Developing Local Wellness & Prevention Effor ts. Promoting Health & Well-being. Improving Health Care Utilization

Transcription

1 Developing Local Wellness & Prevention Effor ts Promoting Health & Well-being Improving Health Care Utilization Strengthening Organizational Capacities C M S P / T C E W E L L N E S S & P R E V E N T I O N P RO G R A M

2 CMSP/TCE WELLNESS & PREVENTION PROGRAM An Investment in Wellness For Rural California Overview General Overview... 3 Map of sites that were served under the CMSP/TCE Wellness & Prevention Program... 7 Wellness & Prevention Projects Contents Phase II, Cycle 3 Report... 9 RFA Process Site-by-Site Project Reports Introduction Case Management Cluster Introduction High-Intensity Level Projects Butte County Humboldt County Mendocino County Sierra County Sonoma County Tuolumne County Moderate-Intensity Level Projects Alpine County Calaveras County Kings County Lassen County Plumas County Siskiyou County Low-Intensity Level Projects Glenn County Lake County Marin County Solano County Sutter County Case Management Cluster Conclusions Outreach and Education Cluster Introduction Imperial County Madera County Mono County Nevada County San Benito County

3 Table of Contents, Volume 1, continued Tehama County Trinity County Yuba County Outreach and Education Cluster Conclusions Increasing Access Cluster Introduction Colusa County Del Norte County El Dorado County Inyo County Mariposa County Modoc County Napa County Shasta County Increasing Access Cluster Conclusions Site Report Conclusion Cost & Service Use Analysis Purpose Data Sources Methodology Results All W&PP Enrollees Case Management Cluster Enrollees Outreach and Education Enrollees Increasing Access Enrollees Individual Case Studies (Butte, Inyo, & Lassen Counties) Categories of Eligibility Financial Report Financial Report Conclusion Lessons Learned and Recommendations Acknowledgements Contact Information Evaluation Findings Vol. 2 The Evaluation Findings are available in a separate volume in print as well as in electronic form (PDF), included on a CD with Volume 1 of this report. Cycle 3 Evaluation by Dennis Rose & Associates (DRA) Enrollee Cost and Utilization Pre- and Post-Enrollment by The Lewin Group Cycle 2 Evaluation by DRA Strategic Direction Summary by DRA Phase II, Cycle Project Administration, Technical Assistance, & Public Relations Administrative Staff Technical Assistance Provided Publicity and Public Relations Phase I Strategic Planning Strategic Planning Report CMSP 101 (Introduction to CMSP) Supplemental Information Vol. 3 This supplemental information is available in a separate volume in print as well as in electronic form (PDF), included on a CD with Volume 1 of this report. CCP s Final Report Pages from 1st annual report about Cycle 1 W&PP Newsletters Cycle 3 Request for Application Financial sheets No-Cost Extension documents Case Management Database Application Instruction and Reference Manual Peer-Reviewed Publications

4 Overview The County Medical Services Program (CMSP) Governing Board s Wellness and Prevention Program (W&PP) was a partnership with The California Endowment (TCE) to support community-based approaches for the creation of wellness & prevention plans and action strategies among 34 of the 58 California counties and to strengthen CMSP s overall organizational capacity to provide technical assistance and related support to its member counties. Wellness and Prevention Program efforts began in 1998 and concluded in Originally, the project was slated to end in January 2003, but a number of delays in processes necessitated a no-cost extension, which was granted by TCE. (Please, refer to the no-cost extension approval letter located in Volume 3 of this report, Supplemental Information.) The objectives of the CMSP/TCE W&PP were to: Institute a process for developing, implementing, and evaluating community-based, collaborative strategies to create wellness and prevention action plans with performance-based objectives for improving health and well-being of the rural underserved individuals residing in the participating counties; Provide wellness and prevention grant allocations to the participating CMSP counties (or groupings of counties) in support of the locally generated plans and strategies; Reduce inappropriate hospitalization admissions and related unnecessary expenditures by a thorough, more effective utilization of resources and a more informed client population; and Strengthen CMSP s organizational ability and capacity to become a proactive and community-responsive health system, committed to improving health and promoting the well-being of its client population. The CMSP/TCE W&PP consisted of two distinct phases to meet the program objectives. Phase I was comprised of a strategic planning effort on the part of the CMSP Governing Board. Phase II comprised grant awards to the 34 rural and frontier counties for the purpose of supporting their efforts to increase capacities to provide wellness and prevention-related services to uninsured and underserved adult residents. These grant awards were distributed in three cycles over a five-year period. 3

5 CMSP/TCE WELLNESS & PREVENTION PROGRAM Table A: Summary of the Phase II time line, funding sources, and grant amounts Phase II Cycles Dates encompassed CMSP Contribution TCE Contribution Total Contributions Cycle 1 July 1, December 31, 1999 $2 million $ 2.0 million Cycle 2 January 1, February 28, 2001 $2 million $1.6 million $ 3.6 million Cycle 3 April 1, March 31, 2004* $6.0 million** $ 6.0 million Totals $ 4 million $7.6 million $11.6 million*** *Project final reports were due May 31, 2004, and the DRA evaluation report was due in June **An additional $1.5 million in interest earned and interest projected was released in Years 3, 4, and 5. *** A fraction of this amount went unspent. Refer to the Financial section of this report for details. Phase I During the strategic planning workshops conducted in Phase I, stakeholders identified several key directions for the CMSP including improvement in the amount, availability, and timeliness of service use and cost data; improving the efficiency of service delivery, including a greater focus on prevention of costly emergent health incidents and disease management and management of complex cases; refining the criteria that define the target population of the CMSP; and maintaining fiscal solvency. Guided by these defined strategic directions, the Governing Board approved number of initiatives and program refinements. (For details, refer to the Phase I Report in this volume, Strategic Planning Activities.) Phase II Cycle 1 projects were funded entirely by the CMSP Governing Board in the form of noncompetitive grants for service-related and capital improvement projects. Although no evaluation requirements were placed on grantees, Cycle 1 activities yielded several lessons learned that guided the administration of the subsequent grant cycles. Refer to the Cycle 1 report in Volume 3 of this report, Supplemental Information, for a list of the funded projects and a summary of the particular lessons learned. Cycle 2 projects, which were undertaken by all 34 CMSP-enrolled counties, were jointly funded by the CMSP Governing Board and TCE. For the Cycle 2 program, an evaluation process was undertaken by Dennis Rose & Associates (DRA). The major lessons learned from this effort were that one year was too short a time for most organizations to start and implement a program; and, collaborative evaluation was new to many organizations, and although they were receptive to the idea, they had little existing capacity or available staff to participate. These lessons learned were important for refining the scope and design of the Cycle 3 program. For details, refer to the Cycle 2 section in Volume 1 of this report. The Cycle 3 W&PP projects are the primary subject of this report (refer to the Individual Site Reports in Volume 1 of this report), and they are also described in great detail in DRA s independent evaluation report located in Volume 2 of this report. A total of 33 of the 34 CMSP-participant counties submitted proposals for and were awarded Cycle 3 grant funds. The process for eliciting proposals is presented in detail in the RFA Process section in Volume 4 1 of this report. A summary of the time lines and funding amounts and sources for the Cycle 1, Cycle 2, and Cycle 3 of the Phase II effort are listed in Table A. The evaluators received documentation of 38,028 individuals who received benefit from W&PP projects Cycle 3 efforts. A map of all sites served by the CMSP/ TCE W&PP is located on page 7. Cycle 3 Evaluation Based on the lessons learned from Cycles 1 and 2, DRA assisted each project in developing logic models, project objectives, and evaluation plans that arose from the needs and interests of the individual projects, as is presented in detail in their evaluation report located in Volume 2, Evaluation Findings, of this report. DRA staff also provided a large amount of technical assistance to project personnel to help them gain the capacity to participate in a meaningful evaluations characterized by collection and analysis of key data. Cycle 3 Cost and Service Use Analysis An additional analysis was planned regarding cost and service use related to the W&PP projects, and to that end each site collected a set of core data of key identifiers for those individuals served by the projects who were enrolled in the CMSP. These data were submitted twice a year to the W&PP administrative staff. The composite data set was then matched with eligibility and claims 4

6 data maintained by CMSP and was analyzed by The Lewin Group regarding the impacts on cost and service use of the various W&PP projects. These results are reported in detail in the The Lewin Group Report section located in Volume 2, Evaluation Findings, of this report, an analysis and discussion of these results is presented in the Cost and Service Use section of Volume 1, and a discussion of highlights of results as they relate the individual W&PP projects and analysis clusters of projects is presented in appropriate locations in the Individual Site Report section. Staff members at rural health and dental clinics were fundamental to the success of W&PP projects. of wellness and prevention services, help build resources, and prepare for sustainability. These efforts by CCP staff are detailed in their final report that is included in Volume 3, Supplemental Information, of this report. Adminstrative staff of the W&PP provided assistance in the form of assisting with supplemental grant proposals, providing publicity and public relations assistance, facilitating grant administration, and assisting with technical training on the electronic case management database program that DRA created. These efforts are detailed in the Project Administration, Technical Assistance & Public Relations section in Volume 1 of this report Grant Administration, Technical Assistance, and Publicity Wellness & Prevention Program projects received technical assistance from a variety of sources in addition to that provided by DRA, including from the Center for Civic Partnerships (CCP) to facilitate collaboration with project partners, assist in the development and delivery Report Conclusion The report concludes with a brief discussion of major outcomes as they relate to the four original objectives stated in the initial grant agreement between The California Endowment and the CMSP Governing Board, along with lessons learned arising from the experiences of the Wellness &Prevention Program. 5

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8 Smith River Crescent City Communities Served By Local Wellness & Prevention Program Efforts: Grants Cycles 2&3 Yreka Cedarville Canby Mt. Shasta Alturas Bieber Arcata Eureka Weaverville Round Mountain Hayfork Redding Bridgeville Shingletown Chester Red Bluff Greenville Corning Quincy Portola Chico Loyalton Willows Oroville Willits Downieville Maxwell Truckee Ukiah Colusa Nevada City Lucerne Williams Grass Valley Lakeport Arbuckle Georgetown Cloverdale Middletown Placerville Markleeville Healdsburg Occidental Santa Rosa SonomaNapa Jackson Petaluma San Andreas GreenbraeLarkspur San Rafael Fort Bidwell Sonora Mariposa Mammoth Lakes Bishop Legend Frontier Rural Urban Communities Served Hollister Chowchilla Madera Hanford Corcoran Avenal Kettleman City Niland Miles Brawley El Centro Calexico 1 inch equals miles Created by: Rural Health Policy Council Source: CMSP/ TCE Wellness & Prevention Program June 2004

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10 Grant Cycle 3. RFA Process.. Site-by-Site Project Reports... Case Management Cluster... Outreach & Education Cluster... Increasing Access Cluster... Grantee Evaluation of the Program... Cost & Service Use Analysis

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12 Request for A pplication Process All Cycle 3 Wellness & Prevention Program projects were designed to address a need within the community s medically underserved residents with a focus on community-based wellness and prevention activities. County agencies or not-for-profit entities in the 34 California counties participating in the CMSP were eligible to apply. This was a noncompetitive grant process between counties; however, only one project was awarded from each CMSPparticipating county. Efforts were made by the W&PP to bring together agencies within a single CMSP county that expressed interest in the grant funds, and a rating procedure was created in the event that the W&PP received more than one proposal from a single CMSP county. The proposed projects were required to be collaborative efforts between a county government entity and at least one nonprofit communitybased entity. The fiscal agent for grantees could be either a county agency or a notfor-profit entity. The third Wellness and Prevention grant cycle incorporated lessons learned in both grant Cycle 1 and Cycle 2. One of the primary differences between Cycle 3 and the previous 2 cycles was that grantees received funds for a three-year period. A multi-year award allowed grantees to build more effective programs that had a greater chance of being sustained over time and aided projects in being able to recruit and secure competent staff. Combining lessons learned from the first two grant cycles, the Wellness and Prevention Program integrated several changes into the W&PP application process. The primary enhancements to the application process from prior years were: Applicants had the opportunity to request county-specific reports based on CMSP paid claims and eligibility data. Applicants were required to clearly describe the target population, the characteristics of the CMSP clients in the community, and discuss how the proposed project will identify the CMSP population. Applicants were required to submit a logic model. Applicants were provided with a standard budget format to complete. Applicants were required to use resources such as W&P Planning Reports, county-level data, or assessment results to plan their projects. Applicants were required to discuss the function, activities, and goals of their collaboration. Applicants were not required to submit a Letter of Intent as in prior grant cycles. 11

13 CMSP/TCE WELLNESS & PREVENTION PROGRAM The release of the Cycle 3 Request for Application (RFA) was coordinated to coincide with the CMSP Governing Board s Strategic Planning Implementation (SPI) Demonstration Grants. The SPI grants were developed through the CMSP Governing Board s Administrative Office and built upon the theme of wellness and prevention by providing $4 million in funding for the development of organized systems in the following areas: disease management, high-cost case management, mental health treatment and case management, and alcohol/ other drug treatment and case management. An RFA release letter was sent to approximately 650 public and private agencies throughout California on December 15, 2000 announcing the upcoming release of the CMSP/ TCE Wellness and Prevention Program Request for Application. The Cycle 3 Wellness and Prevention grant RFA was released concurrently with the SPI grants on January 3, 2001 to facilitate continuity and cohesion among the CMSP grants. The RFA was available for interested parties to download via the Internet at the CMSP Governing Board s Web site, Individuals without Internet access could call or write to the W&PP office to request a hard copy of the grant application. A copy of the Cycle 3 Request for Application is included in Volume 3, Supplemental Information, of this report. The RFA was comprised of the following components: statement of the problem or need within the community; description of the target population and how they would be identified; description of proposed project; logic model; time line; description of collaborative; 3-year grant budget; drugfree workplace certification; a letter of collaboration with signatures from all members of the collaborative; and, a resolution from the County Board of Supervisors or Board of Directors from the lead agency in support the application. A grant application assistance teleconference was held on February 5, 2001 to assist potential applicants with questions regarding the program and with specific questions regarding the application process. Approximately 43 individuals, representing a total of 19 CMSP counties, participated on the teleconference. Bright smiles of W&PP project client and her dental provider. During this time, staff was also available to answer questions regarding the Strategic Plan Demonstration grants. Dennis Rose & Associates (DRA) and the Center for Civic Partnerships (CCP) assisted Cycle 3 applicants with proposal development. Specifically, DRA worked with applicants on developing logic models and individualized evaluation plans. CCP helped applicants with the development/ refinement of program theories and activities and provided feedback to potential grantees after reviewing draft applications. CCP held an additional technical assistance teleconference on February 6, 2001 to provide further assistance to grantees. Potential grantees submitted their Cycle 3 applications by 12 February 26, In all, 31 counties submitted proposals by the deadline. W&PP staff reviewed proposals for both accuracy and content. Of the 31 proposals received, 28 applicants went through a remediation process. Beginning March 13, 2001, applicants were contacted by letter from the W&PP administrative staff to submit additional information regarding the project. Applicants were given until March 28, 2001 to submit to missing information. In general, remediation was provided for three primary reasons: Missing documentation; Incorrect budget; and, Clarification of program elements. During the CMSP Governing Board s March 2001 meeting, the Board voted to approve the proposals of the three applications that did not require remediation. In a separate motion, the Board voted to accept the proposals of the 28 remediation sites pending the receipt of the requested documentation. Upon receiving the requested documentation, applicants were sent an approval letter along with a standard agreement with the CMSP Governing Board. The first year s payments were released beginning June 2001 upon the receipted of a fully executed agreement between the grantee s lead agency and the CMSP Governing Board. The project period for these sites was April 1, 2001 through March 31,

14 Three eligible counties (Amador, Colusa, and Nevada) did not initially submit proposals to participate in Cycle 3. During the CMSP Governing Board s May 2001 meeting, the Board voted to offer agencies within these three counties an additional opportunity to participate in the Wellness and Prevention Program. Program staff contacted agencies within these counties to make them aware of the opportunity and offered assistance preparing the application. Under this effort, proposals were received from agencies within Colusa and Nevada counties. Applications were Tehama W&PP project s diabetes educator, Norma Rodriguez, reviewed and approved by tests her client s blood sugar level. the CMSP Governing Board during its July 2001 meeting. The project period for these July Start Sites was July 1, 2001 through March 31, The fiscal agents for the 33 awarded project were comprised of 11 not-for-profit agencies and 22 county governmental agencies. The Cycle 3 grantee allocations for each county were based upon methodologies that incorporated a fixed minimum of $60,000 for each of the 34 CMSP counties, a proportion of county s population below poverty level per Department of Finance 1997 county population estimates and 1990 Census data, and a relative need index weight based on rankings across 16 health status indicators. Grantees were provided with flexibility as to how they chose to budget their total grant allocation across the three-year period. Grantees were required to take no more than 50% of their total allocation and no less than 10% of their total in a single grant year. Additionally, grantees were required to budget a minimum of 10% of the total grant allocation for evaluation-related activities. During this the Cycle 3 grant period, implementation schedules of projects were extremely varied. Approximately 22 of the Cycle 3 projects were enhancements or continuations of Cycle 2 efforts and therefore were able to hit the ground running and begin delivering services immediately. Eleven sites created completely new projects. Fifteen Cycle 3 projects that were continuations of a Cycle 2 project and that had unspent Cycle 2 funds were allowed to rollover the unspent Cycle 2 funds into their Cycle 3 grant budget instead of returning the unspent grant funds. Grantees in this situation submitted a Rollover Request Form and completed a revised budget that incorporated the project s Cycle 3 allocation in addition to the Cycle 2 rollover funds. W&PP administrative staff tracked the expenditures of the remaining Cycle 2 funds in combination with the Cycle 3 funds. Note that the grant allocations listed in the following Cycle 3 site reports for the 15 sites participating in the rollover program reflect the project s Cycle 3 allocation in addition to the Cycle 2 rollover funds. 13

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16 Site Report Introduction The following individual site reports summarize the activities of each of the 33 Cycle 3 W&PP projects as they relate to the approved objectives in the project proposals. The purpose of these reports is to encapsulate and highlight the hard work, dedication, creativity, and compassion that the staff of each project has invested over the past three years. Our intention is to illustrate how each W&PP project contributed to improving the health status of their community s residents and the ability of each health care organization to engage clients in wellness-focused activities. The following site reports illustrate the power of utilizing a from the ground up approach to project design that is tailored to each community s needs and strengths. For this presentation, the CMSP/TCE W&PP administrative staff has distilled information from the evaluator s report from Dennis Rose & Associates, the cost and service use analysis from The Lewin Group, the projects interim and final reporting, site visits that the administrative staff has conducted, and interpersonal communications with project staff. In an effort to produce an overall evaluation of the degree of success in achieving the project goals, the W&PP administrative staff applied the rating rubric that is shown on the following page to each project s approved objectives, followed by a discussion based on all available quantitative and qualitative data. These ratings are not meant to be punitive, but rather to document each project s successes and challenges as a learning tool for others interested in wellness & prevention strategies for uninsured & underinsured populations. The site reports are organized into the three analysis clusters: Case Management Outreach and Education Increasing Access Each cluster presentation is preceded by an introduction and ends with a set of conclusions and lessons learned. 15

17 CMSP/TCE WELLNESS & PREVENTION PROGRAM Wellness & Prevention Program Rating Rubric for Individual Cycle 3 Site Objectives Achieved Objective (high level of data to support) sufficient quantitative and qualitative data to indicate that the complete objective was achieved Achieved Objective (moderate level of data to support) sufficient anecdotal information and some qualitative and quantitative data to indicate that the complete objective was achieved Partially Achieved Objective (high level of data to support) sufficient qualitative and quantitative data to indicate that a part of the objective was achieved Partially Achieved Objective (minimal level of data to support) sufficient anecdotal information, but little or no qualitative or quantitative data to indicate that a part of the objective was achieved 16 Failed to Achieve Objective no anecdotal, quantitative, or qualitative data to indicate that the objective was achieved Objective Not Attempted the site redefined their objectives during the grant period and decided not to pursue this objective Objective Withdrawn Objective initially attempted but abandoned during the project for various reasons Objective Addressed Outside W&PP Effort grant project was part of a larger community initiative and W&PP resources contributed to but did not have direct impact on the accomplishment of the objective Definitions: Anecdotal information a verbal report from project staff that is not supported by qualitative or quantitative data Qualitative data copies of flyers, ads; verbal survey responses; training materials developed; other materials developed; newspaper, newsletter, journal articles published Quantitative data logs, survey results, patient records, database entries, official data reports (such as OSHPD reports), cost analyses from claims data 16

18 Case Management Cluster. High-Intensity Case Management.. Moderate-Intensity Case Management... Low-Intensity Case Management 17

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20 Case Management Cluster A total of 17 of the 33 Cycle 3 W&PP projects were focused primarily on case management. As noted previously, each site designed their own approach and scope for their case management efforts, resulting in a heterogeneous set of solutions and outcomes that are difficult to consolidate into a group presentation 1. However, the evaluators and administrative staff have identified a classification criterion that works reasonably well to help with analysis. In this system, case management efforts were classified into three groups as follows: Low Intensity (5 sites) Includes basic health assessment, screening such as blood pressure or blood sugar, some health education or information, and a resources or referral for services, with minimal or no follow-up with clients. Moderate Intensity (6 sites) Includes all of the low-intensity activities but adds the development of an individual treatment plan, direct personalized education/ information, repeat contacts with the client (multiple visits), repeat measures of health indicators, and scheduled follow-up with clients. High Intensity (6 sites) Involves all of the activities of the low-intensity and moderate-intensity types but also includes the direct delivery of health services, referral to both health and other needed services (social, behavioral, advocacy services, specialty care, etc.), and more intensive individual support as needed. The following W&PP projects are included in this analysis cluster: Low-Intensity Case Management 2 Glenn Lake Marin Solano Sutter Moderate-Intensity Case Management Alpine Calaveras Kings Lassen Plumas Siskiyou High-Intensity Case Management Butte Humboldt Mendocino Sierra Sonoma Tuolumne 1 A detailed discussion of this issue is presented in the Process and Overall Key Findings section of DRA s evaluation report. 2 DRA included three additional sites as conducting low-intensity case management: Yuba, Trinty, and Tehama, and they did not include Marin. However, since data from low-intensity case management sites was sparse, the low-intensity sites were not included in their data analysis for case management. 19

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22 High-Intensity Case Management Cluster. Butte.. Humboldt... Mendocino... Sierra... Sonoma... Tuolumne 21

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24 Butte County The Butte County W&PP, called the Wellness to Work (WtW) program, was an innovative concept designed to help people overcome health-related conditions that impede their ability to work and/or their level of employability. Wellness and health promotion are integral components of obtaining and retaining meaningful employment and are directly linked to the individual s employability. People with certain health conditions, such as poor dental care, offensive body hygiene, obesity, and lack of physical energy, are all too often dismissed or overlooked by a potential employer simply because of their unattractiveness during the initial interview process. Too many employment opportunities are lost when the employer s primary focus is on these health-related conditions rather than the person s ability to do the work. Eliminating or mitigating these conditions greatly enhances the person s ability to be employed. Historically, the social employment model has lacked a focus on wellness, health promotion, and preventive health care. Program Description continued on the next page> Total Award Expended $464,379 of $464,379 awarded Program Partners Butte County Department of Public Health (BCDPH)* Butte County Department of Employment and Social Services* Butte County Welfare Department Butte County Department of Behavioral Health Butte County Family Support Division Geographic Area Served Butte County Target Population All persons who entered the Butte County Employment Centers seeking services, including Cal-Works participants, CMSP beneficiaries, and indigent persons at all levels of education, income, and ethnicity *primary partners Contact Information Debra Suderman, Clinic Manager Butte County Wellness to Work Program Phone: (530) dsuderman@buttecounty.net 23

25 CMSP/TCE WELLNESS & PREVENTION PROGRAM The Cal-Works (Welfare) program provides extensive training and resource allocation to educational advancement, job preparation, job search, and job placement, but very little attention, energy, or resources go towards wellness and health promotion. The Wellness to Work concept recognized that wellness and health care services could contribute to a higher level of success in this social employment model. CMSP/TCE Wellness & Prevention Program funds supported the WtW efforts in Butte County during grant Cycle 2 ( ) as well as grant Cycle 3 ( ). Butte County received permission to roll over $137,733 of their $195,987 Cycle 2 grant award into Cycle 3 because of construction delays with the Butte County Employment Center Wellness to Work office. In Cycle 3, funds were used to employ a 1.0 FTE health education specialist, public health nursing case managers (at varying levels throughout the project), and clerical staff. The WtW program provided both group wellness education and individual client health services. In addition, WtW provided limited funding to assist indigent clients in obtaining health-related services that were not available through Medi-Cal or CMSP, including certain dental repairs, tattoo removal, and nutritional counseling. Funds were used to purchase health education materials used in workshops, classes, and oneon-one patient education. Finally, funds were also used for office expenses, including rent, supplies, and telephone. Eligible clients included all persons who entered the Butte County Employment Centers seeking services. These included Cal-Works participants, CMSP beneficiaries, and indigent persons at all levels of education, income, and ethnicity. The primary focus was on individuals seeking employment; however, that person s family was also targeted for comprehensive health services such as family planning, immunizations, child exams, and screenings for HIV, STDs, and hepatitis. As a condition of employment, physical exams and drug testing were offered through the Public Health Clinic. Providing comprehensive preventive health care services to individuals and whole families in a common setting was the primary program goal. In Butte County, a one-stop comprehensive service delivery system is provided through two Community Debra Suderman describes the Wellness to Work program to attendees of the 2002 CMSP W&PP Technical Support Workshop >Program Description, continued from the previous page Employment Centers, one located in the northern part of the county in Chico and the other located in the south county area in Oroville. Any person seeking any type of employment-related services can receive many services in one location. Initially, the one-stop employment center was envisioned to facilitate transition of welfare recipients into the job market, but over time has evolved into an innovative, coordinated delivery system of comprehensive human services. In addition to their role in welfare reform, these employment centers promote economic growth and provide a focal point for health services. Participating county agencies include the County s Welfare Department, Public Health and Behavioral Health departments, the Family Support Division, and the District Attorney s Welfare Fraud Section. Private agency partners include State Employment Development 24 Department, Department of Rehabilitation, Economic Development Corp., Work Training Center, Butte Community College, Oroville Adult Education, Valley Oak Children s Services, Green Thumb Program, and the Private Industry Council. All clients entering the Employment Center to obtain employment-related services participated in an orientation program. As part of the initial orientation, clients participated in workshops. The WtW Health Education Specialist conducted healthfocused workshops in conjunction with the Employment Center Job Skills Workshops in both the Chico and the Oroville Employment Center sites. The objective of the wellness workshops was to educate clients about taking personal responsibility for their own health and about the correlation between good health and one s employability. The first workshop was titled Working Well and focused on health as it relates to employment. The class introduced the basic concepts of remaining healthy and avoiding illness. The second class, Avoiding Job Absence, built upon the information presented in the introductory session with the goal of raising the client s awareness of how excessive absence from work impacts employment. Attendees received a certificate of completion to include in their resume packets. Referrals for individualized client services were received from Employment Center Social Service staff, other partner and community agencies, and by selfreferral by clients. The majority of clients entering the 24

26 Butte County Site Report employment center were not prepared for immediate employment and required a significant amount of training and support. Each client was assigned a social service caseworker who assisted in the development and implementation of a customized employment plan for the client. If the caseworker determined that the client had a health condition that impeded his/her ability to obtain or retain employment, a referral was made to the WtW. The Public Health Nursing Case Manager (PHN CM) assessed the client s health history, knowledge level, and needs. In addition, the PHN CM conducted a basic mental health evaluation and domestic violence screening. The PHN CM arranged an employment physical through the BCDPH clinic and provided guided referrals to appropriate health care providers. Clients determined as unlikely to be able to work were provided with Social Security Advocacy assistance. Assisting the client to access medical services was a central component of the WtW program. Many of the clients did not have a primary physician or health care provider. The few health care providers in Butte County who are willing to accept Medi-Cal or CMSP reimbursement usually require a referral before they will accept a client. The WtW nurse case manager provided the required referral and expedited the client s connection with ongoing health care services. Additional guided referrals for WtW clients included assistance in obtaining dental care, smoking cessation assistance, weight reduction, drug/alcohol counseling, mental health services, and specific disease/illness education and support. Finally, the PHN provided followup to the referrals and reported back to the client s social services case manager. Several Public Health employees worked in the WtW program during the three years of operation, including, Public Health Nurses, Health Education Specialists, Case Assistants, and office support personnel. Activities and outcome achievements were tracked through the use of a database constructed for the program. The data collected included demographic information, service delivery data, and scoring of health status surveys conducted with clients during the course of their enrollment with the program. Clients were allowed to remain enrolled in the program for as long as they and/or their social services case workers felt that services were needed. The majority of discharges occurred due to loss of contact or failure to participate by the client. The project reported that over the course of its three years of service delivery, the WtW program became an integral component of the partnership between the Butte County Department of Public Health and the Department of Employment and Social Services. Staff of the Butte County Department of Employment and Social Services welcomed the assistance that the WtW program provided clients as they traversed the rocky course from welfare to employment. In return, Public Health introduced a hard-to-reach target population to the benefits of health care. The program exceeded serving the numbers of clients established in its original goals. Program Objectives and Outcomes 1 Objective 1 To provide nurse case management for at least 300 Butte County Employment Center clients per year. W&PP Rating: Achieved Objective (high level of data to support) The project reported that during the course of the threeyear project, the Wellness to Work program (WtW) provided nurse case management to 1,096 individuals, or approximately 365/clients/year. The majority of clients (44%) were referred to the program by the Butte County Department of Employment and Social Services (DESS) staff or by self-referral (43%). Clients met with their nurse case manager an average of 3.21 times. During the initial visit, the client was enrolled into the program and provided with a detailed health assessment by the nurse case manager. The assessment included a review of the client s physical, mental, and psychosocial health history; drug & alcohol use; domestic violence issues; and current status. Together, the nurse and the client developed a health care plan for the client. Each health care plan began with the nurse case manager arranging for the client to obtain a physical examination either through the Public Health Clinic (77%) or through a local physician (19%). The results of the physical exam were incorporated into the client s health care plan, and the nurse case manager began the work of assisting the client to access the services needed to achieve the goals of the plan. With the client s consent, his/her welfare or eligibility caseworker was provided with a written report of aspects of his/her health status that might affect his/ her ability to participate in job seeking activities. For example, clients might be excused from participation in work-training activities required by their welfare plan in order to attend appointments with medical specialists. Clients interested in obtaining financial assistance from WtW for services not traditionally covered by health insurance (i.e. tattoo removal, individualized nutritional counseling, or cosmetic dental care) were required to submit an impact statement. This impact statement 1 Refer to DRA s evaluation report in Volume 2 of this report for the site's complete evaluation findings. 25

27 CMSP/TCE WELLNESS & PREVENTION PROGRAM was a letter from their DESS caseworker, employer, or potential employer who could attest that the service would improve the client s ability to obtain a new or better job. During the second year of the project, WtW began assisting more and more clients to apply for Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI). By the end of the project, more than half of the referrals made were for Social Security Advocacy assistance. The reports developed through the nurse case manager and clinical assessments proved to be a valuable addition to application packets. Each client was provided with guided referrals for physical, mental, and psychosocial services. The following table illustrates the types of referrals made during the three years of the project: Referral # of Clients % of Clients Primary Care % Medical Specialist % Behavioral Health % Dental Services % Domestic Violence 54 5% Nutritional Services 78 7% Smoking Cessation % Social Security Administration % Stress Mgt % Tattoo Removal 29 3% Types of referrals made for clients of Butte County s Wellness to Work program While clients experienced 3,522 face-to-face visits (3.21/client) with the nurse case manager, another 3,315 (3.02/client) encounters were conducted over the telephone. In addition, 69 visits were made to clients at their home or in the community setting. The services rendered during the client encounters were documented in 10 categories developed to correspond with those required by the Medi-Cal Targeted Case Management (TCM) program and the CMSP Strategic Planning Implementation (SPI) grant, which ran concurrently to the W&PP and focused on disease management strategies for CMSP clients. The following table illustrates the case management services documented to the WtW clients during the three years of the project: Case Management Service # % Initial enrollment into case management % Needs assessment/reassessment % Develop written plan % Link, consult, refer to others % Assist with accessing service % Mental health/substance abuse counseling % Crisis assistance % Patient education 105 1% Medication management % Discharge from case management % Total CM Services 9215 Types of case management services provided for clients of Butte County s Wellness to Work program The project reported that in reality, far more services were provided than are reflected in these tables because initially, staff were directed to choose only the one most descriptive category per encounter. 26 Objective 2 To provide health education classes for at least 600 clients per year. W&PP Rating: Achieved Objective (high level of data to support) During the course of the three-year project, the WtW program provided 322 health education classes to 2,496 attendees. The majority of the classes were presented in conjunction with the Department of Employment and Social Service s (DESS) Job Skills workshops. A level of participation in these workshops is required of all individuals applying for social services including General Assistance funds, welfare, or food stamps. All applicants are required to attend a short series of classes called Introduction to Job Skills workshops. This introductory course included presentations of services available through the one-stop partnership agencies. In addition, applicants for welfare funds are required to participate in a longer series of classes, which included a variety of job skills trainings. WtW was allowed to present a 30-minute class during the Introduction to Job Skills (JSW) workshops. An average of four of these sessions were conducted by the project Health Education Specialist each month, two at each site. The presentation introduced the concept that health and health practices do have an impact on an individual s ability to obtain and to retain employment. In addition, information was provided on the CMSP and Medi-Cal programs. Attendees were invited to access the 26

28 Butte County Site Report WtW program and to attend the follow-up class held the following week as part of the Job Skills Trainings series. As a component of the Job Skills Trainings series, WtW provided a 1.5-hour follow-up class entitled Avoiding Job Absence. An average of four of these sessions were conducted by the project Health Education Specialist each month, two at each site. The objective of the class was to help clients identify and take steps to reduce health-related issues which might be impacting their ability to obtain and/or retain employment. Subjects discussed included nutrition, hygiene, immunizations, family planning, child health care, physical exams, lab tests, and dental care. Attendees received a certificate of completion to include in their resume packets and were invited to access the WtW program for individualized assistance. In addition, 63 topical workshops were held with a total of 298 attendees. These included workshops entitled Healthy Fast Foods, Health Nutrition, Healthy Hygiene (which was renamed to Makeover as clients did not respond positively to the original name), and Stress Reduction. The table below lists the numbers of attendees in each of these classes: Program Year Topic Total Absence Reduction Fast Foods JSW Overview Nutrition Topical Healthy Hygiene Stress Reduction Total Attendance Wellness classes attended by clients of Butte County s Wellness to Work program The project reported that surveys of attendees rated the classes and materials provided with a high level of satisfaction. The project reported that due to the time that the Health Education Specialist spent assisting clients individually, particularly with their applications for a Social Security program, they were forced to eliminate the class, Absence Reduction, from their schedule of classes offered. Objective 3 To increase the employment-related activities of at least 50% of the clients. W&PP Rating: Partially Achieved Objective (high level of data to support) The project reported that it did not achieve its goal of a 50% increase in employment-related activities. The project was able to achieve a modest increase in clients employed during the course of their contact with the project (and increase from 11% to 18% employment comparing the level at enrollment and then 3 months after enrollment). However, there was a reduction in mean job applications during the three months after enrollment compared to the three-month period prior to enrollment (5.27 vs ). There was also a reduction in mean job interviews during the three months after enrollment compared to the three months before enrollment (0.91 vs. 1.86). Staff attributed this unsettling result to the fact that early in the project, they realized that most of the people referred to their program were not able to work for reasons relating to various disabilities. Consequently, after the first year of the project, staff redirected much of their efforts to helping clients apply for Social Security benefits (see the DRA evaluation report for more details). Objective 4 To improve the health status of at least 50% of clients receiving services. W&PP Rating: Objective Withdrawn The project reported that they discovered early in the program that the goal of measuring health status was an unreasonable one because it was too difficult to measure in their population under the conditions of the project. Instead, they decided to administer the Medical Outcomes Study 36-Item Short-Form Survey (SF-36), which was used to quantify the client s perception of his/ her health. The outcome of the SF-36 health status surveys showed a very small (1.3%), but statistically significant increase in the mean score (88.13 vs out of a total possible score of 160), indicating that people felt that their health status had improved very slightly. The staff reported that it was their perception that the introduction of the Social Security Advocacy activities impacted this objective significantly. They observed that clients applying for a Social Security program had a vested interest in maintaining a poor 27

29 CMSP/TCE WELLNESS & PREVENTION PROGRAM health status throughout the process. Although they were open to interventions that helped them feel better, they were reluctant to indicate any improvement in their health that might jeopardize their application. Many clients verbalized concern over the SF-36 surveys, and some refused to complete it. Thus, the project was not able to obtain valid data to measure health improvement. Objective 5 To have at least 50% of Wellness to Work clients with designated health care providers. W&PP Rating: Achieved Objective (moderate level of data to support) Although self-reporting by clients is not the most reliable way to document the achievement of this goal, it was the only reasonable approach with this project. The project reported that the SF-36 survey revealed that the number of clients reporting having a primary or regular doctor increased from 45% to 68% at enrollment compared to at follow-up. Additionally, a larger percentage of clients reported having a regular dentist, as shown on the following graph: 80% 60% 40% 20% 0% Initial Survey Follow-Up Not at all Once or More Yearly frequency of primary care visits by Wellness to Work clients before and after participation in the program Staff reported that it was often difficult to help the client keep that medical home. They reported that many of their clients were viewed as stereotypical welfare, homeless, ex-con, mentally ill, troublemaker types by the clinics and health care providers. The WtW case managers spent a great deal of time smoothing the waters with providers, teaching clients how to advocate for their needs without 28 becoming aggressive, and even accompanying clients to medical appointments to facilitate. They made phone calls and even went to phone-less clients homes to remind them of scheduled appointments to save many hours of negotiation with angry physicians over no-shows to appointments. 80% 60% 40% 20% 0% Have Regular Doctor Have Regular Dentist Initial Survey Follow-Up Percentage of clients of Butte County s Wellness to Work program who reported having a regular doctor or dentist before and after participation in the program Additionally, clients reported making somewhat more visits to their primary care physician as shown on the following graph: 28

30 Butte County Site Report Cost and Service Use Analysis Results The project delivered 282 core data records of CMSP beneficiaries who received services through this program. This data was included in the Case Management cluster for analysis. Additionally, because of the large data set and the unique case management model, the data from the Butte W&PP project was also analyzed separately. The entire analysis is summarized in the Cost and Service Use Analysis section of this report, and the complete report by the analysis contractor, The Lewin Group, is included in Volume 2, Evaluation Findings. Reported here are data specific to the Butte W&PP. The cost and service use results from the Butte W&PP reflect the desired trend for wellness & prevention efforts, namely lower Inpatient Hospital costs as a result of increased use of primary care services, resulting in an overall decrease in costs. As is illustrated on Graphs A and B on the following page, Inpatient Hospital claims and payments as well as Total Payments decreased in the post-enrollment group, while claims and payments for Clinics and Labs increased. Another notable finding of this analysis is the large proportion of clients (18%, refer to Graph C in the following pages) who were classified in the Disability Pending category. This large percentage of people waiting for approval of their applications for Social Security Disability is a direct result of the massive advocacy efforts undertaken by this project (reported previously in this site report.) Helping clients to shift to more appropriate care systems is good for both the clients effected and the CMSP organization. The cost and service use results from the Butte W&PP reflect the desired trend for wellness & prevention efforts, namely, lower inpatient hospital costs as a result of increased use of primary care services, resulting in an overall decrease in costs. Future Directions The end of program funding combined with the budget reductions suffered by Butte County Department of Employment and Social Services will result in the closure of the official Wellness to Work program. Butte County Department of Employment and Social Services is unable to fund the program continuation. Nurse Case Managers of the WtW program will be absorbed into the Public Health Clinic where they will continue to provide case management to Medi-Cal beneficiaries through the Targeted Case Management (TCM) program. Unfortunately, TCM does not reimburse for services to people who are not enrolled in Medi-Cal (for example, CMSP beneficiaries). Public Health administration is researching the number of non-medi-cal clients the agency can support through existing budget limitations. Staff of the Butte County Department of Employment and Social Services have been advised that a cap will be placed on referrals to the case management service. 29

31 CMSP/TCE WELLNESS & PREVENTION PROGRAM Graph A: Claims per 1000 members per month by service-use category for Butte County W&PP enrollees Before Enrollment After Enrollment Hospital IP Days Hospital IP Claims Hospital OP Claims Physician Claims Clinic Claims Lab Claims Home Health Claims 30 All Other Claims $400 Graph B: Payments per member per month by service-use category for Butte County W&PP enrollees $350 $300 $250 $200 $150 Before Enrollment After Enrollment $100 $50 $0 All Payments** Hospital IP Payments Hospital OP Payments Physician Payments Clinic Payments Lab Payments Home Health Payments All Other Payments *Excluding pharmacy claims 30

32 Butte County Site Report Graph C: Enrollment of W&PP clients with disability aid codes vs. all CMSP enrollees Lassen County Inyo County Butte County Increasing Access Outreach and Education Case Managed -- Low Intensity Case Managed -- Moderate Intensity Case Managed -- High Intensity All Case Managed Total W&PP Program All CMSP Enrollees in % 2% 4% 6% 8% 10% 12% 14% 16% 18% 31

33 CMSP/TCE WELLNESS & PREVENTION PROGRAM 32 32

34 Humboldt County The Humboldt County Wellness and Prevention Program consisted of two distinct efforts: 1) support for case management of substance-abusing individuals, principally those on parole or release from jail, who needed stabilization and assistance in entering residential treatment programs, and 2) support for an Alcohol and Other Drug (AOD) Death Review Panel. Program funds were expended on 2 FTE Community Health Outreach Workers (CHOWs), based at the North Coast Substance Abuse Council Crossroads and on contractual services for the AOD Death Review Panel and Report. Program Description continued on the next page> Total Award Expended $281,213 of $281,213 awarded Program Partners Humboldt County Health and Human Services Public Health Branch North Coast Substance Abuse Council Crossroads Humboldt County Mental Health/Alcohol/Other Drug Humboldt County Probation Department Geographic Area Served Humboldt County Target Population The project had two parts. In one part, the target population was substance-abusing individuals who are referred for residential treatment, primarily from the legal system. In the second part, the target population was individuals who died as a result of substance abuse. Contact Information Ann Lindsay, MD, Health Officer Humboldt County Health and Human Services Public Health Branch Phone: (707) alindsay@co.humboldt.ca.us 33

35 CMSP/TCE WELLNESS & PREVENTION PROGRAM Six Steps to Success with Getting People into Substance Abuse Treatment THE HUMBOLDT COUNTY Wellness & Prevention Program (HC W&PP) run by the North Coast Substance Abuse Council has an unusually high rate of success with a very difficult population of abusers. The clients enrolled in this program have been engaged with law enforcement, either having been in jail or referred from the Prop 36 program, which offers substance abusers an alternative to jail. This is a population of people who have significant issues with trust, and who often have the dual problem of mental illness, and some also have serious physical health issues. Program Objectives and Outcomes 1 Objective 1 To provide intensive case management services for convicted substance abusers. W&PP Rating: Achieved Objective (high level of data to support) The project delivered data to the evaluators that documented 259 people interviewed for enrollment into case management, with 109 (41%) judged as having successfully completed the program. In this program, success was defined as enrollment into an outpatient or residential substance abuse treatment program, for which individuals need to be stabilized, clean and sober, housed in clean and sober housing, and free of acute physical, mental, or dental health problems. Data provided to the evaluators had 2 sources: 1) data from the initial interview of the client (259 records) and 2) data from a database that the CHOWs maintained. This database was developed 34 by DRA expressly for this project. The data entered into the database represents a subset of the interviewed clients. The following two charts show that the project was indeed focused on its target population: Key to the success of the HC W&PP are the Community Health Outreach Workers who case manage the clients. Dawn Feddar, a CHOW with the program, is a successful graduate of the treatment program at North Coast Substance Abuse Council, so she is unusually effective at quickly establishing a trustful relationship with new clients. (See also Volume 2, Issue 4 (Winter 2002) of the W&PP Newsletter for more details on the contributions of the CHOWs.) Jail 0.4% Other 10.8% MIOCR 1.2% Unknown 14.3% Self 12.4% Court Doctor 2.3% 0.4% Parole 5.8% Prop % Drug Court 17.8% Mental Health 4.2% Probation 15.8% Source of referrals to the Humboldt County W&PP Feddar described to us the six-step process each client completes as they move towards successful completion of the program: Step 1: Referral The project receives the referral, primarily from the jail, probation, parole, Prop 36, or drug court Step 2: Intake The CHOW then meets with the client in jail or at mutual location (if the client is not incarcerated) to conduct an intake to assess if the client is interested and able to participate in the program. Probation- Summary 4% Probation-Drug Court 10% Probation-Prop. 36 8% Waiting To Be Sentenced 2% Parole 6% Probation-Felony 70% Legal status of individuals referred to the Humboldt County W&PP 1 Refer to DRA s evaluation report in Volume 2 of this report for the site's complete evaluation findings. 34

36 Humboldt County Site Report Records for 109 individuals exist in the database. This data reveals patterns of activity consistent with intensive case management, including 89 referrals to health, mental health, and social services and employment assistance. Additionally, follow-up status was recorded for 83 of the 89 documented referrals, with 77 (87%) having been successfully completed. Such a high level of completion with this population is indicative of intensive case management activities. Goals (a total of 256) were established with 109 clients, with an overall achievement rate of 56%, again, indicating intensive support from case managers. It is recorded that 5 of the 81 unemployed and not disabled clients were able to find full-time employment through the program, another indication of intensive case management, considering the target population. An unexpectedly high expense in the project was for transportation, as case managers (CHOWs) had to transport clients to residential treatment homes outside of the immediate area after a large home closed in Eureka. One CHOW reported that she put 59,000 miles on her car in the course of her work, with included client transportation, over the first 2 years of the grant. Transportation of clients is another activity that is characteristic of intensive case management. Qualitative data in the database also indicates results that could only be expected with the support of intensive case management, including notes about clients enrolling into college and engaging in community service, and accounts of clients substantially turning their lives around as a result of the project s efforts. Objective 2 To promote accurate analysis of the health impact of substance abuse by identifying and analyzing alcohol and other drug related deaths within Humboldt County. W&PP Rating: Achieved Objective (high level of data to support) The CMSP/TCE grant funded two specialists who supported the Humboldt County AOD Death Review Step 3: Get client out of jail (if necessary) The CHOW reviews court documents and works with judicial system to get the client out of jail. The CHOWs accompany clients to court and write letters on their behalf. Step 4: Get the client into clean and sober housing This step requires that the CHOW closely monitor the situation to insure that the housing situation is in fact they drug-free. Often they find that the housing is not drugfree, and then they have to move clients to alternative locations. There is often a lag time between getting into housing and getting into a treatment program, and the CHOWs try to help during this transition time. For example, they work with the client to avoid frequenting situations that are known to harbor drug users. Crossroads original community health outreach worker (CHOW) team of Dawn Feddar and Dawn Marie Cummings Step 5: Make a plan and follow it The plan is created with the vision of getting the client to become a drug-free, productive member of society. The CHOWs primarily use the court documents and meet with probation as a base to develop a treatment plan with the clients. The individualized plan includes realistic goals for the client such as meeting basic needs like food, housing, bedding, and signing up for SSI and CMSP. Often the plan includes adherence to medical and mental health treatments. A huge challenge for the CHOWs is getting the clients compliant with their medications, particularly psychiatric medications. The plan includes the client s goals, what they are willing to do, and any conditional requirements such as undergoing drug testing once per week. The CHOWs follow up with clients weekly to go over the plans. The CHOWs 35

37 CMSP/TCE WELLNESS & PREVENTION PROGRAM also support clients in meeting their goals by providing transportation, making referrals, assisting with applications, and even attending appointments with clients, if necessary. Step 6: Get the client into outpatient or residential treatment There is a shortage of treatment spots in Humboldt County. It can take between 2 weeks to 2 months to find a treatment spot for someone in need. Step 7: Discontinue client from the program The CHOWs mark success by getting a client into a treatment program, not completing treatment. Once in treatment, the CHOWs no longer follows the client. The goal is to stay with a client for no more than 6 months. Feddar stressed that with this process, things happen in baby steps. She stays motivated by knowing that she can make a difference and by trying to help people get back what was given to her. Panel. Dan Chandler, PhD, provided statistical and data analysis expertise, and Nancy Young, PhD, of the Children and Family Futures Agency, provided expertise in confidentiality issues. Both areas of expertise were fundamental to developing the accurate analysis of health impacts of substance abuse. The AOD Death Review relies on confidential data from databases of multiple state and county agencies, including from County Mental Health, Alcohol and Drug Programs, the Coroner, State Highway Patrol, and others. Memoranda of Understanding and Confidentiality Agreements were vital to enable sharing of data. Analysis of the data to get at the root of the causes of death required a high level of specialized training. Therefore, the contributions of these specialists was fundamental to the success of the Death Review. The AOD Death Review Team has met regularly since 2001, reviewing cases and making recommendations to preventing substance-abuse related deaths. The panel produces and maintains a Substance Abuse Prevention Matrix that is published on the Humboldt County Government Web site. An indication of the success of the AOD Death Review is the fact that the Humboldt County AOD Review Project was selected by the National Association of County and City Health Officers (NACCHO) as a best practice. The project will receive an award and will be presented at the annual conference of NACCHO in July, The full text of the AOD Death Review report, as well as other related documents, can be found on the Humboldt County Government Web site: Objective 3 To help refine and improve Humboldt County s response to substance abuse by conducting confidential forums where providers review substance abuse-related deaths, and where cases are chosen for presentation at public community forums. W&PP Rating: Achieved Objective (high level of data to support) 36 Although the CMSP/TCE W&PP grant did not specifically support these forums, the confidential forums nevertheless did occur 3 to 4 times a year from 2001 through Multiple county agencies were invited to attend and did attend. Each forum was dedicated to a particular theme, such as AOD-related deaths from suicide, traffic accidents, and overdoses. A matrix of recommendations was developed and refined at these meetings (see also Objective 2). The project provided the evaluators with the results of a survey of 20 forum attendees. Feedback on the value of the forum effort revealed that 90% felt it was very effective or moderately effective. One forum participant commented on this question: It is another example of how Humboldt County can be rural and isolated, yet way ahead of others example: San Francisco County wants to model a program after OURS! Another member stated: It [forum participants] is a breakthrough, cuttingedge team, and it will have a big long-range impact. These forums impacted Humboldt County s response to substance abuse. For example, the aggregate data assembled by the project was useful in supporting grant applications regarding overdose prevention, and the medical community is responding to the large number of prescription drug overdoses. 36

38 Humboldt County Site Report Objective 4 To refine and improve Humboldt County s response to substance abuse through the completion of three community forums focusing on specific cases of the health impacts of substance abuse. W&PP Rating: Partially Achieved Objective (high level of data to support) The project reported that 1 community forum was held to which more than 75 people attended, including members of the Board of Supervisors and representatives from legislators. Informative discussion groups were held on 5 broad topics. However, the project felt that the extensive effort to organize these events did not seem to be an efficient method for informing policy makers, so no further community forums were held. The CMSP/TCE W&PP grant funds were not expended to support this forum. The project s stated objective for the community forums informing policy makers conflicts with our views on the purpose of community forums, which is to enable inclusive participatory planning. This type of planning approach is very labor and time intensive, so it is easy to understand that organizers without the specific goal of inclusive participatory planning might view community forums as inefficient. Cost and Service Use Analysis The project submitted 62 records of CMSP-eligible individuals who were enrolled in case management prior to October 31, This data was folded into the Case Management cluster that is reported on page 267. Future Directions Unfortunately, money to continue funding the two CHOW positions has not been located despite a concerted effort to secure it. Until such funding is secured, North Coast Substance Abuse Council will not offer the case management function. There has recently been a large demand expressed from the jail, probation and parole officers, and people who have heard positive accounts of the program through word-of-mouth from clients who have completed the program, so staff is optimistic that a way will be found to continue the case management program. Staff is also exploring opportunities to expand the model to focus additionally on child and family health services and support. The AOD Death Review effort will continue with periodic meetings to discuss cases, with the publishing of the upcoming report, and the updating of the recommendation matrix. Objective 5 To refine and improve Humboldt County s response to substance abuse by completing a comparative study ( ) using eleven community indicators of alcohol and other drug impact. W&PP Rating: Objective Addressed Outside W&PP Effort The project reports that a report is planned for publishing in 2004, but this report will not be a comparative study to the report that was published in Rather, the report will emphasize the community response to the challenges of AOD abuse, because it is thought that this is a more positive approach than focusing on the 11 indicators, which reflect a worsening problem (for example, rates of overdose have continued to climb). The CMSP/TCE W&PP grant funds were not expended to support the upcoming study. 37

39 CMSP/TCE WELLNESS & PREVENTION PROGRAM 38 38

40 Mendocino County The Mendocino County Wellness and Prevention Program (MC W&PP), named LIVE*LIFE*WELL by the nurse case manager, provided intensive case management services to a select group of medically needy individuals who were primarily patients of a single practitioner at Mendocino Community Health Clinic. The selected individuals were indigent individuals with chronic disease who were willing to work with a case manager to try to improve their health status and who were not actively abusing drugs or alcohol and had no serious mental health issues. The program provided intensive case management services by a dedicated and talented nurse case manager who was employed by the Mendocino County Department of Public Health. Although the initial intent was to work only with the patients of the single provider, later on, the project accepted referrals from another grant program (MOST, a CMSP Strategic Planning Initiative grant), from the clinic Program Description continued on the next page> Total Award Expended $218,212 of $232,890 awarded Program Partners Mendocino County Department of Public Health Mendocino Community Health Clinic Geographic Area Served Ukiah area Target Population Initially, CMSP beneficiaries in the practice of Tom Feiertag, PA, of the Mendocino Community Health Clinic who had high acuity ratings and were not experiencing active mental illness or substance abuse issues. In years two and three the project accepted referrals from other providers. Contact Information Carol Whittingslow, Director of Nursing Mendocino County Department of Public Health Phone: (707) whittinc@co.mendocino.ca.us 39

41 CMSP/TCE WELLNESS & PREVENTION PROGRAM Encouraging Others to Live*Life*Well Mendocino s Holistic Approach INDIGENT ADULTS OFTEN have multiple factors operating in their lives that overwhelm their ability to self-manage their medical conditions. These factors can include social, mental health, and other physical health issues. Mendocino County constructed an intensive case management program, coined Live*Life*Well, that sought to addresses these issues simultaneously so progress could be made towards less dependence on the catastrophic health care services and an improved health status for clients. Initially led by Aliceann Christy, PHN, nurse case manager (NCM) and Tom Feiertag, PA (primary medical provider of the Live*Life*Well participants), the Live*Life*Well program provided services that reinforced self efficacy and self advocacy with wellness as the main focus rather than chronic care. Key factors that allowed all those involved in this project providers, patients, and the community to embrace and exemplify the concept of living life well are detailed below. Staff possessing a strong perspective and commitment to wellness translates into clients with a strong perspective and commitment to wellness The Live*Life*Well s nurse case manager s goals were to help clients achieve better health status >Program Description, continued from the previous page Nurse case manager, Aliceann Christy, PHN, conferred bimonthly with primary care provider, Tom Feiertag, PA, to coordinate care for Live*Life*Well clients. pharmacy, and from self-referrals prompted by the program brochure. Mendocino s intensive case-management model was the most encompassing of all the case management models in the CMSP/TCE W&PP. The nurse case manager, Aliceann Christy, PHN, hired to create and operate the program, was committed to addressing the whole person, including physical, psychological, social, emotional, and spiritual aspects. Individuals enrolled in this program were supported in addressing not only their physical health needs, including medical treatment, dental services, and other self-care needs of the physical body such as purposeful exercise and nutrition counseling; but also their social needs, including counseling concerning employment and interpersonal skills; their emotional needs, including professional psychological therapeutic support, as well as the support of the nurse case manager in multiple social situations; and their spiritual needs, by methods such as encouraging personal 40 introspection and engaging in yoga and mediation. Creating a network of provider services on behalf of the needs of the client was another focus of the case management effort. Regular bimonthly team meetings, usually involving the case manager and the medical provider, focused on individual cases and next steps that were needed. The nurse case manager was able to facilitate achievement of goals by developing collaborations with providers of specialty health services, behavioral health services, exercise services (health clubs), meditation services (yoga), pharmaceutical suppliers, dental services, and social services, as well as to encourage individual efforts, such as walking regularly and eating sensibly. An important and time-consuming role of the nurse case manager was helping qualified clients apply for Social Security Insurance, providing needed and stable assistance in appropriate situations. The MC W&PP staff reflected that the LIVE*LIFE*WELL program experienced a shift in momentum during the final year of grant Cycle 3 when the full-time nurse case manager had to relocate to another state. Due to the timing of this staff change late in the grant period and the difficulty recruiting for a position that had the possibility of ending in a year, the 40

42 Mendocino County Site Report decision was made to transfer the dedicated nurse case manager s role and responsibilities between two individuals. The nurse case manager made extensive efforts to prepare the enrolled individuals for this change, since she had developed strong relationships with many of the case-managed clients. The licensed vocational nurse (LVN), working exclusively with Tom Feiertag, PA, at the clinic, took on the dual roles of the case management activities in addition to her clinic duties. Because all the enrolled clients knew the LVN, the transition was smooth and fit in with the transition plans for closing the project. However, the LVN was not able to dedicate a full-time effort to the LIVE*LIFE*WELL program and therefore, less time was dedicated to the more intensive case management activities. The county s Public Health Nursing Director took the lead roll in the project s administration. Program Objectives and Outcomes 1 Objective 1 To provide case management services to 30 to 60 medically underserved Mendocino Community Health Clinic (MCHC) CMSP patients, who have been selected out of a target population of 120. W&PP Rating: Achieved Objective (high level of data to support) The project delivered an unusually complete data set for 29 individuals who were intensively case managed in this program. Although the number falls a little short of the objective of 30 individuals, the project explains the reason: a surprising number of people were not willing to engage in the LIVE*LIFE*WELL program, indicating that this population is not always ready to engage in selfimprovement and personal responsibility. Regarding the 29 people who did engage in the program, the project documented 2030 services provided to them, as summarized on Graph A on the following page. In addition, the project documented 152 referrals as summarized on Graph B on the following page. These data provide a succinct picture of what intensive case management looks like. It is sobering to note the intensity of service and attention required to wholistically address the many needs of this population. and gain employment or improve employment situations. These interventions extend beyond concerns related to physical health. I treat the whole person mind, body, and spirit. You can t just deal with the physical health, Christy asserts. This holistic philosophy was subscribed to by all members of the medical team involved with Live*Life*Well. The project allowed the clients to engage in restorative and wellness care. Through their involvement in Live*Life*Well, many clients discovered preventative health care and are now requesting preventative examinations that they had not utilized before such a mammograms and pap smears. The project reported that the clients engaged in Live*Life*Well incorporated behavioral changes that impacted their wellbeing, decreased hospitalizations, and decreased their use of the emergency room. One client who had procrastinated on having a colonoscopy was encouraged through the case management process to follow through with getting this preventative examination. Upon examination, an early cancer was detected and the client was able to obtain treatment before the cancer became a catastrophic condition. Approaching case management with a person first, a case second mind set The NCM conducted a needs assessment of eight key areas linked to emotional, physical, and spiritual well-being with each client. A service plan was created with wellness goals that met the client needs, as determined by the client. The key to this process was finding out what the person wanted to accomplish and helping them get there through a trustful, encouraging, and supportive relationship. The project reported that the successes in the Live*Life*Well program created a heightened awareness by the project team regarding the value of such a relationship and invigorated a continued desire, on the part of the project team, to continue to help clients problem solve. The case manager coached the clients on how to decide what they wanted for a clinic visit, how to ask for they wanted, and how to make a list of 1 Refer to DRA s evaluation report in Volume 2 of this report for the site's complete evaluation findings. 41

43 CMSP/TCE WELLNESS & PREVENTION PROGRAM Graph A: Services provided to Live*Life*Well participants Yoga Class Women's Health Exam Wellness Physical Exam Wellness Counseling Wellness Assessment Urology F/U Urology Consult Transportation Surgical Follow up in office Surgical Consult Surgery Smoking Cessation Education Screening Mammogram Screening Colonoscopy Rheumatology Consult Renal Consult Referral Radiology Psychotherapy thru Grant Psychotherapy - MCHC Podiatry Physical Therapy - Aqua Physical Therapy Periodontal Consult Orthopedic F/U Orthopedic Consult Optometrist Opthamology Consult Nutritional Counseling Neurology Consult Graph A: (continued) Nephrology Follow Up MRI Mental Health Psychotherapy Medication Education Job Care/Worker's Comp Hearing Exam Gastroenterology Consult Fitness Training Establish Care-Second Opinion ENT Consult Enrollment Emergency Room EEG Discharge from Program Diabetes Education & Management Dermatology Clinic Dental X-rays Dental Procedure Dental Exam Dental Cleaning CT Scan Clinic Visit/Med Refills Clinic Visit F/U Clinic Visit - Urgent Case Conferencing Cardiologist Biopsy Aquatherapy with NCM Allergist Consult Advocacy Services Number of Contacts 42

44 Mendocino County Site Report Graph B: Referrals made for Live*Life*Well participants Yoga Classes Veterans Services Urology Consult Sutter Lakeside Surgical Consult Smoking Cessation Education Sleep Study Rheumatologist Consult Residential Treatment Pulmonary Function Testing Psychotherapy Primary Care Physician Podiatrist Physical Therapy Periodontist Pacific Medical Orthopedics Optometry Opthamology Nutritional Counseling Neuro-Psych Consult Narcotics Anonymous MOST Program Mendocino College MCHC Behavioral Health Lion's Club Opthamology Job Care Hepatitis C Support Group Health Club Services Gastroenterologist ENT Specialist Diabetes education & management class Dermatology Department of Social Services Dental Clinic Community Weight Loss Support Group Community Resource Center Community Mental Health Community Development Commission CMSP Enrollment Services Chiropractic Cardiology Consult Cancer Resource Center Bariatric Surgeon Audiology Consult Allergist Number of Referrals Table A: Services reported in a client survey to have been provided to them in the Live*Life*Well program Type of assistance # of responses % of responses Information on available resources 17 94% Personal support 17 94% Help with paperwork 16 89% Wellness counseling 16 89% Contact with other organizations 15 83% Financial assistance to access healthcare & meds 15 83% Counseling services 14 78% Ongoing guidance on how to work with agencies 12 67% Referral to specialty service provider 12 67% Other 11 61% Referral to another health service provider 10 56% Employment assistance 7 39% 43

45 CMSP/TCE WELLNESS & PREVENTION PROGRAM questions they wanted answered before they attended their clinic visit. For clients who would benefit from observing and modeling behavior, the case manager accompanied them to their health care visits. By taking the time to really get to know a person s situation, the NCM realized that many of the Live*Life*Well enrollees were potentially qualified to receive SSI benefits. Through knowing, in extensive detail about their life situation, the NCM was able to successfully assist clients through the SSI application process. Subscribing to the notion that there s no I in TEAM Mendocino s project flourished under an environment of strong collaboration between the Mendocino Community Health Clinic and the Mendocino County Public Health Department. The investment to work collaboratively permeated both agencies structures from the leadership to individual staff members. In the Live*Life*Well program, the NCM invested a significant amount of time and energy into forging relationships with service providers who could aid her clients. In addition to working closely with the primary care provider, she developed collaborative relationships with the clinic s pharmacist, financial officer, health information officer, dentist, nursing supervisor, and nursing providers. Case conferences with the medical team were held and included discussions of medical needs, barriers to care, and potential solutions to issues impacting the health and wellness of the client. These staff members helped her integrate her wellness program into the routine of the clinic s activities. I find people with the capacity to help and who want to help the program, Christy said, then I work to form a functional collaborative relationship with them. For example, Jenniffer Duerson, LVN, the clinic nurse working with Feiertag, was instrumental in Objective 2 To increase the availability and effectiveness of chronic disease management and behavioral health services for selected CMSP clients. W&PP Rating: Achieved Objective (high level of data to support) From the data presented in Graphs A and B, it is clear that a wide range of services related to chronic disease management and behavioral health services was made available to the individuals who elected to participate in the LIVE*LIFE*WELL program. Additionally, clients were surveyed and asked what types of services they received from the program. 18 clients completed the survey, and the results are listed on Table A on the previous page. Evidence of the effectiveness of this approach includes the following: Testimonials from clients When asked in the 44 survey mentioned above how much what they had learned in the program would help to improve their level of wellness, 83% responded very much, or a lot. Clients claimed to know more about how to access services, how to take care of themselves, how to talk to their doctors, the importance of diet and exercise, and what services are available to them. They also reported having greater confidence that they can make a positive change in their health and can do what is necessary to get services they need. When asked how much they were doing to show an increased responsibility to maintain their whole health, 56% said very much or a lot and another 33% said some. Clients cited exercising more, taking their medicines properly, eating better, and getting a job as examples. After 11 months of program operation clients reported feeling physically better and being in less debilitating pain more days (about 2 to 4 days on average) in the previous month than they reported when they entered the program. Tom Feiertag, PA, tends to a Live*Life*Well participant. 44

46 Mendocino County Site Report Health indicator data: - 57% (8/14) of clients who began the program with hypertension were able to lower their blood pressures to normal levels by the end of the program - 1 clients lost 20 pounds and 1 client lost 46 pounds over the course of the program, lowering their body mass indexes from obesity levels to overweight levels. Data from the project regarding improvements in behavioral health were not as positive. In selfassessments 11 months after they entered the program, clients felt their mental health was not good and they felt sad or depressed more days (about 2 on average) in the previous month than when they entered the program. Although staff were able to connect clients with behavioral health services and psychotherapy (which was nevertheless somewhat limited due to the small number of available providers), this access did not seem to be enough to effectively deal with these issues for some of them. Objective 3 To reduce the unnecessary utilization by targeted clients of emergency room services by selected CMSP clients. W&PP Rating: Achieved Objective (high level of data to support) The case management effort caused clients to significantly reduce their usage of emergency services as reported by project staff and as reported by clients. Staff reviewed the records for the case-managed clients that was available at the Ukiah Valley Medical Center and found that although ER use was still high by some clients, it had declined by an overall 75% for the client population as a whole. On a survey, 56% (10/18) reported using the ER less often. Objective 4 To advance positive systems change for indigent health care delivery and management as a result of the Mendocino County collaboration. W&PP Rating: Partially Achieved Objective (high level of data to support) A survey of 45 staff members at the Mendocino Community Health Clinic revealed a moderately positive response on system change questions, such as increased preventing unnecessary emergency room (ER) visits by Live*Life*Well clients by finding a way to squeeze the clients into the provider s full schedule when health issues arose. Prior to the Live*Life*Well program, these clients would have sought care in the ER instead of calling the clinic first. In the project s 2003 annual report, the NCM reflected, surround the project with successful people and it will succeed. This sense of collaboration extended into the community as the project creatively tapped into local resources and reaped the rewards for the clients benefit. The NCM garnered support from local businesses such yoga and fitness centers to provide day passes for Live*Life*Well clients. When Dorothy first enrolled into case management, she was socially isolated and extremely lonely, often calling the NCM up to three times a day. When the NCM discovered that Dorothy loves to write poetry, she found someone who would donate a used computer and found a local teenager to train Dorothy how to use it. Dorothy now writes the newsletter for the retirement center and does some bookkeeping for her sister. Dorothy would still check in with the NCM - but only once per week! If something is not working, try something different! The Live*Life*Well program worked with W&PP administrative staff to make budget modifications throughout the grant s implementation so that grant funds could be best utilized to meet the project s objectives. For example, the project had originally proposed to purchase food vouchers as client incentives; however, this did not fit well into the wellness concept desired by the participants or the case manager. The project determined that a practical and effective incentive would be the provision of day passes to area fitness and yoga centers. The clients responded well to the day passes, with the Arthritis Aqua Class and swimming being the most popular activities, since most clients were dealing with obesity, arthritis, and immobility due to pain. A specialty care services line item was added to the budget, as a result of savings in the office expenses category, that allowed the project to 45

47 CMSP/TCE WELLNESS & PREVENTION PROGRAM access services for which there was no reimbursement mechanism or to meet a client s CMSP share-of-cost obligation. On a case-by-case basis, the grant paid for the client s CMSP share-ofcost obligation, and Christy arranged for the client to have multiple needed procedures during the month for which the share-of-cost obligation had been met. Arranging for multiple specialists appointments within a given month was a challenge. You have to be creative and twist some arms to get all these appointments arranged in one month to get the greatest benefit from the grant s meeting the share-of-cost obligation for the client, Christy said. The following vignette illustrates the impact of Live*Life*Well program had on one client s life. Linda Linda is a 51-year-old woman who, at the time she was enrolled into case management, worked at a fast food grill at Wal Mart, a job she found extremely hard to do and that was not work she wanted to do. She was depressed and occasionally had suicidal thoughts. Linda s dental health was very poor she had only a few teeth in front and this limited her employability. She had a severe phobia of dentists, as she had for all medical procedures. Aliceann Christy, PHN, the Live*Life*Well nurse case Live*LIfe*Well participant with dental provider. manager, worked with Linda on her dental work phobia. She arranged appointments, transported her to appointments, and attended appointments with Linda. The dentist extracted the rest of Linda s teeth, and new dentures made. Linda has been gradually able to work through her phobias, and she can now attend appointments without Christy s presence. coordination of services, with the exception of the dental staff who responded strongly negatively regarding systems changes. The project reported that although provider satisfaction with the case management model was high, it was not feasible to continue because there was no institutional funding available to support a case manager, and no ongoing funding to support the client share of cost, which was important for the success of this model. They state: This program does not appear sustainable without a mechanism to provide a nurse case manager outside of clinic services and to cover share of cost. Presently, there is no effort being made to seek such funding. Objective 5 To compare the cost-effectiveness of case management services for share of cost patients as compared to nonshare of cost clients who are served by Mendocino County s CMSP Strategic Planning Initiative (SPI). 46 W&PP Rating: Failed to Achieve Objective This objective was poorly formulated, since populations of both the Mendocino County W&PP and the Mendocino County SPI projects comprised individuals having both share of cost and non-share of cost status, and in neither group were these populations isolated for the purpose of analysis. In fact, such an effort would have proved extremely difficult, if not impossible, since individuals often change classifications from share of cost to non-share of cost, and vice versa. Staff of the MC W&PP anecdotally noted that individuals having a share of cost were on the whole most benefited by the case management services when their share of cost was met by the grant funds and they could therefore receive services that were available for no cost by the non-share of cost group. Staff noted that individuals having a share of cost were in general in more need of medical and dental care than those with no share of cost because they could not afford to pay for the services. These individuals were more likely to leave conditions untreated and were more likely to progress to expensive emergent conditions. Staff concluded We 46

