Call for Partners Info Sessions: Recordings & Transcripts Available

The audio recordings and transcripts are available for the Call for Partners Info Sessions which took place on May 23 and May 25.  We hope this information helps with the application process; please let us know if we can provide any further clarification or assistance!

Listen to May 23 (session 1): click for audio.  Read transcript: click for pdf.

Listen to May 25 (session 2): click for audio (first two questions missed — see transcript).  Read transcript: click for pdf.

Call for CCAs (Supplement Application)

North Sound ACH is seeking partners who are currently providing care coordination services in the North Sound region to the populations of focus described in the document linked below, that would like to serve as a Care Coordination Agency (CCA) within a Pathways HUB model.

Supplemental Application for Community-Based Care Coordination Agencies (CCA)

NOTE: This application is supplemental to the North Sound ACH Call for Partners. Any agency that is interested in becoming a Pathways Care Coordination Agency will also need to complete the North Sound ACH Call for Partners, found HERE.

FAQ from Convening of Community-Based Organizations

(The following questions were gathered from feedback of those who attended the Convening of Community-Based Organizations on May 1.)

Confidentiality concerns in care coordination/partnership

How will CFR 42 Pt. 2 (Substance Abuse Confidentiality Regulations) be addressed if co-occurring behavioral health (including Substance Use Disorder) is chosen as a population of focus?

Anyone involved with Substance Use Disorder (SUD) treatment with an SUD provider must have a CFR 42 part 2 compliant Release of Information (ROI).  Outreach-only work does not require an ROI, but once someone enters into treatment it is necessary. Newly updated CFR 42 part 2 language includes a provision that “all involved” in treatment can be included in an ROI.  A SUD provider (for example a counselor in an outpatient clinic) can most easily develop ROIs and communicate with a specific individual (identified in the ROI) in various other areas (housing, school, job development, medical).

Becoming a Pathways CCA

How many agencies per county will be chosen and what scope is intended? Where is the training?

The North Sound ACH is not designating a specific number of Care Coordinating Agencies (CCAs). The number of agencies in the network will be contingent upon the responses we get from our call for CCAs because 1) We’re using that call as a final refinement tool to figure out which agencies are available and have the capacity to do the work around our populations and 2) what is their geographical scope of service.

What resources will be given to the new CCAs to support their management of the program in their community and staffing of new community health workers/community care coordinators? And when will they be distributed?

The CCA staff who the agency designates as their Pathways care coordinator, will be trained in the Pathways model and software at no cost to the CCA. Existing staff of CCA agencies are candidates for being designated and trained as care coordinators. The Pathways HUB model creates the potential for additional sources of reimbursement or funding for the work of existing care coordinators, as well as additional funds flow for adding care coordinator staff capacity as the HUB network of referrals is developed.  While the Hub is providing startup funding and training for care coordinators, it is important that a CCA is able to illustrate their ability to sustain care coordinators in the future, and that the Hub is not their only source of funding.

Pathways Planning Process for Conducting Key Informant Interviews

When were key informant interviews conducted, and with whom? 

During the Pathways Community Hub planning phase (January – April 2018), an environmental scan and key informant interviews were conducted to build understanding of care coordination activities and populations served across the North Sound region. Key informant interviews are still ongoing and community input will still be sought out. So far,  interviews have included:

County Resource Centers in Island and San Juan County

Home Health Lead Agencies

The North Sound Behavioral Health Organization

Community Based Organizations such as: The Opportunity Council, Compass Health, Mt. Baker Planned Parenthood

North Sound ACH Leadership: Program Council

Medicaid Managed Care Plans

High Utilizer Group initiatives serving Skagit, Snohomish, Whatcom counties.

Information that helped shape population of focus selection was also gathered during the North Sound ACH Community Based Organization convening on 5/1. Additional information was gathering during consultation, engagement and strategic development input of state and national partners in launching the Pathways Hub model (including Foundation for Healthy Generations, Health Home Lead agencies, and The Pathways Hub Certification Institute, ACHs around Washington State, and other certified Hubs (NEON in La Grande, OR)).

