CONNECTING WITH COMMUNITIES

Transcription

1 HANYS CONNECTING WITH COMMUNITIES COMMUNITY HEALTH INITIATIVES ACROSS NEW YORK STATE EDITION

2 HANYS CONNECTING WITH COMMUNITIES: COMMUNITY HEALTH INITIATIVES ACROSS NEW YORK STATE EDITION

3 TABLE OF CONTENTS INTRODUCTION AWARD RECIPIENT TRANSITIONS: A COMMUNITY PALLIATIVE CARE COLLABORATIVE Jamaica Hospital Medical Center 2008 HONORABLE MENTIONS MOBILE HEALTH LONG ISLAND North Shore-Long Island Jewish Health System ARTIST ACCESS: AFFORDABLE HEALTH CARE FOR UNINSURED ARTISTS Woodhull Medical and Mental Health Center/New York City Health and Hospitals Corporation COMMUNITY HEALTH PROFILES ANNE B. GOLDBERG ALZHEIMER S RESOURCE CENTER Albany Medical Center DIABETES EDUCATION AND CHRONIC DISEASE PREVENTION PROGRAMS Alice Hyde Medical Center DARE TO CARE Arnot Ogden Medical Center THE SENIOR COMMUNITY HEALTH PROJECT Continuum Health Partners (Participating hospitals include Beth Israel Medical Center and St. Luke s-roosevelt Hospital Center, St. Luke s and Roosevelt Divisions) DIABETES SELF-MANAGEMENT EDUCATION PROGRAM Brookhaven Memorial Hospital Medical Center TOBACCO FREE IS THE WAY TO BE! Brooks Memorial Hospital UNINSURED INITIATIVE Catholic Health System Primary Care Centers SMOKING CESSATION INITIATIVE Cortland Regional Medical Center ESSEX COUNTY DIABETES SUPPORT GROUP Elizabethtown Community Hospital LET S NOT MEET BY ACCIDENT Erie County Medical Center BREAST HEALTH PATIENT NAVIGATION PROGRAM F. F. Thompson Hospital TOBACCO CESSATION CENTER AT THE REGIONAL CANCER CENTER Faxton-St. Luke s Healthcare PAGE HANYS COMMUNITY HEALTH INITIATIVES ACROSS NEW YORK STATE EDITION 3

4 TABLE OF CONTENTS (CONTINUED) SEVEN-COUNTY DIABETES NETWORK Glens Falls Hospital GERMBUSTERS: A HAND-WASHING PROGRAM FOR CHILDREN IN THE COMMUNITY Good Samaritan Hospital Medical Center MULTI-YEAR STROKE INITIATIVE: HIP HOP STROKE Harlem Hospital Center/New York City Health and Hospitals Corporation PATIENT AND COMMUNITY EDUCATION Lincoln Medical and Mental Health Center HEALTHY SUNDAYS Long Beach Medical Center BEDS EXCHANGE DATA SYSTEM (BEDS) WEB SITE M. M. Ewing Continuing Care Center/Thompson Health KNOW YOUR NUMBERS Nathan Littauer Hospital and Nursing Home BREAST IS BEST PROMOTING A HEALTHY TOMORROW New York City Health and Hospitals Corporation TARGETED HEALTH FAIRS: TAXICAB DRIVERS HEALTH FAIRS NewYork-Presbyterian Hospital TAKE TEN MINUTES FOR YOUR HEALTH Peninsula Hospital Center QUEENS HEALTH NETWORK LANGUAGE ACCESS PROGRAM Queens Health Network (Elmhurst Hospital Center and Queens Hospital Center) ORAL HEALTH FOR BABY S SAKE Saint James Mercy Hospital LIVING AT HOME PROGRAM Saint Vincent Catholic Medical Centers of New York RENSSELAER CARES: PRESCRIPTION ASSISTANCE PROGRAM Seton Health/St. Mary s Hospital, and Northeast Health Samaritan Hospital FIT-WIC Sound Shore Medical Center of Westchester HEART OUTREACH STUDY TRACT (HOST) PROGRAM South Nassau Communities Hospital MOSAIC (MULTICULTURAL ORIENTATION FOR SUCCESSFUL ACCESS TO IMPROVED CARE) St. Elizabeth Medical Center BARBERSHOP QUARTET PROSTATE CANCER SCREENING PROGRAM St. Luke s-roosevelt Hospital Center/St. Luke s and Roosevelt Divisions INCREASING AWARENESS OF CAR SEAT SAFETY FOR CHILDREN WITH SPECIAL HEALTH CARE NEEDS St. Mary s Healthcare System for Children 4 HANYS COMMUNITY HEALTH INITIATIVES ACROSS NEW YORK STATE EDITION

5 TABLE OF CONTENTS (CONTINUED) PRENATAL CARE ASSISTANCE PROGRAM St. Mary s Hospital at Amsterdam POST-KIDNEY TRANSPLANT CARE MANAGEMENT PROGRAM SUNY Downstate Medical Center and Metropolitan Jewish Health System B.C. WALKS United Health Services CANCER PATIENT NAVIGATION-ACTIVATION University of Rochester Medical Center/Highland Hospital of Rochester PEDIATRIC SUPPORT GROUPS FOR CHILDREN WITH CHRONIC ILLNESSES Vassar Brothers Medical Center WAYNE COUNTY RURAL HEALTH CARE ACCESS INITIATIVE ViaHealth of Wayne NURSE APPRENTICE PROGRAM White Plains Hospital Center HANYS COMMUNITY HEALTH INITIATIVES ACROSS NEW YORK STATE EDITION 5

