1. “A Health System’s Bridge Between Healthcare, Government and Social Systems” Liz Cessor March, 2014

2. STORIES… Who Are Our Patient’s……..

3.  Health System’s are now challenged to transform into a comprehensive health collaboration, capable of responding to acute chronic illness, with a proactive, patient centered and community based care.  Transition of Care….. Patient Experience

4. Interesting Study looked at 450 hospitalized patients who were low income, uninsured/Medicaid. Half worked with CHW’s, half did not.  60% received follow up care with a CHW within 14 days of discharge vs. 48%  Only 2% of the CHW assisted population were readmitted within 30 days vs. 5.5%.  Potential cost savings on this study alone? Over 2 million dollars! * Health Day 02-14 *Health Day 2-2014

5. Challenges Hospital’s Are Facing Today  30 Day Readmissions  Increased Admissions  Increased ED Visits  Patient Satisfaction-HCAP scores  And…..The Affordable Care Act Barrier’s

6. The ACA The ACA was to help guarantee the chance for coverage to more than 32m uninsured. To Date, both Missouri and Kansas have not approved Medicaid Expansion.

7. With Medicaid Expansion In Missouri  Saves as many as 700 lives per year.  Covers almost 300,000 of our hard working family, neighbors and friends.  Save and create over 24,000 jobs  Keeps rural hospitals and ambumances running  Note – Missouri over 5m a day of guaranteed federal dollars! State will save $1billion by 2022. Crucial to insure the truly poor……. * Mo Health Alliance 3-10-2014

8. February 1, 2014, 3.3 m have signed up for marketplace insurance. MissouriKansas 22,000 54,000 83% subsidy 76% subsidy 18% 18-34 yrs. 28% 18 – 34yrs.

9. ACA – Positive facts  Helping to shift US towards a health care system based on primary care by increasing primary care services  Advances this principle by investing in training additioal FP’s and CHW’s  Eliminated the worst practices of insurance companies in dropping high cost patients or those with pre-existing conditions.

10.  Must all have the same basic coverage including mental health and prescriptions. So, how do we reach the community, get this population guided through the process to start utilizing what is now offered to them? COMMUNITY HEALTH WORKER’S

11. What is a Community Health Worker?  A Community Health Worker (CHW) bridges the gap between health care providers and populations in need of care. CHWs are trusted members of and have a close understanding of the communities they serve. They are a link between the patient and health or social service agencies, striving to improve health outcomes. Ultimately, a CHW improves access to services and quality of care for patients.

12. Health System’s are now integrating the use of CHW’s to ensure a smooth transition of care. Goal’s of Joining with Community Health Worker’s  Improved medication management  Earlier Physician intervention  EMR – Shared records  Connect to social support  Promote wellness  Decrease Financial Loss  Patient Satisfaction

13.  KC Care Connections – Decreased readmissions to ED by establishing patients in medical homes and social needs  KC Care PCMH – Follow Up after discharges  Artist’s Helping The Homeless – Decreased homeless in SLH ED by over 87%  Foundations – Financial support in many programs

14.  Sam Roger’s Health Center/Cabot Swope – FQHC’s that support the uninsured  ReDiscover – Mental Health needs from ED  Salvation Army – transition from the hospital to a safe environment to regain health. Just to name a few……