Abington Hospital 2013-2016 Implementation Plan Report

Need/Goal Strategies/Activities Updates

Access to Care Create greater capacity in existing Abington Hospital services in order to decrease barriers to care for low income populations including the uninsured and underinsured.

AJH Dental Clinic: Implement Dentrix system (a practice management, documentation and imaging system) in FY14. Renovate adjacent space to AJH Dental Clinic to expand by 2 dental chairs and 1 new resident (with additional support staff) in FY15.

Dentrix went live for Registration /Imaging /documentation in FY14 Additional dental chair added, 1 additional resident and 2 additional staff hired, increasing volume by 16%.

Specialty Services: Improve access to screening colonoscopies/ outpatient orthopedic visits/outpatient surgical visits/non-surgical sports medicine visits in existing primary care and specialty practices in FY14 utilizing residents/Certified Registered Nurse Practitioners (new hours) and partnering with physician specialists.

Access for patients has improved – Ambulatory Services Unit (ASU) volume for PCP/specialties is up by 9% over FY15. Many new initiatives including new visits for specialties, CRNP assistance with colonoscopies, and dedicated staff to answer phones (through PA Dept of Health Grant). Previous wait time of 6-8 weeks for a new patient is now approximately 2-3 weeks for a new patient, and within 1-2 weeks for an uninsured discharged inpatient. Non-surgical sport medicine visits started at Abington Family Medicine (AFM) to address the needs of patients who have minor orthopedic issues. 50 un/underinsured patients are seen annually at AFM.

Need/Goal Strategies/Activities Updates 40 plus surgical/dermatologic annual appointments taking place in AFM which decreases need for specialist appointments. Certified Registered Nurse Practitioner (CRNP): ASU has appropriate staffing in place to allow CRNP to perform clinical duties started in April 2014 for open routine and urgent visits ~ 800 annually. ASU leadership partnered with Dr. Armstrong, Chief of Ophthalmology. Transitioned visits from ASU to Ophthalmologic specialist’s office formally in September 2013, whereby comprehensive examination and treatment is now completed. With new plan, “comprehensive” eye visits for ~ 260 patients annually. Ophthalmologic comprehensive examination and treatment visits provided in specialist office for one of the MA managed Care Plans. Increased access to GI specialist in ASU with addition of attending physician coverage. Screening and Diagnostic Colonoscopies available for one of the MA Managed Care Plans through the GI specialist office.

Hire Social Worker and establish a Masters clinical internship program to support onsite care coordination for patients in AMH areas identified as having the greatest need: Abington Family Medicine (AFM), Ambulatory Services Unit (ASU), North Hills Health Center (NHHC) and Dental Clinic are initially identified areas.

Social worker supervisor hired. In September 2015, the Social Work supervisor worked with 6 interns (up from 4 in past semesters who worked in AFM, ASU and NHHC. From July 1, 2015 to present the SW interns received approximately 320 referrals from ASU, AFM, and NHHC with an additional 72 cases open currently. They also participate in 3 outreach projects: Hispanic Population Outreach for NHHC, Diabetes Outreach for AFM, and Diabetes Outreach for NHHC. The team is developing a resource guide for patients who are homeless, for employment and career counseling and for community resources. They also just started putting together some local food resources that will be very useful for the patient population. The Gitlin restricted fund funded the hiring of 2 staff members (~16 hrs/week) each summer, who performed their university clinical rotation with AMH. These individuals bridged the gap as paid administrative interns throughout the summer.

Expand clinical hours at North Hills Health Center by increasing the Certified Registered

Clinic hours expanded, CRNP hours increased.

Need/Goal Strategies/Activities Updates Nurse Practitioner (CRNP) hours (along with support staff) by 4 hours in FY14.

Increase # of visits year over year translated to 150 more appointments annually.

In conjunction with community partners and providers, identify and implement ways to improve access to primary and specialty services, which includes behavioral health, as well as dental services throughout the AMH service area.

Evaluate the opportunity to implement Abington Health Physicians electronic health record (eClinical Works) or equivalent in FY15 in the Ambulatory Services Unit and Abington OB/Gyn Center which will enhance the flow of patient information between sites and improve care coordination.

OB/Gyn Center and ASU both on eClinical works by late 2014. Education and re-education continues for the staff and physician providers, over 200 care providers.

