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Edge of Amazing: Breakout Session B - TotalHEALTH™: Increasing access to basic needs for vulnerable populations

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Edge of Amazing: Breakout Session B - TotalHEALTH™: Increasing access to basic needs for vulnerable populations

  1. 1. TotalHEALTH™ Connecting Clinical Care and Community Support Services
  2. 2. TotalHEALTH™ 2018 Session Panel • Wave 1: Clinical Settings • Mallory Taylor / Manager of Outreach, Community Health Centers of Snohomish County • Jan Le / Health Center Administrator, Marysville, Sea Mar Community Health Centers • Heather Attwood Mgr, Population Health, Accountable Care, and Health Homes, PMG • Jimmy Grierson, MD / Founder, Safe Harbor Free Clinic Stanwood • Wave 2: Social Services Settings • Holly Shelton, Supervisor, Snohomish County Dept of Housing & Community Services • Vicci Hilty, Executive Director, Domestic Violence Services • Erin Monroe / Executive Director, Workforce Snohomish • Wave 3: Community Settings • Jessica Figueroa / Refugee & Immigrant Services Northwest
  3. 3. The need clearly exists in Snohomish County. 30% of county respondents lack at least 1 basic need. Education accounted for about half. Source: PIHC 2018 Health & Well-being Monitor
  4. 4. •Supportive housing: 1.3:1 (Minn HMIS) •Housing: 3:1 (Montefiore Health, NY) •Housing: up to 1.9:1 (VHA) •Medical transportation: 7.7:1 (Missouri HealthTran) •Nutrition 16:1 (Global / N4G) •Overall WA state: 6.6:1 (Urban Institute) The return on investment is promising.
  5. 5. So why is this so difficult? •“Free-riders” •“Silos” •Culture •Competition for resources •Focus too downstream •Focus on short-term results
  6. 6. 1. Start in our own communities with trusted partners… 2. Screen & navigate people for 7 key needs while they visit their doctor….social service partners … communities…and track the results 3. Unleash the power of community to improve whole-person health. TotalHEALTH™: Build on Community Trust
  7. 7. Framework for Strategic Focus: Deep Clinic/Community Integration Outpatient Care Acute / In-patient Care Community Care – Social Determinants ©2017ScottForslund/ProvidenceInstituteforaHealthierCommunityAllRightsReserved Q1: Optimizing Well- Being Community Partnerships Q2: Managing Risk Community/ Healthcare Partnerships Acute Care Q3: Recovery & Reconnection Community/ Healthcare Partnerships Q4: Optimizing Well-Being Community Partnerships
  8. 8. Opening New Windows of Hope & Belief GETTING BY 12% / 100,000 people GETTING TRACTION 37% / 305,000 people GETTING THERE 38% / 316,000 people GETTING KUDOS 13% / 109,000 people GIVING BACK HWB Index: 5.9 HWB Index: 6.5 HWB Index: 8.6 HWB Index: 9.1 HWB Index: 9.7
  9. 9. • Make social-needs investment a normal part of the health cost equation… • REDEFINE HEALTHCARE to address whole- person & community health.  Integrate networks of clinical/social services partners committed to collaboration • Improve access to services & build awareness of existing community needs & resources • Influence “supply side” build capacity of needed social services • Compare ROI of social needs investment on Health & Well-being, healthcare cost and utilization  Convene networks of clinical and social service partners  Co-create integrated screening/ navigation system, protocols, processes & training  Screen & Navigate patients for 7 non-medical, social needs  Establish an integrated, community-accessible, HIPAA compliant data & analytic platform CRAWL… WALK… RUN! The TotalHEALTH™ Journey
  10. 10. Clinical needs > Social needs > Overall Well-being clinical Housing food transpo Personal safety education job
  11. 11. Six Dimensions of Health…medicine in its place clinical Housing food transpo Personal safety education job
