Robert Moore, MD, MPH- Chief Medical Officer, Partnership ...partnershiphp.org/Providers/Quality/Documents/... · West County Health Centers has become a thought leader and innovator

Robert Moore, MD, MPH- Chief Medical Officer, Partnership HealthPlan of California

Robert Moore is the Chief Medical Officer of Partnership HealthPlan (PHC), a well-respected Medi-Cal Managed Care plan,

serving 14 Northern California counties. Prior to joining PHC, Dr. Moore was the Medical Director of Community Health Clinic

Ole, an FQHC in Napa County, for 13 years, where he continues to see patients one evening each week. His major professional

interests are quality improvement, operational effectiveness, and delivery system transformation. He is a graduate of UCSF Medical

School and the Columbia University School of Public Health. Dr. Moore completed post-graduate courses and fellowships in health

center management, health care leadership, and quality improvement. His clinical interests include palliative care, intensive

outpatient care management, hospital medicine, diabetes care, and pediatrics.

Ella D. Auchincloss, MTS- Senior Project Lead, Engagement & Stewardship, ReThink Health

Ella heads community engagement efforts for ReThink Health. An expert in community leadership development, Ella leads multi-

site projects, trainings, and workshops and provides coaching for a wide variety of organizations and teams, helping them develop

the skills needed to lead change. She holds a MTS from the Harvard Divinity School and a BS in Finance from Babson College

4665 Business Center Drive, Fairfield, California 94534

(707) 863-4100 fax (707) 863-4117

Karen Smith, MD, MPH- Director and State Health Officer, California Department of Public Health

On March 23, 2015, Karen Smith, MD, MPH, was sworn in as director of the California Department of Public Health and state

health officer. Smith is a physician specializing in infectious disease and public health. Prior to her appointment, Smith served as

public health officer and deputy director at the Napa County Health and Human Services Agency since 2004. She was also been on

medical staff for infectious disease at Queen of the Valley Medical Center in Napa from 2012 to 2014 and has been a faculty

consultant for the Francis J. Curry International Tuberculosis Center at the University of California, San Francisco since 1997.

She served as clinical faculty at the Santa Clara County Valley Medical Center Division of Infectious Diseases from 1997 to 2004.

Smith served as assistant section chief at the California Department of Health Services Tuberculosis Control Branch from 2000 to

2001 and held several positions at the Stanford University School of Medicine from 1992 to 2004, including resident, fellow and

course director. Smith also served as TB Controller for Santa Clara County and served as president of the California TB.

Smith completed her medical training and infectious diseases fellowship at Stanford University after having obtained a Master of

Public Health degree at Johns Hopkins School of Hygiene and Public health. Prior to her medical training, Smith served in the Peace

Corp as Public Health Laboratory Director for the Marrakesh Province in Morocco and at the Wichienburi Regional Hospital in

Thailand.

Jennifer Henn, PhD- Public Health Manager and Epidemiologist, Public Health Division, Napa County Health and Human

Services Agency

Dr. Jennifer Henn received her PhD in epidemiology from the University of California, Davis in 2006. She spent a year as a

California Epidemiologic Investigations Service Fellow at the California Department of Public Health before joining Napa County

as an epidemiologist in 2007. Dr. Henn has had a lead role in the Live Healthy Napa County (LHNC) Collaborative, which was

formed in 2012 with the goal of improving community health by addressing public health problems and developing health

promotion strategies. She was a primary author of the LHNC Community Health Assessment and has been actively involved in

developing data and evaluation strategies for the collaborative over the past three years. She is currently the interim Public Health

Manager for LHNC.


(707) 863-4100 fax (707) 863-4117

Jason Cunningham, DO, Agency Medical Director, West County Health Centers

Jason Cunningham is the Medical Director of West County Health Centers, a Federally Qualified Health Center caring for patients

in western Sonoma County. West County Health Centers has become a thought leader and innovator in re-designing Primary Care

around the principle that a “trusting, long-term relationship” is the most important product of health care and the most influential in

improving health. Dr. Cunningham’s leadership has focused on the use of video and communication technology to improve care

coordination, team-based care for patients with complex medical and social stressors, and the use of data to drive innovation.

Dr. Cunningham is interested in leadership within healthcare delivery and participates in multiple boards and committees with local,

regional and state organizations.

Dr. Cunningham is a Family Physician and remains dedicated to patient care.

He received his Bachelor of Science from the University of Michigan and medical degree from Kirksville College of Osteopathic

Medicine.

