Maryland’s Health Enterprise Zones InitiativeUpstream Strategies to Address Social Determinants of

Health

Maura Dwyer, DrPH, MPHHEZ Program Director

Maryland Department of Health

In Maryland, chronic diseases—such as heart disease, prediabetes, diabetes, hypertension—are the leading causes of death, disability, and health care costs, accounting for 70% of all deaths each year and 75% of all medical costs

(Anderson, 2010)

Chronic Disease Burden

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2013 Asthma ED Visit Rates By Race and Maryland County

County Baseline Black/African American WhiteData : Maryland Health Services Cost Review Commission (HSCRC) 2013

Credit: Lisa Cooper, MD, MPH, FACPJames F. Fries Professor of MedicineDirector, Johns Hopkins Center to Eliminate Cardiovascular Health DisparitiesJohns Hopkins University Schools of Medicine, Nursing, and Bloomberg School of Public Health

Need for Focused Attention

We realized that the areas with the worst health outcomes and the most health disparities, also cost the State the most money

SB 234: Maryland Health Improvement & Disparities Reduction Act of 2012

• In 2012 SB 234, the Health Improvement and Disparities Reduction Act was singed into law, establishing the Health Enterprise Zones and providing $4 million per year for 4 years to support the HEZs

• As legislatively mandated, the purpose of establishing Health Enterprise Zones is to target State resources to reduce health disparities, improve health outcomes, and reduce health costs and hospital admissions and readmissions in specific areas of the State.

What is a Health Enterprise Zone (HEZ)?- A designated local community with documented poverty, health disparities and/or

poor health outcomes, where special incentives and funding streams are available to address poor health outcomes by using healthcare-level, community-level and individual level interventions.

- There are 5 HEZs in MD, based at:- Anne Arundel Medical Center (suburban) - Prince George’s County Health Department (suburban)- Bon Secours Hospital (urban)- Caroline/Dorchester County Health Departments (rural)- MedStar St. Mary’s Hospital (rural)

HEZ Eligibility Criteria 1) An HEZ must be a community, or a contiguous cluster of communities, defined by zip

code boundaries (one or multiple zip codes).

2) An HEZ must have a resident population of at least 5,000 people.

3) An HEZ must demonstrate greater economic disadvantage than MD average: – Medicaid enrollment rate or – WIC participation rate

4) An HEZ must demonstrate poorer health outcomes than MD average:– A lower life expectancy or– Percentage of low birth weight infants

January 2013 – Health Enterprise Zones Designation

MHHD Logic Model: Incorporated into HEZ

• The MHHD Logic Model has six key strategies that are generally applicable to programs.

• These six strategies became HEZ principles:– Cultural, linguistic and health literacy competency– Workforce diversity– Outreach to and targeting of minority populations– Racial, ethnic & language data collection/reporting– Addressing social determinants of health– Balance between provider and community focus

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HEZ Incentive Program • HEZ enabling legislation provides a number of incentives and resources to attract

providers to the Zones: – State income tax credits– Hiring tax credits– Grants for program support, equipment purchase or lease– Loan repayment assistance programs

• Practitioners must meet the following criteria to access tax credits: – Cultural competency training– Accept Medicaid and uninsured patients– Letter of support from the Coordinating Organization

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Broader Health Care Environment

• Affordable Care Act

• Maryland Medicaid Expansion

• Global Budgets– Maryland All Payer model – payment reform/delivery system reform– Emphasis on care coordination and– Community clinical linkages

Health Enterprise Zones: Successes

• Expanding capacity to deliver services:– 22 health care delivery sites opened or expanded across the 5 HEZs– 99.09 FTEs added or retained across HEZs, including 20.2 licensed independent

practitioners, 31.98 other licensed or certified health care practitioners, 12.75 CHWs– $326,985 awarded via 63 income tax credits to HEZ practitioners and 19 HEZ

practitioners awarded loan repayment assistance• Providing new or expanded primary care, behavioral health, dental and wrap-around

public health and social services: – 342,623 visits provided to 194,579 patients across the 5 HEZs– Care coordination programs target ‘high utilizers’ in all HEZs– Linked HEZ data systems facilitate data sharing and co-management of complex

patients– Self-management and community supports address social determinants of health

