1. Intensive Outpatient Care Management Pilots Redwood Community Health Coalition Partnership HealthPlan of California

2. Two Models Embedded model: Care Manager hired by Partnership and Embedded into Health Center – Communicare Health Center, Yolo County Contracted model: Care Manager hired by Health Center

3. Variations of Contracted Model Single Care Manager with backup – Vista Health Center in Santa Rosa Distributed Care Management: – West County Health Centers, in Sonoma County

4. Intake Market program Ask to participate Intake components: – Complete review of history – PHQ-9 (depression) – VR-12 (quality of life) – PAM (patient activation measure) – Care Plan, Action Plan

5. Accountability Every 6 months: – Updated Action Plan – Patient Satisfaction Survey – Repeat PAM, VR-12, PHQ-9 – Hospital Utilization Data

6. Cost effectiveness (6 months) Adjusted Gross Savings = $898,188 Cost of Program = $179,000 Return on Investment= 4.2

7. Other Outcomes (so far) VR 12 Scores (Health Status Survey 200 pt total) – West County: Mean improvement 12.2 points (6%) (=) – Vista County: Mean improvement 3.1 points (2%) (MH) PHQ 9 scores (Depression; 30 pt. scale; avg start 8.3) – West County: Mean worsening 1.2 (3% worse) – Vista: Mean worsening 0.8 (2% worse) PAM scores (Patient Activation; 100 point scale) – West County: Mean improvement 3.4 points **