ST. VINCENT S HEALTHCARE

Transcription

1 ST. VINCENT S HEALTHCARE Jacksonville Metropolitan Community Benefit Partnership Community Health Needs Assessment Implementation Plan Acute Preventive Built Health Disparities Preventive Health Care Built Environment Infant Mortality, Seton Center Heart Disease, Faith Community Nursing Diabetes - Adult Management Diabetes Adult Diabetes Intervention Immunizations Pediatric Immunizations Adult KidCare Pediatric Mammograms Diabetes Childhood Type II Diabetes Childhood Obesity Community Garden 8/5/2013

2 ACUTE-HEALTH DISPARITIES Infant Mortality (SVMCR) SVMCR will reduce the infant mortality rate in infants from birth to one year by increasing the number of mothers who breastfeed to meet Healthy People 2020 target goal of 81.9%. By 2015, increase the number of breast fed and exclusively breastfeed infants at SVR to assist in reducing Duval County s infant mortality. SVMCR Seton Center nurses will provide community education, targeting pregnant women and women who plan to become pregnant, on the benefits of breastfeeding for mother and infant via classes, Brighter Beginnings program, health fairs, physicians and local community programs. SVMCR will provide Board Certified Lactation Consultants to assist newly delivered mothers in the hospital by providing education on the positive relationship between breast milk and better health for infants. SVMCR Inpatient nurses will encourage and support exclusive breastfeeding which has been shown to improve mother s success by transitioning the nursing model of care. SVMCR Nurses will provide information on community resources available post discharge to include: breastfeeding instruction materials; SVMCR Seton Center post partum visits and lactation consults at no charge; Seton Center telephone warm line; reliable Web sites; and local support groups. American Academy of Pediatrics Policy Statements on Breastfeeding & Human Milk Dpt of Health & Human Services (HHS) Blueprint for Action on Breastfeeding Evidence-Based Guidelines for Breastfeeding Management during the First Fourteen Days - International Lactation Consultant Assoc. Breastfeeding Support: Prenatal Care Through the First Year - Association of Women s Health, Obstetric and Neonatal Nurses (AWHONN) CDC Maternity Practices in Infant Nutrition & Care (mpinc) data. Ten Steps To Successful Breastfeeding Babyfriendlyusa.org UNICEF, NIH, AAP, WHO recommend that Breastfeeding can decrease infant mortality Baseline 2012 SVMCR breastfed babies 48%: 5/1/2013=53% 5/1/2014=58% 5/1/2015=63% SVMCR serves an average of 2000 women annually. Evaluate Pre & Post Surveys of expectant mothers & support persons who attend pre-delivery breastfeeding classes or support sessions and Brighter Beginnings classes on knowledge and understanding gained about breastfeeding benefits. Track & compare the number of mothers providing any breast milk at discharge versus those exclusively breastfed at discharge. Track number of breastfed babies at SVMCR who receive only breast milk. Baseline 48%: by 5/1/2013+5%=53% by 5/1/2014+5%=58% by 5/1/2015+5%=63% Survey mothers post SVMCR discharge to determine those who continued to breastfeed for 6 months and to assess the infant s overall health. Track the number of infants readmitted to hospital within first month. Review the Duval Co. Infant Mortality Rate.

3 ACUTE-HEALTH DISPARITIES HEART DISEASE To positively impact the prevalence of cardiovascular health disparity among African Americans in Northeast Florida (Duval). By 2015, St. Vincent s Faith Community Nursing will provide 3,000 blood pressure screenings, prevention education, intervention and linkage/referrals in Northeast Florida with a focus on Health Zone 1 in Duval. St. Vincent s Faith Community Nursing will reach out to faith-based organizations to provide blood pressure screenings at community health fairs and prevention education to attendees to enhance knowledge and understanding of chronic diseases including hypertension, cardiovascular disease and diabetes with a particular focus on Health Zone 1 in Duval Co. Engage collaboration with both new and existing community partners to develop and implement educational interventions and increase resources especially for those who are underserved or lack access to health care. Develop and facilitate a risk assessment to identify cultural beliefs, attitudes and behaviors that may pose as barriers to adherence. Administer risk assessments to attendees at all community health events. Provide individual and group counseling during events following risk assessments. Provide educational sessions; e.g.: nutrition, food preparation, physical activities and identify health risk behaviors. National Heart, Lung and Blood Institute 5/8/06, Premier Trial: Lifestyle Interventions for Blood Pressure Control showed that a single brief counseling session could produce substantial decreases in blood pressure in patients with stage 1 hypertension or highnormal blood pressure. The Dietary Approaches to Stop Hypertension trial, a healthy diet lowered blood pressure about as much as a single drug does, particularly in African Americans Goal = 3,000 BP screenings Maintain existing and develop new community partnerships to facilitate greater awareness regarding factors that relate to hypertension, cardiovascular disease, and diabetes. 1.Documentation of health screenings values, risk assessments and counseling sessions. 2. Documentation of number of referrals and linkage to care and community resources. Track 1 & 2 quarterly Track and document 1 & 2 at the end of FY 2013, 2014 and 2015.

