Linking Clinical Care and Communities Linking Clinical Care and Communities for Improved Preventionfor Improved Prevention

Web SeminarWeb Seminar

Sept. 1, 2011Sept. 1, 2011

Follow this event on Twitter Follow this event on Twitter Hashtag: #AHRQIXHashtag: #AHRQIX

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Using the Webcast ConsoleUsing the Webcast Console

What Is the Health CareWhat Is the Health CareInnovations Exchange? Innovations Exchange?

Publicly accessible, searchable database of health Publicly accessible, searchable database of health service delivery innovative strategies and toolsservice delivery innovative strategies and tools

Successes and attemptsSuccesses and attempts Innovators’ stories and lessons learnedInnovators’ stories and lessons learned Expert commentariesExpert commentaries Learning and networking opportunitiesLearning and networking opportunities New content posted to the Web site every two New content posted to the Web site every two

weeksweeks

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Innovations Exchange Innovations Exchange Web Event SeriesWeb Event Series

How to find archived materialsGo to the Events & Podcasts tab on our site: http://

www.innovations.ahrq.gov. A transcript of this event along with the slides will be available in a week.

Next EventsLook for announcements

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HousekeepingHousekeeping

For help, notify the Vcall team through the For help, notify the Vcall team through the question window at the bottom right hand question window at the bottom right hand side of the screen.side of the screen.

To refresh your screen, hit f5.To refresh your screen, hit f5. Recording, slides, and transcript available Recording, slides, and transcript available

on Web site by next week.on Web site by next week. Today’s slides are available now.Today’s slides are available now.

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Submitting QuestionsSubmitting Questions

Today’s Event ModeratorToday’s Event Moderator

Tess Miller, DrPHTess Miller, DrPH

Director, Prevention & Care Management Portfolio, Center Director, Prevention & Care Management Portfolio, Center for Primary Care, Prevention & Clinical Partnershipsfor Primary Care, Prevention & Clinical Partnerships

Agency for Healthcare Research and Quality (AHRQ)Agency for Healthcare Research and Quality (AHRQ)

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AHRQ’sAHRQ’s MissionMission

To improve the quality, safety, To improve the quality, safety, efficiency, and effectiveness of health care efficiency, and effectiveness of health care

for all Americans for all Americans

Health care providers, patients, policymakers, Health care providers, patients, policymakers, payers, administrators, and others use payers, administrators, and others use

AHRQ research findings to improve health care AHRQ research findings to improve health care quality, accessibility, and outcomes of carequality, accessibility, and outcomes of care

AHRQ’s PortfoliosAHRQ’s Portfolios

Comparative EffectivenessComparative Effectiveness

Health Information TechnologyHealth Information Technology

Innovations & Emerging IssuesInnovations & Emerging Issues

Patient SafetyPatient Safety

Prevention/Care ManagementPrevention/Care Management

ValueValue

P/CM Portfolio P/CM Portfolio Strategic GoalsStrategic Goals

1.1. To support clinical decision making for To support clinical decision making for preventive services through the preventive services through the generation of new knowledge, the generation of new knowledge, the synthesis of evidence, and the synthesis of evidence, and the dissemination and implementation of dissemination and implementation of evidence-based recommendationsevidence-based recommendations

P/CM PortfolioP/CM PortfolioStrategic GoalsStrategic Goals

2.2. Support the evidence base for and Support the evidence base for and implementation of activities to improve implementation of activities to improve primary care and clinical outcomes primary care and clinical outcomes through:through:

Health care redesignHealth care redesign Clinical-community linkagesClinical-community linkages Self management supportSelf management support Integration of health information technologyIntegration of health information technology Care coordinationCare coordination

AHRQ’s GoalAHRQ’s Goal

To understand whether fostering linkages To understand whether fostering linkages between between clinical clinical practices and community practices and community organizations enhances delivery of organizations enhances delivery of preventive services and ultimately improves preventive services and ultimately improves health outcomeshealth outcomes

To understand how to foster and sustain To understand how to foster and sustain linkageslinkages

