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Abington Jefferson Health - Abington-Lansdale Hospital

Community Health Needs Assessment Implementation Plan

Introduction

Abington Jefferson Health (AJH) serves patients primarily in Montgomery and Bucks Counties

in Pennsylvania. AJH conducted a community health needs assessment (a “CHNA”) of the

geographic areas served by Abington-Lansdale Hospital ("Hospital") pursuant to the

requirements of Section 501(r) of the Internal Revenue Code (“Section 501(r)”).1 The CHNA

findings were approved by the Board in April 2016 and are available on the Hospital’s website.2

This implementation strategy (“Strategy”), also required by Section 501(r), documents the efforts

of the Hospital to address and prioritize the community health needs identified in the 2016

CHNA.

The Strategy identifies the means through which the Hospital plans to address needs that are

consistent with the Hospital’s charitable mission as part of its community benefit programs from

2016 through 2019. Beyond the programs discussed in the Strategy, the Hospital is addressing

many of these needs simply by providing care to all, regardless of ability to pay. The Hospital

anticipates health needs and resources may change, and thus a flexible approach was adopted in

the development of its Strategy to address needs identified in the 2016 CHNA. In addition,

changes may be warranted by the publication of final regulations.

Overview of Implementation Strategy

1. Community Served by the Hospital

2. Hospital Mission Statement and Community Benefit Charge

3. Priority Community Health Needs

4. CHNA Implementation Strategy

5. Needs Beyond the Hospital’s Mission or Community Benefit Program

1. Community Served by the Hospital

Abington-Lansdale's Community Benefit (CB) areas are defined as the areas proximate to the

hospital where approximately 70% of inpatients reside. This includes communities in

Montgomery and Bucks counties that are aggregated into 4 geographically contiguous regions

defined by zip codes. For comparison, the combined data for Bucks and Montgomery counties is

provided.

1 The Patient Protection and Affordable Care Act (Pub. L. 111‐148) added section 501(r) to the Internal Revenue

Code, which imposes new requirements on nonprofit hospitals in order to qualify for an exemption under Section

501(c)(3), and adding new reporting requirements for such hospitals under Section 6033(b) of the Internal Revenue

Code. 2 The Community Health Needs Assessment Report is available on the Abington Jefferson Health website at

http://www.abingtonhealth.org.

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In Abington-Lansdale's CB areas, almost 6,600 residents identify themselves as Hispanic and

most live in North Penn and Indian Valley. One third of Hispanics in the Abington-Lansdale CB

area are from Puerto Rico; Mexico, South America, and Central America are each originating

areas for approximately one sixth of residents and the remaining Hispanic population is from the

Caribbean and other places. Although they share a common language, each Hispanic community

is culturally unique, and internally diverse by gender, generation, class, and race.

The Asian community in Abington-Lansdale's CB areas is predominantly of Korean and Asian

Indian descent, with North Penn serving as home to the most residents of Asian origin.

Montgomery County has the oldest population in Southeastern Pennsylvania, and the Abington-

Lansdale CB area has a higher percentage of older adults than Bucks/Mont.

Demographic Bucks/Mont Hospital Community Benefit Area

Population 1,411,000 199,000 (14% of Bucks/Mont residents)

Projected population

growth, 2015-2020 1.3% 2.4%

White, non-Hispanic 80.4% 79.4%

Black, non-Hispanic 6.7% 4.0%

Hispanic 4.9% 3.6%

Asian and Pacific Islander,

non-Hispanic 6.0% 11.2%

Population 65+ 16.7% 17.2%

Source: AJH CHNA, 2016

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2. Hospital Mission Statement and Community Benefit Charge

The Hospital has a long history of engaging our community in identifying health issues and

implementing strategies to address needs. Our mission, "Health is all we do," demonstrates our

commitment to improving well-being, and our vision "to re-imagine health, health education and

discovery to create unparalleled value, and to be the most trusted healthcare partner” expresses

our focus on innovative solutions. Effective community programs are an integral part of our

mission and vision.

To fulfill our Community Benefit mandate, the Abington Health Foundation formed a

Community Benefit Committee. The committee is responsible for overseeing and

recommending policies and programs designed to carry out the charitable mission of Abington

Hospital and Abington-Lansdale Hospital, protect its non-profit status, and to enhance the health

status of communities served by AJH based on the results of a community health needs

assessment.

Specifically, the Committee was charged to:

Oversee the conduct of a community health needs assessment at least every three (3) years.

Review and recommend for approval, a Community Benefit Plan outlining long-term

strategies based on a community health needs assessment and other objective sources of data,

and recommend updates to such Plan.

