November 2018 Executive Director Report

November 2018 Executive Director Report Date: November 1, 2018 To: From: HealthierHere Governing Board Susan McLaughlin 1. HCA Learning Symposium a Big Success! HealthierHere staff, board and committee members participated in the Health Care Authority s first MTP Learning Symposium on October 24 in SeaTac. Topics included panel presentations on the opioid use crisis, the Indian health care delivery system, and value-based payment. Invited national presenters on health equity topics included Professor john a. powell from the Haas Institute for a Fair and Inclusive Society and Sinsi Hernández-Cancio, Health Equity Director from Families USA. Joe Conte, Executive Director from the Staten Island Performing Provider System also spoke on lessons learned from New York state s DSRIP. We will have a follow up meeting with Joe Conte during our New York DSRIP intensive learning trip next week. HealthierHere participated in a poster session in the evening, showcasing some of our work to date. HealthierHere staff also participated in statewide ACH staff planning and coordination meetings hosted by HCA on October 23. Program Directors, Finance Staff, Data Staff and Community Engagement staff met with their collective colleagues from other ACHs to share learnings and coordinate implementation efforts. 2. Implementation Plan Update We heard from the Independent Assessor that there are no write back questions for HealthierHere s Implementation Plan. There is no incentive funding associated with the submission of the Implementation Plan right now. It will be evaluated and assessed a valuation as part of our second Semi-Annual Report for 2018, due to the HCA by January 30, 2019. 3. Hiring Community and Tribal Engagement Manager: HealthierHere is looking for a second Community and Tribal Engagement Manager with Tribal Partnership expertise. The position was posted last week and can be found here: https://www.idealist.org/en/nonprofitjob/7ea76cd125bb473c8c8d88c630d68d92-community-and-tribal-engagement-managertribal-health-focus-king-county-accountable-community-of-health-seattle Page 1 of 3

Please share with any talented candidates you are aware of. The deadline for applications is November 9, 2018. 4. Community Partner Information Sessions Continue HealthierHere continues to host community partner information sessions. We have held 6 in-person sessions throughout King County plus one webinar session. See attached summary for more detailed information to date. Three more in-person information sessions are scheduled in November. Please see attached flyer, which we will also send electronically. If you know any community partners that should know about HealthierHere and would make great partners for our transformation efforts, please pass the flyer along so that they can attend. 5. Training, Technical Assistance and Learning Collaboratives HealthierHere sponsored its first Partner Learning Webinar on Oct. 25th. The lunch-time session Using PreManage: Best Practices and Lessons Learned, was led by Practice Partner, Community Psychiatric Clinic, and included representation from Collective Medical Technologies (CMT), the software company that developed both the Emergency Department Information Exchange (EDIE) and PreManage. Approximately 67 individuals participated, representing 48 Innovation Partners, all at varying stages in implementing and using PreManage. PreManage is a care coordination platform affiliated with EDIE and it is already in place for some of our partners, and of great interest to many others as it has potential to address critical communication barriers that exist within the healthcare delivery system. The topic complements projects under way by the King County Integrated Care Network (KCICN), which plans to help its member behavioral health agencies implement PreManage over the coming year. Partner Learning Webinars are an integral part of HealthierHere s workforce development, training and technical assistance strategies and will complement the Learning Collaboratives, which will launch on November 14 th for our current Practice Partners. The Learning Collaboratives will provide opportunities for Practice Partners to collectively address system transformation, share best practices, and participate in the development of a regional QI Plan. 6. ReThink Health Coming to a close King County ACH and then HealthierHere has been participating with a team of King County leaders on an initiative funded by Robert Wood Johnson called ReThink Health Ventures. ReThink Health Ventures sought to explore how multi-sector partnerships can accelerate change and transform health. King County was one of six sites from around the country that worked together to test a framework for transforming health that includes broad-based stewardship; sound strategy; and sustainable financing. King County focused on the development of a strategy to promote civic muscle, called You Belong Here. Additionally, HealthierHere participated in testing specific tools related to sustainable financing. Page 2 of 3

