St Louis Integrated Health Network

QUALITY AFFORDABLE ACCESSIBLE HEALTHCARE, ESPECIALLY FOR MEDICALLY UNDERSERVED.

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 HOSPITALS WITH A PRIMARY CARE PROVIDER FOR FOLLOW-UP AND PREVENTATIVE CARE. CRCS 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 (1) ENHANCE ACCESS TO A PRIMARY CARE HOME AND HEALTH RESOURCES FOR ALL PATIENTS REGARDLESS OF ABILITY TO PAY, (2) REDUCE NON-EMERGENT USE OF EMERGENCY DEPARTMENTS AND LOW ACUITY READMISSIONS, (3) ENHANCE CONTINUITY OF CARE, AND (4) 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.

RE-ENTRY COMMUNITY LINKAGES (RE-LINK) PROGRAM - THE PURPOSE OF THIS INITIATIVE IS TO IMPROVE THE HEALTH OUTCOMES FOR MINORITY REENTRANTS IN TRANSITION FROM JAIL TO THEIR COMMUNITIES 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 (1) 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, (2) REDUCE HEALTH DISPARITIES EXPERIENCED BY THE REENTRY AND JUSTICE-INVOLVED POPULATION, (3) INCREASE ACCESS TO NEEDED PUBLIC HEALTH, BEHAVIORAL HEALTH, HEALTH CARE COVERAGE, AND SOCIAL SERVICES, AND (4) REDUCE RECIDIVISM.

COVID-19 - THIS PROGRAM IS FOCUSED ON THE PUBLIC HEALTH EMERGENCY RESPONSE WITH RESPECT TO COVID-19, INCLUDING (1) SERVING AS THE CONVENOR AND FISCAL INTERMEDIARY FOR FQHCS CONDUCTING NO COST COVID-19 TESTING AND FLU SHOT EVENTS FOR INDIVIDUALS IN ST. LOUIS CITY, (2) ADDRESSING MISINFORMATION RELATED TO COVID-19 VIA A COMMUNICATIONS FRAMEWORK FOCUSED ON EDUCATION AND TRUST-BUILDING FOR COMMUNITIES MOST IMPACTED BY COVID-19, (3) PROVIDING A LOANED EXECUTIVE TO THE ST. LOUIS REGIONAL RESPONSE TEAM TO ADVANCE SOLUTIONS THAT RESPOND TO THE IMMEDIATE NEEDS OF THE UNHOUSED POPULATION IN THE CONTEXT OF COVID-19, (4) PROVIDING PANDEMIC CRISIS RESPONSE FOR HOMEBOUND PATIENTS WITH SOCIAL NEEDS INCLUDING FOOD INSECURITY, HYGIENE SUPPLIES, MEDICATION DELIVERY, AND TECHNOLOGY TO ENABLE VIRTUAL APPOINTMENTS FOR HEALTH AND BEHAVIORAL HEALTH, AND (5) SUPPORTING THE COMMUNITY LEADERS PROGRAM AS PART OF THE PREPARESTL CAMPAIGN.

ACCELERATE HEALTH EQUITY - THE PURPOSE OF THESE INITIATIVES ARE TO EMPHASIZE ACTION FOR UNDERSERVED PRIORITY POPULATIONS TO CLOSE DISPARITY GAPS BY RACE. THE GOALS INCLUDE: (1) THE CONTINUATION OF ELEVATE WOMEN (FORMERLY KNOWN AS ENHANCED CENTERING PREGNANCY) AS AN EQUITABLE 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) ALIGNING WITH FORWARD THROUGH FERGUSON BY WEAVING THEIR #2039 VISIONING INTO IHN'S VISION AND PRIORITY AREAS AND (4) ADVOCACY FOR COVERAGE OF MISSOURI, A STATEWIDE COLLABORATIVE FOCUSING ON ADVANCING THE MISSOURI BALLOT INITIATIVE TO EXPAND MEDICAID COVERAGE IN MISSOURI.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) IHN WORKFORCE DEVELOPMENT WORK GROUP WHICH IS FOCUSED ON SYSTEMS APPROACHES TO RECRUIT AND RETAIN SAFETY NET WORKFORCE.REGIONAL COLLECTIVE IMPACT - THE GOAL OF THESE INITIATIVES IS TO PARTICIPATE IN REGIONAL COLLECTIVE IMPACT EFFORTS TO ENSURE STRATEGY ALIGNMENT WITH THE HEALTH SYSTEMS THROUGH THE FOLLOWING EFFORTS: (1) PARTNERING TO ADVANCE HEALTH EQUITY TO ALIGN HEALTH AND SOCIAL INFRASTRUCTURE TO SYSTEMICALLY ADDRESS SOCIAL DETERMINANTS OF HEALTH THROUGH THE ST. LOUIS COMMUNITY INFORMATION EXCHANGE (CIE), (2) SUPPORTING REGIONAL AND STATEWIDE STRATEGY TO PROMOTE COMPLETING CENSUS 2020, (3) 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, (4) WORKING WITH PARTNERS TO ENSURE CONTINUED BEHAVIORAL HEALTH INTEGRATION INTO SAFETY-NET CARE DELIVERY, (5) EXPLORING KIDS' NEEDS IN THE CONTEXT OF FAMILY AND COMMUNITY FOCUS, (6) SUPPORTING THE REGIONAL ST. LOUIS PARTNERSHIP FOR HEALTH COMMUNITY EFFORTS AND (7) IHN'S LEADERSHIP SUPPORTING REGIONAL CRISIS RESPONSE FOR COVID-19.