COMMUNITY COMMUNITY

HEALTH WORKSHEALTH WORKS

Celebrating Rural GeorgiaCelebrating Rural Georgia

Georgia Rural Health Georgia Rural Health AssociationAssociation

August 22, 2006August 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 COMMUNITY HEALTH WORKSWORKS

““Community Health Works is a Community Health Works is a bold organizationbold organization seekingseeking innovative health solutionsinnovative health solutions and and providingproviding compassionate compassionate advocacyadvocacy for people financially for people financially compromised by their medical compromised by their medical needs, while needs, while reducing the reducing the burdensburdens on local health on local health providers.”providers.”

•501c3501c3•7 counties in Central 7 counties in Central

GeorgiaGeorgia•5 hospitals5 hospitals•3 clinics3 clinics•135 physicians135 physicians•22 pharmacies22 pharmacies

Who is CHW?Who is CHW?

CHW Board MembersCHW Board Members

• Frank Aaron, CEO, Houston Health Care Frank 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 MembersCHW 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 MembersCHW Board Members

• Bill Hamrick, Twiggs Co. Comm. Past Bill Hamrick, Twiggs Co. Comm. Past ChairChair

• 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 Lelia Anderson, ED, Family

ConnectionsConnections• Dr. Fred Schnell, Chairman GA COREDr. Fred Schnell, Chairman GA CORE• Art Christie, Dir of Oper., Houston Art Christie, Dir of Oper., Houston

Health CareHealth Care

• Created network based on a Created network based on a donated care modeldonated care model

• Uninsured with 4 disease Uninsured with 4 disease states states – DiabetesDiabetes– HypertensionHypertension– Cardiovascular diseaseCardiovascular disease– DepressionDepression

What did we do?What did we do?

•Care Management Care Management •Pharmaceutical assistancePharmaceutical assistance•Primary Care HomePrimary Care Home•Tracked hospital & ER Tracked hospital & ER

utilizationutilization

What did we do?What did we do?

Screening

Eligibility

Care Management

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 WHAT WERE THE RESULTS?RESULTS?

Donated Care ModelDonated Care Model

5 Hospitals 5 Hospitals ++

3 Clinics 3 Clinics ++

22 Pharmacies22 Pharmacies ++

135 Physicians 135 Physicians ++

EQUALS ???????EQUALS ???????

MEMBERS SCREENEDMEMBERS SCREENED60686068

1489

2479

3774

5159

6068

0

1000

2000

3000

4000

5000

6000

7000

2001 2002 2003 2004 2005 2006

Year

Mem

bers

From Inception thru 7/31/06

MEMBERS ENROLLEDMEMBERS ENROLLED19391939

1

277

1358 14381575

1939

0

250

500

750

1000

1250

1500

1750

2000

2250

2001 2002 2003 2004 2005 2006

Year

Mem

bers

Total as of 07/31/06

Donated Care ModelDonated Care Model

More thanMore than

3,500 3,500 Members ServedMembers Served

$ 35 million$ 35 million Care Care CoordinatedCoordinated

$ 2 million$ 2 million Free MedicinesFree Medicines

$ 1 million$ 1 million Medicaid/MedicareMedicaid/Medicare

AND……AND……

A rigorous independent examination A rigorous independent examination ofof

CHW care management results CHW care management results shows:shows:

• $1,300,000 annual saving per thousand $1,300,000 annual saving per thousand members in CHW care managementmembers 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 BEGINNING TO TRACK CLINICAL TRACK CLINICAL

OUTCOMESOUTCOMES

DateDate A1CA1C ReferenceReference Results Results FlagFlag

March 1, March 1, 20042004

7.67.6 3.0 – 6.0 %3.0 – 6.0 % HighHigh

June 24, June 24, 20042004

5.45.4 3.0 – 6.0 %3.0 – 6.0 % NormalNormal

Sept. 30, Sept. 30, 20042004

5.35.3 3.0 – 6.0 %3.0 – 6.0 % NormalNormal

Jan. 5, Jan. 5, 20052005

5.55.5 3.0 – 6.0 %3.0 – 6.0 % NormalNormal

59 Year Old

Female

Date of Enrollment: September 23, 2003

Exercise

Clinical OutcomesClinical Outcomes

• Physician Data SegregationPhysician Data Segregation– Use to show value of Care ManagementUse to show value of Care Management– Use to show effectiveness of treatment Use to show effectiveness of treatment

planplan

• Care Manager Data SegregationCare Manager Data Segregation– Use to incentivize personnelUse to incentivize personnel– Use to allocate personnel/ create care Use to allocate personnel/ create care

teamteam

Peach County ResidentPeach County Resident

• 57 Yr Old African American Male57 Yr Old African American Male• Diagnosed with Diabetes and Vision Diagnosed with Diabetes and Vision

problemsproblems• Did not work because of healthDid not work because of health• Care Manager got him glasses from Care Manager got him glasses from

