community health needs assessment implementation strategy report · 2019-04-30 · 2018 – 2021 |...

Community Health Needs Assessment Implementation Strategy Report

2018 – 2021

2018 – 2021 | Community Health Needs Assessment Implementation Strategy Report 2

Table of ContentsAddressing Community Health Needs..................................................3

Prioritizing Community Health Needs ...................................................4

Recognizing the role of social determinants of health ..........................8

Addressing Priority 1: Behavioral health: Including suicide, substance abuse and mental health .....................................................9

Addressing Priority 2: Obesity & related chronic diseases, including cancer, heart disease and diabetes ....................................13

Addressing Priority 3: Access to services, including not just availability of services, but also transportation needs, literacy and cultural competency.....................................................................16

Monitoring and Evaluation ..................................................................19

The Implementation Strategy development team at Tucson Medical Center included the following participants: Cynthia Carsten, Emergency Department; Heather Jankowski, Outpatient Services; Diana Barrata, Adult Inpatient; Kimberly Fore, Hospice; Joyce Drozd, TMC Geropsych; Maya Luria, Senior Services and Patient Relations; Michelle Ruiz, TMCOne; Brenda Carle, Transitional Care; Jeanne Rhodes, Case Management; Andy Shanks, Southern Arizona Health Alliance; Claudia Koreny, Pharmacy; Jonathan Leicht, TMCOne, Mary Atkinson, Connected Health and Wellness.

The process was led by Community Benefit staff, with input provided by Chief Medical Officer Rick Anderson and the Medical Executive Committee at TMC HealthCare.


Addressing Community Health Needs Our mission is to provide exceptional health care with compassion.

It’s been that way since we were created to care in 1944 and it remains true to this day.

As good stewards of our patients’ health, we rely on diagnostics, information and expertise to help guide them to better health. As good stewards of our community’s health, the same thing is true. You can’t focus on making improvements until you have a road map about where to put your energies.

In the following pages, you will read about a year-long planning effort to help us identify areas of focus to build a healthier Southern Arizona. This effort happens every three years and the last effort not only helped us zero in on key areas – such as the then-burgeoning opioid crisis – but also helped us in building programming to help address gaps that had become evident.

TMC HealthCare worked in collaboration with our counterparts in the community who care about public health to dig into the data to determine behavioral health, chronic diseases related to obesity and access to services are areas where we can pour attention and focus.

In 2018, we provided $62.7 million in community benefit, that included helping the most vulnerable obtain care regardless of their ability to pay as well as providing outreach and education designed to advance medical knowledge and enhance the health of the community.

It is our hope that the work undertaken in the Community Health Needs Assessment and in this accompanying Implementation Plan will help us continue to make strategic investments of those resources as we strive to live our mission and to make a difference to our neighbors.

In closing, please note this is a working document, we commit to regular revisions to look for opportunities as needs change.

Please let us know your thoughts.

Judy Rich President and CEO, Tucson Medical Center


Prioritizing Community Health Needs The Pima County Community Health Needs Assessment Advisory Committee represents a community-wide partnership between health departments, community health centers, hospitals and community organizations such as the Community Food Bank of Southern Arizona and Healthy Pima.

Although Tucson Medical Center and the other partners in this effort recognize the important role other areas throughout Southern Arizona play in building a healthy state and region, the assessment defined the immediate community served as the entirety of Pima County.

How TMC performed on the 2015 implementation plan:Before exploring the 2018 action plan, it might be helpful to see a snapshot of the 2015 Community Health Needs Assessment, which identified the following areas, with TMC adding Cardiac Care and Access to Care as areas of special interest.

• Anxiety, depression spectrum and substance abuse:TMC said it would consider the viability of providing distance access to postpartum support. A series of online videos have been shared with our rural neighbors to provide information and TMC Now will this year begin offering behavioral health consults in addition to addressing medical needs. TMC also agreed to provide leadership around the issue of opioid abuse through efforts to promote responsible prescribing and dispensing policies and practices, as well as to increase public awareness and patient education about prescription drug misuse. We believe we made significant strides in both of those areas.