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7 INTRODUCTION Hospitals and health care systems are integral to the health, well being, and economy of the communities they serve. The services, education, and outreach that hospitals and health systems provide are an extension of their mission to improve the health of the people in their communities every day, with quality and compassion. It is not surprising that communities view hospitals and health care systems as their primary health care resource. For 11 years, HANYS has offered its Community Health Improvement Award to recognize members outstanding initiatives to improve the health and well being of their communities. This year, HANYS received 41 nominations for its Community Health Improvement Award. These nominations illustrate the remarkable services hospitals and health systems offer to their communities. This year, HANYS awarded its Community Health Improvement Award to Jamaica Hospital Medical Center for Transitions: A Community Palliative Care Collaborative. In addition, HANYS awarded Honorable Mentions to North Shore-Long Island Jewish Health System for its Mobile Health Long Island initiative and to Woodhull Medical and Mental Health Center/New York City Health and Hospitals Corporation for its Artist Access: Affordable Health Care for Uninsured Artists program. Contact Sue Ellen Wagner, Vice President, Community Health, at (518) or at swagner@hanys.org for more information about HANYS 2008 Community Health Improvement Award or HANYS advocacy and support for community health initiatives. Additional copies of this document can be obtained by contacting HANYS at (518) Connecting With Communities: Community Health Initiatives Across New York State is also available to members on HANYS Web site at HANYS COMMUNITY HEALTH INITIATIVES ACROSS NEW YORK STATE EDITION 1

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9 2008 AWARD RECIPIENT TRANSITIONS: A COMMUNITY PALLIATIVE CARE COLLABORATIVE Jamaica Hospital Medical Center YEAR THE PROGRAM STARTED 2005 PARTNERS Hospice of New York Care to Knit Jamaica Service Program for Older Adults Rockaway Boulevard Senior Center The Cathedral of the Allen African Methodist Episcopal Church York College CONTACT Gina M. Basello, D.O. Associate Director, Palliative Care Program Jamaica Hospital Medical Center th Street, Suite 3C Jamaica, NY (718) gina.basello@mssm.edu PROGRAM DESCRIPTION AND GOALS In fall 2005, Jamaica Hospital Medical Center (JHMC) designed a hospital-wide, interdisciplinary, patient-centered, culturally competent palliative care program to improve the quality of life for poor, elderly, and minority patients and their families facing life-defining, life-threatening, or life-limiting illnesses. The goals of the program are fourfold. JHMC strives to: educate community and hospital physicians in regard to improving communication skills in prognostication, establishing Accepting the 2008 Community Health Improvement Award on behalf of Jamaica Hospital Medical Center is David Rosen, President and Chief Executive Officer of Medisys Health System (center). Also pictured: HANYS 2008 Chairman of the Board Michael J. Dowling (left), President and Chief Executive Officer of North Shore-Long Island Jewish Health System; and HANYS 2008 Chairman-Elect David G. Kruczlnicki, President and Chief Executive Officer of Glens Falls Hospital. goals of care, obtaining advance directives, and available palliative and end-of-life care options; provide comprehensive, compassionate, and culturally sensitive palliative care to patients; develop community linkages for the purpose of education and sharing resources for training and clinical care; and improve operational efficiency through appropriate allocation and utilization of scarce health care resources. A core team consisting of three attending physicians, two fellows, rotating residents, and a licensed social worker provide palliative care services. Team members provide ongoing education and clinical experience in palliative care for the physicians, residents, medical students, nurses, and staff. JHMC provides community-level health promotion, prevention, and treatment services through participation in community events, health fairs, screening and health education programs, and guest speaker appearances at local community groups. JHMC also has a Palliative Care Medical Consult Service, funded by a large private foundation grant. In addition, JHMC s palliative medicine fellowship program is committed to the education and training of physician specialists dedicated to providing this level of care. The fellowship has enabled JHMC to expand its clinical palliative care program to include services provided to patients in their homes, in long-term care and ambulatory settings, and throughout the community. HANYS COMMUNITY HEALTH INITIATIVES ACROSS NEW YORK STATE EDITION 3

10 TRANSITIONS: A COMMUNITY PALLIATIVE CARE COLLABORATIVE Jamaica Hospital Medical Center (CONTINUED) OUTCOMES JHMC has increased awareness in the community, educated providers and patients, and achieved cost savings through more appropriate utilization of resources. JHMC participates in more than 30 community-based events annually and is able to provide informational materials and education on the importance of advance directives to more than 1,000 people annually. Thousands of people are reached through the program s Web site and the hospital blog, where palliative care is often a focus. JHMC s quarterly Grand Rounds program has reached about 250 community physicians annually and more than 475 hospital attending physicians, residents, and medical students. The program also hosted an end-of-life nursing education course for 100 nurses. In 2006, 15% of JHMC s patients had some form of advance directive upon admission to the hospital and 50% of patients were discharged with advance directives. The following year, 33% of patients presented with advanced directives and 75% were discharged with them. The consult service treats an average of 400 patients per year, allowing JHMC to improve the utilization of hospital resources by reducing length of stay and intensive care unit days. In its first year, JHMC demonstrated a total cost savings of $916,028. JHMC has received more than 50 letters of gratitude from patients and loved ones since the program s inception. LESSONS LEARNED Adequate staffing requires the commitment of both paid workers and volunteers to allow the provision of personalized clinical and comfort care. Community outreach is required so that patients and families dealing with advanced chronic and life-limiting illness obtain this essential level of care earlier. Community and patient needs should guide the development or advancement of clinical services. Passion for doing the right thing unites, motivates, and helps overcome obstacles. Communication is essential to care, education, and progress. 4 HANYS COMMUNITY HEALTH INITIATIVES ACROSS NEW YORK STATE EDITION

