2. * Onsite location at WAH * See You in 7! * All patient appointments made within 7 days of discharge * Transitional Care workflow * Uninsured/Underinsured * Patient-centered care * Enhanced communication * Increased care coordination 2

3. * Data Sharing * Ebola partnership * Chronic disease management-shared care plans * Facility expansion planned 3

4. * Senior Peer Health Advocate * October 30 th * Volunteer based * Leveraging community support * 50+ seniors matched * Low Health Literacy * Risk for Poor Health Outcomes * Risk for unnecessary admissions * Underserved populations 4

5. * 90-day program * Initial visit in the hospital-safe discharge * Home visit * Weekly calls for 1 month * Monthly calls for 2 months 5

6. * Safe Discharge Hospital Visits * New safe discharge checklist * Multidisciplinary effort * Ensuring patient understands all instructions * Ensuring patient has needed equipment or resources to obtain upon discharge 6

7. * Transitional Care Home Visits * “5 Pillars” * Medication Reconciliation * Follow Up Appointment within 7 days of D/C * Personal Health Record * Red Flags/Disease Management Understanding * Home Safety Check 7

8. * Success stories already * Follow up changed from 14 days to 7; transportation arranged to get to the patient’s PCP * Patient out of glucose test strips; had 2 bottles of medications that she was taking that were expired; 1 bottle that was discontinued months ago 8

9. * Grant obtained through Community Reinvestment Act * Partnership with: * Montgomery County EMS * Long Branch Enterprise * H.E.A.L.T.H. partners 9

10. * Situation: * Local EMS is overloaded with calls and are often the only “eyes” into the patient’s home environment * Background: * Montgomery County EMS receives about 80,000 calls per year * Assessment: * Often times safety and social issues are the cause of the call and could be avoided * Recommendation: * EMS/Community partnership to standardize home safety assessment and allocate resources as needed 10

11. * LMI areas of Montgomery County * Home safety and social checks * Community Outreach Workers * Spanish and Korean workers 11