Danielle Oryn, DO, Chief Medical Information Officer

Since medical school at Nova Southeastern University, Dr. Danielle Oryn has been passionate about leveraging technology to

improve health care for the underserved. After completing residency in Family Medicine, she went on to complete a Masters in

Public Health and a graduate certificate in Biomedical Informatics. As Chief Medical Informatics Officer at Petaluma Health Center

and Redwood Community Health Coalition, Dr. Oryn provides leadership for initiatives in clinical systems, health information

technology and quality improvement.


(707) 863-4100 fax (707) 863-4117

Breanne Olmstead, MA, Member Services Director, Open Door Community Health Centers

As Member Services Director for Open Door Community Health Centers, Brea’s work is focused toward program development,

implementation, and sustainability in areas of social determinants of health to support Open Door patients, care teams, and

community. She is especially passionate about projects linked to patient navigation, process improvement, access to care and

programs to support health and wellness, food security, housing, and human dignity. Brea works across Open Door’s 12 primary

care, specialty, and dental sites in Humboldt and Del Norte Counties to integrate enabling/social support programs into the primary

care delivery system. She also serves as point of contact for various County Government projects and collaborative community

initiatives. Brea joined the Open Door team in 2010 and is a graduate of Humboldt State University’s Master of Arts, Social Science

interdisciplinary program in Environment & Community, with certificates in Women’s Studies and Pre-Doctoral College Teaching.

Terri Fields Hosler, MPH, RD- Public Health Director, Shasta County Health and Human Services Agency

Terri has been with Shasta County since 2001, and is currently serving as the Public Health Director for the Health and Human

Services Agency. She is a Registered Dietitian with 25 years of public health experience. In 2005 she created the vision for a

county-wide collaborative to address childhood obesity called Healthy Shasta.

Lessons learned about cross-sector engagement of community partners over the 10 years of Healthy Shasta is foundational to the

current approach Shasta is taking to their Community Health Assessment and Community Health Improvement Plan. Also this

collaborative model is being used to address Shasta County’s social determinants of health, including the promotion of educational

attainment and the prevention of Adverse Childhood Experiences.


(707) 863-4100 fax (707) 863-4117

Social Determinants of Health Best Practices

Sharing Workshop

Partnership HealthPlan of California

November 9, 2015

To educate the audience regarding how social determinants of health impact our member’s health outcomes

To provide information on community engagement and collaboration

To share best practices of initiatives targeting social determinants of health

To launch Partnership HealthPlan of California’s Social Determinants of Health Request for Proposal

OBJECTIVES

Folders

Agenda

Presenter Biographies

PHC Contact Information

Evaluation

Q&A Process

LOGISTICS

Restroom Locations

Electronic Devices

WIFI Code

Presentation Materials Online

HOUSEKEEPING

Begin and end on time

Be open-minded – respect all ideas and opinions

Use technology sparingly and place on silent

If you must take a call, please step out of the room

Be engaged – participate

Have fun!!!

GROUND RULES

Let’s get started . . .

LET’S GET STARTED

ENJOY THE FORUM!

LET’S GET STARTED

Partnership’s Social Determinants of Health

Initiative

Robert Moore, MD, MPH

November 9, 2015

We Care!

1. Common Understanding

2. Big Picture

3. Little Picture

Preparing for Our Day Together

Health Plan

Provider

• SDOH are “the circumstances in which people are born, grow up, live, work and age, and the systems put in place to deal with illness. These circumstances are in turn shaped by a wider set of forces: economics, social policies, and politics”

-World Health Organization

Defining Social Determinants of Health

1.) Economic

2.) Education

3.) Social and Community Context

4.) Health and Healthcare

5.) Neighborhood and Build Environment

5 Key Areas of SDH

-World Health Organization

1.) Economic

Low wages

Food InsecurityHousing Insecurity

2.) Education

Low literacy

Low health literacyLow High School Graduation Rates

3.) Social and Community Context

Post-incarceration

Social IsolationAdverse Childhood Experiences

4.) Health and Healthcare

Poor Access To Care

Lack of Health Insurance

5.) Neighborhood and Build EnvironmentUnsafe Neighborhoods

Poor Quality Housing

Examples in Each Area

Bay Area Regional Health Inequities Initiative Framework



DiseaseBehaviorNeglected

Communities

Policies

& PracticesDeath

Biased

Beliefs

(isms)

Medical Model (individuals)Socio-Ecological (society)

Emergency

Rooms

ClinicsHealth

Education

Building Power

in Place

Policy

Advocacy

Change

the

Narrative

--Tony Iton, MD, JD, MPH, California Endowment

Levels of Intervention

1.) The SDH impact health status through stress

2.) Many of these stressors can be addressed with social services

3.) Other stressors are addressed though advocacy, policy changes and local leadership development

4.) Navigation and Collaboration are key interventions for health care system.

