COMMUNITY BENEFIT COLLABORATION

• Approach to understanding community health challenges, assets and drivers– Data elements/sources– Summarized story

• Approach to designing implementation plans

• Current status of implementation

BACKGROUND

• Kaiser Permanente of Georgia (KPGA) and Grady Health Systems (GHS) partnered with Georgia Health Policy Center to complete CHNA and implementation plan for each system

• Considered the specific needs of each community/ service areas; GHS with Fulton and DeKalb service region and KPGA with 30 additional counties (with implications for design of implementation plan)

• Alignment with Atlanta Regional Collaborative for Health Improvement (ARCHI) areas of focus was an important consideration in development of implementation plans – Priorities for the Atlanta Region :

• Encouraging healthy behaviors• Family pathways to advantage• Coordinated care• Global payment• Capture and reinvest savings• Expand insurance• Innovation fund

GHS SERVICE AREA

H

50 - 199

200 - 399

400 - 999

1,000+

0 - 49

Source: Grady Decision Support

Kaiser Medical Offices

Outline of KP-GA Service RegionM

eriwether

Clayton

KPGA SERVICE REGION

CRITERIA

Criteria Definition

Magnitude/ scale of the problem

Affects a large number of people within thecommunity

Severity of the problem Serious consequences (morbidity, mortality, and/or economic burden) for those affected

Organizational assets Has relevant expertise and/or unique assets to address the need

Existing or promisingapproaches

Effective, promising evidence- based strategies could be applied to address the need

Health disparities Disproportionately impacts the health status of one or more vulnerable population groups.

Ability to leverage* Opportunity to work with existing community partners; build on current programs, emerging opportunities, or other community assets.

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* ARCHI – Healthy Behaviors, Pathways to Advantage, and Care Coordination

GHS PRIORITIES

Top Priorities Middle Priorities Lower Priorities

Coordinated Care • Diabetes• Prostate Cancer• Hypertension/ Heart

Attack and Stroke• AIDS

Health Insurance Coverage• Access to Care

Encouraging Healthy Behaviors• Obesity/Diabetes• Hypertension/ Heart Attack

and Stroke• HIV/AIDS• Unintentional Injuries

Family Pathways to Advantage• Low Birth Weight• HS Educational Non-

AttainmentEncouraging Healthy Behaviors• STDs

Focus Area Health Need: 3- Year Goal Strategies

Care Coordination Effective and efficient patient care coordination among persons served by Grady Health System

Improved coordination of care for patients in Fulton and DeKalb Counties with the following conditions: Diabetes Hypertension/Heart Attack/Stroke Prostate CancerHIV/AIDS

1. Implement Safety Net Medical Home model focused on the use of patient care/treatment protocols and lay health workers to improve disease management and to control and reduce the likelihood of hospital admissions

2. Collaborate with partners to promote and support Care Transitions Programs

Health Insurance Increased opportunities among persons served by the Grady Health System to access appropriate healthcare services

Increased insurance coverage among persons served by the Grady Health System

1. Support navigator efforts to increase enrollment of uninsured and disadvantaged populations in the health insurance exchange.

2. Support outreach efforts to enroll eligible individuals in Medicaid and PeachCare

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GHS IMPLEMENTATION STRATEGIES

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Focus Area Health Need: 3- Year Goal Strategies

Healthy Behaviors

Improved sexual health in high risk populations living the DeKalb and Fulton Communities

Increased messaging to high risk populations to reduce the prevalence of HIV/AIDS

Collaborate and partner with key public health and community based organizations to promote HIV/AIDS prevention

Evidence based interventions aimed at reducing obesity in residents of DeKalb and Fulton

Increased levels of Physical Activity (PA) in adult residents of DeKalb and Fulton counties

Collaborate with key partners including Parks & Recreation, YMCA, Senior Centers, other key partners to promote and facilitate policies and programs that result in increased physical activity:Social support in worksites, senior centers, faith or community sites for walking groupsSocial marketing & point of decision prompts in target locations including worksites and the broader communityEnhancing existing green space & parks improvementSidewalks & complete streets policies

Reduced risk for homicide and injury in target populations in Fulton and DeKalb counties

Increased messaging and education to high-risk populations for homicide and injury prevention

