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Promoting Whole Person Carethrough Value Based Purchasingand Community Reinvestment
Dr. Keith BrownChief Medical Officer
Community Health Plan of Washington
The greatest mistake in the treatment of diseases isthat there are physicians for the body and
physicians for the soul, although the two cannotbe separated.
~ Plato
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Objectives
• Share CHPW’s perspective on opportunitiesand benefits for whole person, integratedcare.– What’s the data and what does it tell us?
• Share CHPW’s approach to supporting highvalue, integrated care through customizedcapacity development and innovativepayment models.
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Opportunities and Benefits OfWhole Person Integrated Care
Prevalence ofBehavioral Health Conditions and Primary Care
• Prevalence estimates for psychiatric disorders of individualsseen in primary care range from 26 to 60 percent. *
• An estimated 20 percent of children in pediatric primary carehave a clinically significant psychosocial problem/condition.
• An estimated 60 percent to 70 percent of physician visits are bypatients with no medical illness.
* Source: Studies of patient populations based on the PRIME-MD
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Behavioral Health PrevalenceSerious Mental Illness 4.1 % US adultsAny Mental Health disorder: 18.6% US adults• (13.4% receive treatment)Substance Abuse: 8% of Americans age 12 and older
About 13% of 95 million ER visits in the United States in 2007were due to a mental health and/or substance abuse problem.Most common mental health diagnoses in ED:• Mood disorder (42.7%)• Anxiety disorders (26.1%)• Alcohol-related problems (22.9%• Other drug disorders (17.6%).
Source: AHRQ-HCUP Statistical Brief July 2010)
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Behavioral Health Prevalence-Comorbidity
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• 9 Million people in US have both a Mental Health andSubstance Use Disorder
• Only 7% receive treatment for both issues
• Substance Abuse patients: 45% have a comorbid MentalHealth disorder
• Mental Health consumers:
• Overall 18.5 % have active Substance Use Disorder• Young adults 55%• Personality disorder 34%• Behavioral Health inpatient: 28%
Prevalence of Behavioral HealthDisorders – CHPW Members
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Medicaid• 13% Serious Mental Illness• 29% Behavioral Health Condition• 13% Substance Use Disorder
Medicare• 32% Serious Mental Illness• 56% Behavioral Health Condition• 20% Substance Use Disorder
Chronic Conditions and Depression
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Adherence and Antidepressant Medications
Premature Discontinuation Rates:• 29% to 42% stop medication at 4 weeks• 63% to 76% stops medications at 6 months• Study of 147 patients: Only 19% took
antidepressants medication for the recommended6-month period
Source: Hunot, V.M., et al (2007) A Cohort Study of Adherence to Antidepressants in Primary Care: TheInfluence of Antidepressant Concerns and Treatment Preferences. Primary Care Companion J ClinPsychiatry. 9:91-99.
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• 80% of children; 70% of adolescents receive at least ayearly PCP visit
• Only 23% of pediatricians and family physiciansroutinely screen their patients for MH disorders
• When pediatricians rely on clinical judgment, 40-80% of children with developmental or MH problemsare missed
Missed Opportunities for Kids
Consequences of Poor Integration
• People with SMI die, on average, 8-25 yearsearlier than the general population
• 60% of premature deaths: due to cardiovascularand pulmonary disease, obesity, and smoking .
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Benefits of Integrated Care:The Value Proposition
• Promote a holistic approach• Reduce fragmentation• Gain operational efficiencies• Create flexibility in service delivery• Focus on quality, outcomes, with less duplication of services
Blending Cultures in Integration
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PhysicianNurses
BehavioralHealth
ConsultantPatient
Four Quadrant Model of Integration
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SAMHSA Levels of Collaboration/Integration
Coordinated
Level 1: Minimal Collaboration
Level 2: Basic Collaboration at a Distance
Co-Located
Level 3: Basic Collaboration Onsite
Level 4: Close Collaboration Onsite with SomeSystem Integration
Integrated
Level 5: Close Collaboration Approaching anIntegrated Practice
Level 6: Full Collaboration in aTransformed/Merged Integrated Practice
Implementing Integrated Physical andBehavioral Care
– BH professionals become part of total health team– Makes medical possible in BH; BH possible in medical– Sustainable payment for value-added integrated services
(bidirectional--true parity)– Challenge--requires change from status quo
Cartesian Solutions, Inc.™ ©
Medical & Behavioral Practice(90% of BH Patients)
Specialty BH Setting(10% of BH Patients)Model 3 “Integrated”
Collaborative Care Team Structure:CHPW Support of Mental Health Integration Program
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Symptom Response Monitoring - PHQ
Videos• PHQ-9 initial visit• PHQ-9 subsequent visit
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Desired Outcomes of Integration
• Improved care– Increased availability of/access to care– Condition/disease management
• Improved health– Health condition– Quality of Life
• Improved patient satisfaction• Improved cost management and cost savings
– Reduced preventable hospitalizations and ED utilization
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How can a Health Plansupport
Whole Person care?