Key Elements of the SDH Paradigm

Stress Pathways from Brain to Body

Center on Social Disparities in Health, University of CA, San Francisco

When the External Becomes Internal: How we Internalize Our Environment

Total Health Care Investment in US is Less

1.) Deeply understand the new paradigm

2.) Invest time

3.) Media and marketing

4.) Tell stories (engage people emotionally)

5.) Understand the language of framing

Reframing our Society’s Understanding of Health

Social Determinants of Health Initiative

Policy

EnvironmentalSystems

Sustainable

Change

Re-framingCollaboration

Potential Levels of Intervention

The role of health care typically falls into one of these three categories:

• Navigation

• Collaboration

• Provision

Implications

• Navigate when services are already available

• Collaborate when there is synergy in the collaboration

• Provide when the services are not available or accessible in the community but necessary to improve health

Navigate, Collaborate, Provide

IHI/Kaiser study of SDOH ---2014

Navigation: Two Levels of Intervention

• Assessment

• Intervention:

1. Referral to other organization

2. Provision of service by same

organization

Collaboration

Essential for tackling SDH that:

• Have complex underlying factors

• That require multiple levels of

intervention

• Provide high quality, equitable, culturally-appropriate, and affordable health care services.

• Anticipate and link vulnerable patients and populations to community and preventive services.

• Employ and train community residents and procure needed materials and services from local community providers.

The Role of The Healthcare System


1. Delivery system changes

2. Bridging clinic community

3. New health care workers

4. Participate in policy advocacy for prevention

5. A Sustained Prevention Campaign

Five Basic Strategies to Address SDH


Healthy Communities

Participant

Convener/

Catalyst

Partner

Advocate

Funder

Leader

Potential Collaborative Roles of PHC

Where to Start?Levels of Change and ROI Impact

PHC

System Reform-

Short Term

Measurable ROI

Policy Change and Shift in

Culture- Medium/ Long

Term Measurable ROI

Environmental

Change-

Medium/ Long

Term

Measurable ROI-

Long Term Effort

Needed

Leader/

Convener/

Participant/

Partner

Advocate

Funder

Community Engagement for

Population Health

A Pathway for Community Engagement for a (Nascent) Population Health Initiative

PHC Social Determinants of Health Best Practices Sharing Workshop

November 9, 2015

Fairfield, CA

Ella D. Auchincloss, MTSSenior Project Leader, Stewardship and Engagement GroupReThink Health

Purpose of Presentation

• To describe ReThink Health’s approach to Community Engagement

• To show some examples of how the approach has been use to launch a population health initiative

• To suggest a process for getting started

• To offer some lessons learned from our work

34

ReThink Health

35

• Support and influence how innovators see, think, and act

• Help leaders see and plan from a whole system perspective and work across boundaries

• Bridge health and health care

• Accelerate and sustain efforts over time

• Remove the barriers and overcome excuses

Action Results

Thinking

ReActing

RETHINKING

…through Project Design, Training, Coaching, Dynamics Modeling, Distance Learning, Research and Curriculum Development

36

ReThink Health’s Pathway for Transforming Regional Health

Guidance that helps users navigate the pitfalls and momentum builders on the road to health system transformation.

36

PHASE I: Campaign

PHASE II: Engage

PHASE III: Align

PHASE IV: Redesign

PHASE V: Integrate

Core Pillars of the Pathway Supported ReThink Health

37

Sustainable Financing

Stewardship-Engagement

Sound Strategy

My story: Pickup Basketball as a ramp on the pathway

38

People:

Organized around a common purpose and shared values

Power:

Comes from the people’s own

gathered resources

Change:

The challenge the people seek to

address through collective action

Empowering People for Change

…people acting together to change the status quo

The work starts with a new, foundational understanding of leadership….

