1. PIP Meeting
May 8, 2018

2. Welcome

3. Phase 1 Action Plan Kathleen Clark
Community Driven Action Plan 3

4. What’s the Work of Interested Medicaid Transformation Participants in 2018?
Complete Portfolio of Assessments
Develop Individual
Phase I Action Plan
Complete Phase II Action Plan for Binding Letter of Agreement 1 2 3
HIT/HIE
Clinical Organization
Community-Based Organization
IMC Self-Assessment
Community
Tactics per system change and focus areas
Settings and sites
Partnerships
Health equity approach
Measuring success
Initial resources
Project plans
Expected outcomes
Measures of success
Individual Partner agreements
Details dependent on state guidance
STEP 1
Complete Portfolio of Assessments
HIT/HIE
Current State Assessment
Transformation Assessment
STEP 2
Develop Individual Change Plans
Receive Change Package Tools: Improvement Plan & Initial Budget Template (Rules of Engagement, Driver Diagrams,)
Settings: Identify which Settings you will transform in which community/geography
AIM: What are you trying to accomplish for each setting you hope to transform
Problem: Which specific problem(s) you want to solve for which priority populations
Partnerships: Identify which partners you will need to collaborate with to solve the identified problems
Outcomes: Describe expected outcomes and objectives
Measures: How will we know the change is an improvement - define the measures to monitor impact
Change Ideas: What changes can we make that will lead to improvement?
Initial Costs: Describe magnitude of resources it will take to make the change occur (FTE, T.A., Technology, etc.)
STEP 3
Complete Binding Letter Agreements
Details of this agreement/contract is dependent on state guidance. Stay Tuned
Complete your individual Partner agreements
March - June
May - June
Sept - October

5. Phase I Action Plan Due June 15 Distributed May 4
Determine team members
to complete plan
Schedule 2-3 hour time frame to complete
Request Improvement Advisor facilitation 5

6. About the Template
Based on system changes that can improve all focus areas
Aim is selected
Primary and secondary drivers selected
Select minimum of eight tactics
At least one tactic per secondary driver
Focus area tactics come from Rules of Engagement
Some tactics required
Other tactics suggested
Includes health equity, workforce, partnerships, integrated managed care, value-based payment
Commitment to sites/settings
Asks for input on metrics
Asks for input on resources needed

7. Pierce County ACH Medicaid Transformation Driver Diagram
What metrics do you expect to track to measure success?
By December 31, 2021, achieve whole-person care by addressing physical and behavioral health integration, opioid misuse prevention and treatment, chronic disease management and prevention, and care coordination
Aim
Primary Drivers
Secondary Drivers
Tactics
Lay the foundation/ build organizational capacity
Build Relationships
Change Care Delivery
Reduce Barriers to Care
Engaged Leadership
Quality Improvement Strategy
Sustainable Business Operations
Empanelment
Continuous, Team-Based Healing Relationships
Organized, Evidence-Based Care
Person/Family Engagement
Care Coordination
Enhanced Access
Metrics
Select your tactics to achieve the aim

8. Pierce County ACH Medicaid Transformation Driver Diagram-Example
What metrics do you expect to track to measure success?
By December 31, 2021, achieve whole-person care by addressing physical and behavioral health integration, opioid misuse prevention and treatment, chronic disease management and prevention, and care coordination
Aim
Primary Drivers
Secondary Drivers
Tactics – Opioid
Lay the foundation/ build organizational capacity
Build Relationships
Change Care Delivery
Reduce Barriers to Care
Engaged Leadership
Quality Improvement Strategy
Sustainable Business Operations
Empanelment
Continuous, Team-Based Healing Relationships
Organized, Evidence-Based Care
Person/Family Engagement
Care Coordination
Enhanced Access
Metrics
Assign Opioid Misuse Disorder Treatment focus to a multi-disciplinary team
Identify quality improvement strategy to facilitate change
Advance data sharing with other organizations who share care for patients
Test and implement a standard process for reviewing panel level data on patients with opioid disorder
Assess training needs of care team and implement training plan w/emphasis on stigma and trauma reduction
Implement validated substance use screening such as SBIRT including evaluation for MAT
Develop/implement or improve process for engaging patients/families in decision making in plan of care
Increase providers with MAT prescribing authority
Document/improve follow-up with patients who have opioid misuse disorder upon discharge from ED, urgent care, or hospital

