Agenda Delivery System Transformation Committee June 13, 2019 4:30 – 6:00pm Samaritan Walnut Building, Endeavor Conference Room For remote connection see videoconferencing instructions 1. Introductions Sherlyn Dahl, Executive Director, Community Health Centers of Benton and Linn Counties 4:30 2. Transformation Update • CCO 2.0 • Unite Us • Expanding Health Care Coordination Scorecard Results • Social Determinant of Health with a Veggie Rx Intervention Scorecard Results p. 7 p. 8 Stephanie Jensen, Regional Project Coordinator, IHN- CCO 4:35 3. Oregon Health Authority (OHA) Update p. 9-14 Joell Archibald, Innovator Agent, OHA 4:40 4. Letter of Intent Review and Decisions p. 15-17 4:45 5. Wrap Up • Next Meeting: June 27, 2019 Sherlyn Dahl, Executive Director, Community Health Centers of Benton and Linn Counties 5:55
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Agenda Delivery System Transformation Committee · 6/13/2019 · Summary: The Community Health Center (CHC) screened patients for Social Determinants of Health (SDOH) with the PRAPARE
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Agenda
Delivery System Transformation Committee June 13, 2019 4:30 – 6:00pm
• Expanding Health Care Coordination ScorecardResults
• Social Determinant of Health with a Veggie RxIntervention Scorecard Results
p. 7
p. 8
Stephanie Jensen, Regional
Project Coordinator, IHN-
CCO
4:35
3. Oregon Health Authority (OHA) Update p. 9-14 Joell Archibald, Innovator Agent,
OHA
4:40
4. Letter of Intent Review and Decisions p. 15-17 4:45
5. Wrap Up
• Next Meeting: June 27, 2019
Sherlyn Dahl, Executive Director,
Community Health Centers of
Benton and Linn Counties
5:55
COMMONLY USED ACRONYMS AND MEANING
Acronym Meaning ACEs Adverse Childhood Experiences APM Alternative Payment Methodology CAC Community Advisory Council CCO Coordinated Care Organization CEO Chief Executive Officer CHIP Community Health Improvement Plan CHW Community Health Worker COO Chief Operations Officer CRC Colorectal Cancer DST Delivery System Transformation Committee ED Emergency Department EHR Electronic Health Records ER Emergency Room HE Health Equity IHN‐CCO InterCommunity Health Network Coordinated Care Organization LCSW Licensed Clinical Social Worker MOU Memorandum of Understanding OHA Oregon Health Authority PCP Primary Care Physician PCPCH Patient‐Centered Primary Care Home PMPM Per Member Per Month PSS Peer Support Specialist PWS Peer Wellness Specialist RFP Request for Proposal RHIC Regional Health Information Collaborative RPC Regional Planning Council SDoH Social Determinants of Health SHP Samaritan Health Plans SHS Samaritan Health Services SOW Statement of Work THW Traditional Health Worker TQS Transformation Quality Strategies UCC Universal Care Coordination WG Workgroup
DST 06/13/19 Page 2 of 17
Acronym Name End Date
C2C CHANCE 2nd Chance 12/31/18
CHIP Community Health Improvement Plan
CORO Community Roots 12/31/19
CSAS Children's SDoH and ACEs Screening 12/31/18
DOUL Community Doula 12/31/19
EHCC Expanding Health Care Coordination 04/30/18
HEST Health Equity Summits and Trainings 09/30/19
HEWG Health Equity Workgroup
HSPO Helping Students to Understand Pain 12/31/19
HTEM Homeless Resource Team 12/31/19
IFCW Integrated Foster Child Wellbeing 12/31/19
PCRC Planned and Crisis Respite Care 12/31/19
PWST Peer Wellness Specialist Training 12/31/19
RDUC REDUCE & Improve 12/31/19
RHEH Regional Health Education Hub 09/30/19
SDoH Social Determinant of Health Screening 12/31/18
MANDATORY Letter of Intent (LOI) Due May 30 5:00 pm
Transformation Department Reviews and Ranks LOIs
Full Pilot Proposals DueJuly 22 8 AM
MANDATORY Technical Assistance
Meetings June 17 – July 18
LOI Decisions June 13
Pilot Proposal Presentations to DST
July 25
Pilot Proposal Presentations to DST
August 8
