Resources Available: • Blue Ridge Behavioral Health Care • Bradley Free Clinic • Carilion Clinic Behavioral Health Services • Carilion Clinic Emergency Department • Catawba Hospital • Family Service of Roanoke Valley • G. Wayne Fralin Free Clinic for the Homeless • Mental Health America of Roanoke Valley • New Horizons Healthcare • Recovery & Resources Service Program
Coordination of Care Healthy People 2020 Objectives • AHS-3: Increase the proportion of persons with a usual primary care provider (Leading Health Indicator) • AHS-5: Increase the proportion of persons who have a specific source of ongoing care • AHS-6: Reduce the proportion of individuals who are unable to obtain or delay in obtaining necessary medical care, dental care, or prescription medicines • HC/HIT-1: Improve the health literacy of the population • HC/HIT-8: Increase the proportion of quality, health-related Websites • HC/HIT-10: Increase the proportion of medical practices that use electronic health records • HC/HIT-11: Increase the proportion of meaningful users of health information technology (HIT)
Barriers and Factors that Impact Mental Health & Substance Abuse: • Demographic and cultural changes in the community • High poverty rates, unemployment & lack of jobs • Cost of services and insurance status • Inappropriate utilization of ED/Urgent Care for mental health & substance abuse services • Waiting list for existing services • Need for additional providers including psychiatrists • Risky behaviors (substance abuse, child abuse/neglect, domestic violence) • Health literacy, cultural competency and language barriers • Social stigma associated with mental health and substance abuse disorders
Goal: Improve coordination of care and ensure access to available resources and services that address the healthcare needs of the community. Expected Outcomes (Success Measure): • Reduce hospital readmissions • Increase the number of people with a primary care medical home • Increase the number of people who “effectively use” health care safety net providers (i.e. proper utilization of Emergency Departments) • Increase the sharing of electronic medical records and the percent of individuals registered in shared database. Evaluation Measures (Metrics for Goal): • Readmission rates for CHF, AMI, PNEU, COPD, and Diabetes • Number of people with a primary care medical home (% change) • Emergency Department utilization rates for inappropriate primary care visits • Establishment of community/regional Health Information Exchange (HIE) • Percent of organizations participating in HIE Suggested Strategies: • Establish an inter-organizational /interdisciplinary work group to
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