Community Health Action Plan 2012
Designed to address Community Health Assessment priorities
County: Appalachian District (Alleghany, Ashe, and Watauga Counties)
Partnership, if applicable: Alleghany Healthnet, Ashe Healthnet (Ashe Health Alliance, and High Country Vision
Council (Watauga)
Period Covered: July 1, 2012-June 30, 2014
LOCAL PRIORITY ISSUE

Priority issue: Access and Affordability of Healthcare Services

Was this issue identified as a priority in your county’s most recent CHA? _X_ Yes __ No
LOCAL COMMUNITY OBJECTIVE Please check one: _X_ New
__ Ongoing (was addressed in previous Action Plan)

By (year): 2014

Objective (specific, measurable, achievable, realistic, time-lined change in health status of population) :
By June 30, 2014, 5% of the uninsured adult population in the Appalachian District will be linked to or receive
direct primary healthcare services to improve individual and population health outcomes.

Original Baseline: : Alleghany 24.5 %, Ashe 22%, Watauga 25.5%

Date and source of original baseline data: 2009-10 NCIOM www.nciom.org

Updated information (For continuing objective only):

Date and source of updated information:
POPULATION(S)

Describe the local population(s) experiencing disparities related to this local community objective:
o Low income populations are at increased risk for lower physical activity and poor nutrition

Total number of persons (19-64 years who are uninsured) in the local disparity population(s):
o Alleghany 2,000 or 24.5%
o Ashe 3,000 or 22%
o Watauga 8,000 or 25.5%
o District-wide 13,000

Number you plan to reach with the interventions in this action plan: 5% (100 in Alleghany, 150 Ashe, 400 Watauga, 650
district-wide )
HEALTHY NC 2020 FOCUS AREA ADDRESSED
__ Tobacco Use
__ Physical Activity and Nutrition
__ Substance Abuse
__ STDs/Unintended Pregnancy
__ Environmental Health

__ Social Determinants of Health
(Poverty, Education, Housing)
__ Maternal and Infant Health
__ Injury
__ Mental Health
__ Oral Health
__ Infectious Diseases/
Food-Borne Illness
__ Chronic Disease (Diabetes,
Colorectal Cancer,
Cardiovascular Disease)
_X_ Cross-cutting (Life Expectancy,
Uninsured, Adult Obesity)
Check one Healthy NC 2020 focus area: (Which objective below most closely aligns with your local community objective?)