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We are a local, Washington-based Health Plan with long-established ties to communitiesthroughout the State and well-equipped to facilitate and coordinate with local resourceson behalf of our members.
As a not-for-profit company, we make decisions that are motivated by the best interestsof our members, providers and communities within the State of Washington. We aregoverned by community organizations (Community Health Centers) that are in turngoverned by individuals that receive care within those organizations.
The health of our members is our primary concern. Our programs are designed toproactively identify and address the behavioral, social, and medical needs of our membersand to recognize the whole person’s needs.
The vision of CHPW is to provide services and supports that impact the health and well-being of our members, both directly and through our valued partnerships withcommunity-based providers. We meet this challenge by identifying and addressing needsthat impact the health of our members both within the clinical setting and beyond.
Who Do We Serve?
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APPLE HEALTH269,000 Members
INTEGRATEDMANAGED CARE17,000 Members
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MEDICARE SPECIALNEEDS PLAN
3,250 Members
MEDICARE ADVANTAGE4,250 Members
BEHAVIORAL HEALTH SERVICES5,000 Members
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COMMUNITYliEAlTHPlA·N',l '25''· ofV,1,,h11,g1o · - · ·. 1un
20 Community Health Centerswith more than 130 clinics
More than 2,500Primary Care Providers
More than 14,000Contracted Specialists
Behavioral Health Networkstate wide
More than 100 hospitals
Provide coverage and services inall 39 counties
One of the first MCOs to provideIntegrated Managed Care
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Whole PersonSystem of Care
)SavingsInvestment in OurCommunity
$ Community Reinvestments
HomelessResources
Housing RespiteServices
Ci)Youth Treatment Services
Harm Reduction Center
Clinic Expansion
Bi-Directional Integrated Care
Integrated Regional team focused on care coordination and transitionsfor individuals with complex behavioral health and physical health conditions.
Example of Activities:• Daily monitoring of members with BH diagnoses in the ED to offer members
connections to inpatient diversion resources and/or follow-up care, including medical.• Cross-system care coordination plan development for members that frequent the ED
and are not engaged in services.
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Flexibility
Key Principalsof Integration
Integrated CareCoordination
• No single model• Collaborative Care/Mental Health Integration Program
(MHIP) and Primary Care Behavioral Health (PCBH)• Bree Collaborative Recommendations• Four Quadrant Model• SAMHSA Levels of Integration
• Person-centered, Recovery oriented• Communication/Information Sharing• Team-based approach to care• Population-based• Measurement-based care
• Improved access to medical and behavioral health information• Single care management plan• Single point of coordination
• Bi-weekly operational meetings; clinicalinformation exchange; strategic planning
Collaboration between MCOsand BH-ASO
• Cross system vehicle for systemimprovement planning
Behavioral Health PlanningCouncil
• MCO/BH-ASO collaboration to align clinicalprocesses and standardsClinical Alignment Group
• Including claims payment and denials,grievances, ED visits
Reporting and Monitoring“Early Warning System”
Indicators
Metrics showing statistically significant improvement for adult Medicaid beneficiariesresiding in the FIMC region, relative to the balance of state:• Adults' Access to Preventive/Ambulatory Health Services• Cervical Cancer Screening• Chlamydia Screening in Women• Comprehensive Diabetes Care - Hemoglobin A1c Testing• Antidepressant Medication Management - Continuation Phase Treatment• Follow-up after ED Visit for AOD Dependence-Within 7 Days• Follow-up after ED Visit for AOD Dependence-Within 30 Days• Percent Homeless - Narrow Definition• Percent Homeless - Broad Definition
Source: DSHS Services and Enterprise Support Administration, Research and Data Analysis Division August 7, 2017
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How can VBP supportintegrated, whole
person care?
