COMMUNITY BENEFIT
COLLABORATION
• Approach to understanding community health
challenges, assets and drivers
– Data elements/sources
– Summarized story
• Approach to designing implementation plans
• Current status of implementation
BACKGROUND
•
Kaiser Permanente of Georgia (KPGA) and Grady Health Systems (GHS)
partnered with Georgia Health Policy Center to complete CHNA and
implementation plan for each system
•
Considered the specific needs of each community/ service areas; GHS with
Fulton and DeKalb service region and KPGA with 30 additional counties (with
implications for design of implementation plan)
•
Alignment with Atlanta Regional Collaborative for Health Improvement (ARCHI)
areas of focus was an important consideration in development of
implementation plans
–
2
Priorities for the Atlanta Region :
• Encouraging healthy behaviors
• Family pathways to advantage
• Coordinated care
• Global payment
• Capture and reinvest savings
• Expand insurance
• Innovation fund
GHS SERVICE AREA
H
1,000+
400 - 999
200 - 399
50 - 199
0 - 49
Source: Grady Decision Support
3
KPGA SERVICE REGION
Kaiser Medical Offices
Outline of KP-GA Service
Region
CRITERIA
Criteria
Definition
Magnitude/ scale of the
problem
Affects a large number of people within the
community
Severity of the problem
Organizational assets
Serious consequences (morbidity, mortality, and/or economic
burden) for those affected
Has relevant expertise and/or unique assets to address the need
Existing or promising
approaches
Effective, promising evidence- based strategies could be applied to
address the need
Health disparities
Disproportionately impacts the health status of one or more
vulnerable population groups.
Ability to leverage*
Opportunity to work with existing community partners; build on
current programs, emerging opportunities, or other community assets.
* ARCHI – Healthy Behaviors, Pathways to Advantage, and Care Coordination
5
GHS PRIORITIES
Top Priorities
Coordinated Care
• Diabetes
• Prostate Cancer
• Hypertension/ Heart
Attack and Stroke
• AIDS
Health Insurance Coverage
• Access to Care
6
Middle Priorities
Encouraging Healthy
Behaviors
• Obesity/Diabetes
• Hypertension/ Heart
Attack and Stroke
• HIV/AIDS
• Unintentional Injuries
Lower Priorities
Family Pathways to
Advantage
• Low Birth Weight
• HS Educational NonAttainment
Encouraging Healthy
Behaviors
• STDs
GHS IMPLEMENTATION STRATEGIES
Focus Area
Health Need:
3- Year Goal
Strategies
Care Coordination
Effective and efficient patient
care coordination among
persons served by Grady
Health System
Improved coordination of
care for patients in Fulton
and DeKalb Counties with
the following conditions:
Diabetes
Hypertension/Heart
Attack/Stroke
Prostate Cancer
HIV/AIDS
1.
Increased insurance coverage
among persons served by the
Grady Health System
1.
Health Insurance
7
Increased opportunities
among persons served by the
Grady Health System to
access appropriate
healthcare services
2.
2.
Implement Safety Net Medical Home model
focused on the use of patient
care/treatment protocols and lay health
workers to improve disease management
and to control and reduce the likelihood of
hospital admissions
Collaborate with partners to promote and
support Care Transitions Programs
Support navigator efforts to increase
enrollment of uninsured and disadvantaged
populations in the health insurance
exchange.
Support outreach efforts to enroll eligible
individuals in Medicaid and PeachCare
GHS IMPLEMENTATION STRATEGIES
Focus Area
Health Need:
3- Year Goal
Strategies
Healthy
Behaviors
Improved sexual health in
high risk populations living
the DeKalb and Fulton
Communities
Increased messaging to
high risk populations to
reduce the prevalence of
HIV/AIDS
Collaborate and partner with key public health and
community based organizations to promote HIV/AIDS
prevention
Evidence based
interventions aimed at
reducing obesity in
residents of DeKalb and
Fulton
Increased levels of
Physical Activity (PA) in
adult residents of DeKalb
and Fulton counties
Collaborate with key partners including Parks & Recreation,
YMCA, Senior Centers, other key partners to promote and
facilitate policies and programs that result in increased
physical activity:
Social support in worksites, senior centers, faith or
community sites for walking groups
Social marketing & point of decision prompts in target
locations including worksites and the broader community
Enhancing existing green space & parks improvement
Sidewalks & complete streets policies
Reduced risk for homicide
and injury in target
populations in Fulton and
DeKalb counties
Increased messaging and
education to high-risk
populations for homicide
and injury prevention
Collaborate and partner with key education and community
based organizations to promote homicide prevention and to
reduce unintended injuries
8
KPGA HEALTH NEEDS CHECKLIST
Health Needs
Drivers
 Asthma
 Drug/Alcohol Abuse
 Cancer
 Educational non-attainment
 Diabetes
 Health Care Inaccessibility
 Heart Disease/Attacks
 Physical Inactivity
 Hypertension
 Poor Nutrition
 Low birth weight infants
 Poverty
 Mental Health
 Tobacco Use
 Obesity
 Sexually Transmitted Diseases
 Teen Pregnancy
9
KPGA HEALTH NEEDS (CONSENSUS)
Upper Tier
Middle Tier
Lower Tier
Obesity
Mental Health
Teen Pregnancy
Diabetes
STD/HIV AIDS
Low birth weight
Heart Disease
Cancer
Asthma
Hypertension/Stroke
KPGA PRIORITIES
The primary foci of activity for the next 3 years:
 Overweight and obesity control
 Diabetes prevention and management
 Heart attack and stroke prevention and management
 Access to care
 Educational attainment and health literacy
11
KPGA IMPLEMENTATION STRATEGIES
Focus Area
Health Need:
