1. Island Community Care Project Connecting People with Community and Health Services October 11, 2007

2. Partners Healthy Acadia Maine Sea Coast Mission Mount Desert Island Hospital –Behavioral Health Center –Healthy for Life Program –Southwest Harbor Community Health Center Hancock County Planning Commission Harbor House Community Center * The Community Care Project received generous support from the Maine Health Access Foundation.

3. Project Goals and Strategies Our goals were simple and ambitious “The Community Care initiative will actively integrate population-based prevention in the community with an individualized care management process in the primary care setting, utilizing evidence based practices to affect behavior change.” “The goals of this initiative are to: 1.increase self-care behavior, readiness to change, and belief in ability to change among at risk persons. 2.provide strategic access to comprehensive primary care for rural, medically underserved populations 3.establish structural changes in community settings in support of self care behavior.” (Source: Community Care Proposal, submitted May, 2005)

4. Target Population The target population for this initiative included persons who by nature of their employment were: uninsured and confront occupational and lifestyle risks. Many people who fell within this category were confronting occupational and physical disabilities resulting from workplace injuries and chronic conditions such as asthma, obesity, diabetes, depression and cardiovascular disease.

5. Community Engagement (Goal 1) Building Organizational Support for Community Care Community Health Outreach Worker - Debra Chalmers –Harbor House –Food Pantry Prescription for Fitness Maine Sea Coast Mission How’s Your Health?

6. All Records177 Younger Women54% Older Women23% Younger Men14% Older Men10%

7. Perceived Needs

10. Adapting Clinical Practice (GOAL 2) Overcoming barriers to health care access MDI Healthy for Life! Nurse Advisor Quality Initiative in Primary Care Services Outer Islands Medical support for outer islands Sunbeam - On site and Tele-health conducts health screenings and referrals Behavioral Health Services expanded in outer islands. Expand dental services (prevention, screenings) to outer islands.

11. Establishing Lasting Community Supports (GOAL 3) “Living Well with Chronic Disease” Collaborative effort by Maine’s Office of Elder Services (0ES) Exploring creation of Federally Qualified Health Clinic (FQHC) for outer islands. New partnership with Southwest Harbor / Tremont Ambulance Service Identify ongoing support for health care service –Bingham Foundation –Island Health Initiative Swans Island health committee - Set up lab on Swans Island for blood work Changing health behavior - Frenchboro Exercise Equipment, Pedometers Identifying new streams of funding for special projects – Right Weight for Me

12. Sustainability Our partners are all committed to moving forward with the community care model. Maine Seacoast Mission –Relationships have been enhanced between MDI Hospital, Maine Sea Coast Mission –Using new technologies including distance medicine and island health clinics to streamline staffing MDI Hospital and the Southwest Harbor Health Center –Healthy For Life! care manager role Healthy Acadia partnering with the Maine Nutrition Network and the USDA to secure funding to address community food security. Harbor House –“Prescription for Fitness Program” –Behavioral health support such as “Right Weight for Me” program. Sustainability will remain a major challenge. Integrating insured, under-insured and uninsured clients Insurers are reducing benefits Clinical programs continually seek alternative funding Continue efforts for early intervention and preventive care Pursue reimbursement for case/care management services Identify local “assets” to support community care through partnerships.