Transforming Our Health System through Accountable Communities for Health (ACHs): Progress - PowerPoint Presentation

Transforming Our Health System through Accountable Communities for Health (ACHs): Progress to Date and Policy Recommendations Tuesday, October 29, 2019California State Capitol, Room 1121315 10th St., Sacramento, CA 9581411:00 a.m. – 12:30 p.m. (PT)

Welcome and Introductions Dora Hughes, MD, MPHAssociate Research Professor for Health Policy and ManagementGeorge Washington University

What Are Accountable Communities for Health? Multi-sector partnerships across health care, public health, and social services collaborating to address the health and social needs of individuals and communities.

The Funders Forum on Accountable Health Collaborative of public and philanthropic funders of Accountable Communities for Health for the purposes of—Sharing “lessons learned” and facilitating future collaboration;Exploring best practices in assessing the impact of ACHs on population health; andIdentifying policy options for supporting the ACH model.

National and State ACH Developments Jeff Levi, PhDProfessor of Health Policy and ManagementGeorge Washington University

Bottom Line Up Front ACHs are a structural approach to address two key drivers in a transforming health system:Growing evidence that improving health outcomes requires addressing the social context of individuals and communities. Succeeding in a value-based purchasing environment requires flexibility to address social needs and social determinants. The federal government and many states have embraced the ACH model as a pathway to health improvement and lower costs.The flexible design of ACHs permits adapting to state and local needs.Early outcomes are impressive, e.g., lower opioid overdoses.

What is an ACH? Multi-sector partnership across health care, public health, and social services collaborating to address the health and social needs of individuals and communities. Accountable care holds providers responsible for managing clinical conditions of a patient population ; accountable health holds multiple sectors responsible for the health of a community. Key premise: addressing social determinants or health-related social needs will achieve this goal in a way that health care/public health alone can not. Key premise: it takes a portfolio of interventions to address the health needs of communities and/or individuals.

Key Principles for ACHs: Funders Forum on Accountable Health A “backbone” organization which serves as convener and integrator for a defined geographic area; that organization (or another) could also serve as the fiduciary agent. A governance structure with respected community leaders builds on a history of collaboration in addressing the health of the community while engaging a diverse consumer perspective. Effective cross-sector alignment is evident among health care providers, health plans, public health, community and social services, education, business, and labor. Active engagement of community leaders and stakeholders in establishing a shared vision, goals, and agenda, with full community engagement in decision making regarding the use of resources and investment in building community capacity for this shared decision making. An ACH is responsible for improving the health of the entire community; however, certain conditions or target populations may be the focus of interventions for joint action.

National Movement, Diverse Starting Points and Focus Geographic diversityNot all are expansion statesAll recognize that coverage is an essential first step; necessary but insufficient to improve health outcomesHealth system interest driven in part by movement toward value-based purchasingNot all start with health care financing link Though sustainability will be dependent on creating that relationshipSome take community approach; some take a defined population approach Some focus on specific challenges; some address range of social/risk factorsMajor federal investment through $150 million Accountable Health Communities demonstrationContinued recognition of ACH model in recent North Carolina waiver

Policy Recommendations ACHs have been most successful where there has been a prior investment in community-level multisector partnershipsCACHI is a starting point for scaling and sustaining an ACH modelSustaining and scaling ACHs to have system-wide impact requires investment from the health care financing sector Current Medicaid policies, in addition to waiver authorities, provide states great flexibility to support ACH infrastructure Investment in ACH infrastructure increases the likelihood that coverage expansion will improve health outcomes and provides community-level partners for other system reform initiatives in California such as Whole Person Care

For Further Information accountablehealth.gwu.edu@AccountableHlth Jeffrey Levi jlevi@gwu.edu

How ACHs May Fit into Health Reform in California Eliot Fishman, PhDSenior Director of Health PolicyFamilies USA

Scaling Integrated Care – Need a “Table” Payment reform is very important but not enough to support more holistic approaches to health that address social drivers of poor health. Payment reform is critical: Payment involving some downside risk for inpatient costs for front line providers gives them a financial incentive to invest in community health workers and other social determinants interventions. In addition to giving providers some level of risk to incentivize activities that involve holistic prevention, engaging medical providers in social service referrals and coordination needs new administrative infrastructure . Need a “table” where human services CBOs, physical health, behavioral health, and payers can work together. That is what “Accountable Care” models have. CACHI model has strong commitment to getting community members and consumer advocates a full seat at that table.

A Local Approach Several states have created new community administrative structures pulling together CBOs, physical health, behavioral health, and others to coordinate service delivery. A “regional or community accountable health” approach. See Jeff Levi and MaryAnne Lindeblad presentations today for how some thoughtful states are approaching accountable health communities.

Accountable Communities for Health and California—Key Advantages California already structures its Medi-Cal program heavily around counties and public health systems.In larger counties, significant degree of sub-capitation: Medi-Cal provider contracting and clinical policy-making already has a substantial community-level component. ACHs are a good fit for CA in multiple key ways:A mechanism for state gov’t to increase its role and to drive whole person care and reformed payment that still reflects Medi-Cal’s historic decentralized structure. Multi-stakeholder approach reflects California’s political culture. Opportunity to develop more transparency around key Medi-Cal payment issues at the community level. Opportunity to keep lived community concerns and problems at the center, such as availability of transportation services and network adequacy, that do not fall under contemporary hot topics but are critically important at the community level.

