Advancing an Action Plan for Community Health Centres in Rural Communities
• 35 mins of presentation, 25 mins discussion • Goals: • • • •
Evolution of CHC organizations Common challenges & opportunities in rural communities Specific value proposition for rural communities Initiate discussion/planning for national strategy and working group on rural CHCs across Canada
Lorraine Burch General Manager Our Health Centre (Chester, NS)
Lyn Linton Executive Director Gateway Community Health Centre (Tweed, ON)
Raymond Babowicz Director of Communications, Government Relations, and Marketing Community Health Center of the North Country (Canton, NY)
OHC: A Community Invests in Health and Wellness Lorraine Burch General Manager
Our Health Centre (OHC): much more than a building • 2005-2012: a vision to achieve “healthy people, healthy communities • Assessment of health and medical needs highlighted: • limited services available in the region • a collaborative health care delivery model was the way of the future
• 2012-2016: Capital Campaign; doors opened in Dec 2016
The Vision As a collaborative health centre, OHC promised to: • Provide health and wellness programs for residents of the Municipality of Chester and surrounding areas • Attract and provide space for primary care practitioners, wellness professionals, and visiting specialists • Become a base for the provincial Health Authority’s programs and services, with room for expansion • Offer health-related information and care
The First 18 months • Problems: • Provincial government transitioning from 7 health districts to 1 • Mixed messages • Competing priorities • Lack of communication • Unhappy communities: wait list for doctors, failure to deliver on Capital Campaign promises • Forced to focus on primary care • ‘Partnership’ language not reflected in actions • Made decision to take control where we can
Where are we now? • NSHA Primary Care Clinic: • 5 salaried physicians • 1 Nurse Practitioner • 1 Family Practice Nurse
• • • •
Other community based physicians Other NSHA services: MH&A, Public Health, Continuing Care OHC programs & services- 50+ within first 2 years OHC Walk in Clinic
Ongoing Concerns • The brand “ Community Health Centre” is used by governments but their definition is much different from true community model; also different meanings for the word “collaborative”. • Partnership model difficult to realize.
• Ensuring we deliver the programs & services the community will respond to and which will have an impact on health outcomes. • Paying for quality programs and services.
Next steps • A truly collaborative model/partnership with ALL parties with vested interest. • Continue to advocate for all citizens across their lifespan. • Continue to insist we are part of the solution and need to be at the table with the provincial government. • Broaden our program/service offerings; collect strong data that demonstrates positives outcomes.
• Community outreach: Hub & Spoke model Thank you !
Community Health in Rural Communities Success Opportunities Risks In a Funded Model
GATEWAY COMMUNITY HEALTH CENTRE
TWEED, ONTARIO JUNE 2019
Rural Hastings
15
Rural Hastings
Rural Community Health Centre Future
Present Past
Rural Hastings Health Link (2013)
Gateway CHC
1992
2011: Oral Health 2011: Pharmacist 2013: Chiropody
Rural Hastings Sub Region (2018) Respiratory Model of Care Respiratory Therapist
Complex Patients 2014: Role of System Navigator Return on Investment Population Health Social Prescribing Collective Impact Determinants of Health
Rural Hastings Ontario Health Team (2019) Integrated Systems of care
Profile of Population
6,976 Square Kilometers
Highest Rates for Material and Social Deprivation 67% lowest Income Quintile
66% highest Social Deprivation Quintile
POPULATION 66, 172
26.1% of the population aged 65+ as compared to 16.9% for the province Diabetes at 8.6% (6.8% for the province) Heart Disease at 7.0% (5.0% for the province) COPD at 8.2% (3.9% for the province)
Gateway CHC Resource Investments INTERPROFESSIONAL TEAM CARE Primary Care Investments
Community Health Investments Lacking Investment in Health Prevention & Promotion
Rural Community Health Centre Future
Present
Rural Hastings Sub Region (2018)
Rural Hastings Ontario Health Team (2019)
Respiratory Model of Care Respiratory Therapist Rural Hastings Health Link (2013) Complex Patients 2014-Role of the System Navigator Return on Investment Population Health Social Prescribing Collective Impact Determinants of Health
Integrated Systems of care
Collective Impact within a Regional System Primary Care Gateway Community Health Centre Governance, Vision and Strategy
Central Hastings Family Health Team
North Hastings Family Health Team
Broader Sector Partners Long Term Care
Common Agenda
Bancroft Family Health Team
Addictions & Mental Health Services
Community Care Access Centre
Community Support Services
SE LHIN Hospital (Quinte Health Care)
Hospice
Steering Committee Shared Measurement
Mutually Reinforcing Activities
Broader Sector Partners
Primary Care
Patient Representative
