Buncombe County Health & Human Services

Community Focused Eliminating Health

Disparities Initiative (CFEHDI)

Program

January 23, 2013

Working Together to improve the health of

minorities living in Buncombe County

Ujima: Collective Work and Responsibility- To build and maintain our community together and make our brother’s and sister’s problems our problems and to solve them together.

Community Based Organization: Collaboration

Mt. Zion Community Development, Inc.

Buncombe County Populations Served

• African American • American Indian • Hispanic/Latina • Other: Uninsured

and Underinsured

Chronic Health Conditions Addressed

• Asthma• Cancer• Diabetes• Heart Disease• HIVAIDS/STD• Obesity and

Stroke

Community Partner Programs

Health Screenings & Outreach

Diabetes Wellness Program

Chronic Disease Self-Management Classes

Body & Soul

Diabetes Prevention Workshops

Project Empower Coordinate

“Ladies Night Out” Case Management

(PACE, Building Brothers)

Role of Buncombe County Department of Health

• Convene partners around common agenda

• Facilitate Communication & cross referrals

• Develop new & existing partnerships to expand reach

• Provide infrastructure for carrying out grant scope of work

• Collect and organize program data for evaluation and analyzing

Data Collection and Common Documentation of Program Events and Outreach

1. Map outreach efforts of sub-contractors

2. Understand chronic disease focus areas

3. Communicate performance and outcome information

4. Reflect access to care and equity efforts of area health care programs

5. Track referral and follow up efforts to Medicaid, Medicare, and Insurance

Health and Wellness Assessment Tool:• Demographics• Chronic Conditions• Medical Home

Status• “Know Your

Numbers” data• Referrals for

medical services by partners

• Community needs

Buncombe County Health & Human Services, Minority Health Equity Project:

Improving Health for Everyone… Building a Better Future Together

Wayne County Health Department

Minority Health Program

Wayne County, NC

Total Population Estimate124,246

White 55%Black/African

American 32%

Hispanic/Latino 10%

Other 3%

Minorities45% White

55%

Disease Focus Areas

Obesity Heart DiseaseDiabetes

HIV/AIDS

7%

21%

18%

54%

Diabetes

Heart Disease

HIV/AIDS/STD

Obesity

Leading Causes of Death for All Minorities (2011)

1. Cancer 26%

2. Heart Disease 17%

3. Cerebrovascular Disease 6%

4. Nephritis 6%

5. Diabetes 5%

The focus of our education intervention is to:

1. Increase knowledge and awareness of modifiable risk factors that contribute to obesity and chronic conditions associated with unhealthy lifestyles

2. Implement strategies to reduce these health risks

3. Build infrastructures by establishing health ministries charged with conducting and promoting health and wellness sessions

4. Establish medical homes for uninsured congregants

5. Modify risk factors for chronic disease and to initiate chronic disease self management strategies.

Programmatic Focus

Programmatic Highlights

• W.A.T.C.H is a free, primary health clinic providing acute healthcare to the uninsured with two locations:• The Mobile Unit travels around the county to 15 pre-determined locations each month• A satellite location is available at the Goldsboro Family YMCA

• Each W.A.T.C.H. clinic is run by a Family Nurse Practitioner and volunteer physicians provide specialty clinics at specified dates and times

• For 2012• Patient Visits: 9,969 and 301 were unduplicated patients• Volunteer Hours: 1,191• Free medications ordered: $1.8 million

• From January – December 2012, $487,000 of free labs were completed

Programmatic Highlights

Faithful Families Eating Smart and Moving More (FFESMM) is a practice-tested intervention that educates faith community members about food, physical activity and becoming advocates for healthy policy and environmental changes within their communities.

Staying abreast of recent health disparities and policy developments Building and maintaining strong relationships with other health and

community advocates to leverage expertise and resources Coalition Building and Community Engagement Engaging the Faith Community Media Outreach

Helping to educate both minority and mainstream media about minority health policy and issues so that these issues get timely an appropriate attention

providing culturally competent program materials for various faith communities, community-based organizations and civic groups in addressing health literacy.

Programmatic Impact

CFEDHI WORK THROUGH A COMMUNITY BASED ORGANIZATION

Tara Robinson, RN, BSN, CCMWake County Medical Society Community Health

Foundation

WCMSCHF

Community Care of Wake &

Johnston Counties

CapitalCare Collaborative

• Improve quality of and access to primary care for the Carolina Access Medicaid and dual (Medicare/Medicaid) population

• Reduce healthcare cost

• Increase access to primary & specialty care for the uninsured & homeless

• Reduce ED visits

Assesses and responds to community health needs

Medical HomeEvidence-Based

Best PracticeCare

Management

• Non-profit• 501(c)3

Wake County

North Carolina's second most populated county Area: 835 sq. miles Persons per sq. mile: 1,078.8 Population: 952,151

21.4%0.8%

10.0%67.8%

Breakdown by Ethnicity

Black or African Amer-icanAmerican Indian & Alaska NativeHispanic or LatinoOther

Sources: US Census Bureau: State and County Quick Facts Wake County Community Health Needs Assessment, 2013

Johnston County

The 77th fastest growing U.S. county with a population of 10,000 or more Area: 791 sq. miles Persons per sq. mile: 213.4 Population: 174,938

15.7% 0.9%

13.1%

70.3%

Breakdown by Ethnicity

Black or African Amer-icanAmerican Indian & Alaska NativeHispanic or LatinoOther

Source: US Census Bureau: State and County Quick Facts

Program Goals

Decrease the number of uninsured minorities in Wake & Johnston counties

Link individuals to a medical home and increase knowledge on how to optimally access health care services

Promote chronic disease self-management among racial and ethnic minorities

Increase cultural competency among staff

WCMSCHF

Understanding the Needs of & How to Reach Our Target Population

Minority Census Tract Project and Sub-Project Advisory Groups Safety Net (Johnston Co) and Collaborative

(Wake Co) meetings Focus groups

3 in Johnston Co 3 in Wake Co

Community Stakeholders ASK and talk to individuals in our target

population Door-to-door, special interest groups

Program Highlights Living Healthy Chronic Disease Self-Management

324* participants have participated in CDSMP/DSMP 82%* have demonstrated an increased level of activation

in managing their health condition(s) Large church in Wake County Men’s Homeless Shelter Day Treatment Facilities for individuals with mental

illness Patient Navigation & Community Outreach

Spreading the word – TV, radio, & newspaper Collaboration with local partners 908* participants attended insurance workshops on

Medicare and Medicaid 265* uninsured individuals linked to a medical home

*Numbers are based on June-November 2013 data

Questions?

Tara Robinson, RN, BSN, CCMDeputy DirectorPh: 919-792-3622E-mail: trobinson@wakedocs.org

Alma Atkins, BSW, MHAMinority Health CoordinatorPh: 828-250-5319Email: aatkins.pcm@gmail.com

Celita GrahamMinority Health CoordinatorPh: 919-731-1235Email: celita.graham@waynegov.com