A final meeting of all six sites was held in Boston last week where we finalized results from the three year grant. ReThink Health will produce a final tool kit for other sites that includes key lessons learned and core elements necessary for successful multi-sector collaboratives. The final product will be released sometime early next year. For more information on ReThink Health Ventures go to: https://www.rethinkhealth.org/our-work/transforming-regions/rethink-health-ventures/. HealthierHere is excited to be continuing our relationship with ReThink Health through another Robert Wood Johnson project called Vistas. Through Vistas, ReThink Health will support us in implementing a framework to design our Equity and Wellness Fund (see below). 7. Equity and Wellness Fund Planning to Begin In 2017, the HealthierHere Governing Board approved the distribution of 6% of earned incentive funding, or approximately $8.4 million dollars over five years, to seed an Equity and Wellness Fund that would be dedicated to addressing social determinants and promoting health and well-being. Beginning in late 2019, HealthierHere will begin to distribute earned incentives to this fund. With the assistance of ReThink Health and under the leadership of the HealthierHere Finance Committee, we will begin work to define elements of the Equity and Wellness Fund including how the fund will be used, how it will be governed, and what potential sources of revenue to build the fund are available. Options and recommendations will be reviewed and approved by the Governing Board. We are in the very early stages of thinking about the process to define the fund beginning with several key informant interviews that will occur over the next two months. We will spend more time on this process for the design of the Equity and Wellness Fund at a future board meeting. 8. Conflict of Interest Policy Getting Signed HealthierHere staff are working with all of our committees to ensure committee members sign our updated Conflict of Interest policy. In addition to all members of the Governing Board, HealthierHere Management Team have signed the policy along with members of the Finance Committee, the Transformation Committee, the Data and Evaluation Committee, the Community and Consumer Voice Steering Committee and the Incentive Funds Flow Work Group. Our goal is to have the policy signed by all members no later than November 30, 2018. We are well on our way to meet that goal. We will continue to practice and utilize our COI at all committee and board meetings. 9. Funding Distribution Continues We continue to distribute funds to our practice partners. HealthierHere distributed $2.2 Million on October 19 th to 25 Medicaid providers who completed change plans. Additionally we distributed $2.2 Million to Behavioral Health Agencies to assist with the transition to fully integrated managed care. The remaining $1.9 Million will be distributed on November 2 nd. Finally, HealthierHere is working in partnership with King County ICN and representatives from the behavioral health network to develop a training and technical assistance plan for fully integrated managed care. The plan will be shared with the board once complete. Page 3 of 3

MTP IHCP Projects Plan An overview of the Indian Health Care Provider (IHCP) projects and how they fit within the Medicaid Transformation Project (MTP)

Medicaid Transformation Project STCs Objectives Integrate physical and behavioral health purchasing and service delivery to better meet whole person needs Convert 90 percent of Medicaid provider payments to reward outcomes instead of volume* Support provider capacity to adopt new payment and care models Implement population health strategies that improve health equity *IHCPs are exempt from the statewide strategy on value-based payments

Indian Health Care Provider Protocol (Attachment H) Objectives Collaborative Medicaid Transformation IHCP Health Systems and Capacity Workforce Capacity and Innovation Health Systems Financial Sustainability CMS State Health Official Letter #16-002 (February 26, 2016) CMS Frequently Asked Questions (FAQs): Federal Funding for Services Received Through an IHS/Tribal Facility and Furnished to Medicaid-Eligible American Indians and Alaska Natives (SHO #16-002) (January 18, 2017) Statewide Improvement of Behavioral Health for AI/AN Medicaid Clients The National Tribal Behavioral Health Agenda

IHCP Projects Plan Development Process HCA and the American Indian Health Commission of Washington State visited 27 of the 31 IHCPs in Washington.

IHCP Projects* Behavioral Health Integration** 12 Tribal FQHC 7 Care Coordination 5 Public health 2 Start/expand a Tribal 638 clinic 2 Traditional healing 2 Workforce Development/CHAP Board 2 Falls Prevention 1 Community Outreach 1 Telemedicine 1 Integrate behavioral health and law enforcement 1 Quality Childcare 1 Dental Integration 1 *Inclusive Counting, will total more than 31 **Includes clinical and systems level integration

The National Tribal Behavioral Health Agenda As indigenous people, we possess the culturally relevant knowledge and expertise to address and enhance the overall health and well-being of all American Indian and Alaska Native people across the country.

