Building momentum one patient at a time

It's happened more than once. The coal miner in his late 30s who passes a booth at a local festival, stops on a whim, finds out he has prostate cancer, and gets treatment before it's too late. Or the truck driver who takes an exam kit home from the county fair and discovers his early-stage colon cancer.

Good Samaritan Hospital serves a number of isolated communities in a 10-county region spanning southwestern Indiana and southeastern Illinois. For some patients, the hospital is miles away, with no car or public transportation to get them there. So, Good Samaritan decided to take free preventive screenings into the community — at schools, farmers markets, YMCAs and anywhere else local people tend to congregate. It convinced retired nurses to return on a part-time basis, and over the past decade, they have provided more than 220,000 screenings.

"Our focus has always been on trying to have a presence in those communities so that it's easy for people to access this health care," says Robert McLin, president and CEO. "It eliminates and reduces the number of excuses: 'I can't possibly travel to get there; I've got no access to transportation.' We've just decided we're going to put our money where our mouth is and we're going to go to the population."

The part-time nurses and volunteers help to keep costs down. Community partners offer up space for free, in exchange for medical services. And they advertise the free screenings in school bulletins or organizational newsletters.

People can be screened for everything from blood pressure to body composition. The hospital places special emphasis on certain populations who face issues that discourage them from visiting the doctor's office, such as migrant workers and the Amish.

Along with screenings, nurses teach schoolchildren about the benefits of eating healthfully and exercising regularly. Nurses found during a recent school year that 41 percent of participating children were overweight or obese.

"The schools are very receptive to it," says Alan Stewart, M.D., medical director. "Rather than the hospital coming by and saying, 'You should teach this or that,' our nurses go into the classroom for 45 minutes and review these things with the kids in a visual way that they'll remember, like putting 12 teaspoons of sugar in a glass the size of a soda can." That provides a vivid lesson on the perils of consuming sugary drinks.

Good Samaritan helps patients manage their health, and links them up with hospital resources where necessary. In Knox County alone, 40 percent of adults have taken advantage of the free screenings and two-thirds of those surveyed are aware of it.

"You have to quit being reactive and start being proactive," McLin says. "You have to stop the mindset of 'Well, there are just so many and it's so overwhelming.' If I just help one person today, that's one more person than yesterday. And if I help two tomorrow, eventually you're going to build momentum and people are going to start understanding and appreciating it."


Serving as a beacon for community health

When leaders at Eastern Maine Healthcare Systems talk about team-based care, they aren't just referring to doctors, nurses and pharmacists. Their approach to serving the community includes everyone from competitors to the community college.

What started as an effort to tackle chronic conditions has morphed into a comprehensive push to improve the health of the region's population, through the Bangor Beacon Community, a collaboration of 12 partners. One key objective was bolstering health IT, and in a few short years, it's increased the number of physicians using electronic health records from 40 to 60 percent, and the number of meaningful users from 0 to 60 percent.

"It's not as though we had to design something brand new," says M. Michelle Hood, president and CEO of EMHS. "It's just arranging our resources with the patient as the centerpiece, and engaging the provider community across our areas of service toward a common goal."

Maine has one of the oldest populations in the United States and a high percentage of residents who are battling multiple chronic diseases, costing the state some $1.4 billion a year. Based on a community health needs assessment in 2010, the three largest hospital networks in the state found a high number of patients using the emergency department for ailments better treated by a primary care physician.

EMHS and its partners received a three-year, $12.75 million grant from the Office of the National Coordinator for Health Information Technology to launch the effort in September 2010. They've now helped build a web of interconnected systems among all partners, including an EHR, disease registries, secure email, home telemonitoring and connections with a statewide health information exchange.

Care managers are a key, says James Raczek, M.D., chief medical officer of Eastern Maine Medical Center, one of seven EMHS member hospitals. They swarm health concerns in the community, finding, for instance, the couple struggling to kick a costly smoking habit and the 99-year-old woman with congestive heart failure and fading vision who suffered from random falls. Chronically ill patients from more than a dozen primary care providers are enrolled in the program. In the first six months alone, those patients saw a 40 percent reduction in hospital admissions, ED use and walk-in care visits.

