2015 Community Health Needs Assessment Implementation Strategy Update

2015 Community Health Needs Assessment Implementation Strategy Update

2015 Community Health Needs Assessment Implementation Strategy Update October 2017 The Mission Effectiveness Road Map Stefani S. McAuliffe Director, Mission Integration UPMC Pinnacle OBJECTIVES What programs is Mission Effectiveness currently providing? Why Mission Effectiveness provides these programs? Where is Mission Effectiveness going with these programs? 56 883 2 34 654 Priority #1: Access to Health Services Primary Care GOAL: Strengthen access to provider-based services and supportive services, and increase the utilization of healthcare services by community members.

STRATEGY: Provide Insurance Enrollment Specialists and Financial Aid Counselors to uninsured Adults and children in appropriate insurance plans. UPDATE: Two Insurance Enrollment Specialists work with inpatient staff and community based partners to identify uninsured patients or potential patients. 53 MA Applications submitted; 36 MA Applications Approved (8/31/17) Established 10 monthly appointment days at community based organizations STRATEGY: Optimize the patient centered medical home UPDATE: Provide Home Visits to High Risk Populations 223 Enrolled in Home Visit Program Increased % of HVP patients A1c <8 by 2.5% Priority #1: Access to Health Services Primary Care GOAL: Strengthen access to provider-based services and supportive services, and increase the utilization of healthcare services by community members (contd). STRATEGY: Collaborate with Community health centers and clinics to coordinate care to uninsured, underinsured, and diverse populations. UPDATE: Weekly care coordination meetings between UPMC Pinnacle Community Health Navigation Team and Hamilton Health and Kline Health Center staff to review cases of high utilization and acuity. Indigent Care Fund provides $20,000 worth of diagnostic services to free clinics in the service area ~ Beacon Clinic, Bethesda Mission, Community Check Up Center, Hamilton Health Center, Hope Within, Mission of Mercy Insurance Enrollment Specialists and Social Worker have established a monthly schedule to go to free clinics to identify social determinants of health and enroll uninsured into appropriate health plans. Priority #1: Access to Health Services Primary Care GOAL: Strengthen access to provider-based services and supportive services, and increase the utilization of

healthcare services by community members (contd). STRATEGY: Collaborate with Community health centers and clinics to coordinate care to uninsured, underinsured, and diverse populations. UPDATE (continued) : UPMC Pinnacles Chief Diversity Officer has developed series of Diversity and Inclusion educational sessions including: Lets Talk: A Conversation About Race; The Ideal LGBT Patient and Family Experience: Policy to Practice; Beyond the Binary: A Look at the Transgender Life and the Special Needs of a Trans-patient; Optimizing Care for our Muslim Patients Somali Culture & Healthcare Embracing Diversity to Achieve Equitable Inclusion (Diversity Level Set Training) Priority #1: Access to Health Services Specialty Care GOAL: Strengthen access to specialty provider-based services and supportive services, and increase the utilization of healthcare services by community members. STRATEGY: Increase heart and stroke health education and screenings through community outreach activities UPDATE : 2016-2017 there was a 2.3% increase in patients seeking emergent stroke care within the 2 hour symptom onset. Education was provided at the Hill Church, Masonic Lodge, the Heart Walk and Fort Indiantown Gap PinnacleHealth conducts monthly Stroke Support Group education sessions to help survivor(s) and care givers learn about their stroke and how to manage the disease A Pharmacist provided education on common stroke medications, Nutrition: diet and healthy meal planning, Panel discussion with Neurology health care providers, Cardiologist for Heart Health, Speak Out (survivors and care givers voice their personal challenges) Tai Chi (for balance, endurance & relaxation). Heart Failure Program maintains a vegetable and herb garden that is used to teach about low-sodium seasonings for foods and healthy food choices. Heart Failure Program have bi-weekly educational programs and host 3 events - Valentines, garden-party, holiday party Heart Failure program distributes blood pressure cuffs to educate patients on managing blood pressure.

Priority #1: Access to Health Services Specialty Care GOAL: Strengthen access to specialty provider-based services and supportive services, and increase the utilization of healthcare services by community members (contd). STRATEGY: Improve adult diabetic care UPDATE: Diabetes educators serve Kline patients at high risk with general diabetes information classes and 1:1 appointments Diabetes educators visit PHMG offices to provide education to patients who prefer to be seen at their family practice 1:1 appointments are available for patients who are not able to attend diabetes classes Patients with A1Cs > 9 are being called in an attempt to be seen by a diabetes educator. Implemented care coordination for patients with frequent hospitalizations and ED visits resulting in reduced utilization STRATEGY: Improve cancer care prevention UPDATE: PinnacleHealth focuses on prevention and treatment for various cancers, with centers located on the east and west shores of Harrisburg Priority #1: Access to Health Services Specialty Care GOAL: Strengthen access to specialty provider-based services and supportive services, and increase the utilization of healthcare services by community members (contd). STRATEGY: Because breast cancer is the second leading cause of cancer deaths among women, free mammograms will be offered to qualifying women 40 years of age and older UPDATE: PinnacleHealth will expand their Mammogram Voucher Program (MVP) to underserved & under insured women STRATEGY: Improve HIV/AIDS care UPDATE: REACCH program opened a Dental Clinic to provide comprehensive care to HIV/AIDS patients 250 Rapid HIV tests completed in community settings 90.13% viral load suppression rate in FY2017 ( baseline is 90.74%) Collaboration with Hamilton Health HOPE program

