During the last breakout session of the day, at Edge of Amazing 2016, a panel came together to discuss the interdependencies that are not the responsibility of any single organization, but are required if we want to achieve population health. They featured the many ways community is linking to the delivery system, including an overiew of the Plan for Improving Population Health and the Practice Transformation Support Hub. Mary Beth Brown, WA State DOH Maria Courogen, WA State DOH Dr. Gary Goldbaum, Snohomish Health District Linda McCarthy, Mt. Baker Planned Parenthood

1. Connecting Community to
the Delivery System
Healthier Washington is the state’s vision for transforming the health
care system to achieve better health, better care and lower costs for the
people of Washington State.

2. The Healthier Washington Initiative
The goals of Healthier Washington are simple:
• Healthier people and communities
• A transformed health care system that treats the whole person
• Affordable care

3. The Healthier Washington Initiative
• Healthier Washington is employing three overarching strategies to
achieve its transformation goals:
• Supporting multi-sector engagement
• Integrating care and social supports
• Paying for value

4. We know that health is more
than health care
Adapted from: Magnun et al. (2010). Achieving Accountability for Health and Health Care: A
White Paper, State Quality Improvement Institute.. Minnesota.

6. The Practice Transformation Support Hub
Goals of the “The Hub”
• Engage providers to connect to and build an integrated system of care that
addresses the needs of the whole person, including behavioral health needs
• Assist providers to respond to Value-based Payment Models
• Support providers to link to community resources for their patients

7. Components of The Hub
• Practice Coaching, Facilitation and Training Program
• Negotiating contract with Qualis Health
• Regional Health Connectors, a Health Extension Network
• Negotiating contract with Qualis Health
• Web-Based Resource Portal
• Led by University of Washington Primary Care Innovation Lab

8. Role of the Regional Connectors
• How will Connectors improve community-clinical linkages?
• An ambassador from the Community to the Providers
• A voice to the community from the Providers
• Inventory and track local resources
• Refer and connect providers to resources
• Track provider requests and needs
• Share successes and gaps in resources with the community

9. An Accountable Community of Health &
The Plan for Improving Population Health
Gary Goldbaum, MD, MPH September 9, 2016

10. The Vision of the North Sound ACH
A coalition with the triple aim of transforming the health system:
 to improve the health of our communities and our people
 to improve the experience of care and access to care
and to lower per capita health care costs
in Snohomish, Skagit, San Juan, Island and Whatcom counties

11.  We can accomplish more together than we can individually
 Trust, respect, transparency, continuous learning, and data-driven decision-making
 Collaboration between sectors is key
 Communities must be engaged to shape strategies
 The way care is currently organized and delivered will not be effective in achieving our shared aim
 To improve overall community health we need to go upstream
The Guiding Principles of the North Sound ACH

12. The Process for the North Sound ACH
 Build on existing strengths, experiences and successes
 Align efforts with existing state, county or local priorities, outcomes, strategies and metrics.
 Create measurable goals and ensure accountability towards outcomes
 Ensure that our plan is clear, robust, well-researched, inclusive, and actionable, yet practical

13. North Sound ACH Governing Body
page 1 of 2
Name Title Sector Geographic area
Carl Bruner, EdD Superintendent, Mt. Vernon School District Education Skagit
Bob Burden, RHU Marketing Development Director, Group Health Cooperative Health Plans Regional
Federico Cruz-Uribe, MD VP of Clinical Affairs, SeaMar Primary Care Regional
Connie Davis, MD Chief Medical Officer, Skagit Valley Hospital Specialty Care, also Hospitals Skagit
Regina Delahunt, MS Director, Whatcom County Health Dept. Public Health Whatcom
Robin Fenn, PhD, LSW Research Dir., Snohomish Human Serv. SS&S, also Behavioral Health Snohomish
Scott Forslund, MBA Dir., Sno. County Health Leadership Coal. At large, also Hospitals Snohomish
Linda Gipson, PhD, RN Chief Nursing Officer, Whidbey General Hospital Hospitals Island
Stephen Gockley, JD Senior. Attorney, Northwest Justice Project Consumers Whatcom
Gary Goldbaum, MD, MPH
Vice Chair Health Officer, Snohomish Health Dist. Public Health Snohomish
Erin Hafer
New Programs Integration Manager, Community Health Plan of
Washington Health Plans Regional
Keith Higman, MPH Director, Island County Health Department Public Health Island
Justin Iwasaki, MD, MPH Director, Lummi Tribal Health Center Lummi Nation Whatcom
Jennifer Johnson Health Director, Skagit County At large Skagit
Tim Key Everett Division Chief, EMS First Responders Snohomish