"Care managers are the heroes of this project, and their ability to connect with patients and get them to engage is remarkable," Raczek says. "It proves the need to approach this from a team perspective because the dynamic that occurs in the exam room with the patient and his or her physician sometimes precludes what really needs to happen with regard to patient engagement."

Bangor Beacon Community participants hope this is just "training wheels" for their Pioneer Accountable Care Organization model and, beyond that, more advanced risk-based models, says Daniel Coffey, president and CEO of Acadia Hospital, an EMHS member.

"Our goal, really, with learnings from the project is to figure out ways to push our services beyond our four walls and totally integrate with not just the greater Bangor region, but the vast region we serve here in Maine," he says.


Meeting patients where they are

Sometimes patients can be hesitant to share with a doctor the economic or cultural factors that might be impeding their care. It can be embarrassing for an individual who can't afford the co-pay for his insulin shot or isn't proficient enough in English to read the instructions.

So Spectrum Health created a team of community health workers to reach the underserved chronically ill at home. These lay health professionals are from the neighborhood they serve and understand the local issues. The practice seems simple, but the results have been profound: better and more appropriate health care and millions of dollars saved by reducing unnecessary emergency department visits and hospitalizations.

"Knowing that the typical approach, having the patient come in and giving them some education, was not going to reach this subset of the population, we took a much more innovative approach," says Erin Inman, director of Healthier Communities for Spectrum. "The community health worker really is the key piece to this, to engage individuals to help remove barriers to care — whether it be language, transportation or other social issues that need to be addressed — and to help them understand their disease."

Spectrum launched its Core Health Program in 2009 with a focus on diabetes and heart failure. It developed a team-based approach to treatment, using registered nurses and community health workers to enhance the work of the primary care physician. Conversations with inpatients, insurance data and various other methods are used to find those who might fit into the program.

CHWs visit patients at home, typically about once a month, educating them to better manage their disease, reinforcing the individualized care plan developed by a registered nurse, and connecting them with community resources. Registered nurses serve as the backbone, educating CHWs on the ins and outs of diabetes and heart failure, coming along on visits when needed, and reporting back to the patient's medical home.

"People want to have health care closer to home," says John Mosley, executive vice president at Spectrum. "To the extent that we can keep people healthy, take care of their issues and work with them in a setting in which they're more comfortable, you get a better result."

Each Core Health patient participates for 12 months in the program and, afterward, he or she can attend sessions to share experiences with others. After three years of operation, the effort has treated 871 uninsured or underserved patients with those two chronic conditions. ED use has dropped by about 87 percent for heart failure patients, and hospital admissions have dropped almost 90 percent, with significant drops in those categories for diabetics, as well. All told, that equates to $4.3 million in net savings for Spectrum.

Inman urges other hospitals that struggle with the chronically ill to get out into the community, and move away from episodic care to a more continuum-based approach.

"As we look at the changing forecast of our health care system, delivery of care does need to look different, and I think this is one of the answers to that change in model," she says.


Making sure that everyone is chipping in

If any community hospital has gotten close to completely mastering the needs of its surrounding neighborhoods, it might be St. Joseph's Hospital.

The Catholic nonprofit has developed an exhaustive approach to improving the health of its community, dating to nearly two decades ago. Working with dozens of partners, St. Joseph's uses interviews, focus groups and needs assessments to root out whatever challenge might be plaguing western Wisconsin. It's possible for hospitals to touch everyone in some way, but not without help, says hospital President and CEO Joan Coffman.

"Many organizations want to control everything," Coffman says. "What you then have to do is step back, make sure you have the right people and resources in place, and allow them to create the movement. If they're out there at the grassroots level building energy around responding to community need, everybody is going to want to participate."

For St. Joseph's, that endeavor is the Chippewa Health Improvement Partnership, or CHIP, a brainchild of former CEO Dave Fish, launched in 1994. Serving as the umbrella organization — with schools, churches, senior centers and other partners — the hospital conducts a community needs assessment every three years or so to stay abreast of what might be ailing its patient population. A 20-member committee representing various local organizations governs the group, and it holds community retreats every November to sort through data and start planning for the next year.