Leadership is accepting responsibility for enabling others to achieve purpose under

conditions of uncertainty.” –Marshall Ganz

40

Key elements:•Decision, not a position

•Focused on building the capacity of others•Grounded in Shared Values and Interests

How do we grow in our collective capacity and power? The Snowflake Model

41

• Team based leadership development

• Interdependent roles

• Strong commitments based upon values

• Designed for achieving “spread”

Zip Code 29203: The Challenge

In South Carolina: •More that 60% of the population is overweight

•30% of the state has high blood pressure•11% of the state has diabetes

In 29203: •One of the highest amputation rates due to

diabetes in the US•30% of residents are uninsured

•Average resident makes two ED visits per year•Translates into 90,000 visits per year including

30,000 from residents who can’t pay

Example of a Relational Strategy

16 participants

Core Leadership

Team Training

July 13-14

91 leaders attend

Town Hall Meeting Aug. 16

32 new leaders at Leadership

Team Training

Sept 27-28

188 people attend

Community Issues

Assembly (campaign decision-making)

November 16

105 newleaders attend Team

Training January

2012

565 PeopleLaunch

CampaignMarch 3

2012

6 Vision Team

Trained

~3,000 people and institutions signed the Community Covenant

132 1:1 meetings in 29203

750 attend 45 house meetings

to vet campaign

ideasOct-Nov

Zip Code 29203: The Response

44

Healthier Roxbury: The ChallengeAbundance of Resources-Ineffective Alignment

Roxbury has the highest rate of Type 2 Diabetes and Pediatric Asthma in Boston

3.6 miles

ResidentsAt risk andDiagnosed

Health Care Delivery SystemHealth Centers (Dimock,

Whittier, others nearby)

Hospitals(BMC, BI-Deac, Joslin, others)

Local MDs

Insurer-based Care

Mgmt

Self-Management Education and Support(American Diabetes Assoc, YMCA, Healthy Living 4 Me, Ethos,

Health Leads Boston, Boston Senior Home Care, Generations Inc.)

Other Health Education and Support(Family Van, Mission Hill Health Mission, Latino Health Insurance

Program, La Alianza Hispana)

Nutrition & Food

(Fair Foods/Fair Shoes; Fresh

Truck; The Food Project; Boston

Collab.for Food & Fitness; Boston

Elderly Nutrition Prog)

Fitness & Recreation

(Boston Centers for Youth &

Families;YMCA; Healthy Kids,

Healthy Futures)

By Location(Lower Roxbury

Coalition; Dudley

Street Neighborhood

Initiative; Project

RIGHT; ABCD;

Housing

developments)

By Age Group(Schools;

Hawthorne Youth &

Community Ctr;

Central Boston

Elder Services;

Ruggles Assisted

Living)

By Ethnic

Group(Nuestra

Comunidad

Development Corp;

Sociedad Latina;

Somali

Development Ctr)

By

Religious

Affiliation(Churches,

Mosques)Public Health Agencies(BACH/Roxbury Community Alliance

for Health; HRIA; Boston Public Health

Comm; MA Health and Human

Services; MA Dept of Public Health;

Area Agencies on Aging)

HEALTHIER ROXBURY ASSET MAP

Tufts Health Care Institute 4/2014 45

46

Healthier Roxbury: Building New Relationships

Listening Learning Sessions held Nov

‘13-Jan ‘14

Learning

Harvested

and

Reported

with Recs

to AG

February

2014

5 orgs agree

to host

three

sessions

each

NOW

HR AG

commits

to

Listening

Training

and

Support for

Listening

and

Learning

Sessions

Nov 1

HR

Diabetes

Project

Goal

Affirmed-

Mobilized

March

2014

APRIL 2014

Healthier

Roxbury

Diabetes

Project

Launched

with new

timeline

Regular AG meetings

RTH Teach-In’s occur monthly

RTHCommunity

Engagement Monthly

“Teach-ins”begin

Nov. 13th

Bridging the Gap between Senior Health and Healthcare:The Urban Baltimore HELPS’s Project (Delmarva Foundation for Medical Care)

HOW DID RTH HELP?

- Trained them to implement community based root cause analysis

- Trained them how to use community organizing practices -more specifically map of actors and relationship building strategies

- Developed their skills for effective convening (creating shared purpose and creative use of existing resources)

- Enabled them to manage internal and external conflicts and tensions

47

- HELPS Coalition with 40 members (local stakeholders) launched and adopted the shared purpose to improve health outcomes for dual eligible seniors

- Number of great new services created for senior citizens (without creating additional cost) such as info about Medicare, cooking demonstrations, “ask the professionals” meetings to discuss diabetes care and ONE STOP Service Centers for senior adults

- HELPS Coalition still exists and it continues to grow under the leadership of Advisory board (incl. Baltimore City Health Department)

