DST Strategic Planning QUARTER ONE 2018

Transcription

1 2018 DST Strategic Planning QUARTER ONE 2018

2 2018 DST STRATEGIC PLANNING Contents IHN-CCO DST History and Evolution: Collective Impact... 5 Collective Impact (CI) Five Core Conditions... 5 Common Agenda... 5 Shared Measurement... 5 Mutually Reinforcing Activities... 6 Continuous Communication... 6 Backbone Support... 6 Evaluating Collective Impact... 6 Cascading Levels of Collaboration... 7 Attachment 1: History and Evolution Documents... 8

3 IHN-CCO DST History and Evolution: See page 8-10 of Attachment 1: History and Evolution Documents Membership Primarily clinical leadership comprised of cross-sector groups; physical, oral, mental, and alcohol and drug dependency Early discussions facilitated partnerships, trust and transparency, creating a common purpose, and aligning focus and strategy Planning/Focus of the DST Movement towards 2% cost savings and addressing high cost/high risk IHN-CCO members Goals include Medical Homes and defining multi-morbidity Nontraditional health workers a focus in the short term 2013 See page of Attachment 1: History and Evolution Documents Membership Primarily clinical leadership Planning/Focus of the DST Established funding criteria for pilots: o Cost savings o Eight Elements of Transformation o SMART Goals o Bring together siloed resources o Compelling to health care reform o Document best practices and share with the broader CCO community Pilots 4 active pilots Pilots proposed throughout the year and 4 are approved Workgroups 5 workgroups formed o Alternative Payment Methodology (APM) o Screening, Brief Intervention, Referral, Treatment (SBIRT) o Quality Initiative: Race/Ethnicity o Health Information Technology (HIT) o Traditional Health Worker (THW) 2014 See page of Attachment 1: History and Evolution Documents Membership Shift from clinical to clinical and those who can positively affect the health outcomes of IHN-CCO members Planning/Focus of the DST IHN-CCO expansion population leads to increased focus on Patient-Centered Primary Care Home (PCPCH) development 2 of 25

4 Shift in industry to APM; DST discussions began in this area of focus Pilots 15 active pilots Pilots proposed throughout the year and 11 are approved Workgroups 6 active workgroups Dental Integration (DI) Workgroup formed 2015 See page of Attachment 1: History and Evolution Documents Membership Average attendance: 21 attendees per meeting DST Charter reaffirmed and updated to reflect less specific attendees and to include leadership representation from key stakeholder groups Continued increased representation and participation from nontraditional clinical setting organizations such as community service agencies Planning/Focus of the DST Through the work of the IHN-CCO Transformation Evaluation Analyst, structure put in place to evaluate individual pilots and the collective impact o Crosswalk of pilots to the Eight Elements of Transformation, Community Health Improvement Plan (CHIP) Health Impact Areas, and the CCO Incentive Metrics o Evaluating pilots became more deliberate with a scorecard around measuring impact Created priority funding areas for pilots Pilots 25 active pilots Pilots proposed throughout the year and 11 are approved Additions to pilot funding criteria: o Outcomes o Sustainability o Must address a CHIP area Workgroups 9 active workgroups 3 workgroups are formed: o Health Equity o CHIP o Training and Education 2016 See page of Attachment 1: History and Evolution Documents Membership Average attendance: 29 attendees per meeting Voting rules established: o Attend at least 5 meetings in 6 months and Sign DST Member Roles and Responsibilities agreement 3 of 25