Increase appointment availability for identified subspecialties in OB/Gyn Center by partnering with physician subspecialists (by FY15)

OB access has improved, up 4% over FY15, with 307 new patient visits in FY15. Wait times for new OB appointments have improved. In addition, the ability to offer more appointments with an additional provider has improved the times. Before the implementation of this grant the wait time for a new OB appointment was 22-37 days, currently the wait time is 7-8 days. 2015 PA Dept of Health grant is being used to expand visits in center with hiring of a bilingual CRNP. To date the Trilingual NP has seen 4,198 visits. 75% of CRNP patient visits speak either Spanish or Portuguese. Patients report that they are more comfortable with a CRNP who does not need an interpreter, as they feel she understands them better. Appointment reminder calls are being made electronically 2 days in advance of visit with the intent to decrease no show rate. Recently completed an Innovator’s Circle Grant Study. This research study called MOM Exchange showed significantly positive results that prenatal breastfeeding education offered to clinic patients yield higher percentages of breastfeeding initiation and duration. Therefore, we will continue to offer prenatal breastfeeding classes monthly in the OB/GYN Center and providers and nurses will encourage participation. Behavioral Health Initiative – screening with validated, reliable postpartum depression screening tool and have warm handoffs to

Need/Goal Strategies/Activities Updates Behavioral Health Specialist embedded within the OB/GYN Center.

Establish a coordinated financial counseling outpatient service which will support the un/underinsured for improved understanding and assistance with eligibility for insurance coverage and/or AH financial assistance (charity care in FY14).

Financial counseling program started in 2014. Center is located in the Patient Registration area of AH. Manager in place, staff hired. In very early stages of this new program.

Evaluate opportunity for on-site (by practice) behavioral health services by partnering with AH and community behavioral health agencies.

Behavioral Therapist joined OB Gyn Center, along with AFM and other practices. Therapists at Warminster Campus continue servicing Warminster campus practices, as well as nearby practices. Drs. Daniel/Delaney and Nancy DeAngelis working very collaboratively with AHP leadership team, physicians, PCMH Care Managers and office staff to proactively continue to refine this new program.

Explore community funding options.

Received $25,000 to continue to support work in the Ambulatory Services for under and uninsured patients, by generous donor. PA Department of Health Community Based Healthcare Program $200,000 grant began January 1st 2014.Patient Centered Medical Home Care Manager hired in January 2014, replaced in Jan 2015 due to transition. PCMH Care Manager hired in January took a strong leadership role in bridging the gap between inpatient to outpatient for patients who have no insurance and NO PCP. Care manager working to visit patient in the inpatient environment before discharged. PCMH Care Manager also working one on one routinely with cohort of Diabetic patients. December 2015: Received required matching grant of $50,000 from generous donor, in addition to 6 additional months of PCMH Care Manager funded (end of grant cycle through December 2015). PA Department of Health Community Based Healthcare Program grant was approved for ~$250,000 (with matching dollars of $75,000 funded through Abington) to continue to support Ambulatory Services. The new telephone system has been installed and includes the ability to listen to menu options in 4 languages (English, Korean, Portuguese, and

Need/Goal Strategies/Activities Updates Spanish). 2/3 of the MOA Staff have been hired (with the third to be hired in next fiscal year) who are being oriented and educated on their new roles. Patients are pleasantly surprised to speak to a live person as opposed to a voicemail.

Behavioral Health Reduce the percentage of the adult population who have a behavioral/ mental health condition but are not receiving services.

Refine depression screening tools to identify those in need including health system, county and nonprofit mental health providers for referrals.

Depression screening tool for inpatients revised and implemented. Established protocol for psych consult based on depression score. Maternity department developed self-depression screen. In homecare, there are two questions, embedded in the OASIS tool, which ask the patient to rate diminished mood and loss of pleasure over a two week period. Those two questions are widely known as the PHQ2 (public health questionnaire). In hospice, the Edmonton Assessment Scale is used, which actually allows rating on a wide spectrum of quality of life issues depression included.

Collaborate with existing behavioral health community service providers in development of a network to serve those in need. Document providers and communicate to health system case management, physicians and nurses.

New behavioral health team determining how to create the network to serve those in need. The Crisis Clinician Coordinator attends county behavioral health meetings. Behavioral Health Access Coordinator hired to link people to appropriate services, office at Warminster Campus. Joined HealthSpark Foundation collaborative (Montgomery County Hospital Partnership) to improve behavioral health access and initiatives throughout the county. Community Mental Health Resources placed on the BING under the new Community Resources section- References/Resources for the Abington Health network. Additionally, key AJH leaders and staff will be emailed all documents for use.