48

DFMC’s Baltimore HELPS’s Project

Tips for getting started…C-SUITE Support

• Get grass-tops “buy-in” for local relationship building

– Senior leaders need to signal their value for the work

• Public commitments

• Attendance at key meetings

• No “Siberia’s”, Ghetto’s or Outposts

• Patience with the process work

• Set goals for building relationships

49

• Mapping the actors early and often

– Have more 1:1 meetings than you think you can schedule

– Be mindful about your “ask”

– Recruit local actors to a core team

– Look for people who will host meetings of many local community members

– Go where the people are

50

Tips for getting started…Map Actors

Tips for getting started…Framing the Vision

• Develop a motivating vision and story

– Speak from the heart; avoid sharing only depressing statistics

– Practice telling the story with your team

– Be clear about your specific request

– Stay grounded in your own sources of motivation and hope

51

Tips for getting started…Equity

Pay Attention to Equity

• Build an equity lens into every step

• Listen

• Be willing to change your approach, your language and your priorities once you get into action.

52

Tips for getting started…Funders Expectations

• Development an evaluation framework that values the short-term ground game and collaborative process work

– Funders/Key stakeholders should see measures such as:

• Number of New Stakeholders engaged

• Number of New Volunteers and Teams recruited

• Number of New Coalitions formed

• Number of Joint Grants applied for

• Number of Leadership Team Meetings

• Number of Public Charters, Town Hall meetings

• Pre-post assessments of understanding

53

Common Scenarios that Impede Progress

Only the Senior Leaders are Engaged Early in the Effort:

54

Structuring the work in such a way that prevents the community from being involved

• Meetings in the middle of the work day

• Meetings held outside of neighborhood

• Community is volunteer only when other key stakeholders are paid to participate

• No offer to pay for transit, child care or parking

55



• Medical Care or Academic Mindset

– Patient versus Partner

– “Just the facts, Mam”—Over-reliance on Data/ Evidence

– Expert with the advice

– Won’t “go” there when the impact of upstream problems emerge

56


• Adopting a Short Term Time Frame for Long Haul Work

57


• Losing connection with your sources of hope and inspiration

58

• Making progress on the symptoms while ignoring the causes

• Sticking with a strategy that you are learning does not work.

59

[More] Common Scenarios that Impede Progress

6060

PHASE I: Campaign

PHASE II: Engage

PHASE III: Align

PHASE IV: Redesign

PHASE V: Integrate

Reactions, Questions and Discussion

ReThink Health’s Pathway to a Healthy Health System

Momentum Builders

Pitfalls

For more information

Ella D. Auchincloss, MTS

Senior Project Leader

Stewardship and Engagement Group

ReThink Health

Cambridge, MA

[email protected]

(617) 686-4169

rethinkhealth.org

61

mailto:[email protected]

Best Practice-Community

Engagement

Live Healthy Napa

County (LHNC) Update

Partnership Health PlanNovember 9, 2015

LHNC Overview

What is

Live Healthy Napa County?

Collaborative process bringing together

diverse stakeholders and community

members.

Public-private-community partnership to

improve the health and wellbeing of

everyone in Napa County.

Why

Live Healthy Napa County?

Increase health and quality of life for all

individuals, families, and communities in

Napa County.

Move away from a focus exclusively on

sickness and disease to one based on

prevention and wellness.

Create sustainable improvements in

health in Napa County.

How?

A collaborative process, Live Healthy Napa

County has gained support and commitment

from stakeholders

Community members have come together to:

articulate and understand the specific needs and

challenges of their own community,

define their own health priorities and goals,

determine solutions to achieve a shared vision of a

healthier Napa County

67

The LHNC Process

Envision

Assess

Plan

Act

Envision

Community members will take

responsibility for improving health

through:

Shared leadership

Strategic planning

Meaningful community engagement

Coordinated action

Assess

Community Health Assessment

Purpose:

A comprehensive assessment that

establishes the foundation for

sustainable improvements in health

in Napa County.

70

Assess


Purpose:

Gathers and analyzes data to

determine the health needs of our

community

Completed April 2013!