48 Mendocino County Site Report believe reduced share of cost to clients would reduce the cost to CMSP for complications and hospitalization. However, from the point of view of Mendocino County and CMSP, the cost-effectiveness may have been greater in the non-share of cost individuals, since the project reported that 25% to 30% of the total population of clients of the MC W&PP were assisted by the case manager to shift to SSI (note the 361 instances of Advocacy Services which primarily concerned assistance with applications for SSI that are recorded in the Services Provided shown on Graph A). This shift provided these individuals with stable funding for living expenses in addition to medical coverage by Medi- Cal or Medicare. Since SSI is paid for through state and federal funding, whereas CMSP is funded by the counties, this shift represents significant cost Aliceann Christy, NCM (right), with Live*Life*Well participant savings in the long run for the County. All of those moving over to SSI coverage were classified as non-share of cost, since an individual with a share of cost would have too much income to qualify. It is interesting to note that whereas 100% of the clients of the program were CMSP beneficiaries when they entered the program (a criterion of enrollment) only 38% were CMSP beneficiaries at last contact, as illustrated by the graph below: Christy also arranged for Linda to undergo a colonoscopy and a mammography procedure during a month that Linda s share-of-cost obligation had been met by the grant for the dental work. Additionally, Linda was stabilized on a medication for anxiety and depression. Linda now feels more confident and in more control. Her self-esteem has risen, and her personal relationship appears to be more stable and positive. She has had two job upgrades since entering case management and is now working as a courier for an auto parts company, a job she likes very much. The new job offers health insurance after the probationary period has been completed, and so the woman will not continue to be enrolled in the CMSP; however, Christy plans to continue to check up on her to make sure she stays stabilized. I feel good about how the program was able to support her, says Christy. 60% 50% I treat the whole person mind, body, and spirit. You can t just deal 40% 30% 20% 10% 0% CMSP non-share of cost CMSP share of cost Medi-Cal Medicare/Medi-Cal Not Covered with the physical health, Aliceann Christy, NCM At Enrollment (n=31) At Last Encounter (n=29) Comparison of client payors at enrollment versus at the last encounter with the Live*Life*Well program 47

49 CMSP/TCE WELLNESS & PREVENTION PROGRAM This shift in coverage reflects in part the large shift to SSI mentioned previously, the fact that some individuals were able to gain employment and no longer qualified for CMSP because of increased income, and one individual who did not re-enroll in CMSP because he wanted to be able to qualify for a pharmacy assistance program. Cost and Service Use Analysis The project submitted 29 records of CMSP beneficiaries who were enrolled in case management prior to October 31, This data was folded into the Case Management cluster that is reported on page 267. Future Directions Unfortunately, due to funding restrictions, there are no plans to continue the case manager position. However, the project reports that collaborative partnerships established during the project between MCHC and Public Health are likely to continue, as funding allows. Additionally, the patient-provider relationships that were established will continue, since clients are more likely to see themselves as part of the team. Staff conjecture, however, that some of the clients will go back to their old ways without the intervention of the nurse case manager

50 Sierra County The Sierra County W&PP funded staff at the Western Sierra Medical Clinic (WSMC) to intensively case manage 53 individuals with chronic illness, develop a referral network, develop a patient education library, and develop and distribute an adult wellness brochure. As part of a comprehensive approach to case management, a quality assurance team of care providers met regularly to discuss effective strategies for serving specific clients and the target population as a whole. Grant funds were used to support the staff participating in the case management effort, including a Nurse Case Manager (0.25 FTE) and a Registered Nurse (0.20 FTE). Grant funds were also used by the Nurse Case Manager (NCM) to attend a diabetes training session and to purchase educational materials. The following case-management process, which has been classified as high intensity, was used: intake, including an initial exam and diagnostic tests; creation of a treatment plan by the NCM in consultation with the primary care provider; Program Description continued on the next page> Total Award Expended $73,423 of $73,423 awarded Program Partners Western Sierra Medical Clinic, Inc. Sierra County Health and Human Services Geographic Area Served Sierra County, particularly in the area within a 50-mile radius of Downieville Target Population Diabetic and otherwise chronically ill patients, including CMSP and Medi-Cal beneficiaries, and uninsured individuals Contact Information Kellie Bolle, RN Western Sierra Medical Center Phone: (530) wsmcmed@sccn.net 49

51 CMSP/TCE WELLNESS & PREVENTION PROGRAM Integrating Diabetes Education and Medical Care A Frontier Experience THE WESTERN SIERRA MEDICAL CLINIC (WSMC) in Downieville (Sierra County) (population 325) provides the only primary and emergency medical and dental care available for a 50-mile radius. Kellie Bolle, Nurse Case Manager and Home Health Nurse for the clinic, reports that they rely on information gathered at medical visits to the clinic to identify new diabetics, rather than on information from outreach events. When someone is newly diagnosed as diabetic, he or she will spend 1½ to 2 hours with Bolle or one of the medical providers going over the packet of information about diabetes that they give them, as well as how to take their medications, use the glucometer, and interpret the results. This quaint structure houses the Western Sierra Medical Center including the region s only emergency room, the Western Sierra Dental Clinic, and the Downieville Food Closet. >Program Description, continued from the previous page follow-up by the NCM to be sure appointments were kept, medications were obtained and taken, and referrals were made and completed (follow-up was by phone or home visit if necessary, and transportation was arranged if necessary); referrals were made to Social Services, housing agencies, the local food bank, mental health services, drug and alcohol services, specialty health care providers, and transportation providers, as needed; monthly quality assurance meetings by the clinic s providers, nurses, and medical director were held to discuss and coordinate courses of care for case managed clients. 50 Program Objectives and Outcomes 1 Objective 1 To provide case management services. W&PP Rating: Achieved Objective (high level of data to support) The project staff delivered data to the evaluator that showed that they case managed 53 individuals during the course of the grant period. The following graph shows the breakdown of payor source for these individuals, illustrating that the project reached their target population. At first patients are scheduled to come in frequently until their blood sugar is brought down to normal levels, and then they are scheduled for 4 times a year for the various ongoing exams and checkups necessary to monitor the disease. When patients have to transition from oral medications to injected insulin, they receive an additional intensive session with the medical provider and more frequent appointments until the provider is satisfied that everything is under control. Each time the patient comes in, either the medical Private Insurance 26% Not Covered 4% Medicare/Private 38% CMSP 17% EAPC 2% Medi- Cal/Medicare 13% Payors for clients enrolled in Sierra County s W&PP 1 Refer to DRA s evaluation report in Volume 2 of this report for the site's complete evaluation findings. 50

52 Sierra County Site Report Graph A: Health issues of clients enrolled in Sierra County s W&PP Alcoholism Anxiety Disorder Asthma Atopic Dermatitis Atrial Fibrillation Atrial Thrombus Bipolar Disorder Blindness Cancer Cerebrovascular Disease CHF COPD Coronary Artery Disease Dementia Depression Esophageal Reflux Former Smoker Heart Disease Heart Murmur Hepatitis C Hepatocellular Liver Disease Hyperlipidemia Hypertension Hypothyroidism Manic Depression Melanoma Obesity Peripheral Vascular Disease Psoriatic Arthritis Pulmonary Fibrosis Schizophrenia Smoker Tobacco Dependency Type 1 Diabetes Type 2 Diabetes Urinary Incontinence The majority of people that were selected for case management had type 2 diabetes, and many had hypertension and hyperlipidemia. Graph A illustrates the range of chronic diseases suffered by patients that were case managed. Data was provided to the evaluators indicating that the case management efforts were successful including: none of the 44 diabetics that were case managed had to be hospitalized for a hypoglycemic or hyperglycemic episode; 58% of the case managed diabetics lowered their HbA1c values, and 37% had values in the normal range at last check; 55% of all clients were able to reduce their BMI, although 52% were still considered obese and 29% were still considered overweight, based on their BMI; 14 of the 31 hypertensive patients had normal blood pressure levels at the last visit, as opposed to 6 of 31 at their first visit; 3 of 8 patients with hyperlipidemia had LDL levels in the normal range at their last visit; 90% of out-of-office referrals were completed by the patients; patient satisfaction, as measured by a survey that was administered twice during the grant period, was very high, measuring an average of 4.87 on a 5-point scale. Objective 2 To develop resources, including a referral network, Case Manager Resource Guide, well-adult brochure, and patient education library. W&PP Rating: Achieved Objective (moderate level of data to support) Although no specific data regarding referrals or resource development were provided to the evaluator, the project reported that 10 to 15 referrals to out-of-town medical specialists were made each month and that 90% of these appointments were kept. The project reported that because of the thorough follow-up by the NCM, the providers in their referral network were happy to accept clients referred from WSMC because they knew the client had been properly evaluated and that the proper followup care would occur. The WSMC medical director requested letters from each specialty provider for each 51

53 CMSP/TCE WELLNESS & PREVENTION PROGRAM provider or Bolle will go over some aspect of selfmanagement, including nutrition, foot care, or in whatever area seems to be needed. Patients also receive appropriate handouts and Web site lists if they have access to the Internet. We re small enough that we can tailor our education to the individual needs, says Bolle. When it is time for their next appointment, each person who is being case managed gets a personal phone call from a nurse, not from the front office staff, because they usually have medical questions they need answered. In addition to a small health education library, the clinic maintains a small pharmacy so patients can get started on medications right away, since the nearest pharmacy is 50 miles away. Clinic staff try to be flexible when people can t make it in because their car has broken down, etc. We try to be as accommodating in scheduling as we can, because getting people in is often half the battle, says Bolle. People are not penalized for not showing up for appointment, since there are usually good reasons. The WSMC has about 50 to 60 diabetics in their patient population, says Bolle, and they are particularly gratified that none of their diabetic patients had to be admitted to the hospital with a diabetes-related problem during the grant period. Western Sierra Medical Center staff Frank Lang, NP, Kellie Bolle, RN, and Bettie Lang, RN, attend a training session to learn how to use the W&PP case management database program. referral detailing the follow-up care required, and specialty providers willingly supplied these. These successful referrals strengthened the referral network. Although the project does not mention the Case Manager Resource Guide in their report, they did produce a well-adult brochure, Guidelines for Adult Health Screenings that details what tests should be performed at what age or time interval to ensure effective health monitoring. The project also developed a modest patient education library, which appeared to be helpful to patients as revealed by the client satisfaction survey that was conducted twice during the course of the grant project. Future Directions 52 Cost and Service Use Analysis The project submitted 8 core data records of CMSP beneficiaries served. This data was folded into the Case Management cluster analysis reported on page 268. The project reports that they plan to continue case management activities, although because of funding limitations, they will not have a dedicated person for case management. Rather, the entire staff will contribute to the effort. WSMC is instituting practice management software that includes capabilities to track patient care, and they are looking forward to incorporating that into their case management efforts. The software will allow front office staff to take a greater role in patient followup. The patient education library will be kept and enhanced as funds allow. The project would like to see a nutritionist/dietitian come into the practice area. 52

54 Sonoma County The Sonoma County Cycle 3 CMSP/TCE W&PP (also known as Next Steps ) was developed as a partnership between the Sonoma County Department of Health Services (SCDHS) and the Redwood Community Health Coalition (RCHC), representing a consortium of eight community health centers in Sonoma County. When proposed, the project represented the next steps in the development of an ongoing effort by SCDHS and the health centers to create and sustain systems of early identification, early intervention, and risk reduction programs for low-income, medically underserved populations throughout the county. Built upon the foundation developed with CMSP Cycle 1 and Cycle 2 Wellness and Prevention grants, Cycle 3 activities were generously supported with funds from a grant to RCHC from The California Endowment. Cycle 3 goals were to: strengthen and sustain community clinic systems to identify, intervene with, and monitor clients at risk for cardiovascular disease; develop clinic-based, client-centered risk reduction programs to effectively motivate and support positive behavior change among atrisk clinic clients; and Total Award Expended $308,888 of $308,888 awarded Program Description continued on the next page> Program Partners Sonoma County Department of Health Services (SCDHS) Redwood Community Health Coalition (RCHC) Geographic Area Served Sonoma County Target Population CMSP-eligible and other low-income individuals, especially targeting Hispanic or Latino individuals, who are at risk for cardiovascular disease, as well as members of neighborhoods and communities that they live in Contact Information Barbara Graves, Director of Prevention and Planning Sonoma County Department of Health Services Phone: (707) bgraves@sonoma-county.org 53

55 CMSP/TCE WELLNESS & PREVENTION PROGRAM Next Steps to Positive Behavior Change SONOMA COUNTY S CMSP/TCE WELLNESS and Prevention project, the Next Steps program, focused on the prevention and early detection of chronic disease with the objective of promoting health in the indigent population and avoiding acute episodes of care. The accompanying site report provides rich quantitative data regarding the project s success; however, the following success stories exemplify the profound impact that prevention-focused activities can have on clients lives and their well-being. Ernesto s story Ernesto, a 44-year-old Hispanic male with strong cultural roots in rural Mexico who speaks only Spanish, was informed that diabetes was threatening his health and his family s livelihood; he needed to make some drastic changes in his eating habits. This news was a tough sell, since diabetes is a silent killer, and Ernesto was being asked to eat more green vegetables (pastura (cow food) as he affectionately calls it) and cut down considerably the consumption of many of his favorite foods. The Next Steps staff also taught Ernesto s wife how to prepare foods that would assist Ernesto in achieving a healthful blood sugar level. Now the entire family is eating these foods. Next Steps staff were able to teach Ernesto how to perform self-administered blood glucose tests and motivate him to do the tests regularly. Using these tests, Ernesto was able to directly see >Program Description, continued from the previous page increase culturally appropriate, accessible, community-based health promotion/risk reduction programming in eight Sonoma County communities. The project had two principal targets within Sonoma County: 1) CMSP and other low-income clinic clients at risk for cardiovascular disease, with interventions designed to reduce risk and establish healthy behaviors and 2) neighborhood and community environments surrounding these clinics, with efforts to develop and sustain community-based chronic disease prevention programming. Interventions were delivered through eight health centers located in both urban and rural communities. Participating clinics were: Alliance Medical Center (Healdsburg), Copper Towers (Cloverdale), Family Practice Center (Santa Rosa), Occidental Next Steps staff member tends to a client. 54 Area Health Center (Occidental), Russian River Health Center (Guerneville), Petaluma Health Center (Petaluma), Sonoma Valley Community Health Center (Sonoma), and Southwest Community Health Center (Santa Rosa). Central to the Next Steps program design was the formation of project teams made up of Public Health Nurses (PHNs) and Community Health Workers (CHWs), physician or midlevel providers, and in some cases, Clinic Nurse Managers from each clinic. PHNs were assigned to each health center team to coordinate project activities and to supervise the CHWs in conducting the inreach, intervention, and follow-up components of the cardiovascular risk-reduction programs delivered at that site. At-risk clinic clients were identified through inreach strategies, such as chart and appointment log review, and through health screenings conducted by health center staff at community sites. The project was designed to utilize the multidisciplinary teams to deliver all aspects of the program including risk identification and referral, assessment for readiness to change behavior, behavior change education, ongoing support, and monitoring and tracking of key clinical indicators. Encounters took place at the health center sites at visits scheduled specifically for the intervention project or at visits book-ended around clinical visits scheduled 54

56 Sonoma County Site Report for other purposes. CHWs utilized both home visits and phone calls to maintain contact with clients. At the first visit, baseline labs were done, and each client developed a self-directed behavior change goals and plan. With follow-up visits, client data was tracked to assess progress on behavior change goals. Referring providers were advised of client progress through chart notes, lab results, and case conferences. The multidisciplinary project teams also collaborated to implement community health promotion projects for each clinic site. In each community, the teams conducted outreach to potential community partners (schools, recreation providers, human service agencies) to explore opportunities to conduct community-based chronic disease screening and prevention events and activities. Participation in health fairs and collaboration on community walking and cooking programs were among the most commonly selected interventions. The Next Steps Wellness and Prevention Project was implemented by the Project Director (SCDHS), Project Coordinator (RCHC), Community Health Outreach Workers (8 one per site), and Public Health Nurses (4 one per two sites). Program results were tracked through the use of intake forms and other flow sheets specifically developed for the project. An ACCESS database was designed for the program and was provided to each health center site, along with training and, in some cases, computer hardware to facilitate timely input of data. Data was aggregated and analyzed quarterly by RCHC staff and was utilized to make modifications in the program as needed. Using experience and expertise from Cycle 2, the Next Steps project further refined its model for intervening with at-risk clinic populations with the use of CHW and PHN teams. The Next Steps project developed intervention tools based on theories of behavior change and utilized them as its principal disease-prevention strategy. The project enhanced data tracking systems for prevention and wellness and blended the public health department s approach to community health with health center practices. Additionally, the project linked the Sonoma County Department of Public Health, participating health centers, and other community agencies. The CMSP/TCE W&PP grant funded the Community Outreach Workers at 8 sites for training sessions in case management and behavior change theory for the outreach workers, and training for conducting health education classes for clients, such as for smoking cessation, walking, and exercise training. the increased blood sugar levels that occurred after eating too much sugar- and starch-containing foods. Armed with this direct self-knowledge, Ernesto felt motivated to make the necessary lifestyle changes. The result of these efforts is that during the three and a half months that Ernesto was seen in the Next Steps program, his HbA1c levels decreased from 9.8% to 6.4% (normal range). His blood sugar at the start of the program was 380 mg/dl and has since decreased and stabilized in the 80 to 120 mg/ dl range (normal). Mary s story For Mary, a 38-year-old woman, the secret to conquering the menace of diabetes was becoming educated on how to directly relate her eating and exercising habits to her blood sugar. Mary was not performing blood glucose monitoring as prescribed by her provider because of her fear of drawing blood from her fingers. Health educators in Sonoma County s Next Steps program taught Mary an alternative method of drawing blood, allowing her to regularly check her blood sugar. Mary was able to see the impact of different types and quantities of food on her blood sugar, as well as the benefits of swimming. As Mary progressed, she lost weight and increased her energy and lung capacity with regular exercise. She was also able to increase the duration of her swimming sessions up to 1 to 2 hours per day. Mary lost 17 pounds during the 3 months she was in the Next Steps program, and her blood pressure and HbA1c levels returned to normal. 55

57 CMSP/TCE WELLNESS & PREVENTION PROGRAM Program Objectives and Outcomes 1 The following table lists the risk factors identified for the 780 clients enrolled in the Next Steps program. Objective 1 Ongoing systems to identify, intervene with, and track low-income clients at risk for cardiovascular disease will be expanded at eight community health centers. W&PP Rating: Achieved Objective (high level of data to support) Each participating health center began Cycle 3 with well-established systems to identify clients appropriate for the program. These systems included chart and appointment log review, sorting by diagnostic code, provider referral, posting of notices in waiting rooms, mailings to clients, and community-based health screenings. The health centers developed a common intake form and health education and marketing materials. A common database was created by RCHC s information technology director to capture client demographics, clinical data, behavior change, and other project data. Information technology specialists conducted classes to train the clinic-based project staff in general data entry skills and how to utilize the specially designed ACCESS database. Database users were encouraged to give input from the field, and this feedback was used to make improvements to the data collection and tracking systems. All program participants were oriented to the program tools and protocols. These systems resulted in the enrollment of 780 clients from the target population in the Next Steps program. Evidence that the target population was reached include demographic and health-risk factor data. The following chart shows that the Hispanic/Latino population was well represented in the enrolled client groups. Filipino Pacific Islander Hispanic or Latino Unreported/ Unknown American Indian/Alaskan Native Asian Black (not Hispanic or Latino) White (not Hispanic or Latino) Ethnicity of individuals who were enrolled into the Next Steps program Risk factors identified for the 780 clients enrolled into the Next Steps program Obesity 472 Sedentary 312 Hyperlipidemia 327 Hypertension 229 Diabetic 338 Smoker 98 Alcohol 97 Other Substance Abuse 29 Family Diabetes 338 Family Cardiovascular Disease 240 Family Cholesterol 117 Family Obesity 176 Other Family Risk 159 Objective 2 Multidisciplinary cardiovascular disease prevention (Next Steps) teams, comprised of medical providers, Public Health Nurses, site 56nurses, and community health workers will be established at eight community health centers. W&PP Rating: Achieved Objective (high level of data to support) Each of the eight participating health centers established a primary team, composed of a PHN (assigned to two health centers) and a CHW who articulated with other site staff, including medical providers and clinic nurses. Most project training activities were designed for and delivered to the project PHNs and CHWs at a shared forum. This approach helped to develop and foster site teams as well as project-wide teams. The PHN would meet with the CHW to discuss the planned educational interventions and strategies for clients care. If a CHW was experienced and comfortable with the project, the PHN would then meet regularly and periodically with the CHW to review all cases. Referring providers were encouraged to read the notes taken by the CHW and PHN and were regularly informed of a client s status. PHNs and CHWs attended separate monthly meetings, and both groups met together quarterly. Camaraderie developed, as well as a bit of competitive attitude about how many referrals a health center might have or how much success was achieved with goals for blood pressure change, weight loss, etc.). Although Medical Directors were part of the planning group sessions, at some sites MDs were concerned and skeptical about the information and/or education a CHW might impart to their patients. Project teams recognized 1 This project was separately evaluated by Samuels and Associates. The project prepared a thorough and complete report that was substituted for an evaluation report by DRA. DRA has included the full text of that report as the Sonoma County evaluation report in Volume 2 of this report. 56

58 Sonoma County Site Report the importance of buy-in by providers and how it would effect referrals from them. Strategies to achieve credibility included asking providers to participate in the development and modification of the CHW education curriculum, arranging for PHN and CHW attendance and case presentation at provider meetings, regular meetings with the Medical Directors, and development of an informative client visit report format. Providers were encouraged to attend a CHW visit with a patient in order to observe their interaction and listen to key educational messages. Implementation of these tactics strengthened CHW credibility and resulted in increased referrals from providers to the project. Surveys of supervisors and medical directors showed most became quite comfortable with the health education and behavior support delivered by CHWs. During the second year of the project, budgetary cutbacks within the Department of Health Services prevented continuation of the PHN component. When SCDHS made the decision to reduce and then discontinue the PHN component, PHNs involved in the project were given the option to select reassignment. This resulted in experienced PHNs leaving the project early and assignment of new PHNs with limited project experience to four health centers. This reduction in staff support coincided with declining W&PP grant funding. A meeting of Next Steps project stakeholders was convened to address the impact of these changes. Grant deliverables and an updated project budget were reviewed. Each health center was given a Next Steps project activity template and was asked to create and submit a project sustainability work plan that would ensure the integrity of the project with reduced budget and staffing. Health centers compensated for loss of PHNs by expanding the role of clinic site nurses. Regular team meetings continued at each site, with PHNs, site nurses, and CHWs meeting to identify common problems and opportunities for system-wide program improvements. One site, the Family Practice Center, withdrew, but the remaining seven sites continued their participation through the end of the grant period. Objective 3 A minimum of 30 community health workers, PHNs, site nurses, Medical Directors and other Next Steps team members will be trained in a multi-session curriculum including chronic disease prevention, behavior change theory, cultural competence, data collection, and other topics. W&PP Rating: Achieved Objective (high level of data to support) The project reported that over the course of the grant, 17 CHWs and 5 PHNs participated in staff training for the project. In addition, medical assistants, allied health staff, and providers from participating health centers accessed Next Steps training activities. The CHWs received a project-specific training of more than 140 hours, combining general skillbuilding, chronic diseasespecific training, and experiential programs to enhance cultural competence. The primary training course was provided by the Northern California Center for Well Being (NCCWB), a community-based health education and training organization, under contract with RCHC. The NCCWB instructors for the Next Steps Next Step s Community Outreach Workers at a training project included Registered program (sponsored by TCE) in Mexico. Nurses, Registered Dietitians, Exercise Physiologists, and Certified Health Educators. The orientation curriculum included an overview of chronic disease prevention and early treatment, behavior change theory, basic and disease-specific nutrition, basic and disease-specific exercise training, self management and goal setting strategies, and development of effective coaching skills. Data collection, and tracking fundamentals were taught by RCHC staff. Cultural competency was woven into all facets of the project and also served by two enrollments, over the course of the grant, in Spanish language and clinical immersion program in Mexico. Each week-long program included Spanish language classes followed by clinical 57

59 CMSP/TCE WELLNESS & PREVENTION PROGRAM experiences that utilized the language lessons and gave them a greater understanding of the challenges of language, culture, and socioeconomic barriers to accessing and adapting to local health care models. Additional training included Boundary-Setting Skills, American Lung Association (ALA) Smoking Cessation, Safety at Home Visits, Identifying Asthma Environmental Triggers, and Walking Group Leader Training. Some training activities were held with medical providers through the RCHC Continuous Quality Improvement (CQI) project. Health center medical assistants and allied health staff members were invited to attend many project classes. With CMSP W&PP Technical Assistance funds, four nurses from four health centers received case management training to support their required roles in the later stages of the program. All classes were well-attended, highly praised, and recognized as having value in supporting staff to function in the project and in future job roles. It was helpful that some of the Next Steps team members had participated in similar activities during the Cycle 2 grant, although additional training was designed and developed specific to The Next Steps Project. In evaluation surveys, CHWs largely described the project training as satisfying and preparatory for their role to assess and assist clients behavior change, to provide education on disease prevention, and to enter and track data in the project designed database. The logistics for such comprehensive training were challenging, given the time required to deliver training and the problem of staff turnover among the CHWs. The CHWs who entered the program after the original training period were mentored and trained by project staff and provided with source materials on chronic disease prevention/education, client coaching, data collection, and behavior change theory. Recruitment, training, and retention of project personnel was an ongoing challenge for the project. It was a challenge to recruit and retain CHWs due to traditionally low salaries, the fact the project CHWs were not funded to work full-time, and the fact that funding was time-limited. PHN recruitment was delayed and impacted by the nursing shortage. The program was only able to hire one Spanish-speaking PHN and was unable to fill the PHN supervisor role. As previously noted, attrition of PHNs was impacted by County budget changes and the preference of the PHNs for positions with ongoing funding. Delivery of the highly comprehensive curriculum took place in a weeklong event that was expensive in staff time and cost. When CHW attrition occurred, it was impossible to duplicate this forum. Although systems were developed (project policy and procedure binder, mentoring of new CHWs, attendance at NCCWB classes), these of course could never match the project-specific orientation training. Although it was a loss to the project whenever a CHW left the program, the community benefited, since many stayed in the county and now serve in a variety of new but related roles such as county immunization coordinator, CPSP coordinator, and family health advocate. Others continue to apply the knowledge gained during their participation in the Next Steps program informally in their families, churches, and schools. Objective 4 50% of clients will have an improved blood pressure of less than 140/90 (normal range). W&PP Rating: Achieved Objective (high level of data to support) 58 Of the total of 780 people enrolled in the Next Steps program over the three-year period, the project documented that 115 (15%) of these had blood pressures exceeding 140/90 when they entered the program. Of these, 82% (94 of 115) had blood pressures in the normal range (<140/90) at their last visit. Moreover, as shown on the following graph, the percentage of total hypertensive individuals who were successful in achieving blood pressures in the normal range increased with each passing year of the grant, demonstrating a continuous increase in project effectiveness. 84% 82% 80% 78% 76% 74% 72% 70% 68% 66% 64% % of Hypertensive Patients Who Achieved Normal Blood Pressures 2002 (n = 67) 2003 (n = 104) 2004 (n = 115) Hypertensive clients who achieved normal blood pressures while enrolled in the Next Steps program 58

60 Sonoma County Site Report Objective 5 75% of all clients will have lipid testing within 6 months of enrollment. W&PP Rating: Partially Achieved Objective (high level of data to support) The project documented that overall, 60% (466 of 780) of the people enrolled in the program had a lipid test within 6 months of enrollment. Although this value does not meet the stated goal, the project was able to improve performance of this measure with each succeeding year of the program, as shown on the following graph: Additionally, by the end of the project, 85.3% (665 of 780) had undergone lipid testing, with 61.4% (408 of 665) of these individuals having 2 or more lipid tests. 70% 60% 50% 40% 30% 20% 10% 0% % of Total Enrollees Having Lipid Testing within 6 Months of Enrollment 2002 (n = 164) 2003 (n = 382) 2004 (n = 466) Hyperlipidemic clients who had lipid testing while enrolled in the Next Steps program Objective 6 90% of selected clients will have an HbA1c test within 90 days of enrollment. W&PP Rating: Partially Achieved Objective (high level of data to support) Of the 338 diagnosed diabetics enrolled over the threeyear project, 85% had an HbA1c test within 90 days of project enrollment, and 73% had 2 HbA1c tests within 6 months. Moreover, as shown on the following graph, the percentage of patients having 2 HbA1c tests within 6 months of each other, a statistic that indicates that active monitoring of a diabetic condition is taking place, increased with each passing year, indicating increasing effectiveness in diabetes monitoring as the project progressed. 80% 70% 60% 50% 40% 30% 20% 10% 0% % of Diabetics Having Two HbA1c Tests in a Six-Month Period 2002 (n = 65) 2003 (n = 182) 2004 (n = 224) Diabetics that had two HbA1c tests within six-months of each other while enrolled in the Next Steps program Objective 7 5% of those identified by BMI as obese will have a reduction in weight 10 pounds or more and maintain that loss for 6 months. W&PP Rating: Achieved Objective (high level of data to support) Of the total enrollees, 57% (445 of 780) were identified as obese using the criterion of a Body Mass Index (BMI) of greater than 30. Thirteen percent (13%) of these clients had a weight loss of 10 pounds after 6 months, and 9% of the obese clients maintained that loss for 12 months. Additionally, 26% of enrollees were identified as overweight using the criterion of BMI of 25 to 29. Of these overweight clients, 7% had a loss of 10 pounds after 6 months, and 5% maintained that loss for 12 months. Objective 8 A percentage of enrolled clients (goals were set by each health center separately) quitting smoking and maintained for six months. W&PP Rating: Achieved Objective (high level of data to support) Smoking was recorded as a risk factor for a total of 98 Next Steps clients, and 427 encounters that included smoking-cessation strategies were delivered to these individuals. 154 clients (duplicated) were registered in classes or for one-on-one educational sessions; 97 of these completed 4 or more encounters, and 79 received prescriptions and vouchers for cessation aides. Matching funds from the County s Master Settlement Agreement were utilized to cover the cost of these smoking- 59

61 CMSP/TCE WELLNESS & PREVENTION PROGRAM cessation medications and aides, which included Welbutrin, nicotine gum, nicotine patch, and inhalers. Smoking-cessation counseling was designed to include 3 one-one-one encounter sessions delivered by CHWs, with an option for receiving vouchers for smokingcessation aides such as nicotine replacement devices. While the one-on-one smoking-cessation program was challenging to implement in part because of scheduling difficulties, group classes, developed later in the program, were somewhat more successful. The project reported that 83 clients enrolled in smoking-cessation classes, and 52 attended the first meeting. Of the 35 who had completed the classes, 32 were issued vouchers for smoking-cessation aides, 27 quit smoking, and 29% of those were still are not smoking at the 3-month follow-up. Ten smokers who received oneon-one intervention and were tracked in the Next Steps database were still not smoking after 6 months. There were equal numbers of men and women who completed their cessation encounters, and English was the primary language for all but 4 clients. Fourteen percent (14%) of the clients enrolled in the smokingcessation program were Hispanic. Since 63% (488 of 780) of the enrollees were Hispanic or Latino, it is clear that Hispanics were underrepresented in the smokingcessation efforts. Project staff reported that Hispanics were generally not convinced of the importance of smoking cessation, and they had the lowest levels of readiness for this effort. Although the Next Steps project was disappointed with these results and viewed their objectives as not having been achieved, they nevertheless achieved their stated objective, to the extent that it is defined. The percentages of successful smoking cessation in this project, although seemingly low, are not surprising. Over the past several years, it has become increasingly apparent to the medical community that nicotine addiction is one of the hardest to recover from. Often smokers must make multiple efforts to quit for the longterm, and they must have the highest stage of readiness for change to be successful. Since smokers are not generally in pain as a result of smoking and they get great pleasure from the habit, a very high level of abstract thinking ability and education (or trust in one s medical provider) is required to move a person into the necessary high level of readiness for change needed for successful smoking cessation. Therefore, we (CMSP/ TCE W&PP administration staff) are impressed that so many people in the Next Steps program were convinced to attend smoking-cessation classes, attempted to quit smoking, and were even able succeed in long-term smoking cessation. Additionally, as a result of the participation in the program, those who were not successful in quitting may be better equipped to tackle the problem successfully at a later date when they are in a higher state of readiness. For those who did not complete the full set of classes, their level of awareness about the risks to their health of their continued smoking habit has nevertheless doubtlessly been increased. Objective 9 90% of enrolled clients will participate in at least one health education class or one-on-one behavior change program. W&PP Rating: Achieved Objective (high level of data to support) All enrolled clients received education encounters. Many clients requested and received education in more than one risk reduction area. The data summary shows that for all types of education, classes were used in only about 2% of the total number of encounters, and that 98% of all encounters were a one-on-one visit. The following table lists the types of educational 60 encounters by the 780 clients enrolled in the Next Steps program that were recorded in the database. Number and Type of Educational Encounters for the 780 Next Steps Participants Exercise OW* 3949 Class 133 Weight OW* 3438 Class 53 Nutrition OW* 3990 Class 107 Smoking Cessation OW* 427 Class 11 Alcohol Reduction OW* 314 Class 13 Other Substance Reduction OW* 75 Class 3 *OW = one-on-one encounter by an outreach worker Objective 10 Fifty percent (50 %) of enrolled clients will complete 3 or more significant contacts with the program within 6 months of enrollment. W&PP Rating: Achieved Objective (high level of data to support) The project reported that a total of 5399 visits occurred with 780 enrollees, for an average of 6.9 visits per enrollee. Furthermore, 86% of enrolled clients were reported to have 3 or more preventive health contacts. 60

62 Sonoma County Site Report Additionally, a total of 12,513 educational encounters were recorded (Refer to Objective 9 for the nature of these program contacts.) On the whole, 31% of entering clients either discontinued or transferred care instead of graduating from the Next Steps program. In most cases, this was an outcome related to clients life changes, including moving out of the area permanently or based on the demands of seasonal work or transfer of care based on changed insurance status. Transportation, difficulty keeping appointments, and family issues were also documented as significant barriers to participation for some clients. Some patients were lost to follow-up, and no documentation of their reasons for dropping the program were available. Objective 11 Community members in communities where health centers are located will have increased access to culturally appropriate community-based health promotion, risk reduction information, and programming. Cost and Service Use Analysis The project submitted 50 records of CMSP beneficiaries who were enrolled into the Next Steps program prior to October 31, This data was folded into the Case Management cluster that is reported on page 267. Future Directions The community clinics plan to continue each of the following components of the program, although at less intense levels than were maintained during the grant project: community outreach and prevention projects, client goal-setting, behavior change support strategies, and use of CHWs for client interventions. Efforts are ongoing to develop additional sources of funding to support the CHW roles and community-based riskreduction projects. However, the PHN participation is discontinued due to budget constraints. W&PP Rating: Achieved Objective (moderate level of data to support) The project reported that one or more community-based health promotion activities were conducted in each of the eight communities. Project teams in each of the target communities identified opportunities to develop programming, and PHNs were assigned to work with CHWs and other health center staff to create community resource maps. The community maps informed project outreach activities to potential local partners including businesses, volunteer organizations, schools, and hospitals. After scans were completed, health center teams met with partners to develop plans for further outreach and community-based health promotion activities. These activities included: walking programs, health fairs (Citrus Fair, Cinco de Mayo festivals, Cesar Chavez Health Fair, Binational Health week) support groups, shoppers tours of Lola s market, and Food- 4- Less cooking demonstrations, Santa Rosa Wednesday Night Market booth, and community-based health promotion classes. 61

63 CMSP/TCE WELLNESS & PREVENTION PROGRAM 62 62

64 Tuolumne County Tuolumne County, consisting of rural foothill communities, was plagued with a high incidence of methamphetamine abuse that negatively affected individuals quality of life, the lives of their families, and the safety of the community. In many cases, families were affective by multiple generations of individuals dealing with an addiction to methamphetamines and other chemicals. In 1999, when Tuolumne County began its Adult Felony Drug Court, there were no model drug court programs available that addressed the needs of the small, rural communities. As often is the case with new program development, the available models are based upon the needs of larger, urban communities and are not easily translated into a small county design. For this reason, Tuolumne County turned to two methods that had worked well in the past and were proven strategies for building an innovative program that meets the needs of the local community: 1) an ongoing collaborative body of local county agencies and 2) the willingness to bring in nontraditional program components, such as a health component through the Wellness & Prevention Program, to meet the needs of the program participants. Program Description continued on the next page> Total Award Expended $133,079 of $133,079 awarded Program Partners Kings View, Tuolumne County Behavioral Health & Recovery Services Tuolumne County Superior Court Tuolumne County Probation Department Tuolumne County District Attorney s Office Tuolumne County Public Defender Geographic Area Served Tuolumne County Target Population Medically underserved adults with felony, drug-related charges and addictions to drugs and/ or alcohol Contact Information Karen Bachtelle, MSW, ASW, Adult System of Care Program Manager Kings View Behavioral Health Phone: (209) kbachtelle@kingsview.org 63

65 CMSP/TCE WELLNESS & PREVENTION PROGRAM Adult Drug Court Program Continues to Fulfill a Wish UPON COMPLETION OF THE intensive treatment program, successful Adult Felony Drug Court participants partake in a formal graduation ceremony that occurs in the courtroom to mark their accomplishments. The judge or commissioner gives a speech outlining the participant s individual accomplishments, such as the completion of a GED, over the course of their treatment. The graduating participant also has a chance to speak to the group about their personal experiences and can introduce family or community members that have been supportive of their efforts while participating in treatment. The judge or commissioner presents the graduate with a plaque and places their name in the Drug Court Wish Box. The Wish Box is a small, painted wooden box made by one of first Adult Felony Drug Court program graduates and given as a gift to the Superior Court s Presiding Judge. Ever since, the judge has used the Wish Box as a method by which to remember all of the accumulated graduates over the years. The judge then announces to the graduate that the felony drug conviction, which resulted in their entry into Drug Court program, is to be removed from their legal record. The judge instructs the probation officer to complete the relevant paperwork to remove the conviction and to notify the participant when the paperwork is complete. The graduation ceremony is topped off with a reception honoring the participants. Clinical treatment professionals state that each addicted person negatively affects the lives of themselves and an average of 32 other individuals >Program Description, continued from the previous page The beauty of Tuolumne County belies the harsh realities of the lives of some of its residents. The expected outcomes of the Adult Felony Drug Court are that program participants will successfully complete all portions of their program, remain clean and sober from all drugs and alcohol and remain free of any violations or new criminal offenses for a minimum of 2 years following graduation. At graduation, the judge or commissioner removes the felony conviction from the successful participant s legal record. The Tuolumne County Adult Felony Drug Court has received Wellness & Prevention Program funds over the course of grant cycles 2 ( ) and 3 ( ) to support a 0.5 FTE case manager (LVN/ substance abuse counselor), a portion of a probation officer s time, physical exams, drug screens, and staff support to track outcomes. Individuals who accept participation in the Adult Drug Court have felony, drug-related charges that are nonviolent, and enter the program on a voluntary basis after referral by their 64 attorney, often the Public Defender, or the Tuolumne County District Attorney s Office. Court, probation, and clinic staff are present in the courtroom when the individual accepts entrance into the program in order to quickly schedule the appropriate intake appointments. Due to the intensive nature of the treatment program, the maximum case load for the Adult Felony Drug Court Program is 30 clients at any given time. The Drug Court Treatment Team is comprised of the judge/ commissioner, the deputy probation officer, the court clerk, and the clinical staff. All members attend weekly Treatment Team meetings and court sessions and give input into any programmatic changes or sanctions that are imposed upon any participant. During the weekly Treatment Team meetings occurring prior to drug court sessions, the clinical and probation staff present updated reports on each program participant. Program participants meet with Kings View clinical staff and undergo a complete psychosocial assessment, and the Addiction Severity Index. The clinician assembles a summary and a treatment plan outlining the participant s program for the court and probation department. Kings View clinical staff provide ongoing clinical services to participants including group and individual counseling for addictions and the related behavioral health issues, education on the addiction process, relapse prevention training, and counseling on the effect of addiction on the family structure. All 64

66 Tuolumne County Site Report participants receive intensive case management, provided by the LVN/ substance abuse counselor, that includes life skills training and assistance obtaining appropriate housing, formulating a health care system for themselves and their family, completion of either a high school diploma program or GED (if they don t have one), job retention skills, and addressing any outstanding legal issues that may be present. The Treatment Team s awareness of the participants use of emergency services for primary care prompted the addition of a life skills component to the treatment curriculum to educate and train participants in the establishment and use of preventive/ preemptive modes of health care. Tuolumne s Adult Felony Drug Court consists of three distinct clinic phases. Each phase is a minimum of four months long and consists of interventions relevant to the particular time frame of the participant s recovery. Participants must complete all three phases of the clinical portion of the program in not less than one full year. Phase I: Consists of addressing topics including: Early Recovery, Education on Addiction, and Recognition of Relapse Triggers. This initial phase also includes sessions on dealing with the legal system, the connection between addiction and criminal behavior, and building responsibility. Phase II: Consists of addressing topics including: Relapse Prevention, Education on Health Care Issues Related to Addiction, Access to Appropriate Outside Resources, GED, and Other Education Issues. Phase III: Consists of addressing topics including: Building Systems of Support, Exploring the Community for Systems of Support, and Relapse: Planning for Prevention. This final phase also includes continued sessions on addiction, health care, responsibility, and family care. Participants are drug tested a minimum of three times weekly, with all positive and negative test results utilized as a treatment tools. If the participant tests positive more than three times during any phase, they must restart that particular phase, successfully completing each phase before moving on to the next. In order to graduate, each participant must complete all three clinical phases and have at least four months of being clean and sober as documented by negative drug tests. Hon. Eric Du Temple, Tuolumne County Superior Court Presiding Judge or Hon. James Boscoe, Tuolumne County Superior Court Commissioner monitors participants progress weekly during mandated court appearances. The judge or commission is responsible for imposing any sanctions for violation of the drug court rules. Sanctions can include community service, such as parents, children, spouses, friends, employers, and neighbors. After completion of the Drug Court Program, there is a ripple effect of positive results that begins with the client reentering the community with a healthy life style and working outward towards those in the individual s life. One successful Drug Court graduate, Paul became involved with the Child Welfare Services and the Juvenile Court system in a dependencyand-reunifications process with his children. Paul utilized the Drug Court treatment program and the case management provided in order to meet the dependency requirements and successfully reunite his family. In this case, not only has the Drug Court treatment program addressed the needs of the direct participant, but due to the case management mode in which it is provided, the needs of the family and dependent children were included in this process. increased treatment contacts, increased drug testing, increased attendance to 12-step meetings, or jail time. While enrolled in the program, participants are granted felony probation monitored by the Tuolumne County Probation Department s Drug Court probation officer. The Drug Court probation officer meets with participants for drug testing and to monitor the participant s compliance with the program s legal requirements. The probation officer meets weekly with clinical staff in order to complete weekly reports that go to the Treatment Team and court sessions. It is important to note that during the Wellness & Prevention Program grant period, California passed Proposition 36, the Substance Abuse and Crime Prevention Act (SACPA). Tuolumne County operates a SACPA program in addition to the Adult Felony Drug Court program. SACPA programs were created to provide treatment opportunities to individuals charged with low-level misdemeanor and felony drug possession charges. With the introduction of the SACPA program, the Adult Felony Drug Court program began to address the needs of clients with more serious drug-related felony offenses and more complex and long-term addiction issues. Clients who do not do well in the SACPA treatment program, due to the lack of mandated structure available to them, can move into the Drug Court program to access the level of care necessary to meet their needs. 65

67 CMSP/TCE WELLNESS & PREVENTION PROGRAM Program Objectives and Outcomes 1 Objective 1 In coordination with Adult Felony Drug Court, provide health screening to participants in order to detect health problems related to long-term substance abuse. W&PP Rating: Partially Achieved Objective (minimal level of data to support) The project proposed to provide Drug Court participants with health screening exams upon entry and completion of the program. In Year 1, the project reported that although the participants were referred to a primary care clinic for a health screening, many participants did not follow through with their appointment. This prompted the case manager to begin to accompany the participants to the health screening examinations. At the onset of the program, it was felt that participants would welcome the addition of a health care component to the treatment interventions. The reality that was uncovered reflects an underlying fear held by many of the participants of knowing the truth about the healthrelated deficits and conditions that result from their longterm substance abuse. Many clients expressed concerns that they would learn through the health exams that they had communicable diseases, liver or other organ system damage, brain damage, heart problems or other major disorders as a result of their addiction. Many female clients expressed fears concerning damage they may have inflicted on their children, due to drugs they used during pregnancy, and concern that if they admitted this fact, Child Welfare Services would become involved with their families. This discovery led to clinicians addressing health care education in a broad based group modality, and working with particular clients on an individual basis to overcome their fears of recognizing and contending with health care conditions. The Treatment Team recognized that most participants were not ready to address their own health issues until Treatment Phase II, when a strong enough relationship has developed between the clinicians and clients to address the reality of a health condition versus the client s fear. In Year 2 of Cycle 3, the Tuolumne W&PP experienced a major set back regarding providing health screenings for Drug Court participants. The local hospital s primary care clinic, which had been conducting the health screenings, underwent both a management and target population change and was no longer willing to provide screenings appropriate to the Drug Court participants. The hospital s former 1 Refer to DRA s evaluation report in Volume 2 of this report for the site's complete evaluation findings. administrator was a champion of the Drug Court Program, so it is disappointing to see that the new management did not hold the program in the same regard. The Tuolumne W&PP tried, but was unsuccessful, at locating a private clinic or medical office that was willing to take on the health screening examinations for Drug Court participants. The project states that they relearned a lesson about the difficulty the medically underserved populations in rural communities have in acquiring primary medical care. Thus, this group of clients became reliant, again, on emergency care to solve their medical needs. The Treatment Team s acute awareness of the participant s dependence on emergency services for primary care prompted the addition of a life skills component to the treatment curriculum to educate and train participants in the establishment and use of preventive/ preemptive modes of health care due to the loss of a health screening site. The case manager, also an LVN, provides participants with counseling and education about communicable diseases, especially those associated with drug abuse such as HIV 66 and hepatitis. With the loss of the health-screening site, the Treatment Team was forced to become very creative in meeting the participant s health care needs on an individualized basis. The Tuolumne W&PP shared a client story that demonstrates the complex nature of contending with both addiction and another health condition. One program participant was diagnosed with a serious degenerative neuromuscular disorder that had been neglected due the participant s lengthy addiction to opiates. The participant s drug addiction had masked the symptoms and related pain until after the participant became clean and sober. The Treatment Team was able to support the participant in obtaining the appropriate diagnosis and treatment for the condition that enabled the participant to have a better quality of life. Though the Tuolumne W&PP was successful at describing the health screening services and referral process, the project supplied no data to the evaluator regarding the health educator services provided by the case manager or the number/type of referrals made to within the community for health-related conditions. This is rather unfortunate, since the site was provided with customized database to aid in the tracking of this information, training of the data entry personnel on how to track this information by the evaluator, and the importance of tracking the information. Contracted personnel outside of the Treatment Team, on a retrospective basis, did the entry of the data into the database by reviewing client charts to find relevant information. The program evaluator s report for the Tuolumne W&PP cites the difficulty in relying on tertiary personnel without an investment or ownership in the 66

68 Tuolumne County Site Report evaluation process to conduct the data collection retrospectively. The W&PP administrative staff concurs with the evaluator s findings, since the project was unable to fully report on the success of accomplishing the grant objective. Objective 2 To provide intensive case management services for Drug Court participants. W&PP Rating: Achieved Objective (moderate level of data to support) Data provided to the evaluators indicated that 73 clients participated in the drug court program. Of the participants, 33 were female and 40 were male. The average age of participants upon enrollment was 33; however, participants ranged in age from 20 to 51 years old. The participants identified race was primarily Caucasian (67/73), with an additional 4 Hispanic clients and 2 American Indian clients. The project utilized the customized database to record the goals identified through the case management process for 57 of the 73 participants. Identified goals included completing of each of the 3 treatment phases, obtaining employment, obtaining stable housing, and obtaining a GED. A total of 176 goals were recorded by the Tuolumne W&PP and supplied to the evaluator. Of the 176 goals, 151 (86%) of the goals are marked as achieved. Please review the evaluator s report on the site, which raises questions regarding the validity of the data, since many of the goals required for graduation in the program are listed as unachieved, yet these clients are indicated as having successfully completed the program. The project experienced an unforeseen difficulty in getting CMSP-eligible clients to actually sign up for benefits. Many participants were unwilling to go through the CMSP application process, and the Tuolumne W&PP relates this unwillingness to the participants fears of learning about any health conditions that resulted from the participants substance abuse (See Objective 1 for further details). In retrospect, the Drug Court Program would have added a requirement, imposed by the judge upon entry in the program, that each participant must explore their health care needs with the Treatment Team, and if eligible, apply for CMSP or Medi-Cal benefits to assist in meeting their health care needs. Objective 3 To improve the overall health, quality of life, and rate of success among case managed participants in the Drug Court Program. W&PP Rating: Achieved Objective (high level of data to support) Data regarding the substances abused by 69 of the 73 Drug Court participants prior to entry in treatment was supplied by the Tuolumne W&PP to the evaluator, with a total of 133 drugs recorded; many participants reported using more than one substance. Not surprising, the primary drug of choice of Drug Court participants upon entry into the program was methamphetamine, with a two-thirds of the participants reporting methamphetamine use (46/69). Many participants also had coexisting addictions to either marijuana and/or alcohol. The participants reported daily use of the majority of drugs, with some participants abusing a drug up to 5 times per day. Twelve of the 69 clients reported intravenous drug use, primarily of heroin. Graph A on the following page breaks down the substances used by Drug Court participants. The Tuolumne W&PP reports a high success rate with regard to participants successfully completing the program, which requires the client to be clean and sober. Of the 73 drug court participants engaged in Drug Court services during grant Cycle 3, 41 successfully completed the program and 19 were in the process of completing the program. This incredible success rate is a strong indicator that participants are on their way to a healthier life style and an improved quality of the life by having overcome their addictions. Only 10 participants failed to complete the program and 3 participants re-offended and were sanctioned out of the program. The project reports that although the court and probation systems regard failure to complete the program as a true failure, the clinic staff recognizes that this small group of individuals has benefited by the interventions they have received. Experience working with the target population has shown that clients who do not successfully complete treatment the first time often will return and participate more positively at the next entrance to a treatment program. The educational interventions and the intensive case management received by Drug Court participants better equip them to function in the larger community even if there is a relapse to drug use. Due to these same interventions returning clients report that subsequent drug use is experienced differently, and often is short-lived before the client attempts another treatment program. Please refer to the accompanying highlight article 67

69 CMSP/TCE WELLNESS & PREVENTION PROGRAM Graph A: Reported drug use among enrollees of the Tuolumne W&PP Alcohol Cocaine/Crack Heroin Inhalants Marijuana/Hash Methamphetamine Other Amphetamine Other Hallucinogen Other Opiates and Synthetics 68 about Tuolumne s success for information about the graduation process from the Drug Court program as well as the impact the program has had on one client and his family. Cost and Service Use Analysis The project submitted 22 records of CMSP beneficiaries who were enrolled in case management prior to October 31, This data was folded into the Case Management cluster that is reported on page 267. Future Directions The Tuolumne County Adult Felony Drug Court will continue to function funded solely through the California State Department of Drug and Alcohol Programs: Drug Court Partnership Funds. The educational portion concerning preventative and ongoing health care will continue to be a part of the Drug Court curriculum. However, the program is unable to continue the same staffing levels and staffing will be reduced at the sunset of the grant. 68

70 Moderate-Intensity Case Management Cluster. Alpine.. Calaveras... Kings... Lassen... Plumas... Siskiyou 69

71 70

72 Alpine County The Alpine County Wellness and Prevention Program funded a half-time home nurse/case manager to visit adults who had been using the Alpine Emergency Medical Services (EMS) system inappropriately or who were referred because of lack of ability access primary health care from their homes or who were having difficulties complying with prescribed doctor s orders. The nurse/case manager also wove together a network of functional referral arrangements among the EMS, Social Services, Health Department, Behavioral Health, and the Sheriff s Department. Program Description continued on the next page> Total Award Expended $78,454 of $78,454 awarded Program Partners Alpine County Department of Health and Human Services Alpine County Health Department Clinic Alpine Emergency Medical Services Geographic Area Served Alpine County Target Population Adult residents with chronic illnesses who were inappropriately using the EMS for non-emergent conditions Contact Information Kimberly Woffinden, Account Clerk Alpine County Health & Human Services Phone: (530) kwoffinden@hhs.alpinecountyca.com 71

73 CMSP/TCE WELLNESS & PREVENTION PROGRAM Outreach Nurse An Agent for Positive Change THE ALPINE W&PP PROJECT made a visible difference after only one year of operation in Alpine County. According to Lynn Doyal, Director of Emergency Medical Services in Alpine, the project has been tremendously successful and has gained considerable favorable notice within the community. It s making a difference. We re seeing positive changes in people s lives, Doyal said. Doyal cited a number of positive indicators, including: Reduced unnecessary use of the Emergency Medical Service; More collaborative intervention efforts in difficult patient scenarios; Greater accessibility of the health clinic services both in the clinic and in the field; Better cooperative efforts with the Native American Health Clinic; More positive visibility of the health clinic within the community. The secret to success in Alpine is Lynnette Bennett, the registered nurse who was hired using Wellness and Prevention grant funds for two days/ week to provide outreach, home visits, and case management to promote wellness and prevention. Outreach and home visits are particularly important in Alpine County, Bennett maintains. People are so spread out and isolated in Alpine County, and many people don t have access to transportation, she explained. The County Board of Supervisors has taken note of the positive turn of events. It is of great significance that in a county that has extremely limited funds has opened a part-time position in Program Objectives and Outcomes 1 Objective 1 To enhance communication and coordination of services among providers in Alpine County. W&PP Rating: Achieved Objective (moderate level of data to support) The project reported that they were able to achieve an increased continuity of care for the high-risk population in Alpine County. They reported that productive relationships were successfully established with key health agencies such as the Washoe Tribal Clinic and Women s Health Center, in addition to the referral relationships mentioned in the Project Description. Project staff also became active on committees such as the Multi-Disciplinary Team and Behavioral Health committees, enabling them to maintain connections with various providers and to make meaningful contributions to service planning efforts. 72 The project staff worked with a new transportation provider in the County to increase the usage of clinics, thereby reducing the need for home visits. However, the project did not provide any specific qualitative or quantitative documentation of the impact of these relationships. Objective 2 To provide health education and case management services to a range of Alpine residents identified as having, or at-risk for: diabetes, asthma, hypertension, and/or other chronic illnesses. W&PP Rating: Achieved Objective (moderate level of data to support) The project reported that 405 contacts were made with 22 clients over the course of the 3-year project. Most (17/22) were Caucasian, and 5 of 22 reported being Native American. The project reported that the ages of the clients ranged from 17 to 92. The project provided a data set regarding the health issues of 18 of the clients that indicates that people with chronic health problems were among those served, as shown on Graph A. 1 Refer to DRA s evaluation report in Volume 2 of this report for the site's complete evaluation findings. 72

74 Alpine County Site Report Graph A: Primary and secondary health issues of clients served by the Alpine W&PP Skin Disease/Condition Heart Disease/Condition Hypertension Degen. Joint Disease MS/Mobility Injury/Infection Respiratory Mental Health Other Primary Secondary 5 Cancer Pain Post Surgical The project reports having performed case management and educational services as well as direct medical services such as screening and lab tests. However, no qualitative or quantitative data was supplied to document any of these activities. Objective 3 To improve health and reduce acute/emergency episodes among case managed clients. W&PP Rating: Achieved Objective (moderate level of data to support) The project recorded in their database only 1 ER visit by the case managed clients, which if true, would represent a significant achievement with this population. However, it was not clear to the evaluators whether that was the real number or whether it represented a limited, incomplete data set. The project did not address this objective in their Final Report to CMSP, and they did not participate in an exit interview with the evaluators, so it was not possible to clarify this point. However, 254 of the home visits were recorded in the database as critical events, suggesting that rather than call the EMS or go to the emergency room on their own, clients called the nurse case manager when an episode occurred. Since few hospital or ER visits followed, it can be assumed that the nurse case manager was able to successfully address the presenting problem via a home visit. Blood pressure was the only health indicator routinely collected over time on 14 of the 22 clients. Of these, 3 had hypertension initially. Blood pressures decreased in all 3 over time, but decrease to the normal range (<140/90) in only 1 client. However, the project reported anecdotally that people were significantly helped to improve their health and avoid unnecessary emergency room visits. Objective 4 To increase access to health resources for Alpine County residents. W&PP Rating: Achieved Objective (moderate level of data to support) The project reported that the outreach nurse promoted the availability health care services to residents at health fairs, various community events, to individuals who spread the information by word of mouth. The network of services, including behavioral health Barton Memorial Hospital in South Lake Tahoe, the Women s Health Center, and Social Services that the outreach nurse was able to weave and fortify was also reported to be important in increasing access to health resources for Alpine County residents. However, the project did not supply any data to support this claim of increased access. 73

75 CMSP/TCE WELLNESS & PREVENTION PROGRAM Cost and Service Use Analysis The project submitted 3 records of CMSP-eligible individuals who were enrolled in case management prior to October 31, This data was folded into the Case Management cluster that is reported on page 267. Future Directions Based upon the reported success of the project, the Alpine County Board of Supervisors created a part-time Social Services position to support the nurse case manager. It is also expected by the evaluator that the partnerships established through this grant will continue and be strengthened as time goes on. social services for Bennett, allowing her to work full time. Doyal emphasized that her full-time availability is invaluable in the community, since the clinic s one nurse practitioner works only 2 days a week, and the one M.D. works only 2 days a month. Bennett is available to field questions for information, attend to problems in people s homes, make referrals, and even provide transportation to the pharmacy, when necessary. I m always educating, Bennett says. I try to always have some printed information on the condition that is of concern to the patient. In the clinic, I m standing in the background, and after the patient finishes the office visit, I produce educational material on the patient s problem 74 and go over it with them. Bennett looks for every opportunity to attend senior events, preschools, health fairs, and other outreach opportunities to provide information about wellness and prevention. She has taken the initiative to prepare materials for diabetes education that appeal to the specific Alpine County s beautiful but rugged terrain is a significant population at risk in Alpine barrier to access to health care services. County, which includes Native Americans. Bennett considers herself the Ambassador at Large for the Health Clinic and for wellness and prevention. I m always educating. I try to always have some printed information on the condition that is of concern to the patient. Lynnette Bennett, Outreach Doyal cited one example of the positive impact of her education efforts: An elderly couple was frequently calling 911. The problem was always that the husband would fall, and the wife could not get him up. This was a particular problem for us here in Alpine, because our EMS is an all-volunteer organization, Doyal said. Bennett conducted home visits and trained the wife in techniques for assisting the husband in getting up. The incidence of 911 calls from this couple has dropped to zero, Doyal said. Nurse for Alpine County 74

76 Calaveras County The Calaveras W&PP created a cross-referral system with multiple service providers throughout Calaveras County and case managed 57 uninsured and underinsured low-income residents, aiming to increase access to needed social, dental, and medical services. To learn about the unmet needs of CMSP beneficiaries, in 2001 the project surveyed 39 people who were currently enrolled in CMSP and who were receiving services at San Andreas Family Practice. The most critical gap identified in this survey was lack of access to dental services. Most (77%) had not seen a dentist in the past year, and 28% had not seen a dentist in more than 3 years. Most indicated that the reason they went to the dentist was because of a toothache. Most (72%) also said that transportation was a barrier to getting dental care. The results of the survey informed the design of the Wellness & Prevention intervention, which became primarily focused on access to dental and counseling services, but also provided access to and assistance with employment, transportation, health education, and social services. Dental and Counseling Access Programs were established, employing subcontractors to deliver services. Elements of the effort to create a cross-referral network included presentations to local agencies, creation and distribution of a CMSP resource list and W&PP Program Description continued on the next page> Total Award Expended $134,820 of $136,102 awarded Program Partners Community Medical Centers (San Andreas Family Practice) Calaveras County Health Services Bruce Dunwell, DDS Calaveras Health Link Geographic Area Served Calaveras County Target Population Uninsured and underinsured low-income residents Contact Information Steve Shetzline, Project Coordinator San Andreas Family Practice Phone: (209) sshetz@goldrush.com 75

77 CMSP/TCE WELLNESS & PREVENTION PROGRAM Calaveras W&PP Targets Gaps in Dental Services ANDY WENT FROM BEING in constant pain, angry all the time, unable to sleep, and unable to look for a job to being employed full time, in no pain, and no longer angry, after Steve Shetzline, case manager for the Calaveras County Wellness & Prevention Program (CC W&PP), helped him get treatment for long-standing dental problems. Such testimonials are not unusual among the 43 people who completed their personal health plan that they established with Shetzline (see also Volume 5, Issue 1 (Spring 2004) of the CMSP/TCE W&PP newsletter for details of Shetzline s case management program). Completing a course of dental treatment was the most frequent aim of the health plans, with 14 individuals completing the Dental Access Program established by W&PP. In a survey, those who completed the program strongly agreed that they now have less pain, eat healthier, feel better about themselves, smile more often, and their lives have changed for the better. When the Calaveras County designed its Wellness & Prevention Program, they did not know at the time that dental services were going to turn out to be their primary area of focus. At the outset of their project, they took an open-minded approach and surveyed their target audience CMSP beneficiaries to find out the gaps in their health care. However, in a survey of people asked what health service they would benefit most from that they not currently have access to, nearly half cited dental care, and most did not engage dentists in preventive care (cleanings and fillings), but >Program Description, continued from the previous page pamphlet, and participation in getting the county registered to participate in the California IMPACT Prostate Treatment Program for uninsured men. The project also contributed to effort of the Dental Community Forum to do a community dental needs assessment, and out of this effort, a Dental Task Force was formed to address the limited availability of dental services in the county. This task force continues to be active and may be sustained by local organizations. A dental provider survey was also conducted under this initiative. Program Objectives and Outcomes 1 Objective 1 To improve potential CMSP clients knowledge of CMSP services and to increase CMSP enrollment through outreach and education activities. 76 W&PP Rating: Partially Achieved Objective (high level of data to support) Although the project did serve a small number of individuals who were enrolled in CMSP (8 of 57 case managed individuals), the project did not demonstrate that potential CMSP clients became more knowledgeable about CMSP services through their outreach and education activities. The project cited the shifting insurance status and difficulty determining the The San Andreas Family Practice Clinic sits in the heart of type of coverage a client had historic downtown San Andreas. as the reason so few people classified as CMSP beneficiaries were served by the program. It is surprising to us that so few CMSP beneficiaries were served by a project that specifically targeted this population. In 1999, there were 1362 people eligible for CMSP in Calaveras County, with 820 of them actively enrolled in CMSP; In 2000, there were 1359 people eligible for CMSP, with 743 of them actively enrolled, according to CMSP records. It would seem that with these kinds of numbers that more than 8 of them would have been accessed by the project. The project reports that after the project began, it shifted its focus from CMSP-eligibles to uninsured and underinsured low-income 1 Refer to DRA s evaluation report in Volume 2 of this report for the site's complete evaluation findings. 76

78 Calaveras County Site Report residents, but this change in focus was not formally made in the project objectives. The project did not submit any data to indicate that they were able to increase CMSP enrollment through their efforts. The project reported anecdotally that they assisted an unspecified number of clients with the enrollment process for CMSP and Medi-Cal. Objective 2 To increase access to health services among the CMSP population through implementation of a tailored case management program. W&PP Rating: Achieved Objective (high level of data to support) The project case managed 57 people, using a written plan to guide efforts and measure results. The following chart summarizes the results of the case management efforts. Did Not Complete All Goals 2% Lost Contact 21% No Longer Needed Services 4% Program completion rates by participants in the Calaveras County W&PP Completed a Goals 73% Notably, 93% (43) of the 45 people who were not lost to follow-up completed all the goals in their plan. Of the people not lost to follow-up, all agreed or strongly agreed to a survey question asking whether they were able to access the services they needed. The project submitted data regarding insurance status to the evaluator for the 57 people who were case managed: 14% CMSP, 16% Medi-Cal, 5% Medicare, 2% private insurance, 63% uninsured. The primary services that the project documented for the evaluator regarding having provided clients access to were dental and counseling services through subcontractors (see also Objective 3) engaged by the project. The project reported that 14 clients received 87 individual service sessions with the dental contractor rather waited until an urgent or emergent situation developed. Almost all said that lack of availability of dental providers was a significant barrier to seeking care. These findings prompted the CC W&PP staff to create a formal program, the Dental Access Program, through which they subcontracted with a dentist, Dr. Bruce Dunwell, to deliver emergency dental services to the project s case-managed clients. Although people were referred to the CC W&PP case management program for help with a variety of problems, including medical, social, mental, and dental problems, a large fraction presented with urgent or emergent dental needs. Since few enrollees were employed full time and most were unemployed and uninsured, the grant funding was vital for delivering the dental services they needed. The findings from the initial survey also prompted the staff of the Calaveras County Wellness & Prevention Program (CC W&PP) to collaborate with the Calaveras Children s Dental Project to form a Dental Task Force to conduct a County Dental Needs Assessment in November That assessment revealed that those in the county having difficulty obtaining dental care were the traditionally underserved including Medi-Cal/CMSPenrolled individuals, very young children, the uninsured working poor, and young men between the ages of 18 and 30. A provider survey was also conducted, revealing that only 2 out of the 13 dental providers in the county served individuals enrolled in Medi-Cal or CMSP, and only 1 was accepting new patients from this population. Dental providers cited low reimbursement rates and cumbersome paperwork requirements as the reasons they do not serve Medi-Cal/CMSP-enrolled individuals. However, the survey also revealed that there was a high level of willingness among dental providers to provide volunteer services, with 9 of 13 indicating they would be willing to volunteer periodically at a community-based clinic, should one be established in the county, 4 stating they would be willing to 77

79 CMSP/TCE WELLNESS & PREVENTION PROGRAM (Bruce Dunwell, DDS, SJ Valley Dental Group), and 7 received counseling services through the counseling subcontractor (Calaveras Health Link), for an average of 15 sessions per client. Additionally, the project reported having referred an unspecified number of clients to San Andreas Family Practice, the Lions Club Vision Program, and CalWorks. Objective 3 To improve access to care by increasing availability of providers who serve the CMSP and medically needy population in Calaveras County. W&PP Rating: Achieved Objective (high level of data to support) Ultimately, the following organizations/individuals collaborated within the cross-referral network for the indicated services: Saint Vincent DePaul Society: Referrals to the Calaveras County W&PP (CC W&PP) MTSJ Hospital: Diabetes Education, Referrals to the CC W&PP, Prostate Cancer Treatment Dr. Simopolous: Prostate Cancer Treatment The IMPACT Program : Prostate Cancer Treatment MTSJ Hospital Clinics: Referrals to CC W&PP CC Mental Health: Referrals to CC W&PP CC Alcohol and Drug Prevention: Referrals to CC W&PP CC Health Services: Referrals to CC W&PP CC Tobacco Prevention: Smoking Cessation Packets West Point Community Clinic: Referrals to CC W&PP San Andreas Family Practice: Referrals Linda Brucklacher, MFT: Subcontractor Calaveras Health Link (Counseling Access Program) Changing Echos: Referrals to CC W&PP Bruce Dunwell, DDS: Subcontractor Dental Services (Dental Access Program) Calaveras Children s Dental Project: Subcontractor Dental Community Forum, Dental Needs Assessment The Lions Club: Client services eyeglasses A county dental forum was held and attended by 36 community members, providers, and agencies/ organizations. The forum concluded that out of 13 dental providers in the county, 2 would serve CMSP clients. However, a dental provider survey conducted as part of the dental needs assessment contracted by the project revealed that 9 of the 13 dentists would volunteer at a community-based clinic if one were available, and 4 would accept specifically referred low-income people into their own practice. Some dentists expressed a preference for a limited amount of volunteerism versus serving Medi-Cal/CMSP clients because of the troublesome paperwork and low reimbursement rate with these programs. As stated previously, a Dental Task Force addressing the gaps in dental services in Calaveras County that was fostered by the project is ongoing and will likely be sustained by local organizations. 78 Cost and Service Use Analysis The project submitted 7 records of CMSP-eligible individuals who were enrolled in case management prior to October 31, This data was folded into the Case Management cluster that is reported on page 267. Future Directions Unfortunately, neither the Community Medical Centers nor the Calaveras County Health Service Agency has the funds to institutionalize the case manager position. Currently, grant funds are being sought for this purpose, and wide support for the service may result in a jointly supported case manager among the service providers. Currently, staff is exploring opportunities to expand the model to focus additionally on child and family health services and support. accept specifically referred low-income patients into their own practice, and 5 saying they would be willing to work with the Calaveras Children s Dental Program in the local schools. The community support and participation in the Dental Task Force s initiatives was strong, and local organizations are considering funding it for future. 78

80 Kings County K ings County has had the highest rate of diabetes deaths in the state for the last three decades. California State Department of Health Services reported there were 48.4 diabetes related deaths based on a population of 100,000 people in Kings County from 1999 to Kings County s rate well exceeds the statewide average rate in California of 20.7 deaths related to diabetes per 100,000. As a continuation of a program instituted in Cycle 2 of CMSP/TCE Wellness and Prevention funding, Kings County Health Department provided outreach and screening as case finding for potential diabetics and diagnosed diabetics who were not receiving adequate care. Medical case management services were also provided through the Health Department s four diabetes clinics to diabetics identified through the screenings and through referrals, with a special focus on Hispanic agricultural Program Description continued on the next page> Total Award Expended $357,051 of $357,051 awarded Program Partners Kings County Health Department* Kings County Human Services Department* Proteus Geographic Area Served Kings County Target Population Adult residents of Kings County who were either diagnosed with diabetes or at high-risk for diabetes with Medi-Cal, CMSP, or no resources for medical care Contact Information Sandra L. Omilianowski, Supervising PHN Kings County Health Department Phone: (559) ext somilian@co.kings.ca.us *Primary partners 79

