Pathways Community HUB Workgroup March 28, 2018 Meeting
PathwaysCommunityHUBWorkgroup
March28,2018Meeting
Care Coordination / Pathways HUB
Transitional Care from acute settings
Whole Person Care
Chronic DiseasePrevention &
Control
Physical & Behavioral Health
Integration
Diversion Interventions
to avoid acute care
Preventing / Addressing Opioid Use
Social Determinants of
Health
Performance (P4P) Metrics
2A: Integ
ratio
n
2B: P
athw
ays
2C: Transition
al
2D: D
iversion
3A: O
pioid
3D: C
hron
ic
Total
Outpatient Emergency Department Visits per 1000 Member Months 1 1 1 1 1 1 6Inpatient Hospital Utilization 1 1 1 1 1 5Follow‐up After Discharge from ED for Mental Health 1 1 1 3Follow‐up After Discharge from ED for Alcohol or Other Drug Dependence 1 1 1 3Follow‐up After Hospitalization for Mental Illness 1 1 1 3Percent Homeless (Narrow Definition) 1 1 1 3Plan All‐Cause Readmission Rate (30 Days) 1 1 1 3Substance Use Disorder Treatment Penetration 1 1 2Mental Health Treatment Penetration (Broad Version) 1 1 2Child and Adolescents' Access to Primary Care Practitioners 1 1 2Comprehensive Diabetes Care: Eye Exam (Retinal) Performed 1 1 2Comprehensive Diabetes Care: Hemoglobin A1c Testing 1 1 2Comprehensive Diabetes Care: Medical Attention for Nephropathy 1 1 2Medication Management for People with Asthma (5‐64 years) 1 1 2Substance Use Disorder Treatment Penetration (Opioid) 1 1Antidepressant Medication Management 1 1Patients on high‐dose chronic opioid therapy by varying thresholds 1 1Patients with concurrent sedatives prescriptions 1 1Percent Arrested 1 1Statin Therapy for Patients with Cardiovascular Disease (Prescribed) 1 1
Opportunitiestosynchronizeourtargetpopulations
ChronicConditions
Behavioral Health
Conditions
High ED UtilizationIncarceration
Homelessness
General DataFood for Thought
RegionalHealthNeeds38
25
25
16
15
14
11
5
2
2
1
0
0
0
0
0
0 10 20 30 40
Mental Health Care Access
Access to care
Education
Obesity
Affordable Housing
Drug and Alcohol Abuse
Access to Healthy Food
Diabetes
Homelessness
Pre‐Conceptual and Perinatal Health
Transportation
Suicide
Accidents/Homicide
Sexually Transmitted Infections
Cancer
Lung Diseases
Source: Community Health Needs Assessment
MedicaidPopulationDemographicsNCACH Region (N=94,451)
Source: Healthier Washington Dashboard (Measurement period = 4/1/2016 – 3/31/2017)https://fortress.wa.gov/hca/tableau/t/51/views/HealthierWashingtonDashboard/FrontPage?:embed=y&:showShareOptions=true&:display_count=no&:showVizHome=no
CHELAN DOUGLAS GRANT OKANOGAN34% of population on Medicaid
N=26,10433% of population on Medicaid
N=13,59240% of population on Medicaid
N=37,63241% of population on Medicaid
N=17,123
Source: Healthier Washington Dashboard (Measurement period = 4/1/2016 – 3/31/2017)https://fortress.wa.gov/hca/tableau/t/51/views/HealthierWashingtonDashboard/FrontPage?:embed=y&:showShareOptions=true&:display_count=no&:showVizHome=no
Acute Care DataHospital and ED Utilization
TopTenMostCommonCausesofAcuteHospitalizationsAmongMedicaidRecipientsRank Cause of Acute Hospitalization Count % State Rank
1 Injury and Poisoning 266 12.1 2 (9.4%)
2 Mental and Behavioral Disorders 171 7.8 1 (18.2%)
3 Diseases of Heart 135 6.1 4 (5.7%)
4 Respiratory Infections 132 6.0 9 (3.6%)
5 Diseases of the Musculoskeletal System and Connective Tissue
115 5.2 5 (4.5%)
6 Substance Use Disorder 105 4.8 6 (4.6%)
7 Septicemia 105 4.8 3 (7.4%)
8 Cancer/Malignancies 102 4.6 8 (3.6%)
9 Diabetes 94 4.3
10 Diseases of Liver, Biliary Tract, and Pancreas 84 3.8 7 (3.7%)
