1. HealthEast Linkage Committee Pennie Viggiano RARE Action Day November 8, 2012 1

2. HealthEast Care System St. Paul, Minnesota HealthEast Care System 4 Hospitals 14 Primary Care Clinics More than 35 specialty services Home Care & Hospice Medical Transportation Hospital Statistics Licensed Beds: 925 Employees 7300 Volunteers 1200 Credentialed Physicians 1400 WoodwindsSt. JosephsSt. JohnsBethesda

3. Membership HealthEast –St. Johns, St. Josephs, Woodwinds, Bethesda, Home Care, Medical Care for Seniors and HealthCare Home, Orthopedics Cerenity Care, Care Choice, Episcopal Homes, Golden Living, Health Dimensions, Good Samaritan –Representing Transitional Care, Long-Term Care and Assisted Living. –Some also have Home Care, Hospice and Other services 3

4. AIM Improve patient safety, quality and experience resulting in improved outcomes in care and reduced readmissions 4

5. SCOPE The scope of the committee lies within the relationship and cross referrals/transfers related to HealthEast Hospitals, Home Care, Hospice, Primary Care, Medical Care for Seniors, Community Care Management, Transitional Care, Long Term Care and Assisted Living provider partners. Within this relationship understanding barriers and opportunities for improvements in care to the patients we mutually serve. 5

6. The Focus Comprehensive discharge planning Medication Management Patient & Family Engagement Transition Care Support Transition Communications Forum for cross continuum discussion and consultation. 6

7. Improvement Work Safe Transitions in Care Initial Admission and Re-Admission Assessment Partnership on Direct Admissions Care Center to Emergency Department (ED) transfers Assisted Living Record Access 7

8. Measurement 8

9. 2012 and Beyond Create quality indicators for partnerships Implement cross continuum pathways for total joint and geriatric hip Ongoing review and root cause analysis of barriers identified by the collaborative 9