ACKNOWLEDGEMENTS Wicomico County Health Department was the lead organization in the preparation of this report, the following people contributed to the preparation of this document: Lori Brewster, Health Officer Tammy Griffin, Director of Prevention and Health Communications Cathey Insley, Office Supervisor Brenda Williams, Accreditation Coordinator
TABLE OF CONTENTS Wicomico County Community Health Priority Areas... 1 Introduction... 2 Tri-County Health Improvement Plan (T-CHIP)... 4 Tri-County Healthy Weight Coalition Goals and Objectives... 9 Tri-County Diabetes Emergency Department Visit Reduction Project... 10 Wicomico County Diabetes Sub-Planning Committee Action Plan... 14 Wicomico County Executive Fitness Council... 24 Behavioral Health (Mental Health and Addictions) Improvement Plan Prescription Drug Task Force... 25 Hospital Diversion Strategic Plan... 33 Wicomico County Asthma Action Plan... 45 Wicomico SHIP Measures... ATTACHMENT A
WICOMICO COUNTY COMMUNITY HEALTH PRIORITY AREAS: 1
Introduction The Wicomico County Community Health Improvement Plan (CHIP) was developed as a result of the findings in the 2009 Professional Research Consultants (PRC) Community Health Assessment (CHA) (http://www.wicomicohealth.org/files/0/0/2009%20tri- County%20Community%20Health%20Assessment%20REPORT.pdf) and has been driven by the Maryland State Health Improvement Plan (SHIP) (Attachment A). PRC CHA data was presented to the Wicomico County Health Planning Board at the 11/5/10 meeting. The following three focus areas were selected for the concentration of resources over the next five years: Diabetes Obesity, overweight and lack of physical activity Mental Health Subsequently sub-planning committees were formed to address two of the focus areas: Diabetes and Mental Health. Volunteers were sought to serve on each committee from the Wicomico County Health Department, community partners and the general public. Meetings for the Diabetes sub-planning committee commenced April 2011 and continue meeting today to continuously update their action plan. The first several meetings focused on the strengths and weaknesses of the community, followed by discussion of opportunities and threats. By 3/26/12 recommendations to improve diabetes outcomes were submitted to the Health Officer for approval. Upon approval the committee was directed to develop an action plan to improve diabetes outcomes in the community. Mental Health sub-planning committee meetings commenced March 2011 and for the first several meetings focused on identifying strengths, weaknesses, opportunities and threats to the mental health services in the community. Recommendations for improvement regarding access to mental health care were submitted to the Health Officer in April 2012. When the recommendations were approved the Health Officer requested that the committee continue to meet and work on an action plan to implement recommendations. In June 2013, the committee agreed to merge into what is now the Wicomico County Behavioral Health Task Force comprised of a hospital diversion committee, a prescription drug task force and Drug Free Wicomico. This merge has proven to be a more collaborative use of resources and membership time. It has helped to reduce the number of multiple committees working on the same issues and created a team of mental health advocates working together strategically to address both mental health needs in Wicomico County. To address the issues of obesity and lack of physical exercise, rather than forming another committee, the existing Wicomico Executive's Fitness Council (WEFC) is the venue used to address this growing epidemic in Wicomico County. A walkability survey of the county is underway and most recently Live Healthy Wicomico was launched. Live Healthy Wicomico is a web-based, team driven wellness program designed to help participants make positive and lasting changes through activity and nutrition. Please visit the Live Healthy Wicomico website: http://livehealthywicomico.org/. Many community partners support the activities of the WEFC. 2
