for Lebanon $ 31,500 $ 8,500 Fuel and Vehicle Maintenance $ 5,000 $ 5,000 Subtotal Travel Expenses $ 36,500 $ 13,500 Meeting Expenses Program Outreach $ 1,000 $ 0 $ $ Subtotal Meeting Expenses $ 1,000 $ 0 Professional Training & Development Program Management Training and Continuing Education $ 10,000 $ 10,000 $ $ Subtotal Professional Training & Development $ 10,000 $ 10,000 Other Budget Items Uniforms $ 500 $ 500 $ $ Subtotal Other $ 500 $ 500 Total Direct Costs $ 514,800 $ 378,000 Indirect Expenses (not to exceed 15 % of Direct Costs) $ $ Total Project Budget $ 514,800 $ 378,000 *If amount requested is different from total cost, please describe the source of the additional funds in the narrative. Cost Allocation or Indirect Rate: Indirect cost may not exceed 15% of the Total Direct Costs. Expenses, such as equipment and/or supplies, should not be included in the Indirect Expenses category but should be itemized in the other budget categories. IHN-CCO reserves the right to request additional detail on cost allocation or indirect rates. 17 of 31

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13 Delivery System Transformation Committee Our Purpose Promote and strengthen partnerships and create new linkages that support transformation of the health care delivery system in the CCO s three-county region through collaborative workgroups and funded pilots. Expand and integrate collaborative partnerships that are aligned with the CCO s goals and the Triple Aim. Promote, foster, support, share innovation, and expand the model of the Patient Centered Primary Care Home as the foundation of the CCO s transformation of health care delivery Areas of Strategic Focus Effectiveness and sustainability. Expand, connect, and demonstrate access to person-centered; Medicaid-focused health care. Connecting social determinants of health and upstream health to the traditional health care system. Coordinated, integrated care. Demonstrate innovation and outcomes in health care. Transformation Pilot Project Selection Criteria In the process of selecting pilot projects for funding, the DST will give priority to proposals that meet the following criteria and qualities: Create opportunities for innovation and new learning for the DST. Yield measurable outcomes that are new or different from previously funded pilots. Establish new connections within and between the health care delivery system and the community. Plan to sustain and continue project after DST funding ends. Must include a strategy for sustaining the project for at least an additional year after the pilot phase is completed. Exhibit consideration of alternative funding sources. Clearly articulate what part of the Medicaid population is affected and how. Target areas of health care associated with escalating health care costs. Develop and validate strategies for collaboration and creating interconnections between community services and health care systems. Demonstrate clear linkage to the Patient-Centered Primary Care Home. Where appropriate, the narrative could include examples from other previously funded DST projects. 19 of 31

14 TOP 5 Proposal Summaries Oral Health Equity in Vulnerable Populations Presented by: Britny Chandler Budget: $143,244 Expected Start and End Date: January 1, December 31, 2017 Project Description and Goals: The Linn County and Benton County Oral Health Coalitions (LBOHC) proposes to offer bi-lingual oral health education in nontraditional community-based settings, deliver education to nurses and/or caregivers about oral health and the geriatric patient, and strengthen connections of organizations working to improve geriatric and children s oral health in Linn and Benton County. The pilot will use two existing outreach programs to work together to diminish duplication of services, expand and implement interactive education to every child in a classroom setting, offer healthy incentive in return for a signed consent form. It will also target local caregivers, in-home nursing programs, and assisted living facilities to offer education on oral health and the geriatric patient, proper referral pathways, and regular dental hygiene visits. Outcomes and Measures: Targeted settings receive bi-lingual education, survey participants show an increased understating of oral health prevention, increase in consent form return rate from schools, increase in IHN-CCO sealant encounters, targeted facilities receive geriatric education, and success referrals for geriatric patients to appropriate dental services. Sustainability Plan: Expanded, bi-lingual education sustained through the Boys and Girls Club of Albany (BGCA), billing for services, and potential to be discussed in future planning of sealant metric funds and possibly flexible spending due to incentive measures. Edits/Changes to Proposal: We adjusted one activity to include participation at a deeper level within the assisted living facilities to include active participation in connecting population to their PCPCH by utilizing already existing positions. This is already sustainable and just connecting these positions with another form of outreach. I left the term broad since we had limited time to connect and receive verbal approval that we will have somebody on hand at the time of screenings. We see that a barrier may exist if no one is willing to step up to fill this role. If all else fails a brief screening and referral to a health care navigator would suffice in connecting the older adult population with their PCPCH. No measure was drawn out at this time since we are unsure of if we will have someone to fill this role. However once we have a clear picture a tracking measure can be created. Traditional Health Worker (THW) Training Hub Presented by: Kelly Volkmann, Renee Smith, Jeff Blackford, Dena McMillen Budget: $156,310 Expected Start and End Date: January 1, December 31, 2017 Project Description and Goals: This proposal seeks to create a THW Training Hub in Benton County to train and supervise Community Health Workers (CHWs) and Health Navigators (HNs) for primary care and community agencies in the IHN-CCO region of Linn, Benton, and Lincoln counties (LBL). Although housed at Benton County Health Services, the hub will be made up of a collaboration of community partners and agencies in the LBL region contributing to the training and education of CHW/HNs in the issues, barriers, solutions, and strategies that best fit the needs of our communities and our clients. In addition, the pilot will build and ensure the quality of service delivery by CHW/HNs that are working in their communities. Their work will impact health engagement, childhood and family trauma, meeting the daily needs of members, and reducing health disparities, all target strategies of health care transformation. 20 of 31