71

OVERVIEW OF THE

COMMUNITY HEALTH

ASSESSMENT

Overview of the Community

Health Assessment (CHA)

The CHA has three chapters:

1. The Community Strengths, Themes, and

Forces of Change Assessment

2. A Local Public Health System Assessment

3. Community Health Status Assessment

Strengths and Challenges

Strengths - examples

Clean, safe neighborhoods

Violent crime/100,000

Air quality

Distance to parks

Extensive partnerships and strong

collaboration

QVMC

St. John the Baptist Catholic ChurchParentsCAN

Napa Valley Vintners

NCOE

Napa County Farm Bureau

On the Move

Napa Valley College

Clinic Ole

Cities of American Canyon, Napa and St. Helena and Town of Yountville

Napa Fire

AAoA

Napa County Agriculture; Planning, Building &

Environmental Services; Housing and Community

Development; HHSA; Sheriff’s Office

Calistoga Institute

CANVSt. Helena Family

Center

Am Can FRCNapa Chamber

SomosNapa

PuertasAbiertas

NCTPANapa Learns

Core Support Team

Cope

NEWS

LHNC Organizations

AngwinCommunity CouncilCommunity

Members

Calistoga Family Center

NVUSD

Strong Community Involvement

2300+ surveys received

Over 300 focus group attendees

Over 200 town hall attendees

Challenges

Challenges

Overweight and obesity

Alcohol and drug abuse

Limited mental health services

Barriers – cost and location

Inadequate educational and economic

opportunities

People living in poverty

Graduation rates

Disparities

OVERVIEW OF THE COMMUNITY

HEALTH IMPROVEMENT

PLAN (CHIP)

Overview of the Community

Health Improvement Plan (CHIP)

Purpose of the CHIP:

To develop common priorities that inform and mobilize coordinated action throughout the County.

CHIP process:

1. Use Community Health Assessment to identify strategic health issues across Napa County.

2. Community stakeholders develop goals and strategies to address strategic issues and health disparities.

Priority Areas

Improve Wellness & Healthy Lifestyles

Address the

Social Determinants of Health

Create & strengthen sustainable

partnerships for collective impact

Ensure access to high quality health services

& social supports across the life course

Plan Development

Prioritize issues

Develop goals

Create strategies

Community Health Improvement Plan (CHIP)

Community Health Action Plan (CHAP)

83

In Progress: Action

Mobilize Community

Develop Leadership

Determine Roles and Responsibilities

Evaluate Results

Report back to the Community

Action Cycle

84

LHNC in 2015

Wellness

and Healthy

Lifestyles

Social

Determinant

s of Health

Sustainable

Partnerships

High Quality

Access

Leadership Communication Structure

Strategies for Implementation

Member engagement: reporting of activities is

critical for action phase

Focus on neighborhoods: 3 neighborhoods

deemed as “higher need” selected to start

Using data to tell our story: GIS mapping and

other data displays to illustrate importance of

SDOH

Strategy teams or “component plans”:

subgroups doing focused work in a particular

area for collective impact; aligns with and

expands on strategies in CHIP

Reporting on Progress

More than 30

organizations are

“leads” on activities

within the CHIP

Annual progress

reports with periodic

updates and

highlights

Progress on Activities

66 activities in the

Community Health

Improvement Plan

54% of activities

completed or in-

progress

0

10

20

30

40

50

60

70

Nu

mb

er

of

Ac

tivit

ies

CHIP Activity Progressthrough July 31, 2015

Total Activities

In progress orcompleted

Leadership group

will focus on

strategies and

activities where

we are not seeing

progress

Phillips Neighborhood Town Hall Meeting

Focus on Higher Need Neighborhoods

Median Income

$106,513

Life Expectancy

85.8 years

Median Income

$61,345

Life Expectancy

75.7 years

Neighborhood

level data helps to

educate and

engage partners

around SDOH

Component Plans/Strategy Teams

“Component Plan” activities:

Healthy Bodies Coalition - Obesity

Prevention Plan

Older Adult Component Plan

Poverty Component Plan

Behavioral Health Component Plan

Component Plans

Live Healthy Napa County Collaborative Planning

Partnership/ Shared

Leadership

Community Input

Community Data Collection

Action Plan

roadmap

Community HealthImprovement Plan

broad priority areas, goals, objectives, and strategies


foundational data on Napa County health and related factors

Co

lla

bo

rati

ve

Pro

cess

Component

Plansfocus on

overarching

subject areas

found in CHA

Healthy Bodies Coalition

Obesity Prevention Plan

Plan touches on strategies throughout the CHIP

LHNC Next Steps

Continue process of monitoring and evaluating

activities in both the CHIP/CHAP and

component plans

Maintain participant engagement with strong

focus on communication and “reporting back”

Update CHIP/CHAP as needed and begin new

assessment process in 2018

Questions?

