Buncombe County Health & Human Services Community Focused Eliminating Health Disparities Initiative (CFEHDI) Program January 23, 2013 Working Together to improve the health of minorities living in Buncombe County

Ujima : Collective Work and Responsibility- To build and maintain our community together and make our brother’s and sister’s problems our problems and to solve them together.

Community Based Organization: Collaboration Mt. Zion Community Development, Inc.

Buncombe County Populations Served African American American Indian Hispanic/Latina Other: Uninsured and Underinsured

Chronic Health Conditions Addressed Asthma Cancer Diabetes Heart Disease HIVAIDS/STD Obesity and Stroke

Community Partner Programs  Health Screenings & Outreach  Diabetes Wellness Program  Chronic Disease Self-Management Classes  Body & Soul  Diabetes Prevention Workshops  Project Empower  Coordinate “Ladies Night Out”  Case Management (PACE, Building Brothers)

Role of Buncombe County Department of Health Convene partners around common agenda Facilitate Communication & cross referrals Develop new & existing partnerships to expand reach Provide infrastructure for carrying out grant scope of work Collect and organize program data for evaluation and analyzing

Data Collection and Common Documentation of Program Events and Outreach 1. Map outreach efforts of sub-contractors 2. Understand chronic disease focus areas 3. Communicate performance and outcome information 4. Reflect access to care and equity efforts of area health care programs 5. Track referral and follow up efforts to Medicaid, Medicare, and Insurance

Health and Wellness Assessment Tool: Demographics Chronic Conditions Medical Home Status “Know Your Numbers” data Referrals for medical services by partners Community needs

Buncombe County Health & Human Services, Minority Health Equity Project: Improving Health for Everyone… Building a Better Future Together

Wayne County Health Department Minority Health Program

Wayne County, NC Total Population Estimate 124,246

Disease Focus Areas  Obesity Heart Disease Diabetes  HIV/AIDS Leading Causes of Death for All Minorities (2011) 1.Cancer 26% 2.Heart Disease 17% 3.Cerebrovascular Disease 6% 4.Nephritis 6% 5.Diabetes 5%

The focus of our education intervention is to: 1.Increase knowledge and awareness of modifiable risk factors that contribute to obesity and chronic conditions associated with unhealthy lifestyles 2.Implement strategies to reduce these health risks 3.Build infrastructures by establishing health ministries charged with conducting and promoting health and wellness sessions 4.Establish medical homes for uninsured congregants 5.Modify risk factors for chronic disease and to initiate chronic disease self management strategies. Programmatic Focus

Programmatic Highlights W.A.T.C.H is a free, primary health clinic providing acute healthcare to the uninsured with two locations: The Mobile Unit travels around the county to 15 pre-determined locations each month A satellite location is available at the Goldsboro Family YMCA Each W.A.T.C.H. clinic is run by a Family Nurse Practitioner and volunteer physicians provide specialty clinics at specified dates and times For 2012 Patient Visits: 9,969 and 301 were unduplicated patients Volunteer Hours: 1,191 Free medications ordered: $1.8 million From January – December 2012, $487,000 of free labs were completed

Programmatic Highlights Faithful Families Eating Smart and Moving More (FFESMM) is a practice-tested intervention that educates faith community members about food, physical activity and becoming advocates for healthy policy and environmental changes within their communities.

 Staying abreast of recent health disparities and policy developments  Building and maintaining strong relationships with other health and community advocates to leverage expertise and resources  Coalition Building and Community Engagement  Engaging the Faith Community  Media Outreach Helping to educate both minority and mainstream media about minority health policy and issues so that these issues get timely an appropriate attention providing culturally competent program materials for various faith communities, community-based organizations and civic groups in addressing health literacy. Programmatic Impact

Tara Robinson, RN, BSN, CCM Wake County Medical Society Community Health Foundation

WCMSCHF Community Care of Wake & Johnston Counties CapitalCare Collaborative Improve quality of and access to primary care for the Carolina Access Medicaid and dual (Medicare/Medicaid) population Reduce healthcare cost Increase access to primary & specialty care for the uninsured & homeless Reduce ED visits Assesses and responds to community health needs Medical Home Evidence-Based Best Practice Care Management Non-profit 501(c)3

 North Carolina's second most populated county  Area: 835 sq. miles  Persons per sq. mile: 1,078.8  Population: 952,151 Sources: US Census Bureau: State and County Quick Facts Wake County Community Health Needs Assessment, 2013

 The 77th fastest growing U.S. county with a population of 10,000 or more  Area: 791 sq. miles  Persons per sq. mile:  Population: 174,938 Source: US Census Bureau: State and County Quick Facts

 Decrease the number of uninsured minorities in Wake & Johnston counties  Link individuals to a medical home and increase knowledge on how to optimally access health care services  Promote chronic disease self-management among racial and ethnic minorities  Increase cultural competency among staff

WCMSCHF PCPs, Safety Net Providers, clinics for the uninsured Sub- Contractor: Strengthening The Black Family, Inc. DSS, SHIIP, DHHS Homeless Shelters, Transitional Housing Facilities Faith Communities - NC Council of Churches, Baptist Aging Ministry NC Council of Aging, Triangle J, Senior Centers, Assisted Living Hospitals

 Minority Census Tract  Project and Sub-Project Advisory Groups  Safety Net (Johnston Co) and Collaborative (Wake Co) meetings  Focus groups  3 in Johnston Co  3 in Wake Co  Community Stakeholders  ASK and talk to individuals in our target population  Door-to-door, special interest groups

 Living Healthy Chronic Disease Self-Management  324* participants have participated in CDSMP/DSMP  82%* have demonstrated an increased level of activation in managing their health condition(s)  Large church in Wake County  Men’s Homeless Shelter  Day Treatment Facilities for individuals with mental illness  Patient Navigation & Community Outreach  Spreading the word – TV, radio, & newspaper  Collaboration with local partners  908* participants attended insurance workshops on Medicare and Medicaid  265* uninsured individuals linked to a medical home *Numbers are based on June-November 2013 data

Tara Robinson, RN, BSN, CCM Deputy Director Ph: Alma Atkins, BSW, MHA Minority Health Coordinator Ph: Celita Graham Minority Health Coordinator Ph: