St. Joseph s Medical Center. Community Benefit 2015 Report and 2016 Plan

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1 Community Benefit 2015 Report and 2016 Plan

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3 TABLE OF CONTENTS Executive Summary Pages 3-4 Mission, Vision, and Values Page 5 Our Hospital and Our Commitment Pages 6-7 Description of the Community Served Pages 8-9 Community Benefit Planning Process Community Health Needs Assessment Process Page 10 CHNA Significant Health Needs Page 11 Community Benefit Plan Development Process Page 12 Planning for the Uninsured/Underinsured Patient Population Page Report and 2016 Plan Summary, Anticipated Impact and Planned Collaboration Pages Program Digests Pages Economic Value of Community Benefit Page 22 Appendices Appendix A: Community Board and Committee Rosters Pages Appendix B: Other Programs and Non-Quantifiable Benefits Pages

4 EXECUTIVE SUMMARY serves Stockton, California with a secondary service area of San Joaquin County. This community has great potential and also has great challenges. The community has strength in its diversity, agricultural heritage and geographic location. However, there are also great needs with nearly a quarter of the residents of Stockton (24.3%) living below the poverty line. There is a large immigrant population in the area with twenty-three percent of people who were born in another country and nearly forty percent who speak a language other than English at home. Primary languages include Spanish, Hmong, Khmer (Cambodian), and Vietnamese. In several of the low-income neighborhoods violence is a major concern, many residents do not have a safe and affordable housing, nearly a quarter of adults in San Joaquin County do not have a high school diploma, and the unemployment rate is over fourteen percent across the county. The disproportionate health needs of the Stockton area are perhaps best reflected in the Community Needs Index score. The Community Needs Index (CNI), developed in 2005 by Dignity Health, accounts for the underlying economic and structural barriers that affect overall health. Using a combination of research, literature, and experiential evidence, Dignity Health identified five prominent barriers for health care access: income, culture/language, education, insurance, and housing. A score of 1.0 indicates a zip code with the lowest socioeconomic barriers, while a score of 5.0 represents a zip code with the most socio-economic barriers. The median CNI score for the service area of is 4.8. The significant community health needs that form the basis of this report and plan were identified in the hospital s most recent Community Health Needs Assessment (CHNA), which is publicly available at Additional detail about identified needs, data collected, community input obtained, and prioritization methods used can be found in the CHNA report. The significant community health needs identified are: 1. Lack of access to primary and preventative care service 2. Lack of or limited access to health education 3. Lack of or limited access to dental care 4. Limited cultural competence in health and related systems 5. Limited or no nutrition literacy/access to healthy and nutritious foods, food security 6. Limited transportation options 7. Lack of safe and affordable places to be active In FY15, took numerous actions to help address identified needs. These included operating the following programs: CareVan Mobile Medical Services Program Diabetes Classes Chronic Disease Self-Management Program Interfaith Caregivers/ Community Senior Services Human Trafficking community awareness and education 3

5 For FY16, the hospital plans to continue the existing programs and add two new programs: Medical Home Linkage through the ED Navigator program Psychosocial Supports through the Frequent User Initiative The economic value of community benefit provided by in FY15 was $38,908,689, excluding unpaid costs of Medicare. With Medicare included, community benefit was $37,868,062. Details are in the Economic Value of Community Benefit section of this report. maintains its strong, mission-based commitment to caring for Medi-Cal enrollees and all members of the community. The hospital served 77,733 Medi-Cal patients in FY15, compared to 61,761 in FY14, a 15 percent increase. This report and plan is publicly available at The 2013 Community Health Needs Assessment executive summary and full report are available on this website as well as on a public website that is owned collectively by the local collaborative that conducts the Community Health Needs Assessment, Executive summaries of the Community Health Needs Assessment have been published and are distributed broadly to community groups and at public events. 4

6 MISSION, VISION AND VALUES Our Mission We are committed to furthering the healing ministry of Jesus. We dedicate our resources to: Delivering compassionate, high-quality, affordable health services; Serving and advocating for our sisters and brothers who are poor and disenfranchised; and Partnering with others in the community to improve the quality of life. Our Vision A vibrant, national health care system known for service, chosen for clinical excellence, standing in partnership with patients, employees, and physicians to improve the health of all communities served. Our Values Dignity Health is committed to providing high-quality, affordable healthcare to the communities we serve. Above all else we value: Dignity - Respecting the inherent value and worth of each person. Collaboration - Working together with people who support common values and vision to achieve shared goals. Justice - Advocating for social change and acting in ways that promote respect for all persons. Stewardship - Cultivating the resources entrusted to us to promote healing and wholeness. Excellence - Exceeding expectations through teamwork and innovation. Hello humankindness After more than a century of experience, we ve learned that modern medicine is more effective when it s delivered with compassion. Stress levels go down. People heal faster. They have more confidence in their health care professionals. We are successful because we know that the word care is what makes health care work. At Dignity Health, we unleash the healing power of humanity through the work we do every day, in the hospital and in the community. Hello humankindness tells people what we stand for: health care with humanity at its core. Through our common humanity as a healing tool, we can make a true difference, one person at a time. 5

