Population Health & Wellbeing

Conceptual Model of ACH in context between State and Neighborhoods

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Population Health & Wellbeing by Mind Map: Population Health & Wellbeing

1. Washington Nonprofits

1.1. Nonprofit Management Institute: Nancy Bacon

1.1.1. Nonprofit Management Institute Tools: Nancy Bacon Independent Learning and Info Online videos and tools 501 Commons Remote Learning Webinars Conference calls Classroom Learning Workshops Pacing Events

1.2. Community Impact Project: Rick Anderson

1.2.1. Community Impact Project Tools: Rick Anderson Dashboards Education Health Social Services (tbd) Local Impact Networks Results-based accountability Designation Multi-sector value propositions Start-up and scale Recognize results (Results WA) Policy influence Funding Collaboratives Statewide Capacity Collaborative Health Philanthropy Partners Philanthropy Forum Braided public and private funding Pay for Success and Social Impact Bonds Health plan foundations (new collaborative) Hospital Community benefit Intermediaries

1.3. Communities Connect: Kristen West Fisher

1.3.1. Communities Connect Board HCA and DOH (2) Healthcare Foundations (2) Accountable Communities of Health (2) Healt plans (1) Public health (1) Medicaid experts (1) Community collaborative experts (2)

1.3.2. Communities Connect Tools: Kristen West Fisher Accelerate Local Action Population health investments Value-based purchasing Adoption of common measure set Primary care and behavioral health integration Multi-sector operational supports Create Liberating Frameworks Health and social service linkages during care transitions Implementation of transformation tools Braided funding approaches Leverage Statewide Affinity Groups Area Agencies on Aging Community Action Housing Authorities Critical Access Hospitals Indian Country Nurture National Partnerships Healthcare Payment and Learning Action Network 100 Million Healthier Lives Communities Joined in Action National Quality Forum National Rural ACO Network Communities Connect is a support system connecting Local customization and priorities to consistent statewide impact Pilots to scale and sustainability strategies Meaningful data to Local Impact Networks Local and regional voice to state policy Results to investments Bright spots to hots spots

1.4. Shared Tools (Pubic-private partnerships for Healthier Washington)

2. Key Concepts

2.1. It is a Large Very Complex System!

2.1.1. Variety Matching approach to Problem Solving Recursive, Nesting, Interleaving, Viable Systems Model Communication as balancing Homeostats Maximum creativity and coordination Why? Who? How? What? Polycentric Governance Governing the Commons

2.2. Criticality of a Safe Space/Place for visualizing, understanding and working on the Whole System Together

2.3. Compelling (entropic) Case for Cooperation

2.4. Criticality of a co-created Linkage Map

2.5. Criticality of Idealized Design

2.6. Program and Project Management

2.7. Process Improvement and Management

3. Trip to Sweden

3.1. Governance

3.2. Management

3.3. Learning and Development

3.4. Infrastructure

3.5. Finance

3.6. Measurement

4. Prinicples

4.1. Person Matters

4.1.1. Respect

4.1.2. Maximum Freedom of Choice

4.2. Place Matters

4.3. Duration of Commitment Matters

4.4. Trusting Matters

4.5. Community, Communication & Collaboration

4.5.1. Who is we and where is home?

4.5.2. Communication as Homeostats.

4.5.3. Nested and Recursive Structure for collaboration at scale.

4.6. Systems & Relationships

4.6.1. It is a Network It should be understood as a Network It should be represented as a network Network patterns (paths) are key to understanding and creativity [Participates] as a key relationship in the graph Mechanisms to see clearly chosen limits and stay within this is a must. Learning is the process of  discovering how best to stay within viable limits. Discovering false limits is critical. Irrational fear, lack of experience or lack of curiosity as social or organizational limits is not acceptable.

4.6.2. Parallel vs. Prioritized Serial Processing

4.6.3. Social System Dynamics: Beauty, Ethics, Knowledge, Economy and Power Idealized Design

4.6.4. System Dynamics Sound Strategic Sequence

4.6.5. Sustainability (Stewardship)

4.6.6. Assessment / Measurement for Action and Coherence / Balance Baldrige framework for Whole Health Community Baldrige Categories

4.6.7. Beer's Viable System Model Operations Baldrige: Workforce Focus Baldrige: Customer & Market Focus Coordination Baldrige: Process Management Management Baldrige: Results Auditing Development & Innovation Baldrige: Measurement, Analysis and Knowledge Management Baldrige: Strategic Planning Baldrige: Long Term Customer & Market Focus Senior Leadership Baldrige: Leadership (for Identity, Balance near-term and long-term) Algedonic Channel

