Community Health Collaboration and Implementation Plans in Georgia

1. COMMUNITY BENEFIT COLLABORATION • Approach to understanding community health challenges, assets and drivers • Data elements/sources • Summarized story • Approach to designing implementation plans • Current status of implementation

2. BACKGROUND • Kaiser Permanente of Georgia (KPGA) and Grady Health Systems (GHS) partnered with Georgia Health Policy Center to complete CHNA and implementation plan for each system • Considered the specific needs of each community/ service areas; GHS with Fulton and DeKalb service region and KPGA with 30 additional counties (with implications for design of implementation plan) • Alignment with Atlanta Regional Collaborative for Health Improvement (ARCHI) areas of focus was an important consideration in development of implementation plans • Priorities for the Atlanta Region : • Encouraging healthy behaviors • Family pathways to advantage • Coordinated care • Global payment • Capture and reinvest savings • Expand insurance • Innovation fund

3. GHS SERVICE AREA H 1,000+ 400 - 999 200 - 399 50 - 199 0 - 49 Source: Grady Decision Support

4. KPGA SERVICE REGION Kaiser Medical Offices Outline of KP-GA Service Region Clayton Meriwether

5. CRITERIA * ARCHI – Healthy Behaviors, Pathways to Advantage, and Care Coordination

6. GHS PRIORITIES

7. GHS IMPLEMENTATION STRATEGIES

8. GHS IMPLEMENTATION STRATEGIES

9. KPGA HEALTH NEEDS CHECKLIST Health Needs Drivers Drug/Alcohol Abuse Educational non-attainment Health Care Inaccessibility Physical Inactivity Poor Nutrition Poverty Tobacco Use • Asthma • Cancer • Diabetes • Heart Disease/Attacks • Hypertension • Low birth weight infants • Mental Health • Obesity • Sexually Transmitted Diseases • Teen Pregnancy

11. KPGA PRIORITIES The primary foci of activity for the next 3 years: • Overweight and obesity control • Diabetes prevention and management • Heart attack and stroke prevention and management • Access to care • Educational attainment and health literacy

12. KPGA IMPLEMENTATION STRATEGIES

13. KPGA IMPLEMENTATION STRATEGIES

14. KPGA IMPLEMENTATION STRATEGIES

15. KPGA IMPLEMENTATION STRATEGIES

16. EXAMPLES OF CURRENT COLLABORATION

17. COMMUNITY CARE MANAGEMENT Project Title: Enhancing Patients’ Lives through Community Care Management Piedmont/Kaiser collaboration provided health care and community resource linkages to low-income, non-Medicare Charity Care-eligible patients with complex, chronic diseases at or below 200% of the Federal Poverty Level to reduce avoidable hospital readmissions and emergency room visits by 20%. Impact and Lessons Learned • The project served 352 patients and 324 caregivers (proposed 961 patients and 961 caregivers). Only 3% of program participants were readmitted to the hospital within 60 days. The hospital’s average readmission rate is 11%. • Over 11,000 telephone support calls, 270 home visits, almost 1,000 contacts with physician offices and made transportation arrangements, community resource linkages and provided pharmacy assistance. • Patients’ health was positively impacted as demonstrated by improved PHQ-9(Patient Health Questionnaire) and PAM (Patient Activation Measure). • Clients needed help addressing their social barriers to accessing care. • Telephonic model didn’t work well, so Piedmont switched to a social medicine model of care, which focused on the sociological factors that contribute to illness. • Patients are able to manage their own care when given the necessary tools. • Low-income patients are more quickly labeled “noncompliant”

18. ATLANTA SAFETY NET COLLABORATIVE • Kaiser Grant for Grady Walk-In Center and Patient Navigator Program • New site on Grady campus for “walk-ins” (Considered FQHC management) • Patient navigators located in the walk-in center, all 4 FQHCs and Grady primary care • 7 navigators • Navigators provided patient education regarding PCMH and scheduled follow up appointments to FQHCs or a Grady clinic • Challenge in getting patients to leave Grady System • History/culture • Co-pays • Impact • While program did not drive down ED volumes as anticipated, ambulatory sensitive conditions decreased as a percent of total volume • Program created a platform for further collaboration among safety net

19. ATLANTA SAFETY NET COLLABORATIVE • United Way Community Health Worker Program • Building on Navigator Program, the CHW program targets high-utilizers from the emergency department • 5 CHWs • 2 year program • CHW’s trained for home visits and ongoing support outside of clinical visits • With underlying behavioral health conditions of high-utilizers, program was re-directed to focus on patients with high-risk for re-admissions • Continue to have the goal of referring patients without a medical home to the FQHCs and Grady clinics • Impact • One year into the program, initial results indicate reduced re-admission rate for patients assigned a CHW • No determination of impact on patients adopting PCMH

20. MODEL FOR REPLICATION New Program developed – Sams Care Program Primary goal: To increase access to necessary care for uninsured community members in Piedmont’s service communities, avoiding preventable emergency department re-encounters, building upon successes and lessons learned through Piedmont/Kaiser collaboration Primary activities: • Deploy EPIC into three charitable clinics – Fayette CARE Clinic (Fayetteville), Coweta Samaritan Clinic (Newnan) and Hands of Hope (Stockbridge) • Provide for midlevel staffing to expand clinic capacity • Provide for licensed medical social worker to address socioeconomic issues • Create streamlined ED referral process • Measure and capture patient care outcomes, impact on hospital, impact on community • Establish sustainable funding for program • Deploy “phase two” components – disease management, further ED integration

21. OPPORTUNITIES FOR COLLABORATIONQ& A