14. North Sound ACH Governing Body
page 2 of 2Name Title Sector Geographic area
David Kincheloe, PhD Advisory Board Vice-Chair, North Sound Mental Health Administration Consumers, also Behavioral Health Regional
Barbara LaBrash Human Services Manager, San Juan County Gov. SS&S San Juan
Debra Lancaster, MEd Executive Director, United Way of Skagit Consumers, also Philanthropy Skagit
Linda McCarthy Executive Director, Mt. Baker Planned Parenthood Specialty Care Whatcom, Skagit & San Juan
John Miller Health Administrator, Samish Nation Samish Nation Skagit
Dan Murphy Executive Director, Northwest Regional Council Long Term Care Whatcom, Skagit, SJ & Island
Suzanne Pak Korean Women’s Association Small Employers Snohomish
Chris Phillips
Director for Community Affairs & Strategic Communications, Peace
Health Hospitals Whatcom, Skagit, San Juan
Glenn Puckett, MPA Senior Program Officer, Washington Dental Service Foundation Specialty Care, also Philanthropy Regional
Marilyn Scott Vice Chair, Upper Skagit Tribe Upper Skagit Tribe Skagit
Jason Smith, MA Dean of Health Sciences & Public Safety, Everett Community College Education Snohomish
John Stephens Programs Administrator, Swinomish Tribe Swinomish Tribe Skagit
Joe Valentine, MSW
Chair Executive Director, North Sound Mental Health Administration Behavioral Health Regional
Kim Williams, RN Chief Operating Officer, Providence Hospitals Snohomish
Greg Winter Homeless Svc Ctr. Dir. Opportunity Council SS&S, also Housing Whatcom

15.  A population health resource for state and local partners
 An evolving toolkit of curated strategies and resources
 A source of current health status information
 Information on current population health work in our state
The Plan for Improving Population Health

16.  Available to all: www.doh.wa.gov/P4IPH
 Three health focus areas:
 Diabetes
 Obesity
 Tobacco
The Plan for Improving Population Health

17.  Within each health focus areas:
 Current work and initiatives
 Emerging issues
 Health equity concerns
 Data and sources
 Recommended strategies
The Plan for Improving Population Health

18. North Sound ACH – Early Win
“Prevention” Project – LARC
Long Acting Reversible
Contraception, reducing
unintended pregnancy

19. Why LARC?
Up to 50% of all pregnancies
are unintended;
78% for women under 20;
70% for women 20-24

20. Unintended
pregnancy may
be an indicator
of increased risk
for some poor
birth and
maternal
outcomes
Slide courtesy of: Mark G. Martens, MD, FACOG

21. Rank Principal diagnosis
Total national
hospital bill
private ins.
% of
national bill
Number of hospital
stays (thousands)
1 Mother’s pregnancy
and delivery
$30 Billion 7.9% 4,664
2 Newborn care $21 Billion 5.6% 791
3 Osteoarthritis $16 Billion 4.3% 919
4 Coronary artery disease $16 Billion 4.2% 4,391
5 Back pain (spondylosis,
intervertebral disc
disorders, other back
problems)
$15 Billion 3.9% 911
Slide courtesy of: Mark G. Martens, MD, FACOG

22. Unintended Pregnancy is a Risk Factor for
• Inadequate prenatal care
• Low birth-weights
• Exposure of the fetus to tobacco, alcohol and other
substances
• Neonatal death
• Domestic violence
• Child abuse
• Economic hardship
• Failure to achieve educational and career goals

23. North Sound ACH LARC Project Goals:
1. Train Providers (first training on 9/15/16) on how to:
• Utilize client centered contraceptive counseling best practices
• Incorporate patient centered reproductive life planning
• Clarify pregnancy intentions
• And inserting/implanting LARC when patients choose
2. Reach out to women to:
• Increase awareness of these highly effective contraception
options “get it and forget it”

24. Thank you!
Questions and discussion