4 ACUTE-HEALTH DISPARITIES ADULT DIABETES MANAGEMENT As a result of St. Vincent s Mobile Health Outreach Ministry s (MHOM) initiatives, its diabetic patients in Nassau & Putnam Counties will be able to better manage their disease and experience better health outcomes. St. Vincent s MHOM will see its patients in Nassau (8% annually) and Putnam (5% annually) Counties will meet American Diabetes Association (ADA) outcomes. St. Vincent s Riverside through St. Vincent s MHOM will equip patients with diabetes in Putnam and Nassau Counties with the tools needed to bring about better health outcomes by providing regularly scheduled lab screenings, treatment, diabetes education, self-management skills, and case management. Provide an opportunity and encourage 100% of Mobile Health Outreach Ministry s patients with diabetes to participate in individual education consultation and DMCP group visits that will enable them to plan healthier meals and learn to monitor personal lab values as well as have a better understanding and awareness of complications related to diabetes. Survey 95% of the DMCP participants before and after each group visit session to determine knowledge and understanding that can impact long-term health outcomes. Conduct yearly Microalbumin, eye exam, foot exam and administer flu and pneumonia vaccines to provide early detection and intervention of complications related to diabetes. Florida Academy of Family Physicians Diabetes Master Clinician Program (DMCP) Dr. Ed Shahady The American Diabetes Association (ADA) goals: hemoglobin A1c (A1C) 7%, LDL cholesterol 100 mg/dl, and blood pressure 130/80 mmhg Goal = End of FY 2013, 2014 & % of Nassau and 5% of Putnam County MHOM patients enrolled in the DMCP will meet or exceed ADA recommended goals of HbA1C, LDL & blood pressure. Track and monitor lab values to ensure patients are attaining ADA goals. The Florida Academy of Family Physicians Diabetes Master Clinician Program Registry will be utilized to track patient progress and create patient and clinic report cards. Review the patients A1C, LDL and blood pressure values during each patient visit. Track and analyze patient pre and post surveys to determine the percentage of patients showing positive knowledge gain during group visits. Determine annually that MHOM patients are receiving the standard of care set by the ADA designed to improve patient outcomes.

5 PREVENTIVE HEALTHCARE ADULT DIABETES INTERVENTION To facilitate early detection and access to referral services for pre-diabetes and diabetes for low to moderate income populations in Clay, Nassau, and Putnam Counties seeking care from St. Vincent s Mobile Health Outreach Ministry. By 2015, 100% of all new patients of St. Vincent s Mobile Health Outreach Ministry in Clay, Nassau and Putnam Counties will be screened for pre-diabetes and diabetes, as well as those low to moderate income groups targeted by St. Vincent s HealthCare throughout the region. St. Vincent s Mobile Health Outreach Ministry (MHOM) will provide screenings for diabetes and pre-diabetes for 100% of the new patients from Clay, Nassau and Putnam counties who seek its care. Obtain and monitor HbgA1c values on all new patients. St. Vincent s MHOM will participate in local community health fairs in order to identify individuals with pre-diabetes or diabetes. Those clients with abnormal values will receive immediate consultation and follow up communication by a health professional to encourage follow-through and to answer questions. Enroll eligible patients into St. Vincent s MHOM for treatment and follow-up care. The American Diabetes Association (ADA) goals: hemoglobin A1c (A1C) 7%, LDL cholesterol 100 mg/dl, and blood pressure 130/80 mmhg FY 2013, 2014, 2015 screenings completed on all new adult MHOM patient population and during community events. Track the number of new patient screenings and provider referrals Track special event patient screenings. Document follow-up for those patients with prediabetes or diabetes. All new patient data will be tracked and reviewed. All new patient data will be tracked and reviewed and compared to previous FY years.

