Population Health & Wellbeing

Conceptual Model of ACH in context between State and Neighborhoods

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Population Health & Wellbeing par Mind Map: Population Health & Wellbeing

1. Supported Through

1.1. People at Geographic Scales

1.1.1. Neighborhoods

1.1.1.1. Neighborhood Functions

1.1.1.1.1. Health & Wellbeing

1.1.1.1.2. Care & Friendship

1.1.1.1.3. Creativity, Art & Recreation

1.1.1.1.4. Curiosity (Education/Learning)

1.1.1.1.5. Safety

1.1.1.1.6. Housing

1.1.1.1.7. Food

1.1.1.1.8. Material Goods

1.1.1.1.9. Utilities

1.1.1.1.10. Transportation

1.1.1.1.11. Work

1.1.1.1.12. Participatory Democracy (Governing the Commons)

1.1.1.2. Neighborhood Assets

1.1.1.2.1. Neighborhood Histories

1.1.1.2.2. Neighborhood Arts & Skills

1.1.1.2.3. Neighborhood Environments

1.1.1.2.4. Neighborhood Economies

1.1.1.2.5. Neighborhood Visions

1.1.1.2.6. Neighborhood Associations

1.1.1.2.7. Neighborhood Plans

1.1.1.3. Neighborhood Policies

1.1.1.3.1. Neighborhood Programs

1.1.1.4. Individuals

1.1.1.4.1. Basic Needs

1.1.1.4.2. Individual Paths (Birth - - - > Death)

1.1.1.4.3. Families

1.1.1.4.4. Friends

1.1.1.4.5. Neighbors

1.1.1.4.6. Neighborhood Associations

1.1.1.4.7. Employees

1.1.1.4.8. Consumer / Client

1.1.2. Communities (incorporated and unincorporated)

1.1.2.1. Community Policies

1.1.2.1.1. Community Programs

1.1.3. Districts

1.1.3.1. District Policies

1.1.3.1.1. District Programs

1.1.3.2. School Districts

1.1.3.3. Educational Service Districts (ESDs)

1.1.3.4. Libraries

1.1.3.5. Fire Districts

1.1.3.6. Hospital Districts

1.1.3.7. Public Health Districts

1.1.3.8. Community Health Assessment Boards

1.1.3.8.1. Community Health Improvement Planning

1.1.4. Counties

1.1.4.1. County Policies

1.1.4.1.1. County Programs

1.1.4.2. Stevens County

1.1.4.2.1. Stevens County Government

1.1.4.3. Spokane County

1.1.4.3.1. Spokane County Government

1.1.4.3.2. Priority Spokane - City or County?

1.1.4.3.3. The Zone (Spokane) -  City or County?

1.1.4.4. Pend Oreile County

1.1.4.4.1. Pend Oreile Government

1.1.4.5. Ferry County

1.1.4.5.1. Ferry County Government

1.1.4.6. Lincoln County

1.1.4.6.1. Lincoln County Government

1.1.4.7. Adams County

1.1.4.7.1. Adams County Government

1.1.4.8. Whitman County

1.1.4.8.1. Whitman County Government

1.1.5. ACH Regions

1.1.5.1. ACH Regional Policies

1.1.5.2. ACH Regional Programs

1.1.5.3. ACH Regional Projects

1.1.5.4. ACH Regional Processes

1.1.6. Washington State

1.1.6.1. State Policies

1.1.6.1.1. Healthier Washington

1.1.6.2. State Programs

1.1.6.3. State Projects

1.1.7. National

1.1.7.1. National Policies

1.1.7.1.1. Affordable Care Act (ACA)

1.1.7.2. National Programs

1.1.7.3. National Projects

1.2. Relevant Institutions

1.2.1. Government

1.2.1.1. Local Governments

1.2.1.1.1. Schools

1.2.1.1.2. Libraries

1.2.1.1.3. Fire Departments

1.2.1.1.4. Police Departments

1.2.1.1.5. Criminal Justice / Courts

1.2.1.1.6. Health Departments

1.2.1.2. WA State Government

1.2.1.2.1. WA Health Care Authority

1.2.1.2.2. WA Dept of Health

1.2.1.2.3. WA Dept. Social & Health Services

1.2.1.2.4. WA State Governor's Office

1.2.1.2.5. WA State Legislature

1.2.1.3. Federal Govenment

1.2.1.3.1. Dept. of Health and Human Services

1.2.2. Foundations, Philanthropies & NGOs

1.2.2.1. Empire Health Foundation

1.2.2.1.1. Empire Health Board Members

1.2.2.2. Prescription Drug Assistance Foundation

1.2.2.2.1. Spokane Prescription Access Network