5 Planning/Focus of the DST Deliberate strategic planning occurred early in the year resulting in the following focus areas: o Effectiveness and sustainability o Person-centered and person-driven o Expanded access o Upstream health o Coordinated, integrated care o Learning systems that honor and demonstrate innovation Targeted Request for Proposal (RFP) process Requested pilots that affect 7 areas recommended by Workgroups and approved by the DST as a priority focus area Pilots 32 active pilots 19 pilots are approved through 2 funding cycles (though pilots approved in 2 nd funding cycle carried over to 2017 due to availability of funds) Workgroups 7 active workgroups Website Workgroup formed 2017 See page of Attachment 1: History and Evolution Documents Membership Average attendance: 22 attendees per meeting Planning/Focus of the DST Deliberate strategic planning occurred early in the year resulting in the definition of the DST s purpose: o Strengthening partnerships o Collaboration o Development of the PCPCH Pilot focus areas: o Peer Support o Navigation o Behavioral Health and Collaboration Pilots 21 active pilots 7 pilots from the 2 nd 2016 RFP process funded and 6 new pilots approved through 1 targeted RFP process Addition to pilot funding criteria: o Must outline an approach to address health equity Workgroups 7 active workgroups 2 workgroups formed: o Universal Care Coordination o Social Determinants of Health 4 of 25

6 Collective Impact Collective Impact (CI) Five Core Conditions Common Agenda Examples: DST Charter, strategic planning Performance Indicators DST includes membership from varying sectors/organizations Community members are aware of the goals and activities Target population and geographical boundaries are understood Partners can accurately describe goals Shared Measurement Examples: Performance Indicators Partners understand the value of the shared measurement system A common set of indicators and data collective methods are agreed upon to provide timely evidence of progress towards the outcomes Partners contribute high-quality data on a common set of indicators in a timely and consistent manner 5 of 25

7 Mutually Reinforcing Activities Examples: DST Charter, and strategic planning documents, DST Workgroups Performance Indicators An action plan specifies activities that the DST partners have committed to implementing Workgroups coordinate activities in alignment with the plan of action (DST Charter) Action plan changes with learnings of successes, challenges, and opportunities Partners understand each other s work and how it supports the common agenda Continuous Communication Examples: Regular DST and workgroup meetings, IHN-CCO website Performance Indicators Workgroups have regular meetings Partners communicate and coordinate efforts regularly Partners publicly discuss and advocate for the goals Backbone Support Examples: IHN-CCO Transformation Department, IHN-CCO Leadership Performance Indicators: Partners look to IHN-CCO and DST for CI support, strategic guidance, and leadership IHN-CCO provides project management support, including monitoring progress towards goals and connecting partners to discuss opportunities, challenges, gaps, and duplications Evaluating Collective Impact Context Community, culture, and history Demographic and socio-economic conditions Political context Economic factors Initiative The effectiveness of the five core elements of CI The effectiveness of capacity The effectiveness of learning culture Systems Changes in individual s behavior Changes in funding flows Changes in cultural norms Changes in policies Impact Changes in population-level outcomes Changes in the initiative s capacity for problem-solving 6 of 25

8 Cascading Levels of Collaboration Collective Impact is best structured using cascading levels of collaboration. The structure typically includes: o An oversight group: Delivery System Transformation (DST) Committee o Working groups: the DST Workgroups o The backbone function: IHN-CCO Information flows both from the top down and from the bottom up including community and system leaders Vision and oversight are through the DST, but also distributed through the workgroups focus of change How to show amplification of impact o Create a map to show the cascading links o Region is aware of DST initiatives 7 of 25