6 ACUTE-HEALTH DISPARITIES PEDIATRIC IMMUNIZATIONS To improve the immune systems of 6 th & 7 th grade students in Duval County by providing access to Tdap immunizations which fight common childhood illnesses: tetanus, diphtheria and pertussis. By 2015, insure that all eligible children (6 th & 7 th grades) in Duval County Full Service Schools who are referred by school nurses or St. Vincent s Mobile Health Outreach Ministry s (MHOM) staff will meet Tdap compliance required by FL.S (3). St. Vincent s MHOM staff will work with DCPS s school nurses to identify and refer children who are Tdap non-compliant. During monthly visits to the Duval County Public Schools served by MHOM, staff will assess a child s eligibility and administer the Tdap vaccines when necessary. MHOM staff will attend school events orientation, open house Back-to-School events to provide information to parents about immunizations and offer opportunities to give those immunizations. MHOM staff will conduct Backto-School events in partnership with community organizations serving local neighborhoods to administer Tdap immunizations to eligible children. (See list under indicator.) Immunization requirements for school entry Florida Statute (3) CDC/ACIP Advisory Committee for Immunization Practices Recommendations for use of Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis (Tdap) Vaccine 10/2010 FY 2012= 766 Annual FY (13-15) Tdap immunizations administered by MHOM Neighborhoods served: Andrew Jackson HS Kirby Smith MS Matthew Gilbert MS Northwestern MS Ribault MS & HS Forrest HS Lakeshore MS Jeb Stuart MS Paxon HS Palm Avenue Track individual Tdap immunizations administered by MHOM Track Monthly Tdap administered by MHOM Track Annual (FY) Tdap administered by MHOM

7 ACUTE-HEALTH DISPARITIES ADULT IMMUNIZATIONS To increase Flu, Pneumonia and Tdap immunization rates for St. Vincent s Mobile Health Outreach Ministry patients in Clay, Nassau, Putnam & St. John s Counties. By 2015, 90% of all eligible St. Vincent s Mobile Health Outreach Ministry (MHOM) patients in Clay, Nassau, Putnam & St. John s Counties will have received the Flu, Pneumonia and Tdap vaccinations. St. Vincent s Medical Centers, Riverside and Southside will actively promote and educate those in Clay, Nassau, Putnam and St. Johns Counties about the benefits of receiving these vaccines St. Vincent s MHOM will offer these vaccines to all eligible clients during primary care clinics and special community health events. CDC/ACIP Recommendations for administration of Flu, Pneumonia and Tdap vaccines. The Healthy People 2020 National Health target is to increase the proportion of adults aged 65 years and older who receive an Influenza and Pneumonia vaccination to 90%. FY 2012 = 689 Flu, Pneumonia and Tdap immunizations FY 2013, 2014 & 2015 Track MHOM immunization rates for Flu, Pneumonia and Tdap vaccines through FY Track the number of patients who receive the Flu vaccine and the number of patients who receive one-time doses of Tdap and Pneumonia vaccines. Compare immunization rates for Flu, Pneumonia and Tdap vaccines over 3 fiscal years.

8 PREVENTIVE HEALTH CARE FLORIDA KIDCARE ST. VINCENT S MEDICAL CENTER RIVERSIDE To see an increase by 3% the number of enrollment in Florida s Healthy Kids by 2015 in Clay and Nassau Counties. By 2015, expand opportunities to enroll children in Florida Healthy Kids. Develop and maintain local partnerships that serve potentially eligible children (schools, early learning centers, Dept. of Children & Families, family-serving non-profits) enabling them to distribute applications and provide enrollment assistance. Establish guidelines for businesses to be invited to participate in a Business Roundtable discussion of enrollment activities Work with Northeast Florida Healthy Start Coalition, Inc. (NEFHSC) and the Northeast Florida KidCare Steering Committee to implement a plan that that will increase Florida KidCare enrollment for local children. Implement a cooperative relationship with St. Vincent s Mobile Health Outreach Ministry to assist Florida Healthy Kids Enrollment. Participate in community health fairs, back to school fairs and other events which target potentially eligible families; Provide direct assistance and enrollment information to families. Work with St. Vincent s HOPE program to assist patients and their families with the application process for Medicaid, KidCare or other eligible public program. Florida KidCare floridakidcare.org Baseline: 2012 FL Clay & Nassau County Enrollment=3,323 Strategy developed and implemented Support local partnerships willing to assist children and families in Florida Healthy Kids enrollment. Achieving a 3% increase in Florida Healthy Kids enrollment.