9. Go to Phase 1 Action Plan
/Clinical Partner Action Plan Form Final

10. HopeSparks and Pediatrics Northwest Improvement Project
Rebecca Carey & Joe LeRoy

11. About Hope Sparks Vision
Primary provider of services to children and families in a continuum of care across the lifespan of families beginning before birth
Expect increase in Medicaid patients with transition to integrated managed care (IMC)
Five Core Behavioral Health programs serving children and families experiencing trauma, abuse and overwhelming life challenges
Largest provider of sexual assault services for children in Pierce County
Four locations
63% of clients are Medicaid patients
In 2016, served 3,343 children and families with over 26,000 counseling sessions and home visits

12. About Pediatrics Northwest
Multi-specialty pediatric group dedicated to improving the health of the children and families in our community
Four locations in Pierce County: Two in Tacoma, one each in Federal Way and Gig Harbor
46% percent of patients served are covered by Medicaid

13. What Are We Trying to Accomplish?
Purpose: Improve the health and outcomes of Pediatrics Northwest and HopeSparks shared patients by improving the collaborative handoffs for patients with mild to moderate BH needs
Project Goals:
Knowing our shared patients
Defining our patients through use of data and reports (Medicaid focus)
Shared understanding of patient population’s needs
Capturing social determinants at intake
Data-sharing of care plans and information through innovative data
Ensuring better clinical outcomes through strong partnerships and seamless hand-offs
Shared case load multi-disciplinary team meeting
Define joint clinical outcome measure

14. How Will We Know It Is an Improvement?
Phase 1- ‘Seeing’ Phase
Knowing shared patients: Age, gender, diagnosis, insurance, referral status, primary care provider
Check in Process: HopeSparks capturing primary care provider at intake and check in
Establish Multidisciplinary Team Meetings: Monthly, representation from both organizations
Shared understanding of patient population’s needs: Most prevalent diagnosis, time frame
Define joint clinical outcome measure
Phase 2 – ‘Improving’ Phase
Developing a system for sharing care plans and data
Social determinants intake process

15. Changes That Lead to Improvement
Change Ideas
Verify primary care provider at check in with front desk at HopeSparks
Identify co-managed patients and identify shared diagnosis, key age groups
Schedule regular multidisciplinary team meeting

16. SAMSHA New Fact Sheets: 42 CFR Part 2: Confidentiality of Substance Abuse Use Disorder Records
Community Driven Action Plan 16

17. SAMSHA New Fact Sheets: 42 CFR Part 2
Screenshot on 05/08/2018 from

18. SAMSHA New Fact Sheets: 42 CFR Part 2 continued…
Screenshot on 05/08/2018 from

19. Integrated Managed Care Learning Network
Community Driven Action Plan 19

20. Integrated Managed Care Learning Community Save the Date

21. Integrated Managed Care (IMC) Learning Network
May 1, 2018 through June 30, 2019
Self-Assessment due May 15, 2018
Convene managed care organizations, behavioral health organizations, the Health Care Authority, the County – May 21, 2018
identify common approach to technical assistance
Create agenda for IMC Learning Community Kick-Off
IMC Learning Community Kick-Off event – June 28, 2018
Monthly webinars July – December 2018
Peer-to-peer support
Share best practices
Subject matter expertise
Early Warning System
1:1 consultation as needed

22. Organization and HIE/HIT Preliminary Results
Community Driven Action Plan 22

23. Organization Assessment

24. Sneak Peak of Results: Substance Abuse and Mental Health Services Administration (SAMHSA) Level of Integration
Physical Health providers look different from BH providers for this one. (Note: Very few organizations fell neatly into just one provider type. Orgs that provide some combination of MH, SUD, and Physical Health services would be counted more than once.)

25. Thank You!