Community-Driven Health Equity Solutions:
A ECHO Learning Collaborative
Overview
Funder
Robert Wood Johnson Foundation Grant, awarded July 1, 2023
Goal
Launch an ECHO learning framework to implement and document community-driven models of care that promote Health Equity goal achievement, using Multi-Payer Alignment to the implementation of Community Health Integration (CHI) HCPCS codes.
Objectives
1. Organize community-clinical teams to implement Community Health Integration (CHI) HCPCS codes and adopt defined health equity goal achievement, into the alignment of the CHI HCPCS model of care, as a multi-payer alignment Alternative Payment Model (APM) strategy.
2. Document the steps to implementing CHI HCPCS codes using evidence-informed models of CHI implementation that leverage blending and braiding of public-private resources to address Health-Related Social Needs (HRSNs) to drive Health Equity.
3. Promote achievement of Medicaid Value-Based contracting goals through the adoption of community-driven CHI model of care, into APMs, with multi-payer alignment.
4. Conduct process and outcome evaluation of the CHI model of care implementation and multi-payer alignment of APMs to drive Health Equity improvement.
ECHO Learning Framework Approach
The ECHO learning framework uses anonymized case studies to facilitate team-based situational learning. The application of the ECHO learning framework to CHI implementation will focus on addressing a community-defined health equity goal, organizing a community-clinical team to address the root causes of inequity, deploying targeted interventions to overcome contributing factors to health inequity, screening for HRSNs, deploying HRSN interventions, and monitoring the health outcomes achieved through HRSN intervention deployment. The initial focus of HRSN interventions will include the deployment of solutions in the following HRSN categories:
Housing Insecurity
Food Insecurity
Transportation Insecurity
Medication and Healthcare Access
Disease self-management capacity
Health literacy
Income Insecurity that impacts healthcare/medication access
Application:
Applications are due by 11:59pm EST on November 13, 2023.
Questions:
HealthEquity@partnership2asc.org
Community-Clinical Teams
The learning collaborative will bring together up to twenty (20) community-clinical teams, that include at least one of each of the following stakeholders on the team:
Medical Providers (i.e., Group Medical Practices, Solo-Practitioners, FQHCs/RHCs, etc.)
Community Care Hub/Community-Based Organization
Person with Lived Experience
Health System/Hospital
Health Plan (Can be TBD at time of application)
Each community-clinical team will work with subject matter experts to implement Community Health Integration HCPCS codes, as a single model of care to address Health Equity; and support multi-payer alignment with this model of care into Alternative Payment/Value-Based Payment (APM/VBC) contracting goals. As a multi-payer alignment strategy, each community-clinical team will implement the CHI HCPCS codes into a model of care with defined Health Equity quality measures. The APM model design will include Health Equity clinical outcomes, into the APM quality measure requirements. and use CHI HCPCS implementation as the model to drive goal attainment. The multi-payer alignment strategy will include approaches to achieve alignment with payers in each of the following categories:
Original Medicare (Medicare and Dual-Eligible Beneficiaries)
Medicaid/Medicaid MCOs
Medicare Advantage
Special Needs Plans (D-SNPs / C-SNPs)
FIDE / HIDE SNPs
Medicaid MLTSS
Questions
Questions regarding the learning collaborative can be directed to the following inbox:
HealthEquity@partnership2asc.org