Hello, and thank you for joining us today with the webinar. We are going to wait for a few more people to join before we get started. Thanks so much for being here with us today. I see some more folks joining us. We're just gonna wait another minute to get started. We're waiting for some more folks to join us today before we jump in. Alright. I think we're gonna get started. So thank you everyone for joining us today for the webinar, expanding impact through community focused care accreditation. I'm going to be your host today. My name is Elizabeth Ryder, and I'm an assistant director in NCQA's product management team. I'm joined today by teams from Elevance Health and Molina Healthcare. And during today's session, you're going to learn directly from those two organizations about how they're scaling their community strategies for maximum and sustainable impact using tools such as NCQA's community focused care accreditation. And if you can move on to the next slide, you know, before we jump in, I did just wanna cover a few housekeeping items about how today's webinar will work. At any time during the webinar, you're welcome to submit questions that we will visit with the panelists or with NCQA at the time of the q and a that we'll do at the end of today's session. You can use the q and a function at the bottom of the screen and just type in your question. We're going to save as much time as we can towards the end to answer those questions. If we don't have time to get to all of them today that come in through the q and a, we can follow-up with you directly after the webinar. And if you'll go on the next slide, I wanna give some insight about how today's session will be structured. I'm gonna do a quick round of introductions for our panelists from Molina and Elevance, and I'll share a bit more about NCQA's community focused care accreditation for those of you who aren't too familiar just to level set on what the program is. But we'll spend most of the call today hearing directly from our panelists. And toward the end of the session, as I mentioned, we're going to save time to do some q and a. We will have a a kind of led q and a session first, and then we'll jump into the audience submitted questions. So, again, please submit at any time. Now if you'll move on to the next slide, I want to introduce our panelists and really thank them all for being here today and sharing their direct experience with you all. From Elephants, we are joined by Jonathan Georges, who is the whole health and equity director at Elephants Health, where he leads enterprise strategies focused on whole person care, health equity, and population health within Medicaid programs. And with experience spanning government and health care transformation, he specializes in advancing equitable care delivery and improving outcomes for underserved communities, particularly in maternal and child health. Elevance is also having us present today Allison Hoots, who is a director of advanced social and equity outcome analytics at Elevance Health, leading analytics, data strategy, and AI initiatives that support social care and health equity efforts. And she's played a key role in developing innovative data solutions and partnerships that improve access to resources and help drive more equitable person centered care. And last but not least, Yolanda Michael, who is an accreditation director at Elevance Health and oversees NCQA's health outcomes accreditation and community focused care accreditation initiatives across multiple product lines and lines of business. She is recognized for her expertise in quality improvement, health equity, accreditation readiness, and building partnerships that support high quality equitable care. From Molina Healthcare, we have Allison Barsam, who is a program manager at Molina Healthcare supporting the organization's health equity and cultural competency program strategy. And with extensive managed care experience, she leads initiatives focused on health equity reporting, quality improvement, cultural competency, and NCQA accreditation with a strong emphasis on data driven outcomes and collaboration. Kristen Kidwell is an assistant vice president of quality and compliance at Molina Healthcare Quality Solutions and bringing more than twenty years of managed care experience. She leads their national quality and compliance initiatives, including health equity programs and has a deep expertise in NCQA accreditation, quality improvement, and regulatory strategy across Medicaid, Medicare, and commercial plans. Nathan Ryder Garcia serves as director of quality improvement at Molina Healthcare where he leads health equity and cultural competency program strategy within the quality solutions team. And his work centers on improving health outcomes, supporting accreditation efforts, and fostering collaboration informed by his background in community development and education. And last but not least from the Molina team, we have Carolina Robleski, who is an assistant vice president of population health at Molina Healthcare, leading their initiatives focused on health equity, population health strategy, and community partnerships. And she's dedicated to improving outcomes for underserved populations through innovative programs that address social determinants of health and expanding access to equitable care. Thank you so much for everyone being here. I I think this is truly the best panel possible that we could have had for this discussion, so thanks so much for joining us. If you move on to the next slide, there's one more thing that I will cover before I hand it over to spend most of our time today hearing from Melina and Elevance. Today's webinar will focus on the experiences of those two health plans that have earned NCQA's accreditation and community focused care, formerly known as HealthEquity Plus for those of you who have been following this program for some time. For those of you who are not familiar with community focused care accreditation, this is a program that helps health care organizations from health plans, such as our panelists today, to other organizations that provide clinical care, wellness services, case management and care management, population health, or patient engagement. It helps them bridge that gap between what happens within the health care system and the factors that influence health across a community and across a population. And it's a data driven program that turns standardized member or patient level data on social needs, like housing, food, and transportation, and community level data on some of those similar factors as they play out at the community level, community wide into a comprehensive population health strategy