Value-based Purchasing
• “Can Integrated Care Save American HealthCare?”(Washington Post January 18, 2013)
• Triple Aim• Improve Outcomes• Improve Process• Lower cost
QualityValue =
Cost
Health Care Payment-Learning Action Network:National and State Framework for VBP
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CHPW’s Approach to VBPEngagement of providers in design of models.
• Supplemental Payments to support infrastructureand operational capacity; incentives for reporting
• Pay for Performance: Rewards and Penalties• Alternative Payment Methodologies with upside
gainsharing and downside risk• Introduction of quality gate and ladder utilization
How MCOs work in partnership withproviders in VBP arrangements
• Define plan value and organizational culture• Data provision, analytics and quality improvement
support• Financial Support for targeted investments• Care management and coordination support• Utilization and disease management• Consultation and training based on capacity assessment• Facilitate partnerships across network participants to
ensure collaboration• Partner with other plans to ensure administrative
simplification
Capacity elements needed for VBP
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Can a health plan provide theright kind of payment and theright kind of support andcapacity development to allowfor a provider to deliver adifferent kind of care?
Yes.
Sample VBP Method with PsychiatricHospitals
• Case rate for each admission• LOS less than 48 hours = no payment• Bonus potential related to reduction in
30- day readmission rate• Bonus Potential related to attendance
at 7-day follow up appointment
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Yakima Neighborhood Health Services
Our mission is to provide accessible, affordable, quality health care, provide learning opportunitiesfor students of health professions, end homelessness and improve quality of life in our communities.
Needs and Challenges in Yakima County
4,400 square miles with limited public transportation
Highest % of uninsured in state (23% in 2015)
32% of County’s children live below 100% poverty
64% of employment is farm labor (low wages) – per capita income is 35%less than state average
Low educational levels (Granger) have less than 9th grade completionrates (32%)
Health challenges of county and our patients worse than state and US:
Obesity (“8th fattest city in the US”)
Diabetes (Yakima County in the “worse” category at 175 per thousand)
STD rate is 42% worse than the state
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Yakima County remains the highest Uninsured County –in spite of our high Medicaid enrollment
1975-YNHS founded
1980 – Maternal Child Health Contract1981 – WIC Contract
1992 – YNHS secures Yakima County designation as Medically Underserved Area / YNHS becomes FQHC-Lookalike
1994 – Yakima Federal Savings & Loan funds 11,000 square foot expansion of 8th Street Campus
1996 – Dental Clinic opens at 8th Street Campus
2000 – YNHS earns first Joint Commission accreditation
2001 – National Recognition comes with “Models that Work” nomination
2002 – Yakima campus adds 10,000 square ft with donation of the “Richey House”
2004 – First onsite pharmacy opens
2007 – Major expansion of Sunnyside site – adding dental services
2007 – Transitional and Permanent Supportive Housing
2010 – Medical respite program opens
2005 – Notice of Award – BPHC Health Care for the Homeless
2011 – First CHC in WA State awarded PCMH Level 3 recognition
2013 – ACA Award to expand Sunnyside Site, includes first Vision Center
2015 – Granger Medical site and Mobile unit begins2016 – Granger Dental opens
2016 – “The Space” LGBTQ Youth Resource Center
2012 – YNHS at Southeast Community Center opens
2010-YNHS@Comprehensive Mental Health opens
2013 – “The Depot” Homeless Resource Center opens
2018- Community Services Resource Center opens
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Partnering in our Communities
Henry Beauchamp CommunityCenter
Comprehensive Health Services
Neighborhood Connections @TriumphTreatment Services
The Depot
YNHS – Sunnyside Campus
Granger MedicalGranger Dental Sunnyside WalmartPlaza
SupportiveHousing
Lower Valley Mobile Unit
Broadening Education & Self Sufficiency for TransitionalYouth
(The BESTY Project)
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Yakima’s Partnership for Homeless Youth
• Provides safe & stable housing• Individualized Graduation Plans• Youth Employment Navigators to
oversee and mentor youth• 260 hours of paid work externships• Partners:
• Rod’s House• ESD 105• South Central Workforce
Development• OIC of Washington
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“The Space” for
LGBTQ Youth (ages 13-24)
Health Care & CounselingTutoringHousing HelpArts & CraftsPeer SupportFamily Re-UnificationTrauma Informed Care
