Find out about HealthierHere and our goals in the future
“I am only well if you are well” – African Proverb
What does HealthierHere do?
HealthierHere is a King County-wide partnership committed to working in new ways to improve the health and well-being of our residents. At the heart of our work is an understanding that many factors affect our health.
We bring together behavioral health and primary care providers, community health centers, hospitals and health systems, social service agencies and community-based organizations to build better systems that improve the health of people in King County.
We’re one of nine developing Accountable Communities of Health that together cover the entire State of Washington in partnership with the Healthier Washington initiative which seeks to transform health and health care.
What are Accountable Communities of Health?
Accountable Communities of Health (ACHs) are regional collaboratives committed to improving health and health equity. ACHs bring together health and social service partners, provide local oversight around population health and wellness, and support initiatives such as the Medicaid Transformation Project. We are one of nine ACHs in Washington State working to develop the systems and linkages needed to improve the health and social services delivery systems and fully address people’s care needs.
Learn about our work
What is the Medicaid Transformation Project?
The Medicaid Transformation Project (MTP) is a five-year agreement between Washington State and the federal government that provides federal investment into regional Medicaid delivery system improvement projects. This effort focuses on large scale system transformation to improve care for the whole person, reduce barriers to care, and use resources more wisely.
As part of the Medicaid Transformation Project, HealthierHere is working to:
- Develop transformation projects that target regional healthcare challenges
- Submit required deliverables to the Washington State Health Care Authority
- Distribute incentive funds to partnering providers for their achievement of defined milestones
- Partner with community members to ensure community voice and equity are embedded in this work
- Coordinate & oversee the work in partnership with local partner organizations
HealthierHere is transforming the way health care is delivered to thousands of residents in King County. We work across medical, behavioral health, social service, and community to build a welcoming, accessible, and integrated delivery system that fosters health and wellness for all.
What is our approach?
We are working on a portfolio of projects that have been approved by the Washington State Health Care Authority: promoting integrated whole person care, care transitions for those leaving jail and hospitals, enhanced services and treatment for Opioid Use Disorder (including improved prescribing practices) and expanded community and self-management support for those with chronic conditions.
We have also identified cross-cutting elements that are foundational to our work. These foundational elements include community-based care coordination, addressing the social determinants of health, improving equity, and reducing disparities.
At the end of the day, HealthierHere and its partners want to make transformative change in our region to prevent disease, promote well-being, and improve the quality of life for Medicaid members in our region.
Over the next several years of the Medicaid Transformation Project, we will be working on the following:
- Collaboration between the health care system and social services, linked by an inter-connected Health Information Technology/Health Information Exchange system connecting providers from both systems and payment models that incorporate social service providers.
- Access to person-centered, multi-disciplinary, culturally competent care teams – inclusive of social services – in health homes for everyone, regardless of where a person enters the system.
- Infrastructure that provides an effective mechanism for meaningful community and consumer involvement and voice in the continuous improvement of the delivery system.
If we are successful, HealthierHere and our partners will have catalyzed transformational change in our region to build a welcoming, accessible, and integrated delivery system that fosters health and wellness for all.
Integrated Whole Person Care
Bi-directional Integration of Physical and Behavioral Health: Integrated Whole Person Care
Preliminary Focus Population:
All Medicaid beneficiaries (children and adults), particularly those at risk for behavioral health conditions, including mental illness and/or substance use disorder.
- Improve access to behavioral health treatment through enhanced screening, identification, and treatment of behavioral health disorders in primary care settings.
- Improve access to physical health services for individuals with chronic behavioral health conditions through increased screening, identification, and treatment of physical health disorders in behavioral health care settings.
- Improve active coordination of care among medical and behavioral health providers and address barriers to care.
- Align new bi-directional integration with successful existing community efforts, including addressing social determinants of health.
Bi-directional integration addresses key care gaps within both primary care and behavioral health settings through screening of the focus population to identify specific conditions, and then ensuring that those with identified conditions are connected to evidence-based/best practice treatment and care coordination.
Because behavioral health and health care are only modest predictors of health outcomes, and social determinants of health are significant contributors, HealthierHere will ensure that social determinants of health are addressed as part of the intervention process. HealthierHere works with consumers and community-based organizations to ensure that community health workers (CHWs) and/or peer support specialists are integrated as part of a multidisciplinary treatment team to assist with care coordination activities and linkages to services and supports. CHWs and/or peer support specialists also help to engage those who have an identified need but who have not, for a variety of reasons, accessed care because of barriers such as language or lack of understanding of how to navigate systems.
