Table of Contents · and suburban residents through a variety of interventions including prevention...

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Table of Contents Overview of Jefferson Health ........................................................................................................ 2 Overview of the Community Health Needs Assessment and Prioritization Process ................... 4 Abington Jefferson Health Community Health Implementation Plan ......................................... 5 Abington Hospital Community Health Implementation Plan .................................................... 10 Domain: Substance Use and Abuse ...................................................................................... 11 Domain: Behavioral Health ................................................................................................... 15 Domain: Access to Affordable, Culturally Appropriate Primary and Specialty Care .......... 20 Domain: Chronic Disease Prevention and Management ..................................................... 24 Domain: Social Determinants of Health ............................................................................... 30 Abington Lansdale Hospital Community Health Implementation Plan ..................................... 31 Domain: Substance Use and Abuse ...................................................................................... 33 Domain: Behavioral Health ................................................................................................... 36 Domain: Access to Affordable, Culturally Appropriate Primary and Specialty Care .......... 41 Domain: Chronic Disease Prevention and Management ..................................................... 45 Domain: Social Determinants of Health ............................................................................... 51

Access to affordable, culturally appropriate primary and specialty care

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Jefferson Health Community Health Implementation Plan

Overview of Jefferson Health

Overview of “Jefferson Health”

Jefferson Health Hospitals and Thomas Jefferson University are partners in providing excellent

clinical and compassionate care for our patients in the Philadelphia region, educating the health

professionals of tomorrow in a variety of disciplines and discovering new knowledge that will

define the future of clinical care.

Jefferson Health (JH), the clinical arm of Thomas Jefferson University, has grown from a three-

hospital academic health center in 2015 to a 14-hospital health system through mergers and

combinations that include former hospitals at Abington Health, Aria Health, Kennedy Health

and Magee Rehabilitation. Jefferson Health has seven Magnet®-designated hospitals

(recognized by the ANCC for nursing excellence); one of the largest faculty-based telehealth

networks in the country; the NCI-designated Sidney Kimmel Cancer Center (one of only 70 in

the country); and more than 40 outpatient and urgent care locations. Thomas Jefferson

University Hospital (TJUH) is one of only 14 hospitals in the country that is a Level 1 Trauma

Center and a federally designated Regional Spinal Cord Injury Center. It also continues its

national record of excellence with recognition from U.S. News & World Report. In 2019-20,

TJUH ranked among the nation’s best in 8 specialty areas, with two in the top 10 —

Ophthalmology (Wills Eye Hospital #2) and Orthopedics (Rothman Institute at Jefferson and the

Philadelphia Hand to Shoulder Center #10). Magee Rehabilitation Hospital – Jefferson Health

ranked the 13th best hospital in the nation for Physical Rehabilitation.

In 2019, Jefferson Health included 2,867 licensed beds; 7,400 nurses, 6,100 physicians and

practitioners; 4,600 faculty and more than 2,100 volunteers. Clinically, in 2019 Jefferson

Health provided care for 127,000 inpatients, 517,000 emergency visits, and more than 3.8

million outpatient visits.

We are 30,000+ people reimagining health care, education and discovery. We are many things,

but every day all of us are dedicated to one thing: Improving lives.

Mission: We Improve Lives.

Vision: Reimagining health, education and discovery to create unparalleled value.

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Values: Jefferson's values define who we are as an organization, what we stand for, and how

we continue the work of helping others that began here nearly two centuries ago. These values

are:

Put People First: Service-Minded, Respectful & Embraces Diversity

Be Bold & Think Differently: Innovative, Courageous & Solution-Oriented

Do the Right Thing: Safety-Focused, Integrity & Accountability

Jefferson Health recognizes that by providing quality health care to our patients, and education

and outreach to our neighbors, we are also enriching the lives and future of our surrounding

communities. The work extends beyond the bedside. By partnering with the community,

Jefferson Health seeks to improve the health and well-being of young and older Philadelphia

and suburban residents through a variety of interventions including prevention and wellness

programs, health education seminars, and screenings, as well as efforts that identify and

address barriers to health, including the upstream factors (social determinants of health) that

impact the health of everyone in the community.

