1. Essentia Health Ely Clinic Age and Disabilities Odyssey Health Care Homes – Minnesota Style June 17, 2013 Essentia Health - Ely Clinic Health Care Home

3. Service Area

4. Co-located with Ely Bloomenson Community Hospital (EBCH) –a non-affiliated critical access hospital Service Area = 6 communities, 7 townships –12,214 residents + 15,000 seasonal residents Closest tertiary care facility is 50 miles away –Essentia Health – Virginia Hospital, Virginia, MN

5. Ely Clinic – What We Do Essentia Health – Ely Clinic (Ely Clinic) –Sole provider of primary care and specialty outpatient services –7 physicians-including 1 internist –2 Nurse Practitioners Outreach Services –Orthopedics, behavioral health, derm, cardiology, OB- GYN, general surgery 25,000 pt visits a year Provide 24 / 7 ER services OB-30-60 deliveries a year

6. The Nature of EH – Ely Clinic Professionals –Live here because we want to live here Community of limited resources –17.4% Poverty St. Louis-15.1% Hennepin-12.1% Ramsey-15.8% –Highest poverty among those 6-34 years of age –Age 22% > 65 years of age Have been a clinic of firsts –Certified Health Care Home: 2012 –Anticoagulation –Electronic Health Record-2004 –Integrated Behavioral Health with Primary Care –Telemedicine (behavioral health, wound care, derm) –DIAMOND –Current Primary Care Redesign Pilot Site –MDH Community Care Team Site

7. Our Health Care Home Strong Chronic Disease Management Program –Top in Diabetes Care for NE MN Grow Nursing-woefully under utilized in Clinic setting Clinic Support Clerk-performs non nursing clinical functions Integrate ALL employees in coordination of services- schedulers, registration –All staff are on look out for patients in need Reserved schedule slots for hospital discharges Community Care Team & Community Health Worker Strong Infrastructure Means Strong Programs –Hardest work is developing the infrastructure

8. Transitions A. EBCH and Essentia Affiliated Hospital admissions, discharges, and ED admissions reports to clinic Daily High acuity patients identified for care coordination and follow up B. Clinical pharmacy consultation for all hospital discharges with extensive med lists. C. Nursing Home Discharge NP provides transitional planning for patient in conjunction with the nursing home social work staff. D. Acuity / Severity Report Reviewed Weekly Identify any patients that may have been "missed" because they are seen outside the local hospital. E. Capture of Hospitalizations / ED admits from Non Essentia Facilities---In development F. Current Care Coordination Patients (includes MSHO & eldercare) Care coordinators participate in discharge planning for all enrolled patients. G. Appointment Holds Each provider has a hold on their schedule each day for discharged patients.

9. Improving Outcomes Through Care Coordination Provide Information and Resources Provide Connection and Warm Handoff Identify and Address Barriers Team Care Coordination

10. Patient Community Care Team Mission: The Community Care Team provides collaborative care and support to help you achieve your wellness goals.

11. Vision Adequate resources are available to citizens when needed to help them with their physical health, mental health and psychosocial challenges. Professionals in health, education, and public service are trained in recognizing when someone is confronted with such challenges and are prepared to provide an appropriate response in giving assistance. Patients and their supporters have the tools and resources to help them be a partner in meeting their wellness, treatment and recovery goals.

12. Ely Area Community Care Team Essentia Health-Ely & Babbitt Clinics Community Hospital Nursing Home 2 Mental Health Agencies 2 School Districts County Public Health & Human Services 2 Community/Family Members Free Clinic Parish Nurse Community College Mental Health Clubhouse Head Start Hospice & Palliative Care Local youth & Family Non- profit Local Respite/Caregiver Support Nonprofit Food Shelf

13. Breaking Down Silos Monthly CCT Meetings Include Opportunities to: Network Learn About Other Services Case Management Develop Tools and Systems for Collaboration Address Specific Concerns Work Together on a Project

14. Improving Outcomes CCT Model In Action Warm Handoffs Holistic View of Individuals Strong Community/ Provider Network Emphasizes Strengths of Each Service Fills in the Gaps Supports the Individual and Family

16. Community Health Worker Coordinate non-medical issues that affect health and wellness of our patients Care Manager for patients whose primary needs are not medical Provides support to RN care coordinator for psychosocial needs of CDM patients. Provides information and warm referrals for patients who need connections to additional resources, but do not need care coordination Provides resource for ALL staff

17. CHW Certification MN certification Several schools in person and South Central College online program Opens DHS billable stream for diagnosis based education Education we are excited to explore offering: –New ADD medication –Budgeting (making sure you allow funds for good food, medications, laundry…) –Organization (state benefit paperwork…)

18. Ely Clinics Internal Model Essentia Health Ely Clinic and Babbitt Clinic Health Care Homes Community Care Team Care Coordination Team RN Care Coordination Community Health Worker {Behavioral Health Specialist}