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-contractors2. Understand chronic disease focus areas3. Communicate performance and outcome
information4. Reflect access to care and equity efforts
of area health care programs5. 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 Estimate124,246
White 55%Black/African
American 32%
Hispanic/Latino 10%
Other 3%
Minorities45% White
55%
Disease Focus Areas
Obesity Heart DiseaseDiabetes
HIV/AIDS
7%
21%
18%
54%
Diabetes
Heart Disease
HIV/AIDS/STD
Obesity
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
CFEDHI WORK THROUGH A COMMUNITY BASED ORGANIZATION
Tara Robinson, RN, BSN, CCMWake 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
Wake County
North Carolina's second most populated county Area: 835 sq. miles Persons per sq. mile: 1,078.8 Population: 952,151
21.4%0.8%
10.0%67.8%
Breakdown by Ethnicity
Black or African Amer-icanAmerican Indian & Alaska NativeHispanic or LatinoOther
Sources: US Census Bureau: State and County Quick Facts Wake County Community Health Needs Assessment, 2013
Johnston County
The 77th fastest growing U.S. county with a population of 10,000 or more Area: 791 sq. miles Persons per sq. mile: 213.4 Population: 174,938
15.7% 0.9%
13.1%
70.3%
Breakdown by Ethnicity
Black or African Amer-icanAmerican Indian & Alaska NativeHispanic or LatinoOther
Source: US Census Bureau: State and County Quick Facts
Program Goals 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
Understanding the Needs of & How to Reach Our Target Population 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
Program Highlights 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
Questions?
Tara Robinson, RN, BSN, CCMDeputy DirectorPh: 919-792-3622E-mail: [email protected]
Alma Atkins, BSW, MHAMinority Health CoordinatorPh: 828-250-5319Email: [email protected]
Celita GrahamMinority Health CoordinatorPh: 919-731-1235Email: [email protected]