Population Health is Not a New Concept

The Patient Protection and Affordable Care Act is only now putting a spotlight on the good work that's been going on in community health programs for decades. This week, five hospital-led collaboratives will be recognized for their work.

For all the media coverage the trendy terms "population health" and "community health" have received in the last few months, it may seem like the idea did not exist before the Patient Protection and Affordable Care Act became law three years ago.

It is true that under PPACA healthcare providers are suppose to be weaned away from fee-for-service, volume-based reimbursements and pushed toward value-based, preventative care and shared savings. That will require some significant outreach beyond hospital walls and into the communities that hospitals serve. It is important to remember, however, that hundreds of providers in towns and cities across the country have been doing this outreach for decades before PPACA arrived.

The American Hospital Association on July 27 will present its annual NOVA award to five hospital-led collaboratives that have improved community health. The winning programs are Bangor Beacon Community in Bangor, ME; Hope Clinic and Pharmacy in Danville, KY; Free Preventive Screenings Program in Vincennes, IN; Chippewa Health Improvement Partnership in Chippewa Falls, WI; and Core Health Program of Healthier Communities in Grand Rapids, MI.

Rhonda Brown, director of the Chippewa Health Improvement Partnership, says the program has flourished since its founding in 1994 because of the "collaborative spirit" within the community.

"You have to be able to get out and get engaged with the community organizations, the agencies. You need to do that at a really grassroots level. You need to talk to the people that are impacted by the programs that you try to put in place," Brown says. "We can guess, as professionals, all we want about what it is that people need. But if we don't ask them, we are not going to be successful."

CHIP monitors the health, environmental, social and economic needs of people of all ages. Working on a shoestring budget and with a lot of volunteers and community support, the AHA says that the program "has successfully established a federally qualified oral healthcare center, provided automated external defibrillators in public venues and established an open door clinic that offers free medical and mental healthcare. 

CHIP has successfully improved food security in the area and increased community awareness of sweetened beverages as part of its goal to lower childhood obesity. CHIP directed a community-wide falls prevention program for the elderly in addition to advance directive education and end of life planning to name a few. CHIP has also been involved with local and international mission activities. St. Joseph's Hospital is the primary funding source for CHIP although local, state and federal grant monies are actively sought and successfully secured."

Brown says CHIP was able to make this happen because it remains focused, inclusive, and structured but not rigid. All of this is accomplished with a budget of around $150,000 and a tiny staff.

"My 'staff' is me, and just recently the hospital was able to give me a half-time staff person," Brown says. "As much as we hate to think about it, you have to keep sustainability in mind. You have to be creative. You have to create an atmosphere of acceptance. You have to be open to other people's ideas and to their creativity and allow anybody and everybody who wants to be a part of it. Everybody has a stake in this game."

"When I started, my budget was probably $30,000, which is like next to nothing, but you can do a lot of stuff on a very small budget if you have community support. A lot of it has to do with how your staff is able to communicate with and network with other people. That means establishing good relationships and partnerships with the other agencies and organizations in our community. You have to nurture those relationships and give and take. When someone calls and needs me to be on a committee, I try to do that even if I don't have any extra time. If I do that, then they are much more likely to help me out." Brown says it's hard to estimate an exact return on investment for the various services CHIP offers. "We started providing free mental health services for patients that are at free clinics that we helped found along with their community agencies and individuals," she says.

"Since June 2011 we have provided 627 counseling sessions free to people in our community. Those are individuals that probably would not be seen anywhere else. So it is hard to put a price tag on what that has meant for those people but I think it is safe to say that we probably made a pretty huge impact by putting that program together."

Good Samaritan Hospital
Good Samaritan Hospital in Vincennes, IN, is another NOVA winner and its Community Health Services preventive health outreach program offers free health screenings for a 10-county areas.

"We wanted to make sure that instead of just expecting people to come on the hospital campus to receive preventative health screenings or education as part of the discharge planning process that we actually took the screenings and the information to the communities we serve," says Sandra Ruppel Hatton, director of Marketing and Community Health at Good Samaritan.

"Since we are a very rural area we wanted to make sure we took it to the areas that were farther away from a healthcare facility where it might be difficult for them to get to a healthcare screenings, or healthcare period."

