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Overview • The Why: Population Health Management  Carmela Coyle, President & CEO, Maryland Hospital Association • The How: Faith Community Health Networks  Reverend Bobby Baker, Chip Clay, Memphis Congregational Health Network  Vincent DeMarco, President, Citizens’ Health Initiative  Darlene Won, LifeBridge Health 3

Population Health Management 4

Population Health Management • “Managing the health outcomes of a group of individuals”  Primary care  Patient activation and involvement  Care coordination for disease and chronic care  Focus on health and wellness  About more than just care – social supports 5

Health is About More Than Clinical Care Health is driven by multiple factors that are intricately linked – of which medical care is one component. Personal Behaviors 40% Family History and Genetics 30% Environmental 10% and Social Medical Factors Care 20% Page 6 Source: Determinants of Health and Their Contribution to Premature Death, JAMA

Population Health Management Changes How Hospitals Think • Do more to earn more  Rewards for efficiency and quality • Care for an individual patient  Care for an entire population • Acute care  Ambulatory care  Community care • Competition  Collaboration • Hospital care  Health care 7

Population Health Management Requires Different Role for Hospitals • Supply proactive, preventive and chronic care to all • During and between encounters • Regular contact with patients • Support patient efforts to manage their health • Manage high risk patients to prevent from worsening Requires Partnership 8

The Maryland Experience Global Budgets and other payment incentives • Apply to all Maryland hospitals • One, annual $$ amount to care for all patients • Spending growth is capped • Payment incentives to manage all readmissions • Payment incentives to manage 65 complications • Focus on removing avoidable utilization • Value-based payment: pedal to the metal in MD 9

The Why Faith Community Health Networks • Need community partners to help coordinate care • Faith community often has established interest in health • Congregations bring the power of community • Often a connection with hospitals’ faith -based missions • Many hospitals and faith orgs share a non-profit tradition • Provides eyes, ears and support outside the hospital • Community benefit opportunity • Greater understanding of diversity in our communities • Creates patient and consumer engagement 10

Welcome to the Memphis Model Dr. Bobby G. Baker,M.Div.

The Healthcare System needs the Faith Community • Acute Care Chronic Care • Episodic Care Relational Care • Personal Care Population Management • Practicing Medicine Partnering with Patients • Fee for Service Value Based

CHN=The Trust Factor Trust is the highest form of human motivation. It brings out the very best in people. Stephen Covey Respect Trust Reliability Make Listen for Talk Straight Commitments Understanding

The Congregational Health Network is a Asset Based, Faith Centered, Social Support Intervention that Improves Outcomes and Organizes Community Resources around Healthcare.

Enhance & Leverage Congregational Strengths • Accompaniment • Convening • Connection • Storying • Sanctuary • Blessing • Prayer • Endure Gunderson, Gary. Deeply Woven Roots: Improving the Quality of Life in your Community. Minneapolis: Fortress Press, 1997.

World Health Organization 1986 Fundamental conditions for Health • Peace • Shelter • Education • Food • Income • Stable Ecosystem • Sustainable Resources • Social Justice • Equity

Safety Net Partners

The CHN Covenant Agreement – A signed document spells out partnership.

Connection – CHN as an example Congregations Congregation and Community Navigators Liaisons Director 579 11 1 695 250,000+ Paid Staff Volunteers

What Does a Liaison Do?  Recruits congregational members into the network  Notifies Navigators of developments/changes  Follows network members into and out of inpatient setting  Coordinates transition from hospital  Marshals community resources  Provides information and referral services  Facilitates wellness activity participation

Member Registration

What Does a Navigator Do?  Develops a network of community resources  Coordinates outpatient care  Helps clients navigate the service systems  Provides avenues for prevention and education  Maintains program documentation and participates in ongoing program evaluation and reporting

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Navigators • Congregation • Population • Disease specific • Community

