1. Silos to Circles A New Continuum Conversation How Do We Go From Here……To Here? Silos Acute/ Ambulatory Public Health Home and Community Based Services Long-Term Care + ++ +++

3. © 1996-2009 Brokenness to wholeness Statement for invitation: We will work collaboratively on shared priorities that will foster wholeness for our currently fragmented continuum. Our opportunity is to collectively promote health at all life stages with services that are integrated, culturally appropriate, equitable, sustainable and that honor our shared humanity. Core Group Vision for invitation – drafted 1.5.2015 Silos to Circles Promote health with upstream stability Capacity for our shared humanity Measuring health and well-being at all life stages Collaborative, integrated, respectful and culturally appropriate New map of health Brokenness to wholeness to thriving to living to being Fragments to continuum Household Person Centered Thinking Value health as people define health Sustainable reward for those providing care Prioritizes and supports preventive practices Consider social determinants, transportation, food, education and impact on 1 or others Daily living needs are met Economic stressors Defining measurable outcomes Maximizing life at all life stages Well-being is redefined and central to work (measurement too) Healthy body, mind, soul Treated with respect Community that is collective, active, and sustainable Collaborative, holistic solutions Integrated, culturally meaningful system of wellness Seamless network that makes a continuum New map of health care Working together on important priorities Choose areas with greatest opportunity to create something new

4. 4 Cause And Effect: Where to Channel Our Efforts to Realize Our Vision Cause And Effect: Where to Channel Our Efforts to Realize Our Vision Promote health at all life stages with services that are integrated, culturally appropriate, equitable, sustainable and that honor our shared humanity. Value: Cost/Quality Value: Cost/Quality Transparency/Info / Data/Technology/ Interoperability Shared Language / Culture / Fear Navigation/ Coordination/ Trusted Advisor Shared Priorities Shared Priorities Regulations Reimbursement / Funding Communication Across Trust / Control / Choice We will work collaboratively on shared priorities that will foster wholeness for our currently fragmented continuum, so that we can collectively:

5. 5 Preliminary Focus Areas View through lenses of: Aging High Utilizers Health Disparities Chronic Disease Prevention & Management View through lenses of: High Utilizers Health Disparities Behavioral Health View through lenses of: Access to Care & Resources High Utilizers System Complexity Navigation & Transitions

6. 6 Guidance for Design Teams Phase I: Within a year, design and commit to an initiative within the focus area that fosters collaboration and improvement in the field with identified success measures (target 3-month check in with Core Group) Phase II: Implement an initiative that will deliver results on outlined success measures in 12 months Make-Sure’s and Success Measures Ensure that any initiatives/pilots are collaborative in nature, meet shared prioritization criteria, and address both traditional and non-traditional components of the continuum Establish shared language/culture within each focus area Give attention to and focus on health disparities Assure that initiatives are both person-centered AND system-focused Set success measures and identify the greatest barriers in each focus area to achieving those measures Quantify financial impact for collaborators Include diversity of people and perspectives Identify how any initiatives/pilots could foster the Silos to Circles shared vision Identify how any initiatives/pilots can be sustained and scaled systemically Address how any outcomes produced would foster a high-level of consumer confidence

7. 7 Preliminary Design Team Invitations Chronic Disease NameOrganizationDesign TeamCore Group Invitee Frank FernandezBCBS of MinnesotaChronic DiseaseN/A Joan PenningtonHealthEastChronic DiseaseN/A Marsha HughesHealthEastChronic DiseaseJoan Pennington Steve Vincent, MDCedar Riverside ClinicChronic DiseaseSiyad Abdullahi Pat SchommerUMN, Center for AgingChronic DiseaseLaurissa Stigen Diane ThorsonOtter Tail Co. Public HealthChronic DiseaseLaurissa Stigen Pam Van Zyl YorkMDHChronic DiseaseLaurissa Stigen Bobbi CordanoWilder FoundationChronic DiseaseFrank Fernandez David Pautz, MDBCBS of MinnesotaChronic DiseaseFrank Fernandez Andrea Hillerud, MDBCBS of MinnesotaChronic DiseaseFrank Fernandez Dr. George SchoephoersterGeriatric Services of MinnesotaChronic DiseaseSteve Gottwalt Sue AbderholdenNAMIChronic DiseaseSteve Gottwalt Jim Abeler Chronic DiseaseSteve Gottwalt Susan Marshalk Network of Hospice & Palliative CareChronic DiseaseKami Norland Jerri Hiniker or Candy Hanson or Mary Beth DahlStratis HealthChronic DiseaseSue Severson TBD ExpertUMNChronic DiseaseSheila Riggs

