Transformation 2018

Community-Based Care Acute Care

Recovery & Rehab Care

A Program of AHS Care Management

History, Impact, Outcomes, and Future

Health Defined

Rates of Visits to the Emergency Department for Select Conditions by Zip Code Poverty Level

Elaine Bautista, Samantha Bell, Matt Beyers, Janet Brown, Sangsook Cho, Roxanne Guide, Tammy Lee, Richard Lechtenberg, Jane Martin, Nicholas Moss, Neena Murgai. "Alameda County Health Data Profile, 2014.” Retrieved from www.acphd.org/media/395851/acphd_cha.pdf.

PROBLEM

Barriers to Health

Housing Crisis

Food insecurity

Unsafe living conditions

Violence Financial insecurity

Lack of insurance

Poor quality education

Organizational Constraints

Healthcare providers lack time and training

Social Workers focus on highest risk Outpatient Social Worker : Patient Ratio = 1 : 11,000

Limited communication and coordination between services

AHS Client

Financial Counselor SW

PCP

Health Psych

Social Services

Social Security

Legal Aid

SOLUTION: Health Advocates

Integrates two nationally recognized, evidence based models Health Leads Medical-Legal Partnership

Volunteer-powered

Consumer-driven

HA & Whole Person Care: Addressing the Barriers

Housing assistance (Enroll-A-Thons) Public benefit application and assistance Food Legal aid VOC Access to care Education Employment Seniors/Veterans services

HA Client-Centered Service Delivery

HA Client

SW

Financial Counselor

PCP

Health Psych Social

Services

Social Security

Legal

Referral Sources

Self-ReferredOtherOther Hospital StaffAdult MedicineEDPediatrics

44%

20%

15%

9%

6% 6%

Who Are We Serving?

Typical Consumer Profile African-American Female 50-59 Annual income of

less than $10,000 Housing

Black/African-American

Hispanic/Latino

White

Asian

Other

43%

27%

12%

8%

10%

Health Advocates Highland Hospital 36 hours/week

Fairmont Hospital 12 hours/week

Hayward Wellness Center 8 hours/week

56 hours of operation x 120 volunteers = 6,720 hours of labor/week

Partnerships

Health Care Services Agency

Oakland Housing Assistance Center

CalFresh with Alameda County Community Food Bank

Mandela Marketplace

USDA – FINI Grant

Health Care for the Homeless

Colleges and Universities (Undergraduate and Graduate Programs)

Medical-Legal Partnerships (MLP) Bay Area Legal Aid Centro Legal de la Raza East Bay Community Law Center Housing and Economic Rights Advocates Victim of Crime Compensation Program (Alameda

County District Attorney’s Office)

Partnerships

January 2016 – December 2016

0 2,000 4,000 6,000 8,000 10,000 12,000 14,000

Interventions

Follow Ups

Health Advocates’ Impact

9,200

12,798

Challenges and Opportunities

Opportunities:

Full integration within AHS Care Management departments

Presence at all AHS sites

PRIME

Challenges:

Full endorsement from hospital personnel

Desk closures

Limited HA staff and bandwidth

Ability to scale

Health Advocates’ Impact

Cost savings for labor in a “Health Advocate Year”: $12.86 x 4.75 hours x 42 weeks = $2,565.57 $2,565.57 x 120 advocates = $307,868.40 total salary

savings

Health Advocate Trajectory

Desire to serve

Health Advocate

Shift Lead

HA Staff

Career and/or educational pursuits

Informing our future work force (MDs, MSWs, public health professionals, health care administrators and attorneys)

Health Advocate Testimonials

“Seeing first hand some of the things our patients have to deal with is much more informative than any

textbook chapter about community health problems.”

“I was allowed to realize that medicine should be much more than treating an individual’s acute condition,

and that social circumstances have an immense impact on someone’s ability to care for themselves.”

“Volunteering has increased my interest in pursuing a career in health policy and management. Prior to volunteering as an advocate, I was interested in

pursuing a medical school degree. Now that I have seen how difficult it is for patients to navigate all of these complex systems, I have become more interested in

health care administration and engaging in policy work to help streamline these systems.”

Health Resource Leads Community Outreach

Fran Waller. Director of Community Engagement & Volunteer Development

Beginnings

3:49 http://www.ted.com/talks/rebecca_onie_what_if_our_healthcare_system_kept_us_healthy?language=en

Four Top Health Conditions: Hospital Association San Diego & Imperial County Community Health Needs in San Diego County

http://www.hasdic.org/chna.htm

• Diabetes (type 2) • Obesity • Cardiovascular Disease • Mental/Behavioral Health

Community Health Assessment

Challenges

A •Admission

D •Discharge

U •Unmet Social

Based Medical Needs

R • Re-admission

A • Admission

D • Discharge

S • Socially

Based Medical Needs

C • Community Partners

R •Re-admission

Strategy: To capture information about socially based medical needs that support timely and meaningful discharge through information gathered and assessment.

Sample Process

• Patient Seeks Medical Care

Presenting Need

• Clinical Assessment

Appointment • Social

Assessment

Assessment

• Community Partners

Resource Connections • Information

Shared with Care Team

Social Needs Addressed

• Volunteer Engagement

Follow-up

Mission: Improve Health in the Communities We Serve • Meet the socially based medical needs of Palomar Health patients

who are discharged back into our communities

• Engage our community partners in serving people

• Opportunities for New Funding Partnerships & Increasing our Volunteer Base

• Demonstrate Palomar Health as North County’s preferred provider

• Reduce recurring readmissions

• Efficient use of beds

• Increase value-based purchasing

Next Steps

• Approval to move forward • Alignment with CAC & Community Agencies • Data Program/Process/Outcome • Recruitment • Training • Collaboration with Care Transition and Case Management to

begin referrals

Questions