Suzie Shupe, CEO Redwood Community Health Coalition Redwood Community Health Network

 Background on RCHC  Community Health Center (CHC) transformation to Value Based Care (VBC)  Patient Centered Medical Homes & Care Teams  Interconnectivity among CHCs and greater system  Accountable Care Organization  Collaboration with hospitals  Other key initiatives focused on integrated services

FQHC Members  Alliance Medical Center  Alexander Valley Healthcare  Coastal Health Alliance  CommuniCare Health Centers  Marin Community Clinic  Marin City Health & Wellness Center  Ole Health  Petaluma Health Center  Ritter Health Center  Santa Rosa Community Health Centers  Sonoma Valley Community Health Center  West County Health Centers, Inc.  Winters Healthcare Clinic Non-FQHC Members  Jewish Community Free Clinic  Planned Parenthood Shasta Pacific  Sonoma County Indian Health Project  St. Joseph Health System, Mobile Health RCHC comprises 17 health center members with over 40 service delivery sites in Napa, Sonoma, Marin and Yolo counties RCHC’s service area covers a total of 4,407 square miles and 1.1 million people* *Sonoma: 1,768 sq mi; population 500,293 *Napa: 788 sq mi; population 141,667 *Marin: 828 sq mi; population 260,750 *Yolo: 1,023 sq mi; population 207,590 RCHC comprises 17 health center members with over 40 service delivery sites in Napa, Sonoma, Marin and Yolo counties RCHC’s service area covers a total of 4,407 square miles and 1.1 million people* *Sonoma: 1,768 sq mi; population 500,293 *Napa: 788 sq mi; population 141,667 *Marin: 828 sq mi; population 260,750 *Yolo: 1,023 sq mi; population 207,590 *Source: 2014 US Census Bureau

 RCHC health centers delivered 912,350 medical, mental health and dental visits to over 242,000 patients in  RCHC health centers serve approximately 62% of all Medi- Cal patients (130,000) and 71,000 uninsured in our four- county service area.  74% of patients have incomes less than 200% of the federal poverty level (FPL), and 56% are below 100% of FPL  52% of our patients are Latino  35% are best served in a language other than English  30% are uninsured Source: 2014 OSHPD Data

 Coalition has long history of trust and collaboration  Made a strategic decision to move CHCs toward providing VBC and preparing for Value Based Payment models

 Care Teams  All CHCs are implementing care teams  Taking varied approaches  National leaders  Patient Centered Medical Home (PCMH)  Currently 7 of 13 FQHC member health centers have PCMH recognition

6 Connected Health Centers, > 120,000 patient records Any EHR can connect EXTERNALY hosted by vendor Locally managed by RCHC RCHIE planned activities for 2016:  Internal health center data sharing  Launch of provider portal  Connection to hospitals for admit, discharge and transfer alerts  Connection to Connect Healthcare and access to regional web- based portal  Connecting additional member health centers

RCCO Petaluma Santa Rosa RCHC John Canova, MD Alliance Alexander Valley West County Clinic OleCoastal The Redwood Community Care Organization (RCCO) Medicare Shared Savings Program (MSSP) ACO began January 1, 2014

Our Framework: Five Accelerators

 Current risk stratification algorithms/tools do not adequately weigh behavioral health diagnoses and social determinants of health seen in our population  Health centers do not currently document and code in a manner that fully characterizes the complexity of patients (medical acuity, behavioral health co- diagnoses, social determinants of health)

A Medicare ACO in the safety is different from the average Medicare ACO

ACO Transformation  Spread of value based care principles learned from Medicare ACO  Shift of focus on population health strategies to a broader population  Joint analytics will be a key component of that work

 “… a single, integrated mature solution that meets all PHM (population health management) IT needs does not exist in today’s market.” -Hunt et al. “Guide for Developing and Information Technology Road Map for Population Heath Management” Population Health Management, Nov. 3, 2015

 Claims analysis  Predictive modeling  Risk stratification using a combination of claims data and clinical review  Strategies specific to risk stratification

 Coordination of Patient Care  Real time utilization data  Continuity of Care documents  Admit, Discharge, Transfer feeds  Care Transitions  Complex Care Management

 Integrating Behavioral Health into Primary Care  Increasing Access to Specialty Care  Complex Care Management  Addressing Social Determinants of Health  Local Programs for Remaining Uninsured in Sonoma and Marin Counties