Frequently Asked Questions

At Elevate Health, our mission is to create affordable, accessible, whole-person health care for all. As an Accountable Communities of Health (ACH) organization, we bring together community and health care stakeholders to create greater health equity for the residents of Pierce County and to advance purposeful health care reform in Washington state.

Our mission is to build and drive community coalitions that transform health systems and advance whole-person health for all.

That every person in every community we serve lives a full, healthy and vibrant life.

Organizations designated as Accountable Communities of Health (ACH) work with healthcare and community leaders to transform population health. In incentivizing providers for quality rather than quantity, and in focusing on whole-person health, ACHs make the healthcare system more responsive and equitable.

We use a data source called Innovaccer. It’s encrypted, flexible, specific to our needs and highly customizable — far more customizable than programs usually considered the industry standard in tracking records of individuals. Among other advantages, it establishes connectivity with other data sources (such as EPIC) and can analyze population health metrics.

Please contact OnePierce’s director at info@onepierce.org.

Elevate Health isn’t simply another player in the healthcare field. Our goal is to improve the field, in accordance with the Quadruple Aim, to make health care more individual-focused, equitable and cost-effective.

Please contact us at ask@elevatehealth.org.

Recognizing that good health and a person’s basic needs are inextricably linked, we employ the Care Continuum Network (CCN) to help vulnerable populations in Pierce County. The CCN serves as a centralized community hub, where individuals, providers, community partners and community-based organizations may refer for services.

This care traffic control model allows CCN staff to assign individuals to one of three care coordination programs — Community Health Action Teams, Health Homes or Pathways Community HUB – administered by our community partners.

The CCN serves as a bridge to all these services. When individuals work with staff in the CCN, they receive help, counseling and referrals designed to address their barriers to health. Commonly these barriers stem from: healthcare access and quality, education, social and community context, economic stability, and neighborhood and built environment.

In this process, network personnel may connect individuals to social services organizations that provide essentials such as food and housing, to healthcare organizations that address chronic health conditions, and to counseling centers or therapists that can help meet needs related to behavioral and mental health.

In addition to helping individuals navigate a complex network of services, the CCN team also helps our organizational partners by identifying and creating resource networks, supporting program quality, developing data strategies and ensuring best practices. Taken together, these services make the local care ecosystem more efficient, equitable and cost-effective.

Your individual will receive a full complement of care and assistance if they become part of the network. Once you refer your individual, they will receive counsel and referrals related to several interrelated goals: pursuing further medical care, following up on behavioral health services, and finding resources related to other needs, such as employment, housing and much more.

Additionally, Elevate Health, which administers the network, serves as a locus for transforming health care and collecting health data in Pierce County. By creating the network and tracking individuals’ progress, we track how interventions — especially for vulnerable people — save and improve lives.

By working with us, you not only provide your individual with a team approach to health, but you also help us reduce health inequities in Pierce County.

Yes. We are interested in organizational partners (community programs that house and/or hire the personnel who work with individuals) or referral partners (community programs who have individuals who could benefit from the network). Given Elevate Health’s focus on health equity, we are especially interested in recruiting partners in service to rural communities and underserved populations, such as people of color, veterans, immigrants and women.

Please use the brief form found here to refer people to the Care Continuum Network.
Thank you.

This care coordination program, developed by Drs. Sarah and Mark Redding at the Pathways Community Hub Institute in Ohio, is based on more than 20 years of evidence gathered through collaboration with community health workers (CHWs).

Adapted by Elevate Health to help Pierce County residents, the Pathways Community HUB trains CHWs to help people navigate health and social service systems. Together, the two select and follow customizable plans of action (called pathways) to eliminate the individual’s barriers to health care.

Elevate Health’s Pathways program is the first and only PCHI certified program of its kind in Washington. It is also one of our central care coordination services. It shares that distinction with two other programs, the Community Health Action Team and Health Homes. Together, the three services form Elevate Health’s Care Continuum Network.

Pathways was originally designated for Medicaid eligible individuals with two chronic conditions (such as diabetes, anxiety, substance-use challenges and so on) related to their physical or mental health.

A person’s circumstances affect their ability to stay healthy or receive good care. These circumstances — including employment status, or access to food, among others — are called the social determinants of health. Sometimes, social determinants become barriers to being healthy and accessing health care. Commonly, these barriers include:

• Poverty and unemployment

• Language barriers

• Mental health challenges and substance use

• Lack of housing and/or food

• Transportation challenges

• Domestic violence

Pathways serves as a bridge between the two. When an individual and community health worker (CHW) begin their work together, they evaluate the social determinants that act as barriers to the individual’s health. Each barrier is assigned a pathway, after which the individual and the CHW work together to complete it. In this process, the CHW — in mentoring, in making referrals to food banks and other organizations, in supporting good medical care — helps an individual navigate the worlds of health services and social services.

