Harford County Local Health Improvement Coalition Update

Susan Kelly, EHSHealth Officer

Russell Moy, MD, MPHDeputy Health Officer

November 12, 2014

www.harfordcountyhealth.com/

Our Local Health Improvement Coalition (LHIC)Where have we been, where are we headed?

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State Health Improvement Process (SHIP) launched in Sept 2011

Harford County Local Health Improvement Process (LHIP)

launched in Dec 2011

Harford County Community Health Assessment (CHA) & Community Health

Improvement Plan (CHIP) released Dec 2012

Harford County LHIC Progress Check on the CHIP in Oct 2013 & Oct 2014

Strengthened Local Health Department, Local Hospital & Healthy Harford LHIC

Collaborative Efforts in 2015

How We Built on Harford County Efforts

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Health Care Reform Mandates

Harford County Health Department

SHIP CHA Mandates

Upper Chesapeake Health CHNA

Mandates

HARFORD COUNTY LHIC COMMUNITY HEALTH IMPROVEMENT PLAN

E m e r g i n g C o n s I d e r a t I o n sAccess to Care, Chronic Disease Prevention, Health Disparities

How We Identified the County’s Health Priorities

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Obesity Prevention/ Healthy Eating &

Active Living

HARFORD COUNTY LOCAL HEALTH IMPROVEMENT COALITION PRIORITIES

Tobacco Use Prevention/ Smoke-

Free Living

Behavioral Health/ Mental Health & Substance Abuse

Prevention

Community EngagementAccess to Healthy Foods

Built Environment

E-CigaretteMinors’ Access

Multi-Unit HousingOther Policy Efforts

PreventionIntervention

Recovery Framework

Harford County, Maryland

Community Health Improvement Plan,

December 14, 2012

Our Community Health Improvement Plan released in December 2012 showed . . .

• Harford County’s Community Health Improvement Plan is a long-term, systematic process for addressing issues identified in its Community Health Assessment in order to improve health outcomes. Strategies include:

• Obesity Prevention– Increasing access to healthy foods– Enhancing the built environment– Creating a “Community of Wellness”

• Tobacco Use Prevention– Promoting community awareness– Encouraging workplaces to be smoke-free– Policy changes regarding sales to minors

• Behavioral health– Integrating and improving the delivery of

substance abuse and mental health services

Where Are Our Hot Spots?

6Source: US Census Bureau, 2010 dataHouseholds with median incomes 80% below the median household income for Harford County

Low-income, high risk areas in the County include Edgewood, Aberdeen, Havre de

Grace & Bel AirBel Air

EdgewoodAberdeen

Havre de Grace

What Were Our Opportunities?

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Maryland Community Health Resource

Commission (CHRC)

Grant Opportunities for

(1)Expanding Access to Care

(2)Expanding Care Coordination

Upper Eastern Shore Connector Entity

Seedco Inc. Subcontracts for Maximizing

Insurance Coverage through(1)Assisters

(2)Patient NavigatorsMedicaid Expansion

DHMH/LHD MCHP Programs  

Community ConnectionsHealthy Harford Inc.

HomevisitingSchools/Libraries/CBOs

Faith-Based GroupsSocial Service Organizations

Others

Clinical Safety Net ServicesHCHD Clinical Services

Upper Chesapeake Health ServicesHealthLink

West Cecil FQHCCommunity Healthcare Providers

Others

Maximize Insurance Coverage“Care Coordination Plus”West Cecil FQHC Satellite

Beacon Health in Havre de Grace

increases access to care

How Did These Opportunities Come Together?

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CHRC LHIC GrantMaryland Community Health

Resources Commission (CHRC)4 Care Coordinators (HCHD)

Connector Entity Assister Grant

Seedco Inc/MHBE4 Assisters (HCHD)

Connector Entity Navigator Grant

Seedco Inc/MHBE5 Patient Navigators

 (Harford Community Action Agency)

DHMH & DHR Medicaid

Medicaid/MCHP Enrollment(HCHD/DSS)

 

TeamCare Coordinator

Assister & Navigator

TeamCare Coordinator

Assister & Navigator

TeamCare Coordinator

Assister & Navigator

TeamCare Coordinator

Assister & Navigator

Bel AirAddictions, HIV,

HCH, DSS, UCMC ED

EdgewoodFP, STD, WIC, Dental,

Immunizations

AberdeenWIC, Homevisiting, Teen

Diversion

Havre de GraceHealthLink, Harford Memorial ED

Clinical Safety Net Services Follow Up & ReferralsMental Health, Substance Abuse, HIV, HCH, FP, STD, WIC, Immunizations, Dental, HealthLink, Core Service Agency,

Breast & Cervical Cancer Program, CRF Colorectal Cancer Program, Community Providers, Others

Community Connections & ReferralsHealthy Harford Activities, Homevisitng, Faith-Based Groups, Libraries, Colleges/Schools, Social Service Organizations, Civic Groups, Others

What Were Our Results?

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Goal 1 – Maximize Health Insurance Coverage

# Screenings for insurance status Target 6,400 – Actual 8,080

# Individuals referred to Assisters, Navigators or Caseworkers Target 640 – Actual 912

# Individuals with Medicaid/QHP referred to Care Coordinators

Target 640 – Actual 314

Goal 2 – Improve Care Coordination

# Individuals offered Care Coordination Plus services

Target 320 – Actual 916

# Individuals who sign “Reverse Consent” form allowing contact with

other programs/servicesTarget 320 – Actual 174

# Individuals completing Care Coordination Plus follow up

Target 160 – Actual 174

Goal 3 – Improve Community Mental Health

# Healthcare professionals who received suicide

prevention/depression risk assessment training

Target 50 – Actual 58

# Individuals enrolled in Care Coordination Plus referred to

behavioral health servicesTarget 50 – Actual 42

# Individuals enrolled in Care Coordination Plus who accessed

behavioral health servicesTarget 25 – Actual 32

What Were Our Lessons Learned?

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LESSON 1 Access to Care is not just about health insurance coverage – It’s about finding the right provider, navigating the healthcare system & overcoming other barriers to care.

LESSON 2 A Big Need for Care Coordination Exists – and not just for those with Medicaid and Qualified Health Plans, but those with other private commercial insurance too.

LESSON 3Effective Care Coordination is more than just giving out pamphlets & phone calls – It is labor-intensive follow up that depends on (1) the trust relationship between the individual and the care coordinator, and (2) the collaborative relationships among community organizations and clinical safety net providers.

LESSON 4Meaningful Evaluations require access to shared data and real money for analytic purposes – money not to be diverted from the service delivery program.

What Are Our Expected Future Activities?

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Harford CountyCommunity Health Team“Care Coordination Plus”

Addressing wrap-around supports: Harford County Health Department Upper Chesapeake Health Healthy Harford Harford County Government Schools, CBOs, Social Service Agencies Others

Harford County

Provider Care Team“Case Management Plus”Addressing chronic disease management:

Upper Chesapeake HealthHarford County Health Department

Healthy HarfordWest Cecil FQHC

Community Healthcare ProvidersOthers

Shared dataShared data

Coordination Plus

Oversight Team

For Addressing the Needs of: Super-utilizersChronically Ill & At-Risk of Becoming Super-utilizers

Chronically Ill, But Under Control