Sarah Robinson, Mesa County Health Department Sharon Raggio, Mind Springs Health Shelly J. Spalding, The Center for Mental Health AHCM Community Leads

Transcription

1 Standard Operating Procedure for Integrator Role Owner: The AHCM Program Director at Rocky Mountain Health Plan will remain ultimately responsible for all Integrator Functions Version: 1.0 Issue date: The date the current SOP version was approved by CMS. Revisions (date, version, description): July 25, 2017 (v. 1.0) Participants: ACHM Director, Rocky Mountain Health Plan AHCM Regional Advisory Board Members Alan Saliman, Montrose Hospital Amy Barry, Southern Ute Carol Keller, Center for Mental Health Chris Lindley, Eagle County Public Health Christie Higgins, Danielle Corbin, Mesa County Dave Ressler, Aspen Hospital Ian Engel, Northwest Colorado Center for Independence Jeremy Caroll, River Valley Family Health Center Jerome Evans, Kathleen McInnis, Southwest Area Health Education Center Kelly Parker, Client Advocate Liane Jollon, San Juan Basin Public Health Lisa Brown, Northwest Colorado Health Lynn Borup, Tri County Health Network Marc Lassaux, Quality Health Network Marguerite Tuthill, Community Care Alliance Marnell Bradfield, Community Care Alliance Mary Baydarian, Garfield County Patrick Gordon, Rocky Mountain Health Plan Ross Brooks, Mountain Family Health Center Sarah Lampe, Trailhead Institute VERSION 1.0 1

2 Sarah Robinson, Mesa County Health Department Sharon Raggio, Mind Springs Health Shelly J. Spalding, The Center for Mental Health AHCM Community Leads Ken Davis, Northwest Colorado Community Health Partnership Cristina Gair, West Mountain Regional Health Alliance Namrata Shrestha, West Mountain Regional Health Alliance Sarah Robinson, Mesa County Health Department Sarah Johnson, Regional Health Connector Rasa Kaunelis, Tri County Health Network Matt Teague, Tri County Health Network Laura Warner, Director of Health Promotion Services, San Juan Basin Public Health Rusty Connor, Southwest Area Health Education Center Author: Kathryn Jantz (v1.0) PURPOSE This SOP outlines how we will successfully implement the Integrator Functions for AHCM including convening an Advisory Board, conducting a gap analysis, prioritizing gaps, and developing and implementing a quality improvement plan. Adherence to this SOP will ensure that we will successfully meet the Center for Medicare and Medicaid Innovation milestones and continue to make purposeful progress towards the broader vision for an Accountable Health Community. This SOP pertains to both the region-wide AHCM Advisory Board and the local community advisory boards. We will use the partnerships formed out of this Advisory structure to create a more effective network to support the social, emotional and physical health of Western Coloradoans. We regard SOPs not as a rigid set of guidelines imposed down a chain of command but as a set of core principles that empower decision-making throughout a diffuse, collaborative network. By supporting and empowering our entire community, especially those members who may have additional resource needs, we will be able to improve the health of the entire community. We are here to make a real difference for real people. BACKGROUND As we gain deeper insight into the importance of non-medical factors in improving health outcomes, we recognize a need to transform how we think about, talk about, and develop systems to support health. The Accountable Health Communities Model opportunity aligns with the growing body of knowledge about social determinants of health and a shift towards valuebased healthcare purchasing based on health outcomes- which are heavily driven by non-medical factors. Recognizing that this shift in focus from clinics to a broader community context requires understanding and responding to a greater diversity of cultural contexts, accountability structures, and sets of assumptions. To unify our efforts across this diverse landscape, it is critical to root our approach in a core set of values. VERSION 1.0 2

