Building a Healthier Prince George’s County PRINCE GEORGE’S COUNTY HEALTH DEPARTMENT HEALTH ENTERPRISE ZONE Pamela B. Creekmur Health Officer Dr. Ernest L. Carter Deputy Health Officer

 Increase accessibility & availability of primary care  Reduce hospitalizations & Emergency Department (ED) visits  Reduce health disparities  Improve health literacy  Increase community resources for health PGCHEZ Goals 2

H EALTH C ARE S ERVICES  Establish 5 patient centered medical homes (PCMH) –Wellness Plan used by all Zone PCPs  Link new and expanded clinical care sites, parent organizations and PGCHD through a local health information technology exchange  Hospital and ED Transition Plans C OMMUNITY - BASED S ERVICES AND I NITIATIVES  Community Health Worker (CHW) Care coordination & patient navigation  Health Literacy Initiative  Care Coordination Team  Sister Circles 3 PGCHEZ Services

 How many primary care and specialty care providers are recruited to the Zone?  How many partners are recruited to provide supportive clinical & ancillary services?  How many Zone residents served?  What are the costs of Zone services?  What is the value of leveraged contributions to the Zone?  How satisfied are patients, providers, residents and partners with the Zone? PGCHEZ- Process Evaluation Questions 4

 Annual key informant Zone provider and partner interviews  Service provider and delivery and material distribution counts  Financial tracking and analysis  Training enrollment data  Care coordination case reviews PGCHEZ – Process Measures 5

 CHW Client Satisfaction Annual Survey N=100 –See Appendix for Survey Questions  Annual PCMH patient satisfaction survey N=100 –See Appendix for Survey Questions  Behavioral Health Intervention Client Satisfaction Survey N=25 PGCHEZ – Process Measures (cont) 6

PGCHEZ- Outcome Evaluation 7 What we are MeasuringHow we are Measuring Impact of increased access to care to the overall community through new providers Hospitalization rates & charges for visits and readmissions Impact of increased access to care on hospitalizations for ambulatory care sensitive conditions PQIs for Inpatient data Impact of CHW services for residents with high acute care utilization Client-level data from referring hospitals and EMS for visits/use and associated charges Cost effectiveness of CHW servicesAnalysis model that includes predisposing, enabling, and need factors

 Increase accessibility & availability of primary care PGCHEZ –Results to Date Part I Goals  25,341 patient visits at Zone PCMHs  18,280 unduplicated patients served  8 FTE providers of which 3.5 FTE are new to the Zone  Licensed Practitioners Total 15.5 FTE  Other Support Staff Total 11.5 FTE  Total Zone FTE is 27.0  New Jobs Created in Zone 17.5 FTE Results as of Q1 Year 3 8

 Reduce hospitalizations & Emergency Department (ED) visits  Provide CHW services  Improve health literacy  Increase community resources for health PGCHEZ –Results to Date Part II Goals  Established of Community Care Coordination Team (CCCT)  142 clients enrolled with 3,228 client contacts  Culturally & linguistically appropriate training started  Health Literacy Campaign launched  Established Public Health Information Network  Linkage to community-based behavioral health services Results 9

PGCHEZ –Results to Date Part III  40 New clients enrolled in CHW program between Jan – March 2015 were seen in two partner hospitals –7 discontinued in the program (Moved, lost to follow-up, deceased)  For the 33 remaining clients: –In Quarter 1 of 2015 they had a total of 137 ED/Inpatient visits (includes data from 2 Hospital EDs and 1 Hospital Inpatient service) –By Quarter 2 of 2015, 67% of clients had reduced ED/Inpatient visits compared to Quarter 1. Total for Quarter 2 was 76 visits. –These clients will continue to be followed to determine if this is sustained over time. Results: Taking a Closer Look at CHW Services (Preliminary Data) 10

Questions

 I’m going to read a list of the different types of services {Name of CHW} provides. For each service that you received from {Name of CHW] please tell me how satisfied you were with the service.[Read service] were you very satisfied, satisfied, dissatisfied or very dissatisfied? –The first telephone call or in-person contact you had with {Name of CHW} –The first Home visit made by {Name of CHW} –The assessment to find out what kind of help you need –Helping you to find a doctor –Helping you get other services you need such as (list service on rows below) –How often does/ did {Name of CHW} contact you? –How would you rate the services {Name of CHW} provided? –Did you change any of your health care practices as a result of working with {Name of CHW} –What the most helpful service provided by {Name of CHW}? –If you were not pleased with any of the services that {Name of CHW} provided what was the issue? Appendix PGCHEZ CHW Client Satisfaction Survey 12

Today’s Visit Here are some questions about your visit to our office today. We would like to know how you would rate each of the following 1. The wait to get an appointment 2. Convenience of the office location 3. Getting through to the office by phone 4. Length of time waiting at the office to be seen 5. Time spent with the person (doctor or nurse) you saw 6. Explanation of what was done for you 7. The technical skills (thoroughness, carefulness, competence) of the person you saw 8. The personal manner (courtesy, respect, sensitivity, friendliness) of the person you saw 9. The sensitivity shown by the person you saw to your special needs or concerns? 10. How would you rate your satisfaction with getting the help that you needed? 11. How do you feel about the quality of the visit overall? Appendix PGCHEZ Patient Satisfaction Survey- Part I 13

General Questions 12. If you could go anywhere to get health care, would you choose this office practice or would you prefer somewhere else? 13. “I am delighted with everything about this practice because my expectations for service and quality of care are exceeded.” 14. In the last 12 months, how many times have you gone to the emergency room for your care? 15. In the last 12 months, was it always easy to get a referral to a specialist when you felt like you needed one? 16. In the last 12 months, how often did you have to see someone else when you wanted to see your personal doctor or nurse? 17. Are you able to get your appointments when you choose? 18. Is there anything our practice can do to improve the care and services offered to you? 19. Would you recommend this practice to others? Appendix PGCHEZ Patient Satisfaction Survey- Part II 14