1. Date:
Presenter, Title
STRENGTHENING SYSTEMS
Social Determinants of Health
Date
Kristen West Fisher, VP of Programs

2. Our Region
Eastern Washington

3. Our Region
Eastern Washington

4. Our Region
Spokane County
86% White
Myanmar Marshall IslandsFormer Soviet
Union
Source: U.S. Census Bureau
Several Refugee Populations
5% Latino
2.3% Asian
1.7% AI/AN
3.7% Two or more races
0.4% Pacific Islander
1.7% Black or African American

5. Our Region
Life expectancy 10+
years shorter in
lower income areas
Spokane: Life Expectancy by
Neighborhood
Sources: Spokane Regional Health District; City-Data.com, accessed 9/16/2015
West Central
2013 Med. Income: $26,194
Avg. life expectancy: 74.49
Southgate
2013 Med. Income: $59,241
Avg. Life Expectancy: 84.01
East Central
2013 Med. Income: $37,098
Avg. Life Expectancy: 72.92
7.2
miles
4.6
miles

6. Our Region
Rural Counties
Adams County
• 61% Latino
• 35% under 18
years old
Lincoln County
• 22.9% over 65
years old
Ferry County
• 21.4% over 65
years old
Pend Oreille County
• 43% under 200%
FPL
Source: U.S. Census Bureau
vs. 13.6%
statewide
vs. 13.6%
statewide
vs. 30%
statewide
vs. 11.9%
statewide
vs. 22.9%
statewide

7. Our Region
Rural Disparities
Adams County
• 37% obesity
rate
Lincoln County
• 12% diabetes
rate
Ferry County
• 10% heart
disease rate
Pend Oreille County
• 45% high
cholesterol rate
Source: BHT Application, ACH Grant?
vs. 8%
statewide
vs. 5%
statewide
vs. 27%
statewide
vs. 40%
statewide

8. Healthcare Expenditures
Challenges and Opportunities

9. Value
National Health Expenditures
30% Waste
Source: Dale
Jarvis,
Sustainability:
Understanding the
Healthcare
Finance
Landscape,
presentation 2015.

10. Value
Regional Health Expenditures
$4 billion
is unnecessary
$900 million
• Overtreatment
• Redundant testing
• Pricing failures
• Poor quality
• Fragmented care
• Fraud
Source: DeLibero, Frank. Letting the Data Speak. www.lettingthedataspeak.com/county-health-
care-costs-washington-state-example/

11. Value
National Health Expenditures
~94M Covered
Lives in Medicaid by
2024
~72M Covered Lives
in Medicare
by 2024*
*Medicare Part A Enrollment
Source: Sustainability: Robin Arnold Williams, Understanding the National Landscape, presentation 2015.
Medicaid is the single largest source of coverage

12. State Health Expenditures
The Cost of Healthcare
Source: Washington State Health Care Authority.
http://www.hca.wa.gov/medicaid/reports/Documents/enrollment_totals.pdf
1.8 million currently
enrolled in WA

13. More Than Healthcare
Social Determinants of Health

14. Health Is More Than Healthcare
Healthcare Providers see only the
tip of the iceberg…
…but what’s
under the
water has a
profound
effect on the
health
outcomes

15. Health Is More Than Healthcare
What Determines Health?
Environment and
Behavior
60%
Healthcare
10%
Genetics
30%
• Quality, affordable housing
• Socioeconomic status
• Early childhood education
and quality schools
• Family and social supports
• Neighborhood safety and
accessibility
• Access to quality nutrition
• Education status

16. Health Is More Than Healthcare
Role of Education

17. Housing Is Healthcare
Breaking Down Silos

18. Housing in Our Region
• Affordable units per 100 extremely low-
income households:
Affordable Housing Shortage
24 19 32 47
Spokane Whitman
Adams, Ferry,
Lincoln, &
Pend Oreille
Stevens
Source: Urban Institute. Mapping America’s Rental Housing Crisis.
http://datatools.urban.org/features/rental-housing-crisis-map/

19. Current Priorities
Housing & Health Investments Spokane
Housing
City and County of Spokane:
$6.65M in 2014
Health
Medicaid expenditures:
$464M annually
Coordinated
Assessment
3%
Emergency
Shelter
11%
Homeless
Prevention
10%
Permanent
Supportive
Housing
28%
Rapid
Rehousing
34%
Transitional
Housing
14%
Source: City of Spokane
Source: DeLibero, Frank. Letting the Data Speak.
www.lettingthedataspeak.com/county-health-care-costs-
washington-state-example/

20. 519
366
16
115
16
1
A DULT S INDIVIDUA LS IN F A MILIE S Y OUT H
SPOKANE COUNTY POINT IN TIME COUNT 2015
Sheltered Unsheltered
Opportunity
Housing Demand
*PIT Count does not include chronically homeless individuals that are in
permanent supportive housing at the time of the count.
Total count non-chronic:
1033
Total count including
chronically homeless*:
1231
Source: HUD Point In Time Count, 2015.