Geographic regions and zip codes served by Jefferson Health

Jefferson Health County and ZIP Codes

Abington Jefferson Health Bucks County: 18914, 18929, 18932, 18966, 18974 ,18976 Montgomery County: 18915, 18936, 19001, 19002, 19009, 19012, 19025, 19027, 19031, 19034, 19038, 19040, 19044, 19046, 19075, 19090, 19095, 19422, 19436, 19437, 19438, 19446, 19454, 19477, 18964, 18969, 19006, 19440

Jefferson Health -Northeast Bucks County: 18940, 18954, 18966, 18974, 19007, 19020, 19021, 19030, 19047, 19053, 19054, 19055, 19056, 19057, 19067 Philadelphia County: 19111, 19114, 19115, 19116, 19120, 19124, 19125, 19134, 19135, 19136, 19137, 19140, 19149, 19152, 19154

Jefferson Health- New Jersey Burlington, Camden, Gloucester, and Ocean Counties

Magee Rehabilitation Region

Jefferson Health - Center City

Philadelphia County: 19102, 19103, 19106, 19107, 19121, 19122, 19123, 19124, 19125, 19130, 19132, 19133, 19134, 19140, 19145, 19146, 19147, 19148

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Overview of the Community Health Needs Assessment and Prioritization Process

The Affordable Care Act (ACA) mandates that, every three years, tax-exempt hospitals conduct

a Community Health Needs Assessment (CHNA). By determining and examining the health

needs and gaps in communities, these assessments drive hospitals’ planning and

implementation of initiatives to improve community health.

Recognizing that hospitals and health systems often mutually serve the same communities,

during 2018 and 2019, a group of local hospitals and health systems convened to develop this

first-ever Southeastern PA (SEPA) Regional CHNA, with specific focus on Bucks, Chester,

Montgomery, and Philadelphia counties. This initiative expanded the focus of COACH

(Collaborative Opportunities to Advance Community Health); a coalition formed by many of the region’s

hospitals and Health systems to address the health and social needs in Southeastern Pennsylvania.

Secondary health data findings and primary data gathered through community meetings, focus

groups, and key informant interviews, were synthesized by Philadelphia Department of Public

Health (PDPH) staff. A list of 16 community health priorities (listed below) was presented to the

COACH Steering Committee that included representation from all of the hospitals participating

in the Community Health Needs Assessment. Using a modified Hanlon ranking method, the

PDPH ranked the size of the problem and the Importance to the community based on

secondary data and input from the community collected during the assessment process. Each

participating hospital and health system rated each of the priorities based on the following

criteria:

Size of health problem

Importance to the community

Capacity of hospitals/health systems to address

Alignment with mission and strategic direction

Availability of existing collaborative efforts

Using these five criteria, an average rating was calculated for each priority area. The community

health priorities for the region are presented below in ranked order.

PRIORITY HEALTH ISSUES/NEEDS

1. Substance/ Opioid Use and Abuse

2. Behavioral Health Diagnosis and Treatment

3. Access to affordable primary/ preventive care

4. Healthcare and Health resources navigation

5. Access to affordable specialty care

6. Chronic disease prevention

7. Food access and affordability

8. Affordable and Healthy housing

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9. Sexual and Reproductive Health

10. Linguistically and culturally appropriate healthcare

11. Maternal Morbidity and mortality

12. Socioeconomic disadvantage (Income, Education, and Employment)

13. Community Violence

14. Racism and Discrimination in Healthcare setting

15. Neighborhood conditions (E.G. Blight, Greenspace, Parks/Recreation, etc.)

16. Homelessness

Jefferson Enterprise Hospitals are working collaboratively to address Substance Use Disorder

and Behavioral Health diagnosis and treatment.

Abington Jefferson Health Community Health Implementation Plan

Overview of Abington Jefferson Health

Abington – Jefferson Health is the organization that encompasses Abington Hospital in

Abington, PA and Abington – Lansdale Hospital in Hatfield Township, PA, as well as a number of

convenient outpatient settings for obtaining expert medical care in Bucks, Montgomery and

Philadelphia counties.

Since 2015, the organization has been part of Jefferson Health, which now includes 14 hospitals

and more than 40 outpatient and Urgent Care Center locations located throughout

Philadelphia, Bucks and Montgomery counties in Pennsylvania and Camden and Gloucester

counties in New Jersey. Outpatient and community-based services are delivered through a

network of owned and affiliated physician practices, satellite medical and surgical centers,

outpatient laboratories and radiology centers. Together, Jefferson Health has 127,000 inpatient

admissions; 517,000 Emergency Department visits, and 3.8 million outpatient visits annually.

Abington – Jefferson Health entities include the following:

•Two hospitals: Together, Abington Hospital and Abington – Lansdale Hospital have 800

licensed beds.

•Outpatient Cancer Center – Asplundh Cancer Pavilion in Willow Grove

•Seven outpatient campuses: Abington Jefferson Health – Blue Bell, Abington Jefferson Health

– Elkins Park, Abington Jefferson Health – Horsham, Abington Jefferson Health – Lower

Gwynedd, Abington Jefferson Health – Montgomeryville, Abington Jefferson Health –

Warminster and Abington Jefferson Health – Willow Grove.