Potential Benefits of LinkagesPotential Benefits of Linkages

Creating sustainable linkages between primary care Creating sustainable linkages between primary care and community settings can be a WIN-WIN-WINand community settings can be a WIN-WIN-WIN Patients: Increased patient access to preventive and Patients: Increased patient access to preventive and

chronic care serviceschronic care services Clinicians: Ability to refer out to services in the setting Clinicians: Ability to refer out to services in the setting

where their patients live, work, and play where their patients live, work, and play Communities: The services that they work hard to provide Communities: The services that they work hard to provide

will get used more, leading to better care and potentially will get used more, leading to better care and potentially sustained funding sustained funding

Community settings have the ability to offer intense, Community settings have the ability to offer intense, ongoing, accessible services that may not be ongoing, accessible services that may not be possible in primary care practicespossible in primary care practices

AHRQ’s ActivitiesAHRQ’s Activities

Co-sponsor of Co-sponsor of Prescription for HealthPrescription for Health First environmental scan and summit 2008First environmental scan and summit 2008 2009-20102009-2010

– Environmental scanEnvironmental scan

– Case studiesCase studies

– Summit of stakeholders to develop a national strategy Summit of stakeholders to develop a national strategy for promoting linkagesfor promoting linkages

Development of Innovations Exchange page to Development of Innovations Exchange page to facilitate the ongoing collaborative work of facilitate the ongoing collaborative work of Summit participants and interested stakeholdersSummit participants and interested stakeholders

Conceptual Model for Linkages Conceptual Model for Linkages

Our InnovatorsOur Innovators

Wayne Action Teams for Community Health (WATCH);

Eastern Carolina College of Nursing

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Centers for Disease Control and Prevention

(CDC)

Colorectal Cancer Screening and Tobacco Cessation in a Free Primary

Care Program for the Uninsured

Carol Ann King, DNP, FNP-BCCarol Ann King, DNP, FNP-BCWATCH Lead Nurse PractitionerWATCH Lead Nurse Practitioner

Clinical Assistant ProfessorClinical Assistant ProfessorEast Carolina University College of NursingEast Carolina University College of Nursing

What is WATCH?What is WATCH?Wayne Action Teams for Community Health Wayne Action Teams for Community Health

Grant and donation-funded since 2000Grant and donation-funded since 2000 Safety net primary health care for the Safety net primary health care for the

uninsureduninsured No charge to the patientsNo charge to the patients Over 10,000 registered patientsOver 10,000 registered patients 1,000 patient visits per month1,000 patient visits per month

WATCH Mobile UnitWATCH Mobile Unit

North Carolina Prevention Collaborative

Joint project with Kate B. Reynolds Charitable trust, Joint project with Kate B. Reynolds Charitable trust, UNC Dept. of Family Medicine, Wake AHECUNC Dept. of Family Medicine, Wake AHEC

1 year quality improvement program 1 year quality improvement program Improvement of office systemsImprovement of office systems CRC screening —only 16% screenedCRC screening —only 16% screened Tobacco use very prevalent with high risk population—Tobacco use very prevalent with high risk population—

40% use tobacco, only 66% offered tobacco cessation 40% use tobacco, only 66% offered tobacco cessation

Why Colorectal Cancer and Why Colorectal Cancer and Tobacco Use?Tobacco Use?

CRC: Third leading cancer diagnosis in 2009CRC: Third leading cancer diagnosis in 2009– 90% survival if localized90% survival if localized– 68% survival if regional68% survival if regional– 10% survival with distant metastasis10% survival with distant metastasis

Deaths can be reduced by 33% with CRC screening Deaths can be reduced by 33% with CRC screening beginning at 50 (CDC)beginning at 50 (CDC)

Socioeconomic and racial disparitiesSocioeconomic and racial disparities High rates of tobacco related mortality and morbidityHigh rates of tobacco related mortality and morbidity Can we do the screening and interventions Can we do the screening and interventions

necessary to address these issues?necessary to address these issues?

