Adams County Community Wellness Program

State: WI Type: Promising Practice Year: 2015

:

The Adams County Community Wellness Program is designed to expand culturally appropriate chronic disease prevention education and navigation services in order to reduce morbidity and mortality from chronic disease in Adams County, WI.  The use of community health workers and health navigators has been shown to be critical in successfully addressing health disparities.  Implementation of an evidence-based model for chronic disease prevention and management will expand options for communities, like Adams County striving to reduce their burden of chronic disease.  By offering a balance of population level strategies and individual intervention, the Community Wellness Program has the potential to reach a majority of the Adams County residents who are at risk for, or diagnosed, with one or more chronic diseases, and offers a unique, program tailored to address the needs of the small rural community.

Adams County, WI consistently ranks in the bottom five Wisconsin counites in the County Health Rankings.
Adams County residents also have high rates of obesity, tobacco use, and inadequate physical activity; all significant factors in the development of chronic disease.

:
Adams County Health & Human Services Department
:
Adams County Community Wellness Program
Adams County faces higher than average premature deaths than the state due to chronic diseases such as cancer, diabetes and heart disease. Adams County consistently ranks in the bottom five Wisconsin counties in the County Health Rankings. In addition, adult county residents self-report that they experience fair or poor health at a rate higher than the statewide average. Adams County residents also have high rates of obesity, tobacco use and inadequate physical activity—all significant factors in the development of chronic disease. The overarching goal of the Adams County Community Wellness Program is to expand culturally appropriate chronic disease prevention education and navigation services in order to reduce morbidity and mortality from chronic disease in Adams County. To achieve this goal, four broad objectives were developed: 1) Increase adoption of chronic disease prevention behaviors, use of screening and access to quality care2) Improve access to voluntary support organizations and health care systems3) Increase program recipient knowledge and decision-making capacity4) Develop a self-sustaining Adams County Community Wellness Program Continuing and building upon the community and academic partnership already established in previous projects, the Adams County Cancer Awareness Team (ACCAT), with guidance from the Adams County Public Health Officer and the UW Carbone Cancer Center Outreach Specialist, used an evidence- based model that has been shown to be critical in successfully addressing health disparities, to develop the Adams County Community Wellness Program. The program is implementing population prevention and individual intervention strategies through a community health worker (CHW) and a health navigator (HN). The CHW and HN were hired in summer 2013 and began delivering services in October 2013. Substantial progress has been achieved in meeting all four program objectives. In addressing the first objective, the HN has interacted with a total of 97 clients.  She made referrals to several different agencies or resources. Follow-up telephone calls were made to the clients as needed. Educational materials were provided to the clients on a variety of chronic disease and other issues (such as transportation, advanced directives, and medications). The CHW began presenting educational sessions focusing on chronic diseases and available community resources. As of October 31, 2014, 18 sessions have taken place with 180 documented participants. Both the HN and CHW have developed a methodology to measure actual increased adoption of chronic disease prevention behaviors. Progress in meeting the second objective can be shown through the identification of barriers that clients face in accessing health care and other support systems. The HN works with clients to identify specific barriers, discusses how to address the barrier, and provides referrals to agencies and programs. The CHW discusses available support and health care resources during her presentations. In addition, the project team developed a detailed list of county resources to help identify available services. In addition to holding educational sessions on a wide variety of subjects, including a shortened Cancer Clear & Simple curriculum, and working with clients to identify barriers, risk factors and making referrals, progress toward meeting the third program objective can also be measured by participant and client satisfaction with the CHW sessions and HW interactions. Satisfaction surveys completed by attendees at the CHW session have been positive, and attendees indicated they learned more about chronic diseases and a healthy lifestyle, and learned more than they expected to learn. The project team has developed a similar satisfaction form for the HN’s clients. To develop a self-sustaining Adams County Wellness Program, needing limited county funding, the community partners and the project team have already identified activities that will be carried out during the course of the program. These include: developing a broader list of partners and organizational stakeholders and meeting with them; publicizing the program through various media; identifying private sources of funding or other payers as well as which CHW and HN services are coordinated with other county or local services to both avoid duplication and perhaps share costs; and identifying possible fiscal sponsors and their wellness needs and interest in the Community Wellness Program. Finally, progress made can also be measured by identifying and resolving problems and barriers that develop.    
