Coordinated By:
Medical Neighborhood Learning Group Work Session March 2, 2016 Record of Learning Meeting Participants Deena Chisolm, Nationwide Children’s Hospital Denise Bugara-Dlugo, Ripple Life Care Planning Kristin Casper, Charitable Pharmacy of Central Ohio Courtney Elrod, AIDS Resource Center Ohio Julie Erwin Rinaldi, Syntero, Inc. Cindy Farson, Central Ohio Area Agency on Aging Linda Gillespie, Central Ohio Area Agency on Aging Jeannette Harrison, National Alliance on Mental Illness Dottie Howe, CliniSync Karen Jibou, Asian American Community Services Matt Kehlmeier, National Church Residences
Liz Kitchen, Ohio Department of Health Rose Kramer, Franklin County Public Health Patty Lattimer, Mount Carmel Medical Group Naomi Makni, Nationwide Children’s Hospital David Maywhoor, UHCAN Ohio Bella Mehta, Ohio State University College of Pharmacy Colleen O’Brien, The Ohio State University Wexner Medical Center Rhiannon Richman, Ohio Department of Health Marian Stuckey, Columbus Public Health King Stumpp, Netcare Access Matt Yannie, United Way of Central Ohio
Review of the Accountable Health Communities (AHC) Model and Collaborative Grant Work The AHC Model is designed to address a critical gap between clinical care and community services in the current health care delivery system by testing whether systematically identifying and addressing the health-related social needs of beneficiaries’ impacts total health care costs, improves health, and quality of care. The grant will award funding for five years that will be used to enhance patient navigation and community service alignment in a target area. Additional information on the AHC Model and the grant can be found by clicking here. Based on feedback from community partners, Nationwide Children’s Hospital and the Healthcare Collaborative of Greater Columbus have been leading a collaborative application process for the AHC Model Grant. The application is being shaped by a diverse group of community stakeholders. If your organization is interested in participating in this process please contact Michelle Missler (michelle@hcgc.org), or Deena Chisolm (deena.chisolm@nationwidechildrens.org). Identify services available in our region that align with the AHC Model health-related social needs The AHC Model requires communities to focus on five core health-related social needs. Communities can also choose to include supplemental health-related social needs in their application. Collaborative partners in our region have decided to focus the grant application on the five core needs, but encouraging patient navigators to assist patients with supplemental needs when they are present. The areas of health-related social needs identified in the grant are listed below: Core Needs (Required) o Housing Instability o Utility Needs o Food Insecurity o Interpersonal Violence o Transportation Supplemental Needs o Family & Social Support o Education o Employment & Income o Health Behaviors o Other Work session participants spent time identifying organizations in our region that offer services for the health-related social needs targeted by the AHC model. To view a list of organizations identified, please click here. NCH and HCGC will use this list to begin building a partnership of Community Service Providers for the grant application.
Closing Participants will continue to be engaged in the process of creating a collaborative AHC model grant application. Results of the value survey administered at the conclusion of the session are listed below. Meeting Scheduled All sessions hosted at the Nationwide & Ohio Farm Bureau 4H Center from 8:30 – 10:00am May 4, July 6, September 7 www.hcgc.org/medical-neighborhood-learning-group/
Learning Session Value Survey Very High High Medium Low No
xxxxx (5) xxxxxxx (7) xxx (3)
What are the key reflections you are taking away from today’s session?
A single record where patient doesn’t keep filling out applicationstracking tool Alignment is needed to have a coordinated system Basics of AHC grant opportunity Better understanding of the grant and goals. Focus needs to be on alignment of system and system policies; not individual Good conversation of available resources. Great to brainstorm social services, learned of a few I wasn’t aware of. I’m excited about the energy from the providers about working together to better serve the community. It’s an ambitious project, but well worth the effort. Appreciate NCH & HCGC taking the lead. I hope the work continues even if we don’t get the grant. Looking to fold in some of our special needs and underserved populations with this program. Multiple organizations provide similar services. Need for alignment among programs across Central Ohio. Need to inventory services related to core health-related social needs. Needed an understanding of this AHC grant. Got that. Glad the community is giving this a shot. No funds available to providers to gather AHC data Resources available in the community to utilize for patient navigation. Same challenge different path Status of AHC grant The need to figure out navigation and how that will work with existing systems. There are many other organizations in Central Ohio who should be involved (see extensive list from harvest sheet) Third time doing service inventory. Can we have other discussion question please? Using healthcare delivery as a foundation to integrate other parts of the service delivery system.
What healthcare transformation topic(s) should we consider discussing at future learning sessions?
Agencies merging their programs and offering a collaborative, more streamlined service. Continue to look at bringing community services together even if we don’t get the grant.
Dental Franklin County Community Pathways HUB. Overview when appropriate and how it aligns with MNRI/AHC Having presentations from social service agencies to share details of what’s being done and currently available. How to better collaborate with the service providers at the table. Involving dentists Learn more about existing Medical Neighborhood and expansion to include these organizations. Population health initiatives Social determinants of health are driving poor outcomes.