Goals of Session

1. District of Columbia dc health systems plan:Public hearingmay 25, 2017899 N. Capitol street neconference room 6002

2. Background & Purpose of Health Systems Plan Overview Approach and Methods Context of Health Systems Plan Review of Core Findings and Recommendations Discussion of Revisions to Certificate of Need Goals of Session

3. Background and Purpose of Health Systems Plan

4. Purpose of DC Health Systems Plan The purpose of the Health Systems Planis to serve as a roadmap for the development of a comprehensive, accessible, and equitable health care system capable of providing the highest quality services in a cost effective manner to those who live and work in DC.

5. Purpose of DC Health Systems Plan • Focus on DC health system & core elements of service • Not a comprehensive community health needs assessment • Not meant to replicate the broad range of health assessments and plans that have been released in past 2-3 years • DOH CHNA, Healthy Communities CHNA, Comprehensive Plan, DC Health Matters, HP2020, BRFSS, Age-Friendly DC, Cancer Control Plan • Meant to add value to other assessments and serve as a guide for the SHCC with respect to the Certificate of Need Program.

6. Components of DC Health Systems Plan • Community Characteristics: Demographics, underlying social determinants of health, barriers to care, and health status • Health System Strengths, Service Distribution, and Utilization: Hospital services, primary care and specialty care, behavioral health, and post-acute care services • Health System Structures: Surveillance, health information technology, workforce development, collaboration, health literacy • Strategic Recommendations

7. Overview of Approach

8. Data Collection • Quantitative and qualitative data was collected from a breadth of sources to explore: • Community need • Barriers to care • Service gaps/assets • Quality of care • System strengths and weaknesses

9. QUANTITATIVE DATA SOURCES

10. QUALITATIVE DATA SOURCES • Key informant interviews with: • Hospitals and Hospital Affiliates: MedStar Georgetown, MedStar Washington, MedStar Health, MedStar Primary Care/Prompt Care, Children’s Hospital, Providence, Sibley, Howard, UMC, GWU, Medical Faculty Associates, etc. • DC DOH: Office of Health Equity, Oral Health, HAHSTA, Health Care Finance, Licensing and Regulation, etc. • DC Government: DBH, Office of Planning, Dept. of Insurance, Securities, and Banking, Fire and EMS, Metropolitan Police Department, etc. • Health Associations and Boards: Hospital Association, Health Care Association, Board of Nursing, Primary Care Association, Home Health Association, Medical Society, etc. • Community Advocacy Groups: DC Coalition for the Homeless, Coalition for Non Profit Housing and Economic Development, Capitol Area Food Bank, etc. • Health Care Providers: Community of Hope, Unity, Mary’s Center, Bread for the City, SOME, Whitman-Walker, Core Health, Planned Parenthood, Psychiatric Institute, Stoddard Baptist Home, etc. • Other: Amerihealth, Health EC, Georgetown University, etc.

11. COMMUNITY ENGAGEMENT Three community forums: Wards 7 and 8: Community of Hope Target: Low income black/African-American residents 10-15 participants Ward 5: Providence Hospital Target: Low income black/African-American residents 6 participants Hispanic/Latinx Residents: Mary’s Center Target: Low income Hispanic/Latinx residents 30 participants • The purpose of the community forums was to: • Explore truths about health in DC • Understand the experience of seeking and receiving care • Identify pain points and opportunities

12. Contextof Health Systems Plan

13. Population Health Model Researchers have consistently determined that only 10-20% of health is attributable to clinical services; the remainder is linked to genetics, behavior, and social and physical environments. http://www.countyhealthrankings.org/ranking-methods

14. Health Equity Health Equity is the “attainment of the highest level of health for all people.” Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, underlying socioeconomic factors, historical and contemporary injustices, and the elimination of health care disparities.”

15. Understanding Health Equity:A PUBLIC HEALTH FRAMEWORK More than an academic concept, health equity is a frame and an approach to analyzing the connections between health outcomes and underlying conditions.

16. Geography of Health Inequity • Looking at the geographic distribution of morbidity and mortality across DC, the effect of social and environmental factors on health is evident.These patterns exist largely independent of access to health care.

17. Disparities in Access and Health-Related Outcomes Barriers to Access & Social Determinants of Health Leading Health Issues • Housing • Poverty, Income, and Employment • Transportation • Food Access • Race/Ethnicity, Culture, and Language Access • Health Literacy/Education • Safety & Violence • Mental health/substance Use • Depression, Anxiety, Serious Mental Illness, Alcohol, Opioids • Chronic/Complex Disease • Heart disease, Diabetes, Asthma/COPD, Hypertension, Cancer • Health Risk Factors • Obesity, Fitness/Nutrition, Tobacco use, Alcohol

18. Segments of the Population Most At-Risk Populations Most At-Risk • Low income individuals and families • Racial/ethnic minorities • Immigrants and refugees • Older adults • Children, youth, and adolescents • LGBTQ • Incarcerated Populations • Developmentally/intellectually challenged or special needs adults and children