Develop a plan in FY15 and FY16 to evaluate the provision of behavioral health services in Primary Care Practices including Pediatric Practices

Currently we have embedded one therapist at Abington Family Medicine, one therapist covers Family Practice Willow Grove and Internal Medical Associates of Abington, one therapist is in the Institute for Metabolic and Bariatric Surgery center and we have two therapists serving Abington Bucks Internal Medicine, Bi-county Medical Associates, Brecher and Knapp, Feasterville Family Health Care Center, Hartsville

Need/Goal Strategies/Activities Updates Medical Practice and Dr. Jerry Roth. Part time therapist hired for the OB/GYN clinic in May 2015. We have recruited a BHC (new title, behavioral health consultant) to serve Women’s Health Care Group (WHCG), she will start May 2016. Additional behavioral health consultant for Building 51 on the Lansdale campus will serve the pediatric clinic, Drs. Seavy and Sestito and North Penn Family Medicine. The physicians and office staff are very engaged around this initiative. Developed and presented a business plan to FOEC to expand the program throughout the Abington Network.

Seek grant opportunities to enhance existing services.

Discussion with Philanthrophy to seek grant opportunities. One family has provided grant money to the family residency program to hire a behaviorist for education purposes; we have a LCSW providing education 16 hours a month which we implemented March 2015 and a psychiatrist 4 hours a month to provide education beginning July 2015.

Enhance behavioral health services for children and adolescents

Enhance educational programming for schools.

Student Assistance Program Coordinator at Creekwood increased communication with school districts, SAP program thriving. Coordinator visits with schools to discuss children’s case management services. Safe Harbor program coordinator contacted SAP director at Hatboro Horsham School and conducted an 8 week bereavement support group for students, which has been extended to the end of the school year. Safe Harbor staff presented at Bryn Athyn School to support teachers after 2 recent traumatic deaths.

Continue to provide educational and support programs related to behavioral health, e.g., community health outreach presentations, Safe Harbor Program.

12 Community Health outreach presentations relative to stress management provided to 209 community members. The Children’s Case Management Department has coordinated 12

Need/Goal Strategies/Activities Updates community outings with the children and families enrolled in the program and have 2 scheduled upcoming community events in the next month to benefit positive peer socializations. Safe Harbor program (for grieving children and their families) has a 25% increase in number of families served over previous years. In order not to have a wait list for families with 6-8 year olds, Safe Harbor has started a second support group for this age. Safe Harbor hosted its first “Harboring Hope” weekend for 22 children/teens. The participants worked together in their modality of choice; music, dance and drama to create a production that was videotaped. A festive Hollywood Night was held for the families to view the video.

Cancer Increase community awareness of cancer risk factors through educational programs focusing on the American Cancer Society and National Comprehensive Cancer Network.

Initiate and maintain working relationship with Faith Community Nurse Network

Cancer program information distributed through Faith Community Nurse Network e-mail distribution list. Continue to network and provide educational programs related to screening and early detection

Develop standard early detection and screening for cancer educational packets and presentations for the general community which can be translated for specific populations. (Using multicultural database on the BING).

Presently using American cancer society power points and educational materials for outreach and education. When applicable language specific information is shared. Programs for lung cancer and colon cancer presented through Eldermed at the local Giant food market. Networking with American cancer society to assist with development of standard education packets.

Determine appropriate dates and locations for 2 cancer education programs for the general community each year. Provide 2 cancer screenings to the general community

Since FY14, over 3400 participants in free cancer related education outreach and screenings. Since FY14, 21 free community cancer screening events held for breast,

Need/Goal Strategies/Activities Updates each year. prostate and skin cancer.

Outreach to the Korean and Latino communities by providing educational programs targeting these populations.

Provide cancer awareness programs at faith communities, focusing on Korean and Latino congregations.

Breast cancer awareness programs presented at Casa Del Pueblo, Willow Grove United Methodist Church, and Bethel Deliverance Church, Korean United Church. Provided materials in Spanish and Korean at Breast cancer outreach programs. Colorectal cancer awareness presentation at St. John Bosco for 30 community members.

Increase community awareness of integrative therapies available through programs focusing on the general health of the population.