STRATEGY: Enhance TeleHealth in the region UPDATE: Telemedicine used in Home Visit Program for dental, oral surgery, podiatry, and wound care Priority #1: Access to Health Services Dental Care GOAL: Strengthen access to dental provider-based services, supportive services, and utilization of dental services by community members. STRATEGY: Increase utilization of the SMILES program to minimize dental care as a barrier to overall health status improvement and coordinate care of urgent dental needs with the Emergency Department UPDATE: SMILES program received 120 referrals from Pinnacle Emergency Rooms $9, 000 worth of free dental services provided by network of volunteer dentists Continue to work with Hamilton Health Center for ongoing dental care/Dental Home Refer patients to Christ Lutheran Church ~ free dental clinic Work with Downey School to increase utilization of school based dental clinic #of unique students seen increased 31% # of encounters increased in 28% Children and Teen clinic held a Gateway Mobil Dental day on site for three days 50 patients seen Priority #2: Behavioral Health Services Mental Health GOAL: Improve access to the best practices in screenings, assessment, treatment and support programs for mental health and child protection .. STRATEGY: Implement an integrated care model for behavioral health services: UPDATE : UPMC Pinnacle is working with PPI to grow a direct admit process Integrate PinnacleHealth Psychological Associates (PHPA) services into the PinnacleHealth Medical Group (PHMG) practices . STRATEGY: Enhance behavioral services for children in need UPDATE:

PPI opened a nine bed Childrens Mental Health Unit for ages 4-12 in November 2016 PPI continues increase awareness of psychological distress symptoms and risk factors for suicide and offers Mental Health First Aid trainings. Priority #2: Behavioral Health Services Substance Abuse GOAL: Provide residents with better access to the best practices in screening, assessment, treatment, and support programs for substance abuse disorders. STRATEGY: Educate the community on how to prevent prescription drug and opioid misuse, abuse, and overdose UPDATE : UPMC Pinnacle participates in South Central Opioid Collaborative with 9 regional hospitals, pharmacies, and several outpatient healthcare providers to promote common messaging; Opioid Summit on 9/15/17. Integrate PinnacleHealth Psychological Associates (PHPA) services into the PinnacleHealth Medical Group (PHMG) practices. UPMC Pinnacle participates in Task Force for Opioid Prescribing with the Partnership for Better Health STRATEGY: Develop inpatient and community based substance abuse education and treatment services UPDATE: UPMC Pinnacle opened the Center for Addiction Recovery in January 2017; have 62 patients to date PPI schedule to open Opiate Treatment Center in October 2017 Priority #3: Healthy Lifestyles Physical Activity GOAL: Increase opportunities for and engagement in physical activity . STRATEGY: Expand existing physical activity programs UPDATE : Updated Eat Smart Play Smart Program 6 preschool locations (5 in Harrisburg, 1 in Perry County); 116 students graduated 19.35% improvement of knowledge 4.41% improvement in behavior

Number of overweight students decreased by 2.7% 10 Major Walking and 5K Events available to UPMC Pinnacle employees East Smart Play Smart Analysis by Yijin Wert, MS Biostatistician of PinnacleHealth System August 3, 2017 Pre and Post Measurement of Nutrition Knowledge (Total Score=5) 4.5 4.1 4 3.5 3.7 3.8 3.7 3.2 3.1 3 2.7 2.7

HACC - AM HACC - PM 2.5 2 1.5 1 0.5 0 All three locations PRE Average Score All Three Locations (n=43) 19.35% Post Average Score Percent of Improvement from PRE to POST Period HACC-AM HACC-PM (n=15) (n=12) 37.04% Scott Headstart 18.52%

Scott Headstart (n=16) 7.89% Pre and Post Measurement of Behavior (Total Score=8) 7.6 7.4 7.2 7 6.8 6.6 6.4 6.2 6 5.8 7.4 7.2 7.1 6.8 7.3 6.8 6.6 6.4 All three locations HACC - AM

PRE Average Score All Three Locations (n=43) 4.41% HACC - PM Post Average Score Percent of Improvement from PRE to POST Period HACC-AM HACC-PM (n=15) (n=12) 8.82% Scott Headstart 3.12% Scott Headstart (n=16) 1.39% Summary Statistics of All Three Locations PRE Health Risk Healthy Underweight Overweight Obese

BMI Aerobic fitness Long jump Ball dribble One leg hold Nutrition knowledge Behavior knowledge Number 23 0 9 5 Average 16.58 5.8 27.2 2.4 6.7 3.1 6.8 Percent 62.16% 0.00% 24.32% 13.51% POST Number Percent 22

