Harnett Health Community Needs Assessment Implementation Plan January 2014

Introduction Harnett Health Community Needs Assessment Implementation Plan January 2014 In accordance with the Affordable Care Act, not-for-profit hospitals are required to develop Community Health Needs Assessments (CHNA) and associated Implementation Plans. In 2013, Harnett Health collaborated with First Choice Community Health Centers (FCCHC), the Harnett County Public Health Department (HCPHD), and Campbell University to create its first required CHNA. The Harnett Health Board approved the CHNA on September 10, 2013 prior to the end of its 2013 Fiscal Year. The CHNA was updated in December of 2013, based on new information received in the fall. This can be viewed on the Harnett Health website at http://myharnetthealth.org/community-needs/. This collaboratively developed CHNA is essentially the same as the CHNA submitted by the Harnett County Public Health Department to the North Carolina Public Health Department and it is the CHNA that is driving the HCPHD s own implementation plan. The Affordable Care Act (ACA) also requires not-for-profit hospitals to develop an Implementation Plan indication how they intend to address the identified needs. The following profile summarizes Harnett Health s Plan for FY 2014. In 2014, the resources available to fund new program initiatives will be greatly constrained by available finances. Fortunately, Harnett Health will also be able to continue and expand on several existing programs that have already been addressing the identified challenges. Without considering steps to reduce the financial barrier to care (such as the write off of unpaid bills) or the continuing uncompensated cast and cash flow challenges of opening a new hospital site in FY 2013, the following community programs reflect investments of operating resources in excess of $4.7 million. Community Responsibilities Versus Hospital Responsibilities Harnett Health is greatly concerned about the health status of the population it serves. This concern goes far beyond its role in providing health care services. Nonetheless, as cited on page four of the CHNA, From community need and health improvement perspectives, it is critical to note that neither the Harnett Health System nor any other organization alone can fully address the many social determinants of health or health behaviors that affect health status. However, multiple, diverse community organizations can work together to address some of these issues. Harnett Health will be a collaborating partner within the availability of its resources. In addition, the CHNA states, Furthermore, it is neither right nor possible for Harnett Health or any other organization to take on the significant challenges of delivering all needed services unilaterally. Many of the issues are profound community issues, not just Harnett Health issues, and they require community strategies and community responsibility. Harnett Health is committed to working with other community partners to address such needs. Harnett Health Community Health Needs Assessment Implementation Plan January 2014 1

Giving the instability of current reimbursement and its existing commitments to its fundamental priorities, Harnett Health is challenged in addressing its continuous responsibilities for providing access to high quality health care services. It cannot address all of the community health issues identified in the CHNA within its current economic capacity. The following discussion addresses the hospital CHNA related priorities for 2014. Predominant Clinical Health Status Concerns The CHNA identified many issues related to health status that should be considered for some form of intervention. The following indicate those areas of most immediate clinical health status concerns as well as concerns associated with access to physicians and other providers. Each identified need is followed by Harnett Health s primary strategies to address these needs. In all cases, especially in areas where community health issues are not Harnett Health s primary responsibility, Harnett Health is committed to being an active partner and engaging in discussions with other community organizations and individuals to develop shared intervention strategies. In order to recruit and retain physician providers, Harnett Health employs physicians. Medical home strategies, integrated care, quality initiatives, and practice-based strategies to address many of the individual community health issues are components of the practices on-gong operations and the cost included in each individual practice s budget. The cost of addressing just the CHNA-related needs cannot be easily segregated. Due to the significant number of patients insured by Medicare and Medicaid, as well as patients without insurance, overall practice operations, including the CHNA-related services are subsidized in most hospital practices. The operating cost subsidies are identified below. In addition, Harnett Health also compensates some private practicing physicians for essential services to the hospital and the community, such as call coverage. Subsidies for several services for 2014 are anticipated to be approximately equal to the hospital s experience in FY 2013. FY 2013 figures are used in most of the following estimates. Identified Need: Oral Health (Oral health care for children is a particular concern as reflected by the Department of Public Health and First Choice.) Harnett Health will collaborate with its CHNA partners to develop strategies to work with Eastern Carolina University as it establishes a Lillington site for its Dental Residency. Discussions will include the development of strategies to integrate the needs of primary medical care and behavioral health patients seen in Harnett Health s primary care practices and by FCCHC with the services provided by residents and faculty. There will also be an assessment of how the new residency program can be integrated with caring for patients, who present in the hospital s two emergency rooms with oral health problems. Harnett Health Community Health Needs Assessment Implementation Plan January 2014 2