9 Attachment 1: History and Evolution Documents 8 of 25

10 Delivery System Transformation Steering Committee Steering Committee Charter Final 7/2012 Objective: To build on current resources and partnerships within the three county region to outline the process and strategies to support transformation of the delivery system. To develop an overarching strategy that supports PCPCH (Patient-Centered Primary Care Home) as the foundation of the CCO, and plan and implement strategies that aligns with CCO goals & described outcomes and pursues the Triple Aim. Structure: The Steering Committee formally reports to and takes direction from the CCO Regional Planning Council The Steering Committee will meet at least monthly and be responsible to develop priorities and identify strategies to facilitate transformation. The Committee will use work groups with broad membership to further develop specific care delivery strategies There will be Co-Chair(s) responsible to develop agendas, facilitate meetings, organize work groups to further the strategies recommended by the steering committee, and assure documentation of activities. The Co-Chair(s) will also be responsible to report to the CCO Operations Council All communications including minutes and agendas will be maintained and available to the CCO Operations Group and other interested stakeholders Membership: To include clinical/program leadership representation from key stakeholder groups Co-Chairs: Kim Whitley, IHN-CCO, Sherlyn Dahl, CHC of Benton & Linn Counties Samaritan Health System: Dr. Kevin Ewanchyna, Medical Director IHN-CCO Dr. Mike May, Chief of Psychiatry, Psychiatry Residency Training Director VP/Medical Director, Samaritan Mental Health VP, Samaritan Integrative Medicine Dr. Lynnea Lindsey, PhD, MSCP Integrated Care Psychologist Angie Gallagher, MS RCEP, Samaritan Albany General Hospital, Cardiopulmonary Rehabilitation Jenna Bates, Transformation Manager IHN-CCO Kerri Woelfle, Nurse Practitioner Corvallis Clinic: Dr. Dennis Regan, Medical Director Rod Aust, Chief Operating Officer Benton Health Services: Stacy Ramirez, Pharm.D. Benton CHC, OSU Clinical Assistant Professor Dr. Rob Nebeker, Medical Director for Mental Health Jeanne Nelson, LCSW, Adult Behavioral Health Program Manager Linn County Mental Health: Clifford Hartmann, PhD, Program Manager Tony Howell, Program Director Linn County Alcohol and Drug Lincoln County FQHC: Rebecca McBee-Wilson FQHC, Division Director, Lincoln County Mental Health: Cheryl Connell, RN BSN Lincoln County Health and Human Services Director Barbara Turrell, LPC, CADCIII, RDMT Behavioral Health Division Director Senior Services: Scott Bond, Director Oregon Cascades West Council of Governments - Senior & Disability Services Partners: Dr. Bruce Madsen M.D, QCA Ann Lavond, Program Administrator Student and Family Support Services Linn, Benton, Lincoln ESD Rich Blum, VP of Business Development & Provider Relations, Trillium Family Services Jan Peterson, Retired Dentist Phil Warnock, Oregon Cascades West Council of Governments, Cascade West Rideline Rebekah Fowler, Ph.D, Community Advisory Council Coordinator Bill Bouska, MPA, Oregon Health Authority, Innovator Agent John Bradner, Fire Chief, City of Albany Key Deliverables and Activities: Recommend a CCO Transformation Plan to Regional Planning Workgroup that meets requirements of IHN-CCO Exhibit K 9 of 25

11 o Transformation plan should include long range planning and short term focus deliverables o Transformation plan should address culture change Identify existing expertise necessary to champion strategies Recommend and support workgroups necessary to develop and execute strategies Oversee workgroups and progress of Transformation plan Committee Member Responsibilities: Commit to developing strategies that strengthen the community system of care Communication to and from each member s area/organization Identify additional membership/expertise to serve on work groups to successfully complete the objectives of the Committee Complete task assignments and share data and information with the Committee 10 of 25

12 Delivery System Transformation (DST) Sub-Committees IHN-CCO Delivery System Transformation Steering Committee Health Information Technology (HIT) & Community Care Plan Development Project Kim Whitley (541) Non-Traditional Health Workers (NTHW s) Project Kelly Volkmann (541) Jenna Bates (541) Mental Health Memorandum of Understanding Long Term Care Memorandum of Understanding Linn County Pilot H2H Care Transitions Scott Bond Linn County Pilot MH Wellness Literacy Campaign Clifford Hartman/Cristie Lynch Training/Education Project Stacy Ramirez (541) Chris Norman (541) Non Emergent Medical Transportation Memorandum of Understanding Benton County Pilot Patient Assignment & Engagement Sherlyn Dahl Screening, Brief Intervention & Referral to Treatment (SBIRT) Project Michael Oyster (541) Tony Howell (541) Dental Memorandum of Understanding Lincoln County Pilot Integration of MH/Addictions/PC Dr. Lynnea Lindsey Quality Initiative - Race & Ethnicity Project Ellen Altman (541) ealtman@samhealth.org Alternative Payment Methodologies Project Carla Jones (541) cjones@samhealth.org Community Health Assessment (CHA) & Community Health Improvement Plan (CHIP) Project IHN-CCO CAC 11 of 25