7 OUR HOSPITAL AND OUR COMMITMENT is nationally recognized as a quality leader and consistently chosen as the most preferred hospital by local consumers. With 366 beds it is the largest hospital in Stockton, California and serves as a regional hospital specializing in cardiovascular care, comprehensive cancer services, and women and children s services, including neonatal intensive care. With more than 2,000 employees, St. Joseph s is also the largest private employer in Stockton. celebrates a history of 116 years of service to the community and is a part of Dignity Health, a not-for-profit network of hospitals and health services providing an extensive continuum of care throughout the western United States. Rooted in Dignity Health s mission, vision and values, is dedicated to delivering community benefit with the engagement of its management team, Community Board and Community Health & Advocacy Committee. The board and committee are composed of community members who provide stewardship and direction for the hospital as a community resource. The Community Health & Advocacy Committee is a committee of the Community Board and provides continuous input on the community benefit work of the hospital. This committee meets monthly to discuss community needs, revise strategies and programs to respond to changing needs, and monitor progress toward goals. The chair of the committee serves on the Community Board, which maintains oversight of the community benefit work. (Please see the appendices for a list of board and committee members.) Specific roles and responsibilities of the Community Health & Advocacy Committee include the following. Participate in Community Benefit planning and oversight, including setting of goals and priorities Evaluate and provide input for community benefit programs including program content, program design, program targeting, program continuation or termination, and program monitoring of outcomes. Review and approve the Annual Report for submission to the Community Board Review and approve the community benefit budget Review and approve the Community Needs Assessment and resulting priority setting process Support environmental concerns Serve as an advocate to address the issues that impact the health of our community Employees are also actively involved with community benefit activities including volunteering for numerous charitable organizations and events. Through St. Joseph s employee philanthropic organization, the Spirit Club, fundraising and volunteerism has assisted local organizations with donations of holiday meals, school supplies, holiday gifts, books and clothing. Community Benefit is linked to the hospital s overall planning process and is incorporated into the strategic plan. In addition the Director of Community Health meets regularly with the Executive Management Team regarding evolving needs, new initiatives and program outcomes. Community Benefit work is also incorporated in the hospital s quality improvement process, including an annual report to the Integrated Quality Committee. 6

8 s community benefit program includes financial assistance provided to those who are unable to pay the cost of their care, unreimbursed costs of Medicaid, subsidized health services that meet a community need, community health improvement services, health professions education and research. The hospital s community benefit also includes monetary grants provided to not-for-profit organizations that are working together to improve health on significant needs identified in our Community Health Needs Assessment. Many of these programs and initiatives are described in this report. The Dignity Health community grants program supports the continuum of care in the community by providing financial support to other not-for-profit organizations. This includes, for example, Community Medical Centers, Women s Center Youth and Family Services and Catholic Charities of the Diocese of Stockton. In addition St. Joseph s Medical Center Foundation is the largest donor for St. Mary s Dining Room, providing significant support each year for their free medical and dental clinics. In addition Dignity Health is investing in community capacity to improve health including by addressing the social determinants of health through Dignity Health s Community Investment Program. The Dignity Health Community Investment Program provides support to expand programs that impact health, including programs that address the social determinants of health. In Stockton the program provides support for two housing programs in low-income neighborhoods. Dignity Health provide a $250,000 predevelopment loan to Mutual Housing for the rehabilitation of housing for the Cambodian refugee community. The housing facility is operated by the Cambodian community through the Asian Pacific Self-Development and Residential Association (APSARA). This housing has been critical for Stockton in providing a place of safety and cultural identify for the Cambodian community. The Community Investment Program also provides a $500,000 loan to a community-based organization for the purchase and rehabilitation of foreclosed homes in high need neighborhoods. This work by the group called Stocktonians Taking Action to Neutralize Drugs (STAND) is eliminating the havens for drug activity while simultaneously providing houses to low and moderate income families. 7

