grant submission

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Table of Contents

4.3 Executive Summary ................................................................................................................................ 2

4.4 Organizational Overview ....................................................................................................................... 5

Overall Mission & Purpose; Relationship to Purpose of the RFA. ............................................................ 5

Types of Prevention, Education, & Outreach Activities ............................................................................ 5

Focal Populations to be Served ................................................................................................................. 7

Area to be Covered ................................................................................................................................... 8

Expected Overall Outcomes ...................................................................................................................... 8

Applicant’s Experience Related to Provision of Proposed Activities ........................................................ 8

Organization’s Capacity & Ability to Direct, Perform, and Complete the Proposed Activities ................. 9

4.5 Statement of Need ................................................................................................................................. 9

Focal Population Demographic Information. ............................................................................................ 9

Impact of the Problem & Prevalence of Issues in the County ................................................................ 10

Avoiding Duplication of Existing Services ............................................................................................... 15

Sources of Other Funds Currently Received & How Funding Will Be Used Differently .......................... 16

4.6 Provision of Services ............................................................................................................................ 17

Activities to be Conducted, Including Strategies, Potential Barriers, Collaboration Plan. ..................... 17

Mobile Integrated Healthcare Program .................................................................................................. 17

Mobile Clinic ........................................................................................................................................... 18

Behavioral Health Services ...................................................................................................................... 19

Proposed Staffing Profile ........................................................................................................................ 21

Collaboration with Stakeholders ............................................................................................................. 21

Intended Outcomes of ICN ..................................................................................................................... 22

4.7 Evaluation Plan ..................................................................................................................................... 22

4.8 Budget Summary and Budget Narrative .............................................................................................. 24

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4.3 Executive Summary Historically, the Manatee County government has assisted in the funding of urgent life sustaining and medically necessary care to the residents of Manatee County through the development of the Manatee County Health Care Fund. This Fund has been used to pay for health care provided to individuals lacking the means to pay (including the uninsured and underinsured) and for other health‐related purposes. For the past 30 years, funds for these health care services have been drawn from Manatee County’s General Revenue and from the proceeds from the 1984 sale of the then‐public Manatee Memorial Hospital. Currently, with these funds depleting, Manatee County government and health care providers are working together to develop an innovative, collaborative, sustainable delivery model to meet the healthcare needs of the county’s most vulnerable citizens, while lowering healthcare costs. The current proposal is in reply to Manatee County government officials’ request for a concrete, sustainable program to meet these health care needs. Five organizations serving public health in Manatee County have partnered to develop a project to establish an Integrated Care Network (ICN). These five organizations are the Florida Department of Health in Manatee County (DOH‐Manatee); Manatee Memorial Hospital (MMH); Centerstone of Florida (COF; Manatee County’s non‐profit mental health services hospital and addiction center); Manatee County Emergency Medical Services (EMS); and Manatee Technical College (MTC). In the current proposal DOH‐Manatee is requesting funds to support implementation of this ICN project. The ICN project mission is to reduce health spending while improving the health status of residents of Manatee County, especially residents who are uninsured and underinsured. Its purposes are consistent with those of AHCA RFA 001‐15/16, Community and Primary Care Services. Namely, the ICN project will (i) increase access to primary care services; and (ii) reduce and prevent unnecessary emergency department visits and inpatient hospitalizations. The ICN will realize its mission and purposes with a set of three integrated programs aimed at more efficient, effective delivery of care through improved primary care access, disease management, patient compliance, and coordination of services. A key theme in the development of the ICN programs was overcoming geographic and transportation barriers through outreach and mobile clinics to meet the needs of low income residents in county locations where primary care providers and public transportation resources are scarce. The programs also respond to specific issues and disproportionate impacts on Manatee County’s most vulnerable populations in the areas of chronic disease, behavioral health, substance abuse, and births to teen mothers. Implementation of the ICN will include expansion of enrollment in Manatee County’s Health Information Exchange (HIE) to prevent duplication of services that are currently being provided.

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The three programs comprising the ICN project are: (1) a Mobile Integrated Healthcare Program (MIHP); (2) a Mobile Clinic; and (3) expansion of Behavioral Health Services. These programs are summarized below: 1) An MIHP will be developed in partnership with Manatee County Emergency Services (EMS)

and Manatee County Technical College (MTC) to replicate Community Paramedicine Best

Practices established in comparable communities (Ft. Worth, TX; Wake County, NC). The

MIHP program will provide targeted case management and primary care services to

frequent utilizers of emergency departments (ED), patients at risk for readmission, and

patients in need of chronic disease management. The community paramedic will partner

with EMS on 9‐1‐1 calls to appropriately direct patients to the right level of care in non‐

emergent cases. The community paramedic will also provide post‐ED case management to

assist with connecting uninsured community members to sustainable primary care

resources, increasing quality of healthcare and diverting future unnecessary emergency

room visits.

2) A Mobile Clinic will be developed in partnership with Manatee Memorial Hospital to pre‐

emptively target patients without primary care physicians who would otherwise utilize the ED. The unit will be used to provide basic, community‐based medical services such as primary care, maternal and women’s health care, and basic laboratory services. The mobile clinic will be staffed by health professionals capable of delivering culturally sensitive care, including local doctors, nurses, and bilingual staff. Staff in the mobile clinic will also understand the local referral system and be able to direct patients as needed to local hospitals and providers of dental, behavioral, and other health services. The mobile clinic will include a health education station. The station will be used to deliver educational workshops to inform all patients served by the mobile unit about their own personal health conditions, as well as common health problems, behavioral health, prevention, and important screening tests. Whereas the community paramedicine program will target frequent users of the emergency room, the mobile clinic will be brought to neighborhoods of high need for community‐wide medical access to prevent unnecessary and costly trips to the ED.

3) In partnership with Centerstone of Florida, Behavioral Health Services will be expanded for

uninsured and underinsured residents in Manatee County. This will reduce unnecessary emergency room visits and preventable hospitalizations by supporting hospital emergency room diversion, and by expanding and coordinating behavioral health and primary care clinical services. To accomplish this, the MIHP will incorporate behavior health intervention training, case management, and referral programs for community paramedics. Additionally, the mobile clinic will implement depression, suicide, and drug use screening, provided by a licensed clinician. The clinician will engage patients using Motivational Interviewing techniques, linking patients to clinical treatment by providing service referrals, and assisting in making appointments when outpatient treatment is indicated. This integration of behavioral health services will assist with diversion of patients from EDs through crisis

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intervention, service linkage, and behavioral change for improved health and decreased emergency services (9‐1‐1, EMS) usage. Finally, Centerstone will provide behavioral health transportation for MIHP and mobile clinic patients in cases where it has been determined that there is no medical emergency and that admission for psychiatric services is necessary to ensure immediate safety. This is necessary as EMS can only provide transfer to ED, and there is no transport available for patients in need of behavioral health inpatient or outpatient services, other than via Centerstone.