81 CMSP/TCE WELLNESS & PREVENTION PROGRAM Cultural Competency Enhances Diabetes Program DELIVERING EFFECTIVE HEALTH SERVICES in many counties in California requires sensitivity and adaptation to the variety of cultures and native languages of the people living there. In rural California, the primary non-english speaking population is "Hispanic or Latino." The Kings County Department of Public Health created the Program for Diabetes that is an outstanding example of delivering effective health services by meeting special cultural and linguistic needs. The program served more than 175 people, providing education, medical case management, and medication assistance at 4 different clinic sites. During the first 2 years of its existence, the program served a total of 383 clients, of which 92% were Hispanic or Latino, and 90% of whom spoke little or no English. Many of the clients of the Program for Diabetes were successful in learning to manage their disease and maintain their blood glucose levels at normal levels, thus greatly reducing the progression of the wide variety of diabetes-related physical complications. An example is Dolores, who was able to reduce her HbA1c level (which reveals the 3-month average blood glucose levels) from 10.7 to 6.2 (normal range is 4.6 to 6.6). She modified her diet and walked two to three times per week. >Program Description, continued from the previous page Joan La Porte, Public Health Nurse (right), watches as a client practices testing her blood sugar using the Accu-Chek glucometer. workers. Late in the grant cycle a series of exercise and nutrition classes for diabetics was added. The grant funded a Family Nurse Practitioner (0.25 FTE), a Public Health Nurse/Health Educator (0.6 FTE), a-bilingual Community Health Aide (0.5 FTE), and a part-time office assistance for data entry, medical and lab supplies related to diabetes care, various diabetes trainings, diabetes-related educational materials, and attendance at the annual Technical Support Conference. Through the Technical Assistance/ Training funds, the project paid for the training and preparation of two public health nurses for the Diabetes Educator Certification examination. The Public Health Nurse, who worked on this project, was successful in obtaining her Diabetes Educator certification during the course of the grant. Her knowledge of diabetes and experience case managing clients with diabetes through the project were factors in her 80 success in this endeavor. Case finding efforts were initiated by the project s Health Educator and bilingual Community Health Aide. These outreach events were oriented toward CMSPeligible and/or medically underserved persons with undiagnosed diabetes, or those with diabetes and no access to medical care, with a special focus on the Hispanic community. A large number of Kings County residents are agricultural and seasonal workers; they are primarily nonmigratory due to the variety of year-round crops and continuous need for labor at the dairies. Although workers live and work in the community, the majority of the project s clients were undocumented and not eligible for benefits beyond emergency-only care. The project worked with the Proteus organization to increase contacts in the Hispanic community, and they were the source of some referrals to the project. Outreach events also contained strong education components prior to providing free blood sugar screenings. Screening and outreach events were held at health fairs, retail establishments, the target populations places of business, agricultural groups, and schools (including migrant education groups). In May 2002, the Health Educator, who had been providing the majority of the health screening, left the program. The project felt that at that time the case management program had reached capacity and decided not to hire a new Health Educator 80

82 Kings County Site Report and to discontinue the case finding efforts. In addition, the project modified roles within the program and moved to a medical-model for providing case management services. Case managed clients received referrals to the Kings County Human Services Department for enrollment services for CMSP, Medi-Cal, or other insurance benefits; referrals to specialist care; assistance with accessing services; medications and supplies; encouragement and monitoring of treatment compliance; education about health maintenance, blood sugar monitoring, diet and wellness; linkages to resources; crisis assistance; and family support and education. Primary medical care was provided by the project s Nurse Practitioner, under the direction of the county s Health Officer, on a monthly basis to case managed clients at four different clinic sites throughout the county. The project discontinued medical case management services in September 2003 due to lack of funding for appropriate levels of medical staffing. Beginning in October 2003, the Public Health Nurse previously involved with case management began providing a series diabetes education classes to diabetic clients. Program Objectives and Outcomes 1 Objective 1 To initiate a case-finding project with a bilingual outreach worker, to identify CMSP-eligible and/or medically-underserved persons with undiagnosed diabetes or diabetes that is not being regularly treated. W&PP Rating: Achieved Objective (high level of data to support) Although the project did not provide any data to the evaluators regarding outreach screening activities, they reported in their annual reports that the following activities were completed: Another example is Roberto, who speaks only Spanish and has a third grade education. Through meal planning and education about and assistance for obtaining equipment for glucose monitoring, as well as with oral medications provided through the Patient Assistance Program, his HbA1c levels dropped from 9.8 to about 6.5 to 7.3. The Kings County Program for Diabetes used several components that combine to help clients be successful in their efforts to manage their diabetes. These include: An effective health service team of Laura Cox, Nurse Practitioner; Joan La Porte, Public Health Nurse and Case Manager; Sally Hernandez, Community Health Aide who serves as the translator; Claudia Hernandez, Student Volunteer; Minako Wallis, Office Assistant and Database Manager, and Sandra Omilianowski, Supervising Public Health Nurse and Program Manger; Diabetes clinics held monthly, biweekly, or weekly at four different locations throughout Kings County, facilitated by a translator; A diabetes education program that has been tailored to their target populations, including using educational workbooks, videos, and cookbooks provided in English and Spanish; A commitment to providing medications, glucometer test strips, and care, including needed specialty services, to clients who do not have the ability to pay full costs; Use of glucometers that store blood glucose data that can be reviewed on a computer. Staff taught all clients how to check their blood glucose levels using the glucometers, which were given to some clients through special funding and to some through the generosity of a private company. When clients came in for a clinic visit, the blood glucose data was downloaded to a computer using the Accu-Chek Compass Diabetes Care Software, a Windows-based software program. The program prints out values, graphs trends, and will even chart the time of day that a client tests their 1 Refer to DRA s evaluation report in Volume 2 of this report for the site's complete evaluation findings. 81

83 CMSP/TCE WELLNESS & PREVENTION PROGRAM blood glucose levels. Because this data was stored automatically when the blood test was performed, clients did not have to keep separate paper-based logs of their test results. They were only required to log the food eaten before an elevated test. At the clinic visit, the client and nurse reviewed the blood glucose levels and dietary logs together, discussing what foods might have contributed to elevated blood glucose levels, as well as possible alternative eating options. For example, one client explained that an elevated test result occurred after a meal that included two pancakes. The client and the nurse practitioner agreed that next time the client should eat just one pancake and see what happens. Clients were also encouraged to conduct mini-experiments, for example testing the effect of a 30-minute walk on their blood glucose levels after an elevated test result. The glucometers allowed clients to get immediate feedback about themselves regarding eating and exercising behaviors. And the graphed results helped them see positive (or negative) trends in their blood glucose levels. Translation services, provided by Sally Hernandez, Community Health Aide, who has roots in the target community, were key to the success of the program. She needed to be present at nearly every meeting. Sally is well educated on the program, on diabetes, and on problem areas to be on the lookout for, said Cox. Enrolling clients in pharmaceutical companies Patient Assistance Programs was a cornerstone of the program and consumed a large portion of La Porte s time. Since many patients were on several medications for treatment of additional conditions besides the diabetes, their medications could cost $400 to $500 per month, La Porte said. Many of the clients did not understand the required forms and many are illiterate, even in Spanish. If we did not provide this service for folks, they would not get medications, said La Porte. Year 1 Year 2 Total Community screening events conducted Number of clients screened for diabetes Number identified with elevated blood sugar Number referred to program for follow-up Screening and referral activity in the Kings County W&PP As noted under the Project Description, screening and outreach events were held at health fairs, retail establishments, the target populations places of business, agricultural groups, and schools (including migrant education groups). Only those individuals who had no regular medical home or primary care 82 provider were referred to the case management program. The project provided the following data to the evaluators regarding the demographics of people who were enrolled into case management, most of whom were identified through these case-finding efforts. Of those enrolled (228 individuals), 92% were Hispanic, 80% spoke primarily Spanish, 56% were legal residents and 32% were undocumented, with 12% of unknown or pending legal status. Regarding coverage for health care services, the following chart illustrates that most (more than 70%) had no health insurance or were only eligible for emergency services: High Share of Cost 2.2% Emergency Medi-Cal 15.8% SSI/SSP 1.8% Not Covered 53.9% Unknown 1.3% CMSP AFDC 14.0% 3.9% Medi-Cal 4.4% Insurance coverage by individuals enrolled into case management in the Kings County W&PP Medicare 2.2% Private Insurance 0.4% Critical factors for motivating the necessary behavioral changes, according to Omilianowski, included speaking the client s language, being aware of cultural factors, including the types of 82

84 Kings County Site Report The data set delivered to the evaluators included health issues on 157 of the 228 individuals referred to case management, showing that all had either Type 1 or Type 2 diabetes, as shown on the following graph: Hypertension 27 Hyperlipidemia 1 Heart Disease 22 Obesity Smoker High Cholesterol Renal Disease 14 Protienuria 1 Asthma 47 Other 4 Gestational Diabetes 11 Type 1 Diabetes 146 Type 2 Diabetes foods that they customarily eat, being aware that modifications in diet need to be made in a stepwise fashion, including their customary foods, and not relying on expensive processed foods that are available for diabetics, because there is no money in their budgets to cover these unnecessary expenses. W e offer so much assistance that our clients become bonded to us. But we also strive to help them achieve independence in their selfmonitoring. One gentleman said that he had been diagnosed with diabetes 18 years ago, but only in the last 2 years since starting our program has he gotten control, LaPorte said. Health issues of case-managed patients in the Kings County The evaluators were disappointed that the project was not consistent from report to report or even within the same report regarding the numbers of people who were reported to be screened and enrolled into case management. However, we (the CMSP/TCE administrative staff) think that taken together, these data document that the project reached their case-finding goal through outreach screening of the target population. The project reported that they could have substantially increased the number of individuals identified in their case-managed population, but they reached the maximum capacity for casemanagement and health care service delivery early in year two of the grant period, and therefore they decided to suspend case-finding activities at that point. However, patients were still referred to the program by providers and other sources after they stopped active case-finding efforts. Materials distributed (by type and/or topic) Claudia Hernandez, Student Volunteer, downloads the blood glucose data from the glucometer. Also important for enabling behavioral change are repetition and relating lessons to the person. People only retain 10% to 20% of what you teach them, so repetition is important, said Cox. The diabetes educators tried to tailor each lesson to relate to the client s own blood glucose and HbA1c levels. They pointed out relationships between the client's blood sugar results, food logs, and activity levels, and they taught clients basic concepts such as starches, carbohydrates, sugars, proteins, and fats, as well as which foods are high in each of these. Therefore, the basic lessons in nutrition were related to the client s eating habits and how their own bodies respond to different types of foods. The educators also used these check-in sessions to review how to do a finger stick, how to use the glucometers, and what the target levels for blood sugar and HbA1c are. We try to focus on the positive, on emphasizing even small improvements, and on working as a team, Cox said. We try to find ways to make our goals their goals. Finally, including the family in the education process is important for long-term success in controlling diabetes. Diabetes is a family disease. 83

85 CMSP/TCE WELLNESS & PREVENTION PROGRAM What happens to the person effects the entire family, said Omilianowski. Family members can help clients remember to take medications, help with food preparations, use portion control, and get adequate exercise. Omilianowski said that home visits were sometimes made when they determined it would be helpful I work with the family regarding healthy eating, because this problem could effect other family members, said La Porte. I encourage family members to learn how to take blood glucose readings with the glucometer. Often I teach the wives of diabetic men first, and they then teach their husbands. Initiating behavioral change is hard, but when the light bulb goes on, that s a success, Cox said. Objective 2 To increase access to medical care for those persons identified through the project s case-finding efforts W&PP Rating: Achieved Objective (high level of data to support) Please refer to Objective 3 regarding this objective, since these are essentially identical for this project. Objective 3 To increase participation in early intervention and/or medical treatment for those persons identified through the project s case-finding efforts. W&PP Rating: Achieved Objective (high level of data to support) This objective was achieved enrolling identified clients into case management as noted under Objective 1. A total of 228 individuals were included in the data set of case-managed individuals provided to the evaluators. Although the data set includes only very general information regarding services that these individuals received, a total of 2158 services were documented, as summarized on the following graph: Lab Work Blood Pressure Initial Follow-up Medication Pick up Services provided to case-managed patients in the Kings County W&PP Other The project reported that 208 of these individuals were provided at least 3 visits with the Family Nurse Practitioner, nurse, and bilingual health aide to receive the education and support needed to maintain health and stabilize their diabetes. The Nurse Practitioner provided primary medical care for 84enrolled clients on a monthly basis throughout the program. The Public Health Nurse and bilingual health aid provided clients with education, referrals, and assistance obtaining medications. Due to a lack of resources and/or inability to qualify for public assistance programs due to their undocumented residency status, many of the clients were unable to pay for glucometer testing strips or diabetes-related medications. The Kings W&PP maximized their ability to distribute medication to the case managed clients through the pharmaceutical manufacturers patient assistance programs and the PIC drug settlement. The project staff became incredibly savvy in understanding the numerous and varied requirements of each manufacturer s program. The project also reported that 160 clients were referred to an optometrist for vision screening, and 60 were referred to a podiatrist. The impact of these services on patient health was documented through a variety of data, including lab results recorded in the data set provided to the evaluators, anecdotal accounts, and weight-loss data in the data set. The project staff reported that, incredibly, no case-managed individual had to seek emergency or hospital care due to complications of diabetes during the three-year grant period, and substantial numbers of individuals were documented in the data set to be successful in reducing blood pressure, reducing HbA1c levels to normal levels, and losing weight. These impacts will be further detailed under Objective 4. 84

86 Kings County Site Report Objective 4 To deliver case management services to targeted diabetes patients. W&PP Rating: Achieved Objective (high level of data to support) The project delivered data to the evaluators that 228 individuals were enrolled into case management. As noted in the Project Description, case-managed clients received direct medical services provided through the county diabetes clinic; referrals for CMSP, Medi-Cal, or other insurance benefits; referrals to specialist care; assistance with accessing services; referrals for medications and supplies; encouragement and monitoring of treatment compliance; education about health maintenance, blood sugar monitoring, diet and wellness; linkages to resources; crisis assistance; and family support and education. Medical case management was provided by the project s Nurse Practitioner under the direction of the county Health Officer at four different clinic sites throughout the county. The data set delivered to the evaluators revealed that 2093 case-management visits were made by 225 clients, an average of 9 visits per client. The number of visits ranged from 1 to 32, with most (145 of 225) having 5 or more visits. A small number of these visits (170) occurred during the Cycle 2 grant period. The project reported that all enrolled clients were evaluated by the Nurse Practitioner, including blood glucose and HbA1c evaluations, weight, and diet. Clients were encouraged to monitor their own blood sugar levels on a regular basis. Diabetes kits comprised of glucometers, lancets, and test strips were provided to 130 clients. At clinic visits, clients were able to review with the Nurse Practitioner the results of their blood glucose monitoring they had done since the last visit with the assistance of a software program (see also the accompanying highlight article for more details). This allowed clients to see a pattern in their blood sugar level and was used as a basis for diet and exercise modifications. Patients were encouraged to schedule monthly foot exams. Since 80% of the clients spoke primarily or only Spanish, each case management session for those Laura Cox, Nurse Practitioner (right), and Sally Hernandez, bilingual Community Health Aide (left), work with Amelia, a client. individuals was conducted with the assistance of a bilingual health aide. The project s nurse conducted blood sugar and HbA1c analyses on site, so patients could get immediate feedback. Data was provided to the evaluator on 2158 services provided to 225 clients, with an average of almost 10 services per client. Unfortunately, the description of the service detail is so general, that little could be learned regarding the nature of services provided. The project delivered data to the evaluator that 112 referrals were made for 93 individual case-managed clients. These referrals included 80 for vision screening and eyeglasses, 26 for podiatrist s services, 5 to a nutritionist, and 1 to a nephrologist. Follow-up information on referrals was not provided to the evaluators however the project reports that followup was document in the client s charts and verified by billing records as many of the services for which referrals were made were reimbursed by the Health Department. A Rural Health Services Small Grants Program grant, in the amount of $24,480, was awarded to the Health Department in October 1, This grant supplemented the Kings W&PP program by allowing the individuals case managed by the project to be referred for eye exams, pay for glasses, podiatry exams, diabetic shoes, and to obtain glucometers and test strips in order to monitor their care and prevent the complications of diabetes The positive impacts of these case management efforts on client health indicators is the most powerful indication of the success of the case management efforts. As noted above, the project reported that there were no diabetes-related hospital admissions or emergency room visits among case-managed clients during the time that they were involved in case management, although the evaluators were disappointed that no data was delivered to them supporting this claim. The project reported that of the 130 clients who were provided glucometers, all were successful in achieving lowered blood sugar levels, although not necessarily to normal levels. Data delivered to the evaluators revealed that 47 of 89 hypertensive clients achieved normal blood pressures, 47 of 80 achieved HbA1c levels below 8.0 or at least 2 points lower than initial values, 10 of 28 clients with hyperlipidemia achieved LDL levels in the healthy range, 85

87 CMSP/TCE WELLNESS & PREVENTION PROGRAM 19 clients were able to lose and keep off at least 10 pounds, with an average weight loss of 15 pounds among these 19 clients. We (CMSP/TCE administrative staff) are most impressed that these results were achieved with the project s target population, many of whom were illiterate even in their native language and for which educational efforts had to be geared to accommodate language and cultural differences. The project demonstrated that the ADA best practice guidelines can be successfully implemented with this population. In spite of the population s poverty and lack of formal education, they were able to learn how to use the technology for selfmonitoring blood sugar levels and understand the data produced by these technologies as it related to their health. Given access to care, these individuals showed that they were motivated to take advantage of it, even though diabetes is a silent disease that does not usually drive patients to seek care because of discomfort they may be experiencing. These clients impressively showed through the results they achieved that they understood and made the necessary life style changes that result in improved health. Much of the credit of this successful project goes to the talented and dedicated staff that implemented it (see also the accompanying highlight story). Objective 5 To provide community education presentations and meetings to promote community awareness and provider knowledge of ADA guidelines and local diabetes-related resources deliver case management services to targeted diabetes patients. W&PP Rating: Achieved Objective (high level of data to support) In October 2003, the Public Health Nurse began holding a series of exercise classes for diabetics. To exercise, not just talk about how to do it ; To gain friendships and meet potential walking partners; To convince clients that exercise is effective in reducing blood glucose; To show that exercise is beneficial for overall health; and To incorporate 10 to 15 minutes of diabetes information into classes. No electronic data was provided to DRA, but the project reports that 10 of these classes were held in Avenal with 10 clients attending each; 6 classes were held in Kettleman City with 5 clients each; 5 classes were held in Corcoran with 7 clients each; and 2 classes per week were held in Hanford with 19 clients each. The project reports that a new series of classes started in 2004, focused on diet and nutrition. Topics for these classes included: Basics of diet, portion size food selection, measuring and menu choices; Identification of food groups carbohydrates, fats and proteins; Reading package labels; and Menu planning. The project reports that 6 of these classes were held in Hanford with 12 attendees, 6 were held in Corcoran with 11 attendees, and 7 classes were held in Avenal with 6 attendees. The project also reported that through their efforts with the Diabetes Coalition in Kings County, they have signed MOUs with a number of rural health clinic physicians, such as internists, 86 family and general practice, ob-gyn providers, podiatrists, nurse practitioners, and other mid-level providers to jointly serve clients according to the ADA guidelines. According to the project, these providers contributed ideas, support, information dissemination, and referrals to the case management program. Initiating behavioral change is hard, but when the light bulb goes on, that s a success. Laura Cox, NP 86

88 Kings County Site Report Cost and Service Use Analysis The project submitted 22 core data records of CMSPeligible individuals enrolled into case management prior to October 31, This data will be folded into the Case Management cluster that is reported on page 267. Future Directions Although diabetes continues to be of primary concern to the Health Department, lack of further funding prohibits the continuation of any of the project activities beyond the ongoing meeting of the Diabetes Coalition, now absorbed as part of the Kings County Health Department Advisory Board. The resources for care in the county for the indigent are extremely limited (for example there is no Federally Qualified Health Clinic in the county and many clients are not able to afford the sliding scale offered at the existing primary care locations) and the costs for the Health Department to provide a case management level of care with clinical services have proved to be prohibitive. The project continues to search for other funding to reinstate case management and/or health education services but has yet to succeed in these efforts. After September 2003 when the project was forced to stop providing clinic services because of lack of funding, they sent certified letters to all case-managed individuals without Medi-Cal benefits with a list of physicians and community clinics, and the PHN worked with clients to continue their medication assistance as long as possible. (For those with Medi-Cal benefits, project staff will continue to provide case management services because these services can be billed to Medi- Cal s Targeted Case Management program.) However, staff believes that the reality for most of their uninsured clients is that they will not be able to afford the cost of ongoing health services. Unfortunately, the project staff fear that clients who were successfully self-managing their diabetes while under case management will probably slide backward towards unmanaged diabetes because of the difficulty experienced, even among highly advantaged populations, of maintaining self-management of diabetes without ongoing support. Kings County s interest and commitment to addressing diabetes has not waned though funding has diminished. Kings County is part of the Regional Diabetes Collaborative with Fresno State that includes five counties in the southern Central Valley impacted with the problems of diabetes. Kings County will have an active role in the planning and implementation of the Regional Diabetes Collaborative s diabetes preventionfocused activities. Finally, the project had applied to HRSA last year for a collaborative grant based in Corcoran to fund a school based obesity prevention program with 3 rd to 5 th grade students and their parents. Although the project was not successful in receiving funding for the project, the site plans to reapply for the next funding cycle in September

89 CMSP/TCE WELLNESS & PREVENTION PROGRAM 88 88

90 Lassen County The Lassen County W&PP provided case management and health education to all high-risk CMSP beneficiaries or CMSP-eligible individuals who sought services at one of Northeastern Rural Health Clinic s six clinic sites in Lassen County (four in Susanville, one in Doyle, and one in Westwood). The nurse case manager conducted an evaluation of patient charts from all six sites, rating the patient for chronic illness, socioeconomic barriers to care, ability to acquire medications, and any past history that indicated issues requiring regular follow-up and maintenance. She assigned an acuity rating (from 1 to 4) to each patient. The description of this rating system is as follows: Acuity 1 = no chronic disease, requiring only reminders for routine preventive care. Acuity 2 = chronic disease, but patient is capable of successfully managing the situation, requiring routine monitoring, follow-up, and prompts for regular medical visits. Acuity 3 or 4 = more serious, advanced illness, and/or the patient is less capable of managing the illness or prescribed course of care without Program Description continued on the next page> Total Award Expended $120,482 of $120,482 awarded Program Partners Northeastern Rural Health Clinics, Inc.* Crossroads Ministry Lassen County Public Health Department Geographic Area Served Lassen County Target Population CMSP beneficiaries and CMSP-eligible individuals living in Lassen County having chronic disease or with acute conditions for which they need assistance to manage the course of care *primary partner Contact Information Michael Wofford, RN, Clinic Coordinator Northeastern Rural Health Clinics, Inc. Phone: (530) mwofford@northeasternhealth.org 89

91 CMSP/TCE WELLNESS & PREVENTION PROGRAM Lassen W&PP Exec Rises to NEMT Challenge LASSEN COUNTY IS ONE OF THE three counties to participate with the CMSP in the Non-Emergency Medical Transportation (NEMT) planning initiative (see page 287 for details), and Janet Lasick, CEO of the Northeastern Rural Health Clinics, Inc. (NRHC), which is the primary Lassen County W&PP partner, has been involved from the beginning as an essential steering committee member. Finding medical providers who serve the indigent population in Modoc, Lassen, and Plumas counties to participate on the NEMT steering committee was not easy, since everyone is pretty swamped with other duties. However, Lasick has invested a great deal of time to make sure that the tricounty planning effort gets the feedback from medical providers needed for a useful solution, as well as helping to keep the planning process on track, providing multiple reality checks from the medical provider point of view. Lasick made sure that a representative number of patient surveys regarding NEMT were completed in the clinics she administers. She helped design medical provider surveys and saw to it that providers from her clinics responded to survey and interview requests by the transportation planning consultant working on behalf of the NEMT effort. Lasick has been the medical provider that is most consistent in participation in the NEMT project, from its initial meetings, through choosing the transportation planning consulting firm, participating in steering committee meetings held in Modoc, Butte, and Sacramento counties, and participating in a community forum held in Lassen county. >Program Description, continued from the previous page assistance, requiring more intensive case management involving working more closely with the patient and their provider; making sure that the patient was enrolled with the appropriate payor; and ensuring that medical appointments were made and kept, the appropriate health education occurred, patients were able to obtain the necessary medications, treatment regimens were followed, and referrals were completed. The nurse case manager then worked closely with the RN Clinic Coordinator and the medical providers to manage these patients course of care. She also revised these acuity scores periodically as necessary. Any changes in acuity scores were reported once per year in the annual report. The goals of this case management effort were to 1) increase compliance with courses of care and 2) improve patients overall health and ability to successfully selfmanage their chronic conditions. Health indicators such as blood 90 Janet Lasick (third right), CEO of the Northeastern Rural Health Clinics, Inc., rubs elbows with Dan Newton (second right), Transportation Planner with the Lassen County Transportation Commission, at the first NEMT steering meeting. pressure, blood sugar, cholesterol, and weight were used along with changes in acuity ratings to evaluate the success of the case management efforts. Patient data regarding demographics, health issues, services received, health indicators, referrals, and acuity scores was collected by the nurse case manager and stored in an MS Access electronic database that was designed by the evaluators. Although it had originally been hoped that the clinic MIS system could be used to collect and report data, that process turned out not to be feasible. Therefore, busy providers were faced with some duplication of data-entry efforts with this project. It appears that some of the information in the database, such as for health issues and health indicators, was entered for only a subset of clients; however, the data still reveals useful patterns of health issues and health indicators within the patient population. The project management originally wanted to staff the nurse case manager position with an RN, but they were not successful in finding a candidate. Therefore, they hired an LVN and trained her regarding case management, and she worked closely with the RN Clinic Coordinator in the course of her duties. The project intended to test this centralized case management model during the grant, with the objective 90

92 Lassen County Site Report of institutionalizing the case management position and its process if it proved valuable. The project conducted outreach efforts, particularly in collaboration with Crossroads Ministry, and clients were also referred from other providers. The grant funds were used to pay for a nurse case manager, LVN (0.5 FTE), a health educator (approximately 0.2 FTE), and a clinic coordinator, RN (approximately 0.2 FTE). Program Objectives and Outcomes 1 Objective 1 To develop a county-wide case management program for high-risk, indigent, and medically underserved individuals. W&PP Rating: Achieved Objective (high level of data to support) The project delivered data to the evaluators on 517 individuals served through this centralized case management strategy, and all of these were classified as CMSP beneficiaries. The following chart illustrates that the project served individuals from throughout the county, although most were from Susanville, the largest population center in Lassen County. Litchfield 1% Levitt Lake 1% Westwood 17% Janesville 7% Herlong 3% Doyle 5% Chester 2% Standish Milford 1% 2% Wendel 1% Susanville 60% City of residence of individuals served by the Lassen W&PP In year one, 309 clients were enrolled, the total number by the end of year two was 497, and the total enrolled by the end of year three was 517. Many clients were tracked for multiple years, and clients remained By forging new and expanded collaborative relationships with personnel from the Lassen County Transportation Commission and personnel at various Lassen social service agencies, Lasick is laying the groundwork for partnerships that will ultimately assist clients of her clinics in attaining better access to health care, both locally at the clinics and in neighboring counties at sites of specialty care that is not available in Lassen County. These relationships, formed during the NEMT transportation planning process, will facilitate the development of a more coordinated and efficient medical transportation system in Lassen County. Non-emergency medical transportation is taking on increased importance for NRHC, because its six clinics that are located in Susanville (Lassen Family Practice, Great Basin Primary Care, Lassen Women s Health Center, Lassen Family Urgent Care, Northeastern Occupational Medicine, and Lassen Family Dental) will soon be consolidating at a new facility that is located several miles outside of town near the hospital. When this move occurs, many indigent clients who formerly could walk, bicycle, or ride the bus to the clinic will then face a more difficult transportation challenge. It is also anticipated that the new clinic next to the new hospital will attract even more local patients than are currently served in NRHC s Susanville clinics, especially considering the expanded services such as a larger dental clinic and a pharmacy. Lasick is working with the Lassen Transportation Commission to devise work able solutions for this problem. It is anticipated that the consolidation of the Susanville clinics near the hospital will produce a large medical complex that will serve as a regional hub for medical services. As such, the medical complex will be providing an increased number of services to surrounding communities and counties, which will further increase the need for transportation services to it from both local and regional points of origin. The tri-county NEMT planning project that was initiated by the CMSP Governing Board and that received so much valuable guidance from Lasick will be an important contributor to transportation solutions for these increasing and changing needs. 1 Refer to DRA s evaluation report in Volume 2 of this report for the site's complete evaluation findings. 91

93 CMSP/TCE WELLNESS & PREVENTION PROGRAM active and were monitored as long as they continued to use clinic services and could be contacted. The large majority were unemployed (87%) or employed part-time (10%), indicating that the project reached its target population of indigent individuals. The project delivered data to the evaluators on 83 of the 517 enrollees regarding health issues, shown below Hypertension Type 1 Diabetes Type 2 Diabetes Hyperlipidemia Heart Disease Obesity High Cholosterol COPD* Smoker Hepatits C Primary Secondary Other Health issues of individuals who were case managed in the Lassen W&PP Although this data is a subset of the total population served, it reveals a pattern of individuals with chronic conditions, again indicating that the project reached its target population. The project delivered client visit data to the evaluator on 154 of the 517 clients. Again, although this data appears to be a subset of the total group, it reveals the pattern of service for these clients. A total of 329 visits were recorded for 154 clients. The number of visits ranged from one to 19, with an average number of five visits per client. Most clients (54%; 84/154) had 1 visit recorded. Approximately 16%(24/154) of clients have two visits recorded, 12%(19/154) had three visits, and 5% (8/154) had five visits. A total of 10 clients (7%) had over five visits. The evaluators analyzed the visits data by year and found that active clients increased the average number of visits from about 1 per client the first year to about 3 per client by the third year of the project. The project reported that overall, the average number of visits/client/year increased from less than 1 to 1.6 over the course of the grant period, a statistic that the project staff interpreted to indicate that better care was being provided and that case management was successful in increasing access to care. The impact of the case management efforts was difficult to evaluate from the health indicator data provided. For example, for diabetics, the project tracked blood sugar levels, not HbA1c levels. Blood sugar levels are much more affected by the contents and timing of the last meal than are HbA1c levels, which give an indication of blood sugar levels over time. Thus, it is difficult to interpret blood sugar levels as they relate to whether diabetes is being controlled or not. Additionally, only a small number of individuals (12) had repeated measures of blood sugar. Of these 5 showed increases, 5 showed decreases, and 2 were unchanged. Regarding blood pressure, only 18 patients had repeated blood pressure measurements, and only 10 of these were classified as hypertensive, even though more than 30 individuals were identified as having hypertensive health issues. Of these 10 individuals, blood pressure became lowered in 9 and dropped to normal ranges in 5 over the course of the program. Thus, although this again is a subset of all enrolled patients with hypertension, a pattern of effective treatment is indicated. Although being overweight is a common problem among diabetic and hypertensive people, only 16 patients had repeated weight measures recorded, indicating again that data was recorded for only a subset of overweight patients. 92 Of these, 6 lost weight, (average of 13.3 pounds), but 8 gained weight (average of 13 pounds). The acuity scores had two intended purposes: 1) to differentiate between patients who did nor did not have chronic disease, those that needed only routine reminders, and those who needed more intensive case management services; and 2) to provide an indication of the effectiveness of case management, with patients effectively managed experiencing a lowering of the acuity score over time. Regarding the first purpose, the acuity scores revealed that acuities of 3 and 4, requiring the most intensive case management, were assigned to only 2%, 9%, and 11% of enrollees during the first, second, and third grant years as shown on the graph below. 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 84% 13% 2% 0% 73% 18% 5% 4% 71% 18% 6% 5% Contract Year Level 1 Level 2 Level 3 Level 4 Acuity levels of case-managed clients of the Lassen W&PP 92

94 Lassen County Site Report Acuity scores of 2, requiring some monitoring and routine appointment reminders for individuals with chronic disease, were assigned to 11%, 18%, and 18% of individuals across the grant years. Thus, it is apparent that most of the 517 enrolled individuals (84%, 73%, and 71%) did not have chronic disease or did not need assistance beyond routine appointment reminders in managing their course of care. It had been hoped by the evaluators that changes in acuity scores might give an indication of the impact of case management, but the manner in which these scores were recorded did not allow repeated measures during the year for a given individual, but rather allowed only one score per individual per year. This process limited the number of individuals with repeated measures of acuity. A decrease in acuity score was recorded in only 14 clients: 11 by 1 point, 1 by 2 points, and 2 by 3 points. On the other hand, 31 patients had increases in acuity scores: 20 by 1 point, 6 by 2 points, and 5 by 3 points. It is difficult to interpret these data. Notwithstanding the limits of the data regarding the impact of case management, it is clear that the clinic s management was impressed with the value of case management because their intention is to retain the nurse case manager position after the sunset of the grant. The clinic management also intends to expand the case management services to all clinic patients, not limiting this service to CMSP beneficiaries. Objective 2 To provide infant car seats, at a reduced cost, to indigent parents. Laraika Gibbs, Nurse Case Manager for the Lassen W&PP the objective was withdrawn from the scope of the project and no Wellness & Prevention Program grant funds were expended on this effort in Cycle 3. Objective 3 To monitor the compliance levels of low-income and CMSP residents, and to assess, the impact of the project on car-seat related injuries in Lassen County. W&PP Rating: Objective Withdrawn Please refer to the rationale as described under Objective 2. Cost and Service Use Analysis Report The project submitted 453 records of CMSP beneficiaries who were enrolled in case management prior to October 31, This data was folded into the Case Management cluster. Additionally, the unique case management model, the data from the Lassen W&PP project was also analyzed separately. The entire analysis is summarized in the Cost and Service Use Analysis section of this report, and the complete report by the analysis contractor, The Lewin Group, is included in Volume 2, Evaluation Findings. The patterns of cost and service use before and after enrollment are shown on Graphs A and B on the following page. The increased Hospital Inpatient claims and payments after enrollment are trends that were not expected. However, it should be noted that the total payments per member per month in the post-enrollment group ($246) was substantially lower than that for the All CMSP group ($414), the All W&PP group ($410), or the All case-managed group ($404) post-enrollment. W&PP Rating: Objective Withdrawn The Lassen County Public Health Department proposed the activities associated with the accomplishment of this objective in the original grant proposal. However, the health department withdrew from the collaborative process soon after the grant award was made. Therefore, Future Directions After the sunset of the grant, Northeastern Rural Health Clinics, Inc. intends to continue funding the nurse case manager position and the case management processes developed in the grant project. Additionally, the intention is to expand this case management service to all clinic patients with chronic disease or difficulty managing their course of care. 93

95 CMSP/TCE WELLNESS & PREVENTION PROGRAM Graph A: Claims per 1000 members per month by service-use category for Lassen County W&PP enrollees Before Enrollment After Enrollment Hospital IP Days Hospital IP Claims Hospital OP Claims Physician Claims Clinic Claims Lab Claims Home Health Claims 94 All Other Claims Graph B: Claims per member per month by service-use category for Lassen County W&PP enrollees $350 $300 $250 $200 $150 Before Enrollment After Enrollment $100 $50 $0 All Payments** Hospital IP Payments Hospital OP Payments Physician Payments Clinic Payments Lab Payments Home Health Payments All Other Payments *Excluding pharmacy claims 94

96 Plumas County The overall goal of this project was to improve access to health care for indigent and underinsured clients who have or are at-risk for diabetes. The Plumas County Wellness and Prevention Program, headed by the Plumas County Public Health Agency, subcontracted with Eastern Plumas Health Care and Seneca Healthcare District to provide for diabetic clinics in Graeagle, Portola, Chester, and the Lake Almanor Basin area. Seneca Healthcare District is located in the Chester/ Lake Almanor area in the north of the county. Eastern Plumas Health Care is located in the Portola/Graeagle area in the southeast section of the county. Quincy, home base for the Project Director, is located near the center of the county between the two clinic sites. The project specifically targeted not only the 87 CMSP clients in the county known to be diabetic (including 12 who had received inpatient hospital services at Seneca Hospital), but also the 186 CMSP-eligible clients already identified in the county who may not be aware of the services available to them. In addition, the project hoped to serve members of the Native American and Hispanic/Latino communities. Because of the project s inability to contact and engage diabetics who were enrolled in or eligible for CMSP, despite making a variety of different types of attempts (detailed in the evaluator s report), the focus of the project was expanded to target indigent and underinsured individuals who were eligible for or enrolled in Medi-Cal, were in the Medicare program, had private insurance, or had no insurance. Program Description continued on the next page> Total Award Expended $120,254 of $120,254 awarded Program Partners Plumas County Public Health Agency Eastern Plumas Health Care Seneca Healthcare District Geographic Area Served Plumas County Target Population CMSP-eligible and other indigent and underinsured individuals who are at risk for or have diabetes Contact Information Tammy White, Supervising Public Health Nurse Plumas County Public Health Agency Phone: (530) tammywhite@countyofplumas.com 95

97 CMSP/TCE WELLNESS & PREVENTION PROGRAM >Program Description, continued from the previous page Culturally and Linguistically Appropriate Diabetes Education Success in Frontier Areas Requires Creativity PLUMAS COUNTY IS AN EXAMPLE of a sparsely populated mountainous region in which health care providers have to wear many hats to cover all the bases. Tammy White, a Supervising Public Health Nurse with Plumas County Public Health Agency, has found that reaching the Spanish-speaking diabetic population in the county is particularly challenging. It is extremely difficult to attract qualified bilingual health care professionals to the county. Although one bilingual dietitian has been hired to serve the county, she can t be everywhere at once. White is often left to her own devices when faced with communicating to a monolingual Spanish speaker. Finding an interpreter continues to be a challenge, and interpreters services are costly, says White. White speaks a little Spanish, but she finds herself primarily communicating through literature and pictures in both English and Spanish. An interpreter is essential, if available. To establish trusting relationships, White borrowed an idea suggested by her dietitian colleague. She brings a map of Mexico with her on home visits so the client can show her where they are from. Then she engages them in talking about their home, their family, and their family history. These things build trust and confidence with people, White says. White tries to include the client s family in each home visit to be a part of the process so they can learn about their family member s condition and learn how to support them, but not to provide translation services. Working with Hispanics having strong roots in Mexico presents special challenges, such as Ultimately, approximately one-half of the 108 individuals who were documented to have been served were older than 65 and enrolled in the Medicare program, one-third had private insurance, less than 4% were enrolled in CMSP, less than 1% were Hispanic/Latino, and none were Native Americans. 1 Each site attempted to identify individuals within the target population and engage them in a disease management program in order to: 1) improve and/or maintain their health; and 2) increase their utilization of available health maintenance resources through referrals to disease management, health and support programs, and necessary specialty services. In addition to providing referrals, the diabetic clinics coordinated a number of case management activities with primary care physicians including medical examinations, lab tests, screenings, assessments and early interventions, health and risk-reduction education, compliance review, prescription response, referrals to specialty services, and nutritional counseling. The expectation was that as a result of these efforts, client health and quality of life 96would improve and costs for preventable conditions related to diabetes would be reduced. A large effort of the project was to attempt to upgrade capacities to acquire and use electronically stored data to document activities and impacts. The evaluators expended an unusual amount of effort towards this end, and one partner (Seneca Healthcare District) embraced the effort and made significant increases in this capacity. The other site was significantly impaired by a very poor infrastructure for electronic data collection 2 as well as a low level of readiness for this activity. Although Eastern Plumas Health Care staff were not able to develop the capacity to deliver data electronically, they do have an increased level of awareness regarding the value of such efforts, and state that they intend to continue development of this capacity. The project staff reports that collaboration in this project was a major challenge. In part because of the poorly developed infrastructure for electronic communications noted previously, and in part because Plumas County is a frontier rural area characterized by large distances and mountainous terrain between communities who, especially during the winter as a result of heavy snowfalls, find themselves largely cut off from surrounding communities. These communities have 1 The data cited in this report reflect the experience of Seneca Healthcare District only; despite intense efforts by DRA to support the site in data delivery, Eastern Plumas Health Care submitted their data in hard copy format too late to be processed and included in DRA s evaluation report. 2 Refer to DRA s site evaluation for details. 96

98 Plumas County Site Report historically found that the qualities of rugged individualism and independence have been functional for them. However, these qualities may at times impede modern collaborative efforts. The Indian tribes in Plumas County also have historically maintained a tradition of isolation from the surrounding communities. Two sites (Indian Valley Healthcare District and Indian Valley/ Greenville) that deliver for health care to the American Indian population in Plumas County were originally planned to participate in the collaborative on this project. However, these organizations did not elect to participate in the evaluation efforts. Program Objectives and Outcomes 3 Objective 1 To identify individuals who have or are at risk for diabetes and engage them in a disease management program in order to improve and/or maintain their health. W&PP Rating: Achieved Objective (moderate level of data to support) The project delivered health issues data to the evaluators for 90 of the 108 enrolled individuals at Seneca Healthcare District, summarized in the charts below, indicating that the target population of individuals with diabetes or at risk for diabetes had been reached. Lake Almanor is one of the jewels of Plumas County. erroneous preconceived notions about the value of some home remedies for treating diabetes. I have to work with clients to assess their level of understanding of the remedy. First I ask the client their understanding of how the remedy works and why it is important to them. I do some research on the remedy (including translation of accompanying literature) to try and determine if the remedy is beneficial, harmful, or is neutral. Timing is everything, and the message is delivered with great sensitivity, especially if the remedy will not help the client, White emphasizes. White attended a physician visit with a client and an interpreter to address as many of the client s questions and problems about their illness at one time, which maximizes the outcome because everyone hears the same thing, gets clarification, and knows which direction to go. Hypertension 13% Hyperlipidemia 2% Type 2 48% Heart Disease 9% Obesity 13% Smoker 7% High Cholesterol Type 1 1% 6% Gestational 1% Primary health issues of individuals enrolled in the Seneca Healthcare District W&PP 3 Refer to DRA s evaluation report in Volume 2 of this report for the site's complete evaluation findings. 97

99 CMSP/TCE WELLNESS & PREVENTION PROGRAM Smoker 20% Hypertension 24% Objective 2 To increase referrals of individuals with diabetes to disease management programs and necessary specialty services. Obesity 24% Hyperlipidemia 8% Heart Disease 24% Secondary health issues of individuals enrolled in the Seneca Healthcare District W&PP As the data shows, 48 of 90 (53%) of the enrolled individuals were identified to have type 1, type 2, or gestational diabetes. The second most common health issues identified in this client population were hypertension and obesity, both at 13% (12/90). The project delivered health indicator data to the evaluators on blood pressure, weight loss, HbA1c test results, and cholesterol levels that indicate that the case management services and access to care resulted in improvements in management of diabetes for enrolled individuals that had diagnostic values outside the acceptable range upon enrollment and for which a second diagnostic value was collected by the project site. Specifically, these data were: 26 of 32 (81%) hypertensive individuals achieved decreases in blood pressure; 25 of 108 individuals lost an average of 12 pounds, for a total of 348 pounds lost; 5 of 6 (83%) individuals with high HbA1c levels achieved significant reductions in those levels; 4 of 4 (100%) of individuals with hyperlipidemia considerably reduced their LDL levels. Further supporting that individuals had been engaged in a program to improve their health status was the data on visits: a total of 387 visits to the diabetes clinic staff were recorded for the 108 Seneca clients, and 164 visits to the diabetes clinic were made by 27 clients at Eastern Plumas Health Care. W&PP Rating: Partially Achieved Objective (moderate level of data to support) A community awareness campaign was designed and implemented to promote participation in diabetic screening and diagnostic services among the target population and the general community. This campaign was implemented through a number of activities including education presentations/sessions conducted with Native American residents, creation and distribution of flyers and informational brochures/materials, community screening events, radio public service announcements, and newspaper articles. Unfortunately, these efforts appear to have been largely ineffective at reaching or persuading 98 the target population. Nearly all program participants (99%; 107/108) were ultimately referred by physicians who had received information on the diabetes case management program. The cumulative number of clients served increased each year with totals of 34 in 2001, 79 in 2002, and 108 in 2003, indicating referrals were ongoing during the project. Since there were presumably no diabetes education or case management services available for the population served prior to the grant program, any referrals that occurred would represent an increase over preexisting levels. The project did not submit any data to the evaluators regarding referrals to specialty services. However, the project reported that all clients who enrolled/participated in the diabetes clinics at either site received the following set of services: Individual health and risk assessment; Personal health/disease management plan development; Basic lab work, including height/weight; blood pressure, blood sugar; HbA1c, where necessary; and lipid/cholesterol tests; Other labs as necessary; Foot checks; Eye checks; Diabetes education along ADA guidelines, including diet and nutrition; Referrals to primary care and/or specialist providers as necessary; and Medications reviews. 98

100 Plumas County Site Report Cost and Service Use Analysis The project submitted 3 records of CMSP beneficiaries who had been enrolled into case management prior to October 31, This data was folded into the Case Management cluster that is reported on page 267. Future Directions Both project sites reported the intention to continue their respective diabetes education and management programs beyond the term of the W&PP grant funding. The diabetes clinic at Eastern Plumas Health Care (EPHC) states that there is no plan to terminate the program and that it will continue to be improved through further attempts at evaluation and program refinement/ modification. EPHC believes that success has been seen in the identification of standards, improved patient outcomes, provider and staff education, and the ongoing effort to develop a mechanism for documentation that will allow further evaluations and (program/service) improvements. Seneca Healthcare District also intends to continue the program. However, Seneca Hospital s outpatient clinic recently received its designation as a Rural Health Clinic (RHC) and as such can no longer receive reimbursement for the diabetes education/case management activities. The hospital feels the program has been successful and was a valuable addition to their spectrum of care. In order to save the program and continue providing these services, the program was rehoused in the hospital s education department. This configuration allows for case management activities to continue uninterrupted and for services to be billed on a fee-for-service basis. The project is thus expected to be self-sustaining from this point forward. 99

101 CMSP/TCE WELLNESS & PREVENTION PROGRAM

102 Siskiyou County Siskiyou County s Wellness and Prevention Program project was a collaboration between Mt. Shasta Medi-Cal Clinic in the southern portion of the county and Siskiyou Family Healthcare, Inc. in the northern portion of the county, and to a limited extent with the Siskiyou Public Health Department. These two clinics operated under the same goals and objectives, but operated independently of one another aside from sharing information about effective strategies and coordinating outreach efforts at the County Fair during year one, which was a collaborative effort between all three organizations. During grant years one and two, the project conducted community-based health screenings in north county and clinic-based health screenings in south county for low-income, rural Siskiyou County community members in order to identify people with chronic illnesses, focusing on diabetes, morbid obesity, hypercholesterolemia, and hypertension. Those identified as at-risk for or having any of the above chronic Program Description continued on the next page> Total Award Expended $190,720 of $190,722 awarded Program Partners Mt. Shasta Medi-Cal Clinic Siskiyou Family Healthcare, Inc. Siskiyou County Public Health Department Geographic Area Served Northern and southern areas of Siskiyou County Target Population CMSP-eligible and other low-income people living in rural Siskiyou County Contact Information Denise Fairhurst, Administrator Mt. Shasta Medi-Cal Clinic Phone: (530) msclinic@snowcrest.net Cheryl Deala, CFO Siskiyou Family Healthcare, Inc. Phone: (530) cdeala.sfhc@sbcglobal.net 101

103 CMSP/TCE WELLNESS & PREVENTION PROGRAM Empowering Patients to Manage their Diabetes Often, a person diagnosed with diabetes requires the support of medical providers, dieticians, and health educators to address aspects of their life and care regimen such as medication, diet, exercise, and medical care in an effort to keep their blood glucose levels in check. Staff at Siskiyou Family Healthcare, Inc. shared the following stories in the project s 2003 annual report that illustrate the assistance a diabetes care team can provide to a patient with documented results in the reduction of HbA1c levels. Wanda Wanda, a 47-year-old patient with Type 1 diabetes, hypertension, hyperlipidemia, and major depressive disorder, was found to have a hemoglobin A1c (HbA1c) level of 17% after a routine checkup. She had a history of erratic control and would allow herself to have high glucose levels for many weeks without contacting her diabetic care team. She was on intensive insulin therapy, and she required more frequent contact for troubleshooting and insulin adjustments. Appointments were scheduled every two weeks until her blood glucose levels were brought under better control. The patient stated, I thought I should be able to manage my diabetes myself. Wanda now knows to contact her physician or diabetes educator at the first sign of problem with control. Wanda s subsequent hemoglobin HbA1c levels were 7.9% and 8.2%, not yet on target, but significantly improved over a 7- month period. >Program Description, continued from the previous page The imposing peak of Shasta Mountain is a focal point of beautiful vistas of Siskiyou County. conditions via participation in the screening events or by their primary care provider were offered case management services including direct health maintenance, education, and referrals to medical care and other services. During year 3, the project reported stopping outreach screenings because very few people with chronic disease problems that were not already engaged with a primary care provider were identified, and therefore, screening outreach did not seem to be a good use of resources. Other community-wide efforts included implementing health education classes open to all community members and a special effort to increase access to specialty care for clinic clients. Grant funds were used to support a Certified Diabetes Educator at the northern site to conduct case management and education; a Registered 102 Nurse at the southern site to conduct blood pressure and blood sugar checks at numerous health education classes regarding cholesterol control, diabetes self-management, hypertension control, medication management, and exercise; data entry and evaluation; diabetes and computer application training; and attendance at the CMSP/TCE W&PP Technical Support Workshops. Additionally, grant funds were used to support the provision of specialty care physician services at both project sites. Siskiyou Family Practice enhanced their services with the addition of contracted Orthopedic Surgeon and Internal Medicine physicians who saw lowincome clients at the clinic site. Mt. Shasta Medi-Cal Clinic added the following specialty services during the grant period: orthopedics, geriatrics, internal medicine, ENT, cardiology, dermatology, diabetic foot care, and mental health services. Though a large portion of the grant resources were expended as an augmentation of medical services provided by specialists, these activities were not reflected in the project s final evaluation plan due to the Wellness & Prevention Program s expressed interest in the projects chronic disease education and case management components. Therefore, evaluation resources were directed at collecting data in regards to changes in clients health status following education and case management interventions. 102

104 Siskiyou County Site Report Program Objectives and Outcomes 1 Objective 1 To provide outpatient case management for clients with chronic illnesses focusing on diabetes, morbid obesity, hypercholesterolemia, and hypertension. W&PP Rating: Achieved Objective (high level of data to support) Siskiyou Family Healthcare (northern site) provided data to the evaluator on 159 case-managed clients who were served through 1699 contacts with the Certified Diabetes Educator (CDE), for an average of 11 contacts per client. Graph A summarizes the types of services received during case management. LDL levels at intake and 11 had normal levels at some point during case management. Regarding weight loss, 25 clients lost 10 pounds or more, with an average lost of 19.8 points. One client lost 77 pounds, from 220 to 143 pounds, over the course of 2 years. The project also reported anecdotally on 6 clients who had particular success gaining selfcare skills. The project reported that upon enrollment into case management, the CDE held individual counseling sessions with each client. These sessions included instruction on all aspects of diabetic self-care, assessments of blood glucose records, and adjustments of diabetic medications. Diabetes flow sheets were used to monitor compliance with American Diabetes Association standards of care. Diabetes follow-up appointments Graph A: Services provided to clients of the northern Siskiyou County s W&PP Enrollment Referral 35 Clinic Clinic Visit Visit/Med F/U Refill Wellness Women's Physical Health Exam Exam Clinic Visit Urgent 31 Diabetic Glucose Education Monitoring Provided There was no specific information regarding referrals to specialty services recorded for these clients. All of these individuals had some form of diabetes, along with one or more of a variety of other health issues. Basic lab values were recorded at visits with the CDE, and data delivered to the evaluators indicated that many clients showed substantial improvements in these health indicators. For example, 43 clients had hypertension when enrolled into case management, and 20 of these had normal blood pressure at their last contact. Additionally, 28 clients had dangerously high HbA1c values (>8.0) at intake, and 17 of these were able to lower these values by at least 2 points or to less than 8.0. Regarding elevated cholesterol, 22 clients had elevated with both the client s primary provider and the CDE were scheduled at each visit. Every effort was made to encourage patients to take responsibility for diabetes self-care and to learn the skills needed to manage their disease. Glucometers were provided to case-managed patients at no charge, and instruction was provided on their use. The Mt. Shasta Medi-Cal Clinic (southern site) delivered data to the evaluator on 88 case-managed clients. For some unexplained reason, services were recorded in the database for only 24 of these clients, who received a total of 328 services, or an average of about 14 per client. Graph B on the following page summarizes the types of services they received. 1 Refer to DRA s evaluation report in Volume 2 of this report for the site's complete evaluation findings. 103

105 CMSP/TCE WELLNESS & PREVENTION PROGRAM Graph B: Services provided to clients of southern Siskiyou County s W&PP Enrollment Clinic Visit/Med Refill Clinic Visit F/U Wellness Women's Health Clinic Visit- Physical Exam Exam Urgent There was no specific information regarding referrals to specialty services for these clients. Health issues were recorded for 84 of the 88 enrollees. All 84 clients had some form of diabetes, and only a total of 15 other health issues were recorded for these individuals, an unexpectedly low number, indicated perhaps again an incomplete data set. Lab results were delivered to the evaluators indicating substantial improvements in various health indicators among these clients. Of 44 clients with hypertension at intake, 29 had normal readings at their last visit. Of the 6 clients with HbA1c values greater than 8.0, these values were reduced by 2 points or to below 8.0 in 5 clients. Again, a limited data set is suspected, since this seems like a low percentage with elevated HbA1c levels (7%, or 6 of 88) of diabetics who had not been case-managed. Regarding cholesterol, 5 of 9 clients with high cholesterol at intake had normal levels at their last visit. Concerning weight loss, 16 clients lost 10 pounds or more, with an average weight loss of 21 pounds. Objective 2 To empower clients to maintain health through health education classes. W&PP Rating: Achieved Objective (moderate level of data to support) Siskiyou Family Healthcare (northern site) reported that they held an- unspecified number of six-week community classes, presumably taught by the CDE, covering topics of diabetes, healthy weight management, and health life styles. The project did not supply any data to the evaluator regarding the number of type of people attending these classes, 104 except to note that they did not reach the CMSP population despite a concerted effort to do so. The project also did not provide any data regarding the impact of these classes. Anecdotally, the project noted that the classes were very successful with active participation and positive feedback. The Mt. Shasta Medi-Cal Clinic (southern site) stated that another funding source (a Local Opportunities grant from The California Endowment) paid for the educational classes. Details regarding these classes are provided in the evaluator s report. Objective 3 To work collaboratively to identify residents who have had difficulty accessing health care and facilitate their entry. W&PP Rating: Partially Achieved Objective (minimal level of data to support) Although neither site delivered any data to the evaluator regarding this objective, Siskiyou Family Healthcare (northern site) reported anecdotally that they collaborated with the Siskiyou County Public Health Department, various businesses, and the local college to provide outreach screening events that reached more than 800 people over the first two years of the grant. There was no information, even anecdotal, about positive impacts on increasing access to health care of this effort. However, the following negative findings were reported: 1) the project found that they were not reaching the 104

106 Siskiyou County Site Report underserved low-income target population, including CMSP-eligible people with these events, and 2) follow-up success was low. Therefore, the project discontinued outreach screening during year three of the grant period. The Mt. Shasta Medi-Cal Clinic (southern site) did not conduct outreach screening; they did report that they participated at the County Fair, handing out information about how to access various health programs. They provided no data to the evaluator of any sort regarding this effort or regarding their reported advertising of clinic services to people without a medical home. Cost and Service Use Analysis The project submitted 21 core data records CMSPeligible individuals enrolled into case management prior to October 31, This data will be folded into the Case Management cluster that is reported on page 268. Future Directions Siskiyou Family Healthcare (northern site) reports that case management services and health education classes will be continued if funding permits. The services of the orthopedic surgeon will still be available once or twice a month. The Mt. Shasta Medi-Cal Clinic (southern site) reports that they will continue case management efforts, however, with a different tracking tool. They have begun an anticoagulation therapy program that has a tracking tool with printouts for patients. Later this year, the tracking tool will be expanded to add the ability to track diabetes, and Mt. Shasta Medi-Cal Clinic will use that tracking tool for patients utilizing the services of the Certified Diabetes Educator. Mt. Shasta Medi-Cal Clinic will continue to provide some health education classes and the specialty care network, established during the grant period, will remain intact. Patrice Patrice, a 50-year-old woman, presented with blood glucose levels in the 300 to 500 range, and a recent HbA1c level of 10.6%. Problems were identified with her medication usage, diet, and general knowledge of handling her diabetes properly. The following interventions were made with Patrice: she was switched to insulin pens to make insulin delivery easier and more convenient, she was switched to a rapid-acting insulin so she could inject and eat immediately, and she was given a correction dose scale and instructed in its dose. She was taught carbohydrate counting and agreed to keep a food diary. Patrice is pleased with her progress and expresses appreciation for the ease of use of the insulin pen. It is expected that Patrice s HbA1c levels will continue to improve through the adherence to her care plan. 105

107 CMSP/TCE WELLNESS & PREVENTION PROGRAM

108 Low-Intensity Case Management Cluster. Glenn.. Lake... Marin... Solano... Sutter 107

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110 Glenn County The Glenn County Wellness and Prevention Program project, headed by Glenn County Health Services, targeted indigent and medically underserved populations with community-wide health education and screening campaigns in order to increase awareness and utilization of available resources. Based upon results from the screenings, individuals were to be referred to a variety of services including: case management, medical, dental, social, and CMSP/other enrollment services. Case management services were provided to those referred from screenings and from other project partners. An adult wellness and prevention collaborative was developed to provide local direction for health and wellness efforts throughout the county. Initially, the case management services were targeted specifically to clients referred from local drug and alcohol programs and jails. However, after two years, Program Description continued on the next page> Total Award Expended $165,989 of $178,376 awarded Program Partners Glenn County Human Resource Agency Glenn County Health Services Glenn Medical Center North Valley Indian Health Geographic Area Served Glenn County Target Population Uninsured and/or underserved residents of Glenn County, including a focus on the Hispanic community Contact Information Nip Boyes, PHN Glenn County Health Services Phone: (530) nboyes@glenncountyhealth.net 109

111 CMSP/TCE WELLNESS & PREVENTION PROGRAM >Program Description, continued from the previous page Glenn County s Client-Centered Care HEALTH CARE WORKERS in the CMSP/TCE W&PP projects have repeatedly found that when clientcentered approaches are used that focus on the whole person and on achievable steps that are prioritized in concert with the desires of the client, indigent adults are often motivated and able to make the necessary life style adjustments to successfully address their particular medical problems. Additionally, clients who are helped to achieve the first of their health care goals often experience a sense of empowerment and develop the ability to begin advocating for their other health and social needs. Thus was the experience in the Glenn County W&PP project, where case managers Sharon Camper, RN and Nip Boyes, PHN, put themselves in their clients shoes as they strove to understand their clients problems and the barriers that they were experiencing. Using this approach, they and their clients could determine the best approach for solving those problems. For example, a 43-year-old gentleman, a Vietnam veteran of limited means and having no health insurance, was denied rabies and asthma treatment at a clinic because of his inability to pay for services or medications. Boyes visited the client s home to better understand his client and his personal challenges. He then walked his client through the process for enrolling in the CMSP. After his client continued to be denied service at the clinic because of misunderstandings by the front office staff about the CMSP program, Boyes again intervened personally and observed firsthand the uncooperative behavior towards his client by the front office personnel. Boyes responded by helping his client establish a relationship with a different clinic, an arrangement that is continuing to work well. Additionally, Boyes arranged for a training session regarding the CMSP for the first clinic s staff. because of very poor follow-through by members of this population, the project expanded and shifted the focus to also providing case management and access to dental services for Spanish-speaking, primarily undocumented Hispanic individuals, as well as offering free immunizations against hepatitis A and B for a few hepatitis C-infected individuals. The grant funds were used to fund an Adult Wellness & Prevention Program nurse to provide screening and case management services, a bilingual case manager for the Hispanic dental effort, dental services for indigent Hispanic individuals who lacked a payor source and the ability to pay, and the hepatitis A and B program advertising and vaccines for 5 individuals. Program Objectives and Outcomes 1 Objective 1 To provide community health screenings and education to at least 200 persons each year in order to increase awareness of health status/risks. 110 W&PP Rating: Achieved Objective (high level of data to support) The project provided data to the evaluators that revealed each year the project offered health screening and education services at four or more community events, including at storefronts, the Glenn County Fair, Hispanic cultural events, low-income resource fairs, flu clinics, local parks, and other community events. The data revealed that at least 743 blood pressure screenings, 212 cholesterol screenings, and 96 blood glucose screenings occurred, showing that the project easily reached its goal. As a result of these screenings, 97 clients were identified as having elevated blood pressure levels, 25 had elevated cholesterol levels, and 8 had high blood sugar. The project reported that 26% of those screened had no health insurance and 8% were covered by CMSP. The project recorded 381 referrals for individuals screened at outreach events as illustrated on Graph A on the following page. 1 Refer to DRA s evaluation report in Volume 2 of this report for the site's complete evaluation findings. 110

112 Glenn County Site Report Graph A: Referrals recorded for clients AWAP Case Management Re-screen CMSP Healthy Families Medical Provider Free Medications Routine Health Health Education Information Only Objective 2 To promote utilization of available health resources and services. W&PP Rating: Achieved Objective (moderate level of data to support) The project reported that the screening events were excellent opportunities for prevention education, where staff handed out adult wellness materials and shared referral and resource information to people waiting for their free screening. The project established, maintained, and distributed a list of health care providers and lowcost/no cost services for low-income adults. Although the project provided no data regarding the educational/ referral materials distributed, they thought that they exceeded their expectations in this area. As stated under Objective 1, 381 referrals were made; however, no follow-up regarding referral completion was done. Individuals without health insurance or who did not have a private physician were referred into the case management program. The case manager facilitated connections with needed services for these individuals. Objective 3 To provide case management to a minimum of 125 clients referred from local drug and alcohol programs and jails over the course of the three-year program. This objective was expanded in year three to include a dental case management program and a program through which vaccinations for hepatitis A and B were made available to hepatitis C-positive individuals. W&PP Rating: Partially Achieved Objective (high level of data to support) During the first two years, staff were disappointed with the numbers of the target population that they were able to successfully case manage, citing difficulties in contacting clients and a very low rate of follow-through with referral appointments by this population. Therefore, they began to focus on individuals who were referred to the Adult Wellness & Prevention case management program from outreach screening events, referrals from providers, and walk-ins or call-ins to the Health Department. The project delivered a data set to the evaluators that revealed that 76 people were enrolled into case management, of which 12 were from the original target population, 13 were referred from screening events, 24 were call-ins or walk-ins to the Health Department, 11 were referred by providers, and 16 were self-referred or other. Case management consisted of assessment, education, referrals, immunizations, screening, assistance with applications, and patient advocacy. 111

113 CMSP/TCE WELLNESS & PREVENTION PROGRAM The AWAP overcame challenges such as attempting to contact individuals with disconnected phones, lack of responses to letters, and often a lack of self-initiative or readiness on the part of the client. The project made 111 referrals for 43 case managed clients as illustrated in Graph B: 35 Graph B: Referrals made for clients of the Glenn County Adult W&PP (AWAP) AWA Emergency Services Health Education Information Given Other 112 Re-screen Resource Routine Services Information Health Care Given All 21 of the case-managed Hispanic clients spoke solely or primarily Spanish, and the translation services of the bilingual dental case manager were very helpful for these clients. In year three, an additional component was added case management and free dental services for Spanishspeaking Hispanics with no health insurance and no ability to pay for services. The project delivered a data set that revealed that 121 clients were enrolled into dental case management from August 2003 to February Dental case management consisted of identifying and prioritizing client needs, educating clients, providing appropriate referrals to dental care, and fostering ongoing preventive dental care. Most clients were not eligible for health insurance because of their undocumented status and had no ability to pay. For those individuals, W&PP grant funds were used to cover the dental services. The project attributed the success of the dental case management program partly to the fact that the afflicted people were in pain and thus motivated to participate, and partly to the effectiveness of outreach of the bilingual case manager who had multiple contacts in the target population. The staff attributed the lack of good success with the original target population to a lack of motivation or readiness for change on the part of clients. Staff found that they had the best success with individuals who had only recently fallen into indigent status. The dental project was originally supported through Cycle 1 Wellness & Prevention Program efforts and was deemed such a success that the County Board of Supervisors agreed to continue funding the dental services and case management with general fund dollars. The dental component operated for three years with this revenue source, but as county funds reduced, the project moved back to relying on grant funding to sustain its efforts. The project reports that the Hepatitis Vaccination Program was conceived under the best intentions but failed to capture the attention of the community despite an intensive media campaign. The program fielded many calls, but only 10 callers were eligible and only 5 clients followed through with receiving the hepatitis A and hepatitis B vaccines. Factors determining eligibility included being a resident of Glenn County, testing hepatitis C-positive, and have no other payment source for the vaccinations. Though only a small number of individuals benefited from the vaccination effort, the project reports that its focus on adult vaccines and hepatitis C proved to be a benefit in increasing the awareness of the community and of providers working with the substance abuse or hepatitis C populations. 112

114 Glenn County Site Report Objective 4 To maintain a collaborative to provide local direction for health and wellness efforts. W&PP Rating: Achieved Objective (moderate level of data to support) Although no data regarding this objective was submitted to the evaluators, the project reported that at the beginning of the W&PP project, a collaborative was formed that met bimonthly. Initially, this collaborative consisted of Glenn County Health Services, local clinics, the local hospital, Glenn County Human Resources Agency, and the County Schools Senior Nutrition Program. As the program evolved, the Glenn County Sheriff s Office Correctional Facility, County Mental Health Services, local physicians, county substance abuse program coordinators, and the County Schools Adult Programs became involved. Out of this partnership another community-based collaborative was formed that meets monthly focusing primarily on the needs of Hispanic older adults. These collaborative efforts have resulted in joint community-wide outreach events and allowed the AWAP program to develop and maintain a list of providers offering low-cost/no-cost services to low-income adults. Referral networks were built, bringing clients into the AWAP program and serving as referral resources for AWAP clients. These partnerships also resulted in opportunities to provide health education regarding adult wellness issues to groups that include members of the project s target population as well as staff in-services. The project further feels that becoming familiar with working with these other agencies will allow them to continue to assist clients with needed services even when the case management component of the project is no longer available. Sharon Camper, RN, of the Glenn County Wellness & Prevention project, attends to a client. In another case, a 56-year-old undocumented, low-income, uninsured Spanishspeaking woman with untreated type 2 diabetes came to the attention of the Glenn County W&PP staff at an outreach event targeted to Hispanics. Camper and Boyes were able to provide diabetes education, coordinate with a primary care provider to obtain low-cost medications that the woman could afford, obtain a donation of a glucometer and test strips, and develop a diet and exercise plan with her. The woman is now successfully maintaining her blood glucose level within the normal range. Camper and Boyes agreed that the key to successfully crafting individual short-term and longterm solutions is to take the extra time to get to know the client and their particular life challenges. According to Boyes, Once clients have experienced a successful resolution of their problem, they often feel more empowered to tackle the next challenge. 113

115 CMSP/TCE WELLNESS & PREVENTION PROGRAM Cost and Service Use Analysis The project submitted 18 core data records of CMSPeligible individuals enrolled into case management prior to October 31, This data will be folded into the Case Management cluster that is reported on page 267. Future Directions Outreach activities informing target populations of available resources will continue through the Health Education Department and will include cholesterol and glucose testing as long as supplies last. The Hamilton City Community Action Group, focused on Hispanics, and a senior nutrition site will also continue to provide outreach on adult health issues in response to partnerships formed through the W&PP grant. The Health Department will also continue to provide referrals to project partners. Components that will not be continued include the case management efforts, including the dental case management, the free dental services, and the free vaccination program for hepatitis C-positive individuals, all due to lack of funding, not because of lack of demand. Once clients have experienced a successful resolution of their problem, they often feel more empowered to tackle the next challenge. Nip Boyes, PHN

116 Lake County The Lake County Wellness & Prevention Program (LC W&PP) conducted outreach education and screening of Lake County residents for diabetes, hypertension, and heart disease, conducted regular diabetes support groups in 4 locations throughout Lake County, and made referrals to health care, educational, and social support services as indicated from screening results. Project staff conducted blood pressure, blood glucose, and cholesterol screening at a variety of free community events and at the Tribal Health Clinics and Senior Centers. Referrals to primary care physicians, the Lakeside Community Health Clinic, diabetes support groups, and/or Social Services (for benefits enrollment) were made for all who had abnormal screening results. Project staff followed up on a large percentage of the referrals, and many people received multiple referrals as Program Description continued on the next page> Total Award Expended $194,844 of $211,803 awarded Program Partners Lake County Department of Health Services Tribal Health Redbud Hospital Lakeside Clinic Latino Coalition Geographic Area Served Lake County Target Population Lake County residents at risk for diabetes, hypertension, or heart disease Contact Information Gail Gibson, Health Education Coordinator Lake County Health Services Department Phone: (707) gailgibson@co.lake.ca.us 115

117 CMSP/TCE WELLNESS & PREVENTION PROGRAM Lake County Support Groups Help Diabetics Cope MAINTAINING LIFE STYLE CHANGES to improve one s diabetes can be just as difficult as making them in the first place. Periodically meeting with a support group or checking in with a health educator can make the difference between success and failure of a diabetes management program. The Lake County Wellness and Prevention Program (LC W&PP) conducted monthly diabetes support groups at four locations throughout Lake County in the communities of Lakeport, Clearlake, Lucerne, and Middletown. Announcements were placed in the local newspapers promoting the monthly support group meetings to encourage participation. The support groups attracted diabetics who have attended the meetings for multiple years. On a monthly basis, the four groups combined averaged a total attendance of 30 participants. The LC W&PP reported that many of the support group participants were socially and geographically isolated, so the monthly meetings provided much more than just an education venue. Participants made friends, shared recipes, and learned from A Middletown diabetes support group member conducts a meeting with skills she acquired at the facilitation training. >Program Description, continued from the previous page necessary. Staff referred persons at risk or diagnosed with diabetes to one of the diabetes support groups that the LC W&PP organized and runs on a regular basis in Lakeport, Clearlake, Lucerne, and Middletown. The LC W&PP funded the training of 2 people in group facilitation, with the aim of training support group members to help run the groups after the grant ended. The Program Coordinator and a member of the Lakeport Support Group traveled to San Francisco to attend a facilitation training conducted by the Interaction Institute for Social Change in March Later that month, the Program Coordinator used that training to conduct a oneday training session entitled Core Training for Guiding Groups and Facilitating Outcomes for representations of each of the diabetes support groups and other interested individuals in Lake County. This training was very well received. One participant, Marta Fuller, RN and Lake County s Dental Disease Prevention Program 116 Coordinator, wrote a follow up letter, saying, I came away with some great new ideas to make groups work better, and the hands-on training was very enlightening... It was especially notable that several group members seemed to blossom during the day, and the sense of empowerment that they came away with was impressive to see. I know you have created some potentially brilliant new group leaders. Initially, the coalition of the organizations involved in the LC W&PP worked well to provide cross-referrals, funding for screening services (including labs), and translation and transportation services. However, as funding from the LC W&PP ceased, the coalition gradually quit functioning (see also Objective 1 for additional details on this). 116

