Good afternoon, this is Carol Bauer from the Minnesota Department of Health Health Care Homes program and I’d like to welcome you to Risky Business: One Healthcare System’s Model of Risk Stratification. Our speaker today is Jill Swenson from Sanford Health an Integrated Health System headquartered in South Dakota. Jill helped developed Sanford’s Advanced Patient Medical Home and Team-based Care Model and recently created a Robust Risk Stratification model which you will hear about today. Jill has a Bachelor’s degree in Nursing from the University of Jamestown and is a Certified Case Manager through the Commission for Case Managers Certification. She has over 20 years of nursing experience in care management and case management. Before we turn the presentation over to Jill I’d like to invite your questions through the chat function throughout the webinar. We’ll address as many as we can during the last ten minutes. And the webinar ends at 12:45. Jill we’re going to turn it over to you at this time. Welcome we’re glad you’re with us. Jill: Great thanks Carol. Can you guys hear me okay? Carol: Good. Jill: Okay sounds good. So perfect I have control here. So thank you so much for inviting me to join you and talk about risk stratification today. I’m really excited about this topic. I’ve done a lot of work at Sanford and for any of you on that, we’re at the learning collaborative at Learning Days in believe it was in April of this past year. We were there from Sanford Health and so I did a very similar presentation there in collaboration with a clinic system from Alexandria, Minnesota too. So I’m hoping I can just elaborate a little bit more on what our process has been and kind of what our journey is with stratifying our patients. And so these are the learning objectives. I’m hoping you can walk away with identifying key components on how to stratify your patient population and provide some examples of how your healthcare organization can implement care management strategies to support your high-risk and complex patient population. So this is a little bit about Sanford Health like Carol said we are a large integrated health system. We’re headquartered in South Dakota. We are currently one of the largest rural non-for-profit health systems in the United States we have 44 medical centers 482 clinics. We recently merged with Good Samaritan Center so we now have 242 senior living facilities and we’re growing all the time. We also have some world clinics. So we are in nine states and nine different countries. So we have some world health clinics in Costa Rica, Ireland, Germany, Ghana, South Africa, China, Vietnam, and New Zealand. So that’s really exciting work that we have been doing here at Sanford. So today we’re going to talk about risk stratification. There’s a lot of different models out there for risk stratification. There’s a lot of information. So hopefully this kind of just perks your interest a little bit today and gives you kind of a starting point as to where you can go with your clinic or practice. Really the goal of risk stratification is to identify patients that will benefit from care management. As a system at Sanford we’ve had a lot of discussions about: is this a predictive tool? So are we predicting something and if we are what is it? So a lot of our clinicians, will come back to us from the care management site and say well you know “What’s the predictive model here, like what are we predicting, are we predicting ED visits, are we predicting risk for admission?” And we’re not. So the goal of risk stratify your patient population, that we have in place, is really just to identify those patients that can benefit from care management. Still, how can we link them into services? How can we improve their health outcomes? How can we look at their utilization? Generally overall, how can we just improve them? And so like I said why risk stratify? It’s giving you that population health approach – so what are those actionable view into the needs of your patient population. So it may be that you know we need to tier patients into different services. So it may be they need a social worker. They need behavioral health therapy. They need an RN care manager. They need dieticians. You know, it’s your whole care team that we’re looking at. What are those actionable needs and how do we target our resources more effectively? Here at Sanford, when we really started down this journey it was back in about 2010 and we have our nurses at that time were called Health Coaches and we’ve recently retitled them into RN Care Managers within our system. So we have about 120 RNs in our primary care clinics that do care management and we have a newer role. So we have six different nurses that are integrated throughout our health system that are Community Care Managers. So they’re really kind of that bridge between our patients that maybe are seeing a lot in our hospital system or our EDs but they don’t necessarily impanel themselves in primary care. And so we have them called Community Care Managers where they’re kind of at that bridge between those services so we can link them back into primary care. So we’ll just give you a little background on some of our journey into this risk stratification model and really kind of our alignment with all of our other accrediting bodies, so probably very similar to many of you on the call. We are Joint Commission certified within our health system. We have, I’m going to say this wrong, I believe we have 42 clinics that are Health Care Homes certified clinics, that are border clinics. So