DST Decisions August 22
InterCommunity Health Network Coordinated Care Organization Delivery System Transformation (DST) Request for Proposal Timeline
Invitations Issued to Submit Full Pilot Proposal
by June 17
Regional Planning Council (RPC)
Funding DecisionsSeptember 5
Proposers Notified of DST Decisionby August 30
Proposers Notified of Pilot Denial or
Approvalby September 24
Contracting Begins by November 1
Pilot Invoices/Payments Begin
January 1, 2020
Pilot Proposer
Action
Key
Transformation Team Action
DST Member Action
Scheduled DST
Meeting
DST 06/13/19 Page 4 of 17
Minutes Delivery System Transformation Committee
May 30, 2019 4:30 – 6:00 pm Samaritan Health Plans Walnut Building: Endeavor (conference room)
Introductions Sherlyn Dahl Present: Sherlyn Dahl, Christine Mosbaugh, Kevin Ewanchyna, Charissa White, Angel Parmeter, Larry Eby, Dick Knowles, Annie McDonald, Rebekah Fowler, Alicia Bublitz, Tyra Jansson, Cassidy Radloff, Kitty Carter, Tony Howell, Renee Smith, Kelly Volkmann, Jeff Blackford, Priya Prakash, Britny Chandler, Tanya Grant, Rachel Grant, Crystal Rowell, Melissa Cheyney, Paulina Kaiser, Phil Warnock, Tony Howell, Ronda Lindley-Bennett, Kacey Urrutia, John Leon, Marit Bovberg, Roslyn Burmood Video: Melissa Jackson, Bettina Schempf, Nicole Fields, Karen Hall
Charissa White Transformation Update Unite Us
• Still working on network development. Referrals are occurring with the organizations on board. Consultants
• The consultants will be working on evaluation of pilots and will be attending the DST in July with an update.
Request for Proposal (RFP) • Letters of Intent (LOIs) are due May 30, 2019. Received 15 so far and it closes at 5 pm.
Upcoming Trainings and Opportunities • Innovation Café is June 5, 2019. Benton County Health Services and IHN-CCO are co-presenting on the
social determinant of health screening model put in place through the pilot. • Interest in doing a meeting to recap after the conference.
• Trauma Informed Oregon is having a statewide conference in October 2019. • The Universal Care Coordination Workgroup is doing a working meeting for the Unite Us Assessments June
10, 2019. Social Determinant of Health Screening with a Veggie Rx Intervention Closeout Timeline: July 2017 to December 2018 Budget: $239,850 Summary: The Community Health Center (CHC) screened patients for Social Determinants of Health (SDOH) with the PRAPARE (Protocol for Responding to and Assessing Patient Assets, Risk, and Experiences) tool to identify those dealing with food insecurity. Once identified as having a food need (access, financial, healthy access) patients were given tokens to spend at an onsite produce stand hosted twice a week by the Corvallis Environmental Center at the Benton Health Center, or the Corvallis Farmers’ Market. Key Outcomes:
• Experience using PRAPARE as a tool to collect SDOH data. • Provided tokens for food resource to patients who were food insecure. • Increased access and opportunity to interact with local food system. • Worked with staff and trained to the importance of SDOH data collection.
Learning Experiences: • Closed loop referral continues to be a ‘unicorn’ across multiple sectors (health and community-based
organizations, health and health, within one site). • Screening form changes mid-project impacted reporting. • Distribution and refresh of tokens needs refining, more information. • Redemption of tokens was equal between two sites; overall, lower than expected. • Cross-sector collaboration led to the success of the pilot.
Remaining Challenges: • Ongoing, regular, standardized screening with PRAPARE at all CHC sites. • Using the data collected in a meaningful way. • Future funding for intervention/farm stand. • Role of increased access with existing programs like SNAP, lunch programs, Meals on Wheels.