Guide and monitor the planning, development, and implementation of programs aimed at

improving the health status of the local community consistent with the Community Benefit

Plan.

Establish criteria for priority-setting among potential community benefit activities and

projects, consistent with financial capabilities and resource limitations.

Periodically make recommendations for program continuation or termination based on

progress toward identified measurable objectives, available resources, level of community

ownership, and alignment with criteria for priorities.

Review and make recommendations regarding the annual Community Benefit Report,

including the information provided to the IRS on Form 990. Additionally, identify

opportunities for disseminating information to the public about the organization’s community

benefit activities.

Review annual goals specifying principal work focus areas for the coming year. Review

hospital financial assistance policies and practices and provide recommendations as

necessary in an effort to increase efforts to communicate these policies.

The Community Benefit Committee are trustees, staff, physicians, nurses, other clinicians, clergy

and various diverse representatives of the communities served by AJH.

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"Actual Needs"

Resources, feasibility,

policy

Public's perceived

needs, priorities

3. Prioritizing Community Health Needs

The focus of the Community Benefit Implementation Strategy is the intersection of the scientific

evidence, public support, and political backing.3 The "A" in this model is the area with the

greatest potential for mobilization of resources and action.

Poor health status is due to a complex interaction of challenging social, economic,

environmental, and behavioral factors, combined with a lack of access to care. Addressing the

root causes of poor community health can improve quality of life and reduce mortality and

morbidity.

The following table describes the community health needs identified through the 2016 CHNA as

priorities. In order to maximize the resources available to the Hospital, the Strategy will focus

on the priority health needs listed as “Most Important.” Many of the remaining needs are

addressed in normal operations of AJH and therefore will not have a dedicated plan.

AJH will not directly focus on youth health behaviors, medication access, community safety,

transportation, or the built environment needs identified as “important or less important” in the

2016 CHNA. Those priorities are beyond the scope of AJH and are being addressed by other

community based and government organizations. AJH will collaborate with groups of experts in

these areas to foster appropriate and safe referrals and identify opportunities for partnership and

inclusion in community benefit initiatives.

AJH will continue our collaboration regionally with other hospitals and health systems within

Bucks and Montgomery Counties through partnerships, cooperation, and coordination on public

health issues.

3 Green and Kreuter, Health Program Planning, 4

th ed., NY; McGraw Hill, 2005, fig 2-3, p.40.

Scientific

Evidence

Political Backing

A Public

Support

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Domain Priority Health Needs/Issue Ranking

Score

Priority Level

Access to Care Mental Health Services 26.3 Most Important

Access to Care and Healthy

Lifestyle Behaviors and

Community Environment

Social and Health Care Needs of

Older Adults 25.7 Most Important

Chronic Disease Management Obesity 24.3 Most Important

Healthy Lifestyle Behaviors

and Community Environment Alcohol/ Substance Abuse 23.3 Most Important

Health Screening and Early

Detection Women's Cancer 22.7 Most Important

Chronic Disease Management Chronic Disease Management

(diabetes, heart disease and

hypertension, stroke, asthma)

21.7 Most Important

Access to Care Health Education, Social Services

and Regular Source of Care 20.7 Most Important

Health Screening and Early

Detection Colon Cancer 20.3 Most Important

Access to Care ED Utilization and Care

Coordination 18.3 Important

Healthy Lifestyle Behaviors

and Community Environment Youth Health Behaviors 18.0 Important

Access to Care Medication Access 18.0 Important

Access to Care Language Access, Health Literacy

and Cultural Competence 17.3 Important

Access to Care Maternal and Child Health 17.0 Important

Healthy Lifestyle Behaviors

and Community Environment Physical Activity 16.3 Important

Access to Care Health Insurance 16.0 Important

Internal Organizational

Structure Hospital Readmissions 14.3 Less Important

Healthy Lifestyle Behaviors

and Community Environment Access to Healthy Affordable Food

and Nutrition Education 14.0 Less Important

Healthy Lifestyle Behaviors

and Community Environment Food Security 14.0 Less Important

Healthy Lifestyle Behaviors

and Community Environment Community Safety 13.7 Less Important

Access to Care Access: Transportation 13.3 Less Important

Healthy Lifestyle Behaviors

and Community Environment Smoking Cessation 13.0 Less Important

Internal Organizational

Structure Workforce Development and

Diversity 12.3 Less Important

Healthy Lifestyle Behaviors

and Community Environment Built Environment 9.7 Less Important

Health Screening and Early

Detection HIV 8.3 Less Important

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To address the needs identified in the 2016 CHNA process, AJH convened 7 Community Benefit

Action teams consisting of key community stakeholders and AJH administrative and clinical

leaders to develop and implement goals and action plans. Leaders of these teams will report on

progress quarterly through reports shared with the Community Benefit Committee.