for coordinated action and measurable performance improvement. And unlike other programs or regulatory expectations that might ask your organization to collect data or seek to understand the population and its needs, This program is primarily focused on data as a way to drive action by connecting members or patients to needed interventions for those social needs, cultivating community based partnerships to actively help address or mitigate some of those needs in the community and continuously measuring improvement on goals. So it is a framework that's intended to transform what is often a siloed initiative or a pilot program to address nonmedical drivers of health or social needs into something that is more of a scalable system level way to address the intersection of clinical and social needs. So I want to now welcome our speakers from Elevance Health, Jonathan, Allison, and Yolanda to the virtual stage to talk about how they've used NCQA's community focused care accreditation to grow their strategy for addressing social needs and turn that framework into something actually actionable that they have been sustaining over time. Thank you, Liz. Good afternoon, everyone. My name is Yolanda Michael. I am the accreditation director here at Elevance Health, and I lead the health outcomes and community focused care strategy across the enterprise. Next slide. Just to give you a little background, Elevance Health is one of the nation's largest health benefits and health care service companies in the nation. We have about a hundred thousand associates that work together across the organization, and we serve more than thirty six million members covered through our health plans, with eight million of those being Medicaid members. Twenty two out of our twenty four Medicaid plans are community focused care accredited, which represents over ninety five percent of our Medicaid membership. Next slide. Our accreditation journey really demonstrates our long term commitment to advancing health equity across our Medicaid plans. In twenty nineteen, our Medicaid plans earned multicultural health care distinction, recognizing our early focus on culturally responsive care. As m MHC distinction was scheduled to be sunset, our Florida plan in twenty twenty two participated in the pilot for health outcomes and community focused care. And also that same year, we pursued health outcomes accreditation for all of our Medicaid plans. In twenty twenty three, for those same plans, we advanced our commitment by pursuing community focused care accreditation. The decision to pursue CFC was really a no brainer for us at the time. We felt that the program really aligned with where we were as an organization and where we were headed as it relates to our whole health strategy and enterprise priorities to improve health outcomes through person centered equitable care. We were also in the process of strengthening our organizational capabilities. We hired whole health and equity directors for each Medicaid market, and these roles are focused on disparity reduction and addressing member social needs. We were also building a strong data foundation, which we'll talk about a little more later, with systems and processes to identify, collect, and aggregate member social needs data. So we weren't really starting at ground zero, and we felt that the program would really strengthen and expand the work we were already doing. Next slide. The community focused care program helped establish some best practices across Medicaid in terms of how we partner with local community based organizations. This model provides a structured data driven approach to identifying and building meaningful partnerships. So the first step is really understanding community needs. We begin by analyzing member data, social drivers of health, and community health data to identify the greatest needs. We then identify priorities. Based on resources or a lack of resources and competing priorities, we're not always in the position to address all of the identified needs. We engage internal teams, community organizations, and stakeholders to validate priorities and align on desired outcomes. We then evaluate existing resources. We assess current programs, whether they're external or internal resources, to identify service gaps and determine where partnerships can have the greatest impact. We then select and engage partners. We identify trusted community organizations that align with our mission, have the necessary expertise, and can effectively serve our members. From there, we implement and collaborate. Together with our partners, we codesign and implement solutions that address community needs and improve health equity. We then monitor performance, evaluate outcomes, and use data to ensure accountability and continuous improvement. And lastly, we strengthen and scale. We use what we've learned to strengthen successful partnerships, expand programs that are effective, and increase sustainable community impact with the overall goal of building trusted and long term partnerships that can create and sustain her healthier communities. Next slide. I'm going to pass to, Allison to talk more about our data driven strategy. Thanks, Yolanda. So one of the biggest lessons that we've learned on our health equity journey is that meaningful action really starts with having the right data in the right place and not only easily accessible, but what's equally important is that it's easy to understand. Like many organizations, we we started in a place where we had a lot of valuable information spread across multiple systems. So we had publicly available community data, member claims data, member assessments from HRAs or social assessments and and social need information, but it really wasn't easy for our whole health or health equity leaders to bring all of that together into one cohesive picture. So that's really what led us to the creation of this self-service analytics tool. It's been really central to our success and and to our journey here. So we combined publicly available community level data, so data at the the state, county, ZIP code, track level for more than fifteen publicly available sources. Then we combined that with aggregated member level clinical and social data. And I think what's really neat about this is because it doesn't contain PHI and PII, it's really broadly accessible for our internal organization and provides really meaningful population level insights. Another thing that I think is really valuable about taking this kind of approach with bringing everything together into a a comprehensive view is that it gives us a chance to look both within a clinical lens and beyond a clinical lens. I know, you