1. HealthRise Rice County HealthFinders Collaborative

2. HealthFinders Collaborative provides quality health care, advocacy and wellness education to people in our community who have limited healthcare alternatives. healthfindersmn.org “Hybrid” community clinic

3. DRAF T

4. Rice County: 65,049 (21,426 “outside town limits”) Median Income: $57,000 Median age: 37 Northfield, MN: 20,036 Median income: $62,253 Median Age: 26 Faribault, MN: 23,392 Median Income $48,303 Median Age: 35 Minnesota: 5.4 million Median income: $55,616 Median Age: 43

5. Latino Immigrants (8%) Somali Refugees (8%) Faribault School District ~40% non-white >67% free/reduced lunch

6. Latino vs. White Poverty rate in MN counties with >2,500 Latinos Source: US Census Bureau, 2007-2011 American Community Survey tables S1701 (Poverty status in the past 12 months) and DP05 (Demographic and housing estimates).

7. 2 hospitals, 4 clinics, 3 systems Clinical leadership Steering committee Community Paramedics Rice County – Health System

8. Intervention Overview Unite a diverse care team that goes beyond the clinic and into the community FLHW: community health workers, patient advocates and organizers, and community paramedics Care coordination hub, effectively uniting clinical and community based resources into a united care team. Care Coordination Hub (community + clinic care coordinators) Community Health Workers Community wellness programs Community Paramedics Other FLHW

9. Objective Increase management and control of CVD and/or diabetes for the underserved population in Rice County by 25% by July 2018. Approaches (from RFA) Approach 1: Increase individual health seeking and adherence behaviors regarding DM/CVD Approach 2: Improve the capacity and effectiveness of frontline health workers to reach, engage, and follow up with those living with DM/CVD Approach 3: Promote policies that stimulate and embed sustainable changes that support increased access to care and treatment for DM/CVD 1.Community embedded disease management programs 2.FLHW and clinic-community care coordination hub 3.Evaluation and communication

10. Target Population uninsured patients with diagnosed DM/CVD underserved patients with diagnosed DM/CVD who may benefit from community-coordinated care underserved patients with undiagnosed DM/CVD, and/or are at-risk of developing DM/CVD “underserved” = patients who are uninsured, or patients with public health insurance (Medical Assistance, MinnesotaCare, or an associated managed care plan) Latino Immigrants Somali Refugees

11. Intervention Activities: Approach 1 Increase individual health seeking and adherence behaviors regarding DM/CVD management through patient empowerment and a reduction in barriers to care Community Embedded Programs Diabetes Self-Management Education Community-based wellness programs Community-based clinical care Mobile support and mass communication

12. Intervention Activities: Approach 2 Improve the capacity and effectiveness of frontline health workers to reach, engage, and follow up with those living with DM/CVD Clinic-Community Hybrid Care Coordination Hub Care coordination hub Clinician engagement Cultivate and coordinate front line health workers Care Coordination Hub (community + clinic care coordinators) Community Health Workers Community wellness programs Community Paramedics Other FLHW

13. Intervention Activities: Approach 3 Promote policies that stimulate and embed sustainable changes that support increased access to care and treatment for DM/CVD Evaluation and Communication Local policy and systems changes Process evaluation and ongoing quality improvement Outcome evaluation Communication and dissemination $

14. Innovation / Promising Practice 1) Care coordination hub FLHW learning community Technology (information exchange, health monitoring) 2) Care team extension into community Combine clinic and community-based resources Trusted community organization, history of community organizing + clinics Patient leadership and community health conversations 3) Contribute to discussion on population health/accountable care Multiple systems/payors, not necessarily managed care arrangement Comprehensive study of emerging professions

15. 2 hospitals, 4 clinics, 3 systems Clinical leadership Steering committee Community Paramedics Key Partners

16. Other Partners Community Engagement FLHW Learning Community

17. Steering Committee FLHW Learning Community Information Technology Care Coordination Hub Quality Improvement and Quality Assurance Communications Project Leadership Clinic-based care teams Community Care Coordinator Model based on past experience with coalition project

18. Core Staff HFC Staff (here today) Charlie Mandile Executive Director Daisey Sanchez Clinic Coordinator Emily Carroll Nurse Practitioner Maritza Navarro Care Coordinator Laura Turek Evaluation Coordinator Dr. Mike Wilcox Community Paramedics New Hires Project Lead (1.0 FTE) CHW – Somali (.75 FTE) CHW – Latino (.75 FTE) Ali Hassan Advocate/Organizer Fatima Ponciano Advocate/Organizer Existing FLHW

19. Timeline for Next 6 Months Sharepoint Site for project tracking Pitches to clinical teams Hiring Program lead/Coordinator 2 x community health workers Develop sub-contracts: Technology/Information Exchange, Community Paramedics, FLHW learning community Launch Workgroups (Workplan/Charge/Procedure and Policy Development) QI/QA; Care Coordination Hub; FLHW; IT; communications Launch Program Improvement Plans Diabetes 3.0; Pura Vida; CP pilot “Pilot” models