North Sound Accountable Communities of Health

Gary Goldbaum, MD, MPHggoldbaum@snohd.orgMarch 6, 2015

North Sound ACH awarded $150,000 Pilot ACH Grant

• February 9 to June 30, 2015

• Cascade Pacific Action Alliance (CHOICE) also awarded pilot grant

• Additional funding opportunity anticipated

• Design Grants of $100,000 awarded to 7

The Promise of Pilot ACHs

3

• Complete a “startup initiative” to demonstrate the valuable role of ACHs

• Test and inform ACH designation criteria, to be finalized by the end of 2015

• Provide learning opportunities as a peer leader to Design communities

• Inform the statewide ACH evaluation design, including rapid-cycle learning and improvement

The Vision of the North Sound ACH

A coalition with the triple aim of transforming the health system:

to improve the health of our communities and our people to improve the experience of care and access to careand to lower per capita health care costs

in Snohomish, Skagit, San Juan, Island and Whatcom counties

We can accomplish more together than we can individually Trust, respect, transparency, continuous learning, and data-driven decision-

making Collaboration between sectors is key Communities must be engaged to shape strategies The way care is currently organized and delivered will not be effective in

achieving our shared aim To improve overall community health we need to go upstream

The Guiding Principles of the North Sound ACH

The Process for the North Sound ACH

Build on existing strengths, experiences, & successes Align efforts with existing state, county or local priorities, outcomes,

strategies & metrics. Create measurable goals, & ensure accountability towards outcomes Ensure that our plan is clear, robust, well-researched, inclusive, &

actionable, yet practical

The North Sound ACH Commitment

• To succeed 1st with a short-term initiative

• Committed to sustainable, health improvement and capturing and reinvesting shared savings in prevention

• The CASE Initiative will continue to build trust while demonstrating the collective impact of working together

North Sound ACH Pilot Grant Deliverables

• Governance• “Backbone” (also known as administrative

organization) development• Regional Health Needs Inventory• Initial plan for sustainability• CASE Initiative

1% of people account for ¼ of costs

CASE Initiative: High level overview

Coordinate care coordination programs that target the highest utilizers of jails, EMS, and EDs

Align on outcome measures and processes

Standardize across programs

Enhance & Expand across programs to bring up to best practice standards

CASE Initiative: Coordinate, Align, Standardize, Enhance, and Expand care coordination programs in our region

CASE Initiative: Tracking

A single, shared Performance Measures Dashboard to display performance in four domains:

Improved outcomes Reduced costs Process measures Sustainability

CASE Initiative: Coordinate, Align, Standardize, Enhance, and Expand care coordination programs in our region

CASE Initiative: Deliverable

By the end of June: Produce a regional care coordination operations

manual that can be supported by the 5 managed Medicaid plans, and

a mini-business plan using findings from the CASE Initiative.

CASE Initiative: Coordinate, Align, Standardize, Enhance, and Expand care coordination programs in our region

CASE Initiative: Deliverable cont.

Provide care coordination services to ≥ 200 high utilizers in ≥ two counties.

In those enrolled, decrease the ED visit rate by 50% and hospitalization rate by 25%.

Show a minimum net health care savings of $1 million dollars.

Have a process for regularly submitting performance reports for integration into the CASE dashboard.

CASE Initiative: Coordinate, Align, Standardize, Enhance, and Expand care coordination programs in our region

For more information:Lee Che Leong

lpleong@hinet.org

Who benefits from care coordination?

1%

4%

15%

80%

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Well population

At-risk population

Complex high-users with multiple chronic diseases and behavioral health co-morbidities and social needs

Health & public health systems

Medical and behavioral health systems

EDs, jails, police, housing, community mental health clinics, federally qualified health clinics

Care coordination efforts in the North Sound: a snapshot

• The Community Paramedic Navigator Program in Snohomish has resulted in a 63% reduction in 911 calls and 54% reduction in ED visits in the initial evaluation.

• Following the launch of Providence’s Care Transitions Program, the readmit rate dropped from 16% to 10%.

• WAHA’s Intensive Case Management Program has observed a 26% decrease in ED visits, a 51% decrease in hospitalizations, and a 31% decrease in incarcerations.