Medicaid Advisory CommitteeMarch 28, 20189:00-12:00pm

1

Webinar Housekeeping• Register: https://attendee.gotowebinar.com/register/8302047649

417864706

• Join audio by calling in:1-888-398-2342Code: 3732275 (public line)*Member code on calendar invite*

• Public line is muted. Please don’t put the line on hold!• Send questions using the “Questions” box in the control pane• Public comment at 10:30. Please indicate in the “questions”

box if you would like to submit written comment.• Meeting/webinar is being recorded and will be posted online

2

Welcome & Introductions

Meeting objectives• Regular business (e.g. approve minutes, review/approve

annual committee report)• Hear from an OHP member about their experience with

Medicaid• Understand the Accountable Health Communities project in

Oregon and how CCOs are engaged• Hear legislative recaps from OHA and DHS related to the

Medicaid program• Hear stakeholder input on MAC recommendations and

consider revisions• Discuss recommendations for implementation/use of MAC’s

recommendations

4

AGENDATime Item Presenter Purpose9:00 Welcome and Introductions

• Adopt minutes• Review/approve 2017 committee report

Co-chairs Action

9:20 Why we are here: member story Brandy Charlan Informational

9:35 Oregon Accountable Health Communities presentation & discussion

Dr Bruce Goldberg Informational & Discussion

10:20 Break

10:30 Public Comment

10:40 Agency Medicaid update – legislative session focus

Dawn Jagger, OHAAngela Allbee, DHS

Informational

11:00 Review/revise MAC recommendations given stakeholder input• Staff review stakeholder input• Committee discuss revisions

Co-chairs & staff Discussion

11:30 Recommendations for implementation/next steps for OHA and stakeholders

Co-chairs Discussion

11:55 Closing Co-chairs

Why we are here story: Brandy Charlan

Workforce Housing

For Klamath County Medicaid Recipients

●During pregnancy - Emergency C-section with the 1st●Children - Broken bones, dental care, check-ups, tonsillectomy, etc.●Medicaid expansion

Personal Impact of Medicaid

● Mandatory enrollment

● Provider availability and wait times

■ Klamath Open Door

■ Cascades East

● Walk-In clinics

Some challenges to accessing health care services in Klamath Co

● Disabling stress

● The house is barely habitable

● Possibility of being homeless

● Exorbitant cost of rent in Kfalls

● Not an anomaly

● Largest demographic in Klamath County, the working poor.

● I’ve been dreaming of a solution though

How factors outside of health care impact my health -Housing

Cultural Climate around Medicaid Recipients in Klamath County

● Boot-strapablity - The ability to pull oneself up out of hard times through mental fortitude, persistence, and continuous effort

● Majority of us workers are forgotten

● Insecurity - Bosses tell us that we are replaceable in the same breath as asking us to do something unethical. Our landlords speak in undertones about ‘remodeling the house soon’ when we mention repairs. We’ll never be able to save enough for 1st, last and deposit.

● Failure - Telling your child ‘no’ to sports because you can’t afford the gear, even if you were awarded the meager scholarship from the Y. Not being able to afford to fix the used car that you just bought with your EIC that only lasted 2 mos. Serving Papa Murphy’s again this week because there is no time to shop and cook again, too busy working.

● Bargaining - Promising our kids a future reward for their forgiveness, ‘I know you're sad. Can imake it up to you later?’ Asking utility companies for payment plans and only ever being able to pay the past-due amount. With our bosses, making promises of great accomplishments in exchange for more hours while simultaneously begging for a couple hours out of the middle of the day to go to our kids’ X-mas program praying we don’t get fired for it. With ourselves, ‘Someday, I’ll do better’, as if the failure of the economy were ours.

There isn’t a bootstrap reliable enough to grab onto. There is nowhere to pull ourselves to. The dream of being rewarded for hard-work is dead.

● In recognizing that the economic climate is not designed for the working class to have upward mobility or assets, be a county that viciously confronts the challenges that workers face when trying to create housing stability for their families.

● Be a community that values the people that grew up here by protecting them from displacement. Population increase and gentrification are inevitable but the devastating impact of gentrification can be minimized with the foresight to prioritize the group most at risk, the working poor.

● Make good on the ideal that people who pull themselves up by their bootstraps who put in the time and effort will be rewarded with security.

