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MINUTES <br /> ORANGE COUNTY BOARD OF HEALTH <br /> June 26, 2024 <br /> Alliance has a new Diabetes management program which is serving as a pilot for chronic <br /> care management programs. She added that the chronic conditions which Alliance <br /> focuses on are selected by the state. In response to Mr. Whitaker's question, Ms. Perry <br /> shared that chronic pain and pain management is not currently covered, but she would <br /> like to see it included and to tease out what's driving chronic pain vs. treating symptoms. <br /> • Ms. Perry shared that Alliance has a strong focus on community integration, including <br /> financial security, employment support, and housing stability. She said that health <br /> literacy and education is a priority, as is creating a supportive built environment—for <br /> example, the presence or absence of sidewalks and adequate lighting impacts people's <br /> reported feelings of safety. Alliance's Tailored Plan will also offer transportation support, <br /> including emergency transportation for oncology patients. <br /> • Alliance offers several services for people in crisis. Alliance provides its own mental <br /> health crisis line, similar to 988, as well as the Mobile Outreach Response Engagement <br /> & Stabilization (MORES) program, which provides follow up and support for <br /> approximately nine months after an individual experiences a crisis. <br /> • Ms. Perry provided an overview of the interdisciplinary care team, saying that Alliance is <br /> looking to add a nutritionist in the next fiscal year. In response to Commissioner Fowler's <br /> question, Ms. Perry explained that the providers within the interdisciplinary care team do <br /> work one-on-one with clients, though each client has a care manager who serves as <br /> their primary point of contact and facilitates connections with other providers in the care <br /> team. The interdisciplinary team also provides strategic guidance for Alliance. <br /> • Alliance has coordinators to assist with transitional care, including transitioning out of <br /> behavioral and physical health hospitals. They also have liaisons based in correctional <br /> facilities to provide support as individuals transition out of incarceration. <br /> • Commissioner Fowler asked how Alliance assists with food insecurity, to which Ms. <br /> Perry replied that they have community health workers who provide support beyond a <br /> resource list, for example assisting with transportation and completing forms. <br /> Commissioner Fowler noted that, as a provider, giving people a list of resources or even <br /> helping sign them up for Supplemental Nutrition Assistance Program Electronic Benefits <br /> Transfer (SNAP EBT) often feels insufficient and she wishes they could provide cash. <br /> Ms. Perry said that Alliance is not permitted to provide cash to clients, but that they are <br /> piloting a food home delivery program. <br /> • In response to Dr. Pickett's question about how Alliance prioritizes issues within the <br /> Social Determinants of Health when a patient is struggling to meet multiple needs, Ms. <br /> Perry replied that it is tailored to the individual and based on their concerns, priorities, <br /> and energy to address any given issue. <br /> • In response to Commissioner Fowler's question, Ms. Perry explained that Alliance has a <br /> robust housing program and another representative from Alliance could speak to their <br /> services more in-depth. She said that Alliance builds partnerships with landlords to <br /> invest in community-based housing, helps provide financial support for housing <br /> programs, and provides individuals with subsidies and connections to actual housing. <br /> • Dr. Stuebe asked how to refer an individual to Alliance, as she has a patient on Medicaid <br /> struggling with complex mental health needs. Ms. Perry explained that the Department <br /> of Health and Human Services (DHHS) uses an algorithm to identify potential Alliance <br /> clients based on their Medicaid claims and utilization patterns and, unfortunately, there is <br /> currently no way for individual providers to directly refer a patient into Alliance. <br /> • In response to Mr. Bagby's question about whether Alliance has a relationship with <br /> Family Success Alliance, Dana Crews, Community Health Services Director, replied yes. <br /> Ms. Perry added that Alliance does not receive grants, as they are funded entirely <br /> through Medicaid, but receives allocations to support community programs. <br /> S:\Managers Working Files\BOH\Agendas &Abstracts\2024 Agenda and Abstracts/ <br /> June Page 6 <br />