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Olmsted County Public Health Services

Preventive Health Services

Five Year Report2011 - 2015

Educating and assisting high risk elderly and disabled individuals to maintain or improve their quality of life

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Olmsted County Public Health ServicesPreventive Health Services Division

Five Year Report2011-2015

March 9, 2016

Olmsted County Public Health Services2100 Campus Drive SERochester, MN 55904

Questions regarding this report or requests for full data tables can be directed to:Daniel Jensen, Associate Director [email protected]

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Table of ContentsIntroduction ------------------------------------------------------------------------------------------------------------------------------------------------------------ 62015 Preventive Health Services Division Snapshot --------------------------------------------------------------------------------------------------------- 7Preventive Health Services Programs ---------------------------------------------------------------------------------------------------------------------------- 8Case Management -----------------------------------------------------------------------------------------------------------------------------------------------------11Care Coordination ----------------------------------------------------------------------------------------------------------------------------------------------------- 15Personal Care Attendant --------------------------------------------------------------------------------------------------------------------------------------------- 19Long Term Care Consultation --------------------------------------------------------------------------------------------------------------------------------------- 23Skilled Nursing Facility Care Coordination ---------------------------------------------------------------------------------------------------------------------- 27Assertive Community Treatment ---------------------------------------------------------------------------------------------------------------------------------- 31Special Needs Basic Care -------------------------------------------------------------------------------------------------------------------------------------------- 33Community Care Team ----------------------------------------------------------------------------------------------------------------------------------------------- 37Customer Satisfaction ------------------------------------------------------------------------------------------------------------------------------------------------ 40Preventive Health Services Strategy Map ----------------------------------------------------------------------------------------------------------------------- 42Vision Casting ----------------------------------------------------------------------------------------------------------------------------------------------------------- 43Conclusions & Next Steps ------------------------------------------------------------------------------------------------------------------------------------------- 45Methodology ----------------------------------------------------------------------------------------------------------------------------------------------------------- 46Data Sources ------------------------------------------------------------------------------------------------------------------------------------------------------------ 46

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Preventive Health Services: Elderly, Disabled and Mental Health NursingMission

Educating and assisting high risk elderly and disabled individuals to maintain or improve their quality of life.Vision

High risk elderly, disabled, and individuals with mental health issues live safe, independent and dignified lives in the community.

IntroductionLetter from the Director of Preventive Health Services

Olmsted County Public Health Services – Preventive Health Services division remains committed to supporting the aging and disabled citizens of OlmstedCounty to live safe, independent and dignified lives in our community. Throughout our long history of supporting the community our mission has beenwoven into the fabric of our divisional culture. We support our clients through programs where we meet directly with them, in their homes, to assesstheir needs and co-develop individualized, client centric plans of care. With the foundational plan of care in place, we work with our clients, at their levelof need, to connect with services and make lifestyle changes to progress towards their goals. Assisting us in our mission are our many community partnersthat work directly with our clients to provide quality care and coordinate the services our clients need to be successful.

During this past year we have focused on reorganizing ourselves to better serve our growing clientele. These changes have included developing an intaketeam, and teams focused on one or two health plans. This specialization has assisted staff to increase their focus in fewer areas resulting in improvementsto their targeted areas of practice. We have also worked with the state of Minnesota to implement their new MnCHOICES assessment software, improvedour partnership with Olmsted County Adult Community Services by transitioning onto a single case management software, and streamlined ourdocumentation code sets as part of the ICD-9 to ICD-10 conversion process.

We are excited to continue building upon our robust history as we work with our community partners to embrace the opportunities change is providing.