15 Outcomes and Measures: Engage two agencies in developing a plan for using CHW/HNs, have four state-certified CHW/HNs trainers trained, complete two CHW/HN training, and have 20 CHW/HNs be eligible to apply for enrollment into the Oregon Health Authority (OHA) state registry. Sustainability Plan: The pilot funds will cover the upfront costs of purchasing the curriculum and training the trainers. Additionally the pilot funds will subsidize the first year s costs of training up to 40 CHWs and HNs (20 participants each workshop session). In the first year, the fees to attend will be $600, half of the amount in the second year for CHWs residing in the IHN-CCO service area. The second year fees, $1200 paid by the participants in the CHW training workshops, will cover the ongoing costs of the training. In addition, sustainability includes developing employment and reimbursement models for CHW/HNs among community based and primary care agencies. This work will start with the CHW/HN Needs Assessment and the engagement of new agencies serving new populations that may not be using CHW/HNs at this time. Edits/Changes to Proposal: No Changes (see p.16 for full response) C.H.A.N.C.E. 2 nd Chance Presented by: Jeff Blackford Budget: $87,080 Expected Start and End Date: January 1, December 31, 2017 Project Description and Goals: Communities Helping Addicts Negotiate Change Effectively (C.H.A.N.C.E.) will focus on meeting daily needs, reducing health disparities and increasing health engagement. The goals of the pilot are to provide case management, provide emergency and nonemergency transformation support, provide employment support, provide workshops, and reduce hospitalizations and engage members with their Primary Care Physician (PCP). The pilot also will provide education around quality health and health care navigation. Outcomes and Measures: The pilot will be successful if members engage in services at C.H.A.N.C.E. and other community agencies. Members who are or near homeless are in supportive housing programs and are provided case management, decrease in members smoking or vaping, and a reduction of Emergency Room (ER) and Urgent Care visits. Sustainability Plan: C.H.A.N.C.E. has 11 years of proven success. The pilot will work with IHN-CCO to develop an Alternative Payment Methodology (APM) and work towards a billable service through regional contracts. The pilot is currently working with the Community Services Consortium, Linn County Alcohol and Drug, and is working to build relationships and contracts with other Linn County branches, Parole Probation, and other community partners. Edits/Changes to Proposal: The only changes are the amount requested, the budget totals to reflect the amount the change in language from a Purchase of a van to a lease of a van per the last conversation with the DST. The total budget would decrease from $87,080 to $80,480. Social Determinant of Health Screening with a Veggie Rx Intervention Presented by: Christine Mosbaugh, Jen Brown Budget: $239,852 Expected Start and End Date: January 1, December 31, 2017 Project Description and Goals: This pilot will roll out a Social Determinants of Health (SDoH) screening in the EHR to measure food security. Patients who screen positive for food insecurity will be referred to local food networks and connected with SNAP/WIC/school lunch programs where eligible. At one clinic, an on-site Veggie Rx intervention will be offered, developing a model that can be replicated across the Community Health Center sites, to provide patients with a referral to 21 of 31

