Annapolis Community Health Partnership

1. Annapolis Community Health Partnership An Update for Community Health Resources Commission June 26, 2014

2. Core Goals of Year One: Complete • Increase access to primary care services capital improvements, hires, infrastructure doors opened October 2013 453 unique patients served, 1,253 visits • Increase community health resources diabetic screening program implementationself-management and health literacy promotion • Promote cultural competency all staff trained

3. Challenges • Being a guest and a host at the same time • Intercultural tensions • Insurance issues • Primary Care Medical Home versus agnostic and flexible Health Resource • Late entrants to care come to us in crisis • Change in Physician

4. Year 2: Strategic Plan andCore Goals • GOAL ONE: Improve diabetes outcomes, measurable by 1/1/15 • Strategies: • Screening program implemented • Patients enrolled in primary care • Population health management tools • Recruitment of additional patients

5. Year 2: Strategic Plan and Core Goals (cont’d) • GOAL TWO: Decrease preventable, costly, crisis-driven care • Objectives: Within 12 months: • Decrease medical 911 calls from Morris Blum by 30% • Decrease emergency room visits from Morris Blum by 30% • Decrease readmissions among Morris Blum residents by 30%

6. GOAL TWO Strategies • Promote site as a health resourcefor residents • Promote health literacy and knowledge regarding proper use of 911, ED. • Resident Health Advisor (HACA) • Care management, transitional services, apartment visits • Palliative care consultations, goals of care discussions