Transcript Welcome SHARON SANDERS, V.P. CLINICAL INTEGRATION, CARROLL HOSPITAL CENTER DOROTHY FOX, CEO/ EXECUTIVE DIRECTOR, THE PARTNERSHIP FOR A HEALTHIER CARROLL COUNTY BARB RODGERS, COMMUNITY HEALTH PROMOTION,

Welcome
SHARON SANDERS,
V.P. CLINICAL INTEGRATION, CARROLL HOSPITAL CENTER
DOROTHY FOX,
CEO/ EXECUTIVE DIRECTOR, THE PARTNERSHIP FOR A HEALTHIER CARROLL COUNTY
BARB RODGERS,
COMMUNITY HEALTH PROMOTION, CARROLL COUNTY HEALTH DEPARTMENT
Care
Integration
Delivering seamless care across multiple settings:
◦ Primary Care and Specialist Offices
◦ Ambulatory Centers
◦ Acute Care Facilities
◦ Community Resources
◦ Long Term Care and Rehabilitation Centers
Developing programs to assure use of the most
appropriate care setting at the right time
Making better use of patient information to
support the care-giving process.
2
Partnering with Long Term Care facilities
Key Initiatives to
Prevent
Avoidable
Admissions and
Readmissions
Increase Focus on Palliative Care and Hospice
Better Identification of High Risk Patients
Improve Patient Engagement and Self Management
Improve the Discharge Process
Improve Patient Call Backs
Home Health Collaboration
Process for Disease Management and Follow Up Care
Working with Community Agencies and Groups to Improve
Access to Care
Physicians align with patients
Hospitals partner with communities
Constant contact with caregivers; 24/7 availability
to patients and access to necessary programs.
Broad Focus on
Readmissions
Through
Partnering
Tighter monitoring of utilization of expensive
healthcare services.
Guaranteed same-day sick visits
Free educational classes and hot-spotting chronic
disease within communities.
Community Education programs and better access
to those programs.
Active engagement with care navigators and care
coordination.
Develop Systems of referral: How do we get community
members to the proper referral systems? Are they enough?
Is more needed?
Integrating
Care in the
Community
Identify our high risk population
◦ Completed Community Needs Assessment.
◦ Identified our high risk populations and areas of need.
◦ Behavioral Health
◦ Stroke
◦ Heart Disease- Specifically Heart Attack and Congestive
Heart Failure
◦ Chronic Obstructive Pulmonary Disease and Pneumonia.
What are our needs for this population?:
◦ Greater access to Primary Care and affordable care.
◦ Transportation
◦ Affordable medications
◦ Many other needs as being identified by hospital
navigators and others in the community
5
Behavioral Health –
Outpatient Mental
Health Clinic Model
Behavioral Health –
Community Benefit/Health Improvement Plan
Objective:
Ensure Carroll County residents have access to integrated, principle-driven
mental health systems of care providing recovery/resiliency-oriented
services. The availability of prescription drugs for potential misuse or illicit
use will be reduced, the percentage of Carroll County adults who
smoke will be reduced.
Example Strategies:
1. Continue current programming:
a. Partner with the Maryland Department of Health and Mental Hygiene, Carroll County
Youth Services Bureau and others to improve communication and resources for mental
health.
b. Promote mental health provider education and outreach —radio talks on WTTR
regarding depression and other top mental health issues.
c. Promote availability of The Partnership’s substance abuse and mental health resource
directory for the community.
