1. Patient Centered Medical Community CTC Progress Report January 9, 2015 1

2. South County Community Health Team (CHT) managed & administered by SC Hospital Healthcare System Primary Care Practices Community Health Team Coastal Narragansett Coastal Wakefield Dr. Cunniff Dr. DelSesto Dr. Demirs SC Internal Medicine SC Hospital Family Medicine SC Walk-In and Primary Care Thundermist Wakefield Wood River Health Services 1 FTE Manager - 9/14 ½ FTE Analyst & 1 FTE CRS- 10/14 1 FTE CRS - 11/14 1 FTE BH Care Manager - 12/14 Office Set Up Medical Office Bldg - SCHHS Co-located within SCMG primary care practice Office furnishings Equipment for office & community visits 2

3. South County CHT Orientation, Training & Activities Hospital Orientation – guiding values, patient confidentiality, safety, environment of care, policies & more PCP Office Meetings – case reviews, warm handoffs, after hours protocols Community Resource Agencies – Basic Needs Network Community Health Services – VNS & other home care; pharmacy services; hospital case management, behavioral health & nutrition resources Trainings – RIPIN Navigation; Skills building including confidentiality, cultural & linguistic sensitivities, home visit safety, MI and other patient engagement techniques; NextGen documentation Program Implementation – development of materials, workflows, data capture and integrating use of NextGen 3

4. South County CHT Target Population Health Plan high risk/cost reports - Spring/Summer of 2014 Practices reviewed reports for patients with “high impactability” Referrals made to CHT Patient data compiled and baselines submitted to the Health Plans - October 2014 Total = 209 patients Outreach NCMs began introducing program to patients - August 2014 CHT began outreach and engagement - October 2014 1 st Wave - 38 patients from 5 practices 2 nd Wave - 14 patients from 2 additional practices 3 rd Wave – 40 patients from 3 additional practices BH Care Manager primarily focused on patients identified by CRS and NCMs 4 BCBSRI = 116United Medicaid =46NHPRI = 41 Medicare = 4Uninsured = 1Tufts = 0

5. South County CHT Activity through 12/31/14 92 patients actively engaged or in outreach/pre-outreach Age range 18 – 100; average 58 years Male = 42; Female = 50 5

6. South County CHT CRS Activity through 12/31/14 6

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8. South County CHT Active Patients as of 12/31/14 Engagement* 35 of 36 were warm handoffs 8 in office, 18 in home, 6 by phone, 4 in community 3 report 5 ED visits in past 6 months, 14 report at least 1 7 report inpatient stays, 1 reports 10 admits 14 report 8 or more Rx 14 either agreed to or report already enrolled in Currentcare Health, Barriers & Limitations* 16 report 3 or more medical 18 report depression or other MH 18 report multiple barriers to health – transportation, housing, healthy food 21 report 1 or more ADL limitations * data base in development 8

9. South County CHT Patient Story Young woman, early 20’s, victim of domestic violence, recent miscarriage and numerous Psych admissions. No longer eligible for shelters due to history of suicide attempts. Involved with CMHC health home. Currently living with her father, his girlfriend, their 5 children. Now working 2 jobs, attempting to save enough $ to afford an apt. Release signed for BH CM to coordinate with health home. CRS assisting with housing and other community resources. 9

10. South County CHT Patient Story Man in his early 50’s, living with his wife. Hx of working full time, staying active. Now unemployed for a few years, several medical issues - obesity, diabetes, chronic pain. Wife works part-time, considerable financial debt. Since loosing his job, he reports rarely leaving his home, daily alcohol use. History of BH issues, but no op tx, 2 inpt admits many years ago. He identifies desire to stop alcohol. CRS assisting with financial resources & budget. BH Care Manager consulting with PCP/NCM, and health plan social worker regarding resources for sobriety. BH care manager providing brief supportive therapy. Goal referral to appropriate detox program when ready. 10

11. South County CHT Patient Story Married woman, late 50’s significant Psych hx with suicide attempts and hospitalizations. Currently in therapy and on medications however many active symptoms as well as substance use. Patient has called on 2 occasions asking advice on psych admission to adjust medication. Has signed release for BH Care Manager to provide care coordination. In agreement to discuss symptoms and SA use with PCP and current therapist. 11

12. South County CHT Successes Challenges RIPIN CRS trained and prepared workforce to assist with navigation and resources Collaboration with NCMs/PCPs - warm hand offs and ongoing case discussions BH CM valuable asset to the team - providing support to patients having difficulty with healthy living & self- management as well care coordination Difficulty determining cost drivers, reasons for high risk/cost or areas of impactability Difficulty not having direct access to the health plan high cost reports Uses valuable case review time with NCMs Incomplete demographic data files 12

13. South County CHT Next Steps Development of NextGen to capture all activity Assessments - Interactions - Care Plans - Releases Data extraction and reporting Matching target population with Meditech information to generate utilization data and timely hospital activity reports Expansion of target population by submitting new patient referrals to the health plan baselines (2 nd cohort?) BH Compacts Improved transportation options 13