List HEALTHY NC 2020 Objective:
Reduce the Percentage of Non-elderly uninsured individuals (aged less than 65 years) from 20.4% to 8.0%
(Detailed information can be found at http://publichealth.nc.gov/hnc2020/ website)
RESEARCH RE. WHAT HAS WORKED ELSEWHERE*
List the 3-5 evidence-based interventions (proven to effectively address this priority issue) that seem the most suitable for
your community and/or target group. *Training and information are available from DPH. Contact your regional consultant
about how to access them.
Intervention
Describe the evidence of
Source
effectiveness (type of evaluation,
outcomes)
Agency for Healthcare Research &
The Institute of Medicine has identified
Care Coordination
Quality –US DHHS-US Preventive
care coordination as a key strategy that
Services Taskforce
has
the
potential
to
improve
the
 Teamwork
 Care management
 Medication management
effectiveness, safety, and efficiency of the
American health care system. Welldesigned, targeted care coordination that
is delivered to the right people can
improve outcomes for everyone: patients,
providers, and payers.
 Health information technology
 Patient-centered medical home
Clinical-Community Linkages
 Coordinating health care delivery,
public health, and communitybased activities to promote healthy
behavior.
 Forming partnerships and
relationships among clinical,
community, and public health
organizations to fill gaps in needed
services.
 Patients get more help in
changing unhealthy
behaviors.
Agency for Healthcare Research &
Quality –US DHHS
 Clinicians get help in offering
services to patients that they
cannot provide themselves.
 Community programs get help
in connecting with clients for
whom their services were
designed.
 Promoting patient, family, and
community involvement in
strategic planning and
improvement activities
Healthcare System Redesign & Quality
Improvements -PCMH
 Adopting strategies for transforming a
practice to improve quality, reduce
costs, and better satisfy the needs
of patients and families.
 Incorporating preventive services and
The patient-centered medical
home (PCMH, or medical home)
aims to reinvigorate primary care
and achieve the triple aim of
better quality, lower costs, and
improved experience of care. This
study systematically reviews the
early evidence on effectiveness of
the PCMH.
Agency for Healthcare Research &
Quality –US DHHS
 Accurate and complete
Agency for Healthcare Research &
Quality –US DHHS
self-management support into
care.
 Empowering all clinic staff to suggest
and help implement effective
changes.
 Develop leadership for change and
ongoing quality improvement.
 May involve practice “coaches” or
facilitators to help with the process
of health care redesign.
Health Information Technology
 Clinical decision support
 Computerized disease registries
information about a patient's
health. That way, providers
can give the best possible
care, whether during a
 Consumer health IT applications
 Electronic medical record systems
(EMRs, EHRs, and PHRs)
 Electronic prescribing
 Telehealth
routine visit or a medical
emergency.
 The ability to better coordinate
the care given. This is
especially important if a
patient has a serious medical
condition.
 A way to securely share
information with patients and
their family caregivers over
the Internet, for patients who
opt for this convenience.
This means patients and
their families can more fully
take part in decisions about
their health care.
 Information to help diagnose
health problems sooner,
reduce medical errors, and
provide safer care at lower
costs.
(Insert rows as needed)
WHAT INTERVENTIONS ARE ALREADY ADDRESSING THIS ISSUE IN YOUR COMMUNITY?
Are any interventions/organizations currently addressing this issue? Yes_X__ No___ If so, please list below.
Intervention
Lead Agency
Progress to Date
Nurse care manager receives
Care Coordination
referrals for Medicaid population
NC Access Care of the Blue Ridge
and some uninsured patients in
(CCNC) and Healthnet collaborative
Watauga County for those who need
(Alleghany, Ashe, and Watauga)
care management (chronic
conditions inc. diabetes, asthma,
congestive heart failure) or may be
non-compliant
Clinical-Community Linkages
Healthcare safety network
Healthnet collaboratives (Alleghany,
collaborative newly formed in
Ashe, and Watauga Counties)
Alleghany and Ashe Counties;
Watauga County has existing
network through Appalachian
Healthcare Project and Appalachian
Regional Healthcare System
Health Information Technology
Current use of telemedicine for
Appalachian District Health
some clinical specialty support
Department
(stroke network)
Alleghany Memorial Hospital, Ashe
Electronic reporting system for
Memorial Hospital, and Appalachian
communicable disease and
Regional Healthcare System
immunization tracking, some
electronic prescribing at ADHD
(Insert rows as needed)
WHAT RELEVANT COMMUNITY STRENGTHS AND ASSETS MIGHT HELP ADDRESS THIS PRIORITY ISSUE?
Community, neighborhood, and/or
demographic group
Alleghany County
Individual, civic group,