The Most Appropriate Setting
Inpatient ADC
18.0
16.0
14.0
Census
12.0
10.0
8.0
6.0
4.0
2.0
0.0
Initiatives:
 Pain Management Contracts
 Care Connect – Health
Navigators
 SBIRT
 Care Plans
 Peer Recovery Support
Specialist
A Collaboration with Results
Patients admitted to Inpatient from ED
Evaluations in the ED
60%
Total Evaluations
3500
3000
50%
2500
40%
2000
30%
1500
20%
1000
10%
500
0%
0
Totals Totals Totals Totals Totals Totals Totals Totals Totals FYTD
FY 05 FY 06 FY 07 FY 08 FY 09 FY 10 FY 11 FY 12 FY 13 FY 14
A Collaboration with Results
High Utilizers*
High Utilizers**
FY12
FY13
Reduction from
previous year
87
58
33%
FY12
FY13
Reduction from
previous year
83
49
41%
*(patients with 3 or more IP admissions)
** (patients with 10 or more ED encounters)
FY14
FY14
Oversight of the System Coordination
for the County
Contains necessary stakeholders
Behavioral
Health Advisory
Council
Structure as a Board with many
Committees and Work Groups
Work Groups and Committee function
closely aligned with Partnership for a
Healthier Carroll County Community
Health Improvement Areas
A true community, linked together by
a central coordinating hub
Carroll County
Health
Department
Carroll Hospital
Center
The
Partnership
Established in 1999.
Founding members:
WHO WE ARE
Carroll Hospital Center & Carroll County Health Department.
Today, over 145 agencies, civic clubs, businesses, public and
private organizations and 300 people are actively involved in
various collaborative activities of The Partnership.
Connecting
people.
Inspiring action.
Strengthening
community.
We work together with individuals,
organizations, and agencies throughout the
county to create a healthier community.
Promote healthy lifestyles.
Generate leadership in the community.
Create new partnerships to address emerging
health needs.
Advocate for changes that translate into better
health and quality of life for our residents.
Assess, track and interpret health data of our
community and monitor results.
Community Health Needs
Assessment
2015
Carroll County Health Department
 Local health improvement committee will
establish a Local Health Improvement Plan
(LHIP) as a component of a State Health
Improvement Process (SHIP).
 In coordination with and within timeline of
CHNA 2015.
Carroll Hospital Center
 Provides needed data for CHC’s strategic
planning initiative.
 Assures compliance with the newest
required elements of the Federal 2010
Affordable Care Act.
 Basis of Community Benefit Plan for
FY2017-FY2019.
The Partnership
Community
 Provides needed data for The Partnership’s
strategic planning initiative.
 Results used in planning and collaboration.
Community
Health
Needs
Assessment
Shared
Accountability
via “Healthy
Carroll Vital Signs”
and annual impact
report to CHC and
PHCC Boards
Creating a Healthier
Carroll County
Community
Shared
Responsibility
The Partnership’s
Leadership Teams &
role as L.H.I.P.
coalition & CHC
Service Lines, PHO,
CHG etc.
CHC’s
Community
Benefit and
Health
Improvement
Plan
Carroll Hospital
Center & The
Partnerships
Strategic Plan
2013-2016
Community Benefit &
Health Improvement Plan
FY 2014-2016
A critical tool in our results accountability effort
SHIP/LHIP
Community Benefit
and Health
Improvement Plan
Community Health
Needs Assessment
At Carroll Hospital Center, we offer
an uncompromising commitment to
the highest quality health care
experience for people in all stages of
life. We are the heart of health care
in our communities
To create and sustain a
community of wellness
in Carroll County
“Striving to build the capacity of individuals
and organizations to improve the health and
quality of life in Carroll County, Maryland”
Population Health
Governance Group
Local Health
Improvement
Coalition(LHIC)
LHIC required as part of the State Health
Improvement (SHIP) process
SHIP’s goals: health equity and improving the health
of Maryland’s residents
In October 2011 The Partnership Board voted to
become the LHIC.
The responsibilities of the LHIC:
◦ Submit the Local Health Improvement Process to
the SHIP
◦ Collaborate with the PHCC Strategic Planning
committee and Carroll hospital Center
Community Benefit Committee to determine and
analyze health needs and propose
recommendations for community health
improvement.
Population
Health
Governance
Group
Multi-agency coordination for Healthcare
needs
Address duplication of efforts
Coordinate care needs based on health risk
needs assessment
Design a conceptual framework for
population health
Advise the LHIC and prioritize population
health initiatives
Population
Health
Governance
Group
Carroll County Health Department
Carroll Hospital Center
Carroll PHO/Carroll ACO
Access Carroll
The Partnership for a Healthier Carroll
County
Carroll County Government (Citizen
Services)