1. 1. Relocate AACI’s enabling services into a Patient Navigation Center while reorganizing clinical services into a Patient Centered Health Home. 2. Redesign workflows to transfer users from AACI clinical services to subspecialty, inpatient and other ancillary services. 3. Retrain AACI clinical staff to provide advice and referral calls. 4. Recruit and train older youth as patient navigators 5. Introduce PNC services to AACI’s referral, admitting and community partners and to community physicians. 1.Community college partners build one year, credit-bearing certificate program based on proven Career Advancement Academy workforce development model. 2.Private physicians link to AACI’s ancillary and enabling services. 3.Community partners refer youth to the PNC training program and patients to AACI services. 4.AACI obtains FQHC designation/NCQA PCMH recognition 1. AACI promotes and supports culturally relevant population management interventions that reflect the epidemiology of target users. 2. AACI uses dashboards, checklists, task lists and indicators 3. AACI tracks the costs of early screening and treatment. 1.Support community education and advocacy that improves health literacy. 2.Raise awareness of health disparities with public education and information campaigns. 3.Link accessible prevention and treatment services that provide more care outside the four walls of a clinic. 1. Organize learning communities 2. Learn, adapt and disseminate evidence-based best practices 3. Implement Plan Do Check Act improvement cycles 4. Use project management techniques to drive results 5. Share early results with key thought, resource partners C. AACI builds electronic health data, call center software and mobile apps, population management, practice reorganization and patient experience into a PCMH. B. AACI builds sustainable partnerships that promote workforce development and health care quality A. AACI reinvents its enabling services with a new PNC that houses one- stop clinical advice, appointment reminder, referral assistance and patient self-care functions that are linked to clinical and social services inside and outside AACI. These linkages improve access to CA and DM prevention and early treatment services. Increased employment improves a social determinant of health for east San Jose residents. D. AACI builds enduring learning and improvement communities to drive to results. PNC advice nurses, social workers and nonclinical health workers (patient navigators) support follow and teach hard to reach AACI patients before and after they use AACI services. E. AACI advocates and educates to improve health and health care in east San Jose By 6/30/2015, AACI will start up a Patient Navigation Center whose enabling services will result in: 1. Better Health for east San Jose residents through: 1) 10 % fewer ER visits for non- emergency diagnoses; 2) improved access to cancer and diabetes prevention and early treatment for 46,806 beneficiaries; and 3) 29 jobs for 165 trained youth 2. Better Care as AACI becomes a patient-centered medical home by 2014 and improves access to health and social services for 46,806 beneficiaries through reinvented enabling services and linked ancillary services. 3. Lower Cost as AACI realizes $3,373,602 in gross medical expenditure savings for east San Jose residents through 10% fewer unnecessary ER visits and early cancer and diabetes treatment for 46,806 beneficiaries. Secondary Drivers Primary Drivers AACI Patient Navigation Center Driver Diagram Aims