We work with several organizations to conduct Pathways. Our partners include health care providers, government agencies and community-based organizations, among others.

They each maintain a bidirectional relationship with Elevate Health and employ trained community health workers (CHWs) who provide knowledgeable, culturally appropriate care, receive referrals generated through the program, and make referrals generated by their respective agencies to Pathways.

If you are interested in becoming an organizational or referral partner, please contact pathways@elevatehealth.org or (253) 208-3702. We look forward to hearing from you.

If you or someone you know might benefit from non-emergent Care Coordination services, please contact us at care@elevatehealth.org or call the Care Continuum Network Referral Line at (253) 331-2380.

Please evaluate whether your friend is having medical or behavioral health emergency.

If you or someone you know if suffering a life-threatening medical or behavioral health emergency, please call 9-1-1 for immediate assistance.

If you or someone you know is experiencing a non-life-threatening but urgent mental health crisis, call one of the following 24/7 Crisis Lines:

Pierce County Crisis Line: 800-576-7764

National Suicide Prevention Lifeline: 1-800-273-8255

Crisis call lines available 24/7:

Pierce County Crisis Line: 800-576-7764

National Suicide Prevention Lifeline: 1-800-273-8255

If your friend needs non-emergent help, please contact us at care@elevatehealth.org. We’re happy to make referrals for care coordination services to our partners, listed above.

Pathways Community HUB at Elevate Health isn’t simply another player in the health care field. Our goal is to improve the field, to make health care more person-focused, equitable, and cost-effective. Importantly, Pathways is also creating a valuable and long overdue bridge between the fields of medicine and social services, which work together to effectively support a person’s health and well-being.

Health Homes is not a physical space. Rather, Health Homes is a service directed at improving the health care delivery system, and it is available to people of all ages.

Individuals who join the Health Homes program work with a care coordinator to assess and access services to meet their medical needs, behavioral health and substance-use challenges, and social determinants of health challenges (conditions such as employment status, language and access to food and housing) that may negatively affect their pursuit of whole person health, wellness, and quality of life.

Through regular meetings, discussions and planning — and through the development of a health action plan (HAP) — coordinators and individuals work together to address an individual’s medical, emotional and social needs. As a result, individuals receive tailored care with appropriate services, and hospitals are better able to focus on addressing acute medical conditions.

Health Homes is an optional state Medicaid plan benefit, and services are free. The Centers for Medicare and Medicaid Services (CMS) pay the costs for this service. However, individuals (both adults and children) must meet a few criteria:

• They must be eligible for Medicaid or Medicare/Medicaid.

• They must meet HCA risk criteria by means of a PRISM scoring (Predictive Risk Intelligence System), a tool used by the Washington State Health Care Authority to estimate healthcare costs for Medicaid recipients.

AND meet ONE of the following criteria:

• Two or more chronic conditions

• One chronic condition with risk of another

• A serious and persistent mental health condition

Once enrolled, a client may remain in the program as long as needed — their entire life, if they wish, so long as they are eligible for Medicaid or Medicare/Medicaid.

Health Homes partners are care coordination organizations (CCO). Contracted CCOs include health systems, clinics, providers and community-based organizations, among others.

The primary responsibilities of the CCO include hiring, training and supervising care coordinators, following Elevate Health’s billing processes and using a specific data platform for documentation and data collection. (Please note that this is a partial list.) In their turn, care coordinators are responsible for a minimum of one individual contact per month to fulfill any number of six key services:

• Comprehensive care management;

• Care coordination and health promotion;

• Comprehensive transitional care from inpatient to other settings, including appropriate follow-up;

• Individual and family support;

• Referral to community and social support services, if relevant; and

• The use of health information technology to link services, as feasible and appropriate.

To learn more about becoming a CCO, please contact Elevate Health at care@elevatehealth.org for more information.

Please contact care@elevatehealth.org to set up a pre-referral discussion.

If you or someone you know might benefit from non-emergent care coordination services, please contact us at care@elevatehealth.org or call the Care Continuum Network referral line at (253) 331-2380.

If you or someone you know if suffering a life-threatening medical or behavioral health emergency, please call 9-1-1 for immediate assistance.

If you or someone you know is experiencing a non-life-threatening but urgent mental health crisis, call one of these 24/7 crisis lines:

Pierce County Crisis Line: 800-576-7764

National Suicide Prevention Lifeline: 1-800-273-8255

CHAT stands for Community Health Action Teams, a program, administered by Elevate Health, for people who live in Pierce County.

