A NEW CONTINUUM CONVERSATION

Our Friends in Boston!

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Meeting Objectives

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• Progress update on Design Team work development and supporting work activity

• Economic analysis update and next steps in phased research effort

• Update on assessing systems integration opportunities and other collaborative efforts

• The spinning plates of the 2016 agenda• Learning from the health supported housing

collaborative (HSH)

Business Case Policy Development Work:

ROI on integrating silos and funding streams via

Core Group member data analysis; existing literature and other

sources

Example: Mental Health Collaboratives

Design Team Work:Community driven

initiative(s) that fosters community capacity for health and well-being as

people define it

Example: Post-Acute

Work

Example: Data

Exchange Initiatives

Each circle informs and shapes the others and all Circles embed a focus on health disparities and health equity

Emerging 2016 Agenda

Weaving Work: Connecting and

coalescing initiatives under a

common framework to leverage

momentum and share learnings

Example: Community

Health Assessments

Core Group Work: Design and support

parallel systems integration initiative

(e.g. continuum navigation)

Business Case Policy Development Work:

ROI on integrating silos and funding streams via

Core Group member data analysis; existing literature and other

sources

Example: Mental Health Collaboratives

Example: Post-Acute

Work

Example: Data

Exchange Initiatives

Each circle informs and shapes the others and all Circles embed a focus on health disparities and health equity

Weaving Work: Connecting and

coalescing initiatives under a

common framework to leverage

momentum and share learnings

Example: Community

Health Assessments

Core Group Work: Design and support

parallel systems integration initiative

(e.g. continuum navigation)

Design Team Work:Community driven

initiative(s) that fosters community capacity for health and well-being as people define it

Design Team Progress

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Design Team Plan To Pursue Charge Of “Fostering Community Capacity To Support Health And Well-being As People And Families Define It”

Design Team Starting Point

Likely and Necessary By-Products

SUPPORT COMMUNITIES IN DEVELOPING RESILIENCY PLANS

COMMUNITY DEFINED MEASURES OF SUCCESS

(building in accountabilities for all, including health systems)

Developed by community and grows out of culture: our way of knowing, being and living. To build a plan, communities will likely draw on:

Lived experience/historical trauma that can lead to prevention Health and well-being Mental health (childhood and adult) Aging throughout life Education Values, norms and traditions Community assets Local health care providers are embedded in process

Design Team Role: Help resource planning and implementation Embed leaders in planning process to learn Invest in determining return on investment Invest in sustainability

1. Identify target communities via readiness for resiliency planning

• Presence of community-based bridge/coach/facilitator/champion• Interest of community in resiliency planning initiative• Precedence for collaborative work in community• Existing or potential organizing structure to house or support work• Opportunity to impact health inequities, disparities and/or

structural racism in the community• Potential to include and engage local health system in initiative

2. Facilitate (through a community member) a collaborative resiliency planning process

• Community invites and convenes • Community scopes focus of work and sets shared goals• Community members articulate roles and responsibilities• Community undertakes resiliency planning approach within

context of health and wellbeing and scoped focus area• Community establishes success measures and desired outcomes

and creates a plan that will foster the measures and outcomes• Community implements and measures progress

3. Implement and track impact • Study progress with a focus on community capacity building• Articulate capacity building elements and connection to health• Document implications for systems integration efforts in serving

those with chronic disease and behavioral health challenges

Scope of Focus

Community Capacity to foster health and

wellbeing

Resiliency planning at the community level

through

Design Team Resiliency Framework

Final Community Candidates

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Name Focus Description Bridge/ Champion Silos Contact Geography

Suburban Ramsey Family Collaborative

Families Improving support systems with a focus on wellness, learning, safety, and security through Concerted Social Action model

Mary Sue Hansen

M. Schoedl and E. Trinty

East Metro

Curanderismo Hispanic/ Latino

Curanderas: traditional healing and self-care

Selma Sroka and Kim Hart

S. Koepplinger West Metro

Leech Lake Tribal Organic resiliency process aligned with general resiliency framework through the Mino-ayaawigamig Wellness Center

Matt Hanson L. Hunter/ S. Koepplinger

Rural tribal reservation

Example: Mental Health Collaboratives

Example: Post-Acute

Work

Example: Data

Exchange Initiatives

Each circle informs and shapes the others and all Circles embed a focus on health disparities and health equity

Weaving Work: Connecting and

coalescing initiatives under a

common framework to leverage

momentum and share learnings

Example: Community

Health Assessments

Core Group Work: Design and support

parallel systems integration initiative

(e.g. continuum navigation)

Design Team Work:Community driven

initiative(s) that fosters community capacity for health and well-being as

people define it

Business Case Policy Development

Work: ROI on integrating silos and funding streams via Core

Group member data analysis; existing

literature and other sources

Business Case Analysis Update

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Business Case Analysis Update

Goal: attempt to quantify and articulate the costs of fragmentation and the benefits of integration to build a case for policy and funding innovation across the continuum.