9 DESCRIPTION OF THE COMMUNITY SERVED serves Stockton, with a secondary service area of San Joaquin County. A summary description of the community is below, and additional community facts and details can be found in the CHNA report online. This community has great potential and also has great challenges. There is a large immigrant population in the area with twenty-three percent of people who were born in another country and nearly forty percent who speak a language other than English at home. Primary languages include Spanish, Hmong, Khmer (Cambodian), and Vietnamese. Approximately fifteen percent of county residents are living on incomes below poverty level. These communities are generally isolated as the majority of low-income families live in county census tracts where more than half of the populations have incomes below 185% of the Federal Poverty Level (FPL). For San Joaquin County, these census tracts are located primarily in the Stockton area. In several of the low-income neighborhoods violence is a major concern, many residents do not have a safe and affordable place to be active, fresh fruits and vegetables are often not available and transportation is limited. Nearly a quarter of adults in San Joaquin County have not graduated from high school, and the unemployment rate is over fourteen percent. Statistics listed below reveal additional information about the community. Total Population 367,082 Hispanic of Latino Ethnicity (any race) 44.8% Race (non-hispanic) White 23.7% Black/ African American 9.5% American Indian & Alaska Native 0.5% Asian/ Pacific Islander 17.8% 2+ Races 3.5% Other 0.2% Median Income $44,735 Uninsured 12.5% Medicaid* 40.4% Unemployed 11.2% No High School Diploma 26.4% * Does not include individual s dually-eligible for Medicaid and Medicare. Source: 2015 The Nielsen Company, 2015 Truven Health Analytics, Inc. The disproportionate health needs of the Stockton area are perhaps best reflected in the Community Needs Index score. The Community Needs Index (CNI), developed in 2005 by Dignity Health, accounts for the underlying economic and structural barriers that affect overall health. Using a combination of research, literature, and experiential evidence, Dignity Health identified five prominent barriers for health care access: income, culture/language, education, insurance, and housing. A score of 1.0 indicates a zip code with the lowest socioeconomic barriers, while a score of 5.0 represents a zip code with the most socio-economic barriers. The median CNI score for the service area of is

10 Over the years, many not-for-profit organizations have developed to respond to the vast needs and serve the unique cultures of diverse communities. Partnership with these organizations is a key part of St. Joseph s strategic plan. Community based organizations are able to bridge cultural and linguistic gaps and have established trust and credibility with the communities they serve. Through partnership St. Joseph s is able to provide access to needed healthcare services and health education, along with professional expertise and support for agency capacity-building 9

11 COMMUNITY BENEFIT PLANNING PROCESS The hospital engages in multiple activities to conduct its community benefit and community health improvement planning process. These include, but are not limited to: conducting a Community Health Needs Assessment with community input at least every three years; using five core principles to guide planning and program decisions; measuring and tracking program indicators; and engaging the Community Health & Advocacy Committee and other stakeholders in the development and annual updating of the community benefit plan. Community Health Needs Assessment Process The Healthier Community Coalition is a strong coalition that jointly conducts the Community Health Needs Assessment every three years and then works together continuously to address the priority health needs identified in the assessment. The Coalition includes area hospitals, the county health department, and community partners. The community wide assessment process, which covers San Joaquin County, was most recently completed on May 31, 2013 and may be found on The assessment process was initiated and co-chaired by, St. Joseph s Behavioral Health Center, Dameron Hospital, Sutter Tracy Community Hospital and Kaiser Permanente, all of whom provided equal financial and in-kind support. First 5 of San Joaquin, Community Medical Centers, Health Plan of San Joaquin, Lodi Memorial Hospital and San Joaquin County Public Health provided additional financial and in-kind support. Many community based organizations within the county also participated in the assessment process. The Collaborative retained Valley Vision, Inc., to lead the assessment process. Valley Vision, Inc. is a nonprofit 501(c) (3) consulting firm serving a broad range of communities across Northern California. The organization s mission is to improve quality of life through delivery of high-quality research on important topics such as healthcare, economic development, and sustainable environmental practices. As the lead consultant, Valley Vision assembled a team of experts from multiple sectors to conduct the assessment, including a public health expert and a geographer as well as additional public health practitioners and consultants to collect and analyze data. A community-based participatory research orientation was used to conduct the assessment, which included both primary and secondary data. Primary data collection included input from more than 180 residents of San Joaquin County, expert interviews with 45 key informants, and focus group interviews with 137 community members. Members of the community representing different demographic groups were recruited to participate in the focus groups. A standard protocol was used for all focus groups to understand the lived experience of these community members as it relates to health disparities and chronic disease. In all, a total of eight focus groups were conducted. Content analysis was performed on focus group interview notes and/or transcripts to identify key themes and salient health issues affecting community residents. Further input was gathered at meetings of the Healthier Community Coalition and the annual Community Health Forum, held in November Secondary data included health outcome data, socio-demographic data, and behavioral and environmental data at the zip code or census tract level. Health outcome data included 10