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•Two urgent care centers, in Flourtown and Willow Grove.

•Physicians – Employed Physician practices located in Bucks, Montgomery and Philadelphia

counties with 80 locations.

Each year, Abington – Jefferson Health treats over 123,000 patients in its two Emergency

Departments with Abington Hospital having the distinction of having one of only two Level II

trauma centers in Montgomery County. Abington Hospital – Jefferson Health has a

comprehensive stroke center and offers highly advanced programs in cancer, cardiac and

orthopedic care.

Our Mission: We Improve Lives.

Our Vision: Reimagining health, education and discovery to create unparalleled value.

Our Values:

Put People First: Service-Minded, Respectful & Embraces Diversity

Be Bold & Think Differently: Innovative, Courageous & Solution-Oriented

Do the Right Thing: Safety-Focused, Integrity & Accountability

Priority Health Issues and Needs to be Addressed

The Table below compares the rankings of the priority health issues of the region to how these

were ranked by senior leaders at Abington Jefferson Health:

Priority Region Ranking

AJH Ranking

Substance/opioid use and abuse 1 1

Behavioral health diagnosis and treatment (e.g. depression, anxiety, trauma-related conditions, etc.)

2 2

Healthcare and health resources navigation 4 3

Chronic disease prevention (e.g. obesity, hypertension, diabetes, and CVD) 6 4

Access to affordable primary and preventive care 3 5

Access to affordable specialty care 5 6

Maternal morbidity and mortality 11 7

Sexual and reproductive health 9 8

Linguistically- and culturally-appropriate healthcare 10 9

Affordable and healthy housing 8 10

Neighborhood conditions (e.g. blight, greenspace, parks/recreation, etc.) 15 11

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Priority Region Ranking

AJH Ranking

Food access and affordability 7 12

Racism and discrimination in healthcare settings 14 13

Socioeconomic disadvantage (income, education, and employment) 12 14

Community violence 13 15

Homelessness 16 16

In order to maximize the resources available, the senior leadership of Abington Jefferson Health (AJH) has chosen to address the first seven priorities listed in the 2019 Regional Community Health Needs Assessment:

Substance Abuse/Opioid Use and Abuse

Behavioral Health Diagnosis and Treatment

Access to Affordable Primary/Preventive Care

Healthcare and Health Resource Navigation

Access to Affordable Specialty Care

Chronic Disease Prevention

Food Access and Affordability Community Health Implementation Plans (CHIP) are written to address these specific seven priorities for both Abington Hospital and Abington-Lansdale Hospital. AJH has convened Community Benefit Action teams consisting of key stakeholders and AJH administrative and clinical leaders to develop and implement goals and action plans. Leaders of these teams report on progress quarterly through reports shared with the Rev. Dr. Martin Luther King, Jr. Community Benefit and Diversity Committee. This standing committee of the Abington Health Foundation Board of Trustees has responsibility for the recommendation, approval and oversight of a Community Benefit Plan, policies and programs designed to carry out the charitable mission of the organization and to enhance the health status of communities served by Abington Jefferson Health. The following five priorities are addressed within normal hospital operations:

Sexual and Reproductive Health

Linguistically and Culturally Appropriate Healthcare

Maternal Morbidity and Mortality

Community Violence

Racism and Discrimination in Healthcare Settings The following four priorities are addressed through work with local and regional collaboratives and referrals to community or government resources:

Affordable and Healthy Housing

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Socioeconomic Disadvantage (Income, Education and Employment)

Neighborhood Conditions (e.g. Blight, Greenspace, Recreation, etc.)

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

conjunction with the hospital’s partnerships. Best and promising practices are 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. Community benefit leaders will continue to monitor the changing landscape and

requirements initiated through future health reform and the IRS including financial assistance

requirements.

Overview of the AJH Implementation Plan (CHIP)

The Abington Jefferson Health CHIP was developed in collaboration with AJH key community

stakeholders, administrative and clinical leaders. The plan is reviewed annually and revised

based on changing community needs, best practices and short-term/intermediate outcomes.

The CHIP is organized into the following four Domains and related Priority Issues:

Domain Health Related Issue

Substance/Opioid Use and Abuse

Alcohol

Marijuana and Vaping

Opiates

Smoking

Behavioral Health Training for health care providers, health

professional students, community based

organizations, youth, schools

Access to timely culturally and linguistically

appropriate care

Prevention and early detection

Access to affordable, culturally appropriate

primary and specialty care Insurance access and support

Healthcare navigation

Culturally and linguistically appropriate care

Chronic Disease Prevention and Management Hypertension/Stroke

Cardiovascular Disease

Diabetes

Cancer

Obesity

Asthma

Injury Prevention

Older Adults

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Domain Health Related Issue

Social Determinants of Health Food Access and Affordability

The Implementation Plan includes an overview of each of the domains, and related priority

health needs/issues. A logic model for each priority health need provides an overview of the

objectives, proposed strategies/activities, outcomes and impact measures, and potential

partners.