know, everyone here believes, understands, knows that health outcomes are influenced by much more than just medical care. And so it really allows us to look at things like housing stability, food security, transportation, environmental conditions, and other community characteristics, and then bring all of those dimensions together with our clinical data so that our teams can better understand the populations that they serve and identify where interventions may may have the greatest impact. So on this slide, I know it's a bit small here. You can see the the various key dimensions for the data. So on the left side of, you know, the blue, that kinda left column, you see we highlight community level data. So that can tell us things like how our health plan's depression rates compare to the states, for example. In the center, you can see there's, you know, different areas here that we look at. So we can filter by demographics, so viewing membership by race, ethnicity, age, community type, like rural, suburban, urban, or gender, as well as clinical conditions. Our teams also placed an emphasis on behavioral health and maternity as part of that clinical view. So we could see things like the prevalence of chronic conditions and see by measurement year and a percentage of rate changes over time. And that can really help our teams answer questions like like, which counties within my market have the highest prevalence of diabetic and food insecure members, or what's the racial ethnic breakdown of my members' preterm birth rates? You know, do I see a disparity there? Or, you know, maybe how's my health plan's infant mortality rate changed over the last three years? We also brought in a utilization dimension. So, for example, the prevalence of, admission rates or readmission rates. And then, of course, social needs, which I'm personally very passionate about. I've led our social data team for Elevance Health for the better part of the last eight years and really getting the, you know, the company to a place where we have this standardized collection and utilization of this information has been really game changing for us and for our members. This really creates a much more comprehensive understanding of population health, and it's it's better than any single data source that could provide insights to us before this. Another piece, you know, that was really important here is the historical prevalence that's available that allows us to identify trends over time rather than just looking at a snapshot of today's population. So that really supports comparisons across health plan markets, across time. It it makes it easier for us to recognize emerging disparities or areas where outcomes are improving or even maybe worsening. I will share, just one quick example. So we had a market that had a focus on maternity, and so we helped them examine, outcomes like preterm birth alongside reported social needs from members. And what we found in that particular market was members that were experiencing transportation insecurity had preterm birth rates that were almost, double compared to the population the overall population. And so by no means am I saying there's any established causation here, but it does identify an important disparity, and it it helps us to ask better questions. Like, if transportation barriers are associated with poor birth outcomes, and how can we identify those members earlier? Are there opportunities to connect them with transportation assistance or care coordination or other supportive services during their pregnancy? Those are really the the kinds of questions and and conversations that this tool's designed to enable, and having all of this data really in one place is such an important part. So having this, you know, available to our teams helps us bring this kind of disparate data into meaningful insights. It helps us to shape our strategic priorities. It helps us measure impact over time. We can understand where disparities exist, what populations need or potentially need additional support, and where resources can be directed before programs are implemented. So we're not we're not working blind. We're it's it's a it's definitely a data driven approach. What we also find is a lot of the time, the data validates kinda what our teams already know, But it really is such a great tool, and it it it absolutely helps kinda measure over time. And I know I I I mentioned this before, but I think, you know, my favorite part of this is that it's self-service. It was designed to be simple for our leaders and our business partners to explore the data, answer important questions, and support their strategic planning without needing to write any complex queries or access any highly restricted systems or data. And I really do believe that, you know, broader accessibility to views and insights like this has made data driven decision making so much more practical across our organization. Next slide, and I'll I'll hand it over to John to share some examples. Good afternoon or good morning, everyone. So just wanna kinda walk us through I know my colleagues did a great job of of providing that broader data infrastructure and kind of the overall plan, but wanna make that approach more concrete and give a New Jersey example. So I'm really excited to kinda go through how we execute that here in in this market. So as I go through these slides, the the through line here for me is pretty straightforward. Right? The data tells us where to focus. Partnership turns that into insight into a, you know, a member facing response. And, you know, measurement tells us whether that actually the help actually happened. And and lastly, I think the most important is the governance makes that work very sustainable over time. So as we look at the slide here, in in New Jersey specifically, the the data made the priority very clear. Forty eight percent of our nearly four thousand documented social needs observations were were food specific. Right? And food ranked first out of all four of our priority counties that we looked at over over over a period of time. But we didn't interpret that as simply, you know, send more food referrals to that to that specific place. Right? We we we looked at food insecurity, and we realized that it often sits alongside transportation, housing, financial, health literacy barriers, and so many other variables, right, that we all know. Those additional barriers can can determine whether a member is actually able to access, you know, a a food resource that that we're offering. So we developed a shared operating model with our our CBOs, and I'll refer to them as CBOs, but they're the community based orgs. They're our our very important community