Health disparities, most often associated with urban ethnic and racial populations, persist in rural America as well. Geographic isolation, low socio-economic status, poor health risk behaviors, and limited job opportunities contribute to health disparities in rural communities.  Wisconsin is a primarily rural state. There is extensive evidence that being removed from population centers creates unique health, and health care, needs.  In Wisconsin, chronic disease morbidity and mortality are higher in rural communities than non-rural communities.  Chronic disease risk behaviors, such as smoking and obesity, are more prevalent in the state’s rural communities, while, on average, rural residents have lower income and educational levels and are less likely to be insured. Chronic disease has an enormous impact on quality of life within our state: seven of the ten leading causes of death are a result of chronic disease.  In addition to years of life lost, chronic disease can be disabling for the individuals and costly to manage for families, communities and the state. Adams County faces higher than average premature deaths than the state due to chronic diseases such as cancer, diabetes and heart disease.  Adams County consistently ranks in the bottom five Wisconsin counties in the County Health Rankings. In addition, adult county residents self-report that they experience fair or poor health at a rate higher than the statewide average. Adams County residents also have high rates of obesity, tobacco use and inadequate physical activity—all significant factors in the development of chronic disease.  Adams County, like much of Wisconsin, is a rural, farming community. Adams County is the second poorest county in the state: the 2009 median household income of $38,192 is far below the state average of $51,257. Only 6.4% of persons over age 25 hold a bachelor’s degree compared to the state average of 17.1%. Years of formal education correlate strongly with improved work and economic opportunities, reduced psychosocial stress, and healthier lifestyles. Poverty can result in negative health consequences, such as increased risk of mortality and increased prevalence of disease, depression, domestic violence, and poor health behaviors. When compared to their urban counterparts, rural populations also experience poorer access to healthcare services due to affordability, proximity, and quality.  Access to healthcare in rural areas like Adams County is an on-going problem compounded by geographic isolation, limited public transportation and few physicians, clinics and hospitals per capita. Access to care was rated a “great or the greatest health concern” by 79% of respondents in the 2011 Community Survey conducted by the Adams County UW- Extension Office. Adams County has been designated a Primary Care Health Professional Shortage Area (HPSA) by the Health Resources and Services Administration. This ranking reflects a primary care provider to resident ratio of at least 3,500 to 1. The proportion of adults reporting that they could not see a doctor in the past 12 months due to cost was 14% in Adams County, compared to the statewide average of 9%. Until recently, health care systems in the United States often lacked a unified approach to prevent and manage chronic disease. Recent efforts have been made to close this gap through various calls for increased collaboration between public health and health care systems to better coordinate provision of services and programs. Currently, the extent to which the public health workforce has responded is relatively unknown.The Adams County Community Wellness Program builds upon the community’s work with the University of Wisconsin Carbone Cancer Center (UWCCC). In 2011, leaders from Adams County Public Health, Adams County Aging, Adams County UW- Extension and Moundview Memorial Hospital and Clinics partnered with the UWCCC and formed the Adams County Cancer Awareness Team (ACCAT). Together, ACCAT and the UWCCC launched a pilot project to improve cancer prevention in the county by developing and testing accessible and culturally appropriate cancer education materials focused on prevention and early detection.  The pilot project involved the establishment of a community-academic partnership and the development of a comprehensive, collaborative evaluation plan. ACCAT members also conducted a county-wide campaign to engage local leaders and organizations in health improvement illustrate the potential impact of a positive, community-driven partnership and promote the pilot project. The pilot project’s independent evaluation revealed a critical unmet need:  to implement a more intensive and sustainable effort that comprehensively addressed chronic disease disparities and promoted a vision of community wellness in Adams County. Local leaders and organizations voiced the importance of improving chronic disease awareness, increasing prevention and screening behaviors, promoting informed patient decision-making and increasing access to care. Furthermore, leaders also recognized the number and value of the many voluntary support organizations in Adams County, while calling for more coordination and alignment among them. The success of the pilot project and the community-academic partnership has increased the capacity of Adams County community leaders, and laid the foundation for implementing a promising, sustainable, evidence-based intervention to comprehensively address chronic disease disparities in Adams County.  In July of 2013 the Adams County Community Wellness Program (ACWP) was launched thus providing Adams County with a Nurse Navigator who ‘bridges the gap’ by serving as a link to available resources for the patient, these resources include: connecting people to support services, providing educational resources, guiding patients thru the health care system, Improving the quality of their care, extending or even saves lives. In addition, the Community Health Worker provides educational sessions which address prevention of the modifiable risk factors of chronic disease which include tobacco, cardiovascular health, unhealthy lifestyles, and screenings.  The ACWP used the Guide to Community Preventive Services which provided guidance in the quest to create an evidence-based program. In Adams County, which has an adult population of 17,400, the ACWP reached a total of 1149 people (6.6%). Community Wellness Programs are new to the field of public health.   High rates of chronic diseases, like diabetes and heart disease, are among the biggest drivers of U.S. health care costs. More than half of all Americans currently live with one or more chronic disease, including heart disease, stroke, diabetes and cancer, many of these are preventable.  Therefore, the Adams County Community Wellness Program is a win-win way to make a real difference in improving the health of Adams county residents.    The Adams County Community wellness Program is making the connection between improving health and improving the economy. The Adams County Community Wellness Program is evidence-based as identified in the Guide to Community Preventive Services.  