3- Year Goal
Strategies
Healthy
Behaviors
Overweight and
obesity control to
prevent long term
chronic disease in the
KPGA service region
Increase access to fresh
fruits, vegetables and
whole grains
1. Provide community-based grants, including technical assistance, to support
policy implementation and programs
2. Provide grants to seed urban policy and environmental redesign of
communities
3. Convene and collaborate with key stakeholders (e.g. YMCA, United Way,
Open Hand, Atlanta Community Food Bank) to facilitate the development of
policies and programs that promote behavior change and provide social
supports
Increase access to
physical activity
opportunities
Increase intake of fruits,
vegetables and whole
grains by youth in the
region
Increase moderate-tovigorous physical activity
(PA) in children & youth
12
1. Provide grants and technical assistance to schools, non-profits and/or
community groups, and other key stakeholders to support, promote and
implement healthy school nutrition, physical activity strategies and physical
education standards
2. Engage Educational Theater Program and other appropriate internal KP
resources to assist in the development and administration of Healthy Eating
Active Living productions & programs
3. Convene and collaborate with key stakeholders (e.g. school systems,
administrators, and non-profit organizations) to facilitate the development of
policies and programs that promote behavior change and provide social
supports
KPGA IMPLEMENTATION STRATEGIES
Focus Area
Health Need:
3- Year Goal
Strategies
Healthy
Behaviors
Diabetes
prevention and
management
among adults in the
KPGA service
region
Increase
percentage of
residents
achieving
glycemic control
in the region
1. Provide grants and technical assistance to support community collaborations aimed at
increasing knowledge, policies and awareness about the prevention, impact and selfmanagement of diabetes
2. Leverage KP assets (i.e. Medical Financial Assistance, Medicaid, Charity Care,
Charitable Health Coverage etc.) and clinical expertise to ensure the availability of, and
access to, appropriate diabetes preventive, screening and clinical services
3. Provide grants to organizations that support and promote the expansion of a welltrained health workforce to improve access to care in the community
Prevention and
management of
heart disease,
hypertension and
stroke among
adults in the KPGA
service region
Increased
percentage of
residents with
normal blood
pressure (BP)
and cholesterol
in the region
1. Provide grants and technical assistance to community partnerships/collaborations to
increase health education and awareness of hypertension risk factors, control and
cholesterol management
2. Leverage existing KP assets and programs (i.e. Medical Financial Assistance,
Medicaid, Charity Care, Charitable Health Coverage etc.) to ensure availability of, and
access to quality cardiovascular preventive, screening and clinical services
3. Provide grants to organizations that support and promote the expansion of a welltrained health workforce to improve access to care in the community
Care
Coordination
13
KPGA IMPLEMENTATION STRATEGIES
Focus Area
Care
Coordination
14
Health Need:
3- Year Goal
Strategies
Access to health
care to ensure
better health
outcomes the
KPGA service
region
Increase in health care
coverage rates for low
income populations in the
KPGA service region
1. Provide grants to support community based organizations in ensuring low
income residents access to quality preventive, screening and clinical
services
2. Leverage KP assets and programs (i.e. Medical Financial Assistance,
Medicaid, Charity Care, Charitable Health Coverage etc.) to assist
individuals in finding health care and enrolling into eligible programs
3. Partner with safety net clinics and community partners to create community
solutions to address coverage and access to coordinated care for lowincome residents.
4. Convene and collaborate with key stakeholders (e.g. ARCHI, Philanthropic
Collaborative and United Way) to facilitate the development of policies and
programs that promote increased access and coverage
Increase in access to health
care services for low
income populations
KPGA IMPLEMENTATION STRATEGIES
Focus Area
Health Need:
3- Year Goal
Strategies
Pathways to
Advantage
Improved education
and health literacy
levels among
residents in the
KPGA service
region
Increase in educational
attainment for children and
youth in elementary and
middle school
1. Provide grants to pre-school and other early childhood programs in service
region focused on promising and evidence-based interventions that improve
students reading through the 3rd grade level (elementary) and support
academic reinforcement
2. Engage Educational Theater Program (ETP) in appropriate settings
throughout the community to promote improved health education and
healthy behaviors
3. Provide grant and technical assistance to support organizations and
partners focused on the dissemination of health information, training and
guidance for the community
15
Increase in the knowledge
and use of health
information in the
community
EXAMPLES OF CURRENT
COLLABORATION
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COMMUNITY CARE MANAGEMENT
Project Title: Enhancing Patients’ Lives through Community Care Management
Piedmont/Kaiser collaboration provided health care and community resource linkages to low-income, non-Medicare Charity
Care-eligible patients with complex, chronic diseases at or below 200% of the Federal Poverty Level to reduce avoidable
hospital readmissions and emergency room visits by 20%.
Impact and Lessons Learned
17