Proposed strategies/activities were considered based on their alignment with national, state,

and county health improvement plans, and national best practices cited by organizations such

as the US Department of Health and Human Services, Agency for Health Research and Quality,

Healthy People 2020, the American Medical Association, National Council on Aging, the Joint

Commission, the American Heart Association, the National Prevention Strategy, the Guide to

Community Preventive Services, and the Guide to Clinical Preventive Services.

Strategies and activities were also included that can impact health issues at multiple levels of

the Social Ecological Model. The model integrates: 1) Individual factors, sometimes called

intrapersonal factors, like genetics and individual behaviors; 2) Interpersonal factors, like social

support and family characteristics; 3) Institutional and community environments, which might

include work sites, schools, service systems and transportation; and 4) Broader social,

economic, and political influences, which could encompass a range of factors from laws and

regulations to racism and discrimination.

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Abington Jefferson Health Abington Hospital Community Health Implementation Plan

Abington Hospital, a regional referral center and teaching hospital located in Abington, Montgomery County, has served the residents of Bucks and Montgomery Counties for over 100 years. In FY19, Abington Hospital celebrated the fifth anniversary of its merging with Jefferson Health. This collaboration continues to enhance Abington’s ability to improve lives by providing high quality care at lower costs, allowing the facility to serve more people when and where needed. In July 2018 the partnership achieved its most important strategic initiative of the year with the opening of the Asplundh Cancer Pavilion, an 86,000-square-foot modern outpatient center which serves as home to the Sidney Kimmel Cancer Center at Abington-Jefferson Health. Conveniently located just off the Pennsylvania Turnpike’s Willow Grove interchange, this exceptional facility sets a new standard for providing comprehensive outpatient cancer care in a soothing and convenient setting. Abington Hospital staff members have the privilege of working with medical students, residents and fellows from Thomas Jefferson University's Sidney Kimmel Medical College and other medical schools and training programs in the Philadelphia area. In FY19, the hospital sponsored five residency programs of its own: family medicine, internal medicine, obstetrics/gynecology, general surgery and dentistry. In addition, the hospital provides postgraduate medical education in affiliation with several area medical schools. FY20 shows a change to a new care delivery model based on reduction of medical residents. Jefferson College of Nursing offers a second Bachelor of Science in Nursing (BSN) program at the Abington – Dixon Campus in Willow Grove. Abington also supports a pharmacy residency program. Targeted Service Area for Community Health Improvement

Abington Hospital defines its targeted service area as the following ZIP codes in Bucks and Montgomery Counties. These areas represent areas proximate to the hospital where 70% of inpatients reside and a total population of 543,386. Bucks County: 18914, 18929, 18932, 18966, 18974, 18976 Montgomery County: 18915, 18936, 19001, 19002, 19009, 19012, 19025, 19027, 19031, 19034, 19038, 19040, 19044, 19046, 19075, 19090, 19095, 19422, 19436, 19437, 19438, 19446, 19454, 19477, 18964, 18969, 19006, 19440

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The zip codes listed above are grouped into the following geographic regions for easy reference: Central/Lower Bucks: 18929, 18932, 18966, 18974, 18976 Perkasie/Sellersville/Indian Valley: 18914, 18964, 18969 Blue Bell: 19422 Greater Abington: 19006, 19009, 19040 North Penn/Lansdale: 18915, 18936, 19438, 19440, 19446, 19454 Upper Dublin: 19002, 19025, 19031, 19034, 19044, 19075, 19436, 19437, 19477 Willow Grove: 19001, 19038, 19090, 19031, 19034, 19038, 19044, 19075, 19096

Lower Eastern: 19012, 19027, 19046, 19095

Domain: Substance/ Opioid Use and Abuse

Drug overdose deaths have tripled and are the leading cause of death among young adults (ages 18 – 34) in the region. Communities are disproportionately impacted by the epidemic. Within Abington Hospital’s service area, the rate of drug overdose deaths is highest in the Central and Lower Bucks regions (35.3 per 100,000 people) in comparison to the Bucks County

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rate (31.1 per 100,000 people. The Greater Abington region rate (25.3 per 100,000 people) is higher than the Montgomery County rate (23.5 per 100,000 people).