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Business Case Analysis Survey Responses

Number of Organizations Responding

Cross-continuum Triple Aim programs

Community-based and/or –owned

programs aimed at fostering

community health

Programs aimed at reducing health

disparities

10 28 21 16

Next Steps:• Initial data scrub and summary• Interviews with all 10 organizations• “Data dump” from 1-2 organizations• Detailed data request to other 8 organizations for most relevant data• Analysis to be delivered end of Decembero Includes: two rounds of qualitative interviewing, one round of quantitative

data analysis, identification of where this project could fit within existing literature on public/community health collaboratives, and an outline sequencing phase two of analysis

Business Case Policy Development Work:

ROI on integrating silos and funding streams

via Core Group member data analysis; existing literature and

other sources

Example: Mental Health Collaboratives

Design Team Work:Community driven

initiative(s) that fosters community capacity for health and well-being as

people define it

Example: Post-Acute

Work

Example: Data

Exchange Initiatives

Each circle informs and shapes the others and all Circles embed a focus on health disparities and health equity

Weaving Work: Connecting and

coalescing initiatives under a

common framework to leverage

momentum and share learnings

Example: Community

Health Assessments

Systems Integration Opportunities

Core Group Work:

Design and support parallel

systems integration initiative

(e.g. continuum navigation)

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Potential Opportunities

• Post-acute “IT” work• Center for Community Health• Health supported housing (HSH)• East Metro Mental Health Roundtable

Goal: top candidates for systems integration pilot(s) are clearer by December Core Group meeting and may be

ready for selection

MINNEAPOLIS HEALTH SUPPORTED HOUSING CIRCUIT BREAKER PROJECT

Circuit breaker n. An automatic switch that stops the flow of electric current in a suddenly overloaded or otherwise abnormally stressed electric circuit

Breaking the Cycle through HSH

Goal: Improve outcomes and reduce total service costs for the target population through multi-sector collaboration

Overview: Integrated health, wellness and social supports delivered in 90 permanent supportive housing units using an innovative, replicable model

Location: Downtown Mpls

Target population: Very low income Homeless or housing

instability Medically fragile with

chronic medical conditions

High utilizer of crisis, ER, hospital and psych services

Mental illness and/or chemical dependency

Health Supported Housing

Million-Dollar Murray

Why problems like homelessness may be easier to solve than to manage.

BY MALCOLM GLADWELL

Minnesota ACA reform saved $61.5 million, can guide innovation

State’s “shared savings” program rewarded providers that cut costs.  By Editorial Board Star Tribune July 4, 2015

The Current System

System Map with Health Supported Housing

Moving Forward

Housing Funding: Secure funding commitments for development

State, County and Health Plan engagement: approval of circuit-breaker “gain sharing” model for health supported housing demonstration

Next Steps: Data: Gather data on

current costs and potential savings

Modeling: Develop economic model to estimate the potential ROI

Partnership: Expand multi-sector and state agency support and collaboration

Project Partners Aeon HCMC Hennepin Health Touchstone Mental

Health Hennepin County Westminster

Presbyterian Church Corporation for

Supportive Housing

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Our Work in 2016

2016 Silos Spinning Plates

CEO Council/

Core Group•Convening•Oversight•Strategy•Ambassadors for change

Messaging & Comms

•Broadly disseminate through web and other social media

•Quarterly reports

Funding Mobilization

•Identify and pursue potential grant opportunities

•Seek funding support from other Silos partner orgs

Design Team

•Articulate key learnings from community resiliency, develop tools for spread, disseminate

Community Resiliency

•Resourcing 2 communities

•Evaluate system implications

•Replication implications

Systems Integration

•Seed 2 initiatives

•Fund•Evaluate•Identify policy implications

Business Case Policy Devpt

•Outline phase two of work

•Implement•Identify and organize around policy implications

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Moving Forward

Core Group Engagement

Potential new Core Group members:• LeadingAge• Care Partners• MHA• UCare• Medica• Touchstone Mental Health• HCMC

• What are our immediate next steps and assignments before our next meeting?

Next Steps

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Appendix

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Core Group Work: Design and support

parallel systems integration initiative

(e.g. continuum navigation)

Business Case Policy Development Work:

ROI on integrating silos and funding streams via

Core Group member data analysis; existing literature and other

sources

Example: Mental Health Collaboratives

Design Team Work:Community driven

initiative(s) that fosters community capacity for health and well-being as

people define it

Example: Post-Acute

Work

Example: Data

Exchange Initiatives

Each circle informs and shapes the others and all Circles embed a focus on health disparities and health equity

Emerging 2016 Agenda

Weaving Work: Connecting and

coalescing initiatives under a

common framework to leverage

momentum and share learnings

Community Health

Assessment

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Shaping the 2016 Agenda

• What’s already emerging?

• What’s still missing and what do we want to do about it?

• Systems change initiatives:– Currently there is not a systems change initiative emerging from the

Design Teams…do we want that to be a point of focus? If so, how will we determine what that is?

• Potential options for doing that:– Letting economic work guide us– Related initiatives (e.g. post-acute “IT” work)– Generating the topic among us