Evidence for InterventionsEvidence for Interventions

Three options: fecal occult blood tests, sigmoidoscopy, & Three options: fecal occult blood tests, sigmoidoscopy, & colonoscopycolonoscopy

Annual three-card FOBTs done on 3 different samplesAnnual three-card FOBTs done on 3 different samples Referral for positive resultsReferral for positive results Tobacco assessmentTobacco assessment Stages of Change Model/PDSA CycleStages of Change Model/PDSA Cycle Multilevel interventionsMultilevel interventions

PartnershipsPartnerships

StaffStaff PatientsPatients Local ProvidersLocal Providers HospitalHospital NC State NC State

ResourcesResources

YMCAYMCA

– In-house In-house clinicclinic

– Mutual GoalsMutual Goals

– Access to Access to mutual mutual servicesservices

– CounselingCounseling

PartnershipsPartnerships

Population investmentPopulation investment Overall community cost savingsOverall community cost savings Building capacityBuilding capacity Mutual benefits and goMutual benefits and goalsals

RecommendationsRecommendations

Promote your Promote your programprogram

OutcomesOutcomes Integrate into the Integrate into the

communitycommunity Help others with Help others with

their goalstheir goals

Discussion/ImplicationsDiscussion/Implications

WATCH able to WATCH able to implement CRC implement CRC screeningscreening

CRC Risk CRC Risk Reduction Reduction EducationEducation

Tobacco cessation Tobacco cessation and reduction and reduction focusfocus

Committed to the Committed to the endend

Trial and errorTrial and error CommitmentCommitment Integrated into Integrated into

existing workflowexisting workflow Policy and Policy and

procedureprocedure

Lessons LearnedLessons Learned

Communicate!Communicate!Revised patient instructionsRevised patient instructionsTrainingTrainingTake advantage of opportunity to screen and Take advantage of opportunity to screen and

educateeducatePatients “buy-in” because provider recommended Patients “buy-in” because provider recommended

No Such Thing as “Free Care”No Such Thing as “Free Care”

$773 for the $773 for the samplesample

$3,500 annually$3,500 annually $1600 staffing for $1600 staffing for

samplesample $8,000 annually$8,000 annually $11.87 per patient$11.87 per patient $475 per polyp $475 per polyp

detectiondetection

Case PresentationsCase Presentations

56 year-old male:56 year-old male: Never screened, no known risks, symptoms or signs, positive FOBTNever screened, no known risks, symptoms or signs, positive FOBT Precancerous polyps removedPrecancerous polyps removed

45 year-old female45 year-old female:: 30 year smoker, 2 packs/day30 year smoker, 2 packs/day Quit and remains tobacco-freeQuit and remains tobacco-free YMCA full membershipYMCA full membership

SustainabilitySustainability

Build costs into Build costs into budgetbudget

Find community Find community partnerspartners

Local, state, and Local, state, and federal resourcesfederal resources

Multiple staff Multiple staff trainedtrained

RemindersReminders Time and repetitionTime and repetition

LaTonya Chavis Keener, MSLaTonya Chavis Keener, MS

RACIAL AND ETHNIC APPROACHES TO

COMMUNITY HEALTH

RACIAL AND ETHNIC APPROACHES TO

COMMUNITY HEALTH

Cooperative Agreement U50DP422161-05

To eliminate disparities in health status experienced by racial and ethnic minority populations in key areas

Goals for REACH 2010Goals for REACH 2010

Focus: Cardiovascular Disease & DiabetesFocus: Cardiovascular Disease & Diabetes Based on disease prevention strategiesBased on disease prevention strategies NW Area of Charlotte (approximately 14 NW Area of Charlotte (approximately 14

defined neighborhoods)defined neighborhoods) 95% African American95% African American

Coalition PartnersCoalition Partners

Carolinas Healthcare System University Park Neighborhood Association Mecklenburg County Health Department Cluster I Neighborhood Leadership McCrorey Family YMCA Substance Abuse Prevention Services, Inc. North Carolina Department of Health and Human