Harnett Health will continue its commitment to developing its primary care practices as Health Homes. It will work with its providers to the improve integration of oral health with primary medical care. Harnett Health will also continue to pursue options for providing children with dental sealants in its primary care practices. Discussions with the Harnett County School System about oral health will occur in conjunction with the ECU discussions. Identified Need: Conditions related to Mental Health and Substance Abuse (including concerns about the illegal use of prescription drugs) Health Home Model Development: Harnett Health will continue its commitment to developing its primary care practices as Health Homes. It will work with its providers to improve integration of behavioral health with primary medical care. Telepsychiatry Services: There are no full-time psychiatrists in Harnett County. Harnett County has limited behavioral health services, resulting in many patients seeking behavioral health services in the Emergency Departments. Harnett Health provides telepsychiatry services to patients in the Emergency Departments and on the inpatient units, particularly in cases where involuntary commitment may be involved and patients may need to be accommodated in medical-surgical beds waiting placement. Expansion of telehealth to address the needs of primary care patients on an outpatient basis will be further considered. Estimated investment: The telepsychiatry service is subsidized by Harnett Health in the amount of approximately $215,000-$300,000 in FY 13. Most of the patients do not have coverage that reimburses for this service. Inpatient Behavioral Health Patients and Safety Sitters During FY13, Harnett Health s Betsy Johnson hospital site averaged 4.5 inpatients per day with primary mental health diagnoses. Some behavioral health admissions have medical comorbidities requiring stabilization, but most are IVC status (involuntary commitment) awaiting placement in a mental health facility. The patient placement is randomly contingent on the bed space available the County s assigned inpatient facility. The prolonged length of stay is largely a function of this process, complicated by a statewide paucity of acute care mental health beds and underdeveloped access to outpatient treatment. The care of mental health patients is uniquely challenging for a community hospital with limited psychiatric resources. The preponderance of IVC patients requires that nearly every patient to have a 1:1 Protective Safety Sitter. This translates to an average of 28 hours of care per patient per day, compared to an average medical surgical patient daily requirement of 9 hours. Mainstreaming mental health patients with the medical surgical population is standard practice in the region. Considering potential for patient elopement, general disruption, staff injury and other risk related events, BJ places mental health patients in one of 6 safe rooms on the third Harnett Health Community Health Needs Assessment Implementation Plan January 2014 3

floor medical unit. These rooms were retrofitted to remove many of the potentially dangerous objects in the environment, which could be used to injure the patient or care provider. These beds are not licensed as a psychiatric unit; the unit is not staffed with mental health workers; and, it does not meet the physical requirements of a psychiatric facility. In FY 2013, wage expenditures for Protective Safety Sitters exceeded $500,000 for the IVC population. Associated labor costs of $140,000 included on orientation training and benefits. In FY 2014 Harnett Health anticipates continuing to make this uncompensated investment of $640,000. Chronic pain management and use of controlled substances has been identified as a major issue by Harnett Health System primary care providers. They will be participating in a 3-hour seminar, "A Guide to Rational Opoid Prescribing for Chronic Pain" as a springboard for standardizing the systems approach to chronic pain management. The seminar is a part of the Lazarus Project, a project of Community Care of the Sandhills, and is funded by the Governor's Council. Identified Need: Diabetes (Early diagnosis and treatment are concerns across all age and racial groups with particular concerns in African American populations.) Our Primary care practices coordinate improvement for diabetes patient outcomes with SR- AHEC, which benchmarks our practices with other like practices. There is a need for diabetes education classes for patients in the County. Due to a lack of community resources, Harnett Health Physician Practices are currently trying to establish diabetes classes taught by Certified Diabetes Educators through two pharmaceutical companies in the eastern and western part of the County. Identified Need: Obesity (Increases in childhood obesity are of particular concern from a prevention perspective. In 2009 over 34% of the children in Harnett County were considered overweight or obese.) In October, 2013, Premiere Pediatrics started a pediatric obesity program entitled "Kick Start Today". This program is now conducted twice monthly with children who have elevated BMIs. Specially trained nurses and a case manager from Community Care of the Sandhills assist with patient/family education and goal setting after the physician visit. Classes have been coordinated with the Harnett County Cooperative Extension Agency and their EFNEP (Expanded Food and Nutrition Education Program). A series of six EFNEP classes are taught by their instructors in the Rehab Department at Betsy Johnson Hospital. Separate classes are provided for parents/ caregivers and children. Referrals to these classes are made from Kick Start Today participants. Harnett Health will continue this program in 2014. The Kick Start Today team continues to discuss other community led initiatives to include a possible "summer camp" for children with elevated BMIs and expansion to the Western Harnett County area. Harnett Health Community Health Needs Assessment Implementation Plan January 2014 4

