Area Served. Pueblo County. Priorities. Behavioral Health, including Acess to Care and Insurance

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Claud Maxwell
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Area Served Pueblo County Priorities Wellness Obesity and Diabetes Behavioral Health, including Acess to Care and Insurance Chronic Lung/ Respiratory and

1 Area Served Pueblo County Priorities Wellness Obesity and Diabetes Behavioral Health, including Acess to Care and Insurance Chronic Lung/ Respiratory and Related Cardiovascular Disease Community Health Implementation Plan (CHIP) FY Community Health Action Plan (CHAP) FY 2017 (CHIP) FY (CHAP) FY

2 Introduction The Patient Protection and Affordable Care Act, enacted March 23, 2010, added new requirements for nonprofit hospitals to maintain their tax-exempt status, including a require- St. Mary-Corwin Medical Center prioritized the top three of the top ten health indicators identified for Pueblo County. All three priorities: Wellness Obesity/Diabetes, Chronic chna Community Health Needs Assessment Every 3 Years Posted to and individual hospital websites. ment to conduct a Community Health Needs Lung/Respiratory Disease, and Behavioral Assessment (CHNA) once every three years Health have the potential, through collective to gauge the health needs of their communities and to develop strategies and implementation plans for addressing them. Additionally, following the CHNA a impact across community partnerships, to alleviate tremendous burdens and costs of health care and stimulate economic development throughout the county. chip Community Health Implementation Plan FY An overarching 3 year strategy to address prioritized needs identified by the CHNA with specific goals. Community Health Implementation Plan (CHIP), which defines specific goals on how the prioritized needs will be addressed, is required. A yearly Community Health Action Plan (CHAP) will provide the specific actions and metrics for each goal. chap FY 2017 Community Health Action Plan FY 2017 A one year plan with specific, measureable, achievable, relevant, and time bound (SMART) goals and actions with an evaluation design. The CHNA, CHIP, and CHAP were conducted in compliance with these new federal requirements and as an opportunity for St. Mary-Corwin Medical Center to fulfill our commitment to our organizational mission to extend the healing ministry of Christ by caring for those who are ill and chap FY 2018 Community Health Action Plan FY 2018 A one year plan with specific measureable, achievable, relevant, and time bound (SMART) goals and actions with an evaluation design. by nurturing the health of the people in our communities. chap FY 2019 Community Health Action Plan FY 2019 A one year plan with specific measureable, achievable, relevant, and time bound (SMART) goals and actions with an evaluation design. 2 ST. MARY-CORWIN MEDICAL CENTER/CENTURA HEALTH (CHIP) FY (CHAP) FY

3 Prioritized Need: Obesity/ Diabetes 1 Expand access to healthy food in zip code 81004, food desert/swamp, through existing programs. The USDA, Behavioral Risk Factor Surveillance System and National Center for Chronic Disease prevention data all attest to the fact that Pueblo s population consumes only a fraction of the daily portions of fruits and vegetables to maintain healthy BMI and blood sugar levels. Therefore, levels of obesity and diabetes in adults stays stubbornly high in comparison to state and national figures, and the rate of childhood obesity and pre-diabetes is increasing. The decision was made to address this priority by increasing access to healthy food in zip code 81004, a food desert. This strategy complements existing resources such as our comprehensive food bank, free school breakfast/lunch programs, free cooking classes, and SNAP/WIC availability. Our St. Mary-Corwin Farm Stand provides access to affordable produce as a public market and structured food prescription program to assist the 17% (three times the state percentage) of our residents who are low income, with low food access. A second decision was to address the emerging young childhood diabetes issue by expanding evidence-based programs in local elementary schools. Partners and Inputs: Colorado State Department of Agriculture, Pueblo County GIS, Southern Colorado Family Medicine Physicians and Residents, Integrated Community ACTIVITIES: Expand the number of clinical food prescription partners. ACTIVITIES: Implement EBT systems for SNAP/WIC incentives and apply for Double Bucks program for SNAP customers. ACTIVITIES: Screen and Recruit families through Southern Colorado Family Medicine Adverse Childhood Events screening for first-time implementation of family food prescriptions. METRICS: Expand the number of clinical food prescription partners from 2-4 in FY17. METRICS: Usage rates for SNAP/WIC and Double Bucks program. METRICS: Track biometric results of implementation of family food prescriptions in medical records. 18% 16% 14% 12% 10% 8% 6% 4% Percentage of individuals who are low income with low food access 17% 6.20% Health Partners (ACO), St. Mary-Corwin Health Foundation, CSU-P Extension Agency, Pueblo Triple Aim, Pueblo City-County Health Department, Care and Share Food Bank, Health Solutions, Innovage (ACO), Arkansas Valley Organic Growers, Valley Roots Food Hub, Colorado Health Neighborhood, LocalFood Pueblo, Neighborworks, Pueblo D60 City Schools, Milagro Church Garden 2% 0% St. Mary-Corwin Community Colorado 4 ST. MARY-CORWIN MEDICAL CENTER/CENTURA HEALTH (CHIP) FY (CHAP) FY

