To: Organizations in Pierce County providing direct services to a clientele of which a significant proportion isMedicaid-eligible

From: Pierce County ACH

Date:8/28/2017

RE: Request for Proposals for Organizations to Hire Pathways Community Care Coordinators

Introduction

The Pierce County ACH is establishing a Pathways Community HUB to support a sustainable community-based care coordination system where Pathways Care Coordinators:

  • find members of the target populationat great riskof having serious health problems or adverse health outcomes;
  • connect them to appropriate care;
  • remove barriers to obtaining care and
  • measure the results.

The Pathways Community HUB model removes duplication through a singular technology system to track care coordinators and outcomes. Using the technology platform, care coordinators use the same checklist for every new client. Based on the checklist, risks of serious health problems or adverse outcomesare identified and treated using the same evidence-based “pathway.” Care Coordination Agencies (CCAs) get paid in anew way, where instead of being paid in 15-minute blocks of time, CCAs get paid based on the outcomes Care Coordinators achieve.

Opportunity

The Pierce County ACH will select employers to become Care Coordination Agencies (CCA). The ACH will support these CCAs to hire, train and employ Pathways Care Coordinators. Within this model, care coordinators are also referred to as Community Health Workers (CHWs). CHWs are trusted members of and/or have an unusually close understanding of the community they serve. This relationship enables CHWs to serve as a liaison, link, or intermediary between health/social services and their community to facilitate access to services and improve the quality and culture competence of service delivery. CHWs also build individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support, and advocacy.

Recognizing that the Pathways Community HUB model uses a new paymentsystem, Pierce County ACH will support organizations to make the transition to a new payment system. Employers who are selected will be eligible for funding to support the salary, benefits and operating costs of hiring and employing CHWs who have been trained, approved and are implementing the Pathways Community HUB model. The CHW must be employed to work on Pathways for a minimum of 20 hours/week for 12 months, but the best outcomes are gained by CHWs who work on Pathways full-time. If the CHW does not remain in the position for 12 months, unspent funds must be returned. When the funds have been spent, Pierce County ACH requires a complete accounting of how the funds were used.

For this initial pilot, funding will be based on the applying CCA’s size, based on annual operating budget. In this way, Pierce County ACH is attempting to take an equitable approach and will work with successful bidders with operating budget less than $30,000,000 to identify the necessary support. The size of the applying CCA will not change the scoring or assessment.

The final intention of the Pathways model is for outcome payments to cover the whole CHW salary. After the first year, the CCA will be responsible for the whole CHW salary.If the outcome payments do not cover these expenses, the organization is expected to sustain the position.

Important Deadlines

Learn more:Two sessions: morningof Wednesday, September 20, 2017 and evening of Thursday, September 21, 2017

This will be an open information session for interested CCAs to learn more about the Pathways Community HUB model, this RFP, and to gain greater clarity about a partnership between the applicant and the HUB. The same presentation will occur at each session.

Applications due: September 25, 2017

Announcement of Awards: September 28, 2017

Description of CHW Rolein the HUB

  1. Work in and according to the training provided on the Pathways Community HUB Model. This includes, but is not limited to: standardized in-take and risk assessment, assignment and administration of Pathways, timely documentation,use of the provided hardware and technology to report progress and outcomes, and attend trainings and meetings hosted by the Pierce County Pathways HUB.
  2. Establish a trusting relationship with the prioritized populations and referred clients. Extend the trusting relationship to be inclusive of CHW HUB partners.
  3. Identify and assist patients with patient identified health and social service goals as appropriate.
  4. Act as cultural translator between the health and human service system(s) and patients. Where appropriate, translate information to patients in a culturally appropriate manner. Where appropriate communicate patients’ cultural preferences and needs with health and human service system(s).
  5. Assist in development of strategies to address or eliminate barriers to care.
  6. Work collaboratively with your supervisor to make sure that all client needs are identified and addressed.
  7. Collaborate with HUB partners to identify high-risk patients and assist in the coordination of various wellness and chronic disease activities.
  8. Demonstrate a commitment to the mission, vision and goals of the Pierce County Pathways HUB, including the ability to integrate Core Values of Community Health Workers as defined by the American Association of Community Health Workers: Access, Acceptance, Advocacy, Excellence, Learning, Partnership, Social Justice, Strength, Trust and Unity.

Eligible Organizations

Organizations are eligible for this RFP if:

  • They provide direct services to residents of the target population in Pierce County
  • They haverelationships and trust in underserved communities of Pierce County, based on geography, race or other criteria
  • A significant portion of their client base receives Medicaid benefits

The Pierce County ACH reserves the right to decide the number of awards made, including the potential of making no awards.

Please answer the following questions on a separate sheet of paper (no more than five pages, standard 1” margins, standard font, size 11 and 1.15 spacing).

Community Health Worker Workforce Development Stipend Application

Applicant Agency:
Main Contact
(Name & Title) / # of Current Outreach Workers/CHWs:
Number of FTE you would/could dedicate to Pathways (at least .5 FTE required):
Street Address
Zip / Phone / Email
  1. Describe how your organization meets the eligibility requirements, include services provided, mission, vision, values, or a charter.
  2. Provide the numbers of your organizations, including people served, number of FTEs employed, etc.
  3. Explain your organization’s history of working with the selected population and how a CHW could help your organization better assist those at risk.
  4. Indicate the primary reason your organization is interested in participating in the Pierce County ACH Pathways HUB.
  5. Include a job description and explanation for howthe CHW will fit into your organizational chart. If you would like a sample job description, please let Pierce County ACH know.
  6. The stipend will cover part of the cost of hiring and employing a CHW for up to one year. The CHW working through the HUB will earn additional outcome payments, which over time is designed to cover the cost of the CHW position. However, these is no guarantee that the stipend and outcome payments will cover the total cost of employing a CHW. Thus, how does your organization plan to supplement funding if necessary?
  7. Not a scored question: Will you be hiring a new employee or will you be re-assigning a current staff member that has completed the Pathways Care Coordinator training? Do you already have a specific person in mind for this position? If so, please provide their resume. If not, please provide application information and, if your agency is selected, the HUB will use its networks for distribution.
  8. Not a scored question: If you receive notice that your organization has been selected for funding for this position, how long will it take to complete the hiring process?

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