1. Programs/Services Overview and Best Practices Karis Grounds, Health Programs Manager, 2-1-1 San Diego/Imperial

2. REAL PEOPLE. REAL CONNECTIONS. REAL HELP. 2-1-1 San Diego’s purpose is to make positive, lasting impacts on people’s lives and drive meaningful change throughout our communities. 2-1-1 San Diego’s mission is to connect people to services and provide vital data and trend information for proactive community planning. 2-1-1 San Diego’s values: Deliver WOW through Service Embrace and Drive Change – Evolve Create Fun and A Little Weirdness Be Adventurous, Creative, and Open-Minded Pursue Growth and Learning Build Open and Honest Relationships with Communication Build a Positive Team and Family Spirit Do More With Less Be Passionate and Determined Be Humble Who We Are 6/13/2016

3. REAL PEOPLE. REAL CONNECTIONS. REAL HELP. 2-1-1 San Diego By the Numbers… 1,500 partnerships with service providers 200+ languages offered 6,000+ service listings98% referrals accuracy 500,000 Connections 6/13/2016

4. REAL PEOPLE. REAL CONNECTIONS. REAL HELP. Who We Serve 6/13/2016

5. REAL PEOPLE. REAL CONNECTIONS. REAL HELP.

6. Programs and Services 2-1-1 Top-Tier Programs Enrollment Center 2-1-1 Pioneered telephonic signatures for public benefit programs. Has submitted more than 30,000 applications for CalFresh, Medi-Cal and Covered California. Health Navigation Provides care coordination addressing health and social aspects of the whole person to clients with complex needs, under/uninsured Military and Veteran Services 2-1-1 answers the Courage to Call peer-to- peer helpline offering care coordination as the single point of access for veterans, active military, reservists, national guards, and their families. 2-1-1 Tiered Programs 6/13/2016

7. REAL PEOPLE. REAL CONNECTIONS. REAL HELP. Examples of Referral Partnerships Warm Hand-off to Mental Health Crisis Are you currently disabled? Already enrolled in CalFresh/Medi-Cal? CARE or Medical Baseline Application Do you have children under 5? Are you pregnant? Appointment Setting During Tax Season >50k

8. REAL PEOPLE. REAL CONNECTIONS. REAL HELP. Information and Assistance: Enrollment Services 6/13/2016

9. REAL PEOPLE. REAL CONNECTIONS. REAL HELP. Enrollment Services San Diego CalFresh Applications San Diego Medi-Cal Applications San Diego Covered CA Applications San Francisco County CalFresh Applications Targeted Outreach projects with San Diego County with current Medi-Cal recipients for re-certification and CalFresh outreach Expanding services to Imperial County in Summer 2016 New Pilot- Navigator Model 6/13/2016

10. REAL PEOPLE. REAL CONNECTIONS. REAL HELP. Step-by-Step Enrollment Customer calls 2-1-1: Information Outreach Pre- Screening Empowermen t Referred to apply: Over-the- phone County Office Community- based partner Online Available 24 hours: 2-1-1 schedules appointment with Enrollment Center via appointment setting software Appointment Date: Completed application is transmitted to County electronically with telephonic signature. 10 Days: 2-1-1 Enrollment staff makes call to customer to remind about documents and check interview status 20 Days: 2-1-1 Enrollment staff makes 2 nd reminder call to customer to ensure completion of necessary steps 30 Days: 2-1-1 Enrollment staff checks County system for status of case; performs additional advocacy as necessary 6/13/2016

11. REAL PEOPLE. REAL CONNECTIONS. REAL HELP. The impact of our Enrollment Services San Diego CalFresh outcomes for the past 6 months: 5,599 applications submitted 3,625 applications approved 721 Expedited approvals $681,293 in approved monthly benefits $119,055 in Expedited benefits 7,298 individuals impacted More than $8 million in annual benefits More than $14 million in economic impact 6/13/2016

12. REAL PEOPLE. REAL CONNECTIONS. REAL HELP. Person-Centric Model: 2-1-1 Health Navigation Program Goal: Single point of access to address social needs of the whole person by better connecting, empowering, educating, and advocating for clients with complex health needs. Address risk factors and social determinants of health to help clients achieve a better quality of life and health outcomes Target Populations: Clients experiencing issues with accessing care, managing chronic conditions and uninsured /underinsured Services:  Assessment: Complete a holistic assessment, and establish a plan to connect to resources to address the needs of each client  Continual follow ups: To address the progress of each client and creating a foundation of support by connecting clients to community partners that provide the required services. Housing Nutrition Primary Care Health Managemen t Community /Social Connection Daily Living Skills Ambulance Use Income Transportatio n 6/13/2016

13. REAL PEOPLE. REAL CONNECTIONS. REAL HELP. Brief Risk Rating Scale

14. REAL PEOPLE. REAL CONNECTIONS. REAL HELP. Care Transitions Intervention (CTI): Care to Community Connections Partners: Feeding America Grossmont Hospital Foundation Sharp Healthcare Sharp Grossmont Hospital 2-1-1 San Diego Shared Goal: Assist in the transition from hospital discharge to medical home and connection to social services. 2-1-1’s Role: 2-1-1 Health Navigators receive referrals from Sharp health educators and social workers to assess and address risks of social determinants of health by connecting to resources in the community. Measures: Percent of individuals readmitted into hospital; number of individuals who improve on shared risk rating scale; Client Satisfaction of Sharp referral program; Percent of patients who felt care was better coordinated. 6/13/2016

