Genesys Regional Medical Center Implementation Plan for 2012 CHNA Fiscal Year

Transcription

1 Genesys Regional Medical Center Implementation Plan for 2012 CHNA Fiscal Year Health Need identified in 2012 CHNA (Genesys Focus Areas) Infant/Child Health Physical Activity & Active Living Nutrition and Diet Effective Care Delivery for Aging Population Genesys Implementation Plans/Strategies/Partnerships CHAP Centering Pregnancy Program Genesys Student Heart Screening Commit to Healthy Hearts Lactation Program Project Healthy Schools Reaching out for Better Health Commit to Fit Project Healthy Schools Women s Farm Center Regional Food System Navigation Advanced Care Planning Program of All-Inclusive Care for the Elderly (PACE) Children s Health Access Program (CHAP) Goal/Description: As a member of the Greater Flint Health Coalition s CHAP Planning Committee, CHAP will improve health outcomes of children on Medicaid while making better use of existing resources and decreasing costs. This program is a collaborative community based medical home improvement program that provides: Technical assistance to improve medical homeness of primary care practices Resource coordination of community services Increased office, patient and family education Needed services for families/children Office efficiency assistance Convening of community stakeholders to address system issues

2 Centering Pregnancy (CP) Goal/Description: Centering Pregnancy is a supportive, educational program for expectant parents and support people to learn about their pregnancy, their babies and themselves at the same time they are receiving prenatal care. It is an evidence-based, culturally appropriate model of group health care delivery with 3 components: health care assessment, education, and support, provided in a group facilitated by a credentialed health provider. CP facilitates patients to participate in their care and allows providers to have a dynamic partnership with their patients. Group participants spend more time with their provider than a usual check-up visit and with others with similar health concerns, giving them an opportunity to learn together and from each other. At each of 10, two-hour sessions, patients receive an individual assessment by the care provider, participate in self-care activities, complete a topic related selfassessment, and have informal conversation with the other participants. Groups are interactive and patient-centered with facilitated discussion about health topics and shared health experiences. Prenatal services such as physical assessment, nutrition, insurance, lab tests, labor preparation, etc. that are traditionally provided separately are bundled, so that women receive cohesive services within a supportive environment. This practice has proven to offer more than 10 times the amount of time with the provider and is shown to be cost neutral. Located at the Downtown Flint Obstetrics Residency Clinic, Over 40 women have participated in this Resident-led program. All Residents, Preceptors and Medical Assistants have been trained in the Centering Curriculum and the site is completing final standards and conditions to receive approval by the Centering Healthcare Institute as an official Centering Pregnancy program site (Summer 2014). Student Heart Screenings Goal/Description: Free Student heart screenings are designed to identify students (ages 12-19) who are at risk for sudden cardiac death. The screenings: Raise awareness of sudden death symptoms among students, parents, physicians, coaches and the community Educate the participants regarding the purpose and need for automated external defibrillators (AED) Offer student heart screening events at local venues including poor and vulnerable areas Provide heart screening result summaries and ECGs for students to share with his/her family physician The student heart screening will include: o A review of the student s heart history questionnaire

3 o o o o A blood pressure check A focused physician evaluation An electrocardiogram (ECG) a non-invasive test performed with the student at rest with patches placed on the surface of skin that maps the rate, rhythm and function of the heart, and prints a tracing for physician review and interpretation A Vscan quick-look echocardiography a non-invasive test that uses ultrasound to show a picture of the heart Commit to Healthy Hearts Goal/Description: Extending its reach of services from within the health system to the Grand Blanc Community, Genesys and its partners will offer the Commit to Healthy Hearts Program to serve all 653 9th grade students at Grand Blanc High School. CHH program components include: CHH Cardiovascular Risk Assessment: A school-based, CV risk assessment will be conducted by volunteer cardiologists and support staff utilizing questionnaires, physical exam, ECGs, and innovative portable ultrasound screening technology to identify youth at risk for SCD and youth with modifiable CV risk factors such as obesity, hypertension, diabetes, and smoking. Youth identified in this assessment with modifiable CV risk factors will be referred for CHH Primary Prevention Services. Data from the initial year will be utilized to develop a screening program. CHH Primary Prevention: Targeted Primary Prevention services will be delivered to youth identified for high CV risk- most notably, obesity. Each student will be offered a standardized, 7-week program, FitKids360, consisting of after school classes with Crim/Genesys physical fitness, nutrition and behavioral health instructors in the school facility; and classes at GAC which will layer in a community-based activity that combines fitness utilizing athletic club resources. CHH Population Health: A constant culture of healthy living will be integrated into the school environment for all 9 th grade students. A variety of interactive resources will be offered including: on-line messaging; nutrition tips and tastes; social media; student led PA infomercials; drop in after-school physical fitness classes; and in classroom augmentation curriculum delivered by health professionals to focus students to achieve healthy lifestyles.