Identified Need: Breast Cancer (Of all the cancers, breast cancer was the second most commonly diagnosed in Harnett County during 2006-2010.) Harnett Health physician practices will begin in January 2014 to print periodic reports to identify and call patients who are past due for recommended mammograms. In FY 2014, Harnett Health will engage its provider staff in evaluating options to develop a more substantive, integrated breast health program. Identified Need: Prenatal and perinatal needs (For minority mothers the percentages of low and very low birth weights are approximately twice the rate among white mothers or mothers overall in Harnett County and statewide.) The Harnett OB/GYN practice has been a Pregnancy Medical Home since early 2011 and coordinates with Community Care of the Sandhills and Care Managers from Harnett County Health Department to reduce preterm deliveries and primary cesareans in the Medicaid population. When high risk patients are identified (chronic disease, tobacco use, etc) they are linked with a Care Manager to work individually with the patient to reduce preterm delivery and cesarean deliveries. Community Care of the Sandhills certifies Pregnancy Medical Homes, provides special funding for the program, and trends results on a quarterly basis. Harnett Health will continue this program in 2014. (See the following discussion related to the cost of supporting this practice.) Identified Need: Hypertension and other cardiovascular disease (particularly in black males) Significant quality improvement efforts focus on cardiovascular disease in Harnett Health Primary Care practices. Benchmarking and education efforts are conducted in collaboration with Carolinas Center for Medical Excellence. Monthly Quality meetings are held to discuss patient outcomes for blood pressure control, aspirin use, LDL control and tobacco cessation assessment and counseling in patients with a diagnosis of ischemic vascular disease. Resources are utilized from the NC Prevention Partners for patient education and the NC Quitline for tobacco cessation counseling and follow-up. Educational materials were provided to patients during February--Heart Health Month and May--Stroke Awareness Month. These initiatives will be continued in 2014. Identified Need: Asthma and other respiratory disease (with particular attention to pediatric asthma and to chronic lower respiratory disease) Harnett Health Community Health Needs Assessment Implementation Plan January 2014 5

In the spring 2012, Premiere Pediatrics initiated a Pediatric Asthma Clinic which continues to be conducted twice monthly with specially trained providers and staff assessing and educating patients/families about asthma control. These efforts are coordinated with Community Care of the Sandhills, which provides a case manager who participates in teaching and makes home and school visits for enrolled patients. Quality data is submitted to SR-AHEC for comparison of patient outcomes to surrounding physician practices with results being reviewed monthly. This program will be continued in 2014. Identified Need: The challenges of patients with compounding chronic diseases (and the need for multiple disease, management strategies) Harnett Health System is committed to a Patient Centered Medical Home (PCMH) strategy for its primary care practices. PCMH standards, which focus on patient access to care, patient education and involvement in management of their diseases, care management for chronic diseases, and preventive health care, serves as the foundation for how our practices manage patient care and services. In 2012, Angier Medical Services, Premiere Pediatrics, Lillington Medical Services, and Dunn Medical Services each received Level 3 Recognition from NCQA for Patient Centered Medical Home. In the fall of 2013, Harnett OB/GYN also received Level 3 Recognition. Implementation of PCMH standards in all Harnett Health physician practices is a priority. In 2014, Harnett Health will apply for recognition for its newest practice, Coats Medical Services. Identified Need: Reducing preventable admissions and readmissions (highly related to primary care access) Identified Need: Access to Services and Associated Provider Access Issues All of the partners that participated in the CHNA concur that access to appropriate health services is critical to community health. Nonetheless, there are many reasons why people in Harnett Health s service area may experience access barriers. Some of the significant reasons are believed to include low health literacy, insufficient awareness of available health services, cultural and racial barriers, language barriers, high health care costs, and other financial barriers, and an absence of adequate transportation. Not only are these parameters access issues, but they are also contributing causes to poor health status. There is also concurrence that these are community issues, not just hospital issues. Better strategies to address these concerns need to be developed through greater multiorganizational collaboration. They will be more thoroughly addressed in future discussions during 2014. Access to Physicians and Other Providers Harnett Health Community Health Needs Assessment Implementation Plan January 2014 6