16 immediate access to fresh fruits and vegetables. Following referrals, a dedicated Health Navigator will follow up with food insecure patients to see if they actually connected with service referrals and were able to meet their needs, this will close the loop on the referral. Information gained will be shared in a toolkit with other IHN-CCO agencies to inform the screening, referral, and follow up around integration of the food resource system within the healthcare paradigm. Outcomes and Measures: Increase capacity for food screening, partner with local agencies, increase access to fresh fruit and veggies, establish referral pathways, and develop a toolkit for replication and sustainability in other organizations. Sustainability Plan: EHR capability, PCPCH team based care, partnerships and support, and building, testing, and scaling. Edits/Changes to Proposal: (see p.19 for full response) Given that if funding of the project is approved, the timeline will need to shift accordingly. If this occurs, the Veggie Rx portion of the project may need to adapt to include alternative modes of delivering produce to patients who are identified at food insecure, as a produce stand may not be logistically sustainable at the Benton County Health Center after October due to weather conditions. In this case, the project would be adapted to also include delivery models designed to increase patient access to fresh fruits and vegetables, such as a CSA/Food Box that can be picked up at the Health Center or another convenient location. Improving Infant and Child Health in Lincoln County Presented by: Nicole Fields Budget: $205,658 Expected Start and End Date: January 1, December 31, 2017 Project Description and Goals: Lincoln County Health and Human services seeks support for developing an innovative model of care for all children from 0 4 years old to improve health outcomes, strengthen families, increase a family s understanding of human development, support healthy growth and development and promote self-sufficiency and socialization skills using culturally appropriate methods for the population. This proposal would support the implementation of an evidence based home visiting curriculum, group parenting sessions, and evidence based group parenting classes. Through this three-pronged approach, this proposal would include elements of tobacco cessation, closed loop referral system development, quality improvement, and assisting clients in finding a Patient Centered Primary Care Home (PCPCH). Outcomes and Measures: The pilot will raise Ages and Stages Questionnaire (ASQ) scores, reduce tobacco use, reduce maternal depression, prevent child abuse and neglect, and lead to improvements in Quality Improvement and Collaboration. Sustainability Plan: Caseloads built up to sustainable levels over the 12 month period and Targeted Case Management (TCM) funding used to bill for visits. Edits/Changes to Proposal: No changes. 22 of 31

17 Dear Delivery System Transformation (DST), As a volunteer workgroup with diverse community representations, we are pleased to submit the Health Equity Strategic Plan IHN-CCO ( ). Per DST Scope of Work document, the Health Disparities Workgroup purpose is to Identify areas of health disparities and develop a strategic plan to address these disparities. Support work that addresses Transformation Elements 7 and 8: (7) Meeting the culturally diverse needs of Members and (8) Eliminating racial, ethnic and linguistic disparities. General Workgroup Member representation includes: Old Mill Center for Children and Families Albany InReach Services CHANCE Community Health Centers of Benton and Linn County Family Tree Relief Nursery Jackson St Youth Shelter Linn-Benton Health Equity Alliance Linn County Public Health InterCommunity Health Network Coordinated Care Organization (IHN-CCO) IHN-CCO Community Advisory Council Oregon Cascades West Council of Governments Oregon State University Samaritan Health Plan Samaritan Health Services At this time, we have initiated two subcommittees which are committed to further support the implementation of the Health Equity Strategic Plan IHN-CCO. The Data membership includes Regional Health Assessment team, IHN-CCO Transformation, and Albany InReach Services. The Training membership includes Oregon State University, Old Mill Center for children and Families, Linn County Public Health, Linn-Benton Health Equity Alliance, and Oregon Cascades West Council of Governments. In addition to countless hours invested by workgroup members, we are grateful to have received expert guidance from two Oregon Health Authority consultants. We appreciate Transformation IHN-CCO s support and feedback on our final draft. We are seeking input and approval for the proposed five-year strategic plan. We hope to move forward with implementation after approval is received. We are also seeking an endorsement of the proposed workgroup name change from Health Disparities Workgroup IHN-CCO to Health Equity Workgroup IHN-CCO to be more inclusive and strengths-based. We are looking forward to presenting and discussing our strategic plan proposal at the April 20 th, 2017 DST meeting. Thank you. Sincerely, Bettina Schempf and Miao Zhao Co-Chair Health Disparities Workgroup IHN-CCO 23 of 31