In September 2011 the Maryland Department of Health and Mental Hygiene (DHMH) launched the State Health Improvement Process (SHIP) and it may be viewed at the following link: http://dhmh.maryland.gov/ship2/sitepages/home.aspx. The SHIP provides a framework to improve Maryland s national health ranking from 21st in the nation, and to reduce persistent health disparities in the State. It is a planned, organized, and measured approach to community health improvement in Maryland localities. It focuses state and local action on population health improvement factors to ensure that people live, work, and play in healthy environments, and that our prevention and health care services are evidence-based and better integrated. The SHIP is a collaborative effort with local health departments, hospitals, and community-based health-supporting organizations. Baselines, targets, and annual updates for 39 health measures at the state and county levels are provided by the SHIP. The goal of this data framework is to drive and support aligned collective local action which betters health through local health improvement coalitions. Until October 2011 Wicomico County Health Department functioned under the Tri-County Local Health Improvement Coalition with their sister counties, Worcester and Somerset as determined by the State of Maryland. In September 2011, the three Health Officers approached the Deputy Health Secretary for the State of Maryland to request recognition as individual coalitions to better address each county s unique public health characteristics. The SHIP has been the driving force for the Tri-County Local Health Improvement Coalition to develop plans and initiatives that address obesity and diabetes in the region. In addition, Wicomico County has organized an asthma initiative to address the high rates of asthma related emergency department room visits. 3
Tri-County Health Improvement Plan (T-CHIP) 4
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Tri-County Healthy Weight Coalition Goals and Objectives Edited April 19, 2012 GOAL #1: Increase the number of youth and adults who are at a healthy weight. Objective 1: By July 1, 2012, a resource guide of regional farmer s markets and co-ops and healthy eating websites such as myplate.gov will be created and distributed in the tri-county area. Action Step: 1. Resource guide will be distributed to adults and be used as a resource tool to educate them in wise food choices for their families. Objective 2: By December 2012, 50% of coalition partners will report healthy meeting environments. Action Steps: 1. A campaign to promote healthy meeting environments will be developed and implemented. 2. A survey will be created and distributed to measure improvement in meeting environments. GOAL #2: Increase the number of youth and their families who engage in physical activity for at least 30 minutes most days of the week. Objective 1: By December 30, 2013, 10% of tri-county area businesses and school systems and programs will report increased physical activity time based on the recommended age specific guidelines. Action Steps: 1. Survey afterschool programs regarding physical activity time and type. 2. Educate program staff on benefits of activity and play first framework 3. Educate parents on benefits of activity and play first framework. 4. Educate businesses on ways to provide and increase staff physical activity time. Objective 2: By September 2012, coalition will identify the area s environmental and societal barriers to physical activity selecting at least one to eliminate. Action Steps: 1. Collect list of barriers for each county. 2. Collectively evaluate and choose most important. 3. Develop campaign to eliminate barrier through education and advocacy. 9
Miscellaneous ideas: 1. Advocate for healthy food options and environments. 2. Establish policies or practices to promote and integrate physical activity opportunities. 3. Promote and educate lifestyle activities for all ages from infant to senior adult. 4. Educate all ages on physical activity recommendations. T-CHIP Diabetes ED Visit Reduction Project (New Initiative, July 2013) In May 2013 the Tri-County Health Improvement Coalition applied for a grant to reduce emergency room visits as a result of diabetes and was successful in receiving funding to work on achieving that goal. Below are the goals and objectives to be achieved with the grant funding: GOAL 1: To reduce diabetes related Emergency Department (ED) visit rates and disparities among residents of Somerset, Wicomico, and Worcester Counties during a period between July 1, 2013 - September 30, 2013. Objective 1: By September 30, 2013, establish a routine procedure for reviewing diabetes-related ED visits to recommend appropriate interventions, targeting high ED utilizers and geographic or racial disparities in ED use. Action Steps: 1. Tri-County Health Improvement Coalition will obtain and review ED data for baseline in all 3 hospitals; explore data for long and short term indicators of ED visits, hot spots and frequent flyers and changes in visit rates. 2. Identify patient lists and geographic regions for targeted outreach and case management. Outcome Measures: 1. For the period of implementation, the program will produce quarterly ED visit data analysis reports, and lists of ED visit indicators for targeted outreach. Dates of reports are October 15, 2013, January 15, 2014, April 15, 2014, July 15, 2014 and October 15, 2014 2. Reduction in overall ED visit rate for the Lower Shore Counties, as calculated from HSCRC data by October 14, 2014. 3. Reduction in racial disparities rate for Worcester, Wicomico and identified areas of Somerset as calculated by HSCRC by October 15, 2014. Objective 2: Implement a Nurse/Social Work/Health Outreach Worker Diabetes Care Management Program to assist diabetes patients in obtaining resources aimed at reducing ED visits related to diabetes. 10
