1. Serving Caldwell, Crittenden, Christian, Hopkins, Lyon, Muhlenberg, Todd & Trigg Counties of rural South Western Kentucky Cohort 1 Learning Community Region 4 Hopkinsville, KY Kecia Fulcher – Project Director kfulcher@pennyroyalcenter.org Lisa Bridges – Nurse Care Manager lbridges@pennyroyalcenter.org 1-877-473-7766

2. Statistics are good sometimes in evaluating programs, but the most important number we see each and every day is ONE. One represents each person whose life has been changed, or even saved as a result of Integrated Health. The 24-year old male client with early onset Diabetes and Hypertension doesn’t care about statistics, but he does care about ONE, and how his life has been improved because we also cared about ONE. Serving Caldwell, Crittenden, Christian, Hopkins, Lyon, Muhlenberg, Todd & Trigg Counties of Western Kentucky

3. Who We Are University of Kentucky – Primary Evaluator – Tina Studts, PhD. Collaborative Agreements – Dentists, Labs, Health Departments, Hospitals Our Own Primary Care Staff – Dr. Stephen Thore / Dual Licensed Psychiatric Addictionist / OB/GYN – Dr. David Gray – Dual Licensed Psychiatrist / Family Practice – Linda Dillard, APRN – Lisa Bridges, RN Nurse Care Manager

4. Program Goals 275 clients per year / 1,100 in 4 years  To improve access to primary care services.  To improve prevention, early identification and intervention as well as treating chronic diseases.  To enhance the program’s capacity to holistically serve individuals through screening techniques and service delivery.  To improve the overall health status of the Hopkinsville community.

5. Individual Grant Program Measures Our Typical Client Female – 59% Mid 40s – Early 50s – 27% Stable place to live in community – 78% Non-Drinker – 76% Obese – (Based on BMI) – 71% Tobacco User – 65% DAST, Audit, SPO 2 – O 2 saturation

6. Successful Strategy : Evaluation/Reassessment We have a subcontract with the University of Kentucky for data collection along with help from our IT Department. Two research assistants complete reassessment interviews. Reassessment Rates : Year 1 - 96% Year 2 - 89%

7. Successful Strategy: HIT Before HIT  Using EHR since April 2009 – Certified  Vendor is NetSmart Since HIT  Obtained 1 st Meaningful Use payments  Installed and have begun using OrderConnect  Will install ConsumerConnect – Client portal to access PHI  Will install CareConnect – HIE Portal  Kentucky GOEHI obtained a National Council Grant – We are working with KHIE and KYREC.  Working toward Year 2 Meaningful Use Criteria

8. Health and Wellness Topics Disease Management Diabetes / Pre-Diabetes Oral health for diabetes Hyperlipidemia Hypertension Hepatitis C Tobacco Cessation Oral health Chronic Fatigue / Fibromyalgia

9. Plans for The Future Sustainability Clinical – Contracts with other primary care providers Administrative – Commitment to long term plans for integration Financial – Developing fiscal services for primary care Next six months: Hire CNA for improved patient flow Add two more exam rooms Become a provider for Medicaid, TriCare, and other third party payors Explore Medical Health Home and ACO activity