This document discusses the role of community-based organizations (CBOs) in achieving population health goals. It describes how the healthcare landscape is shifting away from fee-for-service to value-based payment models that emphasize outcomes over volume. CBOs can play an important role in comprehensive population health strategies by addressing non-clinical factors through community programs. The document provides the YMCA as a case study, outlining its portfolio of evidence-based health programs and efforts to integrate with clinical partners to improve outcomes. Key lessons include the need for CBOs and health systems to establish formal partnerships with shared goals, roles, and sustainability plans.

1. The Role of Community-Based
Organizations in Achieving
Population Health Goals
EMERGING TRENDS FROM THE FIELD
April 23, 2019

2. ABOUT ME
2
MARC ROSEN, MPH
DIRECTOR, HEALTHCARE INTEGRATION AND TRANSLATION
YMCA OF THE USA

3. OBJECTIVES
1. DESCRIBE THE ROLE OF CBO’S IN A CHANGING
HEALTHCARE LANDSCAPE
2. PROVIDE EXAMPLES OF CBO CONTRIBUTIONS TO
POPULATION HEALTH
3. SHARE LESSONS LEARNED FROM THE FIELD REGARDING
CLINIC-TO-COMMUNITY PARTNERSHIPS
3

4. The Role of
CBOs
Examples
From the
Field
Lessons
Learned

5. THE SHIFTING
HEALTHCARE
LANDSCAPE AND
THE ROLE OF
CBO’S

6. MEDICARE AS A SHARE OF THE FEDERAL
BUDGET, 2017
6 | The Role of Community-Based Organizations in Achieving Population Health Goals | ©2019 YMCA of the USA

7. MEDICARE BENEFIT PAYMENTS FOR PART
A, B, AND D, 2007 AND 2017
7 | The Role of Community-Based Organizations in Achieving Population Health Goals | ©2019 YMCA of the USA

8. DISTRIBUTION OF HOSPITAL COST BY
PAYER TYPE, 1980, 2000, AND 2016
8 | The Role of Community-Based Organizations in Achieving Population Health Goals | ©2019 YMCA of the USA

9. PAYMENT REFORM GOALS
9
Health Care Payment Learning & Action Network. Alternative
Payment Models (APM) Framework. July 11, 2017.
| The Role of Community-Based Organizations in Achieving Population Health Goals | ©2019 YMCA of the USA

10. IMPACT OF HEALTH REFORM
• Health reform efforts are shifting the financial
incentives from fee-for-service to health outcomes
• Value-Based Payment Contracting
• Alternative Payment Models
• Success in a value-based payment contract requires a
progressive population health strategy
• Addressing non-clinical care is increasingly important
10 | The Role of Community-Based Organizations in Achieving Population Health Goals | ©2019 YMCA of the USA

11. 11
PRESSURE TO ADDRESS NON-CLINICAL
CARE
| The Role of Community-Based Organizations in Achieving Population Health Goals | ©2019 YMCA of the USA

12. SUCCESSFUL POPULATION HEALTH
STRATEGIES INCLUDE CBO’S
• Comprehensive population health strategy that integrates
health systems, providers, and community-based
health promotion programs to address the breadth of
health issues facing a population
12
Clinical Pathways
connect high-risk
patients to
appropriate
interventions that
promote sustained
lifestyle change
CBOs become the
preferred provider of
an evidence-based
primary, secondary,
and/or tertiary
intervention for a
defined patient
population
CBO evidence-based
programs increases a
partner’s capacity to
provide preventive
health strategies that
improve clinical
outcomes and reduce
overall healthcare
expenditures.
| The Role of Community-Based Organizations in Achieving Population Health Goals | ©2019 YMCA of the USA

13. The Role of
CBOs
Examples
From the
Field
Lessons
Learned

14. THE Y’S JOURNEY
INTO POPULATION
HEALTH: PAST TO
PRESENT

15. OUR REACH

16. Impacting
INDIVIDUALS
Impacting
ORGANIZATIONS
Impacting
COMMUNITIES
Impacting
SOCIETY
Impacting
FAMILIES
Childhood
Obesity
Group Exercise
Falls
Prevention
Cancer
Survivorship
Family Camp
Employee Wellness
BenefitsWellness Centers
Adventure
Guides
Youth Sports
Swim Lessons
Smoking
Cessation
Policies
Promoting
Healthy
Eating
Policies
Promoting
Physical
Activity
Diabetes
Control
Built Environment
Access to Fresh
Fruits & Veggies
P.E. in
Schools
Economic Incentives
and Disincentives
(taxation or
subsidies)
Tobacco-free
Environments
Diabetes
Prevention
Cardiac
Rehab
Arthritis
Treatment
To
PROMOTE
WELLNESS
(Primary)
To
RECLAIM
HEALTH
(Tertiary)
To
REDUCE
RISK
(Secondary)
FRAMEWORK FOR HEALTHY LIVING
Personal Training
➢ Chronic disease and obesity
➢ Aging population
➢ Health inequities

17. Efficacy Validation
DISCOVERY
Translation Scaling
DEVELOPMENT
Dissemination
DISSEMINATION
THE Y’S PORTFOLIO OF EVIDENCE-BASED
(RCT PROVEN) PROGRAMS
YMCA’s Diabetes Prevention Program
Enhance Fitness (Arthritis Self-Management)
LIVESTRONG at the YMCA (Cancer Survivorship)
Moving For Better Balance (Falls Prevention)
Blood Pressure Self-Monitoring
Childhood Obesity
Intervention
Brain Health
Parkinson’s
Tobacco
Cessation
Building the
pool of the
21st century