Initiate and maintain working relationship with Integrative Therapies Council at AMH.

Continued efforts being made by council to be available for patients on regular basis; all new patients provided with a list of integrative therapies offered. Council is available for survivorship day. Planning a program at new cancer center which will include hand massage and Aromatherapy. Cancer community Network also providing integrative therapies for patients.

Initiate and maintain working relationship with the Cancer Support Community. Develop a comprehensive list of cancer support programs available targeting the general Abington Jefferson Health community.

Weekly support groups provided for Breast cancer, Living with Cancer, Metastatic Cancer Support Group, facilitated by Cancer Support Community. Programs and support information provided to patients in all new patient packets. Cancer support community provides a monthly calendar of support programs available on site and off site which is distributed to patients.

Cultural and Linguistically Appropriate Materials Improve communication about Abington Jefferson Health Services and community partners.

Improve communication. List serves or distribution lists created and maintained for electronic communication of health screenings and programs, distributing fliers and program updates to list serve every 4 weeks. New section of TRENDS, “Community Benefit” began November 2015 edition. This section will highlight AJH’s offerings, clinics, FAP, stories, information shared with PR/Marketing for internal communication:

Need/Goal Strategies/Activities Updates Article on the “Guides to AJH Clinics” and translated copies posted to Bing in Community Resources with link to all personnel. Included in March 2016 section is Gift of Life campaign; Heart and Stroke Risk Assessments; Camp Charlie/Safe Harbor and Visit by South Korean Nursing Students to Abington Hospital. Final AJH Financial Assistance Program documents update and review taking place with AJH workgroup. Board approval scheduled for April 26, 2016. Translation of documents into 7 languages and all FAP postings by June 30th to website.

Translation of documents request – improve centralization of inventory. Develop a plan to inventory current documents and create an approvals process for the development of new translated documents.

Recruit diversity summer Co-op students to inventory AH documents.

Diversity Summer Co-Op students initiated inventory in summer 2014 and have completed centralization of translated documents for AJH. Worked with Web Center for inclusion to the enhanced intranet, Bing. Currently working on uploading to files on the Bing for AJH employee access.

Develop an inventory of appropriate health education and prevention information – in the three top languages – from reliable sources – easily accessible to AJH staff.

Recruit student interns for inventory and posting to the intranet.

Multilingual Health Resources and Websites project for health education and prevention information created and maintained by public health student interns. This document placed in the references and resources section. This will be communicated to all staff via PR/Marketing Weekly Email

Assess need and increase signage in a language for simple messages in key locations.

Student Intern site visits to 3 area health systems to review signage and best practices.

Strive to increase AHP will monitor data analytics reflective of cultural competence: language and

Added language and ethnicity to CB Scorecard for 990 narratives in HBI.

Need/Goal Strategies/Activities Updates recruitment and placement of bilingual staff to approved positions. Communicate resource availability.

ethnicity. Monitor standards for report of practice diversity: racial, ethnic, language, other [deaf] and related data reports for review of relevance and inclusion. Continue to monitor meaningful use/EMR/OP side of AHP and ADAM health education modules in Spanish and English for data analytics of interest.

Language and ethnicity are required fields within STAR registration pathway. All patient access teams have been trained.

Monitor and update the Finance/HIM registration improvement process for possible process outcome goal if training is action item in FY15. Plan: communication with AJH leaders and staff will be needed prior to June 2016.

IRS 501r requirements indicate translation of updated financial assistance policies and brochures moving forward based off of languages served by hospital: “The regs require that translations of the FAP and its plain language summary must be available in languages spoken by limited English proficient groups that constitute the lesser of 1000 persons or 5 percent of the community served by the hospital.” Community Benefit, Finance/Business Services. AJH languages identified to meet regulations. FAP materials under review. [7 languages to be translated: Spanish, Russian, Gujarati, Chinese, Korean, Vietnamese, Portuguese.] Community distribution of FAP under discussion including tracking. FY16 – working with Business Services and Finance to meet and complete all regulations

Research and have readily available any/all standards and requirements if any AH language rises above the 5% marker.

FY16 Cultural Action Plan team continues to monitor data with Diversity Leader.

Hypertension Establish protocol for treating hypertension and establish educational programming for physicians that will promote consistency throughout AHP practices

Develop a CME offering for physicians that highlights the scope of the problem with hypertension and identifies evidence-based treatment modalities.