partners. First, we we define the goal together. Right? Because we are going into this together. Second, we complete a very warm handoff, which I think is an important piece of the process. And then third, we receive a very actionable status back, which did it work, did it not work, and kind of ways to pivot. And then lastly, we regularly review what is working and what is not working so that we can pivot and be nimble that way. So I think an important piece that I wanna highlight as well is a referral is is is not an outcome. Right? And it's not the partnership. It's it's the one step in a in a coordinated pathway to getting that that positive health outcome that that we all want. We we treat the the community based orgs as a co design partner. Right? I think my colleagues have kind of mentioned that as well. They're not simply a a downstream referral destination. The goal here is to really strengthen both sides. Members receive a more reliable dignified path to support while our partners also receive clearer information, better aligned referrals, and and and really a voice in improving a very important workflow. Right? So and you'll hear me say this a few times, but for us, sustainability really means aligning that referral volume with a partner capacity using that shared measure and then closing the the the learning loop, which is not simply sending more names into a a community. Right? So but the the county level data also showed us why this this cannot work in a in a kind of one one size fit all approach. Next slide, please. Okay. So in twenty twenty five, we we completed about twenty five hundred social needs screenings. And we saw that a thirty five percent increase over the previous year and documented nearly four thousand need observations. That's approximately one point five seven needs per screening. Okay? So that ratio is really important because it it it shows that members rarely present with one isolated issue. Food ranked first in every priority county, and these are our counties in New Jersey, by the way, folks are are familiar. But the pattern underneath really differed. Transportation was particularly prominent in our access in Camden counties, while education, health literacy were especially visible in Passaic. So, you know, food access may be the common entry point, but the navigation model has to respond to the local barriers as well. And and that that determines whether a member can actually use the resource that we're presenting them with. A member may receive food information, for example, but still need transportation, language, or other important support mechanisms that we have to keep into account. You know, and and I also wanna be precise here about what these figures actually represent. These are documented workflow observations, not estimates of pop you know, population prevalence. Right? So we use them to guide the operations, target the partnerships, and identify where the additional support is needed. But we also interpret food related target alongside that screening volume, case mix, and and confirmed connection outcomes. So it's not a standalone measure. Alright? And once we we knew where the where the need was concentrated, our next question became, you know, can we reliably see what happens after we we make that, you know, referral to our partner? Next slide, please. So the twenty twenty five baseline here exposed one of our biggest improvement opportunities. Right? We we we could see the referral activity, but we couldn't really see the revolt the result rather as clear. So our system showed about thirteen hundred referral records involving a hundred sixty seven unique seekers while only ten closed loops and one documented outcome where where it was visible. So because those counts use different denominators, we didn't wanna present them as a definitive partner effectiveness rate. We present them as as evidence of a workflow and perhaps a documentation gap, which I wanna jump ahead, which we we realized that's that's what it was. So this distinction is extremely important here. You know, we don't wanna assume that a missing status means a community partner failed to help a member. It may mean that our process internally did not make it easy for the partner to return the information back to us or that the status was captured somewhere else in our system that we maybe could not see or maybe not at all. You know, in in twenty twenty six, we we really moved to standardize that that referral status. So we're both sides of the spectrum very clear, making the the handoffs warmer as as, you know, my colleagues always hear me say. But, you know, that escalation trigger is also important. And we we create these routine review of communist and then the un unresolved barriers as well. Our target is to move documented closed loop completion from six to six percent rather to seventy five percent. And as of this morning, we're exceeding that that target. So we we we did realize that there was maybe an internal documentation issue, not that these folks weren't getting the the, you know, care that they needed. So the purpose here is really not to create additional admin burden for our CBOs, but it's it's to know whether the member was contacted, connected, is are they still waiting? Did they decline assistance? Or, you know, any other important variables so that we can really see the next action clearly. We also wanted to avoid measuring partnership success by just referral volume alone. This is a very important part here as well. Sending more referrals to a CBO that lacks the capacity to respond is neither effective nor sustainable for anybody involved. Right? So a stronger model, which we really try hard to do here in in New Jersey is is to improve the referral fit, clarify the roles, and really monitor that that partner burden as well, which allows us to adjust together. So that's how the referral becomes, you know, actionable support. It and and that transaction connection becomes a more durable partnership for our CBOs. Next slide, please. Okay. If anybody knows me, they know OB and maternal health is is my favorite topic to discuss. So this this slide may initially look like a pivot away from the food access that I was discussing, but I just wanna wanna really explain why it's intentionally included here. So it's it's not a second unrelated, you know, intervention. It demonstrates that internal care management infrastructure that makes the the, you know, that community focused partnership so usable inside a real clinical care pathway. You know, here here in WellPoint, our our OB care management is a very strong example because, you know, maternal needs are very time sensitive as as I'm sure all of us