standard operating procedure for integrator role · adherence to this sop will ensure that we will...

SOP: INTEGRATOR ROLE ROCKY MOUNTAIN HEALTH PLAN

VERSION 1.0 1

Standard Operating Procedure for Integrator Role

Owner:

The AHCM Program Director at Rocky Mountain Health Plan will remain ultimately responsible

for all Integrator Functions

Version: 1.0

Issue date: The date the current SOP version was approved by CMS.

Revisions (date, version, description): July 25, 2017 (v. 1.0)

Participants: ACHM Director, Rocky Mountain Health Plan

AHCM Regional Advisory Board Members

Alan Saliman, Montrose Hospital

Amy Barry, Southern Ute

Carol Keller, Center for Mental Health

Chris Lindley, Eagle County Public Health

Christie Higgins, 2-1-1

Danielle Corbin, Mesa County

Dave Ressler, Aspen Hospital

Ian Engel, Northwest Colorado Center for Independence

Jeremy Caroll, River Valley Family Health Center

Jerome Evans,

Kathleen McInnis, Southwest Area Health Education Center

Kelly Parker, Client Advocate

Liane Jollon, San Juan Basin Public Health

Lisa Brown, Northwest Colorado Health

Lynn Borup, Tri County Health Network

Marc Lassaux, Quality Health Network

Marguerite Tuthill, Community Care Alliance

Marnell Bradfield, Community Care Alliance

Mary Baydarian, Garfield County

Patrick Gordon, Rocky Mountain Health Plan

Ross Brooks, Mountain Family Health Center

Sarah Lampe, Trailhead Institute

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Sarah Robinson, Mesa County Health Department

Sharon Raggio, Mind Springs Health

Shelly J. Spalding, The Center for Mental Health

AHCM Community Leads

Ken Davis, Northwest Colorado Community Health Partnership

Cristina Gair, West Mountain Regional Health Alliance

Namrata Shrestha, West Mountain Regional Health Alliance

Sarah Robinson, Mesa County Health Department

Sarah Johnson, Regional Health Connector

Rasa Kaunelis, Tri County Health Network

Matt Teague, Tri County Health Network

Laura Warner, Director of Health Promotion Services, San Juan Basin Public Health

Rusty Connor, Southwest Area Health Education Center

Author: Kathryn Jantz (v1.0)

PURPOSE This SOP outlines how we will successfully implement the Integrator Functions for AHCM

including convening an Advisory Board, conducting a gap analysis, prioritizing gaps, and

developing and implementing a quality improvement plan. Adherence to this SOP will ensure

that we will successfully meet the Center for Medicare and Medicaid Innovation milestones and

continue to make purposeful progress towards the broader vision for an Accountable Health

Community. This SOP pertains to both the region-wide AHCM Advisory Board and the local

community advisory boards.

We will use the partnerships formed out of this Advisory structure to create a more effective

network to support the social, emotional and physical health of Western Coloradoans. We regard

SOPs not as a rigid set of guidelines imposed down a chain of command but as a set of core

principles that empower decision-making throughout a diffuse, collaborative network. By

supporting and empowering our entire community, especially those members who may have

additional resource needs, we will be able to improve the health of the entire community. We

are here to make a real difference for real people.

BACKGROUND As we gain deeper insight into the importance of non-medical factors in improving health

outcomes, we recognize a need to transform how we think about, talk about, and develop

systems to support health. The Accountable Health Communities Model opportunity aligns with

the growing body of knowledge about “social determinants of health” and a shift towards value-

based healthcare purchasing based on health outcomes- which are heavily driven by non-medical

factors. Recognizing that this shift in focus from clinics to a broader community context requires

understanding and responding to a greater diversity of cultural contexts, accountability

structures, and sets of assumptions. To unify our efforts across this diverse landscape, it is

critical to root our approach in a core set of values.

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VALUES These are the shared values and beliefs that guide us as we seek to achieve our mission. They

are derived from initial conversations with core partners and will no doubt evolve over time as

new partners join the network, and serve as a set of first principles to help guide decisions and

collective action.