Geographical Categorization Review of projects by IHCP and ACH region Be conscientious of your response to the information you are about to be given

HealthierHere Muckleshoot Indian Tribe Systems Integration Seattle Indian Health Board Traditional Healers Integrated into Provider Teams Snoqualmie Tribe Tribal FQHC Cowlitz Indian Tribe Systems Integration

Intersection of IHCP work and ACH work If knowledge is power, what do you do with the power you have just been given? What is the role of an ACH in supporting and working with Tribal partners? As opposed to co-opting or working over How does an ACH stay accountable to a Tribe?

IHCP-specific Projects and MTP Objectives Integrate physical and behavioral health purchasing and service delivery to better meet whole person needs Behavioral Health Integration, Traditional Healing, Start/expand a Tribal 638 clinic, Dental Integration Support provider capacity to adopt new payment and care models Tribal FQHC, Telemedicine, Community Outreach Implement population health strategies that improve health equity Workforce Development/CHAP Board, Public Health, Integrate Behavioral Health and Law Enforcement, Childcare

Questions? HCA Tribal Affairs Office Jessie Dean Tribal Affairs Administrator Phone: 360.725.1649 Email: jessie.dean@hca.wa.gov Mike Longnecker Tribal Operations & Compliance Manager Phone: 360.725.1315 Email: michael.longnecker@hca.wa.gov Lena Nachand Tribal Liaison Medicaid Transformation Phone: 360.725.1386 Email: lena.nachand@hca.wa.gov Lucilla Mendoza Tribal Behavioral Health Manager Phone: 360.725.3475 Email: lucilla.mendoza@hca.wa.gov

Medicaid Transformation Project (MTP) Financing Mechanism October 30, 2018 1

Overview of MTP Financing Mechanism CMS approval on January 9, 2017. Approval of $1.5B (state/federal for all three initiatives) over five years for performance based incentive payments to providers partnering with ACHs Funding for the MTP relies on Designated State Health Programs (DSHPs) and Intergovernmental Transfers (IGTs) DSHPs ramps down while IGTs ramp up over the five years (see slide #3) IGT = transfer of public funds between governmental entities such as counties or public hospitals to the state s Medicaid agency. Entities transfer $1 of non-federal share to draw down $1 federal = $2 available to spend 2

DSHP and IGT Totals by Demonstration Year (All three initiatives) MTD - Funding DY1 DY2 DY3 DY4 DY5 Total DSHP Total Computable $189,685,000 $192,000,000 $190,080,000 $157,766,400 $124,636,600 $854,168,000 IGT Total Computable $75,640,000 $91,634,000 $128,048,000 $170,932,600 $203,373,400 $669,628,000 DSHP & IGT Total Computable $265,325,000 $283,634,000 $318,128,000 $328,699,000 $328,010,000 $1,523,796,000 3

Intergovernmental (IGT) Financing Issue Issue: CMS clarified that when an IGT contribution is paid through Delivery System Reform Incentive Program (DSRIP) then both the federal & non-federal share is counted against the DSRIP budget cap vs. only the federal share as previously discussed Effectively, this reduces the overall DSRIP dollar available because the IGT portion must now include both the contribution and the federal match towards the same DSRIP cap Problem: This interpretation reduced about $300M from the project incentives HCA Solution: Use IGT contributors from public hospitals as the state match to draw the federal match. This solves a part of the total $300M. HCA is working on another solution that will address the remaining amount 4

Overview of IGT Process HCA contracts with UW, Valley Medical, Evergreen Healthcare = IGT Contributors Shared Domain 1 Investments will be available to support statewide Domain 1 activities for ACHs ACHs contract with IGT Contributors for shared statewide Domain 1 activities (TBD). Per CMS these entities must earn the dollars by providing activities/support to ACHs Less dollars will be available to ACHs if not all participate HCA will monitor the performance and provides payment schedule to ACHs to enter into Financial Executor (FE) 5