Dr. Haas presented “Ambulatory Blood Pressure Monitoring” at the Primary Care Update on 11/8/13.

Identify opportunities to provide CME education and set up a schedule for AH physician practices and other community-based practices.

CME program not able to be developed at this time, given that the American College of Cardiology (ACC) and American Heart Association (AHA) have started to work on a new guideline to serve as an update to the 2003 JNC-7. The new guideline is expected to be published in

Need/Goal Strategies/Activities Updates and all AJH staff physicians. 2016.

Upon availability of JNC8 hypertension guidelines, provide CME update at Primary Care Physician annual event.

Raymond R. Townsend, MD, Professor of Medicine and Director of the Hypertension Program, Hospital of the University of Pennsylvania and member of JNC8 presented “New Guidelines for Identifying and Treating Hypertension” at the 10/22/14 Medical Grand Rounds at AMH. He was able to provide clarification and explanation for conclusions leading to the JNC8 recommendations.

Increase the number of patients with blood pressure stable at <140/90.

Measure improvements in blood pressure control among patients in AHP practices.

All hypertension measurement data from the Patient Centered Medical Home quality improvement projects (2012-2014) have been collated for all Abington Health Physician (AHP) primary care practices. This information was presented at the June 2015 CB Meeting.

In Abington Health Physician(AHP) practices identify and focus interventions on existing and at-risk patient populations as follows: (a) established hypertensives; (b) newly diagnosed hypertensives; and (c) identification of undiagnosed hypertensives.

Hypertension Guidelines for Abington Health Physician practices were updated in 2013; original guidelines were adopted by AHP in 2010. JNC8 committee recommendations have not changed AHP guidelines or hypertension approach due to the inconsistencies with the ACC/AHA guidelines. Initiated preliminary discussions about the hypertension guidelines based on HEDIS and with adopting the JNC8 panel recommendations. Will continue to discuss internally and with major payers.

Reduce the proportion of persons with hypertension in the AJH service area population to approach the HP2020 goal.

Establish venues where blood pressure screenings can be offered that will maximize reach and support HP2020 objectives

Monitoring community blood pressure screening sites. An updated list of screening locations has been compiled and placed on the AJH website. Revised BP tracking form to include monitoring of community members who have not had their blood pressure measured within the preceding 2 years (HP 2020 goal), if taking B/P meds as ordered, and if providing Clinic / Physician Referral info for those individuals without a healthcare provider. B/P follow-up call tracking spreadsheet created for outcomes measurement purposes to assure participants are following up with their PCP and obtaining serial B/P measurements. Partnering with Montgomery County Health Department (MCHD) who is the recipient of funding from “Million Hearts Campaign” to reach out to

Need/Goal Strategies/Activities Updates underserved communities. They will provide nutrition information while we support the event with blood pressure screenings. AH Healthy Living listserv for February 2015—offers an Interactive and Non-Interactive Decision Point on the topic of “High Blood Pressure: Should I Take Medicine?” The resource for this service is Healthwise. The web page also provides a listing of physicians. “Treating High Blood Pressure” article published 9/29/14 on AH website with 1,584 views. Provided blood pressure screenings to 12,228 community members since FY14.

Continue to work with the Stroke Councils on educating the community

The Stroke program will provide follow-up phone calls seven days post-discharge to patients discharged to home with a dx of (CVA, TIA, etc.). The criteria used with follow-up will include: B/P measurement since discharge; if they have set an appointment with a physician; whether they have filled their prescriptions and whether they are taking their meds (in particular B/P meds).

B/P follow-up calls at AH and ALH focus on whether patients have filled their meds and taking them and if they have set an appointment with physician for follow-up. Revised format focuses on knowledge of type of stroke, signs and symptoms, risk factors and when to call 9-1-1; knowledge of medications, follow-up appointments (PCP, specialist; PT/OT/ST); psychosocial support; evidence based care.

Obesity Decrease obesity in adults through programs that promote active living and healthy eating.

Expand community nutrition talks by establishing or strengthening relationships with local libraries and recreation centers/YMCAs, with particular focus on underserved neighborhoods. Continue to offer nutrition and healthy-lifestyle themed tables at community health and wellness fairs.

Provided nutrition programs and displays to 2,951 community members FY14 through FY16.