• We, individuals and communities, have a right to achieve our greatest potential of health.

• There is room for improvement in the systems that support health. We have a

responsibility and an opportunity to improve those systems.

• Achieving needed change will require risk taking, being nimble, adaptable, and bold.

• Healthcare and systems of health are local.

• We value funding the social determinants that impact individual and community positive

health outcomes and well-being.

• We have an opportunity and responsibility to foster more leaders in our communities.

• Collaboration is built on trust and trust is built on relationships. We will be intentional

and patient with the time-consuming process of relationship-building.

• We seek continuous learning and improvement.

• We work to identify the value proposition of our efforts; to be transparent in discussing

and communicating those tangible/non-tangible short-term/long-term benefits.

INTENDED AUDIENCE This SOP will be reviewed, approved and used by all members of the Regional Advisory Board

and the Community Leads (defined below). In addition to Advisory Board participants, this SOP

will be used by the AHCM Facilitator who will support the convening of the Regional Advisory

Board.

DEFINITIONS For key terms (for example, model participant) or acronyms (for example, PO), provide the

definition in a table. These should be listed in alphabetical order.

Term Definition

Social

Determinants

The social factors which influence the health of populations that include:

income and social status; social support networks; education;

employment/working conditions; social environments; physical

environments; personal health practices and coping skills; healthy child

development; gender; and culture.

Community A geographically-based portion of the broader AHCM catchment area that

has aligned their efforts under a single Community Lead.

Community

Lead

An organization (or potentially two) responsible for a Community Advisory

Board.

Gap

Analysis

“An analysis of the extent to which available community services adequately

address the health-related social needs of high-risk community-dwelling

beneficiaries” (per FOA guidelines).

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Quality

Improvement

Plan

“A guidance document for the bridge organization and other model

participants as they implement the model. The QI plan will describe how

activities that address gaps in community services will be managed, deployed

and reviewed” (per FOA guidelines).

AHCM

Advisory

Board

Previously called the Consortium by AHCM members in the Community, this

board fulfills the requirements of the AHCM and provides overarching

oversight and direction to AHCM.

Community

Advisory

Board

A community-level workgroup for the Regional Advisory Board focused on

activities specific to that part of Western Colorado.

CONTENTS A. REGIONAL AHCM ADVISORY BOARD ............................................................................................................................. 4

B. COMMUNITY ADVISORY PROCESS .................................................................................................................................. 6

B. GAP ANALYSIS AND PRIORITIZATION ....................................................................................................................... 10

A. QUALITY IMPROVEMENT PLAN .................................................................................................................................... 12

APPENDICES ............................................................................................................................................................................. 15

A. REGIONAL AHCM ADVISORY BOARDSTEERING COMMITTEE

1. Description:

The Regional AHCM Advisory Board includes representatives from all parts of the region and

all sectors involved in AHCM (listed as participants above). The AHCM Advisory Board is

responsible for:

• Communications

o Guiding the necessary communications of the program across the network

o Promoting two-way engagement between working groups, local partners and the

Steering Committee

o Reviewing and approving communications with state and federal partners

• Program Review

o Reviewing quarterly program performance metrics such as rates of screening and

completed community navigation assessments

o Identifying and developing solutions to issues in AHCM Program Operations

o Annually reviewing the IT and data infrastructure of the program

o Identifying collaborative learning & program objectives for the Annual Summit

• Continuous Quality Improvement

o Reviewing the Gap Analysis and Quality Improvement Plans for each community

o Supporting those Quality Improvement Plans and Community efforts

• Alignment

o Suggesting opportunities for AHCM to align with other efforts or for other efforts

to support AHCM

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2. Operating Guidelines:

• Meeting Procedures

o Full Advisory Board meetings will be held on a quarterly basis in June,

September, January, and April.

o All scheduled Advisory Board meetings will be posted on an AHCM website

(when possible) at least twelve months in advance.

o All Advisory Board members will be asked to commit to attend or send a proxy to

each meeting.

o All Board meetings will have a call-in option due to the vast distances across the

area.

o All Board meetings will have an agenda that is distributed at least a week in

advance and minutes that are posted within a month of the completion of the

meeting

o Meetings when possible, will be scheduled one year out at a location with access

for people with disabilities.