Montgomery County respondents to focus groups and interviews relative to the 2019 Community Health Needs Assessment process “expressed particular concern regarding substance use in the county. They noted increases in related or concurrent conditions like cirrhosis, HIV, sexually transmitted diseases, and tuberculosis. They also emphasized drug-related mortality, noting that organ donation has actually increased due to young, otherwise healthy individuals dying of drug overdose.”

Rates of adult binge drinking are increased in these two regions as well. In the Central and Lower Bucks region, the rate is 33.5% in comparison to the Bucks County rate of 17.8%. In the Greater Abington region, the rate is 39.9% in comparison to the Montgomery County rate of 16.6%. According to the Montgomery County Office of Drug and Alcohol Prevention Programming and Evaluation Findings 2018-2019, “at least 50% of teen deaths are related to alcohol.” Tobacco use is an underlying cause of chronic disease including cancer, heart disease and stroke. Adult smoking rates range from a low of 7.8% in the North Penn/Lansdale region to 15.4% in the Central/Lower Bucks region. The vaping of marijuana and tobacco is a growing national concern and the Bucks and Montgomery County Offices of Public Health and the Montgomery County Health Alliance are promoting educational programs in schools and limiting access to flavored tobacco products to address this issue. Data from the 2017 Pennsylvania Youth Survey (PAYS) shows that of the vaping substances used by students indicating electronic vaping use within the past year, 64.8% of the surveyed students vaped with flavoring, 31.6% vaped nicotine, and 20% vaped marijuana or hash oil.


Goal : Decrease alcohol and substance use disorder

Objective: Open AJH Detox Unit by end of this CHNA IP Cycle 2022

Strategy/Action Finalize plans to open detox unit for Outpatient treatment with community partner on AJH Warminster campus.

Target Population Individuals suffering from Opioid Use Disorder [OUD] or Substance Use Disorder [SUD].

Outcomes Track # of referrals to outpatient Medication Assisted Treatment (MAT) Program

Enhance Warm Hand Off Program in ER/ETC.

Potential Partners Internal Partners: Behavioral Health, Facilities, Community Health, Jefferson Medical Group (JMG), Administration, Abington Health Foundation, AJH PR/Marketing External Partners: Penn Foundation, Montgomery County Office of Drug and Alcohol, Montgomery County Office of Public Health and Montgomery County Commissioners Office, Bucks County Drug and Alcohol

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Objective: Reduce the number of people who become addicted to opioids by reducing over-prescribing of opioids

Strategy/Action Continue and enhance the work of the AJH Opioid Council to promote information sharing and to monitor opioid prescription distribution.

Target Population AJH patient population and community members.

Outcomes Enhance AJH Opioid Council with an individual in recovery to be considered for membership in the council FY20

Start each meeting with a stigma or patient story – AJH Opioid Task Force meetings

Share successes of Council in Chief of Staff e-newsletter.

Monitor report outs from NICU, OB/GYN, Department of Surgery, AHP/JMG practices

Pilot the Penn Foundation Bucks County Case Manager [Queen Anne practice] to focus on 200 patients with JMG/AHP.

Explore reportable and internal data sources of opioid consumption to review for outcome improvement. [OB, Neonatal Abstinence, and various clinical areas.]

Identify AJH experts to present or be a part of a panel for prevention and education.

Potential Partners Internal Partners: Leadership from AJH Behavioral Health, Department of Nursing, NICU, Department of Surgery, AHP/JMG, Ob/GYN, Community Health, Chief of Staff’s Office, Jefferson MATER Program External Partners: Penn Foundation; other providers will be under consideration

Objective: Increase internal communication strategies on prevention, treatment and rescue

Strategy/Action Communicate AJH Pain Management Resource Center/BH/OUD/SUD services and intranet resources [BING] to workforce

Target Population AJH workforce: Department of Nursing; Case Management; medical staffs; Key Community Stakeholders; community

Outcomes Develop and provide presentations at key AJH departments by end of FY20 serving over 125 leaders and staff.

Publish two editions per year of “Opioid Matters” newsletter and document analytics.

Explore Enterprise- wide communication initiative.

Potential Partners Internal Partners: Behavioral Health leadership, Community Health leadership, Chief of Staff’s Office, Public Relations and Marketing/Web Center External Partners: N/A

Objective: Expand awareness of drug-take back disposal programs

Strategy/Action Maintain and increase education and communications regarding National Drug -Take Back Day (s).

Target Population All AJH Community members, AJH workforce: Department of Nursing; Case Management; medical staffs; Key Community Stakeholders

Outcomes Increase social media presence on drug -take back and document analytics

Include drug-take back information in all editions of “Opioid Matters”

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Distribute information about local drug-take sites internally through weekly e-mail updates.

Distribute information about local drug-take sites externally at all community health outreach events.