know. They're layered and they're very interconnected. A member may simultaneously need clinical care, transportation, food support, BH services, and and help, you know, remaining regional. So in this model, the OB care management serves as the consistent point of coordination. Right? So the care manager, as we call him, you know, understands the member's priorities and urgencies, brings the appropriate internal teams together and the community and the, you know, the the CDOs as well. And they remain that connected through point, you know, in each next clinical step, which is really crucial to moving that needle. And that also helps us prevent the member from being handed to another department or another department without being, you know, kind of heard or expected to coordinate that system of care for themselves. Right? So the transferable principle is is is very clear, and this is something that we we we say quite often. One plan, fewer handoffs, and then a really clear next step. That that same level of, you know, kind of workflow makes our broader social needs and and and food access work very scalable, which is what we want. You know, the community partnerships cannot be sustained as a separate referral program operating on the side. Right? They have to be integrated into the clinical quality and, you know, member engagement and then the overall care management structure as well. So the last part of our approach is ensuring that this operating model is measurable, governable, and then really easy to demonstrate. Next slide, please. So, you know, for the accreditation story, right, we we wanna make the improvement process easy to see and and quite frankly, easy to audit. We we always welcome that. Not simply as just to present a list of activities. We're we're mapping each requirement to the five elements. Baseline, a very, you know, present accountable owner, a measurable goal, evidence show source, and documented improvement action. That that means our prioritized social needs is tied to community and member level data as Allison was kinda going through prior. Our our referral process improvement is tied to that those warm or warmer handoffs, standard status updates, closure measures, and escalation where needed. But, you know, another piece of this too is our partnership effectiveness is is a value you know, we we we kinda look at that on a on a yearly basis, sometimes quarterly basis. And at the end of the day, that is what helps us move move that needle and and not only meet the requirement, but really ensure that our members and the community at large are are getting the the the central care that they need here. So, you know, the lastly, I I wanna add on this slide that the program description we have a program description. We have a a a work plan and an annual eval with media records and and a lot of action tracker that that provides that governance wrapper, which is so key here. Right? We can say all these things and assign these different roles to to to different folks, internal and external. But if we don't have that governance piece, you know, I think we we tend to fall short. So together, that allows us to work, you know, to endure beyond just an individual event, an individual relationship, you know, or even a funding cycle, let's say. They they create kind of a more sustainable workflow that we can reproduce and scale as as needed. Next slide. And this slide here, I just wanted to provide some visuals regarding some of that that those you know, I wanna call them theory, but some of the the the the pieces that we talk through in a in a execution phase. Right? So we work with a lot of our food, you know, access CBOs, and they're not just the one one off partnerships. These are our our sustainable partnerships, and our member engagement team does a phenomenal job of that. You know, we we not only are we just referring folks to, let's say, the CBO and one of these photos here is Fulfill, but we also ensure that Fulfill is is has everything that they need to meet the member where they are. So we create food distribution sites that are that are routine. This is not a one off. These are sustainable, you know, community events, to speak, that members know that this is a routine thing that'll that'll be happening monthly, weekly, quarterly. And if there's any type of, you know, specific need as it relates to food access, they have a variety of ways to to, you know, get the help that they need. And who doesn't love a good photo? Right? So I wanted to include some of these. Next slide, please. Okay. So that's it for Elevance, and I'm happy to pass it over to the other panelist, Melina. Thanks so much. That was a that was an amazing presentation, you guys. I'm that's gonna be tough to follow, but I am thrilled because truly this will just demonstrate that we're all kind of working towards the same goal, which obviously is overall member improved health. I'm Kristen Kidwell. I've been with Molina for about four years and have been in the managed care space for about twenty. And I'm really excited to be here today with my colleagues to talk a little bit about our journey to community focused care accreditation and sort of what that looks like and hopefully gonna get some of you a little bit of good nuggets of information for your own journey. You can go to the next slide. There's a couple slides just based on just giving an overview of Molina. I think I'll probably slide through these because we have quite a bit to cover, but we are, we have about five billion members, about thirty thousand associates, and we are a matrix organization. So we have local health plans that are obviously experts in St. Nuance's demographics, populations, programs, things like that. And then we also have shared service. So that's really typical and we'll talk a little bit about how that model helped us in this sense. Go to the next slide. This is a footprint and like I said earlier, we are we do have all lines of business, Medicare, Medicaid and marketplace. We are currently serving members across twenty one states and those twenty one states are quite diverse and that is also sort of another key to our success but poses a challenge sometimes as we want to bring all the data to the table and use it for actionable outcomes. So we'll talk a little bit about that too. You can go to the next slide. We having all of these government sponsored programs in place and obviously serving some of members around the country with the most risk, you know, we really did have a a desire to continually continuously, improve not only our programs, but, the data that we're using. And we in today's world, we have health plan accreditation, health outcomes, community