  12. 12. TotalHEALTH!: 25 Original MOUs In Place • Providence Medical Group • Community Health Center • SeaMar Community Health Centers • Safe Harbor Free Clinic (onboarding) • The Everett Clinic • Edmonds Family Medicine • Swedish Medical Group • Compass Health • Sunrise Services • Providence Regional Med Center • Swedish-Edmonds • Swedish Mill Creek • HOUSING: Snohomish County Human Services Dept • NUTRITION: Snohomish County Food Bank Coalition • TRANSPORTATION: SnoTRAC • DOMESTIC VIOLENCE: Domestic Violence Services • UTILITIES: HSD SnoCo • EMPLOYMENT: Workforce Snohomish • EDUCATION: Snohomish STEM Network • Farmer Frog • Homage Senior Services of Snohomish County • Snohomish Health District • SnoCo Health Leadership Coalition • United Way of Snohomish County • Volunteers of America • North Sound Accountable Community of Health • Washington State Health Care Authority Community Service Provider Networks & Partners (293 affiliated organizations / gross count) Clinical Delivery Sites (53 unique care sites)
  13. 13. TotalHEALTH™ - THREE WAVES •Wave 1: Clinical (“Patients”) 2017+ • TotalHEALTH7: Seven nonmedical needs •Wave 2: Social Svc (“Homeless” “Jobless” etc.) 2019+ • TotalHEALTH7: Swap sector-partner service for medical •Wave 3: Communities (“People!”) 2019+ • TOTALHEALTH8: 7 social needs PLUS medical care
  14. 14. Wave 2 & 3 Partner Discussions: Refugee & Immigration Services NW (Countywide) Snohomish County Housing Division (Countywide) Workforce Snohomish (Countywide) Domestic Violence Services (Countywide)PMG Monroe Clinic PMG Mill Creek Clinic CHC Central Everett CHC North Everett CHC Lynnwod Edmonds Family Medicine Safe Harbor Free Clinic Sea Mar Marysville CHC Arlington CHC Everett CC PMG Health Homes (covers South County)
  15. 15. TotalHEALTH™ Workflow – tailored to each partner
  16. 16. TotalHEALTH™ QuickCheck Screen
  17. 17. On-site collateral
  18. 18. TotalHEALTH™ Common Portal
  19. 19. Resource Referrals via LiveWell LOCAL • > 1,500 hyperlocal listings and growing • Crowdsourced via Partner/Provider Portal –controlled by partners • Tailored client reports • PDFs and email links • Data-sharing with 211 LiveWellLocal
  20. 20. PMG Monroe Clinic PMG Mill Creek Clinic CHC Central Everett Sea Mar Marysville TotalHEALTH7 COMPOSITE CLINICAL REULTS / Through Sep 2018 Needs Countywide (From 2018 Health & Well-being Monitor™ Total QuickCHECKS: 1,112 Total Needs ID’d: 2,262 Avg Needs/Person: 2.03 Intensity Index: 1.0
  21. 21. PMG Monroe Clinic PMG Mill Creek Clinic CHC Central Everett Sea Mar Marysville TotalHEALTH7 COMPOSITE CLINICAL RESULTS / Through Sep 2018 Needs Countywide (From 2018 Health & Well-being Monitor™ Total QuickCHECKS: 1,112 Total Needs ID’d: 2,262 Avg Needs/Person: 2.03 Intensity Index: 1.0
  22. 22. PMG Monroe Clinic PMG Mill Creek Clinic CHC Central Everett Sea Mar Marysville PMG CLINIC TotalHEALTH PROFILE BY CLINIC / Through Sep 2018 Needs Countywide (From 2018 Health & Well-being Monitor™ Total QuickCHECKS: 713 Total Needs ID’d: 375 Avg Needs/Person: 1.9 Intensity Index:
  23. 23. PMG Monroe Clinic PMG Mill Creek Clinic CHC Central Everett Sea Mar Marysville PMG MILL CREEK / Through Sep 2018 Needs Countywide (From 2018 Health & Well-being Monitor™ Total QuickCHECKS: 263 Total Needs ID’d: 502 Avg Needs/Person: 1.91 Intensity Index:
  24. 24. PMG Monroe Clinic PMG Mill Creek Clinic CHC Central Everett Sea Mar Marysville CHC TotalHEALTH PROFILE BY CLINIC / Through Sep 2018 Needs Countywide (From 2018 Health & Well-being Monitor™ Total QuickCHECKS: 734 Total Needs ID’d: 1453 Avg Needs/Person: 1.98 Intensity Index:
  25. 25. TotalHEALTH™ PUTTING IT ALL TOGETHER Following a user through the process
  26. 26. Sara’s Pathway to Health • Sara visits her local clinic for a flu shot. • At this visit, she is offered the TotalHEALTH™ screen. • Sara’s TotalHEALTH screen identifies needs for food insecurity and education. • Her healthcare provider connects Sara with local resources thru LiveWellLOCAL™ & other sources. • Partners – and Sara use LiveWellLOCAL services to achieve her goals: o SNAP can assist with nutrition for both Sara and her daughter o Career counseling/education resources can help her improve her financial situation over time o Women’s Wellness services will contribute to her staying healthy • Sara takes the Health & Well-being Survey to assess her overall health. • Sara stays engaged with PIHC & Community • Sara takes a follow-up Health & Well-being survey to track her results.