DST 06/13/19 Page 5 of 17
Sustainability: • 2019 will bring replication, expansion, and a scaling of the screen to Rx model. • The CHC is rolling over all unspent funds to:
o Contract with the CEC for farm stand operation at three sites (Benton, Lincoln, Monroe Health Centers).
o Distribute tokens ($30/patient/month) redeemable at the Corvallis, Albany, Lebanon, and Sweet Home Farmers’ Market.
• Continue to work on evaluation of Veggie Rx and mindfulness/planning for funding in a CCO 2.0 world. Discussion:
• The method the pilot has determined as best is to give the screening tool to the client on paper for them to fill out.
• Clients seemed to appreciate the question and were not required to fill them out. • Recipes were provided at all the produce stands and simple education on how to cook the produce was also
provided. • Difficulties defining what a closed loop referral means between different types of agencies.
Spreading Promising Practices Discussion Pilot Categorizations and Heatmap
• See pages 18-21 of the packet. Proposed Process
• See pages 22-25 of the packet. Discussion
• The DST will find out how much funding is available Fall 2019. • Ensure a robust conversation occurs around spreading promising practices.
Decisions • Move forward with entertaining current pilot expansion requests. • Workgroup funding requests will also be considered. • Voting on all proposals (expansion, workgroup, and new pilots) will occur end of August 2019. • Relook at the process at the July 2019 DST. • Discuss spreading promising practices Fall 2019 and potentially have a plan to implement for 2020.
State Health Improvement Plan
• The State Health Improvement Plan (SHIP) identifies our state’s health priorities and addresses unjust and unacceptable disparities.
• It is a key strategic document for the Oregon Health Authority (OHA) Public Health Division and is required for Public Health Accreditation.
• 2020-2024 priorities are: o Institutional bias o Adversity, trauma, and toxic stress o Economic drivers of health o Access to equitable, preventive health care o Behavioral health
• These areas differ quite a lot from the 2015-2019 SHIP priorities that were focused on specific measures such as improving immunization rates.
• The priority shift indicates a focus on infrastructure and social needs.
DST 06/13/19 Page 6 of 17
IHN-CCO DST Pilot Scorecard Results
Expanding Health Care Coordination
Key Outcomes Achieved 6.67
Health Improvement 7.8
Health Equity 7.17
Improved Access 6.83
Transformational 7.33
Barriers 6.83
Partnerships and Collaboration 5.5
Resource Investment 6.83
Reduced Costs 7.2
Sustainability 7.33
Reviewers 6
DST 06/13/19 Page 7 of 17
IHN-CCO DST Pilot Scorecard Results
Social Determinant of Health Screening with a Veggie Rx Intervention
Key Outcomes Achieved 8.29
Health Improvement 6.75
Health Equity 8.88
Improved Access 7.88
Transformational 9.25
Barriers 8.38
Partnerships and Collaboration 9
Resource Investment 9
Reduced Costs 7
Sustainability 6.5
Reviewers 8
DST 06/13/19 Page 8 of 17
1 | P a g e
Innovator Agent Update IHN CCO Delivery System Transformation Team (June 13th, 2019)
CCO 2.0 Resources and Information
Oregon Health Authority is in the decision-making process for the next 5 year contract
period (2020-2024) for organization to serve the approximately one million people on
OHP. There were 19 applications received from current or prospective CCOs by the
April 22nd application deadline. OHA is evaluating those submissions now and will make
a public announcement of those that the agency intends to contract with on July 9th. The
most current information and materials on CCO 2.0 are posted on this public webpage:
No innovation aspects; strategy has been done in this region or type of organization
Little innovation; potentially to new region
Some innovation
New and innovative; new partnerships among agencies with new strategy for one or more partners
New and innovative strategy for all partners involved
Health Equity No health equity plan
Targets IHN-CCO members but plan unclear or does not clearly target IHN-CCO members but has a health equity plan
Little context, approach not clear
Clear approach, target population identified OR plan not clear, but target population obviously high-risk
Hits high-risk population and outlines plan for health equity approach clearly and effectively
DST’s Decision May 2, 2019 (excerpt from minutes)
Letter of Intent (LOI) • Discussion around the Transformation Department ranking the LOIs, the DST agrees that as long as this is transparent it would take the
onus off DST members. • Yes or no requirements include Social Determinants of Health (SDoH) areas and partnerships. • Decision: Transformation will rank and score the LOIs on Transformational and Health Equity and will present to the DST on June 13,
2019.