Data for North Central ACH, Excluding Pregnancy and Child Delivery Related Hospitalizations (Jan 1, 2015 ‐ Oct 31,2015)Source: Health Care Authority Starter Kit, determined by primary diagnosis field in HCA ProviderOne Medicaid Data System
TopTenMostCommonCausesofOutpatientEDUtilizationAmongMedicaidRecipientsRank Cause of ED Utilization Count %
1 Symptoms, signs & abnormal clinical and lab findings 8,007 24
2 Injury, poisoning, and certain other consequences of external causes
7,822 23
3 Diseases of the respiratory system 3,860 11
4 Diseases of the digestive system 2,169 6
5 Diseases of the musculoskeletal system and connective tissue 1,635 5
6 Mental and behavioral disorders 1,554 5
7 Diseases of the skin and subcutaneous tissue 1,423 4
8 Diseases of the genitourinary system 1,352 4
9 Pregnancy, childbirth and the puerperium 1,195 4
10 Infectious and parasitic diseases 1,104 3
Source: Health Care Authority (ED utilization by Facility data set)Data for North Central ACH (Oct 1, 2015 ‐ Sep 30, 2016)
EDUtilizationbyCountyandDiagnosisGroupingBehavioralHealthReasons(Counts)
HCUP CCS Diagnosis Groupings (ICD10) Chelan Douglas Grant Okanogan Grand Total
Anxiety disorders 159 79 182 95 515
Alcohol‐related disorders 197 84 86 114 481
Substance‐related disorders 98 53 116 73 340
Mood disorders 97 38 93 50 278
Suicide and intentional self‐inflicted injury 104 43 69 51 267
Schizophrenia and other psychotic disorders 50 SN 32 21 112
Source: Health Care Authority (ED Utilization Sensitive data set)Data for North Central ACH (Measurement Period = Calendar Year 2016)
SN: Small Number
EDUtilizationbyCountyandDiagnosisGroupingBehavioralHealthReasons(Rates– per1,000membermonths)
HCUP CCS Diagnosis Groupings (ICD10) Chelan Douglas Grant Okanogan
Anxiety disorders 0.60 0.58 0.48 0.54
Alcohol‐related disorders 0.75 0.61 0.22 0.65
Substance‐related disorders 0.37 0.39 0.30 0.41
Mood disorders 0.37 0.28 0.24 0.28
Schizophrenia and other psychotic disorders 0.19 0.07 0.08 0.12
Suicide and intentional self‐inflicted injury 0.39 0.31 0.18 0.29
Source: Health Care Authority (ED Utilization Sensitive data set)Data for North Central ACH (Measurement Period = Calendar Year 2016)
PRISM DataRisk Scores
PRISMRiskScoreDatabyRegion
<1.0 1.0‐1.49 >1.5Count Percent Count Percent Count Percent
NCACH 62,773 2,035 3,522
Chelan 16,693 27.21 606 29.78 826 23.45
Douglas 8,812 14.37 258 12.68 361 10.25
Grant 24,746 40.34 768 37.74 1,447 41.08
Okanogan 11,090 18.08 403 19.80 888 25.21
Source: Health Care Authority and DSHS‐RDA | Measurement period CY2016, updated February 2018Data Notes• Population includes all WA Medicaid full benefit federally‐qualified Title XIX and SCHIP populations. • Members with both Medicaid and Medicare coverage (duals) are excluded. • Those with full third payer liability (TLP) as of the December 31, 2016 are excluded.
PRISMRiskScoreDatabyAge<1.0 1.0‐1.49 >1.5
Count Percent Count Percent Count Percent
0‐10 24,017 39.15 178 8.75 771 21.89
11‐19 16,244 26.48 159 7.81 317 9.00
20‐29 7,702 12.56 261 12.83 430 12.21
30‐39 5,201 8.48 346 17.00 433 12.29
40‐49 3,459 5.64 355 17.44 467 13.26
50‐59 3,379 5.51 515 25.31 750 21.29
60‐69 1,327 2.16 219 10.76 349 9.91
70‐79 SUPPRESSED SUPPRESSED SUPPRESSED SUPPRESSED SUPPRESSED SUPPRESSED
80+ SUPPRESSED SUPPRESSED SUPPRESSED SUPPRESSED SUPPRESSED SUPPRESSED
Source: Health Care Authority and DSHS‐RDA | Measurement period CY2016, updated February 2018Data Notes• Population includes all WA Medicaid full benefit federally‐qualified Title XIX and SCHIP populations. • Members with both Medicaid and Medicare coverage (duals) are excluded. • Those with full third payer liability (TLP) as of the December 31, 2016 are excluded.