1.2.2.3. Catholic Charities

1.2.2.3.1. Inpatient Assisters Program

1.2.2.4. Grant Funders

1.2.2.4.1. Federal

1.2.2.4.2. State

1.2.2.4.3. Local

1.2.2.4.4. Private

1.2.2.5. Service Providers

1.2.2.5.1. Transitional Programs for Women (Transitions)

1.2.3. Access to care and Care Coordination

1.2.3.1. Process Access

1.2.4. Health Systems and Provider Organizations

1.2.5. Health Plans

1.2.5.1. Washington MCOs

1.2.6. WSU Extension

1.2.7. YWCA

1.2.7.1. YWCA of Spokane

1.2.7.1.1. YWCA of Spokane Domestic Violence Advocate

1.2.8. Community Health Assessment Board ???

1.2.9. Spokane Homeless Coalition

1.2.9.1. Members

1.2.9.1.1. Aging and Long Term Care of Eastern Washington

1.2.9.1.2. Ameirgroup

1.2.9.1.3. Center for Justsice

1.2.9.1.4. Children's Administration

1.2.9.1.5. City of Spokane

1.2.9.1.6. City of Spokane - Public Defencer

1.2.9.1.7. Community Health Plan of Washington

1.2.9.1.8. Family Promise of Spokane

1.2.9.1.9. Frontier Behavior Health - Homeless

1.2.9.1.10. Outreach

1.2.9.1.11. Gather Place

1.2.9.1.12. House of Charity

1.2.9.1.13. Martin Luther King Jr. Center

1.2.9.1.14. Monina Health Care

1.2.9.1.15. NW Justice Project

1.2.9.1.16. Priority Spokane

1.2.9.1.17. Safe Families for Children

1.2.9.1.18. Spokane COPS

1.2.9.1.19. Spkane Police Department

1.2.9.1.20. Transitoan Programs for Women - New Leaf Bakery

1.2.9.1.21. Women's Hearth

1.2.9.1.22. Worksource

1.2.9.1.23. YWCA

1.2.10. County Medical Society

1.2.11. Head Start

1.2.12. Economic Development

1.2.13. Businesses

1.3. Social Services

1.3.1. Basic Needs Services

1.3.1.1. Care & Friendship

1.3.1.1.1. Social Support Institutions

1.3.1.2. Creativity, Art & Recreation

1.3.1.3. Safety

1.3.1.3.1. Safety Institutions

1.3.1.4. Stable Housing

1.3.1.4.1. Institutions

1.3.1.5. Food

1.3.1.5.1. Institutions

1.3.1.6. Material Goods

1.3.1.7. Utilities

1.3.1.8. Transportation

1.3.1.8.1. Transportation Institutions

1.3.1.9. Work

1.3.1.9.1. Employment Institutions

1.3.1.10. Money

1.3.1.10.1. Financial Aid Institutions

1.3.1.10.2. Path Navigation Institutions

1.3.1.11. Paths

1.3.1.11.1. By Age or Condition

1.4. Medical Services

1.4.1. Institution Types

1.4.1.1. Physical Medicine Type

1.4.1.1.1. Medical Center Type

1.4.1.1.2. Hospitals

1.4.1.1.3. Emergency Medical Services

1.4.1.1.4. Emergency Departments of Hospitals

1.4.1.1.5. Medical Clinics

1.4.1.1.6. Home Health Services

1.4.1.1.7. Medical Navigation, Access and Coaching

1.4.1.1.8. Pharmacies

1.4.1.1.9. Durable Medical Goods

1.4.1.2. Behavioral Health Type

1.4.1.2.1. Mental Health Type

1.4.1.2.2. Addiction & Recovery Type

1.4.1.2.3. Behavioral Health Organizations (Regional Support Networks {RNS})

1.4.1.3. Dental Health Type

1.4.1.3.1. DENT

1.4.1.4. Public Health Type

1.4.1.5. Purchasers

1.4.1.5.1. Payers

1.4.2. Paths

1.4.2.1. Children & Mothers Path Type

1.4.2.2. Measures

1.4.2.2.1. Actual, Capability, Potentiality

1.4.2.3. Addiction and Recovery Path Type

1.4.2.4. Behavioral Health Path Type

1.4.2.5. Acute Care Path Type

1.4.2.6. Chronic Condition Path Type

1.4.2.7. Complex / Chronic Medical Conditions Path Type

1.4.2.7.1. Diabetes

1.4.2.8. Senior Services Path Type

1.4.2.9. Palliative Care

1.4.2.10. End of Life

1.4.2.10.1. Hospice

1.4.2.11. Screening Path Type

1.4.2.11.1. Substance use

1.4.2.12. Prevention Path Type

1.4.3. Value Based Purchasing

1.4.4. Technology Infrastructure

1.4.4.1. Telemedicine

1.4.4.2. Medical Referral Platform

