community)stakeholder) listeningsession · thebigpicture whole...
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Community Stakeholder Listening Session
October 9, 2017
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Welcome and Introduc9ons
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Agenda
• Pathways to Health + Home Mission & Vision • Welcome & Mayor’s Vision for Sacramento • Whole Person Care Background – Fed & State PerspecKve • Health and Housing Service Approach • Community Feedback Session • CommunicaKon Pathways & OpportuniKes • Next Steps
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Mission & Vision
Mission: To improve the health, quality of life, and housing stability for Sacramento’s most vulnerable individuals experiencing or at-‐risk of experiencing homelessness through an integrated system of care. Vision: A city where all individuals have a home and access to adequate health care.
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Partner Organiza9ons
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Mayor Darrell Steinberg
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Whole Person Care Background – Federal & State Perspec9ve
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The Big Picture
Whole Person Care
CollaboraKve Leadership
Targeted PopulaKons
PaKent Centered Care
CoordinaKon of Services Across Sectors
Shared Data
Financial Flexibility
§ Four-‐year pilot program authorized by CMS and administered by DHCS for high-‐risk Medi-‐Cal beneficiaries who are frequent users of mulKple care systems and have poor health outcomes
§ Provides flexible federal funding to improve health and housing outcomes and more efficiently and effecKvely use health care resources
§ Pilots idenKfy target populaKons, assess health and housing needs, coordinate care in real-‐Kme, and evaluate outcomes
§ Promotes deeper collaboraKon and coordinaKon between service providers by requiring pilots to form partnerships and share data
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Target Popula9on & Eligibility Criteria
Medi-‐Cal enrolled or eligible individuals experiencing homelessness or at risk of homelessness who are: • Individuals with complex health care needs • Frequent users of emergency services and the crisis health system • The most vulnerable and unsheltered • High-‐risk individuals exiKng insKtuKons
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Key objec9ves for Sacramento's program
Align Whole Person Care with the City of Sacramento’s commitment to moving 2,000 individuals experiencing homelessness from the streets to housing by 2020 Align
Integrate the systems of care serving high-‐risk, high-‐uKlizing homeless populaKons through care coordinaKon and data-‐sharing Integrate
Achieve performance outcomes, including a reducKon in unnecessary use of emergency rooms and avoidable hospital stays Achieve
Improve the health and quality of life for individuals experiencing homelessness Improve
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Health and Housing Service Approach
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with a new approach to service delivery
Breakdown the silos…
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Approach to Health and Housing: Service delivery model -‐ 5 Components
1. Referrals, Enrollment, and Eligibility
2. Field-‐Based Interdisciplinary Care Teams
3. Coordinated Access to Health Care, Social Services and Housing
4. Expansion of Sacramento’s ConKnuum of Housing OpKons
5. Care Management Plaborm
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Service Delivery Goals
Outreach (6,800 people)
Care Coordina8on (3,250 people)
Housing Supports (1,625 people)
Respite Beds (144
people)
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WPC Referrals
CBOs
Emergency Shelters
Sacramento Fire
PD Impact Team
Clinics
Emergency Rooms
Eligibility & Enrollment Iden,fy and enroll target popula,on in
Medi-‐Cal and WPC Program
Field-‐Based Interdisciplinary Care Team
Case Management
Housing SupporKve Services & Linkage to
Housing
Peer Support & Empowerment
Mental Health and AddicKon
Assessment & Referrals
Social Services & Benefits
Primary Care
Health Plans
Local Agencies
Service Delivery Model
Homeless Services
ICP + Respite
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Principles and Expecta9ons
§ Coordinate and Align Cross-‐System Health, Behavioral Health, Housing, and Social Services for high risk, high uKlizing homeless individuals
§ Enhance cross-‐sector communicaKon & data sharing § Adopt a “No Wrong Door” approach to working with individuals § Commitment to Learning & Quality Improvement (PDSA tesKng) § ParKcipaKon in learning community to share promising pracKces
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Building on Community Assets
§ Integrated Primary Care & BH/Housing/Social Services § Impact Team § Homeless Health and Housing § Care management/navigaKon services § City commitment
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ACTIVITIES INPUTS
• Related Ini8a8ves • 2K by 2020 • Hospital high uKlizer navigator programs
• Statutory & Regulatory Market Changes
• Community Assets • Integrated Primary Care & BH / Housing/Social Services
• Impact Team • Homeless Health and Housing
• Care management / navigaKon services
• City commitment
OUTCOMES
Short-‐Term ( 2017-‐2020) Longer-‐Term (2021+)
• Enduring plaborm for collaboraKon and coordinaKng health, BH, housing, and social services
• Improved health and quality of life for individuals experiencing homelessness
Pathways to Health + Housing Mission To improve the health, quality of life, and housing stability for Sacramento’s most vulnerable individuals experiencing or at-‐risk of experiencing
homelessness through an integrated system of care.
Interven8on • Aligned & coordinated services across sector, and
alignment with City’s 2k by 2020 IniKaKve • Achieve performance outcomes, including reducKons in
unnecessary ER use and hospitalizaKons • Improved connecKons to the conKnuum of housing
opKons
Governance • Responsive to community stakeholders • Engaged, collaboraKve communicaKon and problem
solving among partners • Accountability and trust among partners
Engage & acKvate community
Align cross sector intervenKons and
enhance collaboraKon
Promote health & equity through accountable systems
Develop Governance Capacity • Shared vision & understanding of the problem
and opportunity • Engaged health, behavioral health, housing, and
social service partners • Engaged community stakeholders
Coordinate and Align Cross-‐System Health, Behavioral Health, Housing, and Social Services for high risk, high u8lizing homeless individuals • “No Wrong Door” Asser8ve Outreach,
Engagement, Enrollment • Field-‐based Interdisciplinary Team • Expand con8nuum and coordina8on of
housing op8ons
Care Management IT Pla\orm Develop Data Sharing Capacity & Measures
Data & Measures • Developed shared measurement system • Established data sharing among key partners • Shared PDSA data used by partners for QI and decision-‐
making • Data reported to partners, community, and DHCS
Service Delivery Targets • Outreach: 6,800 people • Case management: 3,250 people • Housing supports: 1,625 people • Respite beds: 144 people • House 2,000 homeless individuals by 2020
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Audience Feedback Session
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Community Feedback
1. On Card # 1 (green card), please share any reacKons to or feedback
on the Pathways to Health + Home pilot.
2. On Card # 2 (pink card), please share successful examples of cross-‐sector health/housing partnerships in Sacramento. What’s working well and why?
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Communica9on Opportuni9es • Newslener • Future community educaKon sessions • Email [email protected] to provide feedback • Website -‐ www.p2hh.com