COMMUNITY HEALTH WORKS Celebrating Rural Georgia Georgia Rural Health Association August 22, 2006

Who is CHW?Who is CHW? What did we do?What did we do? What were the results?What were the results? COMMUNITY HEALTH WORKS

“ Community Health Works is a bold organization seeking innovative health solutions and providing compassionate advocacy for people financially compromised by their medical needs, while reducing the burdens on local health providers.”

501c3501c3 7 counties in Central Georgia7 counties in Central Georgia 5 hospitals5 hospitals 3 clinics3 clinics 135 physicians135 physicians 22 pharmacies22 pharmacies Who is CHW?

CHW Board Members Frank Aaron, CEO, Houston Health CareFrank Aaron, CEO, Houston Health Care Dr. Joe Swartout, Div. Public Health DirectorDr. Joe Swartout, Div. Public Health Director Dr. Patton Smith, Monroe Co. PhysicianDr. Patton Smith, Monroe Co. Physician Dr. Fred Gaton, Crawford County PhysicianDr. Fred Gaton, Crawford County Physician Don Faulk, CEO, Central GA Health SystemsDon Faulk, CEO, Central GA Health Systems Tom McMichael, Houston Co. CommissionTom McMichael, Houston Co. Commission David Gault, Vice Chair, Jones Co. CommissionDavid Gault, Vice Chair, Jones Co. Commission

CHW Board Members O.J. Booker, CEO, Monroe Co. HospitalO.J. Booker, CEO, Monroe Co. Hospital Nancy Peed, CEO, Peach Regional HospitalNancy Peed, CEO, Peach Regional Hospital Dr. Lynn Denny, Med. Dir., Macon Vol. ClinicDr. Lynn Denny, Med. Dir., Macon Vol. Clinic Dr. Martin Dalton, Dean, Mercer Med SchoolDr. Martin Dalton, Dean, Mercer Med School Ethel Cullinan, CEO, MedCen FoundationEthel Cullinan, CEO, MedCen Foundation Charles Bishop, Bibb Commission ChairCharles Bishop, Bibb Commission Chair James Khoury, Peach Commission ChairJames Khoury, Peach Commission Chair

CHW Board Members Bill Hamrick, Twiggs Co. Comm. Past ChairBill Hamrick, Twiggs Co. Comm. Past Chair Frank Fields, Exec. Dir., River EdgeFrank Fields, Exec. Dir., River Edge Don Blair, Exec. Dir., Phoenix CenterDon Blair, Exec. Dir., Phoenix Center Lelia Anderson, ED, Family ConnectionsLelia Anderson, ED, Family Connections Dr. Fred Schnell, Chairman GA COREDr. Fred Schnell, Chairman GA CORE Art Christie, Dir of Oper., Houston Health CareArt Christie, Dir of Oper., Houston Health Care

Created network based on a donated care modelCreated network based on a donated care model Uninsured with 4 disease statesUninsured with 4 disease states –Diabetes –Hypertension –Cardiovascular disease –Depression What did we do?

Care ManagementCare Management Pharmaceutical assistancePharmaceutical assistance Primary Care HomePrimary Care Home Tracked hospital & ER utilizationTracked hospital & ER utilization What did we do?

Screening Disease/ Age/ Financial/ Insurance Eligibility Face to Face Interview Verify Information Complete BRFSS Assign Physician Care Management Create Care Team & Care Plan Coordinate Interaction With Physician Pharmaceutical Assistance

WHAT WERE THE RESULTS?

Donated Care Model 5 Hospitals + 5 Hospitals + 3 Clinics + 3 Clinics + 22 Pharmacies+ 22 Pharmacies+ 135 Physicians + EQUALS ???????

MEMBERS SCREENED 6068 From Inception thru 7/31/06

MEMBERS ENROLLED 1939 Total as of 07/31/06

Donated Care Model More than More than 3,500 Members Served 3,500 Members Served $ 35 million Care Coordinated $ 35 million Care Coordinated $ 2 millionFree Medicines $ 2 millionFree Medicines $ 1 million Medicaid/Medicare $ 1 million Medicaid/MedicareAND……

A rigorous independent examination of CHW care management results shows: $1,300,000 annual saving per thousand members in CHW care management$1,300,000 annual saving per thousand members in CHW care management ER Utilization Rate 31% < than National Avg.ER Utilization Rate 31% < than National Avg. Hospitalization Rate 49% < than National Avg.Hospitalization Rate 49% < than National Avg.

BEGINNING TO TRACK CLINICAL OUTCOMES

DateA1CReference Results Flag March 1, – 6.0 % High June 24, – 6.0 % Normal Sept. 30, – 6.0 % Normal Jan. 5, 2005 Jan. 5, – 6.0 % Normal 59 Year Old Female Date of Enrollment: September 23, 2003 Exercise

Clinical Outcomes Physician Data SegregationPhysician Data Segregation –Use to show value of Care Management –Use to show effectiveness of treatment plan Care Manager Data SegregationCare Manager Data Segregation –Use to incentivize personnel –Use to allocate personnel/ create care team

Peach County Resident 57 Yr Old African American Male57 Yr Old African American Male Diagnosed with Diabetes and Vision problemsDiagnosed with Diabetes and Vision problems Did not work because of healthDid not work because of health Care Manager got him glasses from LensCraftersCare Manager got him glasses from LensCrafters Blood sugars down, medicine dosages decreasedBlood sugars down, medicine dosages decreased Member now working two jobsMember now working two jobs

How do we use the Network we’ve created to add even more value to the community and our partners?