Action Steps: 1. Hire, train and deploy 2 FTE RNs, 1 FTE LCSW and 2 Community Health Outreach Workers (CHOW) to provide Diabetes Case management services for patients identified as high risk for avoidable ED visits. 2. Increase capacity within the Diabetes Prevention and Education programs with additional funding and targeted outreach to pre-identified patients. 3. Establish the Access to Pharmaceutical care program with Apple Drug - including referral process and covered services or products. Optional: Purchase portable telemedicine unit for recording and transmitting diabetes related biometrics in real time from patient home to primary care provider. Outcome Measures: 1. Two Case Management (CM) teams hired, trained and accepting new patients by September 15, 2013 in all three counties. 2. At least 5 Diabetes CM patients in each county enrolled in the National Diabetes Prevention Program (NDPP) - Lifestyle Balance and/or American Diabetes Association (ADA) Certified Diabetes Education programs by November 1, 2013. 3. At least 1 diabetes CM patient from each county begins utilizing Pharmacy assistance services by November 1, 2013. Objective 3: Establish a protocol that will ensure patients presenting with diabetes related ED visits receive referral into CM services, or at a minimum, a Tri-County Diabetes Alliance (TCDA) Resource Guide upon discharge from the ED. Action Steps: 1. Implement the universal referral form for referral into Diabetes CM services as developed by the TCDA. 2. Educate ED physicians and staff at all 3 hospitals about the Tri-County Diabetes CM services and related Outpatient Diabetes Self-Management Programs, Diabetes Support groups, and the NDPP. Outcome Measure: 1. Three Provider/Medical Staff orientation meetings will be held: 1 at Atlantic General Hospital (AGH), 1 at Peninsula Regional Medical Center (PRMC), and 1 for the Emergency Services Physicians, by January 15, 2014. Objective 4: Contribute to the establishment of a Community Health Record by promoting utilization and participation in Chesapeake Regional Information System for our Patients (CRISP) among Lower Shore healthcare providers. 11
Action Items: 1. Enroll each Health Department which employs the CM team in CRISP participation agreements. Outcome Measures: 1. Worcester and Wicomico signed contracts for CRISP participation. 2. Each CM team will access, if available, pertinent medical information through CRISP-such as laboratory data, medication lists, ED visit data and discharge information on at least 2 patients from each county by April 15, 2014. Goal 2: Assist the State s overall implementation of the Affordable Care Act by expanding access to coverage for residents of the Tri-County area who will become eligible for health insurance in 2014. Action Items: 1. Obtain payer source coverage information from hospital ED records and CM referrals, direct patients to the Navigator entity, as indicated. Outcome Measure: Referral of at least 25 patients from each county to the Lower Shore Navigator Entity by January 15, 2014. Evaluation: The Tri-County Health Planning Board, as the Local Health Improvement Coalition (LHIC) will be the Program Oversight agency, and will receive all performance reports and monitor program milestones. The Tri-County Health Planning Board, through Worcester County Health Department, will submit reports to the Community Health Resource Commission (CHRC) as required or requested. The progress toward each outcome will be assessed quarterly for evidence of progress and potential need to modify strategies or action steps. The Program will be evaluated by the following: Outcome Measures: 1. For the period of implementation, the Program will produce quarterly ED visit data analysis reports, and lists of ED visit indicators for targeted outreach. Dates of reports are October 15, 2013, January 15, 2014, April 15, 2014, July 15, 2014 and October 15, 2014. 2. Reduction in overall ED visit rate for the Lower Shore Counties, as calculated from HSCRC data by October 15, 2014. 3. Reduction in racial disparities rate for Worcester, Wicomico and identified areas of Somerset as calculated by HSCRC by October 15, 2014. 4. Two CM teams hired, trained and accepting new patients by September 15, 2013 in all three counties. 5. At least 5 Diabetes CM patients in each county enrolled in NDPP-LifeStyle Balance and/or ADA certified Diabetes education programs by November 1, 2013. Total of 20 patients per county complete NDPP by October 15, 2013. 12