Lessons Learned from Integrating ACHs into a State Medicaid ProgramMaryAnne Lindeblad, BSN, MPHState Medicaid DirectorWashington State Health Care Authority

Washington’s Health Transformation Landscape After health reform, Washington recognized the need to transform the delivery system to better serve clients.ACHs started as part of a state innovation model (SIM) planning grant in 2013 and a SIM test grant in 2015.To accelerate this transformation, Washington pursued an 1115 Waiver (Medicaid Transformation) in 2016.

Washington’s Accountable Communities of Health (ACHs) Independent regional organizations that work with community partners on health needs and prioritiesBorders are aligned with Medicaid purchasing regions Functions include: Aligning resources and activities that improve whole-person health and wellness in their communityImplementing projects that improve population health outcomesDistributing earned incentives to providers

ACH Funding & FinancingACHs can earn incentives from the following Delivery System Reform Incentive Payment (DSRIP) funding sources: ACH project incentives ACH value-based payment incentives Integration incentives to support integrated managed careIncentives are earned for both reporting and performance The portion of incentives available for reporting is greater initially, and gradually shifts to an emphasis on performance in the later DSRIP years ACHs distribute incentive funds to traditional and nontraditional Medicaid providers participating in Medicaid Transformation initiatives

2019 ACH Evaluation ResultsACHs established the infrastructure and capacity to implement large-scale system change. ACHs created a comprehensive, integrated approach to health system transformation. ACHs incorporated community voice, equity, and the social determinants of health.

Comparison of Statewide Performance Results2017-2018 Table displays a subset of pay-for-performance ACHs are accountable for in 2019. Shaded cells indicate improvement during calendar year 2018, compared to calendar year 2017.* DSRIP Pay for Performance metric Statewide Better Health Together Cascade Pacific Action Alliance Elevate Health HealthierHere Greater Columbia ACH North Central ACH North Sound ACH Olympic Community of Heath Southwest ACH All cause ED visits, 0-17 years Yes Yes Yes Yes Yes Yes No Yes No Yes All cause ED visits, 18-64 years Yes Yes Yes Yes Yes No Yes Yes Yes Yes All cause ED visits, 65+ years Yes No Yes No Yes Yes No Yes Yes Yes Plan all-cause readmissions (30-days) No No No No No No No Yes Yes No Mental health treatment penetration, 0-17 years Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Mental health treatment penetration, 18-64 years Yes Yes Yes Yes YesYesYesYesYesYesSubstance use disorder treatment penetration, 12-17 yearsNoNoNoNoYesNoNoNoYesYesSubstance use disorder treatment penetration, 18-64 yearsYesYesYesYesYesYesYesYesYesYes *These outcomes are not directly attributable to ACHs, and instead reflect overall trends.

Key Lessons LearnedACHs were (and are) woven into the delivery system fabric of the state.We need to involve and collaborate with our Tribal partners earlier on.We are still working toward sustainability.This is messy, hard, long-term work – and absolutely worth it.

General questions:medicaidtransformation@hca.wa.gov MaryAnne Lindeblad State Medicaid DirectorHealth Care Authoritymaryanne.lindeblad@hca.wa.gov Questions?

Innovations and Evolutions in California’s ACH Initiative Barbara Masters, MADirectorCalifornia Accountable Communities for Health Initiative

Let’s Get Healthy California Task Force December 2012

Launched in September 2016, CACHI is now supporting 13 communities throughout California to promote the development of an ACH ACHs are working on cardiovascular disease, asthma, trauma, substance use, community violence, and children’s health and well-being

Equity Essential Elements

Evidence for Impact of ACHs

Public Policy Opportunities

California Accountable Communities for Health Initiative

An On the Ground Perspective: Building an Enduring Platform for Health System Transformation Katherine Bailey, MSWExecutive DirectorSan Diego Accountable Communities for Health

Our Unique Environment Highly integrated regional healthcare marketStrong FQHC presenceMedicaid Geographic managed care Live Well San DiegoHealth Information Exchange, Community Information Exchange, and Connect WellSocial services and behavioral health services outsourced, not run by County

Mission, Vision, Values Mission: To create a “wellness system” that ensures individuals, families, and communities in San Diego have access to all they need to create a lifetime of health and wellness. Vision: Health, wellness, and equity for all of our communities, regardless of zip code. Values: Equity Inclusivity Neutrality Accountability

Our Solution “Our community is rich in partners and programs but lacking in coordination, alignment, and linkages to maximize impact. SD ACH is on a path to fill this gap and support a “wellness system.” Prior to SD ACH, there was no “table” or “place” to have this important discussion.” 1. Create a systems approach

2. Develop new cross-sector relationships “SD ACH sets the table for honest conversations about health equity that aren't happening anywhere else. Its multi-sector approach is unique.”“We have had difficult conversations about equity and race that have unfolded among diverse stakeholders.”

3. Leveraging systems approach + relationships into new solutions

4. Creating a new way of doing business to address SDOH

Thank you! Kitty Bailey760-707-9256kitty@betheresandiego.org

Q&A