PRISMRiskScoreDatabyGenderandMinorityStatus
<1.0 1.0‐1.49 >1.5Count Percent Count Percent Count Percent
Female 31,816 51.87 1,247 61.28 2,056 58.38
Male 29,525 48.13 788 38.72 1,466 41.62
Any Minority 32,941 53.70 738 36.27 1,461 41.48
Non‐ Hispanic White
23,221 37.86 1,218 59.85 1,850 52.53
Unknown/Other 5,179 8.44 79 3.88 211 5.99
Source: Health Care Authority and DSHS‐RDA | Measurement period CY2016, updated February 2018Data Notes• Population includes all WA Medicaid full benefit federally‐qualified Title XIX and SCHIP populations. • Members with both Medicaid and Medicare coverage (duals) are excluded. • Those with full third payer liability (TLP) as of the December 31, 2016 are excluded. • Race/ethnicity data based on population self‐identifying by various standard race/ethnicity reporting categories
Source: Health Care Authority and DSHS‐RDA, PRISM data setMeasurement period CY2016
Source: HCA and DSHS‐RDA
PRISM data set
Measurement period CY2016
Criminal Justice Data
ArrestData(2016)Measure Chelan Douglas Grant Okanogan WA State
Alcohol violation ‐ Adolescents 2.3 1.5 3.1 5.5 1.5
Drug law violation ‐ Adolescents 5.1 7.2 2.9 3.5 2.3
Violent crime ‐ Adolescents 2.0 0.9 1.2 0.3 1.5
Alcohol‐related ‐ Adults 5.1 5.2 3.3 4.4 4.9
Drug law violation ‐ Adults 4.1 2.8 3.2 1.5 2.4
Violent crime ‐ Adults 1.2 0.7 1.7 0.9 1.5
Prisoners ‐ Adults 1861.4 56.7 939.9 1200.3 662.0
Source: DSHS Risk and Protection Profiles for
Substance Abuse Prevention Planning
https://www.dshs.wa.gov/sesa/research‐and‐data‐
analysis/county‐and‐state
Measure definitions• Arrests of adolescents ages 10‐17 for alcohol violations, per 1,000 adolescents• Arrests of adolescents ages 10‐17 for drug law violations, per 1,000 adolescents• Arrests of adolescents ages 10‐17 for violent crime, per 1,000 adolescents• Alcohol‐related arrests for adults age 18+, per 1,000 adults• Violent crime arrests for adults age 18+, per 1,000 adults• Prisoners age 18+ in state correctional system, per 100,000 based on county of conviction
Percentreportingcurrent(past30‐day)substanceuse‐ Grade10
5%
6%
3%
5%
10%
6%
6%
6%
4%
3%
6%
4%
4%
8%
6%
0% 4% 8% 12%
Rx painkillers to get high
Rx drugs, not prescribed
All other illegal drugs
22%
25%
19%
23%
24%
29%
16%
20%
17%
20%
0% 10% 20% 30%
Marijuana
Alcohol
State
Grant
Chelan
Douglas
Okanogan
Source: 2016 Healthy Youth Survey http://www.askhys.net/FactSheets
YouthDetentionRates
Source: Washington State Center for Court Research (Juvenile Detention 2016 Annual Report)
Arrest/IncarcerationData
Source: Washington State Statistical Analysis Center County Profiles
The share of superior court filings for drug
crimes are 3+ times greater than the
share of arrests for drug violations.
Percentages show the share of drug violations/crimes compared to the total, across reported crimes, arrests and superior court filings.
Behavioral Health Data
BehavioralHealthConditions• Nearly 25% of the Medicaid members in the NCACH region have been diagnosed with a mental health condition.
• Anxiety disorders and depression are the most prevalent conditions.
• More than 5,000 Medicaid members have co‐occurring mental illness and substance use disorder diagnoses.
• Mental and behavioral disorders are the second leading cause of acute hospitalizations.
• Mental and behavioral health disorders are the sixth leading cause of Outpatient ED utilization among Medicaid recipients.
BehavioralHealthConditionshealthcareandsocialoutcomes
Source: DSHS Research and Data Analysis, “Measure Decomposition Data” file released October 27, 2017.
Chronic Conditions Data
ChronicConditions• Diabetes was one of the top ten most common causes of acute hospitalizations in our region, even though diabetes did not make it on the top ten list for Washington State.
• Nearly 10% of adults in the region reported having diabetes, the highest rate compared to other ACHs
• Respiratory infections were the fourth most common cause of acute hospitalizations for Medicaid recipients in our region (compared to 9th statewide)
• Diseases of the respiratory system third leading cause of Outpatient ED utilization among Medicaid recipients.
ChronicConditionshealthcareandsocialoutcomes
Source: DSHS Research and Data Analysis, “Measure Decomposition Data” file released October 27, 2017.