1.4.4.3. Health Information Exchange

1.4.5. Generic Medical Process

1.4.5.1. Makes Offer

1.4.5.1.1. Presents with request(s) or condition(s)

1.4.6. Senior Services

1.4.7. Children, Mothers & Families

1.4.7.1. Child Advocacy Center

1.4.7.2. Partners with Families and Children

1.4.7.3. Northwest Autism Center

1.4.8. Addiction and Recovery

1.4.8.1. Youth

1.4.8.1.1. Daybreak Rapid Response Program

1.4.9. Behavioral Health

1.4.10. Complex / Chronic Medical Conditions

1.5. ACH Functions

1.5.1. Governance

1.5.1.1. BTH Leadership Council

1.5.1.1.1. BTH Leadership Council Members

1.5.1.2. BTH Board

1.5.1.2.1. BHT Board Members

1.5.1.3. Community Health Needs Assessment

1.5.1.3.1. Community Health Improvement Plan

1.5.1.3.2. See SRHD Indicators too

1.5.1.3.3. Community Commons Data

1.5.2. Shared Infrastructure

1.5.2.1. Infrastructure Management

1.5.2.2. Communication Technology Infrastructure

1.5.2.2.1. Community Referral Data Integration

1.5.2.2.2. Care Coordination and Case Management Platform

1.5.2.2.3. Mobile Personal Healht Record

1.5.2.2.4. Telehealth Platforms

1.5.3. Stakeholders

1.5.3.1. Governments

1.5.3.2. Neighborhoods

1.5.3.3. Individuals

1.5.3.4. Social Services

1.5.3.5. Medical Services

1.5.3.6. Private Institutions

1.5.3.7. Funding Entities

1.5.3.8. Members

1.5.4. Shared Purposes

1.5.4.1. Shared Purposes Methods

1.5.4.1.1. Community Health Improvement Planning

1.5.5. Agreements on Actions

1.5.5.1. Agreement Management

1.5.6. Measures

1.5.6.1. Policy Measures

1.5.6.1.1. Actual, Capability, Potentiality

1.5.6.2. Program Measures

1.5.6.2.1. Actual, Capability, Potentiality

1.5.6.3. Project Measures

1.5.6.3.1. Actual, Capability, Potentiality

1.5.6.4. Process Measures

1.5.6.4.1. Actual, Capability, Potentiality

1.5.6.5. Examples

1.5.6.5.1. Reduce Dental No-show Rates

1.5.6.6. Root of root measures

1.5.6.6.1. Positive:Negative Affect Ratio

1.5.7. Communication

1.5.7.1. Communication Management

1.5.8. Conflict Management / Trust Management

1.5.9. BHT Programs

1.5.9.1. Dental Emergencies Needing Treatment (DENT)

1.5.9.2. FAR

1.5.9.3. H3

1.5.9.4. Health Homes

1.5.9.5. Hot Spotters

1.5.9.6. Community Health Workers Network

1.5.10. Paths

1.5.10.1. Path Management

1.5.10.1.1. Policies

2. Washington Nonprofits

2.1. Nonprofit Management Institute: Nancy Bacon

2.1.1. Nonprofit Management Institute Tools: Nancy Bacon

2.1.1.1. Independent Learning and Info

2.1.1.1.1. Online videos and tools

2.1.1.1.2. 501 Commons

2.1.1.2. Remote Learning

2.1.1.2.1. Webinars

2.1.1.2.2. Conference calls

2.1.1.3. Classroom Learning

2.1.1.3.1. Workshops

2.1.1.3.2. Pacing Events

2.2. Community Impact Project: Rick Anderson

2.2.1. Community Impact Project Tools: Rick Anderson

2.2.1.1. Dashboards

2.2.1.1.1. Education

2.2.1.1.2. Health

2.2.1.1.3. Social Services (tbd)

2.2.1.2. Local Impact Networks

2.2.1.2.1. Results-based accountability

2.2.1.2.2. Designation

2.2.1.2.3. Multi-sector value propositions

2.2.1.2.4. Start-up and scale

2.2.1.2.5. Recognize results (Results WA)

2.2.1.2.6. Policy influence

2.2.1.3. Funding Collaboratives

2.2.1.3.1. Statewide Capacity Collaborative

2.2.1.3.2. Health Philanthropy Partners

2.2.1.3.3. Philanthropy Forum

2.2.1.3.4. Braided public and private funding

2.2.1.3.5. Pay for Success and Social Impact Bonds

2.2.1.3.6. Health plan foundations (new collaborative)

2.2.1.3.7. Hospital Community benefit

2.2.1.3.8. Intermediaries

2.3. Communities Connect: Kristen West Fisher