4 Lactation Program Goal/Description: Protecting, promoting, and supporting breastfeeding, with its many known benefits for infants, children, and mothers, is a key strategy toward improving the health of mothers and their children. This program is designed to: Provide Local BF resources Improve Access Plan for BF Mother to Mother Support Improve Access Plan for BF Professional Support Integrate Plan for Improved Community BF Support Create/Disseminate Designation for BF Friendly PCP Offices Create/Disseminate Designation for BF Friendly Employers Increase BF Friendly Hospitals Strengthen BF Coalition Work with Insurance Payers to cover LC visits Work with Insurance Payers and Medical Supply to improve Access to Breast Pumps Project Healthy Schools (PHS) Goal/Description: Working collaboratively with the Greater Flint Health Coalition project, the goal of PHS is increase physical activity and healthier food choices to reduce childhood obesity and long term cardiovascular disease risk using evidence-based approach of Education, Environmental Change and Measurement. Project Healthy targets the entire 6 th grade student body in Grand Blanc Schools which includes at risk populations. PHS will: Teach youth healthy habits through PHS fitness and nutrition curriculum lessons delivered by physical education teachers and are reinforced by all staff, especially in health classes. Develop a healthy school middle environment: o Establish a wellness team to ensure overall school support for healthy behavior o Align food services with PHS to implement processes and practices for healthy food service delivery o Highly visible bulletin boards promoting healthy lifestyle messages throughout school Provide regular communication with school staff and parents to encourage healthy behaviors and environments Reaching Out for Better Health Goals/ Description: Genesys Health System (GHS) Diabetes and Nutrition Learning Center (DNLC) has established accessible Diabetes Education and Support Hubs as delivery sites for Diabetes Self- Management Education and Training (DSME/T). The DNLC has made it a strategic priority to reach and retain underserved individuals with diabetes in our community, with the establishment of two new

5 program sites at two GHS community health centers located in Flint, MI. Genesys serves patients within a high need environment characterized by a high incidence of poverty, unemployment and health disparity populations combined with a high prevalence of diabetes. These Hubs are designed to reduce transportation barriers, offer community location familiarity, and provide comprehensive diabetes education and support options in one convenient setting where underserved individuals reside and already receive health services. Physicians will also have accessible referral destinations to support their patients with diabetes. In these strategic locations, diabetes educators facilitate improvement in clinical and behavioral outcomes utilizing the evidence-based AADE Diabetes Education Curriculum. In partnership with the National Kidney Foundation, patients also have the option to participate in post-class support groups and fitness instruction to sustain newly learned information. Consistent with our mission to provide hope through healing and a strategic focus on population health, GHS is committed to achieving a healthcare environment for patients with diabetes that is innovative in its approach to better health, better healthcare, and lower costs. The program s goals are: To address access barriers for patients with diabetes to participate in DSME/T; and to increase their participation and retention through the delivery of community specific programs. To achieve improved, positive, measurable behavioral and clinical changes among previously underserved people with diabetes or pre-diabetes participating in the diabetes education programs. Commit-to-Fit Goal/Description: Community wide health behavior improvement initiative launched by the Greater Flint Health Coalition and its collective partner organizations. Engage local residents in fun, healthy and simple activities to improve health Educate local residents on proper nutrition, hydration, rest and healthy behaviors and ways to incorporate them into your life. Commit-to-Fit plan suggests 99 ways to better health with simple tools that businesses and/or schools can use. Genesys Athletic Club as well as other organizations in Genesee County participate in a Business-to-Business challenge in October logging in physical fitness activities, fruit and vegetable consumption, and hydration totals for a chance to win prizes and see which organization is the most fit over the course of the challenge. Genesys Athletic Club in partnership with Commit-to-Fit and the Greater Flint Area Health Coalition, offer a weekly Zumba Gold class free to the community to encourage and promote healthy behaviors to our local residents.

