Care Coordination Agencies (CCAs)

As part of North Sound’s commitment to improving care coordination across partners who intersect with patients and clients, we are piloting a model that enhances communication and information sharing in real time. To that end, we have selected four Care Coordination Agencies (CCAs) in implementing a Community HUB to better align the delivery of care coordination services and resources.

We had more than 30 organizations apply to be CCAs, and selected these four organizations to begin piloting the work:

  • Compass Health
  • Northwest Regional Council
  • San Juan County (San Juan County Health and Human Services)
  • Sea Mar Community 

These four partners serve clients/patients in all five North Sound counties, and work across clinical and community settings, including work with tribal partners. Some of the initial work will include developing an Advisory Committee with representatives from other providers, referral sources, and community members.  Stay tuned for more on how you might remain involved as this work expands.

 

Introducing our 2018 Partners!

We had close to 70 applicants for our May 2018 Call for Partners!  The organizations below have successfully completed Milestone 1 and are moving forward to work on Implementation Plans for our region.

We are grateful for the time and commitment of all our partners!  The North Sound region is fortunate to have each of these serving here.

The names are listed as best we can with the IRS recognized name in parentheses. When we run reports on who has received funds, it will be by the IRS name that partners entered in the Financial Executor Portal. 

Organizations with their names bolded will be pilot sites for the Community HUB care coordination model. 

The Arc of Whatcom County
Arcora Foundation (Delta Dental of Washington)
Assured Independence
Bellingham Fire Department (City of Bellingham)
Brigadoon Service Dogs
Brigid Collins Family Support Center
Cascade Medical Advantage
Catholic Community Services of Western Washington
Center for Human Services
Children of the Setting Sun Productions
City of Everett
Community Action of Skagit County
Community Health Centers of Snohomish County
Compass Health
Consistent Care Services
Consumer Voices are Born
Edmonds Police Department (City of Edmonds)
Everett Housing Authority (City of Everett)
Family Care Network
Homage Senior Services (Senior Services of Snohomish County)
Island County (Island County Human Services)
Island Senior Resources (Senior Services of Island County)
Island Hospital
Lake Whatcom Residential and Treatment Center
Lifeline Connections
Lopez Island Family Resource Center
Lydia Place
Lynnwood Police Department (City of Lynnwood)
Medical Information Network 
Mt Baker Planned Parenthood
North County Regional Fire Authority
North End Medical Professional Corporation
North Sound Behavioral Health Organization
Northwest Regional Council
Northwest WA Indian Health Board
Opportunity Council
Orcas Community Resource Center (Orcas Family Connection)
Orcas Island Fire and Rescue (San Juan County Fire District #2)
PeaceHealth
Pioneer Human Services
Planned Parenthood of the Great Northwest
Positively Linked
Providence Health & Services
San Juan County (San Juan County Health and Human Services)
San Juan Island Emergency Medical Services
San Juan Island Family Resource Center
Sea Mar Community Health Centers
Skagit County (Skagit County Public Health Department)
Skagit Pediatrics
Skagit Regional Health (PHD 1 DBA Skagit Valley Hospital)
Snohomish County Fire District 7
Tulalip Bay Fire (Snohomish County Fire Protection District #15)
Snohomish County Human Services
Snohomish Health District
South Snohomish Fire & Rescue
Sunrise Services
Swedish Edmonds
Tulalip Health System (Tulalip Tribes) 
United General District 304 (Skagit CO PHD United General)
Unity Care NW
Verdant Health Commission (Public Hospital Dist 2 Snohomish)
Whatcom Alliance for Health Advancement 
WestCare Foundation
Whatcom County Emergency Medical Services (Whatcom County)
Whatcom County Health Department (Whatcom County)
Whatcom Family & Community Network
Whatcom Family YMCA
WhidbeyHealth (Whidbey General)
WSU Extension (Washington State University)
YMCA of Snohomish County

Call for CCAs Info Sessions

The first of two Call for CCAs Info Sessions took place on Monday, June 11.  Listen to the audio recording here (starts approx. 40 seconds in).

The second call was Monday, June 18.  Audio is unfortunately unavailable, however most questions should be answered in the document found here:  Pathway FAQ

Please feel free to reach out to kelly@northsoundach.org  with any further questions.

Call for Partners Info Sessions: Recordings & Transcripts Available

The audio recordings and transcripts are available for the Call for Partners Info Sessions which took place on May 23 and May 25.  We hope this information helps with the application process; please let us know if we can provide any further clarification or assistance!

Listen to May 23 (session 1): click for audio.  Read transcript: click for pdf.

Listen to May 25 (session 2): click for audio (first two questions missed — see transcript).  Read transcript: click for pdf.

Call for CCAs (Supplement Application)

North Sound ACH is seeking partners who are currently providing care coordination services in the North Sound region to the populations of focus described in the document linked below, that would like to serve as a Care Coordination Agency (CCA) within a Pathways HUB model.