6. At least 1 Diabetes CM patient from each county begins utilizing Pharmacy assistance services by November 1, 2013. 7. Three Provider/Medical Staff orientation meetings will be held: 1 at AGH, 1 at PRMC, and 1 for the Emergency Services Physicians, by January 15, 2014. 8. Worcester and Wicomico Health Departments execute contracts for CRISP participation. 9. Each Diabetes CM Team will access, if available, pertinent medical information through CRISP - such as laboratory data, medication lists, ED visit data and discharge information on at least 2 patients from each county by April 15, 2014. 10. Referral of at least 25 patients from each county to the Lower Shore Navigator Entity by January 15, 2014. 13
Wicomico County Specific Community Health Improvement Plans: DIABETES Comment [1]: brendal.williams: Insert Wicomico County Diabetes Sub-Planning Committee Action Plan (on my desktop) 14
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Wicomico County Health Department Diabetes Planning Subcommittee Strengths Identified: Apple Discount Drugs has gone through the accreditation process to provide Diabetes Education. PRMC s endocrinology clinic for pediatric diabetics. Diabetes education available in schools. Two local endocrinologists for adults. (updated 8/5/11 from one to two) School meals will focus on increased vegetable and fruit portions. Weaknesses Identified: (updated 8/4/11) Lack of data from private schools regarding Diabetes morbidity. People do not take diabetes seriously. People do not take the risk factors for diabetes seriously. Pharmacies are not allowed to do finger sticks for diabetes screening because of CLIA regulations. Education available in the schools but not in the students homes. Lack of Diabetes screening/testing/education in Health Dept. Programs such as Community Health, WIC, Mental Health, Addictions, etc. Lack of local Pediatric Endocrinologist. Only one local endocrinologist who is extremely busy making it difficult to reach him if needed. Update 8/4/11 There are now 2 local endocrinologists. Lack of availability of access to out of town specialties. High cost of fresh fruits and vegetables Non-compliant patients who are not held accountable for their own care causing increased healthcare spending. Culture of unhealthy lifestyles Restaurant food portions. High overhead costs for education in hospitals/pharmacies and lack of adequate coverage by insurance. Lack of peer support, diet planning, and psychological support for children with diabetes. Lack of information regarding the home schooled population. Gap with follow-up for diabetic patients Lack of providers for pediatric patients diagnosed with diabetes Lack of Primary Care in the rural community Postpartum follow-up of gestational diabetes 21
Opportunities Identified: Diabetes education for the community and for parents of students with Diabetes. CLIA approval for pharmacies to do finger sticks to screen clients for Diabetes. One stop shopping for clients if pharmacies permitted to do screening for Diabetes patient could pick up their prescriptions, receive education, diabetes assessment and screening. If Diabetes clusters are identified, perhaps group education sessions can be done in schools. Diabetes screening and education for Health Department Clients. Promoting healthy eating and lifestyles in schools to create a new normal in our culture. Engaging University of Md. Extension Service to assist with nutritional education. Incorporating diabetes risk assessment in schools perhaps by sending education materials home to parents at the beginning of the school year. Changing the culture of unhealthy lifestyles and promoting healthy lifestyles in the community. Utilizing social media for education. Engaging in innovative interventions that will motivate change by providing knowledge and changing attitudes. Encouraging workplace educational programs by promoting the cost savings benefits to the employer and to health care costs. Development of a program to support children with diabetes to include: o Diet planning o Psychological support o Peer support Training for CRNP to provide care for Pediatric diabetic patients. Support groups for Adults with Diabetes and pregnant women with gestational diabetes 22
