Adams County Community Wellness Program

State: WI Type: Neither Year: 2016

:
:
:
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 care 2) Improve access to voluntary support organizations and health care systems 3) Increase program recipient knowledge and decision-making capacity 4) 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 University of Wisconsin (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 Nurse Navigator (NN).  To develop a self-sustaining Adams County Wellness Program while keeping in mind the 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; identifying private sources of funding or other payers; determining 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.    Adams County Wisconsin, local Public Health information can be found at the following website: http://www.co.adams.wi.gov/Departments/HealthHumanServices/PublicHealth/tabid/261/Default.aspx    
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 one of the poorest counties in the state:  the 2014 median household income of $42,241 is far below the state average of $51,063, only 12.1% of persons over age 25 hold a bachelor’s degree compared to the state average of 26.8%. 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 10,340 to 1 compared to the Wisconsin ratio of 1,215 to 1. The proportion of adults reporting that they could not see a doctor in the past 12 months due to cost was 13% in Adams County, compared to the statewide average of 10%.  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 both the number and 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.  The Adams County Community Wellness Program was launched in July 2013. Adams County now has 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 through the health care system, improving the quality of their care, extending or even saving lives. In addition, the Community Health Worker provides educational sessions that address prevention of the modifiable risk factors of chronic disease, which include tobacco, cardiovascular health, unhealthy lifestyles, and screenings. The program used the Guide to Community Preventive Services, which provided guidance in the quest to create an evidence-based program.  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 need for chronic disease prevention in Wisconsin 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. In Adams County, which has an adult population of 17,400, the Wellness Program from inception to June 2015 has reached 1,300 people or 7.5%
With keeping in mind the program’s goals to expand culturally appropriate chronic disease prevention education and navigation services in order to reduce morbidity and mortality from chronic disease in Adams County, 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 4) Develop a self-sustaining Adams County Community Wellness Program   The following steps were taken to implement the Community Wellness Program:   1.       Hiring Immediate focus on hiring a nurse with connections to the community for the Nurse Navigator position and a community member with the ability and knowledge to share and teach about topics such as chronic disease, healthy eating, medication adherence, etc. for the Community Health Worker position.   2.       Training Upon Hiring, both the Nurse Navigator and the Community Health Worker progressed through various online and document form modules and information including; Diabetes Education Curriculum: King County’s Steps to Health Chronic diseases cancer clear and simple curriculum, and the background leading up to the Adams County Awareness Team (ACCAT) worksite wellness care coordination health education health navigation including; Kansas Cancer Partnership: Cancer Patient Navigation Toolkit,  Healthcare Association of New York State: Breast Health Patient Navigator Resource Kit, Patient Navigation and the Healthcare System: Self-Paced eLearning Course health promotion medication reconciliation Adams County resources Adams County statistics     3.       Implementation   Initially developed an evaluation grid and continued reassessment of evaluation questions and tools.  Focus was on development of data collection and reporting tools; tracking Navigator interactions with clients; satisfaction surveys for both Navigator and Community Health Worker (and modifications made to address survey comments). Asking about barriers that clients encountered led to development of factsheet that has been shared widely with community partners, possible funders, insurers, medical facilities, etc. and the Nurse Navigator and Community Health Worker have adapted their work to help address identified barriers.     4.        Program staff & Roles   The Nurse Navigator roles: The Nurse Navigator meets individually, on a short term basis, with adults who have chronic illness(es).  The Navigator assists them by assessing their individual needs and addresses those needs by way of education, connecting them with community resources, assisting in communication with their health care providers and/or natural supports, accompanying them to Dr. Appointments,  and provides tools like folders, calendars, schedules, weight scales, and medication boxes as needed.   The Navigator provides emotional support, helps the client set health goals, explains the importance of medication adherence and works to empower the individual to help themselves.  The Navigator follows up with the clients either through in-person visits or phone calls.  The Navigator has also participated in Brown bag reviews with individuals at the local community center on occasion.    The Community Health Workers roles: Created and implemented chronic disease prevention educational sessions throughout Adams County. Participates in Cancer Clear & Simple implementation. Involved in the South central Wisconsin Tobacco free coalition. Created a worksite wellness survey which engaged over 100 county employers from which data was collected and dispersed. Created many public service announcements which were played on our local radio station. Developed and structured orientation checklist and work plan for intern placed with CWP through Area Health Education Center. Created the Adams County Wisconsin Facebook page which currently has more than 200 likes.  