● Craft and hone a replicable workforce housing model – borrow from Housing First programs

Goal

End ProductHave Medicaid workers housing security program where:

● A medicaid recipient can buy a house without subsidies and without a cost of living increase

● Through use of investments from CCO and County● Non-profit manages program● 5yr lease option at fixed rate calculated by percentage of property value (addresses

gentrification)● Recipient required to participate in Credit Counseling program with Klamath Lake County

Action Services● Every “rent” payment is reported as good to credit agencies● Begin ownership transfer paperwork at year 4● At 4th year 60% of total rent payments are credited as a down payment● In 4th year, walk recipient through loan application process (also a service through

KCLAS)● By 5th year recipient is bank ready

Screening for Social Determinants of Health

Bruce Goldberg, MD

TODAY

• Context for identifying and addressing social determinants of health

• Share work going on in Oregon through the Accountable Communities of Health Project

• Discuss future considerations

NATIONAL CONTEXT

• Health care costs growing faster than other economic indicators

• Outcomes are varied and inconsistent

• National health reform efforts – SIM, Medicare, PCMH, CPC+

• A plethora of state health reform efforts

• Growing evidence of importance of social investments, care coordination, primary care

Leadership

20

18

16

14

12

10

8

6

4

2

0

Health Expenditures as % of GDP, 2009

Elizabeth Bradley, PhD

Total Investment in Health as % of GDP

Elizabeth Bradley, PhD

Ratio of Social Service to Health Care Spending

Elizabeth Bradley, PhD

Opportunity Costs!

• 1 ED Visit = 1 months rent

• 2 hospitalizations = 1 year of child care

• 20 MRIs = 1 social worker per year

• 60 echocardiograms = 1 public school teacher per year

SGIM Presidential Speech, Dr. Moran, 2015

HOW DO YOU INCREASE INVESTMENTS MADE INTO SOCIAL

DETERMINANTS??

STATE EFFORTS TO IMPROVE HEALTH &

INCREASE INVESTMENTS IN SOCIAL SPENDING

• Foster better value and efficiency in health delivery systems through payment reforms, value based purchasing and delivery system changes

• Invest some of those savings into social enterprises that improve health

• Increased partnerships across health and social service endeavors

• Creating coordinating/integrating organizations

The Alphabet Soup of Approaches

• ACO• CCO• ACC• ACH• CPC• AHC• RCCO• MCO• PCMH

Oregon Accountable Health Communities

Opportunity to create community-wide wrap-around care for high need residents by:

• Implementing screening for Medicaid and Medicare patients to identify health-related social needs: housing, food, utilities, transportation and violence

• Connecting patients to community services

• Developing a tailored referral and care plan for a subset of high risk patients

• Screening 75,000 Medicare and Medicaid beneficiaries per year using CMS tool for:• housing, food insecurity, transportation, utilities, interpersonal

violence

• Those with a social need get tailored referral summary/information on local community resources

• Navigation for 2,925 persons with 2 or more emergency department visits in the prior year plus 1 or more social needs

Oregon AHC Consortium

• Across 9 counties: Jackson, Josephine, Curry, Crook, Deschutes, Jefferson, Wasco, Hood River

• OHSU-ORPRN as bridge organization (CMS requirement)

• 6 CCO’s – AllCare, Primary Health, Pacific Source Columbia Gorge, Pacific Source Central Oregon, Pacific Source Hood River, Yamhill CCO, Jackson Care Connect

• IPAs, Hospitals, behavioral health organizations, public health, community service providers

• 2-1-1• Vistalogic

The Oregon Consortium

Help Answer the Primary Question

• Does screening for social needs plus tailored navigation to health and social services lead to improved outcomes and reduced costs of care?

SCREENING FOR:

HousingTransportationFoodUtilitiesInterpersonal Violence

Community Referral

• Tailored to address those items identified in positive screen

• Up to date information on resources available in local community

• Computer generated at time of screen

ScreeningSetting:

• Primary Care (Family Medicine, Internal Medicine, Pediatrics)

• Behavioral Health

• Hospital (including Emergency Department, Labor & Delivery, Inpatient Psych, specialty care)

• Public Health

• Dental Providers

• Organizations interested in partnering with clinical sites (CCO, IPA, social service agencies, 211info)

Method:

• In person

• Telephone before visit

• Computer kiosk/tablet in waiting room

• Financial reimbursement - Organizations will receive $10 per completed screen in the first year and $2 per completed screen every subsequent year. Organizations will also receive $100 for every completed navigation.

• Access to a web-based software program that provides tailored referral summaries for connecting patients to community resources

• Better connections to community service providers with plans to develop closed loop referrals in the future

• Opportunity to better understand population/community needs

• Training and technical assistance to develop screening and navigation protocols

Participating Screening Sites

WHY SCREEN IF YOU CANNOT SUCCESSFULLY ADDRESS PATIENT NEEDS??