13 IHNCCO Criteria for Pilots and funding approval 2013/2014 1) Project must show overall Cost savings defined by timeframe and duration 2) Ability to measure and report outcomes using S.M.A.R.T. goals; Define criteria up front. Recommend or consider including HEDIS, PCPCH, meaningful use where applicable. 3) Ability to Replicate with a defined population, demographic or location. 4) Project must bring together previously unrelated or siloed resources; Demonstrates and defines coordination among team members, providers, and multiple organizations 5) Must be compelling to health care reform and supports the 8 elements of transformation; Models and strives to achieve transformation as described in Exhibit K in CCO Contract (see below) 6) Will be required to document process and best practices to share with broader CCO community 7) Clearly identify what resources are needed to move the project forward include budget or proforma as applicable. 8) Other criteria: Populations must include only for IHN-CCO members Timeframe and progress reports will be expected within the year, or per OHA timeframes as required 8 Elements of Transformation per Exhibit K of IHNCCO contract (1) Developing and implementing a health care delivery model that integrates mental health and physical health care and addictions. This plan must specifically address the needs of individuals with severe and persistent mental illness. (2) Continuing implementation and development of Patient-Centered Primary Care Home (PCPCH). (3) Implementing consistent alternative payment methodologies that align payment with health outcomes. 12 of 25

14 (4) Preparing a strategy for developing Contractor s Community Health Assessment and adopting an annual Community Health Improvement Plan consistent with 2012 Oregon Laws, Chapter 8 (Enrolled SB 1580), Section 13. (5) Developing electronic health records; health information exchange; and meaningful use. (6) Assuring communications, outreach, Member engagement, and services are tailored to cultural, health literacy, and linguisitic needs. (7) Assuring provider network and staff ability to meet cultural diverse needs of community (cultural competence training, provider composition reflects Member diversity, nontraditional health care workers composition reflects Member diversity). (8) Developing a quality improvement plan focused on eliminating racial, ethnic and linguistic disparities in access, quality of care, experience of care, and outcomes. Proposal Review Timeline All Pilots/Proposals are reviewed by the Delivery Systems Transformation Committee (DST), whose objective is to encourage and support transformation through Pilots that build on current resources and partnerships within the three county region of the IHNCCO. The DST will review all proposals against the criteria above. The DST meets every other Thursday at Avery Square from 4:30 to 6: Schedule February March April May June July August September October November December 13th & 27th 13 th & 27th 10 th (canceled) & 24th 8 th & 22nd 5 th & 19th 3 rd (canceled) & 17 th & 31st 14 th & 28th 11 th & 25th 9 th (cancelled) & 23rd 6 th & 20th 4 th & 18th Once approved by the DST the proposal goes to the RPC and Finance Committee for final approval and funding. 13 of 25