Daniel Jensen, Associate Director of Public Health

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7

Educating and assisting elderly and disabled individuals to maintain or improve their quality of life

Olmsted County Public Health Services

Preventive Health Services Division

Personal Care Attendant477 clients

436 contacts

Long Term Care Consultation223 clients

1,043 contacts

Assertive Community Treatment51 clients

1,082 contacts

Case Management427 clients

8,608 contacts

Skilled Nursing Facility Care Coordination

120 clients 1,256 contacts

Special Needs Basic Care290 clients

6,397 contacts

Community Care Team55 clients

809 contacts


Case Management/Care CoordinationPublic Health Nurses help clients access needed services (medical, social and other services as required), assure continuity of care, coordinate the service plan andmonitor the delivery of services provided. The goal is to assist clients to remain safe and as independent as possible in the community setting. PHN’s also work withindividuals on Minnesota Senior Health Options (MSHO) and will complete an assessment of a client’s medical, social/environmental and mental health needs anddevelop an interdisciplinary care plan with a preventive focus to meet their needs as determined during the assessment. One component of this care plan may includeassisting the client with planning and writing an Advanced Directive. With the care plan in place the PHN assures continuity of care and coordination by meeting withthe client on a regular basis to evaluate status and modify the care plan as needed. Client contact is required face to face annually with phone interaction every sixmonths or more frequently if the client’s needs warrant increased intervention.

Personal Care AttendantThe Personal Care Attendant (PCA) program provides assistance with activities of daily living for disabled individuals and individuals with special healthcare needs livingindependently in the community and requiring assistance and are enrolled in Medical Assistance. This program assesses the individual to determine eligibility andappropriate level of care and provide information on care options. Assessment visits are completed annually unless a client has documented evidence from a doctorindicating their physical needs have changed and an early assessment is needed.

Assertive Community TreatmentAssertive Community Treatment (ACT) is a team-based treatment model that provides multidisciplinary, flexible treatment and support to people with mental illness24/7. ACT is based around the idea that people receive better care when their mental health care providers work together. ACT team members help the personaddress every aspect of their life, whether it be medication, therapy social support, employment or housing. ACT staff include a psychiatrist, public health nurses,social workers, a substance abuse specialist, a mental health professional and employment specialists. ACT clients are seen at least weekly by a member of the team.For clients needing more intense intervention, visits may be completed one to two times per day.

Long Term Care ConsultationThe Long Term Care Consultation (LTCC) program assists individuals with long term or chronic care needs to make choices about long term care.The LTCC program’s goal is to:

Provide information and early assistance Connect people with special needed services Maintain people in their own homes Support choice and informed decision making Support caregivers

A public health nurse or social worker will visit with the client in their home or long term care facility to help identify the type of program they might want or need andhelp plan those services. There is no charge for this visit regardless of a person’s income or assets or eligibility for other services or funding. This assessment visitoccurs approximately 20 days after referral to the county. Most people have their needs addressed in one visit, but another may be required if the client’s conditionchanges before eligibility is completed or if more information is needed by the assessor.

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Elderly, Disabled, & Mental Health Nursing Programs

Elderly, Disabled, & Mental Health Nursing Programs


Skilled Nursing Facility Care CoordinationSkilled Nursing Facility Care Coordination (SNF CC) is a service that is provided toMSHO and MSC+ seniors who are enrolled in Medica or UCare products. Therole of the SNF care coordinator is to assist clients and familymembers/responsible parties understand their insurance benefits to makeinformed decisions about their health. The care coordinator is available forquestions and to facilitate communication between the appropriate health planrepresentatives, when needed. The care coordinator will also follow up with theclient after a hospital stay to ensure their plan of care continues to meet theirneeds. In addition, if returning home becomes an option, the care coordinatorwill assist in that transition process. Clients are visited by the care coordinatorwithin 30 days of admission or enrollment to the health plan. Consultation canoccur at any time but minimally every six months.