Community Health Works Board of Directors Board of Directors Central Georgia Cancer Coalition Rx for the Uninsured Uninsured Community Health Works- Principal Activities Middle Georgia Multi Share

Central Georgia Cancer Coalition

Through Prevention, Screening, Early Detection, Education, Leading-Edge Treatment & Advanced Research CANCER CAN BE DEFEATED

Community Health Works Central Georgia Cancer Coalition Region DADE CHATTOOGA WALKER CHEROKEE HARALSON GORDON DOUGLAS RABUN JACKSON MURRAY GILMER FORSYTH CATOOSA FANNIN LUMPKIN BARTOW PICKENS FLOYD PAULDING COBB POLK UNION TOWNS FRANKLIN WHITE STEPHENS DAWSON HALL OGLETHORPE BANKS COWETA MADISON GWINNETT CLAYTON CLARKE HART FULTON HEARD DEKALB FAYETTE LAMAR HENRY NEWTON SPALDING CARROLL TROUP HANCOCK PIKE MORGAN JEFFERSON BARROW WALTON OCONEE ELBERT GREENE WILKES JASPER BUTTS UPSON LINCOLN WARREN PUTNAM COLUMBIA BURKE WASHINGTON BALDWIN JONES MONROE WILKINSON BIBB CRAWFORDTWIGGS BLECKLEY EMANUEL JOHNSON JENKINS SCREVEN BULLOCH DODGE HOUSTON PEACH TALBOT HARRIS MUSCOGEE CHATTAHOOCHEE MARION STEWART SUMTER SCHLEY DOOLY PULASKI WILCOX TELFAIR WHEELER BEN HILL LEE TERRELL RANDOLPH QUITMAN WORTHDOUGHERTYCALHOUN CLAY CRISP TURNER TIFT COFFEE JEFF DAVIS TREUTLEN TOOMBS APPLING TATTNALL WAYNE BACON COLQUITTMITCHELL EARLY BAKER SEMINOLE DECATURGRADYTHOMAS BROOKS COOK LOWNDES ECHOLS LANIER ATKINSON WARE PIERCE BRANTLEY CHARLTON CAMDEN GLYNN LONG LIBERTY BRYAN MCINTOSH EFFINGHAM CHATHAM CANDLER EVANS IRWIN BERRIEN MILLER RICHMOND TAYLOR CLINCH TALIAFERRO MCDUFFIE MACON WEBSTER GLASCOCK ROCKDALE MERIWETHER HABERSHAM WHITFIELD LAURENS MONT- GOMERY Yellow: Original CHW Counties Yellow/Green:Cancer RPE Region

HRSA HCAP GRANT Create Medicaid & Disability SoftwareCreate Medicaid & Disability Software Tobacco Cessation OutreachTobacco Cessation Outreach Electronic Health RecordElectronic Health Record Implement vertically integrated cancer care managementImplement vertically integrated cancer care management Implement database to assure access to clinical trialsImplement database to assure access to clinical trials Pharmaceutical assistance programPharmaceutical assistance program

HCAP Grant Cancer Screening Software BreastOral CervicalSkin Ovarian Colorectal LungProstate Testicular

GEORGIA BREAST CANCER LICENSE TAG $50,000 Grant Provide access to mammography screening for uninsured women in GeorgiaProvide access to mammography screening for uninsured women in Georgia –Implement in Peach & Monroe Counties –Access system through primary care physicians –Care coordinated by CHW Care Managers –Assistance with State Cancer Aid for those who qualify

Medcen/Komen Partnership Over 500 Mammograms Detected Several Early Stage Cancers

Prevention & Early Detection Central Georgia has some of the highest tobacco use rates in the state %

TOBACCO USE PREVENTION PROGRAM To extend smoking cessation and education programs to underserved counties.To extend smoking cessation and education programs to underserved counties. Partner - American Cancer SocietyPartner - American Cancer Society Facilitated training - 11 “Master”Facilitated training - 11 “Master” Freshstart Trainers from 6 counties Freshstart Trainers from 6 counties –20 Facilitators trained in Baldwin County –13 CHW Care Managers Training Georgia Tobacco QUIT LineGeorgia Tobacco QUIT Line

Pan African Festival April 29, 2006 PSA Screenings Central Georgia Cancer Coalition Medical Center of Central GA American Cancer Society Phi Beta Sigma

368 Men PSA screenings 36% African American 11 prostate cancers 2 African American

Access & Continuum of Care 2006 Cancer Summit for Pastors & Religious Leaders September 29-30, Pastors are invited1500 Pastors are invited 2 Day Training and Seminar2 Day Training and Seminar –Cancer 101 for Pastors –Best Practices for Churches and Faith Based Organizations –Facilitating & Partnering for Best Cancer Care

Community Health Works Board of Directors Board of Directors Central Georgia Cancer Coalition Rx for the Uninsured Uninsured Community Health Works- Principal Activities Middle Georgia Multi Share

HRSA State Planning Grant Middle Georgia Multi Share

HRSA State Planning Grant Governor Perdue received a grant to explore the abilities of public/private partnerships to help the uninsuredGovernor Perdue received a grant to explore the abilities of public/private partnerships to help the uninsured GA was one of 9 states that received the grantGA was one of 9 states that received the grant CHW was one of the 4 communities asked to do the researchCHW was one of the 4 communities asked to do the research

HRSA State Planning Grant Established Steering CommitteeEstablished Steering Committee Held Focus GroupsHeld Focus Groups –Small Business –Employees In Plan Design PhaseIn Plan Design Phase

HRSA State Planning Grant Received Healthcare Georgia GrantReceived Healthcare Georgia Grant –Marketing Survey –Actuarial Study –Economic Impact Study

For More Information Gregory J. Dent President & CEO Community Health Works 105 Patrol Road, Suite 2 Forsyth, Georgia www. chwg.org