The roles of the five partnering organizations in the ICN project are as follows:

Florida Department of Health in Manatee County (DOH‐Manatee) serves as the applicant for the grant. DOH‐Manatee facilities the Manatee Healthcare Alliance and will manage the mobile clinic and provide oversight to all components of the ICN.

Manatee County Emergency Medical System (EMS) provides all of the EMS visits in Manatee County. It will lead and manage the ICN’s Mobile Integrated Healthcare Program.

Manatee Technical College (MTC)provides training for paramedics and will develop and provide the curriculum for the ICN’s Mobile Integrated Healthcare Program.

Manatee Memorial Hospital (MMH) serves as Manatee County’s safety net hospital,

treating a majority of the county’s uninsured and underinsured patients. MMH also

receives the majority of county’s ER visits. The 319‐bed acute care facilities sees

approximately 15,500 ER visits annually that are uninsured. This represents 20% of all ER

visits in the hospital.

Centerstone of Florida (COF) serves as Manatee County’s psychiatric and mental health services hospital and addiction center. It will provide the training for the behavioral health component of the program, as well as linkage to behavioral health and addiction rehabilitation services.

The project will also be supported by the Manatee Health Care Alliance (MHA), whose broad membership under the facilitation of DOH‐Manatee includes representatives from local governments, universities, hospital administrators, non‐profit and private business representatives, equality advocacy organizations, and concerned citizens. The Focal Population to be served by the ICN includes the following groups: (i) current frequent users of the emergency department and EMS (Frequent System Users); (ii) persons currently receiving no primary care preventive services or primary care treatment for their illness; (iii) persons recently discharged from the hospital who would benefit from a few in‐home monitoring sessions to prevent complications; (iv) persons with inadequately treated behavioral, mental health, or substance abuse problems. (Demographic characteristics of these groups are given below, in the Statement of Need.) The ICN project and its component programs (MIHP, Mobile Clinic, and expanded Behavioral Health Services) will improve health service delivery to members of the Focal Population throughout Manatee County.

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The ICN project will have monthly evaluations in the implementation phase in six domains. These domains include Referral Process, Frequent Emergency Department and EMS System Users, Bed Hours Saved, Patient and Network Provider Satisfaction, Program Discharge, Quality Assurance. The project seeks to provide start‐up and implementation funds for a comprehensive system to

address gaps in healthcare coverage for Manatee County’s robust uninsured and underinsured

population, while simultaneously reducing health care costs. This proposal is being submitted

with the consent and urging of all listed ICN partners and Manatee County Government.

Following the funding period and project implementation, partners will incorporate evaluation

findings to improve methodology and reduce healthcare costs, allowing ICN partners and

Manatee County to sustain future programmatic expenses.

4.4 Organizational Overview Overall Mission & Purpose; Relationship to Purpose of the RFA. In response to the challenge of developing an innovative, collaborative delivery model to meet the needs of the county’s most vulnerable citizens, five organizations serving public health in Manatee County have partnered to establish an Integrated Care Network (ICN): the Florida Department of Health in Manatee County (DOH‐Manatee); Manatee Memorial Hospital (MMH), Centerstone of Florida Department of Health, Manatee County Emergency Medical Services (EMS), and Manatee Technical College (MTC). DOH‐Manatee is requesting funds to support the implementation phase this ICN project. The ICN project mission is to reduce health spending while improving the health status of residents of Manatee County, especially uninsured and underinsured residents who currently lack access to primary care services. The project goals are consistent with those of AHCA RFA 001‐15/16, Community and Primary Care Services, namely to (i) increase access to primary care services; and (ii) reduce and prevent unnecessary emergency department visits and inpatient hospitalizations. The ICN project will achieve its mission and aims with a set of integrated programs aimed at more efficient, effective delivery of care through improved primary care access, disease management, patient compliance, and coordination of services.

Types of Prevention, Education, & Outreach Activities. The ICN project will include three programs directly targeting the needs of Manatee County’s uninsured and underinsured

residents with prevention, education, and outreach activities. A key theme in the development

of the programs was overcoming geographic and transportation barriers through outreach and

mobile clinics to meet the needs of low income residents in county locations where primary

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care providers and public transportation resources are scarce. Development of the ICN’s three

programs was guided by specific issues and disproportionate impacts on Manatee County’s

most vulnerable populations in the areas of chronic disease, behavioral health, substance

abuse, and births to teen mothers (as detailed below, in the Statement of Need).

Implementation of the ICN will include expansion of enrollment in Manatee County’s Health

Information Exchange (HIE) to prevent duplication of services that are currently being provided.

The three programs comprising the ICN project are: (1) a Mobile Integrated Healthcare Program (MIHP); (2) a Mobile Clinic; and (3) expansion of Behavioral Health Services. Below is an overview of each program. (More specific details on strategies used in these three component programs of the Integrated Delivery Network are provided in a later section, Provision of Services.) 1) An MIHP program will be developed in partnership with Manatee County Emergency

Services (EMS) and Manatee County Technical College (MTC) to replicate Community

Paramedicine Best Practices established in comparable communities (Ft. Worth, TX; Wake

County, NC). The MIHP program will provide targeted case management and primary care

services to frequent utilizers of emergency departments (ED), patients at risk for

readmission, and patients in need of chronic disease management. The community

paramedic will partner with EMS on 9‐1‐1 calls to appropriately direct patients to the right

level of care in non‐emergent cases. The community paramedic will also provide post‐ED

case management to assist with connecting uninsured community members to sustainable

primary care resources, increasing quality of healthcare and diverting future unnecessary

emergency room visits.