Please contact us if you have additional questions.  Email Hillary and your email will be forwarded to the appropriate member of our team.


First 2018 ‘Call for North Sound ACH Partners’ Released

The North Sound ACH is seeking clinical and non-clinical partners to improve health in the the North Sound region, who are currently working in the North Sound region, on North Sound ACH Project Areas, serving the North Sound ACH Populations of Focus.

This an open call – please share this packet with organizations in your community and networks who you feel meet the criteria laid out in the documents. 

Please make sure to read/review all sections of this packet before submitting your application to the North Sound ACH:

We look forward to future partnerships!

Convening of Community-Based Organizations

Earlier this month we hosted a convening for community-based organizations that work with people on Medicaid. It was wonderful to have the opportunity to share more about the ACH, make new connections, and discuss ideas with so many potential partners. 

As we move forward, we greatly value feedback and want to give room for additional questions or further discussion.  If you were able to join us, please take a few minutes to complete a brief survey here – we appreciate it!

If you weren’t able to attend, you can access materials here: click here to view the slides presented  and here to access the guide on Developing Community Care Coordination Pathways.

North Sound ACH Data & Research Analyst Awarded Conference Scholarship

Nicole experienced a life highlight when she visited the Center for Disease Control and Prevention in 2016.

The North Sound ACH’s Research & Data Analyst, Nicole Willis, has received a scholarship to attend the Council for State and Territorial Epidemiologists’ (CSTE) Annual Conference, June 10-14 in Florida. The scholarship extends to a daylong Substance Use & Mental Health Surveillance Workshop, where she hopes to gain further insights to support the data-driven needs of North Sound ACH initiatives and learn about the latest tools/resources that can be shared and implemented throughout the region.  

Every year CSTE hosts over 1,400 state and local epidemiologists at its conference to consider pressing public health issues facing the nation. Conference activities will include important workshops, breakout sessions, plenaries and other scheduled events related to a diverse agenda of public health and epidemiology topics. CSTE is a leader in developing standards of practice for epidemiology, informatics and surveillance, their work on establishing core health indicators is vital to the monitoring and tracking of substance use and mental health needs locally. CSTE is also supports effective public health surveillance and epidemiologic practice through training, capacity development, and peer consultation.

The practices of epidemiology, informatics and surveillance is vital to the work of the ACH, as they ensure effective use of data to guide population health improvement. Which is why we are so lucky to have Nicole, who prior to joining the ACH was a public health epidemiologist and a recipient of a CSTE/CDC Informatics Fellowship.

Congratulations, Nicole!   We’re thankful to have you on our team!

For more information on the Council for State and Territorial Epidemiologists visit their website at:

Meet our Tribal & Community Liaison!

North Sound ACH now has a Tribal & Community Liaison!

Candice Wilson, Quatz’ten aut, is from Lummi Nation. She has over 15 years of tribal governance experience and was hired to develop and foster relationships with tribal and community partners.

Candice has a Bachelor degrees in Tribal Governance and Business Management from Northwest Indian College and is currently is pursuing her Masters in Public Administration at Seattle University. She serves on the Ferndale School Board, with Whatcom Family & Community Network, Lummi Nation Services Organization, Children of the Setting Sun Productions, and RE Sources for Sustainable Communities. 

Candice also served on the Lummi Indian Business Council for nine years, with three years as the Vice Chairwoman, also serving as Lummi Nation Vote Coordinator, Lummi Child Support Program Case Manager, and Lummi Dislocated Workers Program Job Counselor. She’s the recipient of the Washington State Native American Coalition Against Domestic Violence & Sexual Assault Envision Spirit Award and Lummi Victims of Crime Honoring Our Champions Award.

Candice enjoys serving and celebrating our diverse communities, especially with our veterans and youth organizations.

Welcome, Candice!  We’re thankful you’ve joined our efforts.