59.46% 1 2.70% 8 21.62% 6 16.22% Average 16.64 5.5 34.2 3.7 9.1 3.7 7.1 Difference between POST and PRE Percent of Improvement -2.70% 2.70% -2.70% 2.70% -4.3% n/a -11.1%

20.0% 0.06 -0.3 7 1.3 2.4 0.6 0.3 0.36% -5.17% 25.74% 54.17% 35.82% 19.35% 4.41% Summary Statistics HACC AM PRE Health Risk Healthy Overweight BMI Aerobic fitness Long jump Ball dribble One leg hold Nutrition knowledge Behavior knowledge

Number 11 4 Average 15.7 5.8 23.6 2.8 7.3 2.7 6.8 Percent 73.33% 26.67% POST Number Percent 12 80.00% 3 20.00% Average 15.61 5.9 37 4.2 11.7 3.7 7.4

Difference between POST and PRE Percent of Improvement 6.67% -6.67% 9.09% -25.00% -0.09 0.10 13.40 1.40 4.40 1.00 0.60 -0.57% 1.72% 56.78% 50.00% 60.27% 37.04% 8.82% Summary Statistics HACC PM PRE

Health Risk Healthy Underweight Overweight Obese BMI Aerobic fitness Long jump Ball dribble One leg hold Nutrition knowledge Behavior knowledge Number 10 0 0 2 Average 16.5 5.8 30.7 1.8 5.1 2.7 6.4 Percent 83.33% 0.00% 0.00%

16.67% POST Number Percent 8 66.67% 1 8.33% 1 8.33% 2 16.67% Average 16.4 6 34.7 3.8 5.8 3.2 6.6 Difference between POST and PRE Percent of Improvement -16.67% 8.33% 8.33%

0.00% -20.0% n/a n/a 0.0% -10.00% 0.2 4 2 0.7 0.5 0.2 -0.6% 3.45% 13.03% 111.11% 13.73% 18.52% 3.12% Summary Statistics Scott Headstart PRE Health Risk Healthy Underweight Overweight Obese BMI

Aerobic fitness Long jump Ball dribble One leg hold Nutrition knowledge Behavior knowledge Number 2 0 5 3 Average 18.1 5.8 28.3 2.5 7.8 3.8 7.2 Percent 20.00% 0.00% 50.00% 30.00% POST Number Percent 2 20.00%

0 0.00% 4 40.00% 4 40.00% Average 18.5 4.4 30.0 3.0 9.3 4.1 7.3 Difference between POST and PRE Percent of Improvement 0.00% 0.00% -10.00% 10.00% 0.0% n/a -20.0% 33.3%

0.4 -1.4 1.7 0.5 1.5 0.3 0.1 2.21% -24.14% 6.01% 20.00% 19.23% 7.89% 1.39% Priority #3: Healthy Lifestyles Inadequate Nutrition/Obesity STRATEGY: Increase opportunities for people to learn about and make healthy food choices. UPDATE: Continue the Power Pack Program 40,041 Power Packs provided to 3,081 students for 2016-2017 school year 39th Annual Childrens Health Fair 800 3rd graders attended Pre and post test results Launched Health Coach Pilot in June 2017 STRATEGY: Identify at-risk youth through school-based assessments and implement community nutrition education and obesity prevention programs. UPDATE: Conduct school-based assessments 7,163 Screenings completed during 12 weeks from August 30 November 18, 2016

2.388 dental screenings completed 5887 vision screened; 23% failed 2812 hearing screened; .2% failed PINNACLEHEALTH Childrens Health Fair 2017 Student Health Awareness Question PRE/POST Test Comparison Results Average Score PRE Test Average Score - POST Test Absolute Difference from PRE to POST School District Percent of Improvement School #1 79.13 84.54 5.41

6.84% School #2 36.09 44.67 8.58 23.76% School #3 74.79 85.05 10.26 13.72% School #4 75.62 82.86 7.24

9.57% School #5 75.42 82.98 7.56 10.02% School #6 74.52 84.59 10.07 13.52% Total 74.28 83.55 9.27 12.47%

Priority #3: Healthy Lifestyles Smoking Cessation GOAL: Increase access to evidence based smoking cessation and prevention programs. STRATEGY: Provide tobacco cessation programs UPDATE : Conduct UPMC Pinnacle smoking cessation lunch and learns Implement Text to Quit and Better Breathers Club STRATEGY: Provide tobacco prevention programs UPDATE: Utilize Healthy Lungs and Tar in a Jar stations STRATEGY: Conduct inpatient initiatives: UPDATE: PinnacleHealths inpatient COPD initiative Next Steps September 2017 Reached out to CHNA partners October 2017 Kick off Meeting Spring 2018 Assessment Process Summer 2018 Final Reports Due September 2018 Board Approves CHNA March 2019 Board Approves Implementation Strategy

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