3 VALUES These are the shared values and beliefs that guide us as we seek to achieve our mission. They are derived from initial conversations with core partners and will no doubt evolve over time as new partners join the network, and serve as a set of first principles to help guide decisions and collective action. We, individuals and communities, have a right to achieve our greatest potential of health. There is room for improvement in the systems that support health. We have a responsibility and an opportunity to improve those systems. Achieving needed change will require risk taking, being nimble, adaptable, and bold. Healthcare and systems of health are local. We value funding the social determinants that impact individual and community positive health outcomes and well-being. We have an opportunity and responsibility to foster more leaders in our communities. Collaboration is built on trust and trust is built on relationships. We will be intentional and patient with the time-consuming process of relationship-building. We seek continuous learning and improvement. We work to identify the value proposition of our efforts; to be transparent in discussing and communicating those tangible/non-tangible short-term/long-term benefits. INTENDED AUDIENCE This SOP will be reviewed, approved and used by all members of the Regional Advisory Board and the Community Leads (defined below). In addition to Advisory Board participants, this SOP will be used by the AHCM Facilitator who will support the convening of the Regional Advisory Board. DEFINITIONS For key terms (for example, model participant) or acronyms (for example, PO), provide the definition in a table. These should be listed in alphabetical order. Term Definition Social Determinants Community Community Lead Gap Analysis The social factors which influence the health of populations that include: income and social status; social support networks; education; employment/working conditions; social environments; physical environments; personal health practices and coping skills; healthy child development; gender; and culture. A geographically-based portion of the broader AHCM catchment area that has aligned their efforts under a single Community Lead. An organization (or potentially two) responsible for a Community Advisory Board. An analysis of the extent to which available community services adequately address the health-related social needs of high-risk community-dwelling beneficiaries (per FOA guidelines). VERSION 1.0 3

4 Quality Improvement Plan AHCM Advisory Board Community Advisory Board A guidance document for the bridge organization and other model participants as they implement the model. The QI plan will describe how activities that address gaps in community services will be managed, deployed and reviewed (per FOA guidelines). Previously called the Consortium by AHCM members in the Community, this board fulfills the requirements of the AHCM and provides overarching oversight and direction to AHCM. A community-level workgroup for the Regional Advisory Board focused on activities specific to that part of Western Colorado. CONTENTS A. REGIONAL AHCM ADVISORY BOARD... 4 B. COMMUNITY ADVISORY PROCESS... 6 B. GAP ANALYSIS AND PRIORITIZATION A. QUALITY IMPROVEMENT PLAN APPENDICES A. REGIONAL AHCM ADVISORY BOARDSTEERING COMMITTEE 1. Description: The Regional AHCM Advisory Board includes representatives from all parts of the region and all sectors involved in AHCM (listed as participants above). The AHCM Advisory Board is responsible for: Communications o Guiding the necessary communications of the program across the network o Promoting two-way engagement between working groups, local partners and the Steering Committee o Reviewing and approving communications with state and federal partners Program Review o Reviewing quarterly program performance metrics such as rates of screening and completed community navigation assessments o Identifying and developing solutions to issues in AHCM Program Operations o Annually reviewing the IT and data infrastructure of the program o Identifying collaborative learning & program objectives for the Annual Summit Continuous Quality Improvement o Reviewing the Gap Analysis and Quality Improvement Plans for each community o Supporting those Quality Improvement Plans and Community efforts Alignment o Suggesting opportunities for AHCM to align with other efforts or for other efforts to support AHCM VERSION 1.0 4

5 2. Operating Guidelines: Meeting Procedures o Full Advisory Board meetings will be held on a quarterly basis in June, September, January, and April. o All scheduled Advisory Board meetings will be posted on an AHCM website (when possible) at least twelve months in advance. o All Advisory Board members will be asked to commit to attend or send a proxy to each meeting. o All Board meetings will have a call-in option due to the vast distances across the area. o All Board meetings will have an agenda that is distributed at least a week in advance and minutes that are posted within a month of the completion of the meeting o Meetings when possible, will be scheduled one year out at a location with access for people with disabilities. Membership o Members serve for a term of one year. o On an annual basis in the June meeting, Board members will be asked to commit to another year of service. Members who choose to resign will be thanked for their service and will be asked to assist with the recruitment of a replacement. The entire board will review all attendees and can choose to add members as needed. o Because maintaining a diverse representation of members on the Steering Committee is both important and challenging, outreach efforts will need to be taken at the work group level and the Community Advisory Board levels to maintain a pipeline of participants to fill open spots. Decision Making o Group decisions will be made on consensus. Consensus is defined as striving for an agreement that all members can actively support. It will be the responsibility of each member to articulate questions and concerns and actively work to create solutions that will attempt to meet this standard. At the minimum, consensus will be defined as there being no members who will actively oppose a decision. o In circumstances when consensus is not attainable despite efforts to address concerns, a formal vote can be called in order to move the agenda forward. A super majority vote (2/3 of the votes) is required to move a proposal forward. o Should voting be necessary, only one vote is allowed per organization. 3. Required resources: Professional Facilitation: The AHCM Advisory Board meeting will utilize professional facilitation services from Bill Fulton, Civic Canopy. Space & Equipment: Rocky Mountain Health Plan or community partners will offer space, phones, video conferencing, and conference call lines for the purpose of the contract. 4. Anticipated challenges and mitigation strategies. VERSION 1.0 5

