Hospital Partnerships

1. Hospital Partnerships Sharon Sanders RN, BSN, MBA Vice President for Clinical Integration

2. Objectives • Strategies employed to more effectively serve people outside of the hospital and ED. • Approaches to more effectively bring together treatment providers, community groups and others to provide care to diverse populations with complex needs. • Where a model like the HEZs might fit.

3. Today’s Healthcare • Characteristics: • Outcomes- oriented • Enabled by technology • Patient -centered • Use of data and analytics • Performance transparency • Ability to partner across organizations

4. Turning the Ship Creating need for new skill sets, policy, tools, and competencies Physician-managed health rather than health plan managed care • New models of care delivery and coordination • Payment aligned with goals • New tools for clinical alignment • Better PHM capabilities • Experience in performance management/ data reporting • Experience in population risk adjustment/ risk mitigation • Increased awareness of prevention and wellness value • Educated, empowered patients • Drivers: • Health care cost crisis • Health reform • Improved • HIT • Greater stake-holder align-ment

5. Creating Value and serving people • Adding community care coordination in primary care clinics and physician offices • Using home monitoring technology linked through Home Care & Care Coordination • Expanding SNF Care Transition Coordinator – Hospitalist consult • Creating dedicated Palliative Care programs • Accountable Care Organizations and Physician Hospital Organizations • Forming a Clinically Integrative Network with our physicians and other partners • Expanding the “Care Connect” Navigation Program to include medication management & focus on high-risk patients • Patient Centered Medical Homes

6. “To create and sustain a community of wellness in Carroll County” At Carroll Hospital, we offer an uncompromising commitment to the highest quality health care experience for people in all stages of life. We are the heart of health care in our communities. “Striving to build the capacity of individuals and organizations to improve the health and quality of life in Carroll County, Maryland” “A Health Care Home for uninsured, low-income people”

7. Access Carroll • Private, nonprofit – 501(c)(3) • Private and Public Health Partnership • Integrated medical, dental, and behavioral health care • Community-based • Volunteer driven • Located in heart of county • Addressing local health access needs • 10 Years Old! 2005-2015

8. Access Carroll Mission To champion health and provide quality, integrated health care services for low-income residents of Carroll County, Maryland.

9. INTEGRATED CARE • Patient (Person) Centered, Integrated Care Model • Utilizes exemplary components of public and private health with shared resources • Patients receive team care that coordinates with other service providers • Integration with CCHD Bureau of Prevention, Wellness, and Recovery since 2009 • Staff implantation to co-location with new facility – Phase II to open soon! • Four Service Lines at one location • Medical • Dental • Behavioral Health • Substance Abuse Services

10. Strategic Partners • 9 Board Members representing community • Strategic Partners – Ex-Officio Seats • Carroll Hospital Center • Carroll County Health Department • Partnership for a Healthier Carroll County • Business Community • Medical Community • Faith Community • Legal • Schools

11. Need and Access 6,700 uninsured (March 2016) 10,000 below federal poverty level (Oct 2015) > 25,000 estimated low-income (200% FPL) High case management needs – social health High Dental Need High Substance Abuse/Behavioral Health Demands Access Carroll is the only full-time safety-net provider targeting the at-risk population

12. DEMOGRAPHICS

13. Integrated Services Primary Health Care – Acute and Chronic Behavioral Health Assessment and Treatment Withdrawal Management – Detoxification Medication Assisted Treatment – Vivitrol and Suboxone Overdose Response Education - Naloxone Family Dental Care Medication Assistance – Medical Supplies Laboratory Testing Radiology Services Referrals to Specialists Medical Case Management – Care Navigation Peer Assisted Support Public Assistance Application Support Patient Education Community Resource Information

14. Benefits of Integrated Care

15. Access Carroll Patients… • Historically, high Emergency Department utilization - need a medical home • Initially present as “very sick” without preventive or maintenance health plan – highly complex needs • Uninsured = 69% - no benefits or insurance on first visit (2014) • Working poor = 24% (2014) – limited health benefits • More than 75% chronically ill • Average patient on 5 or more chronic medications • Require extensive and comprehensive case management/care coordination

16. Care Coordination • Specialty Care – coordinated referral process • High-End Diagnostics • SSI/SSDI Applications • Public Assistance Applications • Case Management • Direct ED Referrals • SOAR • ED Diversion • Criminal Justice Diversion • Social Determinants of Health • Average 160 monthly • open cases

17. Pharmacy • Acute Medications • Chronic Medications • Pharmacy Assistance Programs • Pharmacy Vouchers to local pharmacy • Medical Supplies • Medication Therapy Management * Pharmacy Consults * Disease Management

18. Moving the Metrics! Source: Partnership for a Healthier Carroll County- Healthy Carroll Vital Signs http://www.healthycarroll.org/wp-content/uploads/2015/11/Healthy-Carroll-Vital-Signs-online_DEC-2015.pdf