Access Carroll, Inc.

Improved care coordination, Improved health outcomes, Reductions in health disparities, Reduced readmissions, Increased use of preventive and primary care, Reduced utilization of post-acute care, Reduced utilization of post-acute care, Reduced avoidable utilization, Reduced spending

Access Carroll is a private nonprofit organization that provides fully integrated medical, dental, and behavioral health care to a targeted low-income and vulnerable population. Access Carroll is in strategic partnership with Carroll Hospital and the Carroll County Health Department to directly address local population health issues with a public and private health approach.

Access Carroll is supported through blended funding as a private nonprofit and is a heavy recipient of hospital community benefit funds.

Yes_Complex_and_Chronic_Care_Improvement_Program_CCIP

Care coordination/management, Patient assessment tools, Patient education/coaching/self-management, Multidisciplinary care teams, Patient care plans, Interventions to address social determinants of health, Protocols/agreements with care partners, CRISP tools (e.g., Encounter Notification Service)

Physicians office (primary care), Hospital/health system, Behavioral health provider (e.g., mental health and/or substance abuse), Non-clinical setting

Medicare/older adults, Medicaid, Dual eligibles (Medicare-Medicaid enrollees), Individuals with multiple chronic conditions, Frail/disabled, Younger adults

Approximately 7,000 since 2013

Carroll

Access Carroll utilizes a hybrid staffing blend of 26 paid staff within medical, dental, and behavioral health service lines in addition to in-kind public and private health staff, and professional volunteers. Of a critical nature, hospital implanted staff ensure seamless communication of hospital-based referrals into the ambulatory integrated system of care.

1. Public and private health partnerships at the table - determine who will host and sponsor community health strategy discussions 2. Shared population health goals - needs assessment, identification of needs, and establishment of health goals 3. Regular and intentional communication forums including a population health committee that includes health professionals and community key partners such as human service programs 4. Support of direct service organization (i.e. Access Carroll) - funding, staffing, resources, inclusion into organizational development and goals

False

Expected results include: 1. Reduced avoidable emergency department utilization 2. Access to coordinated and integrated health care 3. Reduced 30 day readmissions 4. Improvement in acute and chronic health conditions for individuals 5. Improvement of impact of social determinants of health 6. Improved cost savings across the system of care 7. Improved utilization of resources 8. Rapid response to identified community health issues

Some of the expected results were achieved

Access Carroll has worked in partnership with Carroll Hospital to make significant impact of the anticipated results as listed for individuals and high risk groups. Quantifiable outcomes in emergency department utilization and 30 readmissions is being monitored. Patient satisfaction and acute and chronic health outcomes of those who have received care at Access Carroll are high and consistent for those who choose to engage in services. Connecting patients to community resources, particularly for identified social determinants of health, are effective though work is still needed for some areas for very high risk homeless populations and those suffering with behavioral health disorders. , Some of the expected results were achieved

The anticipated or expected cost savings results have been achieved in some areas in that patients are receiving coordinated, efficient, and cost-managed outpatient care as opposed to episodic and costly emergent services. Often the ability to quantify savings and costs of preventive care are difficult over short periods of time.

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