12 Emergency Department visits, hospitalization, and mortality rates related to heart disease, diabetes, stroke, hypertension, chronic obstructive pulmonary disease, asthma, safety and mental health conditions. Sociodemographic data included race and ethnicity, poverty, vulnerable groups (female-headed households, families with children, people over 65 years of age), educational attainment, health insurance status, and housing arrangement. Behavioral and environmental data such as crime rates, access to parks, availability of healthy food, and leading causes of death helped describe the general living conditions. Analysis of both primary and secondary data revealed 10 specific Communities of Concern (defined by zip code boundaries) neighborhoods where residents are living with a high burden of disease in San Joaquin County. Age-adjusted rates of Emergency Department visits and hospitalizations for several chronic health conditions were analyzed. Visits due to heart disease, diabetes, stroke, and hypertension were consistently higher in the Communities of Concern compared to other zip codes in the health service area. These 10 communities had consistently high rates of negative health outcomes that frequently exceeded county, state, and Healthy People 2020 benchmarks. Analysis of environmental indicators showed that many of the Communities of Concern had conditions that were barriers to active lifestyles, such as elevated crime rates and a traffic climate unfriendly to bicyclists and pedestrians. Access to healthy food outlets was often limited, while the concentration of fast food and convenience stores was high. The identification of the Communities of Concern was confirmed by experts as areas prone to experiencing poorer health outcomes relative to other communities in the county. CHNA Significant Health Needs After identifying the areas of the county in greatest need for healthcare interventions, the next step was to identify specific needs to focus on. Priority health needs were determined through in depth analysis of qualitative and quantitative data, and then confirmed by socio-demographic data. A health need was defined as a poor health outcome and its associated driver. A health need was included as a priority if it was represented by rates exceeding established quantitative benchmarks or was consistently mentioned in the qualitative data. After examining key findings from all data sources, a consolidated list of priority health needs for the Communities of Concern in San Joaquin County emerged: 1. Lack of access to primary and preventative care service 2. Lack of or limited access to health education 3. Lack of or limited access to dental care 4. Limited cultural competence in health and related systems 5. Limited or no nutrition literacy/access to healthy and nutritious foods, food security 6. Limited transportation options 7. Lack of safe and affordable places to be active 11

13 Community Benefit Plan Development Process As a matter of Dignity Health policy, the hospital s community benefit programs are guided by five core principles. All of our initiatives relate to one or more of these principles: Disproportionate Unmet Health-Related Needs: Seek to address the needs of communities with disproportionate unmet health-related needs. Primary Prevention: Address the underlying causes of persistent health problems through health promotion, disease prevention, and health protection. Seamless Continuum of Care: Emphasize evidence-based approaches by establishing operational linkages between clinical services and community health improvement activities. Community Capacity: Target charitable resources to mobilize and build the capacity of existing community assets. Collaborative Governance: Engage diverse community stakeholders in the selection, design, implementation, and evaluation of program activities. After completing the community-wide needs assessment, priority setting process and asset mapping, each partner of the Healthier Community Coalition developed its own action plan to address various needs that were identified. Together these plans address all of the priority health needs established through the Community Health Needs Assessment process. Building on the steps described above, a facilitator from Valley Vision led a core group from St. Joseph s through a strategic planning process to develop the hospital s implementation plan. This process considered numerous factors including high utilization of acute healthcare services, the vast numbers of people in the target population, the cultural diversity and health disparity in the service area, and the hospital s areas of expertise. The findings from the asset assessment also informed an understanding of needs that could best be addressed by supporting community partners who have expertise in those areas. The hospital evaluated all current Community Benefit programs and their relation to the selected primary health needs. In many instances the structure was in place for existing programs to address the selected primary health needs. Where there was a newly identified need, new programs or practices were developed. Planning for the Uninsured/ Underinsured Patient Population In keeping with its mission, the hospital offers patient financial assistance (also called charity care) to those who have health care needs and are uninsured, underinsured, ineligible for a government program or otherwise unable to pay. The hospital strives to ensure that the financial capacity of people who need health care services does not prevent them from seeking or receiving care. The amount of financial assistance provided in FY15 is listed in the Economic Value of Community Benefit section of this report. Bi-lingual signage that addresses the hospital s Patient Payment Assistance Program is posted in key areas of the hospital facility. Payment Assistance information can be found at In FY 2015 the hospital spent over $31 million in providing care for underserved individuals (unreimbursed costs of providing care to Medicaid and uninsured populations). 12

14 2015 REPORT AND 2016 PLAN This section presents programs and initiatives that the hospital is either delivering, funding or on which it is collaborating with others to address significant community health needs. It includes both a report on activities for FY 2015 and planned programs with measurable objectives for FY Below are the community benefit and community health programs and initiatives operated or substantially supported by the hospital FY15, and those planned to be delivered in FY16. Programs that the hospital plans to deliver in 2016 are denoted by *. SUMMARY Access to Primary and Preventive Care Services - Financial assistance for uninsured/underinsured and low income residents*: The hospital provides discounted and free health care to qualified individuals, following Dignity Health s Financial Assistance Policy. - CareVan*: Mobile medical unit providing free medical care for the uninsured - Dobbins Program for Breast Health Services*: free breast cancer screening services for women under 40 years old - St. Mary s Dining Room - Virgil Gianelli Medical Clinic*: providing free medical services to the homeless, uninsured, migrant workers and other low-income populations - St. Joseph s Interfaith Caregiver Program*: providing friendly visiting, transportation and volunteer assistance to seniors to enable them to maintain independent living - Homecoming Project*: providing transitional care services and transportation to seniors and others with limited support - Special Needs Caregiver Program*: hospital based program to coordinate care and resources for patients with developmental disabilities or other special needs - Human Trafficking Initiative*: Implementation of screening process in hospital to identify victims of human trafficking; community education; and coordinating community volunteer efforts - Homeless Medical Respite Care Program* - interim shelter and services for homeless individuals recovering from an illness or injury Lack of or Limited Access to Health Education - Diabetes Education Program* community classes in English, Spanish, Hmong and Cambodian - COLD Club of San Joaquin County* - Pulmonary Rehabilitation - Stroke Club*- support group for patients who have experienced a stroke - Chronic Disease Self-Management Program* - workshops in English and Spanish - Faith Community Nurse Program*: outreach and health education in faith-based community groups Lack of or Limited Access to Dental Care - St. Mary s Dining Room - St. Raphael s Dental Clinic*: providing free dental services to the homeless, uninsured, migrant workers and other low-income populations 13