Services

Risk Factor Reduction

Participation in Regular Exercise

Smoking Cessation

Blood Pressure

Reduction

Smoking

Cholesterol Reduction

Lay Health Advisors

Educate, Motivate, Recruit, Reinforce

-Enhanced access-Community campaigns-Point of decision prompts-Social Support

-Faith-based settings-Smoking bans-Media Campaigns

Healthy Dietary Habits

-Community Campaigns-Point of Contact Interventions-School Standards

Weight Reduction

Community-Based Primary Prevention Interventions

BehaviorChanges

RiskFactorReduction

-Disease Management

-Quality Improvement

Use of Primary Medical Care

Interventions

““But what it did for me is….help me with my self-esteem. It helped But what it did for me is….help me with my self-esteem. It helped me! I began to exercise, I started at the Y too. I came down here me! I began to exercise, I started at the Y too. I came down here for my financial reasons, I came down here because they have the for my financial reasons, I came down here because they have the

same things down here as they do at the Y, and I exercise, I learned same things down here as they do at the Y, and I exercise, I learned about nutrition because we have the nutritional program here, and about nutrition because we have the nutritional program here, and I’m a lot more outgoing. You would never believe that I was very, I’m a lot more outgoing. You would never believe that I was very,

very, very introverted, very.”very, very introverted, very.”

- Neighborhood Resident- Neighborhood Resident

Neighborhood Farmer’s Market

““It’s just like a meeting place on Saturday It’s just like a meeting place on Saturday mornings, you know, everybody be up there on mornings, you know, everybody be up there on

Saturday mornings to get your little Saturday mornings to get your little vegetables, you stand around and talk. vegetables, you stand around and talk.

Somebody will give you advice on how to cook Somebody will give you advice on how to cook them.”them.”

- Neighborhood Farmers’ Market Customer- Neighborhood Farmers’ Market Customer

Percent Reporting Diabetes

0

5

10

15

20

25

Percent

Males 17.8 19.3 21 19 23.3

Females 17.7 15.7 19 21.1 17.8

Total 17.7 16.9 19.8 20.2 19.9

Year 1 Year 2 Year 3 Year 4 Year 5

Data Analysis by National Opinion Research Center (NORC) and ABT

Increased knowledge of diabetes & community resourcesIncreased knowledge of diabetes & community resources Healthier eating habits (5 or more servings of fruits & Healthier eating habits (5 or more servings of fruits &

vegetables per day)vegetables per day) Greater physical activityGreater physical activity Decrease in reported complications Decrease in reported complications Greater adherence to recommendations for eye examsGreater adherence to recommendations for eye exams Mixed success in adherence to recommendations for foot Mixed success in adherence to recommendations for foot

examsexams

Impact of Charlotte REACH Impact of Charlotte REACH 2010 on Diabetes:2010 on Diabetes:

Data Analysis by National Opinion Research Center (NORC) and ABT

Neighborhood-operated Farmers’ Market remains in community

Diabetes Nurse position maintained at Carolinas Healthcare System

Lay Health Advisors and neighborhood leaders continue to lead efforts

Sustainability

““I think overall I think of the community at large, all I think overall I think of the community at large, all over everyone is encouraging better health, exercise, over everyone is encouraging better health, exercise,

eating better, and the fact that we encourage friends and eating better, and the fact that we encourage friends and family to come, you know, is a real plus, and I think it’s family to come, you know, is a real plus, and I think it’s

like a snowball effect the more we talk about it, the like a snowball effect the more we talk about it, the better we look. As you said we got to walk the walk to better we look. As you said we got to walk the walk to talk the talk, and by losing weight, health, and people talk the talk, and by losing weight, health, and people

commenting, you know, it does make a difference.”commenting, you know, it does make a difference.” - Charlotte REACH LHA - Charlotte REACH LHA

http://www.annfammed.org/cgi/content/full/2/2/103

Additional InformationAdditional Information

Innovator Contact Innovator Contact InformationInformation

Carol Ann King: Carol Ann King: kingca@ecu.edu LaTonya Chavis Keener: LaTonya Chavis Keener:

lchavis@cdc.gov lchavis@cdc.gov

The Innovations ExchangeThe Innovations Exchange

Visit our Web site:Visit our Web site:

http://www.innovations.ahrq.gov/

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