2. Better care for Individuals Better health for Populations Lower Cost

3. 3

4. Source: http://www.kaiseredu.org/Issue-Modules/US-Health-Care- Costs/Background-Brief.aspx

5. 5

6. 6

7. 7 HCP Inpatient Strategy

9. 9

11. Comprehensive Care Programs provide: Medication management Advance care planning Disease education Access to additional community resources 24-hour on-call telephone access to a high risk program provider Interdisciplinary care plan Coordination of treatment plans across multiple providers or locations Teams document in EMR to facilitate care coordination Keep the patient’s PCP abreast of the patient’s care plan

12. HealthCare Partners (HCP) Care Model ACM/Disease Management CHF / COPD / DM / CKD Comprehensive Care Clinic ESRD/Dialysis Palliative Medicine Consults House CallsUrgent Care Hospitalist/SNF Programs Patient Family Primary Physician/Specialists

13. 13 F/U Appointments Red Flags How to get HELP! Medication reconciliation

14. PreInPost Patients48873370 Admits Per Thousand 15751028 (34.%) 913 Days Per Thousand 75105199 (30.8%) 4960 14

15. PreInPost Patients54883021 Admits Per Thousand 1418960 (32.2%) 701 Days Per Thousand 90765644 (37.8%) 4090 ER/1000645581 (9.9%) 527 15

16. 16

17. PreIn Patients523 Admits Per Thousand1377984 (28.5%) Days Per Thousand59403737 (37%) ER/1000385486 (26%) 17

18. HCP High Risk Program Impact

19. 19

20. 20

21. 21 QUESTIONS