In addition, AJH professionals will collaborate with Jefferson colleagues to improve health status

in conjunction with the hospital’s partnerships. Best practices will be shared with the aim of

enhancing infrastructure, stretching resources, and incorporating knowledge about social

determinants of health and health literacy to better the population's health and well-being.

4. CHNA Implementation Strategy

The Hospital has a strong tradition of meeting community health needs through its ongoing

community benefit programs and services. The Hospital will continue this commitment through

the strategic health priorities set forth below that focus primarily on four (4) high-priority health

need domains.

Not all programs provided by the Hospital that benefit the health of patients in the Hospital’s

primary service area are discussed in the Strategy. Further, given evolving changes in health

care, the Hospital maintains the right to change its strategies, and new programs may be added or

eliminated. The Strategy laid out in this document has two major parts: implementing programs

to address the priority needs from the CHNA, then evaluating the impact of those activities.

A. Identifying Areas of Impact and Planning to Evaluate Proposed Community Benefit Programs

The 2016-2019 focus of the Hospital’s grant-funded community benefit and in-kind resources

was identified based on the CHNA findings, the prioritized health needs, and recommended

initiatives to impact the health of the community.

The Strategy is organized according to the following domains:

Access to Care

Chronic Disease Management

Health Screening and Early Detection

Healthy Lifestyle Behaviors and Community Environment

Through implementing evidenced-based strategies to address these four domains of community

health need, the Hospital anticipates the following positive impact and improvements in

community health:

Positive impact on disease management and disease prevalence, including mental health,

substance abuse, obesity and obesity-related diseases (including stroke, cardiovascular

disease, and diabetes), asthma, women's cancers, and colon cancer;

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More appropriate use of health resources, including the social and health care needs of

older adults, health education, social services, and a regular source of care, a reduction in

unnecessary hospital admissions and use of some hospital services including emergency

department visits, improved access to medications, and an increase in use of culturally

appropriate primary care and health screenings; and

Improvement in community health status, including reduction in health disparities,

increased physical activity, reduced rates of smoking, improved health and nutrition

status, and improved maternal and child outcomes.

These improvements will be evaluated through review and monitoring of existing data sources,

which may include but are not limited to:

1. Internal Hospital data, including referral and inpatient and outpatient service data

2. Public Health Management Household Health survey data

3. Surveys and key informant interviews with providers and clients

4. Reports from government agencies, which may include the Bucks and Montgomery

County Health Departments, the Bucks County Area Agency on Aging, Montgomery

County Drug and Alcohol, and the Montgomery Office of Aging and Adult Services

5. External community data sources

B. Address Priority Health Needs through Hospital’s Existing and New Community Benefit

Programs

The Hospital plans to provide community benefit programs responsive to the health needs

identified in the 2016 CHNA. As part of this Strategy, the Hospital will focus first on those

needs designated as “Most Important” between 2016 and 2019, and will continue to evaluate

those needs that were designated as “Important” and “Less Important”. Only those needs

identified as "Most Important" are detailed in this Implementation Plan. The recommended

actions may be modified based on on-going input and recommendation from internal and

external partners, identification of new partnership opportunities, changes in the healthcare and

community environment, and availability of resources. Throughout the implementation period,

the Community Health Department will identify grants and internal and external funding sources

as appropriate to support the strategies and activities. Resources to implement programs are

provided in-kind unless otherwise noted.

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DOMAIN: ACCESS TO CARE

The anticipated impact of the following actions may include: increase in access to primary

care with related reduction in emergency room (ER) visits and hospital readmissions; increase in

the number of insured adults and adults with AJH financial assistance; increase in the number of

patients and providers in dental clinic care; increase in number of patients connected with social

services; improvement in access to and utilization of culturally appropriate primary care,

reduction of health disparities, improvement in maternal and child outcomes; improvement in the

social and health status of older adult; improvement in the capacity of community-based

organizations to address behavioral health issues among clients/program participants; and

reduction in transportation barriers to receiving medication and care.