focused care, we also have LTSS distinction which kind of points out all of those different and sheds a light on some of those different lines of business and products. And community focused care was really one of those accreditations that we were thrilled to be a part of from the beginning because it was important to us given the populations that we serve today. Next slide. So in terms of kind of our overall pursuit and desire to achieve this health equity plus accreditation, now known as outcome accreditation. It really did start with kind of the company's overall commitment, and that is to deliver high quality care. You heard Jonathan sort of mention meeting the members where they are, and that is truly a theme from top down at Molina. And that accountability for total member health, was really what set us up for success here. We have just a fundamental understanding that meeting basic needs is is really a ticket to improving overall clinical care. Not all needs are medical and, again, with these populations, it was really critical that we took a look at what the data we had already available, filled some of those data gaps. And once we started this journey to accreditation and identifying those and really starting to close some of those gaps, you know, the the ball gets rolling and you just kind of you you roll with it. And so, you know, while we are still always working to improve, One of the things that, I think we will all take back and sort of you'll you'll see this in our lessons learned, but, you know, the data is really the key and also getting everybody, all of the correct people to the table. And so that comes from leadership all the way down to our associates who are frontline in engaging the members and making sure that everybody kind of understands what the journey is going to look like, what their role in it is, because it really is everybody's role. And that's kind of what got us and helped us be so successful with this accreditation. Next slide. So specific to California, we were heavily encouraged to pursue and achieve community focused care. Like I said earlier, we were thrilled to be a part of the pilot program, from the very beginning. We wanted to partner with NCQA. We, of course, understood that there were, going to be changes and that we needed to sort of again take the processes and and the programs that we already had in place and refine them in order to achieve this accreditation. It made sense that we pursued this. It ultimately allowed us to use the information that we have, prioritize, the social needs and social risks, and and make them actionable. We started with identification of, what we were already doing operationally. I think we heard Alison and Jonathan both say that, you know, aligning standards to what programs you have in place really sort of helps you see and set the path from the very beginning. Most often, honestly, I've been in accreditation for a long time, and usually, it holds true that the organization already is doing a lot of the work. It's sort of tying up loose ends, again, making sure that end to end process is compliant with NCQA. But in terms of this particular accreditation, it, you know, it it really does give you a sense of, pride. And, when you when you can grab hold of, you know, anything the member needs or or the data that you're getting, really does shed a light on what the member needs that ultimately is going to improve clinical outcomes. And I think we identified very quickly early on that prioritizing and really outlining that plan, and aligning resources. And, like I said, we are so matrix, but really aligning all of our cross functional commitments was going to ultimately be what we, you know, a crucial part of the step to achieving this accreditation. So that was kind of the first place that we started in building that work plan. Go to the next slide. So I think one of the largest challenges that we faced was really getting the right people to the table. There were a lot of areas that were really running parallel to one another. Like I said, we were doing the work, we probably just didn't know it. Care management, community outreach, population health, quality, provider services, you know, it is not an easy thing when you're moving so quickly and when, certainly the landscape is constantly changing as we all know. And so in addition to aligning internally, we also really wanted to make sure that we were aligning externally with stakeholders. Providers and members can it can be a challenge to get feedback. And so that was another area that we worked really **** ** to make sure that we had all of the information and really the critical points from from their point of view. I'm gonna let Carolina speak to how we kind of engaged community partnerships and and and use that in this particular accreditation. Hi. Thank you, Kristen. Yeah. So we, you know, we partner already with a lot of community based organizations, but in California, we've been required actually by the Department of Healthcare Services to partner with our local health departments and the managed care plans. And while initially that was a bit, awkward to be partnering with essentially we've been doing this for well over a year now, and so that really helped us, ensure that we're not competing for priorities and that we're all going towards the same goals and we're all aligned. So that really helped us in this accreditation also because we were already doing a lot of that work. Additionally, for stakeholder input, we have our member provider, community advisory groups that we went to to ensure that, where we the data was showing us, what the that we were they were aligned and that we were all in agreeance that the data was accurate or that our the strategies that we were implementing were the right ones, and so that also helped inform the work that we were doing. Thanks, Carolina. You can go to the next slide. So this was sort of a a slide where we wanted to outline come some of our large implementation steps. As with any project, we we were breaking it out in categories and and sort of figuring out where we where you start. Right? First being data. Always data. Like I said, we heard Allison mention that it really is the key to not only building, but also implementing meaningful programs. And you don't just wanna fly blind and we all have done that before, throw all the spaghetti at the wall and hope something sticks. But in this case, we also built an internal data repository and it was really aimed at specifically, ingesting, storing, organizing, allowing us to analyze all of the data at our fingertips in addition to going out and getting additional data. You know, SDOH and risks outside