2) A Mobile Clinic will be developed in partnership with Manatee Memorial Hospital to pre‐

emptively target patients without primary care physicians who would otherwise utilize the ED. The unit will be used to provide basic, community‐based medical services such as primary care, maternal and women’s health care, and basic laboratory services. The mobile clinic will be staffed by health professionals capable of delivering culturally sensitive care, including local doctors, nurses, and bilingual staff. Staff in the mobile clinic will also understand the local referral system and be able to direct patients as needed to local hospitals and providers of dental, behavioral, and other health services. The mobile clinic will include a health education station. The station will be used to deliver educational workshops to inform all patients served by the mobile unit about their own personal health conditions, as well as common health problems, behavioral health, prevention, and important screening tests. Whereas the community paramedicine program will target frequent users of the emergency room, the mobile clinic will be brought to neighborhoods of high need for community‐wide medical access to prevent unnecessary and costly trips to the ED.

3) In partnership with Centerstone of Florida, Behavioral Health Services will be expanded for

uninsured and underinsured residents in Manatee County. This will reduce unnecessary

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emergency room visits and preventable hospitalizations by supporting hospital emergency room diversion, and by expanding and coordinating behavioral health and primary care clinical services. To accomplish this, the MIHP will incorporate behavior health intervention training, case management, and referral programs for community paramedics. Additionally, the mobile clinic will implement depression, suicide, and drug use screening, provided by a licensed clinician. The clinician will engage patients using Motivational Interviewing techniques, linking patients to clinical treatment by providing service referrals, and assisting in making appointments when outpatient treatment is indicated. This integration of behavioral health services will assist with diversion of patients from EDs through crisis intervention, service linkage, and behavioral change for improved health and decreased emergency services (9‐1‐1, EMS) usage. Finally, Centerstone will provide behavioral health transportation for MIHP and mobile clinic patients in cases where it has been determined that there is no medical emergency and that admission for psychiatric services is necessary to ensure immediate safety. This is necessary as EMS can only provide transfer to ED, and there is no transport available for patients in need of behavioral health inpatient or outpatient services, other than via Centerstone.

Roles of Partnering Organizations

Florida Department of Health in Manatee County (DOH‐Manatee) serves as the applicant for the grant. DOH‐Manatee facilities the Manatee Healthcare Alliance and will manage the mobile clinic and provide oversight to all components of the ICN.

Manatee County Emergency Medical System (EMS) provides all of the EMS visits in Manatee County. It will lead and manage the ICN’s Mobile Integrated Healthcare Program.

Manatee Technical College (MTC)provides training for paramedics and will develop and provide the curriculum for the ICN’s Mobile Integrated Healthcare Program.

Manatee Memorial Hospital (MMH) serves as Manatee County’s safety net hospital,

treating a majority of the county’s uninsured and underinsured patients. MMH also

receives the majority of county’s ER visits. The 319‐bed acute care facilities sees

approximately 15,500 ER visits annually that are uninsured. This represents 20% of

all ER visits in the hospital.

Centerstone of Florida (COF) serves as Manatee County’s psychiatric and mental health services hospital and addiction center. It will provide the training for the behavioral health component of the program, as well as linkage to behavioral health and addiction rehabilitation services.

Focal Populations to be Served. The Focal Population to be served by the ICN includes the following groups: (i) current frequent users of the emergency department and EMS (Frequent System Users); (ii) persons currently receiving no primary care preventive services or primary care treatment for their illness; (iii) persons recently discharged from the hospital who would benefit from a few in‐home monitoring sessions to prevent complications; (iv) persons with

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inadequately treated behavioral, mental health, or substance abuse problems. (Demographic characteristics of these groups are given below, in the Statement of Need.)

Area to be Covered. The ICN project and its component programs (MIHP, Mobile Clinic, and

expanded Behavioral Health Services) will improve health service delivery to members of the

Focal Population throughout Manatee County. Demographic data (reviewed below, see

Statement of Need) and a recent analysis of EMS data suggest that the ICN will have most

impact (namely, improving access to primary and behavioral healthcare and preventing

unnecessary emergency department visits and inpatient hospitalizations) in areas of greatest

need, including five zip codes: 34203, 34205, 34207, 34208, and 34221. These five zip codes

account for almost 50% of the population in Manatee County, but 74% of Frequent System

Users.1

Expected Overall Outcomes. The ICN project will have monthly evaluations in the implementation phase. Evaluations will focus on overall project performance, by direct patient populations after the reduction of Emergency Room diversions. Additional details are provided below in the Evaluation Plan. Improved outcomes are expected in the six domains outlined below.

1. Referral Process. Three outcomes related to the Referral Process will be tracked. 2. Frequent Emergency Department and EMS System Users. Frequent emergency

department and EMS system users will be identified and monitored. 3. Bed Hours Saved. Four outcomes related to Bed Hours Saved will be tracked. 4. Patient and Network Provider Satisfaction. A survey will be used to evaluate satisfaction

outcomes. 5. Program Discharge. The program will monitor the amount of time needed for patients

to be discharged from the community paramedic program. 6. Quality Assurance. Three outcomes will be monitored for Quality Assurance.

The program seeks to maintain medical quality assurance following Florida statute 401, utilizing

a peer review process. Patient outcomes and established benchmarks will be monitored. Data

will be gathered and shared with participating community partners.

Overall program success will be measured by the multiple system benchmarks. This will allow program manager to redirect, improve, and prioritize program needs to ensure overall success. The program manager will periodically meet with community stakeholders and reevaluate community health care gaps.

Applicant’s Experience Related to Provision of Proposed Activities. DOH‐Manatee provides

a wide range of essential clinical and community services to the Manatee County community, 1 Community Paramedicine, presentation by J Crutchfield and P DiCicco, September 2015, Board of County Commissioners Healthcare Workshop)

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both directly and through collaborative community partnerships. These services include health

education, counseling, examinations, treatment, medical management, immunization, drug

assistance programs (for AIDS, diabetes, epilepsy), testing and screening (for diseases, hearing,

and vision), lab testing, and outreach.

Organization’s Capacity & Ability to Direct, Perform, and Complete the Proposed

Activities. DOH‐Manatee is a well‐respected agency, in large part due to the strong working

relationships it has forged over the past 20 years with key organizations and partners at all

levels of the community. Employing over 120 staff, with an annual budget of 12 million dollars,

DOH‐Manatee has demonstrated immense fiscal responsibility with a long history of

exceptional management. Under the leadership of Dr. Jennifer Bencie, DOH‐Manatee

Administrator, and Eddie Rodriguez, Assistant Administrator responsible for fiscal oversight,

DOH‐Manatee has demonstrated foresight in effectively managing its many programs and

funds. DOH‐Manatee’s extensive grant‐ and project management‐related experience includes

recently funded projects for Tobacco Prevention, AIDS Prevention, Breast and Cervical Cancer

Screening, WIC Breastfeeding Peer Counseling, Colorectal Cancer Screening, Chronic Disease

Prevention and Health Promotion, Family Planning, Immunization, and Teen Outreach. In the

past five years alone, DOH‐Manatee’s successes in public health administration have been

recognized at the national level by the National Association of City and County Health Officials,

the Robert Wood Johnson Foundation, the American Public Health Association, Project Public

Health Ready, the Society of Public Health Educators, and the National Institute for Children’s

Health Quality; and at the state level by the Florida Department of Health and the Florida

Sterling Board for Quality Improvement.

4.5 Statement of Need Demographic and health data show a mixed picture of community health in Manatee County.

The county is comprised of coastal and other areas of relative affluence, together with areas

characterized by financial challenge, low health care access, and unmet health needs.

Focal Population Demographic Information. As noted above, the Focal Population to be served by the ICN includes the following groups: (i) current frequent users of the emergency

department and EMS (Frequent System Users); (ii) persons currently receiving no primary care

preventive services or primary care treatment for their illness; (iii) persons recently discharged

from the hospital who would benefit from a few in‐home monitoring sessions to prevent

complications; (iv) persons with inadequately treated behavioral, mental health, or substance

abuse problems.

Also as aforementioned, five zip codes account for almost 50% of the population in Manatee

County, but 74% of Frequent System Users. These zip codes are: 34203, 34205, 34207, 34208,

and 34221. Although the Integrated Care Network will target the Focal Population throughout

the county, demographic and socioeconomic characteristics of these five zip code areas help

illustrate needs of the Focal Population.

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Incomes, access to health insurance, and educational level are also unfavorable within these 5

zip codes compared to Manatee County and Florida as a whole (see table below). Within these

5 zip codes, approximately 22% of the patients or 77,931 are uninsured. As shown in the table

below, about 45% of residents in the five zip codes can be classified as low income (< 200% of

the poverty level), 24% are uninsured, and 18% have less than a high school education.

Location Post Office NameTotal

Population

% Low‐Income

Population

% Population Uninsured

% Population w/ Less Than High School Education

Zip code 34203 Bradenton 36,806 42% 20% 15%




Zip code 34221 Palmetto 41,287 40% 22% 17%

All 5 zip codes n/a 172,177 45% 24% 18%

Manatee County n/a 329,487 35% 19% 12%

Florida n/a 19,091,156 38% 20% 14%

Another set of demographic factors contributing to a cycle of unfavorable economic and health

outcomes in Manatee County is the relatively high numbers of births to mothers without a high

school education and to teenage mothers. Data for the year 2014 (single‐year rates) provided

by the Florida Department of Health Bureau of Vital Statistics show the following:

The percentage of births to mothers ages 18 and over without a high school education

stands at 23% in Manatee County compared to 13% in Florida as a whole; this places the

county in the least favorable quartile among Florida’s 67 counties.

The rate of births to mothers ages 15‐19 stands at 33 per 100,000 in Manatee County

compared to 22 per 100,000 in Florida.

The percentage of repeat births to mothers ages 15‐19 was 22% in Manatee County versus

17% in Florida as a whole.

These high rates of teen births and births to women without a high school education

underscore the importance of outreach, education and expansion of primary care services to

ensure maternal, fetal, and young child health as well as family planning and women’s health

services.

Impact of the Problem & Prevalence of Issues in the County. The 2014 ALICE report on financial hardship in Florida sheds light on the interrelated challenges associated with low

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income, lack of health insurance, and poor health outcomes.2 The ALICE report estimates that

43% of households in Manatee County are either living under the poverty level or earning less

than the basic cost of living. According to the report, households under the ALICE threshold

often lack health insurance or are underinsured. The ALICE report points to a clear link between

financial hardship and poor health outcomes, contributing to a cycle of further hardship: As a

result of financial hardship, these households forgo preventive health care, incur more out‐of‐

pocket expenses, visit the emergency department for non‐emergencies, and suffer lost work

time and productivity due to poor health.

2014 Hospital Emergency Room Visit (ER Visit) data provided by the Health Statistics and Performance Management office of the Florida Department of Health show the large impact of lack of access to health services in Manatee County. Two categories of ER Visits and charges reflect conditions that should be manageable on an outpatient basis without the need for ER services: Ambulatory Sensitive Conditions and Dental Conditions. These data are displayed in the table below, showing significant numbers of visits and charges in both categories:

Ambulatory Sensitive Conditions. There were a total of 28,658 ER Visits for Ambulatory Sensitive Conditions in Manatee County in 2014. Of these ER Visits, 21% resulted in a hospital admission and 79% did not. The total charges for these ER Visits was $312,945,087. Of these charges, 77% were associated with ER Visits resulting in hospital admission, and 23% were associated with ER Visits not resulting in admission.

Dental Conditions. There were a total of 1,152 ER Visits for Dental Conditions in Manatee County in 2014. Of these ER Visits, 2% resulted in a hospital admission and 98% did not. The total charges for these ER Visits was $2,079,831. Of these charges, 31% were associated with ER Visits resulting in hospital admission, and 69% were associated with ER Visits not resulting in admission.

ER Visits for Ambulatory Sensitive Conditions

In Manatee County (2014)

# ER Visits % Total Charges %

ER Visits resulting in Admission 22,644 79% $ 70,967,265 23%

ER Visits Not resulting in Admission 6,014 21% $ 241,977,822 77%

Total ER Visits 28,658 $ 312,945,087

ER Visits for Dental Conditions In Manatee County (2014)

# ER Visits % Total Charges %

ER Visits resulting in Admission 1,132 98% $ 1,437,985 69%

ER Visits Not resulting in Admission 20 2% $ 641,846 31%

Total ER Visits 1,152 $ 2,079,831

2 ALICE (Asset‐Limited, Income‐Constrained, Employed) Report Florida (Fall 2014, United Way of Florida).

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2014 ER data from Manatee Memorial Hospital indicate similar trends. There were 15,456

patients that presented in the ER which represents 21% of all ER visits for 2014. Of the 15,456

visits, about 50% of those visits could have been handled in a setting other than the emergency

room.

The top causes of death among Manatee County residents are as follows. Those highlighted in

red demonstrate substantial racial health disparities that are more pronounced in Manatee

County than in Florida as a whole.

Death rates per 100,000 (age‐adjusted, 3‐yr. rolling)

Manatee County Florida

White Black White Black

Heart Disease 151 230 152 170

Cancer 147 158 161 162

Motor Vehicle Deaths 11 24 13 12

Stroke 30 59 29 47

Kidney Disease 12 45 10 22

Diabetes 12 30 17 40

Homicide 5 28 4 17

HIV/AIDS 2 17 2 20

In terms of behavioral health, death rates from suicide and unintentional injuries (including

drug overdoses) have increased substantially. Manatee county suicide deaths have increased

37% from 2005 to 2014, with county rates much higher than state rate ; suicide (Manatee

county (16 per 100,000) vs. Florida (14 per 100,000); and Manatee county unintentional

poisoning deaths have increased 23% from 2005 to 2014, with averages higher than state rate

(Manatee county (44 per 100,000) vs. Florida (40 per 100,000).

Behavioral health disorders affect millions of Americans annually. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), 43.5 million adults and adolescents experienced a mental health disorder in 2014 and 20.2 million adults experienced a substance use disorder, while 7.9 million adults experienced both a mental health and a substance use disorder. The Agency for Healthcare Research and Quality (AHRQ) identifies mental disorders as one of the top five most costly health conditions in the US.

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According to a recent newspaper report, Manatee County has become the epicenter of the

current heroin epidemic in Florida.3 In Manatee County there have been about 1,000 overdoses

in 2015 so far, versus 700 in 2014 and 339 in 2013. Addictions expert Melissa Larkin‐Skinner

was quoted as saying those numbers give Manatee its epicenter status, and that the supply

appears to be growing, and that the solution to this problem must include health education to

prevent addictions from starting as well as increased attention to addiction treatment centers

and programs.

Individuals with a mental health disorder and/or substance use disorder often have co‐morbid chronic medical conditions such as diabetes, heart disease, and respiratory problems. In 2010, there were 2.2 million hospitalizations and 5.3 million emergency department visits involving a diagnosis related to a mental health diagnosis; and only 41.8% have been shown to follow up with recommended aftercare. AHRQ reports that alternative services such as mobile outreach have proven effective for reducing emergency department visits and hospitalizations. In 2008 the University of South Florida Center for Research in Healthcare Systems and Policy released an analysis of the State of Health Care System in Manatee County. One salient finding was that some residents lacked health care access because they were unaware of health care services that were available to them. The study found that this lack of service awareness was widespread among health care recipients, especially among those who were not insured. Additionally, the most prevalent notion was that there was no reliable resource for continued health care, and as a consequence, that the emergency department was the place to go when one was ill. Another finding was that coordination of care and information exchange for indigent and uninsured patients were inefficient and at times non‐existent among providers. Currently the two large providers on the health information exchange is Manatee Memorial Hospital and MCR Health Services, a Federally Qualified Health Center. It was recommended in the study that a health information be implemented among all providers. Based on an analysis of ten years of historical emergency department data on uninsured patient encounters, the study concluded that 80% of the encounters could have been avoided with timely visits to a health clinic or medical home. These findings underscore the importance of the mobile health services, as well as health education to be provided by the ICN. The need for expansion and better coordination of primary and behavioral health care resources in Manatee County is also demonstrated by its shortages of medical resources, as evidenced in several types of data. The U.S Department of Health and Human Services (DHHS) has developed criteria to determine health shortage designations in state and local communities. There are two types of health professional shortage designations: Health Professional Shortage Areas (HPSA) and Medically Underserved Areas or Populations (MUA/MUP). Criteria for both designations include: infant death rate and low birth weight, primary care physician‐to‐population ratios, poverty, percent of elderly population and barriers

3 Bradenton Herald, September 19, 2015.

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to access care. These designations are used by more than 34 federal programs to determine eligibility for services or funding preferences. For example, the designations can be used to determine the need and location of community and migrant health centers and rural clinics, or for eligibility for National Health Service Corps scholarships and loan forgiveness programs. MUA/MUPs use similar data, an index with scores ranging from 1 to 100 are assigned. A score of less than 62 is required for designation as an MUA/MUP. Manatee County has a designation as a Medically Underserved Population for low income and migrant farm workers county‐wide based on a score of 50.1. Manatee County Health Professional Shortage Areas by Type of Service, population and Year

of Designation

Discipline Population Year Designated

Primary Care Low Income Bradenton/Manatee 2014

Primary Care Low Income Palmetto/Parrish 2014

Dental Low Income Bradenton 2011

Dental Low Income Palmetto/Parrish 2011

Manatee County, when compared to the State of Florida, has a lack of health care providers in

the following areas: Dentists, Physicians, Internists, OB/GYN, and Pediatricians. This lack of

providers contributes to high utilization of emergency department services. According to a

2012 study released by the Center for Disease Control and Prevention about Emergency Room

Use, about 80% of adults visited the emergency due to lack of access to other providers; and

uninsured adults were more likely than those with private health insurance to visit the

Emergency Room due to having no other place to go.

County State

Providers Data Year

Count (Annual Avg)

Rate Per 100,000

Quartile Rate Per 100,000

Total Licensed Dentists (Fiscal Year) 2013 171 50.9 3 53.8Total Licensed Physicians (Fiscal Year) 2013 721 214.7 3 275.7Total Licensed Family Practice Physicians (Fiscal Year) 2013 103 30.7 4 25.5Total Licensed Internists (Fiscal Year) 2013 143 42.6 3 51.8Total Licensed OB/GYN (Fiscal Year) 2013 30 8.9 3 9.9Total Licensed Pediatricians (Fiscal Year) 2013 48 14.3 4 23

Data Source: Florida Department of Health, Division of Medical Quality Assurance, Agency for Health Care Administration. *Data for providers are for a fiscal year, not a calendar year

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The current project has been developed to meet the challenge presented by these needs. The project reflects two important strengths in Manatee County: a strong health care infrastructure and the willingness of key health care organizations to work collaboratively to reduce unnecessary health spending while improving residents’ health status and health care access.

Avoiding Duplication of Existing Services

Manatee County Rural (MCR) Health Services, a Federally Qualified Health Center, provides primary and limited secondary medical services to some uninsured Manatee County residents and has a long history of working productively with the ICN project partners. Due to limited operating hours and the geographic limitations of MCR Health’s permanent sites, there are still significant service coverage gaps for uninsured populations seeking primary care. MCR Health participates in the Health Information Exchange (HIE); HIE enrollment by ICN partners will be undertaken to promote coordination and to prevent duplication of services provided by either entity. In terms of behavioral health, there are no existing mobile mental health screening services at MRC Health or within Manatee County to target the uninsured population and divert them from emergency department admission and hospital readmissions. Screening services and resource referrals provided by the MIHP portion of this proposal will assist and encourage this underserved population to participate in the services they need to prevent future unnecessary emergency department visits. Additionally, there are no public transport options for non‐emergent behavioral health crises which require admission for psychiatric services is necessary to ensure immediate safety. This transport gap will be filled by Centerstone, in collaboration with the Mobile Clinic and MIHP. In‐Kind Funding

This program will be supported by the five partner institutions in this and will be contribution

in‐kind investments to ensure the success of this program.

Manatee Memorial Hospital will provide in‐kind clinical rotations and training for the

Mobile Integrated Healthcare Program. The hospital will also be providing medical

residents to provide primary care services in the mobile clinic.

Centerstone of Florida will provide in‐kind clinical rotations and training for the MIHP as

well as the mobile crisis unit.

Manatee County EMS will provide in‐kind EMS infrastructure for the MIHP, including in‐

kind contribution of medical director supervision

Manatee Technical College will provide in‐kind development of MIHP program suited for

the focal population

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Sources of Other Funds Currently Received & How Funding Will Be Used Differently

Historically, Manatee County has assisted local physicians and hospitals in their mission to render urgent life sustaining and medically necessary care to the residents of Manatee County through the development of the Manatee County Health Care Fund. This Fund has been used to pay for health care provided to individuals lacking the means to pay (including the uninsured and underinsured) and for other health‐related purposes. For the past 30 years, funds for these health care services have been drawn from Manatee County’s General Revenue and from the proceeds from the 1984 sale of the then‐public Manatee Memorial Hospital. Currently, with these funds nearing exhaustion, health care providers in Manatee County face the challenge of developing an innovative, collaborative delivery model to meet the needs of the county’s most vulnerable citizens. Centerstone currently provides mobile crisis services, responding to behavioral health

emergencies at local schools from 9 a.m. to 5 p.m. when contacted by law enforcement or the

schools – funding is provided by the State of Florida. There is currently no funding to support

the proposed licensed clinician availability to respond to emergency services personnel,

community paramedics, nor to provide mobile behavioral health screening as part of an

integrated mobile health unit team. Centerstone provides behavioral health transportation for

persons on an involuntary Baker Act at Manatee Memorial Hospital to Centerstone Behavioral

Hospital. Centerstone also provides transportation from Centerstone Behavioral Hospital to

state psychiatric facilities throughout the State of Florida when a person in Manatee County is

court ordered to such a facility. Funding is provided by Manatee County Government. The

funding does not support the proposed behavioral health transportation in response to

emergency medical services and community paramedics. The proposed services will ensure

transportation is available to emergency medical services and community paramedics and help

achieve the goal of reducing unnecessary emergency department admissions and ensure the

persons served receive the care they need for their behavioral health issues.

DOH‐Manatee receives county, state, and federal funding to support programs, general

revenue, and infrastructure. These funds cannot be used for project development, but will be

used toward sustainability of project following the end of the grant period.

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4.6 Provision of Services Activities to be Conducted, Including Strategies, Potential Barriers, Collaboration Plan.

Activities to be conducted, including strategies, and a collaboration plan are described below. Potential barriers and obstacles will be overcome through the project’s support from the Manatee Health Care Alliance (MHA), whose broad and highly engaged membership includes representatives from local governments, universities, hospital administrators, non‐profit and private business representatives, equality advocacy organizations, and concerned citizens. .

Program Focal Population Total Number of Unduplicated Individuals (annualized numbers provided By ICN partner organizations)

Mobile Integrated Healthcare Program

Frequent utilizers of ER, Patients at risk for readmission, Patients in need of chronic disease management

2,920

Mobile Clinic Patients without primary care physicians who will likely otherwise utilize ER; Patients in need of family planning services

3,600

Behavioral Health Services

Patients in need of social, mental support and drug addiction rehabilitation

800


The specific roles and services of a community paramedic are determined by community health needs and in collaboration with local public health departments and medical directors. In this way, community paramedicine reduces unnecessary emergency department visits and contributes to a greater focus on population health. The MIHP will be a restructuring of existing healthcare resources, not a new means to increase healthcare spending. It is a strategy designed to support and augment other patient‐centered delivery models by providing an optimized mix of health care and patient navigation at a lower cost than traditional models. In the current situation, when a patient requests an ambulance, EMS will respond and then take the patient straight to the emergency department. In the proposed model, EMS will respond and partner with the community paramedics to redirect patients to other options such as mental health, in‐home care, or physician office rather than straight to the emergency department. Upon follow up, the community paramedics will provide home‐based follow‐up and preventive services to the members of the focal population. This will be accomplished by supporting the MIHP’s ER Diversion initiative through training of paramedics in recognizing and responding to acute behavioral health and comorbidity situations. This program will also expand behavioral health clinical services through expansion

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health services, and basic laboratory services. The Mobile Clinic will reduce unnecessary emergency room visits and preventable hospitalizations by means of an expansion of primary care clinical services. This expansion of primary care clinical services and referrals will lead to improved disease management, patient compliance, and coordination of services such as needed physician, diagnostic, dental, nurse practitioner, pharmaceutical, behavioral health, and other supporting services. The mobile clinic will be staffed by DOH‐Manatee health professionals capable of delivering culturally sensitive care, including local doctors, nurses, and bilingual staff. Staff in the mobile clinic will also understand the local referral system and be able to direct patients as needed to local hospitals and health service providers as needed. Most importantly, the mobile clinic will include a health education station that all patients will be required to use. The station will be used to deliver educational workshops to inform patients about common health problems, their own health, and important screening tests. The mobile clinic will operate during weekdays, weekends, and evenings in underserved census tracts, enabling medical providers to reach out to areas of greatest need and bring care directly to residents. The mobile clinic will operate in partnership with established community partners, including food pantries, schools, neighborhood associations, and faith‐based organizations to engage residents, and expand primary care services in these areas. As a result, there will be less unnecessary use of the emergency department due to lack of access to primary care, improved population health, and improved chronic disease management. To help reduce provider expenses, Manatee Memorial Hospital will integrate a community health rotation via the mobile clinic into its current medical residency program.

Behavioral Health Services

A vital component of the Integrated Care Network will be behavioral health training for

community paramedics and emergency services personnel within the MIHP. Centerstone of

Florida, formerly Manatee Glens, is the county's primary hospital for addictions and mental

health treatment. Centerstone will provide classroom and on‐site training to ensure that these

professionals are able to recognize behavioral health disorders, and that they have knowledge

of recommended responses and available resources.

Behavioral health screening, assessment, intervention, and mobile crisis response will be integrated in the mobile clinic. A licensed clinician will provide on‐site behavioral health services at the request of community paramedicine providers when a mental health and/or substance use disorder is suspected or known to be present. Behavioral health screening and assessment services will allow the team to determine the most appropriate intervention. Crisis intervention will be provided on demand. Centerstone will be able to provide behavioral health transportation when it has been determined that there is no medical emergency and that voluntary/involuntary admission for psychiatric services is necessary to ensure immediate safety.

Implemeentation Plann

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21

Proposed Staffing Profile

Program Staff Count Training or Experience Required


Program Manager 1 Community Paramedic training course (below) and experience in business development and operations; Experience in physician office, registration, and front office scheduling

Medical Director 1 Board‐certified and practicing M.D.

Community Paramedics 2 280 class hours and 140 clinical hours divided between the acute and behavioral health hospital

Mobile Clinic Nurse Practitioner 1 Family Practice/Internal Medicine with training in chronic disease management

Medical Assistant 2 Experience with health education and promotion, Ability to drive mobile clinic

Clinic Manager 1 Will develop protocols, guidelines, partnerships

Mental Health Licensed Clinician 1 Motivational Interviewing, Co‐occurring competency, Baker Act, Marchman Act, Chronic medical conditions, Depression Screening, Suicide Screening and Prevention

Supervisor 0.1 FTE Experience in supervision of behavioral health programs

This program will also partner with local providers and organizations in the community to

encourage active participation in these programs from both a clinical and operations

perspective.

Collaboration with Stakeholders This proposal will be supported by Manatee County EMS, Manatee Memorial Hospital, and Centerstone of Florida. Additionally, it is supported by the Manatee Health Care Alliance (MHA), whose broad membership under the facilitation of DOH‐Manatee includes representatives from local governments, universities, hospital administrators, non‐profit and private business representatives, equality advocacy organizations, and concerned citizens. With the support of the MHA, the group will plan the initiative, conduct the study, and disseminate study results. Patient, family member, caregiver, and organizational representative input will be methodically solicited via focus groups and programmatic evaluation and included in program

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development and study results. Partner agencies will work with stakeholders to develop and deploy a marketing and outreach plan targeting the focal population The marketing and outreach plan will be robust, culturally competent, and bilingual. Stakeholders identified in the 203‐2015 community health assessment will assist with this process. Additionally, project partners will coordinate with the United Way of Manatee County to insure the new healthcare model is incorporated into 2‐1‐1, an easy to remember three digit phone number which connects callers with an information and referral specialists.

Intended Outcomes of ICN

Reduced inappropriate ED utilization

Increased patient access through utilization of alternative sources

Improved health outcomes of chronically ill

Reduced hospital readmissions

Decreased inappropriate utilization of emergency medical services

Transition toward population health management

4.7 Evaluation Plan The success of this program will be evaluated in terms of the Triple Aim set forth by the

Institute for Healthcare Improvement: better healthcare, better health, lower costs. In terms of

better healthcare, this program will focus on addressing patient satisfaction and experience,

resource utilization clinical quality, and patient access. With better health, there will be an

increased focus on improving the overall health of a population in terms of both individual and

population health. Finally with lower costs, the goal is to reduce the total per‐capita costs of

healthcare and to focus on the costs to the patients as well as the healthcare system.

The program evaluation process will include a compilation of collected data into relevant

performance measures, the benchmarking of results against established performance targets,

and the use of effective reporting tools to provide a combination of patient‐centered, payer‐

centered and community health‐focused reporting. Once the evaluation is complete, the

results will be made available to all program partners.

In the initial phase, the program will have evaluations every month after implementation. The evaluations will focus on overall program performance, by direct patient populations after the reduction of Emergency Room diversions. Improved outcomes are expected in the six domains outlined below. Referral Process. Three outcomes related to the Referral Process will be tracked:

1) Evaluation of number of patient referrals. 2) Evaluation of number of participating community partners. 3) Evaluation of community resource locations.

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Within the first six months, the Community Paramedic Program seeks to include 30% or greater

of the County funded Providers. This process is projected to add an additional 5% of County

funded Providers every six months.

Frequent Emergency Department and EMS System Users. Frequent emergency department and

EMS system users will be identified and monitored as follows:

1) Community Paramedic program activation with 3 system uses within a 30‐day period.

2) Evaluation of appropriate diversion of program patients.

The Community Paramedic will make contact with a patient after any three emergency

department visits, any three ambulance transports, or a combination of the two within a 30‐day

period.

Bed Hours Saved. Four outcomes related to Bed Hours Saved will be tracked:

1) Emergency Room visit diversions.

2) Readmissions reduction.

3) Total bed hours saved. 4) Total health system savings.

The Community Paramedic seeks to provide the correct referral resources, resulting in a

reduction in Emergency Room visits, hospital readmissions, and an overall cost savings related

to decreased bed hours.

Patient and Network Provider Satisfaction. Pre‐ and post‐service surveys will be used to

evaluate four outcomes:

1) Overall program satisfaction of services rendered

2) Total number of active registered patients within the program

3) Increase in health education knowledge 4) Intended behavior modification

Program Discharge. The program will monitor the amount of time needed for patients to be

discharged from the community paramedic program.

1) The number of patients who “graduate” the Community Paramedic Program with long

term referral to outside resources will be recorded and reported.

Quality Assurance. Three outcomes will be monitored for Quality Assurance:

1) Peer review of patient charts. 2) Tracking of outcomes.

3) Sharing of data with local partners.

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The program seeks to maintain a medical quality assurance following Florida statute 401,

utilizing a peer review process. Patient outcomes and established benchmarks will be

monitored. Data will be gathered and shared with participating community partners.

Overall program success will be measured by the multiple system benchmarks. This will allow

program manager to redirect, improve, and prioritize program needs to ensure overall success.

The program manager will periodically meet with community stakeholders and reevaluate

community health care gaps annually.

4.8 Budget Summary and Budget Narrative This project seeks to provide start‐up and implementation funds for a comprehensive system to

address gaps in healthcare coverage for Manatee County’s robust uninsured and underinsured

population, while simultaneously reducing health care costs. This proposal is being submitted

with the consent and urging of all listed ICN partners and Manatee County Government.

Following the funding period and project implementation, partners will incorporate evaluation

findings to improve methodology and reduce healthcare costs, allowing ICN partners and

Manatee County to sustain future programmatic expenses. The project budget summary and

budget narrative are presented below.

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Budget Summary

Operating Expenses

Mobile Integrated Healthcare Program 7‐months Program Manager and Paramedics (1) 99,462

Benefits (1) 52,956

Vehicles (2) 90,000

Portable Radio/Computer/Monitor (4) 88,795

IT Maintenance Replacement (4) 4,500

Gas / Oil (2) 11,242

Support Costs (Marketing) (3) 5,159

Training (5) 3,600

Vehicle Maintenance / Replacement (2) 14,042

Total Mobile Integrated Healthcare Program 270,294

Mobile Clinic

Mobile Unit (6) 235,000

Insurance (6) 14,000

Gas/Oil (6) 7,000

Maintenance (6) 3,000

Equipment (7) 17,500

Clinic Manager (8) 23,000

Nurse Practitioner (9) 59,500

Medical Assistants (10) 52,240

Total Mobile Clinic Program 411,240

Mental Health Program

Salaries (11)(12) 36,722

Benefits (11)(12) 10,016

Internet/ IT Replacement (13) 801

Insurance / Phone (14) 1,481

Vehicle Insurance (15) 1,138

Gas / Oil (15) 1,260

Vehicle Maintenance / Replacement (15) 4,935

Administrative costs (16) 8,000

Total Mental Health Program 64,353

Health Information Exchange

Centerstone HIE Implementation (17) 48,040

EMS HIE Implementation (17) 25,000

Total HIE Expenses 73,040

Total Operating Expenses $ 818,927

Budget Narrative

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Budget Narrative

Expenses Justification

(1) MIHP Salaries These funds will be used for salary and benefits of two of 20 hour weekly community paramedic positions and one 40 hour Program Manager. The positions will be filled by existing paramedics who will each require completion of a 280 hour training class and 140 hour clinical rotation, to be provided by Manatee Technical College, in partnership with MMH and Centerstone of Florida. Following training, a community paramedic will operate between the hours of 9am to 9pm, seven days a week, excluding holidays.

(2) MIHP Vehicles These funds will be used to purchase, fuel, and maintain two vehicles to support MIHP. One vehicle will be for the manager to use for stakeholder meetings, scheduling of programs, and community engagement initiatives. The other vehicle will be used for the community paramedic in the field. Manager vehicle available for other community paramedic use, as needed.

(3) Marketing These funds will be used for development and printing costs for educational campaign to target patients for MIHP and mobile clinic. Included in this are the plans to incorporate program into 2‐1‐1, an easy to remember three digit phone number which connects callers with an information and referral specialists. Participating agencies will work with community stakeholders to develop culturally competent and bilingual marketing and outreach materials.

(4) MIHP Equipment Costs These funds will be used to purchase equipment including computer, monitor, portable radio, IT support, cell phone and maintenance, marketing supplies, and other supplies (stethoscope, EKG, pulse oximeter, thermometer, and glucometer) necessary for operating MIHP.

(5) MIHP Training These funds will be used toward development and instruction of a 280 hour training course for four community paramedics. Current EMS paramedics will be identified for the community paramedic training, and will be paid salary while undergoing training. By training four paramedics, there will always be a community paramedic available to fill weekly hours.

(6) Mobile Clinic Unit These funds will be used to purchase a mobile clinic (specially designed bus) which will provide accommodations for laboratory services and comprehensive primary care, including dental, behavioral health, health education, and OB‐GYN services. These funds will also be used to maintain the maintenance, insurance, and fuel for the mobile clinic over the 7 month project period.

(7) Mobile Clinic Equipment

These funds will be used to purchase medical equipment such as stethoscope, blood pressure cuffs, EKG, etc. for use in the mobile clinic.

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(8) Mobile Clinic Manager These funds will be used to employ a clinic manager to manage all mobile clinic operations including supplies, scheduling, community engagement, and marketing.

(9) Mobile Clinic Nurse Practitioner

These funds will be used to employ a family practice/internal medicine nurse practitioner, who will be critical in chronic disease management and providing primary care services for mobile clinic.

(10) Mobile Clinic Medical Assistant

These funds will be used for the mobile health clinic to employ two medical assistant to assist with intake, patient history, phlebotomy, and patient health education The Medical Assistants will also be trained and able to drive the mobile unit.

(11) Behavior Health Licensed Clinician

These funds will be used to provide salary and benefits to a LMHC/LMFT/LCSW who will provide behavioral health training to MIHP and mobile clinic staff; as well as behavioral health crisis intervention, engagement, assessment, certificate for involuntary examination, referral and resource linkage, behavioral health transportation, depression screening, suicide screening and prevention to target populations via MIHP and mobile clinic.

(12 ) Behavioral Health Clinical Supervisor

These funds will be used to offset applicable salary and benefits costs for program collaboration and clinical oversight of behavioral health component.

(13) Behavioral Health Internet and IT

These funds will be used toward internet and IT costs necessary for managing off‐site behavioral healthcare practice via MIHP and mobile clinic.

(14) Behavioral Health Insurance and cell

phone

These funds will be used toward cell phone and workman’s comp insurance for behavioral health care staff being utilized for MIHP and mobile clinic.

(15) Behavioral Health vehicle

maintenance, insurance, gas/oil

These funds will be used toward maintenance, insurance, and fuel for crisis vehicle to be used when non‐emergency crisis patient transport is needed to Centerstone behavioral health facilities, as EMS does not have the capacity to provide transport anywhere other than ED.

(16) Behavioral Health administrative

costs

These funds will be used toward indirect administrative costs, including office space, human resources, resouces, and administrative staff support.

(17) HIE Implementation These funds will be used to develop interfaces to be built for HIE with Centerstone and EMS, thus reducing duplicative services.

grant submission

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