Poster Board 11: - Upstream Population Health for Clinical Pathways-Lower

The opportunity to leverage comprehensive primary care with the competencies of the Model of Health and Well-Being and the organization’s focus on health equity and the social determinants of health, has positioned WellFort as a champion of integrated system leadership. [...] Together the leadership offered around the preventative care stream and treatment focus is allowing these integrated system partners to work as a continuum and improved stratification of client need to ensure the client is navigated to the right serviced. [...] Several challenges have required attention in this project, and it is the learnings from these experiences that offers insight to support other primary care teams as we strive to integrate care and utilize primary care as the foundation to care. [...] The experience in embedding this model of care and new role within the community-based team may allow for improved care by supporting primary care clinicians and thereby releasing time to care for more complex care needs of the patients served. [...] The outreach to support other primary care practices will be implemented as well as a commitment to complete self management care plans that leverages elements within the CHC model care such as a focus on health equity, health promotion and social determinants of care.