All partners participating in the CHNA cited a lack of local medical, oral health, and mental health providers and the need to promote recruitment and retention as significant community issues. Further discussion of this topic is found in Appendix E on the CHNA. Assisting the community with access to primary care and specialty care providers is the most significant area of Harnett Health investment in community health strategies. Primary Care The need for additional primary care providers was most frequently cited in the CNHA work group s discussions and reference data. Even while recognizing the broad factors that determine a community s health, appropriate primary care is seen as the core of community health. It is the primary building block. The determination of insufficient access to primary care is most often based on clinical experience and the perceived demand for services. It is also based on the participating partners experience with the difficulties of recruiting and retaining providers. Beyond these observations, the needs are also supported by data and discussion included in the CHNA. Dunn Medical Services: Established to meet the increasing demand for Primary Care Services in the Dunn/Erwin area, this practice has 2 physicians and one PA to provide care. The practice is a certified Patient Centered Medical Home. The practices offer a sliding fee schedule based on the Harnett Health s Charity Care program and is NHSC qualified for loan forgiveness for health professionals. Estimated investment: In FY 2013 the Practice was subsidized from the general revenues of Harnett Health in the amount of $250,000. This subsidy in expected to continue in 2014. Angier Medical Services: This practice was established to meet the increasing demand for Primary Care Services in the Dunn/Erwin area. This practice has 1 physician and two PA(s) to provide care. The practice is a certified Patient Centered Medical Home. The practice offers a sliding fee schedule based on Harnett Health s Charity Care program and is NHSC qualified for loan forgiveness for health professionals. Estimated investment: In FY 2013 the Practice was subsidized from the general revenues of Harnett Health in the amount of $250,000. This subsidy in expected to continue in 2014. Lillington Medical Services: This practice was established to meet the increasing demand for Primary Care Services in the Lillington area. This practice has 2 physician(s) and 1 PA(s) to provide care. The practice is a certified Patient Centered Medical Home. The practice offers a sliding fee schedule based on Harnett Health s Charity Care program and is NHSC qualified for loan forgiveness for health professionals. Estimated investment: In FY 2013 the Practice was subsidized from the general revenues of Harnett Health in the amount of $250,000. This subsidy in expected to continue in 2014. Harnett Health Community Health Needs Assessment Implementation Plan January 2014 7

Premier Pediatrics: This practice provides inpatient and outpatient care to the pediatric patients in Harnett County. The practice is open extended hours. The providers cover the labor and delivery suite for emergencies and C-Sections, the Emergency Department, and inpatient Unit. Estimated investment: The practice is subsidized by Harnett Health over $700,000 annually in 2013 as the Medicaid and charity care payer mix do not cover the cost of the program. This subsidy in expected to continue in 2014. Anderson Creek Medical Services: Harnett Health is working on a joint venture with Campbell University to establish and ambulatory care practice in Anderson Creek in the western region of the service area. It is anticipated that this will require planning time in 2014 and investment in capital and operations start-up in FY2015. Family Medicine Residency Program: During FY 2014, Harnett Health and Campbell University will jointly assess the feasibility of establishing a primary care residency at Harnett Health. It is believed that this will help to assure the adequacy of the primary care workforce in the service area, as well as to attract additional providers interested in faculty positions. Harnett OB/GYN: Harnett Health provides obstetrical and gynecologic services through the physician(s) of this practice. The practice is a Patient Centered Medical Home. The physician(s) provide coverage for the Harnett Health Emergency Department and the Labor and Delivery service at Harnett Health s Betsy Johnson Hospital site. Estimated investment: In FY 2013, the Practice was subsidized from the general revenues of Harnett Health in the amounted to $250,000. This subsidy in expected to continue in 2014. Obstetrical Call Services: Harnett Health provides 24/7 call coverage to the emergency departments and Labor and Delivery (BJH only) services at Betsy Johnson and Central Harnett Hospital (s). Estimated investment: The call coverage is subsidized by Harnett Health in FY 2013 at $150,000. This subsidy in expected to continue in 2014. Non-Primary Care Providers Harnett Health s research indicates shortages and challenges to meeting the communities needs in several non-primary medical care categories, consistent with the goals defined in Appendix E. The Harnett Health is committed to addressing these needs within available resources and through collaboration with other community providers and organizations, e.g., Campbell University. Harnett Health Community Health Needs Assessment Implementation Plan January 2014 8

