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.

Community driven innovation:the purpose of this pillar is to focus on eliminating health disparities that exist in our community on a number of issues and to raise community voice into research and clinical care. The initiative includes: (1) the continuation of elevate women (formerly known as enhanced centering pregnancy) as a model of prenatal care that broadens the culture of medical practice by integrating perspectives from communities with healthcare institutions and aims to demonstrate a pathway to value-based healthcare, (2) community sickle cell initiative collaboration with partners to directly impact policy and care delivery for individuals living with sickle cell disease, (3) reducing chroniccontinued on schedule odisease hrough increasing access to healthy food, addressing childhood obesity, and increasing access to opportunities to be physically active, (4) engaging low-income populations in education and access to st. Louis's long-covid clinic as well as the undiagnosed disease network, and (5) working in partnership to inform osteoarthritis research through community focus groups, the development of a roadmap to make sure everyone has access to potential treatments, and working with payors to evaluate coverage for new treatments, (6) engage health care partners to reduce maternal mortality and increase support in the postpartum period, (7) fostering opportunities for partnership between community health centers and academic institutions to encourage an evidence-based, regional approach to local health care delivery via ihn's network community academic partnerships.

Workforce:the purpose of these initiatives is to promote workforce stabilization and development in the healthcare safety net through (1) pipeline to compassionate care which works with medical students to support their training and develop their intention to enter primary care, community medicine or care for the underserved, (2) community health worker workforce partnership which is focused on training and developing chws, proving the value of the chw model through a regional metrics strategy, and creating inroads for chw reimbursement through medicaid to sustain the workforce in a more permanent way and (3) a number of workforce projects that are focused on assisting the health centers in collaborating on workforce solutions, collecting/analyzing workforce data, working with local high school and institutions of higher learning to build a health academy to prepare students for future jobs in healthcare, data collection and analysis to build strategies for health center workforce recruitment and retention.