11 TRANSITIONS: A COMMUNITY PALLIATIVE CARE COLLABORATIVE Jamaica Hospital Medical Center (CONTINUED) ABILITY TO SUSTAIN THE INITIATIVE The needs of the community and the positive impact of the program motivate JHMC to make this level of care available to all. The cost avoidance realized from improved resource allocation and utilization will provide the financial sustainability that the program requires. The development of the palliative medicine fellowship ensures that community relationships will continue to flourish, as they are essential to the clinical care of patients and the education of physicians. JHMC s administration is committed to the continued support of this program as it reflects clearly the vision of the hospital as a leader in promoting the health and wellness of the community. HANYS COMMUNITY HEALTH INITIATIVES ACROSS NEW YORK STATE EDITION 5

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13 2008 AWARD HONORABLE MENTION MOBILE HEALTH LONG ISLAND North Shore-Long Island Jewish Health System YEAR THE PROGRAM STARTED 2000 PARTNERS United Way of Long Island Family and Children s Association Hagedorn Family Resource Center The Children s Health Fund The Interfaith Nutrition Network Pride for Youth Local school districts PROGRAM DESCRIPTION AND GOALS To address identified health disparities in the communities it serves, North Shore- Long Island Jewish Health System (NS-LIJ) established a pediatric mobile medical project dedicated to providing primary care services to children in under-served and high-risk communities throughout Long Island. Initial funding for the medical unit a licensed Article 28, Winnebago-sized vehicle fully equipped with two examination rooms and a registration/waiting area was secured in 1999 with the assistance of state grants and a generous donation from a private donor. NS-LIJ provides oversight and ongoing operational support for the mobile unit. The pediatric mobile unit began providing services in early Based on the positive response from the community, NS-LIJ began looking at other unmet health needs in the community. Recognizing the need for access to dental care in the community, in 2004, NS-LIJ, in partnership with United Way of Long Island, secured funding from a private donor to purchase a mobile dental unit to complement the services of the medical unit. It was at this point that the pediatric mobile medical project became Mobile Health Long Island (MHLI). The goals of MHLI are to: improve access to medical and dental care for vulnerable populations in need; continue to identify and collaborate with community partners to expand service provision to high-risk populations (e.g., pediatrics, adolescents, homeless adults, and seniors); and ensure the provision of high-quality, comprehensive care. CONTACT Dr. Alec Thundercloud Mobile Health Long Island Medical Director North Shore-Long Island Jewish Health System 175 Community Drive Great Neck, NY (516) athunder@nshs.edu The project uses a model of care that has proven to be successful regardless of the population served. The model of care is referred to as a medical home model and the participating patients consider the mobile unit their primary care site. OUTCOMES PRIMARY CARE: more than 3,000 visits per year to medically under-served residents of the region; all pediatric patients receive age-appropriate immunizations; all pediatric patients receive an oral health screening; and 90% of high-risk adolescents are tested for human immunodeficiency virus (HIV). HANYS COMMUNITY HEALTH INITIATIVES ACROSS NEW YORK STATE EDITION 7

14 MOBILE HEALTH LONG ISLAND North Shore-Long Island Jewish Health System (CONTINUED) DENTAL CARE: dental services began in January 2008 to date, there have been 65 visits; all uninsured pediatric patients are referred for dental screening; and all naturally occurring retirement community (NORC) residents without dental coverage are referred for dental screening. INSURANCE STATUS: the unit has a facilitated enroller onsite to enroll patients into Medicaid and managed Medicaid programs; over the past three years the pediatric uninsured rate dropped from more than 50% to 34%. LESSONS LEARNED Ongoing maintenance for a refurbished mobile unit surpasses any initial cost savings. To reach individuals who need services, develop and maintain successful community collaborations that have common elements such as shared goals, flexible professional roles, and excellent communication. Provide care to different populations by keeping the model of care constant while adjusting for the needs of the population. ABILITY TO SUSTAIN THE INITIATIVE The most difficult aspect of MHLI is ensuring that there is adequate funding. The project has always relied on private philanthropy and government grants. Fundraising is an ongoing effort. NS-LIJ is fortunate to receive support from United Way of Long Island and Children s Health Fund. NS-LIJ also currently has funding from the New York State Health Foundation, the local county legislature, and ongoing support through its employee giving campaign. In addition, the program screens patients to see if they are eligible for insurance. MHLI is a cornerstone of NS-LIJ s community benefit strategy and as such, routinely receives ongoing oversight and program development support from senior leadership, general administrative support, and as needed, operating subsidies. 8 HANYS COMMUNITY HEALTH INITIATIVES ACROSS NEW YORK STATE EDITION

