Suzie Shupe, CEO
Redwood Community Health Coalition
Redwood Community Health Network
[email protected]
707-285-2974
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Background on RCHC
Community Health Center (CHC) transformation to
Value Based Care (VBC)
Patient Centered Medical Homes & Care Teams
Interconnectivity among CHCs and greater system
Accountable Care Organization
Collaboration with hospitals
Other key initiatives focused on integrated services
FQHC Members
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Alliance Medical Center
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Alexander Valley Healthcare
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Coastal Health Alliance
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CommuniCare Health Centers
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Marin Community Clinic
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Marin City Health & Wellness Center
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Ole Health
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Petaluma Health Center
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Ritter Health Center
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Santa Rosa Community Health Centers
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Sonoma Valley Community Health Center
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West County Health Centers, Inc.
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Winters Healthcare Clinic
Non-FQHC Members
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Jewish Community Free Clinic
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Planned Parenthood Shasta Pacific
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Sonoma County Indian Health Project
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St. Joseph Health System, Mobile Health
RCHC comprises 17
health center members
with over 40 service
delivery sites in Napa,
Sonoma, Marin and Yolo
counties
RCHC’s service area
covers a total of 4,407
square miles and 1.1
million people*
*Sonoma: 1,768 sq mi; population
500,293
*Napa: 788 sq mi; population 141,667
*Marin: 828 sq mi; population 260,750
*Yolo: 1,023 sq mi; population 207,590
*Source: 2014 US Census Bureau
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RCHC health centers delivered 912,350 medical, mental
health and dental visits to over 242,000 patients in 2014.
RCHC health centers serve approximately 62% of all MediCal patients (130,000) and 71,000 uninsured in our fourcounty service area.
 74% of patients have incomes less than 200% of the
federal poverty level (FPL), and 56% are below 100% of
FPL
 52% of our patients are Latino
 35% are best served in a language other than English
 30% are uninsured
Source: 2014 OSHPD Data
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Coalition has long history of trust and
collaboration
Made a strategic decision to move CHCs
toward providing VBC and preparing for
Value Based Payment models
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Care Teams
All CHCs are implementing care teams
 Taking varied approaches
 National leaders
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Patient Centered Medical Home (PCMH)
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Currently 7 of 13 FQHC member health centers have PCMH
recognition
6 Connected Health Centers, > 120,000 patient records
Any EHR can connect
EXTERNALY hosted by vendor
Locally managed by RCHC
RCHIE planned activities for 2016:
 Internal health center data sharing
 Launch of provider portal
 Connection to hospitals for admit, discharge and transfer alerts
 Connection to Connect Healthcare and access to regional webbased portal
 Connecting additional member health centers
Petaluma
Santa
Rosa
Coastal
Clinic Ole
RCCO
RCHC
John
West
County
Canova,
MD
Alexander
Valley
Alliance
The Redwood
Community Care
Organization (RCCO)
Medicare Shared
Savings Program
(MSSP) ACO began
January 1, 2014
Our Framework: Five Accelerators
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Current risk stratification algorithms/tools do not
adequately weigh behavioral health diagnoses and
social determinants of health seen in our population
Health centers do not currently document and code
in a manner that fully characterizes the complexity of
patients (medical acuity, behavioral health codiagnoses, social determinants of health)
A Medicare ACO in the safety is different
from the average Medicare ACO
ACO Transformation
 Spread
of value based care principles learned
from Medicare ACO
 Shift of focus on population health strategies
to a broader population
 Joint analytics will be a key component of
that work
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“… a single, integrated mature solution that
meets all PHM (population health
management) IT needs does not exist in
today’s market.”
-Hunt et al. “Guide for Developing and Information Technology Road Map for
Population Heath Management” Population Health Management, Nov. 3,
2015
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Claims analysis
Predictive modeling
Risk stratification using a combination of
claims data and clinical review
Strategies specific to risk stratification
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Coordination of Patient Care
Real time utilization data
 Continuity of Care documents
 Admit, Discharge, Transfer feeds
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Care Transitions
Complex Care Management
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Integrating Behavioral Health into Primary Care
Increasing Access to Specialty Care
Complex Care Management
Addressing Social Determinants of Health
Local Programs for Remaining Uninsured in
Sonoma and Marin Counties