Moderator: Andy Lowe, Director of Program Management Resources, Outer Cape Health Services Presenters: Marta “Dikke” Hansen, MSW, Director of Behavioral Health Andrew Jorgensen, MD, Associate Medical Director Session Description The Outer Cape Cod, Massachusetts region is famed for its beauty as a summer vacation destination. For many residents and migrant workers serving the tourism industry; however, the intersection of isolation, little affordable housing, and limited transportation options can exacerbate problems due to mental health, substance abuse, and co-occurring conditions. Police, emergency responders, and EDs encounter this at-risk population disproportionately. Outer Cape Health Services, the local FQHC, proposed a novel solution: a Community Resource Navigator (CRN) program. The CRN Navigator works with community partners to identify at-risk individuals, engage them right in the community, and guide them to appropriate services/treatment. A modified Self-Sufficiency Matrix based on evidence from other Navigator programs is used as a tool to prioritize needs. The Navigator then helps clients attach themselves to options that make sense. The CRN program is a departure from classical case management approaches that features a light touch, with contact in the community rather than requiring clients to “come in” to the health center. A unique approach is that the Navigator uses a community-donated bicycle to pedal her way around the narrow Provincetown streets which can become virtually impassable during the busy summer tourism season. In addition, the Navigator sees clients in safe, accessible public spaces such as the public library. A critical success factor is community engagement that builds effective relationships with community partners such as police, EMTs, councils on aging, community mental health providers, etc. Since beginning the CRN program, data has been collected that provides some unexpected insights into how the Community Navigator approach can be both an outcome- and cost-effective alternative to traditional case management or social worker-oriented interventions. In addition, the CRN program is proposed as the basis for a research initiative under the auspices of the University of Massachusetts Medical School Center for Clinical and Translational Science.

Moderator: Andy Lowe, Director of Program Management Resources, Outer Cape Health Services Presenters: - Barbara K. Prazak, MD, Internal Medicine, Medical Director, Director of Clinical Quality Outer Cape Health Services - Ellen Dennehy, PA-C, Physician Assistant, Family Medicine, Outer Cape Health Services - Tina Rauch, RN, Registered Nurse, Family Medicine, Outer Cape Health Services - Jennifer Eldredge, Medical Assistant, Family Medicine, Outer Cape Health Services Session Description Outer Cape Health Services (OCHS) is an independent, federally-qualified health center with three locations in the outermost towns of Cape Cod, an area hit hard by the opiate epidemic of recent years. After years of updates to the OCHS Controlled Substance Policy and Procedure, Medical Director Dr. Barbara Prazak worked with the Director of Nursing to develop the Chronic Pain Case Management (CPCM) Program, to be implemented March 1, 2016. The CPCM program uses a team-based case management approach to monitoring patients on opioid prescriptions, with systematic tracking of patient data such as PEG scales, MEQ dosing, concurrent use of benzodiazepines, annual agreements, UDS and PMP checks and visit compliance, and regular provider-to-provider case reviews. While the CPCM program supports the primary care prescriber with consistent, data-based risk management and evaluation, it also aims to shift provider behavior and practices in opiate prescribing, towards an approach that is more collaborative, individualized to patients’ needs, and integrated with primary care. Through this breakout session, we will engage with other prescriber teams to learn about other team-based approaches to chronic pain case management, discuss best practices, and begin formulating issues that warrant research.

One quarter of the population of Cape Cod is over age 65, and in the eight outermost towns on the peninsula of Cape Cod, known as the Lower and Outer Cape, the challenges of caring for an older population are compounded by the effects of rural isolation. As many residents have chosen to “age in place” with little family or social support, medical and behavioral health needs often go unaddressed due to the lack of access to needed healthcare and supporting services that plagues underserved rural areas. Outer Cape Health Services (OCHS), a federally-qualified community health center and the primary medical and behavioral health provider in the area, has established a home visit program to reach isolated patients who may otherwise be denied access to these services. This program is lead by the Care Coordination team, which collaborates with local Councils on Aging, the Visiting Nurses Association, EMS, and other community resources to identify and engage these complex, high-acuity patients and provide wrap-around services. However, gaps remain in communication among agencies regarding existing and potential cases. Additionally, little data exist on the health challenges faced by this underserved population, and how care coordination can better address medical and psychosocial needs. To address these gaps, a cross-departmental team at OCHS has begun a community-based research project with the goal of developing a network of consumers, providers and agencies to develop research questions and collaborate on interventions. The team is in the process of identifying key stakeholders and developing community-building strategies.