New Enhancing the Health of Our Communities · 2018. 12. 12. · patient care Lifeline Phone • Connected Jerry to specialists for his Retinal Detachment and Cataracts Services for

Enhancing the Health of Our CommunitiesAlisahah Cole, MD & Chief Community Impact Officer

December 2018

GoalsGET

INFORMED

GET UNCOMFORTABLE

GET INSPIRED

GET ACTIVATED

Carolinas HealthCare System Is …

Our Mission:To improve health, elevate hope and advance healing – for all.

Our Vision:To be the first and best choice for care.

Presenter

Presentation Notes

Arlene

National Landscape – Market Pressures1. Aging Population 2. Significant Spend Increase

4. Chronic Conditions3. Not Fiscally Sustainable

15.5%16.0%16.5%17.0%17.5%18.0%18.5%19.0%19.5%20.0%20.5%

$0$2,000$4,000$6,000$8,000

$10,000$12,000$14,000$16,000$18,000

National Health Expenditures, per capita

Medicare

Medicaid

Social Security

National Health

Expenditureas a % of

GDP

Cardiovascular DiseaseHistory of Heart AttackHistory of StrokeDiabetesHypertensionArthritisDyslipidemiaTotal US PopulationAsthma

Slide Source: Premier

Presenter

Presentation Notes

Competing on Value is becoming increasingly important across the nation as market pressures such as growth of the aging population, increases in health care spend, unsustainable financial models, and the climb in number of chronic conditions in the population continue to challenge the healthcare industry

Strategy Map

Community Health Strategic Priorities

ENHANCE COMMUNITY HEALTH AND BENEFIT IN PARTNERSHIPS WITH OTHERS:

Improve Mental Health and Substance Abuse Awareness, Education, and Access

Impact Reduction in Tobacco Use and Obesity Rates

Facilitate Improved Access to Primary Care, Mental Health, and Dental Services

Participate in Improvement of Social and Economic Indicators

Know What Affects Health

30%

40%

20%Physical

Environment 10%

HealthBehaviors

SocioeconomicFactors

Clinical Care

HEALTH OUTCOMES

HEALTH FACTORS

POLICIES & PROGRAMS

Health Behaviours (30%)

Tobacco Use

Diet & Exercise

Alcohol & Drug Use

Sexual Activity

Access to Care

Quality of Care

Education

Employment

Income

Family & Social Support

Community Safety

Air & Water Quality

Housing & Transit

Length of Life (50%)

Quality of Life

Clinical Care(20%)

Social & Economic Factors(40%)

Physical Environment(10%)

Ready to Get Uncomfortable?

A comfort zone is a beautiful place, but nothing ever grows there.

High (red) values show neighborhoods with the highest disparities among the Social Determinants of Health.

• Interactive web map• 10-county region• 12 SDH indicators at

the neighborhood level (Census Tracts)

• Index summarizing indicators into a single variable

http://tinyurl.com/SDH-Story-Map

http://tinyurl.com/SDH-Story-Map

Food Deserts

Food deserts are communities with limited access to affordable fresh fruit, vegetables, and other healthy foods.

Low access to healthy food is defined as living more than ½ mile (urban areas) or more than 10 miles (rural areas) from the nearest supermarket, supercenter, or large grocery store.

Food Insecurity

ADULTS

• Higher rates of Obesity in women, DM, HTN, Depression

• In pregnancy, low birth weight, preterm birth, gestational DM

• Elderly, reduced independence

CHILDREN

• More frequent infections

• Increased use of mental health services

• Increased rates of hospitalizations

• Poorer academic performance

Time to Get Inspired!

• New Resources• DHHS launches statewide resource

• http://arcg.is/0Xm5yn

• New community partnerships and collaborations

• New Work

http://arcg.is/0Xm5yn

Mental Health

MENTAL HEALTH FIRST AID AT “NO GREASE!” BARBERSHOP

All “No Grease” students will be required to take MHFA

Trainings are open to all community members

Training all YMCA employees

Obesity

YMCA HEALTH REFERRAL PROGRAM

Total schools surveyed: 33

Healthier options highlighted

SMARTER LUNCHROOMS MOVEMENT

Tobacco Use

TOBACCO TREATMENT SPECIALIST TRAINING

• 4 days of face-to-face training

• Combines findings from the most current evidence-based research on:

• pharmacotherapy

• population-based issues

• guidance on running a practice

• targeted skills in tobacco dependence counseling

17 from Atrium Health 17 from Novant Health 16 from Mecklenburg Public Health

50people registered

Access

Mobile Medicine• YMCA & Once Charlotte Health Alliance

Dowd YMCA• Charlotte Internal Medicine & Specialty Group Physical

Therapy, and Sports Performance• Virtual

Social Determinants

20

AT R I U M H E A LT H P I L O T:H U N G E R V I TA L S I G N S

NO ONE CANTHRIVE ON AN

EMPTY STOMACH

WITHIN THE PAST 12 MONTHS:

