1. CSI-RI: Community Health Team Planning Workgroup 11/8/13

2. Guiding Principles Triple Aim Utilizes Community Needs Assessment Data Identifies short term measureable gains for high risk, high cost, high impact Brings together resources in community that are effective and non-duplicative Incorporates responding to BH needs Incorporates ability to manage data for CHT Implements Memorandum of understanding Uses PDSA to try things out Includes metrics to measure success

3. South County CHT Report Out Mission Statement Communities to be served; CSI practices Assessment of Community Needs Assessment of other Community Resources Goals/Outcomes Anticipated shared services Staffing Plan Budget Plan

4. Pawtucket CHT Report Out Mission Statement Communities to be served; CSI practices Assessment of Community Needs Assessment of other Community Resources Goals/Outcomes Anticipated shared services Staffing Plan Budget Plan

5. Community Needs Assessment Hospital Association of R.I. led the Community Health Needs assessment in a timeline to comply with requirements set forth in the ACA and to further the hospitals commitment to community health and population health management Conducted September 2012 – May 2013 Memorial Hospital (Care New England Health System) and South County Hospital participated

6. South County Hospital  Identified Areas of Need  Access to Care  Alcohol  Cancer Incidence  Immunizations  Mental Health Status  Overweight and Obesity

7. South County Hospital

8. DIABETES Goal: To promote healthy lifestyles that reduce obesity, improves pre-diabetes awareness, and results in better management of diabetes care (including self-management). Strategies: 1. Improve awareness of healthy lifestyles and prevention of obesity through Community Education and Health Screening Programs 2. Improve access to medical specialists for diabetes and endocrinology 3. Improve diabetes metrics within the Patient Centered Medical Community (PCMC) initiative 4. Maintain and ensure access to formal Diabetes Self-Management Education Programs

9. South County Hospital MENTAL HEALTH AND SUBSTANCE ABUSE Goal: Improve mental health by increasing access to appropriate, quality mental health services including substance abuse services, and improve care coordination across the continuum of care. Strategies: 1. Ensure that the SCHHS collaboratively addresses mental health related needs in the community it serves 2. Enhance access to mental health clinicians in primary care physician offices 3. Improve awareness of warning signs and symptoms of Mental Health and Substance Abuse to help ensure that interventions are managed at the most appropriate level of care

10. South County Hospital CANCER Goal: To provide a multidisciplinary, patient-centered cancer program that ensures a continuum of care that spans prevention, diagnosis, treatment, palliative and hospice care, and survivorship. Strategies: 1. Create a community cancer center facility that supports achievement of the stated goal 2. Ensure the availability and local access to cancer specialists and clinicians for cancers that can be appropriately managed in a community setting 3. Provide community outreach and cancer screening efforts to educate residents about the risk factors for cancer and benefits of early diagnosis 4. Increase the proportion of cancer patients referred to the STAR program service offerings

11. South County Hospital Heart Disease Goal: Reduce the burden of heart disease through early identification, and early and appropriate treatment/management. Strategies: 1. Improve awareness of healthy lifestyles and risk factors for heart disease through Community Education 2. Increase the proportion of adults who have appropriate screening for hypertension and/or high cholesterol 3. Reduce re-hospitalizations rates for adults with heart failure as the principal diagnosis 4. Increase the proportion of heart attack survivors who participate in cardiac rehabilitation program upon discharge

12. Memorial Hospital  Identified Areas of Need  Access to Care  Asthma  Breast Cancer  Cardiovascular Health  Diabetes  Mental Health Status  Overweight & Obesity

13. Memorial Hospital

14. Implementation Plan Mental Health and Substance Abuse – Goal 1: Decrease morbidity from diabetes and heart disease among persons with mental illness, including substance abuse disorders. – Goal 2: Improve mental health by increasing access to appropriate, quality mental health services including substance abuse services. Heart Disease – Goal 1: Increase the number of women who are aware of their risk for heart disease. – Goal 2: Reduce heart disease through early identification, and early and appropriate treatment/management. Diabetes – Goal 1: Increase the number of people who are aware of the risk factors for diabetes. – Goal 2: Increase diabetes self-management education for people living with diabetes.

15. Medicare FFS Extracted from Presentation: “Readmissions in Rhode Island: Deep Dive into the Data.” Butterfield, Kristen

17. Medicaid Top 5% high cost members 1.Mental Deficiency or Retardation 2.Psychosis, Neurosis, Depression, Psychotherapy 3.Septicemia 4.Autism 5.Renal Failure 6.COPD 7.Diabetes Mellitus 8.Coronary Artery Disease 9.Cerebral Palsy-Infantile 10.Pneumonia

18. Medicare Top 5% high cost members 1)Renal Failure 2)Septicemia 3)Fractures 4)Psychosis, Neurosis, Depression, Psychotherapy 5)Congestive Heart Failure 6)Pneumonia 7)Stroke, Cerebral 8)Coronary Artery Disease 9)Aortic or Mitral Valve Disease 10)Prosthetic Device Complication

19. Commercial Top 5% high cost members 1)Pregnancy 2)Psychosis, Neurosis, Depression, Psychotherapy 3)Coronary Artery Disease 4)Osteoarthritis 5)Cancer-Breast 6)Renal Failure 7)Fractures 8)Newborn child-Single 9)Spondylolisthesis or Spondylosis 10)Congenital Heart Disease

20. Potential Community Resources: Peer Navigators Presentation by Bill McQuade D.Sc.MPH Chief Health Program Evaluator _______________________________________ Evaluation report on Peer Navigators “Community Health Workers: A Review of Program Evolution, Evidence on Effectiveness, Value and Status of Workforce Development in New England” (5/24/13 Institute of Clinical and Economic Review )

21. Community Resources/Team members Other resources/team members to consider based on community needs assessment  Pharmacy ?  Care Links ?  Community of Care Expansion?  Other?

22. Next Steps?