Participate in community coalitions which focus on drug-take back efforts

Potential Partners Internal Partners: Behavioral Health leadership, AJH Community Health, Chief of Staff’s Office, Public Relations and Marketing/Web Center External Partners: Abington Community Task Force (ACT), Indian Valley Character Coalition (IVCC), Bucks-Mont Collaborative, Community Health Key Stakeholder Distribution list.

Objective: Enhance external partnerships and collaboration

Strategy/Action Continue to attend Regional and County meetings, task force, coalitions, and share

results/activities with AJH Opioid Planning Group and Opioid Council.

Target Population AJH Community Members

Outcomes Collaborate with Montgomery County Drug and Alcohol Task Force and support their efforts with Narcan trainings; school prevention/education and communicate within AJH.

Attend meetings of ACT, IVCC, Bucks-Mont Collaborative, Youth Marijuana Prevention Project (YMPP), etc.

Provided by Montgomery County at AJH Opioid Council report outs – quarterly.

Potential Partners Internal Partners: AJH Behavioral Health, Public Relations and Marketing, Community Health, Chief of Staff’s Office External Partners: Leadership from Montgomery County Drug and Alcohol; Significant number of regional partners from 5 counties – key community stakeholders including government, ACT, IVCC, YMPP, School districts; Opioid Learning Action Network of Hospital Association of PA

Objective: Increase community awareness of the impact and prevalence of binge drinking.

Strategy/Action Create an education and communication campaign around the effects of binge drinking.

Target Population AJH community members and AJH workforce

Outcomes Effectively communicate and biannually update the AJH Support and Self Help group. AH and ALH provides a minimum of one AA or NA group on its campus.

Educate 25 or more nurses, APPs and BHCs on binge drinking, OUD, SUD issues.

Incorporate educational materials into community outreach, health fairs, spin wheel

Investigate use of AJH social media for binge drinking education.

Potential Partners Internal Partners: AJH Behavioral Health, AJH Community Health, departments on each campus room bookings; PR/Marketing External Partners: Regional AA, NA; area provider community

Objective: Provide screening for alcohol and/or substance use for specific AJH patient populations.

Strategy/Action Implement CAGE AID screening assessment tool to identify individuals with alcohol

and/or SUD.

Target Population AJH Patients

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Outcomes FY20 build or design in EPIC for universal screening assessment in FY21. Use this tool and create a baseline. Explore data for future reference.

Educate staff on how to screen for CAGE AID

Track # of patients screened CAGE AID

Potential Partners Internal Partners: JMG leadership, Behavioral Health leadership, Center for Patient Safety and Quality; EPIC IS&T External Partners: NA

Objective: Provide education to youth regarding vaping hazards and marijuana use.

Strategy/Action Participate in the Montgomery County Youth Marijuana Prevention Project (YMPP).

Target Population Youth in Montgomery County

Outcomes Develop county wide school vaping policies

Participate in education programs targeting educators, student support staff, pediatricians and policymakers

Create county wide messaging campaign

Potential Partners Internal Partners: AJH Behavioral Health, AJH Children’s Clinic, Jefferson Medical Group External Partners: Montgomery County Office of Drug & Alcohol, Be A part of the Conversation, Family Services, Montgomery County Health Alliance, Indian Valley Character Counts Coalition

Domain: Behavioral Health

Behavioral health needs emerged as one of the top priorities in the community health needs assessment for Philadelphia and the surrounding counties. One in five adults in the region report diagnosed depression and more than one in 10 adults report experiencing frequent mental distress. Undiagnosed and untreated conditions like depression, anxiety and trauma-related conditions result in higher emergency department utilization particularly among youth, persisting suicide rates, and substance use and abuse. Particularly vulnerable populations include individuals experiencing poverty, homelessness/housing insecurity, racial and ethnic minorities, immigrants and refugees and those who identify as LGBTQ. Nearly two-thirds of all gun related deaths are due to suicide. Suicide is the second leading cause of death among adolescents aged 10–19 in the U.S. In 2017, approximately 1 in 5 deaths in youth were attributed to suicide. Risk factors for youth suicide include a previous suicide attempt, psychiatric disorders (such as major depression, bipolar disorder, generalized anxiety and personality disorder traits), substance use, lack of social support, and availability of lethal means. Adverse childhood events, family discord, fights with friends, poverty, and legal trouble risk factors related to suicide ideation and attempts. Data from the 2017 PAYS survey shows that 18.8% of 12th grade students in Montgomery County reported suicide ideation and 9.1% reported having attempted suicide 1 or more times. According to key informants and focus group participants, behavioral health priorities include addressing depression, anxiety and chronic stress in the community related to exposure to

https://webappa.cdc.gov/sasweb/ncipc/leadcause.html




https://www.ncbi.nlm.nih.gov/pubmed/19644372

https://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/suicidal_behavior_practice_parameter.pdf


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trauma (violence, suicide, poverty and substance use). Key informants and focus group participants also described knowledge about and access to behavioral health care resources and services as limited, and community awareness about how to assist individuals with mental health problems as an area for improvement.