4.7. Participation

4.7.1. The intersection of Freedom and Solidarity

4.8. Abiltiy for direct action matters

4.8.1. Not building docks for cargo cults ships

4.8.2. Ability and history of taking participatory action to improve your groups situation.

5. Speculative Models

5.1. Tripod Beta

5.1.1. [Unprotected]->(Target) + [Unconfined]-->(Hazard)-[Results_in]-->(Event)

5.2. (People)-[To]->(Government)

5.2.1. Type Government National State County City Community Neighborhood

5.2.2. Map Thurston Thrives Parts and Relationships

5.2.3. Citizen Actions Vote Policies Legislators Executives Administrators Judges Sue Protest Advocate Lobby Organize Testify / Present in Public Forum

5.3. Focus on Cross-Sector Infrastructure in support of citizens (consumers-products, customers-businesses, clients-services), students-schools, etc.) and neighborhoods.

5.4. Philanthropy Focus Areas for Upward Mobility

5.4.1. Support holistic child development from birth through kindergarten • Establish clear and viable pathways to careers • Decrease rates of over-criminalization and over-incarceration • Reduce unintended pregnancies • Create place-based strategies to ensure access to opportunity across regions • Build the capacity of social-service delivery agencies to continuously learn and improve

5.5. The par

6. Viable ACHs???!! Viable Neighborhoods?

6.1. WHY? (system 5, plus three recursions)

6.1.1. Policies

6.1.2. Principles

6.1.3. Identity

6.2. WHO? (three recursions at least)

6.2.1. Politics

6.2.2. Stakeholders

6.3. HOW? (systems 4 and 2)


6.3.2. Core Infrastructure Necessary AND Sufficient

6.3.3. Methods

6.3.4. Roles & Competencies

6.4. WHAT? (system 3, 3*, 2 & 1)

6.4.1. Ongoing Improvement and Management of: Purpose, Program, Project and Process for Results

7. Supported Through

7.1. People at Geographic Scales

7.1.1. Neighborhoods Neighborhood Functions Health & Wellbeing Care & Friendship Creativity, Art & Recreation Curiosity (Education/Learning) Safety Housing Food Material Goods Utilities Transportation Work Participatory Democracy (Governing the Commons) Neighborhood Assets Neighborhood Histories Neighborhood Arts & Skills Neighborhood Environments Neighborhood Economies Neighborhood Visions Neighborhood Associations Neighborhood Plans Neighborhood Policies Neighborhood Programs Individuals Basic Needs Individual Paths (Birth - - - > Death) Families Friends Neighbors Neighborhood Associations Employees Consumer / Client

7.1.2. Communities (incorporated and unincorporated) Community Policies Community Programs

7.1.3. Districts District Policies District Programs School Districts Educational Service Districts (ESDs) Libraries Fire Districts Hospital Districts Public Health Districts Community Health Assessment Boards Community Health Improvement Planning

7.1.4. Counties County Policies County Programs Stevens County Stevens County Government Spokane County Spokane County Government Priority Spokane - City or County? The Zone (Spokane) -  City or County? Pend Oreile County Pend Oreile Government Ferry County Ferry County Government Lincoln County Lincoln County Government Adams County Adams County Government Whitman County Whitman County Government

7.1.5. ACH Regions ACH Regional Policies ACH Regional Programs ACH Regional Projects ACH Regional Processes

7.1.6. Washington State State Policies Healthier Washington State Programs State Projects

7.1.7. National National Policies Affordable Care Act (ACA) National Programs National Projects

7.2. Relevant Institutions

7.2.1. Government Local Governments Schools Libraries Fire Departments Police Departments Criminal Justice / Courts Health Departments WA State Government WA Health Care Authority WA Dept of Health WA Dept. Social & Health Services WA State Governor's Office WA State Legislature Federal Govenment Dept. of Health and Human Services

7.2.2. Foundations, Philanthropies & NGOs Empire Health Foundation Empire Health Board Members Prescription Drug Assistance Foundation Spokane Prescription Access Network Catholic Charities Inpatient Assisters Program Grant Funders Federal State Local Private Service Providers Transitional Programs for Women (Transitions)

7.2.3. Access to care and Care Coordination Process Access

7.2.4. Health Systems and Provider Organizations

7.2.5. Health Plans Washington MCOs

7.2.6. WSU Extension

7.2.7. YWCA YWCA of Spokane YWCA of Spokane Domestic Violence Advocate

7.2.8. Community Health Assessment Board ???

7.2.9. Spokane Homeless Coalition Members Aging and Long Term Care of Eastern Washington Ameirgroup Center for Justsice Children's Administration City of Spokane City of Spokane - Public Defencer Community Health Plan of Washington Family Promise of Spokane Frontier Behavior Health - Homeless Outreach Gather Place House of Charity Martin Luther King Jr. Center Monina Health Care NW Justice Project Priority Spokane Safe Families for Children Spokane COPS Spkane Police Department Transitoan Programs for Women - New Leaf Bakery Women's Hearth Worksource YWCA