• Accidents, chronic pain:The single most important tool in reducing health-care associated infections is also one of the simplest: Handwashing. TMC already was briefly a world record holder in a hand sanitizing relay attempt and worked diligently to increase awareness around hand hygiene. Those efforts paid off by paying a significant role in quality successes TMC demonstrated in 2018, including a 40 percent drop in Clostriudium dificile infections over one year.


• Diabetes:At the time of the last report, TMC was exploring an expansion of pediatric diabetic services and has since hired three pediatric endocrinologists and staff who provide assistance to families with newly-diagnosed children.

TMC also planned to work with chef Janos Wilder to create and share heart healthy recipes.

We were not able to identify grant funding to screen adolescents in a school-based program but are continuing to actively work with the school nurse population to work toward prevention and management of chronic conditions, such as diabetes.

• Cardiac:TMC indicated in 2015 that we would pursue telemedicine consults to better care for patients too sick to travel great distances to see a provider. While TMC was able to make some inroads in utilizing this new approach to medicine, we believe the coming years will show more promise with the hiring of a coordinator who will have an exclusive and focused approach on growing those services.

TMC at the time planned to expand its interventional procedures in its structural heart program and has successfully managed that expansion. TMC’s customer relationship manager capabilities also have allowed us to share patient education and lecture opportunities with those at risk for cardiac and stroke events.

• Access to care:TMC pledged to explore the viability of having patients register online prior to visiting the emergency department. That convenience is now available to patients, as is virtual health care visits and an online app that aggregates TMC services such as campus wayfinding and bill pay portals.


The Building Blocks of the 2018 Community Health Needs Assessment

Secondary Data

Prioritized Community

Needs

Focus Groups

Surveys

Prioritization forum

Key informant interviews

The assessment relied on the collection and analysis of secondary, quantitative morbidity and mortality data from a variety of local, state and national sources as well as primary, qualitative data collected from community stakeholders, key informants and community members at large. When available, data is compared to appropriate benchmarks to evaluate progress.


Sources consulted:

• Secondary data: Multiple sources were consulted, including previous Pima County Community Health Needs Assessment, County Health Rankings and Roadmaps, the Centers for Disease Prevention and Control and the Arizona Department of Health Services Health Status and Vital Statistics Annual Reports.

• Key informant interviews: Interviews ranging from 45-60 minutes were conducted with 18 community members to help identify the most important health concerns and their root causes, as well as the strengths and assets that can be deployed in improvement efforts.

• Focus Groups: Five different group discussions, including 48 participants, were held, with specific focus on health providers, community health outreach workers, first responders and school health.

• Surveys: Surveys were disseminated throughout the study area, available in both English and Spanish. In total, nearly 200 surveys were used for analysis.

• Community health forums: Two community forums were held, including 134 participants. The second forum included the prioritization process to identify the three top needs.

Areas of opportunity:

After reviewing the data and the community input, the following three issues were identified:

1. Behavioral Health

2. Obesity and related chronic diseases

3. Access to services


Additionally, for the first time, the report identified four social determinants of health that have the highest regional impact, including:

1. Poverty: 24 percent of Pima County residents earned less than 125 percent of the federal poverty level, with 37 percent of African Americans and 47 percent of American Indians experiencing these levels.

2. Physical environment: Pima County ranks 10th of 15 Arizona counties for physical environment. These factors include air pollution/particulate matter, drinking water violations, severe housing problems, driving alone to work, and having a long commute.

3. Geographic disparities: Certain areas across Southern Arizona have more challenges than other, tending to represent lower-income and/or more rural populations that struggle with access to health care, healthy foods, and other key social determinants of health.

