ST LOUIS INTEGRATED HEALTH NETWORK

The community - clinical integration pillar includes two major initiatives: 1) care transitions initiative - the care transitions initiative (formerly known as community referral coordinator (crc) program and p.u.l.s.e. Program) is used to assist patients/community members to understand the levels of care available in the community and when and how to engage. It is a tiered, community intervention program at the patient level through the community referral coordinator program and at the systems level through the transitions of care (toc) task force. The crc program uses community referral coordinators to connect patients in inpatient units and/or emergency departments of hospitalscontinued on schedule owith a primary care provider for follow-up and preventative care. The community referral coordinator program's work to ensure established community health center patients are reconnected to their primary care homes as well as help those identified patients with chronic diseases establish pcp care following a hospitalization. The goals of the program are to (a) enhance access to a primary care home and health resources for all patients regardless of ability to pay, (b) reduce non-emergent use of emergency departments and low acuity readmissions, (c) enhance continuity of care, and (d) strengthen communications/processes among safety net providers. The toc task force is a cross-functional and collaborative group that works to foster effective transitions of care for patients. The toc task force is charged with oversight of the crc program. 2) the justice initiative includes the re-entry community linkages (re-link) program which works to improve the health outcomes for those reentering community from jail or prison by utilizing collaborative community efforts through a health and social services network comprised of physical health, behavioral health, and social support service partners. The goals are to (a) improve coordination and linkages among criminal justice, public health, social service, and private entities to address health care and health care access of community re-entrants, (b) reduce health disparities experienced by the reentry and justice-involved population, (c) increase access to needed public health, behavioral health, health care coverage, and social services, and (d) reduce recidivism. The justice initiative also includes the health and social service network table of partner organizations that work to address system barriers to successful prevention of incarceration and re-entry and the transitions clinic model which is a partnership with health centers in our region to provide a half-day clinic each week to specifically serve those people reentering the community from jail or prison.