118 Lake County Site Report Program Objectives and Outcomes 1 Objective 1 To collaborate with local stakeholders to bring persons into the local health care system through outreach efforts including canvassing, health fairs, and screenings W&PP rating: Achieved Objective (moderate level of data to support) The evaluation report mentions that health education and screening was provided at community events throughout the county, but no specifics regarding stakeholder collaboration are provided except for mention of a number of free community events held at the Tribal Health Clinics and senior centers. Otherwise, the evaluation report states qualitatively that outreach occurred at grocery stores, community events, senior centers, and clinic sites. The only outreach event other than diabetes support groups that was specifically reported by the project in their final report was the Latino Health Fair in 2001, but they did mention a collaborative effort with Tribal Health and the Preventive Health Care for the Aging Program to provide blood tests and health screenings at the diabetes support group meetings. The evaluation report also qualitatively notes that flyers, radio and television ads, and newspaper articles were published, which are not mentioned in the project s final report, but many of these were included in interim projects. The following quantitative data was submitted by the site to demonstrate the success of outreach efforts Agencies/Orgs CHOW Flyer Friends & Family Market Clinic Newspaper Outreach Clinic PCHA/Other Health Radio Television Tribal Health Source of referrals to the Lake County W&PP Walk-in Other one another s experience. Survey results, shared by the LC W&PP staff, showed that 80% to 85% of participants felt that the support groups helped them feel less helpless and isolated by providing contact with others who are experiencing similar issues. An essential feature of LC W&PP s continued support group success is the combination of ongoing support with continuing education in diabetes care. Topics addressed at the support group meetings changed monthly, depending on the needs of the participants. Educational topics were designed to empower the participant to take an active part in his/her health care to prevent negative outcomes associated with uncontrolled diabetes. The project staff constructed clever topic names such as Days of Our Eyes, The Blood Sugar Blues, Diabetes Head to Toe, and Laughter- the Wonder Drug to provide some degree of levity to serious educational sessions on blood glucose monitoring, psychological aspects of contending with diabetes, and the prevention of diabetes-related complications such as foot ulcers and retinopathy. Qualified guest speakers, such as physicians, pharmacists, and nutritionists, were often on hand to present self-care techniques as well as information on state-of-the-art developments in diabetes management to support group participants. A local podiatrist conducted foot examinations at the diabetes support group, and several participants had commented that their doctor had never looked at their feet before! Please refer to the accompanying Lake County site report for the support groups sustainability plan and future directions. Of the people referred to Social Services for enrollment into medical coverage programs, 65% (61 of 93) were referred for enrollment assistance into CMSP; 1 Refer to DRA s evaluation report in Volume 2 of this report for the site's complete evaluation findings. 117

119 CMSP/TCE WELLNESS & PREVENTION PROGRAM Graph A: City of residence of clients served by the Lake County W&PP Clearlake Cleralake Oaks Clearlake Park Cobb Mountain Finley Glenhaven Kelseyville Lakeport Lower Lake Lucerne Middletown Nice Upper Lake Witter Springs Out of County Unknown Number of Clients however, the project reported only 8 CMSP enrollees for their core data set over the 3-year period. The broad geographical distribution of those receiving attention from the LC W&PP staff shown above in Graph A also supports the claim of successful outreach efforts. However, the collaboration between the partners consisted primarily of cross referrals and did not always last for the entire duration of the grant; there were no formal memoranda of understanding adopted. The project and evaluation team reported that in general, when the funding from the LC W&PP ran out, the collaboration between stakeholders ended. The duration of collaboration between the LC W&PP and its partners was as follows: Tribal Health, ; Redbud Hospital, ; Lakeside Clinic, ; and the Latino Coalition, The collaboration with Tribal Health changed in 2003 when Tribal Health wanted to shift their focus from adults to children at risk. Due to the decrease in funding in the last year of the Program, the collaboration with Redbud Hospital changed. Since the Program could no long afford to continue offering screening tests, their services did not continue past The collaboration with Lakeside Clinic changed in the final year, since the Program funding would no longer allow for offsetting the cost of the first visit. The Latino Coalition infrastructure could not maintain the transportation and translation services after the Latino Health Fair, and so that collaboration ended following the Fair in It should be noted that at the onset of Cycle 3, W&PP projects were given flexibility as to the disbursement of their grant allocation over the three-year grant cycle. While the majority of grantees elected to receive approximately one-third of their total allocation in each of the three years, Lake County elected to receive 50% of their total grant allocation in Year 1, 30% in Year 2, and 20% in Year 3. Consequently, there was progressively less money available to pay for services as time progressed. Thus, although qualitative and quantitative data was presented that outreach efforts occurred and successfully resulted in some people throughout Lake County being drawn into the health care system for attention to a disease, only limited qualitative data was presented to demonstrate that stakeholders collaborated to produce these outreach efforts, and what collaboration may have existed appears to have dissolved when the funding stream stopped. Objective 2 To empower clients to maintain health through education, support groups and self-management tools W&PP rating: Achieved Objective (moderate level of data to support) The LC W&PP staff conducted monthly diabetes support groups at 4 locations throughout Lake County at Lakeport, Clearlake, Lucerne, and Middletown. These support groups were reported by the project staff to be well attended; however, no quantitative attendance data was submitted to support that claim. An indication of the

120 Lake County Site Report Graph B: Health issues of individuals enrolled in the Lake County W&PP Hypertension Hyperlipidemia Heart Disesase Obesity High Cholesterol Smoker Vision 17 Dental 9 Depression 18 Other Chronic Other Unspecified 8 Type 1 Type 2 success of these groups in terms of adding value for diabetics in Lake County is that some support group members were motivated to attend a group facilitation workshop to help prepare them to assist in running the support groups, contributing to their sustainability after the grant program ended. Additionally, staff reports that these support groups are still being supported by the Lake County Department of Health Services, even though all grant funds have been expended. The project reported that the demand for more supportive classes in weight loss and exercise was greater than they could meet. The project staff reported that the content of support groups was rich with a variety of topics and knowledgeable guest speakers, which contributed significantly to the popularity, value, and long-term success of these groups. It was also reported, but not documented, that blood tests and health screenings were also offered at the support groups. The project staff reported survey results showing that 80% to 85% of participants felt that the support groups helped them feel less helpless and isolated by providing contact with others who are experiencing similar issues. However, no data was submitted to the evaluation team to corroborate this claim. Thus, although project staff reports of popularity, value, success, and desire to continue meeting indicate that people were probably empowered to maintain health by attendance of diabetes support group meetings, and it seems reasonable to assume that this is the case, there was no quantitative data submitted that would support the claim that this objective was successfully achieved. Objective 3 To provide medical case management with referrals to medical care facilities, agencies, and services. W&PP rating: Achieved Objective (high level of data to support) Data submitted to the evaluator regarding the health issues of 310 of the 685 persons managed by the LC W&PP staff as shown on Graph B and the chart below indicate that the project did serve its target population. Unknown 32% Tribal Health 1% Veterans Admin 5% None 13% CMSP or Eligible 11% Medi-Cal 5% Private 14% Medicare 19% Payors of the individuals enrolled in the Lake County W&PP Data was delivered to the evaluator that a total 685 people received attention from the W&PP case manager in a total of 1308 contacts, and a total of 335 referrals to medical and social services were made over the 3-year period. The following chart summarizes the types of referrals made. 119

121 CMSP/TCE WELLNESS & PREVENTION PROGRAM Unspecified Medical 1% PHCA clinic Redbud Hospital 2% Other 11% 6% Lakeside Clinic 26% Cost and Service Use Analysis The project submitted 8 records of CMSP-eligible individuals who were enrolled in case management prior to October 31, This data was folded into the Case Management cluster that is reported on page 267. Social Services 28% Weight Management 3% A considerable effort was made by LC W&PP staff to follow up on referrals. Of the 335 referrals, the outcome of 133 (40%) referrals were documented, with appointments made and kept in 61 instances (18% of all referrals and 46% of those successfully tracked). Objective 4 To reduce inappropriate use of emergency room facilities by CMSP clients and improve health outcomes. W&PP rating: Failed to Achieve Objective Diabetes Support Group 23% Types of referrals made by the Lake County W&PP According to the evaluation report, the project staff was not able to collect data from the local hospital on emergency room visits because of concerns about HIPAA regulations. The project staff reported that they felt this objective was overly ambitious and opted to let the final cost/service use analysis by the CMSP/TCE staff reveal this information. However, insufficient data regarding CMSP beneficiaries served under the project was submitted for the CMSP staff to conduct a meaningful analysis of the claims data for impacts emergency services usage. Complete data records (core data) required for inclusion in the analysis of claims data were submitted for only 8 CMSP beneficiaries, even though staff reported that 78 clients with CMSP coverage were enrolled into case management. Future Directions Although the Lake County Department of Health Services (LCDHS) would like to continue the outreach, case management, and referral components of the W&PP, no funding has been found to do so. A grant proposal for this purpose to The California Endowment was not funded. The support groups will continue to meet as long as participants will perform the work of organizing and conducting them. The LCDHS will still provide supervision of the support groups by qualified medical staff. 120 I know you have created some potentially brilliant new group leaders. Marta Fuller, RN, Lake County s Dental Disease Prevention Program Coordinator, referring to the success of the support group facilitators training Although beautiful, Clear Lake presents a barrier to accessing health care services for the widely dispersed population of Lake County. 120

122 Marin County Four community agencies in Marin County, including two community clinics provided medical, health educational, and mental health services to members of the target population. The services were provided at Marin Community Clinic, Greenbrae; Coastal Health Alliance, Pt. Reyes Station, Bolinas, and Stinson Beach; Ritter House (homeless service center), San Rafael; and the Asthma Education Resource Center, Greenbrae. With the Marin County Division of Health Services (MCDHS) as the lead agency, grant funds were divided amongst four services providers and the Pacific Health Consulting Group as shown on the following chart: Program Description continued on the next page> Total Award Expended $121,231 of $146,166 awarded Program Partners Marin County Division of Health Services (MCDHS) Marin Community Clinic Coastal Health Alliance Asthma Education Resource Council Ritter House Pacific Health Consulting Group Geographic Area Served Marin County Target Population CMSP enrollees and other medically underserved adults living with chronic illness, particularly diabetes, cardiovascular disease, asthma, and mental illness who access services through the community clinics, emergency room, and a homeless service center Contact Information Gregory Fearon, Resource Development Administrator Marin County Division of Health Services Phone: (415) gfearon@co.marin.ca.us 121

123 CMSP/TCE WELLNESS & PREVENTION PROGRAM An Assessment of the Marin County CMSP Program Executive Summary Prepared by Pacific Health Consulting Group Purpose of This Report: Marin County Department of Health and Human Services (DHHS) commissioned Pacific Health Consulting Group (Principals: Bobbie Wunsch and Tim Reilly) in 2002 to conduct an analysis of how the Marin County Medical Services Program (CMSP) can optimize care given to indigents given available funding as well as how the existing funds are expended. This report explores the background of CMSP, Marin s participation in the program, how funds have been used - for what populations and for what health services and also suggests option that are available for Marin County to manage its responsibility for providing health care services to its indigent community members. This report is intended to help Marin County health officials understand more clearly Marin County s situation. CMSP Program Overview: The state County Medical Services Program Governing Board allocates funds for small and rural California counties to pay for health care services to indigent county residents as one way for these counties to meet their obligations under Welfare and Institutions Code Section CMSP s mission is to help assure the delivery of timely and quality primary, preventive outpatient and inpatient health care services to indigent adults in rural communities. The program was launched in 1983 and has undergone a number of economic, funding and programmatic changes in it history. It currently has contracts with 34 counties. The Governing Board sets eligibility requirements, which address such areas as: age limits, residency and citizenship criteria, personal property limits, motor vehicle limits, real property limits, responsibility of family 1 Funded by Marin County Department of Health and Human Services and the CMSP Governing Board (through the CMSP/ TCE Wellness & Prevention Program grant) >Program Description, continued from the previous page Pacific Health Consulting Group Ritter House evaluation consultant Asthma Education Resource Council Marin Community Clinic Costal Health Alliance Division of funds in the organizations participating in the W&PP Essentially, these agencies operated independently from one another. Grant funds were used to support nursing time in the clinics to initiate treatment and education for new diabetic 122patients and develop and implement a diabetes registry to track patient outcomes (Marin Community Clinic and Coastal Health Alliance); provide mental health case management (Ritter House); provide asthma education (Asthma Education Resource Council); and to conduct an analysis of Marin County s participation in the CMSP (Pacific Health Consulting Group). Regarding patient services, funds were used to supplement existing programs, not in new projects. Project implementation and coordination between the disparate activities was further impeded when four different staff members from the Marin County Division of Health Services were assigned to manage the grantrelated activities over the course of the three-year grant and the MCDHS experienced changes within its executive-level leadership. The final project director joined the effort as the project was completing the last few months of the grant period and made an admirable attempt to pull together as much information about the three prior years as possible. Additionally, staff assigned to the Marin W&PP project were changed in three of the four participating programs, presented challenges in maintaining a cohesive focus and accomplishing results. With so many organizations using relatively small amounts of funds on completely separate ongoing programs and the lack of consistent leadership within Marin County for the grant, evaluation of the impact of the grant was not possible, in spite of laudable efforts by the W&PP evaluators. Many of the participating organizations expressed their frustration with the administrative and data requirements of the CMSP/TCE W&PP grant, since each of the four agencies were 122

124 Marin County Site Report receiving a relatively small amount of grant funds. Some data was submitted to the evaluators by the various organizations, and this is presented in full in the DRA evaluation report for Marin County. However, these data concern overall efforts of the various organizations, not specifically the impact of the W&PP grant funds. Please refer to the accompanying highlight article regarding the findings of the study by the Pacific Health Consulting Group, commissioned by Marin County Health and Human Services Agency, concerning Marin County s participation in the CMSP program. This report was part of a larger effort by Marin County Health and Human Services Agency to assess a variety of data to help Marin develop a comprehensive plan to increase access to health care for uninsured and underinsured residents in Marin County, including those enrolled in CMSP and Medi- Cal. Additionally, the DRA evaluation report lists some additional key findings in the report that may be of interest to readers. Program Objectives and Outcomes 2 Objective 1 To develop, implement, and evaluate a disease management model for target population members who suffer from chronic diseases such as diabetes, cardiovascular disease, asthma, and mental illness. W&PP Rating: Failed to Achieve Objective As a whole, the Marin County W&PP failed to achieve objective. As noted previously, grant funds were used to supplement existing case management and health education efforts in four separate organizations that operated independently of each other with regards to the CMSP/TCE W&PP. What can be said about this project is that some indigent patients with chronic disease received more case management services and health education at the various locations than they would have in the absence of the grant funds. It is important to note that many of the individual participating agencies experienced degrees of success in the provision of case management and health education services to the target population, but the project as a whole lacked evidence of success relating to model building and evaluation. Please refer to DRA s individual report on the Marin W&PP for details about each agency s experience. The failure of this collective project to accomplish meaningful results can be categorized as a lessoned members/relatives, need standard, and share-ofcost. CMSP benefits are comprehensive and mirror those covered by the Medi-Cal program. To participate as a medical provider in the County Medical Services Program a provider must participate in California s Medi-Cal program. CMSP Demonstration Projects: As Marin County assess how it uses CMSP funds, it is important to look at the variety of interesting and valuable demonstrations conducted in CMSP counties around the state, funded by CMSP in collaboration with The California Endowment. At their core, each project was designed to improve county infrastructure and test alternative approaches for providing disease management and/or case management and evaluation. Marin County has received funding for two projects, including a demonstration project in disease management and case management and a cost containment project grant that funded this report. Current CMSP Financial and Contract Status: Currently CMSP receives most of its funding from two sources: base fees from each participating county derived from their share of vehicle licensing fees and a sum, not linked by county, transferred directly to CMSP that reflects Realignment Growth Revenue. The current budget projections show expenditures exceeding revenues program-wide, so the Governing Board has adopted a number of cost saving measures. CMSP is likely to continue to require additional funding for its county shareholders. Marin s contribution has been approximately $8.3 million each year from 1998 to During this period, Marin has paid more in fees than the cost of providing health services to the residents of Marin County eligible for CMSP. Marin County s excess funding was used to offset deficits in the collective statewide budget. However, this situation is changing. As Marin County evaluates its options, it must identify the possible consequences if it elected to withdraw for the CMSP Program. In so doing, it would accept direct responsibility for the management and financial risk of its own medical indigent program. Evaluating Alternative CMSP Options: This report lists three criteria for evaluating options: 1) whether Marin has the administrative capabilities 2 Refer to DRA s evaluation report in Volume 2 of this report for the site's complete evaluation findings. 123

125 CMSP/TCE WELLNESS & PREVENTION PROGRAM in-house to administer the program; 2) whether Marin has the ability to implement the appropriate cost and utilization controls to manage the program; and 3) whether Marin is willing to assume financial risk. The following options were described: Option #1: Continue participation in state CMSP program. Option #2: Terminate relation with state CMSP Program and continue program as a self-funded and self-administered program. Option #3: Re-open and expand discussions with Partnership HealthPlan to include CMSP administrative contract. Option #4: Add additional case management services to current Marin program. Option #5: Adopt a monthly case conference technique. Option #6: Survey other counties. Recommendations: The report makes six recommendations, given the financial risk exposure, the current utilization of CMSP services in the county, and the opportunities for implementing tested cost containment measures: 1. Continue participation in the state CMSP program. a. Marin County should strongly urge that CMSP establish a performance auditing program. b. Marin County should advocate for the exploration of a county-level financial risk program to create stronger incentives for all participating CMSP counties to bear responsibility for the performance. c. Marin County should urge CMSP to monitor its experience on an incurred basis even if it maintains a cash accounting system. learned by the W&PP administrative office with regard to: 1) assessing true collaboration versus splitting a pot of money for disparate activities, and 2) the importance of consistent, local-level leadership to a project s success. This was a case of a re-granting program serving as a pass-through to existing programs of multiple community-based organizations, which diluted the grant funds to the point where attribution of outcomes as a result of W&PP funding was not possible and the participating organizations lacked the incentive and/or resources/infrastructure to fully participate in evaluation efforts. The MCDHS reports to have learned valuable lessons from the project s less-than-effective structure. In retrospect, the MCDHS would have approached the W&PP project design with the intention of testing a unified case management model versus using the grant funds to support disparate activities. Though the project was unable to demonstrate overall outcomes, staff report that the granting effort allowed MCDHS to build better relationships with the local-level clinic providers through improved communication. 124Through these newly forged relationships, the MCDHS has established a routine meeting schedule with the clinics to identify and address barriers to MCDHS s key service delivery programs such as maternal child health services and a senior health assessment project. Additionally, the MCDHS reports that the Assessment of the Marin County CMSP Program: was a beneficial process for the county to participate in. Initially, when the county s economic condition was healthier, the county was looking towards this assessment as the launching point to pilot an intensive case management program to address resource-intensive cases. Due to the current fiscal climate, efforts to move forward with this pilot have stalled. However, county officials are more informed about the CMSP program as a whole and the utilization patterns of Marin County CMSP beneficiaries through this study. Finally, the MCDHS has made a concerted effort to become more engaged in CMSP activities at the Governing Board and committee levels. 2. Become more active in CMSP Governing Board activities and committees. 3. Assign a DHHS staff member with the responsibilities to regularly monitor CMSP utilization and costs. 4. Develop an intensive case management program for the enrollees on whose behalf the costs of care are the highest ( Top Users ). 124

126 Marin County Site Report Cost and Service Use Analysis The project submitted 49 records of CMSP beneficiaries who were enrolled in case management in the various programs prior to October 31, This data was folded into the Case Management cluster that is reported on page 267. Future Directions According to the evaluators, Marin Community Clinic and the Coastal Health Alliance report that the diabetes case management will continue, including medical provider time and support staff tracking time. In addition, they expect tracking may improve if an upcoming information technology proposal is funded, allowing the projects to incorporate follow-up as a routine duty of medical assistants and referral staff. Coastal Health Alliance has indicated that they will partially sustain programs by way of a reallocation of staff time supported by state and federal grants. Both organizations also indicate that they received diabetes case management funding from The California Endowment through a collaboration with the Redwood Community Health Coalition. Both the Asthma Education Resource Center and Ritter House will also continue to provide services to their target populations as funding allows. The Marin County Division of Health Services reports that they are engaged in preliminary discussions with the clinics about the possibility of co-locating clinical services provided by the county at the clinics facilities. 125

127 CMSP/TCE WELLNESS & PREVENTION PROGRAM

128 Solano County The Solano County Health and Social Services Department W&PP project addressed the problem of chronically ill homeless and/or substance-abusing individuals in Fairfield who were at high risk of contracting serious health conditions that would require costly emergency room services or hospitalization. These individuals were primarily homeless and often had mental health and/or substance abuse issues that contributed to their homeless condition. It was expected that once these needy individuals were linked to needed primary care, behavioral health/social/substance abuse services, housing, and public benefits, their overall health status would improve and hospitalizations would be reduced. Outreach/case finding was conducted by outreach workers and health assistants at locations where homeless individuals gather, including parks, food banks, and Program Description continued on the next page> Total Award Expended $192,993 of $192,993 awarded Program Partners Solano County Health and Social Services (HSS) Department Family Health Services clinic Various substance abuse treatment providers Various housing providers Various mental health providers Geographic Area Served Solano County, particularly the Fairfield area Target Population Chronically ill indigent adults having difficulty accessing and utilizing appropriate health services, particularly homeless and/or substanceabusing individuals Contact Information Marcia Jo, Project Coordinator Solano County Health and Social Services Department Phone: (707)

129 CMSP/TCE WELLNESS & PREVENTION PROGRAM A Personal Approach to Case Management For Solano County s Homeless Population THE MULTIPLE ISSUES that afflict members of the homeless community, including substance abuse and psychiatric conditions; lack of a payor source; lack of transportation; lack of having a safe place to stay during the day or a warm, dry place to sleep at night; and lack of access to consistent primary medical care, frequently cause minor medical problems to escalate into serious conditions that require emergency services or inpatient care. Case managers and medical providers working with the homeless must employ a variety of creative strategies to meet these challenges. Solano County s Wellness & Prevention Program efforts targeted chronic illness in the homeless population through a case management approach. The variety of strategies required to be successful with this population are well illustrated by the following success stories told by Patrick Stasio, Health Assistant for the Solano project, which is run through the Solano County Health and Social Services Department. Stasio is known for his creative problem solving and his extensive network of provider contacts throughout the county and region. These stories illustrate the multiple challenges faced by many ill homeless people, as well as the patience, perseverance, willingness to meet clients where they are, and creativity required of case managers who are trying to assist these people. >Program Description, continued from the previous page homeless shelters. The Community Action Agency, Health and Social Services Department, and local hospital were also key case-finding sites. Individuals with medical conditions were referred to the Family Health Services (FHS) clinic. If individuals identified as having chronic conditions failed to appear for their scheduled appointments at the FHS clinic, the health assistant or outreach worker would find the client and work to address the barriers and challenges preventing the client from effectively utilizing services. An intervention was considered complete when the client was successfully connected with a provider. Once a client was connected to a primary care provider or mental health service provider, the W&PP team no longer provided case management services. These responsibilities were turned over to the care provider. The project experienced a slow, confused start (refer to the evaluator s report for details) and never seemed to fully 128 Patrick Stasio, Health Assistant for the Solano County Health and Social Services Department, (right) works with a homeless client recover regarding data collection and reporting. Thus, data regarding project activities is scanty and incomplete. However, the project submitted some illustrative anecdotal accounts of project activities, which are presented in the accompanying highlight article. Note, the Wellness & Prevention Program administrative office reduced the project s original Cycle 3 grant allocation of $309,404 to $192,993 due to the site s contracting and implementation delays. The grant funds were used to support a Public Health Nurse (0.45 FTE), a Health Assistant (0.50 FTE), and Office Assistant/Data Clerk (0.25 FTE, year 3 only); client support services, particularly housing and transportation; evaluation expenses; and support for development of a collaborative grant proposal. 128

130 Solano County Site Report Program Objectives and Outcomes 1 Objective 1 To conduct outreach and other case-finding activities in order to identify and access at least 125 indigent clients with a medical problem each year. W&PP Rating: Partially Achieved Objective (minimal level of data to support) The Solano County W&PP provided data to the evaluator that indicated that 216 individuals were contacted via outreach efforts between April 2001 and November However, to reach their stated goal, they would have had to contact a total of 375 during the three-year grant period. The project provided data regarding gender, age, and race, but not place or nature of each contact. As noted above, the project reported generally that outreach was conducted at locations where homeless individuals gather, including parks, food banks, and homeless shelters. The Community Action Agency, Health and Social Services Department, and local hospital were also key case-finding sites. Patience is especially important, Stasio emphasized. It s not going to happen overnight. Umberto s Story The first encounter with Umberto (53-year-old, Hispanic male) was sometime in 1998 at the homeless day center in Fairfield. He would come in for something to eat, shower, and visit with friends for a while, then he would leave and end up in Allen Whitt Park. We would not see him for several days and then he would reappear disheveled and ill. The process would again be repeated all over. After several months of this, it was becoming clear that Umberto was having a hard time breathing. After some talking, we convinced him to allow us to take him to the emergency room at North Bay Medical Center. After the examination, he was prescribed an inhaler and released. He did not have health insurance of any kind, so we transported him to Solano County Health & Social Services where he applied for CMSP. Objective 2 To conduct health screenings for case-found clients at program venues, and when warranted, to refer clients to the Family Health Services clinic. W&PP Rating: Partially Achieved Objective (minimal level of data to support) The project provided no data to the evaluators or in their annual reports to the CMSP administrative staff regarding this objective. The project did provide some anecdotal stories (see accompanying highlight article) that suggest that health screens occurred. And some referrals were made to primary care physicians (see Objective 3). Objective 3 To forge linkages between clients, program case managers, and local service providers. W&PP Rating: Achieved Objective (moderate level of data to support) The project delivered data to the evaluator that 233 referrals were made for 116 individuals. The types of referrals made are shown on the following chart: Our next encounter was several months later when we were informed that he had been picked up by an ambulance in Allen Whitt Park. Upon checking with the hospital, we were informed that he had an angina attack and that they were going to keep him in the hospital with prescriptions for nitroglycerin plus inhalers. After this episode, we lost track of Umberto until a client came and informed me that Umberto was out of his medicine and could not get his refills because he could not pay for them. Upon checking with Solano County Eligibility, I found that Umberto had not turned in his status reports as required by CMSP; therefore, he had to reapply, which he did. This has been Umberto s pattern for the past few years. As time went by, the episodes have become more frequent, and he is showing signs of dementia. Since approximately August 2002, he has been appearing at the hospitals at the emergency room (ER) on an average of once a month, to the point that he would not stay away for more than 2 to 3 days. In December of 2002, we were able to catch up with him at North Bay 1 Refer to DRA s evaluation report in Volume 2 of this report for the site's complete evaluation findings. 129

131 CMSP/TCE WELLNESS & PREVENTION PROGRAM Hospital after an episode. We provided him with a room at the Courtyard Suites in Fairfield. A taxi was provided for him to get to the motel, and we had a Public Health Nurse from Older and Disabled Adult Services and a clinician pay him a visit. Also, some community care providers were contacted, and they provided him with food and clothing. Forty-eight hours later, he walked away from the motel, and he was picked up by the police and taken to North Bay Hospital ER; we were called again to see what we could do to assist him. We had a long talk with Umberto about his situation and offered him some alternatives that could assist him with some changes in his life. He was agreeable to these suggestions and the boundaries that we would set for him. Umberto was moved into the Courtyard Suites Motel under supervision. We had applied [on his behalf] for food stamps, general assistance, and supplemental security income. He was connected to his primary care physician and received a checkup. It was thought that he may have a cancer, but that has not been confirmed yet. He is getting around much better; he is taking better care of his personal hygiene and is looking 100% better than he was three months ago. He has not stopped his consumption of alcohol, but it is down to one or two beers a week as opposed to two or three six-packs a day. He is eating regular meals and is getting the proper rest that his body requires. He is taking his medication daily as instructed by his doctor. During this period, his ammonia levels have gotten out of acceptable perimeters, causing some disorientation for him, but he was brought down and under control within a short period of time. I believe that Umberto is a good example of what we can do for someone that is out of control with themselves if we can take the time to work with their condition and help them obtain the proper services and not rush them along but let them go at their own pace, Patrick says. Peggy s Story Peggy was referred to the program in January 2003 by the social service department at Solano SSI 10% Veterans 11% The evaluators noted that individuals who were referred for substance abuse treatment tended to have more total referrals than those without substance abuse problems. The accompanying highlight article illustrates the highly intensive nature of interventions required for successful case management of individuals from this population. The project delivered data to the evaluator that indicated that 61% (143 of 233) of the referrals resulted in successful linkage with the provider. Data regarding whether the linkage with 130 the referred provider was actually made is shown on the following graph: Housing 27% PCP/CMSP 26% Substance Abuse 12% Mental Health 14% Types of referrals made for Solano W&PP clients 39 PCP/CMSP Mental Health Substance Abuse Hard In this presentation, hard referral successes are those for which staff did the follow-up, whereas soft referral successes are those in which the client was asked to notify staff that the appointment had been kept and did so. 7 Veterans Soft 3 8 SSI Percentages of referrals that were completed 4 130

132 Solano County Site Report Objective 4 To develop systems change recommendations. W&PP Rating: Achieved Objective (moderate level of data to support) Apparently, systems change recommendations have been made, since a number of systems changes have occurred subsequent to the grant project (see Objective 5). However, no specific mention of these recommendations was reported to the project evaluators or the CMSP administrative staff. The project did not participate in an exit interview so that this matter could be clarified. Objective 5 To analyze systems change recommendations and to advocate for adoption of the recommendations. W&PP Rating: Achieved Objective (moderate level of data to support) Apparently, systems change recommendations were analyzed and advocacy occurred, since a number system changes have occurred. One goal of this effort was to create a stronger link between those providing services to the homeless and mental health services. The Solano County W&PP staff have become active members of the Mental Health Services Dual Diagnosis Treatment Planning Collaborative and are now meeting regularly with the behavioral health clinician at county primary care sites to ensure ongoing sharing of information and case conferencing. In early 2004, Health and Social Services (HSS) implemented a redesign of substance abuse treatment services. The project reports that the design ensures that all clients seeking public funds for treatment will have a standard assessment and an authorized treatment plan, with services billed to HSS. In addition, Solano County now has access to a Virtual Clinic Network through which Public Health, Mental Health, and medical staff are able to access medical histories and utilization information on all CMSP and Medi-Cal clients. This is reported to be of great assistance in the coordination of treatment planning and follow-up. Regional Medical Center. She just was discharged after having a mild heart attack. Because she was homeless and did not have a place to go, the social worker called us and asked if our program could help with some sort of shelter. We felt that due to the severity of her condition we could assist with a week or so in the Town House Inn in Fairfield. Peggy stated that she also suffering with sugar diabetes and high blood pressure. Upon taking her blood pressure we found that her blood pressure was way out of normal perimeters, and we transported her to her primary care physician. He then sent her back to the hospital, and they admitted her for a few more days for observation and to regulate her medications. We then put her into the motel until something else could be done with her. While we were looking for a shelter for her, we were able to have her apply for general assistance and food stamps. Later on after several tries, we placed her at the Heather House, a local homeless shelter. From there we could monitor her to see if she was taking her medications as directed and assist her with transportation to her appointments. We made an appointment for her with Mental Health, and they diagnosed her as having major depression; they prescribed medication for her and put her in a depression support group. Peggy is still at Heather House and is taking her medications and is very stable. She will soon be moving from the shelter into transitional housing into her own apartment. These stories illustrate the multiple strategies required for successful case management that included services from the medical, social services, mental health, and substance abuse treatment communities. 131

133 CMSP/TCE WELLNESS & PREVENTION PROGRAM Cost and Service Use Analysis The project submitted 69 records of CMSP beneficiaries who were enrolled in case management in the prior to October 31, This data was folded into the Case Management cluster that is reported on page 267. Patience is especially important. It s not going to happen overnight. Future Directions The project reports that the experiences gained through the three years of the CMSP/TCE W&PP project gave the Health and Social Services department enough data and experience to apply for a federal Healthcare for the Homeless grant. If awarded, this grant is expected to allow the project to continue and expand to other areas of the county. The project also reports that the effort encouraged the primary care site to initiate a chronic disease case management project, which they expect to be partially funded through HRSA. Additionally, the project reports that Solano HSS submitted an acceptable claiming plan to CMS for Federal Financial Participation (FFP) through Medi-Cal Administrative Activities. This FFP provides a 50% match for all costs related to assisting clients to apply for federal aid, and for linking them to a Medi-Cal covered service such as healthcare, dental care, substance abuse, or mental health services. This federal match, combined with opportunities for homeless outreach and linkage through the AB2034 program for the homeless mentally ill, has allowed Solano to continue working with this very difficult, high risk & high cost population. Patrick Stacio, Health Assistant, referring to qualities needed for case managing members of the homeless population

134 Sutter County Using a multifaceted approach, the Sutter County Wellness & Prevention Program (SC W&PP) aimed to reduce the damage caused by diabetes, as well as the unnecessary use of emergency services and hospital admissions from complications of diabetes in the target population in Sutter County. They strove to 1) help increase awareness about diabetes among the population in general; 2) identify low-income and underserved individuals in need of medical care or education to improve self-care regarding their actual or potential case of diabetes; 3) provide medical case management and diabetes education to individuals who were identified as needing such services to better manage the disease; and 4) update local medical providers regarding standards of care for diabetes. Project staff used a variety of creative strategies to accomplish these goals. Program Description continued on the next page> Total Award Expended $258,427 of $258,427 awarded Program Partners Sutter County Human Services Department Diabetes Society of Yuba-Sutter Geographic Area Served Sutter County Target Population CMSP enrollees, CMSP eligibles, low income, under/uninsured, and minority populations being referred from a variety of sources, such as the on-site clinic at the Sutter County Public Health, community clinics, private practice physicians, off-site screening events, and health fairs. However, any person with diabetes or at risk for diabetes within Sutter County was welcomed into the program. Contact Information Kelly A. Anderson, Health Program Specialist Sutter County Human Services Department Phone: (530) kanderson@co.sutter.ca.us 133

135 CMSP/TCE WELLNESS & PREVENTION PROGRAM W&PP Bolsters Sutter County s Power to Fight Diabetes THE THREE YEARS EXPERIENCE provided by the Sutter County Wellness & Prevention Project (SC W&PP) has increased the capacity and refined the focus of Sutter County health professionals in the campaign to reduce the damage caused by uncontrolled diabetes. Because of their demonstrated utility, almost all of the strategies used in this project have been absorbed into the ongoing Sutter County Public Health operations, thus sustaining the program for the long term. In addition to the skilled and dedicated staff, which many programs can lay claim to, were a few notable strategies that produced this successful outcome. Ingredients of success: defining realistic and measurable goals In crafting the goals for their project, the SC W&PP staff were careful to select well defined, achievable, and measurable goals, as follows: o Outreach to least 2000 for screening and/or education. >Program Description, continued from the previous page Poster created by the Sutter W&PP to help their diabetic clients understand the relationship between their blood sugar levels and their Hb1Ac test results To help increase awareness of diabetes as a growing problem in Sutter County, the project, in collaboration with the Sutter-Yuba Diabetes Society and the Health Division, created and distributed a Diabetes Resource Guide in English, Spanish, and Punjabi to more than 30,000 Sutter County residents in both 2001 and 2002 in a variety of venues, especially using the Sacramento Bee newspaper s direct mail service. The Guide, which was also distributed at public blood sugar screenings, health fairs, and the Sutter County Public Health Clinic, included topics regarding getting good care, proper nutrition, and preventing diabetes complications. The project also organized an eight-hour diabetes educational seminar for the general public. To identify unmet need among low-income and underserved people, the project conducted outreach events to more than 40 different locations 134 in Sutter County, including churches and temples, stores, parks and festivals, county services offices. At these events, more than 2000 people were screened for high or low blood sugar levels, and referrals to health care and/or education were made as appropriate. To update the medical provider community on diabetes standards of care, the project organized one-hour and eight-hour seminars on diabetes care for medical providers throughout Sutter County. These educational seminars were conducted by diabetes specialists and highlighted effective strategies and current standards of care for diabetes To provide medical case management and diabetes education to individuals who were identified as needing such services to better manage the disease, the project opened a dedicated Diabetes Education Room at the Public Health Clinic from which they could do testing and education of walk-in clients and people who were referred to the program; conducted extensive follow-up of referrals made at screenings; held a seminar for families; 134

136 Sutter County Site Report and brought in a specialist to do one-on-one counseling in some especially complex cases. During 2001 the SC W&PP focused primarily on outreach, screenings, and referral follow up. At the end of the year, they reassessed their focus, because they discovered that only a small number of the people (27 of 1351) they screened who were not already diagnosed with diabetes had high blood sugar levels. Additionally, they found that many people who were given referrals did not follow up on them, indicating to staff that these people were still in denial about their disease and were not ready to make the necessary commitment needed to manage it. In contrast, their experience had shown that the one-on-one educational sessions conducted at the Public Health Clinic were much more effective in motivating and supporting self-management behaviors. Consequently, in 2002 and 2003, project efforts were devoted largely to diabetes education and disease case management from the Public Health location. Although free blood sugar testing was still available for walk-in clients, the outreach efforts were substantially curtailed. Program Objectives and Outcomes 1 Objective 1 To provide blood sugar screening and general health education services to approximately 2000 people whom may have or be at risk for diabetes W&PP Rating: Achieved Objective (high level of data to support) Data submitted to the evaluator showed that 1756 people received blood sugar tests, and the project records show that a total of 2104 people were contacted with screening and education over the course of the project. Data submitted to the evaluator showed that the target population, in terms having diabetes, of ethnicity, and economic status was effectively accessed with this effort. The following chart illustrates that the large fraction (23%) of those receiving blood sugar tests that had already been diagnosed with diabetes were not effectively managing their disease: o At least 250 diabetics to be disease case managed o At least 2 seminars for community members and for health professionals regarding best practices for diabetes care. The overarching aim of reducing damage and unnecessary ER and hospital usage due to complications of diabetes was not included as a goal because they understood the difficulty of measuring this outcome. By defining measurable goals, there is no doubt about when the goal has been achieved. After only 1 year, first goal had been achieved, and the project staff paused to analyze the results. Using data to help make decisions Reflection and evaluation revealed that the overall goal of reducing damage and unnecessary ER and hospital use due to diabetes complications was probably not being as well served as hoped by blanket screening at outreach events. Data showed that after 1 year, the outreach effort was reaching few at risk people given the amount of effort that was going into it. Only 2% of the people screened who were not already diagnosed with diabetes had high blood sugar levels. Of even more concern was that the outreach screening venue did not appear to be ideal for motivating people to make additional efforts to address their disease. The data revealed that of people who had received referrals to doctors and had been successfully contacted for follow up, more than 50% had not made and kept an appointment. In contrast, patient compliance was found to be high following the one-on-one consultations with W&PP staff at the Public Health Clinic s Diabetes Education Room. More than half of the people who completed one consultation completed multiple consultations, up to a maximum of 11, as staff worked through the Eleven Keys to Good Diabetes Care curriculum with clients. Therefore, for the second and third years of the project, the primary focus of the project was on this one-on-one approach in the dedicated health care facility, combined with other disease 1 Refer to DRA s evaluation report in Volume 2 of this report for the site's complete evaluation findings. 135

137 CMSP/TCE WELLNESS & PREVENTION PROGRAM management efforts for clients participating there. Over the next 2 years, 757 clients participated to one degree or another in disease management efforts conducted by the project. High 55% Low 8% On Target 37% Data collected on client demographics at outreach events contributed to decision making about how to structure multicultural and multilingual efforts. A surprising finding was that East Indians were proportionately at the greatest risk for developing diabetes or experiencing complications from existing diabetes. For East Indians who had not been previously diagnosed as diabetics, 17% had elevated blood sugar levels (compared to 11% of non-diagnosed Caucasians and 9% of non-diagnosed Hispanics). And among the diagnosed East Indian diabetics, 66% had elevated blood sugar levels (compared to 44% of Caucasians and 56% of Hispanics). This data supports the decision to produce the Diabetes Resource Guide in Punjabi, since many East Indians in Sutter County do not read English. Having a dedicated room to consult with clients According to Kelly Anderson, Program Director for the SC W&PP, having a dedicated Diabetes Education Room was an important factor in the success of their program. This dedicated room made it possible to schedule appointments more effectively and to serve walk-ins in a more successful fashion, Anderson said. Most clients felt more relaxed and spent time learning, listening, and asking questions than in the previous situation. That situation had been noisy and distracting and offered no privacy for conversation. Clients and educators frequently had to stand at the front counter amid the hustle and bustle of the Public Health Clinic to perform the blood sugar test, which was not only uncomfortable, but was even physically difficult for some clients, she said. Anderson added that the Diabetes Education Room is stocked with educational materials and supplies for conducting blood sugar tests and decorated with educational posters, providing an effective atmosphere for focusing patient attention on learning about diabetes care. Blood sugar levels of diagnosed diabetics who were screened by the Sutter W&PP (n = 405) Staff reported that frequently these were uninsured people who sought the free blood sugar test to learn what was happening with their disease. The following chart illustrates the ethnicity of those screened: Hispanic 26% East Indian 25% 136 Other 7% Caucasian 42% Ethnicity of individuals screened by the Sutter W&PP (n = 1756) Economic status of people screened can be inferred from the type of insurance coverage they had, as illustrated in the following chart: No Coverage 34% Private 32% CMSP 1% Medi-Cal 22% Medicare 11% Payor status of individuals that were screened by the Sutter W&PP (n = 1756) On the other hand, the outreach efforts were less effective in targeting people who are at risk for diabetes. 136

138 Sutter County Site Report Only 2% of those that had not been previously diagnosed with diabetes had high blood sugar, as illustrated by the following chart: Mildly Elevated 10% High 2% Low 2% Normal 86% Blood sugar levels among individuals screened by the Sutter W&PP who were not diagnosed diabetics (n = 1351) Engaging Qualified and Talented Diabetes Educators for Community and Medical Provider audiences The SC W&PP made sure that community members and medical providers felt their time had been well used when they chose to attend the educational seminars they organized. By producing lively, informative, and authoritative events, SC W&PP staff supported their goal of increased interest and awareness about diabetes within Sutter County. Over the course of the grant, SC W&PP organized multiple educational events having Certified Diabetes Educators and Diabetes Nurse Specialists as presenters. Objective 2 To provide disease management services for at least 250 individuals previously or newly diagnosed with diabetes in order to support self-management behaviors W&PP Rating: Achieved Objective (high level of data to support) The project used counseling/education protocol that was based on the American Diabetes Association s Eleven Keys to Good Diabetes Care. Data delivered to the evaluator revealed that 757 clients participated in at least one of the 11 diabetes disease management activities or were enrolled in disease management. The following table lists these activities and the number of clients completing each one. Care Item # Clients Completed Self Monitor Taught % Foot Care Given % Tobacco Education Given % Immunization Ed Given % Dietitian Seen % Blood Pressure Checked % Self Management Taught % Lipid Profile Done % HbA1c Done % Microalbuminuria Done 83 11% Eye Exam Given 74 10% Types of referrals made at Sutter W&PP outreach events and the percentage of services that were completed The result of the excellent planning and implementation of the SC W&PP are that the Health Division and the Public Health Clinic have gained a better feel for the diabetic population in Sutter County and the strategies that are effective for helping them successfully manage the disease. Moreover, the Health Division of Sutter County has absorbed diabetes education and disease management into its ongoing activities. In addition, the program distributed 435 home glucose testing meters to clients, and people in need were given a one-time allotment of 50 strips and 100 lancets to begin regular testing immediately. Objective 3 To conduct at least two community/provider educational sessions in order increase knowledge and awareness regarding best practices in the area of diabetes health management. W&PP Rating: Achieved Objective (high level of data to support) To update the medical provider community on diabetes standards of care, an eight-hour seminar was held in 2001 given by a Certified Diabetes Educator and Diabetes Nurse Specialist, focusing on diabetes and diabetes care from the basics about the disease to drug therapy to meal planning. In March 2002, two Certified Diabetes Educators gave a one-hour seminar for medical 137

139 CMSP/TCE WELLNESS & PREVENTION PROGRAM professionals, including Public Health Nurses, Physician s Assistants, Medical Doctors, and Family Nurse Practitioners. The topics included diabetes care standards and medical nutrition therapy. A further seminar by a Diabetes Nurse Specialist focused on A Family Approach to Diabetes Management. All of the seminars detailed above were also presented in separate events to the lay community, in the same time format by the same diabetes experts, and tailored to the lay perspective. Cost and Service Use Analysis The project submitted 39 core data records of CMSP beneficiaries served. This data was folded into the Case Management cluster analysis reported on page 267. Future Directions The evaluation report states that most of the functions of the SC W&PP, including screening events, have been absorbed into the daily activities of the Health Division of Sutter County. The one aspect that will require additional funding (as yet unsecured) is the direct referral link to a certified diabetes dietician. The grant paid for this service entirely, and at the close of the grant, clients will no longer have free access to this valuable nutrition counseling

140 Case Management Conclusions Data delivered by the projects indicates that all types of case management provided benefits to clients. However, the different approaches yielded different benefits to different types of clients. Low-intensity case management seems to have helped those who were more highly functional, such as those who were willing and able to attend support groups, learn self-advocacy skills, and independently follow through with referrals. According to the evaluators, moderate-intensity and high-intensity levels of case management seemed to be approximately equivalent in assisting clients with improving key health indicators, as suggested by the blood pressure, Hb1Ac test, and cholesterol data delivered from these sites, as summarized in the following graph: 80% 70% 60% 50% (n=218) (n=164) (n=123) (n=178) (n=63) 40% (n=207) 30% 20% 10% 0% Blood Pressure HbA1c Cholesterol Moderate High Percentage of clients with improvements in key health indicators in moderate-intensity versus high-intensity case management programs High-intensity case management was uniquely effective in providing advocacy for clients to assist them in accessing needed services beyond health care and in gaining greater self-sufficiency. For those clients who were at the lowest levels of functionality and were essentially disabled in terms of ability to work, case managers involved in high-intensity efforts, such as those in the Butte and Mendocino W&PP projects, were able to assist large numbers of clients in successful applications for Social Security Insurance benefits. Case managers working at the high-intensity level in Butte, Mendocino, Humboldt, and Tuolumne were able to assist those who were at the highest levels of functionality in removing barriers to more independent life situations that included advancing education and getting better jobs, sometimes ones that provided health insurance benefits. For clients with chronic disease, high- 139

141 CMSP/TCE WELLNESS & PREVENTION PROGRAM intensity efforts, such as those of the Sierra W&PP, were perhaps uniquely successful in preventing diabetesrelated hospitalizations. Therefore, although the high-intensity case managers could serve fewer clients at a time, they were able to facilitate a wider range of positive benefits for clients. Cost and Service Use Analysis Results The core data records for enrolled CMSP beneficiaries that were collected by each project were used to conduct a cost and service use analysis with the aim of describing impacts of the W&PP. This analysis is summarized in the Cost and Service Use Analysis section of this report, and the complete report by the analysis contractor, The Lewin Group, is included in Volume 2, Evaluation Findings. Reported here are data specific to the Case Management Cluster. Kellie Bolle, Nurse Case Manger with Sierra County s W&PP, which was able to avoid hospitalizations of their clients due to complications of diabetes during the grant period Inpatient Hospital payments per member per month also decreased in the post-enrollment group, while payments for Outpatient Hospital, Clinics, and Labs increased (Graph D). An additional impact of high-intensity case management was the large numbers of enrollees that were helped to apply for Social Security Disability benefits, particularly by the Butte and Mendocino projects. This impact is illustrated on Graph E. Note that the Butte project had a separate cost and service use analysis, which is 140 discussed in the Butte Site Report as well as in the Cost and Service Use section. Moderate-intensity case management cluster All Case-Managed Enrollees Cluster The patterns of service use for all case managed enrollees are illustrated in Graph A (claims data) and Graph B (payments data). Both Claims per 1000 members per month and payments per member per month were higher for every category in the post-enrollment compared to the preenrollment groups, with surprisingly the greatest increase occurring in the Hospital Inpatient category. These findings are partially contrary to expectations that Hospital Inpatient claims and payments would go down and Clinic claims and payments would go up. Possible explanations lie in the cluster analyses reported below, as well as in the fact that a very short post-enrollment time period was available for analysis, and expected changes in cost and service use could take longer to occur and document. High-intensity case management cluster The expected pattern of reduced numbers of Inpatient (IP) and Outpatient (OP) Hospital claims and increased numbers of Clinic and Lab claims did occur for the highintensity case management group (Graph C). The number of claims per 1000 members per month in the post-enrollment group was slightly lower than that of the pre-enrollment group, largely because of reduced numbers of Hospital Outpatient claims (Graph F). In contrast to the expected pattern after enrollment, there were increased numbers of Inpatient Hospital claims and reduced numbers of Clinic claims. Inpatient Hospital payments per member per month increased in the post-enrollment group (Graph G). However, it should be noted that the total payments per member per month in the post-enrollment group ($246) was substantially lower than that for the All CMSP group ($414), the All W&PP group ($410), or the All casemanaged group ($404) post-enrollment. Note that the Lassen project had a separate cost and service use analysis, which is discussed in the Lassen Site Report as well as in the Cost and Service Use section. Low-intensity case management cluster In contrast to the expected pattern after enrollment, the number of Inpatient Hospital claims and days per 1000 members per month in the post-enrollment group was much higher than that of the pre-enrollment group (Graph H). All other categories of claims were also 140

142 Case Management Cluster Conclusion Graph A: Claims per 1000 members per month by service-use category for all case-managed enrollees Before Enrollment After Enrollment Hospital IP Days Hospital IP Claims Hospital OP Claims Physician Claims Clinic Claims Lab Claims Home Health Claims All Other Claims Graph B: Payments per member per month for all case-managed enrollees $450 $400 $350 $300 $250 $200 Before Enrollment After Enrollment $150 $100 $50 $0 All Payments** Hospital IP Payments Hospital OP Payments Physician Payments Clinic Payments Lab Payments Home Health Payments All Other Payments *Excluding pharmacy claims 141

143 CMSP/TCE WELLNESS & PREVENTION PROGRAM Graph C: Claims per 1000 members per month by service-use category for high-intensity case management enrollees Before Enrollment After Enrollment Hospital IP Days Hospital IP Claims Hospital OP Claims Physician Claims Clinic Claims Lab Claims Home Health Claims 142 All Other Claims Graph D: Payments per member per month for high-intensity case management enrollees $450 $400 $350 $300 $250 $200 $150 Before Enrollment After Enrollment $100 $50 $0 All Payments** Hospital IP Payments Hospital OP Payments Physician Payments Clinic Payments Lab Payments Home Health Payments All Other Payments *Excluding pharmacy claims 142

144 Case Management Cluster Conclusion Graph E: Enrollment of W&PP clients with disability aid codes vs. all CMSP enrollees Lassen County Inyo County Butte County Increasing Access Outreach and Education Case Managed -- Low Intensity Case Managed -- Moderate Intensity Case Managed -- High Intensity All Case Managed Total W&PP Program All CMSP Enrollees in % 2% 4% 6% 8% 10% 12% 14% 16% 18% 143

145 CMSP/TCE WELLNESS & PREVENTION PROGRAM Table F: Claims per 1000 members per month by service-use category for moderate-intensity case management enrollees Before Enrollment After Enrollment Hospital IP Days Hospital IP Claims Hospital OP Claims Physician Claims Clinic Claims 144 Lab Claims Home Health Claims All Other Claims $350 Table G: Payments per member per month for moderate-intensity case management enrollees g $300 $250 $200 $150 Before Enrollment After Enrollment $100 $50 $0 All Payments** Hospital IP Payments Hospital OP Payments Physician Payments Clinic Payments Lab Payments Home Health Payments All Other Payments *Excluding pharmacy claims 144

146 Case Management Cluster Conclusion Table H: Claims per 1000 members per month by service-use category for low-intensity case management enrollees Before Enrollment After Enrollment Hospital IP Days Hospital IP Claims Hospital OP Claims Physician Claims Clinic Claims Lab Claims Home Health Claims All Other Claims Table G: Payments per member per month for low-intensity case management enrollees $700 $600 $500 $400 $300 Before Enrollment After enrollment $200 $100 $0 All Payments** Hospital IP Payments Hospital OP Payments Physician Payments Clinic Payments Lab Payments Home Health Payments All Other Payments *Excluding pharmacy claims 145

147 CMSP/TCE WELLNESS & PREVENTION PROGRAM increased in the post-enrollment group, with the exception of Hospital Outpatient claims. Inpatient Hospital payments per member per month were dramatically higher in the post-enrollment group (Graph I). Also higher post-enrollment were Hospital Outpatient, Physician, and Other payments. Clinic, Lab, and Home Health payments were lower. This pattern of cost and service use is similar to that of the Increasing Access group, suggesting that lowintensity case management is primarily facilitating a relatively unfocused increased access to care

148 Outreach and Education Cluster. Imperial.. Madera... Mono... Nevada... San Benito... Tehama... Trinity... Yuba 147

149 148

150 Outreach & Education Cluster Eight W&PP projects focused on outreach and education, primarily targeted to people with undiagnosed diabetes or who were at risk for developing diabetes, but also including individuals with asthma, needing dental care, who were at risk for hepatitis C virus infection, or who had poor access to general primary care services. These projects utilized strategies such as one-on-one education sessions, community screenings, support groups, and social marketing campaigns to elevate their community s awareness about the harms of certain disease process and the benefits of proactive health management. These eight Cycle 3 W&PP projects and their primary focus were: Imperial Madera Mono Nevada San Benito Tehama Trinity Yuba Asthma Diabetes Dental Access to general primary care Diabetes and access to general primary care Diabetes Diabetes and access to general primary care Hepatitis C Additional projects had outreach and education components (Glenn, Kings, Siskiyou), but these projects primarily focused on case management and thus are reported in that section. 149

151 CMSP/TCE WELLNESS & PREVENTION PROGRAM

152 Imperial County The Adult Asthma Project, coordinated by the Imperial County Public Health Department, is part of a collaborative of projects, the Imperial Valley Asthma Initiative (IVAI), which is directed at reducing acute asthma episodes across the entire spectrum of the population. Partners in the IVAI are the Imperial County Child Asthma Project, the California Asthma among the School-Aged Project (CAASA), Community Action to Fight Asthma (CAFA), and local providers and provider groups. Numerous other state, county, and community-based organizations also collaborate. The Adult Asthma Project targeted their efforts toward the CMSP and otherwise indigent adult population in a predominately agricultural worker community, while other partners targeted younger and more elderly ages, as well as the general community at large. The staff of the Adult Asthma Project are a half-time health educator, a half-time program coordinator, and the promotoras trained in the program. The Adult Asthma Program Description continued on the next page> Total Award Expended $278,804 of $315,189 awarded Program Partners Imperial County Public Health Department El Centro Regional Medical Center Valley Family Care Centers Clinicas de Salud del Pueblo, Inc. American Lung Association Dr. James Ellis Geographic Area Served Imperial County Target Population The CMSP-eligible population and other indigent and medially underserved clients living in a predominantly agricultural community, including many monolingual Spanish-speaking individuals Contact Information Yolanda Bernal, Health Program Coordinator Imperial County Public Health Department Phone: (760) yolandabernal@imperial county.net 151

153 CMSP/TCE WELLNESS & PREVENTION PROGRAM Imperial W&PP Project Aids County-Wide Asthma Initiative A UNIQUE COMBINATION of factors in Imperial County contribute to an unusually high rate of asthma: dust, agricultural pesticides, smog from neighboring San Diego, pollution from the factories directly across the border in Mexico, and temperatures that can reach 120 F. These conditions contributed to the highest childhood asthma hospitalization rate and the second-highest asthma hospitalization rate for all age groups during in California. The Imperial Valley Asthma Initiative (IVAI), a county-wide effort established in 2001 to reduce the damage and cost of asthma, is comprised of multiple partners including the Imperial County Child Asthma Project, California Asthma Among the School-Aged Project, local providers and provider groups, and the Adult Asthma Project, which is the Imperial County Wellness & Prevention Project (ICW&PP), the Adult Asthma Project. While other partners in the IVAI collaborative addressed asthma in infants, children, families, and the elderly, the ICW&PP focused on indigent adults not served under other programs. Members of the Adult Asthma Project s target population include uninsured people who may be monolingual Spanish-speaking or Englishspeaking members of the agricultural community and CMSP-eligible individuals. 1 >Program Description, continued from the previous page Project provides client-centered education sessions, home visits, individual sessions, asthma presentations, focus groups, and tool kit education sessions. The Adult Asthma Program staff participated with other agencies in a survey of local providers regarding their asthma treatment practices, focus groups with medical providers to reveal the particular challenges to effective treatment of the target population, and the distribution of a standard of asthma care to all local providers serving asthma patients to encourage compliance with national asthma treatment guidelines. The Adult Asthma Program staff, completed more than 100 educational sessions including 25 home visits, held 5 community focus groups in school cafeterias, and conducted 50 outreach events, including participation in health fairs. An example is participation in a collaborative event with 152 Promotora Emma Rosa conducts an asthma education session. multiple agencies, the Family-Focused Workshop for children and adults suffering from asthma, held at the Imperial Valley Expo. At this event, a local physician, Dr. Luz Elva Tristan, who functioned as an advisor throughout the project, was the keynote speaker. The effectiveness of the educational presentations by the promotoras was evaluated from clients written responses on an evaluation questionnaire and were summarized by project staff. Asthma tool kits containing information in both English or Spanish and supplies critical to an adult asthmatic s ability to self-manage the disease were designed, developed, and distributed by the project staff in collaboration with clinical subject matter experts,. Project staff conducted two train-the-trainer sessions at medical provider locations to instruct frontline staff on how to train patients in the use of the supplies and information in the tool kit. The utility of the client training and tool kits was evaluated from written evaluations obtained from some of the tool kit recipients. 152

154 Imperial County Site Report Program Objectives and Outcomes 3 Objective 1 To develop, disseminate, and promote implementation of a standard of care for adult asthma to providers serving CMSP clients within Imperial County. W&PP Rating: Partially Achieved Objective (high level of data to support) No data was delivered to the evaluator regarding this objective. However, the project reported that a provider survey was undertaken, in collaboration with other funding partners, including to establish a baseline regarding the extent to which local providers adhere to the National Asthma Education and Prevention Program (NAEPP) guidelines. The project reported that this survey was completed by 44 of 80 eligible providers. The survey results showed that Imperial County providers have incorporated several aspects of the NAEPP guidelines into clinical practice, but only 33% reported often specifically following the NAEPP guidelines. The results of this survey were presented to 2 focus groups involving a total of 11 providers. These focus groups were conducted to gain further insight into local issues in treating asthma. The project also published the results of this survey in a peer-reviewed journal, The California Journal of Health Promotion (Vol. 1, Issue 2, pp ; see also the accompanying highlight articles.) The project reports that the results of the survey and focus groups along with a copy of the NAEPP guidelines, which providers were encouraged to follow, were sent to all 80 eligible providers in the county. However, importantly, no follow-up was conducted to evaluate the impact of this effort. Furthermore, no further work on developing a widely agreed-upon standard of care was documented in the record. Additionally, no distinction between the extent of the involvement of providers who serve CMSP clients was documented. 3 Note: Most of the outcomes regarding project success are drawn from the final report produced by the project staff, not from the independent evaluation, which was judged to be unsuccessful by the evaluators due to a failure by the project to provide the required data. See DRA s full evaluation report for Imperial County in Volume 2 of this report for the detailed account. Imperial County W&PP promotoras undergo training. Initial surveys and focus groups 2 of medical providers revealed that their target population was particularly challenged regarding education and materials for self-management of asthma. Providers reported that language and cultural barriers often prevented effective patient education concerning self-management of the disease, and that people without insurance were often not able to obtain the treatment equipment, such as peak flow meters and spacers that are fundamental for successful self-management of asthma. Consequently, the project focused on these areas in two novel ways: 1) training and use of promotoras, or peer health educators, and 2) creation and distribution of asthma tool kits containing critical information and equipment for selfmanagement of asthma. Working closely with their physicianchampion, Dr. James Ellis, a local registered nurse, and staff from Latino Health Access, the Adult Asthma Project staff adapted curriculum materials in English and Spanish that had previously been developed for use with children for promotoras to use in their educational sessions. Five promotoras were recruited and trained in 4 two-hour training sessions conducted by local physicians. The promotoras also received ongoing training by asthma specialists as needed. Clinical asthma specialists were also present at the first several of the presentations by the promotoras to ensure that accurate information was being distributed and to assist the promotoras as needed. So far, the promotoras have reached more than 100 patients in home visits and workshops. The promotoras were paid for their time delivering educational services through W&PP grant. Each participant in these asthma education sessions received an Asthma Tool Kit and 153

155 CMSP/TCE WELLNESS & PREVENTION PROGRAM instructions on how use the materials provided. The tool kits, designed by health educators and clinicians and purchased with W&PP grant funds, contained the following: peak flow meter spacer One-Minute Asthma What You Need to Know booklet Asthma Action Plan worksheet laminated asthma first-aid poster Living Well with Asthma Fast Guide brochure flu shot record card brochures developed by the EPA on asthma Global Initiative for Asthma guidebook These materials were available in a tool kit that was entirely in English or entirely in Spanish. Everything was handily stored in a high quality, attractive, canvas messenger-style bag. As testimony of the value of delivering training in a culturally and linguistically appropriate fashion, all 20 of the respondents who completed the follow-up evaluation of the promotora-delivered tool kit training agreed that they know how to use a peak flow meter and spacer and that they know how to complete their asthma action plan. Most (17 of 18) found the tool kit to be effective in helping to manage their asthma. The Asthma Tool Kit, created by the Imperial W&PP, was produced in both English and Spanish versions. Objective 2 To deliver asthma education to adult asthma patients using curriculum developed for workshops to be led by promotoras. W&PP Rating: Achieved Objective (high level of data to support) The project reported that 5 people received asthma promotora training, 3 became active trainers, and 2 ultimately delivered most of the workshops. The project reported that the promotora education modules were created by a collaborative effort that was not funded by the W&PP. According to the project, post-training tests revealed that the promotoras felt confident that they would be effective instructors. A 154 clinical monitor was present at the first few presentations by the promotoras to assist them if necessary and verify their competence. Records were presented to the evaluators that 6 home visits and 39 workshop participants received presentations by a promotora: 36 females, 3 males, 9 in English and 30 in Spanish. The project reported that 115 people received training from a promotora and health educator, and 114 of these completed post-training evaluations. These evaluations revealed that 95% were Hispanic/Latino and 78% were female; 80% to 90% strongly agreed that they had an increased awareness of asthma triggers and symptoms and knew what to do in the case of an asthma attack; and 93% agreed or strongly agreed that the asthma education was effective in teaching how to manage an asthma attack. 154

156 Imperial County Site Report Objective 3 To promote asthma self-management through the development and distribution of asthma education tool kits. W&PP Rating: Achieved Objective (high level of data to support) Data was delivered to the evaluators indicating that 70 clients (35 Spanish-speaking and 35 English-speaking, 79% women) received tool kits. Follow-up evaluation results revealed that 19 of 20 people completing the evaluation form agreed or strongly agreed that the materials made sense to them and they were helpful. All respondents agreed that they felt confident about using a peak flow meter and spacer and how to complete their asthma action plan. 94% found the tool kit to be effective or extremely effective in helping to better self manage asthma. The racial distribution of those returning forms was 60% Hispanic/Latino, 20% multiracial, 10% African American, and 5% American Indian/Native American (1 unknown). The project reported that 500 tool kits were created containing asthma treatment supplies and instructions and information in English and Spanish. A total of 162 tool kits were distributed to clients and providers Valley Family Care Centers in El Centro and Calexico, resource centers, pediatricians, and other doctors offices and at asthma presentations and educational workshops, home visits, and clinic visits. Train-the-trainer sessions were given to 11 staff members of 3 doctor s offices, where 30 English and 30 Spanish tool kits were left for distribution by the staff. Although initially, plans were to distribute tool kits and the El Centro Regional Medical Center s emergency room (ER), experience proved that the fast-paced ER environment was not appropriate for tool kit distribution and education regarding its use. The project reported that the remainder of the tool kits will be distributed as the need arises. Imperial County s W&PP promotoras present their first clientcentered asthma education session. Staff of the Adult Asthma Project also distributed tool kits to medical providers offices and trained frontline staff on how to effectively instruct patients to use the materials and equipment in the tool kits. In one instance where there were no qualified staff to deliver the training, the providers distributed the tool kits to patients and referred them to the Imperial County Public Health Department (ICPHD) for the training on how to use the tool kit. Thus, the collaborative relationship between the provider and the ICPHD was strengthened. Although the promotoras trained through the program are not currently delivering asthma education because of lack of funding, they continue to work in the community, making informal referrals to ICPHD for asthma education. And one of them is currently working for the Housing Authority delivering diabetes education. 1 Presented in a journal article: Christopher Kelsch, Sunny Bishop, Alison Kellen, Kelly Elder. Essential Attributes of Wellness and Prevention Programs in Rural Latino Communities. Californian Journal of Health Promotion 1(2): ; full text available online at 2 Results of these surveys and focus groups are formally presented in a journal article: Paula Kriner, Yolanda Bernal, Amy Binggeli, India Orneas. Attitudes, Beliefs, and Practices Regarding Asthma Care Among Providers and Adult Asthmatics in Imperial County. Californian Journal of Health Promotion 1(2):88-100; full text available on-line at 155

157 CMSP/TCE WELLNESS & PREVENTION PROGRAM Objective 4 To build collaborative, coordinated approaches to asthma treatment and education among local stakeholders. W&PP Rating: Partially Achieved Objective (high level of data to support) The collaborative body that was formed in 2001 is the Imperial Valley Asthma Initiative (IVAI), which includes the partners listed earlier in this report as well as the Imperial County Board of Supervisors, Department of Education and Department of Social Services, the California Office of Border Health, and numerous other county organizations. The IVAI is funded from a variety of sources, including the Adult Asthma Project, The CAASA, CAFA, and Department of Health Services Childhood Asthma Initiative. They have held 19 meetings as of April 2004, and plans are for continued monthly meetings in Public Health facilities. The IVAI has been successful regarding coordinated educational efforts, which include numerous outreach events promoting asthma awareness and education. Increased collaboration between the El Centro Regional Medical Center (ECRMC) and the Imperial County Public Health Department (ICPHD) concerning promotion of asthma self-care occurred as certified nursing assistants (CNAs) at the ECRMC gave tool kits to patients and referred them to the ICPHD for training (the CNAs were not qualified to do the training). However, this activity will not be continued due to lack of funding. No additional efforts regarding coordinated, collaborative asthma treatment beyond those implied in Objectives 1 through 3 were documented. Cost and Service Use Analysis The project delivered 7 core data records of CMSP beneficiaries served by the project. This data was folded into the Education and Outreach cluster that is reported on page 268. Future Directions The IVAI plans to continue holding monthly meetings at the Public Health Department and to work collaboratively and in a non-duplicative manner addressing the problem of asthma in Imperial County. These efforts will include future fund-raising initiatives for new asthma programs. The Public Health Department plans to continue to provide client-centered asthma sessions, asthma outreach presentations, and tool kit trainings. Although the promotoras trained through the program are not currently delivering asthma education because of lack of funding, they continue to work in the community, making informal referrals to ICPHD for asthma education. And 156 one of them is currently working for the Housing Authority delivering diabetes education. 156

158 Madera County The Madera County W&PP funded the staff to create and operate a diabetes program incorporating community and provider awareness and education campaigns; early detection through screening; diabetes education; referrals for ongoing treatment; and ongoing support for persons identified as having, or at risk for, diabetes. Staff supported by the grant were 1 FTE Project Coordinator and 0.2 FTE bilingual clerical support person. Project staff provided diabetes screening and education services at locations and community events throughout Madera County that were frequented by the target population. All those with abnormally high blood sugar levels were referred to primary care, and follow up was attempted on these referrals. Also supported by grant funds were: 3 diabetes support groups, offered in English and Spanish, meeting monthly; a billboard on highway 99 targeted at diabetes awareness; incentives and supplies for health fairs; indigent medication and diabetes testing supplies assistance; Program Description continued on the next page> Total Award Expended $175,000 of $261,714 awarded Program Partners Madera Community Hospital Madera County Public Health Department Darin Camarena Health Centers, Inc. Geographic Area Served Madera County Target Population Medically indigent people of color with a special emphasis on the Hispanic/Latino communities and agricultural workers Contact Information Carolyn Schroeder, LVN, Project Coordinator Madera Community Hospital Phone: (559) cschroeder@maderahospital.org 157

159 CMSP/TCE WELLNESS & PREVENTION PROGRAM >Program Description, continued from the previous page Meeting People Where They Are for Effective Diabetes Outreach and Education staff training activities; a diabetes seminar for providers by Joseph Hawkins, MD. Because of staff turnover in the first two years of the grant, most of the project activity occurred during the third year. Consequently, one year of funding was not released to the project. Program Objectives and Outcomes 1 Objective 1 THE MADERA DIABETES PROJECT found that outreach, screening, and education go hand in hand. The screening activities are an opportunity to educate people about their risk level for contracting diabetes, the consequences of uncontrolled diabetes, and the opportunities for treating and controlling diabetes that exist locally. Finding out that you are seriously at risk for diabetes, or what is a more powerful motivator already have diabetes and are experiencing consequences of uncontrolled high blood glucose levels, provides what every educator seeks: a teachable moment. In that moment, a person may be open to receiving information that they might otherwise ignore. Carolyn Schroeder, Diabetes Coordinator, and Madeline Martinez, bilingual health worker, of the Madera Diabetes Project frequented country grocery markets, swap meets, and thrift stores where people in their target populations go to shop. They made presentations to organizations such as the Hispanic Chamber of Commerce, local Lions Clubs, NAACP, and AARP. They visited English-as-a second-language adult education classes. The primary purpose of these outreach events was to identify people who are at risk for or have diabetes and do not know it and to help them get connected to medical care. The Madera Diabetes Project conducted this outreach event at a convenience store that is frequented by farm workers. To coordinate all diabetes-related services and providers at the County level, with special emphasis on prevention and early detection of diabetes. W&PP Rating: Partially Achieved Objective (high level of data to support) 158 The project staff accomplished the following: Coordinated the signing of memoranda of understanding between the three project partners; formed a Steering Committee overseen by a Medical Director, which met monthly; produced an inventory of providers offering diabetes services; and sent a letter, followed up by phone calls, to 42 providers inviting them to participate in focus group targeted at coordinating efforts regarding diabetes, including establishing a bestpractices policy for the county. Since not a single provider responded to the invitation to participate in the focus group, with the primary reason being stated to be lack of time, it was not possible to pursue the goal of establishing best practices and coordinating services towards that end. Objective 2 To standardize guidelines for clinical management and prevention practices for diabetes. W&PP Rating: Partially Achieved Objective (high level of data to support) 1 Refer to DRA s evaluation report in Volume 2 of this report for the site's complete evaluation findings. 158