15 Limited Cultural Competence in Health and Related Systems - Culturally Competent Care*: Training for healthcare personnel regarding special populations in the service area - Community Health Connectors* - training local residents to provide healthcare navigation, health education, and community organizing for health promotion in the language, culture and context of their faith-based community or neighborhood Limited or no nutrition literacy/ access to healthy and nutritious foods, food security - Community Health Connectors* - training local residents to provide healthcare navigation, health education, and community organizing for health promotion in the language, culture and context of their faith-based community or neighborhood Limited transportation options - St. Joseph s Interfaith Caregiver Program*: providing friendly visiting, transportation, and volunteer assistance to seniors to enable them to maintain independent living - Homecoming Project*: providing transitional care services and transportation to seniors and others with limited support Lack of safe and affordable places to be active - Community Health Connectors* - training local residents to provide healthcare navigation, health education, and community organizing for health promotion in the language, culture and context of their faith-based community or neighborhood Community Grants Addressing Above Needs - Dignity Health Community Grants Program* o Catholic Charities of the Diocese of Stockton: Community Health Connector Program o Community Medical Center: After School Dental Care & Education Program o Women s Center Youth & Family Services: Human Trafficking Task Force New Initiatives for FY Emergency Department Patient Navigator Program: assist patients in establishing a medical home for primary care and preventive services* - Frequent User Initiative: intensive out-patient case management services to assist patients with complicated psycho-social needs* Anticipated Impact The anticipated impacts of specific program initiatives, including goals and objectives, are stated in the Program Digests on the following pages. Overall, the hospital anticipates that actions taken to address significant health needs will: improve health knowledge, behaviors, and status; increase access to care; and help create conditions that support good health. The hospital is committed to monitoring key initiatives to assess and improve impact. The Community Health & Advocacy Committee, hospital executive leadership, Community Board, and Dignity Health receive and review program updates. In addition, the hospital evaluates impact and sets priorities for its community benefit program by conducting a Community Health Needs Assessment every three years. 14

16 Planned Collaboration Healthier Community Coalition chairs the Healthier Community Coalition (HCC) and serves as the fiscal agent. HCC is a collaborative of the local hospitals, Medicaid managed care plans, county public health department, First Five of San Joaquin, and community based organizations. The group works together to implement programs that address the needs identified in the previous Community Health Needs Assessment. One of the initiatives developed through the Healthier Community Coalition is the Community Health Connector program. Community Health Connectors (CHCs) are outreach workers who are trusted members of and/or have an unusually close understanding of the community served. This trusting relationship enables CHCs to serve as a link between health/social services and the community to facilitate access to services. The CHCs focus on healthcare navigation and health education. Community Dental Task Force chairs this task force, which includes local hospitals, the dental society, University of the Pacific Dental Hygiene school, Community Medical Centers (the local Federally Qualified Health Center), and other community-based organizations. Homeless Medical Respite Care program The Gospel Center Rescue Mission has partnered with Community Medical Centers to create a respite program for homeless individuals in need of recuperation from an illness or injury. is a funder of this program and participates in the healthcare advisory group. Reinvent South Stockton Several partners have come together to focus on the needs of the underserved area of South Stockton. Coalition members include a city councilmember, Visionary Home Builders, Fathers & Families of San Joaquin, Community Partnership for Families, San Joaquin County Public Health, STAND, and. Responsiveness This community benefit plan specifies significant community health needs that the hospital plans to address in whole or in part, in ways consistent with its mission and capabilities. The hospital may amend the plan as circumstances warrant. For instance, changes in significant community health needs or in other community assets and resources directed to those needs may merit refocusing the hospital s limited resources to best serve the community. The following pages include Program Digests describing key programs and initiatives that address one or more significant health needs in the most recent CHNA report. 15