15 YEAR THE PROGRAM STARTED 2005 PARTNERS Woodhull s offices of the medical director, business affairs, finance, and creative arts HHC Options Program The Dance Theatre Workshop New York Foundation for the Arts The Actors Fund of America Elsie Management Broadway Cares Equity Fights AIDS Rush Philanthropic Arts Foundation Brooklyn Arts Council Jazz Foundation of America 2008 AWARD HONORABLE MENTION ARTIST ACCESS: AFFORDABLE HEALTH CARE FOR UNINSURED ARTISTS Woodhull Medical and Mental Health Center/New York City Health and Hospitals Corporation PROGRAM DESCRIPTION AND GOALS The goal of the Artist Access Program is to increase access to affordable primary care among the artistic community living in the area around Woodhull Medical and Mental Health Center. Woodhull utilized the existing New York City Health and Hospitals Corporation (HHC) Options Program, which uses a sliding scale based on annual income and family size to make health care affordable to the uninsured. Artists are typically self-employed, sporadically paid, and ineligible for Medicaid due to annual income. However, they lack the resources to absorb out-of-pocket expenses for medical care. The Artist Access Program provides the artist with credits to be used against the payment plan under the HHC Options Program. Each hour of service (e.g., entertainment or art therapy) provided by the artists results in the equivalent of 40 credits ($40), which is banked to be used to pay for future health care expenses under the Options Plan. In effect, the artist trades his/her craft for health care. Artistic services include individual and group services in the inpatient and outpatient settings and public performances in the hospital s lobby or auditorium. Woodhull markets the program with advertisements in local newspapers, television coverage, and large-scale events. OUTCOMES Over two years, 384 artists enrolled in the program. There was an increase of 111% in service utilization from 2006 to 2007 (from 27 to 57 visits) with greatest growth in dental (five to 28 visits), primary care (ten to 14 visits), and ambulatory surgery (three to ten visits). Further, the program helped refocus the importance and access of primary care vs. emergent care in this community. CONTACT Lynn Schulman, Esq. Senior Associate Executive Director, Business Affairs Woodhull Medical and Mental Health Center 760 Broadway Brooklyn, NY (718) lynn.schulman@woodhullhc.nychhc.org LESSONS LEARNED Each non-traditional community defined as a community of people bound by a common characteristic, like being a member of the arts has its own culture and needs to be understood to reach the target audience. Other non-traditional communities, such as seasonal workers and workers in local bodegas, share the need for access to primary health care and are part of the working poor. They earn just enough to not qualify for public assistance and Medicaid, thus leaving them with limited alternatives to pay for health care. By working with these communities, a public hospital can benefit from the talents of the community and partner with them to provide affordable health care. Buy-in from hospital leadership is essential to program success. HANYS COMMUNITY HEALTH INITIATIVES ACROSS NEW YORK STATE EDITION 9

16 ARTIST ACCESS: AFFORDABLE HEALTH CARE FOR UNINSURED ARTISTS Woodhull Medical and Mental Health Center/New York City Health and Hospitals Corporation (CONTINUED) The partners played a key role in the development of the program, ensuring that it was sensitive to the culture of the artistic community. They were also vital in participating in outreach activities, and provided access to the artists in the community. ABILITY TO SUSTAIN THE INITIATIVE Through Artist Access the hospital gained more than 100 hours ($4,000) in bartered services, including one-on-one art therapy with inpatients, entertainment in the congregate waiting areas, and exercise through dance events. At most, the hospital would have gained $1,010 in copayments from this population. The program has become part of the fabric of the hospital and the commitment of the institution helps sustain it. The long-term savings to the facility results from a reduction in emergency room visits and building a loyal following. 10 HANYS COMMUNITY HEALTH INITIATIVES ACROSS NEW YORK STATE EDITION

17 COMMUNITY HEALTH PROFILES ANNE B. GOLDBERG ALZHEIMER S RESOURCE CENTER Albany Medical Center YEAR THE PROGRAM STARTED 2002 PARTNERS Alzheimer s Association, Northeastern New York Chapter Alzheimer s Disease Assistance Center (New York State Department of Health) Eddy Alzheimer s Service (Northeast Health) CONTACT Elizabeth Smith-Boivin, M.S.H.S.A. Program Director, Anne B. Goldberg Alzheimer s Resource Program Albany Medical Center 47 New Scotland Avenue Albany, NY (518) boivin34@aol.com PROGRAM DESCRIPTION AND GOALS The program is designed to assist patients with Alzheimer s disease, their families, and caregivers with any challenges they may face. Whether they need basic information about the disease, the latest reports concerning clinical trials, contact numbers for community organizations, an appointment with a provider, or just a supportive ear, patients and their family members find vital help and solace within this program. The Anne B. Goldberg Alzheimer s Resource Center has four goals: Assist patients and family caregivers by providing support, counseling, assessment, case management, and education. Assist formal caregivers (program and long-term care staff) by providing a wide variety of informational and educational programs. Increase the sensitivity and awareness of the community about normal aging memory, dementia, and Alzheimer s disease. Support the work of clinicians and scientists working in the Alzheimer s Center of Albany Medical Center. OUTCOMES More than 100 patients and their family members from a 17-county region of northeastern New York receive professional counseling, assessment, and case management services. Hundreds of caregivers receive educational support to deal more effectively with Alzheimer s patients and their family members. Thousands benefit from the more than 40 educational programs at nursing homes and assisted living facilities. The Anne B. Goldberg Alzheimer s Resource Center staff have presented educational lectures to more than 30 civic organizations. Dozens of students from Albany Medical College, Union College, and Siena College are mentored each year. The Alzheimer s Connection radio program and television interviews have brought useful information about Alzheimer s disease to thousands of people. LESSONS LEARNED Family caregivers are able to provide better care longer after receiving support and education. Long-term care providers are better able to modify challenging behavior by patients after learning best practices. Educational outreach programs can increase the number of those participating in important Alzheimer s research projects. HANYS COMMUNITY HEALTH INITIATIVES ACROSS NEW YORK STATE EDITION 11

18 ANNE B. GOLDBERG ALZHEIMER S RESOURCE CENTER Albany Medical Center (CONTINUED) ABILITY TO SUSTAIN THE INITIATIVE The vision of the late Allen Goldberg continues to be shared by the Goldberg Foundation, which remains committed to funding this vital program. The program is also sustained by the Friends of the Alzheimer s Center, which provides additional funds and program development. There are also a number of grateful patients who make financial gifts to support the program. 12 HANYS COMMUNITY HEALTH INITIATIVES ACROSS NEW YORK STATE EDITION