Equality vs. Equity

The North Sound ACH team will be traveling to Chicago in April to attend Equity Summit 2018.  More information can be found on the event here.

Equality vs. Equity

As we prepare for the 2018 Equity Summit, we continue to explore the concepts of equality and equity. Equality is the equal distribution of resources, while equity focuses on providing for those based on need, in order to gain equality. Achieving health equity requires collaboration and collective action.

In our work, equity and equal opportunity are inextricably linked.  We want all communities to be healthy and connected, but different communities have different structures which interact in different ways, to produce different outcomes. Structures can be cultural, physical or social. The placement of these structures in our lives can take us where we want to go, or they can prohibit us from getting where we’d like to be. Achieving equity requires creating targeted interventions to adjust or create structures that work for everyone. In our work, we pull from Targeted Universalism and Dr. John Powell’s theory that through these targeted interventions, we can affirmatively build structures to produce the better outcomes for everyone.

Would you like to know more about equity? The following resources can help give a better understanding of the root causes of health inequity.

Roots of Health Inequity: A web-based online learning collaborative

This course provides an online learning environment from which to explore the root causes of inequity in the distribution of disease, illness, and death.

Waiting For Health Equity

This graphic novel contextualizes health equity issues using both historical and personal perspectives.

Unnatural Causes

A seven-part documentary series exploring racial and socioeconomic inequalities in health.

Targeted Universalism

The UC Berkeley HAAS Institute and Dr. John Powell’s theory of Targeted Universalism.

Please feel free to connect with our team at the North Sound ACH if you are interested in screening any part of Unnatural Causes or having a community discussion on equity. We are able to help facilitate or support a community conversation. Email or send us a message on our Facebook page


A Reminder of Mindfulness

As 2018 begins, my brain is a buzz with ideas, plans, deadlines, and I’m sure I’m not the only one.

Our convoluted, intertwined, and sometimes abstract work in the Medicaid Transformation process can bring about anxiety and feelings of uncertainty (and can lead to sleepless nights). One highly effective and evidence-based tool that can help is the practice of mindfulness. Research reveals that by paying attention to what’s going on around us, we can reduce stress, unlock creativity, and boost performance. Mindfulness exercises promote intention through breathing and focus; the practice can turn the mundane into something with purpose. 

As innovators in Healthcare Transformation, the benefits of mindfulness are extensive and can assist of in our work—research shows a link between mindfulness and innovation! The practice is also relevant to the clinical workplace, as it can help improve patient engagement and satisfaction. The Institute for Health Improvement (IHI) offers a free course: Incorporating Mindfulness into Clinical Practice. During the 2017 Edge of Amazing conference in Snohomish County, neuroscientist Dr. John Medina discussed the biology behind stress, empathy, the “Theory of Mind and Mindfulness”, and suggested tools on how to implement these findings into the practical world.  One his suggested tools is the book Mindfulness: An 8 Week Plan for Finding Peace in a Frantic World.

We all experience work and life stress, and mindfulness can be used to help move past fears and root us in the present moment, allowing us to deal with challenges with a clear head and calm mind. 

Sample Exercises

Come Back

When you catch yourself caught up in worries about the future or guilt and regret about the past, simply and kindly say to yourself, “come back.” Then take a calming breath and focus on what you are doing right now.

Three Senses

Simply notice what you are experiencing right now through three senses – sound, sight, touch. Take a few slow breaths and ask yourself:

  • What are three things I can hear? (clock on the wall, car going by, music in the next room, my breath)
  • What are three things I can see? (this table, that sign, a person walking by)
  • What are three things I can feel? (the chair under me, the floor under my feet, my phone in my pocket)

Think of these answers to yourself slowly, one sense at a time. It’s impossible to do this exercise and not be present and mindful!


IHI Incorporation Mindfulness Course

Mindfulness book



Martin Luther King Jr Day in the North Sound

In observance of Martin Luther King Jr. Day the offices of North Sound ACH will be closed on Monday January 15th, 2017. During this day we encourage everyone to spread the message of freedom, equality, justice, tolerance and love.  There are several events happening around the North Sound and around the State.  In this time of turmoil let’s remember and act on Dr. Kings message of hope. 