Special Needs Basic CareSpecial Needs Basic Care (SNBC) is a voluntary managed care program for peoplewith disabilities ages 18 through 64 who have Medical Assistance. The role ofthe SNBC care coordinator is to assist clients understand their insurance benefitsto make informed decisions about their health. The care coordinator is availablefor questions and to facilitate communication between the appropriate healthplan representatives, when needed. The care coordinator will also follow upwith the client after a hospital stay to ensure their plan of care continues tomeet their needs as well as assist with making referrals for other neededservices covered by insurance or Medical Assistance benefits. The carecoordinator contacts the client within 30 days of enrollment into the program,with outreach required every 90 days thereafter. The program is voluntary so ifthe client is stable they may choose to decline face to face visits.

Community Care TeamCommunity Care Teams (CCT) are community-based interdisciplinary care teamsthat include primary care and public health providers to help clients managetheir chronic health conditions. The goal of the CCT is to wrap critical health andcommunity service around the client and their family to address needs that aremost important to them. The CCT is a collaboration between Mayo Clinic,Olmsted Medical Center and Olmsted County Public Health. Client interactionincludes a home visit, followed by an interdisciplinary team meeting and 12weeks of intervention. The PHN may complete additional home visits as neededduring this time. The program is concluded by another interdisciplinary meetingat the end of 12 weeks.

9Preventive Health Services Team

10

Preventive Health Services Contacts Per Client

The following chart shows the average number of contacts made with clients by program.

0.9

4.7

10.5

14.7

14.9

20.2

21.2

22.1

0 5 10 15 20 25

Personal Care Attendant

Long Term Care Consultation


Community Care Team

Care Coordination

Case Management

Assertive Commununity Treatment

Special Needs Basic Care

Average Contacts Per Client

2015 Preventive Health ServicesAverage Contacts Per Client by Program

Case Management

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Case Management

Clients, Contacts and Staffing

12

From 2011 to 2015, Preventive Health Services PHNs had an average of 6,226 contacts with 783 case management clients annually. There was a 56%decrease in clients from 2011 (962) to 2015 (427), but the contacts increased by 26% (6,807; 8,608). There were an average of 2.4 full-time equivalentsdedicated to the Case Management Program; with an increase from 2.42 in to 3.05 in 2015.

962 917 742 511 427

6,807

5,654 5,7616,682

8,608

2.42 2.16 2.35 2.72 3.06

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

9.00

0

2,000

4,000

6,000

8,000

10,000

2011 2012 2013 2014 2015

Tota

l FTE

's

# Cl

ient

s an

d Co

ntac

ts

Case Management Clients, Contacts and Staff FTE's2011 - 2015

Clients Contacts Staff FTE

Case Management

The majority (52%) of case management clients are 71 years and older; 60% are female and 40% male. The majority (83%) are white, followed byblack (11%), with 2% being Hispanic.

Client Demographics

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Case Management Clients

60% Female 40% Male

5%6%

3%

6%

12%

16%

52%

Case Management Clients by Age2011 - 2015

0-1819-3031-4041-5051-6061-7071+

83%

11%5% 2%

98%

0%

20%

40%

60%

80%

100%

120%

% o

f CM

Clie

nts

Case Management Clients by Race & Ethnicity, 2011 - 2015

White Black Asian Hispanic Non-Hispanic


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Care Coordination

15

Care Coordination


16

From 2011 to 2015, Preventive Health Services PHNs had an average of 4,960 contacts with 377 care coordination clients annually. There was a 79%increase in clients from 2011 (227) to 2014 (407), but a 17% decrease from 2014 (407) to 2015 (339). During this same time period, there was a 36%increase in contacts (3,727; 5,055). In 2011, there was a .7 full-time equivalent dedicated to the Care Coordination Program. This has almost doubledfrom .74 in 2011 to 1.3 in 2015.

227 444 470 407 339

3,7274,948

5,7275,344

5,055

0.74

1.42

1.63

1.401.32

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

1.60

1.80

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

2011 2012 2013 2014 2015

Staf

f FTE

's

# of

Clie

nts

and

Cont

acts

Care Coordination Clients, Contacts and Staff FTE's2011 - 2015


Care Coordination

Client Demographics

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Care Coordination Clients

57% Female 43% Male

The majority (62%) of care coordination clients are 61 years and older; 57% are female and 43% male. The majority (48%) are white,followed by black (30%), with 4% being Hispanic.