4 2 Work upstream to prevent diabetes through expansion of existing community programs. ACTIVITIES: Participate in one community activity for obesity/diabetes prevention in collaboration with the CSU-P Student Nurse Association. METRICS: Track number of consults at the community activity for obesity/ diabetes prevention in collaboration with the CSU-P Student Nurse Association. Prioritized Need: Chronic Lung/ Respiratory Disease ACTIVITIES: Initiate experiential education regarding healthy nutrition for children K-3 in two local elementary schools where prediabetes rates are increasing. ACTIVITIES: Initiate 2 evidence-based cohorts of the year-long Centers for Disease Control (CDC) Diabetes Prevention Program one Spanish-speaking only and one English speaking for pre-diabetic adults. 3 METRICS: Number of experiential education events at local elementary schools. METRICS: Program completion rates and improvements in BMI in medical records. Provide short- and long-term education in best organic gardening practices and food safety protocols for the emerging interest groups who are organizing neighborhood, agency, school and church community gardens. Colorado County Health Rankings reveal that Pueblo s physical environment has slipped from 9th to 41st among 56 ranked counties since 2010, an alarming negative health indicator. The Behavioral Risk Factor Surveillance System (BRFS) measures asthma as 3.7 higher than state average due to dust and pollutants from over a century of steel mill production. The decision was made to prioritize this health issue and to work toward greater community awareness of the pervasiveness of the issue, because 40% of preventable hospital visits (data source: Dartmouth Atlas of Healthcare 2012) involve respiratory ailments contributing to our unimproved mortality ranking (51st out of 56 ranked counties). Medicine, Los Pobres Migrant Ministry Clinic, Pueblo Fire Department DOTS Program (Directing Others to Service), Pueblo Police Department Code Enforcement, Pueblo City-County Health Department, Centura Medical-Legal Partnership ACTIVITIES: Host two community-wide workshops in safe/best gardening practices and written safety plan development for at least 6 groups interested or actively engaged in a community garden projects. METRICS: Number of community-wide workshops in safe/best gardening practices and development of written safety plan. Partners and Inputs: Grifols and Alpha-1 Genetics Laboratory at University of Florida, Our Lady of the Meadows Catholic Church, Neighborworks, St. Mary-Corwin Respiratory Services, Southern Colorado Family ACTIVITIES: Hand off this education program to LocalFood Pueblo to provide for future sustainability in community garden safety and education. METRICS: Successful transition of the program by ST. MARY-CORWIN MEDICAL CENTER/CENTURA HEALTH (CHIP) FY (CHAP) FY

5 1 Prioritized Need: Identify older adolescents and young adults at genetic risk of COPD. ACTIVITIES: Provide one health fair quarterly to test at-risk population for AAT deficiency. ACTIVITIES: Create public awareness campaign about AAT deficiency and availability of free testing and access to treatment paid for by most insurance, including Medicaid. Behavioral Health METRICS: Screen at least 150 persons and test at least 35 for AAT deficiency. METRICS: Awareness of AAT free testing. The decision was made to prioritize Behavioral Health because stressors such as high unemployment (5.6% compared to Colorado s 4%), high disability (16.3% compared to Colorado s 9.9%), living in households with income 200% below the federal poverty line 2 Church of Pueblo, Pueblo Community Health Clinic, CSU Health Promotion Department, Catholic Charities, Southern Colorado Family Medicine, St. Mary-Corwin Medical Records Department, St. Mary-Corwin Spiritual Care chaplains (40.2% per American Community Survey) and social isolation (20% BRFSS) all drive Increase healthy home hygiene for individuals at risk for lung disease. mental health hospitalizations to nearly double the Colorado rate (Colorado Health and Hospital Assn ). Extremely ACTIVITIES: Implement hospital alignment with DOTS to determine best strategies for implementation in FY18. METRICS: Implementation of strategies in limited hospital beds for in-patient treatment of mental health issues for Medicaid and addicted patients, as well as the limited number of therapists in Pueblo, exacerbate the need and demand creative strategies to begin to improve this health indicator over the next three years. Partners and Inputs: St. Mary-Corwin Mindfulness-Based Stress Reduction evidence-based program (Jon Kabat-Zin), St. Mary-Corwin Loss and Bereavement program (Alan Wolfelt Center for Loss and Transition Model), First United Methodist 8 S T. MARY- COR WIN MEDIC AL C ENT ER/C ENT U RA H EALT H (CH I P ) F Y (CH A P ) F Y