LensCraftersLensCrafters• Blood sugars down, medicine dosages Blood sugars down, medicine dosages

decreaseddecreased• 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 WorksCommunity Health Works Board of DirectorsBoard of Directors

Central GeorgiaCentral GeorgiaCancer Coalition Cancer Coalition

Rx for theRx for the UninsuredUninsured

Community Health Works- Principal Activities

Middle GeorgiaMiddle GeorgiaMulti ShareMulti Share

Central Georgia Cancer Central Georgia Cancer CoalitionCoalition

Through Prevention,

Screening,

Early Detection,

Education,

Leading-Edge Treatment

& Advanced Research

CANCER CAN BE DEFEATED

Community Health WorksCentral Georgia Cancer Coalition

RegionDADE

CHATTOOGA

WALKER

CHEROKEE

HARALSON

GORDON

DOUGLAS

RABUN

JACKSON

MURRAYGILMER

FORSYTH

CATOOSA FANNIN

LUMPKIN

BARTOW

PICKENS

FLOYD

PAULDING

COBBPOLK

UNIONTOWNS

FRANKLIN

WHITE

STEPHENS

DAWSONHALL

OGLETHORPE

BANKS

COWETA

MADISON

GWINNETT

CLAYTON

CLARKE

HART

FULTON

HEARD

DEKALB

FAYETTE

LAMAR

HENRY

NEWTON

SPALDING

CARROLL

TROUP

HANCOCK

PIKE

MORGAN

JEFFERSON

BARROW

WALTONOCONEE

ELBERT

GREENE

WILKES

JASPER

BUTTS

UPSON

LINCOLN

WARREN

PUTNAM

COLUMBIA

BURKE

WASHINGTON

BALDWINJONES

MONROE

WILKINSONBIBB

CRAWFORD TWIGGS

BLECKLEY

EMANUELJOHNSON

JENKINSSCREVEN

BULLOCH

DODGE

HOUSTON

PEACH

TALBOTHARRIS

MUSCOGEE

CHATTAHOOCHEEMARION

STEWART SUMTER

SCHLEYDOOLY

PULASKI

WILCOXTELFAIR

WHEELER

BEN HILLLEETERRELL

RANDOLPH

QUITMAN

WORTHDOUGHERTYCALHOUNCLAY

CRISP

TURNER

TIFT

COFFEE

JEFF DAVIS

TREUTLEN

TOOMBS

APPLING

TATTNALL

WAYNEBACON

COLQUITTMITCHELL

EARLY BAKER

SEMINOLE

DECATUR GRADY THOMAS BROOKS

COOK

LOWNDES

ECHOLS

LANIER

ATKINSON

WARE

PIERCE

BRANTLEY

CHARLTONCAMDEN

GLYNN

LONG

LIBERTY

BRYAN

MCINTOSH

EFFINGHAM

CHATHAM

CANDLER

EVANS

IRWIN

BERRIEN

MILLER

RICHMOND

TAYLOR

CLINCH

TALIAFERROMCDUFFIE

MACON

WEBSTER

GLASCOCK

ROCKDALE

MERIWETHER

HABERSHAM

WHITFIELD

LAURENS

MONT-GOMERY

Yellow: Original CHW Counties

Yellow/Green: Cancer RPE Region

HRSA HCAP GRANTHRSA HCAP GRANT

• Create Medicaid & Disability Create Medicaid & Disability SoftwareSoftware

• Tobacco Cessation OutreachTobacco Cessation Outreach• Electronic Health RecordElectronic Health Record• Implement vertically integrated Implement vertically integrated

cancer care managementcancer care management• Implement database to assure Implement database to assure

access to clinical trialsaccess to clinical trials• Pharmaceutical assistance programPharmaceutical assistance program