CHN Congregations 46 Level 4 229 Level 3 36 Level 2 195 Level 1 695 trained liaisons 21,335 members registered Training Participation: 917 in Care & Visitation 313 in Care for Dying 168 in Mental Health First Aid 125 in Aftercare 95 in Transplant 80 in Disease Live With 52 in Today’s Health Iss 297 in Navigate Health System 166 Cancer, Med, Miracles 71 in Better Brains 6/10/15 - 09/09

Congregation Engagement Levels 1. Signed Covenant 2. Active Liaisons, Registered Members 3. Building Connections and Capacity 4. Community Engagaement

Focus Areas Elderly and Advanced Disease Mental Health Chronic Disease Infants and Mothers

Care Pathways Education Prevention Intervention Access Aftercare

CHN CLASSES 1. Alliance Aftercare Training 2. Better Brains 3. Caring for the Dying 4. Congregational Care and Visitation 5. Disease Conditions We Live With 6. Healing Homes Family Violence Training - Organized Crime Commission & Victims to Victory 7. Mental Health Issues & Resources for your Congregation 8. Navigating the Health System 9. Avoiding Burnout in Ministry 10. Healthy Hearts: Prevention, Detection, & Treatment of Heart Disease 11. Cancer, Medicine and Miracles 12. Living W ith Alzheimer’s 13. Living Well at Any Age 14. Food & Faith from the Farm to Lord’s Table - Memphis Food and Faith 15. HIV and STD’s Uncovered 16. Christian PREP – Successful Relationship/Successful Lives 17. Principals of Manhood 18. Faith in the Face of Cancer 19. Law School for the Community 20. Living with Stroke Series 21. Fighting Cancer Together 22. Diabetes Empowerment Education Program 23. Eyes, Vision, and Health: Making the Connection 24. Creating Success Through Right Relationships 25. Power to Forgive is Power to Heal

CHN Information Database

CHN INTERVENTION • Focus on residents of ZIP Code 38109 -Assets • Provide community Navigator -Trust/Relationships • Leverage CHN congregations -Assets • Restore Parish Concept -Congregation/Community 32 •

All CHN Patients Have A Longer Time-to-Readmission LONGITUDINAL DATABASE (2005 -2011) Regardless of diagnosis or Time to Readmission conditions, all patients in the 426 Congregational Health Network had significantly longer time- 306 to-readmission than matched patients out of the network (CHN=426 vs. Non-CHN =306 days) from 2008 through 2011, first quartile. CHN Non-CHN 33

Summary of Findings At 25 months into the work of CHN , there were 473 people in the network. We have identified a subset that came through the hospital prior to CHN and looked at hospital utilization for the subset pre and post CHN, excluding trauma, expiration and hip replacement. SUBSET N=50 Pre-Post Within Subject Cohort Comparison Hospital Metrics Pre-CHN Post-CHN Total admissions 159 101 Admits/patient 3.2 2 Total readmits 37 17 Readmits/patient 0.74 0.34 Total patient days 1,268 772 Days/admit 8 7.6 Days/patient 25.4 15.4 Total charges $6,396,111 $3,740,973 Average charge/admit $40,277 $37,409 Average charge/patient $127,922 $74,819 ER admissions 84.90% 80.20% 34

MLH Decreases Charity Care Costs from 2011-2012 100,000,000 90,000,000 80,000,000 70,000,000 60,000,000 38109 Residents 50,000,000 All Patients 40,000,000 30,000,000 20,000,000 10,000,000 0 2010 2011 2012 35 35

Maryland Faith Community Health Network Replicating the Congregational Health Network Model Vincent DeMarco , Maryland Citizens’ Health Initiative Education Fund February 2016

Overview  Maryland’s Health System Transformation  Regional Public Forums  Development of pilot of the Maryland Faith Community Health Network at LifeBridge Health

Maryland’s Health System Transformation  New incentives for hospitals to develop/deepen partnerships to keep patient’s healthy— both within and beyond the medical field  New charge for our coalition to engage in health system transformation  Searching for models with strong evidence of impact both on health outcomes and spending