• Membership

o Members serve for a term of one year.

o On an annual basis in the June meeting, Board members will be asked to commit

to another year of service. Members who choose to resign will be thanked for

their service and will be asked to assist with the recruitment of a replacement. The

entire board will review all attendees and can choose to add members as needed.

o Because maintaining a diverse representation of members on the Steering

Committee is both important and challenging, outreach efforts will need to be

taken at the work group level and the Community Advisory Board levels to

maintain a pipeline of participants to fill open spots.

• Decision Making

o Group decisions will be made on consensus. Consensus is defined as striving for

an agreement that all members can actively support. It will be the responsibility of

each member to articulate questions and concerns and actively work to create

solutions that will attempt to meet this standard. At the minimum, consensus will

be defined as there being no members who will actively oppose a decision.

o In circumstances when consensus is not attainable despite efforts to address

concerns, a formal vote can be called in order to move the agenda forward. A

super majority vote (2/3 of the votes) is required to move a proposal forward.

o Should voting be necessary, only one vote is allowed per organization.

3. Required resources:

• Professional Facilitation: The AHCM Advisory Board meeting will utilize professional

facilitation services from Bill Fulton, Civic Canopy.

• Space & Equipment: Rocky Mountain Health Plan or community partners will offer

space, phones, video conferencing, and conference call lines for the purpose of the

contract.

4. Anticipated challenges and mitigation strategies.

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• Maintaining a diverse membership on the Steering Committee (remedy included in

procedures above).

5. Responsible party:

• The AHCM Program Director at Rocky Mountain Health Plan and the Advisory Board

Facilitator, Bill Fulton, will share responsibility for the successful execution of the

Advisory Board.

6. Timing/Frequency

• Meetings will be held quarterly in January, April, June and September.

Notes: This section is optional and can include notes or comments to be documented. For

example, things that need to be considered moving forward. If there are any references that

support this component, they should be noted here.

B. COMMUNITY ADVISORY PROCESS

1. Description:

The size and diversity of Western Colorado means that one advisory process for the entire region

would not allow for the relationship building and Community specific efforts that will be

necessary to make improvements. We will support the critical alignment necessary for AHCM

through the five Community Advisory boards, one for each of the regions in this Western

Colorado AHCM project. The regions and leads are displayed below.

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The role of the Community Advisory Board is:

• Communication

o The Community Advisory Board will distribute any AHCM information relevant

or important to their community

• Gap Analysis

o The Community Advisory Board will review and ensure that the gap analysis is

consistent with the community’s perception

o The Community Advisory Board is required to prioritize gaps in community

resources.

• Quality Improvement

o The Community Advisory Board will develop a plan to address the prioritized

gaps in community resources.

• Solicit Community Engagement

o The Community Advisory Board will recruit clinical providers or community

based organizations to join AHCM as they see fit.

To reduce the burden on local community members who must often attend multiple meetings

with overlapping membership, the Community Advisory Boards will be integrated into existing

structures and expanded to address the needs of the AHCM program to greatest extent possible.

All agencies with signed AHCM MOUs will be on the Advisory Board. In cases where no

existing body exists that can fulfil the necessary functions, a new body may need to be

established.

2. Operating Guidelines

Step One: Community Leads in each region will identify their assigned staff for this project and

the Community Engagement forums. The current staffing and forums are outlined below.