Collaborate and partner with key education and community based organizations to promote homicide prevention and to reduce unintended injuries

GHS IMPLEMENTATION STRATEGIES

KPGA HEALTH NEEDS CHECKLISTHealth Needs Asthma Cancer Diabetes Heart Disease/Attacks Hypertension Low birth weight infants Mental Health Obesity Sexually Transmitted Diseases Teen Pregnancy

Drivers Drug/Alcohol Abuse Educational non-attainment Health Care Inaccessibility Physical Inactivity Poor Nutrition Poverty Tobacco Use

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KPGA HEALTH NEEDS (CONSENSUS)

Upper Tier Middle Tier Lower Tier

Obesity Mental HealthTeen Pregnancy

Diabetes STD/HIV AIDS Low birth weight

Heart Disease Cancer Asthma

Hypertension/Stroke

KPGA PRIORITIES

The primary foci of activity for the next 3 years: Overweight and obesity control Diabetes prevention and management Heart attack and stroke prevention and management Access to care Educational attainment and health literacy

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KPGA IMPLEMENTATION STRATEGIESFocus Area Health Need: 3- Year Goal Strategies

Healthy Behaviors

Overweight and obesity control to prevent long term chronic disease in the KPGA service region

Increase access to fresh fruits, vegetables and whole grains

Increase access to physical activity opportunities

1. Provide community-based grants, including technical assistance, to support policy implementation and programs

2. Provide grants to seed urban policy and environmental redesign of communities

3. Convene and collaborate with key stakeholders (e.g. YMCA, United Way, Open Hand, Atlanta Community Food Bank) to facilitate the development of policies and programs that promote behavior change and provide social supports

Increase intake of fruits, vegetables and whole grains by youth in the region

Increase moderate-to-vigorous physical activity (PA) in children & youth

1. Provide grants and technical assistance to schools, non-profits and/or community groups, and other key stakeholders to support, promote and implement healthy school nutrition, physical activity strategies and physical education standards

2. Engage Educational Theater Program and other appropriate internal KP resources to assist in the development and administration of Healthy Eating Active Living productions & programs

3. Convene and collaborate with key stakeholders (e.g. school systems, administrators, and non-profit organizations) to facilitate the development of policies and programs that promote behavior change and provide social supports

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KPGA IMPLEMENTATION STRATEGIESFocus Area Health Need: 3- Year Goal Strategies

Healthy Behaviors

Care Coordination

Diabetes prevention and management among adults in the KPGA service region

Increase percentage of residents achieving glycemic control in the region

1. Provide grants and technical assistance to support community collaborations aimed at increasing knowledge, policies and awareness about the prevention, impact and self-management of diabetes

2. Leverage KP assets (i.e. Medical Financial Assistance, Medicaid, Charity Care, Charitable Health Coverage etc.) and clinical expertise to ensure the availability of, and access to, appropriate diabetes preventive, screening and clinical services

3. Provide grants to organizations that support and promote the expansion of a well-trained health workforce to improve access to care in the community

Prevention and management of heart disease, hypertension and stroke among adults in the KPGA service region

Increased percentage of residents with normal blood pressure (BP) and cholesterol in the region

1. Provide grants and technical assistance to community partnerships/collaborations to increase health education and awareness of hypertension risk factors, control and cholesterol management

2. Leverage existing KP assets and programs (i.e. Medical Financial Assistance, Medicaid, Charity Care, Charitable Health Coverage etc.) to ensure availability of, and access to quality cardiovascular preventive, screening and clinical services

3. Provide grants to organizations that support and promote the expansion of a well-trained health workforce to improve access to care in the community

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KPGA IMPLEMENTATION STRATEGIESFocus Area Health Need: 3- Year Goal Strategies

Care Coordination

Access to health care to ensure better health outcomes the KPGA service region

Increase in health care coverage rates for low income populations in the KPGA service region

Increase in access to health care services for low income populations

1. Provide grants to support community based organizations in ensuring low income residents access to quality preventive, screening and clinical services

2. Leverage KP assets and programs (i.e. Medical Financial Assistance, Medicaid, Charity Care, Charitable Health Coverage etc.) to assist individuals in finding health care and enrolling into eligible programs

3. Partner with safety net clinics and community partners to create community solutions to address coverage and access to coordinated care for low-income residents.

