SOUTHERN PRAIR IE COMMUNITY CARE 'S  BI -MONTHLY NEWSLETTER

PRAIRIE PRESS

NOVEMBER 2018   I SSUE 6 VOL .   1

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OUR STORY

Southern Prairie Community Care (SPCC) is a regional 12 county

organization that works collaboratively with community partners on

innovative strategies to improve the health of people in our region.

Our work is centered on population health initiatives, developing an

electronic medical record to support care delivery, and

implementing integrated collaborative community care processes

that respond to individual patient needs and dynamics to improve

their health status.

C O N T E N T S : S P C C A C H I E V E M E N T S

607 W. Main St., PO Box 513 Marshall, MN 56258 507.532.1336 info@southernprairie.org www.southernprairie.org

{contact us}

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A NOTE FROM THE DIRECTORBY  NORRIS ANDERSON

As we are coming toward the end of 2018, let me highlight some of the ways that

we, along with our collaborative partners, have truly impacted the health of our

communities:

1.  We have continued to work with 140 active cases with clients across our

counties.  Many of our clients have been referred to us by our provider and

community network.  Much of the work leads to addressing the significant social

determinants an individual is dealing with so that health can be focused on.

Coaching individuals on resources, chronic disease management, and navigation

of the local health care system are core focus areas as well.  In providing the

community-based coordination, we have been able to also measure the positive

impact on lowering total cost of care.

2.  The Center for Community Health Improvement (CCHI) has now embarked on

developing into an independent non-profit.  Our work and learnings with the

Community Health Worker (CHW) model based in community has proven to be

very significant.  Nagi, our CHW with the East African community in Willmar, has

many stories of health impact as she works with education, connections, and

cultural awareness.  We are excited to see this grow and evolve further in the

years ahead.  We remain convinced that this model is key to improving health

and cost of care in our diverse communities.

3.  Our work with the Minnesota Integrated Health Partnership has been going

well.  Data available through 6 months of 2018 shows a positive trend in being

below our performance targets.  We continue to be fully engaged with continuing

the IHP program through 2019.

If you have any questions or thoughts that you would like to share, please reach

out to us.

 

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HEALTH INFORMATION EXCHANGE

AND ANALYTICSBY JAMES DUNGAN -SEAVER

Southern Prairie and the Department of Human Services began a pilot project in

April 2017 looking at ways of combining DHS' MA case management information

with a person's clinical information that they have consented to share.  A personal

health record (PHR) offered by Southern Prairie's health information exchange,

CareTrac, is the tool that brings these two strands of information together onto a

single screen that is owned and managed by the Medicaid beneficiary.  The

number of participants in the project is small – just over 20 – but there are a few

who find it very valuable to have their clinical information and the contact

information for all the people working with them (e.g. case worker, financial

services, guardians, and emergency contact) all in one place.  Agencies participating

in the project include Southwest Health and Human Services, Des Moines Valley

Health and Human Services, Southwest Mental Health, Western Mental Health, and

Kandiyohi County Health and Human Services.

Two project participants found the PHR particularly useful.  One of the early

adopters of the PHR in this project is an 80-year-old retired administrative worker

who regularly uses her computer and scanner to take care of things, which only

proves age doesn't necessarily matter when it comes to technology.  And another

user, after a little coaching on how to use the PHR combined with Medicare's Blue

Button technology, planned to download his records from all his various providers

and upload them to his PHR so he could have all his medical records and case

management info in his PHR.  

The PHR's usefulness comes from the person who is the patient/client having their

MA caseworker information and health information in one place and controlling

what providers and case workers can see that information.  As powerful as the PHR

is, the low adoption rate makes it a little-known tool. 

CareTrac and the Personal Health Record Project:

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CENTER FOR COMMUNITY HEALTH IMPROVEMENT

POPULATION HEALTHBY TR ISTA RADUNZ

While CCHI continues down the path of independency from SPCC, we are working

diligently at filling our open Executive Director role as well as securing funds to

continue the work of our Community Health Worker (CHW).

On 11/8, we received news that Otto Bremer awarded us an operational grant for

2019. General operating support will enable us to build the internal policies and

procedures that underpin our work as we transition to a fully independent

organization as well as provide staff and board training to increase capacity to

support program implementation. This will ensure that CCHI is well positioned to

be a long-term champion for the well-being and health access of all community

members.

www.spcchi.org