Counties

AHCM Community

Lead Staffing

Community Engagement

Forums

Northwest

Colorado

Community

Health

Partnerships

Routt, Moffat, Grand,

Jackson, Rio Blanco

Ken Davis- Executive

Director, RCCO

Community Care

Team Manager, new

communications

specialist

Monthly County Human

Resource Council Meetings in

Routt, Moffat, Grand,

Bimonthly NCCHP Board

(quarterly focus on AHCM),

annual resident meetings

West

Mountain

Regional

Health

Alliance

Eagle, Garfield,

Pitkin & Summit

Cristina Gair,

Executive Director

WMRHA eight annual Board

meetings and quarterly

community meetings

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Mesa County

Public Health

Department Mesa

Sarah Robinson,

Manager, Program

Integration

Mesa County Health

Leadership Consortium &

Community Transformation

Group

Tri-County

Health

Network

Ouray, San Miguel,

Montrose, Delta,

Gunnison

Rasa Kaunelis -

Director of Strategic

Initiatives,

New Quarterly AHCM

Advisory Board Meeting with

in-person, video conferencing

meetings

San Juan

Basin Health

Department &

Southwest

Area Health

Education

Center

Hinsdale, Dolores,

San Juan,

Montezuma, La

Plata, Archuleta

Laura Warner,

Director of Health

Promotion Services,

Mary Dengler- Frey,

La Plata, Archuleta Counties:

Community Health Assessment

Steering Committee

Montezuma, Dolores Counties:

TBD

Step Two: If using an existing forum, the Community Leads will assess the list of individuals

involved in that forum and identify organizations who signed MOUs for AHCM that are not

involved. The Community Lead will also evaluate that list to ensure that clinical representation

from hospitals, behavioral health providers and primary care providers and community service

representation from organizations who provide transportation, housing, food, utilities and

interpersonal violence are included or invited to the AHCM forum.

Step Three: The Community Lead will send the RMHP AHCM Director a list of names,

organizations, titles and email addresses of all members of the Advisory Committee (or

Committees). This list shall be updated and revised on a quarterly basis.

Step 4: The Community Lead will develop a master calendar of meetings related to AHCM, with

scheduling completed at least six months out. Community Leads will work towards having a full

calendar for the year.

Step 5: The Community Leads will submit notes from the AHCM portion to the Advisory

process to the RMHP AHCM director within thirty days of the meeting. Those notes will be

posted on the RMHP site so that individuals engaged in AHCM in one community can learn

about the activities in another community.


Each Community Lead will have funding for a .5 FTE. That .5 FTE must have a laptop, phone

and workspace.

4. Anticipated challenges and mitigation strategies. Describe challenges likely to be encountered

in this phase. This can be presented as a table or text.

Challenge

(example)

Description

(example)

Mitigation Strategy

(example)

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Clinical Sites

who are

already doing

social needs

screening

Clinical sites who

already have a tool that

they are using and like

may be resistant to

switching.

We will support clinical sites to the greatest extent

possible in workflow changes and providing

meaningful data that increases the value of

switching tools.

Engagement

of clinical

sites

In some areas of the

state, engaging clinical

providers, especially

hospitals, can be

challenging.

-Identify program champions within clinics and/or

regions to support the program

-Provide data and information on how addressing

health-related social needs can improve access,

reduce costs for clinics, and improve health

outcomes

-Make participation a part of other heatlh reform

sites

-Utilize Regional Health Connectors, a Colorado

workforce dedicated to bridging traditional and

non-traditional healthcare providers in Colorado,

many of whom have strong collaborative

relationships with clinics

Rural and

Frontier

Relationship

building

Although the

Communities are less

populous than urban

communities, they

encompass large and

expansive geographic

areas in mountainous

regions where travel can

be extremely difficult

and time consuming.

-The community leads live in their community and

many of the community lead host organizations

have staff living and working throughout their

region, thus improving the potential for

relationship building and leveraging of existing

relationships

- Utilize technology to allow face-to-face

meetings, which is critical when establishing

relationships, without requiring travel

-Leverage existing meetings in order to minimize

the amount of new travel required by our partners.