of of clinical, associated data is not, easy to get. So we're really proud of this data repository and and and the work that we've done. It allowed us to further dig into the population, how we can meet them in their space, how we can foster and how we can help, not only get them to, appropriate, care, but what they need along the way. What's going to help them prioritize, managing conditions and things like that. We all know there are other factors that are going into this into the healthcare spectrum. And so it was important that we organized that data that we already knew we had in order to really make sure that we were meeting the member where they are. The second thing we did was we made sure that HealthEquity was embedded into all of our existing programs. Most already had a little piece and what I mean by that is either population health and quality programs and the way that we measure program effectiveness and outcomes, the benchmarks that we use, staff training around health equity and cultural competency, provider training, any any way that we already engage members. We wanted to make sure that health equity and and any real, you know, information about it was was also embedded into the way that we were handling each transaction. And that became important not only from care coordination and care management and community outreach, but from provider services and the way that we, you know, work with our providers and the training and the information we can offer our providers who are serving these members. So those two things are where we started. Carolina, do you want to speak to kind of the way again we engage community partners for feedback and obviously the closed loop referral process is also a big one here. Yeah. So, when we were and I think Elements and well, I know Jonathan, I heard him say that there was an opportunity there for getting more data from the community partners. We, have that allows our external partners to document close loop referrals, so that was helpful in in getting more data back. But we also integrated that system into our case management platform because it it made it easier for our case managers to document in one single platform for, community, social needs, so that we had a good close loop referral. Of course, it's not perfect. It identified an opportunity for us to continue working on collecting that data, more collectively. So it's always a work in progress, and I I I know Elevance mentioned the same thing. There's always an opportunity for that. But we had enough data to do something and and to identify gaps and to and to create initiatives out of that data. So it was it doesn't have to be perfect. It just needs to be good enough. When we looked at the data, it helped us see the impact of social needs with health outcomes, and we knew that focusing on a holistic needs were going it was going to be very important. So the bottom line is when members are worried about having a roof over their head and food on their table, they're not going to really focus on going to the doctor. So we needed to we were able to solicit feedback from our members directly, from our community based organizations, from our providers, and then incorporate all that feedback into the work that we were doing. And so we also identified where we had an opportunity to scale or enhance any existing programs for this work. Thanks. Next slide. So I don't think it's a secret that it can be really difficult to obtain some of this member level data. We're sort of all at the mercy of, you know, eight thirty fours and, supplemental data sources that we may or may not be able to ingest. But, we included, similar to other sources, local health departments, z code analysis, some predictive data. And, again, that allowed us to really drill down in into member specific social needs, and that goes for, you know, areas that they live in. And once we got a lot of that data analysis onto paper, we were able to really start streamlining some of our actions and processes that we wanted to put in place. Enable in in order to refine some of those programs, it's important that you know what what you're intending to or who you're intending to really, impact. And so having that information and using all of that different data really allowed us to, pay really close attention. And and those and in order to, make something actionable, we were able to act you know, we were able to justify with the data that we brought to the table. Carolina, do you wanna talk a little bit about the partnerships for, food insecurity and housing and transportation and things like that? Yeah. Sure. So what we found when we looked at the data is that we were already, partnering with the right people, and, really, we just needed to make some minor tweaks and and and maybe, partner with some additional community based organizations that targeted certain populations when it comes to decreasing disparities. But we were we were on the right we were going along we were moving in the right direction, and Elevance mentioned the same thing. It just reinforced the fact that food insecurity, housing instability, and transportation barrier were definitely our top priorities, and they continue to be. So that help in sort of where we put our resources in and the the type of partnerships that we create in the community. And then I mentioned already that the data from the referral wasn't as strong as we would like it to be, so we are working to improve that in our documentation. That's always a work in progress. Alright. Next slide. And I think we're gonna I'm gonna jump two slides right to the results. I think it's slide twelve. One more. Perfect. So truly, the benefits of of taking time to analyze and dig in, you know, and and understand the population better, the benefits of that are endless. Partnerships with providers, community based organizations in the Medicaid space, I feel like we're all sort of constantly challenged with trying to figure out the best way to help a member prioritize their health. You know, we also in this case, our improved CHW network, our community health network was really a key to one of our really one of the keys to our success. You know, identifying gaps in the network and closing those gaps helped ensure that anyone engaging with the member has all of the information that they need, all of the relevant information including resource referrals, utilization, diagnosis, medication, things like that. And so, you know, that was one of the areas where we really saw an impact on the end results of our program. Additionally, you heard Carolina speak to the referral process, and we also heard speak to how important it was that we not only continue to