0%

5%7%

11%

15%

31%

31%

Care Coordination Clients by Age2011 - 2015

0-18

19-30

31-40

41-50

51-60

61-70

71+

48%

30%19%

4%

96%

0%

20%

40%

60%

80%

100%

120%

% o

f Ca

re C

oord

inat

ion

Clie

nts

Care Coordination Clients by Race & Ethnicity, 2011 - 2015


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From 2011 to 2015, Preventive Health Services PHNs had an average of 752 Personal Care Attendant (PCA) contacts with 608 clients annually. During this same time period, there was a 26% decrease in clients (640; 476) and a 68% decrease in contacts (1,377; 436). The staffing dedicated to the PCA Program has decreased from 1.04 FTE in 2011 to .83 FTE in 2015. In 2015, any children that were open to developmental disability case management or waiver services along with PCA services, were only being followed by the case manager and not the PCA assessor. This change resulted in in a loss of approximately 250 PCA cases.

640 591 628 695476

1,377

653 628661

436

1.04 0.99 1.04

1.24

0.83

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

0

200

400

600

800

1,000

1,200

1,400

1,600

2011 2012 2013 2014 2015

Tota

l FTE

's

# Cl

ient

s an

d Co

ntac

ts

PCA Clients, Contacts and Staff FTE's2011 - 2015



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Referrals

From 2011 to 2014, OCPHS received an average of 192 referrals peryear for PCA services. Referrals decreased by 85% from 2014 (208) to2015 (32). In 2015, PCA assessments were no longer considered aseparate assessment type and were included in the Long Term CareConsultation. This change resulted in a significant decline number ofPCA referrals.

Client DemographicsThe majority (36%) of PCA clients are 18 years and younger, followed by71 years of age and older (23%); 51% are female and 49% male. Themajority (32%) are white, followed by black (25%), with 5% beingHispanic.

PCA Clients

51% Female 49% Male

152180

228208

32

0

50

100

150

200

250

300

2011 2012 2013 2014 2015

# Re

ferr

als

# PCA Referrals into Agency

32%25%

13%5%

95%

0%

20%

40%

60%

80%

100%%

of

PCA

Clie

nts

PCA Clients by Race & Ethnicity2011 - 2015


36%

6%6%7%

9%

13%

23%

PCA Clients by Age2011 - 2015

0-1819-3031-4041-5051-6061-7071+


22


23


Clients, Visits and Staffing

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From 2011 to 2015, Preventive Health Services PHNs had an average of 676 contacts with 329 Long Term Care Consultation (LTCC) clients annually.During this same time period, there was a 47% decrease in clients (424; 223). From 2011 (619) to 2014 (320), there was a 48% decrease in contacts,but from 2014 (320) to 2015 (1,043) there was a 225% increase in contacts. There was an average .79 FTE dedicated to this program. The FTEincreased from .37 in 2014 to .79 in 2015. This dramatic increase in client contacts in 2015 was multifactorial: the use of a new assessment tool (MNChoices) required more time and contact with clients and the addition of the PCA component of the assessment, as well as the increase in complexityof the clients assessed.

PROMOTING AND SUPPORTING INDEPENDENT COMMUNITY LIVING1

424 416 388

194 223

619 637759

320

1,0430.66

0.580.57

0.37

0.79

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

0100200300400500600700800900

1,0001,1001,200

2011 2012 2013 2014 2015

Tota

l FTE

's

# Cl

ient

s an

d Co

ntac

ts

Long Term Care Consultation Clients, Contacts and Staff FTE's

2011 - 2015



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Client Demographics

ReferralsFrom 2011 to 2015, OCPHS received an average of 561 referralsannually for LTCC services. The number of referrals decreased 67%from 2011 (759) to 2015 (254). In 2015, the Department of HumanServices separated aging and disability services. In May of that year,PHS began the use of an assessment team for all referrals that consistedof two PHNs and two social workers. These changes resulted in allreferrals under age 65 going to the disability group and onlyapproximately half of aging referrals coming to PHS (the remaining wentto Community Services Aging Division).

