Building a Collaborative Community for Population Health Management Jason Barrett Executive Vice President & Chief Administrative Officer

Hospital Snapshot Located in St. Augustine, FL 335 Beds 1900 Employees Established in 1889 Sole Community Hospital JACKSONVILLE ST. AUGUSTINE PALM COAST PALATKA DAYTONA

Setting a Vision Our focus today is on successfully transforming both Flagler Hospital’s care model and our business model to become a national model for community-based care.

The Burning Platform Unsustainable healthcare costs

The Burning Platform Self-Insured Employers on the Rise

A Special Community Sole community hospital A culture of partnership Healthiest County Highest ranked school system Health Leadership Council

Regional: Local: Partnerships & Clinical Integration Coastal Community Health Key FCHA Initiatives: Florida Blue contract - 3.5M in savings Hospital Quality & Efficiency Care Coordination

Integrated Care Delivery

Behavioral Health Care Coordination Quarterly Readmission Statistics Performance Period Q. 3 2015 – Q. 1 2016

Transitional Care Patients being followed by Care Coordinators who follow up with PCP within 7 days = 95% All Cause Readmission Rate for patients being followed by a care coordinator: 14.9%

Bundled Payment for Care Improvement Initiative Initial Results: Readmission Rates Historical Rate (Pre BPCI Program) 11.00% Q3 2015 7.23% Q4 2015 6.90% Q3 + Q4 2015 7.04%

Wildflower Chronic Care Clinic Community Outreach : Diabetes Management Wildflower Chronic Care Clinic Flagler Hospital partners with the Wildflower Clinic by providing grant funding, plus diabetic testing supplies, lab work and radiology exams In 2015: 79% of patients have improved their HbA1c and 33% are at their goal of below 7.0. 74% have reached their target Blood Pressure goal 62% of patients have successfully lowered their LDL levels and 21% have reached their cholesterol goal. 100% of patients have received their annual diabetic foot exam (preventative) 35% of patients have demonstrated a decrease in BMI   WCCC patients admitted to Flagler due to diabetes diagnosis= 0 Overall Chronic Care Management $403,366 Cost of lab work and radiology exams provided to Wildflower Clinic patients at no cost

What’s Next: Expanding the Medical Neighborhood Collaboration across the entire continuum of care

What’s Next: Community Resource Alliance

What’s Next: Community Resource Alliance Serving as a “Hub” for community resources, the CRA will enhance coordination of community resources by: Recruitment of community resource providers to join the CRA CRA member analysis of current resource availability vs. identified community need Communication between community resource providers Community Resource Navigator Program As the "Hub", the CRA will provide multiple community resource access points throughout St. Johns County. These access points allow community members to be screened and qualified for all applicable community resources through a single application.

What’s Next: Community Resource Alliance Serving as a “Hub” for community resources, the CRA will increase access to community resources by: Universal intake application for community resources provided through the CRA CRA Membership Card for St. Johns County residents that grants access to all eligible community resources Multiple “Hub” access points throughout the community Integration of community resources into healthcare continuum Centralized scheduling for community resource services

Questions