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A Resource Center
2017 at “The Space”57 Youth, 1,963 Encounters
Why they came… “Because I came to The Space…”
Self Esteemimproved
80%
Sense ofBelongingimproved
61%
My mentalhealth
improved87%
Betterconnected tohealth care,
50%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
BehavioralHealth
89
CommunityBuilding
655
Life Skills1116
Housing Help173
GroupLearningSessions
110
VocationalHelp106
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Users22,784
Users5,481 Users
2,825 Users686
Visits84,807
Visits19,087
Visits13,441
Visits2,036
-
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
90,000
Universal agricltural homeless SMI-PC Clinic
Users Visits
Primary Care Clinicinside CommunityMental Health
2017 Users and Visits
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79,113
16,649
10,779
82,623
18,128
10,855
84,807
19,087
13,441
- 10,000 20,000 30,000 40,000 50,000 60,000 70,000 80,000 90,000
Universal Visits
Agricultural Visits
Homeless Visits
2017 2016 2015
Continued Growth for all Populations(All Sites within 10 Minutes of Public Housing)
Health Coverage – Twice as Many MedicarePatients at the SMI Clinic than any other Site
Uninsured16%
Uninsured3%
Uninsured13%
Medicaid65%
Medicaid64%
Medicaid75%
Medicare10%
Medicare29%
Medicare12%
Private Insurance9% Private Insurance
4%Private Insurance
0%0%
10%
20%
30%
40%
50%
60%
70%
80%
Universal SMI - PC Clinic Respite
Uninsured Medicaid Medicare Private Insurance
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(UDS Table 5 Staffing)Visits by User (2017)
Universal3.72
SMI - PC Clinic2.97
Sup Housing44.29 Respite
43
Homeless4.76 Agricultural
3.48
0
5
10
15
20
25
30
35
40
45
50
Patient Services Coordinator
2-3 PCPs each have their own MA
One Nurse Per TeamCare Coordinator for each Adult MedPCP (shared for Pediatricians)
BH Specialists – 1 per team
One “floater” MA Per Team
1 Clinical Pharmaciston the floor
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The Heart of Our Patient Centered Medical Home
Roomingpatient,Vitals,Histories
PSCs identifycare gaps,populationhealth, team“hub” forworkflow needs
Standing Orders:HBa1, retinalexams, leadscreens, rapidstreps, etc
PHQ-9s,SBIRTS,MCHATs,ASQs,PRAPARE
Additional Medical Assistant Roles:Patient Services Coordinator (PSC)
Medical Assistant Team LeadOB Coordinator
Medical Respite Care Case ManagerCare Coordinator
Referral Coordinator
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Multi-Disciplines – “All In”
Vitals
Medical History
Medications
Allergies
Help is On the Way… “Trackers”
Patient Navigators
Dietitians
Behavioral HealthSpecialists
“Shooters” (Immunizationstaff)
Housing Specialists
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Multi-Disciplines – One Record
HousingStatus
HealthInsurance
MentalHealth
SubstanceUse
Disability
HIV/AIDS
AcuteConditions
ChronicConditions
HMIS
UDSICD-10
Where do they overlap?
(Slide Courtesy CSH)
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“Electronifying” Arizona Self Sufficiency Assessment
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15 Domains of Self SufficiencyProgress is Different – Families Vs Adults
Families Individuals
400+ Care Coord. patients Material Security
Food and basic needs
Employment Poverty Stress Social integration Education
100 Homeless Patients Homeless / housing Material Security
Food and basic needs
Employment Education Poverty Stress
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PRAPARE Dx added directly to Problem List
Universal62%
SMI - PC Clinic76%
Sup Housing81% Respite
78%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
UDS Table 7 - Controlled Hypertension - by PopulationLast visit BP less than 140 / 90
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Cervical Cancer Screening by Population
Universal50%
SMI - PC Clinic43%
Sup Housing24%
Respite15%
0%
10%
20%
30%
40%
50%
60%
Health Coverage by Population
Uninsured16%
Uninsured29%
Uninsured13%
Medicaid65%
Medicaid64%
Medicaid75%
Medicare10%
Medicare29%
Medicare12%
Private Insurance9%
Private Insurance4% Private Insurance
0%0%
10%
20%
30%
40%
50%
60%
70%
80%
Universal SMI - PC Clinic Respite
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Inter-disciplinaryteams are needed toserve high needsindividuals andfamilies
• Primary Care
• Mental Health
• Chemical Dependency
• Domestic Violence
Universal34%
SMI - PC Clinic100%
Sup Housing36%
Respite54%
Homeless74%
Agricultural11%
0%
20%
40%
60%
80%
100%
120%
Patients with at least one Mental Health Diagnosis
Universal SMI - PC Clinic Sup Housing Respite Homeless Agricultural
UDS Table 6A – Patients with at Least One Mental Health Dx During theYear
(Depression, Anxiety, PDSD, ADHD, etc.)