For more information visit:

www.livehealthynapacounty.org

http://www.livehealthynapacounty.org/

Lunch and Resource Table

What are Health Centers and

Communities Doing?A Paneled Discussion

West County Health Centers

West County Health Centers

Social Determinants of Health

Individual

SDOH

Outcome

Data

Contextual

Data

Social Determinant Overview

Contextual

Data

Contextual

Data

Individual

SDOH

Outcome

Data

THANK YOU

Petaluma Health Center

Social Determinants of Health Data!

Petaluma Health Center

Opened 1996, FQHC since 2000

23,000 patients & 114,000 annual visits• Medical

• Dental

• Women’s Health

• Mental Health

• Wellness

• School based health

Choosing the Questions

External Factors

IOM Recommendations –Stage 3 MU

Prepare tool

Health Begins tool

Internal Factors

Current information collected

Capacity for collection

Community needs

Resources already available

Choosing the Questions

Collection Methods

Front line staff need the tools!

Mild – Works with home team to get needed resources!Person with one or two needs

Moderate = Work 1:1 with patient navigatorPerson with >2 needs (unless needs are only mental health)

Severe = Work 1:1 with Case ManagersPerson >2 needs AND medical complexityMedical complexity = ANY of the following1 or more chronic illness (DM, COPD, or other) that are out of control 2 or more hospitalizations in the last six months5 or more ED visits in the last six months

Front line staff need the tools

Improving population health

Challenges and Lessons (so far)Meaningful Use and the convergence of quality measures is affecting what and how we collect SDOH data.

Patients have differing preferences about how they give us information.

Kiosk positioning makes a difference.

Staff need resources to be able to do something with the new information they are given.

In the beginning of SDOH data collection look at the process measures and later (with more data available) understand more about the population.

Contact Information

Danielle Oryn, DO, MPH, Chief Medical Informatics Officer

[email protected]


Open Door Community Health Centers

Open Door Community Health Centers believes in leveling the playing field of

human dignity by providing quality medical, dental, behavioral health, and health

services to members of our community regardless of circumstance.

Best Practices: Addressing Social Determinants of Health

1. Shifting culture of HEALTH care

away from SICK care

2. Leveraging resources and

partnerships

3. Integration into the patient-

centered primary care delivery

system

Social Determinants

of Health

1 EDUCATON: PATIENTS, STAFF, COMMUNITY

2

SUPPORT SYSTEMS FOR CARE TEAMS3

1 LEVERAGING PARTNERSHIPS

2DEL NORTE COUNTY:

TCE BUILDING HEALTHY COMMUNITIES

3HUMBOLDT COUNTY:

DHHS COMMUNITY HEALTH IMPROVEMENT PLAN

Culture of Whole Person Care

Resources and Partnerships

ENGAGEMENT: PATIENTS, STAFF, COMMUNITY

1

• Targeted Patient Populations

• Document Processes

• Seek Sustainability

1

Pediatric BMI ProjectChildren ages 6-12 in 95% for BMI

WEEK 1: Let’s Get Started!

WEEK 2: Food logs & Understanding our Food

WEEK 3: Growing Healthy with Gardening

WEEK 4: Cooking for Health

WEEK 5: Farms, Farmers’ Markets, & Family Health

WEEK 6: Let’s Move!

WEEK 7: Shop Smart at the Grocery Store

WEEK 8: Celebration and Next Steps

1

images

Promotores

Health Connections

Coaches

Behavioral Health Member Services

CARE TEAMS,

PATIENT CENTERED MEDICAL/HEALTH HOME,

HEALTH AND WELLNESS CENTERS….

Case Managers

INTEGRATION INTO PRIMARY CARE DELIVERY SYSTEM Interdepartmental & Interdisciplinary Support Staff

Quality Healthcare, Access For All Since 1971

Best Practices: Addressing Social Determinants of Health

Brea Olmstead, Member Services [email protected](707) 269-7073


Shasta County Health and Human Services

Agency

Public Health – Provider Partnership Perinatal Substance Use and Mental Health

Terri Fields Hosler, MPH, RD, Director

Shasta County Health and Human Services Agency

Public Health Branch

Adverse Childhood Experiences

Abuse

Physical

Emotional

Sexual

Neglect

Physical

Emotional

Household Dysfunction

Mental Illness

Incarcerated Relative

Mother treated violently

Substance Abuse

Parental Loss/Separation

Shasta County ACE Data, 2012

Shasta County ACE Data, 2012

Shasta County Perinatal Substance Use Data

Addressing Perinatal Substance Use

Healthy Babies

Program:

Public Health Nurse conducts initial home visit to assess and link to treatment

Nurse follows up with the referring provider

Nurse maintains contact throughout the treatment program

Shasta County Perinatal Mood & Anxiety Disorder Data

12th highest rate of maternal depression of 58 counties per California MCAH Home Visiting Assessment conducted in 2010.