• Screen 75K and better understand social need• Understand if screening health care settings and

connection to resources can improve health and reduce health care costs

• Better understand social need/unmet social need • Gain experience and knowledge in how and where

to screen• Improve connection between health and social

service providers and learn what is needed and can work

• Get experience in data and information sharing between health and social service agencies

Short Term Goals

• Ability for information sharing between health and social service organizations

• Closed loop referrals between health and social service organizations

• Real time information on need and services available across a community

• Better understand where and how to screen and address social determinants

Longer Term Goals

Break

Public Comment

OHA/DHS Legislative Session Recap

MAC Social Determinants of Health Recommendations:

Stakeholder Feedback and Revisions

June-Sept 2017

Oct Nov Dec Jan 2018 Feb March April May June

27

PHASE 1: Recommendations for Addressing SDOH in Oregon CCOs

PHASE 2: Health-related services and Housing guide

Committee background and work plan

HRS guide drafted

SDoHdefinition drafted

Final definition and recommendations approved (Phase 1)

Mar 12 consultation with CCOs at QHOC

• Housing identified as priority area for health-related services guide

• Approved draft recommendations for stakeholder feedback

SDoH CCO stakeholder survey fielded

Milestone 1

Milestone 2

Milestone 3

Milestone 4

Milestone 5

MAC SDOH Timeline & Critical Milestones

Feb 1: consultation with HITOC

Milestone 6

HRS guide final (Phase 2)

Milestone 7

MAC selects SDOH at 2017 retreat

March 22 consultations with Allies for a Healthier Oregon and HITAG; Health Equity Committee survey

CCO and Stakeholder Presentations to MAC

Stakeholder feedback: Six recommendations• Connect to community health needs assessment and

community health improvement plan (HEC, AHO)• What are the MAC’s thoughts about how CCOs will pay

for/justify spending on work in SDOH? (QHOC)• Suggest removing the term “equity lens” and talking

about equity as a foundational tool for addressing SDOH (HEC)

• There needs to be more transparency of investments in SDOH (e.g. HRS) for communities (AHO)

• Much of the work to address SDOH is done at the provider level (AHO)

• Is there a way to emphasize consumer engagement in care more? (QHOC)44

4545

Six recommendations to OHA on CCO roles to address SDOH (DRAFT 3/26)

1. CCOs select SDOH role(s) based on the needs and resources in a given community. This includes:

a) Relying on regional plans such as Community Health Assessments and Community Health Improvement.

b) Working directly with Community Advisory Councils (CACs), providers, and other community partners already engaged in addressing the SDOH.

2. CCOs support & leverage existing internal, community, and provider efforts to address SDOH, in order to increase the effectiveness of these existing efforts.

3. CCOs build from their roles as the main Medicaid payer in a community, and use the unique tools provided by the CCO model to spend funds on SDOH, including:

a) Health-related services

b) Value-based payment strategies that incent providers to address SDOH

45

Six recommendations to OHA on CCO roles to address SDOH, Cont. (DRAFT 3/26)

4. CCOs support providers and community partners in working together with patients to identify and address the SDOH challenges patients face and would like help to resolve. This includes:

a) Addressing provider needs and infrastructure to impact SDOH (e.g. need for data systems or technology to track and address SDOH)

b) Ensuring providers have the necessary SDOH data to deliver both SDOH-informed and SDOH-targeted healthcare

5. CCOs consider equity and the SDOH as the foundation in all policies and programs they develop. This includes being conscious of the critical infrastructure needed – such as culturally competent providers – to address SDOH in a way that also addresses the social determinants of equity.

6. CCOs address SDOH in a way that promotes person and family-centered care, including tailoring SDOH efforts around member needs and desires.

a) For example, member-based efforts (e.g. flexible services) consider a patient’s desires and priorities when it comes to addressing their SDOH barriers. Population-based SDOH initiatives should be tailored to the needs and priorities identified through community health assessments.

Stakeholder feedback: Definition

• Positive feedback about the definition – no changes (QHOC)• Caution against framing health equity as a “lens” in the

recommendations – recommend framing as a foundation to the work in the definition and in the recommendations (HEC)

• Appreciate that SDOH and social determinants of equity are both included (HEC)

• The definition is slightly long – look for ways to condense if possible (HEC & AHO)

47

Definition: Social Determinants of Health & Equity (DRAFT 3/26)

Health begins where we live, work, learn, and play. The social determinants of health are the social, economic, political, and environmental conditions in which people are born, grow, work, live, and age. These conditions significantly impact length and quality of life and contribute to health inequities.

The social determinants of health are not fairly distributed in communities, but are shaped by structural factors, like racism. These structural factors are called the social determinants of equity, and they are evident in social norms, policies, and political systems, both historical and current.

