Harford County Local Health Improvement Coalition Update Susan Kelly, EHS Health Officer Russell Moy, MD, MPH Deputy Health Officer November 12, 2014 www.harfordcountyhealth.com/
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Harford County Local Health Improvement Coalition Update Susan Kelly, EHS Health Officer Russell Moy, MD, MPH Deputy Health Officer November 12, 2014 www.harfordcountyhealth.com/ Our Local Health Improvement Coalition (LHIC) Where have we been, where are we headed? State Health Improvement Process (SHIP) launched in Sept 2011 Harford County Local Health Improvement Process (LHIP) launched in Dec 2011 Harford County Community Health Assessment (CHA) & Community Health Improvement Plan (CHIP) released Dec 2012 Harford County LHIC Progress Check on the CHIP in Oct 2013 & Oct 2014 Strengthened Local Health Department, Local Hospital & Healthy Harford LHIC Collaborative Efforts in 2015 2 How We Built on Harford County Efforts Health Care Reform Mandates Upper Chesapeake Health CHNA Mandates HARFORD COUNTY LHIC COMMUNITY HEALTH IMPROVEMENT PLAN Harford County Health Department SHIP CHA Mandates 3 How We Identified the County’s Health Priorities HARFORD COUNTY LOCAL HEALTH IMPROVEMENT COALITION PRIORITIES Obesity Prevention/ Healthy Eating & Active Living Community Engagement Access to Healthy Foods Built Environment Tobacco Use Prevention/ SmokeFree Living E-Cigarette Minors’ Access Multi-Unit Housing Other Policy Efforts Behavioral Health/ Mental Health & Substance Abuse Prevention Prevention Intervention Recovery Framework Emerging ConsIderatIons Access to Care, Chronic Disease Prevention, Health Disparities 4 Our Community Health Improvement Plan released in December 2012 showed . . . Harford County, Maryland Community Health Improvement Plan, December 14, 2012 • Harford County’s Community Health Improvement Plan is a long-term, systematic process for addressing issues identified in its Community Health Assessment in order to improve health outcomes. Strategies include: • Obesity Prevention – Increasing access to healthy foods – Enhancing the built environment – Creating a “Community of Wellness” • Tobacco Use Prevention – Promoting community awareness – Encouraging workplaces to be smoke-free – Policy changes regarding sales to minors • Behavioral health – Integrating and improving the delivery of substance abuse and mental health services Where Are Our Hot Spots? Low-income, high risk areas in the County include Edgewood, Aberdeen, Havre de Grace & Bel Air Bel Air Havre de Grace Edgewood Aberdeen Source: US Census Bureau, 2010 data Households with median incomes 80% below the median household income for Harford County 6 What Were Our Opportunities? Medicaid Expansion DHMH/LHD MCHP Programs Community Connections Clinical Safety Net Services Healthy Harford Inc. Homevisiting Schools/Libraries/CBOs Faith-Based Groups Social Service Organizations Others HCHD Clinical Services Upper Chesapeake Health Services HealthLink West Cecil FQHC Community Healthcare Providers Others 7 How Did These Opportunities Come Together? CHRC LHIC Grant Maryland Community Health Resources Commission (CHRC) 4 Care Coordinators (HCHD) West Cecil FQHC Satellite Beacon Health in Havre de Grace increases access to care Connector Entity Assister Grant Seedco Inc/MHBE 4 Assisters (HCHD) Connector Entity Navigator Grant DHMH & DHR Medicaid Seedco Inc/MHBE 5 Patient Navigators (Harford Community Action Agency) Medicaid/MCHP Enrollment (HCHD/DSS) “Care Coordination Plus” Maximize Insurance Coverage Team Team Team Team Care Coordinator Assister & Navigator Care Coordinator Assister & Navigator Care Coordinator Assister & Navigator Care Coordinator Assister & Navigator Havre de Grace HealthLink, Harford Memorial ED Aberdeen WIC, Homevisiting, Teen Diversion Edgewood FP, STD, WIC, Dental, Immunizations Bel Air Addictions, HIV, HCH, DSS, UCMC ED Community Connections & Referrals Healthy Harford Activities, Homevisitng, Faith-Based Groups, Libraries, Colleges/Schools, Social Service Organizations, Civic Groups, Others Clinical Safety Net Services Follow Up & Referrals Mental Health, Substance Abuse, HIV, HCH, FP, STD, WIC, Immunizations, Dental, HealthLink, Core Service Agency, Breast & Cervical Cancer Program, CRF Colorectal Cancer Program, Community Providers, Others 8 What Were Our Results? Goal 1 – Maximize Health Insurance Coverage # Screenings for insurance status Target 6,400 – Actual 8,080 # Individuals referred to Assisters, Navigators or Caseworkers Target 640 – Actual 912 # Individuals with Medicaid/QHP referred to Care Coordinators Target 640 – Actual 314 Goal 2 – Improve Care Coordination # Individuals offered Care Coordination Plus services Target 320 – Actual 916 # Individuals who sign “Reverse Consent” form allowing contact with other programs/services Target 320 – Actual 174 # Individuals completing Care Coordination Plus follow up Target 160 – Actual 174 Goal 3 – Improve Community Mental Health # Healthcare professionals who received suicide prevention/depression risk assessment training Target 50 – Actual 58 # Individuals enrolled in Care Coordination Plus referred to behavioral health services Target 50 – Actual 42 # Individuals enrolled in Care Coordination Plus who accessed behavioral health services Target 25 – Actual 32 9 What Were Our Lessons Learned? LESSON 1 Access to Care is not just about health insurance coverage – It’s about finding the right provider, navigating the healthcare system & overcoming other barriers to care. LESSON 2 A Big Need for Care Coordination Exists – and not just for those with Medicaid and Qualified Health Plans, but those with other private commercial insurance too. LESSON 3 Effective Care Coordination is more than just giving out pamphlets & phone calls – It is labor-intensive follow up that depends on (1) the trust relationship between the individual and the care coordinator, and (2) the collaborative relationships among community organizations and clinical safety net providers. LESSON 4 Meaningful Evaluations require access to shared data and real money for analytic purposes – money not to be diverted from the service delivery program. 10 What Are Our Expected Future Activities? Harford County Harford County Community Health Team Provider Care Team “Care Coordination Plus” “Case Management Plus” Addressing chronic disease management: Addressing wrap-around supports: Upper Chesapeake Health Coordination Harford County Health Department Plus Harford County Health Department Upper Chesapeake Health Oversight Healthy Harford Team Healthy Harford West Cecil FQHC Harford County Government Shared Community Healthcare Providers Schools, CBOs, Social Service Agencies data Others Others For Addressing the Needs of: Super-utilizers Chronically Ill & At-Risk of Becoming Super-utilizers Chronically Ill, But Under Control 11