Community Health Needs Assessment 2013 Oakwood Heritage Hospital Implementation Strategy

Community Health Needs Assessment 2013 Oakwood Heritage Hospital Implementation Strategy

Community Health Needs Assessment 2013 Oakwood Healthcare CHNA Implementation Strategy Community Health Needs Assessment Implementation Strategy Introduction The Patient Protection and Affordable Care Act (PPACA) require all tax- exempt hospitals to assess the health needs of their community through a Community Health Needs Assessment (CHNA) once every three years. A CHNA is a written document developed for a hospital that includes: a description of the community served by the hospital; the process used to conduct the assessment including how the hospital took into account input from community members including those with special knowledge of or expertise in public health; identification of any persons with whom the hospital has worked on the assessment; and the significant health needs identified through the assessment process. In addition, the CHNA document must include a description of the process and criteria used in prioritizing the identified significant health needs. A CHNA is considered conducted in the taxable year that the written report of its findings, as described above, is approved by the hospital governing body and made widely available to the public. Oakwood Healthcare completed a CHNA in the first half of 2013. The CHNA report has been finalized and will be presented to the Oakwood Healthcare governing bodies for approval in October 2013. In addition to identifying and prioritizing significant community health needs through the Community Health Needs Assessment (CHNA) process, PPACA requires creating and adopting an Implementation Strategy. An Implementation Strategy is a written plan addressing each of the significant community health needs identified through the CHNA and is a separate but related document to the CHNA report. The Implementation Strategy must include a list of the significant health needs the hospital plans to address and the rationale for not addressing the other significant health needs identified. The Implementation Strategy (a.k.a. Implementation Plan) is considered implemented on the date it is approved by the hospital s governing body. The CHNA Implementation Strategy is filed along with the organization s IRS Form 990, Schedule H and must be updated annually. The Oakwood Healthcare CHNA process identified significant health needs for the Oakwood Healthcare community (see box below). Significant health needs were identified as those where the qualitative data (interview and focus group feedback) and quantitative data (health indicators) converged. Oakwood Healthcare prioritized these significant community healthcare needs based on the following criteria with an underlying foundational purpose of serving vulnerable populations: Magnitude of the need the number of people impacted by the problem Severity of the need the risk of morbidity and mortality associated with the problem High Data / High Qualitative Access to Care Primary Care Prenatal Care Dental Care Uninsured/Cost Lifestyle/Prevention Obesity Activity Nutrition Tobacco Alcohol Drug Abuse Conditions/Diseases Heart/Cardiovascular Disease Hypertension Chronic Lower Respiratory Disease* Diabetes Mental Health Mental Health Maternal Health Infant Mortality Birth Outcomes Environment Air Quality Access to Healthy Food Transportation Violence Socioeconomic Poverty Unemployment Education * Includes COPD and Asthma 1

Community Health Needs Assessment 2013 Oakwood Healthcare CHNA Implementation Strategy Alignment of the problem with organizational strengths The organization has existing resources to address the problem (including dollars, ability to partner, organization infrastructure/leadership support, and organization capacity) Ability to measure change organization impact on the need can be monitored and measured Through the prioritization process, four significant needs were selected to be addressed via the Oakwood Healthcare CHNA Implementation Strategy: Heart/cardiovascular disease Diabetes Obesity Access to care All other significant health needs were not chosen for one or more of the following reasons: It was determined they are not as impactful in terms of magnitude or severity as those that were chosen They are not as aligned with organizational strengths There are not enough existing organizational resources to adequately address the need The ability to measure impact (change) would be difficult While each of the significant health needs identified through the community health needs assessment process is important, and many are currently addressed by existing programs and initiatives of Oakwood Healthcare or an Oakwood Partner Organization, allocating significant resources to the four priority needs above prevents the inclusion of all health needs in the Oakwood Healthcare CHNA Implementation Strategy. The implementation strategy for the chosen health needs of heart/cardiovascular disease, diabetes, obesity, and access to care is outlined in the following pages as a written Implementation Plan. 2

