csi ri community health team planning workgroup
Download
Skip this Video
Download Presentation
CSI-RI: Community Health Team Planning Workgroup

Loading in 2 Seconds...

play fullscreen
1 / 22

CSI-RI: Community Health Team Planning Workgroup - PowerPoint PPT Presentation


  • 109 Views
  • Uploaded on

CSI-RI: Community Health Team Planning Workgroup. 11/8/13. Guiding Principles . Triple Aim Utilizes Community Needs Assessment Data Identifies short term measureable gains for high risk, high cost, high impact Brings together resources in community that are effective and non-duplicative

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'CSI-RI: Community Health Team Planning Workgroup' - feleti


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
guiding principles
Guiding Principles
  • Triple Aim
  • Utilizes Community Needs Assessment Data
  • Identifies short term measureable gains for high risk, high cost, high impact
  • Brings together resources in community that are effective and non-duplicative
  • Incorporates responding to BH needs
  • Incorporates ability to manage data for CHT
  • Implements Memorandum of understanding
  • Uses PDSA to try things out
  • Includes metrics to measure success
south county cht report out
South County CHT Report Out
  • Mission Statement
  • Communities to be served; CSI practices
  • Assessment of Community Needs
  • Assessment of other Community Resources
  • Goals/Outcomes
  • Anticipated shared services
  • Staffing Plan
  • Budget Plan
pawtucket cht report out
Pawtucket CHT Report Out
  • Mission Statement
  • Communities to be served; CSI practices
  • Assessment of Community Needs
  • Assessment of other Community Resources
  • Goals/Outcomes
  • Anticipated shared services
  • Staffing Plan
  • Budget Plan
community needs assessment
Community Needs Assessment
  • Hospital Association of R.I. led the Community Health Needs assessment in a timeline to comply with requirements set forth in the ACA and to further the hospitals commitment to community health and population health management
  • Conducted September 2012 – May 2013
  • Memorial Hospital (Care New England Health System) and South County Hospital participated
south county hospital
South County Hospital
  • Identified Areas of Need
    • Access to Care
    • Alcohol
    • Cancer Incidence
    • Immunizations
    • Mental Health Status
    • Overweight and Obesity
south county hospital2
South County Hospital

DIABETES

  • Goal: To promote healthy lifestyles that reduce obesity, improves pre-diabetes awareness, and results in better management of diabetes care (including self-management).
  • Strategies:

1. Improve awareness of healthy lifestyles and prevention of obesity through Community Education and Health Screening Programs

2. Improve access to medical specialists for diabetes and endocrinology

3. Improve diabetes metrics within the Patient Centered Medical Community (PCMC) initiative

4. Maintain and ensure access to formal Diabetes Self-Management Education Programs

south county hospital3
South County Hospital

MENTAL HEALTH AND SUBSTANCE ABUSE

  • Goal: Improve mental health by increasing access to appropriate, quality mental health services including substance abuse services, and improve care coordination across the continuum of care.
  • Strategies:

1. Ensure that the SCHHS collaboratively addresses mental health related needs in the community it serves

2. Enhance access to mental health clinicians in primary care physician offices

3. Improve awareness of warning signs and symptoms of Mental Health and Substance Abuse to help ensure that interventions are managed at the most appropriate level of care

south county hospital4
South County Hospital

CANCER

  • Goal: To provide a multidisciplinary, patient-centered cancer program that ensures a continuum of care that spans prevention, diagnosis, treatment, palliative and hospice care, and survivorship.
  • Strategies:

1. Create a community cancer center facility that supports achievement of the stated goal

2. Ensure the availability and local access to cancer specialists and clinicians for cancers that can be appropriately managed in a community setting

3. Provide community outreach and cancer screening efforts to educate residents about the risk factors for cancer and benefits of early diagnosis

4. Increase the proportion of cancer patients referred to the STAR program service offerings

south county hospital5
South County Hospital

Heart Disease

  • Goal: Reduce the burden of heart disease through early identification, and early and appropriate treatment/management.
  • Strategies:

1. Improve awareness of healthy lifestyles and risk factors for heart disease through Community Education

2. Increase the proportion of adults who have appropriate screening for hypertension and/or high cholesterol

3. Reduce re-hospitalizations rates for adults with heart failure as the principal diagnosis

4. Increase the proportion of heart attack survivors who participate in cardiac rehabilitation program upon discharge

memorial hospital
Memorial Hospital
  • Identified Areas of Need
    • Access to Care
    • Asthma
    • Breast Cancer
    • Cardiovascular Health
    • Diabetes
    • Mental Health Status
    • Overweight & Obesity
memorial hospital2
Memorial Hospital

Implementation Plan

  • Mental Health and Substance Abuse
    • Goal 1: Decrease morbidity from diabetes and heart disease among persons with mental illness, including substance abuse disorders.
    • Goal 2: Improve mental health by increasing access to appropriate, quality mental health services including substance abuse services.
  • Heart Disease
    • Goal 1: Increase the number of women who are aware of their risk for heart disease.
    • Goal 2: Reduce heart disease through early identification, and early and appropriate treatment/management.
  • Diabetes
    • Goal 1: Increase the number of people who are aware of the risk factors for diabetes.
    • Goal 2: Increase diabetes self-management education for people living with diabetes.
medicare ffs
Medicare FFS

Extracted from Presentation: “Readmissions in Rhode Island: Deep Dive into the Data.” Butterfield, Kristen

slide16
Extracted from Presentation: “Readmissions in Rhode Island: Deep Dive into the Data.” Butterfield, Kristen
medicaid top 5 high cost members
Medicaid Top 5% high cost members
  • Mental Deficiency or Retardation
  • Psychosis, Neurosis, Depression, Psychotherapy
  • Septicemia
  • Autism
  • Renal Failure
  • COPD
  • Diabetes Mellitus
  • Coronary Artery Disease
  • Cerebral Palsy-Infantile
  • Pneumonia
medicare top 5 high cost members
Medicare Top 5% high cost members
  • Renal Failure
  • Septicemia
  • Fractures
  • Psychosis, Neurosis, Depression, Psychotherapy
  • Congestive Heart Failure
  • Pneumonia
  • Stroke, Cerebral
  • Coronary Artery Disease
  • Aortic or Mitral Valve Disease
  • Prosthetic Device Complication
commercial top 5 high cost members
Commercial Top 5% high cost members
  • Pregnancy
  • Psychosis, Neurosis, Depression, Psychotherapy
  • Coronary Artery Disease
  • Osteoarthritis
  • Cancer-Breast
  • Renal Failure
  • Fractures
  • Newborn child-Single
  • Spondylolisthesis or Spondylosis
  • Congenital Heart Disease
potential community resources peer navigators
Potential Community Resources: Peer Navigators

Presentation by Bill McQuadeD.Sc.MPH

Chief Health Program Evaluator

_______________________________________

Evaluation report on Peer Navigators

“Community Health Workers: A Review of Program Evolution, Evidence on Effectiveness, Value and Status of Workforce Development in New England” (5/24/13 Institute of Clinical and Economic Review )

community resources team members
Community Resources/Team members

Other resources/team members to consider based on community needs assessment

  • Pharmacy ?
  • Care Links ?
  • Community of Care Expansion?
  • Other?
ad