9 PREVENTIVE HEALTH CARE MAMMOGRAPHY To improve care, outcomes and access to service by providing screening mammography to uninsured and under insured women of Jacksonville, Florida and the surrounding areas. By 2015, provide 200 screening mammograms using donations provided by the St. Vincent s HealthCare Foundation. St. Vincent s Medical Center Riverside s Breast Health Center and Mobile Mammography, in collaboration with Patient Access Services, will provide access to screening mammographs (including Computer Aided Detection (CAD), and technical and professional components for the service). Ascension Health s strategic direction committed to providing 100% access to healthcare services. American Cancer Society recommends screening mammography after age 40 to increase early detection of breast cancer and reduce deaths from breast cancer. 200 Screening Mammograms Monitor monthly volume of screening mammography, especially those provided through the Foundation. Monthly review of volume (as stated above) Review of total volume (as stated above)

10 PREVENTIVE HEALTH CARE CHILDHOOD TYPE II DIABETES Promote testing and treatment referrals for children who are at risk of type II diabetes or who have previously been diagnosed with type II diabetes that visit St. Vincent s Pediatric Outreach Clinics. By 2015, greater than 95% of identified children who are at risk of type II diabetes will benefit from appropriate referrals and information. Identify risk based on ADA guidelines i.e.: elevated BMI, ancanthosis and family history Communicate with parent or guardian in writing and/or by telephone the child s risks and potential diabetes complications Provide referrals to primary care physicians, labs and to KidCare and HOPE as appropriate. Broaden education by distributing preventive handouts, showing videos and access to appropriate websites American Association of Diabetes (ADA) guidelines Baseline: FY 2013/14 >95% of children seen will receive the benefit of appropriate referrals and information. Neighborhoods served: Andrew Jackson HS Kirby Smith MS Matthew Gilbert MS Northwestern MS Ribault MS & HS Forrest HS Lakeshore MS Jeb Stuart MS Paxon HS Palm Avenue Raines HS Identify the pediatric patient, notify the parent(s) and provide appropriate referrals. Quarterly review of patient tracking data. Annual review of patient tracking data.

11 BUILT ENVIRONMENT CHILDHOOD OBESITY To improve healthy living behaviors among middle school students in Duval County by providing instruction related to nutrition and physical activity. By 2015, increase knowledge gain for 95% of those who participate in St. Vincent s Pediatric Wellness Education Initiatives. Students will be identified using BMI and other clinical data collected during physicals, lab results ordered by St. Vincent s Pediatric Outreach Medical program. Students identified as participants will be referred to Way to Go Kids or Way to Go Families for group education on healthy nutrition and physical activity. A Registered Dietician, Health Educator, a physician and nursing staff will facilitate these specialized educational classes. Provide adult participants with biometric screening during the first and last class visits (blood pressure, hemoglobin A1C and total cholesterol). Health Education to Reduce Obesity HERO Jacksonville, FL Eat Well, Play Hard Elyria, OH Baseline 2012 = 85% 2015 Goal = 95% Program participation. Knowledge gained measure by pre and post surveys. Analyze behavioral change in adults by comparing biometric data from first visit to last visit. Long term evaluation: Over three years, review the comprehensive data of BMI studies on student participants. Provide a joint program for children and their parents that offer a practical application to wellness. Administer to all participants pre and post tests to evaluate knowledge gain.

12 BUILT ENVIRONMENT ACCESS TO FOOD COMMUNITY GARDEN (SVMCR) To improve access to and availability of healthy food by supporting the development of a sustainable garden program at the Northside Community Involvement Center located in Health Zone One. Achieve access to healthy food for approximately 200 households in Health Zone One. Strategy: HOW THE Best/Leading Practices Indicator Evaluation OBJECTIVE WILL BE REACHED Partner with Second Harvest, the Duval County Health Department, Mayo Hospital, Baptist Health, University of Florida Health, and Brooks Rehabilitation Hospital to develop a 100 X 100 community garden featuring 46 raised beds and 3 in-ground rows translating into a configuration that will feed nearly 200 households. Second Harvest will provide instruction to neighborhood residents on planting, harvesting, storing, and cooking foods grown in the garden. Blue Zones Vitality City Project- Albert Lee, MN Back Yard Gardens- West Oakland, CA People living below the federal poverty level: Duval County Baseline=14.9% Low- income and low access to grocery store: 2010 Duval County Baseline: 6.9% Adult fruit and vegetable consumption: 2007 Duval County Baseline=23.9% Housing units that do not have a car and are more than one mile from a supermarket or large grocery store if in an urban area, or more than 10 miles from a supermarket or large grocery store if in a rural area: 2010 Duval County Baseline: 1.5% Implementation of project plan Short-term evaluation: Track seasonal yield Track number of households served Track annual yield Monitor adult fruit and vegetable consumption