15 Delivery System Transformation Steering Committee (Committee of the Regional Planning Council) Charter 2015 Objective: To build on current resources and partnerships within the three county region to outline the process and strategies to support transformation of the delivery system. To support, sustain, and spread transformation that supports PCPCH (Patient-Centered Primary Care Home) as the foundation of the CCO. To welcome innovative ideas, plan and transparently implement collaborative strategies that align with CCO goals & described outcomes, and pursue the Triple Aim. Structure: The DST Committee formally reports to and takes direction from the CCO Regional Planning Council The DST Committee will meet at least monthly and be responsible to develop priorities and identify strategies to facilitate transformation. The Committee will use work groups and pilots with broad membership to further develop specific service delivery strategies The Transformation Department will be responsible to develop agendas, facilitate meetings, organize work groups to further the strategies recommended by the steering committee, and assure documentation of activities. The Co-Chair(s) will also be responsible to report to the CCO Regional Planning Council. All communications including minutes and agendas will be maintained and available to all interested stakeholders Membership: To include leadership representation from key stakeholder groups that can affect transformation of the healthcare delivery system. Key Deliverables and Activities: Maintain a CCO Transformation Plan to Regional Planning Workgroup that meets requirements of IHN-CCO Exhibit K o Transformation plan should include long range planning and short term focus deliverables o Transformation plan should address culture change Identify existing expertise necessary to champion strategies Recommend and support workgroups and pilots necessary to develop and execute strategies Oversee workgroups and pilot and progress toward Transformation. Recommend system changes or identify gaps to Regional Planning Council IHN-CCO staff will keep the DST informed and provide two-way communication for sharing opportunities to add or leverage resources through available grants Committee Member Responsibilities: Commit to developing strategies that strengthen the community system of care Communication to and from each member s area/organization Identify additional membership/expertise to serve on workgroups and pilots to successfully complete the objectives of the Committee Complete task assignments and share data and information with the Committee Attend meetings on a regular basis Sign in at each meeting to assist tracking of attendance 14 of 25

16 Delivery Systems Transformation (DST) Transformation Funding Priorities 2015 Goal: To be more targeted in funding decisions for the transformation fund and prioritize funding to accelerate alignment of payment, transformation plan goals, and improved outcome metrics. Funding decisions will promote strategies that support transformation at the system level, integrated Patient Centered Primary Care Home (PCPCH) care delivery, and innovative community partnerships that impact transformation goals. Amount Available: $5,983,718 Recommendations for prioritized funding: 1. Accelerate spread of Alternative Payment Methodologies (APM) Rationale: Align payment incentives with the desired direction and outcomes defined in the transformation plan. Assist in building individual practice capacity for PCPCH through encouraging participation in APM; participation in the pilot will give clinics access to capacity payments in addition to the Per Member Per Month (PMPM) Next steps: Schedule a presentation to DST from Carla Jones for an update on APM pilots to date and plans for spread 2. Spread promising practices from the current pilots Rationale: Build on initial pilot investments by expanding promising practices. Next steps: Identify promising practices and discuss readiness for spread. Request the DST give consideration to those pilots that assist practice sites in building internal capacity to meet PCPCH standards 3. Support any proposals that will positively impact Coordinated Care Organization (CCO) metrics Rationale: Supports the alignment of quality outcomes with reimbursement incentives Next steps: Quality Management Committee (QMC) leads this work; DST can assist by supporting pilots that may positively impact metrics. Identify existing pilots that may influence priority metrics, particularly Screening, Brief Intervention, Referral to Treatment (SBIRT) & adolescent well-child exams; assess their performance and spread promising practices 4. Fund gaps and new ideas Rationale: Continue to identify and refine our vision for the direction/outcome for transformation in our region and use transformation funds to support advancement of the vision and priorities Next steps: a) Consider having a standing DST agenda check-in item asking members to share gaps; b) Continue DST discussion on priorities and whether DST drafts a Request For Proposal (RFP) to invite specific proposals or continue current process of accepting applications and reviewing them in the context of fit to identified priorities; c) Use the grid on transformation elements and Community Health Improvement Plan (CHIP) areas to identify gaps. Consider using Community Advisory Council (CAC) Health Impact Areas once finalized as an additional reference for identifying gaps and priorities; d) Continue discussion at DST to identify the interest and process for developing a learning collaborative on PCPCH. 15 of 25