6 Maintaining a diverse membership on the Steering Committee (remedy included in procedures above). 5. Responsible party: The AHCM Program Director at Rocky Mountain Health Plan and the Advisory Board Facilitator, Bill Fulton, will share responsibility for the successful execution of the Advisory Board. 6. Timing/Frequency Meetings will be held quarterly in January, April, June and September. Notes: This section is optional and can include notes or comments to be documented. For example, things that need to be considered moving forward. If there are any references that support this component, they should be noted here. B. COMMUNITY ADVISORY PROCESS 1. Description: The size and diversity of Western Colorado means that one advisory process for the entire region would not allow for the relationship building and Community specific efforts that will be necessary to make improvements. We will support the critical alignment necessary for AHCM through the five Community Advisory boards, one for each of the regions in this Western Colorado AHCM project. The regions and leads are displayed below. VERSION 1.0 6

7 The role of the Community Advisory Board is: Communication o The Community Advisory Board will distribute any AHCM information relevant or important to their community Gap Analysis o The Community Advisory Board will review and ensure that the gap analysis is consistent with the community s perception o The Community Advisory Board is required to prioritize gaps in community resources. Quality Improvement o The Community Advisory Board will develop a plan to address the prioritized gaps in community resources. Solicit Community Engagement o The Community Advisory Board will recruit clinical providers or community based organizations to join AHCM as they see fit. To reduce the burden on local community members who must often attend multiple meetings with overlapping membership, the Community Advisory Boards will be integrated into existing structures and expanded to address the needs of the AHCM program to greatest extent possible. All agencies with signed AHCM MOUs will be on the Advisory Board. In cases where no existing body exists that can fulfil the necessary functions, a new body may need to be established. 2. Operating Guidelines Step One: Community Leads in each region will identify their assigned staff for this project and the Community Engagement forums. The current staffing and forums are outlined below. Northwest Colorado Community Health Partnerships West Mountain Regional Health Alliance Counties Routt, Moffat, Grand, Jackson, Rio Blanco Eagle, Garfield, Pitkin & Summit AHCM Community Lead Staffing Ken Davis- Executive Director, RCCO Community Care Team Manager, new communications specialist Cristina Gair, Executive Director Community Engagement Forums Monthly County Human Resource Council Meetings in Routt, Moffat, Grand, Bimonthly NCCHP Board (quarterly focus on AHCM), annual resident meetings WMRHA eight annual Board meetings and quarterly community meetings VERSION 1.0 7

8 Mesa County Public Health Department Tri-County Health Network San Juan Basin Health Department & Southwest Area Health Education Center Mesa Ouray, San Miguel, Montrose, Delta, Gunnison Hinsdale, Dolores, San Juan, Montezuma, La Plata, Archuleta Sarah Robinson, Manager, Program Integration Rasa Kaunelis - Director of Strategic Initiatives, Laura Warner, Director of Health Promotion Services, Mary Dengler- Frey, Mesa County Health Leadership Consortium & Community Transformation Group New Quarterly AHCM Advisory Board Meeting with in-person, video conferencing meetings La Plata, Archuleta Counties: Community Health Assessment Steering Committee Montezuma, Dolores Counties: TBD Step Two: If using an existing forum, the Community Leads will assess the list of individuals involved in that forum and identify organizations who signed MOUs for AHCM that are not involved. The Community Lead will also evaluate that list to ensure that clinical representation from hospitals, behavioral health providers and primary care providers and community service representation from organizations who provide transportation, housing, food, utilities and interpersonal violence are included or invited to the AHCM forum. Step Three: The Community Lead will send the RMHP AHCM Director a list of names, organizations, titles and addresses of all members of the Advisory Committee (or Committees). This list shall be updated and revised on a quarterly basis. Step 4: The Community Lead will develop a master calendar of meetings related to AHCM, with scheduling completed at least six months out. Community Leads will work towards having a full calendar for the year. Step 5: The Community Leads will submit notes from the AHCM portion to the Advisory process to the RMHP AHCM director within thirty days of the meeting. Those notes will be posted on the RMHP site so that individuals engaged in AHCM in one community can learn about the activities in another community. 3. Required resources: Each Community Lead will have funding for a.5 FTE. That.5 FTE must have a laptop, phone and workspace. 4. Anticipated challenges and mitigation strategies. Describe challenges likely to be encountered in this phase. This can be presented as a table or text. Challenge Description Mitigation Strategy VERSION 1.0 8