we have a lot of sites that are right on the Minnesota, North Dakota and South Dakota border that we certify through MDH. We have a plethora of clinics that are South Dakota Medicaid Home, Medicaid Health Home clinics in our South Dakota region. We have been part of the Compass Practice Transformation Network. So that grant just ended at the end of September or it’s just ending here. And then our most recent journey is with Comprehensive Primary Care Plus and we became a 2018 starter in this Medicare program CPC Plus. I’m really looking at value-based care and care management strategies and care delivery requirements. So we found that Comprehensive Primary Care Plus program in our Health Care Homes program, the standards aligned very close together. So, we were we were thankful for having many of our clinics already health care home certified in the past because it was really much easier to bring in that Comprehensive Primary Plus model into the clinic locations and get those clinics up and running. Carol: Jill this is Carol. We are hearing some background noise. Is that traffic or what are we hearing? Jill: It’s traffic. It’s a motorcycle outside my office window, yes. Carol: Alright, so we’ll put up. I just wanted to acknowledge it, thank you. Jill: Yeah, I apologize and if there’s an ambulance that goes by, it gets really loud too. It won’t be too bad. So we really kind of you know, we found that we risk stratified patients in many different ways. So throughout this journey, we found that there’s lots of different ways to identify your patients to say how do we risk stratify them for what services and care management strategies they need? So we really use data to look at what that could be. So we have many, many registries built within our EMR. We have the Healthy Planet Platform with an Epic. So we have many registries that are built. We’ve worked with many of our payer and ACO contracts to look at different care management and risk needs with our patients. Through CMS, we look at the utilization data so we look at the identified high utilizers. We can look at them. We can break it down by even diagnosis code to see at a clinic you know which diagnosis is really kind of driving that utilization within our clinic locations. And then we also have what are called daily huddle sheets, so it’s really those talking points we pull from our EMR to really engage and create that daily huddle structure within our clinics. Like I said, this is our data sources. So when we really started down this population health care management strategies within our clinics. We really started by looking at registries, so doing that proactive outreach to our patients. So we have many registries built on preventive screenings, so colorectal cancer, mammogram, cervical cancer screening is one of our newest ones, and then adding on those chronic diseases. We have hundreds of registries built out there. So we have many different ways that we can pull these patients. And then like I said, before our huddle sheets, they really will pull out, so they will dig into our EMR prior to our patients coming to the clinic and pull some of this this health maintenance data out for us. So it’s going to look at you know, what was the last time our patient was weighed and what’s their BMI. What’s their blood pressure like, what’s it been trending like over the last couple visits that they have been in? For pre-diabetes, again it’s pulling in that BMI maybe looking at their lab values over time, so we can kind of watch that pre-diabetes or diabetes suspect patients when they come in – same with asthma and same with anxiety. So that’s been a little bit proactive for us as we get prepared to see that patient in our clinic. So our risk stratification process at Sanford it was built by us as a system. It’s one of the care delivery requirements that we needed to have an infrastructure in place for our CPC Plus our CMS care model. And we had to have that up and running by, we had really, kind of, the first year of the program to get it up and going. So we started reporting out on that as of quarter four of 2018, so the end of last year. So our risk stratification is really an algorithm based criteria and that is the majority of it. We also have the opportunity to use clinical intuitions to adjust that score and I’ll talk through that as we get into this a little bit more. So for our defined algorithm, we really looked at defined criteria. So you can look at doing this in many different ways within your clinic system. So you can look at models out there and really kind of define what your criteria is. From there you will you’ll begin to start to categorize your patients into different risk levels. I’ve seen models where they’ve used diagnoses and clusters. We’ve seen some where they actually have claims based data that they’re able to pull into the algorithm. We pulled everything from structured fields within our EMR and it being automated is really a key. We’ve seen some models that we’ve gone through the the CPC plus education and worked with different systems out there and there are some systems that are actually using a paper copy of a risk stratification methodology. But we have all that algorithm built within our EMR and I’ll kind of get into what that looks like coming up here. The second portion of how we created a risk stratification model within our clinic was pulling in clinical intuition. So we know that our EMR can’t hold everything surrounding what the patient needs are. So we have a field within our physician visit notes and