Illustrative IGT Process Note: Rounded funding amounts are provided as examples. IGT Contributors (e.g., public hospital) How IGT Supports Washington s DSRIP Waiver IGT contributors provide $10M to HCA. HCA receives $10M in federal matching funds for IGT contributions for a total of $20M. HCA allocates $20M to DSRIP pool. IGT Requirements IGT contributors must be a public agency, which could be a public hospital, public entity or a county/city. IGT contributors must use non-federal funds (e.g., commercial revenue). DSRIP Pool ACHs draw down $20M from DSRIP pool. Transformation Projects IGT contributors are not guaranteed to receive its IGTs back. DSRIP payments are nonpatient service revenue and do not count toward DSH or upper payment limit caps. Accountable Communities of Health ACHs allocate $7.5M for regional transformation projects and $12.5M to the shared investment pool from which IGT contributors can earn incentives for Domain 1 support. Expected DY 1 funding amounts communicated to ACHs already take into account remaining dollars after payments to IGT contributors. Source: 42 CFR 433.51 - Public Funds as the State share of financial participation. 6

Next Steps GB approved the first IGT transaction on February 1, 2018. October 16 th HCA sent the Partnering Provider Achievement Report to ACHs. November 7 th Deadline for ACH Boards to approve payment to IGT contributors. December 14 th ACH approves payment schedule in FE Risk to ACH: less money available if not all ACH participates with all IGT contributors 7

Questions 8

Administrative Revenues/Budget Projections by Year % of Total Incentives Total CY2017 CY2018 CY2019 CY2020 CY2021 Revenues Earned: Phase 1 Design Funds $ 6,000,000 6,000,000 0 0 0 0 ACH Direct Operations 12% $ 14,044,800 2,448,000 3,423,600 3,166,800 2,760,000 2,246,400 ACH Project Support 3% $ 3,511,200 612,000 855,900 791,700 690,000 561,600 Total Revenue 15% $ 23,556,000 9,060,000 4,279,500 3,958,500 3,450,000 2,808,000 ACH Administration Budget: Operations, Project and Domain 1 Support 23,556,000 1,872,207 4,746,038 5,885,792 6,000,000 5,051,963 Total Expenses $ 23,556,000 $ 1,872,207 $ 4,746,038 $ 5,885,792 $ 6,000,000 $ 5,051,963 Balance $ 0 $ 7,187,793 $ 6,721,255 $ 4,793,963 $ 2,243,963 $ 0

