1. occhd.org Aundria Goree, MPH Community Health Administrator Oklahoma City-County Health Department Aundria_goree@occhd.org Public Health in Emergency Departments: Engaging the Uninsured in Care Management

2. occhd.org Summary In a pilot project intended to reduce inappropriate emergency detention utilization across two health systems in Oklahoma County, community health workers have been deployed to work hand-in-hand with uninsured patients. Most participants suffer from chronic co-morbidities, many of which include a diagnosed mental health need. Screening clients for core social determinants of health including food and housing security, interpersonal violence and transportation barriers are examples of needs identified and met as a part of the intensive case management services. Within four months financial and utilization improvements have been realized.

3. occhd.org Learning Objectives Understand the importance of consistently screening for social determinants of health and how to implement it in your organization. Learn the challenges of engaging high risk populations in behavior change and strategies for overcoming barriers. Know how to apply components of an emerging best practices in case management and referral linkages in your community.

4. occhd.org What are Social Determinants of Health and Why Are They Important?

5. occhd.org Social Determinants of Health: A Definition “The social determinants of health (SDH) are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems.” - World Health Organization

6. occhd.org Wellness Now Coalition Launched in April 2010 Mission: To improve the health of Oklahoma County through community partnerships that create policies systems and environments that make living well easier. # of current Partners- over 100+ Wellness Score Workgroups: Adolescent Health, Health at Work, Mental Health, Nutrition and Physical Activity, Tobacco Use Prevention, Care Coordination, Faith- based

7. occhd.org What’s Going On In Our Community? Access to Transportation: (City of OKC Planning and Development)

8. occhd.org What’s Going On In Our Community? Food Security (Regional Food Bank Data) Housing Instability: In 2015, 1,300 homeless individuals identified through a point in time survey by Homeless Alliance. This can be extrapolated to approximately 5,200-6,500 people who were homeless in Oklahoma County in 2015. (Homeless Alliance) Healthcare Access: 18.8% of the Oklahoma County Population does not have health insurance Hungry PopulationCountyState Total126,990 people656,000 people Children45,740 children242,990 children Seniors16,152 seniors94,061 seniors

9. occhd.org Addressing the Root

10. occhd.org Engagement with Hospital systems Emergent needs: INTEGRIS 5/50 Project- Collaborations and partnerships Clients in need of a primary care medical home. ED follow-up Prevention or management of chronic diseases/co-morbidities after leaving ED Need for community services to address basic needs of clients

11. occhd.org Engagement with the Hospital Systems Wellness Now Care Coordination Workgroup Goal: To improve the health of patients by the coordination and collaborative efforts of hospitals and community partners. Co-chairs: Mercy and INTEGRIS Hospitals Members: Community Partners OCCHD: Provide staff support

12. occhd.org Engagement with the Hospital Systems Hospital Pilot Project: -4 Community Health Workers (2 in each hospital- levy funded positions) -CHW training -Data collection and evaluation -monthly audits for quality assurance

13. occhd.org Community Health Worker A community health worker is a frontline public health worker who is a trusted member of and/or has a close understanding of the community served In Oklahoma, this is currently an unlicensed position

14. occhd.org Community Health Worker Training Community Transformation Grant Funding helped with building a partnership with Langston University to create and Beta Test an online CHW curriculum. 12 modules(Community Health, The Role of the Community Health Worker, Health Promotion and Health Education, Disease Epidemiology, Chronic Diseases in Oklahoma, Health Disparities, Community Nutrition, Community Resources, Health Advocacy, Documentation, Safety, Work and Life Balance)

15. occhd.org Additional CHW Training CPR/First Aid Blood Borne Pathogens Health Screening Home Visit Safety Medication Training Mental Health First Aid

16. occhd.org Data Collection/Evaluation Resource Needs Questionnaire-Identify and link to health/social services Access to PCP Baseline and Q4 clinical measures(lipids, BP, glucose) Tracking CHW phone calls/face to face appointments; LTFU Evaluating Hospital Financial Data

17. occhd.org Impact of CHW Hospital Pilot (As of 7/31/2016) 127 clients enrolled 43 newly enrolled in primary care during program Cohort 1 (first group enrolled) realized more than a 30% decrease in reported ED use & tobacco use 75% reduction in client direct costs!

18. occhd.org Impact of CHW Hospital Pilot One client was diabetic, had a below the knee amputation, no insurance and no income. CHW, care coordination team and Hanger Clinic provided client with a $15,000 prosthetic leg and follow up appointments free of charge!

19. occhd.org Questions! Contact information: Aundria Goree, MPH Community Health Administrator Oklahoma City-County Health Department Aundria_goree@occhd.org 405-425-4409