Engagement

of partners

supporting all

of the health-

related social

needs

Western

Colorado

intends to

address for

our diverse

populations

In some of our rural

communities, there may

not be a single provider

that supports one of the

core health-related needs

or there may not be a

provider offering

culturally-/linguistically-

competent services to

support our diverse

populations

-Bring as many diverse partners to the table as

possible, and use the strong relationships in many

of our rural/frontier communities to identify

partners that may be interested in providing a

service even if they currently do not

-Utilize other Communities and Community Lead

Advisory Committees as partners and draw from

the expertise of those partners if the resources do

not exist in a certain Community


The Community Leads will be responsible for the development and oversight of the Community

oversight process.

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5. Timing/frequency:

Community convening will occur at least quarterly, although it can be more frequent at the

discretion of the Community Advisory Committee or Community Lead.

Notes:

B. GAP ANALYSIS AND PRIORITIZATION

1. Description: This describes the annual process the Community Leads will use to identify gaps

in community resources or in the process of connecting members to community resources. Once

those gaps are identified, the Community Leads will prioritize them.

2. Process:

Step one: The Community Lead will collect information about the gaps in resources in their

community. They will leverage pre-existing gap reports and resource maps to the extent possible.

The Community Lead will use the Community Advisory Board forum to collect qualitative

information about gaps in community services. In addition, the Community Lead will review the

following data sets and will share relevant information from those data sets with the advisory

board.

o Western Colorado 2-1-1 data

o AHCM-specific data- produced by RMHP for each Community Lead

▪ Prevalence of Social Needs in the region (based on social needs

screening)

▪ Outcomes of the referrals

▪ Qualitative survey of Community Navigation

o RMHP Claims and Clinical Data Report- produced by RMHP for each

Community Lead. This report will provide insight into the prevalence of

diseases in the Medicaid population in the region.

▪ Rocky Mountain Health Plan Claims

▪ Medicaid Claims Data

▪ Clinical Data-Quality Health Network

▪ Patient Activation Measure Data

o Publicly Available Data Sources

▪ CDC Diabetes Interactive Atlas

▪ Colorado Behavioral Risk Factor Surveillance System

▪ USDA Food Environments, Map the Meal Gap

▪ Comprehensive Housing Affordability Strategy (CHAS)

▪ Colorado Child Health Survey

▪ Healthy Kids Colorado Survey

▪ County Health Rankings

o Local Data

▪ Local Public Health Agency Local Needs Assessment

▪ Hospital Community Needs Assessment

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▪ Community Assessment Survey for Older Adults and Area Plans on

Aging from the local Area Agency on Aging

Step two: By September first of every year, the Community Lead will prepare a short

PowerPoint summarizing the information on gaps in the community. The Community Lead will

share this PowerPoint with the AHCM Director to be posted on the AHCM website.

Step three: The Community Lead will work with the Community Advisory Board forum to

prioritize the gaps in community resources. They may use a variety of techniques to develop

these priorities. For example, Community Leads may begin the process of prioritizing by setting

criteria such as how many people must be impacted by the gap, how deeply the gap impacts the

people affected, the cost to the community, alignment with other community activities, and

community perception of the issue. The process of ranking may rely on a number of techniques

such as those described on this website: http://ctb.ku.edu/en/table-of-

contents/assessment/assessing-community-needs-and-resources/criteria-and-processes-to-set-

priorities/tools

Step four: By October 15th, the Community Leads will submit a list of two or more prioritized

gaps with a description of the process to identify those gaps.


RMHP will provide the Community Leads with a number of reports to inform their work.

4. Anticipated challenges and mitigation strategies. Describe challenges likely to be encountered

in this phase. This can be presented as a table or text.

Challenge

(example)

Description

(example)

Mitigation Strategy

(example)

Prioritizing With a diverse group of

stakeholders, the

priorities for each

stakeholder will be

different and so

developing one cohesive

set of priorities may be

challenging

-The Community Leads will carefully develop a

transparent, inclusive prioritization process with

clear criteria to support the development of

priorities.

Availability

of resources

and services

to address

health-related

social needs

in rural

communities

Resources to address

prioritized gaps may

often be scarce or

nonexistent in our

rural/frontier region,

resulting in frustration

-Celebrate successes when prioritized gaps are

filled in order to continue to keep partners engaged

-Utilize other Community Leads as a learning

community to determine how similar prioritized

gaps are being filled in their respective

communities

5. Responsible party: Community Leads

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VERSION 1.0 12

6. Timing/frequency: The Gap analysis will be conducted annually in the late summer and early

fall with the gaps report due September 1st and the prioritized gaps due October 15th.