4. Convene and collaborate with key stakeholders (e.g. ARCHI, Philanthropic Collaborative and United Way) to facilitate the development of policies and programs that promote increased access and coverage

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KPGA IMPLEMENTATION STRATEGIESFocus Area Health Need: 3- Year Goal Strategies

Pathways to Advantage

Improved education and health literacy levels among residents in the KPGA service region

Increase in educational attainment for children and youth in elementary and middle school

Increase in the knowledge and use of health information in the community

1. Provide grants to pre-school and other early childhood programs in service region focused on promising and evidence-based interventions that improve students reading through the 3rd grade level (elementary) and support academic reinforcement

2. Engage Educational Theater Program (ETP) in appropriate settings throughout the community to promote improved health education and healthy behaviors

3. Provide grant and technical assistance to support organizations and partners focused on the dissemination of health information, training and guidance for the community

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EXAMPLES OF CURRENT COLLABORATION

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COMMUNITY CARE MANAGEMENT

Project Title: Enhancing Patients’ Lives through Community Care Management Piedmont/Kaiser collaboration provided health care and community resource linkages to low-income, non-Medicare Charity Care-eligible patients with complex, chronic diseases at or below 200% of the Federal Poverty Level to reduce avoidable hospital readmissions and emergency room visits by 20%.

Impact and Lessons Learned The project served 352 patients and 324 caregivers (proposed 961 patients and 961 caregivers). Only 3% of program

participants were readmitted to the hospital within 60 days. The hospital’s average readmission rate is 11%. Over 11,000 telephone support calls, 270 home visits, almost 1,000 contacts with physician offices and made

transportation arrangements, community resource linkages and provided pharmacy assistance. Patients’ health was positively impacted as demonstrated by improved PHQ-9(Patient Health Questionnaire) and PAM

(Patient Activation Measure). Clients needed help addressing their social barriers to accessing care. Telephonic model didn’t work well, so Piedmont switched to a social medicine model of care, which focused on the

sociological factors that contribute to illness. Patients are able to manage their own care when given the necessary tools. Low-income patients are more quickly labeled “noncompliant”

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• Kaiser Grant for Grady Walk-In Center and Patient Navigator Program – New site on Grady campus for “walk-ins” (Considered FQHC

management) – Patient navigators located in the walk-in center, all 4 FQHCs and Grady

primary care• 7 navigators

– Navigators provided patient education regarding PCMH and scheduled follow up appointments to FQHCs or a Grady clinic

– Challenge in getting patients to leave Grady System• History/culture • Co-pays

• Impact – While program did not drive down ED volumes as anticipated,

ambulatory sensitive conditions decreased as a percent of total volume – Program created a platform for further collaboration among safety net

ATLANTA SAFETY NET COLLABORATIVE

• United Way Community Health Worker Program – Building on Navigator Program, the CHW program targets high-utilizers

from the emergency department • 5 CHWs • 2 year program

– CHW’s trained for home visits and ongoing support outside of clinical visits

– With underlying behavioral health conditions of high-utilizers, program was re-directed to focus on patients with high-risk for re-admissions

– Continue to have the goal of referring patients without a medical home to the FQHCs and Grady clinics

• Impact – One year into the program, initial results indicate reduced re-admission

rate for patients assigned a CHW – No determination of impact on patients adopting PCMH

ATLANTA SAFETY NET COLLABORATIVE

MODEL FOR REPLICATIONNew Program developed – Sams Care Program

Primary goal: To increase access to necessary care for uninsured community members in Piedmont’s service communities, avoiding preventable emergency department re-encounters, building upon successes and lessons learned through Piedmont/Kaiser collaboration

Primary activities:• Deploy EPIC into three charitable clinics – Fayette CARE Clinic (Fayetteville), Coweta

Samaritan Clinic (Newnan) and Hands of Hope (Stockbridge)• Provide for midlevel staffing to expand clinic capacity• Provide for licensed medical social worker to address socioeconomic issues• Create streamlined ED referral process• Measure and capture patient care outcomes, impact on hospital, impact on

community• Establish sustainable funding for program• Deploy “phase two” components – disease management, further ED integration

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OPPORTUNITIES FOR COLLABORATIONQ& A

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