1. Linking with Community Resources Across Health System, In Your Community

2. Source: http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2

3. Community Resources Identify effective wellness and disease management programs and encourage patients to participate in them (e.g., hospital programs, Weight Watchers, walking clubs). Form partnerships with community organizations to support or develop programs (e.g., housing, transportation, food). Advocate for policies to improve care. Source: http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2

4. Health Care Organization Practice/System leaders visibly support quality improvement and include measurable goals in the strategic/business plan. Align incentives (salary increases, performance reviews) to encourage care coordination, team care, quality improvement. Partner with hospitals, health plans, specialists, pharmacies, nursing homes, etc. to coordinate care, share information. Source: http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2

5. Discussion How do you identify patient need?

6. Discussion How do you currently identify/provide resources?

7. Case Discussion 55 y/o male patient, newly diagnosed with diabetes. Scheduled to lose his job in 2 months, but he has full insurance coverage now. What resources do you offer? Are there any resources you feel he needs but you can not find? What next?

8. PCMH 4: Self-Care Support and Community Resources Element B: Provide Referrals to Community Resources Current resource lists Track referral Arrange or provide treatment for mental health, substance abuse Offer health education programs (group classes, peer support)

9. Where To Start: What is Available Around you? Weight loss programs Options for exercise Transportation options Meals on wheels, etc. Self-management support (i.e. support groups) Buying healthier foods What else? Create lists/handouts Reach out to organizations

10. Discussion on Linkages Community Resources What are common patient needs? Which community resources do you refer patients to? How are you tracking referrals? What kind of information exchange do you have with these resources? Any resource lists to share?

11. Discussion on Linkages Health System Who gets same-day hospital/ER reports? What resources do you use to help patients afford their medications? What kind of information exchange do you have with these resources? Any resource directories to share?

12. How can we help you?