17 2016 CCO Metric/CHIP Target Areas Charge: A subgroup of the DST was tasked to use the newly refined and adopted CHIP areas and CCO metrics to find gaps in current Transformation efforts and make recommendations for target areas for a Request for (Pilot) Proposals. Recommendations for RFP Target Areas: 1. Maternal Health o Increase the percentage of women of childbearing age who receive early and adequate preconception and prenatal care and who connect with appropriate resources throughout their pregnancy. (CHIP MH2 and possible crossover with BH2a, CCO Metric 18) o Reduce the rate of unplanned pregnancies. (CHIP MH1, CCO Metric 14) Examples: One Key Question initiatives Referral Pathways to A&D or Mental Health, Dental or other Specialty Care 2. Tobacco Cessation o Reduce the percentage of members who use and/or are exposed to tobacco. (CHIP CD3 with possible crossover with BH3, CCO Metric Examples: Tobacco cessation interventions that incorporate Behaviorists with Peer Support Specialists. APM for intervention with incentive structure for successful cessation. Targeted outreach and intervention with subpopulations who experience a high rate of tobacco use (i.e. Native Americans, pregnant women, those suffering mental illness or substance use disorder. 3. Health Engagement o Increase the percentage of members who receive care communicated in a way that ensures members can understand and be understood by their care providers and members are effectively engaged in their care. (CHIP AC2a, AC1c, Transformation Plan Element 7 Trauma Informed Care ) Examples: Improvement in Trauma Informed Care in the PCPCH Member outreach and engagement in the PCPCH Health literacy in the PCPCH 4. Establishing and Refining Referral Pathways - particularly between PCPCH and Specialty or Community based care. Examples: Examination of who transits the referral system vs. who does not and identify and implement best principles for creating/improving follow-up on referrals. Develop referral pathway and care coordination when SBIRT or Depression Screening identifies a member needing treatment. 16 of 25

18 Fall 2016: 1-4 of Spring RFP &: 5. Trauma Informed Care o Incorporate an equity lens and trauma informed care in all settings. 6. Meeting Daily Needs o Increase the availability of resources to meet daily needs of individuals and families (e.g., local healthy food, affordable and safe housing, opportunities for physical activity and transportation). 7. Reduce Health Disparities o Focus on populations experiencing health disparities, especially populations with special needs including, behavioral health needs, chronic conditions, disabilities, and older IHN-CCO members. 17 of 25

19 As a Steering Committee Member of the Delivery System Transformation Committee I agree to: Adopt and support the goal of Delivery System Transformation o To build on current resources and partnerships within the three county region to outline the process and strategies to support transformation of the delivery system. To welcome innovative ideas, plan and transparently implement collaborative strategies that align with CCO goals & described outcomes, and pursue the Triple Aim. Provide strategic guidance, vision, and oversight for the Delivery System Transformation including: o Developing and refining the Common Agenda for change, including the problem, goal(s), and guiding principles. o Using data to inform strategy development learning. o Tracking progress of the work using agreed-upon indicators at Steering Committee and Working Group levels. o Making connections between Working Groups to ensure coordination and efficiency. o Interacting with the IHN-CCO on strategy, community engagement, and shared measurement. Provide leadership by: o Considering how my own organization or those in my network can align to the Common Agenda. o Serving as a vocal champion of the collective impact effort in the community. Play an active role by: o Participating in-person at the regularly scheduled meetings (every 2 weeks). o Reviewing pre-read materials prior to meetings and coming prepared for engaged discussion, active listening, and respectful dialogue. o Committing to year-long membership of the Steering Committee. Avoid Conflicts of Interest by: o Abstaining from voting on pilots that I m actively involved in. o Communicating conflicts of interest that arise to the committee and abstaining from voting on those issues. o Always acting in the best interests of IHN-CCO members. Please see the back of this form. This action planning template was adapted from FSG s work with the Community Center for Education Results(CCER) and the Health and Wellness Alliance for Children, and is 18 of 25 licensed under a Creative Commons Attribution-NoDerivs 3.0 Unported License.