21. Opportunity
Housing Supply
Spokane has made strides in meeting this need…
267
77
152
41
438
401
0
53
184
166
37
0
0
0
0
0
0
200
0
46
0
0
205
0
0
EMERGENCY OTHER PERMANENT
HOUSING
PERMANENT
SUPPORTIVE
HOUSING
RAPID REHOUSING TRANSITIONAL
SPOKANE
SPOKANE COUNTY HOUSING STOCK, 2014 HUD INVENTORY
Sum of Families
Sum of Adults
Sum of Youth
Sum of Veteran
Sum of Chronic
1562 non-emergency
beds total
687 permanent
875 non-permanent

22. Housing Types
• Emergency Shelter
– 90 days or less emergency shelter
• Rapid Re-Housing
– Vouchers and rent assistance for housing as
quickly as possible
• Transitional Housing
– Up to 24 months interim housing
• Permanent Supportive Housing
– Housing First concurrent w/ treatment
Varying Requirements and Timeframes

23. Opportunity
• 63 unsheltered and 135 sheltered chronically
homeless individuals (2015)
– Does not include chronically homeless individuals
already in Permanent Supportive Housing (481*)
• Permanent Supportive Housing stock: 610
beds
• Not enough beds left for the 198 chronically
homeless individuals
Chronic Homeless and Supportive
Housing
*Source: City of Spokane

24. Systems Approach
Seeing and Filling Gaps in the
Housing Stock
Father Bach Haven
II
The Marilee
On Track
15 units
Family housing
Avail. July 2016
51 Units
PSH/Housing First
Avail. 2016
51 Units
PSH/Housing First
Avail. 2016

25. Spokane Housing
• Housing type poorly matched to client needs
• Lack of sustainable funding for supportive
services
• Need to strengthen relationships with landlords
of potential rapid rehousing units
• Limited funding focuses on high risk instead of on
prevention
• Homeless Prevention rental assistance hasn’t
been effective in Spokane County
Opportunities for improvement

26. Service Delivery Networks
Integrating Systems

27. Transforming Systems
Our Approach
• Public-private co-investment and co-design
– Health, Housing, & Homelessness
– Better Health Together
– Family Impact Network
• Networked approach to service delivery
– Network hub administrator
– Network service delivery
– Show wins for multiple “bottom lines”
– East and West side intermediaries
• Performance driven payments

28. Systems Approach
• Utilize Accountable Communities of Health
– Tailored menu of care options
• Housing and community-based service
integration
– Increased capacity for supportive housing
– Increase access to long-term supports and
services
• Opportunity for local savings reinvestment
Medicaid Section 1115 Waiver

29. Systems Approach
• Highly skilled, flexibly deployed
• Specialty areas include:
– Outreach, Enrollment, and Connectors
– Culturally Connected CHWs
– Peer Model CHWs
– Behaviorally and/or Socially Complex
– Medically Complex/Chronic Disease Management
Community Health Workers*
*Nomenclature varies: Community Connector, Patient Navigator, Resource Specialist, et al

30. Integrating Systems
H3/Hotspotters Programs

31. Community Care Programs
3-year outcomes,
2015-2018
2015 Program
Measurements
Key Activities
Reduce ER visits for
BHT clients by 50%
Serve 2500
complex clients by
12/31/2015
Develop an
integrated
Community Care
Program to serve
highest utilizers
of ED, EMS, &
Medicaid by
4/30/15
Develop integrated process for
referrals, intake, client tracking, &
management
Develop adequate data sharing
agreements
Reduce EMS usage
for BHT clients by
50%
Build a financially sustainable
model
Deliver high
quality programs
& services to
complex clients
Dental Emergencies Needing
Treatment
Reduce per capita
Medicaid enrollee
expenditures in the
region by 15%
Family Assessment Response
Health, Housing, & Homelessness
Hot Spotters
Service Model Integration

32. Community Care Programs
Service Model Integration
3-Year Outcomes, 2015-2018
Reduction in
ER visits for
BHT clients
Reduction in
EMS usage for
BHT clients
Reduction in regional
per capita Medicaid
enrollee expenditures

33. H3
Community Care Programs
Problem: Perverse Policies
• Policies drive low-income
people to access high-cost
health care.
Opportunities: Cost Savings
• Medicaid/Medicare
• Emergency Room
• Criminal Justice System
• Child Welfare
Approach: Integrated
Service Delivery
• Co-investment
• Network hub administrator
• Rapidly adaptive

34. Connecting Housing & Health
Current State:
• Early positive results
• Networks developing, still
incomplete
Challenges:
• Creating a new way of doing
business
– Fitting people into program silos
– Accessing funding to operate
network
– Capturing savings
• Lack of specialized housing
Current State & Challenges

35. For more information
• http://www.betterhealthtogether.org
• http://www.empirehealthfoundation.org

36. Who We Are
• Private health conversion foundation formed in
2008
• $80 million in assets; $18 million annual grants
• Focus Areas:
Improving Health Outcomes
Growing Physician Supply
Strengthening Health Systems
Building Nonprofit Capacity
Empire Health Foundation

37. Discussion
• What opportunities do you see to improve
on this work?
• How can we better leverage work that is
already being done?