Increased and successful transitions for those leaving jail and hospitals
Transitional Care: Increased safe and successful transitions for those leaving jail and hospitals
Preliminary Focus Populations:
- Medicaid beneficiaries returning to the community from jail.
- Medicaid beneficiaries with serious mental illness or substance use disorder discharging from inpatient care (psychiatric hospital or substance use disorder residential treatment).
- Medicaid beneficiaries transitioning from hospitals, including older adults and people with disabilities.
- Increase access to community-based care coordinators and peer support specialists to ensure safe and successful transitions from institutional settings to the community.
- Ensure post-discharge connection between the individual and their care team, using a “warm hand-off.” Establish the care team connection for those who don’t yet have a primary health home.
- Improve transitional care services to reduce hospital or jail readmissions.
The “transition period”—the days and weeks following a person’s discharge from a institutional setting such as a hospital, psychiatric hospital, or jail—is a time of great vulnerability and risk. Proven, evidence-based approaches have shown that in-person guidance and support during this time can make the difference between a safe landing back in the home and community versus a preventable rebound back to a high-cost, high-intensity institutional setting.
Expanded access to appropriate services and treatment for Opioid Use Disorder and improved prescribing practices
Addressing the Opioid Crisis: Expanded access to appropriate services and treatment for Opioid Use Disorder and improved prescribing practices
Preliminary Focus Population:
The focus population for this project is Medicaid beneficiaries with Opiate Use Disorder (OUD) and additional beneficiaries who are screened for OUD who are not yet diagnosed.
Support the achievement of the state’s goals to reduce opioid-related morbidity and mortality through strategies that target prevention, treatment, and recovery supports including:
- Improved prescribing practices.
- Increased access to treatment.
- Overdose prevention.
- Long-Term Stabilization through use of recovery coaches.
This project will support sustainable health system transformation for the Medicaid population using the following four strategies:
- Improved Provider Prescribing Practices
Support providers to prescribe opioids appropriately and increase the number of providers trained on Washington State Agency Medical Directors Group (AMDG) Interagency Guideline of Prescribing Opioids for Pain, thereby resulting in a decrease in the number of individuals on high-dose chronic opioid therapy and individuals with concurrent sedative prescriptions.
- Increased Access to Treatment
Increase access to Medication Assisted Treatment (MAT) and overall substance use disorder (SUD) treatment, resulting in an increase in treatment penetration, and supporting individuals to receive treatment and recover from addiction. This includes improving low-barrier access to buprenorphine that provides for treatment on demand, and working with managed care organization (MCO) partners to identify value-based payment (VBP) models that support easier access to MAT.
- Overdose Prevention
Support community partners and other stakeholders through training and distribution of naloxone kits, resulting in a decrease in opioid-related deaths.
- Long-Term Stabilization through Use of Recovery Coaches
Provide ongoing recovery support for individuals with OUD and linkage to a primary health home, resulting in long-term stabilization to help individuals achieve their full potential. This includes increasing availability and access to recovery coaches and ensuring linkage to whole person care through a primary health home.
Expanded community and self-management supports for those with chronic conditions
Chronic Disease Prevention and Control: Expanded community and self-management supports for those with chronic conditions
Preliminary Focus Population:
Medicaid beneficiaries – adults and children – with or at risk of developing one of the following: chronic respiratory disease (including asthma and chronic obstructive pulmonary disease, or COPD) or cardiovascular disease (including type 2 diabetes).
- Integrate health system and community approaches to improve chronic disease management and control.
- Expand community and self-management supports for those with chronic conditions.
The Chronic Disease Prevention and Control Project integrates health system and community approaches to improve chronic disease management and control for individuals with chronic respiratory and/or cardiovascular diseases.
This project strategy proposes to:
- Use Community Health Workers (CHWs) to offer individuals additional support in culturally and linguistically appropriate ways. CHWs provide support where individuals are most comfortable, including in the home and community, and enable clinical providers to ensure that individual outcomes improve.
- Consult panel data and registries to find, educate, provide care for, and track individuals, focusing on self-management support and available community resources. Data will be stratified by disease, risk, and family need.
- Increase access to evidence-based self-management programs like the National Diabetes Prevention Program and Stanford Chronic Disease Self-Management Program. Participating in these community-based programs will help individuals proactively manage their disease, stay active, informed, and engaged in their care plan, and result in more productive interactions with the health system and improved outcomes
- Fully implement ICD-10 codes to track disease severity and use for value based payment in the future.
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