This page addresses chronic disease topics and is update regularly to address pertinent topics. Assists HN with data collection by creating and inputting data into spreadsheet form for ease in proving evidenced based data. Serves on the Be Healthy Adams County planning group whose primary focus is physical activity and healthy nutrition. Created newspaper public service announcements about chronic disease prevention which were and will continue to be placed in our local newspapers.      5.       Partners & Roles   Adams County Health and Human Services and its Academic Partners from the UW Carbone Cancer Center received $398,166 for a 3-year large-scale implementation grant through the Wisconsin Partnership Program to implement the Adams County Community Wellness Program. Through the first two years of the program, a total of $225,609 was spent, with grant funds providing $166,824 (73.9%) for salaries, fringe benefits, travel and supplies and cash match and in-kind funds providing an additional $58,785 (26.1%), mostly for salaries and fringe benefits. Additional in-kind support has been supplied by support from Adams County Aging and Disability Resource Center for education. Year three has begun an intensive sustainability process with billing for chronic disease management happening for behavioral health clients, an MOU to provide home visiting as part of a bundled payment program a regional long term care provider is executing and through a pilot with the county’s health insurance provider.     Budget breakdown as noted:   Year 1 Actual 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 Actual Paid through UW, Salary $14,701, fringe benefits $6,027, travel $746, total budget $21,474. Paid through Organization, salary $65,750, fringe benefits $38,866, travel $902, supplies $2,500, total budget $108,018.   Year 3 Projected Paid through UW, Salary $19,704, fringe benefits $8,079, travel $764, total budget $28,547. Paid through Organization, salary $67,723, fringe benefits $40,032, travel $925, supplies $2,500, total budget $111,179.   TOTAL Paid to date: 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.   TOTAL Project Budget: Salary $252,865, fringe benefits $139,410, travel $4,391, total budget $398,166        
The following section details, for each program activity, the objective targeted by the activity and, where available, the measurable outcomes to date for the activity.  Objective 1:  Increase adoption of chronic disease prevention behaviors, use of screening and access to quality care a.    A NN was hired to address all three parts of this objective through working in the community to identify resources and working with clients to guide them through the health system. The NN was hired in July 2013 and began providing services in October 2013. b.    To date, the NN interacted with 124 clients. Some of the clients who had only a limited contact with the NN met this objective. There were 64 clients classified as “engaged” in the program’s data system. When contacted by the NN, 40 of the engaged clients did not want any service from the NN. However, the NN had one or more contacts with the other 24 individuals and provided them with advice or a resource, such as educational materials, a referral, medication management, or emotional support. They did not want any additional services from the NN and are not, therefore, part of the “enrolled” client list.  The source of referral for engaged clients was broken down into four categories: hospitals, nursing homes, local agencies (Aging and Disability Resource Center, other community organizations) and other (self-referred or family member).  Source of Referrals for Enrolled Clients to NN with their totals: Hospitals                                                                                                                                        Moundview Memorial Hospital & Clinics (Friendship) = 29                   Mile Bluff Hospital (Mauston) = 5                                              St. Claire (Baraboo) = 2 Local Agencies   Aging & Disability Resource Center (Friendship) = 14 Adams County Health & Human Services (Long term Support Division) = 5 Other   Self-Referred = 4 Family or Friends = 3   c.    Using the detailed intake form, the HN also identifies clients’ risk factors. The most frequent health/risk factors identified by clients include arthritis, heart and stroke issues (including high blood pressure), COPD and diabetes. Once identified, the NN can determine what actions the clients can take to address their health, what educational materials might be useful, and what referrals to other services might be appropriate. d.    Limited information is available regarding achieving or making progress toward adoption of chronic disease prevention behaviors and goals proposed during a client’s meetings with the NN. Based on final closeout calls or a follow-up call three months after the closeout call, all of the six Year 1 clients reached had either achieved their goal (one client) or was making progress toward achieving their goals (five clients). In addition, 19 Year 2 clients had achieved their goals and 10 were making progress toward achieving their goals. e.    A CHW was hired in August 2013 to develop and provide educational sessions focusing on chronic diseases and available community resources. CHW services began in October 2013. As of May 31, 2015, 17 educational sessions have taken place, with 194 documented participants. f.     Adams County Public Health received $1,000 from the Department of Health Services to implement the Striving to Quit program. The NN enrolled eight county residents since December 2014.  Objective 2:  Improve access to voluntary support organizations and health care systems a.    The UW-Extension, a partner of the project, received a Robert Wood Johnson Foundation grant to facilitate local collaborative activities. This grant provides coaching services from the County Health Rankings and Roadmaps program (also funded by the Robert Wood Johnson Foundation; the coaching team is part of the UW Population Health Institute). The CHW has participated as the public health representative and to help with the community education piece in the launch of the Be Healthy Adams County program, with a goal to rebuild the local nutrition and physical activity coalition. g.    