19. Health System Strengths: Review of Core Findings

20. Core Finding # 1: SERVICE GAPS/CAPACITY Distribution and capacity of services is not the leading concern across service sectors • DC is rich in health-related resources • Limited to no gaps in service • Reasonably well-distributed services • High quality of care • This is not to say that all segments of the population are fully engaged in care or that there are not some who face barriers to access

21. HOSPITAL SERVICES • Total licensed bed = 3,298 • In 2014, DC had the highest rate of beds/1,000 pop. in the nation • DC = 5.4 beds/1,000 • US rate = 2.5 beds/1,000 • Substantial licensed capacity • Distances relative to national standards not extreme • Quality not a concern except in targeted cases

22. PRIMARY CARE SERVICES • Network of well-distributed FQHCs, hospital-based, private, and specialized practices • DC has the highest rate of physicians/100,000 pop. in the nation (2015) • DC = 849 Physicians/100,000 • US rate = 266 Physicians/100,000 • Isolated gaps may exist but capacity not leading issue • JSI working with DC DOH on detailed PC Needs Assessment

23. BEHAVIORAL HEALTH SERVICES • Core network of mental health and substance use sites • Well-distributed, particularly in areas of high need • Mental health and substance use services remain very “siloed” • Need for integration of MH/SA services into all aspects of medical services

24. POST ACUTE CARE SERVICES • Stable, well-distributed network of long-term care hospitals, skilled nursing/in-patient rehabilitation facilities, and home health agencies • DC’s rate of discharge to PAC settings slightly lower than US and regional rate • Universal concern related to perfecting care transition process

25. SERVICE CAPACITY CONCERNS • There is a need to explore if there are isolated primary care gaps for specific geographic/demographic segments of pop. • Lack of primary care providers in some communities that do not take insurance at all or only limited plans (“concierge” medicine) • Medical specialty care and oral health services are not well-distributed and there are gaps for low income Medicaid insured, uninsured, and underinsured populations • Need for greater integration of behavioral health services in primary care settings • Enhance access and/or address barriers to hospital inpatient services in selected wards in DC

26. Core Finding/Recommendation # 2: SOCIAL DETERMINANTS OF HEALTH Social determinants of health and barriers to care are at the heart of poor outcomes and disparities

27. Core Finding/Recommendation # 2: SOCIAL DETERMINANTS OF HEALTH Social determinants of health and barriers to care are at the heart of poor outcomes and disparities

28. Core Finding/Recommendation # 3: ENGAGEMENT IN PRIMARY CARE There is lack of primary care engagement particular for low income, Medicaid insured populations most at-risk • Areas with the higher density of Medicaid enrollees also have highest portion of enrollees who are engaged in primary care • However, most of these areas still show primary care utilization only just above 50%

29. Core Finding/Recommendation # 3: ENGAGEMENT IN PRIMARY CARE There is lack of primary care engagement particular for low income, Medicaid insured populations most at-risk

30. Core Finding/Recommendation # 3: ENGAGEMENT IN PRIMARY CARE There is lack of primary care engagement particular for low income, Medicaid insured populations most at-risk • 20% of all hospital inpatient and emergency department discharges are for ambulatory care sensitive conditions that could be preventable/avoidable with appropriate PC

31. Core Finding/Recommendation # 4: CARE COORDINATION/FRAGMENTATION Services are often fragmented, leading to poor care coordination service integration within or across service categories/sectors • DC residents travel significant distances to access hospital and specialty care services

32. Core Finding/Recommendation # 4: CARE COORDINATION/FRAGMENTATION Interestingly, DC residents also opt to travel significant distance to access primary care services, despite the fact there are other access points in their community

33. Core Finding/Recommendation # 4: CARE COORDINATION/FRAGMENTATION • Differential patterns of hospital utilization for privately insured and Medicaid insured

34. Core Finding/Recommendation # 5: BEHAVIORAL HEALTH INTEGRATION Need for integration of behavioral health screening, assessment, and treatment into medical care services of all types. • Mental health conditions was the second most common inpatient hospital discharge among all DC residents in 2014 • 3rd most common inpatient discharge for residents ages 0–17 • 2ndmost common inpatient discharge for patients ages 18-44 • 2ndmost common for African Americans/Blacks • Among Hispanic/ Latinx residents, schizophrenia and other psychotic disorders were the second most common inpatient discharge, followed by mood disorders • Roughly 1 in 4 adults reported as binge-drinkers

35. Core Finding/Recommendation # 5: BEHAVIORAL HEALTH INTEGRATION Need for integration of behavioral health screening, assessment, and treatment into medical care services of all types. • Mental health and substance abuse services continue to be siloed, leading to barriers to care and poor care coordination • Suicide 2nd most common cause of morbidity for adolescents • Need for broad awareness and education campaign regarding impacts, risk factors, signs, and symptoms of leading behavioral health issues (i.e., depression, anxiety, alcohol, and opioid use) • Need for evidence-informed, multi-sector strategies for those with behavioral health issues that promote recovery and independence

36. Core Finding/Recommendation # 6: EVIDENCE INFORMED/PLACE-BASED Evidence-informed and place-based strategies are critical to improving outcomes and addressing disparities • Major disparities in health outcomes by race/ethnicity and geography. • Need for targeted, evidence-informed strategies to address outreach, engagement, treatment, and self-management support.

