1. Blackstone Community Health Team Patient Centered Medical Community CTC Progress Report February 13, 2015

2. Background Goal: To demonstrate directional improvement in health and total cost outcomes for the identified high risk/high cost/high impact patients. Patients targeted:  Health Plans sent CSI practices lists of patients flagged as high risk/high cost  CSI practices screened lists to identify patients who are high impact  Screened lists were sent back to Health plans to establish Baseline target population

3. Background Aim of Interventions: o Identify and address social needs that affect health and barriers to care o Provide “high touch” support for Care Management plans established by practice Nurse Care Managers o Provide patients with social support to manage their health o Bring relevant information back to primary care teams

4. Structure Blackstone Community Health Team is based out of Blackstone Valley Community Health Center Offices are located at 36 Park Place, Pawtucket, Rhode Island Staffing Model o 3 FTE Community Resource Specialist* o.5 FTE Coordinator o.5 FTE Manager o.75 FTE Behavioral Health Nurse Care Manager# *(Staffing down to 2 FTE from 11/3/2014-1/9/2014) #(Start date: 12/29/2014)

5. Structure Current Participating Practices: o Blackstone Valley Community Health Center (BVCHC) o Memorial Hospital of Rhode Island Family Care Center (FCC) o Hillside Family Medicine Potential Expansion Practices: o Family Medicine at Women’s Care o Memorial Hospital of Rhode Island Internal Medicine Center o Nardone Medical Associates o University Internal Medicine o University Medicine- East Avenue

6. Structure Community Health Team Activities: o Weekly Meetings with CSI Practice Nurse Care Managers to review patients for outreach and active cases and develop methods to integrate CHT with the practice o Patient engagement via telephone, “warm-handoff” in at the practice, or visit to a patient’s home o Conduct assessment of social needs and barriers to care, during patient home visits when possible o Develop and implement patient care plans: Provide assistance to patients to obtain social resources and connect with community agencies Support and extend nurse care manager care plans Help patients navigate health care system Provide social support to patients in managing their health

7. Structure o Participate in training provided by BVCHC and RIPIN o Program development and implementation: Move from concept to operation Workflows, policies, procedures Documentation, data-capturing, reporting capability Integration between CHT and primary care teams

8. Baseline Target Population Total Number of Patients: 413 Insurance: o BCBS: 120 o NHP: 190 o United: 102 o Tufts: 1 Practice: o BVCHC: 160 o FCC: 189 o Hillside: 64 Demographics: o Mean Age: 49.77 years of age o Age Range: 15-99 years of age o Gender: M 144 F 269

9. Outreach Activity 8/25/2014-12/31/2014 55 29 16

10. Outreach Activity 8/25/2014-12/31/2014 18 63 19

11. Outreach Activity 8/15/2014-12/31/2014

13. Successes: Actively engaging patients- “warm- handoffs”, establish relationships Regular communication with practices Enhancement of Nurse Care Management Activities Identifying and resolving social needs and barriers to care “High touch” patient support Gleaning information from home visits to inform clinical team. Challenges: Are we targeting the right patients? – o Review of high risk list is time intensive o It is difficult to gauge ‘impactability” with unfamiliar patients. Synthesizing CHT and Clinical assessment and plans (starting to make progress) Targeted CHT interventions – Drivers of cost are unclear, relying upon broad approach to impact cost Limited ability to communicate electronically with practices Insufficient community resources Adding patients onto busy NCM panels/work loads

14. Next Steps Develop and Implement CHT Behavioral Health Interventions Complete development of EHR documentation and reporting Establish Pawtucket/Central Falls Community Health Council Explore potential Pharmacy and Dietary interventions Enhance Community Resource Specialist skill sets to support behavioral change (e.g. Health Coaching)