Buncombe County
Health & Human
Services
Community Focused
Eliminating Health
Disparities Initiative
(CFEHDI) Program
January 23, 2013
Working Together to
improve the health of minorities
living in Buncombe County
Ujima: Collective Work and Responsibility- To build and
maintain our community together and make our brother’s and
sister’s problems our problems and to solve them together.
Community Based Organization:
Collaboration
Mt. Zion Community Development, Inc.
Buncombe County Populations Served
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African American
American Indian
Hispanic/Latina
Other: Uninsured and
Underinsured
Chronic Health Conditions Addressed
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Asthma
Cancer
Diabetes
Heart Disease
HIVAIDS/STD
Obesity and Stroke
Community Partner Programs
 Health
Screenings
& Outreach
 Diabetes Wellness
Program
 Chronic Disease
Self-Management
Classes
 Body & Soul
 Diabetes
Prevention
Workshops
 Project Empower
 Coordinate “Ladies
Night Out”
 Case
Management
(PACE, Building
Brothers)
Role of Buncombe County
Department of Health
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Convene partners around
common agenda
•
Facilitate Communication & cross
referrals
•
Develop new & existing
partnerships to expand reach
•
Provide infrastructure for carrying
out grant scope of work
•
Collect and organize program
data for evaluation and analyzing
Data Collection and
Common Documentation of Program Events
and Outreach
1.
Map outreach efforts of sub-contractors
2.
Understand chronic disease focus areas
3.
Communicate performance and outcome
information
4.
Reflect access to care and equity efforts
of area health care programs
5.
Track referral and follow up efforts to
Medicaid, Medicare, and Insurance
Health and Wellness
Assessment Tool:
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Demographics
Chronic Conditions
Medical Home
Status
“Know Your
Numbers” data
Referrals for medical
services by partners
Community needs
Buncombe County Health & Human Services,
Minority Health Equity Project:
Improving Health for Everyone… Building a
Better Future Together
Wayne County Health Department
Minority Health Program
Wayne County, NC
Total Population Estimate
124,246
Hispanic/
Latino
10%
Black/
African
American
32%
Other 3%
Minorities
45%
White
55%
White
55%
Disease Focus Areas
Leading Causes of Death for All Minorities (2011)
1. Cancer
26%
2. Heart Disease
17%
3. Cerebrovascular Disease
6%
4. Nephritis
6%
5. Diabetes
5%
 Obesity
7%
Heart Disease
Diabetes
Diabetes
21%
HIV/AIDS/STD
54%
 HIV/AIDS
Heart Disease
18%
Obesity
Programmatic Focus
The focus of our education
intervention is to:
1. Increase knowledge and awareness of modifiable
risk factors that contribute to obesity and chronic
conditions associated with unhealthy lifestyles
2. Implement strategies to reduce these health risks
3. Build infrastructures by establishing health
ministries charged with conducting and
promoting health and wellness sessions
4. Establish medical homes for uninsured
congregants
5. Modify risk factors for chronic disease and to
initiate chronic disease self management
strategies.
Programmatic Highlights
• W.A.T.C.H is a free, primary health clinic providing acute healthcare to the uninsured with
two locations:
• The Mobile Unit travels around the county to 15 pre-determined locations each month
• A satellite location is available at the Goldsboro Family YMCA
• Each W.A.T.C.H. clinic is run by a Family Nurse Practitioner and volunteer physicians
provide specialty clinics at specified dates and times
• For 2012
• Patient Visits: 9,969 and 301 were unduplicated patients
• Volunteer Hours: 1,191
• Free medications ordered: $1.8 million
• From January – December 2012, $487,000 of free labs were completed
Programmatic Highlights
Faithful Families Eating Smart and Moving More (FFESMM) is a practice-tested
intervention that educates faith community members about food, physical activity and
becoming advocates for healthy policy and environmental changes within their
communities.
Programmatic Impact
 Staying abreast of recent health disparities and policy developments
 Building and maintaining strong relationships with other health and
community advocates to leverage expertise and resources
 Coalition Building and Community Engagement
 Engaging the Faith Community
 Media Outreach
 Helping to educate both minority and mainstream media about minority health
policy and issues so that these issues get timely an appropriate attention
 providing culturally competent program materials for various faith
communities, community-based organizations and civic groups in addressing
health literacy.
Tara Robinson, RN, BSN, CCM
Wake County Medical Society Community Health Foundation
WCMSCHF
Community Care of
Wake & Johnston
Counties
CapitalCare
Collaborative
• Non-profit
• 501(c)3
• Improve quality of and access to
primary care for the Carolina Access
Medicaid and dual
(Medicare/Medicaid) population
• Reduce healthcare cost
• Increase access to primary & specialty
care for the uninsured & homeless
• Reduce ED visits
Assesses and responds to community health needs
Medical Home
Evidence-Based
Best Practice
Care Management
Breakdown by Ethnicity
Black or African
American
21.4%
0.8%
67.8%
10.0%
American Indian &
Alaska Native
Hispanic or Latino
Other
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North Carolina's second most populated county
Area: 835 sq. miles
Persons per sq. mile: 1,078.8
Population: 952,151
Sources: US Census Bureau: State and County Quick Facts
Wake County Community Health Needs Assessment, 2013
Breakdown by Ethnicity
15.7%
0.9%
13.1%
Black or African
American
American Indian &
Alaska Native
Hispanic or Latino
70.3%
Other
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The 77th fastest growing U.S. county with a population of 10,000 or more
Area: 791 sq. miles
Persons per sq. mile: 213.4
Population: 174,938
Source: US Census Bureau: State and County Quick Facts
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Decrease the number of uninsured minorities in
Wake & Johnston counties
Link individuals to a medical home and increase
knowledge on how to optimally access health care
services
Promote chronic disease self-management among
racial and ethnic minorities
Increase cultural competency among staff
PCPs, Safety
Net Providers,
clinics for the
uninsured
SubContractor:
Strengthening
The Black
Family, Inc.
Hospitals
NC Council of
Aging,
Triangle J,
Senior
Centers,
Assisted
Living
WCMSCHF
DSS, SHIIP,
DHHS
Faith
Communities NC Council of
Churches,
Baptist Aging
Ministry
Homeless
Shelters,
Transitional
Housing
Facilities
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Minority Census Tract
Project and Sub-Project Advisory Groups
Safety Net (Johnston Co) and Collaborative (Wake
Co) meetings
Focus groups
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3 in Johnston Co
3 in Wake Co
Community Stakeholders
ASK and talk to individuals in our target population
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Door-to-door, special interest groups
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Living Healthy Chronic Disease Self-Management
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324* participants have participated in CDSMP/DSMP
 82%* have demonstrated an increased level of activation in
managing their health condition(s)
 Large church in Wake County
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Men’s Homeless Shelter
Day Treatment Facilities for individuals with mental illness
Patient Navigation & Community Outreach
Spreading the word – TV, radio, & newspaper
 Collaboration with local partners
 908* participants attended insurance workshops on
Medicare and Medicaid
 265* uninsured individuals linked to a medical home
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*Numbers are based on June-November 2013 data
Alma Atkins, BSW, MHA
Minority Health Coordinator
Ph: 828-250-5319
Email: aatkins.pcm@gmail.com
Celita Graham
Minority Health Coordinator
Ph: 919-731-1235
Email: celita.graham@waynegov.com
Tara Robinson, RN, BSN, CCM
Deputy Director
Ph: 919-792-3622
E-mail: trobinson@wakedocs.org