6 1 Use programs developed in the past three-year CHNA cycle to continue supporting mental resilience in adults with compromised health issues and resultant anxiety and stress levels. 3 Offer Mental Health Certification Courses and continue Adverse Childhood Experiences (ACES) screening and training. ACTIVITIES: Provide 5 Mindful Me series. METRICS: Track numbers of sessions and health outcomes through statistical analysis. ACTIVITIES: Offer 4 Mental Health certification workshops through a Centura trainer or other contract trainer. METRICS: Number of Mental Health certification workshops held. ACTIVITIES: Provide 2 Bereavement Support workshop series. 2 METRICS: Track number of workshops and health outcomes through statistical analysis. Embed a chaplain with a high level of mental health training into the safety net clinic at Southern Colorado Family Medicine. ACTIVITIES: Continue Adverse Childhood Experiences (ACES) screening and training. METRICS: Continue to track the number of adult patients screened for ACES at Southern Colorado Family Medicine; embedded case manager; and the number who complete classes for which they are referred at Catholic Charities. ACTIVITIES: Schedule chaplain one afternoon per week for patient visits in exam rooms prior to doctor visits at Southern Colorado Family Medicine. METRICS: Track decrease in numbers of patients who leave before being seen and increase face-time for patient to discuss socio-economic concerns that doctors do not always have time to hear and make referrals to services when appropriate; track outcomes in patient charting and referrals. 10 ST. MARY-CORWIN MEDICAL CENTER/CENTURA HEALTH (CHIP) FY (CHAP) FY

7 Population Demographics in St. Mary-Corwin Medical Center s Service Area Race St. Mary-Corwin Service Area Associate s Degree or Higher 30.5% 44.7% High School Graduation Rate Ethnicity n White 82.85% n Black 2.67% n Asian.70% n Native American/Alaska Native 1.87% n Other 11.91% St. Mary-Corwin Service Area 71.4% 77.6% Non-Hispanic Hispanic 63.16% 36.84% 0% 20% 40% 60% 80% 100% Limited English Proficiency 4.5% St. Mary-Corwin Service Area 6.7% Unemployment Rate 5.6% St. Mary-Corwin Service Area 4.0% Households Below 200% of Federal Poverty Level 40.2% St. Mary-Corwin Service Area 29.6% 12 ST. MARY-CORWIN MEDICAL CENTER/CENTURA HEALTH (CHIP) FY (CHAP) FY

The Socio-Ecological Model that Informs Our s To achieve long-term health outcomes among our communities, changes at every level of the model will both support people making the healthy choices and

Public Policy Community Cultural values, norms Organizational Environment, ethos Interpersonal Social network Urgent Care Hartsel US-24 Other Park Fremont Howard Coaldale Legend Stark Service Area

NHC GF ST 9 Cotopaxi 24 50 Westcliffe Pike National Forest Guffey Jefferson CO-9 Silver Cliff Lake George Florissant STM Hospital Divide GF Douglas Westcreek ST 67 Teller GF Cripple Creek Victor

8 The Socio-Ecological Model that Informs Our s To achieve long-term health outcomes among our communities, changes at every level of the model will both support people making the healthy choices and removing the barriers to making the healthy choices. Public Policy Community Cultural values, norms Organizational Environment, ethos Interpersonal Social network Urgent Care Hartsel US-24 Other Park Fremont Howard Coaldale Legend Stark Service Area Centura Facilities v Hospital "? NHC GF ST 9 Cotopaxi Westcliffe Pike National Forest Guffey Jefferson CO-9 Silver Cliff Lake George Florissant STM Hospital Divide GF Douglas Westcreek ST 67 Teller GF Cripple Creek Victor Perry Park ST 105 ST v "? 115 Penrose GF Williamsburg Florence Rockvale ST ST 120 Coal 67 Creek ST 96 C O-67 ST 86 Larkspur ST 83 Elbert Elbert Service Area Facilities Map Palmer Lake Monument GF Woodmoor Gleneagle "? ST 217 Woodland Peyton Black Park Forest 24 St Francis Green Mountain Falls v Cascade Penr ose GF ST 21 El Paso Manitou "? Springs "? Cimarron ST 94 Hills v "? Stratmoor Fort Carson GF 85 Wetmore CO-115 CO- CO-115 N Fort Carson 50 CO-96 St. Mary Corwin Stark ST N "? Fountain 25 Pueblo West CO-45 SMC Hospital v CO-94 CO-86 Calhan Yoder Pueblo Chemical Depot ST 47 Boone ST 233 Avondale Pueblo 50 Simla Ramah Rush Fowler Individual Knowledge, attitude, skills Crestone Custer ST 165 San Isabel National Forest Beulah CO-1 65 Colorado City ST 167 Saguache Rye ST 181 ST 69 Great Sand Dunes Nat'l Park & Prsrv CO-69 Gardner ST 10 Alamosa ST 150 Blanca Costilla 160 Huerfano ST 12 La Veta 85 Las Walsenburg Animas 350 US-350 Pinon Canyon Military Reservation 14 ST. MARY-CORWIN MEDICAL CENTER/CENTURA HEALTH (CHIP) FY (CHAP) FY

9 St. Mary-Corwin Medical Center 1008 Minnequa Avenue Pueblo, CO ST. MARY-CORWIN MEDICAL CENTER/CENTURA HEALTH

Area Served. El Paso County. Priorities. Obesity Intentional Injury Access to Care. Community Health Implementation Plan (CHIP) FY

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