1. The ‘C’ of Acronyms: CCOs, CACs, CHAs, CHIPs and CHWs Bill Bouska, MPA Innovator Agent Belle Shepherd, MPH Innovator Agent Health Systems Division, Oregon Health Authority 10/12/2015 1

2. Today’s Topics Coordinated Care Organizations and Model Community Advisory Council structure Community Health Assessments Community Health Improvement plans Community Health workers 10/12/20152

3. COORDINATED CARE MODEL 3

4. Wrong focus = wrong results 10/12/20154

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6. Oregon’s Health System Transformation Began implementing the coordinated care model within coordinated care organizations (CCOs) in 2012 o CCOs are networks of all types of health care providers (physical health, addictions and mental health, and dental care) who work together to serve Oregon Health Plan (Medicaid) members Now spreading the coordinated care model to other payers 10/12/20156

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8. COMMUNITY ADVISORY COUNCILS (CAC) 8

9. Community Advisory Councils (CACs) Oregon Statute: CCOs must have a CAC to ensure that the health care needs of the consumers and the community are being addressed. CACs must: Include representatives of the community and of the government of each county served by the CCO. Consumer representatives must constitute a majority of the membership. 10/12/20159

10. Community Advisory Councils (cont.) Identify and advocate for preventive care practices to be utilized by the CCO Oversee a community health assessment and adopt a community health improvement plan to serve as strategic guidance for the CCO to address health disparities and meet health needs for the communities in their service area(s) Annually publish a report on the progress of the community health improvement plan 10/12/201510

11. Total number of CACs around the state = 37 over 400 members AllCare Health Plan: 3 Cascade Health Alliance: 1 Columbia Pacific CCO: 5 Eastern Oregon CCO: 13 FamilyCare, Inc: 1 Health Share of Oregon: 1 Intercommunity Health Network: 4 Jackson Care Connect: 1 PacificSource Central Oregon: 1 PacificSource Columbia Gorge: 1 PrimaryHealth of Josephine County: 1 Trillium Community Health Plan: 2 Umpqua Health Alliance: 1 Western Oregon Advanced Health: 1 Willamette Valley Community Health: 1 Yamhill Community Care Organization: 1 1110/12/2015

12. COMMUNITY HEALTH ASSESSMENTS (CHA) 12

13. Community Health Assessments: Overview A CHA: is a process of collecting, analyzing, and interpreting information about a community’s health assets and needs. helps to identify and prioritize areas needing improvement. informs policy formulation, implementation, and evaluation. must be overseen by each CAC every five years. 10/12/201513

14. The Community Health Assessment OAR 410-141-3145 (5) “The CCO’s Community Advisory Council shall oversee the community health assessment and adopt a plan to serve as a strategic population health and health care system service plan for the community served by the CCO. The Council shall annually publish a report on the progress of the plan.” 10/12/201514

15. CHA alignment 10/12/201515

16. COMMUNITY HEALTH IMPROVEMENT PLANS (CHIP) 16

17. Community Health Improvement Plans: Overview A CHIP is based on data from the CHA. It is a detailed working outline used to: identify priority issues. develop strategies for action. ensure accountability for creation of measurable health outcome improvement. guide our work as CAC members. 10/12/201517

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19. Community Health Improvement Plan (CHIP) The activities, services and responsibilities defined in the plan may include, but are not limited to: a)Analysis and development of public and private resources, capacities and metrics based on ongoing community health assessment activities and population health priorities; b)Health policy; c)System design; d)Outcome and quality improvement; e)Integration of service delivery; and f)Workforce development. 10/12/201519

20. Community Health Improvement Plans: summary of priorities Public health/social determinants/health equity: 60% of CHIP priorities o Public health: maternal and child health/early childhood; chronic disease; tobacco use; obesity prevention o Social determinants: housing, transportation, jobs o Health equity: addressing disparities; cultural competency; health literacy Clinical: 40% of CHIP priorities o Mental health/substance abuse; oral health; access 10/12/201520

21. Community Health Improvement Plans: priority areas o Mental health integration (13 CHIPs) o Maternal health, early childhood & youth (11 CHIPs) o Access to care (8 CHIPs) o Health equity and socioeconomic disparities (7 CHIPs) o Oral health (7 CHIPs) o Healthy housing and the built environment (7 CHIPs) o Public health, chronic disease and chronic illness prevention (6 CHIPs) 10/12/201521

22. Jackson and Josephine Counties: 2 counties, 3 CCOs, 4 CACs overlapping CHIPs 10/12/201522

23. One page strategic maps of all three CCO CHIP’s Similar Design Elements & Collective Goal Areas 10/12/201523

24. C ommunity A dvisory C ouncil 10/12/201524

25. Community Representation  Regional CAC Structure 12 IHN-CCO members (63%) 3 county staff 3 community members 1 Chair  Three Local Advisory Committees 6 CAC Representatives plus county & community partners Provide broader, deeper level of community involvement 10/12/201525

26. CHIP: Community Health Improvement Plan  CHIP Focus Areas Access to healthcare Behavioral health Chronic disease Maternal & Child health  Strategic Planning The CHIP focus areas are used to prioritize transformation pilot projects 10/12/201526

27. COMMUNITY HEALTH WORKERS (CHW) 27

28. How is coordinated care changing the workforce needs? o Team based care Working at the top of degree o Traditional Healthcare Workers/Community Health Workers Healthcare Navigators Outreach Workers Peer to Peer specialists Doulas Dental care specialists Behavioral Health Specialists Emergency Department guides 10/12/201528

29. THWs help individuals in their communities by providing physical and behavioral health services. There are 5 THW types: Community Health Workers (CHW): Assist community members in receiving the health care they need. Peer Support Specialists (PSS): Provide support, encouragement, and assistance to addictions and mental heath consumers. Peer Wellness Specialists (PWS): Provide support, encouragement, and assistance to address physical and mental health needs. Personal health navigators (NAV): Provide care coordination for members from within the health system. Birth Doulas: Provide companionship and personal, nonmedical support to women and families throughout the childbirth and post-partum experience. 10/12/201529

30. Local success stories Mid-Willamette Valley Southern Oregon 10/12/201530

31. Health System Transformation Health.Oregon.gov More information at: TransformationCenter.org Contacts: Bill.bouska@state.or.us Belle.shepherd@state.or.us 10/12/201531