2.3.1. Communities Connect Board

2.3.1.1. HCA and DOH (2)

2.3.1.2. Healthcare Foundations (2)

2.3.1.3. Accountable Communities of Health (2)

2.3.1.4. Healt plans (1)

2.3.1.5. Public health (1)

2.3.1.6. Medicaid experts (1)

2.3.1.7. Community collaborative experts (2)

2.3.2. Communities Connect Tools: Kristen West Fisher

2.3.2.1. Accelerate Local Action

2.3.2.1.1. Population health investments

2.3.2.1.2. Value-based purchasing

2.3.2.1.3. Adoption of common measure set

2.3.2.1.4. Primary care and behavioral health integration

2.3.2.1.5. Multi-sector operational supports

2.3.2.2. Create Liberating Frameworks

2.3.2.2.1. Health and social service linkages during care transitions

2.3.2.2.2. Implementation of transformation tools

2.3.2.2.3. Braided funding approaches

2.3.2.3. Leverage Statewide Affinity Groups

2.3.2.3.1. Area Agencies on Aging

2.3.2.3.2. Community Action

2.3.2.3.3. Housing Authorities

2.3.2.3.4. Critical Access Hospitals

2.3.2.3.5. Indian Country

2.3.2.4. Nurture National Partnerships

2.3.2.4.1. Healthcare Payment and Learning Action Network

2.3.2.4.2. 100 Million Healthier Lives

2.3.2.4.3. Communities Joined in Action

2.3.2.4.4. National Quality Forum

2.3.2.4.5. National Rural ACO Network

2.3.2.5. Communities Connect is a support system connecting

2.3.2.5.1. Local customization and priorities to consistent statewide impact

2.3.2.5.2. Pilots to scale and sustainability strategies

2.3.2.5.3. Meaningful data to Local Impact Networks

2.3.2.5.4. Local and regional voice to state policy

2.3.2.5.5. Results to investments

2.3.2.5.6. Bright spots to hots spots

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

3. PURPOSE of Healthy Washington

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

3.2. Dramatic reduction in health inequities through healthy living

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

3.4. Equitable and fair chance for everyone

3.5. Improved experience at work and at homve

4. Key Concepts

4.1. It is a Large Very Complex System!

4.1.1. Variety Matching approach to Problem Solving

4.1.1.1. Recursive, Nesting, Interleaving, Viable Systems Model

4.1.1.1.1. Communication as balancing Homeostats

4.1.1.1.2. Maximum creativity and coordination

4.1.1.1.3. Why?

4.1.1.1.4. Who?

4.1.1.1.5. How?

4.1.1.1.6. What?

4.1.1.2. Polycentric Governance

4.1.1.2.1. Governing the Commons

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

4.3. Compelling (entropic) Case for Cooperation

4.4. Criticality of a co-created Linkage Map

4.5. Criticality of Idealized Design

4.6. Program and Project Management

4.7. Process Improvement and Management

5. Invested in Local Action

5.1. County Comissioners

5.2. State Purchasers

5.3. Health Plans

5.4. ACHs

5.5. Linking Service Providers

5.6. Safety-net Health Systems

5.7. State Public Health

6. Local Actions

6.1. Population Health Investments

6.1.1. Policies

6.1.2. Programs

6.1.3. Projects

6.1.4. Processes

6.1.5. Children and Youth

6.1.6. Elderly

6.1.7. Community Development

6.1.8. Work, employment, business

6.2. Readiness for value-based purchasing

6.2.1. Policies

6.2.2. Programs

6.2.3. Projects

6.2.4. Processes

6.3. Incorporation of Common Measure Set

6.3.1. Policies

6.3.2. Programs

6.3.3. Projects

6.3.4. Processes

6.4. Clinical Support of Whole Person Integration

6.4.1. Policies

6.4.2. Programs

6.4.3. Projects

6.4.4. Processes

6.5. New Operational Infrastructure (Capacity Building)

6.5.1. Policies

7. Trip to Sweden