9 Clinical Sites who are already doing social needs screening Clinical sites who already have a tool that they are using and like may be resistant to switching. We will support clinical sites to the greatest extent possible in workflow changes and providing meaningful data that increases the value of switching tools. Engagement of clinical sites Rural and Frontier Relationship building Engagement of partners supporting all of the healthrelated social needs Western Colorado intends to address for our diverse populations In some areas of the state, engaging clinical providers, especially hospitals, can be challenging. Although the Communities are less populous than urban communities, they encompass large and expansive geographic areas in mountainous regions where travel can be extremely difficult and time consuming. In some of our rural communities, there may not be a single provider that supports one of the core health-related needs or there may not be a provider offering culturally-/linguisticallycompetent services to support our diverse populations -Identify program champions within clinics and/or regions to support the program -Provide data and information on how addressing health-related social needs can improve access, reduce costs for clinics, and improve health outcomes -Make participation a part of other heatlh reform sites -Utilize Regional Health Connectors, a Colorado workforce dedicated to bridging traditional and non-traditional healthcare providers in Colorado, many of whom have strong collaborative relationships with clinics -The community leads live in their community and many of the community lead host organizations have staff living and working throughout their region, thus improving the potential for relationship building and leveraging of existing relationships - Utilize technology to allow face-to-face meetings, which is critical when establishing relationships, without requiring travel -Leverage existing meetings in order to minimize the amount of new travel required by our partners. -Bring as many diverse partners to the table as possible, and use the strong relationships in many of our rural/frontier communities to identify partners that may be interested in providing a service even if they currently do not -Utilize other Communities and Community Lead Advisory Committees as partners and draw from the expertise of those partners if the resources do not exist in a certain Community 4. Responsible party: The Community Leads will be responsible for the development and oversight of the Community oversight process. VERSION 1.0 9

10 5. Timing/frequency: Community convening will occur at least quarterly, although it can be more frequent at the discretion of the Community Advisory Committee or Community Lead. Notes: B. GAP ANALYSIS AND PRIORITIZATION 1. Description: This describes the annual process the Community Leads will use to identify gaps in community resources or in the process of connecting members to community resources. Once those gaps are identified, the Community Leads will prioritize them. 2. Process: Step one: The Community Lead will collect information about the gaps in resources in their community. They will leverage pre-existing gap reports and resource maps to the extent possible. The Community Lead will use the Community Advisory Board forum to collect qualitative information about gaps in community services. In addition, the Community Lead will review the following data sets and will share relevant information from those data sets with the advisory board. o Western Colorado data o AHCM-specific data- produced by RMHP for each Community Lead Prevalence of Social Needs in the region (based on social needs screening) Outcomes of the referrals Qualitative survey of Community Navigation o RMHP Claims and Clinical Data Report- produced by RMHP for each Community Lead. This report will provide insight into the prevalence of diseases in the Medicaid population in the region. Rocky Mountain Health Plan Claims Medicaid Claims Data Clinical Data-Quality Health Network Patient Activation Measure Data o Publicly Available Data Sources CDC Diabetes Interactive Atlas Colorado Behavioral Risk Factor Surveillance System USDA Food Environments, Map the Meal Gap Comprehensive Housing Affordability Strategy (CHAS) Colorado Child Health Survey Healthy Kids Colorado Survey County Health Rankings o Local Data Local Public Health Agency Local Needs Assessment Hospital Community Needs Assessment VERSION

11 Community Assessment Survey for Older Adults and Area Plans on Aging from the local Area Agency on Aging Step two: By September first of every year, the Community Lead will prepare a short PowerPoint summarizing the information on gaps in the community. The Community Lead will share this PowerPoint with the AHCM Director to be posted on the AHCM website. Step three: The Community Lead will work with the Community Advisory Board forum to prioritize the gaps in community resources. They may use a variety of techniques to develop these priorities. For example, Community Leads may begin the process of prioritizing by setting criteria such as how many people must be impacted by the gap, how deeply the gap impacts the people affected, the cost to the community, alignment with other community activities, and community perception of the issue. The process of ranking may rely on a number of techniques such as those described on this website: Step four: By October 15 th, the Community Leads will submit a list of two or more prioritized gaps with a description of the process to identify those gaps. 3. Required resources: RMHP will provide the Community Leads with a number of reports to inform their work. 4. Anticipated challenges and mitigation strategies. Describe challenges likely to be encountered in this phase. This can be presented as a table or text. Challenge Prioritizing Availability of resources and services to address health-related social needs in rural communities Description With a diverse group of stakeholders, the priorities for each stakeholder will be different and so developing one cohesive set of priorities may be challenging Resources to address prioritized gaps may often be scarce or nonexistent in our rural/frontier region, resulting in frustration 5. Responsible party: Community Leads Mitigation Strategy -The Community Leads will carefully develop a transparent, inclusive prioritization process with clear criteria to support the development of priorities. -Celebrate successes when prioritized gaps are filled in order to continue to keep partners engaged -Utilize other Community Leads as a learning community to determine how similar prioritized gaps are being filled in their respective communities VERSION