Working Groups Patient Representative
Care Coordination System Planning
Data Quality & Privacy E-System Planning
EOL/ Palliative Care System Planning
Patient Engagement Continuous Communication
Backbone Support
Steering Committee Participants
Adaptive Leadership
Working Group Participants
Communications
Finance
Patient Engagement
E-Health
Patient Feedback
Knowledge Management
Admin Support
Influencing Models for Provision of Care Impacting Social and Medical Complexities
A Registered Nurse System Navigator was embedded in primary care: Hospital
Conducts Home Visits - 100% of complex patients Medical and Social Plan of Care
Primary Care Provider
Primary Care Patient’s Voice
7 day follow - up
Medication reconciliation
System Navigator
Navigates transitions in Care Coordinated Care Plan
Social Supports
Home & Community Care
Community Support Services
Primary Care
Hospice
Addictions & Specialists MH
Monitors ED utilization, hospital admissions and discharges Shared-care planning
Ongoing monitoring & evaluating
Community Assets
Solo Providers
Addressing Social Complexities 100% of complex patients we serve have social complexities Leveraging Community Assets
Connecting to Social Services
Churches The Legion Service Clubs Alzheimer’s Society Library
Provincial and Federal Income Support Programs Legal Services Housing (maintenance) Community Support Services Housing applications
52% report Low Income
Reducing Social Isolation Home visits to assess home environment Connecting to community social groups
56% Report Social Isolation
55%
64% Transportation Barriers
Ensure Food Security Local food banks Community diners Meals on wheels Meal planning on a limited budget
report barriers to accessing and affording food
Return on Investment Population Health
Medically Complex
Socially Complex
Integrated Plan of Care
Reduction of Costs
From October 1, 2013 to March 31, 2019 in Rural Hastings
Patient & Provider Experience
Improved health outcomes Seamless Transitions System Integration Return on Investment
ďƒź Net program benefit or a cost savings of $5, 806, 590 ďƒź Return on investment of 352%, or for every $1 invested we return $3.52 back to the system.
Rural Sub Regional System of Care Present
Rural Hastings Sub Region (2018) Respiratory Model of Care Respiratory Therapist
Future
Rural Hastings Ontario Health Team (2019) Integrated Systems of care
Rural Hastings SUB REGION SYSTEM OF CARE
Integrating Social Complexities within Clinical Practice
Ontario Health Teams Future
Ontario Health Team (2019)
ďƒź Integrated Systems of care
Simple
Complicated
Complex
Making Soup
Sending a Rocket to the
Raising a Child
Moon
Right recipe essential Gives same results every time
KNOWN
Formulae & experts needed, Experience built over time and can be repeated with success
KNOWABLE
No right recipes or protocols, Outside factors influence, Experience helps, but doesn’t guarantee success
UNKNOWABLE
Source: Brenda Zimmerman, late Director of Health Industry Management Program, Schulich School of Business
Success RHHL / Sub-Region CHC Leadership Introduced Quadruple Aim Promoting System Transformation Creating Spread SDH Established Trusted Relationships Introduced new concepts System Navigation ROI / System Costs Created a platform for health system evolution Experience in a Regional System of Care
Opportunities Ontario Health Teams Influence Rural Focus Innovation Demonstrate CHC Value within a system of care Build on Trusted Relationships & Success RHHL / Sub-Region
Risks Ontario Health Teams CHC Model of Care Health Promotion Health Equity Addressing Social Complexity CHC Culture Funding
Thank You Contact Information Lyn Linton: llinton@gatewaychc.org Julia Swedak: jswedak@gatewaychc.org Web Site www.gatewaychc.org
Since 1965 Expanding Access, Improving Outcomes, Lowering Costs
• Located in high-need areas identified by federal government as having elevated poverty, higher than average infant mortality, and few physicians • Offer services that help their patients access health care, such as transportation, home visitation services, translation, case management, and health education. • Tailor their services to fit the special needs and priorities of their communities. • Funded under Section 330 of the Public Health Service Act • $25,597,401,177 in 2017 or $941.97/per patient
• Federal Tort Claims Act (FTCA) • HRSA-supported health centers may be granted medical malpractice liability protection with the Federal government acting as their primary insurer.
• National Health Service Corp (NHSC) • Builds healthy communities by supporting qualified health care providers dedicated to working in areas of the United States with limited access to care. Loan repayment.
National Association of Community Health Centers (NACHC) • 20 national committees focused on issues of strategic importance NACHC Rural Health Committee The Rural Health Committee considers issues relative to health care for individuals and families in rural and frontier areas and makes recommendations to the appropriate standing committees in their respective functional areas.
