Community Record of Care for Accountable Communities of Health

January 28, 2016

Medicaid Transformation Project Proposals

Written by Duncan West


The state Health Care Authority (HCA) has requested $3 billion in federal Centers for Medicare and Medicaid Services (CMS) funds to transform the delivery of care to Medicaid enrollees in Washington. The application for the 115 Waiver Demonstration was submitted. HCA is now in discussions with CMS about the initiatives the grant would support. HCA updates on the status of the waiver request can be found here.

As part of the discussions with CMS the HCA requested short proposals for transformation projects. In the spirit of be careful what you ask for, they received 178 proposals, links to which can be found here. MIN-NS submitted two of the 20+ proposals focused on the North Sound.

MIN-NS proposals are based upon the ‘glue’ a regional Health Information Exchange can provide across providers of Project Name Wordcloudcare and services, regardless of payer.

  • Coordinating Jail Transitions and Care addresses the Medicaid enrollees who end up in local jails. Care delivered in jail is not covered by Medicaid and is not coordinated with care delivered either before booking, or after release. Medicaid enrollees with medical, behavioral or substance abuse problems in need of coordinated management get none of that while incarcerated or after release.
  • Integrating Community and Social Services into Care Coordination addresses the gap between medical/behavioral/substance abuse treatment providers and the agencies which deliver non-medical social services. Working with social service providers, MIN-NS proposes to deliver a secure means of coordinating communication about patient’s health and social determinants of health. We propose a secure means of Meals on Wheels or chore services staff to update a patient’s entire care team about patient need.

Both projects focus on MIN-NS’ strengths and experience connecting rural and not-so-rural care providers and their supporting community of social services. MIN-NS brings the state-wide EDIE connections to the broader care team in the community already, and is an early adopter of the new HCA Clinical Data Repository (CDR). MIN-NS has the advantage of providing care records for community patients across payers, care settings and care coordinators.

A locally based Health Information Exchange is key to ensuring providers have the best information about their patients regardless of payer. When a Medicaid enrollee gets a job with insurance, ages into Medicare coverage or goes to jail and their care becomes the responsibility of the jailing jurisdiction, their care needs remain, coordination of care is still critical. In the case of the newly employed, or the jail inmate, their circumstances may change and they may go back onto Medicaid.

In the communities we serve there are numerous social service and community groups who focus on populations which are in need because of their medical or behavioral care. Those organizations help with basic needs such as food, shelter and transportation have informal links with care providers. Those links are best exemplified by organizations such as the Skagit County Population Health Trust at our local level and statewide by organizations such as the North Sound Accountable Community of Health. Both organizations, like MIN-NS focus on the needs of the entire community, not just those enrolled in Medicaid. The MIN-NS’ proposals will focus on Medicaid enrollees, but the same support for care and services coordination will be available for all patients, regardless of payer.

Stay tuned to this blog for updates on the transformation project proposals and the processes of comment and acceptance by the state.