In 2013, maternal depression rate was 37.3, and anxiety rate was 40.9 per 1,000 Labor & Delivery discharges.

HBP Expands to Address Maternal Mental Health

In 2011, expanded to address perinatal

mood and anxiety disorder

with First 5 Shasta

funding.

Women who are pregnant or parenting a child under

two:First 5 pays

for counseling

for uninsured/

underinsured women.

Peer support classes

offered to enhance

coping skills, bonding and attachment.

Local trainings related to perinatal

mood and anxiety

disorders.

Expanded to allow referral from other community

partners.

Next Steps…

Adding another full-time nurse to focus on the substance use

Expand to serve women of childbearing age for both substance abuse treatment and family planning services

Re-brand program to reflect expanded scope of services

Lessons Learned

Providers are happy to screen if they can refer to a warm handoff.

Myths still exist among some providers.

Expanding to other community based organizations will help increase referrals.

Women get connected to the services needed and the referring doctor stays in the loop.

Enhances our relationships with agencies and providers for the other work we do.

PHC RFP Introduction

PHC’s SDH Grants:

An OverviewAmy Turnipseed

Director of Policy and Program Development

November 9th, 2015

Authority for SDH Grants

At the June 2015 PHC Board of

Director’s Meeting, the Board approved

supporting SDH under the “Local

Innovation Grants.” This will provide a

total of $1.5 million, allocated among

the PHC regions and awarded through

a competitive process to local

organizations.

Background

• As a follow-up to the Board discussion on SDH in

June, PHC convened a meeting with interested board

members and invited guests to have a discussion on

SDH.

• Then we dove into what PHC’s role should be. The

optimum role (or roles) for a health plan in any given

program promoting a social determinant of health will

vary over time.

• For the purposes of these grants, PHC will serve the

role of funder, targeting SDH programs at the health

care system level.

Two levels of SDH grants

PHC will be funding two type of opportunities under

the SDOH Initiative:

• Implementation Grants

• Planning Grants

Implementation Grant Criteria

• Focused on helping local organizations improve the

health of PHC members.

• The proposed project is the work of a coalition

addressing SDH in general.

• The intervention is tied to the effectiveness of the health

system, including but not limited to

• access to Health Care

• health literacy programs

• initiatives integrating social services and health care

• population health management programs targeted at

high risk individuals

• Grants requests are for two years and must not exceed

$500,000.

Planning Grant Criteria

• The grants will empower communities to develop a

community collaborative to focus initiatives on SDH that

impact their region.

• Identify community partners interested in participating

in this coalition.

• Each grantee will submit a strategic planning document

on how the coalition will be sustainable in future years.

• Grants will total no more than $50,000.

Timeline

Deliverable Date

Release of RFP Friday, November 6, 2015

Applicants’ Conference Monday, November 9, 2015

Application due date Friday, December 18, 2015

Announcement of grantees Friday, January 29, 2016

Grant period March 1, 2016- February 28, 2018

Key tentative dates for SDOH Local Innovation Grant Initiative 2015/2016 grant cycle:

Questions and Submission

Application Submission:

Each Application must include all contents required as documented in the

RFP. Failure to follow these specifications will result in disqualification.

All Applications are due by Friday, December 18, 2015. Applications

received after 5pm will not be considered.

Applications should be e-mailed to PHC Local Innovation Grants at

[email protected].


Questions?

Closing and Evaluation

• Leader?

• Convener?

• Catalyst?

• Advocate?

• Participant?

• Partner?

• Other?

What is your role?

Policy Change System Change

Environmental Change

• Reframing the narrative of health and health care

• Collaborate

• Navigate

• Use data to develop strategic frameworks

• Partner, lead, convene, catalyze, participate, and advocate

Summary of Day

• What are your leaders passionate about?

• What does your community care about?

• What is the investment?

• What change is expected?

• How will change be measured?

• Who are the other partners working to address the issue?

• What is PHC’s role?

• How are PHC’s resources leveraged?

Questions to Consider

Please email questions related to the SDH Project to:

Danielle Niculescu, Project Coordinator II

SDH Project Lead

[email protected]

Please email questions related to the RFP to:

[email protected]

Thank you!