The program provides fast, direct and personalized support and counsel to individuals who need help understanding and accessing different types of medical and social services.

CHAT is one of our central care coordination services. It shares that distinction with two other programs, Health Homes and Pathways Community HUB. Together, the three services form Elevate Health’s Care Continuum Network.

CHAT individuals should meet all of these requirements:

• They use the emergency room or the hospital frequently.

• They’re a hospital readmission risk because of chronic disease, behavioral health and/or substance use challenges.

• They have an infection related either to a chronic medical condition or IV drug use.

• They have risk(s) related to the social determinants of health (these are environmental factors — such as access to employment, education and food — that can become barriers to health and health care).

We work with several organizations to conduct CHAT.

Our Pilot Partners

• Sea Mar Community Health Centers (Clínica de la Comunidad) specializes in primary care family medicine and in serving the Latinx community. CHAT is housed at Sea Mar.
• MultiCare is a not-for-profit healthcare organization in Washington state that includes multiple hospitals and a network of primary care, urgent care and specialty services.

Our Referral Partners

• CHAT accepts individual referrals from a number of organizations, including health care providers, government agencies and community-based organizations, among others. CHAT is actively recruiting more partners.
  

Please contact care@elevatehealth.org or (253) 331-2380.

Your client will receive a full complement of care and assistance if they work with CHAT. CHAT includes a medical expert and a mental health expert as well as a community health worker. As a result, once you refer your patient to CHAT, the team will counsel them in three interrelated goals: pursuing further medical care, following up on behavioral health services, and finding resources related to other needs, such as employment, housing and much more.

Additionally, Elevate Health, which administers CHAT, serves as a locus for transforming health care and collecting health data in Pierce County. By founding programs like CHAT and tracking individuals’ progress, Elevate Health is able to track whether interventions — especially for vulnerable people — save and improve lives. By working with CHAT, you not only provide your client with a team approach to health, but you also help us reduce health inequities in Pierce County.

If you or someone you know might benefit from non-emergent care coordination services, please contact us at care@elevatehealth.org or call the Care Continuum Network referral line at (253) 331-2380.

If you or someone you know if suffering a life-threatening medical or behavioral health emergency, please call 9-1-1 for immediate assistance.

If you or someone you know is experiencing a non-life-threatening but urgent mental health crisis, call one of these 24/7 crisis lines:

Pierce County Crisis Line: 800-576-7764

National Suicide Prevention Lifeline: 1-800-273-8255

OnePierce is a nonprofit community asset dedicated to helping vulnerable Pierce County residents and the organizations that support them.

OnePierce blends revenue from Elevate Health with funding from investors, businesses, philanthropists and public entities, then distributes that funding — via grants and loans — to community organizations that help people improve their whole-person health. Its goal is to create a long-term, sustainable source of funding for community organizations.

The social determinants of health are conditions in the places people live, learn, work and play — such as employment and access to housing — that affect a person’s health, quality of life, and their access to health care.

OnePierce does offer some grants, but its purpose is broader. The nonprofit also manages investments, turning investors’ funds into loans available to applicants who address the social determinants of health. In addition, OnePierce works with public entities to manage and distribute funds to other organizations.

OnePierce is the first of its kind in Washington state and in the nation; Elevate Health pioneered the creation of an investment strategy arm that offers grants and community loans to create long-term, sustainable resources for its community. Working together, OnePierce and Elevate Health intend to transform healthcare in Pierce County.

We would be delighted to hear from you and to answer your questions about our investment vehicles. To start the conversation, please contact OnePierce Director Lauren Fulton at info@onepierce.org.

We would be delighted to hear from you and to answer your questions about our work. To start the conversation, please contact OnePierce Director Lauren Fulton at info@onepierce.org.

Our loan application process begins with an the OnePierce Expression-of-Interest form.

Please note that the information asked of in the form is introductory and we encourage you to reach out to us so we may best support you. Please contact info@onepierce.org.

For grants, we issue RFPs (requests for proposals) related to specific projects, so please check our website for the most current information.

OnePierce gives out grants, which do not have to be repaid, and loans, which need to be repaid with (low) interest. Although both grants and loans will benefit community organizations, loans have an added benefit for the community. As they are paid back, loans create an ongoing, revolving funding stream that can be used, in part, to sustain OnePierce and to continue to meet the needs of local organizations. Loans are also used to pay back our own investors.

Generally, grants do not need to be repaid, and loans must be repaid with interest. There may be circumstances in which OnePierce would ask for a return of funds, i.e., if an organization were not meeting its goals, but all terms will be clearly outlined during the application process and in the final documentation.