17 PROGRAM DIGESTS CareVan Mobile Medical Services Program Significant Health Needs Primary and preventive health care services Addressed Community Health Education Program Emphasis Disproportionate Unmet Health-Related Needs Primary Prevention Seamless Continuum of Care Collaborative Governance Program Description The CareVan is a mobile medical clinic offering free health services to the uninsured and underserved 2-4 times per week in various high need areas. Services include health screening, education and referral services, medical diagnosis and treatment. Planned Collaboration Patients are referred to primary care providers for ongoing care. Partners include Community Medical Centers and St. Mary s Medical Clinic. Community Benefit Category A2f, Community Health Improvement Services-Community Based Clinical Services-Mobile Unts FY 2015 Report Program Goal / Anticipated Impact Partner with Catholic Charities to provide patients assistance with the healthcare coverage application process. Link patients with a medical home for ongoing care with their assigned Primary Care Provider. Outreach to the remaining uninsured population who are not eligible for free or subsidized coverage options. Engage them in healthcare services. As more people become enrolled with healthcare coverage and are established with a medical home, provide flexible scheduling of Measurable Objective(s) with Indicator(s) Baseline / Needs Summary Intervention Actions for Achieving Goal Program Performance / Outcome Hospital s Contribution / Program Expense Program Goal / Anticipated Impact Measurable Objective(s) with Indicator(s) Baseline / Needs Summary Intervention Actions for Achieving Goal clinics to respond to the changing needs of the community 75% of patients provided with health navigation services. 75% of patients indicate that they are uninsured and do not qualify for subsidized or free coverage. Clinics provide services to an average of 25 patients per clinic day. The Health Access Coordinator began providing services on the CareVan in April % of patients indicated that they were uninsured and ineligible for the subsidized or free plans. Clinic volume decreased from 577 patients per month in January 2014 to 310 patients per month in June This led to a decrease in the average daily patient volume to 18 patients per clinic day in June Partner with Catholic Charities to continue funding the Health Access Coordinator. Conduct outreach at health fairs, flea markets, churches, and other locations where the remaining uninsured can be reached. Operate flexible scheduling of the clinic hours to ensure a minimum mean of 25 patients per clinic day. All patients were provided with access to health navigation services. The Health Access Coordinator provided services on the CareVan for one year. During this time patients were linked with application assistance and received helped with establishing a medical home. With Medi-Cal eligible patients transitioning to a medical home, the CareVan focused services on the remaining uninsured population with nearly all patients indicating that they were uninsured. Clinics provided services to an average of 29 patients per clinic day, with a total of 3,813 patients served. $570,707 total Program Expense, $462,387 in Community Benefit FY 2016 Plan Provide individual educational consultation for patients with diabetes or high blood pressure. 50% of patients with diabetes or high blood pressure will be offered individual educational consultation on-site. The community served by the hospital has very high rates of diabetes and high blood pressure. According to the UCLA Community Health Interview Survey 12.6% of adults have been diagnosed with type 2 diabetes, compared to the state average of 8.5%. High blood pressure is also very prevalent with a rate of 32.6% compared to the state average of 27.4%. The Licensed Vocational Nurse will provide initial education for patients with the identified chronic disease. The Registered Nurse/ Certified Diabetes Educator will provide individual consultation by referral and one day per week at the same location as the CareVan. 16

18 Community Health Education Significant Health Needs Cultural competence in health and related system Addressed Community Health Education Program Emphasis Disproportionate Unmet Health-Related Needs Primary Prevention Seamless Continuum of Care Collaborative Governance Program Description Health education workshops, presentations and classes are provided for free throughout the area in languages of the target population. The diabetes education program is a six part educational series taught by a team including an RN, Certified Diabetic Educator and bilingual health educators. The Chronic Disease Self-Management Program (CDSMP) is an evidence-based model developed at Stanford University. It is a six part workshop led by trained lay leaders from the community. In addition single presentations are provided to many groups as part of early intervention and prevention strategies. Planned Collaboration The workshops are co-led with community based organizations including Community Partnership for Family, Lao Family, Community Medical Centers and Catholic Charities. Presentations and classes are hosted by partner agencies including schools, faith-based groups, libraries and workplaces. Community Benefit Category A1a, Community Health Improvement Services-Community Health Education- Lectures/Workshops FY 2015 Report Program Goal / Anticipated Impact Health education programs will be expanded to offer services in more languages in order to reach populations with great health disparities. Measurable Objective(s) with Indicator(s) Baseline / Needs Summary Intervention Actions for Achieving Goal Program Performance / Outcome Hospital s Contribution / Program Expense Program Goal / Anticipated Impact Measurable Objective(s) with Indicator(s) Baseline / Needs Summary Intervention Actions for Achieving Goal The Diabetes Education class series will be initiated in the Cambodian language. The CDSMP program will be implemented in Hmong and Cambodian. Both the Diabetes Education class series and the CDSMP program will continue to be provided in both English and Spanish on an ongoing basis. The Hmong diabetes class has made a significant impact on program participants. There is a great demand for more of these classes as participants learn to manage their chronic disease and are empowered to take care of their health. Cambodian-speaking instructors will be recruited and the Certified Diabetes Educator will provide them with training. The CDSMP curriculum will be translated into Hmong. The Master Trainers will provide a training course for bilingual community members to become workshop leaders. The Diabetes Education class series was initiated in the Cambodian language and pilot tested. The CDSMP curriculum was translated into Hmong and bilingual community members were recruited to become workshop leaders. $550,423 total program expense, $543,966 in Community Benefit FY 2016 Plan The health education classes will be expanded to target the needs of the Cambodian and Hmong populations. Follow-up with participants from all health education classes will enhance health outcomes. The Diabetes Education program will be modified to meet the cultural and dietary needs of the population and will be translated into Khmer. The class will be taught on a regular basis in neighborhoods with a high density of Cambodians. The Hmong CDSMP workshops will be initiated and pilot tested in the Hmong community. Three month follow-up sessions will be held with program participants from the classes. Although the Asian population in general does not have high rates of diabetes, there are great disparities between various groups. The Hmong and Cambodian populations in particular have very high rates of diabetes. Reinforcement of information learned is critical to retention of information and behavior change. Translate Diabetes class materials into Khmer. Start Cambodian classes. Start Hmong CDSMP class and pilot test for cultural relevance. Conduct three-month follow-up sessions for program participants. 17

