Network Sustainability

Richard D. Silverberg MSSW LICSW Managing Director

Caring Community Network of the Twin Rivers

Exec. Dir Health First Family Care Center

Franklin NH

•To promote public health and prevent illness

•Agency and community Reps all sectors

•Founded in 1996 501 c 3

•10 Essential PH services, plus supports to network members

•Needs assessment, Health promotion, chronic disease prevention, community development focused on creating healthy individuals in healthy environments, training. work force, access to personal health care, policy development.

Caring Community Network of the Twin Rivers (CCNTR)

Individual

&

Family

Primary Care Teams

LRGHealthcare

Family Practices

Health First Family Care

Center (FQHC)

Inter agency adult and children’s

care coordination

teams

Caring Community Network of the Twin Rivers Health Home Model

Primary Care Network

Community Action Programs

School Administrative

Units

Dentists

Child Care Centers

Elder Service Providers

Faith-BasedGroups

Municipal Services

Visiting NurseAssociations

AcuteHospital

Mental HealthProviders

Police, FireEMT

Medical Specialty Services

Informed,ActivatedPatient

ProductiveInteractions

Prepared,ProactivePractice Team

DeliverySystemDesign, Group Visits

DecisionSupport, Specialty

Care

ClinicalInformation

Systems Wellcentive

Registry Program,

EMR

Self-Management

Support MFC, Stanford Model

Health SystemMercy General, Health Project,Diabetes Network

Resources and Policies, Access toSuppliesAnd Meds

Community

Health Care Organization,MFC Team Approach

Chronic Care Model,CHIP Project Partners

Improved Outcomes,

Measurable Indicators

CCNTR RHO Partners

Healthy Eating Active Living

(HEAL NH)

Medication Assistance

Health Link

Clinical Team Care

Management

Health First-National Collaborative

LRGH-NCQA (DPRP)

Planned

Visits

Nutritionist, Behavioral Health,

Social Work

Patient Disease

Registry, EMR

Key Measures

Clinical: Lower A1c Average (DM), Lower BP Average (CVD)Healthcare: Reduced ER Utilization

Coalition Development

Gather together the right people

Agree to agree

Identify develop, support local leadership

Find projects early on that will yield success

Celebrate success

EvolutionEvolution

CCNTR is recognized on a national level for its work in cross-agency team development and collaboration. Coordinating how agencies work together to deliver services for individuals is a primary focus of the network.

Not only do network agencies work together to govern CCNTR, they jointly apply for funding and share staff positions to deliver services.

CCNTR also strengthens the community by providing staff development, training and new technology to agencies in the network.

CCNTR is recognized on a national level for its work in cross-agency team development and collaboration. Coordinating how agencies work together to deliver services for individuals is a primary focus of the network.

Not only do network agencies work together to govern CCNTR, they jointly apply for funding and share staff positions to deliver services.

CCNTR also strengthens the community by providing staff development, training and new technology to agencies in the network.

Recognition

Vision LT Outcomes

EvaluateEffectiveness/

Collect and analysis

indicator data

ImplementMethods/ Activities

Plan forMethods

/Activities

IterativeProcesses

Goal Development Strategy and long

term outcome development

Needs/ProblemsStatement

NeedsAssessment

Priorities and Strategic Issues Identification

Short term & intermediate Outcomes

Development

Joint funding development and grant writing

CCNTR PLANNING PROCCESS

Methods of Engaging the Public

Choose an issue that the residents care about, and that is measurable

Use the skills and talents of the participantsAsk the participants ‘Who else should we be talking to?’

Reinforce, celebrate success and positive shared leadership

Fostering Ownership and Leadership

Identify local leaders

Start at the level comfortable for the leader

Have method to support and train leaders

Share leadership, give power to many

Public and Community Health ImprovementHow the community-driven str ucture engages people in planning and development

Community members, law enforcement officials, public health officers, school personnel, health and human service professionals, town officials, business people, civic groups, youth, and consumers of service are invited to participate in planning and development taskteams to address each area of regional need.

Interested individuals and organizations come together and form task teams, which address areas of need identified by CCNTR through the community health assessment process.

Task teams identify methods to meet community needs, based on review of model programs and other research supported by CCNTR staff.

Task teams then refine the methods they have selected to meet identified community health into a feasible program plan based on discussions with community health and human service agencies.

Task teams’ recommendations are taken to CCNTR’s Development Commit tee, which looks for funding opportunities.

A subcommittee made up of task team members and development committee members drafts proposals for funding.

Some task team members and CCNTR representatives, continue to meet in order to oversee the implementation of the program, its evaluation, and its continuation.

CCNTR member agency takes on responsibility of the program’s operation as the fiscal agent for the program grant(s).

CCNTR(c)2001 turningpoint/presentation/graphics/communityassurance 9/01

Process is brought back to the general population through the delivery of a service, and the participation of consumers andresidents in the evaluation of that service. See diagram Public and Community Health Assessment.