Nutrition, Physical Activity, and Obesity|Tobacco
The overarching goal of the Adams County Community Wellness Program is to expand culturally appropriate chronic disease prevention education and navigation services in order to reduce morbidity and mortality from chronic disease in Adams County. To achieve this goal, four broad objectives were developed: 1) Increase adoption of chronic disease prevention behaviors, use of screening and access to quality care;2) Improve access to voluntary support organizations and health care systems;3) Increase program recipient knowledge and decision-making capacity; and4) Develop a self-sustaining Adams County Community Wellness Program. In 2011, leaders from Adams County Public Health, Adams County Aging, Adams County UW- Extension and Moundview Memorial Hospital and Clinics partnered with the UWCCC and formed the Adams County Cancer Awareness Team (ACCAT). Together, ACCAT and the UWCCC launched a pilot project to improve cancer prevention in the county by developing and testing accessible and culturally appropriate cancer education materials focused on prevention and early detection.  The pilot project’s independent evaluation revealed a critical unmet need:  to implement a more intensive and sustainable effort that comprehensively addressed chronic disease disparities and promoted a vision of community wellness in Adams County. The use of community health workers and health navigators has been shown to be critical in successfully addressing health disparities. Implementation of an evidence-based model for chronic disease prevention and management will expand options for disparate communities striving to reduce their burden of chronic disease.This proposal aligns with Healthier Wisconsin 2020 pillar objectives to increase resources to eliminate health disparities and improved and connected health system services, as well as several HW 2020 infrastructure focus areas: access to high-quality health services, health literacy, collaborative partnerships for community health improvement, and public health research and evaluation. This project’s primary health focus area is chronic disease prevention and management. This project meets the following WPP guiding principles: prevention of chronic disease, partnership with community organizations and academic partners, responsiveness to needs identified during our current pilot project concerning chronic disease prevention, and effectiveness through the use of evidence-based programs.By offering a balance of population level prevention strategies and individual intervention, the Community Wellness Program has the potential to reach a majority of the county’s residents who are at risk for, or diagnosed with, one or more chronic diseases, and offers a unique, sustainable program tailored to address the needs of smaller rural counties. The Adams County Community Wellness Program applies to both community and individual-level chronic disease prevention and management strategies through the integration of evidence-based Community Health Worker and Health Navigator functions. By offering a balance of population level prevention strategies and individual intervention, the Community Wellness Program has reached 6.6% of the county’s 17,400 adult residents who are at risk for, or diagnosed with, one or more chronic diseases, and offers a unique, sustainable program tailored to address the needs of smaller rural counties. The need for chronic disease prevention in our state is widely recognized. “Chronic Disease Prevention and Management” is one of 23 key health focus areas of Healthier Wisconsin 2020. Our project most directly addresses objectives 2 and 3:Objective 2 - Increase access to high-quality, culturally competent, individualized chronic disease management among disparately affected populations. The Community Wellness Program serves all Adams County residents and seeks to reduce barriers and connect rural residents to timely, quality care. Objective 3 - Reduce the disparities in chronic disease experienced among populations of differing races, ethnicities, sexual identities and orientations, gender identifies, and educational or economic status. The Adams County Community Wellness Program addresses health disparities by increasing residents’ awareness and practice of chronic disease prevention behaviors, increasing their decision making capacity and improving access to health resources and supportive care. In addition, the Adams County Community Wellness Program addresses other HW 2020 infrastructure focus areas: access to high-quality health services, improving health literacy, building collaborative partnerships for community health improvement, and advancing public health research and evaluation. Any Adams county resident over the age of 18 is eligible for the Adams County Wellness Program.  Adams County Health and Human Services, county board, hospitals, employers, businesses, clinics, aging and disability resource center, community organizations and other community stakeholders are actively involved with the Adams County Community Wellness Program. Adams County Health and Human Services and its Academic Partners from the UW Carbone Cancer Center recieved $398,166 for a 3-year large-scale implementation grant through the Wisconsin Partnership Program to implement the Adams County Community Wellness Program.  