19 Dignity Health Community Grants Program Significant Health Needs Lack of access to primary and preventive care services Addressed Lack of or limited access to Community Health Education Lack of or limited access to dental care Program Emphasis Disproportionate Unmet Health-Related Needs Primary Prevention Seamless Continuum of Care Building community capacity Collaborative Governance Program Description Providing funding to support community based organizations who will provide services to underserved populations to improve the quality of life. The objective of the Community Grants Program is to award grants to organizations whose proposals respond to the priorities identified in the most recent Community Health Needs Assessment (CHNA) and are located in one of the 10 specific Communities of Concern (identified by zip code). Planned Collaboration Community Benefit Category Program Goal / Anticipated Impact Measurable Objective(s) with Indicator(s) Baseline / Needs Summary Intervention Actions for Achieving Goal Program Performance / Outcome Hospital s Contribution / Program Expense Program Goal / Anticipated Impact Measurable Objective(s) with Indicator(s) collaborates closely with all of the grantees that are selected through the Community grants program. E2a, Financial & In-Kind Contributions-Program Grants FY 2015 Report Provide funding for programs that align with strategies developed by the Community Health & Advocacy Committee and the community-wide efforts of the Healthier Community Coalition and align with needs identified in the most recent CHNA. Partnership grants in the following areas: Dental program in schools and after school programs Community Health Worker program Mental health In response to the identified priority health need of lack of access to dental care, the Community Dental Task Force was formed. First year priorities include creating a dental program in schools and after school programs. To respond to the priority health needs in the Communities of Concern, the Healthier Community Coalition developed plans for a Community Health Worker program. The Community Health & Advocacy Committee and through the most recent CHNA identified mental health as an ongoing need in the service area. In June 2014 local non-profit organizations received information regarding the start of the grant application process for The new process requires a partnership with two or more community based organizations that would leverage resources and address one or more of the prioritized needs (1) expanding dental care (2) implementing a Community Health Worker Program and, (3) expanding Mental Health Services. Six LOI s were received; the Local Review Committee invited three organizations to submit full proposals. Three Community Based Organizations were awarded grants totaling $208,548, Catholic Charities of the Diocese of Stockton, $75,000, health priority identified Community Health Worker Program (Access to Care) Community Medical Center, Inc., $70,860, health priority identified Dental Care (Access to Care) Women s Center Youth & Family Services, $62,688, health priority identified Mental Health Services (Access to Care and Health Education) $208,548 FY 2016 Plan Provide funding for programs that align with strategies developed by the Community Health & Advocacy Committee and the community wide efforts of the Healthier Community Coalition and align with the needs identified in the most recent CHNA. Funding will be provided to implement programs that support the following areas, Creation of a multi-faced, comprehensive approach to addressing the social determinants of health in a neighborhood with concentrated poverty Implementing or strengthening a Community Health Worker Project, 18