ChronicConditionsCo‐occurringwithMHorSUD
0
500
1000
1500
2000
2500
3000
3500
4000
4500
5000
Musculoskeletal Cardiovascular Gastrointestinal Pulmonary Diabetes
Coun
ts based
on Claims /
Encou
nters
Mental Health SUD
Source: Health Care Authority (Behavioral Health and Chronic Conditions data set)Data for North Central ACH | Measurement Period, June 2016
Project Performance Metrics
CommunityBasedCareCoordination– PerformanceMetricsP4P Measure NCACH Statewide
Follow‐up After Discharge from ED for Mental Health (30 day) 83.3% 68.5%
Follow‐up After Discharge from ED for Mental Health (7 day) 77.6% 56.8%Follow‐up After Discharge from ED for Alcohol or Other Drug Dependence (30 day) 32.2% 30.4%
Follow‐up After Discharge from ED for Alcohol or Other Drug Dependence (7 day) 25.9% 22.5%
Follow‐up After Hospitalization for Mental Illness (30 day)* 88.9% 79.8%
Follow‐up After Hospitalization for Mental Illness (7 day)* 76.7% 65.8%
Inpatient Hospital Utilization, per 1000 members 53 65Outpatient Emergency Department Visits, per 1000 member months (Broad measure) 38 52
Percent Homeless (Narrow Definition) 2.8% 5.3%
Plan All‐Cause Readmission Rate (30 Days) 12% 15%
Mental Health Treatment Penetration 18+ 44.7% 45.6%
Mental Health Treatment Penetration (6‐17) 58.2% 61.5%
Substance Use Disorder Treatment Penetration 21.0% 26.7%
Source: Health Care Authority and DSHS‐RDA | Measurement period CY2016 for most measures (CY2015 for those that are starred)
CommunityBasedCareCoordination– PerformanceMetricsP4P Measure NCACH Numerator Denominator
Follow‐up After Discharge from ED for Mental Health (30 day) 83.3% 145 174
Follow‐up After Discharge from ED for Mental Health (7 day) 77.6% 135 174Follow‐up After Discharge from ED for Alcohol or Other Drug Dependence (30 day) 32.2% 92 286
Follow‐up After Discharge from ED for Alcohol or Other Drug Dependence (7 day) 25.9% 74 286
Follow‐up After Hospitalization for Mental Illness (30 day)* 88.9% Not available Not available
Follow‐up After Hospitalization for Mental Illness (7 day)* 76.7% Not available Not available
Inpatient Hospital Utilization, per 1000 members 53 1,555 29,277Outpatient Emergency Department Visits, per 1000 member months (Broad measure) 38 37,213 984,614
Percent Homeless (Narrow Definition) 2.8% 684 24,225
Plan All‐Cause Readmission Rate (30 Days) 12% 186 1,491
Mental Health Treatment Penetration 18+ 44.7% 4,301 9,625
Mental Health Treatment Penetration (6‐17) 58.2% 2,475 4,250
Substance Use Disorder Treatment Penetration 21.0% 851 4,062
Source: Health Care Authority and DSHS‐RDA | Measurement period CY2016 for most measures (CY2015 for those that are starred)
All‐CauseEDVisits,per1000MMGeographicdetailOutpatient Emergency Department Visits per 1,000 member months
Rate Numerator Denominator
Chelan 37 9,978 268,365
Douglas 34 4,865 141,458
Grant 37 14,735 395,285
Okanogan 43 7,635 179,506
Source: Health Care Authority and DSHS‐RDA | Measurement period 1/1/2016‐12/31/2016Updated February 2018 *Data is preliminary ‐ encounter reporting completeness issues still affect many regions in CY 2016. Preliminary baselines will be updated as data matures.
InpatientHospitalUtilization,per1000MembersGeographicdetail
Inpatient Hospital Utilization, per 1000 Members
Rate Numerator Denominator
Chelan 49 410 8,419
Douglas 50 196 3,927
Grant 57 612 10,760
Okanogan 55 337 6,171
Source: Health Care Authority and DSHS‐RDA | Measurement period 1/1/2016‐12/31/2016Updated February 2018 *Data is preliminary ‐ encounter reporting completeness issues still affect many regions in CY 2016. Preliminary baselines will be updated as data matures.
PlanAll‐CauseHospitalReadmissions– ages18to64Geographicdetail
Plan All‐Cause Hospital Readmissions – ages 18 to 64
Rate Numerator Denominator
Chelan 11% 49 429
Douglas 13% 24 188
Grant 16% 89 542
Okanogan 7% 24 332
Source: Health Care Authority and DSHS‐RDA | Measurement period 1/1/2016‐12/31/2016Updated February 2018 *Data is preliminary ‐ encounter reporting completeness issues still affect many regions in CY 2016. Preliminary baselines will be updated as data matures.