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. Care Coordination Clinical Integration Care Management 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. 4 Turning the Ship 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 Creating need for new skill sets, policy, tools, and competencies Drivers: Health care cost crisis Health reform Improved HIT Greater stake- holder align- ment

5. 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 Creating Value and serving people

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. for people in all stages of life. We are the heart of health care We are the heart of health care in our communities. 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” 6

7. 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 7 Access Carroll

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 9

10. 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 Strategic Partners

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 Carroll County 2013-14Access Carroll 2014 Non-Hispanic White93.1%87% Black3.5%7% Asian1.6%2.7% American Indian0.2% < 1% Other/Mixed1.8%2.3% Hispanic2.9%21% Median Age46 years43 years Elderly14.8%7% Children under 1822.9%7% Females50.6%51.6% 12

13. 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 Integrated Services

14. Access Carroll and CCHD Bureau of Prevention,Wellness & Recovery Utilize Best Practices of public/private health – Whole Person Approach Shared Resources – Staff, Supplies, Overhead, Administration Improved access for BH/SA Patients – 7 days access to care post discharge, release, etc. Improved Leveraging of Funding Advanced Substance Abuse Services Integration & Support Shared Health Record and Consent for Care– Improved Communication Reduction in Disease Exacerbations – Improved Outcomes Comprehensive Services Access – Reduce Confusion of Referrals from Community Reduction in Recidivism & Program Disruption No Wrong Door – Integrated Team can address multi-discipline service needs Access to Patient-Centered Team with Wrap-Around Services Patients more likely to keep appointments Sustainability of Community Safety-Net Provider Entity Medical Home Environment reduces patient anxiety and reduces stigmas from BH and SA Benefits of Integrated Care 43

15. 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 Access Carroll Patients… 15

16. 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. 17 Acute Medications Chronic Medications Pharmacy Assistance Programs Pharmacy Vouchers to local pharmacy Medical Supplies Medication Therapy Management * Pharmacy Consults * Disease Management Pharmacy

18. 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.pdfhttp://www.healthycarroll.org/wp- content/uploads/2015/11/Healthy-Carroll-Vital-Signs- online_DEC-2015.pdf Moving the Metrics!