1. Action: Improve access to Mental Health Services

Include behavioral health professionals in primary care and specialty practices

Explore the feasibility and enhancement of depression screening in practices and ER

Develop and implement Mental Health First Aid training

Partner with community based organizations and behavioral health professionals to

develop a comprehensive network of care

Promote the Safe Harbor program for grieving children, teens, and families

2. Action: Social and Health Care Needs of Older Adults

Continuously refine Elder Med programming with input from community members

and community based organizations

Increase the number of Medicare recipient annual wellness visits

Decrease appointment wait times at the Geriatric Assessment Center

Offer the Hospital Elder Life Program at both the Abington and Lansdale campuses

Coordinate community based health fairs, health screenings, and speaker requests

Offer caregiver support groups

Offer activities to improve cognitive health

Offer programming to promote falls reductions

3. Action: Improve access to Health Education Social Services and Regular Source of

Care

Assist patients and their families in accessing government based insurance options

(Medical Assistance, children’s health insurance program [CHIP], health insurance

marketplace). For patients who are over 65 or disabled options include Medicare,

Medical Assistance, private insurance (Medigap, Medicare advantage plans), and

supplements (PACE, PACENET, Part D providers)

Assist patients and their families who are not eligible for public or private health

insurance with the application process for the AJH Financial Assistance Program

Ensure that all staff participate in cultural diversity training

Provide patient education materials in multiple languages

Ensure that eligible babies receive free care at the Abington Children's Clinic until

their insurance coverage is processed

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Maintain and enhance AJH’s strong health education outreach programs

Enhance the services offered by the AJH Dental Clinic and AJH Dental Care Access

Program by increasing the number of available appointments, improving satisfaction

for patients and providers, and referring individuals not eligible for services to other

dental providers. Continue to provide a clinic social worker to facilitate enrollment

and coordinate the AJH Dental Access Program. Foster the relationship between the

AJH Dental Clinic and AJH Dental Access Program.

Utilize a clinic social worker and/or students to conduct outreach and provide direct

assistance to patients in need at AJH Children’s Clinic, Ambulatory Services Unit

(ASU), Abington Family Medicine, and North Hills Health Center to connect them

with relevant social services such as Supplemental Nutrition Assistance Program

(SNAP), subsidized housing, subsidized child care, and Lifeline (free cell phone

program). Cultivate relationships with local community organizations to keep abreast

of available services/programs.

Increase the number of under and uninsured patients receiving care at ASU primary

care practice by:

charging an ASU RN Care Manager to audit ER visits and make appointments for

interested patients at ASU

assigning an RN Care Manager in ASU to schedule post discharge ASU

appointments

empowering the Social Work team to provide assistance to ASU patients in need

of transportation assistance

Increase access for women with language barriers at the OB/GYN Center; schedule

according to availability of multi-lingual clinicians, currently fluent in Spanish,

Portuguese, and Korean

DOMAIN: Chronic Disease Management

The anticipated impact of the following actions may include: improved health behaviors

including utilization of preventive screenings, improved disease management including

adherence to treatment recommendations and better communications between patients, families,

and providers, and elevated health status as a result of increased continuity of care.

1. Action: Reduce Obesity

Continue/expand existing nutrition education programs: presence at kids' days, health

fairs, and community events; participation in the Million Hearts program in

partnership with Montgomery County Health Department; preschool, elementary, and

after school nutrition curriculum at North Penn YMCA

Establish new partners for nutrition education programming and physical activity

opportunities such as libraries, faith based organizations, and community centers

Educate health care providers on strategies and available resources for reducing

obesity in their patient populations

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Develop partnerships and resources to communicate physical activity opportunities

Create opportunities on campus for healthy food choices including evaluating a

healthy vending machine pilot, a Community Supported Agriculture (CSA) program

for AJH employees, farmers' market days in the cafeteria, digital display of nutrition

information, and events encouraging healthy choices

2. Action: Enhance Chronic Disease Management (diabetes, heart disease and

hypertension, stroke, asthma)

Offer comprehensive diabetes education programs

include intensified insulin self-management training, nutrition counseling, pre-

diabetes intervention, and gestational diabetes management at the Abington

Health Center-Willow Grove, Jefferson Health

support inpatients and refer to diabetes resources

refer patients identified as at risk for diabetes at community based assessments for

appropriate follow-up

provide Save Your Soles education and screening programs in underserved

communities

Provide education and support programs to reduce hypertension prevalence and

improve hypertension management

offer health coaching, educational materials, and referrals for people identified at

blood pressure screenings with Stage I and higher hypertension

make follow-up calls to consenting participants to refer to needed services such as

health care providers, screening locations, chronic care management programs,

and other community resources

Provide education and support programs to reduce stroke and heart disease

prevalence and improve disease management

offer blood pressure and risk assessments to raise awareness about prevention and

early detection and tPA (for stroke)