All clients seen by the NN are asked to identify personal barriers to care. A form was developed by the NN, CHW and evaluator that listed potential barriers and is completed for each client. The major barriers identified that impact social and economic factors include inadequate knowledge to manage disease; inadequate or unavailable transportation; and difficulty paying bills. The major barriers identified that impact access to care or quality of care include unmet extended care needs and difficulty managing daily needs; unmet needs for medical equipment; and inability to manage daily medication. b.    In order to provide information to the community about the Community Wellness Program, and to demonstrate how the program addresses barriers to care, program staff produced a two-page fact sheet – Reducing Barriers to Care:  Adams County Community Wellness Program – detailing specific barriers clients shared with the NN.  Objective 3:  Increase program recipient knowledge and decision-making capacity a.    Satisfaction surveys completed by attendees at the CHW sessions have been positive. Almost all of the attendees who completed a satisfaction survey indicated they learned more about chronic diseases, learned more about a healthy lifestyle, and learned more than they expected to learn. b.    Using the detailed intake form, the HN also identifies clients’ risk factors. The most frequent health/risk factors identified by clients include arthritis, heart and stroke issues (including high blood pressure), COPD and diabetes. During the first two years of the program, 17 of 60 referrals (28%) were made to the Aging & Disability Resource Center. Five referrals (8%) were made to the Quitline. Five referrals (8%) were also made to Moundview Memorial Hospital.  Objective 4:  Develop a self-sustaining Adams County Community Wellness Program a.    Identifying private sources of funding or other payers would be the ideal way to sustain the Community Wellness Program. b.    Identifying which CHW and NN services are coordinated with other services is a way to sustain the Community Wellness Program. If another agency or provider is consistently sending clients to meet with the NN, partnering with that agency or provider would both ensure a constant stream of clients and a possible way in which costs could be shared.  Ideally, identifying sources of funding would help ensure the sustainability of the Community Wellness Program. This can be achieved by identifying private sources of funding or other payers. Program staff are meeting regularly with local and regional groups, that have an interest in improving the health of county residents and who understand how the services of the NN can achieve this goal. Staff updated the program’s brochure that highlights the services provided and the reach the program has already achieved in the community. Using information on actual barriers to care that clients shared with the NN, the program produced a two-page fact sheet about reducing barriers to care, that has been shared with potential funders and other partners. In addition, program staff are working with partners such as other county agencies, hospitals, clinics, insurance companies, to identify how services these partners provide can be coordinated with the Nurse Navigator and Community Health Worker services.
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 Nurse 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. Through a recent partnership with UW Stevens Point, a senior nursing student worked with the NN to capture data collected from patient referrals from Moundview Hospital with a goal of gaining evidence to show the benefit of the Community Wellness Program.  This process is still occurring to date.  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. Steps toward sustainability include current billing for chronic disease management for behavioral health clients of the agency at 100% reimbursement including education. In addition we have promoted our service to our long term care provider and local hospital which both have incentives to keep their patients healthy post-discharge. This has developed into an MOU to provide services as part of a bundled payment program approved by the Center for Medicaid and Medicare Services. The nurse navigator will also begin seeing county employees through an agreement with their insurance provider with a focus on medication adherence.   An ongoing list of lessons learned includes the following: a.    Be flexible and ready to revise the forms, or develop new ones, as needed. Some forms originally developed did not work at all while others needed to be tweaked. This will be an ongoing activity during the program. b.    Getting the word out about the CHW educational component to organizations, businesses and adult living homes resulted in well-attended sessions. c.    Establish limits of what health navigator can/will do with patients, but be flexible in responding to individual needs, such as helping sign up for insurance under the Affordable Care Act. d.    Identify ways to collaborate with clinical providers to help improve the clients’ care, thereby benefiting the hospitals, providers, clients, and community. e.    Schools can be used to focus on teachers and staff (in-services); and parents (parent teacher conference days/evenings; parent meetings) – these are two separate audiences. f.     Advertise “service” of medicine review to be done after educational session. The program may draw more people to the session for this “service.” g.    A better use of the HN is to collaborate with other service providers to avoid both duplicative services and stepping over each other. (For example, the HN should work with a patient after home health service provider is no longer providing services.) Such collaboration can lead to sustaining the Program. h.    Identify ways to inform county/other local entities/hospital/clinics of services available so they can make appropriate referrals to HN. i.      Data collection spreadsheets (to enter information collected by hand, i.e., intake information, surveys, attendees at CHW sessions) were difficult to develop but they are a helpful tool used by the NN and CHW to organize evaluation data.       
I am a previous Model Practices applicant
 
Processing...


Driving Walking/Biking Public Transit  Get Directions