Social Determinants of Health & Equity Factors (DRAFT 3/26)

Social Determinants

of Health

Neighborhood and Built

Environment

Health and health care

Social and Community

Health

Education

Economic Stability

Social integration Civic participation/community engagement Meaningful social role (e.g. meaningful work) Discrimination (e.g. race, ethnicity, culture,

gender, disability) Citizenship/immigration status Incarceration/Corrections Trauma (e.g. adverse childhood experiences)

Early childhood education and development

Language and literacy High school graduation Enrollment in higher

education

Poverty Employment Food insecurity Diaper insecurity Access to quality childcare Housing instability,

including homelessness Access to banking/credit

SOCIAL DETERMINANTS OF EQUITY

SOCIAL DETERMINANTS OF EQUITY

Access to healthy foods/protection from food “swamps”

Access to transportation (non-medical) Quality, availability, and affordability of housing Crime and violence (including domestic

violence) Environmental conditions Access to the outdoors/parks

racism sexism

ableism Homophobia & transphobiaageism

Access to health care Culturally and linguistically

appropriate care Health literacy

Stakeholder feedback: 10 possible roles• It’s helpful for CCOs to have a menu of possible roles to play

in addressing SDOH (HITAG)• Appreciate that the MAC called out the importance of

partnership in communities (QHOC)• Foundational role: include engaging with the communities

that a CCO serves (HEC)• Direct investment role: concern about sustainability if the

focus is on grants. What about calling out the CCO’s role in direct investment to develop community infrastructure to support SDOH work? (HEC)

• Data/analytics support role: A big barrier in clinic-level SDOH work is technology (AHO/HEC). Maybe include a reference to Health Information Exchanges? (HEC)

50

Ten possible roles for CCOs to address SDOH (DRAFT 3/26)CCO Role Description ExampleFoundational role: Internal infrastructure changes

Hiring, training, retention, recruitment, and community engagement strategies necessary toensure entity is well set up to address SDOH

CCO employs staff to meet the social, racial, and cultural needs of the community

Direct Investment Grants or more permanent funding to build infrastructure in communities to addressing SDOH, often by providing funding providers and community-based organizations.

CCO partners with local farmers’ market organization to establish a farmers’ market in a food desert/food swamp (area with limited access to healthy food)

Health-related Services Form of direct investment. Health-related services are non-state plan, non-covered services (HRS) intended to improve care delivery and member health. HRS include flexible services (member-specific services) and community benefit initiatives.

CCO funds non-medical transportation for members to go to parenting classes, food bank, job interview

Alternative Payment Models (APM)/Value-Based Payment (VBP)

Payment models designed to pay for value (i.e. outcomes) rather than volume (i.e. services). Payment can be designed to incentivize SDOH activities, allow flexibility address holistic medical/social needs to improve health.

CCO provides incentive payments to providers to support SDOH work, e.g. incentives for SDOH screenings, for PCPCHs to adopt optional program standard for tracking community/social service referrals

Workforce Contracting with or otherwise funding healthcare workers to address social determinants of health (e.g. community health workers)

CCO contracts with community health worker to provide social service referrals to high utilizers or operates a care coordination hub, such as the Pathways model

Convener Bringing together diverse, multi-sectoral partners to identify common priorities and work toward addressing SDOH

CCO engages social service and other community partners to integrate social determinants of health into its community health assessment and community health improvement plan; facilitate identification of common SDOH priorities for community

Data/analytics support Providing health care data or data resources (e.g. Health IT, supporting development of Health Information Exchange) to partners, such as social service entities

CCO supports building a social determinant of health screening instrument into EHR for provider use

General alignment/collaboration

Aligning CCO SDOH priorities with community-selected goals or strategies

CCO adopts common metrics with local early learning hub

Policy/government relations

Advocating for policies that address SDOH in communities

CCO advocates for improved transportation options for residents in service area

Social needs/resource clearinghouse

Compiling and distributing social needs/resource data to providers and other partners

CCO assembles social needs data on members and shares risk scores with providers to inform care51

MAC Social Determinants of Health Recommendations:

Implementation/Use of MAC’s recommendations

Questions for discussion:

• What does the MAC recommend OHA do to implement its recommendations? (e.g. how does the MAC recommend the agency use its definition?)

• What other work is needed to support the MAC’s recommendations? For example, how can OHA aid CCOs to address SDOH in ways that align with the MAC’s recommendations?

53

Starting list for discussion: Recommendations to OHA• Provide SDOH learning and information sharing opportunities for CCOs to

promote replication and scaling up of SDOH efforts• Increase tracking of CCO SDOH initiatives and data, and share information

publicly to identify best practices and areas for improvement• From increased tracking and data, establish clear goals and metrics to

assess CCO spending and work on SDOH• Strengthen requirements for Community Health Improvement Plans (CHP)

to ensure CCOs work with appropriate community partners and include SDOH strategies in their CHPs

• Increase transparency of CCO spending and policies/procedures related to SDOH

54

Thank you!

Next MAC Meeting: April 25, 20189:00am-2:00pm

Oregon State Library, Salem

55