Promote “Healthy Living” AH website Attended meetings with Public Relations and Web Committee regarding development of a “Healthy Living” site on AH Web. Site went live in January, 2014. There have been 43,258 views of the Healthy Living

Need/Goal Strategies/Activities Updates site as of 5/15/16.

Maintain funding and full recognition status for the yearlong CDC National Diabetes Prevention Recognition Program run by the Diabetes Centers of Abington Health.

Received full recognition status and maintained funding for 3 cohorts of participants.

Continue “Cooking with the Docs” program at GIANT Willow Grove with a lecture by and Abington Health cardiologist and a nutritionist teaching new and healthy ways to prepare meals.

2 programs held annually over the past 3 years.

Develop programs in partnership with Montgomery County Health Department (MCHD) on PA DOH Safe & Healthy Communities Grant and Million Hearts Initiative.

Provided financial support for printing of 2500 shopping tablets created by MCHD to be distributed to students within Wissahickon, North Penn, and Hatboro Horsham School Districts as well as community programs. Partnered with MCHD on Million Hearts programs.

Produce a quarterly newsletter on practice strategies in weight management.

Will be developed with contractual dietitian and student intern in FY17 and will carry into 2016 -2019 implementation plan.

Hold a panel on programs available through Abington Health and the community-at-large to support weight management.

Tabled for this year, but will carry into 2016 -2019 implementation plan.

Decrease obesity in children through programs that promote active living and healthy eating.

Expand “Weigh-to-Go” and “5-2-1-0” program to targeted organizations and underserved areas

Presented 5-2-1-0 at PAL event in Upper Moreland, Horsham Township, Cheltenham Township,Wordsworth Academy. Fit and Fun one-week mini-camp was held at Willow Grove PAL camp, which included 5-2-1-0 and exercise. 5-2-1-0 program presented at International Spring Festival April 26, 2014. New program introduced as weigh to go enrollments down: Let's Move: Ballroom Dancing for Kids, ages 5-16 / Presented by Dr. Crisci to Willow Grove Brownie Troop.

Educate and engage physician practices and staff on identification & interventions for

Established relationship with Amy Wishner, RN, MSN, Director, EPIC® Pediatric Obesity: Evaluation, Treatment and Prevention in Community

Need/Goal Strategies/Activities Updates obese patients through the American Academy of Pediatrics Epic Program. Encourage community providers such as school nurses to utilize the American Academy of Pediatrics’ EPIC Program to help practices work as a team to address obesity prevention and treatment.

Settings. EPIC program presented at pediatric grand rounds on 4/28/15. EPIC program also completed school nurses’ in-services in the Horsham-Hatboro, North-Penn, Cheltenham, and Wissahickon School Districts. Information shared with FCN network re: PA AAP “EPIC®: Pediatric Obesity – Evaluation, Treatment, and Prevention in Community Settings” offers a free, one-hour program that will help you and your entire staff better address the common and challenging issues of pediatric overweight and obesity.

Design a program based on proven methods for decreasing pediatric obesity that utilizes the Abington Health network and existing resources in the surrounding community.

Created curriculum and implemented program for the Afterschool Nutrition Education Program, a collaboration between Abington-Jefferson Health Community Health and the Abington YMCA. It is designed to teach nutrition basics to children grades K-6 enrolled in the School Age Child Care (SACC) run by the Abington YMCA for Abington School District. Lessons are geared toward children who have just completed a full day of school plus up to an hour of homework, and as such must be very hands on and preferably active and play-based. New curriculum also created and implemented for Abington YMCA preschool students.

Investigate and create educational spots for use in Middle and High School closed-circuit television systems.

MPH Intern creating educational spots for presentation at Plymouth Whitemarsh High School in January. Pre and post survey tools created. Program completed.

Older Adults Remaining As Independent and Community-Connected as Possible In collaboration with AH Physicians [AHP] and AMH Home Care, develop a model to enhance In Home Primary Care and its integration with Medical Home.

Deep Dive or Benchmark 3-5 best practices for home care, home visitation programs/PCPs.

Quarterly meetings held with Long Term Care facilities to discuss issues. AH representation includes lab, case management, social work, Muller staff. Model for In Home Primary Care being developed in PCMH with staff geriatrician. With the bulk of practice in long term care facilities currently unavailable to provide in home care.

Enhance knowledge of older adults regarding existing

Continue to explore new and enhance existing collaborative community partnerships to serve older adults.