organization, business, facility,
etc. connected to this group
Alleghany Healthnet (coordinated by
Appalachian District Health
Department)
3
July, 2012-June, 2014
How this asset might help
Key healthcare providers in
Alleghany County committed to
developing a network of care to
direct existing resources and obtain
new resources for primary health
care for low income, uninsured
Ashe County
Ashe Healthnet (a part of Ashe
Health Alliance led by Appalachian
District Health Department and Ashe
Memorial Hospital)
Watauga County
Watauga Healthnet/Appalachian
Regional Healthcare System
Community Outreach
Watauga County
High Country Vision Council
adults in the community
Key healthcare providers in
Alleghany County committed to
developing a network of care to
direct existing resources and obtain
new resources for primary health
care for low income, uninsured
adults in the community
Leader in the community,
experience building health safety
networks, link to primary healthcare
community in Watauga County
Cross sector leadership and
connection with Avery County; an
initiative that is part of the High
Country United Way but also owned
by the community
(Insert rows as needed)
INTERVENTIONS:
SETTING, & TIMEFRAME
INTERVENTIONS SPECIFICALLY
TARGETING HEALTH DISPARITIES
Intervention: Clinical-Community Health
Linkages
Intervention: Community-Clinical
_X_ new __ ongoing __ completed
Setting: Community and Clinical practices
Start Date – End Date (mm/yy): 07/1206/14
Level of Intervention - change in:
_X_ Individuals _X_ Policy &/or
Environment
COMMUNITY PARTNERS’
Roles and Responsibilities
Lead Agency: Appalachian District
Health Department
Role: lead healthnet collaborative in
enhancing system for linking
individuals to community health
resources as a part of Healthnet
Partners: Ashe Memorial Hospital,
Alleghany Memorial Hospital
Role: direct services to support
linking uninsured adults to
community health needs by referring
to healthnet
Partners: Appalachian Regional
Healthcare System
Role: Serve as regional lead for
healthnet (grant writing, report
submission, planning, etc)
Partners: Private Physician
Practices, Free Clinics
Role: Refer patients to healthnet,
provide healthcare services as a
part of healthnet collaborative
Partners: Alleghany, Ashe
Healthnet, Watauga Healthnet
Role: promote services available
through healthnet, link individuals to
community health resources
(medication assistance, labs, etc)
Intervention: Care Coordination
Start Date – End Date (mm/yy): 07/1206/14
Lead Agency: Access Care of the
Blue Ridge (CCNC)
Role: lead steering committee
meetings in Allgh/Ashe and
Watauga; provide nurse care mgrs;
link to care management information
and best practices (market care
coordination among providers)
Level of Intervention - change in:
_x_ Individuals _x_ Policy &/or
Partners: Appalachian District
Health Department
Role: develop care referral system
Intervention: Community-Clinical
_x_ new __ ongoing __ completed
Setting: Community and clinical practices
PLAN HOW YOU WILL EVALUATE
EFFECTIVENESS
1. Quantify what you will do
(# classes & participants, policy
change, built environment change,
etc.)
6 new organizations (2/year district
wide) will refer eligible uninsured
adult patients to healthnet services
500 new adult patients will be linked
to community health resources
through healthnet coordinator
200 new adults will participate in
group enrollment to Healthnet (50
Alleghany, 100 Ashe, 150 Watauga)
2 events annually per county will
promote the healthnet services
available by providing a presentation,
brochure, etc.
2. Expected outcomes: Explain how
this will help reach the local
community objective
Linking uninsured adults to
community services through healthnet
collaborative will increase the number
(%) of patients who receive primary
healthcare which will be tracked
through referrals, outreach reports,
meeting minutes, and healthnet
reports
3. Quantify what you will do
(# classes & participants, policy
change, built environment change,
etc.)
4. Expected outcomes: Explain how
this will help reach the local
community objective
Increased number of uninsured adults
who are enrolled in care management
services (tracked in CMIS and by HN
Environment
as a part of Alleghany and Ashe
Healthnet with Access Care and
Healthnet partners
Coordinator and Access Care) which
will help increase patient compliance
which will support better health
outcomes and lower costs
Partners: Private clinical practices,
free clinics
Role: refer patients for care
management by notifying Healthnet
Coordinator (at ADHD)
INDIVIDUAL CHANGE INTERVENTIONS
Intervention: Healthcare System
Redesign
Intervention: Clinical
_x_ new __ ongoing __ completed
The lead agency is Appalachian
District Health Department and it will
implement new policies and
procedures to become a Patient
Centered Medical Home (PCMH)
Setting: Clinical practices
Each of the three health department
clinic offices will become a
certified PCMH
A.
Start Date – End Date (mm/yy): 01/1306/14