Access to Care Oakwood Heritage Hospital Initiative Strategy Activity Anticipated Impact of the Activity Performance Metrics Data Source Activity Increase access to care for the uninsured, underinsured or underserved Provide services through Oakwood School and Community based Child and Adolescent Health Centers and School Wellness Programs 1) Provide primary healthcare, mental health services, health promotion, disease prevention education and referral services Increased access to, and utilization of, primary care services to youth 1,600 youth to be provided primary care services MDCH-CRT * Oakwood Adams Child & Adolescent Health Center, Westland * Oakwood Inkster Teen Center * Oakwood Taylor Teen Center 2) Medicaid education and outreach activities in schools and the community Increased awareness of Medicaid eligibility a) 6,600 individuals provided with Medicaid information MDCH-CRT b) 265 individuals assisted with Medicaid applications MDCH-CRT Provide services through Oakwood Center for Exceptional Families for children with special needs Provide primary healthcare, social work, mental health, physical therapy and referral services to children with special needs Increased access and utilization of integrated care for children with special needs 4,500 unduplicated youth to be served annually MHA database December 2016 Provide services through the Oakwood Healthcare Center - Westland Clinic for Infectious Disease 1) Clinical services to out-wayne County residents with active/suspected tuberculosis Health care access for those with TB 100% of referrals evaluated within two weeks LTBI Stats December 2016 2) Medical care for HIV patients in the Detroit metropolitan area Access to care for those coping with HIV who do not have sufficient health care coverage or financial resources a) 207 patients served b) 697 units of service CAREWARE Database January 2014-3) Assistance with healthcare plan enrollment Increased patients enrolled in health plans 100% of uninsured individuals seeking treatment assessed and assisted with medical coverage options LTBI Stats Enhance access to primary care 1) Partnerships with: * Western Wayne FQHC's * Hope Clinic * Covenant Community Care * Faith-based outreach Enhance access to care for each hospital community a) Document developed with Identification of services available through these partnerships with communication plan for each hospital community CB Dept. plan December 2016 b) Semi-annual meetings of Community Benefit staff with these partnership entities. Minutes 3

Access to Care Oakwood Heritage Hospital Initiative Strategy Activity Anticipated Impact of the Activity Performance Metrics Data Source Activity Increase access to care for the uninsured, underinsured or underserved Enhance access to primary care 2) Explore addition of Community Health Workers Oakwood Foundation to provide financial support to each hospital for resources and support for the lowincome, underinsured, or uninsured Funding support for patients of each hospital in need of resources or other support Connect individuals with Primary Care Providers Enhance capacity for those in need to obtain the services and supports needed for health Two grant submissions for Community Health Workers a) Foundation Funding plan developed for Community Benefit at each hospital Foundation report 2014 Foundation Funding report June 2015 b) Community Benefit Activities listed in annual MHA Community Benefit report MHA Database Assist individuals with enrollment into Medicaid or other healthcare plans Medicaid and Health Plan enrollment for individuals 1) OakAssist Patients assisted to determine eligibility for coverage such as Medicaid, Charity Care, Victims of Crime and COBRA 1,200 individuals assisted with determining eligibility for coverage OakAssist CB reporting form 2) Utilize AmeriCorps HealthCorps members from the Michigan Primary Care Association to conduct health care plan education and outreach in Oakwood communities Increased enrollment in health care plans and increased number of individuals with a medical home a) Number of uninsured assisted with enrollment in health care plans b) Number of individuals connected with a medical home Health- Corps CB reporting form 3) Partnership with ACCESS for Health Care Navigator ACCESS Navigators to enhance capacity for uninsured enrollment at each hospital Strategy and plan developed on how to best utilize ACCESS Navigators MOU 4) Partnership with Western Wayne FQHC (Taylor & Inkster) FQHC Navigators to enhance capacity for uninsured enrollment at each hospital Strategy and plan developed on how to best utilize FQHC Navigators MOU 4

Access to Care Oakwood Heritage Hospital Initiative Strategy Activity Anticipated Impact of the Activity Performance Metrics Data Source Activity Assist individuals with enrollment into Medicaid or other healthcare plans Medicaid and Health Plan enrollment for individuals 5) Partner with Enroll America Increased awareness of Health Insurance Plan options in each hospital service area Five events planned with Enroll America for health care plan outreach CB Database 6) Partner with CMS as a "Champion for Coverage" Increased awareness of Health Insurance Plan options in each hospital service area Marketing campaign created to assist individuals with information on the Health Insurance Marketplace Plan Developed Increase awareness of health resources Increase community members' knowledge of the healthcare and safety net resources that are currently available in the community 1) Post Oakwood Healthcare Resource Guide on website Internal and external stakeholders in each hospital community will have information on available resources a) Resource Guide posted on Oakwood website and United Way website Website March 2014 b) Resource Guide shared through Oakwood Communications CB Database c) Resource Guide sent to The Information Center Electronic Communication 2) Obtain funding to create Healthy Communities Advisory Committee Collaboration and collective Impact on improving health in the each hospital community Two grant submissions for project funding Foundation report December 2016 5