  27. 27. Sara’s Pathway to Health • Individuals are treated as whole persons • Clinic and community partners have new tools & pathways to work together. • Health improves, cost increases slow. • The collective health & well-being of Snohomish County improves.
  28. 28. TotalHEALTH™ - Partner Storytelling • Wave 1: Clinical Setting • Mallory Taylor / Community Health Centers of Snohomish County • Jan Le / Sea Mar Community Health Centers Marysville • Heather Attwood / Providence Medical Group & Health Homes • Jimmy Grierson, MD / Safe Harbor Free Clinic Stanwood • Wave 2: Social Services Settings • Holly Shelton / County Dept of Housing & Community Services • Vicci Hilty / Domestic Violence Services • Erin Monroe / Workforce Snohomish • Wave 3: Community Settings • Jessica Figueroa / Refugee & Immigrant Services Northwest
  29. 29. Engagement Huddles: Fierce Questions •Share a hope or aspiration about improving access to basic needs for vulnerable populations. •Where do you see the biggest gaps / opportunities? •How might YOU PERSONALLY support one of the “three priorities”? •If you could use a partner, who might that be?
  30. 30. Six Dimensions of Health…one step at a time clinical Housing food transpo Personal safety education job
  31. 31. Framework for Strategic Focus: Deep Clinic/Community Integration Outpatient Care Acute / In-patient Care Community Care – Social Determinants ©2017ScottForslund/ProvidenceInstituteforaHealthierCommunityAllRightsReserved Q1: Optimizing Well- Being Community Partnerships Q2: Managing Risk Community/ Healthcare Partnerships Acute Care Q3: Recovery & Reconnection Community/ Healthcare Partnerships Q4: Optimizing Well-Being Community Partnerships
  32. 32. PMG Monroe Clinic PMG Mill Creek Clinic CHC Central Everett Sea Mar Marysville CHC COMBINED CLINIC TotalHEALTH PROFILE / Through Sep 2018 Needs Countywide (From 2018 Health & Well-being Monitor™ Total QuickCHECKS: 734 Total Needs ID’d: 1453 Avg Needs/Person: 1.98 Intensity Index:
  33. 33. PMG Monroe Clinic PMG Mill Creek Clinic CHC Central Everett Sea Mar Marysville PMG COMBINED CLINIC TotalHEALTH PROFILE / Through Sep 2018 Needs Countywide (From 2018 Health & Well-being Monitor™ Total QuickCHECKS: 375 Total Needs ID’d: 713 Avg Needs/Person: 1.9 Intensity Index:
  34. 34. PMG Monroe Clinic PMG Mill Creek Clinic CHC Central Everett Sea Mar Marysville PMG MONROE / Through Sep 2018 Needs Countywide (From 2018 Health & Well-being Monitor™ Total QuickCHECKS: 106 Total Needs ID’d: 196 Avg Needs/Person: 1.85 Intensity Index:
  35. 35. PMG Monroe Clinic PMG Mill Creek Clinic CHC Central Everett Sea Mar Marysville SEA MAR MARYSVILLE CLINIC TOTAL HEALTH PROFILE / Through Sep 2018 Needs Countywide (From 2018 Health & Well-being Monitor™ Total QuickCHECKS: 734 Total Needs ID’d: 1453 Avg Needs/Person: 1.98 Intensity Index:
  36. 36. Opening New Windows of Hope & Belief GETTING BY 12% / 100,000 people GETTING TRACTION 37% / 305,000 people GETTING THERE 38% / 316,000 people GETTING KUDOS 13% / 109,000 people GIVING BACK HWB Index: 5.9 HWB Index: 6.5 HWB Index: 8.6 HWB Index: 9.1 HWB Index: 9.7

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