Enhance Access
and Continuity

Access During
Office Hours

After-Hours
Access

Electronic Access

Continuity of Care

Meet medical
home
responsibilities

Culturally and
Linguistically
appropriate
services (CLAS)

Develop,
implement a
Practice Team
B. Identify and
Manage Patient
Populations
Patient information system
Clinical data system
Conduct comprehensive
risk assessment
Use data for population
management
C. Plan and Manage
Care
Implement evidence-based
guidelines
Identify high-risk patients
Care management
Medication management
Use electronic prescribing
D. Provide self-care
support and
community
resources

Support Selfcare process

Provide
referrals to
1. Quantify what you will do (#
classes, # participants, etc.)
5
July, 2012-June, 2014
At least 1200 individuals will be
served through the PCMH sites.
2. Expected outcomes: Explain how
this will help reach the local
community objective
Increase number of adults receiving
high quality care, which achieve
better health outcomes. Increasing
the number of services provided to
uninsured adults. This will be tracked
using the patient enrollment and
service provided reports (see F)









community
resources
E. Track and
Coordinate Care
Test Tracking and Follow
Up
Referral tracking and follow
up
Coordinate with facilities
and manage care
transitions
F. Measure and
Improve
Performance
Measure Performance
Measure Patient/Family
Experience
Implement Continuous
Quality Improvement
Demonstrate Continuous
Quality Improvement
Report Performance
Report Data Externally
List other agencies and what they
plan to do:
Supporting agency: Access Care of
the Blue Ridge will coach ADHD in
achieving deliverables
Intervention: Healthcare Quality
Improvement
Intervention:
_x_ new __ ongoing __ completed
Setting: Clinical
Start Date – End Date (mm/yy): 07/1206/14
Level of Intervention - change in:
_x_ Individuals _x_ Policy &/or
Environment
Include how you’re marketing the
intervention
Lead Agency: Appalachian District
Health Department
Role: Facilitate link between NC
AHEC Hypertension/High
Cholesterol Quality Coach and area
healthcare providers in the three
county district to implement quality
improvement initiatives to increase
the number of providers using best
practices for screening and increase
number of patients being served
Partners: NC AHEC
Role: provide regional quality
improvement coach to work with
Healthnet Coordinator (ADHD) and
practices to implement QI initiatives
for hypertension, high cholesterol
(part of NC CTG/CTP)
Partners: NC DHHS-NCDPH-PAN
Role: Keep ADHD current on
strategies and activities to make
links for coaches to practices
5. Quantify what you will do
(# classes & participants, policy
change, built environment change,
etc.)
Six primary care practices/clinics will
adopt hypertension/high cholesterol
quality improvement plans
6. Expected outcomes: Explain how
this will help reach the local
community objective
Increased number of adults who receive
screening and treatment following
evidence-based practice for prevention
and treatment for hypertension and high
cholesterol which will be tracked through
outcome reports
Partners: Alleghany, Ashe, Watauga
Healthnet Collaboratives will market
the intervention at group meetings to
help support provider participation
Intervention: Health Information
Technology
Intervention:
Lead Agency: Appalachian District
Health Department
Role: Lead healthnet collaborative in
utilizing CMIS for data tracking of
7. Quantify what you will do
Two healthnet collaborative groups
will utilize CMIS as a tracking tool for
data collection
_X_ new __ ongoing __ completed
healthnet enrolled patients
Setting: Clinical
Partners: Access Care of the Blue
Ridge and other healthnet providers
Role: Review reports for care
management (Access Care), and
track progress of patient
enrollment/referrals (Healthnet
groups)
Start Date – End Date (mm/yy): 07/1206/14
Level of Intervention - change in:
_x_ Individuals _x_ Policy &/or
Environment
(Insert rows as needed)
7
July, 2012-June, 2014
8. Expected outcomes: Explain how
this will help reach the local
community objective (CMIS reports
will provide reports to Access Care for
care management referrals and
provide information to track patient
enrollment, some services provided