8. 8 Preliminary Design Team Invitations Behavioral Health NameOrganizationDesign TeamCore Group Invitee Frank FernandezBCBS of MinnesotaBehavioral HealthN/A Suzanne KoepplingerCatalyst InitiativeBehavioral HealthN/A Rebecca MelangCSHBehavioral HealthN/A Sheila RiggsUMNBehavioral HealthN/A Paul Goering, MDAllina HealthBehavioral HealthJan Malcolm Janny BrustCenter for Community HealthBehavioral HealthJoan Pennington Diane ThorsonOtter Tail Co. Public HealthBehavioral HealthLaurissa Stigen Lynn Price or Darren HeltBCBS of MinnesotaBehavioral HealthFrank Fernandez TBDMN Urban Health NetworkBehavioral HealthFrank Fernandez TBDNAMIBehavioral HealthSuzanne Koepplinger Lori KnutsonTouchstone Mental Health ServicesBehavioral HealthSuzanne Koepplinger Carol AckleyRiver RidgeBehavioral HealthSuzanne Koepplinger Amy WardWilder FoundationBehavioral HealthJoan McCusker Kami Norland or Angie LaflammeAccountable Communities for HealthBehavioral HealthKami Norland Grace Tangjerd SchmittGuild Inc.Behavioral HealthRebecca Melang TBDDHS Adult Mental Health / SABehavioral HealthRebecca Melang TBDLakeland Mental HealthBehavioral HealthLaurissa Stigen Ross Owen or Mark BrooksHennepin HealthBehavioral HealthSheila Riggs Amy Helkenen or Kim McCoyStratis HealthBehavioral HealthSue Severson Jeff Sawyer or Margaret GavianNorth MemorialBehavioral HealthSuzanne Koepplinger Sue AbderholdenNAMIBehavioral HealthValerie DeFor Mary RosenthalHFMNBehavioral HealthValerie DeFor Caroline Dillon (or other appropriate person – there are likely several)DHSBehavioral HealthValerie DeFor Joan ClearyCHW AllianceBehavioral HealthValerie DeFor TBD Mental Health Workforce Steering CommitteeBehavioral HealthValerie DeFor Louisa D’AltiliaLutheran Social ServicesBehavioral HealthGeorge Klauser

9. 9 Preliminary Design Team Invitations System Complexity NameOrganizationDesign TeamCore Group Invitee Mike BinghamPresbyterian HomesComplexityN/A Georgia LanePresbyterian HomesComplexityMike Bingham Jen van LewMVNAComplexitySheila Riggs Alyssa Meller National Rural Health Resouce CenterComplexityKami Norland Janel Scheres or Sue SeversonStratis HealthComplexitySue Severson Lali SilvaHealthEastComplexityJoan Pennington Jonette Lucia Zuercher NW Hennepin Family Service CollaborativeComplexitySiyad Abdullahi TBD ExpertUMNComplexitySheila Riggs Gail SkoglundAugustana CareComplexityOlivia Mastry

10. 10 Questions

11. Cross-Continuum Activities Minnesota Senior Health Options (MSHO) Hennepin Health Generation Next Southern Prairie Community Care East Metro Mental Health Roundtable Integrative Health: Catalyst Initiative eHealth Roadmaps (SIM) Community Collaboratives (SIM) Many change initiatives underway—could they be better connected and leveraged? How can successful models be taken to scale faster? Public HealthAcute / AmbulatoryLong-term Care Social Services SHIP Statewide Health Improvement Plan Community Health Needs Assessments (Center for Community Health) Back Yard Initiative Healthy Communities Partnership Diabetes Collective Impact project Healthy Minnesota Partnership Health Care Delivery System demos (e.g., NW Alliance) Aligned Incentive Activity Pioneer ACOs Medicaid IHPs Medicare MSSPs Accountable Communities for Health (SIM ) NCQA ACOs Health Care Homes CHAIN (Collaborative for Healthcare Acquired Infections Network) Community Projects RARE Honoring Choices Choosing Wisely ACT on Alzheimer’s Citizen Engagement Citizens League / TPT MN 2020 Long Term Care Imperative Post-Acute Care Futures work (Leading Age & Stratis Health) National Nursing Home Quality Care Collaborative (Stratis Health) LSS “My Life My Choices” Altair Social Services ACO Policy Ideas Health Outcome Trusts Community Health Business Models A Partial View:

12. 12 Draft Logos #1 #2 #3

13. Five Conditions for Collective Impact 13 Common/shared agenda Mutually reinforcing activities Continuous monitoring/shared measurement Continuous communication Backbone support

14. Essential Functions of Backbone 14 Backbone support helps a collaboration Hold guiding vision and strategy through neutral/shared forum and process Support aligned activities Gauge and share progress Build public will Advance policy Mobilize funding

15. 15 Shared Prioritization Criteria Greatest opportunity to collaborate Greatest potential to empower consumer Patient perspective Readiness for change Greatest ability to impact Builds collective infrastructure Screens out that which supports the status quo Environmental – Threats Environmental – Opportunities Prohibited by public policy Easy versus hard Impact/reach largest population