Transcript Island Community Care Project Connecting People with

Island Community Care
Project
Connecting People with Community and Health Services
October 11, 2007
Partners
• Healthy Acadia
• Maine Sea Coast Mission
• Mount Desert Island Hospital
– Behavioral Health Center
– Healthy for Life Program
– Southwest Harbor Community
Health Center
• Hancock County Planning
Commission
• Harbor House Community Center
* The Community Care Project
received generous support from
the Maine Health Access
Foundation.
Project Goals and Strategies
Our goals were simple and ambitious
“The Community Care initiative will actively integrate population-based
prevention in the community with an individualized care management
process in the primary care setting, utilizing evidence based practices to
affect behavior change.”
“The goals of this initiative are to:
1. increase self-care behavior, readiness to change, and belief in ability to
change among at risk persons.
2. provide strategic access to comprehensive primary care for rural, medically
underserved populations
3. establish structural changes in community settings in support of self care
behavior.”
(Source: Community Care Proposal, submitted May, 2005)
Target Population
• The target population for this initiative included persons who
by nature of their employment were:
• uninsured and
• confront occupational and lifestyle risks.
Many people who fell within this category were
• confronting occupational and physical disabilities resulting
from workplace injuries and
• chronic conditions such as asthma, obesity, diabetes,
depression and cardiovascular disease.
Community Engagement (Goal 1)
• Building Organizational Support for Community Care
• Community Health Outreach Worker - Debra Chalmers
– Harbor House
– Food Pantry
• Prescription for Fitness
• Maine Sea Coast Mission
• How’s Your Health?
How’s Your Health?
All Records
Younger Women
Older Women
Younger Men
Older Men
177
54%
23%
14%
10%
Perceived Needs
Bothered by…Part 1
Question
All Records
Women
Men
Bothered (often or always) in the Past Month by:
177
135
42
% Limit Daily Activities
3%
2%
5%
10%
11%
7%
5%
5%
2%
% Limit by Pain
12%
12%
12%
% Limited Social Support
10%
10%
10%
3%
4%
2%
11%
13%
5%
5%
6%
0%
15%
16%
10%
% Limit by Feelings
% Limit Social Activities
% Limited Physical Function (Fitness)
% Headaches
% Abdominal Pain
% Dizzy/Fatigue
Care Quality
Question
Care Quality Summary
All Records
Women
Men
177
135
42
% Taking 3 or more medications
14%
13% 17%
% unable to participate fully in daily work- 2 weeks
26%
29% 14%
22
25% 10%
% Hospitalized or ED for Chronic Disease
9%
3% 27%
% Hospitalized for Any Reason in Past Year
6%
6%
% With Sick Days in 3 Months
5%
% Having a PCP
76%
75% 79%
% Having Perfect Care
35%
33% 40%
% Having Very Easy Access
42%
39% 52%
% Having Confidence in self-management
51%
50% 57%
% Seldom Wasted Time
59%
58% 60%
% Get Exact Care Needed
22%
19% 31%
Health Score
Question
All Records
Women
Men
177
135
42
% Lifestyle - Doing Well
22%
24%
4%
% Lifestyle - Could be Better
41%
39%
61%
% Lifestyle - Opportunities for Improvement
36%
37%
36%
% Healthcare - Doing Well
21%
19%
24%
% Healthcare - Could be Better
22%
20%
31%
% Healthcare - Opportunities for Improvement
57%
61%
45%
3%
5%
0%
% Problems - Could be Better
31%
31%
34%
% Problems - Opportunities for Improvement
66%
63%
66%
Health Score
% Problems - Doing Well
Adapting Clinical Practice (GOAL 2)
Overcoming barriers to health care access
MDI
• Healthy for Life! Nurse Advisor
• Quality Initiative in Primary Care Services
Outer Islands
• Medical support for outer islands
• Sunbeam - On site and Tele-health conducts health screenings and
referrals
• Behavioral Health Services expanded in outer islands.
• Expand dental services (prevention, screenings) to outer islands.
Establishing Lasting Community Supports (GOAL 3)
• “Living Well with Chronic Disease” Collaborative effort by Maine’s Office
of Elder Services (0ES)
• Exploring creation of Federally Qualified Health Clinic (FQHC) for outer
islands.
• New partnership with Southwest Harbor / Tremont Ambulance Service
• Identify ongoing support for health care service
– Bingham Foundation
– Island Health Initiative
• Swans Island health committee - Set up lab on Swans Island for blood work
• Changing health behavior - Frenchboro Exercise Equipment, Pedometers
• Identifying new streams of funding for special projects – Right Weight for
Me
Sustainability
Our partners are all committed to moving forward with the community care model.
• Maine Seacoast Mission
– Relationships have been enhanced between MDI Hospital, Maine Sea Coast Mission
– Using new technologies including distance medicine and island health clinics to streamline
staffing
•
MDI Hospital and the Southwest Harbor Health Center
– Healthy For Life! care manager role
•
•
Healthy Acadia partnering with the Maine Nutrition Network and the USDA to secure
funding to address community food security.
Harbor House
– “Prescription for Fitness Program”
– Behavioral health support such as “Right Weight for Me” program.
Sustainability will remain a major challenge.
• Integrating insured, under-insured and uninsured clients
• Insurers are reducing benefits
• Clinical programs continually seek alternative funding
• Continue efforts for early intervention and preventive care
• Pursue reimbursement for case/care management services
• Identify local “assets” to support community care through partnerships.