CSI-RI: Community Health Team Planning Workgroup

1. CSI-RI: Community Health Team Planning Workgroup 10/25/13

2. Reactions to Community Health Team Learning Collaborative: Maine

3. Maine PCMH Pilot Practice “Core Expectations” • Demonstrated physician leadership • Team-based approach • Population risk-stratification and management • Practice-integrated care management • Same-day access • Behavioral-physical health integration • Inclusion of patients & families • Connection to community / local HMP • Commitment to waste reduction • Patient-centered HIT

4. Maine PCMH Pilot Community Care Teams Schools Transportation Environment • Community Care Team Housing Outpatient Services Workplace Care Mgt Family Food Systems High-need Individual PCMH Practice Med Mgt Specialists • Community Resources Shopping Coaching Hospital Services Behav. Health & Sub Abuse Income Physical Therapy Heat Literacy 4 Faith Community

5. CCT Populations Served CCTs review data from available sources (Medicare RTI reports, MaineCare Utilization reports, other payers, HIN) to identify • Hospital Admissions • 3 or more admissions in past 6 months • 5 or more admissions in past 12 months • Emergency Department Utilization • 3 or more E.D. visits in past 6 months • 5 or more E.D. visits in past 12 months • Payer identification of high-risk or high-cost patients 5

6. Reactions to Community Health Team Learning Collaborative: Vermont

7. Department of Vermont Health Access Principles of Team-Based Care • Shared Goals • Clear Roles • Mutual Trust • Effective Communication • Measureable Processes and Outcomes • Mitchell et al, Core Principles & values of effective team-based health care, 2012 (Discussion Paper, Institute of Medicine, Washington, DC. www.iom.edu October 21, 2103 7 7 7 7

8. Community Health Needs Assessments Slides 9-17 Extracted from Community Health Needs Assessment Summary Reports completed by Holleran Consulting

9. Background • 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

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

11. South County Hospital

12. South County Hospital 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

13. 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

14. 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

15. 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

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

17. Memorial Hospital

18. Memorial Hospital 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.

19. Medicare FFS Top Diagnoses

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

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

22. Next Steps?