When patients kept showing up in the emergency department with dental problems, CHIP helped to establish a federally qualified dental center. A group of local business owners raised money, and the center now operates with a staff of 60, treating 150 patients a day from 27 different counties.

After conducting a "food audit" of Chippewa County, CHIP participants located the food deserts in the region, and distributed 1,500 brochures listing all the locations and hours of local food pantries. St. Joseph's has even gone so far as to establish a community garden on more than two acres of its grounds, with plots for residents and organizations to grow their own produce.

Financial support is one of the biggest challenges for CHIP, says Rhonda Brown, the program's director. St. Joseph's serves as its primary funder. Those involved have pulled together supplies, in-kind donations and grants from numerous sources to keep CHIP chugging along for so many years.

"If we can find a grant that fits with a project we're doing, we try to apply for it," Brown says. "Even for me to be able to secure $800 is a big deal for CHIP. We can spend a little bit of money and make it go a long way."

Coffman says any hospital that's serious about treating the health of the population can and must do this; it just takes a governance structure and a way to gather community input.

"It's so important," she says. "We all want stronger, healthier communities. We want that for ourselves, for our families, for our neighbors — and if we don't begin this at a grassroots level and duplicate it one community at a time, we won't ever get there. It'll overcome us."


Providing hope to the chronically ill

Diabetes or obesity can be hard enough on a patient. Add poverty, lack of coverage, poor road conditions and limited public transportation, and staying healthy can be a nearly insurmountable challenge for the chronically ill in rural south central Kentucky.

Ephraim McDowell Health — along with a bevy of partners from United Way to the Salvation Army — strives to dispel that sense of despair through its Hope Clinic and Pharmacy. Since 2006, it has provided 4,287 visits, and scored high satisfaction scores in a six-county region that's typically rated its health options as "fair/poor."

"You can't read the patient satisfaction survey comments without tears welling up in your eyes," says Vicki Darnell, R.N., president and CEO of the health system. "It just resonates true, the very significant impact that the Hope Clinic has on these folks. I'm really convinced, without this program, many of these people would not be alive right now."

Facing rising poverty rates, unemployment and emergency department visits for nonurgent ailments, the local United Way brought together a group of community leaders in 2004. From that emerged the region's first free clinic, opening two years later to serve the uninsured, chronically ill.

Getting there wasn't easy, though. Ephraim and its partners had to seek out unpaid volunteers and physicians willing to donate their time, and pay part-time, advanced practice nurses. Group visits have helped to expand access, and grants from a variety of resources have helped the health system to create two dedicated staff positions at the clinic, and a permanent location in a medical park.

Results are promising. In 2011 alone, the Hope Clinic conducted 761 patient visits, filled 4,400 prescriptions, and performed 618 free procedures worth $574,887. The quality of care that year was impressive: two-thirds of patients with hyperlipidemia lowered their cholesterol; more than half of patients with hypertension lowered their blood pressure; and almost half of diabetics treated lowered their A1C levels.

Moreover, patient satisfaction hit close to 97 percent. That's because everyone involved in Hope displays a level of compassion in the care they provide, says Audrey Powell, R.N., executive director of community services.

"They're treated with dignity and not treated like charity," she says. "For people who have become accustomed to working and being self-sufficient, it's sometimes just demoralizing to have to go through all these hoops to get services. And not being treated well is a recurring event that they experience. So Hope Clinic really stands out to them as a place where they're listened to and treated with respect, as well as having their medical needs addressed."

Most communities have a Salvation Army, United Way, churches and a health department, making the program easily duplicated, says Darnell, who believes rural communities like Danville have an obligation to treat the less fortunate.

"The health care system is generally the largest employer in any city or county, and as that leader, you have an immense responsibility for not only the health, but also the financial well-being of your community," she says.


Each year, the American Hospital Association honors up to five of its member organizations as "bright stars of the health care field" with its prestigious AHA NOVA Award. Winners are recognized for improving community health by looking beyond patients' physical ailments, rooting out the economic or social barriers to care, and collaborating with other community stakeholders. Visit for more information.