Cardiology Services: Harnett Health in partnership with Wake Med has established a community cardiology practice to serve the needs of the residents of Harnett County. The community has high levels of CHF, Hypertension, and atherosclerotic cardiovascular disease. The clinic provides direct and consultative services to the inpatients of Harnett Health System, to the patients of the community and as a referral for primary care providers in the community. Estimated investment: It is estimated that in FY 2014, this practice will be subsidized from the general revenues of Harnett Health in the amount of $250,000. Harnett Health Hospitalist Program: The Harnett Health Hospitalist Program is a partnership, with WakeMed physicians. The program provides inpatient hospitalists for Betsy Johnson Hospital and Central Harnett Hospital. The program provides care for patients of over 20 outpatient-only providers as well as patients from the emergency department. Estimated investment: The mix of Medicare, Medicaid, and uninsured patients does not cover the cost of this program. The operating deficit is approximately $1,500,000 annually. This balanced by other operating funds. Surgical Call Services: Harnett Health provides 24/7 Call coverage to the emergency departments and inpatient services at Betsy Johnson and Central Harnett Hospital (s) through an agreement with its general surgeons. Estimated investment: The cost of obtaining call coverage is $225,000. Emergency Services: Harnett Health and Community Care of the Sandhills are piloting an Emergency Department Navigator Program. Together they have embedded a social worker in the Emergency Department at Betsy Johnson Hospital. The focus in on reducing inappropriate ED visits, educating patient on the importance of identifying and using a medical home, assisting patient with follow-up appointments, assisting patient in obtaining social services and other community resources, and referring patient to Care Management. (Depending on success and funding this program it may be extended to the Emergency Department at Central Hospital in Lillington.) Other Implementation Plan Strategies Assuring an Adequate Workforce: Harnett Health supports the education of a diverse mix of health professional students, such as nurses, physical therapists, and medical students. It has entered into arrangement with Campbell University to support numerous medical students associated with the University s new School of Osteopathic Medicine. This includes supporting the salary of several faculty members who practice part-time in Harnett Health Practices. The time of hospital staff associated with educating students is largely uncompensated and in some cases, such as time spent by practicing physician, leads to lost revenue. In other cases, lost productivity must be made up by hiring additional staff. This is part of Harnett Health s Harnett Health Community Health Needs Assessment Implementation Plan January 2014 9

educational investment, as a not-for-profit hospital. In FY 2014, Harnett Health will further assess and document its investments in these areas. Expanding Dialogue with the Harnett county School System: Harnett Health and the Harnett County Public Health Department plan to engage the Harnett County School Department in discussions to determine several community needs affecting children can be better addressed through collaboration. This will include such issues as oral health care, obesity, nutrition, and teen pregnancy. Health Harnett: Harnett Health will continue to support and participate in the Healthy Harnett Community Health Coalition and its efforts to address any of the identified community health needs. Conclusion This Implementation Plan reflects the anticipated strategies to address numerous significant clinical and health status challenges faced by the population served by the Harnett Health System and identified in its Community Health Needs Assessment. All strategies are subject to changes in action steps, investment, timing, and priority based on changes in needs, workforce, regulatory impacts, and financial capacity. This Plan will be reviewed throughout the fiscal year and updated by the end of September 2014. Harnett Health Community Health Needs Assessment Implementation Plan January 2014 10