7.1. Governance

7.2. Management

7.3. Learning and Development

7.4. Infrastructure

7.5. Finance

7.6. Measurement

8. Prinicples

8.1. Person Matters

8.1.1. Respect

8.1.2. Maximum Freedom of Choice

8.2. Place Matters

8.3. Duration of Commitment Matters

8.4. Trusting Matters

8.5. Community, Communication & Collaboration

8.5.1. Who is we and where is home?

8.5.2. Communication as Homeostats.

8.5.3. Nested and Recursive Structure for collaboration at scale.

8.6. Systems & Relationships

8.6.1. It is a Network

8.6.1.1. It should be understood as a Network

8.6.1.2. It should be represented as a network

8.6.1.3. Network patterns (paths) are key to understanding and creativity

8.6.1.3.1. [Participates] as a key relationship in the graph

8.6.1.4. 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.

8.6.1.4.1. Discovering false limits is critical. Irrational fear, lack of experience or lack of curiosity as social or organizational limits is not acceptable.

8.6.2. Parallel vs. Prioritized Serial Processing

8.6.3. Social System Dynamics: Beauty, Ethics, Knowledge, Economy and Power

8.6.3.1. Idealized Design

8.6.4. System Dynamics

8.6.4.1. Sound Strategic Sequence

8.6.5. Sustainability (Stewardship)

8.6.6. Assessment / Measurement for Action and Coherence / Balance

8.6.6.1. Baldrige framework for Whole Health Community

8.6.6.1.1. Baldrige Categories

8.6.7. Beer's Viable System Model

8.6.7.1. Operations

8.6.7.1.1. Baldrige: Workforce Focus

8.6.7.1.2. Baldrige: Customer & Market Focus

8.6.7.2. Coordination

8.6.7.2.1. Baldrige: Process Management

8.6.7.3. Management

8.6.7.3.1. Baldrige: Results

8.6.7.4. Auditing

8.6.7.5. Development & Innovation

8.6.7.5.1. Baldrige: Measurement, Analysis and Knowledge Management

8.6.7.5.2. Baldrige: Strategic Planning

8.6.7.5.3. Baldrige: Long Term Customer & Market Focus

8.6.7.6. Senior Leadership

8.6.7.6.1. Baldrige: Leadership (for Identity, Balance near-term and long-term)

8.6.7.7. Algedonic Channel

8.7. Participation

8.7.1. The intersection of Freedom and Solidarity

8.8. Abiltiy for direct action matters

8.8.1. Not building docks for cargo cults ships

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

9. Speculative Models

9.1. Tripod Beta

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

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

9.2.1. Type Government

9.2.1.1. National

9.2.1.2. State

9.2.1.3. County

9.2.1.4. City

9.2.1.5. Community

9.2.1.6. Neighborhood

9.2.2. Map Thurston Thrives Parts and Relationships

9.2.3. Citizen Actions

9.2.3.1. Vote

9.2.3.1.1. Policies

9.2.3.1.2. Legislators

9.2.3.1.3. Executives

9.2.3.1.4. Administrators

9.2.3.1.5. Judges

9.2.3.2. Sue

9.2.3.3. Protest

9.2.3.4. Advocate

9.2.3.5. Lobby

9.2.3.6. Organize

9.2.3.7. Testify / Present in Public Forum

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

9.4. Philanthropy Focus Areas for Upward Mobility

9.4.1. 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

9.5. The par

10. Viable ACHs???!! Viable Neighborhoods?

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

10.1.1. Policies

10.1.2. Principles

10.1.3. Identity

10.2. WHO? (three recursions at least)

10.2.1. Politics

10.2.2. Stakeholders

10.3. HOW? (systems 4 and 2)

10.3.1. MODELS / NETWORKS

10.3.2. Core Infrastructure

10.3.2.1. Necessary AND Sufficient

10.3.3. Methods

10.3.4. Roles & Competencies

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

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