1. Annapolis Community Health Partnership An Update for Community Health Resources Commission June 26, 2014

2. Core Goals of Year One: Complete 1) Increase access to primary care services capital improvements, hires, infrastructure doors opened October 2013 453 unique patients served, 1,253 visits 2) Increase community health resources diabetic screening program implementation self-management and health literacy promotion 3) Promote cultural competency all staff trained

3. Challenges  Being a guest and a host at the same time  Intercultural tensions  Insurance issues  Primary Care Medical Home versus agnostic and flexible Health Resource  Late entrants to care come to us in crisis  Change in Physician

4. Year 2: Strategic Plan and Core Goals  GOAL ONE: Improve diabetes outcomes, measurable by 1/1/15  Strategies:  Screening program implemented  Patients enrolled in primary care  Population health management tools  Recruitment of additional patients

5. Year 2: Strategic Plan and Core Goals (cont’d)  GOAL TWO: Decrease preventable, costly, crisis-driven care  Objectives: Within 12 months:  Decrease medical 911 calls from Morris Blum by 30%  Decrease emergency room visits from Morris Blum by 30%  Decrease readmissions among Morris Blum residents by 30%

6. GOAL TWO Strategies  Promote site as a health resource for residents  Promote health literacy and knowledge regarding proper use of 911, ED.  Resident Health Advisor (HACA)  Care management, transitional services, apartment visits  Palliative care consultations, goals of care discussions