National Rural Health Association • National nonprofit membership organization with more than 21,000 members. The association’s mission is to provide leadership on rural health issues through advocacy, communications, education and research.
New York State defines a county as being rural if it has a population of less than 200,000. More than two thirds of all New York counties are classified as rural. Every $1 in federal investments generates $9.28 in economic activity across New York State. In total, CHCs in New York State deliver $4.89 billion in economic activity.
Health Centers in NY # of Grantee Organizations
65
# of Delivery Sites % Grantees with PCMH Recognition % Grantees w/ Staff Authorized to Prescribe MedicationAssisted Treatment (MAT) for Opioid Use Disorder
678 95% 54%
% of Grantees Utilizing Telehealth
38%
NY Health Center Patients Children Served Homeless Patients Served Veterans Served Growth in Patients since 2010 Total Patients
656,134 104,968 18,989 50% 2,132,003 NY Health Center Patients
NY Residents
US Residents
% at or Below 100% Poverty % at or Below 200% Poverty % Racial/Ethnic Minority
68% 88% 71%
14% 30% 45%
13% 31% 39%
% Uninsured % Medicare % Medicaid
16% 10% 53%
5% 17% 22%
9% 17% 17%
NY Health Center Staff Provide a Comprehensive Range of Services FTEs
Physicians NPs/PAs/CNMs Nurses Dentists Dental Hygienists Behavioral Health Specialists Pharmacy Enabling Services Vision Other Staff Total Staff
1,275 849 1,852 420 169 951 77 1,878 90 6,433 17,726 Patient Visits
Chronic Conditions
1,902,404
Behavioral Health Preventive Services Dental Services Total Visits
2,342,054 2,666,264 1,280,201 9,854,101
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NYS Delivery System Reform Incentive Payment Program (DSRIP) • Performing Provider Systems (PPS) • Purpose is to fundamentally restructure the health care delivery system by reinvesting in the Medicaid program, with the primary goal of reducing avoidable hospital use by 25% over 5 years.
Community Heath Care Association of New York State (CHCANYs) Fort Drum Regional Health Planning Organization (FDRHPO) • Rural Health Network Development Programs (RHNDP) • Population Health Improvement Programs (PHIPs) • Linking Interventions For Total Population Health (LIFT)
North Country Health Compass Partners • A collaborative of local hospitals, public health agencies, behavioral health providers, prevention councils, insurance providers, community-based organizations and others.
Bridge To Wellness Coalition • An active committee with twenty-six participating organizations including Public Health, higher education, hospitals, Federally Qualified Health Centers and community based organizations. Meetings are facilitated by the Local Public Health Department, and the St. Lawrence County Health Initiative, Inc. Partners work collaboratively to plan, implement and oversee the St. Lawrence County Community Health Improvement Plan and Community Service Plan(s).
Primary Care Associations (PCAs) • PCAs are designated to serve as the major link between community health centers (CHCs), their satellite sites, the Bureau of Primary Health Care of the Department of Health and Human Services and state and local governments. PCAs provide a communication forum for providers of primary health care, relative to administrative, managerial and clinical issues.
WWW.CHCNORTHCOUNTRY.ORG
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Approximately two-in-five adults in the region in 2018 report that they have been diagnosed with at least one of these six chronic conditions (Diabetes, High Blood Pressure, Mental Health, Heart Disease, COPD, Pre-Diabetes. Barriers To Care: • Geographic Isolation • Lack of Transportation • Food Insecurity • Unsafe Housing • Recruitment and Retention of Providers (1 dentist for every 3K residents in St. Lawrence County)
How Community Health Center of the North Country documents & expresses its value: • Patient Centered Medical Home (PCMH) Accreditation Level 3 • A model of primary care developed by the National Committee for Quality Assurance. It focuses on patient-centered care, communication among providers, elimination of duplicate tests and procedures, and greater patient education and access. • HRSA Quality Measures • Delivery System Reform Incentive Payment Program • FQHC Branding
What is the particular value proposition of CHCs for rural communities: • Provide integrated, accessible health and human services; offering those services to people of all income levels. • A healthy community is more likely to be an economically vibrant community. • Triple Aim: More Access, Better Health, Provided at Lower Costs
• Partnerships and collective action through National Association of Community Health Centers (NACHC), Community Health Care Association of New York State (CHCANYS), Fort Drum Regional Health Planning Organization (FDRHPO), and North Country Initiative (NCI) • Collaboration with other FQHCs/sharing of resources • •
Hudson Headwaters helps manage our 340B Program North Country Family Health Center
• Participating in advocacy
• Collaboration with other Community Based Organizations •
i.e. Volunteer Transportation Grant(s) for non reimbursable trips “Rides To Healthier Options”.
• Documenting our impact and value