15. REAL PEOPLE. REAL CONNECTIONS. REAL HELP. City of San Diego EMS: Reverse 2-1-1 Partners: City of San Diego San Diego Rural Metro Medical Services 2-1-1 San Diego Shared Goal: Providing proactive engagement to high utilizers of emergency services to connect clients to available resources including benefits, insurance, medical homes, and social service programs. 2-1-1’s Role: Receive at-risk, medic identified electronic referrals through Street Connect with consent of the patient, to reach out and engage with clients to provide referrals to resources in the community to address health concerns/needs. Measures: Number of clients receiving follow-up assistance on basic needs after an emergency visit, decrease in the number of repeat emergency calls, improvements on risk rating scale 6/13/2016

16. REAL PEOPLE. REAL CONNECTIONS. REAL HELP. Family Support Outreach Specialist Peer Guidance and Support to Military Families and Loved Ones Direct Community Outreach Provide Awareness Trainings to Service Providers and the Community Assist with On Base, Off Base, VA, & Civilian Services and Entitlements Community Liaison Liaison with key community leaders, groups, organizations and community support to build coordination and collaboration Assists Organizations in Developing Programs to Meet Veteran Population Needs Identify and Reach-out to Special Needs Groups Manage Courage to Call Social Media Veterans Peer Outreach Specialist Peer Guidance and Support to Service Members, Veterans, Reserves, & Guard Direct Community Outreach Provide Awareness Trainings to Service Providers and the Community Assist with On Base, Off Base, VA, & Civilian Services and Entitlements Veteran Peer Support Specialist Provide a 24/7 Peer Support Line / Chat Line Offer Peer Support and Community Resource Referrals Reduce Stress and Improve Overall Mental Health Maintain and Update Resources and Services 8 Navigators 2-1-1 San Diego Courage to Call

17. REAL PEOPLE. REAL CONNECTIONS. REAL HELP. Provides peer service coordination/ case management for assigned group of clients Develops, evaluates and implements intervention goals and plans in conjunction with clinical team Provides individual supportive coaching in all areas of client’s life Proactively checks-in starting at 7 days, and up to 12 months, to ensure client receives needed services & successful transition support. MSW Level/ Veteran or Spouse Navigators Deeper Level of Care: Navigation 6/13/2016

18. REAL PEOPLE. REAL CONNECTIONS. REAL HELP. Public Benefits Housing Health Benefits Military / Veteran Services Meals Community Services Utility Assistance Financial Literacy Programs Crisis Services Disaster Coordination Aging Services Childcare Transportation Connecting Social Service Providers

19. REAL PEOPLE. REAL CONNECTIONS. REAL HELP. Data Exchange Process Agreements for Data Exchange and Privacy/Security Universal and Program Specific Data Elements across 10 Tabs Written Client Consent for Care Coordination API to CIE Client Dashboard Other Data: Sheriff Booking, EMS Transports, Senior Services, Medical Home Single Sign-On Within Source System Messages and Alerts To Enhance Care Coordination Hyperlinks for Notifications, Data Quality, & Opt-Out Client Dashboard Updates By Any Network Participant Aggregate Data To Identify Trends/Patterns

20. REAL PEOPLE. REAL CONNECTIONS. REAL HELP. Regional Information Exchange virtually integrates with its participants to enable the automation of secure, private, flow of information between regional service and healthcare providers to: Greatly Enhance Care Coordination Reduce the Cost to provide services Improve the Quality of care Achieve Improved Population Health Regional Information Exchange Partnership Regional Information Exchanges in San Diego

21. REAL PEOPLE. REAL CONNECTIONS. REAL HELP. Best Practices Quality Assurance Department 100% calls recorded Call Coaching by Scorecard Client Satisfaction Survey 10 staff per QA Specialist Follow-Up (7-10 days) Service Delivery Client Record Management System Call Volume on Screens In-Reach to other Programs/Services Call Logic/Call Flow Options for Client: Chat, E-mail, Direct Referral, Conference Business and Partnership Development Pay for Performance Resource Team Data Analyst Communication and Marketing Innovative and Collaborative Approaches— Collective Outcomes Training/Staff Development Monthly All-Staff Training Talking Points Ongoing Agent Messaging Internal Training Team E-Learnings Call Logic and Process Flows

22. REAL PEOPLE. REAL CONNECTIONS. REAL HELP. Technology Systems WFM (Work Force Management) InContact telephony system Vision Link-Community OS Salesforce InView (staff ability to self-manage) Quality Monitoring (Recording the Screen) TimeTrade (2EnrollMe) IVR (skill-based routing)

23. REAL PEOPLE. REAL CONNECTIONS. REAL HELP. Best Practices Running A Call Center AIRS (Alliance of Information and Referral Services) www.airs.orgwww.airs.org Process Improvement/Change Community Engagement Skillset of Staff & ACE Training (Assessment, Conversational Intent, Empathy) Executive Leadership (President, Vice President, Gov’t Affairs) Management Supervisors Call Center/ Specialty Program Staff Internal Executive Leadership External Executive Leadership

24. REAL PEOPLE. REAL CONNECTIONS. REAL HELP. Questions? Karis Grounds, Health Programs Manager 2-1-1 San Diego/Imperial