18 DRAFT v Page 1 of 8 InterCommunity Health Network Coordinated Care Organization Health Equity Workgroup Five-Year Health Equity Strategic Plan ( ) Vision: A community where all members of IHN-CCO can meet their potential for optimum health and well-being. Mission: IHN-CCO meets the culturally diverse needs of Members and eliminates health disparities, including promoting a diverse workforce. Goals: A. DATA: Increase the availability and knowledge of quantitative and qualitative data to inform, prioritize, and monitor strategies to meet the needs of culturally diverse members and to reduce health disparities. B. TRAINING: Support and champion cultural competence and health equity trainings for the IHN-CCO Health Equity Workgroup, IHN-CCO staff, IHN-CCO providers, and other community stakeholders. C. DIVERSE WORKFORCE: Support and encourage IHN-CCO provider and staff composition that reflects member diversity. D. TRADITIONAL HEALTH WORKERS (THW): Increase, retain, and sustain support for THW to address health disparities across IHN-CCO services and in Linn, Benton and Lincoln counties. E. COMMUNICATION: Ensure regular communication between the IHN-CCO Health Equity Workgroup, IHN-CCO staff, IHN-CCO DST Steering Committee, IHN-CCO CAC, other stakeholders and IHN-CCO workgroups about health disparities and health equity activities in the community. The IHN-CCO Health Equity Workgroup supports delivery system transformation that identifies and reduces health disparities and advances health equity by: supporting the culturally diverse needs of members (cultural competence training, provider composition reflects member diversity, Certified Traditional Health Workers and Traditional Health Workers composition reflect member diversity); supporting quality improvement focused on eliminating racial, ethnic, linguistic, and other disparities in access, quality of care, experience of care, and outcomes; and supporting IHN-CCO s Community Health Needs Assessment and Community Health Improvement Plan. Acronyms: CAC: Community Advisory Council DST Steering Committee: Delivery System Transformation Steering Committee IHN-CCO: InterCommunity Health Network Coordinated Care Organization THW: Traditional Health Workers Definition: THW have been defined by Oregon Statute and include Community Health Workers, Peer Wellness Specialists, Personal Health Navigators and Doulas. 24 of 31

19 DRAFT v Page 2 of 8 Goal A: DATA: Increase the availability and knowledge of quantitative and qualitative data to inform, prioritize, and monitor strategies to meet the needs of culturally diverse members and reduce health disparities. Strategies Actions Responsibility Progress Completion/ Evaluation Measures A1. Collaborate with local data experts to A1a. Establish IHN-CCO Health Equity Workgroup Data A1a. IHN-CCO Health Equity Workgroup A1a. 7/26/2016: First in-person meeting of Data A1a. 7/26/2016: First in-person meeting of Data identify data (Charissa White, Peter Banwarth, Miao Zhao) resources, needs, and gaps A2. Identify and prioritize health disparities experienced by IHN- CCO members A1b. By June 2017, identify potential data sources about health disparities relevant to IHN-CCO members A1c. By December 2017, assess available data sources A1d. By December 2017, identify data gaps and needs A1e. Through December 2021, continue reviewing and providing feedback about health disparities data A2a. By June 2017, identify potential health disparities, e.g, contraceptive use, prenatal care, emergency department utilization, substance abuse and mental health services, oral health, etc. Consider incentive metrics A2b. By June 2017, inventory IHN- CCO Transformation Pilots projects for populations served and demographic data collected A1b. IHN-CCO Health Equity Workgroup Data A1c. IHN-CCO Health Equity Workgroup Data A1d. IHN-CCO Health Equity Workgroup Data A1e. IHN-CCO Health Equity Workgroup Data A2a. IHN-CCO Health Equity Workgroup Data A2b. IHN-CCO Health Equity Workgroup Data A1b. 8/10/2016: Data reviewed potential data sources about health disparities A1c. Feb 2017: completed A1b. List of data sources compiled by June 2017 A1c. completed A1d. A1d. Report created by Dec 2017 that identifies data gaps and needs A1e. Regular re-assessment schedule set by June 2017 A2a. 5/2016: Data reviewed Medicaid Behavioral Risk Factor Surveillance System data for IHN-CCO members on access to care, chronic disease, behavioral health, and emergency department utilization 11/17/2016 Health equity consultation supported by OHA Transformation Center reviewed potential disparities for IHN-CCO members by race, ethnicity, household language, and disability in quality measures related to contraceptive use, prenatal care, emergency department utilization, substance abuse and mental health services, oral health A2b. 2016: Began mapping of IHN-CCO Transformation Pilots (n=33) A2a. Health disparities identified from existing data sources by June 2017 A2b. Workgroup sub group established in March 2017 Framework developed by June 2017 and presented to DST 25 of 31

