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Health System Innovation in the Safety Net

This overview provides background information on RCHC, a community health center, and its transformation to value-based care. It discusses patient-centered medical homes, interconnectivity among health centers, accountable care organization, collaboration with hospitals, and other key initiatives focused on integrated services.

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Health System Innovation in the Safety Net

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  1. Health System Innovation in the Safety Net Suzie Shupe, CEO Redwood Community Health Coalition Redwood Community Health Network sshupe@rchc.net 707-285-2974

  2. Overview • Background on RCHC • Community Health Center (CHC) transformation to Value Based Care (VBC) • Patient Centered Medical Homes & Care Teams • Interconnectivity among CHCs and greater system • Accountable Care Organization • Collaboration with hospitals • Other key initiatives focused on integrated services

  3. Service Area & Health Centers RCHC comprises 17 health center members with over 40 service delivery sites in Napa, Sonoma, Marin and Yolo counties RCHC’s service area covers a total of 4,407 square miles and 1.1 million people* *Sonoma: 1,768 sq mi; population 500,293 *Napa: 788 sq mi; population 141,667 *Marin: 828 sq mi; population 260,750 *Yolo: 1,023 sq mi; population 207,590 FQHC Members • Alliance Medical Center • Alexander Valley Healthcare • Coastal Health Alliance • CommuniCare Health Centers • Marin Community Clinic • Marin City Health & Wellness Center • Ole Health • Petaluma Health Center • Ritter Health Center • Santa Rosa Community Health Centers • Sonoma Valley Community Health Center • West County Health Centers, Inc. • Winters Healthcare Clinic Non-FQHC Members • Jewish Community Free Clinic • Planned Parenthood Shasta Pacific • Sonoma County Indian Health Project • St. Joseph Health System, Mobile Health *Source: 2014 US Census Bureau

  4. Redwood Community Health Coalition

  5. Patient Snapshot • RCHC health centers delivered 912,350 medical, mental health and dental visits to over 242,000 patients in 2014. • RCHC health centers serve approximately 62% of all Medi-Cal patients (130,000) and 71,000 uninsured in our four-county service area. • 74% of patients have incomes less than 200% of the federal poverty level (FPL), and 56% are below 100% of FPL • 52% of our patients are Latino • 35% are best served in a language other than English • 30% are uninsured Source: 2014 OSHPD Data

  6. Transition to Value Based Care • Coalition has long history of trust and collaboration • Made a strategic decision to move CHCs toward providing VBC and preparing for Value Based Payment models

  7. Continuing the Trend in Care Transformation • Care Teams • All CHCs are implementing care teams • Taking varied approaches • National leaders • Patient Centered Medical Home (PCMH) • Currently 7 of 13 FQHC member health centers have PCMH recognition

  8. Redwood Community Health Information Exchange (RCHIE)

  9. RCHIE 6 Connected Health Centers, > 120,000 patient records Any EHR can connect EXTERNALY hosted by vendor Locally managed by RCHC RCHIE planned activities for 2016: • Internal health center data sharing • Launch of provider portal • Connection to hospitals for admit, discharge and transfer alerts • Connection to Connect Healthcare and access to regional web-based portal • Connecting additional member health centers

  10. RCCO History The Redwood Community Care Organization (RCCO) Medicare Shared Savings Program (MSSP) ACO began January 1, 2014

  11. Our Framework: Five Accelerators

  12. We’ve Learned Valuable Lessons • Current risk stratification algorithms/tools do not adequately weigh behavioral health diagnoses and social determinants of health seen in our population • Health centers do not currently document and code in a manner that fully characterizes the complexity of patients (medical acuity, behavioral health co-diagnoses, social determinants of health)

  13. We’ve Learned A Medicare ACO in the safety is different from the average Medicare ACO

  14. ACO Transformation • Spread of value based care principles learned from Medicare ACO • Shift of focus on population health strategies to a broader population • Joint analytics will be a key component of that work

  15. Data Analytics • “… a single, integrated mature solution that meets all PHM (population health management) IT needs does not exist in today’s market.” -Hunt et al. “Guide for Developing and Information Technology Road Map for Population Heath Management” Population Health Management, Nov. 3, 2015

  16. We’ve learned a lot about data analytics • Claims analysis • Predictive modeling • Risk stratification using a combination of claims data and clinical review • Strategies specific to risk stratification

  17. Collaboration with Hospitals • Coordination of Patient Care • Real time utilization data • Continuity of Care documents • Admit, Discharge, Transfer feeds • Care Transitions • Complex Care Management

  18. Other Key Initiatives • Integrating Behavioral Health into Primary Care • Increasing Access to Specialty Care • Complex Care Management • Addressing Social Determinants of Health • Local Programs for Remaining Uninsured in Sonoma and Marin Counties

  19. Questions?

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