7.2.10. County Medical Society

7.2.11. Head Start

7.2.12. Economic Development

7.2.13. Businesses

7.3. Social Services

7.3.1. Basic Needs Services Care & Friendship Social Support Institutions Creativity, Art & Recreation Safety Safety Institutions Stable Housing Institutions Food Institutions Material Goods Utilities Transportation Transportation Institutions Work Employment Institutions Money Financial Aid Institutions Path Navigation Institutions Paths By Age or Condition

7.4. Medical Services

7.4.1. Institution Types Physical Medicine Type Medical Center Type Hospitals Emergency Medical Services Emergency Departments of Hospitals Medical Clinics Home Health Services Medical Navigation, Access and Coaching Pharmacies Durable Medical Goods Behavioral Health Type Mental Health Type Addiction & Recovery Type Behavioral Health Organizations (Regional Support Networks {RNS}) Dental Health Type DENT Public Health Type Purchasers Payers

7.4.2. Paths Children & Mothers Path Type Measures Actual, Capability, Potentiality Addiction and Recovery Path Type Behavioral Health Path Type Acute Care Path Type Chronic Condition Path Type Complex / Chronic Medical Conditions Path Type Diabetes Senior Services Path Type Palliative Care End of Life Hospice Screening Path Type Substance use Prevention Path Type

7.4.3. Value Based Purchasing

7.4.4. Technology Infrastructure Telemedicine Medical Referral Platform Health Information Exchange

7.4.5. Generic Medical Process Makes Offer Presents with request(s) or condition(s)

7.4.6. Senior Services

7.4.7. Children, Mothers & Families Child Advocacy Center Partners with Families and Children Northwest Autism Center

7.4.8. Addiction and Recovery Youth Daybreak Rapid Response Program

7.4.9. Behavioral Health

7.4.10. Complex / Chronic Medical Conditions

7.5. ACH Functions

7.5.1. Governance BTH Leadership Council BTH Leadership Council Members BTH Board BHT Board Members Community Health Needs Assessment Community Health Improvement Plan See SRHD Indicators too Community Commons Data

7.5.2. Shared Infrastructure Infrastructure Management Communication Technology Infrastructure Community Referral Data Integration Care Coordination and Case Management Platform Mobile Personal Healht Record Telehealth Platforms

7.5.3. Stakeholders Governments Neighborhoods Individuals Social Services Medical Services Private Institutions Funding Entities Members

7.5.4. Shared Purposes Shared Purposes Methods Community Health Improvement Planning

7.5.5. Agreements on Actions Agreement Management

7.5.6. Measures Policy Measures Actual, Capability, Potentiality Program Measures Actual, Capability, Potentiality Project Measures Actual, Capability, Potentiality Process Measures Actual, Capability, Potentiality Examples Reduce Dental No-show Rates Root of root measures Positive:Negative Affect Ratio

7.5.7. Communication Communication Management

7.5.8. Conflict Management / Trust Management

7.5.9. BHT Programs Dental Emergencies Needing Treatment (DENT) FAR H3 Health Homes Hot Spotters Community Health Workers Network

7.5.10. Paths Path Management Policies

8. PURPOSE of Healthy Washington

8.1. Dramatic improvement in health of whole population, at a lower total cost

8.2. Dramatic reduction in health inequities through healthy living

8.3. Everyone has timely access to high quality medical, behavioral health and social services.

8.4. Equitable and fair chance for everyone

8.5. Improved experience at work and at homve

9. Invested in Local Action

9.1. County Comissioners

9.2. State Purchasers

9.3. Health Plans

9.4. ACHs

9.5. Linking Service Providers

9.6. Safety-net Health Systems

9.7. State Public Health

10. Local Actions

10.1. Population Health Investments

10.1.1. Policies

10.1.2. Programs

10.1.3. Projects

10.1.4. Processes

10.1.5. Children and Youth

10.1.6. Elderly

10.1.7. Community Development

10.1.8. Work, employment, business

10.2. Readiness for value-based purchasing

10.2.1. Policies

10.2.2. Programs

10.2.3. Projects

10.2.4. Processes

10.3. Incorporation of Common Measure Set

10.3.1. Policies

10.3.2. Programs

10.3.3. Projects

10.3.4. Processes

10.4. Clinical Support of Whole Person Integration

10.4.1. Policies

10.4.2. Programs

10.4.3. Projects

10.4.4. Processes

10.5. New Operational Infrastructure (Capacity Building)

10.5.1. Policies