1. Aging and Disability Services Advisory Council
What Is the Medicaid Transformation Project? How will it affect Medicaid Services in King County?
Aging and Disability Services Advisory Council
August 11, 2017
Cathy Knight, Director, Aging and Disability Services
Jeff Sakuma, Health Integration Strategist, City of Seattle Human Service Department
Jeff

2. Healthier Washington Initiative*
Better Health
Build healthier communities through a collaborative regional approach
Better Care
Ensure health care focuses on the whole person
Lower Costs
Improve how we pay for services
Jeff
Better Health, Better Care, Lower Costs – The Healthier Washington initiative is the larger state-wide initiative that the Accountable Communities of Health and the Medicaid Transformation waiver request sit under

3. What is the Medicaid Demonstration Project?
A contract between the federal government (Centers for Medicare and Medicaid Services) and the state (Health Care Authority) to allow for innovation to improve health outcomes for Medicaid beneficiaries.
A five-year demonstration program ( ) funded by up to $1.5 billion in new investment.
Demonstration goals are to:
Integrate physical and behavioral health purchasing and service delivery
Convert 90% of Medicaid provider payments to reward outcomes
Implement population health strategies that improve health equity
Provide targeted services that address the needs of our aging populations and address the key determinants of health
Jeff
The approved waiver – feds to state to initiative
While a demonstration program (not a grant!!) – the funding is about demonstrating how these changes in processes and payment will live-on in perpetuity
What we cannot speak to today is the potential impact of a repeal and replacement of the Affordable Care Act – while this may not have an impact on the intent and work of the demonstration waiver, it could impact the future size and scope if fewer individuals are eligible cannot be supported by Medicaid (expansion population)
Right now, however, this work moves forward

4. Medicaid Demonstration Project: Three High-Level Initiatives
$1.1 Billion
$375 million
Initiative 1: Delivery system transformation strategies led by regional Accountable Communities of Health (ACHs)
Initiative 2:
Long-term services and supports
Initiative 3:
Supportive housing and supported employment services
Jeff
The Medicaid Transformation Demonstration Project includes three initiatives
Initiative 1 – Transforms the delivery system through ACH and receives the majority of funds
Initiative 2 – Long Term Services and supports builds on the AAA’s work with family caregivers
Initiative 3 - Is moving forward through various housing and social services entities including HSD’s Office on Housing

5. Initiative 1: Transformation through Statewide Accountable Communities of Health (ACH’s)
ACH’s are a cross-sector regional collaboration with the goal of improving health at the local level.
Regional ACHs will pursue projects aimed at transforming Medicaid and accelerate the move toward value based purchasing.
Transformation Projects will:
Be systems based
Address social determinants of health
Increase efficiency & effectiveness
Jeff
Initiative 1 – Read slide
Decisions will be made locally and collaboratively
Again, value-based purchasing is an extremely important piece of this puzzle –from 30% to 90% by the end of the five year period

6. King County Medicaid Recipient Profile
Approximately 23% of Medicaid recipients in the State reside in King County
Approximately 21% of King County residents are covered under Medicaid
427,914 individuals
58% adults and 42% children (under the age of 18)
Approximately 200,000 residents in King County are covered under Medicaid Expansion
Approximately 26% of the Medicaid population in King County have an identified mental health treatment need
Approximately 9% of the Medicaid population in King County have an identified substance use disorder treatment need
Jeff
This slide is to set some context in the breadth and scope of who will be impacted – it is important to remember that these are individuals with many great strengths to build on but who also have vulnerabilities to be cognizant of –
We sometimes forget that upward to 50% of all children in our state are born under Medicaid – that doesn’t mean that they always stay in Medicaid but that we have made a commitment to cover kids up to 300+% of the federal poverty level (fpl). Note: Statewide – as of February of this year 1.8 million people were under Medicaid

7. King County Accountable Community of Health (ACH)
Jeff
As of April this is the new structure that was put into place in order to begin to draw down these Medicaid waiver funds
The top two boxes are now in place with the middle box in action as we speak
Update on ED hiring and other positions