AHA noted that Good Samaritan nurses "work within the community to provide health-related education and screenings ranging from blood pressure checks to lipid profiles. Collaborative partners provide the space necessary to see patients and include senior and community centers, Goodwill and Salvation Army facilities, housing authorities, churches, farmers markets, parks departments, YMCA and other not–for–profit sites.

Screening results are shared with the individual and their physicians and appropriate follow?up and treatment referrals are arranged. The program has provided more than 220,000 free screening over 10 years." The program has also gone into Knox County schools to teach its "Fit Kids" obesity and nutrition classes for third, fifth, seventh and ninth graders.  

Ruppel Hatton says CHS could not truly be called a community health program if it didn't actively go out into the community it serves to understand what care people need and how best to delivery that care.

"We have said that that is our role as a hospital. We have taken that stance for years—that we should set the standard for healthcare and be the leader in healthcare and set the standard on lifestyle," she says. "We could not perform these services if we didn't collaborate with the community centers, libraries, farmers markets, farm preview shows, Ag Days—those events that people come to in rural communities."

Like CHIP, Ruppel Hatton says CHS operates on a shoestring budget, a tiny staff, and a lot of volunteers. Several retired nurses work part-time for the program, using their own vehicles to drive to these screening events. Ruppel Hatton says these nurses are highly motivated because they can see the positive effect they're having on their fellow citizens.

"I like to remind our nurses that you do save lives," Ruppel Hatton says. "We had a woman who was in total renal failure and had no idea. We caught a guy who was 41-year old on his way to eating a Pronto Pup. We told him you don't need that. Get your cholesterol checked. Come to find out he had prostate cancer in this 40s. There was the truck driver we found at Old Oaken Days who had colorectal cancer and he didn't know it. They do save lives."

[Here's a quick overview that AHA provided for the three other NOVA winners. Space considerations kept me from speaking with the folks who run these programs, but I hope to chat with them in the coming weeks and months. Congratulations to all the winners.]

Core Health Program of Healthier Communities

Spectrum Health – Grand Rapids, MI.

The Core Health Program of Healthier Communities seeks to improve the health of underserved adults with chronic disease, remove barriers to care, teach self?management skills and work collaboratively within a continuum of care to improve adherence to medication regimens and dietary requirements and to ensure patients receive follow?up care such flu shots, eye exams and foot care.

The services are provided using a cost?efficient approach to chronic disease management by reducing health care costs when compared to conventional approaches for managing chronic diseases. A registered nurse and community health worker team up to provide home visitation services to work with the patient to improve clinical and behavioral outcomes through motivational interviewing, disease management and cultural sensitivity.

Caregivers assist in having a patient assigned to a primary care provider should the patient not have one. The voluntary program extends for 12 months. Collaborative partners include federally qualified health centers, insurers, community centers, food pantries, primary care providers, including the Visiting Nurses Association and other hospitals.

Bangor Beacon Community

EMHS – Brewer, ME St. Joseph Healthcare – Bangor, ME

The 12 partners of the Bangor Beacon Community worked to improve the health of chronically ill people in the Bangor region by using health information technology to ensure better patient care coordination. The goal of the collaboration was to reduce variation in care delivery, improve care quality and alleviate high use of emergency departments and hospitals by chronically-ill patients with symptoms and conditions that could be addressed more appropriately in primary care settings.

The program led six clinical interventions focused on patients with diabetes, cardiovascular disease, chronic obstructive pulmonary disease (COPD), and asthma and a community initiative on immunization, including sharing immunization data among providers. Nurse care managers in each primary care practice worked with high-risk patients. The program's goals, successes and collaborations continue through a newly created accountable care organization. 

Hope Clinic and Pharmacy

Ephraim McDowell Health – Danville, KY

Established in 2006, the Hope Clinic and Pharmacy serves low?income, uninsured and chronically ill patients by providing access to care for the people of Boyle, Casey, Garrard, Lincoln, Mercer and Washington counties. Advanced practice registered nurses (APRNs) lead the clinic's efforts to provide preventive care and care management, as well as access to prescriptions and medications with the goals of reducing reliance on emergency department care and improving health status across the region. In addition to part?time paid APRNs, volunteers and physicians donate services including health education and counseling, specialist referrals and securing medical procedures at no charge to patients. In 2011, the clinic had 223 active patients and the hospital provided 618 free procedures. Collaborative partners include Ephraim McDowell Health, Ephraim McDowell Health Care Foundation, the Presbyterian Church of Danville, The Salvation Army, United Way and the Boyle County Health Department.