20 DRAFT v Page 3 of 8 A2c. By June 2017, review IHN-CCO Community Needs Assessment and Community Health Improvement Plan, and other regional health assessments (from hospitals, public health departments, etc,) for data on health disparities A2c. IHN-CCO Health Equity Workgroup Data A2c Completed review of data in current IHN-CCO Community Health Needs Assessment and in Community Health Improvement Plan about priority Health Impact Areas (access, chronic disease, maternal health, child health, behavioral health) A2c. Completed initial review Set work plan for annual review by June 2017 A3. Develop a plan to improve data collection, analyses, and reporting about health disparities A3a. By September 2017, identify recommendations to improve data collection, analyses, and reporting about health disparities, including improved reporting through electronic health records and from IHN-CCO Transformation Pilots A3b. By November 2017, develop an implementation plan to improve data collection, analyses, and reporting about health disparities (including barriers to implementation, resources needed, timeline for implementation, schedule for ongoing reporting) A3c. By December 2017, submit implementation plan to IHN-CCO Health Equity Workgroup, and then to IHN-CCO DST Steering Committee for adoption A3a. IHN-CCO Health Equity Workgroup Data A3b. IHN-CCO Health Equity Workgroup Data A3c. IHN-CCO Health Equity Workgroup Data ; Health Equity Workgroup; IHN-CCO DST Steering Committee A3a. A3b. A3c. [DATE] A3a. Recommendations prepared by September 2017 and approved by workgroup A3b. Implementation Plan prepared by November 2017 and approved by workgroup A3c. Implementation Plan submitted to DST by December of 31

21 DRAFT v Page 4 of 8 Goal B: TRAINING: Support cultural competence and health equity trainings for the IHN-CCO Health Equity Workgroup, IHN-CCO staff, INH-CCO providers, and other community stakeholders. Strategies Actions Responsibility Progress Completion/ Evaluation Measures B1. Identify needs and resources for cultural competence and health equity trainings B1a. Establish IHN-CCO Health Equity Workgroup Training B1a. IHN-CCO Health Equity Workgroup B1a. 10/28/2016: First meeting of Training (Bettina Schempf, Sandy Phibbs) B1a. 10/28/2016: First meeting of Training B2. Develop proposed training plan for IHN- CCO Health Equity Workgroup, IHN-CCO staff, IHN-CCO providers, and other community stakeholders B1b. By September 2017, identify and prioritize cultural competence and health equity training topics Meet with IHN-CCO training staff and local health system/ hospital/provider training staff about current efforts and needs, and potential training resources and opportunities (including licensing, orientation, and continuing education requirements) B1c. By December 2017, identify and secure training resources (collaborate whenever possible, use train-thetrainer models, and secure funding if needed) B2a. Meet with IHN CCO Executive team to clarify vision for training by December 2017 B2b. By June 2018, identify existing training schedules/ opportunities for IHN-CCO Health Equity Workgroup, for IHN-CCO staff, for IHN-CCO providers, and for other community stakeholders B2c. By June 2018, develop proposed training plan for adoption by IHN-CCO Health Equity Workgroup, IHN-CCO staff, IHN-CCO providers, and for other community stakeholders B1b. IHN-CCO Health Equity Workgroup Training B1c. IHN-CCO Health Equity Workgroup Training B2a. IHN-CCO Health Equity Workgroup Training B2b. IHN-CCO Health Equity Workgroup Training B2c. IHN-CCO Health Equity Workgroup Training ; IHN-CCO Health Equity Workgroup; IHN-CCO; IHN-CCO DST Steering Committee B1b. 10/28/2016: Training began to identify existing training resources 11/17/2016: existing training resources shared with Health Equity Workgroup (via Basecamp) B1c. B2a. B2b. B2c. [DATE]: B1b. Prioritized training list created by September B1c. List of training resource funding created by December B2a. By March 2018, identify specific cultural competence and health equity training needs for IHN-CCO Health Equity Workgroup, for IHN-CCO staff, for IHN-CCO providers, and for other community stakeholders B2b.Training schedules identified by June 2018 B2c.Training plan adopted and approved by June of 31