IMPACTING COMMUNITIES FROM OUR DOORSTEP Stacey Lane, RN, BSN, MA, HN-BC Carmela Valentino, MPH, CHES, CPHQ 10/26/2016

YNHHS Culture of Health Progression 2010 2011 2012 2013 2014-2015 2007 2008 2009 YNHHS goes tobacco free Tobacco use surcharge on annual medical plan premium --Preventive services: 100% coverage under YNHHS plans --On-line HRA (completion = $50 gift card) --Active Health telephone coaching 42 conditions + prenatal care -- livingwell CARES pilot launched - focus on diabetes Get Active, YNHHS! team fitness challenge with special website --livingwell program launched --Disease management (6 conditions) coaching by medical plan Tobacco cessation program livingwell vision: Taking Care. Giving Care. Taking excellent care of our employees. Giving excellent care to our patients. -- Screenings + on-line HRA = $500 credit on 2014 medical plan premium --livingwell CARES program expansion – priority/high risk and preventiont

YNHHS Multifaceted Approach to Nurture Health and Wellbeing Employees and Families Patients and Families Communities and Neighborhoods Corporate Clients and Municipalities

Culture of Health Promotion Patient and Families Communities and Neighborhoods Corporate Clients and Municipalities Smoke Free Campus Employee and Family Resources On-site Fitness Center Know Your Numbers-HRA and Biometrics Revamped all the cafeterias Free Nutritional Counseling Legal and Financial Support Mindfulness-Stress Management livingwellCARES Asthma Action Plan Shared medical Appointments Disease management Registries Clinical Practice Guidelines Emmi MDLive My Chart Safe neighborhoods Fitscripts Agency on Aging Malta House of Care Project Access Tuesday/Friday in person and phone Meditations Labyrinth walks Get Healthy CT Grocery Tours Biometric Screenings Flu vaccinations Health Coaching/ Disease Management Nutrition Counseling Workplace Challenges On-site Walk-in Clinics

Leverage Technology for millenniums Work life balance Intervention Design Leverage Technology for millenniums Work life balance Bringing programs and resources into their environment

So How are We Doing?

LWC-Fitscript Video

Patient Pilot Summary Fitscript Measure Pre Fitscript Post Fitscript Mean Annual Rx Spend $16, 174.98 $7689.27 Annual Cost Savings for Rx Spend 8485.70 Mean Weight Loss per Patient 9.7 lbs Mean A1c 9.8 7.6 Average A1c Improvement 2.2

Diabetes Campaign Annual Diabetes Office Visit/Gaps in Care Utilized the Epic Diabetes Registry NEMG PCP (16 pilot providers) only 271 patients called 36% engagement rate with patients 32 patients transferred to the office and 40 patients were given the scheduling information 30-60-90 day report indicated that 123 patients in this campaign had completed the appointment to date

livingwellCARES Objectives Healthier Employees (individuals, groups, and communities) Establish trusting relationships Improve engagement Improve productivity Identify risk factors/address barriers to care Decrease unnecessary health care utilization and cost

LWC INTERVENTION DESIGN Meeting individuals where they are Support in self-motivation Goal setting Track Outcomes Build accountability Monitor Progress Waived/Reduced co-pays

Measured Outcome Indicators Financial and Efficiency Metrics Utilization Metrics Clinical/Biometric Tests/KYN+ Lifestyle Indicators/Goal Progression Participant Satisfaction/Engagement Compliance with; Annual Exams/Tests/Immunizations

livingwellCARES Outcomes 1/2013-7/2015 Managed Pre Post Declined PMPM 1,040 1,722 2,912 7,182 ED Visits 334 305 534 680 Admissions 150 124 364 1,138 Hospital Days 639 561 2,276 5,529 Progression to and or goals met NA 78% 55% Source Conifer

livingwellCARES "My  coordinator is very sincere in showing the personal interest in making progress to help take better care of my health. I always leave the office with updates and encouragement.“ "My personal time with my coordinator is encouraging and sincere. It blows my mind how she follows up with whatever she has me working on. She always has goals for me. She has a caring heart. I love her. She is real. She tells me what I need, not always what I want to hear“

Lessons Learned

Tour de Cure 2016 livingwellCARES staff “stuck by me until I was in a better place,” Jordan said. “It sounds dramatic to say this, but I credit them and this program with saving my life.”