18. High level
overview of
CMMI grant
• Historic certification of cost
savings by CMS actuary: $2,650
in savings over 15 months (5 to
1 ROI)
Y-USA’S CMMI-FUNDED HEALTH CARE
INNOVATION AWARD PROJECT
The YMCA’s Award
YMCA of the USA and its
partners worked to engage
nearly 8,000 Medicare
beneficiaries with prediabetes
in the YMCA’s Diabetes
Prevention Program.
• The intervention was delivered by
17 Ys in 8 states
• Claims were “reimbursed” using
2011 fee schedule from commercial
market
• About 1/3 of these participants
were covered by Medicare
Advantage plans
1Hamman RF, Wing RR, Edelstein SL, et al. Effect of weight loss with lifestyle intervention on risk of
diabetes. Diabetes Care. 2006;29:2102–2107

19. COMMUNITY INTEGRATED HEALTH
19
Healthier Communities
Initiative
Across 247 communities, Ys
have used a collective impact model to
implement policy, system, and environmental
changes so that healthy choices are the easy
choices for all. Building on this knowledge,
Y-USA’s Talent and Knowledge Management
department is testing new and advanced
models of collaboration over the next three
years.
Health Equity
Y-USA infuses principles of equity into
services to ensure everyone has the
opportunity to live their healthiest
lives, and that underserved
populations have access to
health-promoting resources.
Capacity
Building
Health
Equity
Shared
Spaces
Community
Health
Navigation
Compliance
THE YMCA’S
MODEL OF
COMMUNITY
INTEGRATED
HEALTH
Healthier
Community
Initiative
Capacity Building
Y-USA is engaging Ys from the earliest stages to
ensure they have the staff, competencies, and
relationships necessary to implement evidence-
based programs.
Community Health Navigation
Ys help individuals develop the relationships necessary to
manage health by conducting home visits, spreading
awareness of recommended preventive services, and helping
connect people to health care exchanges and marketplaces.
Shared Physical Spaces
Ys are exploring the value of shared
spaces with health practices, rehab
and cancer centers, primary care
within Y facilities, retail
programming space with health care
systems, clinical facilities at camps,
and other health services.
Compliance
Y-USA is helping YMCAs
and other community-based
organizations comply with
privacy laws and health
care regulations.
Evidence-based
Interventions
Ys are discovering, developing, and
disseminating research-tested, high-fidelity
health interventions to improve health.
Evidence-
based
Interventions
| The Role of Community-Based Organizations in Achieving Population Health Goals | ©2019 YMCA of the USA

20. A CONTINUUM OF SUPPORT
Evidence-
Based Health
Programs
Membership
Health and
Wellness
Services
20 | The Role of Community-Based Organizations in Achieving Population Health Goals | ©2019 YMCA of the USA

21. CLINICAL INTEGRATION EXAMPLES
Y
Rural Health
Clinic
Optimize
fitness for
joint
replacement
surgery
21
Y
Next Gen
ACO
Participant
Pre-and-post
joint
replacement
falls
prevention
program
Y
ACO/Health
System
Diabetes
management
/Falls
Prevention
Y
Shared
Space Health
Care Partner
Falls
Prevention,
Weight Loss,
Cardiac
Rehab
Extension
| The Role of Community-Based Organizations in Achieving Population Health Goals | ©2019 YMCA of the USA

22. ADDRESSING SOCIAL DETERMINANTS OF
HEALTH
22 | The Role of Community-Based Organizations in Achieving Population Health Goals | ©2019 YMCA of the USA

23. DOCUMENTING BEST PRACTICE MODELS
• Y-USA with the support of the Robert Wood Johnson Foundation
began implementing a broad national initiative to support the
expansion of CIH:
• Provide Technical Assistance to support clinical integration between local
Ys and their healthcare partners
• Identify best practice models of CIH
• Document steps to implement clinical integration
• Disseminate & replicate best practices with other Ys across the Country
• Share best practices with other community-based organizations to
support CIH in every community
23 | The Role of Community-Based Organizations in Achieving Population Health Goals | ©2019 YMCA of the USA

24. The Role of
CBOs
Examples
From the
Field
Lessons
Learned

25. LESSONS
LEARNED

26. EMERGING TRENDS
26 | The Role of Community-Based Organizations in Achieving Population Health Goals | ©2019 YMCA of the USA
Approach to health IT
integration
CBO business models and
integration into the
reimbursement pathways
Build it, buy it, or hybrid
Think outside of community
benefits
New landscape,
new partnerships

27. Articulate and codify
the following:
• Shared goals
• Roles
• Sustainability
pathway
• Disparate access
to institutional
resources,
capacities, and
competencies
DEVELOP FORMAL
REFERRAL PATHWAY
• CBO receives direct referrals
for evidence-based, preventive
health strategies
INTEGRATE INTO
REIMBURSEMENT MODEL
• CBO demonstrates value-add to
health care stakeholder and
receives fair market reimbursement
for evidence-based
service/program
CBO BECOMES
PREFERRED PROVIDER
• CBO demonstrates improvement
of clinical outcomes (and
reduction in overall healthcare
expenditures)
ONGOING PARTNERSHIP
EVALUATION
• Bi-directional information and
outcome sharing drives
refinement of referral pathway
and reimbursement model
NEW, EFFECTIVE PARTNERSHIPS WITH
CBOS
Impact
• Understanding each partner’s value statement
• Shared goals
• Shared accountability for sustainability

28. QUESTIONS

29. THANK YOU
Marc Rosen, MPH
Director, Healthcare Integration and Translation
YMCA of the USA
Marc.Rosen@ymca.net