160 Madera County Site Report Although the project staff went to great lengths to try to engage providers in this effort, there was an almost universal lack of interest and response from the providers (see details under Objective 1). The project staff also put on a mini walk-through health fair that was fairly well attended (approximately 150 medical personnel) and a lecture by Joseph Hawkins, MD that was lightly attended by 1 physician and 14 nurses. However, the lack of any participation by providers towards standardizing guidelines for clinical management and prevention practices for diabetes within the county resulted in no progress being made towards this goal. Objective 3 To increase access to diabetes services, including diabetes screening, diagnosis, referral to services, disease-related clinical services, educational services and/or self-help diabetes management materials. Travelers on Madera County s HWY 99 get the message about reducing the risk of diabetes through exercise. Through their regular outreach events, such as their bimonthly visits to the local swap meets, they established an identity and built trustful relationships with the people who attended. They know who we are and where to find us, says Schroeder. For example, one woman whose blood glucose tested very high at a swap meet outreach event was attentive to the list of consequences of uncontrolled high blood glucose. On hearing about these, she said, Oh, I didn t know about that. Would you please look at my feet? It turned out that she had severe foot fungus and deep cracks that weren t healing. She was sent to the emergency department for immediate treatment, possibly avoiding a very serious consequence such as amputation. W&PP Rating: Achieved Objective (high level of data to support) The project delivered data to the evaluator that project staff reached 6500 people for diabetes screening and education at 75 outreach events (see table below), 34 presentations, 17 displays, and 6 health fairs. A total of 3342 people received blood glucose tests, diabetes education/information, and referrals at these events. Grocery Stores 22 Thrift Shops 4 Pharmacies 5 Pow Wows 2 Swap Meets (4/month) 32 Other 10 Total # of Screening Events 75 Locations of the outreach events conducted by the Madera County W&PP project The project was highly successful at reaching its target population in terms of ethnicity as shown on the following chart: In another example, a man who is deafmute and did not know sign language was brought to a swap meet by his brother-in-law to get screened, and he was found to have diabetes. The Madera Diabetes Project staff coordinated his treatment at the Darin Camarena Health Clinic, and they also coordinated enrollment for him and his family into a program for the deaf at the local community college. He now has his diabetes under control, and he and his family are doing well in the college program. In yet another example, a man reluctantly at the prodding of his wife had his blood glucose tested at a thrift store outreach event and discovered that he had an unusually high blood glucose level. He had been scheduled to undergo surgery, but surgery was postponed until the diabetes was brought under control. The project staff provided the patient s physician with his blood glucose reading from the outreach event. 159

161 CMSP/TCE WELLNESS & PREVENTION PROGRAM 2% 17% 1% 2% 78% African American Hislpanic/Latino Native American White Other Ethnicity of people screened by the Madera County W&PP Persons who tested abnormally high for their blood glucose levels were referred to a physician/clinic, and project staff followed up to see whether the appointment had been kept. Approximately 18% of those screened had elevated blood glucose levels, as illustrated on the following graph: African American Hispanic Native Latino American White Other Tested >140mg/dl Ethnicity of screened individuals who had elevated blood sugar levels. The man is now a regular participant in diabetes support group meetings established through the W&PP project. In a final example, at an outreach event set up at a Native American Indian powwow, the local tribal Chief was persuaded to have his blood glucose checked, even though he was not feeling ill. His blood glucose level tested at 570. This gave us an opportunity to discuss the fact that diabetes is known as the Silent Killer and to give him some literature, says Schroeder. He was given a referral to see a provider as soon as possible. At a subsequent powwow outreach, the Chief told us he had gone to the doctor and was now on oral medications and was maintaining his blood glucose levels below 120. I believe we have made an important difference with many of the people we have contacted, says Schroeder. For those diagnosed with diabetes, attendance was encouraged at one of three diabetes support groups that offered monthly education, self-care skill development, and peer support. There are three support groups: two are held in English (at the Madera Community Hospital and in Chowchilla), and one is held in Spanish (at the Darin Camarena Health Center) that have a total monthly attendance of approximately 100. The support group at Madera Community Hospital has been running for many years and has 40 to 50 participants. The support group in Chowchilla is newly established, but successful, and is held at Dewitt s Pharmacy. The group held at Darin Camarena Health Center was established March 2003, and has 11 participants. Objective 4 To ensure that clients are aware of and/or referred to services that promote the well-being and positive family functioning of diabetic clients. 160 W&PP Rating: Achieved Objective (high level of data to support) The project submitted data to the evaluator that 94% (574/611) of those whose blood sugar test results were above normal received referrals, staff was successful at reaching 50% (289/574) of these at follow-up, and 70% (203/289) of those reached at follow-up reported having sought the care of a doctor/provider. All those diagnosed with diabetes were also invited to attend a monthly diabetes support group (see also, Objective 3). Cost and Service Use Analysis The project did not submit any core data records of CMSP beneficiaries served, since they did not have access to health care payor data or social security numbers. Therefore, this project was not included in the cost and service use analysis. Future Directions The project reports that they will not be able to sustain this project fully unless they can secure additional grant funds. In particular, outreach screening activities will not be maintained. However, the support groups will probably be maintained, and presentations regarding diabetes will continue. Through collaboration with several other central valley counties in an effort funded by The California Endowment, health care for diabetics will be available. 160

162 Mono County The Mono County W&PP, also called the Rural Oral Outreach Health Development project, funded a portion of the salary of an Oral Health Outreach Coordinator during the three-year grant cycle. The Oral Health Outreach Coordinator engaged in the following activities: publicizing the services available at the Sierra Park Dental Clinic; providing case management services to ensure that appointments were made and kept; arranging, coordinating and providing transportation to and from the clinic from outlying rural areas; assisting families with enrollment into Healthy Families; conducting outreach to schools and day care centers, along with a dental hygienist from the Dental Clinic, to teach preventive dental behaviors to students and their families. The project had three different Oral Health Outreach Coordinators; the first two were bilingual in English and Spanish, enabling them to effectively reach the monolingual Hispanic population. The multiple changes in Oral Health Outreach Coordinators may have negatively effected the project s evaluation because of failure to institutionalize Program Description continued on the next page> Total Award Expended $77,409 of $77,409 awarded Program Partners Mono County Office of Education Mammoth Hospital s Sierra Park Dental Clinic Mono County Public Health Department Geographic Area Served Mono County and parts of Inyo County Target Population Underserved populations in Mono County Contact Information Rosanne Higley, Director Learning Support, Dental projects Mono County Office of Education Phone: (760) rhigley@monocoe.org 161

163 CMSP/TCE WELLNESS & PREVENTION PROGRAM >Program Description, continued from the previous page The Human Side of Case Management Selected Success Stories EFFECTIVE CASE MANAGEMENT often requires case managers to find creative ways to engage and maintain contact with clients. Many times, the case manager must employ the support of other local agencies to refer and assist in case management interventions. The following client success stories shared by the project s second Oral Health Outreach Coordinator illustrate the Oral Health Outreach Coordinator s involvement with multiple agencies outside the Sierra Park Dental Clinic in addition to the positive impact the provision of dental services at Sierra Park Dental Clinic have had on the lives of three Mono County residents. Jorge Jorge is a 15-year-old, undocumented boy who attends the local high school in Mammoth Lakes. Jorge was referred to Mono s Dental Health Program by the school principal. Jorge was a student who missed school often and after some investigation by one of his teachers, it was discovered that Jorge was suffering from a toothache. After consulting with Jorge s parents, the Oral Health Outreach Coordinator arranged for Jorge to apply for CHDP. Jorge received a physical exam and was then referred to the Sierra Park Dental Clinic to obtain dental care for the aching tooth. training and procedures regarding data collection. The training and procedures that were established with the first coordinator by the evaluators regarding data collection and reporting were not passed on to subsequent coordinators. The project reports that the first 2 coordinators left the project with barely two weeks notice and, though not neither intentional nor willful, the project did not inform the W&PP staff or evaluators of the staff changes in a timely manner. Therefore, in spite of a concerted effort by the evaluators to retrain and work with the second and third coordinators, there is comprehensive data regarding the case management activities in year 1 only. (Refer to DRA s evaluation report for full details.) The project reports that the breakdown in maintaining the reporting systems was more a factor of changing hospital policies and practices. At about the same time that the first coordinator left the program, Mammoth Hospital, which housed the dental clinic, became responsible to HIPAA rules. The Hospital s interpretation of these privacy rules were stringent, and would not allow for any 162 questions to be asked of patients that it had not approved. Thus, many of the questions required by the project were deleted from any paperwork. As noted elsewhere, the presence of the Oral Health Outreach Coordinator, an employee of the Mono County Office of Education, on site at the hospital and having access to its computerized database, was a cause of strain. The strain was not so much among the employees of the dental clinic as with the Hospital s information systems managers. The project director reported that change is always difficult, and the HIPAA regulations were a challenge to people used to the small town ways of keeping track of people, their needs, and private information. Program Objectives and Outcomes 1 The Oral Health Outreach Coordinator had to devise a way to get Jorge to his dental appointments because, like school, he often missed his appointments. The Coordinator was able to work with one of Jorge s favorite teachers to insure that Jorge could make his appointments. The Coordinator would call the teacher when Jorge had an appointment, and the teacher would send Jorge to the dental clinic, which is located a twominute walk away from the high school. The Oral Health Outreach Coordinator gained the trust of Jorge s family after she aided them with Objective 1 To conduct outreach and promote the dental services available at the Sierra Park Dental Clinic. W&PP Rating: Achieved Objective (high level of data to support) Although the project did not provide the evaluators any data to support the achievement of this goal, the project did submit in their annual reports to the CMSP W&PP staff examples of ads and television spots that were used to publicize the Sierra Park Dental Clinic. The project reported that the Oral Health Outreach Coordinator 1 Refer to DRA s evaluation report in Volume 2 of this report for the site's complete evaluation findings. 162

164 Mono County Site Report made outreach visits to WIC clinics, preschools, dental/ health fairs, and other public presentations, making referrals to the Dental Clinic as appropriate. Flyers were mailed to potential and current CMSP clients and were posted in Mammoth Lakes at locations frequented by the target population. Moreover, the data provided to the evaluators regarding the number of people served by the clinic shows that increasing numbers of people used the clinic each year. This data revealed that there were 373 visits by CMSP beneficiaries to the clinic in the first grant year, 420 in the second, and 412 in the first 11 months of the third year. A limited data set from the first year showing how 130 CMSP clients heard about the clinic, 21% had heard from the dental coordinator, and another 5% from ads in the newspaper or radio. The project staff stated that the activities of the Oral Health Outreach Coordinator were important in producing this increased usage. The staff had expected the visits by CMSP beneficiaries for preventive dental care to increase at a rate of 5% per year, but in fact experienced and increase of 12% and 20% in 2002 and 2003, respectively. Regarding all visits to the Dental Clinic, the project expected to have 200 visits/month but in fact by visits/month were occurring. Additionally, initially the clinic was open two days per week from 8:30 a.m. to 5 p.m. Now the clinic is open eight hours per day on three days, and for four hours on two days per week. It should be noted that a part-time Oral Health Outreach Coordinator was also funded through the Cycle 1 and Cycle 2 W&PP grants, so the Dental Clinic has had the benefit of an outreach worker/coordinator through the CMSP/TCE W&PP for the past 5 years (see also the accompanying highlight story as well as the Dental Outreach in Mono County article in Volume 1, Issue 2 of the W&PP Newsletter). Mono Dental Clinic Dental Hygenist conducts outreach education. resolving a bill they had incurred from the hospital emergency department for Jorge s dental pain prior to his enrollment in the Dental Health Program. The Coordinator worked with the financial services department at the hospital, assisted the family in completing paperwork stating their need, and was eventually able to get the bill taken care of as a result of a grant obtained by the hospital for uncompensated care. Pedro Pedro, a 2-year-old Spanish-speaking boy, and his family were referred to Mono s Dental Health Program from the Mono County Public Health Department. The young child had severe dental decay and needed a complete dental restoration. The Oral Health Outreach Coordinator assisted Pedro s family in obtaining health insurance coverage and taught them about dental hygiene. The Oral Health Outreach Coordinator arranged for Pedro to be seen in Mammoth Lakes at the Sierra Park Dental Clinic by a pediatric dentist who volunteers his time away from his private practice in Long Beach, CA. The Oral Health Outreach Coordinator provided translation services to the family at every dental visit. Pedro is now feeling better and his family has learned the importance of dental care for all members of the family regardless of age. Larry Larry, a new CMSP beneficiary, was referred to the Dental Health Program after applying for CMSP at the county s social services department. He presented at the Sierra Park Dental Clinic in severe pain. The Oral Health Outreach Coordinator arranged for Larry to be seen by the dentist the same day. After numerous extractions, fillings, crowns, and ongoing deep gum cleanings, Larry was on his way to being pain-free and enjoying his decay-free smile. 163

165 CMSP/TCE WELLNESS & PREVENTION PROGRAM Objective 2 To provide dental services to the underserved population of Mono County. W&PP Rating: Objective Addressed Outside W&PP Effort This goal was not addressed by the grant, since grant funds only went towards the salary, training, and activities of the Oral Health Outreach Coordinator. Please refer to the Sierra Park Dental Clinic statistics listed under Objective 1. Objective 3 To establish a case management system to track patients who utilize the dental services. W&PP Rating: Achieved Objective (moderate level of data to support) The project provided only a subset of data regarding the case management activities. They provided data on some (130) of the CMSP beneficiaries seen during the first year of the grant. The data reveal that follow-up activities were undertaken, with 104 of the 113 patients requiring follow-up care keeping their appointments by a population not known for their diligence in keeping appointment, indicating that efforts by the Oral Health Outreach Coordinator had been successful to some extent. The project reported that a case management system was established that including: reminders in the person s primary language of upcoming appointments; assistance with transportation to and from the appointment; assistance with transportation to out-ofcounty specialists appointments; one-year recall reminders; family case management services, meaning that when a family member was contacted for a reminder, etc., the dental coordinator asked about possible need for dental services by other family members; assistance with Healthy Families applications; referrals to Social Services for other health care payor coverage. The project claims that everyone visiting the clinic was case managed, with an average case-management load of 75 people per month. The project s definition of case management is anything necessary to get clients needed services. Objective 4 To provide and/or coordinate transportation to patients visiting the dental clinic W&PP Rating: Achieved Objective (moderate level of data to support) Although the project did not provide any data to the evaluators regarding this goal, the project reported that an important duty of the Oral Health Outreach Coordinator was to arrange for transportation for patients living in outlying rural areas. According to the project, rides were coordinated or arranged for approximately 40 clients per month. The 164 activities of the Oral Health Outreach Coordinator regarding transportation including: providing coupons for public transportation and assistance with how to use them for people without reliable personal transportation; coordinating the awarding of stipends through the First 5 program for children requiring services out of county; coordinating with other service providers regarding transportation to increase efficiency by arranging for more than one person to ride in a contracted vehicle; working with Health Start Coordinators to make transportation referrals to families throughout Mono County; coordinating transportation by volunteer drivers. The Chart A on the following page illustrates the large geographic area served by the Sierra Park Dental Clinic. 164

166 Mono County Site Report Graph A: City of residents of clients served by the Mono County W&PP Big Pine Bishop Bridgeport Chalfant Valley Coleville Crowley Lake Independence June Lakes Clients Visits Lee Vining Lone Pine Mammoth Mammoth Lakes Other Areas Note that the towns of Big Pine, Bishop, Chalfant Valley, Independence, and Lone Pine are in Inyo County at distances of up to 90 miles from Mammoth Lakes. Objective 5 To maintain a collaborative of local stakeholders who promote and support the dental services provided at the Sierra Park Dental Clinic. W&PP Rating: Objective Addressed Outside W&PP Effort This goal was not specifically addressed by the grant, since grant funds only went towards the salary, training, and activities of the Oral Health Outreach Coordinator, who was a member of the cooperative, the Mono County Dental Task Force, but was not actively involved in maintaining the collaborative. On the other hand, the Oral Health Outreach Coordinator position was designed and generally supervised by the Mono County Dental Task Force. Cost and Service Use Analysis The project submitted 139 unduplicated records of CMSP beneficiaries who received dental services from April 1, 2001 through October 31, This data was folded into the Outreach and Education analysis cluster on page 268. Future Directions The project reports that they will not be able to continue to fund an Oral Health Outreach Coordinator unless they can secure additional grant funds. Consequently, the outreach activities will not be continued. However, the project reports that many of the case management activities have been absorbed by clinic staff and will be continued, perhaps in a less proactive and comprehensive manner. The Mono County Office of Education will continue to pursue funds to provide preventive dental education. The project has recommended that the Dental Task Force reconvene to address issues that include the need to support preventive education and oral surgery, particularly for children. 165

167 CMSP/TCE WELLNESS & PREVENTION PROGRAM

168 Nevada County N evada County is divided by the Sierra Nevada Mountain range, and all of the Nevada County Community Health Public Health Nurses (PHN) were based in the Western portion of the county prior to the Wellness & Prevention Program grant. The target population underutilized the out-stationed Nevada County Human Services Agency services housed within the Joseph Government Center in Truckee, such as a public health clinic and human services, and the County did not have a positive presence in the community. The site was not respected in the town of Truckee and was viewed as unreliable and unable to follow up on clients. Therefore, providers had stopped referring patients to the clinic. Initially, the project proposed hiring a bilingual Public Health Nurse for the Eastern community with the W&PP grant funds. However, implementation of the project was hindered due to a hiring delay of 15 months. The county unsuccessfully attempted to hire a bilingual Public Health Nurse for the project through extensive recruiting efforts locally, in Sacramento, in the Bay Area, and in the State of Nevada. Recruiting in the Truckee area was especially challenging, since Truckee is a rural, Program Description continued on the next page> Total Award Expended $95,395 of $108,586 awarded Program Partners Nevada County Community Health Nevada County Adult & Family Services Nevada County Behavioral Health Geographic Area Served Tahoe Truckee Region of Nevada County Target Population Uninsured and/or underserved residents of the Tahoe Truckee region with a special focus on the Hispanic community Contact Information Alison Lehman, Program Manager Nevada County Human Services Agency Phone: (530) Alison.Lehman@co.nevada.ca.us 167

169 CMSP/TCE WELLNESS & PREVENTION PROGRAM Turning an Outreach Event into a Fiesta ONE FALL SUNDAY AFTERNOON in Truckee was transformed into a celebration promoting health and celebrating Latino culture. An estimated 450 community members, primarily Hispanic, attended the Fiesta de Comunidad Latina, held at the Sierra Mountain Middle School in Truckee in October This was not the typical health fair, as the Nevada W&PP created a festive and fun fiestalike atmosphere by providing authentic Mexican cuisine, live music from a grupo Norteño band, and games in addition to providing direct health services and health education information. Forty local, nonprofit agencies were on-site to provide information on smoking cessation, nutrition, and a variety of social services as well as direct services such as car seat checks. Fiesta participants were provided with body density scans, flu shots, blood glucose testing, dental screenings, and blood pressure checks. Emergency response vehicles such as the care flight helicopter and a fire engine were on-site with staff available to provide tours and respond to questions. The actual event day was a success due to the community s participation and the diligent, wellthought-out planning by the participating locallevel agencies. The Nevada W&PP also cites the additional benefit provided by the four months of planning prior to the fiesta as valuable relationships and trust were built between the Musicians helped turn a health fair into a fiesta! >Program Description, continued from the previous page mountainous community with high housing costs, and Nevada County s pay scale cannot compete with many neighboring communities. Eventually, an enthusiastic Registered Nurse was hired (0.5 FTE) for the position with the addition of a 0.25 FTE bilingual health technician to provide translation services during outreach activities. The Registered Nurse, permanently stationed in the community of Truckee, provided extensive community outreach in an effort to establish community relationships and acted as the referral source for Community Health. She has actively worked to become the face to the clinic in the community, and the fact that she is a resident of the Truckee area greatly helped her ability to be welcomed in the community. The project s nurse pounded the pavement to conduct outreach activities at 168 untraditional venues, like places of employment such as construction sites and restaurants, to pro-actively engage the target population versus waiting on the target population to seek services. The W&PP provided Nevada County with the opportunity to build relationships with community providers and to enhance services. Successful interagency coordination was established with Adult & Family Services and Behavioral Health to link clients engaged in the outreach activities with services including Medi-Cal, Healthy Families, CMSP, food stamps, as well as individual and group counseling. The project worked closely with Sierra Nevada Children s Services, Wellsprings Counseling Center, Tahoe Forest Hospital, and Project MANA (a food distribution center) during the project s implementation. The project sponsored the Fiesta de Comunidad Latina (Latino Health Fair) in Truckee that included health screenings and booths from forty different nonprofit agencies in addition to authentic Mexican cuisine and a live band (please see the project highlight for further information on the fiesta). Additionally, grant funds were used to support the mobile van and to purchase medical supplies, health education materials, and incentives. A Kids Zone Health Education Learning Center interactive display was also sponsored by the project. 168

170 Nevada County Site Report Program Objectives and Outcomes 1 Objective 1 To increase awareness among the medically indigent and bilingual/monolingual Spanish-speaking in East Nevada County by providing outreach, education, and appropriate referrals to services. W&PP Rating: Achieved Objective (moderate level of data to support) Originally, the project planned to utilize the Community Health Mobile Van to conduct the outreach events. This planned effort was proven unsuccessful when ice, snow, and locating a certified driver presented as challenges. In the light of the challenges, the project adjusted its strategy decided to conduct outreach on a face-to-face basis. The nurse successfully built relationships with the local businesses that often employ the target population by joining the Truckee Chamber of Commerce. The nurse arranged to go on-site to the business, such as local construction sites, to provide education about local health and human services, and to provide direct services such as flu shots, tetanus booster vaccinations, and blood pressure screenings. Local business owners responded favorably to the services provided to their employees and nominated the Nevada County Community Health Department for Nonprofit Agency of the Year in The Town of Truckee recognized the County s outreach to the Hispanic community and presented Nevada County with a proclamation for providing quality services to a diverse community. Outreach and health screening events were also performed at low-income and senior housing complexes. Over the grant period, the project reports providing outreach events to 1,570 (duplicated count) residents. In addition to the outreach events, the project utilized the local media including the local community television station, community billboard, and local newspaper to gain visibility in the community and promote the availability of health and human services in the Truckee community. Ads were run in both English and Spanish. Project staff participated in Truckee s Fourth of July Hometown Parade to highlight Nevada County s Mobile Health Van. The project reports to have These Truckee Fiesta attendees are all smiles as they learn how to maintain good health. participating agencies. Due to the success of the first Fiesta de Comunidad Latina, the event will become an annual event in Truckee. The project has secured a $5,000 commitment from the Nevada County Adult and Family Services for fiestarelated costs in reached up to 30,000 residents through these promotional activities. Due to the inability to recruit and hire a bilingual PHN, the project included a part-time bilingual health technician to assist the outreach nurse during outreach efforts. In the final year of the W&PP, the project used grant funds to send the outreach nurse to a week-long high-intensity Spanish language class to increase her ability to communicate with clients without the need for an interpreter. Objective 2 To increase utilization of preventative health services among the medically needy and bilingual/monolingual Spanish-speaking in East Nevada County. W&PP Rating: Achieved Objective (moderate level of data to support) Data provided by the site to the evaluator indicates an increased utilization of the Nevada County Human Services Agency s services in the Truckee community since the start of the grant. Graph A on the following page shows the increasing enrollment in human services programs such as Medi-Cal and CMSP at the Adult and Family Services (AFS) Truckee location from 2001 through Refer to DRA s evaluation report in Volume 2 of this report for the site's complete evaluation findings. 169

171 CMSP/TCE WELLNESS & PREVENTION PROGRAM Jul-01 Graph A: Increasing enrollment in human services programs Sep-01 Nov-01 Jan-02 Mar-02 May-02 Jul-02 Sep-02 Nov-02 Month/Year The Truckee clinic experienced a large increase in the utilization of family planning and immunization services between the periods of to Family planning encounters at the clinic increased by 244 visits during this period, and immunization encounters at the clinic increased by 233 visits during this period. Graph B illustrates the increased encounters by type from 2000 to 2001 compared to 2002 to Jan-03 Mar-03 May-03 Jul-03 Sep-03 Case Counts CalWORKs Case Counts Total FS Case Counts NA FS Case Counts PA FS Case Counts Medi-Cal Case Counts CMSP Person Counts CalWORKs Person Counts Total FS Person Counts NA FS Person Counts PA FS Person Counts Medi-Cal Person Counts CMSP Graph B: Truckee Clinic usage for versus Breast Examination Chest Clinic Child Health Screen Employee Physical Family Planning HIV Testing Immunization Pap Clinic Physical Exam Adult Pregnancy Testing Primary Care Sexually Trans. Disease Sterilization Well Baby Fiscal Year July 00-June 01 Fiscal Year July 02-June

172 Nevada County Site Report Through the grant, the Nevada County Community Health Department was able to build community partnerships and initiate collaborative partnerships through the Latino Health Fair, a Special Multi-agency Resource Team (SMRT), and the Tahoe Truckee Perinatal Outreach Team (TPOD). The project noted an increased level of network interaction, increased number of referrals to County services, and increased satisfaction with County services. As stated previously, the relationship between the town and the County was initially a tenuous one. The outreach nurse and program manager actively worked to smooth over the relationship between the town of Truckee and the County. The project was invited to present information on the services offered at the Truckee clinic to the Town Counsel meeting, and the clinic staff attended the counsel meeting to show support. In November 2003, the project surveyed 15 community-based agencies to their gauge perception of Nevada County Human Services Agency s services such as the public health clinic, CPS, and benefits assistance in the Truckee community. Stakeholder survey respondents commented that they had seen a great improvement in the Health Services Agency s public presence and attempts at coordination with other agencies over the past year. One respondent wrote, Collaboration, customer service, and staff attitude have all gone up. Cost and Service Use Analysis Project staff did not have access to medical payor information or social security numbers, so no core data records of CMSP beneficiaries who were contacted during outreach efforts were delivered the CMSP/TCE W&PP administrative staff. Therefore, this project will not be included in the cost analysis. Future Directions The project reports that just as the Truckee Clinic s presence in the community is being expanded, the county is facing fiscal challenges due to the estimated $2.5 million in property taxes being cut from the county budget as well as rising costs from workers compensation, PERS, and liability insurance. It was reported by the County CEO that the county might experience layoffs due to budget constraints. Every effort will be made to provide the same level of service as in , understanding that this will require, for many agencies, departments and programs, reorganization or streamlining of current resources. In response to a difficult budget, the county has proposed during the next fiscal year to evaluate the Truckee health clinic. Community forums will be held to balance fiscal concerns with community needs. Recommendations will be brought back to the Board in early However, it should be noted that the Truckee health clinic has been fully funded for 2004/05 fiscal year. Regarding project activities, the outreach nurse funded through the W&PP will be reduced to 0.5 FTE for 2004/05 fiscal year. Truckee Clinic outreach nurse administers a shot in the arm. 171

173 CMSP/TCE WELLNESS & PREVENTION PROGRAM

174 San Benito County This program targeted low-income, uninsured or underinsured adults residing in San Benito County. Special emphasis was placed on providing outreach, education, referrals, and benefits enrollment assistance to the agricultural worker population. The goals were twofold: first, to increase awareness of diabetes prevention and management among those at risk or diagnosed with the disease. Secondly, the project aimed to increase awareness and utilization of available health services and health benefits, including CMSP-associated efforts; to work with lunch truck vendors to provide healthier foods; and to identify and promote the use of insurance that may be provided through agricultural employers. The project also conducted a provider assessment to determine the number of local doctors and dentists that served CMSP clients and the reasons why providers may or may not be willing to accept CMSP as a form of payment for care. The project provided education and information regarding the CMSP system with the hope of prompting an increase in the number of providers willing to serve this population. Grant funds were used to support a Health Education Associate (0.5 FTE), to fund a needs assessment, and to purchase advertising and promotional items. Funds Total Award Expended $102,466 of $114,515 awarded Program Description continued on the next page> Program Partners San Benito Health Foundation* San Benito County Health and Human Services Agency* Hazel Hawkins Hospital San Benito Home Care Hazel Hawkins Community Clinic Geographic Area Served 72 outreach sites throughout San Benito County Target Population Latino adults (21 to 64) living in agricultural campsites, some with their families and some alone. A small percentage of participants represented the working poor. Some were homeless and/or in transition. Others were students or low-income residents new to the county. *Primary partners Contact Information Carlos Lopez, Health Education Associate II San Benito County Health and Human Services Agency Phone: (831) clopez@sanbenitohhsa.org 173

175 CMSP/TCE WELLNESS & PREVENTION PROGRAM >Program Description, continued from the previous page Savvy Duo Contribute to Project s Success IT IS A RAINY WINTER DAY, but that did not stop Carlos Lopez and Josie Trujillo from making their weekly rounds to the migrant worker camps that ring the town of San Benito. Lopez and Trujillo are Health Education Associates working for San Benito County Health and Human Services. They conduct outreach efforts to people who don t usually have access to or knowledge about healthcare options low-income people living in migrant farm housing, working on farms and ranches and in factories, and frequenting markets, thrift shops, and other locations. were also used to support staff in attending a training regarding HIV in the Latino population and a computer software training. Program Objectives and Outcomes 1 Objective 1 To increase knowledge and awareness of diabetes and associated risk factors among the agricultural work population of San Benito County. W&PP Rating: Achieved Objective (high level of data to support) The San Benito Health Foundation clinic reported seeing an increase in the numbers of agricultural workers and their families seeking screening and information about diabetes at the clinic, with a total of 350 being screened and diagnosed with diabetes in 2003, which clinic staff reported to be more than were screened in Objective 2 Their first stop today is San Benito Labor Camp, a men s only facility. They methodically knock on each door and introduce themselves to whoever answers. Speaking in Spanish, Lopez delivers some information about the CMSP program and Trujillo talks about diabetes. Often they must acknowledge that only emergency services are covered by CMSP for the people they talk to in this camp, but frequently the men are not aware of even this option. During the conversation, Lopez and Trujillo are alert to any potential health issue that might be mentioned. Depending upon what ends up being discussed, they might urge the person to seek treatment at the San Benito Health Foundation clinic, which offers services with fees on a sliding scale and has bilingual/bicultural staff. Since turnover is very high in the Labor Camp, Lopez and Trujillo rarely see the same people for more than a few weeks. Nevertheless, Lopez is often able to establish a trustful relationship with the men who then sometimes reveal health problems they are experiencing. Lopez s quiet but confident style and depth of medical knowledge encourage interaction by people who can be quite shy and non-communicative. Prior to 2001, Lopez, whose position was partially funded by the W&PP project, was a practicing To provide diabetes health education and referrals to agricultural workers having or at risk for diabetes. W&PP Rating: Achieved Objective (high level of data to support) Project staff provided data to the evaluators showing that 3,628 individuals participated in diabetes education sessions and received referral information regarding available health-care services; outreach activities were conducted at 72 sites. Project staff documented the distribution of diabetes and CMSP information as shown in the figure below: Nutrition 20% Exercise 20% Questionnaire 1% Flyers 20% Brochure 19% Ed. Material 20% Materials distributed (by type and/or topic) 1 Refer to DRA s evaluation report in Volume 2 of this report for the site's complete evaluation findings. 174

176 San Benito County Site Report Spanish-language radio spots regarding risk factors for diabetes were aired on the local Spanish Language radio station, estimated at reaching 5,000 Hispanic/Latino community members. Objective 3 To increase awareness of CMSP services among agricultural workers and increase enrollment. W&PP Rating: Achieved Objective (high level of data to support) Applications for CMSP in San Benito County increased 300% from 2001 to 2003 (annual applications: 312 and 1,126, respectively); San Benito County social service workers reported that assistance with preapplication/screening paperwork that W&PP staff provided to applicants was fundamental for the completion of many applications. physician in Peru. Having made the decision to immigrate, Dr. Lopez must now sit and pass rigorous exams to continue his vocation in the United States. San Benito County was fortunate to gain his services while he brushes up on his English language skills in preparation for the exams. The next stop is a camp that houses families. Here Lopez and Trujillo are able to conduct more indepth interviews, because they have developed trustful relationships with the families, who tend to be more stable in their housing patterns. One woman who they visit regularly invites them into her home, and Trujillo listens as she talks about efforts she has been making to control her diabetes. The woman mentions some of the changes she has made in the family s meals to help her keep her blood sugar in check. She is eager to talk about her efforts and progress. Objective 4 To 1) increase awareness of CMSP among providers and 2) increase the number of local providers who accept CMSP. W&PP Rating: Partially Achieved Objective (high level of data to support) According to surveys conducted by project staff, in 2001, 22% and 24% of doctors and dentists, respectively, accepted patients receiving Medi-Cal or CMSP benefits; in 2003 the numbers were essentially unchanged, with only one doctor added to the list of providers accepting Medi-Cal or CMSP patients. This lack of change occurred in spite of a concerted effort by project staff to educate providers about the CMSP program. The percentages of doctors and dentists who do or do not accept Medi-Cal and CMSP patients In San Benito County are illustrated on the following charts: Trujillo was born and raised in San Benito and has relatives Carlos Lopez, Health Educator for San Benito County working in agriculture. She Health and Human Services, works with a student in a has extensive knowledge Spanish-language diabetes education class. about the community and where people tend to congregate. With her knowledge of the San Benito area and Lopez s medical expertise, they make an especially effective outreach team. Before the day is over, Lopez and Trujillo visit 9 migrant camps and talk with dozens of people. Even though it is winter, a surprising number of people are available to talk, perhaps because of the rain. The Lopez-Trujillo duo are an outstanding example of culturally and linguistically competent health care professionals making a real difference for the medically underserved people of rural California. 175

177 CMSP/TCE WELLNESS & PREVENTION PROGRAM Accept Only Referrals 5% Other 2% Only Referrals 0% Other 5% Do Accept 22% Do Accept 24% Do Not Accept 71% Survey results from doctors in San Benito County regarding whether they accept patients enrolled in Medi-Cal or CMSP Do Not Accept 71% Survey results from dentists in San Benito County regarding whether they accept patients enrolled in Medi-Cal or CMSP Reasons given by doctors and dentists as to why they do not treat patients who are enrolled in Medi-Cal or CMSP included that they think these payors do not pay enough or do not pay on time, or that there are too many requirements by these payors. Note, however, that project staff were surprised at how many doctors do provide services to Medi-Cal and CMSP beneficiaries, and the survey results served as a useful referral resource. Objective 5 Increase the availability of healthy lunches to agricultural workers. W&PP Rating: Failed to Achieve Objective No change in the types of food offered on food trucks occurred, and consumers continued to prefer junk foods in spite of repeated educational visits by project staff. Note, however, that over time and after repeated visits from project staff, catering truck owners seemed to become more responsive to the idea of offering healthful food alternatives. Objective 6 To increase the awareness of insurance benefits among agricultural workers. W&PP Rating: Partially Achieved Objective (high level of data to support) Applications for CMSP in San Benito County increased 300% from 2001 to 2003 (annual applications: 312 and 1,126, respectively); San Benito County social service workers reported that assistance with pre-application/ screening paperwork that W&PP staff provided to applicants was fundamental for the completion of many applications. Note, however, that many agricultural workers still do not have access to any benefits other than emergency services because of their undocumented status. No employer-provided health benefits were identified. Cost and Service Use Analysis Due to the nature of the services provided and population served, no cost and service use by CMSP beneficiaries was possible, because no patient identification information was collected in this project. Therefore, this project was not included in the analysis. Future Directions The San Benito County Health and Services Agency plans to continue the outreach/education activities, which they consider important because of the high rate of diabetes among people who are faced with difficult barriers and challenges regarding health care access in the county. They have applied and been approved for a grant under TCE s Diabetes In Control program to fund the continuing efforts. They have received funding to continue and expand outreach efforts to include: Conducting support groups; Promoting diabetes self-management strategies; Family support systems. 176

178 Tehama County The Tehama County Wellness and Prevention Program, headed by the Tehama County Health Services Agency-Public Health Division, sought to improve the health and increase the knowledge of indigent Spanish-speaking diabetics in Tehama County in order to affect long-term changes in their clients behaviors. Program Description continued on the next page> Total Award Expended $200,848 of $210,813 awarded Program Partners Tehama County Health Services Agency (TCHSA)* Public Health Division Mental Health Division Medical Clinic Tehama County Department of Social Services* Tehama County Latino Outreach* Maria Johnson, RN, Independent Certified Diabetes Educator Mercy Medical Center s Certified Diabetic Educator St. Elizabeth s Community Hospital Sacred Heart Catholic Church The Vineyard Church North Valley Catholic Social Services Seely Medical Group Geographic Area Served Tehama County Target Population CMSP-eligible and Spanish-speaking indigent and underserved individuals *primary partners Contact Information Linda Wimer, PHN II Tehama County Health Services Agency Phone: (530) wimerl@tcha.net 177

179 CMSP/TCE WELLNESS & PREVENTION PROGRAM Grupo Latino de Apoyo del Diabetes ONGOING DIABETES SUPPORT GROUPS can provide excellent opportunities for refreshing memories or for acquiring new information regarding self-care techniques. The advantages of this venue are that people get to know and trust each other over repeated attendance, the groups tend to be small and nonthreatening, and there is opportunity for wider group participation. In Tehama County, Norma Rodriguez, a bilingual Health Educator, and Linda Wimer, Public Health Nurse with the Tehama County Health Service, reported that the Grupo Latino de Apoyo del Diabetes (Spanish language support group) was unusually successful, with many longtime attendees. Due to the abundance of orchards and the relative dearth of row crops, the farm worker population in Tehama County is more permanent than in other California counties therefore Tehama County was able to address the needs of monolingual, Latinos with diabetes through the development of a stable, ongoing support groups, conducted in Spanish to best reach the community. Monthly Spanish-speaking diabetic support groups began in June 2001 and were held in Red Bluff, CA during the evenings to accommodate workers and their families. Participants and attendance at the support group increased on a continual basis through the threeyear grant. The first support group had only one attendee, however as outreach efforts and word of mouth increased, so did the number of support >Program Description, continued from the previous page Norma Rodriguez, TCHSA health educator, celebrates a diabetes support group member s one-year of attendance Initially, the program consisted of two parts: first, to provide case management services to monolingual Latino diabetic clients and their families, including monthly diabetes support group meetings and biannual education classes; and second, to conduct community outreach to increase awareness of diabetes via health screenings and education at community events. The project also wanted to serve CMSP clients, and thus they formulated each of their objectives to include both Spanish-speaking individuals and CMSP clients, as though both qualities would be found in a large number of individuals in Tehama County. During the first two years of the grant project, staff discovered that the terms Spanish-speaking and CMSP clients were nearly mutually exclusive in Tehama County. They found that most of the monolingual Spanish speakers they encountered were undocumented and therefore did not qualify for CMSP, except for emergency care, which would not be helpful for assisting 178 clients in managing their chronic disease. Others belonged to families with children and were likely to qualify for Medi-Cal. Rather than change their objectives; the project chose to add another dimension to their efforts to attempt to involve more CMSP-eligible individuals. During year three of the grant, the project also provided screening services, in collaboration with TCHSA Mental Health Division, at churches that ran The Lord s Table, a free lunch project for homeless individuals who were predominately Caucasian males. However, they found that working with this population was not playing to their strengths, which were providing linguistically and culturally appropriate case management and educational services to indigent Spanish-speaking diabetics. With regard to this third objective of serving clients that were screened at The Lord s Table project, first located at Sacred Heart Catholic Church and ultimately at The Vineyard Church, the project delivered data to the evaluators indicating that 272 individuals were provided health screening and referrals and 4 were identified as candidates for case management. All four clients were CMSP-eligible men, and three were diabetics, and the fourth had tertiary syphilis. The three individuals with diabetes received the same case management services as did those in the Spanish-speaking population, including individual education, being supplied with 178

180 Tehama County Site Report glucometers and testing supplies, referrals to establish a primary care provider, coordination and transportation assistance to medical appointments, and medication management. Case management services were provided for them at The Lord s Table location and the Public Health office. The client with syphilis was provided with education, home visits, multiple laboratory testing, medical care coordination, medication management, sexually transmitted disease testing, and referrals to family planning, a primary care provider, and a nonemergent ER visit for a penicillin allergy challenge prior to receiving medication administration. With regard to case management of Spanish-speaking clients, all members of the support groups were eligible to receive various case management services through the project. These services included: transportation to and from meetings and health care appointments; home visits; enrollment into the Patient Assistance Program for free medications; referrals to the Job Training Center; referrals to stress management services; and, referrals to weight and nutrition counseling. Seely Medical Group and the TCHSA Medical Clinic provided the primary care services for those without a medical home. Staff felt that case management was the most effective intervention in helping clients improve their health and reach their goals of self-care maintenance. They believe the bond between a client and case manager is often the catalyst for improving the client s self-perception and providing the motivation necessary to make life style changes that will positively effect quality of life. The project delivered data on 50 people who were case managed, of whom 45 were Spanish-speaking Latinos and 5 were Caucasians. A reported 83% of the Latinos who were case managed were undocumented. The grant funded a Public Health Nurse (PHN) (0.25 FTE), a bilingual Health Education Assistant (0.75 FTE), and a Supervising PHN (.05 FTE), operational support of the Mobile Clinic, medications and lab and health education supplies, and attendance at a conference and an educational class for the PHN to become a certified Diabetes Nurse Educator. Since the project made a good-faith effort to include CMSP-eligible individuals in their efforts, but found them to be rare in their true target population, we conducted the following analysis ignoring the term CMSP in each of the project objectives. group members. The largest support group meeting conducted had 27 adults and 7 children participating. Family members were encouraged to attend the support group meetings. The majority of clients joined the support group through referral by friends or support group participants. Meetings provided a venue for individuals with diabetes to gain information about their condition and share resources. In an environment where their native language was encouraged and their culture celebrated, participants were able to problem solve challenging situations and share emotions associated with the rigors of proper diabetic selfmanagement care. Linda Wimer, PHN, conducts a foot screening at a Tehama County diabetes support group meeting Tehama s success in establishing the Grupo Latino de Apoyo del Diabetes can be summarized to the following components: Bilingual and bicultural staff provided the project with a crucial link in developing trust between support group members and the case managers. Removed barriers to attendance by 1) allowing the participants children attend the meetings, 2) providing transportation to meetings and health care appointments, and 3) holding meetings in the evening hours, after work was completed. 12 children attended the support group meetings with their parents so that child care would not become a barrier to members. Transportation was provided (through the provision of bus tickets or by directly transporting clients) on a regular basis to 13 clients to assure access to health care visits, support group meetings, and diabetes classes. Staff also provided home visits to participants when additional education was needed. 179

181 CMSP/TCE WELLNESS & PREVENTION PROGRAM Program Objectives and Outcomes 1 Incorporated health screenings into each support group meeting. Staff conducted the following health screens on a monthly basis: blood glucose monitoring, blood pressure checks, oxygen saturation levels, heart rates, and diabetic sensory foot screens. Additionally, flu and pneumonia vaccines were administered to support group participants and their families. Staff documented progress notes, referrals provided, education provided, vital sign measurements, and diabetic foot screening results for each support group member. Focused on portion control of traditional ethnic foods to improve client nutrition and blood glucose levels versus carbohydrate counting. Food was provided and prepared by the support group staff as a client incentive as well as a teaching tool. Education efforts were focused on better blood sugar control via portion size control and following the food pyramid, rather than changing cultural food preferences. On the support group s annual anniversary and at Christmas, the support group had a potluck in which traditional foods were integrated with nontraditional healthy options. Assured access to primary care and medication by successfully securing a primary care physician for all support group members that attended on a regular basis. Additionally, the project assisted 72% of the regular support group members in enrolling in pharmaceutical companies patient assistance programs to receive their medication without charge. While assisting clients in accessing health care, the project staff recognized that many clients didn t know how to negotiate through the health care system effectively. The project found that case management interventions greatly improved the outcomes of health care visits by advocating for the client s needs or simply knowing the right questions to ask. Assessed each participant s literacy level and used verbal, written, and visual education tools. For example, the staff printed stickers illustrating morning and night to place on non-reading participants medication bottles to assist those patients in taking the proper medication at the correct time of day. Objective 1 To increase outreach to Spanish-speaking diabetic CMSP clients. W&PP Rating: Achieved Objective (high level of data to support) The project reported that in each of the three grant years, a major effort was made to reach the Spanishspeaking population by conducting screening for diabetes at two Latino cultural events each year, the Cinco de Mayo celebrations and the annual Feria de Salud. To advertise these events, more than 1300 flyers were distributed to 37 sites including local health and human service providers, Latino cultural fairs, Latino markets, the Tehama County Latino Outreach group, Catholic churches, and Laundromats. 180 Objective 2 To increase health screenings of Spanish-speaking diabetic CMSP clients. W&PP Rating: Achieved Objective (high level of data to support) The project delivered data to the evaluators that indicated that 371 clients had been screened for diabetes at six Latino cultural fairs in years two and three of the grant. This was reportedly a large increase from the number screened in year one (about a combined 30 for two events). The project reported that in grant years two and three, about 80 to 125 people were screened at each of the four outreach events), largely, if was believed, because of the addition of the use of the Mobile Clinic at screening events. The Mobile Clinic was highly visible, provided a professional medical environment for the screenings to take place, and displayed a more official presence. Ethnicity data delivered to the evaluators on 233 of those screened in grant years two and three revealed that 82% were Latino. The project reported that everyone screened who had elevated blood sugar levels (about 11% had blood sugar levels high enough >200 mg/dl to warrant concern) was referred to education classes and diabetes support groups. Those who took advantage of this opportunity generally chose to attend the two-day class rather than to join the ongoing support group. However, a 1 Refer to DRA s evaluation report in Volume 2 of this report for the site's complete evaluation findings. 180

182 Tehama County Site Report majority of the people who attended support groups were first contacted at screening events. Everyone with dangerously high blood sugar levels >385 mg/dl, about 5% of those screened was referred to the emergency room or their primary care provider if they had one for immediate treatment. Health screens were also conducted for all diabetes support group members and diabetes education class attendees. Overall, the project reported that 1226 health screens were provided over the three-year grant period, with all clients offered education and referrals. Objective 3 To increase knowledge of diabetes management and self-care for Spanish-speaking diabetic CMSP eligible clients. W&PP Rating: Achieved Objective (high level of data to support) The project reported that support groups for Spanish-speaking diabetics were held 30 times over the course of the grant with a total attendance of 399 (duplicated) clients. According to the project, the support group maintained 19 clients on a regular basis, and 75% of the regular clients attended over 50% of the group meetings. This stable support group population was built up steadily over the first few months of the program. Most members of the support group stayed with the program once they become involved, e.g., the support group maintained 52% of all clients from year one of the grant. The support groups provided clients with diabetes education, referrals for services, flu and pneumonia vaccinations, monitoring of key health indicators, instruction in home blood sugar monitoring, and nutrition counseling. Two-day education classes led by a bilingual Certified Diabetes Educator were held every six months over the course of the grant, serving 56 individuals, many of whom returned at later dates to refresh their selfmanagement skills. The total attendance for all 12 class days was 173 clients (56 unduplicated). All class participants received health screens that included blood glucose, blood pressure, heart rate and oxygen saturation tests. Any client who did not already have a glucose monitor was provided with one, and all clients received Routine health screenings, such as blood pressure checks, were a main component of Tehama s monthly support group training on how to use the monitors effectively. According to the project, nearly 75% of the regular support group members attended the education classes, and 15 education class participants became support group participants. Staff felt that the overlap of clients between the classes and the support group, as well as the repeated class visits by many clients, indicated a motivation on the clients part to improve their knowledge about their disease, a desire to be successful with self-care, and a high satisfaction with the classes. According to the project, a measure of the success of the support groups was that 80% of the regular clients demonstrating improved monitoring skills and stable blood glucose levels. Clients also showed improved understanding of food portion controls and the food pyramid. The project found that their Latino clients with diabetes responded better to learning about portion control of their ethnic foods rather than carbohydrate counting to improve their nutrition and blood glucose levels. Objective 4 To increase enrollment of Spanish-speaking diabetics in CMSP. W&PP Rating: Partially Achieved Objective (high level of data to support) The project staff reported that they found at least 83% of their Spanish-speaking case managed clients were undocumented workers and thus ineligible for CMSP benefits except for emergency services. Another large fraction (13%) had private insurance, and 5% qualified for Medi-Cal. Therefore, no Spanish-speaking individual was enrolled into CMSP. Staff found that because of generally low literacy levels, individuals receiving referrals to complete a Medi- Cal application could not complete the process without case management intervention. The project reports that 72% of the clients served had a grade school education only and many were illiterate in their native language. The Latino culture is very family oriented hence; the majority of the clients served by the project were married and had families. If their legal status had not been a 181

183 CMSP/TCE WELLNESS & PREVENTION PROGRAM barrier, the clients served by the project would have likely qualified for Medi-Cal instead of CMSP. Objective 5 To increase the number of health-maintenance outpatient visits for Spanish-speaking diabetic CMSP clients by 10%. W&PP Rating: Achieved Objective (moderate level of data to support) The project staff reported that patients who were case managed did meet their expectations for increased health-maintenance outpatient visits. They had this information because very often they accompanied individuals to their appointments or otherwise assisted them in completing the appointment, since many clients did not know how to negotiate the health care system effectively. However, the project staff were not able to collect any data to document this. They attempted chart reviews but concluded that it was an inefficient use of time, and client reporting was inconsistent. Objective 6 To decrease hospitalization and ER utilization of Spanishspeaking diabetic CMSP clients due to hypo/ hyperglycemia episodes. W&PP Rating: Achieved Objective (moderate level of data to support) The project staff reported that hospitalizations and ER visits were decreased in their case managed population. However, they were not able to collect any data to document this. Perhaps telling is that only two support group attendees needed emergency care over the three-year period, one due to a myocardial infarction, and the other due to a long-term fragile diabetic with persistent foot ulcers who required an amputation. These occurrences and that of a support group member who was lost to care because of a difficult family situation were disappointing to staff, who were highly committed to helping clients successfully managing their chronic disease. They learned that sometimes client values and life events can interfere with the efforts of intensive case management efforts. The project reported that these episodes were difficult for the case manager both personally and professionally and had the potential to lead to staff burn-out. Objective 7 To decrease amputations, neuropathies, and retinopathies related to diabetic Spanish-speaking CMSP clients. W&PP Rating: Achieved Objective (moderate level of data to support) As noted under Objective 6, staff reported that hospitalizations and ER visits were reduced because of the program. The project reported that two hospitalizations occurred, with only one amputation out of all 50 case managed clients, and one person had elective surgery for retinopathy, which restored nearly all her sight after sinking into near blindness. However, the project was not able to supply information about rates of diabetes-related amputations, neuropathies, and retinopathies in this population before the program started, so this claim could not documented. 182 Cost and Service Use Analysis The project was not able to collect payor information or social security numbers (because of perceived restrictions due to HIPAA regulations), so they did not submit any core data records for CMSP beneficiaries. The project determined that during outreach events, which serve a large number of individuals at a time, requiring all participants to sign the Tehama County Health Services Agency s Notice of Privacy Policy consent form would decrease the staff s ability and the client s willingness to be screened. Therefore, this project was not included in the cost and service use analysis. Future Directions Outreach activities will be sustained through other Public Health programs, but the no plans are in currently in place to continue the case management, support groups, or educational classes. A Spanish-language diabetes resource library will be kept at Public Health for medical providers and Spanish-language diabetes resources will be donated to the Tehama County Public Library for community use. The weekly community health screenings at The Lord s Table will continue in conjunction with the TCHSA Mental Health Division. The Public Health staff will continue to work collaboratively with other agencies should any decide to implement all or a portion of these activities. 182

184 Trinity County The Trinity County Wellness and Prevention Program project was a two pronged effort focusing on individuals at risk or diagnosed with diabetes as well as other chronic illnesses. In the southern part of the county, Southern Trinity Health Services (STHS), a community-based, nonprofit primary care clinic, targeted two populations: lowincome underserved clients suffering from chronic illnesses; and the frail elderly, with educational activities, in-home nursing, case management and support services. The project was essentially a continuation of the visiting nurse program that was established in 1998 with the assistance of the Cycle 1 W&PP. In northern Trinity County, education classes, individual consults and home visits were provided through the Health and Human Services Department in order to increase knowledge, awareness and active health management among those at risk for or diagnosed with diabetes. This was a new program for Trinity County. Grant funds were used to fund the Certified Diabetes Educator and the visiting home health nurse. Program Description continued on the next page> Total Award Expended $150,123 of $173,560 awarded Program Partners Trinity County Department of Health and Human Services - Public Health Department Southern Trinity Health Service Trinity Hospital/Community Health Clinic Geographic Area Served Trinity County Target Population CMSP-eligible and other low-income people living in Trinity County Contact Information Cathy L. Larsen, Executive Director Southern Trinity Health Service Phone: (707) clarsen@northcoast.com Elise Osvold-Doppelhauer, PHN, Public Health Nursing Director Trinity County Department of Health and Human Services Phone: (530) eosvolddoppelhauer@trinitycounty.org 183

185 CMSP/TCE WELLNESS & PREVENTION PROGRAM Effective Formal Diabetes Education Classes in Frontier Areas DURING THE WELLNESS & PREVENTION PROGRAM grant period, Charlene Dunaetz, Certified Diabetes Educator for the Trinity County Public Health Department, preferred to conduct formal classes so she could reach more people in a given period of time. However, if someone was home bound, she would go to his or her home to conduct an individual session, with the visit usually arranged by a home health nurse. She worked entirely outside clinics, but she received referrals from them. Dunaetz strove to pare down the material she presented in her classes to the really critical issues, which included: learning the food pyramid, what carbohydrates are, portion sizes, and how to read labels; knowing what the consequences of uncontrolled diabetes are; knowing how to interpret the blood sugar and other test results; knowing how to talk with their primary care provider. Dunaetz modified her classes to adapt to local conditions. She used to conduct 8-hour classes, lasting 4 hours on 2 consecutive days. However, she modified that approach and condensed her classes to one 3-hour session because she was getting low attendance with the longer class schedule, largely because of long travel times. Lewiston Lake in Trinity County >Program Description, continued from the previous page Southern Trinity County Southern Trinity s program aimed to reduce access-tocare barriers for the most vulnerable populations in the county s communities, and to identify, treat and monitor their health status with individually designed preventionoriented strategies. People in their target population were neither receiving appropriate health care nor having their multiple social and logistical problems addressed. Most could not access services available to them at the Southern Trinity Clinic in Mad River or higher-level services available in regional population centers because of geographic and economic barriers. Many had no reliable transportation for the distances they had to travel for care, or money for gas. The project staff reported that large portions of this population are weak or uncomfortable enough with their medical problems that they could not easily travel the 184 difficult mountain roads to reach care. The result was that many were not receiving care at all and their conditions deteriorated sufficiently to become acute, requiring hospitalization and often long-term institutional care following hospitalization. With the help of the Cycle 1 Wellness and Prevention Grant, a program was launched in 1998 to address the problems of this population with goals of assuring access to care, early intervention, and education information, whether the service was provided directly in the home or with the help of transportation to medical facilities. STHS clinic staff members, families, physicians, and allied health care providers identified appropriate clients. Direct medical and social case management services were provided to these clients, as well as ongoing monitoring and treatment of their conditions. Additionally, referrals, follow-up, and patient education were provided. Northern Trinity County The county s Diabetes Educator provided classes to anyone with diabetes in three areas of the county: Weaverville in the north, Hayfork in the county center, and Mad River in the south. Classes were advertised in the county newspaper and flyers were placed in doctors offices and clinics starting two weeks prior to each class. Patients were also referred to the classes from their primary care doctors. When the classes first started they were held on two consecutive days for four hours each 184

186 Trinity County Site Report day. This proved to be a hardship on many clients who had to drive long distances to attend the classes, so the class was condensed to one three-hour session. During the first year or so, the classes were only held on a quarterly basis, so the educator also provided a considerable number of individual consults between classes. When the classes were shortened, they were held on a monthly basis, so consults became less necessary. Education classes, individual consults, and home visits were conducted to increase knowledge, awareness, and active management for diabetics and those at risk for diabetes. (See also the accompanying highlight article for more details on this program.) Program Objectives and Outcomes 1 Objective 1 To conduct education classes and home visits in order to increase knowledge, awareness and active health management among those at risk for or having diabetes. W&PP Rating: Achieved Objective (high level of data to support) The Diabetes Educator s initial expectations were to reach every diabetic in the county through her classes. Although this did not happen, a high percentage of diabetics were reached. She reports that she held 12 eight-hour classes and 19 three-hour classes with a total of 278 participants. Some of the participants attended more than one time, which was encouraged by the educator because there is much information to absorb in a limited amount of time. Especially during year one of the grant, the diabetes educator gave one-on-one instruction in the person s home, if necessary. The project provided data to the evaluators regarding the health issues for 90 of 112 clients of the Diabetes Educator as shown on the following graph: Gestational Diabetes 19 Heart Disease 29 Hyperlipidemia Hypertension 48 Kidney Disease 4 1 Neuropathy 5 Type 1 Diabetes 82 Type 2 Diabetes 7 Vision Problems Health issues of clients served by the Diabetes Educator in Trinity County Even though she conducted classes in three different areas of the county, some people had to travel more than one hour each way to get to the class. I give clients the words to say, such as standard of care, when they go in for their 15 minutes with their primary care provider. I teach them what the norms are. Normal or acceptable blood pressure and blood sugar levels as well as lipid (cholesterol) panel values for nondiabetics are different for diabetics, and some primary care providers may not be aware of that. Scientists have found recently that people can have blood sugar levels within normal ranges before meals, but they may have unacceptable levels after meals. A blood sugar of 140 is OK for a nondiabetic, but not for a diabetic. I encourage my clients to show their primary care provider the card that I give them that is produced by the ADA and that has the best practices guidelines for blood sugars and Hb1Ac on it, as well as best practice guidelines for ongoing tests, such as frequency of foot and eye exams. I also tell them what signs indicate that they need to go to the ER for treatment if they cannot obtain an appointment with their primary provider, Dunaetz explained. Patient self-sufficiency was a prime goal for Dunaetz because of the lack of diabetes education support coming from the area s hospitals and clinics, many of which have totally disbanded diabetes education programs. The monitoring technology has enabled patients to be more selfsufficient in managing their diabetes. This technology and clients abilities to self-advocate have become critical self-management tools. Dunaetz augmented diabetes education with other services that enable people to keep their diabetes under control. She helped patients get onto patient assistance programs offered by the various pharmaceutical companies because many could not afford all the mediations they were taking, which often include medications for high blood pressure, high cholesterol, and others, in addition to their diabetic medications and test strips. Dunaetz also relied on pharmaceutical representatives who donate test strips and glucometers. 1 Refer to DRA s evaluation report in Volume 2 of this report for the site's complete evaluation findings. 185

187 CMSP/TCE WELLNESS & PREVENTION PROGRAM The project reported that the majority of participants were older, had Medicare or a combination of Medicare and Medi-Cal, and were Caucasian or Native American. CMSP beneficiaries comprised 18% of the clients in the data submitted to the evaluator. At the beginning of each class/consult the participants signed-in and took a pretest to assess their knowledge of diabetes. At the end of each class a posttest and evaluation were completed. Although no data was provided to the evaluators, the diabetes educator reported that unless a client, typically one who had been diagnosed with diabetes for many years, had attended a class in Redding they had no information whatsoever about diabetes or its management. She therefore felt that a significant knowledge change was been made in every client based on the question and answer sessions at each class. Participants were routinely encouraged to take the class more than once because the large amount of material presented was difficult to absorb at one time. However, the diabetes educator believes that measuring the number of questions a client gets right before and after a class does not really demonstrate an increased ability to manage the disease. She believes that life style changes are the key, and those can only be accurately measured in a more structured case management-like setting. Regarding barriers to participation in diabetes education, the educator felt the main one was clients denial of the need to manage their disease. Therefore, not everyone in the county with diabetes participated in this opportunity. The evaluators were displeased with the lack of impact data presented by this project, and they were not able to measure the impact of the program. However, we (W&PP administrative staff) have concluded that given the lack of established infrastructure supporting this project, the amount of data delivered was reasonable and indicates that significant impacts towards improved diabetes education in Trinity County occurred as a result of this effort, largely because there had been no access to diabetes education at all in the county prior to this program. The project was originally administered by the Trinity County Grant Administration Department who initially assumed responsibility for conducting the project s evaluation. As the projects underwent implementation, the role of the Grants Administration Department staff faded and was often duplicative of the projects conducting the work. The Grants Administration Department disengaged from involvement in the project and was no longer funded by the grant for evaluationrelated activities. The removal of this leadership, though faulty, left a structural void in the administration and evaluation of the grant. Objective 2 To provide a range of support, provider referrals and case management services in order to increase health maintenance behavior and improve overall health among clients with chronic illness. W&PP Rating: Achieved Objective (moderate level of data to support) The Southern Trinity project submitted an incomplete data set to the evaluator that was largely not consistent with data included in annual reports, so it was impossible for the evaluator to determine exactly how many people were served or in what manner. Therefore, the evaluator decided to rely primarily on the data included in the annual reports, since it seemed to be more complete. The project reported the data shown on Table A on the following page regarding the number of clients served and number of encounters. Regarding the types of services, data on Table B on the following 186 page was reported by the project, demonstrating that a wide range of services, including case management, referrals to clinics and specialists, and other support was provided. The project delivered a data set on a subset of 46 of the clients served that included information on their health issues, indicating at least for this subset of people, various chronic illnesses were issues, as shown on the following table: Issue Number of Clients Chronic Obstructive 22 Pulmonary Disease (COPD) Heart Disease 20 Hypertension 20 Hyperlipidemia 11 Cancer 10 Type 2 Diabetes 8 Obesity 7 Type 1 Diabetes 4 Degenerative Joint Disease 4 Stroke 4 Health issues of clients served in the Southern Trinity W&PP project Regarding the impact of these services, little data was available, but anecdotally, the project reported that transports to the emergency room were down by 40% by the target population and hospitalizations were reduced. A few clients were able to avoid traveling out of county to nursing homes and or experiencing long-term hospital stays by receiving final stage hospice-style care in their homes with the families around them for comfort and support. 186

188 Trinity County Site Report Table A: Number of clients served and visits performed by the Southern Trinity County W&PP Grant Year Number of clients served Number of encounters Average Number of visit/client Apr. 01-Mar Apr. 02-Mar Apr. 03-Feb Table B: Types of services rendered by the Southern Trinity County W&PP The visiting nurse reported in detail on one of these families that was provided with hospice-style support. This individual eventually succumbed to cancer. However, the nurse stated, I was able to train family members to care for that cancer patient after it was decided to stop therapy and begin hospice care. She died peacefully in her sleep overlooking her garden with her husband holding her hand. In the limited data set on 22 clients submitted to the evaluators, 5 of 10 hypertensive clients had normal blood pressures by their last encounter, and 2 of 3 people had lowered their elevated HbA1c values at their last encounter. Thus the project appeared to meet this goal, although the amount of data documenting the activities and impacts was less than expected. Report Year Data Category # of clients new over age home visits clinic encounters phone visit emergency refer to clinic ref to PMD/Spec 15 5 home health visits hospice visits 0 14 arrange IHSS 4 3 home treatment transportation arranged DME other DME 6 5 case management encounters Cost and Service Use Analysis The project submitted 6 core data records of CMSPeligible individuals enrolled into services prior to October 31, This data was folded into the Outreach and Education cluster that is reported on page 268. Future Directions According to their final report, STHS will be continuing to provide case management and in-home care to their clients. This was not surprising to the evaluators, considering that these services were in place prior to the start of the grant and funds were used to subsidize existing, institutionalized activities. Unfortunately, in Northern Trinity the diabetes education classes will not be continuing because there are no funds available without some manner of grant or external support. According to staff, the local hospital is facing potential bankruptcy and closure, and the Department of Public Health has no money available to provide support for the Diabetes Educator position; even part time. Also unfortunate is that reimbursement for the expenses for diabetes education, even by a Certified Diabetes Educator, is difficult to obtain from public or private health care payors, according to the experience of the project s Certified Diabetes Educator. In responding to the ending of services, one client has already made plans to use her own van to drive herself and other diabetics from the W&PP support group/ class to Redding. One collaborative activity will be continuing the Trinity Coalition for Activity and Nutrition, which strives 187

189 CMSP/TCE WELLNESS & PREVENTION PROGRAM to improve the health of children and their families through the prevention of chronic disease and weight problems. Through this initiative, funded through a small grant from the University of California, the Diabetes Educator will provide educational presentations on diabetes risk factors, nutrition, and the hazards of inactivity to teenagers in the schools. I give clients the words to say, such as standard of care, when they go in for their 15 minutes with their primary care provider. Charlene Dunaetz, Northern Trinity County s Certified Diabetes Educator

190 Yuba County The Yuba County Wellness & Prevention Program (YC W&PP) consisted of two different projects over the course of Grant Cycle 3 The first project, the Health Passport Program, terminated in February 2002 after the project director was removed from the program and the County began to reassess the project, which had been troubled from the beginning. 1 The second, the Hepatitis C Program, was proposed in September of 2002 and began operations in November This article reports on the second program. Yuba County has an unusually high incidence of hepatitis C (3.5% compared to 2% statewide). Until the YC W&PP began delivering services, patients in Yuba County with hepatitis C were referred out of county (usually to UC Davis Medical Center) for treatment because no in-county expertise existed to conduct the complex and of Program Description continued on the next page> Total Award Expended $112,789 of $120,782 awarded Program Partners Yuba County Health & Human Services Peach Tree Clinic Northern California Hepatitis C Task Force Geographic Area Served Yuba County Target Population CMSP-eligible and other low-income individuals who are at risk for or have contracted the hepatitis C virus (HCV) Contact Information Cyndi Journagan, Administrative Analyst Yuba County Health & Human Services Phone: (530) cjournagan@co.yuba.ca.us 189

191 CMSP/TCE WELLNESS & PREVENTION PROGRAM >Program Description, continued from the previous page Personal Touch Yields Hep C Program Success BECAUSE OF THEIR CAREFULLY planned procedures, the continuity of personnel that they see, assistance with transportation, such as gas or bus vouchers, reminders about appointments, and the respectful environment that the staff strive to cultivate, patients undergoing hepatitis C treatment at the Peach Tree Clinic rarely miss appointments, in spite of the fact that side effects of the medications cause them to feel bad as though they constantly have the flu and often feel depressed. Cissy Hern, Medical Assistant for the Peach Tree Clinic, works with Dr. Joseph Coulter as the dedicated medical personnel for the Peach Tree Clinic s Hepatitis C Services. Hern notes that she has been impressed with patients ability to overcome two major hurdles, with the first being the patients ability to take the steps necessary to turn their lives around to start the treatment (which usually means becoming clean and sober). Secondly, Hern is impressed with the patients ability to stick with the rigorous and lengthy treatment while maintaining a positive attitude. Over her year and a half working with the program, Hern has observed patients undergo an entire attitude transformation. With her years of experience working in the medical field, Hern notes that the staffs development of strong personal relationships with the patients is what makes the hepatitis C clinic at Peach Tree different than other medical settings she has worked in. Due to the duration of treatment (either six months or a year), the staff really gets to know the patient and often the patient s families, and the staff become part of the patient s support system as they undergo treatment. hepatitis C by a primary care provider, but only treatment by a hepatology specialist, and Yuba County has none of these specialists in residence. This strategy is not appropriate for indigent people because they often lack sufficient capacity (for example, transportation, resources for out-of-town travel, and self-management skills) to follow through with a lengthy and complex treatment regimen that is administered out of county. Thus, indigent population in Yuba County were generally excluded from access to hepatitis C treatment prior to this project. In order to open access to hepatitis C treatment to indigent individuals, including CMSP-eligibles, Joseph Cassady, DO, Yuba County Health Officer, and Joseph Coulter, MD, a primary care provider at the Peach Tree Clinic in Marysville, proposed to establish a clinic-based hepatitis C screening and treatment program. The program would operate under the training and supervision of an internationally renowned hepatitis C expert, Lorenzo Rossaro, MD, Medical Director of the Liver Transplant Program and Chief of Hepatology at the UC Davis (UCD) Medical 190 Center in Sacramento. In addition, the Yuba County Department of Health & Human Services, which is co-located with the Peach Tree Clinic along with one of the project collaborators, Yuba County For Our Recovering Families, proposed that outreach education to raise awareness about hepatitis C among the public, including high-risk populations, and health care providers would be conducted. 1 The Health Passport Program was intended to target indigent substance-abusing individuals to increase their access to primary health care and provide case management services regarding physical health issues. The case management tool was a Health Passport card that would concisely list the client s health visit record and health issues. The Health Passport Program suffered from a lack of communication between the project director and the collaborative partners. For example, partners and clients were not helped to understand the purpose of the Health Passport card, mistakenly thinking that it was an insurance card that relieved clients of the need to pay for services. Other failures of collaboration occurred, and events outside the control of the project also interfered with its success, all of which are detailed in the evaluator s report. Ultimately, the County decided that the project was doomed to failure and the County and the CMSP Governing Board mutually agreed to terminate the project. A total of $13,540 of grant funds was spent on this effort and the unspent funds were returned to the CMSP Governing Board. The County was given an opportunity to submit an entirely revised proposal to the CMSP/TCE W&PP administrative staff to implement for the duration of grant Cycle 3 with the remaining grant funds. The County selected a Hepatitis C Program, as detailed in this report, and entered into a new agreement with the CMSP Governing Board for the project. 190