Draft 2019 Proposed Administrative Budget CY2018 CY2019 Expense Categories Budget Line Item Budget Actual + Projected Expenses Variance 2019 Proposed Budget % Change from prior year Assumptions Administration Project Planning Community/Consumer Engagement Domain 1 Activity Support # of Staff 11 14 Salaries & Benefits (14.0 FTEs) $ 1,600,000 $ 1,165,453 $ 434,547 $ 1,850,795 Costs for 11 full time staff and new hire for CTEM position in January. Placeholder for two additional staffs to address communication, quality improvement, and other needs (1 FTE in Q2 and 1 FTE in Q3) and 4% for COLA/Merit. HH will review additional staffing needs and use of contractor(s) where appropriate with 15.7% Finance Committee. Seattle Foundation Fiscal Sponsor Fee $ 364,000 $ 320,000 $ 44,000 $ 400,000 9.9% Aligns with service level agreement Office Space Lease $ 88,560 $ 92,492 $ (3,932) $ 95,000 7.3% Aligns with lease agreement Insurance $ 5,000 $ 1,463 $ 3,537 $ 5,000 0.0% Contracts: $ 150,000 $ 230,485 $ (80,485) $ 373,000 148.7% Increase due to the following new activities: Communication $ 100,000 Estimated costs to implement communication plan Medical Director (CMO) $ 78,000 Annualized 2018 contract for Chief Medical Officer services Hulet Consulting (Governance) $ 100,000 Estimated amount based on 2018 contract Inslee, Best, Doezie (Legal Contractor) $ 20,000 Estimated amount based on 2018 usage Equity/Capacity Training for GB, Committee and Staff $ 25,000 This is to provide equity/capacity training Other $ 50,000 Estimated for unanticipated contracts B&O Tax $ 64,193 $ 1,729 $ 62,464 $ - -100.0% No longer needed due to passage of SHB2998 on March 15, 2018 Office Supplies/Equipment/Furniture/IT/Phone $ 200,000 $ 168,023 $ 31,977 $ 150,000-25.0% Reflects reduction of one-time furniture/equipment purchases in 2018 Staff professional development/training $ 20,000 $ 20,357 $ (357) $ 45,000 125.0% About $2,000/staff and ED coaching contract Travel/Meals/Parking $ 20,000 $ 33,109 $ (13,109) $ 35,000 75.0% Increased to account for all staff over the year vs. 2018 hiring ramp up KC Backbone Payment $ - $ 485,377 $ (485,377) $ - Other/Miscellaneous $ 50,000 $ 31,279 $ 18,721 $ 50,000 0.0% To account for unanticipated costs Subtotal $ 2,561,753 $ 2,549,767 $ 11,986 $ 3,376,795 31.8% # of Staff 3 3 Salaries & Benefits (3.0 FTEs) $ 375,000 $ 201,360 $ 173,640 $ 358,997-4.3% Costs for 3 full time project staff and 4% COLA and merit Project Management (Point B) $ 500,000 $ 292,863 $ 207,137 $ - -100.0% Data Analysis - KC PH Contract $ 500,000 $ 375,000 $ 125,000 $ 500,000 0.0% Estimated continuation of contract DSRIP Expertise $ 300,000 $ 742,711 $ (442,711) $ 400,000 33.3% Estimated costs which is currently provided by Manatt Subtotal $ 1,675,000 $ 1,611,934 $ 63,066 $ 1,258,997-24.8% Community, Consumer, Tribal Engagement: $ 100,000 $ 100,000 $ - $ 450,000 Updated budget category and line item to reflect HH's approach for this wo.rk. Estimated contract based on 2018 contract and additional work in 2019 with Center for Multicultural Health. Details will be finalized by 350.0% December 31, 2018 Staff Capacity for CCV Small Grants Program Stipends Program Other TBD Education and Training $ 100,000 $ 100,000 $ - -100.0% Tribal Consultation $ 50,000 $ 50,000 $ - -100.0% Outreach & Communication $ 100,000 $ 100,000 $ - -100.0% Subtotal $ 350,000 $ 350,000 $ - $ 450,000 28.6% Consultant Support and Technical Assistance for HIE/HIT, Workforce and VBP $ 800,000 $ 234,337 $ 565,663 $ 800,000 0.0% Underspent of $566k from CY2018 is carried forward. HH is developing the workplan for 2019. Subtotal $ 800,000 $ 234,337 $ 565,663 $ 800,000 0.0% $ - Total Expenses $ 5,386,753 $ 4,746,038 $ 640,715 $ 5,885,792 9.3%

Integrated Managed Care (IMC) Transition MCO Update Healthier Here Governing Board November 1, 2018

King County IMC Specifics King County will continue to have all 5 Medicaid MCOs contracted for IMC All 5 MCOs have contracted with King County to serve as Network Manager for the King County Integrated Care network (KCICN). KCICN is an IPA-like structure that will manage the behavioral health provider network under Contract with the MCOs for Medicaid Covered outpatient and residential services for SMI/SED* populations and all Medicaid Covered SUD services. (This was required for the Transition period per HCA) King County will also manage the behavioral health administrative service organization (BH-ASO) contract, and act as the payer for crisis services and other non-medicaid funding sources such as block grants * SMI/SED Serious Mental Illness/Serious Emotional Disturbance

Integrated MCO Contracts for Medicaid Beneficiaries Medicaid Covered Services (IMC Contract) Medical Mental Health Substance Use Disorders Medicaid Covered Services (IMC Contract) Non-Medicaid Services for Medicaid Beneficiaries (Wrap-Around Contract) Behavioral Health services funded by State General Funds AH-IMC: Enrollees with managed medical and behavioral health care Two Types of Enrollment BHSO: Enrollees with managed behavioral health care only 3