Goal: Improvement in the capacity of Abington Jefferson Health (AJH) and community-based

organizations to address behavioral health issues within the community.

Objective: Increase access and referral to behavioral health services.

Strategy/Action Continue and enhance access with Behavioral Health Consultants [BHCs] in primary care and specialty practices.

Target Population Adults/children who are Abington Health Physicians (AHP)/Jefferson Medical Group (JMG) patients.

Outcomes Maintain or increase current level of BHCs within practices.

Track # of patients served and # of practices with embedded BHCs.

Potential

Partners

Internal Partners: AHP/JMG, AJH Behavioral Health leadership External Partners: N/A

Strategy/Action Expand one Behavioral Health Consultant [BHC] into all OB practices and expansion in the

OB/GYN clinic at AH to focus on peri-partum and postpartum mood disorders and fetal

loss referring all other to BHC’s in primary care.

Target Population OB/GYN patients of AJH including OB/GYN clinic

Outcomes Track # of patients seen by BHC

Potential

Partners

Internal Partners: Behavioral Health leaders and BHCs, Women and Children’s Services, OB/GYN clinic; OB GYN practices External Partners: N/A

Objective: Improve knowledge, skills of trainees to safely and responsibly identify and address a potential mental illness or substance use disorder.

Strategy/Action Collaborate with Penn Foundation to implement empathy training in OB/GYN and all hospital medicine Advanced Practice Professions [APPs] and consider hospital wide module to reduce stigma.

Target Population AJH piloted workforce; Leadership Behavioral Health, BHCs, Crisis Clinicians, APPs

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Outcomes Track # of professionals trained

Work with Penn Foundation to develop and implement pre and post evaluation.

Potential

Partners

Internal Partners: Jefferson Department of Diversity and Inclusion, Jefferson IS&T, AJH Behavioral Health, Jefferson Community and Trauma Counseling Department External Partners: Penn Foundation, Bucks Mont Collaborative partners or Lakeside Educational Network

Strategy/Action Collaborate with community based provider to implement stigma and trauma training for BHC’s and Crisis Clinicians

Target Population AJH piloted workforce; Leadership Behavioral Health, BHCs, Crisis Clinicians

Outcomes 100% of BHCs and Crisis Clinicians to be trained in trauma informed care FY20-22.

Track # of professionals trained

Potential

Partners


Objective: Provide depression and suicide screenings for specific AJH patient populations.

Strategy/Action Promote and provide [PHQ2 and PHQ9] and suicide [CSSRS] in ETC/ER depression and

suicide screenings in ALH ER and AH Emergency Trauma Center.

Target Population Adults/children admitted to AJH Emergency Center and ALH Emergency Room.


All patients admitted into emergency services will be screened.

Track # of patients screened for depression and suicide /number of patients admitted

Potential

Partners

Internal Partners: AH ETC/ALH Senior Leadership, Nursing Leadership, Physician Leadership, EPIC IS&T External Partners: N/A

Strategy/Action Initiate maternity mental health bundle for depression, suicide and SUD, to include

Edinburgh [depression] and CSSRS [suicide] and 4 P’s [Pregnancy, Past, Partner, Parents]

for SUD.

Target Population AJH OB patients and their partners.

Outcomes AJH OB patients meeting the maternity bundle criteria will be screened.

Track # of patients screened for depression, suicide, SUD / # of patients seen

Potential

Partners

Internal Partners: AHP/JMG, Behavioral Health leadership, Women and Children’s Services, BHC External Partners: N/A

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Strategy/Action Pending [Epic Rollout AH and ALH October 2020], implement depression and suicide

screenings in AJH practices.

Target Population Adults/children who are AHP patients.

Outcomes All AJH patients will be screened at annual wellness visits by FY21 – educate staff for compliance

Track # of patients screened for depression/# of patients seen through EPIC

Potential

Partners

Internal Partners: AHP/JMG, Behavioral Health leadership External Partners: N/A

Objective: Improved knowledge, skills of trainees to safely and responsibly identify and address a potential mental illness or substance use disorder.

Strategy/Action Provide Mental Health First Aid training, QPR and Trauma Informed Care for workforce and/or community FY20-22.

Target Population AJH workforce and community members.