19 DIABETES EDUCATION AND CHRONIC DISEASE PREVENTION PROGRAMS Alice Hyde Medical Center YEAR THE PROGRAM STARTED 1998 PARTNERS Alice Hyde Medical Center s nursing department, nutritional services department, and community wellness program Community physicians and medical providers American Diabetes Association Seven County Diabetes Network Local school districts CONTACT Anne E. Slocum Chief Clinical Dietitian/Diabetes Education Program Coordinator Alice Hyde Medical Center 133 Park Street Malone, NY (518) aslocum@alicehyde.com PROGRAM DESCRIPTION AND GOALS The goal of the Diabetes Education and Chronic Disease Prevention Programs is the maintenance of a comprehensive American Diabetes Association-recognized education program that serves the community, providing a broad array of programs. The programs seek to maintain the availability of group and individual self-management diabetes training for all individuals with diabetes, provision of a diabetes support group, community diabetes screenings, weight management programs with a focus on healthful lifestyle behaviors, and collaboration with local school districts to promote healthful eating and exercise. Data are collected and reviewed continuously so that Alice Hyde Medical Center can adjust its diabetes and weight management programs to meet participants needs. OUTCOMES Systematic data collection from the diabetes education and weight management programs is monitored and analyzed to assure participant and program needs are met. Hemoglobin A1c and exercise goal achievement are monitored for diabetes program participants; weight change is monitored for weight management program participants. Recent data show an improvement in Hemoglobin A1c measures to American Diabetes Association recommendations for the majority of diabetes program participants. Weight management participants have achieved an average 12-pound sustained weight loss after completing the eight-week program. LESSONS LEARNED Provision of diabetes self management training results in decreased risk of diabetes-related complications as evidenced by improvements to participants Hemoglobin A1c measurements and implementation of individual exercise goals. Weight management program participants achieve significant weight improvement and behavior changes consistent with their individual goals for health achievement. ABILITY TO SUSTAIN THE INITIATIVE The Diabetes and Chronic Disease Prevention Programs are maintained with insurance and Medicare-billable services, fee-for-service billing for the weight management programs, and commitment from the Alice Hyde Medical Center for health and wellness programming for all community members. The services are supported by a referral process from surrounding community physicians and health care providers who use the programs to enhance the medical care of their patients. HANYS COMMUNITY HEALTH INITIATIVES ACROSS NEW YORK STATE EDITION 13

20 DARE TO CARE Arnot Ogden Medical Center YEAR THE PROGRAM STARTED 2006 PARTNERS Arnot Ogden Medical Center s Vascular Institute, Health on Demand Call Center, and radiology department Cardiothoracic and vascular surgeons/arnot Medical Services Primary care physicians The Associated Radiologists of the Finger Lakes Healthy Living Partnership of Chemung County CONTACT Richard N. Hoffman, F.A.C.H.E. Executive Director, Product Line Services Arnot Ogden Medical Center 600 Roe Avenue Elmira, NY (607) rhoffman@aomc.org PROGRAM DESCRIPTION AND GOALS This free, two-day program provides a physician-led educational program and noninvasive screenings for at-risk program participants at sites throughout the region. On the first day, participants attend a lecture program presented by a cardiologist, nephrologist, interventional radiologist, and vascular surgeon on risk factors and prevention of vascular disease. On the second day, participants receive cholesterol, blood pressure, and other screenings. Upon completion of the screening, each participant meets with a specially trained vascular nurse practitioner or vascular surgeon to review the results and receive advice and encouragement. Results are also shared with the primary care provider and patients; positive results are referred to specialist care. OUTCOMES Since the program s inception, 2,012 people have participated in both its educational and screening components. Screening reports are discussed with each participant and are forwarded to the primary care physician of record to advise them of the results and provide recommendations for additional follow-up, if necessary. The program has identified and provided medical or surgical treatment or monitoring for the following number of patients and diseases: carotid artery disease: 91 abdominal aortic aneurysm: 72 peripheral artery diseases: 119 atherosclerotic plaque: 964 LESSONS LEARNED These education and screening programs are now offered on a quarterly basis. The need in the community has not abated, as there is a consistent waiting list to get into the program. The key lesson learned is that a collaborative effort between Arnot Ogden Medical Center and physicians can ensure community benefit. ABILITY TO SUSTAIN THE INITIATIVE Dare to CARE screenings are now offered on a quarterly basis throughout the region and are hardwired into the strategic community services plan of Arnot Ogden Medical Center. As a dedicated program, budgetary resources will continue to support the program into the future. 14 HANYS COMMUNITY HEALTH INITIATIVES ACROSS NEW YORK STATE EDITION