Services included in Apple Health, Integrated Managed Care, BHSO & BH-ASO Contracts Contract Services MCO Apple Health Contract - present Primary Care Specialty Care MCO Integrated Managed Care Contract Includes ALL MCO Apple Health Services noted above plus MH and SUD services shown here: Behavioral Health-Administrative Services Organization (BH-ASO) MH Inpatient E&T Residential MH Includes ALL MCO Apple High intensity treatment Health Services noted Day support above plus MH and SUD Group Treatment Services services shown here: Family Treatment Intake Medication Management Medication Monitoring Rehab Case Management Community Psych Services Peer Support Therapeutic Psychoeducation WISe PACT Crisis Services BH Services for non-medicaid Mental Health Ombudsman Federal Block Grants Hospital Pharmacy (including BH Rx) SUD Assessment Detox Outpatient Outpatient- Group Opiate Treatment Residential IOP Criminal Justice Treatment Account County-Funded Services, Ombuds Other

King County Transition Period eff 1/1/19 MCO-KCICN Delegated Sub-Contract for BH Services HCA Direct Contract Integrated Managed Care MCO Delegated Subcontract King County ICN BH Provider Network (SMI/SED MH & SUD)* Delegated Subcontract Integrated Managed Care MCO Direct Contract PH & BH (for non-smi/sed) PH & BH (for non-smi/sed) Continuum of Integrated Clinical Services Individual Client * KCICN Sub-contracted and at risk for Serious Mental Illness (SMI)/Serious Emotional Disturbance Mental Health & All SUD services.

Services not included in MCO Contracts Crisis services for all members of the community Includes DCRs State-funded services for Non-Medicaid beneficiaries Countyfunded services for Medicaid and Non-Medicaid Miscellaneous BH Ombudsman Committees formerly led by BHO WISe, CLIP, Behavioral Health Advisory Board, etc.

How will the crisis system be managed? HCA HCA Contract with BH- ASO Integrated Managed Care MCO Required sub-contract King County BH-ASO Required sub-contract Integrated Managed Care MCO Continuum of Integrated Clinical Services Individual Client

King County IMC Transition Period What s different on 1/1/2019 BH services will NOT look substantially different to King County Contracted BH Providers: BHAs will continue to directly contract with King County for all SUD and SMI/SED Mental Health Services BHAs will continue to directly contract with MCOs for all mild to moderate Mental Health Services BH Providers will need to verify MCO Eligibility with the County Assessment process will continue to be used for determination on which members are meeting mild-to moderate mental health and SUD & SMI/SED levels of care MCOs may also be contracting directly with King County Contracted BH Providers to expand networks providing mild-to-moderate Mental Health services & SUD services covered under Apple Health (e.g. - Medication Assisted Treatment) and to serve members in border counties for IMC-level services. Community Hospitals- Inpatient- will be authorized (both Prior Authorization and Concurrent Review) and paid directly by MCOs (after initial intake through Crisis Connections)

Preparing for IMC Working to assure a smooth transition Client Outreach & Communication HCA outreach - Mid November - HCA Notice of Assigned MCO (In King County clients will be assigned to their current MCO) MCO Outreach (Notice Letters, ID cards, etc.) Continuity of Care for Clients in active treatment Access to current King County Provider Network thru KCICN Collaborating with County & HCA to obtain open Inpatient service authorizations for Inpatient at 12/31/2018 (Authorization and Payment for Inpatient Hospital Services will transition from HCA to MCOs) Collaborating with the County to define clinical workflows BH Provider Readiness Provider Symposium Dec 10 th & 11 th material and work flows relevant for 1/1/19 for King County providers (e.g. clinical, providing BH serving clients who reside outside of King County) Monitoring Community Impact Early Warning System

What s Next? Learning together with KCICN Working on clinical integration efforts that are supported by integrated contracts and Medicaid Transformation Establishing measures to promote integration and value based care

Questions?