Oakwood Heritage Hospital 6 Cardiovascular Disease Initiative Strategy Activity Anticipated Impact of the Activity Performance Metrics Data Source Activity a) Partnership agreements; event enrollment a) Target communities with high CNI scores Improved self-management and followup care by identifying and counseling individuals with elevated blood pressure and cholesterol levels 1) Oakwood Heart Health Screening Program Provide screening and education services Decrease cardiovascular disease risk factors (blood pressure, cholesterol, glucose, overweight, physical inactivity, smoking) b) Heart Health Screening database b) Baseline measurement of referrals for follow-up care c) Oakwood event participant survey c) Track 7 outcome and process evaluation measures for continuous improvement Oakwood event participant survey Track 7 outcome and process evaluation measures to improve comprehension 2) Oakwood Speakers Bureau Improved knowledge of heart disease prevention, treatment and selfmanagement December 2016 Medical Avatar reports 20% increase from 2013 baseline in Avatar awareness, acquisition, retention, engagement, and conversion Improved understanding of cardiovascular disease prevention, diagnosis and treatment options 3) Oakwood Medical Avatar personalized 3D representation of the user s body with downloadable health content Meeting records Conduct an exploratory meeting with American Heart Association Health Equity Lowered blood pressure levels of individuals over four months Explore collaboration with American Heart Association Heart 360: Get to the Goal hypertension initiative targeting the African American community with screenings, education, and follow-up Collaborate with local organizations to expand outreach of Oakwood cardiovascular programs

Oakwood Heritage Hospital Cardiovascular Disease Initiative Strategy Activity Anticipated Impact of the Activity Performance Metrics Data Source Activity Provide education and support services 1) Oakwood and The Senior Alliance Reduced re-admissions and improved a) Enrollment TSA CTI data (TSA) Care Transitions Intervention (CTI) self-management upon discharge systems program for Medicare patients with Congestive Heart Failure and Heart b) Primary Care Physician follow-up visit Attack (Acute MI) Reduce cardiovascular disease complications and sudden death from cardiac arrest c) Patient Activation Measure d) Re-admission rate Percent of individuals certified American Heart Association posttest and skills test 2) Oakwood Infant/Child CPR classes Increased knowledge and skills to resuscitate infants/children suffering sudden cardiac arrest 7

Oakwood Heritage Hospital 8 Diabetes Initiative Strategy Activity Anticipated Impact of the Activity Performance Metrics Data Source Activity December 2016 Develop and execute business plan Oakwood Strategic Plan Enhanced capacity to Improve treatment and self-management by identifying and treating individuals with pre-diabetes and diabetes 1) Explore implementing OHS Metabolic & Nutrition Disorders Program at Oakwood Annapolis Hospital Provide screening and education services Decrease rate of new diabetes cases and of diabetes complications through prevention, early detection, and education a) Event enrollment a) Develop six new community partners to increase participation from 2013 baseline by 500 Improved self-management and followup care by identifying and counseling individuals with elevated glucose levels 2) Oakwood Diabetes Screening Program b) Diabetes Screening database b) Baseline measurement of referrals for follow-up care c) Oakwood event participant survey c) Track 7 outcome and process evaluation measures for continuous improvement Oakwood event participant survey Track 7 outcome and process evaluation measures to improve comprehension Improved knowledge of diabetes risk factors and prevention strategies 3) Oakwood Diabetes Prevention Workshops Oakwood event participant survey Track 7 outcome and process evaluation measures to improve comprehension 4) Oakwood Speakers Bureau Improved knowledge of diabetes treatment and self-management 5) OHS Diabetes Support Group at OHH Improved diabetes self-management Number of participants Attendance figures in Community Benefit database

Oakwood Heritage Hospital Diabetes Initiative Strategy Activity Anticipated Impact of the Activity Performance Metrics Data Source Activity Improved diabetes self-management Provide two programs MOU 1) Partner with the National Kidney Foundation of Michigan to provide the Diabetes PATH (Personal Action Toward Health) program (six week workshop) in communities with high CNI scores Collaborate with community agencies to increase programming Decrease rate of new diabetes cases and of diabetes complications through prevention, early detection, and education Prevent Type II diabetes Provide one program MOU 2) Partner with the National Kidney Foundation of Michigan to provide the National Diabetes Prevention Program (12 month lifestyle change program with group coaching) in communities with high CNI scores a) Pilot four programs a) MOU Improved nutrition practices, eating habits, healthy meal preparation and food budgeting knowledge and behaviors 3) Cooking Matters Extra for Diabetes classes in collaboration with Gleaners Community Food Bank of SE Michigan in communities with high CNI scores b) Graduation rate (Goal 80%) b) Attendance figures from Community Benefit database c) Track 20 outcome measures c) Pre- and Postparticipant survey Meeting minutes Conduct an exploratory meeting with The Senior Alliance Reduced re-admissions and improved self-management upon discharge 4) In collaboration with The Senior Alliance (TSA) explore expanding the Oakwood/TSA Care Transitions Intervention (CTI) program to Medicare patients with diabetes 9

Oakwood Heritage Hospital 10 Obesity Initiative Strategy Activity Anticipated Impact of the Activity Performance Metrics Data Source Activity 2013-2014 academic year a) MOU's with school partners a) Expand program to six elementary schools in Dearborn School District Improved knowledge and practices in youth grades K-5 to make healthy dietary and physical activity decisions Provide education on healthy eating physical activity, and weight management Decrease rate of obesity in children and adults by promoting regular physical activity and healthy eating behaviors b) MHA Report 1) Oakwood CATCH Kids Club (Coordinated Approach to Child Health) after-school physical activity and nutrition program in collaboration with schools and with YMCA of Metro Detroit b) Maintain program in 11 school and YMCA locations c) Pre- and Post- CATCH participant survey c) Track 50 outcome measures from CATCH survey to improve comprehension and health behaviors a) Pilot eight programs a) MOU January 2014- b) Graduation rate (Goal 80%) b) Attendance figures Improved nutrition practices, eating habits, healthy meal preparation and food budgeting knowledge and behaviors 2) Oakwood Cooking Matters classes in collaboration with Gleaners Community Food Bank of SE Michigan in communities with high CNI scores c) Pre- and Postparticipant survey c) Track 20 outcome measures from Cooking Matters survey to improve comprehension and health behaviors MDCH -CRT a) 100% of youth with a BMI over 85% will be seen by a nutritionist Improved nutrition practices of youth 3) Nutrition counseling at Oakwood Taylor Teen Center, Oakwood Inkster Teen Center, and Oakwood Adams Child & Adolescent Health Center-Westland b) 90% of program participants will report making positive changes in the nutrition and dietary habits. MDCH -CRT 75% of youth in the program will see a decrease in their BMI Youth will increase their physical activity over 12 weeks walking at least 8,000 steps per day 4) Oakwood Taylor Teen Center Stepping Towards Wellness program

Oakwood Heritage Hospital Obesity Initiative Strategy Activity Anticipated Impact of the Activity Performance Metrics Data Source Activity a) Weight tracker a) 70% of program graduates meet the criteria for optimal weight loss (10% weight loss in 6 months; 3.33% weight loss in 2 months) 5) Oakwood Weight Loss Program Improved knowledge and skills to achieve weight loss goals Provide education on healthy eating physical activity, and weight management Decrease rate of obesity in children and adults by promoting regular physical activity and healthy eating behaviors b) Participant survey b) At least 80% of program graduates identify that they have obtained the knowledge and skills to plan meals for health and weight loss c) Participant survey c) 80% of program graduates acknowledge an improvement in overall quality of life after completing the program a) Attendance figures a) Deliver two programs impacting 20 participants Improved knowledge and skills to achieve weight loss goals 6) Oakwood Vtrim online weight management b) Utilize Vtrim aggregate analysis b) Participant survey and selfreported data a) Attendance figures a) Deliver two programs impacting 15 participants Improved knowledge and skills to achieve weight loss goals 7) Oakwood Losing for Good group coaching weight management b) Utilize LFG analysis b) Participant survey and selfreported data a) Attendance figures a) Deliver two programs impacting 15 participants Improved knowledge and skills to achieve weight loss goals 8) Oakwood Lose Weight Your Way 12 week program with coaching b) Utilize LWYW analysis b) Participant survey and selfreported data 11

Oakwood Heritage Hospital 12 Obesity Initiative Strategy Activity Anticipated Impact of the Activity Performance Metrics Data Source Activity a) Member visits a) Member management software Improved fitness level, health status, weight management 9) Oakwood Wellness Center for eligible community members & employees Provide education on healthy eating physical activity, and weight management Decrease rate of obesity in children and adults by promoting regular physical activity and healthy eating behaviors b) Member satisfaction b) Member feedback Oakwood event participant survey Track 7 outcome and process evaluation measures to improve comprehension 10) Oakwood Speakers Bureau Improved knowledge of obesity prevention and treatment options October 2014 1,400 participants Attendance figures 11) Oakwood Red October Run Improved awareness of the benefits of physical activity MOU's with four school districts Four school districts will be sponsored to implement mynutratek 12) Oakwood mynutratek Program Improved awareness of the benefits of healthy eating and physical activity practices among children and their families December 2016 a) MOU's with identified partners a) Explore partnership with two municipalities in 2014 Expanded outreach and access to obesity programs 1) Oakwood "Healthy Community" designation Collaborate with local municipalities and coalitions to expand outreach of obesity prevention and weight management programs b) Submit one grant application in 2014 b) Oakwood Foundation Grant Report Minutes and work group reports of the MOTION coalition Participation of Oakwood Community Benefit staff on MOTION coalition work groups Coordination of services and programs through the Wayne County Health Authority's MOTION coalition 2) Wayne County MOTION coalition child obesity prevention and treatment coordination