4. Housing: In Pima County 9.4 percent of homeowners and 25.8 percent of renters were severely burdened by cost, meaning they spent 50 percent or more of their income on housing. These rates are slightly higher than both Maricopa County and Arizona as a whole.

To address the needs identified in the assessment, TMC HealthCare formulated an internal prioritization team that gathered to consider the three priority issues based on magnitude, alignment with our hospital’s mission, existing resources that might be leveraged to address the problem and TMC’s unique ability to effect change.

Participants included physicians, nursing directors and other leaders with specialization in a variety of areas, including cardiac services, case management, nutritional needs, geropsychiatric care and primary care services.

Ultimately, recognizing that resources and expertise are both finite, TMC has developed the following implementation plan that builds on existing initiatives, advocacy and partnerships to improve the health and wellness of our community in these three areas that we feel singularly prepared to address as a nonprofit, locally governed community hospital.


Health Priority Area 1: Behavioral Health; including suicide and substance abuseData determined that Pima County residents report an average of 3.9 poor mental health days per month, and 12 percent of community members report frequent mental distress.

Statistics also showed:

• Among seniors on Medicare, 13.5 percent are treated for depression;

• Suicide is the 10th leading cause of death in Pima County

• Alcohol is the second cause of morbidity in Pima County

• Drug induced deaths, including from opioid, heroin and pharmaceutical abuse, are statistically higher in Pima County than in the state

• Pima County’s population to mental health providers is half the ratio that top performing communities demonstrate, with a particular lack of pediatric and adolescent mental health specialists

Services TMC currently provides:TMC provides direct behavioral health treatment to the senior population through the TMC Geropsychiatric Center, a 16-bed unit that opened in early 2015 that focuses on treating acute emotional and behavioral issues related to aging, including depression and dementia.

TMC for the most part, however, serves the needs of the population by building coalitions and partnering with those organizations that provide expertise to those struggling with behavioral health needs.

TMC works closely with Palo Verde Behavioral Health, which shares our campus. Palo Verde assists in evaluating patients who present to TMC’s Emergency Department to ensure a safe disposition and treatment. They also work closely with TMC when needs are identified on the inpatient unit.

In addition to screening for suicide and domestic violence in our inpatient areas, our outpatient areas similarly perform suicide screenings at access points for patients at high risk for suicide because of struggles with wounds, pain or sleep.


TMCOne has recently added a pediatric behaviorist to help address the increasing needs of our pediatric and adolescent patients. Additionally, all patients complete a PHQ-9 screening and receive follow up specific to any self-identified depression or suicide ideation.

TMC Hospice offers bereavement services for those experiencing loss, as well as a community grief group for those experiencing those emotions.

While TMC does not have a specific addiction unit, we readily refer to community addiction services and provide patient education around opioid abuse. These services include:

• A consulting doctor who specializes in seeing patients with opioid abuse routinely works with TMC patients, as needs are identified through case management.

• TMC has a partnership with Connections Arizona in which patients and families struggling with substance abuse are provided a liaison to assist with education and support to identify appropriate resources.

• The Newborn Intensive Care Unit works closely with CODAC Health, Recovery and Wellness to provide substance abuse services on site for parents of babies born with drug exposure and we have a separate unit designed specifically to care for these babies with such unique needs.

• TMC is working with Old Pueblo to secure two medical respite beds for patients struggling with behavioral health, substance abuse and homelessness so they have a place to recover from complex conditions.

TMC has been actively working to find alternate methods of pain control that does not include the use of opioids, offering services such as biofeedback, interventional procedures and injections. Patients can get access to these other services through the TMC Integrative Pain Center as well as at the hospital. Just as one example, TMC routinely uses an On-Q pump for patients with hip fractures or who have had surgery to immediately control pain through a catheter that feeds a localized anesthetic to the site without the use of opioids.

