march 2016 ahc online work group

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AHC Online Work Session

Accountable Health Communities (AHC) Model Grant

March 16, 2016

www.nationwidechildrens.org

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Today’s Agenda

• Review the AHC Model Overview

• Review Collaborative Work That Has Already Taken Place

• Explore AHC Key Driver Diagram

• Explore subpopulations impacted by health disparities in the community

• Next Stepswww.nationwidechildrens.org

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Model Background

The Accountable Health Communities (AHC) model addresses a critical gap between clinical care and community services in the current health care delivery system by testing whether systematically identifying and addressing the health-related social needs of beneficiaries’ impacts total health care costs, improves health, and quality of care.


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Key Dates

• LOI Due (Optional & Non-Binding): February 8, 2016

• Proposal Due: May 18, 2016

• Grant Awarded: March 3, 2017

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


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Model Background

Bridge Organization

Evaluation

Referral Infrastructur

eScreening

Tools

Care Coordinatio

nFiscal Role

Providers -1 PCP

-1 Hospital -1 Behavioral

Health

State Medicaid Agency

Social Service

Agencies

What will it take to advance AHC in Greater Columbus?


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What does the model fund?

Over a five-year performance period, CMS will implement and test a three-track model:

• Track 1 – Awareness: Increase beneficiary awareness of available community services through information dissemination and referral

• Track 2 – Assistance: Provide community service navigation services to assist high-risk beneficiaries with accessing services

• Track 3 – Alignment: Encourage partner alignment to ensure that community services are available and responsive to the needs of beneficiaries


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Exploring the Funding Tracks

Track 3 - Alignment


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Health-Related Social Needs

Core Needs (Required)Housing InstabilityUtility NeedsFood InsecurityInterpersonal ViolenceTransportation

Supplemental NeedsFamily & Social SupportsEducationEmployment & IncomeHealth BehaviorsOthers

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

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


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Partner Roles

• State Medicaid Agency

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

• Community Service Providers

• Bridge Organization


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Goals of AHC Model Grant

• Address gap between clinical care and community services, improve collaboration

• Identify and address health-related social needs

• Reduce healthcare cost

• Reduce inefficient use of healthcare services

• Improve healthcare


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AHC Model Overview

Questions of Clarity?


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AHC Model Grant

Review Collaborative Work That Has Already Taken Place


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Exploratory Session Recap

What Geographic Area has the greatest opportunity to be impacted by the AHC Grant?

Collaborative Agreement• Implement screening process for all patients in

Columbus/Franklin County

• Start by providing patient navigation and measurement to beneficiaries in targeted zip codes. Targeted zip codes TBD

• Spread navigation and measurement throughout the community over time.


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Target Zip Codes

Proposed 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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What is a good place to start for health-related social needs?

Collaborative Agreement• Grant application will focus on core needs.

• Patient navigators will address supplemental needs with patients on an individual basis.

• Many supplemental needs will have to be addressed to impact core needs.


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What organizations have the interest and capacity to fill various project and grant writing roles?

Collaborative Agreement• Collaborative grant application led in partnership between

Nationwide Children’s Hospital (NCH) & HCGC

• NCH serving as the formal bridge

• HCGC serving as neutral convener of community partners


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Key Driver Diagram

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

Ex)


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Key Driver Diagram

• 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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Key Driver Diagram

• 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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Key Driver Diagram

• 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 StatementInterventions

• 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 4/1/2018to 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 structure

Established 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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Key Driver Diagram



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Key Driver Diagram

What reflections can you share about this Key Driver Diagram?


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Health Equity Definition

–Study and causes of differences in the quality of health and healthcare across different populations (race, ethnicity, gender, disability status, language, and/or geographic area)

–Equal opportunity to attain their highest level of health

–Achieved by addressing social determinants

–Inequities exist when barriers prevent individuals from reaching their full potential


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AHC Health Resource Equity Statement (HRES) Purpose

–Identify and target minority and underserved populations

–Assess the geographic target area in relation to targeted subpopulation

–Evaluate the inclusion of subpopulations in the AHC interventions

–Track progress on outcomes and engagement of these subpopulations


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AHC Health Resource Equity Statement (HRES)



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HRES Proposed Subpopulations

What subpopulations are a good place to start?

– AHC Grant must focus on 3-5 subpopulations

– Proposed subpopulations1. Women of childbearing age2. Children with medical complexity (ABD)3. African Immigrants4. Dually eligible individuals with mental

health issues


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What reflections can you share about the proposed subpopulations?


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• Are there additional subpopulations that should be considered for the AHC?

• Should any of the proposed subpopulations be removed?


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Next Steps

• HCGC and Nationwide Children’s will use feedback to continue shaping the AHC Grant Application

• Michelle and Deena will be following up with individual organizations to secure their commitment to participate

• May 5 Final Pass Webinar


march 2016 ahc online work group

Documents