ApproachApproach

Funding Strategies

Service Design through Blended Funding SourcesService Design through Blended Funding Sources

HRSA Rural Health Outreach

Topic Areas: Chronic Disease, Telehealth

• Quarterly Planned Care Prevention Focused Visits

• EMR, Disease Registry, Quarterly Outcome Evaluation

• Health First Family Care Center (FQHC) participation in HRSA Health

Disparities Collaborative

• LRGHealthcare involved in NCQA, DPRP

Multi-State Learning Collaborative: Lead States in Public Health

Quality Improvement

Topic Areas: Reducing Childhood Obesity

• EMR Supporting Primary Care Recommendations to Identify,

Prevent, and Manage Childhood Obesity

• Primary Care Practices in Region Documenting at Least 72% of Youth

BMI Risk Rating

• 5210 Assessment and Behavioral Goal Setting at Well Child Visits

New Hampshire Healthy Eating Active Living Community Grant

Program

Topic Areas: Increasing Nutrition and Physical Activity Resources

• School

• Community

• Food & Recreation Industry

• Reducing childhood and adult obesity

Funding Source Delivery System Design Results

Evaluation

•Programs/services: process and outcome measures for each project / each funding source matched to overall community plan

•Demonstrated value: through changes over time from baseline measures of major community health indicators

•Agency functioning : board evaluation

Return on Investment

•Healthy communities

•Agencies, towns, employers, residents that have learned the value of collaboration and carry this forward

•On going community leadership

•We can do it if we all work together

Organizational Chart of the Caring Community Network of the Twin Rivers

Twin Rivers Community

Founded 199614 Community Member Seats

CCNTR Board of Directors14 Member Agencies 11/09

ManagingDirector

Nominating ExecutiveDevelopmentHealth

OfficersTrip

Standing Committees

Basic Needs

EnvironmentalHealth

Community Involvement

AdolescentRisk

BehaviorPrevention

Team

Public & Community

Health SystemsImprovement

HealthEducation &

Disease Prevention

Care, Coordination

Outreach, andAccess

Subcommittees(program oversight)

Task Teams

Care Coordination TeamsRegional

Emergency All Hazards

Health Planning and

Response

NewfoundPrimary

CareTeams

FranklinElder &

AdultTeam

FranklinChildren’s

Team

AccessManagers

Group

Healthy Homes

11

Results in Partnering Results in Partnering Sustainable network Number of uninsured patients in region now

receiving preventative services, primary care and specialist treatment 1995: <100 uninsured patients 2010: >4,000 uninsured patientsAs a Result of:

Health First Family Care Center (FQHC) Increase in Primary Care Physicians Two Office Locations

HealthLink and Healthcare Financial Counseling Information and referral system that provides healthcare financial

counseling, Shared sliding fee scale and access to medical, dental, wellness, and prescription services for those in financial need.

Sustainable network Number of uninsured patients in region now

receiving preventative services, primary care and specialist treatment 1995: <100 uninsured patients 2010: >4,000 uninsured patientsAs a Result of:

Health First Family Care Center (FQHC) Increase in Primary Care Physicians Two Office Locations

HealthLink and Healthcare Financial Counseling Information and referral system that provides healthcare financial

counseling, Shared sliding fee scale and access to medical, dental, wellness, and prescription services for those in financial need.

Results in Partnering 2Results in Partnering 2

Comprehensive network of agencies that provides the ten essential public health services for the region.

Bring new resources to the region. 5 million $ in the past 5 years. Developed seamless Electronic referral

system between agencies.

Comprehensive network of agencies that provides the ten essential public health services for the region.

Bring new resources to the region. 5 million $ in the past 5 years. Developed seamless Electronic referral

system between agencies.

Focus on meeting the needs through long term planning process

Use savings from collaboration and eliminating duplication of effort to sustain core network functions

Institutionalize the relationships of one agency to another not just the personal relationships

SustainabilitySustainability

Sustaining Engagement

Identify both short and long term activities

Early successes are vital!

Celebrate your success

Include large group in planning process

Segment plan into doable committees and tasks

Develop long term funding streams through policy change

Fostering Ownership and Leadership

Sustainability of Membership

Identify local leaders

Start at the level comfortable for the leader

Have method to support and train leaders

Share leadership, give power to many

Lessons Learned

Build the coalition so it can partially run it self

Find and maintain solid leadership

Build and maintain trust

Always maintain open communications

Don’t tackle a coalition breaking project Focus on the things you can do together

Leave the ones you don’t agree on until a future time when you may bring them up again and may than find a compromise

Never Let It Rest

•The process must be attended to

•Evaluate the work of the coalition as well as the programs

•Continue to recruit and engage new people

•Share leadership

* Toot your own horn, if the community knows what you do they will help do more of it

Questions?