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

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

3. 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.

4. The Burning Platform
Unsustainable healthcare costs

5. The Burning Platform
Self-Insured Employers on the Rise

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

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

8. Integrated Care Delivery

9. Behavioral Health Care Coordination
Quarterly Readmission Statistics
Performance Period Q – Q

10. 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%

11. 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%

12. 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

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

14. What’s Next: Community Resource Alliance

15. 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.

16. 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

17. Questions