Participating on neighborhood advisory council for Visiting Nurses’ Association- Community Services (VNA-CS)United Way grant program, “Aging at Home – A Community Network, as well as Prime Time Health.

Need/Goal Strategies/Activities Updates health care and community services

Attend monthly meetings, researched ability to share data between VNA-CS and AJH. Currently exploring Memory Café idea with Aging at Home. Recent collaboration with the Alzheimer’s Association to offer a presentation at Giant. Memory Fitness Center collaborated with Phila ARTZ for art show in Northern Liberties, Phila.

Create and maintain a current inventory of community assets in AMH service area of non-profit organizations serving seniors. Educate nursing, case management/social workers and include inventory on the intranet, BING.

2016 CHNA Asset mapping completed and list of assets available under resource area on the BING.

Monitor the use of Abington Health website to evaluate ease of navigation and usage of older adults.

Page views related to Senior Health continue to increase, as seen by increase of 5.57% over same time period FY15. 51.5% are new users to the senior health web site The Lansdale service area continues to see a significant increase in visitors to the Senior Health pages over the previous year.

Support and maintain programs that encourage and coach older adults to maximize their functionality.

Provide opportunities for older adults to engage in health education tailored to the needs of the geriatric population.

Eldermed (free wellness program dedicated to helping people age 60 or older stay healthy, active and well-informed about medical topics) (programs provided to 4,335 older adults since FY14.

Expand key Muller Center Programs to ALH campus.

H.E.L.P. program (Hospital Elder Life Program is an innovative approach to protect older patients from declining physically and mentally while they are hospitalized)and Memory Fitness Center now available on Abington Lansdale Hospital (ALH)Campus. ALH Memory Fitness Center attendees now total 5; H.E.L.P. program now active at LH with 2 active volunteers.

Smoking Serve as a resource for faith Present smoking cessation program overview Presented smoking cessation lecture to FCN’s on 9/16/13 at Willowood.

Need/Goal Strategies/Activities Updates congregations and community organizations to develop and implement evidence based smoking cessation programming and policies.

lecture to Faith Community Nurse Network and Martin Luther King Committee. Provide newly created smoking cessation brochure, and investigate conversion of brochure to PDF document for electronic distribution.

Converted Smoking Cessation Brochure to PDF and distributed via list serve to FCN network. Smoking cessation brochure updates and class information consistently distributed to over 300 Faith Community Nurses and key community stakeholders via list serve.

Distribute newly created smoking cessation brochure to all AHP practices, and dental offices within the service area.

Ongoing distribution. Brochures also available on all clinical units and on the BING intranet as well as the Abington Jefferson Health website.

Draft introductory letter to AJH community stakeholders identifying AJH resources for smoking cessation programs.

New Smoking cessation flyer created and distributed to community stakeholder list. Information sent to all key community stakeholders with updated smoking cessation brochure and smoking cessation program flyer.

Increase access to comprehensive tobacco cessation programs for adults.

Provide smoking cessation program at Dock Village in First quarter of FY 2014 to prepare residents for smoke free community mandate of January 1, 2014.

Smoking cessation program scheduled for Dock Village 10/16/13 and 2/10/14. COMPLETED, and will continue to offer classes at this site as requested.

Partner and participate in Montgomery County Health Alliance Coalition for a Tobacco-Free Montgomery County

Nursing Program Coordinator, Community Health Outreach active participant in coalition. MCHA involved in county grant for “A Million Hearts Campaign”. AH will develop display and presentation for International Spring Festival. Smoking cessation class flyers and brochure distributed at all community outreach events.

Working with the nursing staff on inpatient units, provide appropriate information and materials regarding smoking cessation programs and options.

Staffed tables in AH and ALH cafeterias during Great American Smoke Out week and distributed smoking cessation booklet and flyers. Revised and fully implemented new smoking prevention protocol at ALH. Providing follow-up calls to ALH discharged patients with the hope of recruitment to smoking cessation classes.

Develop alternative methods for smoking cessation programs and post class support.

Total of 51 community members attended smoking cessation classes since FY14.

Need/Goal Strategies/Activities Updates When possible, will continue to offer group classes. If unable to meet registration goal, will offer individual counseling. Initiating trial of Information Sessions this Spring to facilitate recruitment to classes or individual counseling

Information reflected in this document is related to Abington Jefferson Health Community Health 2013-2016 Needs Assessment. June 2016