TMC was at the forefront of efforts to collectively address opioid dependency and substance abuse disorder. In addition to supporting a community visioning session with 75 community leaders, hosting a national


expert to share expertise on combating the epidemic, and collaborated with other medical professionals to determine appropriate treatment guidelines for opioid usage for chronic pain in emergency settings. The work around opioid work culminated in a lawsuit against opioid manufacturers to hold them accountable for loss of lives and the broader cost of mitigating the epidemic.

TMC is actively working on workplace violence strategies from providing de-escalation strategies to staff to establishing a contract with patients that shares expectations as well as their rights.

In a unique project, TMC was proud to work with CODAC to open the Connie Hillman Family Foundation House, providing treatment for mothers recovering from substance abuse. The 16-unit complex provides aftercare treatment, pediatric and maternal care, life-skills training and other services to help women be successful in their recovery, to keep families together and to provide a bridge to independence.

Community outreach: TMC invests significant resources in community education around medical services and prevention. TMC for Seniors and The Core at La Encantada routinely offer lectures and workshops on stress relief, relaxation, mindfulness and other strategies to assist with behavioral health.

Recognizing that regular exercise may help reduce depression and anxiety, and may benefit those with substance abuse, TMC also offers a wealth of fitness and exercise programming through Seniors and The Core, as well as offering employees access to an on-site gym.

As the market leader in labor and delivery, TMC hosts a weekly postpartum depression support group and participates in a coalition with other area hospitals to provide support services to affected families.

TMC every year sponsors Girls on the Run, designed to assist girls in resisting bullying, as well as alcohol, tobacco and drugs by reinforcing healthy habits and conflict resolution skills.

TMC works with government partners to support medication drop off events.


Future state: TMC is working on bolstering support for those fragile community members who call 911 to help them get the right level of service for their needs.

Many of those callers call 911 because they’re hungry or scared or just don’t know who else to call.

The Tucson Collaborative Community Care – commonly known as TC3 – engages frequent callers to 911 who often call because they are in crisis. The program helps them find solutions to their needs by tapping into more appropriate community services rather than utilizing emergency services.

Consider that 81 clients made 710 calls for service in the first six months of 2018. In the subsequent six months, since working with the TC3 team, those individuals made 238 calls - a reduction of 67 percent.

TMC HealthCare and its charitable foundation have partnered with Tucson Fire to expand the program by helping secure grant funding and provide other resources.

TMC also is currently working on developing a program to provide peer support to patients while they’re in the hospital. The program will involve training peers who have overcome behavioral health challenges to help advocate for patients and connect them to services.

TMC is committed to continuing to work AHCCCS and other policy leaders to ensure incentives are aligned around coordinated physical and behavioral health.

TMC will work to further strengthen in-house behavioral health services that are connected to community behavioral health services, by modeling the work being done in the NICU with parents struggling with substance abuse issues.

TMC will explore further expanding behavioral health offerings through TMCOne, including telemedicine options.


Health Priority Area 2: Obesity and related chronic diseaseCancer and heart disease continue to be the two leading causes of death among Pima County residents, as they are throughout Arizona and the U.S. These causes of death are connected to many of the health indicators in this report, including physical activity, smoking, obesity, nutrition, and social determinants of health.

Heart disease has surpassed cancer as the leading cause of death in Pima County, with 170.6 deaths per 100,000 people. Additionally in Pima County, there were an estimated 155 deaths from cancer per 100,000 population in 2016 - higher than the state of Arizona at 142.2.

In 2014, 25 percent of Pima County’s residents were obese- an increase from 22 percent in 2012.

Data indicates:

• An estimated 13.11 percent of adults had ever been told they were diagnosed with diabetes.

• Approximately 14 percent of Pima County adults are smokers.

• About a quarter of Pima County residents reported eating the recommended amounts of fruits and vegetables.

• About 18 percent of community members report no leisure time physical activity.

Services TMC currently provides:TMC offers a comprehensive weight loss program ranging from surgical options for those who have struggled to lose weight to a supervised weight loss program for those who need support. Our bariatric program is an accredited center through the American Society for Metabolic and Bariatric Surgery.