Elevate Health and its organizational partners — from healthcare providers, community-based organizations, social service agencies and government agencies to tribal councils and other authorities — are working together to transform community health in Pierce County.

Our focus is to create an accurate snapshot in time of what’s taking place in our community by taking into account the data we hold and the data from individual organizations.

By integrating these stores of data we will be able to better coordinate an individual’s care and help them address multiple challenges. We’ll also be able to help policymakers find and address community health challenges in our region.

We often think of health in individual and personal terms: my health, my mother’s health, my child’s health. Population health involves looking at the health outcomes and the social determinants of health that affect large groups of people. Public health, on the other hand, is what we do as a society to assure the conditions in which people can be healthy.

When we blend individual health, population health and public health data, we can begin to understand community health and operate from a place of prevention to improve health outcomes.

The Community Data Trust supports not only the health of individual, but also leverages population health data to inform community health. By analyzing large quantities of de-identified data, the trust can help pinpoint emerging or existing health challenges within a region or ZIP code, and plan interventions to affect outcomes.

To date, partners include Tacoma-Pierce County Health Department, Pierce County, Sea Mar Community Health Centers, Community Health Care, Pierce County Superior Court, and United Way of Pierce County. All the behavioral health care providers we work with in our region are working with us to onboard, as well as several managed care organizations and payors.

Yes, we do. We know that more partnerships and larger collections of data will lead to better population health visualizations. Once we have a more thorough, detailed picture of needs and care gaps in Pierce County, we can work to address them.

The Washington State Health Department and the Washington Department of Health have created health information exchanges (HIE) to allow health care professionals, providers, public health, and health systems to securely exchange clinical or business information in standardized messages.

However, both HIE are centered solely on healthcare information, do not have analysis and reporting capabilities standards set in today’s marketplace, or the ability to forecast community health needs.

The Community Data Trust extends the intent of the state HIE and buttresses its available data to incorporate other systems for a truly comprehensive and 360-degree view of community data in real time.

Elevate Health is, first and foremost, a government seeded and government regulated entity. Our sole purpose is to be stewards of health equity in our region and facilitate improvements for the social determinants of health. We are held to a higher standard and have a higher level of accountability as a result.

The greater the diversity of the data shared with the Community Data Trust, the more opportunities will arise for its members and stakeholders to improve the health of our communities. Elevate Health is taking a conservative, pragmatic approach with our partners to ensure the trust is a true community asset with the ability to support the use cases of its membership. All use cases will be decided upon by the Community’s Data Trust’s set governance, and will adhere to rules and regulations in place by state and federal authorities.

For instance, data may be used to create risk-scores for the identification, stratification, and management of high-risk individuals, central to improving quality and cost outcomes for healthcare organizations. Other use cases may include leverage data in order to invest in community needs that encourage more positive living conditions and health outcomes – such as increased transportation infrastructure, increasing WiFi access for neighborhoods with low access, or making lasting investments in early learning opportunities for a larger number of children.

Elevate Health is seeding the establishment of the Community Data Trust using its own resources, but it will take commitment from everyone in the community to sustain the trust’s success.

Members of the collective will be able to access an incredible array of up-to-date information that will allow each to forecast, assess, create efficiencies, use resources more effectively, and best serve the populations in their communities.

Once governance for the Community Data Trust is set, interested organization will also be able to set-up a graded fee structure for services that align with agreed-upon data uses.

Data ingested into the trust will enter a single, secure, HIPAA-compliant and HITRUST platform. The model for trust around the trust will be based upon the agreement of its governance and their shared adherence to its policies, guidelines and use cases. Each member organization has a vested interest in the safety and security of the platform so it will remain the highest priority during the Community Data Trust’s establishment and its long-term sustainability.

When the Community Data Trust is crunching numbers for risk stratification in an individual’s case management there will be a greater depth of information available for the appropriate and authorized uses. In most cases, information will be de-identified and encrypted so privacy and patient rights are preserved.

We’d be delighted to speak with you. Please contact us at datatrust@elevatehealth.org.

If you or someone you know might benefit from non-emergent care coordination services, please contact us at care@elevatehealth.org or call (253) 331-2380.

If you or someone you know if suffering a life-threatening medical or behavioral health emergency, please call 9-1-1 for immediate assistance.

If you or someone you know is experiencing a non-life-threatening but urgent mental health crisis, call one of these

24/7 crisis lines:
Pierce County Crisis Line: 800-576-7764
National Suicide Prevention Lifeline: 1-800-273-8255