6 Women s Farm Center Goal/Description: This initiative is designed to benefit schools, farmers and the entire community by reducing significant barriers to starting a successful farm business and providing greatly needed access to fresh vegetables by Flint area schools. A viable collective working farm (moving towards a sustainable business model) will serve as a community-based resource sharing and educational center for producers & consumers in the region in which the Farm Center and local schools will together build capacity in the regional food system. This initiative will: Establish a Women s Farm Center (WFC) to assist Women Farmers to become economically independent farm business owners; Support Farm to School (F2S) programming to provide a sustainable pathway for locally produced vegetables to be served in schools. Regional Food System Navigation Community Foundation of Greater Flint Goal/Description: Genesys Associates are serving in key leadership roles within a Community Foundation of Greater Flint led effort to address access to and consumption of healthy food. The Regional Food System Navigation Model will facilitate a coordinated approach to food system work to achieve optimal food access throughout the Genesee County region. Each element of the system will build upon existing resources in the community that will be organized in a non-proprietary fashion. Model objectives include: Stewardship of Resources; Program and Service Coordination; and Collaborative Planning & and Alignment of Funding to achieve collective and sustainable regional impact on health outcomes by diverse stakeholder organizations. A Food Navigator will maintain connectivity and leverage resources within and between key model elements. The role of the Navigator is to support each element to function on its own and in concert with all other elements -- an intersection of concepts to creatively support current programs, solve problems and generate new ideas to support optimal food access. Key model elements include: Food Policy - How local policy can support the food system Leveraging Resources - Bringing resources to our community Health Outcomes and Evaluation - How do we know if we are making a difference? Healthy Food Access - Getting quality food to those who need it Healthier Kids - Helping our kids select healthier foods Economic Development- Job creation and new businesses Advance Care Planning (ACP) Goal/Description: Advance Care Planning is aimed at improving performance around end-oflife care. As Genesee County residents with a life limiting illness and disease age, the need to identify medical decision makers will increase. Having a community wide standardized approach to

7 medical decision making will assure Genesee County residents wishes are followed resulting in a better quality of life, less anxiety, pain and suffering and satisfaction among family members, decision makers and the medical community. All activities, programs and activities are documented in the Greater Flint Health Coalition s Advance Care Planning work plan: Create and determine the basics for pilot implementation (Months 3-5) Submission of pilot implementation plans (Month 6) ACP Facilitator training and finalization of pilot plans (Month 7-8) Pilot implementation (Months 9-14) Celebration of pilot success and review of lessons learned (Month 15) Begin phase II of pilot site implementation (expand pilot sites; train additional 50 facilitators; Train the Trainer) Program of All Inclusive Care for the Elderly (PACE) Goal/Description: PACE is designed to meet the medical and social needs of individuals age 55 and older, particularly those who are low-income and /or frail who are dual eligible for Medicare and Medicaid and 65 years or older, through the delivery of non-institutional, longterm, comprehensive, cost efficient health care. Consistent with the Affordable Care Act, PACE: Emphasizes primary care for a growing, identified population; Focuses on prevention and timely intervention; 100% coordination of care into a single, comprehensive, individualized care plan regardless of who provides health services; Interdisciplinary team develops care plan that will emphasize maximum independence thereby reducing inpatient and skilled nursing facility utilization and lower program expense; Alignment with ACO model -- Functions as a fully accountable care organization, responsible for the quality and cost of all care The PACE Center is the focal point of the PACE Program and combines services of: Primary Care Social Work Nursing Personal Care Home Care Pharmacy Transportation Recreational Therapy

8 Occupational Therapy Physical Therapy, and Nutrition