Trend in Total Discharges per 1,000 Residents for HEZ, HEZ-eligible and Non HEZ Zip Codes, 2010-2015

Trend in Discharges for HEZ-related Conditions per 1,000 Residents for HEZ, HEZ-eligible and Non HEZ Zip Codes, 2010-2015

HSCRC data prepared by the Johns Hopkins Center for Health Disparities Solutions

Trend in Readmissions per 1,000 Residents for HEZ, HEZ-eligible and Non HEZ Zip Codes, 2012-2014

Emergency Room Visits (per 1000)

Emergency Room Visits for HEZ Related Conditions (per 1000)

Greater Lexington Park Health Enterprise Zone (HEZ)

Project

Lori WerrellProgram Director, GLPHEZMedStar St Mary’s Hospital

VisionEstablish accessible, integrated, culturally

competent healthcare in the HEZ supported by clinical care coordination, prevention services,

community outreach and education

Core Disease StatesDiabetes, Asthma, Hypertension, Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Behavioral/Mental Health Diseases

Greater Lexington Park Health Enterprise Zone

• Lexington Park:– Life Expectancy: 77.6 (lower than 79.1

years eligible)– Medicaid Enrollment: 200.93 (higher

than 109.1 per 1000 eligible)– WIC participation: 38.77 (higher than

18.0 per 1000 eligible)• Great Mills:

− Average % low birth rate: 7.4 (higher than 6.4 per 1000 births eligible)Medicaid enrollment: 128.84WIC participation: 20.49

**Needed to meet either life expectancy or low birth weight and Medicaid enrollment or WIC participation thresholds.

HEZ Demographics

• Population of approximately 34K in 3 zip codes (20653,20634,20667)

• Clients being assisted– 31% identify as Hispanic– 46% identify as Black or

African American

White62%

Black or African

American28%

American Indian and

Alaska Native

1%

Asian6%

Some Other Race3%

Zone Population

Approximately 7% identify as Hispanic

AccessHealth

• Care Coordination• Community Health Workers • Transportation – shuttle,

minivan, car• Dental – mobile unit • East Run Health Center• Behavioral Health• Trainings, classes, events and

screenings• Health Disparities/Hispanic

outreach

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Major Program Components

Care Coordinator

Outpatient Primary /

Specialist/ Ancillary Care

Hospital encounter

• Inpatient (readmission risk factors triggers Care Coordinator)• Emergency Room (follow up by Community Health Worker

Care Coordinator

• Home visits, care plans, phone support, medication reconciliation• Working with other care coordination programs and primary care

Community health worker

• Removing Barriers (Their training is offered to whole community)• Transportation (shuttle and medical specialty routes)

Outpatient Care

• Primary and specialist appointments, Dental• PT ,Dialysis, Cardiac Pulmonary Rehab etc

Self management

programs

• Walk with Ease, CDSMP, NDPP, diabetes self management program, support groups, Walden Sierra programs

Provider RecruitmentPrimary Care and Psychiatry

• Opened new Primary care and Psych access point

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East Run Health Center

A Success StoryJust wanted to share…..

On Friday morning (1/6/17), Antonio (CHW) had gone to The Mission to assist a client we had been working with. While there, he met a family who were relatively new to the area, from Virginia. Antonio was telling this family about AccessHealth and how we help folks in the community. The patient stated he had been out of diabetic testing strips for over a week. The patient also said his insurance was not active yet and the next available appt with a new provider was not until 2/9/17. Antonio called me (RN care coordinator), and we started looking into options. Debbie (NWA) looked up the insurance, found out that it was, in fact active, and was able to print out the information for the family. They had just not received the card in the mail yet and were surprised to hear it was active. MedStar St Mary’s Primary Care was called and they confirmed they could see gentleman the same day. The family was given the phone number and called to schedule a time. He was seen Friday afternoon and received his prescription refill for diabetic testing strips. Good stuff!!