our care management visit notes where those care team members can actually modify the patient’s risk score. And we do that based on what are their social needs, so looking at the social determinants of health screening for that patient, looking at utilization that may be outside of our system. So we have many clinics that are small rural clinics and they’re not always tied directly into a Sanford emergency room or hospital. So we know that sometimes we can’t automate that capture of that utilization. What’s that patient’s health literacy, how activated are they? That kind of ties into a big component of their actual engagement. What’s their caregiver support, so do they live alone, are they in a care facility, what’s that caregiver support like, and then what are the behavioral and medical needs of that patients that are outside of our algorithm? So those are different things that our our teams can use to adjust that score. So the next couple of slides will kind of get into what our actual criteria is and what that looks like. So we kind of broke it up, down into some different buckets. So the first thing that we look at within our criteria is is utilization. So for capturing the patient’s hospital encounters within the past year their ED encounters in the past years and then those no-show office visits. So behind the scenes, our EMR is pulling all of that out and then calculating that score based on how many of these encounters they have had within the past year. We pull in different lab values. So we’re looking at that hemoglobin A1C, so where is that setting at, what’s the patient’s blood pressure, what’s that cardiovascular risk score? Some of our screening tools that we use, so we do the GAD and the PHQ-9. So where we’re sending up questionnaires for patients to look at. What is their anxiety level, what’s their depression questionnaire look like? So we’re calculating those scores in and then also their asthma control tests or their ACT score. And then different diagnoses so these are the chronic disease diagnoses that are built into the current state of our algorithm. So if the patient has COPD diabetes, CHF, any of these chronic diseases we’ll pull into the patient’s score. Other criteria we pull in on, what’s the patient’s age, what’s their smoking status? So we’re looking at tobacco and also non tobacco. So you know we’re looking at smoking cigarettes, we’re looking at vaping, all those different things are pulling into that smoking status. And then the patient’s BMI. So we’re looking at that overall for the patient. Our look-back period is one year, so we’re looking back and pulling all these criteria together, for the past year for this patient. So in the end, when we calculate everything out we’ll break it down into this pyramid that I have shown here. So we consider our high-risk population to be that top 5% of patients. The medium risk criteria are the medium risks here. They fall into would be the next 20% and then our low risk are 75% of our patient population. And what we did was once we built this criteria into our electronic medical records, we had our enterprise data analytics team, so they went and took all of the scores of all of our patients within our primary care clinics and then looked at what was the score of that top 5% that medium 20% of patients and that low risk. So that’s how we were kind of able to break it down by scores for our patients. So this is a screenshot kind of showing you what it looks like. So like I said we have EPIC, that’s our EMR platform and it’s a Healthy Planet Built report within our EMR. So we can run this panel based on the physicians panel of patients. So I can put in Dr. Jones and I can pull out all of the patients that are attributed or impaneled to Dr. Jones and then each patient will have their score show up on this registry. So then you can sort it by high risk, medium risk, low risk patients. You can sort it highest to lowest kind of however you want that to be. So as you hover over the red bubble of the 17 then this screenshot will show. So it will tell you how that patients scored out. So this patient, you can see they have a point based on the patient’s age, they have three points for hospital admissions, in the last year, three for ED visits, two points for no-show. You can see how that goes and then it will calculate up there their complete score. One of the biggest eye openers for us is we knew patients have high utilization, but once we really started to look at this, if you see this patient here had 31 ED visits in the past year. So we found that we needed to do a little bit tweaking to our scores because we were we were maxing out our utilization score at 3 points based on how many visits these patients had. So from there, that really takes us into kind of what’s that care management structure and models that we have. And we we’ve used our risk score or risk stratification score to really start to drive what does that care management model begin to look like for us at Sanford Health. So our overall goal with our patients is always that they can self manage. So we know we aren’t going to cure them of chronic diseases. But we’re going to hopefully get them to be able to have self management within those disease processes, working on looking at utilization with those patients and how can we begin to help them start to manage their own healthcare. We kind of break our pair management structure into into different buckets of care. So number one is looking at risk stratification. So we can take that risk stratification score and we can pull it into the provider schedules. So when they’re going through and looking at their patients that are coming in for the day, they can see right there what that risk stratification score is for their patients. So they know if they have high risk, medium risk or low risk patients coming in. For longitudinal care management, that’s really our kind of long-term relationship based care management with our patients. So we’re creating that individual plan of care with that patient. We may be helping to refer them to different resources, making sure that they’re linked up with the social worker or the behavioral health therapists within the clinic or the different resources sources that they may need. So dieticians, diabetic educators whatever those ancillary services may be. We also have a group of patients we pull into what we call episodic care management. So, we do post-hospital discharge outreach to all of our patients. Our goal is that we get a phone call to them within two days of discharge and that wraparound service is that they come into the clinic based on diagnosis within three to seven days post hospital discharge. We’ve recently started to followup with our patients that have been in the emergency department. So our patients will get a phone call a letter or a message via their portal, their patient portal, within a week of a ED visit. And then our follow-up phone calls really for ED, we’re trying right now to just call our high-risk patients. Otherwise it gets to be quite a list of people that we have each day. So right now that ED follow-up phone calls are really for those high-risk patients or patients that our care managers have recently worked with. And then looking at those transitions in care, so if the patient is moving to a different level of care and what that may look like. So our care management program like I said we’re really looking at supporting patient self-management, activation, looking for that awareness of community resources and social support. Our screening for patients for social determinants of health or social care needs is something that we’ve really started to work on within the past year. So making sure that we’re asking those patients those questions and we recently are having an upgrade to our EMR system and so we’ll be able to actually deploy that out to patients via their their patient portal also. Looking at coordination or care transitions and follow up with that, really wrapping that care team together so understanding that it’s not up to just a physician or their care manager as a nurse to coordinate everything with the patients but kind of wrapping that care team together. And then like I said receive and review timely information on our hospital, our emergency department admissions and discharges so that we’re following up with those patients. We have all of our care managers trained in motivational interviewing. We do a lot with agenda setting and goal setting too with our patients as we’re getting ready and prepped for their visits. This kind of shows the different care team members that we have in our clinics and this will vary. So like I said we have some larger Metro clinics within the bigger cities where our health system is but we have some some clinic locations that are very small and they may only be open three days a week for half day at some of our very rural locations. So the care team members will vary, based on kind of the location. So at the the center is always the patient so like I said, we have RN Care Managers in our clinics, so all of our care managers are registered nurses. We have Panel Assistants, so that’s those Panel Managers they’re running the registries or making outreach to our patients, the Providers, the Social Workers, so we have recently within the past year and a half started integrating Social Workers within our clinics. So they sit right in the same office as a Care Manager and the Integrated Health Therapist. So, they’re a close-knit team that works together. We are currently getting more and more Pharmacists within our clinics. They are such an invaluable piece of the care team. I’ve just been amazed at some of the work that our Pharmacists do. In our internal medicine clinics, in one of our metro areas, they’re actually doing our post-hospital discharge and med rec calls to patients. So they have just been a really wonderful piece of that team. We’ve had our Pharmacists take phone calls from patients that they call in with medication questions. If they call in to our triage line, we’ve had them reach out and talk with the patient. We’ve had some avoidable ED visits just based on that Pharmacists outreach with our patients. We have Integrated Health Therapists, so these are licensed independent social workers and they do our behavioral health triage therapy within our clinics. We have a Community Paramedic in our in our clinics within the Fargo area. We are currently getting more and more of those and so we have found they are doing a lot of home visits to patients. They’re coordinating closely with our Community Care Manager going out and seeing patients. So I think I explained the Community Care Manager earlier. So they are really integrating into that community and seeing patients and helping them engage and become active with a primary care provider or clinic. We have a Health Guide it’s a very similar role to a Community Health Worker. Our Health Guide is a non licensed individual and they are going out and working with patients linking them to community services, linking them to resources. They will go out and help teach patients how to ride the Metro bus system. If they say I don’t have access to get to the clinic you know I’m unable to get to my appointment, they will help them learn how to ride the bus. So they’re just a wonderful team member. And then we have a Community Health Worker in one of our our regions. So we’re really interested in getting more Community Health Workers within the system also. So our care management, we really kind of group them into these low, medium and high risk panel locations. So our low-risk patients, that kind of really are our Panel Assistant, our Care Team Associates, they will work with those patients. They will do the chronic disease registries through the outreach to the patients, kind of round them up, make sure they’re getting back into the clinic. They’re working our wellness registries. So looking at those proactive outreaches for patients for mammograms, colorectal cancer screenings. We’d really define workflows for these individuals. So we even have scripted phone calls for them. So they will call patients and do a follow-up on depression screening with them or be able to schedule them in for whatever their services are that that patient may need. Our medium-risk panel of patients, based on our risk stratification score, really have our frontline nursing staff really kind of own that group of patients. So they are being real proactive and looking at preventative health care needs for the patients. They’re providing patient education making sure that their goals are flowing through to their after-visit summary. These individuals really run our daily huddle. They know the providers schedule they know where they can fit patients in. They’re working closely with the providers all day. So they were kind of running that schedule and running that panel of patients for the day. Over to the right, you can see there’s some, it’s called a BMI Gap Card or Diabetes Gap Cards. So these are used a lot by our frontline staff, if patients come in with one of these chronic diseases or they have a real high BMI, the nurses can use these gap cards to really identify some of the outreach and some of the interventions that our care team needs for these patients. So they will start working on the Gap Card with the patient and then also leave it for the provider if there’s anything that provider needs to address with the patient during that visit. And then our high risk panel of patients, so like I said, that’s really our care team members, our RN Care Managers working together to make sure that this patient is receiving the appropriate level of care and care management services that they need. This is just a little screenshot of what our daily Team Huddle report looks like. So like I said, it will pull in some of the demographics of the patient, it will pull in their last weight, their last height. If they have a specific blood pressure goal, it will pull in some of those proactive or those health maintenance screenings that the patient has. So have the have their colonoscopy or are they overdo? It will pull in mammogram for patients, if they need a lung screen done. And then the chronic diseases, it will pull in for the patient. There we go. One of the really cool things that since we’ve implemented risk stratification our clinic care teams have started doing a separate huddle for really a high risk assessment team. So they are pulling together on a weekly basis, to really kind of talk about, who are the high risk patients in their clinic and what can they do for them. So the care team members that they are bringing in for this high risk assessment team that meets each week is a Community Care Manager the clinic Social Worker, if we have a Social Worker within that clinic or if it’s a shared Social Worker, they will be present at that team meeting, the Care Manager from within the clinic, our Integrated Health Therapist, they work with our behavioral health patients and sometimes our Health Guides will will be part of this group. And like I said they meet weekly. They review the high-risk patients and they kind of go over really who’s going to take point on this patient. So what are the needs of the patient, who’s going to take point. So each team member will review. So they’ll pick two to three different patients each week to review. And the team members know of the patient’s prior so that they can review the patient. The high-risk patient is really presented kind of almost like a case study so they’ll talk through the patient’s demographics, what is their risk score, who is their primary care physician and what are some of the upcoming appointments they have within primary care and then within our specialty care clinics also and then what type of utilization is that patients using. So are they in the ED a lot or are they in the clinic a lot, are they not coming to the clinic, what does that look like? And then also coordinating with the community teams for these patients. They come up with kind of this high-risk action plan. So what are the top things we want to work on with this patient, what’s our target date, who’s taking points, so who is that responsible person? So it might be the social worker because there’s some unmet social needs of that patient that we need to really address before we can move into some of the other needs with them. Each month this high-risk team will go back and review the previous patients so they can complete that action plan and they can have a complete date in there and then some of the outcomes of these patients. They’ll talk about their current health status figure out what ongoing needs these patients have. They continue to really evaluate and kind of figure out the effectiveness of how their care coordination is going within the clinic and are we improving the health outcomes of the patient. So like I said, it’s kind of a new process that we’re really starting to on-board in our different clinics, but we’re seeing some really good results from this. So some of the future enhancements that we have, so that really kind of talks about you know what is our care management structure, how do we identify our patients? So we’re taking that risk stratification score and then really implementing it into the care management structure and strategies within our clinic. We’ve had our risk score live for a year. I think it was a year this week actually was our goal live date with it, so it was it was September of 2018. And so we have been meeting as a team to really look at refining what that is because when we first launched it we had a lot of feedback for different things to kind of add and to finesse that criteria a little bit. So we are going to increase our look-back period especially for chronic diseases and some of those lab values to two years. Our utilization – so hospital and ED admissions, we’re going to keep it that one year mark. We know that we’re probably not scoring some of our patients high enough on utilization right now, like that example I showed, where the patient had 31 ED visits and they were maxing out that point set three. So we’re kind of finessing some of that, we’re looking at Poly Pharmacy – so how many patients have a high number of prescription medications. For some of the chronic conditions, we’ve had some asks to look at certain things like chronic kidney disease. You know, could we base points based on that the stage of disease that those patients are at? Pediatric criteria – we have a whole separate team that’s really looking at a separate risk stratification and risk scoring system for our pediatric patients within our family medicine clinics right now. Our current risk score really just it doesn’t pull in a lot of the pediatric measures that we need. We are seeing some successes with some of our you know 16 to 18 year old patients that are pulling in based on chronic diseases diagnoses for them. And then that social determinants of health – we’ve had a lot of asks if we can build that into the score and and what could that look like. So we’ve done some work with that. So we are able at this point to screen our patients for social determinants of health based on the EPIC build of those social history questions. And so we looked at being able to pull that total score in to the risk stratification score that we have. The more we’ve kind of dug into that, the more I think we’re probably going to keep them separate. And then just really continue to use that social care aspects for really that ability to adjust that risk score on our own. So this is kind of some of the references that we used on some of the different articles and different models that we use to to build our system off of. And so, I think from here we’re open to questions. Carol: All right Jill, well that was great. Dorothy, do we have any questions that have come in over the chat function? Dorothy: Yes, we have one I can read it to you, it’s: Do you utilize the chronic care management code to bill for your services? Jill: We do not. We’ve had a lot of discussion recently around that and we currently have one of our clinic locations, that is going to start piloting using the chronic care management code and so we’re doing some EPIC build to be able to track that so to be able to track those twenty minutes and all those different criteria that we need for them. So we don’t, but I’m hoping a year from now I can say that we do. Carol: We’ll check back. Hey, I’ve got a couple of questions and others we still have about five to eight minutes left on this webinar so please if you do have a question feel free to submit it. In the meantime, I’d like to go back to this the whole data thing. So it’s amazing how much data you’re able to pull out of your system now. Who’s looking at that data? Because it’s one thing to have data and it’s another to analyze and work with it. Can you talk about that a little bit? Jill: Yes, absolutely. So within our clinics, we have Quality Improvement Advisors that are really assigned to our different clinic systems. So we have we have Quality Improvement Advisors for primary care, for specialty care systems in our clinic locations. And so they are really our data gurus. So they will look at you know what are our scores for our overall depression screening or our colorectal cancer screening. And then they are assigned to different clinics and so they work with those clinical teams. So they will give them back the data at the end of every month or every quarter. And then work with teams within our clinic on if there would be anything special like if the clinic was starting to struggle with their outreach for colorectal cancer screening then that quality improvement team will will work with that clinic on that. We have visibility boards in our clinics. So we’re really transparent with our data. Some clinics actually have their data posted in their clinic lobbies. Some of them have them in their hallways so patients can see it as they go by, back and forth to exam rooms and then some of our clients have it more like in a break room. So it really kind of varies based on what the location is comfortable with. That answer your