Budget breakdown as noted in the Community-Academic Partnership Fund Development & Implementation Application dated:09/06/2012  Year 1 Expense paid through UW, salary $21,153, fringe benefits $8,673, Travel $340,total $30,165. Paid through Organization salary $63,835, fringe benefits $37,734, travel$715, supplies $500, total budget $102,784.  Year 2 Paid through UW, Salary $14,701, fringe benefits $6,027, travel $746, total budet $21,474. Paid through Organization, salary $65,750, fringe benefits $38,866, travel $902, supplies $500, total budget  $106,018. Year 3 Paid through UW, Salary $19,704, fringe benefits $8,079, travel $764, total budet $28,547. Paid through Organization, salary $67,723, fringe benefits $40,032, travel $925, supplies $500, total budget $109,179. TOTAL: Paid through UW, Salary $55,557, fringe benefits $22,779, travel $1,850, total budget $80,185. Paid through Organization, salary $197,308, fringe benefits $116,631, travel $2,542, supplies $1,500, total budget $317,981.  PROJECT TOTAL: Salary $252,865, fringe benefits $139,410, travel $4,391, total budget $398,166
The overarching goal of the Adams County Community Wellness Program is to expand culturally appropriate chronic disease prevention education and navigation services in order to reduce morbidity and mortality from chronic disease in Adams County. To achieve this goal, four broad objectives were developed:1) Increase adoption of chronic disease prevention behaviors, use of screening and access to quality care;2) Improve access to voluntary support organizations and health care systems;3) Increase program recipient knowledge and decision-making capacity; and4) Develop a self-sustaining Adams County Community Wellness Program. Substantial progress has been made in achieving all four program objectives as described below:1)The nurse navigator has interacted with a total of 97 clients and provided these individuals with advice or a community resource. Referrals on were made on the clients behalf to agencies and resources. Medical appointments were made for clients as well as follow-up telephone calls. Clients were provided educational materials on a variety of chronic disease and other health issues. Increased disease prevention behavior changes, health screenings and access to quality care have been documented. The community health worker reached 180 participants through educational sessions. In addition, the community wellness program team has reached 872 additional Adams County residents. 2)Progress in meeting the second objective can be shown through the identification of barriers that clients face in accessing health care and other support systems. The nurse navigator works with clients to identify specific barriers, discusses how to address the barrier, and provides referrals to agencies and programs. Voluntary support organizations were enlisted to provide drivers to transport clients to medical appointments. Help for clients was achieved by reaching out to local organizations that assisted clients with basic needs such as assistance with laundry, emotional support and house cleaning. Furthermore, health care providers and facilities were engaged through meetings and communication. The community health worker reached out to local community groups which resulted in three educational sessions reaching 72 additional Adams County residents. The community wellness program developed a detailed list to help identify available services. Discussions about available support and health care resources are provided during educational sessions and during client interactions. 3) The nurse navigator was able to increase clients’ knowledge and decision making capacity by providing education and information, which is documented after visits with clients and through surveys returned. Recipient knowledge was evaluated via a comment form distributed by the community health worker at educational sessions. All data was sent to a research evaluator. The objectives are being met through trial and error. Ongoing revisions are the norm. The program has been evaluated on an ongoing basis, beginning even before its implementation. Evaluation and program staff developed a project work plan and a detailed evaluation plan to measure the program’s effectiveness based on community perception, utilization, and impact. Data are collected by the Community Health Worker and the Nurse Navigator based on their activities and interactions with educational session attendees; clients; and community members, such as employers, hospital and clinic staff, county health staff, and others, who can play a role in the implementation of the program. The evaluator summarizes the data and prepares reports for program staff and other interested parties. Performance measures, along with expected outcomes, include:The successful development of the Adams County Community Wellness Program will result in:• Hiring and training of the community health worker and the nurse navigator• Identification of barriers to care (measured by interviewing clients)• Increased community partners awareness of barriers (measured by interviews with community partners)• Identification of and access to local resources, relevant health promotion curricula, voluntary support organizations, and local health care providers (measured by interviews with community partners, agencies, program staff)• Effective coordination of Adams County Community Wellness Program services with other county programs (measured by referrals to and from county services as well as interviews/discussions with county program staff)The successful implementation of the Adams County Community Wellness Program will result in:• Integration of evidence-based practices to address and reduce identified barriers to care (measured by the nurse navigator’s record of interaction with the clients and subsequent survey of clients six months post service)• Increased program staff knowledge and utilization of local resources, relevant health promotion curricula, voluntary support organizations and health care systems (measured by interviews regarding the effectiveness of training provided to the community health worker and nurse navigator and interviews with program staff)• Utilization of the Adams County Community Wellness Program (measured by number of attendees, clients, demographic information collected by program staff, etc.)