DST 06/13/19 Page 15 of 17
IHN‐CCO DST Letter of Intent Target Area Crosswalk
Bravery
Youth
Center
Food and
Pharma
Food
Environment
ASsessment
Toolkit
Hub City
(Tiny
Home)
Village
Improving
Health via
Mobile
Dental Care
Life
Enrichment
Program
Mental
Health
and
Wellness
Program
Peer
Recovery
Child
Welfare
Parent
Mentors
Reflexus
Skills and
Connections
to Support
Housing
Social
Determinants
of Health
Referral
Screenings
Stepping
Up
Together
in Lincoln
County
Supportive
Rehabilitation
Transport to
Great
Futures
Upstream
Transportation
for Seniors
Wellness
to SmilesTotal
Food Security 1 1 1 1 1 1 1 1 8
Housing 1 1 1 1 1 1 1 7
Transportation 1 1 1 1 1 5
DST 06/13/19 Page 16 of 17
Name Organization PartnersBudget
Low
Budget
High
Bravery Youth Center Olalla Center for Children and Families Community Services Consortium (CSC) $100,001 $150,000Hub City (Tiny Home) Village Creating Housing Coalition SquareOne Villages, Habitat for Humanity, Linn County Mental Health (LCMH) $50,001 $100,000
Stepping Up Together in Lincoln County Lincoln County Sheriff's Office Northwest Coastal Housing, C.H.A.N.C.E., Lincoln County Parole and Probation $50,000 $50,000
Wellness to Smiles Advantage Dental from DentaQuest
Housing Authority of Lincoln County, Centro de Ayuda, Food Share of Lincoln
County, OSU SNAP Education Program $50,001 $100,000Skills and Connections to Support
Housing Corvallis Housing First Community Services Consortium (CSC) $50,000 $50,000
Food and Pharma Samaritan Health Services
SHS Care Management, Oregon State University (OSU) College of Pharmacy, Good
Samaritan Regional Medical Center (GSRMC) Food and Nutrition Services $50,001 $150,000
Transport to Great Futures Samaritan Health Services Boys & Girls Club of Corvallis – Johnson Center for Youth Excellence $100,001 $150,000
Food Environment ASsessment Toolkit OSU Center for Health Innovation
Linn County Public Health, Regional Health Assessment for Linn, Benton, and
Lincoln Counties $150,001 $200,000Social Determinants of Health Referral
Screenings Lincoln County Public Health Lincoln Community Health Centers, Food Share of Lincoln County $100,001 $150,000
Life Enrichment Program Signs of Victory Ministries
Linn-Benton Food Share, CSC, CASH, LCMH, Linn Co. Health Department and Family
Tree Relief Nursery $100,001 $150,000
Improving Health via Mobile Dental Care Capitol Dental Care C.H.A.N.C.E, Samaritan Health Services (SHS) $150,001 $200,000
Upstream Transportation for Seniors The City of Newport Friends of the Newport Senior Activity Center $50,001 $100,000Peer Recovery Child Welfare Parent
Mentors Morrison Child and Family Services State of Oregon Child Welfare, District 4 $316,579 $316,579
Mental Health and Wellness Program Corvallis School District Boys and Girls Club, Samaritan Mental Health $450,000 $450,000
Reflexus Reflexus Company None $50,001 $100,000
IHN‐CCO DST Letter of Intent Target Area Ranking*
*Ranking by the Transformation Department as requested by the DST based on the components of Transformation and Health Equity.