192 Yuba County Site Report Treatment of hepatitis C infection requires the coordinated effort of multiple physical health, mental health, substance abuse treatment, and social service professionals. Hepatitis C infection, caused by a bloodborne virus, generally occurs in IV substance abusers. Therefore, individuals who are infected with hepatitis C virus generally have multiple physical and psychosocial issues that must be addressed. Before acceptance into the Yuba County Hepatitis C Program, a participant cannot be actively using illegal substances. Additionally, the participant must be cleared through mental health for disorders such as depression, because the lengthy and physically uncomfortable treatment (patients experience flu-like symptoms and other side effects including depression) requires a high level of mental function to sustain participation. The treatment program can last up to a year and includes weekly visits to the doctor for required therapy, which is delivered by injection, and failure to complete treatment means a wasted effort, so patients must be in a high state of readiness to participate and need a great amount of support and intensive case management. Therefore, the following collaborators were assembled and coordinated in the Hepatitis C Program: the Peach Tree Clinic (medical care provider), Yuba County Health & Human Services (fiscal agent), Sutter-Yuba Mental Health (mental health screenings and treatment for depression), UC Davis (hepatitis C treatment expertise and liver transplant referrals), the Fremont Rideout Health Group in Marysville (referrals), Yuba County For Our Recovering Families (referrals and substance abuse expertise), Pathways (housing and substance abuse treatment provider), and the Northern California Hepatitis C Task Force (training, counseling, and social marketing campaign). The grant funded a health care coordinator (0.6 FTE), professional fee reimbursement (0.2 FTE), data entry personnel (0.125 FTE), office rent, transitional housing for program participants, hepatitis C educational materials, and the hepatitis C social marketing campaign (billboards and brochures). As part of their successful hepatitis C program, Yuba County s W&PP included social marketing, such as creation of this billboard that they displayed at busy intersections. This support system is extended beyond the clinic staff, as the patients have created their own support system among each other. The patients diagnosed with hepatitis C are seen by the clinic on either Tuesdays or Thursdays. With the consistency in scheduling, the patients undergoing treatment have developed a sense of camaraderie with each other, such as sharing tips to deal with the side effects of the medications, comparing notes, and encouraging each other through the treatment process. The Tuesday patients rarely want to switch their appointments to Thursday, and viceversa, since the clinic s waiting room turns into an impromptu support group with their fellow hepatitis C treatment patients that they have grown to know well. These positive support systems are vital to many of the patients undergoing hepatitis C treatment, as many were former IV drug users who have had to modify their prior social connections in an effort to maintain sobriety. Many of these patients have had to inform friends, and even family members, engaged in active drug use that they can no longer be around them if they are engaged in taking drugs. These patients have acted as role models among their friends and family and have raised their awareness about hepatitis C often referring these friends and family members to get tested for hepatitis C. Patients are generally in high spirits as they near the end of the treatment protocol. There is a great deal of satisfaction knowing that the patient successfully completed the treatment regimen. However, there is a moment of sadness on the part of the staff, as they will miss their weekly visits with these patients they have grown to cherish. 191

193 CMSP/TCE WELLNESS & PREVENTION PROGRAM Program Objectives and Outcomes 2 Objective 1 To develop and implement a hepatitis C community awareness and education campaign to increase awareness of prevention methods and treatment options. W&PP Rating: Achieved Objective (high level of data to support) In collaboration with the Northern California Hepatitis C Task Force, the project developed an informational brochure on hepatitis, its treatment options, and relevant resources within Yuba County and distributed it throughout the county to providers and the public. A billboard, promoting hepatitis C awareness and testing, shown on the previous page, was also developed and strategically placed at four different locations for a threemonth period coinciding with Hepatitis Awareness Month. Evidence of the effectiveness of this campaign includes the large number of referrals that have been made by other providers throughout the county and even from neighboring counties. Currently, nearly one-half of all participants in the program have been referred from other providers outside the Peach Tree Clinic. Provider services for the program have had to increase from two half days per week at the start of the program to 2.5 days per week in April 2004 (a 250% increase in a little more than one year). Objective 2 To provide two inclusive education and training sessions on long-term clinical management of hepatitis C to local professionals. W&PP Rating: Achieved Objective (moderate level of data to support) The project reported that Dr. Coulter provided in-service courses to staff at the Peach Tree Clinic and Rideout Hospital (including medical residents) on identifying HCV, case management, counseling, and administering of medications. Objective 3 To increase awareness of infection control among professionals and high-risk populations. W&PP Rating: Achieved Objective (moderate level of data to support) As noted under Objective 2, the project reported that Dr. Coulter provided in-service courses to staff at the Peach Tree Clinic and Rideout Hospital (including medical residents) on this issue. Additionally, the project reported that all individuals who were screened as positive for the hepatitis C virus (HCV) at the clinic received education about hepatitis C infection control. Objective 4 To promote hepatitis C primary prevention activities in nontraditional settings. 192 W&PP Rating: Failed to Achieve Objective The project did not report to the evaluator or to the W&PP administrative staff any such efforts. Objective 5 To increase access to HCV infection prevention and control strategies by integrating hepatitis C counseling, testing, and referral into programs currently accessing high-risk populations. W&PP Rating: Partially Achieved Objective (minimal level of data to support) The project reported that Pathways, which provides substance abuse treatment services, delivered hepatitis C education to 153 individuals in their program, and as noted previously, other medical providers have begun to refer individuals to the program. Objective 6 To identify hepatitis C virus (HCV)-infected persons through diagnostic screening and testing. W&PP Rating: Achieved Objective (high level of data to support) 1 Refer to DRA s evaluation report in Volume 2 of this report for the site's complete evaluation findings. The 2004 final report submitted by the project indicated a cumulative total of 100 clients, including those from the previous year plus 79 new clients had been screened 192

194 Yuba County Site Report for HCV and were found to be infected with the virus. The project reported the following screening practices: The screening process includes taking a patient history along with providing a detailed explanation of the program and the potential side effects of the drugs. If the doctor feels that the patient is a good candidate for the program, (s)he is referred to Dr. Coulter for an in-depth interview and further information on the treatment protocol and side effects. Clients who are currently using illegal drugs, experiencing mental health problems such as depression, and/or are suffering from diabetes or hypertension must complete a treatment program or receive counseling/psychiatric consultation before starting the hepatitis C treatment program. If a patient appears to be a good candidate, a liver biopsy and labs are ordered. The lab results are reviewed with the patient at a follow-up visit, and Dr. Coulter again interviews the client to determine readiness and candidacy for the program. The medications for a patient are ordered only after they have committed to beginning the treatment program. The screening component of the project is rigorous and designed to weed out individuals who are more likely to be non-compliant or quit altogether. It is important that clients continue with the treatment once it is started because, if the protocol is interrupted, the client will have to wait at least 3 months before restarting the process. In addition, treatment is a costly and fairly labor-intensive investment on the part of the clinic and the providers. Clients in this population typically have many challenges that can interfere with compliance and follow-through. Since these behaviors are critical to the success of the treatment program, much effort is made to ensure that clients get to their appointments and get the support that they need to see the treatment through; the staff want to be sure their investment will be met with equal commitment on the client s part. The project delivered data to the evaluator on 17 of the 55 clients that were judged not ready to begin treatment (shown on the following chart), which illustrates the various reasons why treatment is not started on some patients who test positive for HCV infection. Client Wants to Wait 12% Not Indicated 29% Mental Health Assessent 12% CMSP-enrolled clients represented the majority of these (13/17) who were determined to be non-eligible for treatment, primarily because of coincident drug use or because treatment was not indicated for some reason, including spontaneous clearance of the virus from the person s blood by their own immune systems. Objective 7 Not Accepted 12% Cost 6% Drug Use 29% Reasons why some individuals were not enrolled into Yuba s W&PP hepatitis C treatment program To provide appropriate education, medical management, and antiviral therapy for those identified as infected. W&PP Rating: Achieved Objective (high level of data to support) The 2004 final report submitted by the project indicated that a total of 45 individuals began treatment. Of these, 60% (27/45) had tested positive for genotype 1 and required the 48-week treatment regime. An additional 10 (22%; 10/45) clients engaged in the 24-week treatment regime indicated for genotypes 2 and 3. No data on the treatment type for the remaining 8 (18%; 8/45) clients was delivered. As of March 2004, 2 clients were reported to have successfully completed the treatment program. Once a client begins the program they receive testing, specialized hepatitis C treatment, and medical case management. Chronic cases are referred to a liver specialist for treatment, both through direct patient contact and telemedicine consults. In addition, clients receive educational information on hepatitis C, referrals to appropriate counseling services, and education on prevention of transmission. The course of treatment depends upon the patient s hepatitis C genotype: 24 weeks for genotypes 2 and 3 and 48 weeks for genotype

195 CMSP/TCE WELLNESS & PREVENTION PROGRAM The success rate of clients in this program is well worth noting. Eighty percent (80%; 35/45) of clients, in spite of knowing that they are going to endure many months of difficult side effects from the medications, continue with the treatment. Staff report that the noshow rate among their hepatitis C clients is approximately 2%, compared to a no show rate of 30% among the same clientele utilizing general clinic services at the Peach Tree Clinic. Cost and Service Use Analysis The project submitted 32 records of CMSP beneficiaries who had been found to be positive for HCV through screening and received education or counseling through the program as of October 31, This data was folded into the Outreach and Education cluster that is reported on page 268. Future Directions The project reports that the program will continue to grow, and the Peach Tree Clinic will continue the hepatitis C clinic after the grant sunsets. They anticipate that it will take several years to obtain a measurable decrease in the number of people who are newly diagnosed with HCV. Because of the program s success, Dr. Rossaro plans to present it as a model for hepatitis C treatment in rural communities. Also because of its success, the clinic program has gained sufficient credibility to allow them to receive reimbursement from payors for medical services and medications provided in the hepatitis C treatment program. Therefore, the project is becoming selfsustaining

196 Outreach & Education Conclusions The degree of efficacy regarding outreach screening efforts appears to be dependent upon the particular situation. As the evaluators pointedly noted, two sites (Sutter and Siskiyou) found that their screening efforts resulted in few discoveries of undiagnosed diabetes, and that consequently, these sites stopped most of their outreach efforts part way through the grant period, focusing instead on delivery of education and services to those already identified with diabetes or diabetes risk factors. Furthermore, they found that individuals given referrals at screening events were not likely to follow up on them. On the other hand, the Madera and Kings projects, which targeted primarily indigent Hispanic individuals, particularly farm workers and their families, discovered many individuals with undiagnosed diabetes or who had diabetes risk factors that were unknown to these individuals. Furthermore, these projects found a high level of willingness on the part of at-risk individuals discovered by screening to enter into a treatment program and actively participate in the management of their illness. In fact, the Kings project had to stop their outreach screening efforts after the second year because their capacity to treat those identified with diabetes at screening events was insufficient to meet the demand. Most projects found that outreach events were good places to conduct awareness education. The Madera project provided many examples of the value of the teachable moment that arises when undiagnosed diabetes is discovered. The Mono project found that their dental education outreach resulted in an increased usage of dental services at the Mammoth Hospital Dental Clinic. The San Benito project found that outreach events were the only access to education about diabetes and available primary health care services possessed by many in their target population primarily migrant farm workers. The outreach education efforts by the Yuba project resulted in such a demand for hepatitis C treatment services that they had to significantly expand capacity over that originally planned to serve all individuals presenting for treatment. Regarding in-depth outreach education efforts, in Trinity County, outreach classes were effective modalities for delivering in-depth diabetes education. However, according to data delivered to the evaluator, most of those served were not enrolled in CMSP or Medi-Cal, but rather had private insurance or were covered under Medicare, indicating a lesser focus on the indigent population. Cost and Service Use Analysis Results The core data records for enrolled CMSP beneficiaries that were collected by each project were used to conduct a cost and service use analysis with the aim of describing impacts of the W&PP. This analysis is summarized in the Cost and Service Use Analysis section of this report, and the complete report by the analysis contractor, The Lewin Group, is included in Volume 2, Evaluation Findings. Reported here are data specific to the Outreach and Education Cluster. 195

197 CMSP/TCE WELLNESS & PREVENTION PROGRAM Graph A: Claims per 1000 members per month by service-use category for outreach and education cluster enrollees Before Enrollment After Enrollment Hospital IP Days Hospital IP Claims Hospital OP Claims Physician Claims Clinic Claims Lab Claims Home Health Claims All Other Claims 196 $400 Graph B: Claims per member per month by service-use category for outreach and education cluster enrollees $350 $300 $250 $200 $150 Before Enrollment After Enrollment $100 $50 $0 All Payments** Hospital IP Payments Hospital OP Payments Physician Payments Clinic Payments Lab Payments Home Health Payments All Other Payments *Excluding pharmacy claims 196

198 Outreach and Education Cluster Conclusion It should be noted initially that 75% of the enrollees in this cluster were clients of the Mono W&PP, which focused on dental outreach. Those included in this data set were patients at the Sierra Park Dental Clinic, comprising all CMSP beneficiaries served there during the reporting period. The rationale for including all clinic clients is that the outreach and education efforts were believed by project staff to significantly increase the numbers of CMSP beneficiaries seeking services there. Other outreach and education projects were usually not able to capture the needed social security number and payor information from clients that they served. Therefore, the significance of the cost and service use data for this analysis cluster is unknown. The reader is invited to review the data in Graphs A and B. Most notably, Clinic payments increased from $51 per member per month (PMPM) prior to enrollment in W&PP to $142 PMPM following enrollment. 197

199 CMSP/TCE WELLNESS & PREVENTION PROGRAM

200 Increasing Access Cluster. Colusa.. Del Norte... El Dorado... Inyo... Mariposa... Modoc... Napa... Shasta 199

201 200

202 Increasing Access Cluster Eight W&PP projects primarily addressed the lack of adequate access to health care. Cycle 3 grant funds were used by these projects to help plan and staff new facilities; staff and supply a mobile outreach health clinic and a homeless outreach clinic; provide funds for dental care and transportation to dental care; pay for laboratory services and support enrollment into Indigent Pharmaceutical Programs; and support the provision of specialty health care services. Following is the list of W&PP projects that focused primarily on increasing access to health care services: Colusa Del Norte El Dorado Inyo Mariposa Modoc Napa Shasta 201

203 CMSP/TCE WELLNESS & PREVENTION PROGRAM

204 Colusa County The Colusa County W&PP funded the staff, travel expenses, and supplies to operate a Del Norte Clinic s Mobile Clinic once a week at various locations in Colusa County. Initially, the intended function of traveling to remote communities via the Mobile Clinic was outreach to provide screening, referrals to community clinics and social service agencies, and education regarding chronic disease and accessing health care coverage programs. However, due to patient demand, the program evolved to also provide health care services, including exams, lab tests, treating injuries and infections, dispensing medications, and a variety of other primary care services. This evolution came about because many clients did not have transportation to get to a clinic for needed services and were more comfortable receiving services from the staff of the Mobile Clinic. The grant funds paid for 0.2 FTE for each of the following: a Nurse Practitioner, a bilingual Medical Assistant, a bilingual outreach worker/translator/case coordinator, and a mobile driver/receptionist. Additionally, the grant funds were used to buy medical supplies and educational materials, as well as to fund attendance at the CPCA Annual Conference and National Association of Community Health Clinics Conference. Program Description continued on the next page> Total Award Expended $167,185 of $167,185 awarded Program Partners Del Norte Clinics, Inc. Colusa County Department of Health and Human Services Geographic Area Served Colusa County Target Population Primarily, migrant and seasonal field laborers of Colusa County, as well as any person needing education regarding how to access health care services Contact Information Veronica Alcantar, Accountant Del Norte Clinics, Inc. Phone: (530) AlcantarV@dnci.org 203

205 CMSP/TCE WELLNESS & PREVENTION PROGRAM Mobile Clinic Selected Patient Stories Overcoming Complex Challenges THE MOBILE CLINIC HAS BECOME the permanent medical home for many individuals in the remote agrarian communities of Colusa County. Faced with geographic and social isolation coupled with the lack of financial resources, many patients present to the mobile unit with both complex health and psychosocial challenges. These selected patient stories, shared by Suzie Yost, FNP and the mobile unit s primary provider, illustrate the level the of trust that developed between the Mobile Clinic s patients and staff as well as the various situations the staff must be prepared to contend with when they venture out into communities in the Mobile Clinic. >Program Description, continued from the previous page The Mobile Clinic sets up shop at an outreach site. Initially, the Mobile Clinic traveled weekly to one of several towns, including Maxwell, Williams, and Arbuckle. However, it eventually developed that it only went to Arbuckle. That change allowed the Mobile Clinic to make regular weekly visits to the same location that clients could count on and plan for. As a result, utilization increased from 227 visits the first year to 622 in the third year, averaging 11 visits per day during year three. The majority of clients served were monolingual Spanish speakers who had little experience with the health care system in this country and who often had limited formal education. Outreach and delivery of services was tailored to this population, using the bilingual skills of the outreach worker, who has many contacts within the target population, and the medical assistant. The project 204 reported that patients typically sought services at the Mobile Clinic when they had an acute health condition, and that they typically had no available history of health care. After completing a medical history form, patients were examined by the Family Nurse Practitioner, lab tests were performed on-site or samples were taken for laboratory analysis, treatments such as breathing treatments were administered, medications were dispensed or prescribed, referrals were made, and health education was performed. Rosa We have a 45-year-old Hispanic female who now sees us regularly for hypertension, depression, allergies, and her annual female care. It was during her annual female exam that she disclosed her plight to the outreach worker and FNP. She came illegally to California to be with her husband after he was diagnosed with an incurable brain tumor. As a result, she has a lot of sadness about not being able to see her elderly parents, but she feels she should stay with her husband due to his limited life expectancy. The children are happy in the American school system and would prefer not to return to Mexico when the father dies (he continues at this time to do field labor). The patient is stabilized at this time on antidepressant medication, with the support of Program Objectives and Outcomes 1 Objective 1 To provide health education and screening to agricultural workers using mobile facilities. W&PP Rating: Achieved Objective (high level of data to support) The project delivered data to the evaluators that documented that 376 individuals (222 females and 154 males) made a total of 1149 visits to the Mobile Clinic and for which 956 health issues were identified. Of these 376 individuals, the project submitted data to the evaluator that 93% were Hispanic and 90% spoke Spanish. 1 Refer to DRA s evaluation report in Volume 2 of this report for the site's complete evaluation findings. 204

206 Colusa County Site Report The project reported conducting routine screening for hypertension, diabetes, anemia, and asthma. Evidence supporting this claim is found in the data delivered to the evaluator regarding diagnoses made during Mobile Clinic visits as shown on Graph A on the following page. Additionally, 3 months of care, from April to June 2003 were analyzed, revealing that for 119 patient encounters, there were 9 blood sugar, 14 hemoglobin, 4 vision, and 5 audiometry tests conducted. Although the project did not provide data that specifically documented the extent of the educational activities, they reported anecdotally that education was a dominant feature of their activities. According to the project, all staff were supportive of the idea that, if a person understands the basic reason why a medication or a life style change is recommended...[and]... the impact the intervention may have on their health status, the likelihood of self participation in and compliance with their health care plan is enhanced. The project reported spending a great amount of their time educating the clientele they served, including topics such as education about the particular health issue being experienced by the patient, explaining Western medical approaches (which were often poorly understood by native Hispanic patients), and the value of preventative strategies, including regular Pap tests, childhood and flu immunizations, and pediatric physical exams. As a result, demand for preventative services increased; for example, the project reported that Pap smears and flu shots increased over the course of the grant to the point that the number of Pap tests given equalled the number of acute infections treated, and the demand for flu shots exceeded the Mobile Clinic s supply. Additionally, the project reports noting that over time patients become more compliant regarding taking medications, as indicated by their returning for refills prior to running out of medication, and patients reported that they felt better as a result of taking medications and making dietary changes. An informal survey of patients conducted at 3 separate intervals revealed that most patients felt they learned something or a lot to help them stay healthy. An outreach worker mans a table at the Mobile Clinic event in Colusa County. friends, and even inquired recently if perhaps she should try to begin working before her husband passes away so that she has a work history. Lourdes Another female patient recently disclosed, during her first visit the Mobile, also for female concerns, that her husband is emotionally and physically abusive to her, ostensibly because she has not become pregnant in their several years of marriage. She even recently tried to shoot herself with his pistol because she feels hopeless of ever living a different existence. If she did return to Mexico to be with her mother, certainly he would be able to find her there to kill her. While we have not solved this woman s problems, we shared her examples of his wrong thinking, that she indeed has a right to be free of abuse, and what the number is of the closest domestic violence shelter. Though she has not yet agreed to leave, she has agreed she will not hurt herself until we see her again, and she will pack a small container of vital documents/money, for if she has to leave in an emergency because he is aggressive. She does not believe the police would be able to protect her from his physical aggression. Alejandra A 25-year-old Hispanic female came into the Mobile Clinic for an initial visit because of persistent fatigue, cough, and weight loss. A chest x-ray confirmed the presence of an active infiltrate (interpreted as pneumonia at the time). She also had very significant anemia. Because she wanted to work in her children s grade school classroom, and had a prior history of a positive skin test for tuberculosis (with a subsequent negative chest x-ray), we also requested the radiologist to rule out tuberculosis. This required a second x-ray after the initial infection was cleared. We were all surprised that the 205

207 CMSP/TCE WELLNESS & PREVENTION PROGRAM Graph A. The most common diagnoses made at the Mobile Clinic in Colusa County Reactive Airway Disease Upper Respiratory Infection Cough Fever Allergies Otitis Media Bilat Allergic Rhinitis Sinusitis Irregular Menses Diabetes Melitus Depression Bilateral Hearing Loss Allergic Dermatitis Otitis Externa Hypertension Allergic Conjunctivitis Insomnia UTI Bronchitis Facial Abrasion Anemia Ear Fungal Infection Number of Visits Objective 2 To provide direct medical care to agricultural workers using mobile facilities. W&PP Rating Achieved Objective (high level of data to support) As previously noted, the project delivered data to the evaluator that 92% of the 376 patients who visited the Mobile Clinic were Hispanic, and 90% spoke primarily or only Spanish. The project reported that most of the patients who were employed stated they worked in the fields, or in canning/processing plants. As already noted, these patients made 1149 visits to the Mobile Clinic and received the wide variety of services that have already been mentioned (see Objective 1). Objective 3 To refer clients to appropriate follow-up care. W&PP Rating: Achieved Objective (moderate level of data to support) The project did not deliver data to the evaluator regarding referrals made. However, the project reported that referrals to specialty care were made primarily regarding pediatric dental care as well as referrals to a urologist (1 case), to a surgeon for a colposcopy due to an abnormal Pap test (1 case), to a cardiologist for ischemic cardiac changes, and to an audiologist. The project reported that patients also received referrals for diagnostic services at the Colusa Family Health Center. Staff reported making substantial efforts to ensure that referral appointments were kept, and they were willing to re-refer if an appointment was missed. The project reported that these efforts eventually resulted in greater compliance in keeping referral appointments. Objective 4 To bring agricultural workers into the health care system. W&PP Rating: Achieved Objective (high level of data to support) The project reported that most of the people who were served by the project were agricultural workers or their family members. The project initially conducted extensive outreach advertising the Mobile Clinic, including distributing flyers in English and Spanish at schools, churches, and stores. Especially since the facility has operated at one location in Arbuckle at the 206

208 Colusa County Site Report same time each week, word-of-mouth has become the greatest source of referrals. When a client makes the first visit, staff assesses their payor source status and determines whether the person might be eligible for the sliding fee program, Child Health and Disability Program, Family Planning, Breast Cancer Early Detection Program, Healthy Families, or CMSP. Since most of the uninsured patients were undocumented, only 1 person was identified as being eligible for CMSP. Staff then assisted with applications or with referrals to social services. The following chart shows the breakdown of payor source for clients of the Mobile Clinic: home. An informal survey of patients, conducted at three separate intervals, yielded almost exclusively satisfied or very satisfied ratings for the Mobile Unit s services. Objective 5 To collaborate with Colusa County Public Health Department to provide additional screening and promotion of new programs. W&PP Rating: Partially Achieved Objective (minimal level of data to support) The project provided no data to the evaluator regarding this objective. The project reported that there were not Child Health and Disability Program 3.5% Family Planning 3.7% Sliding Fee 31.9% Breast Cancer Early Detection Program 0.5% CMSP 0.3% Medi-Cal 31.9% subsequent x-ray was very worrisome for possible tuberculosis. The Colusa County Health Department was very responsive to our request for assistance as the patient has no insurance and is not eligible for Medi-Cal. She is currently on a regimen of four daily medications, and the county is performing Daily Observed Therapy. Healthy Families 4.3% Not Covered 12.5% Medicare 1.9% Private Insurance* 9.6% Insurance coverage breakdown of Colusa s Mobile Clinic clients Suffice to say that on the Mobile Clinic, even when the health problems are not particularly complicated, the social and/or economic complications can be, and it requires the Mobile Clinic staff to be flexible in their approaches to problem solving to get the right medication or treatments to promote patient health and optimal functioning. The project reported that many of the privately insured patients only used the Mobile Clinic for advertised school sports physicals available for $10 in August and September. The project estimates that approximately 3% of the other visits were covered by private insurance. Although the original intent was for the Mobile Clinic to be an intake point to help establish a medical home at the Colusa Family Health Center, patients often preferred to be seen at the Mobile Clinic because they were familiar with it and were comfortable with the staff. Thus, the Mobile Clinic became their medical Mobile Clinic health provider examines a client. 207

209 CMSP/TCE WELLNESS & PREVENTION PROGRAM many collaborative efforts with the Colusa County Public Health Department regarding screening and new programs. However, they did collaborate in the care of certain patients, particularly in response to concerns about tuberculosis and during flu season. Additionally, both organizations were sometimes participating at the same event, such as the annual Colusa Community Fair. Cost and Service Use Analysis The project submitted 1 record of a CMSP-eligible individual that received services prior to October 31, This data was folded into the Increasing Access cluster that is reported on page 268. Future Directions The project reports that the Board of Directors of Del Norte Clinics, Inc., which is part of the health care safety net for underinsured and uninsured persons in the northern California valley, recognizes the Mobile Clinic as an asset to service delivery to patients. Therefore, the services of the Mobile Clinic are scheduled to continue for the foreseeable future. Additional funding is being sought, but even in the absence of additional grant funding, it is anticipated that the Board will support the continued operation of the Mobile Clinic. One important focus for additional funding is the addition of another medical provider on the Mobile Clinic because service demand has grown to the point that on some occasions, some patients have to be turned away due to lack of provider time

210 Del Norte County Open Door Community Health Centers operates the Del Norte Community Health Center, the only community clinic in Crescent City that serves all regardless of the ability to pay. The Del Norte W&PP was a loosely knit collection of activities designed to increase access to health care services by the target population. The activities that were funded by the grant included: Support for participation by Del Norte Community Health Center and Del Norte County Health & Social Services in the collaborative planning activities for the planned co-located service center (Del Norte Wellness Center) in Crescent City; Support of a coordinator for obtaining medications through the Indigent Patient Programs offered by various pharmaceutical companies (0.3 to 0.5 FTE throughout the 3-year grant period); Various lab tests; Program Description continued on the next page> Total Award Expended $178,251 of $178,251 awarded Program Partners Del Norte Community Health Center (DNCHC)* Del Norte Healthcare District* Del Norte County Department of Health and Social Services* Del Norte Children and Families Commission College of the Redwoods Area 1 Agency on Aging Pharmaceutical companies (various)* Geographic Area Served Del Norte County, particularly the area around Crescent City Target Population CMSP-eligible and low-income adults ages 21 to 64 who have little or no health insurance and who have a family income below 200% of the federal poverty level and who access services at the DNCHC *primary partners Contact Information Marylee Bytheriver, Development Director Open Door Community Health Centers Phone: (707) x139 mbytheriver@opendoorhealth.com 209

211 CMSP/TCE WELLNESS & PREVENTION PROGRAM Del Norte Wellness Center One Community s Vision Will Become a Reality IN 2005, CONSTRUCTION WILL BEGIN on the grounds of the College of the Redwood s Crescent City campus for the new Del Norte Wellness Center, a one-stop shop of health and social services serving California s northwestern communities in Del Norte County. The Wellness Center will become a reality through the culmination of the community s vision, political and community support, extensive and well-thought-out planning, and the investment of local agencies to commit resources to a collaborative planning process. This highlight article briefly chronicles the key events and processes that have allowed the Wellness Center to progress from being a great idea into an actual co-located services center designed to better serve the community. At the 1999 Del Norte Health Summit, the idea was born to create a betterinformed public by promoting wellness and educating residents on available health and social services through the creation of a one-stop or single-entry system. The Summit, a group of 72 community leaders, developed this set of strategic priorities based upon health information and data collected from 4600 community surveys, a provider access survey, and 26 key informant interviews. In August 2000, the Del Norte Health Care District began a planning process to replace the existing Susie Jacobsen worked with Del Norte W&PP clients to enroll them in the Indigent Patient Programs of various pharmaceutical companies to obtain their medications that they could not afford to buy. >Program Description, continued from the previous page Psychotherapy services; Purchase of equipment and supplies to do in-house testing of HbA1c levels; Recruitment for vacant clinician positions; Student loan reimbursement for a physician; and, A survey of patients served through the program. The Del Norte W&PP used the Technical Assistance/ Training funds available through the grant to send staff to specialty trainings on migrant health and childhood obesity. Additionally, basic reference materials were purchased for medical and case management staff for important subpopulations including diabetics and farm workers. Program Objectives and Outcomes 1 Objective To provide basic diagnostic and maintenance services to CMSP clients who are at risk for chronic medical conditions such as diabetes, hypertension, depression, asthma, and chronic obstructive pulmonary disease. W&PP Rating: Achieved Objective (high level of data to support) The project achieved this objective through a variety of approaches that included coordination of access to medications through the Indigent Patient Programs (IPP) that are offered by many pharmaceutical companies, providing free lab services for individuals who could not afford them, providing access to some psychotherapy services; developing the capability to conduct in-house Hb1Ac tests, increasing the capacity of the clinic to serve by recruiting providers, and providing incentives for staff retention. The project provided various types of data to the evaluators to document these activities. Regarding coordination of the IPP access, the project reported that 291 patients in the target population were 1 Refer to DRA s evaluation report in Volume 2 of this report for the site's complete evaluation findings. 210

212 Del Norte County Site Report assisted by the coordinator with access to medications through these programs. The graph below illustrates the types of medications that were distributed through the IPP during : Thyroid Agents 4% Pain relievers 7% Osteoperosis 1% Other 9% Antianxiety 2% Anticholinergics 1% Anticoagulant 2% Anticonvulsant 1% Antidepressants 10% Antihistamine/ Decongestant 3% Del Norte Community Health Center, since it had outgrown its current location. As part of the clinic expansion planning, the Health Care District opted to explore the feasibility of a one-stop Wellness Center that included the clinic and its services, as well as additional health-related social, educational, and illness prevention services. Hormones 4% GERD/ulcers 10% Diabetes 7% Chloresterol lowering agents Asthma 12% 4% Arthritis 3% Antihypertensive Agents 19% Medications obtained for clients of Del Norte s W&PP through the various Indigent Patient Programs The project reported that they estimate that hundreds of thousands of dollars worth of medications were provided to needy clients through this program. A subset of clients (111) who received this service responded to questions on the SF-36 questionnaire regarding the specific impact of increased access to medications through this program, indicating a very high level of satisfaction with this program. Regarding the question, In the past year have you ever not taken prescribed medications because you could not afford them, a majority (76 of 107) responded Yes. A large majority (102 of 110) said they would not be able to buy the medications they were receiving through the IPP, and almost all (90 of 95 and 103 of 105) believed that their health would suffer in the short-term and long-term, respectively, without the medications. Clients were nearly unanimous (99%) saying that they felt their health had improved as a result of receiving the medication through this program. Regarding access to lab services, the project delivered data to the evaluators that revealed that 415 clients received from 1 to 34 free lab procedures, with an average of 5 services per client, costing an average of Staff of the Del Norte Community Health Center Consultants were retained by the Health Care District to conduct the feasibility study for a co-located services center. A District Planning Team was formed from Health Care District board members and the project consultants. Additionally, a Wellness Center Community Action Team was appointed by the Health Care District s Board and was comprised of 18 members of the community as well as local health care providers. The feasibility study consisted of 28 key informant interviews, 4 focus groups, a community Town Hall meeting attended by more than 50 people, and preliminary architectural concept drawings. It built upon the work of the 1999 Del Norte Health Summit and a prior feasibility study conducted by the Area 1 Agency on Aging. The feasibility study determined that the success of the Wellness Center Project will depend on strong and continuing leadership that accomplishes key tasks including securing needed capital to build the center, coordinating services and program, ensuring effective center management and governance, and building community support for and awareness of Wellness Center services. The feasibility study cited that a Wellness Center would provide the community with benefits by making it easier for people to get help they need, providing opportunities for the district and other local agencies to pool resources, and reducing the possibility of duplicating services by agencies. Through the 211

213 CMSP/TCE WELLNESS & PREVENTION PROGRAM study and the associated consensus-building efforts, the concept of building the Wellness Center around anchor partners developed. Open Door Community Health Centers (operators of the Del Norte Community Health Center), the Del Norte County Department of Health and Social Services, Del Norte Children and Families Commission, Del Norte Healthcare District, College of the Redwoods, and the Area 1 Agency on Aging began an extensive planning effort for the co-located services center. These organizations had the common goal of enhancing the quality of health care for their community by developing partnerships among four anchor groups with the intent of integrating the distinct functions of each group with one another, producing a whole that is greater than the sum of its parts. This one-stop shop seeks to co-locate and integrate a community health clinic, public health and social services, a family resource center, and a satellite building for the community college s licensed vocational nursing classes as the four anchor providers. Open Door Community Health Centers Del Norte Community Health Center (DNCHC), an anchor partner in a planned Community Wellness Center, will begin construction on an expanded health center facility in Health center services will include primary care, dental, and mental health services within the facility. At the time of this report, one member of the Open Door Community Health Center management team spends 0.5 FTE on the planning efforts related to the Wellness Center. A portion of the planning time by Open Door Community Health Center and the county s Health Officer was supported by Wellness & Prevention Program grant funds in both grant cycles 2 and 3. $50 per client. The following table shows examples of services provided in 2002 and 2003, showing an increase in services provided in 2003: Test # in 2002 # in 2003 % Increase Lipid Panel % Metabolic Panel % Blood Count (CBC) % Thyroid (TSH) % Hepatitis B & C % Regarding developing the capability to conduct inhouse Hb1Ac tests, the clinic instituted a systems change to enable the results of tests to be available to the provider at the same visit that the blood sample 212 Provider and patient at the Del Norte Community Health Center Grant-funded services to clients of Del Norte s W&PP was taken. In many instances, this timely data resulted in an increase in quality of care for these patients, the project reported. However, the project reported that use of the in-house testing was less than expected, in part because providers did not necessarily see the advantage of in-house testing when they were already sending out a blood sample for other lab tests. However, overall, data from the clinic indicates that diabetes control improved, with 69% of patients with HbA1c levels below 8.0 in February 2004 compared to 58% in Regarding the increase in capacity to serve patients, the clinic reported that as a result of active recruitment and staff retention programs, the clinic had 7.02 medical staff in 2003 compared to 6.56 in 2001, and the clinic provided 24,571 medical visits in 2003 compared to 22,058 in The increase in staffing level was modest compared to expectations, especially since the clinic recruited 6 new clinical staff during the grant period (three physicians, two mid-level practitioners, and a clinical psychologist) but at least the clinic was able to do better than stay even in the face of staff leaving or reducing to part-time schedules. 212

214 Del Norte County Site Report Objective 2 To increase the coordination of local health care providers and social service organizations to insure that at-risk uninsured and underinsured populations access assistance programs and services for which they are eligible. W&PP Rating: Objective Achieved (high level of data to support) The project worked towards this objective through its participation in the planning process for the Del Norte Wellness Center to be opened in Crescent City in This center will provide a one-stop shop for a wide range of services needed by the target population, resulting in easier and better coordination of health and social services. The partners involved in the planning of this center include the Del Norte Community Health Center, the Del Norte Children and Families Commission, the Del Norte County Department of Health and Social Services, the Del Norte Healthcare District, the Area 1 Agency on Aging, and the College of the Redwoods. The project reported that all partners are working together on planning for the construction of the Wellness Center, including working together with the architect and planning for integration of services, including integration that can occur prior to the completion of the construction. Please refer to the accompanying article regarding the Del Norte Wellness Center. Provider and patient at the Del Norte Community Health Center Committees made up of local medical, public health, and social service providers continue to meet to discuss governance, services integration, and financing prior to the construction phase. The planning team took slow but important steps prior to construction to ensure that the architectural layout of the Del Norte Wellness Center would be conducive to the integration of services between many different agencies to better serve the community. The project staff reports that collaborative planning is hard work and takes time, as it takes a great deal more time to develop a project in collaboration with others than to do a portion of the project on your own. Though worthwhile, consensus on the details for a project of this magnitude is often difficult for the partners to reach. The community has been successful at orchestrating various funding sources to fund the planning and construction of the Del Norte Wellness Center. The College of the Redwoods has committed 8 acres of land (estimated value of $930,000) for a lease price of $1 to the Wellness Center, and the Del Norte Healthcare District will provide the core funding for construction of the Wellness Center project by contributing $2.4 million. A USDA loan of $2.6 - $3 million and a capital campaign will raise the remaining funds. The California Endowment and the Tides Foundation, among other funders are supporting the construction of the Wellness Center. The collaborative planning process will continue until the Wellness Center construction is completed. After the completion of construction, the collaboration of the Wellness Center partners will continue through the establishment of the Wellness Center s Governance and Services Integration committees. The facility will be owned and administrated by the Del Norte Health Care District with input from the anchor partners provided through their votes on the Governance committee. 213

215 CMSP/TCE WELLNESS & PREVENTION PROGRAM Cost and Service Use Analysis The project delivered 121 core data records of CMSP beneficiaries served through this program through the end of October This data was folded into the Increasing Access cluster that is reported on page 268. Future Directions The project plans to continue coordinating access to Indigent Pharmaceutical Programs with the help of a software program that combines on-line access to pharmaceutical company forms, programs, and guidelines with an in-clinic patient medications database, absorbing the cost of coordination into ongoing clinic services and hopefully through a grant from the federal Office of Rural Health Policy. Based on the experience from this project, this function was expanded to other Open Door health centers. The project has Del Norte Community Health Center s current location in also begun participating in a Crescent City, California federal chronic care collaborative and diabetes registry, which will allow the clinic to keep track of diabetic patients and health status data, including Hb1Ac values. They have added a Registered Dietician to their staff and have allocated funds for increased disease case management and diabetes education. Due to lack of funding, there is no plan currently to continue offering free lab services, though the center has modified its sliding fee scale to improve access to basic screening and monitoring lab tests. Open Door Community Health Centers looks forward to the opening of the Del Norte Wellness Center in 2005, for which it will be an anchor partner. They are continuing to support this activity with the participation of approximately 0.5 FTE of their management staff and anticipate contributing additional resources as the construction schedule moves forward

216 El Dorado County This program supported the development of a new Federally Qualified Health Center (FQHC) for providing primary medical care in Placerville, California by funding a Program Coordinator and a part-time Health Advocate. The funding for the physical plant and start-up operating costs was provided by the El Dorado County Board of Supervisors in March 2001 with approximately a $2,000,000 allocation of the Master Settlement Agreement funds for the development of the Western Slope Community Health Center (subsequently renamed the El Dorado County Community Health Center EDCCHC). The Program Coordinator funded by the W&PP performed, managed, or participated in all of the following: Finding the location for the new facility; Recruiting members for the Board of Directors; Supporting the Board of Directors of the new El Dorado Community Health Center with general staff support; Program Description continued on the next page> Total Award Expended $143,974 of $143,974 awarded Program Partners El Dorado County Community Health Center (EDCCHC) El Dorado County Public Health Department El Dorado County Board of Supervisors Geographic Area Served Western Slope area of El Dorado County Target Population The CMSP-eligible population and other indigent and medially underserved clients living in the Western Slope area of El Dorado County, including undocumented migratory workers, with an emphasis on monolingual Latino populations Contact Information Kirsten Rogers, Supervising Health Education Coordinator El Dorado County Public Health Department Phone: (530) krogers@co.el-dorado.ca.us 215

217 CMSP/TCE WELLNESS & PREVENTION PROGRAM Shifting the Paradigm from County to Community El Dorado County Community Health Center Experience ON MAY 19, 2003, access to primary and preventative medical services dramatically improved for medically underserved people living in the Western Slope region of El Dorado County. That s when the El Dorado County Community Health Center (EDCCHC) opened its doors after several years of planning and building community, as well as political, support. The new health center came into existence thanks to an effective lobbying effort by a coalition of concerned community members who felt that increased access to health services was the #1 priority in El Dorado County. The Need for a New Health Center Was Clear For more than five years since the Molina Medical Center closed, indigent people had limited local access to primary care before the EDCCHC opened in the community of Placerville, CA. As an interim measure, Marshall Medical and the El Dorado County Public Health Department partnered to open a Mobile Clinic to serve this population. Unfortunately, the Mobile Clinic was only able to serve a small portion of those in need. Other patients needing primary care were faced with several challenging options: do without care, go to The El Dorado County Community Health Center, which was developed with the assistance of the W&PP, opened in Placerville in May >Program Description, continued from the previous page Recruiting, interviewing, and hiring of the Executive Director of the EDCCHC; Creating a Board of Directors Resource Manual and conducting formal training sessions for new Board members; Selecting and purchasing the office furniture and most of the medical equipment for the new facility; Developing a specialty-care provider network; Building professional working relationships and memorandums of understanding with ancillary health service providers, community-based agencies, and other social service providers; Preparing applications to state health programs, including Vaccines for Children, Children s 216Health Disabilities Program, California Children s Services, Healthy Families Insurance Providers, and the Cancer Detection Program; Writing a successful $100,000 grant application to improve infant/toddler immunization levels; Writing a successful $50,000 grant application to the El Dorado First 5 for subsidies for health care for children aged 0 to 5 years; Producing an ed newsletter, Community Health Center Update; Conducting patient surveys; Coordinating data collection. The Health Advocate funded by the W&PP assisted clients in filling out insurance program eligibility forms and accessing other health-related services. The grant also funded attendance by staff to several Northern California Rural Roundtable meetings and two National Association of Rural Health Clinics conferences (2001 and 2002). 216

218 El Dorado County Site Report Program Objectives and Outcomes 1 Objective 1 To support the planning, financing, constructing, and putting into operation a new primary medical care facility to serve the medical needs of CMSP and non- CMSP residents. W&PP Rating: Achieved Objective (high level of data to support) The El Dorado County Community Health Center opened for operation on May 19, Objective 2 To increase access to quality primary care services for the medically needy in El Dorado County. W&PP Rating: Achieved Objective (high level of data to support) According to the EDCCHC s 2003 Office of Statewide Planning and Development (OSHPD) report, between the opening of the EDCCHC in May, 2003 and December 31, 2003, 1,820 patients were seen (4,812 separate encounters), which constituted a full case load. As of April 2004, there was a 1000-person waiting list for appointments. The clinic is currently recruiting more medical practitioners. It is estimated that there is a need for at least 6 full-time practitioners to meet the current needs of the underserved population. From the table below it can be calculated that 989 of 1,820 (54%) of the people receiving care at the clinic were enrolled in health coverage programs that target low-income people Medi-Cal, CMSP and Healthy Families. Coverage Type # of Clients % of Clients Medicare % Medi-Cal % CMSP % Healthy Families 4 0.2% Private Insurance % Self-Pay/Sliding Fee % Other 2 0.1% CHDP Total % * Payors for patients seen at the El Dorado County Community Health Center from May through December, the emergency room, travel for one hour for health care to the community of Georgetown for care, or go to Sacramento for care. Links to specialty care were difficult to establish at these locations. Therefore, many patients were forced to go to local emergency rooms for any condition requiring specialty care. Consequently, emergency rooms, such as the one at Placerville s Marshall Hospital, reported a significant increase in visits by indigent patients. From September 2001 to March 2002, Margaret Williams, Health Program Manager, El Dorado County Public Health Department, conducted nearly 60 stakeholder interviews to solicit interest and involvement in the health center development project. This process was funded by the CMSP/TCE Wellness & Prevention Program grant funds. According to Williams, all of those interviewed were supportive of the project, many committed to collaborating with service/referral provision, and several expressed an interest in serving on the Governance Board. All wanted to be included on the distribution list for updates on the project. To gain a clearer picture of the health care needs in the county, the El Dorado County Health Alliance commissioned a community health needs assessment. During this process, numerous community and provider meetings, interviews with key informants, and agency site visits were conducted; additionally, databases were mined for information. The resulting report, Making a Difference: Opportunities for Improving Health in El Dorado County, published in October 2002, provided a detailed picture of the community and a description of existing assets, gaps, and perceived needs that help guide the County as it strives to improve services. In 2002, the ad hoc El Dorado County Health Alliance, representing more than 16 community groups and other individuals, successfully persuaded the El Dorado County Board of Supervisors to allocate the next six years of the county s allotment of the tobacco settlement funds to health-related issues. The El Dorado County Board of Supervisors voted to designate approximately $2,000,000 of the tobacco settlement funds set aside for health for the establishment of the new El Dorado County 1 Refer to DRA s evaluation report in Volume 2 of this report for the site's complete evaluation findings. 217

219 CMSP/TCE WELLNESS & PREVENTION PROGRAM Community Health Center as one of the first projects. Demonstrating the depth of community feeling on this issue, the Alliance was able to generate 11,000 signatures in support, said Gayle Erbe-Hamlin, Director of the El Dorado County Public Health Department. Creating the New Center Was a Multi-phase Process The Public Health Department took the lead role in the first phase of organizing the establishment of the new health center. Chris Weston, a Public Health Program Manager, was hired to serve as the interim Executive Director. Organizing a new health center was a huge job, involving much more than acquiring a building site, doing the construction, ordering equipment, and hiring staff. Two of the prime concerns regarding the health center were its sustainability and its connections to medical specialists. Two pressing questions are: how will the health center sustain itself after the tobacco settlement funds are gone, and how can relationships with medical specialists be built given the low reimbursements for specialty care provided for indigent patients? The County believed that the Federally Qualified Health Center (FQHC) structure was the key to solving these problems. Since FQHCs receive better reimbursement rates and can wrap the cost of specialty care into their fees, specialists would be motivated to see patients referred from the health center. Step one was to form a nonprofit organization, El Dorado County Community Health Center which was accomplished in January We hoped the community would own this issue, explained Erbe- Waiting room of the new El Dorado clinic Thus, at a minimum, more than half of the people served at the clinic during 2003 could be classified as medically needy. These 989 medically needy clients had an average of 2.2 visits during the 6 1/2 months covered by the OSHPD report. Objective 3 To develop and refine a specialty care referral system for the target populations: CMSP enrollees, CMSP enrollees family members, uninsured, medically indigent persons, undocumented migratory and agriculture workers, with an emphasis on monolingual Latino populations. W&PP Rating: Achieved Objective (high level of data to support) As of April 2004, 23 specialists had signed contracts to provide services 218on a rotational basis as follows: allergist (1), anesthesiologists (3), cardiologist (1), dentist (1), ear, nose, and throat specialist (1), general surgeons (3), geriatric/ palliative care specialist (1), hematologists/oncologists (2), neurologist (1), obstetrics/gynecologists (4), oncologist (1), ophthalmologist (1), orthopedic surgeons (4). Still to be recruited are specialists in gastroenterology care and hepatitis C treatment, as well other specialists needed to augment the rotation policy. Staff interviews revealed that the majority of referrals were to orthopedic and neurology providers. Efforts are ongoing to recruit additional specialists into the clinic s referral network. Referral logs indicated that 67 patients were referred to specialists between 6/1/03 and 12/31/03. Although data on insurance coverage and income were not collected on these logs, it is reasonable to assume that a majority of these referrals were for medically indigent individuals. Data regarding ethnicity was also not collected in these logs, so it is not possible to say whether any monolingual Latino patients received referrals. The 93% rate for keeping appointments was high relative to staff expectation, reflecting an effective 218

220 El Dorado County Site Report system of educating clients on the importance of showing up for specialty care appointments. Objective 4 Through the provision of specialty care, to reduce the levels of emergency room visits for non-emergent conditions. W&PP Rating: Objective Withdrawn The project staff and the evaluation team determined that it would not be feasible to track changes in levels and types of emergency room use at this time. Objective 5 Hamlin. This strategy has promoted a paradigm shift from doing the project as a County to doing it as a Community. Please refer to the accompanying El Dorado site report under grant Objectives 5 & 6 for more information about project s transformation from an initial Board of Directors to a Governance Board comprised of a minimum of 51% of clinic patients. Step two was obtaining a designation as a Medically Underserved Area (MUA), which was accomplished in February The MUA designation qualified the health center to apply for FQHC certification, which they applied for in February To develop a community body to oversee the clinic. W&PP Rating: Achieved Objective (high level of data to support) A start-up Board, comprised of skilled professionals and whose purpose was to oversee the building and start-up of the clinic, became a Governance Board, comprised of both skilled professionals and unskilled clinic users, to oversee the ongoing clinic operations. An Advisory Committee recruited, screened, and trained 10 clinic clients, as well as recruited 6 professionals for nomination to the permanent Governance Board. The project staff sees the inclusion of clinic clients on the Board as providing a vital component for keeping the needs of the target population in the forefront of business operations. Additionally, designation as an FQHC requires that at least 51% of the Governing Board be comprised of individuals who use clinic services. This goal was met, and FQHC status was applied for in February This process will be refreshing from the community s point of view. We [County Public Health] will get to step back and give governance of the clinic back to The Board of Directors, working closely with County Public Health and an administrative staff funded in part by the CMSP/TCE Wellness and Prevention grant, set up the health center infrastructure including obtaining the FQHC designation, overseeing health center construction, and hiring the initial staff for the health center. Kirsten Rogers, Supervising Health Education Coordinator at El Dorado County Public Health, was one of two members of the administrative staff. She worked with the County Health Officer to establish the vital links to medical specialty providers. The assistance of the County Health Officer has been important for opening channels of communication, Rogers said. In an interview conducted in late 2002, Erbe- Hamlin reflected on the membership of the Board of Directors expanding and changing to include at least 51% who are clients who use the health center s services a requirement for gaining FQHC certification, This process will be refreshing from the community s point of view. We [County Public Health] will get to step back and give governance of the clinic back to the community. Please refer to the accompanying El Dorado site report documenting the EDCCHC s many successes in serving the medically underserved population living in the Western Slope region of El Dorado County and EDCCHC s plans for the future. the community. Gayle Erbe-Hamlin 219

221 CMSP/TCE WELLNESS & PREVENTION PROGRAM Objective 6 To develop leadership within the clinic oversight group so that this leadership can transition into a Board of Directors when the group becomes a 501(c)3 organization. W&PP Rating: Achieved Objective (high level of data to support) Not only did the organization successfully achieve 501(c)3 status in January 2002, but they went on to organize the Governance Board in such a way that they became eligible for FQHC status, which they applied for in February 2004 (see also Objective 5). The start-up Board was comprised of skilled professionals who were able to set up the nonprofit organization. Then, the entire start-up Board rolled over into the Governance Board. Since these skilled professionals and leaders committed to one-year terms, a turnover of 6 members occurred in June 2003, and additional professionals were recruited, representing diverse areas of expertise. Cost and Service Use Analysis The project submitted 46 core data records of CMSPeligible individuals enrolled into services prior to October 31, Due to the time-frame parameters of the cost and serivce use analysis relative to the opening date of the clinic, El Dorado s data could not be included in the analysis. Future Directions The EDCCHC plans to expand the number of medical providers at least by 6 in the near future to accommodate the overwhelming demand for services. The attainment of FQHC status will encourage greater participation by area medical specialists because of the higher reimbursement rates under that structure. The clinic has become self-sustaining with its large client load, continued Master Settlement Agreement allocations, and procurement of grants, thereby assuring its continued operation

222 Inyo County This project was a culmination of a six-year strategic initiative to establish a Rural Health Clinic in Northern Inyo County to fill gaps in access to health care among low-income and underserved individuals living in the region, including monolingual Spanish speakers. The new clinic was to have a commitment to case management to facilitate continuity of care, and to encourage the most cost-effective use of the health care system. Funding from all 3 cycles of the CMSP/TCE W&PP has contributed crucially to this effort. Cycle 1 funding was used to help fund the physical plant of the new Rural Health Clinic, including furnishings and building costs. Cycle 2 funding supported the effort to gain Health Professional Shortage Area and Rural Health Clinic (RHC) status. And Cycle 3 funding supported a clinic case manager with the aim of demonstrating to the Northern Inyo Hospital (NIH) District Board of Directors the value of such a position in the clinic. Initially, the lead agency in this effort was the Inyo County Health and Human Services (ICHHS) Department. It was the vision of Tamara Cohn-Pound, RN with the ICHHS to expand access to primary care in Inyo County via the creation of a new Program Description continued on the next page> Total Award Expended $116,938 of $116,938 awarded Program Partners Northern Inyo Hospital Rural Health Center Northern Inyo Hospital Inyo County Health and Human Services Geographic Area Served Northern Inyo County Target Population Uninsured and underinsured low-income residents, including monolingual Hispanic individuals Contact Information Tracy Aspel, Nurse Manager Northern Inyo Hospital Rural Health Center Phone: (760) Tracy.Aspel@nih.org 221

223 CMSP/TCE WELLNESS & PREVENTION PROGRAM Creative Outreach Builds Clinic Success THE NORTHERN INYO HOSPITAL S new Rural Health Clinic, opened in November 2001, has been a phenomenal success, necessitating rapid expansion just to keep up with demand. Patient demand has tripled since it opened its doors. This growth in demand is due partly to the need for the service, partly because of the excellent service since doors opened, and partly because of the numerous creative outreach strategies that clinic staff have used to raise public awareness of its existence. Some of those outreach efforts are more traditional ones, such as advertising outreach events in the newspaper, radio, and television; conducting diabetes outreach at local store sites; and presentations to local service clubs, such as the Lions. Other efforts are creative new approaches and have generated a lot of interest. Like the Drive- Thru Flu Shot Clinic they held last year. Even though the newspaper published the wrong dates for the event; one day the cars started going through the drive-thru backwards; and another day they ran out of prepared vaccine doses 15 minutes after the clinic opened, organizers met their goal of nearly 300 people vaccinated, largely through word of mouth advertising. In another creative effort, the local high school s multimedia class was engaged to interview and videotape a number of the providers and staff in the clinic on topics such as How patients can >Program Description, continued from the previous page Rural Health Clinic, and she wrote the initial grant proposals. However, after the clinic was built and all the efforts of Cycle 3 were being made by the NIH RHC, the lead agency was changed to the NIH to simplify communications. A new contract was executed between NIH and the CMSP Governing Board. $2,000 was paid to ICHHS, in Grant Cycle 3- Year 1, under the initial agreement. The NIH RHC opened its doors in November 2001, operating 3 days a week. During first month of operation, the clinic provided 335 patient visits. Patient demand quickly induced the clinic to operate 6 days a week and add providers up to its maximum capacity. By the summer of 2002, it was obvious that the physical plant, basically a large double-wide trailer with 4 exam rooms, one provider room, a small 222 Tracy Aspel, Nurse Clinic Manager, gives Dr. Stacey Brown, the NIH RHC s medical director, a flu shot at their Drive-Thru Flu Shot Clinic. (Photo by Darcy Ellis) waiting room, no nurse s station, and a medicalrecords/administration area that was inadequate for the need. Clinic staff was able to make a compelling case to the NIH Board of Directors about the need for a larger facility, and plans were quickly made and executed to accomplish this. In February, 2003, the clinic moved to their new location, which has 10 exam rooms, a larger waiting room, and a nurse s station. By December of 2003, the clinic provided more than 1000 patient visits per month. As might be expected in newly established organization, the NIH RHC underwent a steep learning curve with regard to the case management position. Initially, the position was staffed with an individual who focused primarily on patient counseling and education. However, this individual was not focused on the vital activities of establishing a network of specialty care providers and facilitating the making and keeping of appointments by a patient population that was used to going to the Emergency Department for all health care visits. The business of collecting data for the purpose of managing chronic disease was delegated to an aide with insufficient training, resulting in an incomplete data set that was not useful in the case management effort. However, the project staff quickly refocused as soon as they received feedback. They hired staff with the necessary training and motivation to conduct the critical function of the case manager coordinating care. They 222

224 Inyo County Site Report also realized that their goal of tracking patients, services, and outcomes regarding hypertension, hyperlipidemia, diabetes, and asthma was too ambitious given their resources and start-up challenges, so this goal was shelved for a later date. Ultimately, the focus of case manager position was refined to that of arranging for specialty care upon order by the provider, which may include assistance with funding or transportation, since many referrals involve out-of-town trips; assisting patients in accessing medication assistance programs; interfacing with Inyo County Social Services to assist patients with application to medical coverage programs; and surveying patients regarding their experiences with the clinic. The grant also funded nutrition education for the clinic s diabetic, overweight, and hyperlipidemic patients. Program Objectives and Outcomes 1 make the clinic work for them, How to get a prescription filled, How to take advantage of the Every Woman Counts program, When to schedule mammograms, Introducing the clinic providers, and other topics of interest to patients. The plan is for these interviews to be edited into one tape that will be played continuously in the waiting room as a low-cost way to increase clinic-patient communications. Instead of doing standard TV ads, the clinic produces Infomercials featuring the clinic s medical director and primary care physician, Stacey Brown, MD, and the clinic s Nurse Manager, Tracy Aspel, RN. They have taped a number of short health information pieces to be aired on the local TV station, and of course they always put in a plug for the clinic somewhere in the presentation. Objective 1 To continue to provide access to care for CMSP and Medi- Cal patients at the RHC who have in the past not had a medical home. W&PP Rating: Achieved Objective (high level of data to support) A significant challenge for a new health institution is to effectively provide services that prove to be needed, resulting in continued demand for its services and obvious evidence of its success. The NIH RHC has fully met this challenge, even exceeding its original expectations. As noted above, the clinic had to rapidly expand hours, provider numbers, and operating space in order to keep up with demand. The success of the clinic has been noted and appreciated by the NIH Board of Directors who are charged with decision making regarding the funding of the clinic. By agreeing to fund the larger facility as well as to continue funding for the case manager position, the NIH Board demonstrated its approval and support of the clinic and its operation model. This support from the NIH Board insures that the RHC will be able to continue its operations and thus be available for access by people enrolled in CMSP and Medi-Cal. Prior to the opening of the clinic, there were no options for primary care in Northern Inyo County for this population, who then received their health care in the Emergency Department of NIH. According to data delivered to the evaluator, during the period of April, 2002 through March, 2004, 6% and It is hard to believe that so much activity can be generated with the tiny staff that is stretched thin just delivering patient care. Much of the credit goes to the spark plug in the RHC s engine, Aspel, an energetic disciple of wellness and prevention, an active community member, and mother. Because of her infectious personality; in-depth knowledge of every aspect of the clinic, and unflagging sense of humor, Aspel is the one who is called upon to promote the clinic to area organizations. Her lively presentations have prompted multiple requests from organizations throughout the community. By building this wide community awareness and support, these creative outreach efforts support the sustainability of the new NIH RHC. 1 Refer to DRA s evaluation report in Volume 2 of this report for the site's complete evaluation findings. 223

225 CMSP/TCE WELLNESS & PREVENTION PROGRAM 17% of the patient visits (830 and 2324 of 13,416) were by CMSP and Medi-Cal enrollees, respectively. The staff of the NIH RHC effectively served their target population, as demonstrated not only by the steadily increasing demand for their services, but also by multiple patient surveys. The project reported results of their patient satisfaction surveys, conducted in 2002, 2003, and 2004, and their patient quality of life surveys, conducted in 2003 and These surveys, although they involved a limited number of patients, indicated a high degree of satisfaction with the clinic staff and services and suggest that clinic services were effective in resolving health issues. For example, in 2003, 16 of 19 agreed or strongly agreed that I believe that my condition has improved considerably since I began receiving services at the Rural Health Clinic, and in 2004, 13 of 18 responded the same way to this statement. Objective 3 To decrease by 10% the over-utilization of costly emergency department services by providing another option for care (the adjacent clinic). W&PP Rating: Achieved Objective (high level of data to support) During the 10 months prior to the opening of the NIH RHC, 83% (4407/5293) of the visits to the NIH Emergency Department (NIH ED) (the only emergency department in the region) were rated as level 1 or 2, a rating that indicates the problem could have been treated at the NIH RHC. During the first 38 months of clinic operation, the average number of level 1 or 2 visits was 72%, for a decrease of 11%. Furthermore, the trend over that period is for steady reductions on these visits, as shown on the following graph: Objective 2 To increase hours of service, clinic size/service capacity, and nurse practitioner and physician hours in order to provide greater numbers with services and reduce the number of people that are turned away. W&PP Rating: Achieved Objective (high level of data to support) As previously noted in the Project Description, the clinic increased its hours of operation from 3 days/week to 6 days/week by the end of the grant period, moved to a larger facility, and increased the number of people served per month from 335 in its first month of operation to 1080 in December As the capacity to serve patients was maximized, the clinic added more providers, moving eventually to 3 providers. Finally, the clinic applied for and received a California Rural Health Policy Council grant to fund a sliding-scale fee program, in which indigent cash-paying clients paid a co-payment of $10 to $20 per visit, with the remainder of the visit cost covered by the grant funds. Although the hospital has a charity fund, clinic staff found that many people would not seek care under a charity program, but they would participate in a sliding-scale program. The clinic staff were able to demonstrate the benefits of this program to the NIH Board of Directors who have now committed to supporting the program after the grant funding ended. % ED visits that were level 1 or 2 (non-emergent) /1/01-10/31/01 (n=5293) 224 Northern Inyo Hospital s Rural Health Clinic opens 11/1/01-04/30/02 (n=3053) 05/1/02-09/30/02 (n=2846) Date of ED visit 10/1/02-04/40/03 (n=3435) 05/1/03-09/30/03 (n=2141) 10/1/03-03/17/04 (n=2835) Percentage of ED visits to Northern Inyo Hospital that were non-emergent Looking at the hours of clinic operation, prior to the opening of the clinic, 36% of NIH ED visits were level 1 or 2 as compared to 27% after the clinic opened. In a NIH RHC client satisfaction survey conducted in February 2003, 47% said that they would have gone to the NIH ED if the clinic were not available, and 25% said that they would not have received any care. Based on the analysis done for this grant, the NIH and RCH are engaged in a systems change. The analysis revealed that a high level of rechecks (follow-up for wound care, medications, etc.) was occurring in the NIH 224

226 Inyo County Site Report ED. A new referral protocol to divert all recheck services to the RHC is now being developed. The data analysis for the ED use was made possible because of the able cooperation of the IT department of the NIH. It is commendable that this analysis was done, especially considering that although many of the W&PP projects set out to document impacts on ED usage, the Inyo project was the only one to successfully do so. The project reports that free blood pressure checks are always available at the clinic, but no data on the number of people served under this program was provided. The project also reported that mini-health fairs were held at the clinic and at a local store, but no further details were provided. Objective 4 To utilize at least 50% of nurse practitioner provider hours to ensure excellent care while being cost effective. W&PP Rating: Achieved Objective (high level of data to support) Presently, the clinic is staffed with 2 full-time Nurse Practitioners and full-time 1 Physician. When demand increases, the plan is for fulltime 3 Nurse Practitioners and full-time 1 Physician. The Physician is charged with treating the most complex patients and supervising the Nurse Practitioners. Objective 5 To encourage education and standard of care treatment of patients with diabetes, hypertension, and hyperlipidemia by utilizing outreach programs to diagnose and refer patients for care. W&PP Rating: Partially Achieved Objective (moderate level of data to support) The project reported on a number of outreach efforts regarding diabetes, hypertension, and hyperlipidemia were made, and they included documentation for some of these events in their final report (see also the highlight article for details), but no data was supplied to the evaluators on this objective. There is no follow-up documented for these referrals, so it is not possible to assess the impact of this effort. Staff reported that the number of people at risk identified at two outreach clinics for diabetes was low 3 and 6, respectively and most of these had already had been diagnosed with diabetes. The capacity of this original facility for the NIH RHC, which opened in November, 2001, was rapidly exceeded, and the clinic now operates from a new, much larger facility. Objective 6 To develop and implement hypertension, hyperlipidemia, diabetes and asthma tracking programs in order to measure performance improvement in patients with these diagnoses. W&PP Rating: Partially Achieved Objective (high level of data to support) Initially, this objective was the focus of a great deal of attention by the project. Software audits for tracking diabetes and hypertension were developed, and a medical assistant entered data after review of each diabetic and hypertensive patient visit. At an interim review of the data, staff realized that the information being entered was not adequate in detail to describe the full range of services being provided. It was determined that someone with a higher skill level and experience in chart review was needed for data entry. However, funding for that position was not available, and the project decided to terminate the effort on this objective. Project staff feel, in retrospect, that their expectations regarding this objective were overzealous within the available resources, and they refocused their efforts to increasing access to primary care. It is very much to the project s credit that they performed an interim assessment regarding this objective and made course corrections to refine their focus based on the results of that data review. 225

227 CMSP/TCE WELLNESS & PREVENTION PROGRAM Cost and Service Use Analysis Results The project delivered 203 core data records of CMSP beneficiaries who received services at the clinic. This data was folded into the Increasing Access cluster. Additionally, because of the large data set and the unique situation in Inyo County for which this data gives us a clear-cut before and after picture regarding the impact of access to primary health care on service use, the data from the Inyo W&PP project was also analyzed separately. The entire analysis is summarized in the Cost and Service Use Analysis section of this report, and the complete report by the analysis contractor, The Lewin Group, is included in Volume 2, Evaluation Findings. Reported here are data specific to the Inyo W&PP. The cost and service use results from the Inyo W&PP reflect the desired trend for wellness & prevention efforts, namely, lower inpatient hospital costs as a result of increased access to primary care services, resulting in an overall decrease in costs. Both Hospital Inpatient claims and payments as well as Total Payments declined in the post-enrollment group, which is comprised of the clients of the newly opened NIH RHC. Access to the clinic resulted in increased Clinic claims and payments in the post-enrollment group, but these increases did not equal the decrease in Inpatient Hospital costs, therefore resulting in lower overall costs. The cost and service use results from the Inyo W&PP reflect the desired trend for wellness & prevention efforts, namely, lower inpatient hospital costs as a result of increased access to primary care services, resulting in an overall decrease in costs. 226 Future Directions This project was highly successful in demonstrating the value of access to primary health care and case management services. The NIH RHC has become a permanent asset to the community of Bishop, and the NIH Board of Directors has demonstrated its support by approving and funding expanded facilities, additional providers, and a continuation of the case manager position. One possible development could be the addition of Obstetric and Gynecology services, which are very much needed in the community. These could possibly be housed in the original RHC facility. Keeping specialty care providers in the community is an ongoing challenge that requires community-wide attention, because periodically the area loses key health care specialists. The staff of the RHC plans to continue its outreach to community organizations to maintain visibility and focus attention on the health care needs of the community. The NIH ED and RHC are also continuing planning regarding referrals from the ED to RHC for recheck procedures. 226

228 Inyo County Site Report Graph A: Claims per 1000 members per month by service-use category for Inyo County W&PP enrollees Before Enrollment After Enrollment Hospital IP Days Hospital IP Claims Hospital OP Claims Physician Claims Clinic Claims Lab Claims Home Health Claims All Other Claims Graph B: Claims per member per month by service-use category for Inyo County W&PP enrollees $450 $400 $350 $300 $250 $200 $150 Before Enrollment After Enrollment $100 $50 $0 All Payments** Hospital IP Payments Hospital OP Payments Physician Payments Clinic Payments Lab Payments Home Health Payments All Other Payments *Excluding pharmacy claims 227

229 CMSP/TCE WELLNESS & PREVENTION PROGRAM

230 Mariposa County Ultimately, the project sought to increase access to services in Mariposa County through the provision of specialty care services at the John C. Fremont Healthcare District s (JCFHD) rural health clinic over the three-year grant period. In its final design, grant funds helped support mental health services at JCFHD by subsidizing a portion of a psychiatrist and behavioral health therapist s salary at approximately 0.15 FTE. The project s success was hampered by many administrative challenges experienced throughout the grant period. Initially, the site s original application was written under the incorrect assumption that Mariposa was eligible to receive $118,099 each year for three years versus the correct amount of $118,099 over three years. Upon receipt of the grant application, remediation occurred between the site and the W&PP to correct the error and to scale back the project to reflect the accurate grant award. The project was furthered hindered when their grant coordinator, who wrote the grant application and participated in the W&PP s database training, terminated her agreement with the hospital and did not pass along necessary information regarding the evaluation tools and requirements. Program Description continued on the next page> Total Award Expended $118,099 of $118,099 awarded Program Partners John C. Fremont Healthcare District Mariposa County Health Department Mariposa County Ministerial Fellowship Geographic Area Served Mariposa County Target Population CMSP-eligible clients and the underserved populations of Mariposa County in need of specialty care services Contact Information Kym Brownell, Administrative Assistant John C. Fremont Healthcare District Phone: (209) jcfadm@jcfhospital.com 229

231 CMSP/TCE WELLNESS & PREVENTION PROGRAM >Program Description, continued from the previous page Community Connections Pay Off for John C. Fremont Healthcare District IN 1999, John C. Fremont Healthcare District (JCFHD) in Mariposa County was in serious financial trouble and came perilously close to closing. Running substantially in the red, the hospital had cut employee hours and implemented drastic costcutting measures. Because of its small size it has 34 acute and skilled nursing beds the hospital had difficulty providing a full range of specialty health care services, which had prompted affluent local citizens to opt for traveling to Merced or Fresno for hospital care, approximately a 60 or 90 minute drive each way. Nevertheless, the hospital has a substantial amount of community support. The John C. Fremont Hospital Foundation and the John C. Fremont Hospital Volunteers both conduct numerous fund-raising events throughout the year on behalf of the hospital district. The Foundation and Volunteers are vitally important in the hospital district s efforts to maintain good communications and partnerships in the community. Additionally, both organizations continue to grow in volunteer participation all with enthusiastic interest in the hospital. Eleanor George, CEO/CFO, and her staff also make regular presentations at local community groups, including the Rotary and Kiwanis Clubs. She also hosts luncheons for local pastors, facilitated by the Mariposa County Ministerial Fellowship, to keep them informed about the services available at the hospital as well as the challenges the hospital is facing. At these gatherings, she is also receives feedback regarding perceptions about the most serious gaps in health care services in the community. Additionally, the Unfortunately, from the beginning, the project suffered from a grave disconnect between the activities initially proposed, what activities were included in the awarded grant budget, and the grant-related activities that occurred over the course of the W&PP. The grant coordination position was not refilled and the hospital s administrative assistant assumed responsibility for grant management, reporting, and evaluation activities. These grant-related duties were added to an already full work load, which is often commonplace within many small organizations of one staff person wearing many hats though they may not have the time and/or the skill set to accomplish the tasks. Program Objectives and Outcomes 1 Objective 1 To improve knowledge of health services and enrollment of the eligible CMSP population through outreach and education activities. 230 W&PP Rating: Partially Achieved Objective (minimal level of data to support) The site provided minimal anecdotal information regarding this grant objective. The project reports that they held a well-attended community-wide health fair in August 2003 and decided to make it an annual event. JCFHD held monthly support groups focused on gastric bypass reduction as well as living with cancer. In addition, the healthcare district reports becoming an integral part of the Merced Asthma Coalition. JCFHD also participated in the Mariposa County Health Department s tobacco awareness campaign. However, the site failed to supply any data regarding the extent of the efforts, the numbers of individuals reached through the efforts, nor the number of individuals (CMSP eligible or medically needy) referred to services through participation in these efforts as outlined in the site s approved evaluation plan. The project did recognize the benefit of outreach efforts as they wrote in their W&PP Final Report: The more we are out in the community and the more visible the various parts of the District are [available services] the more the residents of this community are aware of what we have to offer. We can save them the long trip down to the cities [Stockton, Fresno, Merced, Modesto] when they know we have the services right here in their backyard. Please refer to the accompanying highlight article for information about John C. Fremont s efforts to market their services and build local-level support for the healthcare district. 1 Refer to DRA s evaluation report in Volume 2 of this report for the site's complete evaluation findings. 230

