1. Harford County Local Health Improvement Coalition Update Susan Kelly, EHS Health Officer Russell Moy, MD, MPH Deputy Health Officer November 12, 2014 www.harfordcountyhealth.com/

2. Our Local Health Improvement Coalition (LHIC) Where have we been, where are we headed? 2 State Health Improvement Process (SHIP) launched in Sept 2011 Harford County Local Health Improvement Process (LHIP) launched in Dec 2011 Harford County Community Health Assessment (CHA) & Community Health Improvement Plan (CHIP) released Dec 2012 Harford County LHIC Progress Check on the CHIP in Oct 2013 & Oct 2014 Strengthened Local Health Department, Local Hospital & Healthy Harford LHIC Collaborative Efforts in 2015

3. How We Built on Harford County Efforts 3 Health Care Reform Mandates Harford County Health Department SHIP CHA Mandates Upper Chesapeake Health CHNA Mandates HARFORD COUNTY LHIC COMMUNITY HEALTH IMPROVEMENT PLAN

4. E m e r g i n g C o n s I d e r a t I o n s Access to Care, Chronic Disease Prevention, Health Disparities How We Identified the County’s Health Priorities 4 Obesity Prevention/ Healthy Eating & Active Living HARFORD COUNTY LOCAL HEALTH IMPROVEMENT COALITION PRIORITIES Tobacco Use Prevention/ Smoke- Free Living Behavioral Health/ Mental Health & Substance Abuse Prevention Community Engagement Access to Healthy Foods Built Environment E-Cigarette Minors’ Access Multi-Unit Housing Other Policy Efforts Prevention Intervention Recovery Framework

5. Harford County, Maryland Community Health Improvement Plan, December 14, 2012 Our Community Health Improvement Plan released in December 2012 showed... Harford County’s Community Health Improvement Plan is a long-term, systematic process for addressing issues identified in its Community Health Assessment in order to improve health outcomes. Strategies include: Obesity Prevention – Increasing access to healthy foods – Enhancing the built environment – Creating a “Community of Wellness” Tobacco Use Prevention – Promoting community awareness – Encouraging workplaces to be smoke-free – Policy changes regarding sales to minors Behavioral health – Integrating and improving the delivery of substance abuse and mental health services

6. Where Are Our Hot Spots? 6 Source: US Census Bureau, 2010 data Households with median incomes 80% below the median household income for Harford County Low-income, high risk areas in the County include Edgewood, Aberdeen, Havre de Grace & Bel Air Bel Air Edgewood Aberdeen Havre de Grace

7. What Were Our Opportunities? 7 Maryland Community Health Resource Commission (CHRC) Grant Opportunities for (1)Expanding Access to Care (2)Expanding Care Coordination Upper Eastern Shore Connector Entity Seedco Inc. Subcontracts for Maximizing Insurance Coverage through (1)Assisters (2)Patient Navigators Medicaid Expansion DHMH/LHD MCHP Programs Community Connections Healthy Harford Inc. Homevisiting Schools/Libraries/CBOs Faith-Based Groups Social Service Organizations Others Clinical Safety Net Services HCHD Clinical Services Upper Chesapeake Health Services HealthLink West Cecil FQHC Community Healthcare Providers Others

8. Maximize Insurance Coverage“Care Coordination Plus” West Cecil FQHC Satellite Beacon Health in Havre de Grace increases access to care How Did These Opportunities Come Together? 8 CHRC LHIC Grant Maryland Community Health Resources Commission (CHRC ) 4 Care Coordinators (HCHD) Connector Entity Assister Grant Seedco Inc/MHBE 4 Assisters (HCHD) Connector Entity Navigator Grant Seedco Inc/MHBE 5 Patient Navigators (Harford Community Action Agency) DHMH & DHR Medicaid Medicaid/MCHP Enrollment (HCHD/DSS) Team Care Coordinator Assister & Navigator Team Care Coordinator Assister & Navigator Team Care Coordinator Assister & Navigator Team Care Coordinator Assister & Navigator Bel Air Addictions, HIV, HCH, DSS, UCMC ED Edgewood FP, STD, WIC, Dental, Immunizations Aberdeen WIC, Homevisiting, Teen Diversion Havre de Grace HealthLink, Harford Memorial ED Clinical Safety Net Services Follow Up & Referrals Mental Health, Substance Abuse, HIV, HCH, FP, STD, WIC, Immunizations, Dental, HealthLink, Core Service Agency, Breast & Cervical Cancer Program, CRF Colorectal Cancer Program, Community Providers, Others Community Connections & Referrals Healthy Harford Activities, Homevisitng, Faith-Based Groups, Libraries, Colleges/Schools, Social Service Organizations, Civic Groups, Others

9. What Were Our Results? 9 Goal 1 – Maximize Health Insurance Coverage # Screenings for insurance status Target 6,400 – Actual 8,080 # Individuals referred to Assisters, Navigators or Caseworkers Target 640 – Actual 912 # Individuals with Medicaid/QHP referred to Care Coordinators Target 640 – Actual 314 Goal 2 – Improve Care Coordination # Individuals offered Care Coordination Plus services Target 320 – Actual 916 # Individuals who sign “Reverse Consent” form allowing contact with other programs/services Target 320 – Actual 174 # Individuals completing Care Coordination Plus follow up Target 160 – Actual 174 Goal 3 – Improve Community Mental Health # Healthcare professionals who received suicide prevention/depression risk assessment training Target 50 – Actual 58 # Individuals enrolled in Care Coordination Plus referred to behavioral health services Target 50 – Actual 42 # Individuals enrolled in Care Coordination Plus who accessed behavioral health services Target 25 – Actual 32

10. What Were Our Lessons Learned? 10 LESSON 1 Access to Care is not just about health insurance coverage – It’s about finding the right provider, navigating the healthcare system & overcoming other barriers to care. LESSON 2 A Big Need for Care Coordination Exists – and not just for those with Medicaid and Qualified Health Plans, but those with other private commercial insurance too. LESSON 3 Effective Care Coordination is more than just giving out pamphlets & phone calls – It is labor-intensive follow up that depends on (1) the trust relationship between the individual and the care coordinator, and (2) the collaborative relationships among community organizations and clinical safety net providers. LESSON 4 Meaningful Evaluations require access to shared data and real money for analytic purposes – money not to be diverted from the service delivery program.

11. What Are Our Expected Future Activities? 11 Harford County Community Health Team “Care Coordination Plus” Addressing wrap-around supports: Harford County Health Department Upper Chesapeake Health Healthy Harford Harford County Government Schools, CBOs, Social Service Agencies Others Harford County Provider Care Team “Case Management Plus” Addressing chronic disease management: Upper Chesapeake Health Harford County Health Department Healthy Harford West Cecil FQHC Community Healthcare Providers Others Shared data Coordination Plus Oversight Team For Addressing the Needs of: Super-utilizers Chronically Ill & At-Risk of Becoming Super-utilizers Chronically Ill, But Under Control