37. Core Finding/Recommendation # 6: EVIDENCE INFORMED/PLACE-BASED Evidence-informed and place-based strategies are critical to improving outcomes and addressing disparities • Heart disease, mental health conditions, and respiratory diseases are the leading hospital conditions by discharge status

38. Core Finding/Recommendation # 7: HEALTH LITERACY AND EDUCATION Need for comprehensive health literacy, health education, and awareness campaign(s) • Extremely high rates or chronic disease, behavioral health issues, and many health risk factors combined with tremendous disparities among certain segments of population • Many segments of the population struggle with health literacy and lack basic levels of health literacy • Hispanics – 41% , American Indians/Alaskan Natives – 25%, African Americans/Blacks – 24%, Asian/Pacific Islanders – 13%, Whites – 9% • Older Adults - 29% • In DC, more than 20% of individuals in Wards 1, 2, 3, and 4 speak a second language at home.

39. Core Finding/Recommendation # 8: MULTI-SECTOR COLLABORATION Need to develop systems and structures that enhance collaboration and partnership across and within sectors • Expand existing relatively robust collaboratives currently in place and promote • Increasing understanding that sustainable solutions arise from multiple interacting factors • Organizations must actively coordinate actions, share lessons learned, and implement mutually reinforcing activities

40. Core Finding/Recommendation # 9: ALIGNMENT OF STRATEGY/PRIORITIES Alignment of priorities, core strategies, and messaging is critical to promoting cross sector collaboration • Sectors, agencies, organizations, service providers, community coalitions across spectrum must align priorities, goals, strategies, and measures • Establish multi-sector, District-wide priorities and develop detailed action plans. • Drive accountability by tracking and monitoring impact.

41. Health System Structures:Strategic Recommendations

42. Health System Structures: Recommendations • Promote multi-sector collaboration and strategic alignment within and across service systems and sectors. • Enhance population health surveillance. • Promote health literacy “universal precautions” to improve health outcomes. • Enhance health information exchange and technology systems in the District and surrounding region. • Support workforce training and capacity building efforts. • Explore sustainable financing structures to address SDOH, barriers to access and engagement, care coordination, and service integration.

43. Community Health Improvement:Strategic Recommendations

44. Community Health Improvement: Recommendations and Objectives/Strategies • Promote health equity by implementing policies and practices across all sectors that aim to address social determinants of health, improve health outcomes, and reduce disparities. • Support initiatives to expand affordable and safe housing. • Promote economic prosperity for low-income individuals and families. • Expand access to affordable and nutritious foods to promote healthy eating and reduce food insecurity. • Promote healthy aging.

45. Questions / Comments

46. Certificate of Need Facilitate SHPDA/SHCC implementation of CON and continue to align with health systems planning Goal Update CON chapter of HSP, including: • Six general criteria: 1) need, 2) accessibility, 3) quality, 4) acceptability, 5) continuity of care, and 6) financial impact • Focus on prioritized services: 1) primary care, 2) urgent care, 3) emergency departments, 4) home health, and 5) non-emergency medical transport Objective Process • Conducted background research • DC law and regulations • Regulations of and review of literature for prioritized services • Conducted interviews • Drafted CON chapter of HSP

47. Certificate of Need Findings • Identifying service-specific requirements: In reviewing other states, most prioritized services did not have specific requirements (if any) with the exception of Home Health • Convening workgroups: All states interviewed convened stakeholder workgroups to develop and maintain the service-specific requirements they did have • Calculating unmet need, capacity and utilization: In some states, CON staff collaborated with workgroups to calculate the additional need for services • CON national perspective: CON programs are continuing to change in conjunction with health reform efforts, often requiring robust data systems Approach • Clarified definitions and requirements for six criteria • Developed service-specific sections, with recommendation to refine through workgroups in the future

48. Certificate of Need: Summary of Changes to HSP • Identified National Standards: Not comprehensive • General Criteria: Combined definitions and requirements for six criteria, reorganized criteria, and updated requirements • Compliance: Drafted compliance requirement – all applicants should be in compliance with any existing certificate of need • Service Sections: Drafted sections for each of the five services including rationale, a definition, and specific requirements. Workgroups are recommended to make requirements more specific.

49. Certificate of Need: Criteria Definitions and requirements have been aligned. Requirements have been organized to reduce redundancy.

50. Certificate of Need: Specific Services Current draft chapter requires applications that include the following services to address service-specific requirements: