In an effort to challenge the current care delivery system and processes the Community Care Network was piloted in 2013 to address issues of readmissions and frequent emergency room visits. A further goal was to identify ways to actively engage patients in greater management of their chronic conditions. It was clear that something was not working outside the walls of the hospital and that we did not understand the reality patients’ were navigating, or attempting to navigate. A unique aspect to the CCN is in the use of community health coaches (local college students), which has added a new dimension to the health care team and patient support. As the CCN began many lessons were learned and remarkable outcomes achieved. Three years later the value of the approach used in the CCN continues to emerge and expand connecting to population health strategies.

This organization has engaged in population health strategies through both a state initiative and a CMS initiative in 2015 and 2016 respectively. As a result, two key community populations are under a shared savings model (Medicaid/Medicare). The CCN is a core sub-strategy linked to the shared savings program focused on engaging patients, utilizing data, and re-designing the care delivery process to achieve mutual goals of better health and better health care in the community.