Flu Vaccines 2017
Universal25%
SMI - PC Clinic39%
Sup Housing39% Respite
37%
Homeless25%
Agricultural24%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
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Average Respite Stay in 2017 = 21.5 Days
• Daily checks by Nurse / Behavioral Health /Case Manager.
• Wound care.
• Behavioral Health counseling.
• Transport / accompany to PCP andspecialty and OT/PT appointments.
• Evaluate and support ADLs.
• Assist with applications for SSI/SSDI, BasicFood and other federal/state benefits.
• Facilitate family interaction when possible.
• Initiate housing stabilization.
• Provide discharge summary to patient /PCPat time of respite exit.
60 patients stayed 1,311 Days- Here’s Why
Length of Stay People Reason for Respite Needed
One Week or Less 17% Pneumonia, cellulitis, MATinduction
1 to 2 weeks 21% Abscess, COPD, mental health,gangrene, cellulitis
2 – 4 weeks 27% Fractures, surgery recovery,cellulitis
4 weeks or longer 21% Gunshot wound, endocarditis,surgical recovery, fractures, MATstabilization
Sicker population than previous years
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How Our Patients Came to Respite in2017
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Hospital30%
PCP57%
Same Day[CATEGORY
NAME][PERCENTAGE]
Other8%
Respite Exits in 2017
34
Housed21%
Transfer to hospital7%
Return to shelter /street72%
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Health Coverage of Patients in Respite
Medicaid75%
Medicare12%
Uninsured13%
Medical Respite Care Saves $$
Hospital Staff Report a Saving of 67 Inpatient Days in2017
($135,269 for Depression or $392,400 for Rehab)
*WSHA Hospital Pricing –www.wahospitalpricing.org
Respitecarereducespubliccostsassociatedwithfrequenthospitalutilization.
AverageHospital
Charge forDepression*
AverageHospital
Charge forRehab*
AverageRespiteProgram
Average Lengthof Stay
13 days 8.1 days 21.5 days
Average ChargePer Patient
$16,133 $29,166 $2,533
Average Charge/ Cost per Day
$1,241 $3,600 $116
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48 People denied Respite in 2017
Respite full-novacancy
26
Too high acuity5 Not capable of ADLs
4
not homeless9
placed in PSH instead4
0
5
10
15
20
25
30
1
Supportive Employment“Depot JobMatch”
Employment coaching andsupervision
At YNHS, a non-profit,willing business
15-25 hours per week “Occasional status”
employee of YNHSwherever placed
Funded by localcontributions
Foundational CommunitySupportsMedicaid Supportive
Employment
Medicaid Supportive Housing
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NEW OPPORTUNITIESTHROUGH
MEDICAID TRANSFORMATIONDEMONSTRATION
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New in 2018Community Service Resource Center
Transitional Housing for 40individuals
Monitored kitchens, restrooms, showers
Public laundry Food service and
distribution Self-sufficiency supports Case management and
linkage to neighborhoodservices – Health care Legal services Treatment services Veterans services Supportive employment
Remember Dude from the Big Lebowski ?
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2017 ProfileSome Patients Need a Little -- Some Need A LOT
All Primary Care Patients 22,784Medical, Dental,Mental Health Visits
84,811
Prescriptions Filled 111,222
Enrolled WIC Clients 8,058
Affordable Care ActApplications
26,021
Homeless Patients 2,825Medical, Dental,Mental Health Visits
13,411
Permanent SupportiveHousing-
106 households154 people
Hotel/Motel Vouchers 406 people250 households
Medical Respite 60 People1,311 nights
Housing & EssentialNeeds (HEN)
327 households