20 Baseline / Needs Summary Intervention Actions for Achieving Goal Increase access to Mental Health Services And align with the five core principals 1) focus on disproportionate unmet health related needs; 2) emphasize primary prevention/address underlying causes of health problems; 3)contribute to a seamless continuum of care, and 4) build community capacity; and 5) emphasize collaborative governance. San Joaquin County is a federally designated Medically Underserved area (MUA) with Stockton being home to almost half the county s residents. The 2013 CHNA revealed 10 specific Communities of Concern living with a high burden of disease. These 10 communities had consistently high area of negative health outcomes that frequently exceeded county, state and Healthy People 2020 benchmarks. We will continue to provide Dignity Health Community Grants to non-profit organizations that share are values, work to improve the health of the community and address prioritized needs as identified in the most recent CHNA. To fund three non-profit community organizations, in partnerships with three or more organizations totaling $186,955 St. Joseph s Interfaith Caregivers/Community Senior Services Significant Health Needs Lack of access to primary and preventive care services Addressed Lack of or limited access to Community Health Education Limited transportation options Program Emphasis Disproportionate Unmet Health-Related Needs Primary Prevention Seamless Continuum of Care Building community capacity Collaborative Governance Program Description St Joseph s Interfaith Caregivers program provides free services to seniors living at home. Services include transportation, friendly visiting, respite care, yard clean-up, home safety assessments and referrals which are provided by trained volunteers. This program recently expanded to include the Homecoming Project, which provides assistance to patients after hospital discharge. A social worker visits the home to assist with arranging for follow-up medical visits and medication as well as linking seniors with other assistance and social services. Volunteers provide free services. Planned Collaboration Homecoming Project is a partnership of St Joseph s Medical Center with Catholic Charities for a.5 FTE social worker; St Joseph s Interfaith Caregivers has a MOU with RSVP, Department of Aging San Joaquin County Community Benefit Category Program Goal / Anticipated Impact Measurable Objective(s) with Indicator(s) Baseline / Needs Summary Intervention Actions for Achieving Goal Program Performance / Outcome Hospital s Contribution / Program Expense E2a, Financial & In-Kind Donations-Program Grants FY 2015 Report Expand the Homecoming Project to provide services for 80 patients and provide on-going assistance through the Interfaith Caregivers program. 100 seniors to receive assistance through St Joseph s Interfaith Caregivers. 67 care receivers in the St Joseph s Interfaith Caregivers Program with 1,182 encounters. 32 patients in the Homecoming Project Provide funding to the partner agency, Catholic Charities, to conduct home visits and provide Homecoming Project services. Visited, assessed and assisted additional 43 care receivers for a total of 110 seniors assisted. Provided companionship for 6 patients through cancer treatments. Interviewed and oriented 5 volunteers who were matched with 8 care receivers. Assisted with transport of 3 Homecoming patients. 93 Homecoming Patients received home visits and follow up services for 4-6 weeks. $219,023 total program expense, $204,964 in Community Benefit 19

21 Program Goal / Anticipated Impact Measurable Objective(s) with Indicator(s) Baseline / Needs Summary Intervention Actions for Achieving Goal FY 2016 Plan Identify and train 5 new volunteers for the St Joseph s Interfaith Caregivers. Oversee expansion of Homecoming Project. Monitor work of partnering agency to ensure timely and quality delivery of services. 100 seniors to receive assistance through St Joseph s Interfaith Caregivers. 160 Homecoming Patients will be served. Readmissions among these patients will be monitored. Seniors face many health issues and social challenges as they age. Without additional support many are forced to move into assisted living and skilled nursing facilities prematurely. Support in the form of friendly visiting, transportation and assistance with light chores can allow seniors to remain in their homes and live independently. 64 current care receivers in St Joseph s Interfaith Caregivers. 24 volunteers providing average of 200 hours / month. Average of 20 pts/month receiving services from Homecoming project. Readmission rates indicate continued needs for this transitional care program. Provide additional outreach to reach a wider audience. Present 3 workshops at senior centers. Provide additional staff and language skills to meet Homecoming Project goals. Increase Homecoming Project staff to 1.5 FTE at Catholic charities with bilingual staff to assist with case management. Medical Home Linkage and Psychosocial Supports Significant Health Needs Lack of access to primary and preventive care services Addressed Lack of or limited access to Community Health Education Limited transportation options Program Emphasis Disproportionate Unmet Health-Related Needs Primary Prevention Seamless Continuum of Care Building community capacity Collaborative Governance Program Description Two new programs are starting this year which will focus on the needs of high utilizers of acute care services. The ED Navigator program will work with patients who present to the ED for primary care needs. The ED Navigator will identify barriers and link patients to their primary care provider for followup care and future care needs. The Frequent User Initiative will focus on patients with complex psycho social needs who present to the ED for more than 6 months in a six month period. These patients will receive intensive outpatient case management from social workers along with primary medical care, interim housing and behavioral health services. Planned Collaboration The ED Navigator is a partnership with Community Partnership for Families and Community Medical Centers. Community Partnership for Families will staff the ED Navigator position and place that person in the ED. The Frequent User Initiative is done in partnership with Community Medical Centers, the Health Plan of San Joaquin and Housing Solutions. Community Medical Centers will do the intensive case management, the Health Plan of San Joaquin will track the data, and Housing Solutions will provide interim housing for some of the program participants. Community Benefit Category A3g (Frequent User Initiative), Community Health Improvement Services-Health Care Support Services-Case Management post-discharge A3e (ED Navigator), Community Health Improvement Services-Health Care Support Services-Information & referral FY 2015 Report Program Goal / Anticipated Impact Stakeholders will gain an understanding of the barriers to primary care and methods for overcoming those barriers. Measurable Objective(s) with Indicator(s) Gain support for the programs through inclusion in the hospital s strategic plan, contracts with community partners and processes developed for referrals. Baseline / Needs Summary Over half of patients who present to the ED come with primary care diagnosis. These patients will be assisted through the ED Navigator program. Patients with complex psycho-social needs who frequently visit the ED are not receiving the ongoing care that the need. The Frequent User Initiative will respond to this need. 20

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