refer, but that we were tracking referrals and that we were ensuring that the referral actually got that the member actually engaged. We ended up integrating our referral platform, and what that did was allowed our associates to not have to jump from platform to platform. And that really does make a difference when you are engaging members. Having it all easily having all of that information easily accessible It can only improve the engagement with the member and and ultimately, hopefully, improve their health outcomes too. From a data collection standpoint, I talked a little bit about how we partnered with IT. And really not only the data that we have, that we already had and and organizing that and making sure that, it was readily available, for analysis, but also talking more about other data sources that we could use and ingest, to be able to gain even more insights. And then, community partnerships. We really pride ourselves on how strong and meaningful our community partnerships are. Especially in the quality space, like I said, the pop health space, you know, making sure that we are that total member includes health equity and that only strengthens all of our different programs and doesn't keep everybody in a silo. So and then the last slide. And, Kristen, I I hate to cut this off because I was looking forward to hearing how Yeah. This slide. That's okay. Just in the interest of time, if you wanna just share kind of a last thought on where you've been leading us with this journey. And I apologize to the audience because I feel like either of our panelists today could have filled an entire hour given the experience that you have. I do wanna answer one or two q and a questions. So if you can just kind of take us home, Krista. Yeah. Absolutely. I would say, I think the largest message here, is that, you create a pathway, identify your gaps, and really make sure that you have that leadership support. I think it's it's so important to ingrain in everyone how important this is, and especially making sure that those people who do engage with members understand what health equity is, why it's important, and then certainly as you start to partner with more community, based organizations, that you're using any and all information that they have. And and and that becomes important because that those wraparound services and and people who know and are in the community with the members, you can gain such valuable insights from that. Alright. Thank you so much to all of the speakers. I know that we are running short on time, but a couple of questions came in. You know, given where we are with time and that I'm already starting to see those questions, I'm going to encourage everyone to drop their questions in the q and a now. If, you know, we are not able to get to your question, then we will try to find another way to follow-up with you as long as it is in the the q and a, if you're joining us by LinkedIn in the comments there. So the one question I saw come in first, and I think I'll kind of I'll I'll pitch this to elephants first, and then, Molina, if you have any thoughts. Any advice that you give to organizations struggling to move from data collection to meaningful community action? Yeah. I'll I'll take this one. One piece of advice that I would offer is don't focus on collecting more data. Focus on making the data that you have actionable. I think a lot of organizations already have a tremendous amount of information. In our case, you know, our challenge was not a lack of data by any means. It's that it lived in so many different places. It wasn't easy for people to use. And so we really found that bringing that clinical data together with community and social data into a single accessible view helped shift the conversations that we were having from what does the data say to actually what should we do next. The second thing I'd say is to pick a particular, you know, a specific question or priority rather than trying to solve everything at once and boil the ocean. For example, if you're focused on improving maternity outcomes, look at where the disparities exist for maternity and what social needs might be contributing, then partner with your community, you know, organizations to design interventions around those barriers with that focus. And then my last piece of advice would be making the data accessible to people who are actually making the decisions. If the insights are only living with the analysts or or or the data SMEs, they're less likely to translate into action. And so that was a really important part of our design was making it self-service so that health equity leaders and business partners could explore it themselves and then use those insights to actually shape their strategies and intervention. So the short of it is I really think meaningful community action comes from when, know, you use the data to help you prioritize where to invest, who to partner with, and then use that to measure whether you're you know, the efforts are actually making a difference. Yep. Thank you, Allison. I know we are out of time, but I wanna give Molina a chance to share any thoughts, anyone from you your side. Yeah. No. I would have said the same thing. Truly, this is about, using what you have. As Allison said, it's usually you usually have the information. It's really just organizing it. But then in order to in order to make that actionable, I think two things. One, you know, partner make give some strong partnerships with providers in community based organizations. Like I said, they don't know what they don't know. And so I think it was really important for us to bring some of that to the table, and and for them to gain some insights, and and really to collaborate. And and I think that that those conversations ultimately is what designs the best kind of interventions and actions and making sure that you have those partnerships. Well, thank you so much to both of the organizations. Certainly, having a strong team, I think, is part of your secret sauce as well. So we really appreciated having your expertise today. I'm going to make a shameless plug that it is not too late to register for NCQA's health innovation summit, which will be in Atlanta this year. Some of the topics that the panelists brought to the table today will also be the subject of sessions at the summit. If that's of interest, and, of course, networking. And, for those of you that shared other written questions that we didn't get to answer today, we will try to find another way to follow-up with you and get you an answer from the panelists. So, panelists, we will be in touch. And thank you again, and I hope everyone enjoys the rest of their day. Take care. Thank you. All.