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Results (Year 3)

• Readmission rate of RN Care Coordinated patients - 7.03%– State data has the overall zone Readmissions rate dropping from 13.4%

to 6.8% (around a 50% drop)– Emergency Room Visits are down (this is still a challenge)– PQI Composite scores are below state averages

• # of new clients served by CHWs – 271• # of client encounters with CHWs – 4421

• Shuttle ridership – 7497• Medical Specialty rides – 440

• # of patients served behavioral Health – 656• # of unduplicated Psychiatric patients– 87• # Dental patients seen – 42• # Primary Care patients seen - 2105

Readmissions

Emergency Department Use

Lessons Learned

• Don’t be afraid to change from the original plan

• Take risks• Data – blessing and a curse• Be patient – don’t stop trying• Listen to the community

Sustainability

• A work in progress• A commitment from MedStar• A lasting imprint

– East Run Health Center– Community Health Workers

• Strong Partnerships– Medical Respite– Regional transportation planning grant

QUESTIONS?Lori.K.Werrell@MedStar.net

Caroline-Dorchester HEZCompetent Care Connections

2017 Maryland Rural Health ConferenceMaryland’s HEZs: Upstream Strategies to Address Social Determinants of Health

October 5, 2017

Competent Care Connections Region

Population Health Approach

▪ Collaborative effort among different types of organizations

▪ Shared values and goals

▪ Coordination to address complex health determinants

▪ Coalition made up of 23 leaders, community members, advisory partners, etc. with different skill sets and resources meets monthly to strategize

Goals for HEZ 4-Year Grant Period

1. Improve outcomes and reduce risk factors related to diabetes, hypertension, asthma, and behavioral health issues

2. Expand the primary care workforce

3. Increase the community health workforce

4. Increase community resources for health

5. Reduce preventable emergency department visits and hospitalizations

6. Reduce unnecessary costs in healthcare

Primary CareChoptank Community Health System

▪ Contracted for care coordination efforts

▪ Nurse Care Coordinator & Community Support Specialists ensure patients referred appropriately and assist patients with navigating healthcare system

Dorchester County School Based Wellness Center

▪ Expanded access to pediatric care in school setting (in collaboration with providers)

▪ Nurse Practitioner at middle school provides primarily somatic, but also primary mental health services

▪ Implemented Asthma Management Program

Community HealthMaryland Healthy Weighs▪ Obesity treatment program proven to reduce BMI▪ Allows access for low income patients by offsetting costs not covered by insurance

Associated Black Charities▪ Established Community Health Worker Team to solidify reach into homes and

communities through various services▪ Build trusting relationships to connect individuals to needed care and resources

Behavioral HealthCaroline County Health Department▪ Federalsburg Mental Health Clinic – Licensed clinical social workers and

psychiatrist provide adult outpatient mental health services▪ Provided school-based mental health services

Affiliated Sante Group Eastern Shore Mobile Crisis Response ▪ Established Dorchester/Caroline Team to reduce dispatch crisis response time and

divert from hospitalization or incarceration▪ Resource help for people in crisis with mental health issues, substance abuse, etc.

Peer RecoveryChesapeake Voyagers, Inc.▪ Provides mental health peer

recovery support services

DRI-Dock▪ Drop-in center▪ Provides substance abuse peer

recovery support services

Recruitment & TrainingMedChi Promotes incentives to providers to open/expand services in Zone Recruited satellite office – Chesapeake Women’s Health and 6 additional physicians

Eastern Shore Area Health Education Center Developing CHW workforce by providing core training and updates and working

to establish CHW training institute Advocated for preceptor tax credit bill Assisted with 2 mini-residency rotations in one of our high schools

HEZ Participants Receiving Services

HEZ Metrics Year 1 Year 2 Year 3 Year 4 Total

Total Number of Unduplicated Patients 591 1,253 1,550 2,704 6,098

Total Number of Patient Visits 2,687 7,899 9,240 7,261 27,087

Residual BenefitsContinuing to address chronic disease burden!

Established partnerships for other initiativesEnhanced community clinical linkages

Leveraging of resources

Angela Mercier, Health Education Program ManagerDorchester County Health Department

3 Cedar StreetCambridge, MD 21613

Phone: 410-901-8126Email: angela.mercier@maryland.gov

Contact Information: