Island Community Care Project

Connecting People with Community and Health Services

October 11, 2007

Partners

• Healthy Acadia• Maine Sea Coast Mission• Mount Desert Island Hospital

– Behavioral Health Center– Healthy for Life Program– Southwest Harbor Community

Health Center• Hancock County Planning

Commission• Harbor House Community Center

* The Community Care Project received generous support from the Maine Health Access Foundation.

Project Goals and Strategies

Our goals were simple and ambitious

“The Community Care initiative will actively integrate population-based prevention in the community with an individualized care management process in the primary care setting, utilizing evidence based practices to affect behavior change.”

“The goals of this initiative are to: 1. increase self-care behavior, readiness to change, and belief in ability to

change among at risk persons.2. provide strategic access to comprehensive primary care for rural,

medically underserved populations 3. establish structural changes in community settings in support of self care

behavior.”

(Source: Community Care Proposal, submitted May, 2005)

Target Population

• The target population for this initiative included persons who by nature of their employment were:

• uninsured and

• confront occupational and lifestyle risks.

Many people who fell within this category were

• confronting occupational and physical disabilities resulting from workplace injuries and

• chronic conditions such as asthma, obesity, diabetes, depression and cardiovascular disease.

Community Engagement (Goal 1)

• Building Organizational Support for Community Care

• Community Health Outreach Worker - Debra Chalmers– Harbor House

– Food Pantry

• Prescription for Fitness

• Maine Sea Coast Mission

• How’s Your Health?

How’s Your Health?

All Records 177

Younger Women 54%

Older Women 23%

Younger Men 14%

Older Men 10%

Perceived Needs

Bothered by…Part 1

10%16%15%% Dizzy/Fatigue

0%6%5%% Abdominal Pain

5%13%11%% Headaches

2%4%3%% Limited Physical Function (Fitness)

10%10%10%% Limited Social Support

12%12%12%% Limit by Pain

2%5%5%% Limit Social Activities

7%11%10%% Limit by Feelings

5%2%3%% Limit Daily Activities

42135177Bothered (often or always) in the Past Month by:

MenWomenAll RecordsQuestion

Care Quality

31%19%22%% Get Exact Care Needed

60%58%59%% Seldom Wasted Time

57%50%51%% Having Confidence in self-management

52%39%42%% Having Very Easy Access

40%33%35%% Having Perfect Care

79%75%76%% Having a PCP

5%6%6%% Hospitalized for Any Reason in Past Year

27%3%9%% Hospitalized or ED for Chronic Disease

10%25%22% With Sick Days in 3 Months

14%29%26%% unable to participate fully in daily work- 2 weeks

17%13%14%% Taking 3 or more medications

42135177Care Quality Summary

MenWomenAll RecordsQuestion

Health Score

66%63%66%% Problems - Opportunities for Improvement

34%31%31%% Problems - Could be Better

0%5%3%% Problems - Doing Well

45%61%57%% Healthcare - Opportunities for Improvement

31%20%22%% Healthcare - Could be Better

24%19%21%% Healthcare - Doing Well

36%37%36%% Lifestyle - Opportunities for Improvement

61%39%41%% Lifestyle - Could be Better

4%24%22%% Lifestyle - Doing Well

42135177Health Score

MenWomenAll RecordsQuestion

Adapting Clinical Practice (GOAL 2)

Overcoming barriers to health care access

MDI

• Healthy for Life! Nurse Advisor

• Quality Initiative in Primary Care Services

Outer Islands

• Medical support for outer islands

• Sunbeam - On site and Tele-health conducts health screenings and referrals

• Behavioral Health Services expanded in outer islands.

• Expand dental services (prevention, screenings) to outer islands.

Establishing Lasting Community Supports (GOAL 3)

• “Living Well with Chronic Disease” Collaborative effort by Maine’s Office of Elder Services (0ES)

• Exploring creation of Federally Qualified Health Clinic (FQHC) for outer islands.

• New partnership with Southwest Harbor / Tremont Ambulance Service

• Identify ongoing support for health care service – Bingham Foundation

– Island Health Initiative

• Swans Island health committee - Set up lab on Swans Island for blood work

• Changing health behavior - Frenchboro Exercise Equipment, Pedometers

• Identifying new streams of funding for special projects – Right Weight for Me

SustainabilityOur partners are all committed to moving forward with the community care model. • Maine Seacoast Mission

– Relationships have been enhanced between MDI Hospital, Maine Sea Coast Mission – Using new technologies including distance medicine and island health clinics to streamline

staffing • MDI Hospital and the Southwest Harbor Health Center

– Healthy For Life! care manager role • Healthy Acadia partnering with the Maine Nutrition Network and the USDA to secure

funding to address community food security.• Harbor House

– “Prescription for Fitness Program” – Behavioral health support such as “Right Weight for Me” program.

Sustainability will remain a major challenge. • Integrating insured, under-insured and uninsured clients • Insurers are reducing benefits • Clinical programs continually seek alternative funding • Continue efforts for early intervention and preventive care • Pursue reimbursement for case/care management services • Identify local “assets” to support community care through partnerships.