20 Please describe how you will be able to take back the information heard at the DST and use it to affect the health outcomes of IHN-CCO members? Signature: Date: Printed Name: Organization: 19 of 25

21 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. 20 of 25

22 TARGETED STRATEGIES FOR 2017 PILOT PROPOSALS Proposals will not be limited to these areas; however, by their identification; the DST hopes to reach out to community agencies and providers to encourage proposals that focus on Peer Support, Navigation, and/or Behavioral Health Integration and Collaboration efforts. Proposals with one of these focus areas that have not been previously funded will be given additional consideration for funding. PROPOSAL REQUIREMENTS Goals of the pilot Target population; ensure the IHN-CCO population is specifically addressed in terms of numbers of members expected to be served and/or the percentage of clients that are IHN- CCO members Describe the intervention and detailed activities List any community partners that will be working on the pilot and the tasks they will undertake Describe the individuals tasked with portions of the pilot and their roles and experience Explain the expected outcomes and how they help meet the pilot goals Describe potential risks and how the pilot plans to address them Describe how the pilot will address health equity SMART Goals and Measures Sustainability o Explain how the pilot is innovative, scalable, and transferable. Describe how the pilot, if successful, will be sustained within the organization and how it could be spread to other organizations. Describe other organizations that have a vested interest in the pilot. Be sure to include other resources and organizations contributing to the success of the pilot. Explain how funding will continue after the year-long DST funding is over. 21 of 25

23 Delivery System Transformation (DST) Committee (Committee of the Regional Planning Council) Charter 2018 Objective: To build on current resources and partnerships within the tri-county region to outline the process and strategies to support transformation i of the delivery system for the Medicaid population. To support, sustain, and spread transformation that supports PCPCHs (Patient-Centered Primary Care Homes) as the foundation of IHN-CCO. To welcome innovative ideas; plan and transparently implement collaborative strategies with a focus on the Medicaid population that align with IHN-CCO goals, described outcomes, and pursue the Triple Aim. Structure: The Committee formally reports to and takes direction from the IHN-CCO Regional Planning Council (RPC) The Committee will meet at least monthly and be responsible to develop priorities and identify strategies to facilitate transformation. The Committee will use workgroups and pilots with broad membership to further develop specific healthcare delivery system strategies The Transformation Department will be responsible to support Workgroups through historical documentation and helping to connect various pieces together, but does not have the resources to offer clerical support such as agenda creation, minute taking, etc. Workgroups further the strategies recommended by the Committee. The Co-Chair(s) will be responsible to report transformation activities and progress to the RPC Communications materials will be maintained and available DST Workgroups drive the Committee s objectives forward, by convening a smaller group of individuals and organizations with like-objectives Membership: To include anyone that can positively affect the health outcomes of IHN-CCO members in the tri-county region. Key Deliverables and Activities: Support components of Transformation Quality Strategies (TQS) o Through long range planning and short term focused deliverables o Effectiveness and sustainability o Expand, connect, and demonstrate access to person-centered care with a focus on the Medicaid population o Connect social determinants of health and upstream health to the traditional healthcare system o Coordinated and integrated care o Demonstrate innovation and outcomes in healthcare Support new partnerships and linkages Identify existing expertise necessary to champion strategies Recommend and foster workgroups and pilots to develop and execute strategies and progress toward Transformation Recommend system changes or identify gaps to the RPC 22 of 25