The majority (68%) of LTCC clients are 51 years and older; 62% arefemale and 38% male. The majority (80%) are white, followed by black(12%), with 3% being Hispanic.

759 740665

389

254

0100200300400500600700800900

1000

2011 2012 2013 2014 2015

# Re

ferr

als

# LTCC Referrals into Agency

80%

12%6% 3%

97%

0%

20%

40%

60%

80%

100%

120%

% o

f LT

CC C

lient

s

Long Term Care Consultation Clients by Race & Ethnicity, 2011 - 2015


8%

6%

6%

12%

24%

44%

Long Term Care Consultation Clients by Age2011 - 2015

0-18

19-30

31-40

41-50

51-60

61-70LTCC Clients

62% Female 38% Male


26


27



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From 2011 to 2015, Preventive Health Services PHNs had an average of 779 contacts with 125 Skilled Nursing Facility Care Coordination clientsannually. The number of clients seen from 2011 to 2015 remain fairly stable (between 115 and 136). Client contacts have tripled from 2011 (404) to2015 (1,256). There was an average of .32 FTE dedicated to this program, increasing from .22 in 2011 to .41 in 2015.

115 136 124 130 120

404494

785

958

1,256

0.220.24

0.33

0.42 0.41

0.00

0.05

0.10

0.15

0.20

0.25

0.30

0.35

0.40

0.45

0

200

400

600

800

1,000

1,200

1,400

2011 2012 2013 2014 2015

Tota

l FTE

's

# Cl

ient

s an

d Co

ntac

ts

Skilled Nursing Facility Care CoordinationClients, Contacts, and Staff FTE's

2011 - 2015



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Client Demographics

Skilled Nursing Facility Care Coordination clients are 71% female and 29% male. The majority (95%) are white, with 1% being Hispanic.

Skilled Nursing Facility Care Coordination Clients

71% Female 29% Male


30

Assertive Community Treatment

31

Assertive Community Treatment

Clients and Visits

32

ACT is identified by the Substance Abuse and Mental Health Services Administration as an evidence-based practice that consistently demonstrates positive outcomes and is considered by experts as an essential treatment option.2

From 2011 to 2015, Preventive Health Services PHNs had an average of 1,248 contacts to 53 Assertive Community Treatment (ACT) clients. During thissame time period, visits decreased by 23% (1,405; 1,082) while clients decreased by 18% (62; 51).

1,405 1,3751,283

1,093 1,082

62 47 52 53 51

0

200

400

600

800

1,000

1,200

1,400

1,600

2011 2012 2013 2014 2015

# of

Clie

nts

and

Cont

acts

ACT Clients and Contacts2011 - 2015

Visits Cllients


33



34

From 2011 to 2015, Preventive Health Services PHNs had an average of 4,843 contacts with 300 Special Needs Basic Care (SNBC) clients annually. Thenumber of clients seen from 2011 (181) to 2015 (290) increased by 60%. During this same time period contacts increased by 220% (2,777; 6,397) TheFTE dedicated to this program increased from .68 to 1.45.

181 321 375 334 290

2,777

4,0484,601

6,390 6,397

0.68

1.21

1.58 1.65

1.45

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

1.60

1.80

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

2011 2012 2013 2014 2015

Tota

l FTE

's

# Cl

ient

s an

d Vi

sits

Special Needs Basic Care Clients, Contacts and Staffing

2011 - 2015Clients Contacts Staff FTE's


Client Demographics

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Over half of SNBC clients are 41 to 60 years old; 54% are female and 46% male. The majority (60%) are white, followed by black (32%), with 3% beingHispanic.