TMC provides comprehensive medical services for those grappling with heart disease, cancer and diabetes.


TMC is an accredited Chest Pain Center and performs more cardiac procedures than any other hospital in Southern Arizona, from minimally invasive treatments to traditional open heart surgery.

TMC’s transitional care unit ensures patients with complex conditions, such as heart failure, have their best chance at avoiding readmissions into the hospital. TMC also assists patients with heart conditions get back to a healthy lifestyle through a cardiac rehabilitation program in a safe, supported environment.

TMC employs chronic disease coordinators and patient navigators to ensure patients have the information they need to manage their conditions and live their healthiest lives.

TMC’s outpatient nutrition provides nutrition therapy to patients dealing with chronic conditions that are affected by diet.

Clinical diabetes educators work closely with adult and pediatric patients in the hospital as well as post discharge to provide education about how to best manager their disease. We have employed additional specialists in endocrinology to better assist patients who are newly diagnosed or to assist those having difficulty managing their conditions.

Patients with diabetes who lack insurance and cannot afford their medications are eligible for 30 days of medication, including insulin, test strips and lancets, or for gift cards at retail pharmacies.

TMCOne, as well as affiliated physicians at Arizona Community Physicians, also offer monthly educational visits with primary care providers so patients can receive the education they need to better manage their chronic conditions.

The TMC Wound Care Center offers monthly campaigns designed to provide education for those whose chronic conditions exacerbate wounds, from heart-associated wounds to Love Your Feet month for patients with diabetes. The Center also educates community caregivers and home health providers to supplement the care we give our patients.


Community outreach:TMC offers many wellness opportunities to support community members in leading active, healthy lives. We sponsor wellness events across the community, from 5k runs and community walks, to cycling events and Girls on the Run for adolescent girls.

The Core and TMC for Seniors offer a variety of free or low cost fitness opportunities for community members as well, from yoga to line dance to strength and toning. Both of those outlets also offer ongoing lectures by medical experts about managing and preventing chronic disease.

TMC’s certified diabetes educators offer individual and group training in diabetes self-management in an outpatient setting. They also facilitate free classes and support groups for uninsured individuals and those diagnosed with pre-diabetes.

As one of this community’s largest employers, TMC offers stress management coursework, free exercise and health coaching to employees, as well as providing access to an on-site gym.

TMC utilizes a customer relationship management system, which directly engages consumers with information and tips for patients with specific chronic disease, and has developed a wellness plan to assist other employers in helping to build engagement among their employees.

Future state:For patients who are struggling with serious chronic disease but are not yet ready for hospice care, TMC is establishing a transitional care program to help them better manage their conditions and reach their best quality of life in the time they have left.


Health Priority Area 3: Access to servicesAccess to health care services is so much more than whether someone has health insurance.

Access to care can be harder to measure, but can include helping patients overcome a variety of barriers, including whether someone has transportation to get to a doctor or to pick up medication, whether someone can get into see a provider who can care for their physical or behavioral needs, and whether someone has sufficient literacy to understand instructions about care at home.

Overall, while Pima County has more primary care providers per population and has a slightly better transportation score than the state, there are disparities among areas throughout the County that face greater challenges in access to services.

Services TMC currently provides: As a locally governed nonprofit community hospital, TMC cares for the most vulnerable in our community. In 2018, TMC provided $62.7 million in community benefit, including $12.4 million in uncompensated care for those who could not afford to pay for the full cost of medical care.

One of the ways TMC HealthCare is helping make care more convenient and more affordable is by expanding virtual avenues.

TMC offers online scheduling for emergency appointments and offers a portal for patients to provide ready access to their medical record.

In 2018, TMCNow launched, offering virtual care for patients through an app on their phone or computer. Patients can speak to a board-certified doctor anytime, anywhere, for a low cost of $49 per session.