AV E R A G E A S S I S TA N C E : $ 2 0 0 / M O N T H

• We worried whether our food would run outbefore we got money to buy more

• The food we bought just didn't last and wedidn't have money to get more

ACROSS OUR REGION, ONE IN SIX EXPERIENCEFOOD SHORTAGES

Summer of Opportunity

Stronger Together I ONE CHARLOTTE Health Alliance

Public Health

Stronger Together Partnerships

Renaissance West Steam Academy

Second Harvest

Mobile Health Units Read Charlotte

Get Activated: Understanding Jerry’s Journey60 Year Old Homeless Male

Living behind Ford’s Used Tires and on streets for years

Alcohol Use Disorder, Malnutrition, Chronic Right Retinal Detachment (Legally Blind)

36 ED Visits in 2017 at Atrium Health

Presenter

Presentation Notes

Jerry lived on the streets for several years prior to our intervention. Dr. Griggs provided a number to contact the patient in a care plan and the Community Caring Bridge team connected with him on 4/5/17. He was living behind Ford’s Used Tires and suffering from several ailments, including near blindness. Over the course of a 12 month period, he was in the Atrium ED 36 times.

Bringing Health, Hope and Healing for Jerry

• Facilitated connection to Niece for Family Support

Family

• Coordinated transportation to Primary Care and Specialty Appointments

Coordination of Transportation

• Advocated for Patient Placement in Mecklenburg County Supportive Housing

Housing

• Facilitated applications for Medicaid, Food Stamps, and SSI

Government Sponsored Assistance

• Provided a means of contact for patient care

Lifeline Phone

• Connected Jerry to specialists for his Retinal Detachment and Cataracts

Services for the Blind

• Provided clothing and connections to services and agencies in the area

Community Resources

Presenter

Presentation Notes

Beginning with the first interaction, the CCB team began working with Jerry to connect him to health and community resources. They engaged in over 231 interactions with him and provided him with assistance in coordinating his care through applications to Medicaid, SSI and other government programs. They provided him with clothing for the winter months and connected him to transportation so he could attend PCP and specialty appointments, including needed treatments for his retinal detachments and cataracts. Further, they advocated for Jerry to be placed on a waiting list at the Meck County Supportive Housing program. His high vulnerability score prioritized him and the team worked with Jerry to complete the application and formally accept a home for the first time in years. Further, the team facilitated a connection to his niece to help him manage he needs and he has begun working on his alcohol disorder now that he is homed. Year to date, Jerry has only visited the ED 3 times and only once since receiving his home.

Bringing Health, Hope, and Healing for All Facts about the Community Care Bridge Team and our Patients

Total enrollment of 97 patients in 2017

40 Graduated Patients

(defined as achieving maximum goals of the program and/or

obtaining insurance)

Financial Savings of over $1M in Emergency

Department Charges

43% decrease in Hospital and ED

Utilization

Additional Patients Pending for

Enrollment into Program

SDOH Food Insecurity

• Summer Food Service Program, USDA

• First hospital facility to offer program in NC

• Started June 14th

• The program operates Monday through Friday, 7am-9am for breakfast and 11am-2pm for lunch.

• Summer of 2018- 3400 meals served

Kids Eat Free at CHS University

Network of PartnersWhat if we couldconnect all the dots?

Resource Coordination

CarolinasHealthCare.org/CommunityResourceHub

Support

Assistance

Service

Help

https://www.carolinashealthcare.org/CommunityResourceHub

Initial Pilot Sites

On Deck Q3-Q4 2018

Anson

“For All” Health Equity Strategy

Partnership between Community Health and Diversity & Inclusion

Quality metrics

Equity of Care Pledge

GOAL ICollection, Stratification

& Use of Data

Demographic Data Platform

For All Health Equity Goal

GOAL IICultural

Competency Training

Physicians & ACPS

RNs

Other Clinical Professionals

Non-Clinical, Patient-Facing Teammates

GOAL IIIDiversity in Leadership &

Governance

Men’s Diversity Leadership Program

Women’s Executive Leadership Program

GOAL IVCommunity Partnerships ONE Charlotte Health Alliance

Atrium Health’s Pledge

Demographic Data Wall

The Numbers

2018 ACCOMPLISHMENTS

Declinations of Colorectal Sscreenings

160Hispanic Male Patients scheduled/ confirmed receipt of screening

240Outreach to

Hispanic Male Patients(Attempts)

6,400

Presenter

Presentation Notes

One area of focus is the Hispanic males and Colorectal screening. This is a patient population that historically not received appropriate follow-up We found that bi-lingual follow-up did not exist This is a collaborative effort across the System including Diversity and Inclusion, Regional Operations Center, GI, Quality and Community Health

What Can You Do?

“Start where you are. Use what you have. Do what you can.”

• Get Informed

• Get Uncomfortable

• Get Inspired

• Get Activated

Arthur Ashe

First & Best

Documents

New Enhancing the Health of Our Communities · 2018. 12. 12. · patient care Lifeline Phone • Connected Jerry to specialists for his Retinal Detachment and Cataracts Services for