SNBC Clients

54% Female 46% Male

10%

17%

22%33%

18%

SNBC Clients by Age2011 - 2015

19-30

31-40

41-50

51-60

61-70

60%

32%

5% 3%

97%

0%

20%

40%

60%

80%

100%

120%

% o

f SN

BC C

lient

s

SNBC Clients by Race & Ethnicity2011 - 2015



36

Community Care Team

37

Community Care Team


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The Community Care Team (CCT) focuses on the intersection of medical and social needs of patients and is a mechanism for helping primary care patients whose psychosocial problems are impacting their ability to participate in and benefit from medical services and treatments.

A community care team is a group of primary care and community/public health experts that work together with patients and family members/support person, if available, to develop and implement creative solutions to complex patient problems. The CCT links adult patients with chronic medical conditions with community services to support primary care efforts to assist patients with self-management of chronic medical conditions.

The purpose of the CCT is to identify barriers to engaging in self-management (such as with finances, housing, social isolation etc.) and to recommend solutions to remove barriers to increase care effectiveness. Patients receive an in-home assessment by a public health nurse and community health worker. The patient, along with any support, meet with four members of the team where an action plan is developed to address their needs and to increase their community-based support system if necessary.

The target population for the CCT is adult patients (age 40+) with chronic medical conditions who: 1) are not actively participating in their health care or 2) with known complex non-medical/social needs.

The Community Care Team was created May 2014. There were 55 clients in 2015, with 809 contacts.

Community Care TeamMayo Clinic – Olmsted County Public Health - Olmsted Medical Center

Community Care Team

Client Demographics

39

In 2015, the majority of CCT SNBC clients were 51 to 70 years old (66%); 64% are female and 36% male. The majority (78%) are white, followed byblack (13%), with 7% being Hispanic.

Community Care Team

64% Female 36% Male

78%

13% 9% 6.7%

93.3%

0%10%20%30%40%50%60%70%80%90%

100%


CCT Clients by Race & Ethnicity, 2015

White Black Asian Hispanic Non-Hispanic4%

9%

33%

33%

22%

CCT Clients by Age, 2015

31-40 41-50 51-60 61-70 70+

Client Satisfaction

40

Preventive Health Services Client Satisfaction Survey Results

41

Additional services clients feel would help them increase their safety and independence at home

More visits More PCA services Semi Independent Living services

PHN was…very helpfulsupportiveinformativecaringvery responsive

96% of PHS clients surveyed felt they were treated well

96% of PHS clients surveyed felt that the services provided and community referrals helped

maintain their independence

73% of PHS clients surveyed reported learning something

Client Satisfaction

42

Preventive Health Services routinely seeks out satisfaction levels from the clientele served. Surveys are distributed quarterly and assess overallsatisfaction with the services provided. Customers complete questions on how well they were treated, if the PHS staff helped them with their problemsand if they learned anything from the PHS staff. The survey also offers an opportunity to provide suggestions for improvement. In 2015, 129 clientscompleted the survey.

Overall, most PHS clients surveyed agreed or strongly agreed that they were treated well during their visit (96%). Clients described public healthnurses as very helpful, supportive, informative, caring and very responsive.

PHS clients agreed or strongly agreed (91%) that the services provided and community referrals helped maintain their independence. Clientsmentioned that knowing support will be provided, exploring insurance, person-to-person contact, and detailed descriptions of what was happing wereall helpful.

In 2015, 73% of PHS clients reported learning something during their visit. Clients reported learning a wide variety of topics from their visit such as:how to get help if something happens, opportunities available, about health insurance and how to apply, and transportation information.

PHS clients were also asked about additional services they feel would help them increase their safety and independence at home. Clients shared manyideas including: More visits More PCA services Semi Independent Living services

PHS clients as provided opportunities for improvement,Including clarifying public health nurses’ role and risk assessmentfor falls.