21 THE SENIOR COMMUNITY HEALTH PROJECT Continuum Health Partners (Participating hospitals include Beth Israel Medical Center and St. Luke s-roosevelt Hospital Center, St. Luke s and Roosevelt Divisions) YEAR THE PROGRAM STARTED 1999 PARTNERS Co-op Village Senior Care Lincoln Amsterdam Senior Care Elliott Chelsea NORC A local town community health alliance and local housing complex Chinatown Neighborhood NORC Morningside Gardens NORC Village View NORC PROGRAM DESCRIPTION AND GOALS Since 1999, Continuum Health Partners and its member hospitals, in partnership with their communities, have been engaged in a process that seeks to address critical issues of an aging population and supports the creation of an elder-friendly community a community that is a good place to grow old. Continuum s hospitals are in urban settings with large concentrations of residents who have aged in place. These aging communities, where more than 50% of the population is over the age of 60, have become known as Naturally Occurring Retirement Communities (NORCs). The Senior Community Health Project is an innovative partnership that combines health care, social, and recreational services that enable New Yorkers to remain in their own homes as they age. These programs benefit the older adults and the health care system by empowering seniors to become active partners in their care, which prevents or delays institutional placement and helps residents manage chronic conditions, thereby reducing unnecessary emergency room visits and ensuring an appropriate level of care. Currently, the Senior Community Health Project reaches more than 11,000 New Yorkers. James Mandler Assistant Vice President, Public Affairs/ Corporate Communications Continuum Health Partners 555 West 57th Street, Suite 1829 New York, NY (212) jmandler@chpnet.org Senior Community Health Project goals include: healthy and engaged older adults who can remain vital members of their communities; expanded and positive relationships between health care providers and the aging community; coordinated access to primary and specialty care services; programs that promote healthy behaviors and build upon community needs; cost-effective coordination across the continuum of care; and creation of a replicable and sustainable model. OUTCOMES The Senior Community Health Project, now in its eighth year, demonstrates that an innovative, interdisciplinary, collaborative, and community-based model of care can improve health outcomes for older adults, enabling them to remain active, vital members of a healthier community while at the same time reducing costs to an already overburdened health care financing system. HANYS COMMUNITY HEALTH INITIATIVES ACROSS NEW YORK STATE EDITION 15

22 THE SENIOR COMMUNITY HEALTH PROJECT Continuum Health Partners (CONTINUED) The following summarizes programs offered by The Senior Community Health Project: Improving Access to Primary Care A survey conducted two years after the My Doctor initiative began found that 96% of participants indicated that they had a usual source of care. The Healthy Heart Program Physicians, nurses, health educators, physical therapists, and nutritionists were brought together to work in a NORC community in a nine-week interactive program designed to reduce risk factors and promote healthy behaviors. Results indicated that 95% of the program participants accomplished their personal goals, normalizing blood pressure, losing weight, and learning ways to achieve better health. The Waterworks Program Waterworks is a free, ongoing aquatic exercise program made possible through the Project s collaboration with a local college. The Linkage Project By forming a strong linkage between the emergency department and the community, patient care was improved, discharge planning was enhanced, and social admissions to the hospital were reduced. MyMeds An up-to-date medication profile is available for every MyMeds member whenever medical care is sought. ABILITY TO SUSTAIN THE INITIATIVE Senior Community Health Project and its NORC partnership programs represent a new and promising model of care for the growing aging segment of the population. Currently, NORC programs and The Senior Community Health Project are funded by a variety of city, state, foundation, and hospital vehicles. It is probable that this funding will continue for the near future. It is also encouraging that the Centers for Medicare and Medicaid Services is now seriously looking at the issue of post-acute care and what the health care provider, working in tandem with community agencies, can do to prevent re-hospitalizations. 16 HANYS COMMUNITY HEALTH INITIATIVES ACROSS NEW YORK STATE EDITION

23 DIABETES SELF-MANAGEMENT EDUCATION PROGRAM Brookhaven Memorial Hospital Medical Center YEAR THE PROGRAM STARTED 2007 PARTNERS Local AARP Chapter Lion s Club Sam s Club Pharmacy BMHMC outpatient clinics Bayport Blue Point, Longwood, Mastic- Moriches-Shirley, Patchogue, Sachem, and South Country public libraries Home care agencies, a dialysis center, and community physicians PROGRAM DESCRIPTION AND GOALS In 2006, the Lion s Club of Suffolk County provided a grant to Brookhaven Memorial Hospital Medical Center (BMHMC) to develop an outpatient Diabetes Self- Management Education (DSME) program. The goal of the DSME program is to promote improved diabetes self-management to prevent and/or delay complications associated with diabetes. The program includes diabetes health and wellness lectures in the community and regularly scheduled educational programs at BMHMC s conveniently located, easy to access Diabetes Wellness Center. Each DSME participant receives a pre- and post-participation diabetes evaluation. The DSME program employs an experienced adult nurse practitioner and registered dietitian. These Certified Diabetes Educators facilitate the development of individualized, outcomesoriented life plans for people with diabetes that improve their quality of life, decrease morbidity and mortality, and reduce health care costs. A part-time secretary is also part of the DSME program. OUTCOMES During its first year, the BMHMC DSME program provided diabetes education to about 400 people. This includes participants in the DSME diabetes classes and community partnerships. Word-of-mouth continues to increase the number of participants in the DSME program. Upon entering the classes, participants are assessed regarding their diabetes knowledge. Their self-evaluation of diabetes knowledge is typically low and their readiness to learn about their disease is moderate. Post-class tests indicate an increase in diabetes knowledge. Verbal responses from participants indicate improvement in their ability to problem-solve. Program evaluations report that participants are very satisfied, the highest level on the evaluation form. CONTACT Mary Sweeney, Ed.D., R.N., A.N.P., C.D.E. Adult Nurse Practitioner/Certified Diabetes Educator DSME Coordinator, Instructor, and Resource Person Brookhaven Memorial Hospital Medical Center 101 Hospital Road Patchogue, NY (631) mpsweeney@bmhmc.org LESSONS LEARNED The DSME program is an essential part of a sound, compassionate health care system. Making changes in behavior can be difficult; however, people want to learn and make positive changes. Recognizing that participants may have diabetes health-related problems prompts questions and allows assistance with individualizing health care plans for participants. Allowing participants to maintain a dialogue with the instructors during the classes helps clarify information. Providing problem-solving skills improves self-awareness of behaviors and helps improve decision making. Extending an invitation for participants to continue attendance at future classes provides a link to ongoing diabetes knowledge. A community-based site provided convenient and easy access to participants. HANYS COMMUNITY HEALTH INITIATIVES ACROSS NEW YORK STATE EDITION 17

