Community Assessment

Creating a Community Assessment Christi Robbins

Community Health Practicum – NURS506March 10, 2014

Teresa M. O’Neill

Introduction• This presentation is a windshield assessment of my community• Approximately 20 slides, total 5-7 minutes in length• Identifying State and County and Statistical Data • Identify Government and County initiatives • Interpretation of data• A statement of a population nursing diagnosis/problem• Community Highlights • Introduce an intervention plan using evidence-based research

Statistical Data, California

• California Medicare Beneficiaries exceed 4.5 million• Projected to double to 9 million by 2030• California Medicare Beneficiaries comprise of:

• 85% Elderly• 14% Disabled Adults• 1% ESRD

Variables of Health Statistics, California

Poverty & Ethnicity• Poverty, 2005

• 33% beneficiary income less than $15,000• 21% have income between $15,000 to $24,000• 13% have income from $24,000 to 35,000

• Ethnicity, 2005• 79% White• 9% Asian• 6% Latino • 5% Black• 4% Other

Projected Ethnicity• By 2020 Ethnic Outlook• 50% White• 27% Latino• 15% Black• 9% Asian• 3% other

Variable of Health Statistics• California’s Medicare reimbursements are approximately $600.00

higher per beneficiary than the national average. • Average cost per beneficiary with one chronic disease $9,025• Average cost per beneficiary with three chronic diseases are $26,707• Ethnic variations as they relate to chronic disease

• Forward thinking…Sustainability requires we reduce healthcare costs to become more cost efficient on how care is delivered and managed

Statement of the Problem/Diagnosis

• 79% of Medicare Beneficiaries suffers from Multiple Chronic Conditions MCCs

• MCCs are defined by:• Two or more conditions at least one year or more requiring ongoing medical

attention• Physical Conditions (Arthritis, asthma, chronic respiratory conditions, diabetes, HD,

HTN, • Behavioral conditions: (Mental disorders, substance and addiction, and dementia), and• Intellectual and developmental disabilities

• Complex Medication Management

Statistical Data, San Diego

• San Diego’s Medicare enrollment was 11.5-13% with the highest proportion in the rural areas. • Future Problem Statement: Access to care (a future assignment

should continue my practicums).

• 2011 Hospital discharges in San Diego County of aged 65 and above were 97,647

Palomar Health District

Financial Implications of Health• VBP

• Aligns clinical process of care measures• Patient experience measures• Outcome measures, and • Efficiency measures • Concepts of

• Better patient outcomes• Higher quality • Increased safety • Lower Medicare costs

• Hospitals are reimbursed for• High quality care• High patient satisfaction• Low incidence of:

• HAIs• Never events• Low hospital < 30 day

readmisisons

Collaborative Initiatives

• CMS• Community-based Care Transitions Program (CCTP)

• 98 participating counties, including San Diego (SDCTP)

• 12 measures characterizing an “avoidable” readmission• Some include all-cause readmissions following

• AMI• HF• PNS• PCI

Summary of Interview

• 30 programs for San Diego’s Elderly population • Although some readmissions are progression of disease

processes, other causes for “potentially avoidable” reasons are people don’t choose healthy lifestyles

• Declination of services • Char W. indicated that in addition to access to healthcare as a

barrier, multiple chronic conditions as well as poor medication compliance continue to be reasons for the CCTP readmissions.

Community HighlightsEvidence-based Research

• Hospitalizations:• Heart Disease were 1,423.8 incidents per 100,000 population• Cancer at 1,319.9 incidents per 100,000• Stroke at 1,309.4 incidents per 100,000• Unintentional injury at 2,707.0 incidents per 100,000

• Falls comprise 1,1995.0 incidents per 100,000 (likely to worsen with age)

• Hip fracture 595.7 per 100,000 (likely to increase with age)

Community HighlightsEvidence-based Research

• Hospitalizations, cont.• Arthritis at 1,400.9 incidents per 100,000• Mental illness or depression at 606.0 incidents per 100,000• COPD at 606.0 incidents per 100,000• Infectious disease

• Flu and pneumonia at 302.0 per 100,000, and • 19.3 active cases of TB per 100,000

Goals• Build a better health system and delivery system with less fragmentation

through better transitions/coordination of care.• Pursue infrastructure changes by changing the culture from within• Advocate for policy and environmental changes• Engage patients for early intervention success• Strengthen self=management through positive support • Primary, secondary, and tertiary health promotions to “increase quality

and years of health life for individuals of all ages, and eliminate health disparities between different groups of the population

Proposed Nursing Interventions, MCC

• Foster trust and rapport to enhance collaboration and partnership• Self-management of the whole person

• Assess for most common barriers• Lack of awareness• Physical symptoms• Transportation problems• Lack of cost/lack of insurance coverage

• Identify home-based interventions

MCC Interventions• Assess functional debilitations caused by chronic conditions and refer

to PT, OT• Teach to develop and articulate personal care goals (visualize goals)

• Develop regimen and take steps towards personal goal• Fosters better adherence to a self-care & increased self efficacy

• Assess interested in home self-management (to promote active engagement)

• Assess and remove barriers to active self-management • Depression, isolation, and unable to socialize

Proposed Nursing InterventionsHealth Promotions

• Primary Prevention: • Flu & PNA vaccinations (2009, only 69.4% of seniors had a flu shot)

• Secondary Prevention: • Screening for high-blood pressure, cholesterol, and BS• Mammograms & PSA

• Tertiary: smoking cessation: nearly 1 out of ever SD senior smokes• Fill gaps in knowledge about MCCs

Proposed Nursing InterventionsHealth Promotions

• Connect patient with resources: • Care Transitions• Team San Diego• Chronic Disease Self-

Management • Diabetes Self-Management• Feeling Fit Club• Abuse, protection, advocacy

• Suicide Hotline• Caregiver Services • Fall Prevention

• Matter of Balance• Stepping on• Tai Chi Moving for Better

Balance

Closing

• Special needs of my population are self-management of:• MCC

• Collaboration with government and counties seek cost savings initiatives• CCTP, MCC workgroup, SDCTP, Live Well San Diego all seek to carry out…

• Healthy People goals designed to increase quality of years of health life for individuals of all ages, and eliminate health disparities between different groups of the population

References

• California Healthcare Foundation (CHF). (2010). California health care almanac: Medicare facts and figures

• Centers for Medicare & Medicaid Services (CMS). (2014). Hospital value-based purchasing

• Centers for Medicare & Medicaid Services (CMS). (2014). Community-based Care transitions program

• County of San Diego, Health and Human Services Agency (HHSA). (2013). Healthy People 2010: Health indicators for san diego county a decade of progress at-a-glance

References• County of San Diego, Health and Human Services Agency (HHSA). (2013). San Diego

County Senior Health Report: Update and Leading Indicators

• County of San Diego, Health and Human Services Agency (HHSA). (2013). 3-4-50: Chronic Disease in San Diego County

• H-CUP. (2012). HCUP Methods Series: Overview of key readmission measures and methods

• Jerant, A. F., von Friederichs-Fitzwater, M. M., & Moore, M. (2004). Patients’ perceived barriers to active self-management of chronic conditions. Patient Education and Counseling. 57(2005), 300-307

• Palomar Health. (2014). History of palomar health• U.S. Department of Health and Human Services (HHS). (2011). Inventory of programs

, activities, and initiatives focused on improving the health of individuals with Multiple Chronic Conditions (MCC).