present education programs at community outreach events

offer stroke support groups for patients and caregivers

Provide education and support programs to reduce asthma prevalence and improve

disease management

offer community based education to raise awareness about warning signs of

asthma to promote earlier diagnosis, avoid "asthma triggers," gain better control,

and understand treatments

reduce asthma-related health disparities through outreach to faith-based

organizations

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Collaborate with community based organizations and other health care providers to

support chronic disease prevention and management initiatives

coordinate a faith based advisory council that trains congregational nurses with

chronic disease management and community health programming skills

partner with community based organizations that serve non-English speaking

communities to expand the capacity of bilingual staff to provide chronic disease

prevention and management education refer smokers to smoking cessation programs

expand AJH chronic disease self-management programming at community sites

DOMAIN: Health Screening and Early Detection

The anticipated impact of the following actions may include: increased screening rates for

breast, cervical, colon and other women's cancers

1. Action: Increase access to care and screening for women's cancers, especially cervical

and breast cancer, for underserved populations

Recruit AJH staff members to assist with screenings and education

Enhance strategies to effectively reach Latino, Korean, and other Asian

populations

Develop strategies to increase screenings for low income non-Latina white

women

Educate primary care and gynecology practices about the Pennsylvania Healthy

Woman Program for breast screening services and the Pennsylvania Breast

Cancer and Cervical Cancer Prevention and Treatment Program and provide

assistance for qualified women to enroll in these programs

2. Action: Increase access to care and screening for colon cancer

Develop multi-disciplinary approach with the American Cancer Society (ACS) to

educate and promote screening colonoscopies

Schedule meetings with primary care physicians to educate them about the ACS

goal of screening 80% of people age 50+ and available resources

Explore primary care physician partnership to advocate for the ACS 80% goal and

continued screening

Provide educational outreach to Latinos and low income communities using

culturally and language appropriate presentations

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DOMAIN: Healthy Lifestyle Behaviors and Community Environment

The anticipated impact of the following actions may include: increased identification and

referral of patients to addiction counseling and services

1. Action: Decrease alcohol and substance abuse

Collaborate with the Montgomery County Hospital Partnership (MCHP) to

commit all prescribers to abide by the new CDC recommendations for prescribing

opioids for chronic pain

Educate AJH physicians using the Pennsylvania Medical Society approach to

prescribing opioids and Naloxone

Implement the AJH/Abington Health Physicians (AHP) commitment to increase

compliance with patient "contracts" for chronic opioid use

Integrate education on alcohol and opioid use issues and CDC guidelines into

continuing medical education

Incorporate pain management curricula into AJH's educational framework for all

levels of providers starting with students

Educate prescribers on voluntary guidelines developed by PAMED

Work with law enforcement to communicate about "Drug Take Back" programs;

evaluate initiation of an AJH program

Review sponsorship requests from school districts and other non-profit agencies

to host events that educate parents, students, or professionals on alcohol and/or

substance abuse

Expand the relationship with Gaudenzia, a provider of drug and alcohol treatment

programs

Develop a relationship with Montgomery County Drug and Alcohol leadership for

information and communication of programs and services

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C. Collaborate with Community Partners to Address Health Needs

This Strategy will be implemented in collaboration with other entities including but not limited

to:

Southeastern Pennsylvania Collaborative Opportunities to Advance Community Health

(COACH)

This community health collaborative sponsored by the Hospital and Health System Association

of Pennsylvania (HAP) brings together hospitals, public health, and community partners to

address community health issues in southeastern Pennsylvania. COACH participants prioritized

community health needs most important to address collaboratively and identified chronic disease

prevention/management and mental health as top priorities.

Montgomery County Hospital Partnership

This partnership engages all Montgomery County hospitals, federally qualified health centers,

behavioral health providers, the Montgomery County Health Department, and other stakeholders

to collaborate to address key community needs within the county. The partnership will focus on

specific activities to address behavioral health needs in Montgomery County.

5. Needs Beyond the Hospital’s Mission or Community Benefit Program

Addressing all of the health needs present in a large community requires resources beyond what

any single hospital or social service agency can bring to bear. The Hospital is committed to

fulfilling its mission as well as remaining financially viable so that it can continue its

commitment to excellence in quality care and provide a wide range of community benefits.

Between 2016 and 2019, the Hospital will focus its efforts in order to make a true and

measurable impact, and thus plans to implement actions that will address those needs identified

through the Community Health Needs Assessment as “Most Important”. The Hospital will

continue to evaluate opportunities for funding or resources to commit to addressing the

remaining needs.

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