24 DIABETES SELF-MANAGEMENT EDUCATION PROGRAM Brookhaven Memorial Hospital Medical Center (CONTINUED) Convenient scheduling of classes encourages greater participation. Providing DSME program information to physicians reached more people and strengthened the relationship between participants and their caregivers. ABILITY TO SUSTAIN THE INITIATIVE The grant from the Lion s Club of Suffolk County enabled the BMHMC diabetes program to prove its worth in the community. The DSME is now a budgeted, hospitalsupported program and is an integral part of BMHMC and its community. The continued growth in attendance in the DSME program and the community s positive response to the program are evidence of its sustainability. 18 HANYS COMMUNITY HEALTH INITIATIVES ACROSS NEW YORK STATE EDITION

25 TOBACCO FREE IS THE WAY TO BE! Brooks Memorial Hospital YEAR THE PROGRAM STARTED 2003 PARTNERS New York State Smokers Quitline Chautauqua County Tobacco Control Program Steps to a Healthier New York Southern Tier Healthcare System/Tobacco Cessation University of Pittsburg Smoking Cessation: Practical Skills for Healthcare Professionals Brooks Memorial Hospital s administration, management, nursing staff, medical staff, wellness committee, and employee health department PROGRAM DESCRIPTION AND GOALS The Tobacco Free is the Way to Be! program is part of Brooks Memorial Hospital s goal to promote health and wellness for its inpatients, outpatients, employees, and community members. Tobacco Free is the Way to Be! began in 2003 when hospitalized patients diagnosed with acute myocardial infarction, congestive heart failure, or pneumonia were screened for a history of tobacco use and were educated on tobacco cessation prior to discharge. The education consisted of an informational packet and one-on-one intervention. Realizing this intervention needed to be offered to the entire tobacco-dependent population, the tobacco use screening was expanded to include all hospitalized patients regardless of diagnosis. In 2006, the program was expanded to provide smoking cessation programs to hospital employees, their family members, and community members. Through grant funds from Southern Tier Healthcare System, the hospital was able to print weekly educational advertisements in the local newspaper. The advertisements contained information on the risks of smoking and the benefits of quitting, and informed the community of the facility s move to a smoke-free campus in January An outside banner and permanent signage were placed around the facility. The Chautauqua County Tobacco Control Program provided additional education, materials, and nicotine replacement therapy. OUTCOMES The facility s rate for tobacco cessation intervention went from 51% in 2003 to 87% in The goal is to continue this upward trend to reach and sustain 100%. From August 2006 to January 2008, 164 referrals were made to the New York State Smokers Quitline, in addition to providing initial counseling for each referral. Brooks Memorial Hospital became the first smoke-free campus in Chautauqua County on January 1, CONTACT Susan Lis, R.N., B.S.N., C.I.C. Infection Control Practitioner/ Employee Health Director Brooks Memorial Hospital 529 Central Avenue Dunkirk, NY (716) slis@brookshospital.org LESSONS LEARNED Tobacco use is a difficult behavior to change. Individuals are aware of the negative effects of tobacco use and know cessation is beneficial. Despite this knowledge, quitting is very challenging Counselors can feel frustrated and ineffective when they provide instruction to individuals, but still observe those individuals using tobacco. The counselors take heart in knowing that although not all attempts are successful, every attempt brings the individual closer to becoming tobacco-free. HANYS COMMUNITY HEALTH INITIATIVES ACROSS NEW YORK STATE EDITION 19

26 TOBACCO FREE IS THE WAY TO BE! Brooks Memorial Hospital (CONTINUED) ABILITY TO SUSTAIN THE INITIATIVE All patients continue to be screened for tobacco use, with positive screens receiving the two-minute intervention with a smoking cessation informational packet. People expressing an immediate desire to quit are seen by a smoking cessation counselor, and a referral is generated to the New York State Smokers Quitline. Employees are continuously offered smoking cessation materials and the opportunity to receive counseling and nicotine replacement therapy. Additionally, counselors attend a vast array of community events/wellness fairs. 20 HANYS COMMUNITY HEALTH INITIATIVES ACROSS NEW YORK STATE EDITION

27 UNINSURED INITIATIVE Catholic Health System Primary Care Centers YEAR THE PROGRAM STARTED 2005 PARTNERS Fidelis Care New York Catholic Health System Primary Care Centers PROGRAM DESCRIPTION AND GOALS The Uninsured Initiative is a collaborative effort between Catholic Health System (CHS) and Fidelis Care New York to provide uninsured people health insurance and health care services. When a potential new patient calls one of the CHS Primary Care Centers for an appointment and has no insurance, the appointment is readily scheduled. Upon arrival for the visit, the patient receives a form to complete that inquires whether the patient would like a home visit from Fidelis Care to assist him/her with enrolling in a health insurance option. Once the form is completed, CHS Primary Care Centers faxes it to Fidelis Care, where a marketing representative contacts the patient and sets up an appointment for a home visit. OUTCOMES Since the initiative began in March 2005, about 2,800 patients have been enrolled in Fidelis Care. During that same period, more than 6,000 patients were referred from CHS Primary Care Centers to Fidelis for inquiries regarding managed care product offerings. LESSONS LEARNED Patients can sometimes object to home visits, for a variety of reasons. Consequently, Fidelis Care frequently works with the CHS Primary Care Center associates to find a quiet, private place at the Centers for the meeting to take place. Providing an environment that meets the needs of patients highlights the importance placed on advantages afforded patients through Medicaid managed care enrollment. CONTACT Honor Martin, R.N., M.S., C.N.A., C.H.C.Q.M.-M.C.-F.A.I.H.Q. Administrative Director Catholic Health System Primary Care 21 Appletree Business Park Cheektowaga, NY (716) hmartin@chsbuffalo.org ABILITY TO SUSTAIN THE INITIATIVE The initiative is now in operation three years and receives the continuous support of administration and hospital personnel. The successful reduction of uninsured patients has meant an increase in reimbursement; therefore, the activity is self-sustaining. HANYS COMMUNITY HEALTH INITIATIVES ACROSS NEW YORK STATE EDITION 21