232 Mariposa County Site Report Objective 2 To increase access to health services among the CMSP population and other medically needy clients through implementation of a tailored case management program. W&PP Rating: Objective Not Attempted After a site visit to JCFHD by the evaluator, technical assistance provider, and the W&PP staff, this objective related to case management was removed. To improve access to local care by increasing availability of providers and services for the CMSP and medically needy population in Mariposa County. W&PP Rating: Partially Achieved Objective (minimal level of data to support) Objective 3 The project had initially hoped to bring orthopedic, ear, nose, and throat (ENT), as well as mental health professionals to Mariposa County. This expectation was determined by the site to be unreasonable. Wellness & Prevention Program grant funds were primarily used by JCFHD to support the salaries associated with a Marriage and Family Therapist and a Psychiatrist. These mental health services were in tremendous need in the community as the project reports that Mariposa County Mental Health was without a psychiatrist, psychologist, or therapist, so John C. Fremont Healthcare District became the de-facto location to meet the entire community s mental health needs. Data supplied by the project shows that the largest number of 4,000 hospital patient encounters attributable to CMSP beneficiaries during the period of April 2001 to January 2004 occurred at the JCFHD s rural health clinic, followed by specialty physicians at the rural health clinic, and laboratory. The project reports that in the three years prior to this granting effort April 1998 to March 2001, John C. Fremont Healthcare District The dynamic duo of Elnora George, CEO, CFO of the John C. Fremont Healthcare District, and her Administrative Assistant, Kym Brownell, successfully recruited a variety of specialist providers. hospital surveys patients routinely and seeks to improve the hospital s services with the patient s input. From health fairs to newspaper advertisements, the hospital has been actively advertising the services available at JCFHD. Marketing to the Community Pays Off This substantial marketing and outreach effort paid off in March 2000, when the community voted to approve a 0.5% increase in the sales tax for the Mariposa County Healthcare Authority district. In order to motivate the community to vote to support the sales tax increase, hospital staff canvassed the community to speak to the importance of keeping the hospital open and posed questions to the community such as what would you do if your child got hit by a car and what would you do with Grandma if she falls and breaks something. When put to the ballot, the sales tax increase received a 72% support rate, and the sales tax increase was instituted in Greatly assisted by the tourism industry generated by the Yosemite National Park, the sales tax increases generates approximately $800,000 annually for the hospital. Now on better financial standing, the hospital has recently been steadily improving the range of services it offers. For example, the facility has purchased state-of-the-art mammogram, ultrasound/echo, pulmonary function, treadmill, and CT scanning machines. The hospital continues to provide new and upgraded equipment in order to provide the community with services right where they live. The hospital and clinic are also taking advantage of advances in telemedicine to insure that radiographs and mammograms are interpreted in a timely manner and to keep the response time to a minimum. 231

233 CMSP/TCE WELLNESS & PREVENTION PROGRAM provided 2,900 patient encounters to CMSP beneficiaries, thus increasing the total patient encounters by CMSP beneficiaries by 1,100 during the three-year grant period Acute Inpatient Clinic Clinic Specialty Physicians CT Scan Emergency Department Please note that the site did not provide information regarding the total unduplicated number of clients served, so it is impossible to determine whether more clients were served during the grant period or whether the same (or reduced) number of clients were served but individuals incurred more encounters. Both the W&PP administrative office and the program evaluator made unsuccessful attempts to obtain the data from JCFHD needed to fully support the achievement of this objective, especially supporting the claim of increased access to the specialty services subsidized by the grant funding. The project did not provide data regarding the following process/outcome measures as listed in their approved evaluation plan: increase utilization of available health services, decrease in required out of area referrals, and decrease utilization of urgent care and emergency rooms. With regard to out-of-area referrals, though no data was supplied, the project reports having difficulty referring any CMSP or Medi-Cal patients out of Mariposa County due to the lack of specialty providers accepting CMSP or Medi-Cal. To deal with the lack of specialty provided in Mariposa County, the hospital is able to offer attractive arrangements for out-of-town specialists to come periodically to provide specialty services needed in the community. We keep them fully booked. They just have to come up here and work, said Elnora George, JCFHD s CEO/CFO in an interview with W&PP staff. In part, using the beauty of the area and proximity to Laboratory Observation Radiology Respiratory Sonogram Location of specialty services provided to CMSPenrolled patients in the John C. Fremont Healthcare District from 4/1/2001 through 1/21/2004 Surgery Yosemite National Park as enticements, the hospital now has regular visits from cardiologists, obstetricians, psychiatrists, a neurologist, dermatologist, gastroenterologist, pediatrician, podiatrist, endocrinologist, rheumatologist, urologist, and surgeon who live in Merced, Fresno, San Francisco, Modesto, and Los Banos. We ve been well blessed with people who like to get away for a day or two into a rural setting, George said, People like coming up here. Cost and Service Use Analysis The project did not submit any core data records of CMSP beneficiaries served. Therefore, it was not included in the cost and service use analysis. Future Directions John C. Fremont Healthcare District will continue to provide specialty health services locally as funding and staffing permits. 232 Elements of Marketing Success at John C. Fremont Healthcare District During an interview with W&PP staff, George discussed some of her successful marketing strategies. Some of these include: Never take no for an answer. Maintain honesty, reliability, and accountability. Use the art of negotiation to get what you want. Get out into the community and network. Marketing efforts have contributed to the building of partnerships within the community. To support the hospital, a local service club has developed a nursing scholarship program to assist community members in obtaining a nursing degree. Thus, community members can also benefit from the hospital as an income source through employment. George and her staff continue their community outreach efforts to inform the community about the many new specialty services that are available at the hospital and clinic through luncheons and public hospital tours. It used to be that JCFHD was a hospital on a hill, and people ran it, and no one talked to anyone, George said. Extensive community outreach activities have changed all of that. 232

234 Modoc County The Modoc W&PP had two goals: 1) to support local access to care and 2) to support the provision of care at four locations in remote Modoc County. The project partners equally divided the grant funds to support physician and dental providers at their respective agencies. Over the 3 year grant period, both Modoc Medical Center and Surprise Valley Health Care District used $32,607 each to support emergency room physician fees at their respective facilities, Canby Family Practice Clinic expended $32,607 for dentist fees, and Warner Mountain Indian Health applied $32,607 in grant funds to physician fees. Grant funds were also set aside to purchase gas vouchers, which were equally available to each of the partner agencies, in an effort to address transportation barriers in this frontier county. Please refer to the accompanying highlight article for further detail on the project s transportation component. Program Description continued on the next page> Total Award Expended $150,301 of $150,301 awarded Program Partners Modoc Medical Center in Alturas, CA Surprise Valley Healthcare District in Cedarville, CA Canby Family Practice Clinic in Canby, CA Warner Mountain Indian Health in Fort Bidwell, CA Geographic Area Served Modoc County Target Population CMSP-eligible clients and the underserved populations of Modoc County Contact Information Teresa Jacques, Executive Director Modoc Medical Center Phone: (530) mmc1@frontiernet.net 233

235 CMSP/TCE WELLNESS & PREVENTION PROGRAM Removing the Barriers of Lack Transportation GETTING FROM POINT A TO POINT B is often not an easy task in the frontier communities of Modoc County. In addition of the geographical distance that must be traveled, the costs of gas money is often a barrier cited by patients in missing doctors appointments or not following through with medical care. Mindful of the difficulties the lack of transportation can have on a patient s access to and follow-up on medical and dental services, the Modoc W&PP incorporated a Gas Voucher Program into their Cycle 3 project to help defray the cost of transportation to patients. Grant funds were distributed by the project to a local nonprofit organization named TEACH (Training Employment and Community Help) to maintain and track the Gas Voucher Program. The first two years of the grant, TEACH issued a paper form to the 4 project sites, which was filled out and faxed to TEACH every time one of the four clinics handed out a gas voucher. The completed form was then given to the patient, who took the form to a participating gas station and got $5.00 worth of gas. The participating gas stations would in return, submit the form back to TEACH for reimbursement for the gas provided. Four gas stations participated in the Gas Voucher Program, one in Canby, one in Cedarville, and two in Alturas. The clinics staff used their discretion to determine an individual s need for a gas voucher. The Canby Clinic reports that they looked at the client s need and tried to distribute the gas vouchers fairly. Some people ask every time and want more than >Program Description, continued from the previous page Program Objectives and Outcomes 1 Dentist at Canby Family Practice s dental clinic working on a client Objective 1 To provide follow-up monitoring of clients following Emergency Room visits (Modoc Medical Center and Surprise Valley Healthcare District). W&PP Rating: Partially Achieved Objective (minimal level of data to support) Modoc Medical Center Modoc Medical Center set out to provide follow-up primary care at the hospital s clinic to CMSP and indigent patients that presented to the Emergency Room (ER) for care in an 234 attempt to reduce catastrophic illness and improve primary care and medical management. The initial target population was female, CMSPeligible patients between the ages of 41 to 50 who presented at the ER. The target population was later expanded to include females 30 to 50 who presented at the ER in an effort to increase enrollment in the project s activities. Data delivered to the evaluators from Modoc Medical Center indicated that 29 women enrolled in CMSP and between the ages of 30 to 50 years old were seen in the ER for a total of 67 times over the grant s three-year period. 55% (16/29) were only seen in the ER once, but 1 patient was seen in the ER 16 times in 8 months. The project reports that they were surprised by the lack of chronic disease cases, with the majority of ER visits relating to back pain and addiction/ withdrawal conditions. No data indicating any follow-up monitoring of clients served in the ER was provided to the evaluators; therefore, it is impossible to ascertain the project s success or failure at meeting the planned 1 Refer to DRA s evaluation report in Volume 2 of this report for the site's complete evaluation findings. 234

236 Modoc County Site Report objective. Please refer to DRA s evaluation report for a summary of the data provided by Modoc Medical Center. In the 2003 Annual Report filed by the project, information was presented on the outcomes of 11 patients that matched the project criteria. 5 of the 11 patients entered the ER 2 to a catastrophic event or disease process. Of these 5 patients, one had no followup for diabetes, two had compliance issues at other places of care and are seen in the ER, 1 patient was seen in the ER for seizures and has followed up appropriately, and one had chest pains and followed up appropriately at the clinic. Of the remaining 6 of the 11 patients, one moved and the five had one-time only ER visits and followed up appropriately in the hospital s clinic and did not use the ER for disease management. The project cites that the younger female CMSP patients were harder to medically manage in the clinic setting; however, no explanation to the phenomenon or data to support this claim was provided. The project states that the three-year study was completed without any conclusive results; however, Modoc Medical Center and its physicians remain committed to encouraging patient education in the primary care setting in order to reduce catastrophic illness in the ER. The project was hindered by the lack of consistent providers in the ER by using locum tenens physicians but has rectified the situation by hiring permanent ER and clinic physicians in May Surprise Valley Healthcare District (SVHD) Surprise Valley Healthcare District applied their portion of the grant funds to subsidizing ER-physician costs in an attempt to provide follow-up care at the hospital s clinic for patients presenting with chronic diseases. The efforts were targeting to the uninsured and CMSP-eligible residents of Fort Bidwell, Lake City, Eagleville, and Cedarville in northeastern Modoc County. The ER was staffed with an on-call physician and a registered nurse 24 hours a day. The emergency physician is also the clinic physician and the project reports that this has not only improved the continuity of care but has also established a physician-to-patient relationship. Patients that present for ER care were encouraged to follow-up at the clinic. Patients with chronic health conditions and who are patients of the Staff of Canby Family Practice s Dental Clinic: a valuable resource one gas voucher, but the clinic would not give more than one voucher unless there was a compelling reason. One patient at the Canby Clinic learned devastating news that she had cervical cancer and was referred to a specialist in Redding for treatment. The clinic s ability to assist the patient with the gas vouchers helped the patient to get across three mountain passes to get the treatment she needed for the cancer. Though the provision of gas vouchers seems trivial compared to the trauma of having cancer, the patient was appreciative of the vouchers, and the clinic staff felt helpful in being able to offer this additional assistance to the patient during a difficult time. At Fort Bidwell, local transport is not provided by the tribe, and the Gas Voucher Program assisted many of their clients in getting to their medical appointments in cities over 25 miles away. TEACH learned a valuable lesson in closely tracking the amount of gas vouchers released, since in the first two years, it was discovered that the clinics issued more vouchers than there was money for. Therefore, in the final year of the project, TEACH issues 80 gas vouchers to each of the 4 project sites. Modoc County remains engaged and committed to developing innovative transportation solutions for frontier communities. The Modoc County Transportation Commission has taken the lead role in the Non-Emergency Medical Transportation (NEMT) project (funded by Caltrans) and in partnership with the CMSP Governing Board, Plumas County, and Lassen County. Further information is detailed within Section III of this Final Report. 235

237 CMSP/TCE WELLNESS & PREVENTION PROGRAM provider-based clinic have a managed-care medical record on file. The project reports that SVHD s emergency room has experienced a decrease in non-emergency visits by CMSP eligible patients over the past three years of the grant period. In its final project report, SCHD reports to have served 16 patients over the three-year period through the grant effort. The project reports that visits were greatly reduced from years 2002 to In the 2003 Annual Report, the project reports that 6 of the 11 CMSP patients served in that year at the ER returned to the clinic for follow-up treatment. The project noted some difficulty in getting CMSP-eligible patients to comply with the physician s medical recommendations. Please note that no data indicating any follow-up monitoring of clients served in the ER was provided to the evaluators, therefore it is impossible to ascertain the project s success or failure at meeting the planned objective. Please refer to DRA s evaluation report for a summary of the data provided by Surprise Valley Healthcare District. Objective 2 To refer emergency dental clients into follow-up care (Canby Family Practice Clinic). W&PP Rating: Achieved Objective (high level of data to support) Canby Family Practice Clinic (CFPC) sought to educate patients about the importance of oral hygiene and preventative dental care versus seeking care on an emergency basis to remedy toothaches. Over the course of the grant, CFPC provided 123 CMSP beneficiaries with dental care through 815 visits. During these visits, clients received a total of 1554 procedures as detailed on Graph A on the following page. Data supplied to the evaluator indicates that 76 out of the 123 CMSP clients initiated services at the dental clinic in response to an emergent condition, such as a toothache. Most impressively, 79% (60/76) of those CMSP patients initially served on an emergency dental basis returned to the clinic for further non-emergent dental treatments. 16 out of 76 (21%) of the CMSP clients that were treated for emergent dental conditions at CFPC did not return for follow-up dental care. CFPC was the only project partner from the Modoc initiative that was able to deliver any data to the evaluators that could speak to any of the program s objectives. Though the data supports the success of the project, it is often difficult to quantify the impact that CFPC s dental services have made on the lives of those served through the project. The project shared the following success story from a client that had missing and damaged front teeth for 13 years: My job requires me to look my best as I am often working with the public but my teeth look really bad. What was I to do as I m not rich by any means. Then I heard about CMSP. The CMSP program helped me to get my upper teeth fixed with a partial denture and some crowns. Now I look like I have perfect teeth and am often complimented on my smile. I used to focus on not smiling because my teeth looked so bad. The project overcame challenges and learned several valuable lessons during the Wellness & Prevention Program. After seven years of service, CFPC received the resignation of their dentist who provided general dentistry, oral surgery, and orthodontic care. The dental provider went into private practice in Modoc County. Many of CFPC s patients with dental insurance or that paid out-of-pocket for care had their records copied and their care transferred from CFPC to the dental provider. In retrospect, the CFPC s administrator would have included a clause in the 236 dental provider s contract protecting the clinic from losing patients, especially those patients with the ability to pay for services. Fortunately, an interim dentist was hired to cover the clinic for 3 months until a new permanent dentist was hired in January 2003 and has transitioned well into the dental clinic. With the closure of Modoc Medical Center s dental department in March 2003, CFPC became the only provider of dental services to low-income and Medi-Cal/ CMSP patients in the county. This closure has put increased pressure on CFPC s dental clinic in terms of scheduling and taking on new patients. In a positive effort, the dental clinic added a Registered Dental Hygienist to the staff to increase clients access to preventative oral health care and education. CFPC utilized the W&PP technical assistance and training funds to train and certify the clinic s registered dental assistant (RDA) to perform coronal polishing (prophy). The RDA s additional skill set is an assist and valuable time saver for the dentist, who can now focus efforts on more complex dental procedures. In the last year of the grant, CFPC began a recall system for dental services that complements the effort to promote the benefit of routine dental care. The system generates a monthly list of patients that are due for a dental service, and staff mails cards out to those patients requesting that the patient make appointment. This system has only been in place for a short time, and therefore, the effectiveness in promoting preventative dental care has yet to be measured. 236

238 Modoc County Site Report Graph A: Dental services provided to CMSP clients enrolled in the Modoc W&PP Miscellaneous General Office Visits Oral Surgery Extractions Dentures Debridment and Periodontal Maintenance Perio Scaling and Root Planing Endontic Procedures-Root Canals Crowns Resins Amalgams Preventative Oral Hygiene Instruction Preventative Prophys and Prophys with Fluoride Diagnostic Pulp Test and Cast Panoramic X-Rays Diagnostic X-Rays Comprehensive Exams Periodic Oral Exams Objective 3 To provide diabetes management to CMSP clients with monitoring on a weekly basis (Warner Mountain Indian Health). W&PP Rating: Partially Achieved Objective (minimal level of data to support) Warner Mountain Indian Health (WMIH) states that the level of the project s success was difficult to measure due to patient compliance issues but felt they had met their expectation at a level of 50%. WMIH s initial objective was to provide diabetic management to clients with monitoring on a weekly basis. This objective seemed reasonable to the project at the time of submitting the proposal; however, their perception has changed slightly over the past 3 years with staff changes. The project notes that it is difficult for patients to come to the WMIH on a weekly basis for monitoring. Warner Mountain Indian Health found that a patient s compliance and physical improvement can be noted if the patient s laboratory tests are within normal limits, medication is being taken correctly, and a physical exam is performed on a regular basis. The project failed to submit data on the tracking of the diabetes management activities to the evaluators; therefore, there is no quantitative evidence to either support or refute the project s claims. Over the three-year grant, the WMIH states that the diabetes management program enrolled 32 unique patients. Of the patients served, 31 were Native Americans and 1 was Caucasian and they ranged in age from 25 to 42 years old. The project claims to have measured improvement in 9 of the 12 critical monitoring tests that WMIH monitors diabetic patients for including HbA1c, better blood pressure control, and in increase in the number of influenza and pneumococcal vaccinations given. The project attributes the improvements to now having a Family Nurse Practitioner at the clinic on a fulltime basis, along with increased education training, and increased documentation of test performed. WMIH encountered challenges in getting patients into the clinic on a regular scheduled basis and therefore, the clinic had to become very flexible with its scheduling practices. The clinic adopted an open schedule practice and was not phased when a drop-in patient presented himself or herself for monitoring. In their 2002 Annual Report, the project stated that it had failed to meet its expectations due to patient noncompliance. Warner Mountain Indian Health states that they made frequent attempts to recruit CMSP- 237

239 CMSP/TCE WELLNESS & PREVENTION PROGRAM eligible clients, but only one actually participated in the program, and he was non-compliant. In their 2003 Annual report, the project reported a positive trend in that 24 diabetic patients were participating in the diabetic management program. Four of the 24 patients were CMSP beneficiaries. The project reports that patients receive educational handouts and education on proper nutrition, exercise, and diabetic management to promote positive outcomes. The clinic manager claimed that although the project was not able to get patients in on a weekly basis, they were able to see weight loss and blood pressure decreases in many of the patients. The project reported that they held 2 well-attended diabetes workshop sessions at which a Registered Dietitian presented information on diabetes and local vendors presented many new items for diabetic control. Objective 4 To increase enrollment of eligible clients into CMSP. W&PP Rating: Failed to Achieve Objective Cost and Service Use Analysis The project delivered 111 core data records for CMSP beneficiaries served through the program, as follows: Canby Family Practice Clinic (79), Modoc Medical Center (19), Surprise Valley Hospital District (3), and Warner Mountain Indian Health (10). This data was included in the Increasing Access analysis found on page 268. Future Directions The Modoc project plans to continue all efforts, with the exception of the gas voucher program, in the same manner barring any organizational finances changes. The Modoc County Health Coalition, which was in place many years before the W&PP grant effort, will continue as the partners recognize the need to stay connected in order to attempt to meet the community s health care needs. 238 No data indicating any enrollment changes was supplied to the evaluator by the project; therefore, it is impossible to ascertain the project s success or failure at meeting the planned objective. Surprise Valley Healthcare District reported that the process for enrolling in CMSP is apparently intimating to those who qualify or there is not enough follow up by social service staff to ensure that these individuals get approved. Both Canby Family Practice Clinic and WMIH reported that they aided uninsured clients in obtaining enrollment into social services program for which the clients were eligible. 238

240 Napa County The Napa County Wellness & Prevention Program (NC W&PP) enabled Napa s Community Health Clinic Ole to open a primary care clinic on site at the Hope Resource Center to serve homeless individuals. The grant supported Clinic Ole s outreach clinic staff, including an MD (0.2 FTE), RN (0.2 FTE), and receptionist (0.2 FTE), who provided direct medical services, assisted with enrollment into medical health coverage and social services programs, provided referrals to medical specialists and social services including employment development, and conducted outreach events targeting the homeless; paid for, labs, medications, and x-rays; bought incentives distributed at outreach events; and supported the building of the collaborative that serves the homeless population in downtown Napa at the Hope Resource Center. On September 26, 2001, a health clinic for the homeless run by Clinic Ole was established in the Hope Resource Center, a day shelter and resource center for the homeless in Napa County established in Prior that time, Clinic Ole s homeless Program Description continued on the next page> Total Award Expended $129,520 of $129,520 awarded Program Partners Community Health Clinic Ole* Hope Resource Center* Napa County Health and Human Services Department (Mental Health and Eligibility Divisions) Job Connection Napa/Solano Health Project Napa s Downtown Merchant Association Geographic Area Served City of Napa and surrounding area Target Population Homeless individuals *primary partners Contact Information Maria Stel, Development Director Community Health Clinic Ole Phone: (707) mstel@clinicole.org 239

241 CMSP/TCE WELLNESS & PREVENTION PROGRAM Homeless-outreach clinic becomes permanent asset in Napa County IT WAS A CALL FOR HELP from Napa County homeless advocates: Would Clinic Ole be willing to come downtown to the church and see the homeless patients? We ll give you some room in the gym. From its humble beginnings one-half day a week in makeshift quarters in kitchen and gym of the First United Methodist Church in 1999 to its current operations 2.5 days a week in a dedicated facility in the Hope Resource Center, which is located on the church s campus, Clinic Ole s homelessoutreach clinic has been providing critical primary health care for the homeless population in Napa County. Clinic Ole s homeless-outreach clinic, staffed by Colleen Townsend, MD, Jesus Prado, RN, and Amilcar Ibarra, MA, provides primary and preventive health care, follow-up care, health education, and referrals to the multiple social and mental health services that also have outreach staff located in the Hope Resource Center. When the homeless-outreach clinic started, only a limited number of regular clients were served because of the difficulty establishing trustful relationships with members of the homeless population. But as a result of creative outreach efforts, 1 referrals from other agencies with staff in >Program Description, continued from the previous page Colleen Townsend, MD, the primary medical provider at Clinic Ole s outreach clinic in the Hope Resource Center, charts a patient s progress. health clinic had been operating in makeshift quarters at the First United Methodist Church in Napa. Initially operating one day per week, demand for services has resulted in operation 2.5 days/week. The Hope Resource Center provides showers, laundry services, computer access, mail services, and in collaboration with its partners, health care, mental health services, violence counseling and support, CMSP and other social service enrollment assistance, job search assistance, and HIV education, testing, and counseling. In an outreach effort to reach more of the homeless population in Napa, the clinic physician, Dr. Colleen Townsend, Clinic Ole Director, Stacey Dahlin, and a street outreach worker from another agency, conducted three outreach events to homeless people that may not have accessed services from Clinic Ole. They went into homeless camps, under the bridges of Napa, to shopping center parking lots, 240 and to the church that provides free daily meals. Homeless individuals contacted on these trips were given backpacks filled with first aid kits and personal care items, which were purchased with W&PP grant funds. This effort revealed that there were a number of homeless that were not accessing needed health services at the Hope Resource Center because they were unwilling to adhere to the Hope Resource Center rules, including a felony check, and declined to register to use the center. Therefore, an alternative arrangement was devised such that these individuals would not have access to the other center facilities, such as showers and the activity room, but would wait in the center s lobby in a separate waiting area until they could be seen by the doctor in the health clinic. Finally, the grant funded a planning retreat for all of the agencies that collaborate to deliver services at the Hope Resource Center, including Clinic Ole, Napa County Health & Human Services Eligibility, County Mental Health, the First United Methodist Church, the Napa Emergency Women s Shelter, Job Connection, Napa/ 240

242 Napa County Site Report Solano Health Project, and the Downtown Merchant Association. Program Objectives and Outcomes 2 Objective 1 To coordinate and manage CMSP and homeless clients health and social service-related needs. W&PP Rating: Achieved Objective (moderate level of data to support) Although the project provided a substantial amount of anecdotal information that coordination and management of the health and social service-related needs of homeless clients, including CMSP-eligibles, occurred during the grant period, the evaluator reported that due to technical difficulties, the project did not submit any usable raw data to them for analysis. However, the grant enabled the co-location of primary health care services with outreach operations of a wide variety of social services, previously listed, as well as with a representative from County Mental Health. This co-location undoubtedly facilitated better collaboration and management. The project reports that an advisory group, comprised of representatives from Clinic Ole, social services for the homeless, the legal, law enforcement, and business communities, met monthly to assess program functioning and client needs. The project reported extensive efforts by this group to bring about the collaboration with County Mental Health. Additionally, the grant funded a planning retreat for the collaborating agencies of the Hope Resource Center. These efforts undoubtedly have facilitated the management of the health and social service needs of people seeking assistance at the Hope Resource Center. At the stakeholder planning retreat held in February 2003 with five of Hope Resource Center s key partners, attendees were surveyed and unanimously strongly agreed that the Clinic Ole services delivered at the Hope Resource Center improved access to medical care for the homeless population in the city of Napa. All also agreed or strongly agreed that the Clinic Ole worked collaboratively to increase communication between the agencies that service the homeless population in the city of Napa, and also that Clinic Ole worked with Health and Human Services to create a system that facilitates better access to care for the homeless. A couple of client success stories serve to illustrate the types of challenges encountered by the medical staff the Hope Resource Center, and word-of-mouth recommendations, the client base has expanded considerably. During the past year, the clinic provided 438 clients with services at 648 visits. The clinic owes its ongoing and increasing success to several factors: The commitment of Clinic Ole to provide affordable health care services to the medically underserved population in Napa County; The support of a number of members of the business in Napa; The vision of the Napa community to support a one-stop-shop and resource center in the city of Napa; The opportunity to co-locate with other vital services for the homeless population; A committed medical and administrative staff at the clinic; Funding from the CMSP/TCE W&PP. Clinic Ole s Commitment Clinic Ole was established in Napa County in 1972 as a single, part-time drop-in clinic for migrant farm workers. The clinic has expanded over the past 30 years to provide primary and preventive medical care at six sites in Napa County. Clinic Ole is the only health care provider in Napa County that charges for services on a sliding fee scale according to ability to pay. Business Community Buy-In The business community in Napa County has been a vital partner in the effort to open the Hope Resource Center, a one-stop-shop for the homeless population that in Napa, providing access and assistance for application to multiple social services, showers, mail and laundry services, counseling, mental health assistance, and primary medical care. For example, In 2000, the Napa Valley Vintners Association (NVVA) made a $92,547 grant to the Napa County Council for Economic Opportunity s (NCCEO) Shelter Project to 2 Refer to DRA s evaluation report in Volume 2 of this report for the site's complete evaluation findings. 241

243 CMSP/TCE WELLNESS & PREVENTION PROGRAM assist with funding the development of the Hope Resource Center. Although additional funds for the Hope Resource Center were provided by the U.S. Department of Housing and Urban Development (HUD) and Napa County, without the NVVA grant for the Center s renovation and operation, the HUD funds would have been withdrawn. The Downtown Merchant Association is an active partner in the Hope Resource Center s operations. Although some downtown Napa business owners were initially concerned about the opening of the Hope Resource Center in their vicinity, after 3 years of operation, they now agree the Hope Resource Center is a community asset that they welcome. Benefits of Co-Location Location of the medical clinic at the Hope Resource Center is a key to the success, and its operation there for the first three years was possible because of the CMSP/TCE W&PP funds. The grant funded the entire clinic staff for their participation 1 day per week at the clinic, which was the amount of time the clinic initially was open. As demand grew, Clinic Ole provided the additional funding as necessary to cover the increased days of operation. Because co-located social service staff members ensure that homeless clients are enrolled into any aid program they eligible for, the Hope Resource Center has developed the capability to recoup some of its expenses from these programs. For example, last year, about 44% of the medical visits were billed to CMSP. Benefits to the Community Anecdotal evidence suggests that the homeless population in Napa County have experienced The First United Methodist Church of Napa was home to Clinic Ole s original outreach clinic for homeless individuals, and the new Hope Resource Center is also located on its campus. and how they met them (see also the Volume 4, Issue 3 of the W&PP newsletter (Fall 2003) for more examples): Sarah s Story Sarah who has been addicted to heroin for 30 years and whose children were taken from her as a result, came to the homeless clinic for chronic respiratory problems. She began coming to the clinic every week, and was convinced by Dr. Townsend to enter a drug rehabilitation program. After completing the drug rehabilitation program, she found housing, got a job with a shelter program in Napa, and has regained visitation rights with her children. 242 Bert s Story Bert, in his 40s, has peripheral vascular disease. He needed to stay off his feet in order for the swelling of his feet and legs to stay under control, but because he was homeless, he would push his cart around town for hours each day, resulting in his developing serious ulcers on his feet. He came to the clinic with open sores on his feet, and Dr. Townsend began treating him weekly for two months and his feet eventually healed. Dr. Townsend educated him on how to manage his disease, and he continues to do well. Objective 2 To provide primary health services, referrals and support to homeless adults in Napa County through the Hope Resource Center and Clinic Ole. W&PP Rating: Achieved Objective (moderate level of data to support) Although no raw data was submitted to the evaluator for analysis, the project staff submitted summary data showing that during the first full year of operation, the clinic provided primary health care services to 527 individual adult patients for a total of 829 visits. The project reported that in the final year, 438 individual clients received care via a total of 648 visits, of which 285 were billed to CMSP. The project provided 242

244 Napa County Site Report 143 records (core data) of CMSP eligible individuals served through October 31, Although no data was submitted regarding referrals to specialists and social services, the co-location with a number of other services enabled referrals to be easily made, as they undoubtedly were. For example, as a result ongoing negotiations, the Manager of the County Mental Health program is now on-site regularly to provide mental health services and to coordinate referrals, which was extremely difficult for Hope Resource Center staff to accomplish before this development. However, no data regarding these efforts was provided by the project. Cost and Service Use Analysis The project submitted 143 records of CMSP-eligible individuals served at Clinic Ole s outreach clinic at Hope Resource Center who received services through October 31, This data was folded into the Increasing Access to Care cluster that is reported on page 268. improvements in health and have reduced inappropriate use of emergency services as a result of access to the homeless-outreach clinic at Hope Resource Center. Surveys of downtown businesses have revealed that there is an impression that the homeless people who congregate there seem healthier. And in a survey of homeless clients served by the clinic, 100% reported that prior to the clinic s opening they went to the emergency room for care or went without needed care and engaged in self-medication. Commitment to Future Operations Clinic Ole has committed to sustaining the homeless-outreach clinic at Hope Resource Center following the termination of the W&PP grant by reallocation of funds. The program team plans to also look for additional resources, including other grant opportunities, and is interested in expansion of the model to other counties. Future Directions Community Health Clinic Ole acknowledges that a segment of the Napa County population that did not have access to primary care health services prior to the opening of their outreach clinic now has regular access to that care in a venue that facilitates coordination of a variety of other services for these individuals. Clinic Ole is committed to sustaining the program through a reallocation of funds. Clinic Ole is also continuing to look for additional resources, including grant opportunities, to support these efforts and to possibly support expansion of the model to other counties. 1 Refer to Volume 4, Number 3 (the Fall 2003 issue) of the CMSP/TCE Wellness & Prevention newsletter for more detail on these outreach efforts, as well as for details of some client success stories. 243

245 CMSP/TCE WELLNESS & PREVENTION PROGRAM

246 Shasta County The grant supported efforts in Shasta County to provide access to primary care physicians and behavioral health professionals at three community health centers in Shasta County. Over the three-year grant period, Shasta Community Health Centers used $108,222 in grant funds to support a 0.25 FTE physician, Hill Country Community Clinic maintained a 0.20 FTE mental health provider with $46,752 in grant funds, and Shingletown Medical Center used $42,126 to maintained a 0.13 FTE physician. The remaining grant funds, in the amount of $44,727, were to be used by the Shasta Consortium of Community Health Centers to support staff time for evaluation and project coordination efforts. The project sought to improve the screening and enrollment assistance capacities of the remote clinic staff to aid patients in obtaining public insurance benefits, such as Medi-Cal and CMSP. Additionally, the project attempted to strengthen linkages between the participating clinics and the Shasta County Mental Health Department. Though the project was able to describe the grant-related activities that occurred over the three-year grant period, the project lacked the ability to supply usable data to quantify the impact of the W&PP funds. Please refer to the evaluator s individual report for Shasta County for details regarding the lead agency s inability to supply usable data and the lack of compliance with the grant s reporting Program Description continued on the next page> Total Award Expended $241,827 of $241,827 awarded Program Partners Shasta Consortium of Community Health Centers Shasta Community Health Center (SCHC) in Redding Hill Country Community Clinic (HCCC) in Round Mountain Shingletown Medical Center (SMC) in Shingletown Shasta County Department of Social Services (SCDSS) Shasta County Mental Health Department (SCMH) Geographic Area Served Shasta County Target Population CMSP-eligible clients and the underserved populations of Shasta County Contact Information Pam Tupper, Executive Director Shasta Consortium of Community Health Centers Phone: (530) admin@shastaconsortium.org 245

247 CMSP/TCE WELLNESS & PREVENTION PROGRAM >Program Description, continued from the previous page requirements. Therefore, the information presented in this article was supplied in the project s annual and final reports in addition to an exit interview conducted with the evaluator. During the project s exit interview with the evaluator, the project described evaluation as the effort s greatest ongoing challenge. They attribute the lack of success to two factors. First, staff reported that very little of the grant dollars went to support collection and management of data. Staff stated that giving the resources to the clinics to support direct services by was the best way to increase access. In retrospect, the project staff does feel that if they had used the funds that were set aside to pay for their own time to develop information, rather than rely on their clinic partners and Mental Health to provide data, the evaluation effort would have been much more successful. In the opinion of the Wellness & Prevention Program, this statement is extremely contradictory and unfounded, since the project expended 18% of the grant allocation for supposed grant management and evaluation activities. 1 Secondly, staff reports that the clinic sites and County Mental Health were extremely challenged technologically. The project repeatedly cited the lack of technical capacities as the primary reason that data could not be collected. Program Objectives and Outcomes 2 Objective 1 To improve CMSP screening and enrollment assistance capacities of local health care delivery staff in order to increase enrollment of those eligible for CMSP. W&PP Rating: Partially Achieved Objective (minimal level of data to support) Shasta County Department of Social Services (SCDSS) provided an Eligibility Worker to train clinic staff on benefit assistance eligibility criteria and how to complete the benefit assistance application mail-in forms. The Eligibility Worker compiled a training manual for each clinic site outlining the general guidelines for the Medi- Cal and CMSP intake procedures. Additionally, the SCDSS Eligibility Worker established monthly visits to the Round Mountain and Shingletown sites to provide onsite application and eligibility assistance and was available via phone call to clinic staff in an effort to provide technical assistance on an as-need basis. The monthly visits to the remote clinic sites were advertised in the local newspapers. The Eligibility Worker kept the 1 The project failed to provide any follow up information or data in response to these claims. The W&PP Program Manager made several failed attempts to obtain additional information from the site following an in-person conversation, phone call, and correspondence. clinic abreast of changes in the CMSP eligibility requirements/ processes as well as ensuring that the sites had an ample supply of mail-in applications. The project reports that enrollment/ eligibility staff positions were established at each of the clinics to interface with clinic patients and SCDSS. The project reports that after the establishment of these positions and the linkages to SCDSS staff, the payor mix at the clinics shifted 3% to 4% from uninsured to some form of public insurance. In its 2003 annual report, Hill County Community Clinic reported that because of the efforts of their enrollment/ eligibility staff position and the visiting Eligibility Worker, the number of HCCC patients covered by CMSP or Medi-Cal increased by 16.5% in the first quarter of 2003 compared to the same period in The Shingletown Medical Center site stated, [We] appreciated having a CMSP liaison to provide training and support to assist patients with CMSP eligibility and enrollment. The project reports that the enhanced screening and enrollment assistance efforts with SCDSS efforts resulted in 315 successful applications, largely by individuals who would 246 not otherwise have completed the enrollment process without assistance. However, the project did not provide data on how many clients were screened for enrollment, the break down of the types of applications (Medi-Cal, CMSP, Healthy Families) that were successful, or any staff satisfaction surveys to document their increased capacity to assist patients in the benefits assistance process. In the project s first annual report, the project supplied three months of activity reports from the Eligibility Worker that provided a summary of the CMSP applications processed by SCDSS each month, with the further detail provided on the applications submitted from the rural areas of Shasta. This data would have been extremely valuable for further supporting project s success at accomplishing the stated grant objective; however, this level of record keeping was not maintained after there was a change in the Eligibility Worker staffing when the original worker was promoted within SCDSS. Initially, the project reported that the mail-in applications completed through this effort would have a special stamp to allow SCDSS to track the utilization data. The project reports that SCDSS would not grant Shasta Consortium of Community Health Centers (the grant s lead agency) permission to obtain the personal identifiers for CMSP patients that SCDSS assisted with the mail-in enrollment process at the clinic site for the purpose of core data reporting. The original SCDSS Eligibility Worker assigned to provide eligibility support to the clinic sites presented the project s process and successes to the CMSP Governing Board s meeting held in Redding in Interestingly, the activities associated with this grant 2 Refer to DRA s evaluation report in Volume 2 of this report for the site's complete evaluation findings. 246

248 Shasta County Site Report objective were deemed the most successful of the project s objectives; however, no W&PP grant funds were used by the project to support the SCDSS Eligibility Worker or the efforts of the clinics towards this objective. Objective 2 To decrease unnecessary utilization of emergency room services by CMSP clients. W&PP Rating: Objective Withdrawn This objective was eliminated from the project s evaluation plan following a site visit with the program evaluator, because the project indicated it did not have the ability to collect data on emergency room utilization. Objective 3 To improve access to mental health services and the overall quality of care by increasing collaboration between the Community Health Centers and Shasta County Mental Health. W&PP Rating: Partially Achieved Objective (minimal level of data to support) This project had hoped to improve access to mental health care for the target population not only by increasing availability of services at clinics, but also by collaborating with Shasta County Mental Health (SCMH) on the planning and development of a process allowing Community Health Clinic (CHC) providers to work with the Mental Health Clinical Care Committee to present difficult mental health patients for case consultation, peer review, and appropriate referral/placement. Ultimately, it was the intention of the project to improve clinics ability to treat those clients with mental health issues not yet serious enough to require the specialty mental health services provided by SCMH, and to promote appropriate cross referrals. The evaluation plan included a plan to track the referrals of clients from SCMH to the clinics and visa versa as a measure of increased coordination of services and treatment efficiencies; however, this plan never came to fruition. The project conducted initial meetings with Shasta County Mental Health staff to discuss the proposed activities and the potential partnership. In August of 2002, an SCMH intern conducted a survey of staff to assess the referral process between SCMH and the Shasta Community Health Center (SCHC) in Redding. The project reports that the results indicated that followup on referrals was sporadic and difficult because many patients/clients cannot be easily contacted (no residence, no phone, etc.) and staff time at both SCMH and SCHC is extremely limited for case managementrelated activities. Project staff also reported that the County Mental Health Department has faced many challenges over the last few years that have interfered with its ability to focus time and energy on increased collaboration with the clinic consortium, including a loss of nearly $3 million in state funding, a county-wide layoff and hiring freeze, and high staff turnover. In addition, staff identifies the lack of information technology, connectivity, and basic capacities to manage information as major barriers to any information development effort. The project utilized the Technical Assistance/ Training Funds available through the grant to conduct an in-service provided by Shasta County Mental Health s Director to behavioral health staff at the Hill Country and Shingletown clinics. The in-service covered the history of the mental health system in California, funding sources for local treatment, and details regarding SCMH s different mental health care teams. Objective 4 To improve access to mental health services for CMSP clients in Shasta County by increasing the number of local providers and their hours of operation. W&PP Rating: Partially Achieved Objective (minimal level of data to support) The Shasta Community Consortium of Clinics intended to improve access to primary care and mental health services by increasing provider time in each of the Community Health Centers. Initially, a key element of this strategy focused on ensuring that those with mental health needs could receive comprehensive health care through cross referral with County Mental Health and an increase in the available mental health services through the clinic system. The work with County Mental Health, though often positive, was less productive in this regard than the project expected. The Community Clinic Consortium used a portion of the W&PP funding allocated to clinics to increase the number of mental health professionals (Licensed Clinical Social Workers (LCSW) or Marriage, Family, and Child Counselors (MFCC)) and primary care physicians serving clients through the clinics by one full day a week. Shasta Community Health Center The funds were applied to the support (0.25 FTE) of a general practitioner with a focus on adult medicine. This primary care provider (PCP) is reported to have conducted over 4,000 client visits during the first reporting period (May 2001 through March 2002). Of these, 343 were visits were billed to CMSP, with at total of 441 procedures. In year two of cycle 3 (the

249 CMSP/TCE WELLNESS & PREVENTION PROGRAM month period from April of 2002 to March of 2003), the PCP reported 4,187 patient encounters, with 117 CMSP clients representing over 353 visits. During the final year of W&PP Cycle 3 (April of 2003 through February of 2004), the physician conducted 4,409 patient visits, with 373 of these encounters billed to CMSP. The project reports that CMSP is the third largest public insurer of patients seen by this PCP. Less than 4% of patients are reported to have private insurance, and the remaining patients were either covered by public benefits (Medi- Cal, Medicare, CMSP) or were uninsured. No usable data was supplied indicating the mental health needs of the patients served by the provider in support of the grant objective. Hill Country Community Clinic The individual program goals set by Hill Country Community Clinic (HCCC) included the maintenance of a mental health provider at.20 FTE and provision of 240 mental health visits per year, including but not limited to CMSP clients and targeted populations of uninsured and under-insured patients living at or below 200% of the federal poverty level. The clinic also hoped to maintain clinic clerical staff at.10 FTE to conduct eligibility screening and provide application assistance to the CMSP eligible population. The clinic was able to secure a.20 FTE LCSW during the initial year of Cycle 3. The clinic reports easily meeting their goals with a total of 269 counseling encounters during the initial report period. In year two, staff once again exceeded their goal of 240 visits, this time by 26%, providing a total of 303 counseling visits. In the final year of the grant cycle, HCCC reported 967 individual mental health visits. Shingletown Medical Center The individual program goaels set by Shingletown Medical Center (SMC) include the maintenance of a physician at 0.13 FTE and provision of 520 mental health visits, including but not limited to CMSP clients and targeted populations of uninsured and under-insured patients living at or below 200% of the federal poverty level. In the first year of the grant period, SMC was able to use W&PP funding to support the maintenance of a primary care physician at the level of 0.4 FTE. A project reports that a total of 1331 primary health care visits were conducted, 372 of which were with patients covered by CMSP/Medi-Cal and 110 with uninsured individuals. SMC determined that full-time physician services were needed in order to meet the overwhelming demand for primary care. A second part-time physician was hired to help meet the growth and was able to conduct an additional 315 primary health care visits, 113 of which were billed to CMSP/Medi-Cal and 42 provided to uninsured patients. The clinic underwent a reorganization effort in order to accommodate positions for 1.6 FTE physicians and a 1.0 FTE Family Nurse Practitioner. No information was provided for SMC in the year-two progress report, but the final report indicates that through funding from this grant, they were able to once again exceed their expectations, reporting over 1,373 primary care visits. No usable data was supplied indicated the mental health needs of the patients served by the provider in support of the grant objective. Cost and Service Use Analysis The Shasta County W&PP submitted core data records on the entire set of CMSP beneficiaries served by the three clinics, even extending in some cases to years before the grant project started. Because of the design of the project, it was not possible to attribute which individuals were or were not specifically served by the project. Therefore, the data from this site was not included in the cost and service use analysis. There were no core 248 data records submitted for individuals receiving CMSP benefits application assistance at the sites, so the cost and service use impact of this effort could not be analyzed. Future Directions The participating clinic sites will continue to provide access to mental health and primary care services in addition to assisting patients with completing benefits assistance applications as funding allows. The project plans to continue collaborative activities with the Shasta County Department of Social Services through an oral health program for indigent patients. Collaboration with the Shasta County Mental Health Department (SCMH) will continue in spite of the challenges. The County Mental Health Hospital is slated for closure in June of The cost savings to the county will allow the Mental Health Department to continue to serve the county s mental health care needs by treating acute patients on an outpatient basis and contracting with private psychiatric services in the area to provide care to patients with more chronic conditions. Mental Health Teams will also be created to provide care at the traditional points of entry for patients in the county: the hospital, the county jail, and the homeless shelter. The Mental Health Teams will be designed to bring the care to the patient, with the goal of increasing flexibility and availability of clinical resources at the point of need. It is expected that this will enable a more efficient approach to long-term outpatient treatment. It is also hoped that by partnering with local hospitals and other service providers, including the community clinics, whole patient care will be provided something the project reports that SCMH did not have the capacity to 248

250 Increasing Access Conclusions All efforts at increasing access to health care for indigent populations were met with success beyond expectations, indicating a very large unmet need. In the cases of opening of new facilities in Inyo and El Dorado counties, both found that initial planning underestimated the actual demand. Northern Inyo Hospital s new Rural Health Clinic reached the capacity of its staffing and facility almost immediately after opening and has now moved to larger facilities with increased staff. The El Dorado County Community Health Center has increased its initial staff, and now has a waiting list for service of more than In the case of supporting access to dental care, transportation support had to be rationed in Modoc County because the demand exceeded the grant funds designated to support it. The mobile clinic outreach effort by the Colusa W&PP transformed from simple outreach screening and education to provision of primary health care services because of patient demand. The Indigent Patient Pharmaceutical program of the Del Norte W&PP took on a greater role than originally planned and is so needed that the Del Norte Clinic organization is now planning to institutionalize the position of the nurse providing this service. Projects that supplemented specialty care services Shasta and Mariposa were not able to demonstrate an impact of this approach, but they did report that the services were very much appreciated. These projects demonstrated that there is a large need for access to primary health care, specialty health care, and dental care among indigent and underinsured populations in the communities served by the W&PP efforts. Cost and Service Use Analysis Results The core data records for enrolled CMSP beneficiaries that were collected by each project were used to conduct a cost and service use analysis with the aim of describing impacts of the W&PP. This analysis is summarized in the Cost and Service Use Analysis section of this report, and the complete report by the analysis contractor, The Lewin Group, is included in Volume 2, Evaluation Findings. Reported here are data specific to the Wellness & Prevention Program Increasing Access cluster. The numbers of Inpatient and Outpatient Hospital claims per 1000 members were lower post-enrollment (Graph A on the following page). The increased number of claims post-enrollment is primarily driven by increased Clinic claims, reflecting the opening of a new Rural Health Clinics in an area (Northern Inyo County) that previously had not had a clinic, the supporting of two new outreach clinics (Colusa 249

251 CMSP/TCE WELLNESS & PREVENTION PROGRAM Graph A: Claims per 1000 members per month by service-use category for increasing access cluster enrollees Before Enrollment After Enrollment Hospital IP Days Hospital IP Claims Hospital OP Claims Physician Claims Clinic Claims 250 Lab Claims Home Health Claims All Other Claims Graph B: Claims per member per month by service-use category for increasing access cluster enrollees $500 $450 $400 $350 $300 $250 $200 $150 $100 $50 $0 Before Enrollment After Enrollment All Payments** Hospital IP Payments Hospital OP Payments Physician Payments Clinic Payments Lab Payments Home Health Payments All Other Payments *Excluding pharmacy claims 250

252 Increasing Access Cluster Conclusion and Napa counties), and supporting increased access to existing clinic services (Del Norte and Modoc counties). Payments were higher in all categories of services in the post-enrollment group, with the largest increase occurring in the Clinics category (Graph B on the previous page). It is fair to say that when access to services is increased, more services will be used. However, it is encouraging to note that in this program, most of the increases occurred in clinic services, and it would be expected that over time fewer costly emergent hospital inpatient services would be required. In the Inyo case study, this trend seems to have already begun (refer to the Inyo Site Report for details). The newly opened Northern Inyo Hospital Rural Health Clinic had to expand into this larger facility less than 2 years after it opened. (A picture of the original facility is contained in the Inyo Site Report.) 251

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254 Site Report Conclusion what impact did W&PP grantees feel their efforts had on improving the well-being of their community and strengthening relationships with local stakeholders? This overarching question was one of the purposes of the final survey of the 33 participating grantees that was conducted at the end of Cycle 3. The questions on that survey related to the perceived impacts and outcomes of the W&PP projects, along with the results, are listed on the following table (1 = strongly disagree and 5 = strongly agree): Survey Question N Mean Overall, our project has met our expectations to date Overall, our project is benefiting our entire community Overall, our project is benefiting the CMSP population in our community Our W&PP project has improved the health and well-being of our local residents The services that our project provided are critical to supporting the health of our population. Our project has improved or strengthened relationships with our clients Our project has improved or strengthened relationships with our team/staff Our project has improved or strengthened relationships with our organization Our project has improved or strengthened relationships with our partner organizations/agencies Our project has improved or strengthened relationships with primary care providers. Our project has improved or strengthened relationships with specialty care providers. Our project has improved or strengthened relationships with our community Results of the final survey of W&PP grantees: Questions relating to overall outcomes of their projects. 253

255 CMSP/TCE WELLNESS & PREVENTION PROGRAM From the preceding table, it appears that project staff thought that the overall outcomes of their efforts had met their expectations. They agreed that the projects benefitted their clients, themselves, their partners, and the communities at large. They thought that their projects met critical health care needs in their communities while strengthening relationships at the client, health system, and community levels. Sustainability Project staff were also surveyed regarding their expectations surrounding the sustainability of their projects. The following table lists the questions and responses on questions that related to sustainability (1 = strongly disagree and 5 = strongly agree): At a group training session, Sierra W&PP project staff learn to use the case management data base application that was developed by DRA. These staff members increased their capacities to use data to secure additional funding. Project staff agreed overall that their efforts were vital for the well-being of their target populations. Most indicated that some or all of their efforts would be continued, although some projects qualified that intention by noting that adequate funding would be required. A few projects particularly those targeting undocumented Hispanics unfortunately will not be continued because of lack of funds. Please refer to the Future Directions sections contained within each of the preceding Cycle 3 site reports to learn specific details about each project s sustainability efforts. 254 Overall, projects agreed that they were able to make use of the data collected during Cycle 3 to make the case for sustaining their programs. Survey Questions N Mean If our project does not continue, these services will still be available to our client/participant population elsewhere. Our organization is committed to continuing the program/services. We have used our data to build sustainability of our project or a successful component of our project in the following way: Reallocated internal resources to support our project or components of it. We have used our data to build sustainability of our project or a successful component of our project in the following way: Secured additional resources (funds, staff commitments, space, etc.) to support continuation of our project or components. We have used our data to build sustainability of our project or a successful component of our project in the following way: Engaged local partners in order to address the issue/provide the services. We have used our data to build sustainability of our project or a successful component of our project in the following way: Used data to make presentations with the goal of garnering community support for our program or similar services Final survey responses by W&PP grantees regarding the sustainability of their projects and whether they were able to utilize the data they collected during the Cycle 3 projects to contribute to sustainability. Cost and Service Use Analysis Results The core data records for enrolled CMSP beneficiaries that were collected by each project were used to conduct a cost and service use analysis with the aim of describing impacts of the W&PP. This analysis is summarized in the Cost and Service Use Analysis section of this report, and the complete report by the analysis contractor, The Lewin Group, is included in Volume 2, Evaluation Findings. Reported here are data specific to the Wellness & Prevention Program as a whole. For the W&PP as a whole, the number of claims per 1000 members per month every service category of the post-enrollment group was greater than in the preenrollment group except for the Inpatient Hospital category, in which no change was seen in the number of claims, but the number of Inpatient Days was slightly higher in the post-enrollment group (Graph A). The largest increases were seen in the Clinics and Labs categories. A similar pattern appears on the payments per member per month analysis that is summarized on Graph B. Every category of service type is higher in the post-enrollment group, with the smallest increase occurring in the Inpatient Hospital category. 254

256 Site Report Conclusion Table A: Claims per 1000 members per month by service-use category for all W&PP enrollees Before Enrollment After Enrollment Hospital IP Days Hospital IP Claims Hospital OP Claims Physician Claims Clinic Claims Lab Claims Home Health Claims All Other Claims Table B: Payments per member per month by service-use category for all W&PP enrollees $450 $400 $350 $300 $250 $200 Before Enrollment After Enrollment $150 $100 $50 $0 All Payments** Hospital IP Payments Hospital OP Payments Physician Payments Clinic Payments Lab Payments Home Health Payments All Other Payments *Excluding pharmacy claims 255

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258 Cost &Service Use Analysis. Purpose.. Overview... Data Sources... Methodology... Paid Claims and Payments for Each Analysis Cluster... Categories of Eligibility 257

259 258

260 Cost & Service Use Analysis The purpose of the cost and service use analysis was to provide data regarding the impact of the W&PP projects on the amount and kind of services provided to CMSP beneficiaries. The analysis focuses only on CMSP beneficiaries, who comprised 13% of the total population served by the local-level wellness and prevention efforts, because the CMSP Governing Board administrative staff had access to only paid claims and eligibility files for CMSP beneficiaries. One of the primary objectives of the grant program was to create community-based programs designed to reduce inappropriate hospitalization admissions and related unneccessary expenditures by a thorough more effective utilization of resources, and a more informed client population. To assist the W&PP in measuring progress towards accomplishing this objective, grantees were required to collect core data elements, which are defined subsequently in this section, on the CMSP beneficiaries served by their W&PP project to serve as the link between the intervention and the paid claims/ eligibility files. The analysis was performed by The Lewin Group and is reported in full in Volume 2, Evaluation Findings, of this report, which is entitled CMSP s Wellness and Prevention Program: Enrollee Cost and Utilization Pre-and Post-Enrollment. The Lewin Group was selected to perform the analysis because they had recently completed a similar analysis on the case management test projects undertaken by the CMSP Governing Board as part of their Strategic Planning Initiative (SPI) pilot (Contact the CMSP Governing Board for details on that effort.) That report is published elsewhere. However, since the analyses were similar in some areas, some data from that analysis is included in this discussion of the W&PP cost and service use analysis as comparison data. Although the power of this analysis is limited, as noted in detail in the following discussion and in Enrollee Cost and Utilization Report, it provides some important, if preliminary, feedback regarding cost and service use impacts of the W&PP projects that will be of particular interest to the CMSP Governing Board and its stakeholders. Assessing the cost impacts of wellness and prevention initiatives is extremely complex and there is no consensus among published experts regarding the best methodology. Moreover, there are few published cost-benefit studies, and those that have been published are controversial as to their conclusions. One emerging pattern seems to be that the cost benefits of wellness and prevention campaigns, which are 259

261 CMSP/TCE WELLNESS & PREVENTION PROGRAM expected to occur because prevention or early intervention of preventable disease should result in fewer costly emergent inpatient events, can only be measured by including several years of data following the intervention. Because of the required timing of this report, a lengthy post-enrollment period could not be included. Additionally, only a part of the CMSP population served could be included in the analysis. The following factors contributed to these limitations: 1) The long lag time (up to 6 months) between the date of service and the date the claim is filed in the paid claims file necessitated that only paid claims up to October 31, 2003 could be used for the 2003 paid claims data set that was collected in April ) The need to allow a sufficient post-enrollment period for enrollees for meaningful results this necessitated that all individuals enrolled in W&PP efforts after May 1, 2003 had to be excluded from the analysis, an estimated 20% of the total set of CMSP beneficiaries for which sufficient data was submitted to include them in the analysis. In particular, this cut-off date unfortunately excluded all of the CMSP enrollees from the El Dorado W&PP project, which was only able to collect data starting in May 2003 when their new clinic opened. 3) Most of the projects classified in the Outreach and Education Cluster and some of them in the Increasing Access Cluster were not able to capture from the CMSP beneficiaries they served the necessary data for inclusion, particularly the social security numbers and payor source. Thus the cost and service use impacts of those projects could not be assessed. Another important limitation of the analysis is that none of the changes in reimbursement rates and policies that were implemented during the reported period of 1999 through 2003 were included. Although most of the changes in rates and scope of service in the CMSP policy have occurred in the last half of 2003 and in 2004, there is undoubtedly some effect on the results of not factoring in these adjustments. Furthermore, it was necessary to exclude the pharmacy claims from the entire analysis because the Pharmacy Benefit Management (PBM) program was implemented in 2003, and those claims are not included in the EDS paid claims files, but rather are collected by the PBM contractor. Finally, it must be noted that the numbers of beneficiaries are small for this type analysis, because the presence of a few randomly occurring catastrophic cases, which in CMSP s experience can result in sixfigure costs, can skew the data. In this analysis, there was no attempt to control for the effects of catastrophic cases on the results. The Lewin Group has fully documented the methodology, assumptions, exclusion criteria, and limitations of their analysis in their report contained in Volume 3, Evaluation Findings of this report, and the reader is encouraged to review these for a more complete understanding. Notwithstanding these limitations, the cost and service use analysis provides and indication of the patterns of cost and service used changes that might be expected following implementation of a particular wellness and prevention strategy. The analysis was conducted on the full set of data and on 6 subgroupings of data as follows: All case- managed enrollees; High-intensity case management enrollees; Moderate-intensity case management enrollees; Low-intensity case management enrollees; The outreach and education analysis cluster; and 260 The increasing access analysis cluster. Refer to the Site Report section of this report for the listings of projects included in these analysis clusters, criteria for inclusion in the clusters, detailed project descriptions, the numbers of CMSP beneficiaries contributed to the analysis, and the particular results of the cost and service use analysis that relate to that analysis cluster. Additionally, three individual W&PP projects reported data on a sufficient number of CMSP beneficiaries to qualify for an individual analysis as follows: Butte County, representing a high-intensity case management project; Inyo County, representing an increasing access project; and Lassen County, representing a moderateintensity case management project. Data from the analysis that is specific to these individual projects is included in that project s site report. Following are annotated excerpts from Enrollee Cost and Utilization Report and a listing of some of the most informative summary data contained in it, which is displayed comparatively with composite data from all CMSP beneficiaries in 2002 that was compiled for the SPI evaluation report. Again, the reader is encouraged to review the entire Enrollee Cost and Utilization Report for a full understanding of the analysis. 260

262 Cost and Service Use Analysis Overview The Wellness and Prevention Program is a grant-funded program supporting local efforts to address the health care needs of underserved and uninsured residents through initiatives designed to avoid catastrophic health care events and reduce barriers to effective preventive and primary care. Programs were operated at the county level and focused on case management, outreach and education, or efforts to increase access to care. Enrollment in the program occurred in 2001 through March 2004, with the majority of participants enrolling in Thirty-three counties participated in W&PP, although seven of the counties created W&PP programs designed to generally improve the population s health and did not enroll individual CMSP beneficiaries into a discrete program. This report provides descriptive statistics on those CMSP beneficiaries who enrolled in a W&PP intervention. The statistics are categorized into before enrollment and after enrollment periods, with the pre-enrollment period defined by each individual enrollee s actual month of enrollment in W&PP. The analysis period for the after enrollment period ends with October CMSP eligible months and incurred claims associated with November 2003 or later are excluded from the analysis due to the lack of claims completion for these months. The Enrollee Cost and Utilization Report, which is printed in full in Volume 3, Evaluation Findings, presents 13 data tables as follows: Table 1 provides the distribution of total W&PP participants by program type and demographic characteristics. Table 2 presents the distribution of total CMSP eligible months for W&PP participants across aid codes. Table 3 displays the distribution of W&PP participants by length of continuous CMSP eligibility. Table 4 presents the number of W&PP participants with and without paid claims for services incurred in the applicable period. Tables 5 and 6 tabulate the number of claims and the number of claims per member per month (PMPM) by provider type, program type and enrollment period. Tables 7 and 8 provide total CMSP payments and CMSP payments per member per month by provider type, program type and enrollment period. Tables 9 through 12 provide the count of emergencyrelated claims and claims payment, in total and PMPM, by type of claim, program type, and enrollment period. Table 13 presents additional detail on inpatient claims by the type of admission. Data Sources CMSP provided data on W&PP enrollment, CMSP eligibility, and paid claims covering the 1999 through 2003 time period examined. The W&PP enrollment file identified all CMSP eligibles who had enrolled in W&PP over the course of the program, by enrollment data and county program, and included additional enrollee demographic information including birth date, sex, ethnicity, and county of residence. The paid claims data provided information on each CMSP claim paid for a CMSP eligible, for services incurred between January 1, 1999 and December 31, 2003 and paid through April All services with the exception of outpatient prescription drugs following implementation of the pharmacy benefits management (PBM) contract were included in the claims extract. The PBM contract was implemented on 2003, and claims for prescription drugs incurred following implementation were not readily available for this analysis. Consequently, all prescription drug claims were excluded from the tabulations described below in order to ensure consistency across time periods. The CMSP eligibility data provided the CMSP eligibility history and relevant aid category by each calendar month across the time period examined. All three types of data provided information tied to individual social security numbers permitting the linkage of CMSP eligibility history, W&PP enrollment, and claim data by individual. Methodology Step One: Creation of W&PP Participant List The first step was to create a Master W&PP Participant File to determine those CMSP eligibles to include in the analysis. The W&PP enrollment data file, containing over 1,700 W&PP enrollees, was used to identify these individuals. Several exclusions were applied to the enrollment data file to derive the final Master File. Individuals with multiple records in the W&PP enrollment file were identified and removed from the analysis, reducing the number of W&PP participants by ten. These individuals were removed due to the need to assign enrollees by program type and to assign their CMSP eligible months and claims experience to before 261

263 CMSP/TCE WELLNESS & PREVENTION PROGRAM enrollment and after enrollment periods. The member IDs of the W&PP participants in the enrollment file were compared to the CMSP eligibility file. Any W&PP enrollee who did not have at least one month of CMSP eligibility between January 1999 and October 2003 was excluded at this stage from further analysis. To reduce the number of W&PP enrollees with little or no claims experience in the post-enrollment period, W&PP participants with enrollment dates of May 1, 2003 or later were discarded from the analysis. The cut-off date chosen was selected to minimize the loss of W&PP participants from the analysis, while improving the representation of post-enrollment experience. Early in the data analysis, a tabulation of enrollment months from the W&PP enrollment file yielded the distribution shown below. Although this tabulation was created prior to completion of some of the data cleaning steps and is based upon a slightly different set of exclusion criteria than was applied for the final analysis, the distribution demonstrates that less than 15 percent of the W&PP enrollees was excluded as a result of restricting enrollment dates (Table A). Date of Enrollment # of W&PP Enrollees % of Total Cumulative % Dec 2001 or % 12.60% earlier % 70.00% Jan % 74.90% Feb % 78.10% Mar % 82.10% Apr % 85.20% May % 89.40% Jun % 92.10% Jul % 95.50% Aug % 98.20% Sep % 99.50% Oct % 99.90% Nov % % Total % Table A: Distribution of W&PP enrollment dates among CMSP enrollees that were included in submission for inclusion in the cost and service use analysis. As a result of these exclusions, the total number of W&PP participants included for purposes of this analysis was 1,490. In subsequent steps, the CMSP eligible months and claims cost and utilization information was categorized into two periods: before enrollment in W&PP and after enrollment in W&PP. To accomplish this categorization, the W&PP enrollment date was used for each individual. The before enrollment period corresponded to those calendar months preceding the month of W&PP enrollment. The after enrollment period began with the month of each individual s enrollment in W&PP, regardless of the day of the month of enrollment. For an enrollee to be counted in an enrollment period, the enrollee must have had a month of CMSP eligibility in the corresponding period. Consequently, some individuals recorded as enrolled in the W&PP, and included in the Total W&PP Program counts in the following tables, were not counted in the after enrollment period because there was no month of CMSP eligibility corresponding to the month of W&PP enrollment or later. Similarly, if there was no CMSP eligibility prior to W&PP enrollment, the individual is not included in the enrollee count in the before enrollment period. The Master W&PP Participant File also captured the program characteristics used in the tabulations. These characteristics included the program type (case management, by intensity level; outreach and education; and increasing access) as well as the enrollment county. The tabulations break enrollees and their associated eligible months, cost and utilization into program type, and also break out the 262 three counties with the largest W&PP participation Butte, Inyo, and Lassen counties. Butte County implemented a high-intensity case management program; Inyo County implemented an increasing access program; and Lassen County implemented a moderate-intensity case management program. The tabulations include participants in these three counties in both the county-specific data and the data by program type. Each W&PP enrollee included in the analysis was categorized by age based upon a comparison of his or her birth date to the date of W&PP enrollment. Consequently, the distribution by age displayed in Table 1 of the Enrollee Cost and Utilization Report does not reflect the age of W&PP participants at a single point in time, but the age of participants on the date of their W&PP enrollment. This categorization appeared more descriptive, given the differences in the implementation dates and start-up efforts across individual county programs. Step Two: Identification of CMSP Eligible Months For each of the individuals in the Master W&PP Participant File, each month of CMSP eligibility between January 1999 and October 2003 was identified. Claims associated with each participant were compared to the participant s CMSP eligible months before and after W&PP enrollment. If a CMSP paid claim for a service incurred in a non-eligible CMSP month was found, the month was recorded as CMSP eligible. The length of uninterrupted periods of CMSP eligibility was then examined to permit tabulation of the continuous enrollment patterns from January 1999 to 262

264 Cost and Service Use Analysis October 2003 for Table 3 of the Enrollee Cost and Utilization Report (Volume 2, Evaluation Findings). A sum of CMSP eligible months was created for each individual in the Master W&PP Participant File for the before enrollment period and the after enrollment period. The W&PP participants eligible months were categorized based upon the demographic and program type characteristics included in the W&PP enrollment file. These eligible month counts were then used for all calculations of costs per member per month and claims counts per 1,000 members per month. Step Three: Analysis of Claims Counts and Costs Only those non-prescription drug claims that matched to a CMSP eligible month for a W&PP participant were included in the analysis. As described in Step Two, the eligibility history for W&PP participants who had incurred a claim in a month originally recorded in the source data as non-eligible was modified to record the applicable month as eligible. Claims incurred after October 31, 2003 were excluded from the analysis. The Technical Notes following the tables in the Enrollee Cost and Utilization Report (Volume 2, Evaluation Findings) provide important information on the fields used to categorize claims by type of service. Claims costs are provided in aggregate by program type and by enrollment period, and are also presented on a per member per month (PMPM) basis. The PMPM statistics are derived by dividing total costs by the number of CMSP eligible months within the applicable enrollment period and program type. Claims counts and hospital days are also provided by program type and enrollment period. In addition, these statistics are provided per 1,000 members per month (i.e., total units divided by total eligible months, times 1,000). It is important to recognize that all costs are in nominal dollars and no adjustment has been made for provider fee changes. Consequently, increases or decreases in CMSP provider fee schedules and changes in cost-based provider payments occur throughout the preand post-implementation period. This is further complicated by the fact that the pre- and post-periods are defined on the basis of each individual s W&PP enrollment date, resulting in a given calendar month being represented in both the pre- and post-periods. For example, if Mary and Jim were eligible for CMSP for the entire five-year period, and Mary enrolled in W&PP in July 2001 and Jim in March 2003, the claims and eligible months associated with the period from July 2001 to March 2003 would be included in the post period for Mary s information but included in the pre period for Jim s information. Finally, the claims costs do not reflect gross adjustments such as post-audit hospital settlements. The Technical Notes at the end of the Enrollee Cost and Utilization Report include additional details relating to the selection criteria and manipulation of the source data and are essential to the interpretation of the final tables. Results As noted previously, matched paid claims and number of months of eligibility were divided into pre-and post-enrollment groups as summarized on Table B. Enrollees Enrollee Months Pre-enrollment Post-enrollment Table B: Total number of enrollees and enrollee months pre- and post-enrollment into the W&PP These data show that there was a substantial amount of data available for both groups, but the amount of data was not completely balanced. Although the Enrollee Cost and Utilization Report includes both raw and adjusted data, because of the imbalance shown above, the adjusted, per member per month or per 1000 members per month data is the more accurate comparison. Therefore, the following presentation contains only the adjusted data. However, the reader may review the raw data in the full report contained in Volume 3, Evaluation Findings, of this report. Paid claims and payments before and after enrollment Tables C and D on the following pages list the summary of claims per 1000 members per month by service type and payments per member per month, respectively, for the 9 analysis groups as well as a comparison with similar data for all CMSP beneficiaries in All W&PP enrollees Compared to the CMSP population as a whole, the population served by the W&PP projects had lower numbers of Inpatient Hospital and Physician claims and greater numbers of Outpatient Hospital and Clinic claims, both before and after enrollment in the W&PP projects. This difference may reflect in part that fact that core data was collected on very few Aid Code 50- classified beneficiaries because the projects that targeted that population focused primarily on outreach and 263

265 CMSP/TCE WELLNESS & PREVENTION PROGRAM Table C: Total Claims per 1000 Members per Month by Service Type and Analysis Group, Before and After Enrollment in the W&PP ( ) All Claims** Hospital IP Days Hospital IP Claims Hospital OP Claims Physician Claims Clinic Claims Lab Claims Home Health Claims All Other Claims All CMSP Enrollees in 2002* 2, Total W&PP Program All Case Managed Case Managed -- High Intensity Case Managed -- Moderate Intensity Case Managed -- Low Intensity Outreach and Education Increasing Access Butte County Inyo County Lassen County Before 2, After 2, Before 2, After 2, Before 2, , After 3, , Before 2, After 2, Before 2, After 2, Before 1, After 2, , Before 1, After 2, Before 3, , After 3, , Before 1, After 2, Before 2, After 1, *Data from the 2004 Lewin Evaluation of the SPI grants. **Excludes pharmacy claims. Note: Although dental data is included in the tables contained in the Enrollee Cost and Utilization Report, located in Volume 2, Evaluation Findings of this report, they are not included in this table because dental claims were not included in the SPI analysis of All CMSP Enrollees in 2002, and dental services provided by Rural Health Clinics (RHCs) and Federally Qualified Health Clinics (FQHCs) are not included in the "Dental Claims" category. Claims in the Dental Claims category are those that were processed by Delta Dental. Dental services provided to CMSP beneficiaries in RHCs and FQHCs are billed through EDS and are included within the "Clinic Claims" category. 264