Wicomico County Diabetes Planning Subcommittee Membership Age, Tracy, R.N., BSN - WCHD Barga, Barbara UMD, Wicomico County Local Extension Service bbarga@umd.edu Chullin, Jodi RN Anchorage Nursing Home Jchullin@AnchorageNursing.com Cockey, Dr. James Wicomico County Health Department Cooper, Sharon Wicomico County Health Department Cottongim, Susan PRMC Diabetes Program Davidson, Teri MAC, Inc. Griffin, Tammy Wicomico County Health Department Kundel, Regina Peninsula Regional Medical Center Marine, Alison Wicomico County Health Department Motsko, John Apple Drugs Paskins, Deloise MOTA Pellegrino, Diane, R.N., BSN Wicomico County Board of Education, Health Services Coordinator Siggers, Von Vonsiggers@hotmail.net - 607 Pearl Street, Salisbury, Md. 21801 443-366-1686 Waide, Mary Beth CEO, Deers Head Center Williams, Brenda Wicomico County Health Department 23
OBESITY AND PHYSICAL FITNESS PLANS: Wicomico County Executive Fitness Council THE COUNTY EXECUTIVE S COUNCIL ON PHYSICAL FITNESS & HEALTHY LIVING MISSION STATEMENT The mission of the County Executive s Council on Physical Fitness and Healthy Living is to promote and encourage citizens of all ages throughout Wicomico County to adopt a personal goal of physical activity and responsible living habits to ensure a healthy quality of life. The Council will see to publicize the many on-going efforts across the county designed to promote healthy living and to serve as an umbrella organization for important information and strategies available to achieve the goal. A particular emphasis will be placed on methods and opportunities to combat childhood obesity through awareness campaigns designed to educate and inform about the real risks of heart disease and diabetes. COUNCIL GOALS (Revised March 2010) 1. Develop and promote community partnerships among county health, education, service provider, youth and adult-focused agencies and organizations to: A. Improve coordination of wellness services for county residents of all ages. B. Identify service and program gaps and work to eliminate them. 2. Develop a health and fitness public awareness campaign to address youth and adult obesity. A. Create a website with program information on nutrition and physical activity, events, programs, statistics, curriculums, a blog, community resource links and more. B. Highlight existing youth and adult resources and programs. C. Educate business community about importance of worksite wellness initiatives. 3. Recommend and lobby for policy and environmental change to: A. Local and state agencies for safer physical activity opportunities (ie: sidewalks, bike paths, crosswalks, lighting, and security). B. Businesses to support worksite wellness initiatives. C. Public and private schools for higher standards for school menus and increased physical activity time. 4. Create and award a County Executive Award of Excellence to area schools and businesses that have made significant strides towards improving the health of their community through model health and wellness programs and environmental and policy change. 24
BEHAVIORAL HEALTH (MENTAL HEALTH AND ADDICTIONS) IMPROVEMENT PLANS 25
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Hospital Diversion Strategic Plan 33
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WICOMICO COUNTY ASTHMA ACTION PLAN (New initiative 2013): Nearly 1 in 12 people in the U.S. have asthma, a number that grows every year and costs $56 billion in medical expenses, missed school and work days, and early deaths. Asthma in young children is a serious public health problem in the U.S. The National Health Interview Survey has found that persons under 18 years have higher rates of asthma than any other age group. Asthma in children results in missed days of school, limitations on daily activities, emergency department (ED) visits for treatment of asthma symptoms, and hospitalization. In Maryland, there are nearly 50,000 ED visits related to asthma each year. Health Services Cost Review Commission (HSCRC) data from the Maryland State Health Improvement Process (SHIP) website indicates that in Maryland the rates of ED visits due to asthma (per 10,000 population) were 62.8 in 2010 and 59.1 in 2011. Non-Hispanic blacks were at a rate of 123.1 in 2010 and 116.3 in 2011. In Wicomico County, overall rates were above the state average at 89.4 in 2010 and 84.5 in 2011. Data from the Maryland Governor s Office for Children indicated that in 2010, 19.9% of children in middle school had been diagnosed with asthma in the state of Maryland and in Wicomico County that percentage was again