28 SMOKING CESSATION INITIATIVE Cortland Regional Medical Center YEAR THE PROGRAM STARTED 2006 PARTNERS Cortland Community Action Team Blue Ribbon Committee: Cortland County Health Department Seven Valleys Health Coalition State University of New York Cortland Community Outreach Partnership Center United Way Tobacco Free Cortland Reality Check American Cancer Society Seven Valleys Council on Alcoholism and Drug Abuse PROGRAM DESCRIPTION AND GOALS Cortland Regional Medical Center joined the Cortland County Health Department in leading an initiative to decrease tobacco use in the community. The first step occurred in March 2006 when the medical center transitioned to a smoke-free facility. The no-smoking policy was implemented after careful planning to initiate an expanded smoking cessation program for the community, including the medical center s 780 employees and 336 volunteers. The program includes: providing nicotine replacement products; smoking cessation counseling by the medical center s respiratory therapy staff; seven-week Tobacco Free for Life programs; with four agencies, sponsoring and hosting The Great American Smoke- Out celebrations; and participating in anti-smoking campaigns at area high schools in conjunction with Tobacco Free Cortland and Reality Check. In addition, the medical center recently automated its process for identifying inpatient smokers to quickly offer smoking cessation services. The goal of the facility s smoking cessation initiative is consistent with a county health objective: To decrease rates of alcohol, tobacco, and other drug use. CONTACT Susan Eoannou Director, Business Development/Planning Cortland Regional Medical Center 134 Homer Avenue Cortland, NY (607) seoannou@cortland OUTCOMES Of the 86 employees who received nicotine replacement therapy from 2005 to 2007, 20 have quit smoking. Thirty-one community members have participated in Tobacco Free for Life classes; five have quit smoking. An increased number of inpatient smokers are offered cessation counseling. In 2006, 590 inpatient admissions received the counseling; in 2007, the number grew to 820. Soon after Cortland Regional Medical Center became a smoke-free facility, Family Health Network of Central New York followed the example. Family Health Network is a not-for-profit organization that operates five federally funded health centers. LESSONS LEARNED Smoking cessation clinics should be held at flexible times to accommodate as many members of the community and staff as possible. Follow-up with program participants is necessary to ensure quitting for life as well as to offer additional services. 22 HANYS COMMUNITY HEALTH INITIATIVES ACROSS NEW YORK STATE EDITION

29 SMOKING CESSATION INITIATIVE Cortland Regional Medical Center (CONTINUED) Clear communication with staff and the community about the status and health benefits of the smoking cessation program is necessary. Staff and visitors will leave the medical center premises to smoke, so consider the needs of the facility s neighbors. ABILITY TO SUSTAIN THE INITIATIVE Cortland Regional Medical Center s administration, board of directors, and medical staff fully support the Smoking Cessation Program. The facility s senior leadership is aware of the high prevalence of preventable disease and morbidity secondary to smoking and authorized funding for the initiative, including staffing, space, and materials for the future. HANYS COMMUNITY HEALTH INITIATIVES ACROSS NEW YORK STATE EDITION 23

30 ESSEX COUNTY DIABETES SUPPORT GROUP Elizabethtown Community Hospital YEAR THE PROGRAM STARTED 2006 PARTNERS Essex County Cornell Cooperative Extension Seven County Diabetes Network Eastern Adirondack Health Care Network PROGRAM DESCRIPTION AND GOALS The Essex County Diabetes Support Group is a collaboration of local partners to address the lack of education and support for those who suffer from diabetes. Surveys throughout Clinton, Essex, and Franklin Counties in 2005 identified chronic disease, diabetes in particular, as a critical issue needing attention to improve the health of residents. The increased demand for the kidney dialysis unit at Elizabethtown Community Hospital was another indicator of the severe need for diabetes education in the community. The Essex County Diabetes Support Group sponsors diabetes self-management and insulin intensive therapy classes several times a year. The group works with physicians to provide continuous glucose monitoring systems for patients. The group holds monthly meetings with educational lectures about various diabetic control topics and time to speak among the members to share stories and ask questions. A diabetes health fair is held annually in November. The fair hosts several diabetic pharmaceutical companies that set up displays and hand out free information and materials. OUTCOMES The Essex County Diabetes Support Group has seen life-improving outcomes from its education and support services. For example, one man had been living with diabetes for 17 years, but was in denial. With the help of his wife, who attended the support group meetings, one year later he has lost several pounds, has his blood sugar under control, and is counting his carbohydrates. CONTACT Kerry Haley Director of Community Relations Elizabethtown Community Hospital P.O. Box 277 Elizabethtown, NY (518) khaley@ech.org LESSONS LEARNED Group members learn better through hands-on experience, particularly with carbohydrate counting and in understanding the glycemic index. The certified diabetes educators have found that the group is most interested in hearing presentations and addressing issues that their medical providers do not have a chance to discuss or that patients do not feel comfortable discussing. The Diabetes Health Fair gives diabetics direct access to pharmaceutical representatives, allowing them to learn more about products and interactions of food and medications, try samples, and in some cases get free testing equipment that they are not able to afford themselves. This allows each participant to be proactive about his or her health and realize that they have control of their lifestyles. 24 HANYS COMMUNITY HEALTH INITIATIVES ACROSS NEW YORK STATE EDITION