12 6. Timing/frequency: The Gap analysis will be conducted annually in the late summer and early fall with the gaps report due September 1 st and the prioritized gaps due October 15 th. Notes: A. QUALITY IMPROVEMENT PLAN Using the outline below, detail each component/action of the SOP that will be undertaken. Each section should identify required resources (including staff) and any challenges likely to be encountered in implementing the component/action. 1. Description: This describes the process by which Community Leads will develop a Quality Improvement Plan to address the identified gaps. 2. Process: Step one: The Community Leads will take the prioritized gaps and adapt them to become measurable goals. Step two: For each quality goal, a Quality Improvement Team Leader will be identified. This person should be someone who is closest to the activity requiring improvement or the gap that needs addressing. So for example, if the gap is the process for applying for low income housing then the team lead might be someone who is responsible for low income housing applications in the community. Step three: The Quality Improvement Team Leader for each goal will convene a small workgroup of people who have interest in that topic. They will start by narrowing the goal into something that is SMART (Specific, measureable, achievable, realistic and timelines). So for example, the goal of increasing access to low income housing may be changed to streamlining the process for applying for low income housing. The workgroup will develop a plan for how to achieve the goal. That plan will include specific activities and timelines for those activities, and assignment of specific activities to partners or team members. In the development of the goal and the quality improvement plan, the Community Leads and Quality Improvement Team Leads may use the following frameworks as relevant: Plan-Do-Study-Act Process mapping Causal loop diagrams Change management history Assessment Desire Knowledge Ability Reinforcement (ADKAR) Step Four: The Community Leads will combine the plans from each Quality Improvement Team Leader into one cohesive Quality Improvement Plan for the Community. They will submit that plan to the AHCM Director by February 15. The AHCM Director will combine those into a VERSION

13 region-wide plan to share with all Community Leads, the Advisory Boards and eventually to submit to CMMI by March 1. Step five: The Quality Improvement Team Leaders and the Community Leads will work to execute the plan utilizing the selected framework(s)! Step Six: Between Community Advisory Board meetings, the Community Lead will update the Community on the Quality Improvement Activities through a format that works best (Facebook, closed website, local media sources, postings in public forums). 3. Required resources: Developing the Quality Improvement Plan will require a significant amount of time from the Community Leads and Quality Improvement Team Leaders. RMHP will facilitate a learning community amongst the Community Leads (if needed) so that the Leads may learn from what the other Communities are proposing. 4. Anticipated challenges and mitigation strategies. Challenge Staffing shortage Turf issues Description Availability of qualified staff to initiate activity and need to identify a Quality Improvement Team Leader and workgroups to volunteer additional time to developing a plan Partners addressing the prioritized gap may become defensive when other providers offer recommendations on how to address priorities Mitigation Strategy -Recruit and train new staff -Offer technical assistance to Quality Improvement Teams to support the development of SMART goals -Use technology for the development of the Quality Improvement plan to reduce necessary time for Team Leader and workgroup members -Quality Improvement Team Leader will be someone closest to the activity requiring improvement -Continually celebrate successes and stress that the entire Community is there to support all partners and improve the health of our residents 5. Responsible party: Community Leads & AHCM Program Director 6. Timing/frequency: VERSION

14 The Quality Improvement Plan update will be due annually on February 15 th. Many of the activities on the Quality Improvement Plan will require multiple years so the plan may have some of the same content as the year prior. Notes: VERSION

15 APPENDICES Include additional documents/templates (for example, forms, samples, outlines, etc.) when applicable/relevant. Provide a list of items included below and include those items within the subsequent pages. 1. Form 1 2. Outline 1 3. Sample 1 VERSION