question? Carol: Yes it does. So and I noticed that one of the one of the comments that you made is that it’s really important to automate and I get that – to automate your data collection and analysis. For the smaller clinics though, I mean you have a lot of smaller clinics in your in your orbits as well. How are they, they’re still in your system and can you give any advice to smaller independent clinics who may not be part of a big system and have access to the kind of data collection tools that you do? Jill: Yeah and so we really drive our data collections from our EMR. So I think for systems that are on an electronic EMR it’s really finding the way to do that. And we’ve been on Epic believe it was 2011 is when Sanford went live and even at the beginning of that we didn’t we didn’t pull data real, not necessary accurately, but maybe we didn’t use the system as much as we could have. So you know we had many different ways that we were pulling and extracting and creating spreadsheets and you know so we’ve kind of come a long way with our system over time. But I think using your electronic EMR to the best that you can, is really important to do. Carol: Yeah for sure. Dorothy anything come in? Dorothy: Yes, we have two more questions. The first question is: What criteria is looked at for the pediatric risk stratification? Jill: So right now the PD that the children in our clinics we are we’re pulling a risk score on patients on anyone that’s attributed to. So if it’s a family practice location and there’s an eight-year-old, they’re probably going to get a risk score of zero based on our criteria right now. So we don’t have a separate pediatrics score built at this time. But we do have a pediatric intensivists doctor that is in the process of starting to create one. And you know a pediatric criteria could look like separate from the adult criteria. So we do have – I’ve seen a sixteen-year-old come out pretty high risk. It was an individual that had a higher BMI. They had diabetes. I think there was some depression, and there was quite a bit of utilization. So a lot of ED utilization for this patient and I think an admission or two. So they actually kicked out as high-risk, in one of our clinics. But nothing going .. Dorothy: Go ahead, I’m sorry. Jill: I just was saying we don’t really have anything specific to just our pediatric population built yet. Carol: Once again we’ll check back in a year. Dorothy we had one more question? Dorothy: Yes kind of a two-parter it says: What is the role of CHW in your system and do SW provide functions of care management? Jill: So CHW, we have one Community Health Worker and they are in one of our northern Minnesota regions where we have several clinics. And so that Community Health Worker really kind of works similar to the role I described, is kind of a Community Care Manager. So they work a lot with, we have patients that in that region, that a lot of them are on an Indian Reservation and so our Community Health Worker can kind of help integrate those services back and forth to these patients. They work a lot with community resources for patients and they will accompany them to clinic appointments at times. So that’s really what that role is doing. And I think the second part of that was asking about the social workers. So we currently have some grants and so we are getting more and more social workers. And they, for the most part, we try and co-locate them, if we can within our clinics. And so they actually sit in office right within our clinic team. So they’re with our Health Therapists, Integrative Health Therapists, our Care Managers, our Nurses and then the Social Worker is in there. And so they meet with a lot of patients if they have housing issues, if they need services that they need to help coordinate with whatever those social care issues may be. They really incorporate it as part of that healthcare team. Carol: All right, well we are out of time and so I’d like to start by thanking Jill. And as we close things up I’ve got just a couple of announcements for you. Within the next month, look for a new e-learning course on risk stratification, where you’ll be able to go back and reference a lot of the information that you heard today and additional resources to get started with your own risk stratification. If you haven’t already done so, check out the Foundations of Care Coordination course, which was introduced over the summer. And whether you’re just getting started with care coordination or introducing new members to the care coordination concept this is a great starting place. If you haven’t visited the Health Care Homes Learning Center lately the MDH Learning Center lately, you’ll notice a new look and feel and some new features and some changes that will improve your functionality and navigation on on the site. Slides from this webinar and past webinars are posted on the Health Care Homes website where you can also get recordings of the webinars on the MDH YouTube channel. To find those, go to the home page of the Health Care Homes website top right corner. You’ll see the YouTube link there. Receive a certificate of attendance for participating in today’s webinar, complete the evaluation that will be emailed to you following this webinar. Thanks once again Jill for being with us today and thanks to all of you for being a part of our Health Care Homes learning community. We learn best when we learn from each other. So if you have ideas or information to share, please be sure to reach out to us. We do love hearing from you. Thank you, have a great day!