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The second community: Franklin County Maine: Socio-economic status is not destiny

The second community: Franklin County Maine: Socio-economic status is not destiny. NB Record, MD Sandra Record RN FCHN & ScoreHealth System 2010. Franklin County, ME in the 1960s: Death Rates Exactly As Predicted By Socioeconomics. SHS-PCMH. 3. 1970-1994: Mortality Outcomes

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The second community: Franklin County Maine: Socio-economic status is not destiny

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  1. The second community: Franklin County Maine: Socio-economic status is not destiny NB Record, MD Sandra Record RN FCHN & ScoreHealth System 2010

  2. Franklin County, ME in the 1960s:Death Rates Exactly As Predicted By Socioeconomics SHS-PCMH 3

  3. 1970-1994: Mortality Outcomes Franklin…lowest death rate despite low income SHS-PCMH 4

  4. In 2010, Franklin County, ME Health Behaviors Better Than Predicted By Socioeconomic Factors Franklin County, ME Actual Predicted

  5. In 2010, Franklin County, ME Clinical Care Better Than Predicted By Socioeconomic Factors Franklin County, ME Actual Predicted

  6. In 2010, Franklin County, ME Health Outcomes Much Better Than Predicted By Socioeconomic Factors Actual Franklin County, ME Predicted

  7. How did we get here?The Franklin-ScoreHealth Model

  8. ScoreHealth 3-Person Team: Effective, Efficient Proactive Patient and now Interconnected ! WebScore Caring Coach, Nurturing Nurse Deliberative Doctor FullScore ScoreConnect EMR HL-7 Interface

  9. ScoreHealth supports cost-effective nurse care managers, who… Frequently see their patients in-person. Teach their patients how to take their medications. Interact frequently with their patients' physicians. Work closely with local hospitals. Manage patients who are neither too well nor too sick to make a difference. "Effects of care coordination... among Medicare beneficiaries..." JAMA 1/11/09;301(6):603-618.

  10. If we want to continue to achieve best health outcomes…

  11. We must continue to attend to all health factors…not just clinical…forever.

  12. The Traditional Hospital Model Hospital takes care of sick people from surrounding communities and refers as needed for tertiary care.

  13. An effective health system based ACO Hospital also reaches out to people and communities it serves with comprehensive measures to promote health and prevent disease.

  14. What improving community health is really like on the front lines!

  15. Every morning in Africa, a gazelle wakes up. It knows it must outrun the fastest lion to survive.

  16. Every morning in Africa, a lion wakes up. It knows it must outrun the slowest gazelle, or it will starve.

  17. Whether you're a lion or a gazelle - when the sun comes up, you'd better be running!

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