Supplemental Application for Community-Based Care Coordination Agencies (CCA)

NOTE: This application is supplemental to the North Sound ACH Call for Partners. Any agency that is interested in becoming a Pathways Care Coordination Agency will also need to complete the North Sound ACH Call for Partners, found HERE.

FAQ from Convening of Community-Based Organizations

(The following questions were gathered from feedback of those who attended the Convening of Community-Based Organizations on May 1.)

Confidentiality concerns in care coordination/partnership

How will CFR 42 Pt. 2 (Substance Abuse Confidentiality Regulations) be addressed if co-occurring behavioral health (including Substance Use Disorder) is chosen as a population of focus?

Anyone involved with Substance Use Disorder (SUD) treatment with an SUD provider must have a CFR 42 part 2 compliant Release of Information (ROI).  Outreach-only work does not require an ROI, but once someone enters into treatment it is necessary. Newly updated CFR 42 part 2 language includes a provision that “all involved” in treatment can be included in an ROI.  A SUD provider (for example a counselor in an outpatient clinic) can most easily develop ROIs and communicate with a specific individual (identified in the ROI) in various other areas (housing, school, job development, medical).


Becoming a Pathways CCA

How many agencies per county will be chosen and what scope is intended? Where is the training?

The North Sound ACH is not designating a specific number of Care Coordinating Agencies (CCAs). The number of agencies in the network will be contingent upon the responses we get from our call for CCAs because 1) We’re using that call as a final refinement tool to figure out which agencies are available and have the capacity to do the work around our populations and 2) what is their geographical scope of service.

What resources will be given to the new CCAs to support their management of the program in their community and staffing of new community health workers/community care coordinators? And when will they be distributed?

The CCA staff who the agency designates as their Pathways care coordinator, will be trained in the Pathways model and software at no cost to the CCA. Existing staff of CCA agencies are candidates for being designated and trained as care coordinators. The Pathways HUB model creates the potential for additional sources of reimbursement or funding for the work of existing care coordinators, as well as additional funds flow for adding care coordinator staff capacity as the HUB network of referrals is developed.  While the Hub is providing startup funding and training for care coordinators, it is important that a CCA is able to illustrate their ability to sustain care coordinators in the future, and that the Hub is not their only source of funding.


Pathways Planning Process for Conducting Key Informant Interviews

When were key informant interviews conducted, and with whom? 

During the Pathways Community Hub planning phase (January – April 2018), an environmental scan and key informant interviews were conducted to build understanding of care coordination activities and populations served across the North Sound region. Key informant interviews are still ongoing and community input will still be sought out. So far,  interviews have included:

County Resource Centers in Island and San Juan County

Home Health Lead Agencies

The North Sound Behavioral Health Organization

Community Based Organizations such as: The Opportunity Council, Compass Health, Mt. Baker Planned Parenthood

North Sound ACH Leadership: Program Council

Medicaid Managed Care Plans

High Utilizer Group initiatives serving Skagit, Snohomish, Whatcom counties.

Information that helped shape population of focus selection was also gathered during the North Sound ACH Community Based Organization convening on 5/1. Additional information was gathering during consultation, engagement and strategic development input of state and national partners in launching the Pathways Hub model (including Foundation for Healthy Generations, Health Home Lead agencies, and The Pathways Hub Certification Institute, ACHs around Washington State, and other certified Hubs (NEON in La Grande, OR)).

Please contact us if you have additional questions.  Email Hillary and your email will be forwarded to the appropriate member of our team.

 

Convening of Community-Based Organizations

Earlier this month we hosted a convening for community-based organizations that work with people on Medicaid. It was wonderful to have the opportunity to share more about the ACH, make new connections, and discuss ideas with so many potential partners. 

As we move forward, we greatly value feedback and want to give room for additional questions or further discussion.  If you were able to join us, please take a few minutes to complete a brief survey here – we appreciate it!

If you weren’t able to attend, you can access materials here: click here to view the slides presented  and here to access the guide on Developing Community Care Coordination Pathways.

Meet our Tribal & Community Liaison!

North Sound ACH now has a Tribal & Community Liaison!

Candice Wilson, Quatz’ten aut, is from Lummi Nation. She has over 15 years of tribal governance experience and was hired to develop and foster relationships with tribal and community partners.

Candice has a Bachelor degrees in Tribal Governance and Business Management from Northwest Indian College and is currently is pursuing her Masters in Public Administration at Seattle University. She serves on the Ferndale School Board, with Whatcom Family & Community Network, Lummi Nation Services Organization, Children of the Setting Sun Productions, and RE Sources for Sustainable Communities. 

Candice also served on the Lummi Indian Business Council for nine years, with three years as the Vice Chairwoman, also serving as Lummi Nation Vote Coordinator, Lummi Child Support Program Case Manager, and Lummi Dislocated Workers Program Job Counselor. She’s the recipient of the Washington State Native American Coalition Against Domestic Violence & Sexual Assault Envision Spirit Award and Lummi Victims of Crime Honoring Our Champions Award.

Candice enjoys serving and celebrating our diverse communities, especially with our veterans and youth organizations.

Welcome, Candice!  We’re thankful you’ve joined our efforts.