266 Cost and Service Use Analysis Table D: Total Payments per Member per Month by Service Type and Analysis Group, Before and After Enrollment in the W&PP ( ) All CMSP Enrollees in 2002* All Payments** Hospital IP Payments Hospital OP Payments Physician Payments Clinic Payments Lab Payments Home Health Payments All Other Payments $414 $268 $34 $47 $43 $5 $1 $14 Before Total W&PP Program $305 $173 $30 $30 $47 $4 $1 $11 After $410 $223 $39 $36 $72 $7 $1 $20 All Case Managed Before $292 $152 $33 $31 $49 $4 $1 $11 After $404 $218 $42 $38 $56 $10 $1 $24 Case Managed -- Before $335 $171 $46 $32 $55 $4 $1 $11 High Intensity After $386 $161 $53 $35 $73 $20 $0 $28 Case Managed -- Before $250 $118 $30 $28 $48 $3 $0 $12 Moderate Intensity After $312 $142 $42 $36 $49 $3 $0 $24 Case Managed -- Before $353 $235 $16 $37 $40 $7 $4 $7 Low Intensity After $647 $506 $19 $45 $39 $5 $1 $15 Outreach and Before $296 $162 $23 $27 $51 $2 $0 $16 Education After $355 $149 $30 $20 $142 $3 $1 $6 Increasing Access Before $335 $220 $25 $27 $43 $3 $1 $10 After $439 $253 $36 $36 $84 $4 $0 $17 Butte County Before $375 $202 $58 $36 $45 $2 $2 $14 After $349 $133 $57 $33 $64 $5 $1 $38 Inyo County Before $381 $287 $28 $28 $23 $1 $0 $9 After $361 $154 $47 $29 $97 $2 $0 $22 Lassen County Before $246 $116 $29 $27 $49 $3 $0 $13 After $288 $125 $41 $34 $48 $3 $1 $23 *Data from the 2004 Lewin Evaluation of the SPI grants; Solano County not included. **Excludes pharmacy payments. Note: Although dental data is included in the tables contained in the Enrollee Cost and Utilization Report located in Volume 2, Evaluation Findings of this report, they are not included in this table because dental Payments were not included in the SPI analysis of All CMSP Enrollees in 2002, and dental services provided by Rural Health Clinics (RHCs) and Federally Qualified Health Clinics (FQHCs) are not included in the "Dental Payments" category. Payments in the Dental Payments category are those that were processed by Delta Dental. Dental services provided to CMSP beneficiaries in RHCs and FQHCs are billed through EDS and are included within the "Clinic Payments" category. 265

267 266 Table E: Months of Enrollment in CMSP by Aid Code of W&PP enrollees Group Total Aid Code 84 (no SOC) Aid Code 85 (SOC) Disability Pending (no SOC) Disability Pending (SOC) Disability Pending (All) Aid Code 50 Not Reported n n % of Total n % of Total n % of Total n % of Total n % of Total n % of Total n % of Total All CMSP Enrollees in , , % 193, % 13, % 3, % 16, % 54, % % Total W&PP Program 31,516 22, % 6, % 1, % % 1, % % % All Case Managed 19,926 14, % 3, % 1, % % 1, % % % Case Managed -- High Intensity 6,653 4, % % % % % % Case Managed -- Moderate Intensity 9,824 7, % 2, % % % % % Case Managed -- Low Intensity 3,449 2, % % % % % % % Outreach and Education 2,225 1, % % % 0.0% % % Increasing Access 9,365 6, % 2, % % % % 6 0.1% % Butte County 4,230 3, % % % % % % Inyo County 3,130 2, % % % % % % Lassen County 8,824 6, % 1, % % % % % CMSP/TCE WELLNESS & PREVENTION PROGRAM *Data from the 2004 Lewin Evaluation of the SPI grants; Solano County not included. 266

268 Cost and Service Use Analysis education and were not able to access social security numbers or payor information for most of those served. Overall, the number of claims per 1000 members per month every service category of the post-enrollment group was greater than in the pre-enrollment group except for the Inpatient Hospital category, in which no change was seen in the number of claims, but the number of Inpatient Days was slightly higher in the postenrollment group (Table C). The largest increases were seen in the Clinics and Labs categories. A similar pattern appears on the payments per member per month analysis that is summarized on Table D. Every category of service type is higher in the postenrollment group, with the smallest increase occurring in the Inpatient Hospital category. Refer to the Site Reports Conclusion section of this report for graphic displays of the pre-and postenrollment claims and payments. All case-managed enrollees The patterns regarding the number of claims per 1000 members per month for all case-managed enrollees was similar to that seen for the entire group (Table D), reflecting perhaps that case-managed enrollees comprised the majority of the data set. Differences from the entire groups are that the high number of Hospital Outpatient claims in the pre-enrollment group (compared to the All CMSP group) was reduced in the post-enrollment group, perhaps reflected the effort by case managers to direct clients to seek services at clinics. Compared to the All CMSP data, the number of claims per 1000 members per month for both pre-and post-enrollment groups was significantly higher, perhaps reflecting the target population, those with chronic disease and those with complex problems that overwhelm their abilities to self-manage. Similarly, payments per member per month were higher for every category in the post-enrollment compared to the pre-enrollment groups (Table D), with surprisingly the greatest increase occurring in the Hospital Inpatient category. However, compared to the All CMSP group, overall payments per member per month were lower in both the pre- and post-enrollment W&PP groups. This finding reflects the much lower Hospital Inpatient payments for the W&PP groups, perhaps owing to the fact that core data was collected for very few Aid Code 50-classified beneficiaries, as noted previously and in Table E. Refer to the Case Management Conclusion section of this report for graphic displays of the pre-and postenrollment claims and payments. High-intensity case management enrollees The number of claims per 1000 members per month was notably much higher in both the pre- and post-enrollment groups compared to those of the All CMSP group, reflecting no doubt the complex and chronic nature of the cases enrolled into high-intensity case management (Table D). Likewise, the number of claims per 1000 members per month in the post-enrollment group was higher than that of the pre-enrollment group. Notably, however, the expected pattern of reduced numbers of Inpatient and Outpatient Hospital claims and increased numbers of Clinic and Lab claims did occur for the high-intensity case management group. Inpatient Hospital payments per member per month also decreased in the post-enrollment group, while payments for Outpatient Hospital, Clinics, and Labs increased (Table D). Refer to the Case Management Conclusion section of this report for graphic displays of the pre-and postenrollment claims and payments. A case study of cost and service used analysis for a high-intensity case management project is reported in the Butte County site report. Moderate-intensity case management enrollees The number of claims per 1000 members per month in both the pre- and post-enrollment groups was similar to that of the All CMSP group, reflecting perhaps a less focused selection of clients, compared to the highintensity case management group (Table C). The number of claims per 1000 members per month in the post-enrollment group was slightly lower than that of the pre-enrollment group, largely because of reduced numbers of Hospital Outpatient claims. In contrast to the expected pattern after enrollment, there were increased numbers of Inpatient Hospital claims and reduced numbers of Clinic and Lab claims. Inpatient Hospital payments per member per month also increased in the post-enrollment group, while payments for Outpatient Hospital and Clinics increased, as did overall payments (Table D). However, Total Payments were still substantially lower than those for the All CMSP group, the All W&PP group, and the All Case- Managed group (Table D). Refer to the Case Management Conclusion section of this report for graphic displays of the pre-and postenrollment claims and payments. A case study of cost and service used analysis for a moderate-intensity case management project is reported in the Lassen County site report. 267

269 CMSP/TCE WELLNESS & PREVENTION PROGRAM Low-intensity case management enrollees The total number of claims per 1000 members per month in both the pre- and post-enrollment groups was lower than that of the All CMSP group as well as that those of the moderate- and high-intensity case management groups, reflecting perhaps a group that was less ill and/or more able to self manage. (Table D). In contrast to the expected pattern after enrollment, the number of Inpatient Hospital claims and days per 1000 members per month in the post-enrollment group was much higher than that of the pre-enrollment group. All other categories of claims were also increased in the post-enrollment group, with the exception of Hospital Outpatient claims (Table D). Inpatient Hospital payments per member per month were dramatically higher in the post-enrollment group (Table D). Also higher post-enrollment were Hospital Outpatient, Physician, and Other payments. Clinic, Lab, and Home Health payments were lower. This pattern of cost and service use is similar to that of the Increasing Access group reported subsequently, suggesting that low-intensity case management is primarily facilitating a relatively unfocused increased access to care. Refer to the Case Management Conclusion section of this report for graphic displays of the pre-and postenrollment claims and payments. Outreach and education enrollees It should be noted initially that 75% of the enrollees in this cluster were clients of the Mono W&PP, which focused on dental outreach. Those included in this data set were patients at the Sierra Park Dental Clinic, comprising all CMSP beneficiaries served there during the reporting period. The rationale for including all clinic clients is that the outreach and education efforts were believed by project staff to significantly increase the numbers of CMSP beneficiaries seeking services there. Other outreach and education projects were usually not able to capture the needed social security number and payor information from clients that they served. Therefore, the significance of the cost and service use data for this analysis cluster is unknown. The reader is invited to review the data in Tables B and C for this category. Refer to the Outreach and Education Conclusion section of this report for graphic displays of the pre-and post-enrollment claims and payments. Most notably, Clinic payments increased from $51 per member per month (PMPM) prior to enrollment in W&PP to $142 PMPM following enrollment. Increasing Access cluster enrollees The total number of claims per 1000 members per month in the pre-enrollment period was dramatically lower than that of the All CMSP group, and in the postenrollment group was somewhat higher, reflecting that increasing access results in increased service use. (Table D). The numbers of Inpatient and Outpatient Hospital claims per 1000 members were lower post-enrollment (Table D). The increased number of claims postenrollment is primarily driven by increased Clinic claims, reflecting the opening of a new Rural Health Clinics in an area (Northern Inyo County) that previously had not had a clinic, the supporting of two new outreach clinics (Colusa and Napa counties), and supporting increased access to existing clinic services (Del Norte and Modoc counties). Total payments per member per month were lower in the pre-enrollment period compared to the All CMSP group and were higher than the All CMSP group in the post-enrollment group. (Table D). Payments were higher in all categories of services 268in the post-enrollment group, with the largest increase occurring in the Clinics category. It is fair to say that when access to services is increased, more services will be used. However, it is encouraging to note that in this program, most of the increases occurred in clinic services, and it would be expected that over time, fewer costly emergent hospital inpatient services would be required. In the Inyo case study, this trend seems to have already begun (refer to the Inyo Site Report for details). Case studies: Butte, Inyo, and Lassen Three counties, Butte, Inyo, and Lassen, reported a sufficient number of CMSP beneficiaries to which impacts of their W&PP projects could be directly attributed to result in meaningful results. Therefore, data from these three projects was also analyzed separately and is reported and discussed in the Butte, Inyo, and Lassen site reports. 268

270 Cost and Service Use Analysis Categories of Eligibility among W&PP Analysis Groups The proportions of W&PP enrollees in categories of eligibility compared to those of All CMSP enrollees (Table E) differed as follows: W&PP projects served proportionately more non-share of cost [aid code 84 and disability pending (aid codes 88 and 89)] beneficiaries than were present in the All CMSP group. W&PP projects served proportionately fewer share of cost (aid code 85) and substantially fewer emergency services-eligible (aid code 50) beneficiaries than were present in the All CMSP group. Across W&PP analysis groups, the most notable finding was regarding the high proportion of enrollees that were classified as disability pending (aid codes 88 and 89; Table E and Graph A). The Butte County case study reveals a particularly large proportion of enrollees who were classified as disability pending. For a discussion of this finding, refer to the Case Management Conclusion section of this report. Graph A: Enrollment of W&PP clients with disability aid codes vs. All CMSP enrollees Lassen County Inyo County Butte County Increasing Access Outreach and Education Case Managed -- Low Intensity Case Managed -- Moderate Intensity Case Managed -- High Intensity All Case Managed Total W&PP Program All CMSP Enrollees in % 2% 4% 6% 8% 10% 12% 14% 16% 18% 269

271 CMSP/TCE WELLNESS & PREVENTION PROGRAM

272 Grant Cycle 2. Introduction.. Project Summaries... Evaluation Summary

273 272

274 Grant Cycle 2 Report All thirty-four counties participating in the CMSP received a Cycle 2 Wellness and Prevention grant. Grants were awarded in March of 2000 and scheduled to end in December of A total of $3.6 million was released for Cycle 2 grants ($1.6 million from TCE and $2 million from CMSP). For a brief description of each county s grant proposal and grant amount, refer to Table A on the following page. As with Cycle 1, Cycle 2 grantees found it difficult to completely implement their programs in a single year. Several grantees wanted to continue a significant portion of their programs into Cycle 3. Thus, 17 grantees made requests to roll their unspent Cycle 2 funds into their Cycle 3 ( ) grant. One grantee, Colusa, was unable to implement any part of their program. The hospital in Colusa that was to provide services filed for bankruptcy soon after the W&PP grant was awarded. Colusa was invoiced for the entire grant amount, and funds were returned to the W&PP in a timely fashion. Cycle 2 efforts were reported on extensively in the 2001 and 2002 Annual Reports of the W&PP to TCE. Summary of Evaluation Process According to DRA s evaluation report, DRA s evaluation team was met with nearly universal cooperation from W&PP grantees. However, with 33 preexisting projects, the attempt to build a collaborative approach to evaluation was met by three initial challenges: 1) few of the projects had made evaluation a priority for their projects, 2) very little (if any) evaluation technical assistance had been offered or delivered to projects either by CMSP state staff or through working relationships among counties, and 3) the W&PP projects had been operating for nearly two years before the evaluation team arrived on the scene. However, even with these challenges the W&PP projects were generally open to exploring how the evaluation could be integrated into their past and future project efforts. DRA s attempt to spread ownership of the evaluation effort to the projects yielded adequate to excellent results. It is fair to say that the highest levels of collaboration have to do with various combinations of the Strengths listed in Table B. Where barriers to collaboration were encountered, they typically were related to some combination of the Challenges listed in Table B. Because of the extensive and repeated contacts between DRA and the projects, there was no reason to suspect that any of these barriers would be insurmountable. As it happened, none of the barriers were insurmountable. 273

275 CMSP/TCE WELLNESS & PREVENTION PROGRAM Table A: Grant Cycle 2 Project Summaries County Total Funding Project Proposal Alpine $43, Amador $59, Butte $195, Calaveras $69, Colusa $100, Del Norte $106, El Dorado $86, Glenn $93, Humboldt $159, Imperial $189, Inyo $71, Kings $170, Lake $127, Lassen $72, Madera $157, Marin $84, Multi-strategy approach incorporating: Outreach and education component. Once a week, a RN will perform nutrition, health and welfare outreach and education. Patients will be referred from multiple sectors. Purchase of snowmobiles to resond to emergencies. Multi-agency collaboration to develop health indicators in conjuction with community based organizations. Wellness to Work Program. Health education and collaboration project utilizig case management to assist with wellness & prevention activities for persons entering through social services employment portal. Also a referral service for medical/dental care. Developing a collaborative long-term strategy to better serve the indigent population. Improving knowledge of/ and access to care through public information activities and provider recruitment. Implementation of a patient transportation. Hiring a bilingual interpreter to assist healthcare professionals. Provision of childcare through rural clinics.capital outlay devoted to the interior redesign of health clinic and equipment. *Project discontinued and funds returned. Recruitment of primary care physicians and physician assistants. Establish emergency fund to cover laboratory and medications to patients who have no available coverage.increase access to Spanish population & specialty 274care through payment program. Transportation and outreach using van services. Bilingual health educator. Vouchers for health and dental services not provided under CMSP. Nursing education and case management for county residents ages 50 to 64. Activities will include blood pressure checks and cholesterol screenings. Educational classes will be taught on topics such as exercise, nutrition, and prescription drug use. Case management for substance abusers upon release from jail. Evaluation and assessment of alcohol and drug issues in county.infrastructure development for community based organizations that focus on the indigent population that abuse substances. Purchase of a mobile outreach van to provide health education and clinical services to remote areas.creation of prevention orientated Unintentional Injury Prevention Program. Focus placed on residential & recreational injuries, water & firearm safety. Establishment of a Rural Health Clinic (RHC) to increase access the indigent population s access to routine medical care. Sponsor trainings for the medical community and public on rural health services. Complete & submit a Health Professional Shortage Area application. Diabetes education and screening provided through a mobile unit. Unit will be staffed by an RN, LVN, and diabetes educator. Patients screened for diabetes and cerebrovascular disease will receive follow-up for needed education and clinical services. Program is targeted towards the county s Latino and Native American populations. Infant safety seat project including the provision of low-cost car seats as well as safety seat screening days.patient education program.capital outlay to enhance counseling space, purchase clinic equipment, and create a pharmacy room. Chronic diabetes management incorporating clinical services with educational and dietary services. Capital outlay for an on-site day care facility. Acquisition of Geographic Information System software to assist in the mapping of health indicators. Development of disease management model for diabetes, asthma, and hypertension.case management and support services to homeless population with mental and physical health issues & substance abusers with hepatitis C. 274

276 Grant Cycle 2 Report Table A: Grant Cycle 2 Project Summaries, continued County Total Funding Project Proposal Mariposa $70, Provide Psychiatrists for evaluation and assessment of pediatric and adult population. Mendocino $139, Modoc $83, Mono $46, Napa $77, Nevada $65, Plumas $72, San Benito $57, Shasta $145, Sierra $44, Siskiyou $98, Solano $185, Sonoma $171, Sutter $123, Tehama $105, Trinity $100, Tuolumne $79, Yuba $145, Build a co-located community service center for Public Health, Mental Health, Social Services, and other community based organizations. Renovate clinics and hospitals. Provide staff and equipment for medical and dental services. Gas voucher program. Expansion of service day at Warner Mountain Indian Health. Retain a Dental Outreach Coordinator and part-time administrative assistant to promote dental services. Integrate medical and mental health services into local church s homeless shelter. Project will fund a case manager, an outreach worker, a medical doctor, and a mental health professional. Form collaboration at clinic level.case management at Tahoe hospital.fund adult day care to participate in national data set.substance abuse screening and testing for homeless. Case management and outreach activities utilizing Community Health Outreach Workers. Create Community Health Indicators.Count wide, public information campaign focused on nutrition and physical activity targeting indigent living in remote and rural areas. Obtain software applications for data collection, analysis, and reporting. Train staff to collect, analyze, and report local data and compare it with external databases. Provide outreach and education to at-risk persons. Build community collaboration and health development plan for Shasta Lake City. Supply equipment for clinic such as exam tables, stools, and charts. Outcome monitoring with RN staff at clinic. Implementation of a recall system. Capital outlay for equipment used in the treatment of chronic diseases. Outpatient case management for chronic diseases such as diabetes, hypertension, and cholesterol. Augmentation of medical services provided by specialists. Hiring translators. Build collaboration and strategic plan among constituents for indigent population. Focus will be on planning and service delivery. Expand case management and interventions for chronic disease including asthma, diabetes, hypertension, substance abuse, and smoking. Production of health education outreach material in Spanish and Punjabi. Identification and increased case management for diabetic population. Dental care and nutritional services provided through mobile clinic. Prevention based, case management for chronically ill indigent population. One fulltime Public Health Nurse and one ¾ bilingual health education assistant will incorporate outreach, education & link to transportation for chronically ill. Health education for diabetes through mobile outpatient diabetes program. Home health and hospice care for chronically ill. Health issues newsletter targeted towards indigent population, residents of remote areas, and the senior population. Clinic remodel. Expansion of drug court to include CMSP eligible population. Program includes drug testing, health status screening, group treatment sessions, and individual treatment sessions. Substance use treatment programs will be enhanced with a focus on support, life skills training, and counseling. Programs will target low-income, intravenous drug users and the substance abusing, homeless population. Dental care,1 day/week for year. Total $3,599,

277 CMSP/TCE WELLNESS & PREVENTION PROGRAM Table B: Strengths and challenges encountered by the evaluators of Cycle 2 W&PP projects Strengths The projects are administratively sophisticated, i.e.: they are accustomed to reporting; they are longer-lived organizations; they have a history of making use of detailed data in their day-to-day operations, and, importantly; they employ a sufficient number of staff in support of projects goals and objectives. The projects are clinically oriented, i.e., they already develop, collect and use client/patient and service data that is fundamental to the organization s ability to meet its mission. The projects have at least some past experience with evaluations, i.e., they understand and appreciate the power of evaluation information to improve services and/or accessing resources The projects see DRA s approach as no-cost technical assistance and de facto training, i.e., an opportunity for building organizational capacity through on the job training. DRA is perceived to be part of the team as opposed to an external, and potentially threatening, enforcement organization. Challenges The projects: have no experience with collaborative evaluation; and tend to relate to traditional researchoriented evaluations where they have nearly no role other than to simply comply with the evaluators demands as these demands are delivered. The projects are understaffed, i.e., the number of staff and the types of staff positions available for the project are not consistent with the needs of the project Many projects are in need of intensive technical assistance, especially in the areas of: project organization; 276 developing clear and feasible goals and objectives; accessing models of effective services tailored to their locales and clientele; and effective methods of accessing the technical assistance they need. The projects: have participated in more traditional approaches to evaluation; and appreciate the opportunity to work with an evaluator in a truly participatory fashion. The DRA team found that many of the projects were under the impression that they had been collecting evaluation data, or that they were conducting evaluations of their efforts. For the most part, these evaluations were very cursory although there were good-faith attempts to gather some data on their project efforts: testimonials, basic levels of services delivered, basic demographics about clients served or some combination thereof. In working with these projects, DRA began a modeling process for matching data to questions to be answered. As an additional part of the Cycle 2 evaluation effort, five projects were selected to take part in a special retrospective evaluation. These five projects were selected for a variety of reasons, but primarily because of the projects topical/focus areas, and because at the time of selection (October 2000) these projects appeared to have the best potential for either delivering or developing information on their efforts. Regrettably, nearly all of the projects failed to deliver on this potential, despite the efforts of all involved. A copy of this complete Cycle 2 Evaluation Report by DRA is located in Volume 2, Evaluation Findings of this report. This special evaluation provided compelling lessons regarding a variety of factors that can either help or hinder local evaluation efforts (e.g. being part of larger 276

278 Grant Cycle 2 Report evaluation efforts can be helpful; depending upon untried and ultimately inadequate subcontractors can be a hindrance. In short, very little direct knowledge was gained regarding the five projects effectiveness. That is, although the projects very well may have been effective, the lack of data from the projects precluded any informed assessments of the projects effectiveness or impact. This lack of data, plus the fact that many projects served populations other than CMSP clients Medi-Cal clients, and uninsured indigent populations has served as an important refinement to the W&PP s future evaluation and program efforts and expectations. As a result of the W&PP Beautiful wintertime landscape in Shasta County team s Cycle 2 experiences, special efforts were made by both DRA and the CMSP W&PP staff to make grantees aware of CMSP s renewed commitment to evaluation. They also made grantees aware of at least some of the general information they should expect to develop during their Cycle 3 projects. In addition, CMSP W&PP staff reiterated their commitment to evaluation in a very serious way by requiring logic model presentations as part of all Cycle 3 grant proposals. The use of logic models where target populations, program theory of change, project activities, project outcomes and impacts were tied together in a coordinated fashion effectively set the stage for the collaborative building of Cycle 3 evaluation plans. Many projects found the development of these logic models a substantial learning curve, and both DRA and W&PP staff received many calls requesting technical assistance. However, by the time Cycle 3 proposals were produced, grantees clearly had built their capacities with respect to program planning, and the stage was set for much more ambitious evaluation activities as part of the Cycle 3 program. 277

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280 Project Administration, Technical Assistance, Publicity, and Public Relations. W&PP Administrative Staff and Consultants.. Technical Assistance Provided by the Center for Civic Partnerships (CCP)... Technical Assistance Provided by Dennis Rose & Associates... Technical Assistance Provided by the W&PP Administrative Staff... Technical Assistance & Training Funds... Evaluation of the effectiveness of the technical support provided... Publicity and Public Relations... Grantee Feedback Regarding the W&PP Administration

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282 Project Administration, Technical Assistance, Publicity and Public Relations The CMSP/TCE Wellness & Prevention Program required a blend of work performed by Wellness & Prevention Program administrative staff in addition to the expert consultants retained through contracts and the support from the California Department of Health Services for its successful operations. The consultants engaged for this program included the following: Dennis Rose & Associates (evaluation services), the Center for Civic Partnerships (technical assistance provider), and The Lewin Group (CMSP beneficiary cost and service use analysis). Finally, the California State Department of Health Services provided inkind support, functioning as the grant s fiscal intermediary and providing office space and equipment and IT support for Wellness & Prevention Program staff through May W&PP Administrative Staff The County Medical Services Program (CMSP) Governing Board (GB) served as the oversight-body for the Wellness & Prevention Program grant initiative. Monthly updates regarding the Wellness & Prevention Program s progress were provided to the CMSP GB s Planning & Benefits Committee. Through an employment contract process, the CMSP GB hired staff to administer the Wellness & Prevention Program grant operations as well as to oversee the grant s evaluation and technical assistance components. Prior to the hiring of staff in late 1999 and early 2000, the Wellness & Prevention Program s Cycle 1 effort was guided by the Wellness & Prevention Program Oversight Committee (a work group of the CMSP Planning Committee) and an interim Program Manager. Staff from the CMSP unit within the Office of County Health Services provided additional support to the effort. The original Wellness & Prevention Program staffing configuration consisted of a Program Director, a Grants Manager, and a Data Analyst. The Data Analyst position was later refined to a new position, Grant Writer/ Database Manager, which incorporated a grant writing and information development component into the original Data Analyst job description. A part-time Administrative Assistant position was funded in the middle of grant Cycle 2 through the first portion of grant Cycle 3 to assist with administrative functions. In 2003, Program Director left the Wellness & Prevention Program to pursue another employment opportunity, and the roles of the Grants Manager and Grant 281

283 CMSP/TCE WELLNESS & PREVENTION PROGRAM Writer/ Database Manager positions were modified to incorporate the Program Director s tasks. With the modification of job duties, the Grants Manager position was re-titled Program Manager and the Grant Writer/ Database Manager position was re-titled Information and Communications Specialist. In January 2004, the Information and Communications Specialist opted to alter her relationship with the CMSP GB from an employee status to that of an independent consultant. Throughout the many changes in Wellness & Prevention Program staffing, the CMSP GB s Administrative Officer oversaw the Wellness & Prevention Program staff. The California State Department of Health Services, through its Office of County Health Services Division, provided on an inkind basis the office location for the Wellness & Prevention Program from initiation until In May 2003, the Wellness & Prevention Program was co-located within the CMSP GB s Administrative Office on an in-kind basis. Thank you very much for your understanding of the strengths and barriers of a rural county, and for quality technical support over the years. grantee feedback on the final survey The Center for Civic Partnerships recruited Ann Albright, PhD, RD, with the California Diabetes Control Program, to present to the 2002 Technical Support Workshop attendees. Technical Assistance Provider An integral component of the original grant proposal to The California Endowment included technical assistance services designed to help grantees build collaborations among community agencies, support program development and implementation, and build local capacity for obtaining additional resources. To fulfill this component, the Center for Civic Partnerships (CCP) began work on the CMSP/ TCE Wellness and Prevention Program on July 1, CCP provided technical assistance services to individual grantees during the period of July 1, 2000 to June 30, The Center for Civic Partnerships was selected as the technical assistance provider through a competitive process. A Request For Proposal (RFP) was posted on the Internet via the Department of Health Services Web site. In addition, letters were sent to the business offices of local and national contractors to solicit proposals. The RFP was released on March 26, 2000, and proposals were due May 1, A review panel was developed to evaluate the proposals received. Members of the panel included individuals from the Wellness and Prevention Oversight Committee, Department of Health Services staff, community-based provider staff, CMSP GB members, and grant-funded staff. Review panel members were given explicit criteria for evaluating each proposal, and reviews were completed independently. All proposals were sent to The California Endowment for review. The top two applicants for were contacted for inperson interviews. At the conclusion of in-person interviews, the review panel was asked to select their top choice. The Center for Civic Partnerships was unanimously chosen as the technical assistance contractor. The results were provided to The California Endowment, the Administrative Officer of the CMSP GB, and the CMSP GB for review and approval. Unanimous approval of the contract was formerly granted from all parties on May 25, Formal contracts were developed and signed, and services began in earnest on July 1,

284 Project Administration, Technical Assistance, Publicity and Public Relations The technical assistance consultant reported to the Project Director of the CMSP/TCE Wellness and Prevention Program. Day-to-day management of the technical assistance activities, including oral and written communication with the technical assistant consultant, was the responsibility of the Grants Manager. Evaluation Services Provider Paramount to the original grant proposal to The California Endowment were evaluation-related components designed to assess: 1) individual wellness and prevention grant programs; 2) the development and implementation of the CMSP strategic plan; and, 3) the overall impact of these activities on the CMSP. Beginning July 1, 2000, Dennis Rose & Associates (DRA) began work for the CMSP/TCE Wellness and Prevention Grant Program to address these program components. DRA provided evaluation services to the grantees and the CMSP GB during the period of July 1, 2000 to June 30, The evaluation consultant, Dennis Rose & Associates, was selected through a competitive process. A Request For Proposal (RFP) was posted on the Internet via the Department of Health Services Web site. In addition, letters were sent to the business offices of local and national contractors to solicit proposals. The RFP was released on March 26, 2000, and proposals were due May 1, A review panel was developed to evaluate the proposals received. Members of the panel included individuals from the Wellness and Prevention Oversight Committee, Department of Health Service staff, community-based provider staff, CMSP GB members, and grant-funded staff. Review panel members were given explicit criteria for evaluating each proposal, and reviews were completed independently. All proposals were sent to The California Endowment for review. The top two applicants for were contacted for inperson interviews. At the conclusion of in-person interviews, the review panel was asked to select their top choice. Dennis Rose & Associates was unanimously chosen as the evaluation contractor. The results were Yolanda Bernal, staff member from the Imperial County W&PP project presents her group s work during the Making Your Data Work for You session at the 2003 Technical Support Workshop. provided to The California Endowment, the Administrative Officer of the CMSP GB, and the CMSP GB for review and approval. Unanimous approval of the contract was formerly granted from all parties on May 25, Formal contracts were developed and signed, and services began in earnest on July 1, Due to the 18-month no-cost extension of the Wellness & Prevention Program, DRA and the CMSP GB entered into an extension of the original evaluation contract which extended DRA s work with the program until June 30, The evaluation consultant reported to the Project Director and later to the Program Manager of the CMSP/ TCE Wellness and Prevention Program. Cost Analysis Consultant The initial plan was to have the selected evaluation consultant perform the tasks associated with completing an analysis of medical service utilization and cost data and trends highlighting the cost impact of the various projects wellness and prevention efforts on CMSP. However, issues arose regarding confidentiality and the provision of protected health information by the Wellness & Prevention Program grantees to an outside entity. Therefore, the decision was made by the W&PP Administrative Office that Wellness & Prevention Program grantees would supply core data reports, containing identifiers for CMSP beneficiaries served through each project s efforts, on a biannual basis to the Wellness & Prevention Program. The W&PP would then be responsible for conducting the cost analysis based on linking the core data report information to the CMSP paid claims and eligibility files. The many changes to the Wellness & Prevention Program s staffing structure left a void in expertise required to complete the analysis of medical service utilization and cost data and trends highlighting the cost impact of the various projects wellness and prevention efforts. Therefore, the CMSP GB retained the services of The Lewin Group to perform the analysis entitled CMSP s Wellness & Prevention Program: Enrollee Cost and Utilization Pre- and Post-Implementation, which is presented in Volume 2, Evaluation Findings, of this report and is discussed in the Cost and Service Use 283

285 CMSP/TCE WELLNESS & PREVENTION PROGRAM section of this report. The Lewin Group had conducted a similar analysis on CMSP paid claims and enrollment information for the Strategic Planning Implementation (SPI) grants funded by the CMSP GB. The Lewin Group and the CMSP GB had an established Business Associates Agreement, which allowed for the sharing of protected health information between the two entities. Funds to support the cost of the analysis were available through salary savings incurred when the Program Director ceased employment. Wellness & Prevention Program staffed worked with The Lewin Group to develop a scope of work for the analysis as well as inclusion and exclusion criteria. Fiscal Agent Through the CMSP GB s contractual relationship with the California Department of Health Services (DHS) to administer the indigent health care program, the GB was able to garner in-kind support from the DHS Fiscal and Data Analysis Unit (FADAU) to be the fiscal intermediary for Wellness & Prevention Program grant funds. Once approved by the Wellness & Prevention Program Director, FADAU staff processed grant and contractual payments as well as tracked Wellness & Prevention Program fund expenditures, grant recoupments, and interest earned on the grant funds. Registration at the 2003 Technical Support Workshop Technical Assistance Provided To support the individual grantees in the design, implementation, and evaluation of their wellness and prevention-related activities, efforts were made to supply grantees with training and support throughout the Wellness & Prevention Program in both Cycles 2 and 3. The Center for Civic Partnerships, Dennis Rose & Associates, and the W&PP administrative staff engaged in technical assistance-related activities geared to strengthen the grantees capacity. Technical Assistance Provided by the Center for Civic Partnerships (CCP) The goal of the W&PP Technical Support Program conducted by 284 the CCP was to improve the capacity of the 33 W&PP communities to (a) build and strengthen their collaboratives; (b) design, implement,and evaluate their wellness and prevention efforts, and (c) sustain the successful efforts. The approach and methods undertaken by CCP were designed to increase the capacities of W&PP grantees so communities were prepared to continue wellness and prevention efforts after the sunset of the grant funding. They accomplished this goal through the following activities: Planning and implementing three Technical Support Workshops (TSW). Over 90 individuals attended one or more of the programs. As part of the Center s learning community approach, over half of the workshop presenters/facilitators were from W&PP projects. Conducting sustainability sessions at each of the Technical Support Workshops to assist grantees with deciding how to sustain their work post-cmsp funding. Center staff also disseminated over 40 copies of the Sustainability Toolkit to the grantees. Providing customized technical support to 33 county programs. The Center initiated or received over 370 individual, , or inperson contacts and conducted 20 site visits. They also linked grantees for peer support. 284

286 Project Administration, Technical Assistance, Publicity and Public Relations Assessing the technical support needs and assets of grantees through written surveys, individual consultations, and discussions with CMSP and evaluation staff. Posting 185 messages on the technical support listserv, with multiple resources regarding funding opportunities, conferences, publications, and other items of interest. Developing and updating web-based technical support materials; Writing 11 articles for the W&PP newsletter; Participating in meetings and conference calls with CMSP staff, evaluation contractor, CMSP Planning and Benefits Committee, and the GB to coordinate technical support responses/activities, discuss the accomplishments and share lessons learned. Kelly Elder (right), of associate of DRA, listens as Joan LaPorte, RN, staff member from the Kings County W&PP project presents at the 2003 Technical Support Workshop. For complete details on the technical assistance provided by DRA, refer to the DRA Evaluation report in Volume 2, Evaluation Findings, of this report. Thank you for your flexibility. It allowed us to be creative, strengthen community partnerships and gather data to Refer to CCP s Final Report in Volume 3, Supplemental Information, of this report, for further details on CCP s technical assistance efforts. work for change in our community. Technical Assistance Provided by Dennis Rose & Associates Dennis Rose & Associates (DRA) prioritized the development of information from data collected during project operations as a focus because of the power of valid information in supporting efforts for renewed funding. To this end DRA engaged in the following activities regarding development of capacities to collect and report data: Interactive development of evaluation plan and logic models Development of electronic databases tailored to individual site needs Training in the use of the various tailor-made electronic databases Specialized reporting capacities from electronic databases Customized data summaries for grantseeking efforts by certain counties grantee feedback on the final survey Technical Assistance Provided by the W&PP Administrative Staff Staff from the Wellness & Prevention Program engaged in activities to provide grantees with improved access to data for CMSP-enrolled individuals, grant implementation assistance, as well as assistance securing additional resources to support wellness and prevention-related activities. Planning Reports Utilizing the CMSP paid claims and eligibility files, the W&PP administrative staff created Planning Reports for each of the 34 CMSP counties. The purpose of the planning reports was to better equip the grantees and potential grantees with information regarding the CMSPenrolled population in their respective communities. 285

287 CMSP/TCE WELLNESS & PREVENTION PROGRAM Planning reports were created during Cycle 2 and Cycle 3 with data from calendar years 1999 and The planning reports included the following components for each county: the number of CMSP eligibles and active enrollees, demographic information, most frequent and most costly primary and secondary diagnoses, emergency-indicated claims, top providers in-county, top providers out-ofcounty, top pharmaceuticals prescribed, and a break down of mental health-related and substance abuse-related claims. As described previously in the Request for Applications section, potential grantees were encouraged to utilize the data contained in their county s Planning Reports to plan for their wellness and prevention activities. Presentations Over the course of the Wellness & Prevention Program, staff made the following presentations to W&PP grantees: Emergency Service Use and the County Medical Services Program (CMSP) Population Technical Support Workshop Redding, CA May 9, 2001 Projects, Analysis, & Future Directions Technical Support Workshop Sacramento, CA May 14, 2003 CMSP/ TCE Wellness & Prevention Program Orientation Technical Support Workshop Sacramento, CA May 14, 2003 County-Level Data Reports 1999 and 2000 for County Medical Services Program (CMSP) Technical Support Workshop Sacramento, CA May 15, 2002 Christopher Kelsch, W&PP Project Director, presents at the 2003 Technical Support Workshop CMSP/ TCE Wellness & Prevention Program Orientation Technical Support Workshop Sacramento, CA May 15, 2002 Summary of Program Progress: Evaluation Expectations and Information Presentation to the CMSP GB October 24, Site Visits Given the opportunity, W&PP staff traveled to many of the communities with Wellness & Prevention Program projects. The time spent with grantees in their own surroundings provided an invaluable learning opportunity for W&PP staff that augmented the information they received about projects from the data and reports the projects submitted. The W&PP staff learned more about the unique local challenges faced by each project, gained an appreciation for the environment in which projects are providing health services, and had the opportunity to meet with providers and clients. Over the course of the Wellness & Prevention Program, staff visited 29 of the 33 W&PP projects. Often the site visits were coordinated with the evaluation consultants and technical assistance providers. Grant Writing Assistance The W&PP administrative staff provided grant writing assistance to five projects: Inyo, Lake, Mono, Modoc, and Kings. In the case of the Inyo and Lake proposals, W&PP staff contributed to a substantial degree. In the case of Inyo, the grant was funded (refer to the Inyo Site Report in Volume 2, Evaluation Findings, of this report for details); for Lake, it was not. Following minor contributions to the Mono, Modoc, and Kings grant writing efforts, the Modoc project was funded, and the Kings projects was not funded, but the project was encouraged to make another attempt the following year. In Mono County, substantial staff turnovers occurred, and the outcome of that grant procurement effort was not reported to W&PP staff. 286

288 Project Administration, Technical Assistance, Publicity and Public Relations Grant Administration Assistance The Wellness & Prevention Program project staff was successful at working collaboratively with communities agencies in Modoc, Lassen, and Plumas counties to secure a transportation planning grant to address issues associated with non-emergency medical transportation (NEMT), in addition to working with nonprofit and county agencies in Sonoma County to secure funding to examine issues and develop solutions for frequent users of the emergency departments. Caltrans Non-Emergency Medical Transportation Planning (NEMT) Grant for Environmental Justice Lack of transportation services is a barrier to access and an impediment to health care for the medically indigent population in rural areas. Previous needs assessments conducted by the CMSP GB have found that the lack of transportation is one of the top barriers to access of health care among the medically indigent population. As part of its strategic plan, the CMSP GB through the W&PP has identified transportation grants as a direction for future initiatives. In October of 2002, CMSP, together with the Modoc, Lassen, and Plumas County Transportation Commissions, received a planning grant from Caltrans. The objective of the $220,000 project is to develop a transportation plan, using an inclusive participation process, for addressing the problem of inadequate non-emergency medical transportation (NEMT) for the medically indigent population in the Lassen-Modoc-Plumas tricounty region. Specifically, the plan will develop a flexible and efficient NEMT strategy to serve these populations. In addition, the plan will provide a framework for future grantfunded medical transportation activities in other counties that participate in the CMSP and will serve as a model for other rural counties in California. Activities since April 2003 include the completion of extensive outreach efforts into Modoc, Plumas, and Lassen counties by members of the Nelson/Nygaard Associates organization, which is the transportation planning consultant on the project. The purpose of this outreach effort was to collect feedback from multiple Sonoma County FUHSI Planning Team members gathered with projects throughout California to share lessons learned from the planning process. photo: Margaret Petela stakeholders regarding unmet needs for NEMT, as well as to identify community assets that might be utilized to meet those needs. The outreach effort took the form of one-on-one in-person interviews and focus groups, telephone interviews, and paper surveys. A large number of individuals from the medical provider, transportation provider, social service provider, clinic patient, indigent adult, American Indian, and Hispanic communities were included. Also held were a series of three community workshops (one in each county) to which the public was invited and at which multiple medical, social service, and transportation agencies were represented. The results of the outreach effort were published in a technical memorandum that will be incorporated into the NEMT Final Report, which will be a public document. The NEMT project is guided by an Executive Steering Committee, including representatives from each county as well as regional medical and transportation organizations and a representative from the CMSP W&PP staff. Seven Executive Steering Committee meetings have been held. The project, which began in January 2003, be extended until December 31, 2004 in order to coordinate with two other related initiatives, The Graying of the North State, and the Rural Health Design Program, which both have NEMT concerns; plans for sharing data among these projects are developing. The Final Report from the NEMT planning effort is anticipated in Fall Frequent Users of Health Services Initiative (FUHSI) In May 2003, the CMSP GB, working in partnership with various Sonoma County agencies, was awarded a planning grant for the Frequent Users of Health Services Initiative (FUHSI) funded by The California Endowment and California HealthCare Foundation. The planning project will run from June 1, 2003 through October 1, The goal of the FUHSI project is to plan a care coordination program for frequent users of health care services, who have medical, behavioral health, and social issues that overwhelm their abilities to manage their own care. The model of care will focus on patients with chronic health conditions and coexisting mental health, substance abuse, and social issues who frequently use 287

289 CMSP/TCE WELLNESS & PREVENTION PROGRAM emergency department services. The planning team has approached the project with the understanding that multidisciplinary teams and coordination between existing service providers will be keys in the effort to coordinate care for individuals with needs across many delivery systems. The FUSHI project involves the following community-based and county agencies in Sonoma County: Catholic Charities Coastal Valleys Emergency Medical Services Community Housing Development Corporation of Santa Rosa Community Resources for Independence Redwood Community Health Coalition representing the nonprofit health clinics Sutter Medical Center- Santa Rosa St. Joseph Health System Sonoma County Task Force on the Homeless Santa Rosa Police Department Sonoma County Human Services Department Sonoma County Health Services Department (Public Health, Mental Health, & Alcohol and Other Drug Services) Wellness & Prevention Program staff provided support to the project in creating the project model, assembling stakeholders, and conducting data analysis on the emergency departments frequent users. The planning team, with St. Joseph Health System as the lead agency, submitted a proposal for project implementation to the FUHSI funders and will be notified of a determination in September Database Training and Manual Creation Wellness & Prevention Program s Information and Communications Specialist worked with DRA to design and develop the training and a corresponding user s guide for participants using the Wellness & Prevention Program case management database to track outcomes of their grant efforts. Refer to Volume 3, Supplemental Information, of this report for a copy of the database manual. DRA staffers look on as W&PP project staffers learn to use the case management database application developed by DRA. Two training sessions were held in Sacramento on January 23 rd and February 6th, 2002 to introduce grantees to the data entry and reporting functions contained in the Access database. Wellness & Prevention Program staff coordinated the logistics and hotel accommodations for the training attendees. The Office of County Health Services lent the use of their computer classroom for the training purposes. Refer to DRA s complete evaluation report in Volume 2, Evaluation 288 Findings, of this report for further details regarding the case management database and the training effort. The technical services we received have been extremely helpful. We are very thankful to the staff. The staff at DRA has also been beneficial to the success of the project. grantee feedback on the final survey Grant Implementation Assistance & Grant Monitoring Wellness & Prevention Program staff strove to assist each project in achieving the goals it had set for itself as well as to best met the needs of the low-income and underserved residents within the projects communities. Staff worked collaboratively with projects by developing trusting and professional relationships with key project staff. Wellness & Prevention Program staff offered assistance in modifying project activities and budgets when projects encountered unexpected difficulties and challenges. 288

290 Project Administration, Technical Assistance, Publicity and Public Relations W&PP staff kept an up-to-date call log for each county in an Excel spreadsheet that was accessible to all staff members. The call logs contained the date of the call, grantee contact, W&PP staff contact, and details regarding the nature of the call. These call logs were especially helpful in documenting challenges encountered by sites. Additionally, program files for each W&PP project were maintained for annual and final reports, evaluation plans, grant agreements, budget revisions, and written correspondence between the site and the W&PP office. Finally, the W&PP Information and Communications Specialist created an Access database to maintain the contact information of key project contacts as well as an interested parties and a newsletter mailing list. During grant Cycle 3, grantees were required to submit two annual reports and one final report using a standard reporting format. The annual and final reports were comprised of a narrative section that allowed grantees to provide an update on the project s activities, encountered challenges, and successes over the prior year. Additionally, grantees were required to submit documentation of the prior year s grant expenditures. Wellness & Prevention Program staff reviewed each component of a grantee s report to ensure the proper and accurate documentation of grant expenditures and compliance with the required reporting requirements. The submission of the annual reports also allowed for grantees to request budget modifications in response to a new need, unexpected costs, or grant savings. All budget modification requests were reviewed by the Grants Manager and approved by the Program Director. Core Data Database Development In addition to the annual reports, projects were required to submit core data reports on a biannual basis to the Wellness & Prevention Program. The core data reports of the following data elements for CMSP-enrolled patients only who were engaged in a project s Wellness & Prevention Program efforts: Date of first service under the program (referral, screening, etc.) or enrollment into case management W&PP grantee staffers learn to use the case management database application developed by DRA. Location of service FirstName of beneficiary LastName of beneficiary Address of beneficiary Social security number Date of birth Ethnicity Primary Language Spoken The core data reports provided the necessary data elements for the Wellness & Prevention Program to link CMSP-enrolled individuals engaged in community-based wellness efforts to the CMSP-paid claims and eligibility files. Please refer to the Cost & Services Use Analysis information presented in Section II of this Final Report for further information. Technical Assistance & Training Funds As reported previously, Amador County elected not to submit a proposal for Cycle 3 grant funds. The Wellness & Prevention Program, with the support of the Planning & Benefits Committee and CMSP GB, created an additional funding opportunity called the Technical Assistance & Training Funds with the un-awarded Amador grant allocation in addition to recouped Cycle 1 funds. In September 2001, Cycle 3 grantees were notified of the availability of additional funds for technical assistance and training activities. These funds were designed to be used for training or assistance to the program staff working directly with the Wellness and Prevention project and for developing collaborative activities. Grantees were sent individualized memorandums detailing the amount of funding designated to that site and the procedure to obtain reimbursement. Of the $137,441 allocated to grantees for training and support activities, $89,804 was expended. The following table summarizes the percentage of each site s total technical assistance allocation expended. 289

291 CMSP/TCE WELLNESS & PREVENTION PROGRAM Percentage of Allocation Expended Number of Sites 100% 8 > 50% 13 < 50% 7 None 5 Usage of technical support funds by W&PP projects Many of the Cycle 3 grantees took full advantage of these additional resources to support staff trainings, professional development sessions, and the furtherance of community collaborations; but surprisingly, five of the sites did not utilize any of the funds available to them. Evaluation of the Effectiveness of the Technical Support Provided At the end of the Cycle 3 grant period, all W&PP projects were asked to complete a survey regarding several overall aspects of the W&PP, including the value of the technical assistance support. The following table lists the relevant questions and the mean response score (on a scale of 1 to 5, 1 = strongly disagree and 5 = strongly agree). Survey Question N Mean The training we received was very valuable The annual Technical Support Workshops were very valuable Creating the [final grantee] report gave me an opportunity to reflect on the project over its entire history, a process which I found very valuable. We have enjoyed the opportunity to work with you on this project. I have especially appreciated the high level of support that you and your staff have provided to us. It has been a pleasure to conduct the project with our The program support and technical assistance (TA) that we received from W&PP staff and consultants (CCP & DRA) was very helpful. The technical support we received around evaluation reporting was very helpful. 290 The TA we received contributed to increased organizational competencies in the areas of planning and/or evaluation. Our participation in this grant program has helped us to better understand the value of good program information. The information developed through our evaluation effort was useful to me personally. The information developed through our evaluation effort was useful to the project team/staff. The information developed through our evaluation effort was useful to our organization. The information developed through our evaluation effort was useful to our partners. The information developed through our evaluation effort was useful to our clients. The information developed through our evaluation effort was useful to our community. My evaluation skills or the skills of our team (staff, partners, etc.) have improved as a result of our participation in this program partners here and to have Survey responses regarding the value of technical assistance efforts by W&PP staff and the consultants participated in an effort which we know benefited many needy individuals in our community. Overall, project staff agreed that each of the surveyed technical assistance efforts provided through the W&PP had been of value to them. grantee feedback on the final survey 290

292 Project Administration, Technical Assistance, Publicity and Public Relations Publicity and Public Relations Californian Journal of Health Promotion Articles Wellness & Prevention Program Pages In Spring 2000, the Wellness & Prevention Program produced and distributed its first edition of the Wellness & Prevention Program Pages, a quarterly newsletter designed to acts as a medium to share successes and program highlights within the Wellness & Prevention Program to a broader constituency. Over the course of the Wellness & Prevention Program, Wellness & Prevention Program staff produced a total of 17 issues of the newsletter. The Center for Civic Partnership made routine contributions to the newsletters by highlighting resources for grantees, providing information on best practices, and addressed other topics as identified as a need area by grantees. Wellness & Prevention Program administrative staff interviewed grantees and created highlight articles about key components of many W&PP projects. Newsletter readership included approximately 450 parties throughout California with an expressed interest in wellness and prevention activities and/or rural health. The Wellness & Prevention Program Pages issues tended to revolve around a key theme, target population, or strategy employed within the Wellness & Prevention Program, and the newsletter served as a forum to highlight the successes of individual W&PP projects. Examples of topics addressed in the newsletters include: the provision of culturally competent care, diabetes education & outreach strategies, the provision of health services to the homeless, substance abuse treatment, client-centered case management interventions, sustainability, and ways to address transportation barriers to health care. Refer to Volume 3, Supplemental Information, of this report for complete reprints of all 17 issues of the Wellness & Prevention Program Pages. Descriptions of the processes used for the development of the W&PP projects in Imperial, Sonoma, San Benito, and Tehama counties were published in the Californian Journal of Health Promotion edition dedicated to Mexican American Health and Health Education in California. Christopher Kelsch, Sunny Bishop, and Alison Kellen with the Wellness & Prevention Program and Kelly Elder with Dennis Rose & Associates authored the article entitled Essential Attributes of Wellness and Prevention Programs in Rural Latino Communities that appeared in the Californian Journal of Health Promotion, Volume 1, Issue 2, (available on the Web at and is also reprinted in Volume 3, Supplemental Information, of this report). An additional article concerning the Imperial County Asthma Project that contains a report on a provider survey funded in part with Wellness & Prevention Program funds also appeared in the same issue. Paula Kriner, Yolanda Bernal, Amy Binggeli, and India Ornelas authored the article Attitudes, Beliefs, and Practices Regarding Asthma Care Among Providers and Adult Asthmatics in Imperial County that appeared in the Californian Journal of Health Promotion, Volume 1, Issue 2, (available on the Web at: and is also reprinted in Volume 3, Supplemental Information, of this report). Involvement in Rural Roundtable and Other Conferences Regarding Rural Health Wellness & Prevention Program staff engaged in numerous forums related to the provision of health services in rural Christopher Kelsch, W&PP Project Director, addresses the Rural Health Roundtable in California. Staff routinely attended the quarterly Northern California Rural Health Roundtable to keep rural health care providers abreast of changes within the CMSP as well as to provide updates on Wellness & Prevention Program activities. Staff attended the annual conferences of the California State Rural Health Association as well as the Insured the Uninsured Project. 291

293 Grantee Feedback Regarding the W&PP Administration The Wellness & Prevention Program Administrative Team sought the constant feedback of grantees to improve the operations of the overall initiative. W&PP staff was available to hear feedback and problem solve with grantees on a daily basis. Grantees were provided with a formal venue to provide feedback to the W&PP through a survey contained in the annual reporting forms. Cycle 3 grantees provided the Wellness & Prevention Program with their final feedback on their thoughts about the overall operations and achievements of their project in the form of a Project Capacities and Sustainability Survey. In addition to garnering grantee s feedback on the own project accomplishment, the W&PP sought to find out whether the technical assistance and support provided was through the initiative was helpful to the grantees, their clients, their project, their organization, and/or their community. The survey provided an opportunity to gauge whether the capacities of the grantees improved to in regard to being better able to collect, manage, and use data in order to respond the health needs of their community; and if grantees entire program or some of its components would continue when the Wellness and Prevention Program come to an end. The results of this survey have been incorporated into this report in the appropriate sections. The results of survey questions regarding overall operations are listed in the following table (on a scale of 1 to 5, 1 = strongly disagree and 5 = strongly agree). Survey Question N Mean Overall, the CMSP/ TCE Wellness & Prevention Program s expectations are clear. The amount of grant paperwork we were required to submit to W&P over the course of Cycle 3 was reasonable. Overall, we were able to staff our W&PP project adequately to meet our stated goals and objectives. Overall, we were able to staff our W&PP project appropriately to meet our stated goals and objectives. In looking back at what we were able to accomplish over the past three years, a different approach or strategy may have led to improved outcomes/results Additionally, grantees were provided with an opportunity to add additional written comments they had on any aspect of the project including, but not limited to, the granting process, project administration, the results achieved, or plans for future projects. Some of these comments follow: Positive Comments on Overall Grant Administration/ Support: Thank you very much for your understanding of the strengths and barriers of a rural county, and for quality technical support over the years. Thank you for your flexibility. It allowed us to be creative, strengthen community partnerships and gather data to work for change in our community. I am grateful for all of the support and encouragement I have received in this project. I know I would not have what it takes without all 292 of you giving me your best. I thank you. Creating the [final grantee] report gave me an opportunity to reflect on the project over its entire history, a process which I found very valuable. We have enjoyed the opportunity to work with you on this project. I have especially appreciated the high level of support that you and your staff have provided to us. It has been a pleasure to conduct the project with our partners here and to have participated in an effort which we know benefited many needy individuals in our community. The Madera County Diabetes Coordination grant would not have survived the first year without the support and encouragement from the CMSP and DRA staff. This has been a great grant for us, and the CMSP staff is among the easiest to work with of all the grants we have. The technical services we received have been extremely helpful. We are very thankful to the staff. The staff at DRA has also been beneficial to the success of the project. CMSP project administration and DRA have always been available to address staff s needs and concerns. Survey responses from staff of W&PP projects regarding overall grant operations 292

294 Constructive Feedback Comments: Fiscal still complains about number of papers they have to copy and the amount of time it takes. Redundancy of the reporting when it has already been submitted is a waste of our small resources. It is difficult to evaluate and give feedback on our project as we were unable to implement the program due to the difficulty of recruiting the necessary staff. We were disappointed in the low number of CMSP recipients involved with our program (although poor utilization of services has been a trademark of CMSP) Implementation Delays Related Comments: We had some trouble collecting and transmitting the core data due to our inferior technology. This has been resolved. Evaluation-Specific Comments: This beautiful Sonoma County valley is in CMSP s area of service. Initially we had some concerns about the support from Dennis Rose and Associates. This has been resolved with the involvement of Kelly Elder. She has been terrific to work with; she has provided great support. 293

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296 Phase I Report. Strategic Planning Report.. CMSP 101 (Introduction to CMSP)

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298 Phase I Report : S trategic Planning One of the principal goals of the Wellness and Prevention grant was to: Strengthen CMSP s organizational ability and capacity to become a proactive and community-responsive health system committed to improving health and well being of its client population. To this end, the CMSP Governing Board as conducted three strategic planning workshops and has implemented several initiatives as a result of the strategic directions that were established. Three strategic planning workshops that have involved multiple stakeholders in the CMSP were held during the grant period on December 1,2001; April 24, 2002; and December 3, Each of these workshops was conducted with a specific focus. At the first half-day workshop, the Governing Board confirmed its overall strategic plan priorities, its continuing focus on the needs of indigent adults, and its emphasis on improving the organization and delivery of care to CMSP clients. The second workshop was an all-day affair that was professionally facilitated, and multiple rural constituency groups including staff from rural health clinics, hospital provider groups, dental associations, and mental health programs participated and provided input. The third strategic planning workshop was also held for a full day. The specific focus was to refine CMSP s strategic directions given the deteriorated economic climate of the time, particularly to discuss in detail the specific target population that should be served by the program. The strategic planning process yielded eight general strategic objectives to help guide Governing Board decisions on policy. Following is a listing of these objectives along with the activities that the Governing Board has approved to move in those directions. Objective 1: Support infrastructure to promote access Solano County Pilot Project The CMSP Governing Board (Governing Board) and Solano County executed a pilot project agreement under which Solano County is providing comprehensive health coverage to Solano County CMSP clients. As of January 2004, approximately 4,000 CMSP clients were being served through the pilot project on a monthly basis. Under the terms of the agreement, which began February 1, 2002, the County is contracting with the county s organized health system, the Partnership HealthPlan of 297

299 CMSP/TCE WELLNESS & PREVENTION PROGRAM CMSP 101 THE COUNTY MEDICAL SERVICES PROGRAM (CMSP) was established in January 1983, when California law transferred responsibility for providing health care services to indigent adults from the State of California to California counties. This law recognized that many smaller, rural counties were not in the position to assume this new responsibility. As a result, the law also provided counties with a population of 300,000 or fewer with the option of contracting back with the California Department of Health Services (DHS) to provide health care services to indigent adults. DHS utilized the administrative infrastructure of Medi-Cal s fee-for-service program to establish and administer the CMSP program. In April of 1995, the CMSP Governing Board was established to oversee and direct the provision of health benefits coverage for uninsured, indigent adults in 34 primarily rural California counties. Under California law, the Governing Board is responsible for setting overall policy for the program, which includes defining participant eligibility requirements, setting the scope and type of benefits available, and setting payment levels and reimbursement rates for health care providers participating in the program. The CMSP Governing Board is composed of eleven members. Ten members are county representatives who are elected by the 34 participating CMSP counties. These representatives include three County Supervisors, three County Administrative Officers, two County Health Officials and two County Welfare Directors. One member is an ex-officio, nonvoting representative of the Secretary of the California Health and Human Services Agency. Additionally, the CMSP Governing Board has three standing committees: Planning & Benefits, Eligibility, and Executive. Representation of the Planning & Benefits and Eligibility committees is comprised of Governing Board members, county-agency representatives from CMSP counties, beneficiary advocates, and provider advocates. CMSP s reach extends over 90,000 square miles from Imperial County at the U.S.-Mexico border to Del Norte, Siskiyou, and Modoc Counties at the Oregon border. The 34 counties that participate in CMSP represent a California (PHC), to provide care to all Solano County clients who are eligible for CMSP without a share-of-cost obligation. The goal of the pilot project is to test the ability of an organized health care system that provides access to necessary primary and specialty care to costeffectively serve the needs of an indigent adult population. The Governing Board hired The Lewin Group to conduct an interim evaluation of the pilot project, and a report on the project was provided in December 2002 Objective 2: Utilize case management and education to address client needs Strategic Plan Demonstration Projects The Governing Board established and funded from CMSP funds the Strategic Plan Implementation (SPI) grant program. Approximately $4 million in grant funding was provided by the Governing Board to test county strategies on management of selected disease conditions and/or the development of case management and treatment of behavioral health needs. Two-year grants were awarded to nine 298 CMSP counties (Butte, Del Norte, Imperial, Marin, Mendocino, Modoc, Solano, Sonoma, and Tehama). The Lewin Group, which was hired by the Governing Board to evaluate the overall grant program, worked with each county grantee to develop sitesspecific evaluation plans and develop and implement data collection protocols. Frequent Users of Health Service Initiative (FUHSI) In June 2003, the Governing Board, in partnership with Sonoma County, was awarded a planning grant from The California Endowment and California HealthCare Foundation to gain a better understanding the issue of frequent and ineffectual use of emergency departments in Sonoma County and to develop a strategy to address the problem. The issue is being examined as a problem that reaches beyond the health care delivery system; therefore, the planning project has engaged representatives from hospitals, primary care clinics, social services, behavioral health, housing advocates, homeless advocates, criminal justice, and disability advocates to devise potential solutions. A detailed account of this project is presented in the Administration, Technical Assistance, and Publicity section of this report. Medical Case Management (MCM) Program Currently, the Governing Board supports a 1.0 FTE position with the California State Department of Health Service s Medical Case Management Program (MCM). MCM case managers are located throughout California 298

300 Phase I Report: Strategic Planning and review cases of Medi-Cal and CMSP beneficiaries to consider for case management. Individuals eligible for MCM services generally have complex, chronic, and/or catastrophic medical conditions. The MCM case manager assists in planning the discharge from an acute hospital to a home setting. The MCM typically approves home health care services and other related medical services. The MCM staff follow up with the beneficiary to ensure services are meeting their needs. Objective 3: Expand/enhance data collection capacity Pharmacy Benefit Manager (PBM) and Timely Access to Data In 2003, the Governing Board selected MedImpact as the PBM to administer CMSP s prescription drug program, and implementation occurred April 1, Under the agreement with MedImpact, Governing Board clinical staff have access to MedImpact s paid claims database, which is updated daily. This access has opened an important new portal into timely data about CMSP beneficiaries prescription drug utilization. This information is currently being utilized by a nurse case manager in the Governing Board s Administrative Office to identify likely candidates for federal Social Security Insurance and Disability programs and Medi-Cal disability. The strategy is being pursued to achieve two objectives: to assist clients in obtaining Medi-Cal and/or SSI disability and benefits when appropriate, and to assure that CMSP resources are dedicated to clients who are not otherwise eligible for Medi-Cal or other health programs. Additionally, through access to this data, the Governing Board is learning more about the health characteristics of the CMSP beneficiary population. Data Mart and Query System (DMQS) Obtaining access to CMSP eligibility, paid claims, and medical provider data has been a high strategic planning priority for the Board. Access to this type of information is essential to the Governing Board s understanding of the medical needs and conditions of the CMSP population and the care provided to CMSP clients. With the implementation of the Governing Board s DMQS and execution of an agreement with the State Department of diverse collection of mostly rural California counties. The following counties currently participate in CMSP: Alpine, Amador, Butte, Calaveras, Colusa, Del Norte, El Dorado, Glenn, Humboldt, Imperial, Inyo, Kings, Lake, Lassen, Madera, Marin, Mariposa, Mendocino, Modoc, Mono, Napa, Nevada, Plumas, San Benito, Shasta, Sierra, Siskiyou, Solano, Sonoma, Sutter, Tehama, Trinity, Tuolumne, and Yuba. CMSP acts as the medical safety net in these counties by providing services to approximately 115,000 unduplicated eligible individuals each year with average monthly enrollment of approximately 45,000. Slightly more than half of enrollees are white and one third are Hispanic. Enrollees are slightly more likely to be male than female. CMSP provides services to low-income uninsured adults ages 21 to 64 years old; beneficiaries over 50 years old make up about one quarter of the annual enrollment. W&PP client in the Mendocino project consults with the pharmacist at the Mendocino Community Health Clinic. CMSP has an annual budget of approximately $235 million derived from county contributions. The program covers most of the same benefits and offers a similar provider network as Medi-Cal (California s Medicaid Program), with the exception of pregnancyrelated services, long-term care services, and services provided by chiropractors, acupuncturists, licensed clinical social workers, and psychologists, and dental services and vision services. Like Medi- Cal, CMSP faces challenges assuring the availability of the full range of covered services due to the limited provider network available in the mainly rural counties serviced by the program. In calendar year 2002, services provided to CMSP enrollees generated approximately 1.77 million paid claims and $220 million in payments. Approximately half of these payments were for hospital inpatient services, for which enrollees had approximately 11,000 claims and 42,000 inpatient hospital days. 299

301 CMSP/TCE WELLNESS & PREVENTION PROGRAM Health Services for monthly data feeds, the Governing Board has timely access to CMSP data. In addition, the Governing Board has extended access to the DMQS to participating CMSP counties in confidential and nonconfidential data formats. Confidentiality of the data is assured through execution of appropriate county and employee confidentiality agreements. Eligibility Streamlining Efforts Efforts are currently underway to streamline CMSP eligibility processing through an automated eligibility determination system changes that will institute timelimited eligibility for CMSP (determined by aid code) and elimination of various client reporting requirements, including quarterly status reports (QSR), monthly income and family changes, and certain asset verifications. The system changes will take effect January 1, 2005, and changes are expected to reduce CMSP eligibility administration costs by approximately one-third. Objective 4: Maintain focus on indigent adults The primary purpose of the Governing Board s December 3, 2003 Strategic Planning Meeting was to provide a forum for the Governing Board and stakeholders to consider and discuss CMSP program priorities and longterm goals within the context of an increasingly constrained fiscal environment. Among the financial pressures facing CMSP is a $25 million structural budget problem that results from a continued loss of General Fund and Proposition 99 funding, in combination with declining Realignment revenue growth and increasing health care costs. Moreover, due to actions by the Governor and the Legislature, the continued viability of Vehicle License Fee (VLF) funding for CMSP has been uncertain. It was the consensus among Governing Board members and stakeholders at the meeting that there are three overarching program priorities for CMSP: The CMSP population is significantly affected by chronic physical illness. Mental illness and substance abuse are frequently co-occurring conditions. Further information about the County Medical Services Program and the CMSP Governing Board s activities can be located at the CMSP Governing Board s Web site at CMSP maximally assists participating CMSP counties in meeting their Welfare & Institution Code (WIC) Section responsibilities; The fiscal viability of CMSP is maintained; and, As much as possible, CMSP preserves benefit coverage for the most vulnerable populations. The Governing Board reflected upon these priorities as it considered proposals the following day, December 4, to reduce program eligibility and program benefits. Objective 5: Address the continuum of CMSP client needs In the current state budget environment, counties have not received expected funding from the state that was targeted to the CMSP program. The loss of revenue has created additional financial pressures for CMSP and the ability of CMSP to address the continuum of CMSP client needs has become increasingly 300 problematic. Because of fiscal constrains, the Governing Board was forced to make reductions in provider rates, reductions in the scope of benefits (including reductions in dental care, follow-up care for undocumented, eyeglasses) and reductions in eligibility (cap on eligibility at 200% of the federal poverty level (FPL)). The Governing Board has tried to limit such reductions as much as possible, but fiscal constraints have forced a variety of reductions. Objective 6: Assure fiscal integrity and stability Assuring the fiscal integrity and stability of the CMSP program has been a dominant theme for the Governing Board and its committees over during this reporting period. As discussed under Objective 5, a number of program changes have been driven by the need to bring spending down to match the level of available revenues. Some of the program changes that were adopted, such as the new PBM program, have resulting in significant savings without adversely affecting the level of patient care, scope of benefits, or access to health services. In the first year of the PBM contract, CMSP has experienced a savings of nearly $20 million below projected costs had CMSP maintained its association with Medi-Cal s prescription drug program. The Governing Board also directed the administrative staff to develop a request for proposals (RFP) for an alternative third party administrator for CMSP in lieu of the State Department of Health. An RFP was released in early 2004 and a process is underway for the Board to determine if a contract will be executed with an alternative vendor. 300

302 Phase I Report: Strategic Planning Objective 7: Support local community needs The primary purpose of the CMSP/TCE W&PP is to support local community needs in the area of wellness and prevention. These efforts are detailed under the Phase II section of this report (W&PP Grant Cycles 1, 2, and 3) and in the evaluation report from Dennis Rose Associates that is presented in Volume 2, Evaluation Findings, if this report. Non-emergency Medical Transportation Planning Grant and Frequent Users of Health Care Services Initiative Administrative staff of the W&PP, working in collaboration with organizations in Modoc, Lassen, and Plumas counties were successful in winning a planning grant award from Caltrans to develop a plan to increase capacities and access to non-emergency medical transportation (NEMT). Details of the NEMT project are presented in the Administration, Technical Assistance, and Publicity section of this report. Also successful were efforts by the W&PP staff in collaboration with Sonoma County organizations in winning an award from the California HealthCare Foundation and The California Endowment to plan an effort to address the problem of frequent and inappropriate use of emergency department services (FUSHI planning grant), which was previously noted under Objective 3. These efforts are also detailed in the Administration, Technical Assistance, and Publicity section of this report. Objective 8: Exercise leadership In the present economic environment, the Governing Board continues to seek ways to reduce spending that do not significantly impact the delivery of care to the core population that is the focus of this program. Because significant lead time is required for the implementation of any program change, the Governing Board has elected to be proactive to make the necessary changes in the program before the CMSP program experiences a fiscal crisis. As discussed under Objective 6, the Governing Board has initiated various efforts to find creative solutions to the ongoing and severe budget problems. By conducting its strategic planning meetings, including its most recent meeting on December 3, 2003, the Governing Board has continued to demonstrate leadership in promoting the long-term viability of CMSP for the clients served by CMSP and for the counties participating in the program. Evaluation of Phase I Efforts Lee Kemper, Administrative Officer for the CMSP Governing Board, leads attendees of the W&PP 2002 Technical Support Workshop in a discussion about HIPAA. The CMSP Governing Board (Governing Board) retained the services of an independent evaluation firm, Dennis Rose & Associates (DRA), to evaluate the Governing Board s efforts to accomplish the grant objective of Strengthening CMSP s organizational ability and capacity to become a proactive, and communityresponsive health system, committed to improving health and promoting the well-being of its client population, in addition to DRA s other evaluation work with the Wellness & Prevention Program (W&PP). The resulting evaluation report prepared by DRA entitled CMSP Strategic Direction Summary is reprinted in its entirety in Volume 2, Evaluation Findings, of this report. The report provides a detailed summary of the Governing Board s strategic planning efforts, historical and environmental context for the report, and an explanation of the study methodology. In summary, a Study Planning Group (comprised of CMSP Governing Board staff, W&PP administrative staff, and DRA) identified six major areas on which the evaluation efforts would focus, based upon objectives specified in the original Wellness & Prevention Program grant. These six areas include: Clearly-focused program direction; Focused program activities; CMSP impact on the safety net; Communication with stakeholders; Competent and satisfied staff; and Judicious financial management. DRA employed a two-pronged strategy to gather information based on the identified focus areas. The first strategy was a review of CMSP documentation such as CMSP Governing Board meeting minutes, results of strategic planning meetings, and material distribution lists. The second strategy was the surveying of CMSP stakeholders, 301