• Increased knowledge of the Adams County Community Wellness Program and its services among Adams County residents, community partners, health care providers, county employers, etc. (measured by surveys of educational session attendees and nurse navigator notes of discussions with clients, and interviews)• Increased knowledge of chronic disease prevention behaviors among Adams County residents, community partners, health care providers, county employers, etc. (measured by surveys of educational session attendees and nurse navigator notes of discussions with clients, and interviews)• Adams County Community Wellness Program recipient satisfaction (measured by satisfaction survey conducted after educational session and interaction with nurse navigator)The longer term outcome measure that we hope will show improvement is behavior change that results in the lowering of the rate of chronic disease in Adams County. Additionally, a sustainable Community Wellness Program will be possible through coordination of the Program’s services with other services provided in the community and collaboration with clinical providers.No modifications have been made to the practice as a result of the data findings. However, program and evaluation staff are constantly monitoring the implementation of the program and ensuring that complete and accurate data are being collected so that the program can be tracked and outcomes evaluated.
LESSONS LEARNED Nurse Navigator: Better data collection tools Assemble outreach packets Need better understanding of Health & Human Services organizational structure and how referrals should be made To establish a Health Care Provider protocol    Community Health Worker: Educational sessions should not be planned when the temperatures are extreme Presentation sites should be visited in advance Community wellness program: Flexibililty in: Forms and data collection tools information requested identify "important" topics for educational sessions scheduling Collaborate with clinical providers Publicize program in more "health care agencies"   To develop a self-sustaining Adams County Wellness Program, needing limited county funding, the community partners and the project team have already identified activities that will be carried out during the course of the program. These include: developing a broader list of partners and organizational stakeholders and meeting with them; publicizing the program through various media; identifying private sources of funding or other payers as well as which CHW and HN services are coordinated with other county or local services to both avoid duplication and perhaps share costs; and identifying possible fiscal sponsors and their wellness needs and interest in the Community Wellness Program. The following stakeholder have utilized the community wellness program: Adams County Public Health Department Adams County Aging Unit Adams County UW-Extension Adams County Health and Human Services Moundview Memorial Hospital and Clinics ADRC Mile Bluff Riverview Hospital Villa Pines The long-term objective is an Adams County Community Wellness Program which would provide a cost- share agreement and/or contracts to provide wellness programs; cost saving analysis for county government and large county employers for utilization of health navigator and community health worker; analysis of alternative sources of funding including billing for services to insurance could exist through the coordination of all community partners.  Sustainability is integral to a successful program. Sustainability of the Community Wellness program requires evidence of an increase in wellness behaviors, participant satisfaction and reduced morbidity and broad-based community awareness and support, but in the end, it will depend upon documented health care cost-savings. Community partners recognize that including a cost analysis is an essential component of the Community Wellness Program. The cost analysis and other evidence of sustainability is being shared with the county board, local hospital, employers, and other community stakeholders. Plans call for the Community Wellness program to be coordinated with other programs offered through Adams County Health and Human Services, and the possibility to bill Medicare and Medicaid exists for those who are eligible.  Additional revenue sources will be also investigated over the course of the project.  Finally, the possibility of a cost-share agreement exists through the coordination of currently funded charity programs to the benefit of all community partners.  
Colleague in my LHD
 
Processing...


Driving Walking/Biking Public Transit  Get Directions