island community care project connecting people with community and health services october 11, 2007
TRANSCRIPT
Island Community Care Project
Connecting People with Community and Health Services
October 11, 2007
Partners
• Healthy Acadia• Maine Sea Coast Mission• Mount Desert Island Hospital
– Behavioral Health Center– Healthy for Life Program– Southwest Harbor Community
Health Center• Hancock County Planning
Commission• Harbor House Community Center
* The Community Care Project received generous support from the Maine Health Access Foundation.
Project Goals and Strategies
Our goals were simple and ambitious
“The Community Care initiative will actively integrate population-based prevention in the community with an individualized care management process in the primary care setting, utilizing evidence based practices to affect behavior change.”
“The goals of this initiative are to: 1. increase self-care behavior, readiness to change, and belief in ability to
change among at risk persons.2. provide strategic access to comprehensive primary care for rural,
medically underserved populations 3. establish structural changes in community settings in support of self care
behavior.”
(Source: Community Care Proposal, submitted May, 2005)
Target Population
• The target population for this initiative included persons who by nature of their employment were:
• uninsured and
• confront occupational and lifestyle risks.
Many people who fell within this category were
• confronting occupational and physical disabilities resulting from workplace injuries and
• chronic conditions such as asthma, obesity, diabetes, depression and cardiovascular disease.
Community Engagement (Goal 1)
• Building Organizational Support for Community Care
• Community Health Outreach Worker - Debra Chalmers– Harbor House
– Food Pantry
• Prescription for Fitness
• Maine Sea Coast Mission
• How’s Your Health?
How’s Your Health?
All Records 177
Younger Women 54%
Older Women 23%
Younger Men 14%
Older Men 10%
Perceived Needs
Bothered by…Part 1
10%16%15%% Dizzy/Fatigue
0%6%5%% Abdominal Pain
5%13%11%% Headaches
2%4%3%% Limited Physical Function (Fitness)
10%10%10%% Limited Social Support
12%12%12%% Limit by Pain
2%5%5%% Limit Social Activities
7%11%10%% Limit by Feelings
5%2%3%% Limit Daily Activities
42135177Bothered (often or always) in the Past Month by:
MenWomenAll RecordsQuestion
Care Quality
31%19%22%% Get Exact Care Needed
60%58%59%% Seldom Wasted Time
57%50%51%% Having Confidence in self-management
52%39%42%% Having Very Easy Access
40%33%35%% Having Perfect Care
79%75%76%% Having a PCP
5%6%6%% Hospitalized for Any Reason in Past Year
27%3%9%% Hospitalized or ED for Chronic Disease
10%25%22% With Sick Days in 3 Months
14%29%26%% unable to participate fully in daily work- 2 weeks
17%13%14%% Taking 3 or more medications
42135177Care Quality Summary
MenWomenAll RecordsQuestion
Health Score
66%63%66%% Problems - Opportunities for Improvement
34%31%31%% Problems - Could be Better
0%5%3%% Problems - Doing Well
45%61%57%% Healthcare - Opportunities for Improvement
31%20%22%% Healthcare - Could be Better
24%19%21%% Healthcare - Doing Well
36%37%36%% Lifestyle - Opportunities for Improvement
61%39%41%% Lifestyle - Could be Better
4%24%22%% Lifestyle - Doing Well
42135177Health Score
MenWomenAll RecordsQuestion
Adapting Clinical Practice (GOAL 2)
Overcoming barriers to health care access
MDI
• Healthy for Life! Nurse Advisor
• Quality Initiative in Primary Care Services
Outer Islands
• Medical support for outer islands
• Sunbeam - On site and Tele-health conducts health screenings and referrals
• Behavioral Health Services expanded in outer islands.
• Expand dental services (prevention, screenings) to outer islands.
Establishing Lasting Community Supports (GOAL 3)
• “Living Well with Chronic Disease” Collaborative effort by Maine’s Office of Elder Services (0ES)
• Exploring creation of Federally Qualified Health Clinic (FQHC) for outer islands.
• New partnership with Southwest Harbor / Tremont Ambulance Service
• Identify ongoing support for health care service – Bingham Foundation
– Island Health Initiative
• Swans Island health committee - Set up lab on Swans Island for blood work
• Changing health behavior - Frenchboro Exercise Equipment, Pedometers
• Identifying new streams of funding for special projects – Right Weight for Me
SustainabilityOur partners are all committed to moving forward with the community care model. • Maine Seacoast Mission
– Relationships have been enhanced between MDI Hospital, Maine Sea Coast Mission – Using new technologies including distance medicine and island health clinics to streamline
staffing • MDI Hospital and the Southwest Harbor Health Center
– Healthy For Life! care manager role • Healthy Acadia partnering with the Maine Nutrition Network and the USDA to secure
funding to address community food security.• Harbor House
– “Prescription for Fitness Program” – Behavioral health support such as “Right Weight for Me” program.
Sustainability will remain a major challenge. • Integrating insured, under-insured and uninsured clients • Insurers are reducing benefits • Clinical programs continually seek alternative funding • Continue efforts for early intervention and preventive care • Pursue reimbursement for case/care management services • Identify local “assets” to support community care through partnerships.