1. Courage Center Primary Care Clinic: Health Care Home for Persons with Disabilities

2. 2 Courage Center Guided by the vision that one day, all people will live, work, learn and play in a community based on abilities, not disabilities.

3. 3 Courage Center A comprehensive rehabilitation and resource center for persons with disabilities service individuals with lifelong and newly acquired conditions at every point in the life cycle since 1928 Largest nonprofit provider of rehabilitation services in Minnesota

4. Courage Center Serves 12,500 people with disabilities and complex health conditions annually at 4 sites in the Minneapolis and St. Paul metropolitan area Has long recognized the unmet need for primary care for our patients Research staff are located within the Public Affairs and Research Department, a unique linkage to advocacy and public affairs.

5. Target Population Identified for our HCH Persons with disabilities or complex health conditions Require combination of medical and social services to live successfully and participate fully in their home communities Require multiple services that span the continuum from acute to long-term medical care

6. The 50% of the population that costs the least. The 5% of the population that costs the most.

7. Planning for the Clinic

8. Our goals for the clinic were the triple aim Improve population health Reduce health costs Improve client experience

9. GoalMeasure Better Health Improve patient’s perception of health Center for Disease Control and Prevention Healthy Days Decrease the complexity of dealing with health conditions Secondary Conditions Surveillance Instrument Decrease severity of depression Patient Health Questionnaire - 9 (depression measure) Decreased Cost Decrease the rate of hospitalizations Per member Year hospitalization days Better Experience of care Improved patient engagement in their health care Patient Activation Measure Satisfaction SurveysCourage Center Patient Satisfaction Surveys

10. Measures Healthy Days PHQ-9 Hospital Days Emergency Room Visits Secondary Conditions Surveillance Instrument

11. After 36 months After 3 years, we have served 278 patients, with 207 active members in the clinic Chart review on 50 patients found –Average of 12.5 health conditions –80% of patients also have a major mental health diagnosis –Average of 12.4 medications (including OTC)

12. GoalMeasurePilot Outcomes Better Health Improve patient’s perception of health CDC Healthy Days 45% of clients entered with 0/30 healthy days. After one year, average client had increased from 7 healthy days a month to 14 healthy days. Decrease the complexity of health conditions Secondary Conditions Surveillance Instrument No significant decrease in the number of secondary conditions, slight decrease in severity of conditions. Decrease severity of depression PHQ-9Decrease in depression score in first year of enrollment Decreased Cost Decrease the rate of hospitalizations PMPY hospitalization days Reduced hospital days by 75% after admission to HCH. Saved $19,100 per person per year, $3.4 million a year on 177 clients Better Experience of care Improved patient engagement Patient Activation Measure Increased PAM scores by 5 points in first year. Satisfaction Surveys Courage Center Patient Satisfaction Surveys 97% of clients would recommend Courage Center Primary Care Clinic to others.

13. Components of the CMS Grant Expand the clinic from 200 to 500 clients Implement a Chronic Disease Self-Management Program with our population Develop low-cost in-home support for clients in the clinic who don’t qualify for waiver services (similar to Independent Living Skills) Expand telemedicine program to provide on- going monitoring of chronic conditions Implement Payment Reform to make the clinic viable

14. Questions Nancy A. Flinn Nancy.Flinn@couragecenter.org