24 IHN-CCO staff will provide two-way communication for sharing opportunities to add or leverage resources through available grants to keep the Committee informed Utilize a trauma informed approach ii and health equity lens iii while focusing on social determinants of health Committee Member Responsibilities: Commit to developing strategies that strengthen the community system of care Two-way communication between member s area/organization Identify additional membership/expertise to join the Committee, workgroups, and pilots to successfully complete objectives of the Committee Complete task assignments and share data and information with the Committee Attend meetings on a regular basis Sign in at each meeting to assist tracking of attendance Attend at least five meetings within the last six months to vote i Transformation is defined as keeping the Patient-Centered Primary Care Home (PCPCH) at the center, but includes creating different relationships, community connections, and linkages outside of the traditional health services setting. Includes upstream health and recognizes there are pieces outside of the PCPCH setting that influence an individual s health. Being willing to risk trying something different, even failed projects provide a learning opportunity. Transformation is constantly changing and is not static, has elements of innovation, but is broader and involves system change. ii According to SAMHSA s concept of a trauma-informed approach, A program, organization, or system that is trauma-informed: 1. Realizes the widespread impact of trauma and understands potential paths for recovery; 2. Recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system; 3. Responds by fully integrating knowledge about trauma into policies, procedures, and practices; and 4. Seeks to actively resist re-traumatization. SAMHSA S Six Key Principles of a Trauma-Informed Approach: 1. Safety 2. Trustworthiness and Transparency 3. Peer support 4. Collaboration and mutuality 5. Empowerment, voice and choice 6. Cultural, Historical, and Gender Issues iii Health Equity means that everyone has a fair and just opportunity to be as healthy as possible. Health Equity broadens the disparities concept by asking, Why are some populations at greater risk of illnesses and preventable deaths than others? This question leads to a deeper analysis and exploration of the causative factors that contribute to disparities. Health equity is achieved when every person has the opportunity to attain his or her full health potential and no one is disadvantaged from achieving this potential because of social position or other socially determined circumstances. Equality is not equity. Those with worse health and fewer resources need more efforts expended to improve their health. 23 of 25

25 Work Group Name Alternative Payment Methodologies (APMs) Community Health Improvement Plan (CHIP) Scope Defines key elements in a sustainable alternative payment methodology (APM). Evaluate APM pilots that will lead to payment models that promote and support transformation at the system and care level. This group is gathering Health Impact Area suggestions from the three local CACs and using this information to make suggestions to the Regional CAC. The Regional CAC will approve final suggestions and give them to the IHN- CCO. As IHN-CCO comes up with improvement projects, the CAC members will give feedback. *Important to note that this group does not report to the DST. The work does impact the Transformation Plan reporting. Dental Integration Health Equity (HE) Health Information Technology (HIT) Quality Initiative Race & Ethnicity Screening, Brief Intervention & Referral to Treatment (SBIRT) Social Determinants of Health (SDoH) Traditional Health Workers (THW) Training & Education Universal Care Coordination (UCC) The goal of this subcommittee is to provide information and recommendations to the Delivery Systems Transformation Steering Committee and Quality management Committee in order for the IHN-CCO community to evaluate oral health disparities and new dental integration models. Supports delivery system transformation that identifies and reduces health disparities and advances health equity by: supporting the culturally diverse needs of members; supporting quality improvement focused on eliminating racial, ethnic, linguistic, and other disparities in access, quality of care, experience of care, and outcome; and supporting IHN-CCO s Community Health Needs Assessment and Community Health Improvement Plan. This group is working on ways to share information between those involved in the care of patients. For instance, doctors, hospitals, insurance company, clinics, specialists, transportation This project is finding out if we (IHN-CCO) get information that tells us the ethnicity and race of our members. Once we get this information, we will look to see if different members seem to have more illnesses than others and is this connected to ethnicity and/or race. This group is working on getting providers, doctors and nurses trained on a way to identify patients who are having problems with alcohol or drugs, so they can get the help they need. Develop and promote the transformational integration of Social Determinants of Health into the health delivery care setting with an initial focus on Patient-Centered Primary Care Home (PCPCH). Advances the development of THWs in the transformation of healthcare to advance the Triple Aim. Promotes utilization of THWs to address social determinants of health. This group is working on trainings for CCO staff, providers, and partners so they will understand the needs of different cultures, and how health equity (where you live, availability to good food, transportation, sidewalks, parks, safe housing) affects your health. Convenes and aligns community around a common referral process that can be electronically captured and made available to the Primary Care Physician at the time of service to capture Social Determinants of Health in an electronic form, have a common assessment form for all programs that have assessments, and reduce duplication of services along with helping members navigate the healthcare system (and potentially other systems). 24 of 25

26 Work Group Name Website Scope Support communication and engagement with IHN-CCO members, stakeholders and community partners. Increase the use of health literate communications to support a member s ability to obtain, process, and understand information on the IHN-CCO website. 25 of 25