above the state average at 24.5%/ ED data collected locally from Peninsula Regional Medical Center between July 1 and October 31, 2012 showed that the number of pediatric ED asthma visits peaked at age 9 and age 16 during this time frame and that the number of Black/African American children treated in the ED was more than twice the number of all others. That data also showed that most patients treated in the ED either had no insurance or were Medicaid recipients. A review of the above data, shows a clear need to focus efforts on reaching low income, African American families with children under the age of 19 who suffer from asthma. Wicomico County is home to approximately 99,190 individuals (White alone-69.7%, Black or Afro- American alone- 24.9%, American Indian and Alaska Native alone-.3%, Asian alone-2.7%, Native Hawaiian/Pacific Islander alone-.1%, Two or More Races-2.2%). Demographically, this diverse population roughly mirrors the state population. However, education and economic indicators are slightly lower in this county than in the state overall, as are several important health indicators including asthma. Maryland has targeted asthma related ED admissions as one of its SHIP measures and Wicomico county ranks near the bottom of all counties in Maryland. Risk factors (genetic and environmental) play a role in affecting the health status of the targeted population. Risk factors such as: having a parent or sibling with asthma, having another allergic condition such as atopic dermatitis or allergic rhinitis (hay fever), low birth weight, exposure to secondhand smoke, having a mother who smoked while pregnant, stress, exposure to exhaust fumes and other types of pollution, and exposure to occupational triggers, such as chemicals used in farming, hair dressing and manufacturing. Home environmental triggers including dust/dust mites, animal dander, mold, perfumes/detergents, and cigarette smoke may be more likely to be present in sub-standard living conditions of the identified population. In addition, notable psychosocial triggers 45
such as family tensions, lack of physical activity, anxiety/stress, and friends/peer pressure, play an important part of the overall health status of the targeted population. Goal: To reduce the number of ED asthma visits in Wicomico County by 3% by the end of 2014. Objective 1: Develop and implement a home-based multi-trigger, multicomponent intervention using an environmental focus for children and adolescents with asthma. Action Steps: 1. Review the model practice recommendations from the Community Resource Guide. 2. Recruit and hire a Community Health Outreach Worker (CHOW) to assist in the development of the program and carry out the implementation plan. 3. Develop educational materials to be utilized in the program. 4. Provide education and training for the CHOW. 5. Develop partnerships with community agencies for referrals to the program. Outcome Measures: 1. Formalized asthma workplan 2. CHOW hired and trained 3. Community partnerships established Objective 2: Home visits including an environmental assessment, education, and case management provided to every referral within 2 working days. Action Steps: 1. Create a record for every referred patient. 2. Develop an electronic reporting system to capture all patient data. 3. Conduct environmental assessments and educational sessions with each referral. Outcome Measures: 1. Electronic reporting system established with quarterly reports generated. 2. Standardized chart for every patient. 3. Number of home visits with environmental assessment and educational session Objective 3: Community education provided to county residents. Action Steps: 1. Create educational packets to distribute to community members at health fairs. 2. Develop educational programs to present to community groups. 46
Outcome Measures: 1. # of health fairs with participation 2. # of community educational programs Conclusion As we prepare to conduct a robust 2014 CHA and identify additional health priorities as well as new partners, work will continue to improve outcomes in our current four priority areas: Diabetes Behavioral Health (Mental Health and Addictions) Overweight, Obesity, and Lack of Physical Exercise Asthma A task force has already been created to look at Wicomico County s high rate of Sexually Transmitted Infections (STIs) and to develop an improvement plan that will assist the efforts to reduce the rate of STIs in Wicomico County. When this plan is completed, it will be included in the overall CHIP for Wicomico. Ongoing we look forward to engaging additional partners and community members as we develop our next cycle of plans. 47