HCAP GrantHCAP Grant

Cancer Screening SoftwareCancer Screening SoftwareBreastBreast OralOral

CervicalCervical SkinSkin

Ovarian Ovarian ColorectalColorectal

LungLung ProstateProstate

TesticularTesticular

GEORGIA BREAST CANCER GEORGIA BREAST CANCER LICENSE TAGLICENSE TAG$50,000 Grant$50,000 Grant

• Provide access to Provide access to mammography mammography screening for screening for uninsured women in uninsured women in GeorgiaGeorgia– Implement in Peach & Implement in Peach &

Monroe CountiesMonroe Counties– Access system through Access system through

primary care physiciansprimary care physicians– Care coordinated by Care coordinated by

CHW Care ManagersCHW Care Managers– Assistance with State Assistance with State

Cancer Aid for those Cancer Aid for those who qualifywho qualify

Medcen/Komen Medcen/Komen PartnershipPartnership

Over 500 MammogramsOver 500 Mammograms

Detected Several Early Detected Several Early Stage CancersStage Cancers

Prevention & Early Prevention & Early DetectionDetection

Central Georgia has some of the highest tobacco use rates in the state

24 - 49%

TOBACCO USETOBACCO USE PREVENTIONPREVENTION PROGRAM PROGRAM

• To extend smoking cessation and To extend smoking cessation and education programs to education programs to underserved counties.underserved counties.

• Partner - American Cancer Partner - American Cancer Society Society

• Facilitated training - 11 “Master”Facilitated training - 11 “Master” Freshstart Trainers from 6 countiesFreshstart Trainers from 6 counties– 20 Facilitators trained in Baldwin County20 Facilitators trained in Baldwin County– 13 CHW Care Managers Training13 CHW Care Managers Training

• Georgia Tobacco QUIT LineGeorgia Tobacco QUIT Line

Pan African Festival Pan African Festival April 29, 2006April 29, 2006

PSA ScreeningsPSA ScreeningsCentral 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 CareAccess & Continuum of Care

2006 Cancer Summit 2006 Cancer Summit

for Pastors & Religious Leadersfor Pastors & Religious Leaders

September 29-30, 2006September 29-30, 2006• 1500 Pastors are invited1500 Pastors are invited• 2 Day Training and Seminar2 Day Training and Seminar

– Cancer 101 for PastorsCancer 101 for Pastors– Best Practices for Churches and Faith Best Practices for Churches and Faith

Based OrganizationsBased Organizations– Facilitating & Partnering for Best Cancer Facilitating & Partnering for Best Cancer

CareCare

Community Health WorksCommunity Health Works Board of DirectorsBoard of Directors

Central GeorgiaCentral GeorgiaCancer Coalition Cancer Coalition

Rx for theRx for the UninsuredUninsured

Community Health Works- Principal Activities

Middle GeorgiaMiddle GeorgiaMulti ShareMulti Share

HRSA State Planning HRSA State Planning GrantGrant

Middle Georgia Multi Middle Georgia Multi ShareShare

HRSA State Planning HRSA State Planning GrantGrant

• Governor Perdue received a grant Governor Perdue received a grant to explore the abilities of to explore the abilities of public/private partnerships to public/private partnerships to help the uninsuredhelp the uninsured

• GA was one of 9 states that GA was one of 9 states that received the grantreceived the grant

• CHW was one of the 4 CHW was one of the 4 communities asked to do the communities asked to do the researchresearch

HRSA State Planning HRSA State Planning GrantGrant

• Established Steering Committee Established Steering Committee

• Held Focus GroupsHeld Focus Groups– Small BusinessSmall Business– EmployeesEmployees

• In Plan Design PhaseIn Plan Design Phase

HRSA State Planning HRSA State Planning GrantGrant

• Received Healthcare Georgia Received Healthcare Georgia GrantGrant

– Marketing SurveyMarketing Survey– Actuarial StudyActuarial Study– Economic Impact StudyEconomic Impact Study

For More InformationFor More Information

Gregory J. DentGregory J. Dent

President & CEOPresident & CEO

Community Health Community Health WorksWorks

105 Patrol Road, Suite 105 Patrol Road, Suite 22

Forsyth, Georgia 31029Forsyth, Georgia 31029

478-994-1914478-994-1914

Gdent@chwg.orgGdent@chwg.org

www. chwg.orgwww. chwg.org