8. King County ACH Governing Board
Name
Title
Organization
Adrienne Quinn
Director
King County DCHS
Amina Suchoski
VP Business Development
United Healthcare Community Plan
Betsy Lieberman
Consultant
Affordable and Public Housing Group
Ceil Erickson
Director of Community Programs
The Seattle Foundation
Daniel Malone
Executive Director
Downtown Emergency Service Center
David Johnson
CEO
Navos Mental Health Solutions
Elise Chayet
Associate Administrator
Harborview Medical Center
Erin Sitterley
Councilmember, City of SeaTac
Sound Cities Association
Esther Lucero
Seattle Indian Health Board
Jeff Sakuma
Health Integration Strategist
City of Seattle HSD
Jihan Rashid
Program Staff
Somali Health Board
Marya Gingrey
Strategic Advisor
Regional Equity Network
Maureen Linehan
Seattle Aging & Disability Services
Molly Carney
Evergreen Treatment
Patty Hayes
PHSKC
Preston Simmons
Chief Operating and Administrative Officer
Swedish Health System, Providence
Roi-Martin Brown
Consumer/Community Member
Washington Community Action Network
Sarah Rafton
WA - American Academy of Pediatrics
Shelley Cooper-Ashford
Center for MultiCultural Health
Steve Daschle
Southwest Youth and Family Services
Steve Kutz
Cowlitz Indian Tribe
Teresita Batayola
International Community Health Services
Tizzy Bennett
Seattle Children’s Hospital
This is hard to read but just wanted to emphasize that this new board has a broad cross-section of stakeholders including consumers/community members
Over 30% are people of color
Primary Care
FQHC
Hospital/health systems (3)
Behavioral health providers (3)
MCO
Public Health
King County
City of Seattle
Suburban Cities
Community-based equity network/consumer (3)
Tribes (2)
Urban Indian Health Board
Housing
LTC Services
Non-profit social services (2)
Philanthropy , At large

9. Fund Flow ACH determines if project milestones have been met
To a fiscal intermediary
Funds flow from Federal Government to State Government
Project partners earn incentive payments
Jeff
Over the course of the first two years the ACH will be paid for planning and reporting and will begin paying for outcomes by the third year
Pay for planning
Pay for reporting
Pay for outcomes
up to $1.1 billion

10. Required Project #1: Physical and Behavioral Health Integration
Focus
Address physical and behavioral health needs through an integrated network, better coordination, seamless access.
Outcome Metrics
Medicaid clients with or at risk for:
Behavioral health conditions
Mental illness
Substance use disorders
Evidence Based Approaches
Overuse measures (emergency department visits, readmissions)
Behavioral health measures
Physical health measures
Target Groups
Two approaches for integrating behavioral > primary (Bree Collaborative, Collaborative Care Model)
Cited approaches for integrating primary > behavioral
Jeff
Connecting the head to the body – this doesn’t mean the all services need to be delivered under one roof, though that could happen, but that services are well coordinated including shared incentives
There are established evidence-based approaches to this work

11. Required Project #2: Opioid Use as Public Health Crisis
Focus
Reduce opioid related morbidity and mortality through:
Prevention
Treatment
Recovery supports
Target Groups
Medicaid Clients
Focus on youth who use prescription opioids and/or heroin.
Outcome Metrics
Systems wide Opioid
Treatment penetration
Overdoses per 100,000
Deaths per 100,000
Project Outcomes
Treatment indicators
MAT with Bupe
MAT with Methadone
Evidence Based Approaches
Clinical Guidelines: AMDC interagency guidelines
CDC Guidelines
Substance abuse during pregnancy guidelines
Jeff
The work of our KC Heroin and Prescription Opiate Addiction Task Force has already set us on a very good course to further this work as we already have the majority of our workplan in place
This will apply to much of the recommended work around prevention, expansion of treatment and treatment options, the distribution further distribution of naloxone and expansion of syringe exchange programs

12. Process and Time-line for Projects
Convene Interested Parties
King County ACH selects / submits portfolio to HCA
Identify project focus & implementing partners
2017
Jan
Feb
March
April
May
June
July
Aug
Sept
Oct
Nov
Dec
Develop project proposal
Projects approved
Jeff
Review timeline
Submit to King County ACH
2018 through 2021
Projects Implemented ( )