Island  County

Trinity Lutheran Church Minister of Music, Karl Olsen, is planning to perform gospel music and movements in the program. A speech from New Orleans Mayor Mitch Landrieu will also be read; Landrieu gave the speech against white supremacy as his city removed Confederate statues.

Whidbey Island Center for the Arts in Langley is hosting a performance at 7:30 p.m. Friday that combines theater with archival film, called “The Right to Dream.”

The performance is from award-winning Seattle “historical theater troupe,” Living Voices, that tells an African-American student’s coming of age story in Mississippi during the 1950s and 1960s.

On Jan. 15, Whidbey Island Friends Meeting is showing a video of King’s speech delivered from Riverside Church, “Beyond Vietnam.”

King denounced the Vietnam War in the speech. The viewing is 7 p.m. Monday at the Unitarian Universalist meeting house in Freeland.

Read the entire article

Whatcom County

Noon-1 p.m. 210 Lottie St. Free. The city of Bellingham hosts a celebration at City Hall and a day of service at Maritime Heritage Park. The celebration includes music by the Kulshan Chorus, with City Council member Roxanne Murphy as emcee. Speakers include Mayor Kelli Linville; Kristen French, director of WWU’s Center for Education, Equity, and Diversity; musician Edwin “Skip” Williams; and poet and activist Ellen Murphy. This year’s theme: “Infinite Hope: The Courage of the Movement.”

10 a.m. to 1 p.m. Nooksack Salmon Enhancement Association, Bellingham Parks and Recreation Department, and the Volunteer Center of Whatcom County, work to improve salmon habitat at Maritime Heritage Park. Volunteers should come dressed for the weather and prepared to work on steep slopes. Gloves, tools, directions, and refreshments will be provided. nd Recreation and NSEA. Park in the C Street parking lot.

Celebration details: Marie Marchand, 360-778-8202 or Park work details: Rae Edwards, 360-778-7105 or

17th Annual MLK Jr. Poetry Reading and Open Mic

6 to 8 p.m., Community Food Co-Op, 1220 N. Forest St. People of all ages can share a poem or song focusing on diversity, human rights, or related issues (limit presentation to five minutes). Kevin Murphy emcees. Details: 360-734-8158.


Snohomish County

 The annual Whidbey Island Martin Luther King Jr. “Blessed Are The Peacemakers” event at St. Augustine’s-in-the-Woods from 1 to 2:30 p.m. Jan. 16 will feature interactive readings on the martyrs of Selma and voting rights, recordings of King’s speeches, musical performances and a keynote speaker.

Free lunch provided from noon to 12:45 p.m. 

St. Augustine’s is at 5217 Honeymoon Bay Road, Freeland. Call 360-678-5071 for more.

Also in Freeland, Unitarian Universalist Congregation of Whidbey Island will screen the PBS Tavis Smiley special, “A Call to Conscience,” at 6:30 p.m. Jan. 16. The church is at 20103 Highway 525. 

On April 4, 1967, King delivered the controversial speech, “Beyond Vietnam,” about his opposition to the war in Vietnam. The one-hour special includes his speech and commentary. Call 360-342-1457 for more. 

Global Peace Foundation USA, Service for Peace, Corporation for National &Community Services, and Lynnwood Parks &Recreation are hosting an MLK Day of Service for youth ages 14-18 on Jan. 18. Meet at Prestige Care Inc., 21008 76th Ave. W, Edmonds, to volunteer from 9 a.m. to 3 p.m.

Service projects will include poster making for Meadowdale Elementary School, writing letters for the Lynnwood Food Bank and trail rehabilitation at the Lynnwood Golf Course. 

Lunch will be provided.

Call 406-794-2847 or email for more information.

Treat your fellow Americans with dignity and respect, regardless of their background.

— Sara Bruestle, Herald writer (Read the article)

Seattle/King County Celebrations