The project served 352 patients and 324 caregivers (proposed 961 patients and 961 caregivers). Only 3% of program
participants were readmitted to the hospital within 60 days. The hospital’s average readmission rate is 11%.

Over 11,000 telephone support calls, 270 home visits, almost 1,000 contacts with physician offices and made
transportation arrangements, community resource linkages and provided pharmacy assistance.

Patients’ health was positively impacted as demonstrated by improved PHQ-9(Patient Health Questionnaire) and PAM
(Patient Activation Measure).

Clients needed help addressing their social barriers to accessing care.

Telephonic model didn’t work well, so Piedmont switched to a social medicine model of care, which focused on the
sociological factors that contribute to illness.

Patients are able to manage their own care when given the necessary tools.

Low-income patients are more quickly labeled “noncompliant”
ATLANTA SAFETY NET COLLABORATIVE
•
•
Kaiser Grant for Grady Walk-In Center and Patient Navigator Program
– New site on Grady campus for “walk-ins” (Considered FQHC management)
– Patient navigators located in the walk-in center, all 4 FQHCs and Grady primary
care
• 7 navigators
– Navigators provided patient education regarding PCMH and scheduled follow up
appointments to FQHCs or a Grady clinic
– Challenge in getting patients to leave Grady System
• History/culture
• Co-pays
Impact
– While program did not drive down ED volumes as anticipated, ambulatory
sensitive conditions decreased as a percent of total volume
– Program created a platform for further collaboration among safety net
ATLANTA SAFETY NET COLLABORATIVE
• United Way Community Health Worker Program
– Building on Navigator Program, the CHW program targets high-utilizers from the
emergency department
• 5 CHWs
• 2 year program
– CHW’s trained for home visits and ongoing support outside of clinical visits
– With underlying behavioral health conditions of high-utilizers, program was redirected to focus on patients with high-risk for re-admissions
– Continue to have the goal of referring patients without a medical home to the
FQHCs and Grady clinics
• Impact
– One year into the program, initial results indicate reduced re-admission rate for
patients assigned a CHW
– No determination of impact on patients adopting PCMH
MODEL FOR REPLICATION
New Program developed – Sams Care Program
Primary goal: To increase access to necessary care for uninsured community members in Piedmont’s
service communities, avoiding preventable emergency department re-encounters, building upon
successes and lessons learned through Piedmont/Kaiser collaboration
Primary activities:
•
Deploy EPIC into three charitable clinics – Fayette CARE Clinic (Fayetteville), Coweta Samaritan
Clinic (Newnan) and Hands of Hope (Stockbridge)
•
Provide for midlevel staffing to expand clinic capacity
•
Provide for licensed medical social worker to address socioeconomic issues
•
Create streamlined ED referral process
•
Measure and capture patient care outcomes, impact on hospital, impact on community
•
Establish sustainable funding for program
•
Deploy “phase two” components – disease management, further ED integration
20
OPPORTUNITIES FOR COLLABORATION
Q& A
21