13. Initiative 2: Long Term Services and Supports (LTSS)
Projected Growth of Older Population in WA State as % of 2012 Population
Cathy
WA state has been a national leader in keeping people in their homes and communities, saving billions of dollars over the past two decades.
Although, we have been successful, our population is aging, increasing the number of individuals who will need these services.
The demonstration will allow the state to prepare for the age-wave by testing new services that support unpaid family caregivers
and provide targeted supports to people who may or may not be eligible for Medicaid.
The main goal of initiative 2 is to delay the need for more intensive Medicaid-Funded LTSS

14. Initiative 2: LTSS – Supporting Caregivers
80% of care statewide is provided by family members and other unpaid caregivers
Unpaid caregiving has an economic impact on families:
Loss of earning potential
Decreased savings for retirement
Impacts on ability to provide for their own children’s needs
Increased health care costs due to stress and burden
If just 1/5 of unpaid caregivers stopping providing care, it would double the cost of long-term services and supports
Cathy

15. Initiative 2 - Two New Services: Supporting Caregivers
Medicaid Alternative Care (MAC)
A new choice designed to support unpaid caregivers in continuing to provide quality care
Has benefits similar to the state family caregiver program such as respite, counseling, support groups
Tailored Supports for Older Adults (TSOA)
A new eligibility group to support individuals who need LTSS and are at risk of spending down to impoverishment.
Note: No Co-Pays or Estate Recovery
Cathy

16. Initiative 2: LTSS – Implementation
HSD/ADS staff are engaged in:
Systems development - designing benefit package, testing data systems, working with current providers on contracting
Hiring of staff
Case Manager - assessment, eligibility review
Planner – gather input and Develop policies
Training staff
All HSD/ADS units involved - Planners, Contract Staff, Case Management
Outreach to increase numbers
Target Implementation – August 2017
Cathy

17. Initiative 3: Foundational Community Supports Supportive Housing
Community Transition Services
One-time supports for individuals transitioning out of institutions or at imminent risk of becoming institutionalized
Includes rental deposit, move-in costs, household furnishings and other necessary supports
Community Support Services
Housing assessment and development of a plan to address barriers
Assistance with applications, community resources, and outreach to landlords
Education, training, coaching, resolving disputes, and advocacy
Supportive housing services do not include funds for room and board or the development of housing
Cathy
3rd initiative will address unemployment and job insecurity, along with homelessness and unstable housing. Research is clear that these issues affect physical and mental health. The goal of Initiative 3 is to create targeted benefits to enhance the availability of employment and housing for the most vulnerable.

18. Initiative 3: Supportive Housing Target Population
Chronically homeless (HUD definition)
Frequent/lengthy institutional contact
Frequent/lengthy adult residential stays
Frequent turnover of in-home caregivers
PRISM Score (Predictive Risk Intelligence System)

19. Initiative 3: Foundational Community Supports Supported Employment
Individual Placement and Support (IPS) model
Principles of supported employment:
Open to anyone who wants to work
Focus on competitive employment
Job development and benefit counseling
Client preferences guide decisions
Integrated with treatment
Individualized long-term supports
Services may include:
Employment assessment and development of a plan to address barriers
Assistance with applications, community resources and outreach to employers
Education, training, coaching to maintain employment

20. Initiative 3: Supported Employment Target Population
Aged, Blind, Disabled (ABD)/Housing and Essential Needs (HEN)
Individuals with severe and persistent mental illness, individuals with multiple episodes of inpatient substance use treatment and/or co-occurring
Working age youth with behavioral health conditions
Individuals receiving long-term services and supports

21. Initiative 3: Funds Flow
Program Oversight Data Benefits administrator Providers
Medicaid
HCA – DBHR - ALTSA
Third Party Administrator
State agencies – HCA, DBHR, ALTSA have oversight
Third Party Administrator – has oversight of benefits, contracts with providers, authorizes services, distributes payments, and tracks data/encounters
Provider networks – CBOs, Health Care providers, LTSS providers, Tribal providers, community behavioral health agencies
Reimbursement rates are still in development
HSD/ADS is considering being a contracted provider
SH/SE - CBO
SH/SE – Health Care Providers
SH/SE – Comm. BH Agencies
SH/SE – LTSS Providers
SH/SE – Tribal Providers

22. What are the expected Outcomes?
Better Health
Better Care
Lower Costs

23. Questions & Discussion