Notes:

A. QUALITY IMPROVEMENT PLAN

Using the outline below, detail each component/action of the SOP that will be undertaken. Each

section should identify required resources (including staff) and any challenges likely to be

encountered in implementing the component/action.

1. Description:

This describes the process by which Community Leads will develop a Quality Improvement

Plan to address the identified gaps.

2. Process:

Step one: The Community Leads will take the prioritized gaps and adapt them to become

measurable goals.

Step two: For each quality goal, a Quality Improvement Team Leader will be identified. This

person should be someone who is closest to the activity requiring improvement or the gap that

needs addressing. So for example, if the gap is the process for applying for low income housing

then the team lead might be someone who is responsible for low income housing applications in

the community.

Step three: The Quality Improvement Team Leader for each goal will convene a small

workgroup of people who have interest in that topic. They will start by narrowing the goal into

something that is SMART (Specific, measureable, achievable, realistic and timelines). So for

example, the goal of increasing access to low income housing may be changed to streamlining

the process for applying for low income housing. The workgroup will develop a plan for how to

achieve the goal. That plan will include specific activities and timelines for those activities, and

assignment of specific activities to partners or team members. In the development of the goal and

the quality improvement plan, the Community Leads and Quality Improvement Team Leads may

use the following frameworks as relevant:

• Plan-Do-Study-Act

• Process mapping

• Causal loop diagrams

• Change management history

• Assessment Desire Knowledge Ability Reinforcement (ADKAR)

Step Four: The Community Leads will combine the plans from each Quality Improvement Team

Leader into one cohesive Quality Improvement Plan for the Community. They will submit that

plan to the AHCM Director by February 15. The AHCM Director will combine those into a

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region-wide plan to share with all Community Leads, the Advisory Boards and eventually to

submit to CMMI by March 1.

Step five: The Quality Improvement Team Leaders and the Community Leads will work to

execute the plan utilizing the selected framework(s)!

Step Six: Between Community Advisory Board meetings, the Community Lead will update the

Community on the Quality Improvement Activities through a format that works best (Facebook,

closed website, local media sources, postings in public forums).


Developing the Quality Improvement Plan will require a significant amount of time from the

Community Leads and Quality Improvement Team Leaders. RMHP will facilitate a learning

community amongst the Community Leads (if needed) so that the Leads may learn from what

the other Communities are proposing.

4. Anticipated challenges and mitigation strategies.

Challenge

(example)

Description

(example)

Mitigation Strategy

(example)

Staffing

shortage

Availability of qualified

staff to initiate activity

and need to identify a

Quality Improvement

Team Leader and

workgroups to

volunteer additional

time to developing a

plan

-Recruit and train new staff

-Offer technical assistance to Quality Improvement

Teams to support the development of SMART

goals

-Use technology for the development of the

Quality Improvement plan to reduce necessary

time for Team Leader and workgroup members

“Turf” issues Partners addressing the

prioritized gap may

become defensive when

other providers offer

recommendations on

how to address

priorities

-Quality Improvement Team Leader will be

someone closest to the activity requiring

improvement

-Continually celebrate successes and stress that the

entire Community is there to support all partners

and improve the health of our residents


Community Leads & AHCM Program Director

6. Timing/frequency:

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The Quality Improvement Plan update will be due annually on February 15th. Many of the

activities on the Quality Improvement Plan will require multiple years so the plan may have

some of the same content as the year prior.

Notes:

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APPENDICES

Include additional documents/templates (for example, forms, samples, outlines, etc.) when

applicable/relevant. Provide a list of items included below and include those items within the subsequent

pages.

1. Form 1

2. Outline 1

3. Sample 1

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standard operating procedure for integrator role · adherence to this sop will ensure that we will...

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