A NEW CONTINUUM CONVERSATION

2 Overarching Approach To Initiative We will test our collaborative capacity and identify potential breakthrough opportunities in two principal focus areas Design Team Focus Areas Chronic Disease: Prevention & Management Behavioral Health Charge for Design Teams 1.Analyze the current landscape in the focus area 2.Identify shared goals that could foster the vision 3.Propose specific initiatives in which we might pilot breakthroughs in collaboration that would improve our work across the continuum and the resulting outcomes Core Team

3 Design Team Guidance and Charges Design Team Role, Process and Timeline April-May 2015  Establish the charge and key questions that the design teams will answer  Articulate terms and realities of work (e.g. answer key questions, suggest breakthroughs, share with core team, work may or may not go forward)  Core team members invite design team participants (using template language)  Lab support finalizes team list and coordinates development of issues paper Setting System ContextSetting Person-Centered Context June-September 2015  White Paper/Issues Briefing  Synthesis of Critical Data Sets  Focus groups  Observation leveraging design principles  Design Team Output: o Fill in gaps, develop and learn from use-case o Identify and answer the big questions, including the following:  What are the greatest needs in navigating the system  What gets in the way of achieving right levels and use of care  How do life stages impact the discussion  Propose potential breakthroughs* that could be achieved in this area to foster the vision and outline how the breakthrough could be modeled or tested in a pilot, demonstration or initiative  Include in the proposal how any successful pilot could be scaled and spread *Breakthrough could include: - Scrapping and redesigning all or part of the system - Putting existing components of system together differently to create new whole and achieve desired results *Breakthrough is NOT tinkering with broken parts of system or adding new broken parts

4 Comparable Large-scale Systems Change Efforts

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Refine Initiati ves Propose One or More Initiatives that Would Foster Vision Desig n Team Core Group Set Vision + Mission + Design Team Scope + Charge Jan-May 2015June-Aug 2015 Implemen t or Not Explore Possible Approaches Assess Current Landscape Sept-Dec 2015 System User/ Provide r Issues Briefs Shared Learning Mapping Economic Analysis

Design Team Role, Process and Timeline April-May 2015  Establish the charge and key questions that the design teams will answer  Articulate terms and realities of work (e.g. answer key questions, suggest breakthroughs, share with core team, work may or may not go forward)  Core team members invite design team participants (using template language)  Lab support finalizes team list and coordinates development of issues paper Setting System ContextSetting Person-Centered Context June-September 2015  White Paper/Issues Briefing  Synthesis of Critical Data Sets  Focus groups  Observation leveraging design principles  Design Team Output: o Fill in gaps, develop and learn from use-case o Identify and answer the big questions, including the following:  What are the greatest needs in navigating the system  What gets in the way of achieving right levels and use of care  How do life stages impact the discussion  Propose potential breakthroughs* that could be achieved in this area to foster the vision and outline how the breakthrough could be modeled or tested in a pilot, demonstration or initiative  Include in the proposal how any successful pilot could be scaled and spread *Breakthrough could include: - Scrapping and redesigning all or part of the system - Putting existing components of system together differently to create new whole and achieve desired results *Breakthrough is NOT tinkering with broken parts of system or adding new broken parts Design Team Guidance and Charges 7

8 Questions

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:

© 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 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

11 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:

Five Conditions for Collective Impact 12 Common/shared agenda Mutually reinforcing activities Continuous monitoring/shared measurement Continuous communication Backbone support

Essential Functions of the Lab 13 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

14 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