96% 96%

73%

0%

20%

40%

60%

80%

100%

Treated WellDuring Their Visit

Helped withTheir Problem

LearnedSomething

% o

f Cus

tom

ers

PHS Customer Survey Results, 2015

Build Teams With Complementary Individual

Strengths

Provide Continuous Growth and Development through Targeted

Opportunities

Develop Efficiencies Through Process Improvements

Build, maintain, participate in collaborations and

partnership

Support Positive Family Involvement With Client

Individualized Client Centered Care Plans

Support Community Resource Improvements

How

?

Why

?

Build the Community

Manage the Resources

Run the Business

Develop the Employees

OCPHS Preventive Health Services: Aged & Disabled ProgramsVision: All aged and disabled individuals live safe, independent and dignified lives in the community.

Mission: Educating and assisting elderly and disabled individuals to maintain or improve their quality of life.

Leverage Limited Capacity and Resources

Ensure Access to Appropriate Community

Based Resources

Preventive Health Services Strategy Map

46

Conclusions and Next Steps

Conclusions Next Steps

As we look ahead we see our work impacted by the aging babyboomers, declining health of our clients, and stagnation of the economyprecipitating changes to current models of care. We are working withthe state and federal government on piloting models that keep ourclients in their homes as long as possible while moving us towardsAccountable Communities of Health (ACH) models of healthcare wherewe share accountability for outcomes instead of being paid for services.We welcome these changes and are implementing strategies tostrengthen our relationships with community providers, developingvalue add relationships, improving our technology, improving ourdocumentation around outcomes and return on investment, trainingour partners as they develop their ACH programs, and makingimprovements to targeted population interventions.

Preventive Health Services Tactical Plan

Current Strategic Priorities: Flat funding to serve greater numbers of clients – improve

efficiencies enabling staff to cover larger case load State mandated systems don’t support work efficiencies Excessive stakeholder requirements for documentation –

work with health plans Ensure screening consistency with the elimination of dual

screening with social worker and public health nurse –educate to reduce incidence of fraud, waste and abuse

Develop strategies that address cultural barriers that negatively impact client outcomes and cause increased staff frustration

Olmsted County Public Health Services – Preventive Health Servicesdivision remains committed to supporting the aging and disabledcitizens of Olmsted County to live safe, independent and dignified livesin our community.

Overall, the PHS client population is 69% white, 18% black, and 11%Asian, with 3% of Hispanic ethnicity. Females make up 57% of thepopulation, with 43% being male. The majority (73%) of PHS clients areage 51 and older; 10% are 18 and younger.

From 2011 to 2015, the PHS division received an average of 768referrals for services annually.

During this past year we have focused on reorganizing ourselves tobetter serve our growing clientele. These changes have includeddeveloping an intake team, and teams focused on one or two healthplans. This specialization has assisted staff to increase their focus infewer areas resulting in improvements to their targeted areas ofpractice. We have also worked with the state of Minnesota toimplement their new MnCHOICES assessment software, improved ourpartnership with Olmsted County Adult Community Services bytransitioning onto a single case management software, and streamlinedour documentation code sets as part of the ICD-9 to ICD-10 conversionprocess.

PH-Doc – the electronic health record program used by OCPHS1Minnesota Department of Human ServicesMinnesota Board on Aging2National Alliance on Mental Illness (NAMI)

47

Methodology and Data Sources

Methodology Data Sources

The data in this report was collected from PH-Doc, the electronichealth record program used by OCPHS. This report combinesPreventive Health Services program information, demographicinformation about the populations served by PHS, and customersatisfaction results.

Frequencies & Descriptive StatisticsFrequencies (counts and percentages) were calculated for the numberof clients, contacts, referrals and client satisfaction associated withPHS’s program areas.

Each PHS program area serves a unique clientele population. Todescribe each population, demographic characteristics were analyzedand included: gender, age, race and ethnicity.

Trend AnalysisAll PHS program areas have data that is comparable over the previousfive years. This allows for the display of trend data which ultimatelyassists in detecting any substantial movement (i.e. increase in clients)that need further programmatic strategic discussions.

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