TMCOne practices, along with many affiliated providers through Arizona Community Physicians, are ensuring improved access to care through same-day appointments as well as offering extended and weekend hours. TMCOne offers dedicated patient ambassadors to assist patients with scheduling and giving them one point of contact. And they also offers assistance with co-pays.


TMC Urgent Care, launching first on the TMC campus, further expands choice for patients.

For those patients with limited resources, TMC funds Lyft rides home from inpatient or clinic care, as determined by case management.

It is indisputable that Arizona is facing a severe physician shortage that will be exacerbated in the coming decade as more physicians retire. In part because of the need for effective specialty care, but also because physicians often tend to practice where they train, TMC has built a panel of pediatric sub specialists to not only provide care to the community, but to help train new doctors. TMC has long been a training hospital for doctors, but has started a new pediatric residency program this year.

TMC actively seeks out ways to expand care for patients in need by partnering with other local organizations. Jewish Family & Children’s Services, for example, is able to assist with affordable durable medical equipment. Southwest Medical Aid helps provide equipment for homeless populations and case management similarly keeps a loan closet of donated goods for patients in need. TMC works closely with St Elizabeth’s Health Center to identify resources for patients who have dental pain. The TMC Wound Care Center also provides several charity cases a year, often for patients experiencing homelessness or extreme poverty.

TMC HealthCare continues to advocate for the preservation of Medicaid expansion and is an active participant in annual enrollment outreach and education.

TMC is committed to providing a safe, culturally-appropriate health care experience for patients with limited English proficiency. In addition to providing certified Spanish medical interpreters, TMC has provided training for bilingual employees to assist with routine interpretations and offers CyraCom around the clock to ensure appropriate translation for more than 200 languages and dialects. TMC has had a focus on building relationships with hospitals in Mexico to ensure more seamless care for patients seeking care here.


We know that a factor contributing to inappropriate utilization of services and poor management of medical conditions is related to an individual’s lack of a primary care provider. TMC strives to assure that < 5% of patients are discharged without a primary care provider in place; this is commonly accomplished in collaboration with our local FQHCs and we also follow up with patients post-discharge through an active campaign to connect them with a provider.

Importantly, as a founding member of the Southern Arizona Hospital Alliance, a network of five independent hospitals, TMC HealthCare has worked to shore up the strength of Southern Arizona’s network of rural hospitals by helping to identify gaps and opportunities for additional efficiencies in purchasing, insurance, medical records and specialty care.

Community outreach:TMC runs a resale retail boutique that provides vouchers for patients and families in need of clothing.

TMC for Seniors hosts low-income food delivery for seniors every day, as well as offering 1:1 nutritional counseling with UA seniors for senior citizens and a wide variety of informational sessions to ensure access to information. TMC also has been a key partner for Mobile Meals of Southern Arizona since 1970, with nutritious meals prepared at TMC each day for elderly and disabled adults in the Tucson area.

Future state: Arizona’s physician shortage is one of the worst in the nation, ranking 44th of 50 states in primary care physicians, with extensive wait times for specialist care. The problem is exacerbated in rural communities.

TMC continues to expand telehealth services with a particular focus on our rural partners in the Southern Arizona Hospital Alliance to provide access to specialty care, behavior health services and chronic disease management.

Engage local, state and federal policy leaders to address critical community health needs on a broader level, and continue to participate in community efforts to address poverty, literacy, and other social determinants.


Implementation, monitoring and evaluationThis report is a working document and is not intended to be a static report.

TMC HealthCare is committed to monitoring and tracking the implementation plan as appropriate to each strategy.

A performance review will be published and provided to the Board of Directors and made available on Tucson Medical Center’s website. TMC also will continue to work with community partners to identify gaps in service and seek ways, where possible and appropriate, to better address priority health needs.

community health needs assessment implementation strategy report · 2019-04-30 · 2018 – 2021 |...

Documents