Welcome SHARON SANDERS V P CLINICAL INTEGRATION CARROLL

Welcome SHARON SANDERS, V. P. CLINICAL INTEGRATION, CARROLL HOSPITAL CENTER DOROTHY FOX, CEO/ EXECUTIVE DIRECTOR, THE PARTNERSHIP FOR A HEALTHIER CARROLL COUNTY BARB RODGERS, COMMUNITY HEALTH PROMOTION, CARROLL COUNTY HEALTH DEPARTMENT

Care Integration Delivering seamless care across multiple settings: ◦ Primary Care and Specialist Offices ◦ Ambulatory Centers ◦ Acute Care Facilities ◦ Community Resources ◦ Long Term Care and Rehabilitation Centers Developing programs to assure use of the most appropriate care setting at the right time Making better use of patient information to support the care-giving process. 2

Partnering with Long Term Care facilities Key Initiatives to Prevent Avoidable Admissions and Readmissions Increase Focus on Palliative Care and Hospice Better Identification of High Risk Patients Improve Patient Engagement and Self Management Improve the Discharge Process Improve Patient Call Backs Home Health Collaboration Process for Disease Management and Follow Up Care Working with Community Agencies and Groups to Improve Access to Care

Physicians align with patients Hospitals partner with communities Constant contact with caregivers; 24/7 availability to patients and access to necessary programs. Broad Focus on Readmissions Through Partnering Tighter monitoring of utilization of expensive healthcare services. Guaranteed same-day sick visits Free educational classes and hot-spotting chronic disease within communities. Community Education programs and better access to those programs. Active engagement with care navigators and care coordination.

Develop Systems of referral: How do we get community members to the proper referral systems? Are they enough? Is more needed? Integrating Care in the Community Identify our high risk population ◦ Completed Community Needs Assessment. ◦ Identified our high risk populations and areas of need. ◦ Behavioral Health ◦ Stroke ◦ Heart Disease- Specifically Heart Attack and Congestive Heart Failure ◦ Chronic Obstructive Pulmonary Disease and Pneumonia. What are our needs for this population? : ◦ Greater access to Primary Care and affordable care. ◦ Transportation ◦ Affordable medications ◦ Many other needs as being identified by hospital navigators and others in the community 5

Behavioral Health – Outpatient Mental Health Clinic Model

Behavioral Health – Community Benefit/Health Improvement Plan Objective: Ensure Carroll County residents have access to integrated, principle-driven mental health systems of care providing recovery/resiliency-oriented services. The availability of prescription drugs for potential misuse or illicit use will be reduced, the percentage of Carroll County adults who smoke will be reduced. Example Strategies: 1. Continue current programming: a. Partner with the Maryland Department of Health and Mental Hygiene, Carroll County Youth Services Bureau and others to improve communication and resources for mental health. b. Promote mental health provider education and outreach —radio talks on WTTR regarding depression and other top mental health issues. c. Promote availability of The Partnership’s substance abuse and mental health resource directory for the community.

The Most Appropriate Setting Inpatient ADC 18. 0 16. 0 14. 0 10. 0 8. 0 6. 0 4. 0 2. 0 13 FY TD 14 FY 12 FY 1 1 FY 0 1 FY 9 0 FY 7 8 FY 0 0 FY 6 0 FY 0 5 0. 0 FY Census 12. 0 Initiatives: � Pain Management Contracts � Care Connect – Health Navigators � SBIRT � Care Plans � Peer Recovery Support Specialist

A Collaboration with Results Patients admitted to Inpatient from ED Evaluations in the ED 60% Total Evaluations 3500 3000 50% 2500 40% 2000 30% 1500 20% 1000 10% 500 0% 0 Totals Totals Totals FYTD FY 05 FY 06 FY 07 FY 08 FY 09 FY 10 FY 11 FY 12 FY 13 FY 14 t To 5 14 08 06 07 09 10 11 12 13 Y 0 FY FY FY s s s s l l l l TD ta ta FY To To F als

A Collaboration with Results High Utilizers* FY 12 FY 13 87 58 High Utilizers** Reduction from previous year 33% FY 12 FY 13 83 49 FY 14 Reduction from previous year 41% FY 14 *(patients with 3 or more IP admissions ) ** (patients with 10 or more ED encounters)

Behavioral Health Advisory Council Oversight of the System Coordination for the County Contains necessary stakeholders Structure as a Board with many Committees and Work Groups and Committee function closely aligned with Partnership for a Healthier Carroll County Community Health Improvement Areas

A true community, linked together by a central coordinating hub Carroll Hospital Center The Partnership Carroll County Health Department

Established in 1999. Founding members: WHO WE ARE Carroll Hospital Center & Carroll County Health Department. Today, over 145 agencies, civic clubs, businesses, public and private organizations and 300 people are actively involved in various collaborative activities of The Partnership.

Connecting people. Inspiring action. Strengthening community. We work together with individuals, organizations, and agencies throughout the county to create a healthier community. Promote healthy lifestyles. Generate leadership in the community. Create new partnerships to address emerging health needs. Advocate for changes that translate into better health and quality of life for our residents. Assess, track and interpret health data of our community and monitor results.

Community Health Needs Assessment 2015 Carroll County Health Department § Local health improvement committee will establish a Local Health Improvement Plan (LHIP) as a component of a State Health Improvement Process (SHIP). § In coordination with and within timeline of CHNA 2015. Carroll Hospital Center § Provides needed data for CHC’s strategic planning initiative. § Assures compliance with the newest required elements of the Federal 2010 Affordable Care Act. § Basis of Community Benefit Plan for FY 2017 -FY 2019. The Partnership Community § Provides needed data for The Partnership’s strategic planning initiative. § Results used in planning and collaboration.

Community Health Needs Assessment Shared Accountability via “Healthy Carroll Vital Signs” and annual impact report to CHC and PHCC Boards Creating a Healthier Carroll County Community Shared Responsibility The Partnership’s Leadership Teams & role as L. H. I. P. coalition & CHC Service Lines, PHO, CHG etc. CHC’s Community Benefit and Health Improvement Plan Carroll Hospital Center & The Partnerships Strategic Plan 2013 -2016

Community Benefit & Health Improvement Plan FY 2014 -2016 A critical tool in our results accountability effort

SHIP/LHIP Community Benefit and Health Improvement Plan Community Health Needs Assessment At Carroll Hospital Center, we offer an uncompromising commitment to the highest quality health care experience for people in all stages of life. We are the heart of health care in our communities To create and sustain a community of wellness in Carroll County “Striving to build the capacity of individuals and organizations to improve the health and quality of life in Carroll County, Maryland” Population Health Governance Group

Local Health Improvement Coalition(LHIC) LHIC required as part of the State Health Improvement (SHIP) process SHIP’s goals: health equity and improving the health of Maryland’s residents In October 2011 The Partnership Board voted to become the LHIC. The responsibilities of the LHIC: ◦ Submit the Local Health Improvement Process to the SHIP ◦ Collaborate with the PHCC Strategic Planning committee and Carroll hospital Center Community Benefit Committee to determine and analyze health needs and propose recommendations for community health improvement.

Population Health Governance Group Multi-agency coordination for Healthcare needs Address duplication of efforts Coordinate care needs based on health risk needs assessment Design a conceptual framework for population health Advise the LHIC and prioritize population health initiatives

Population Health Governance Group Carroll County Health Department Carroll Hospital Center Carroll PHO/Carroll ACO Access Carroll The Partnership for a Healthier Carroll County Government (Citizen Services)