Outcomes Participate in COACH initiatives to increase provision of community trainings; track # of community trainings/participants held at AJH

Increase workforce trainings, track # of workforce trainings/participants held at AJH

Explore and develop enterprise wide communication/education programming.

Potential

Partners

Internal Partners: AJH PR/Marketing, AJH Community Health, AJH Behavioral Health, AJH Senior Leadership, Jefferson Community and Trauma Counseling Department, Jefferson Health External Partners: COACH, Montgomery County Office of Mental/Behavioral Health, Regional Mental Health Services Coordination Office, Lakeside Educational Network

Objective: Explore and enhance community partnerships for potential outreach to educate on issues and topics relevant to behavioral health.

Strategy/Action Explore partnerships with community based organizations and behavioral health

professionals to develop a comprehensive network of care and/or education and

outreach.

Target Population General AJH community

Outcomes Support “Girls on the Run” in Montgomery County through annual sponsorship

Support NAMI in Montgomery County through annual sponsorship

Explore partnership with NAMI program community education and outreach “Friends in the Lobby” program

Potential

Partners

Internal Partners: AJH Behavioral Health, AJH Community Health External Partners: Girls on the Run-Montgomery County, PA; NAMI of Montgomery County

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Objective: Provision and promotion of grief support programs for AJH community

Strategy/Action Continue to provide free Safe Harbor program.

Target Population Grieving families/children in AJH communities.

Outcomes Track # of programs and # of participants

Track program effectiveness through evaluation of post-program survey results.

Potential

Partners

Internal Partners: Safe Harbor coordinators, Community Health, Behavioral Health, AH Foundation, Public Relations and Marketing External Partners: Area school districts, Faith Community Network, Community Health key community stakeholders

Strategy/Action Continue to provide bereaved spouses/partners support groups.

Target Population Grieving spouses/partners in the AJH service area.

Outcomes # of programs and # of participants

Potential

Partners

Internal Partners: Jefferson Home Health and Hospice, AJH Community Health, Behavioral Health, AH Foundation, Public Relations and Marketing External Partners: Faith Community Network, Community Health key community stakeholders

Objective: Increase provider and community based organizations awareness and understanding of behavioral health needs and resources available through AJH Behavioral Health Navigators.

Strategy/Action Increase frequency and monitor effectiveness of current communication strategies to increase awareness of AJH resources.

Target Population All AJH community members and behavioral health providers

Outcomes Track # of contacts with Behavioral Health Navigator (Access Coordinator);

Track # of referrals made by Behavioral Health Access Coordinator

Potential

Partners

Internal Partners: Behavioral Health leadership, Navigator [Access Coordinator], Community Health, Public Relations and Marketing External Partners: Area provider community; area non-profit organizations; Bucks and Montgomery Counties programs and services

Domain: Access to affordable, culturally appropriate primary and specialty care

According to Healthy People 2020, “access to comprehensive, quality health care services is important for promoting and maintaining health, preventing and managing disease, reducing

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unnecessary disability and premature death, and achieving health equity for all Americans.” This topic area focuses on three components of access to care: insurance coverage, health services, and timeliness of care. When considering access to health care, it is also important to include oral health care and obtaining necessary prescription drugs. In addition, navigating healthcare services can be challenging due to lack of awareness and fragmented systems. Within the AJH service area, the Lower Eastern Montco region has the highest rate of adults (19-64) without insurance at 7.9% compared to the Montgomery County rate of 6.5%. The rate of children (<19) without health insurance is high in the Perkasie, Sellersville/Indian Valley region at 4.0% compared with the Bucks County rate of 2.6%. In Montgomery County, the highest rate of children without health insurance is found in the Blue Bell area, 4.1% as compared with the Montgomery County rate of 2.7%. Emergency room utilization is also highest in the Perkasie, Sellersville/Indian Valley, North Penn and Lower Eastern Montco regions. While some ED visits may be attributed to preventable or treatable conditions, a high rate of ED visits may be an indicator of inadequate access to care.


Goal : Improve access to affordable primary/preventive care

Objective: Increase access to primary dental care.

Strategy/Action Continue the services offered by the AJH Dental Care Access Program and the AJH Dental Clinic. Foster relationship between AJH Dental Care Access Program and AJH Dental Clinic.

Target Population All AJH Community Members who are uninsured or underinsured; individuals/ families with low income; immigrants

Outcomes Maintain or increase # of patients served. Baseline = 5,000

Maintain or increase # of dental providers at AJH Dental Care Access Program. Baseline = 20

Maintain high level of engagement of dental providers as noted by 90% of the respondents in a dental provider satisfaction survey stating that they intend to continue as a provider with our program.

Potential Partners Internal Partners: AJH Dental Clinic, AJH Dental Care Access Program, AJH Dental Staff, AJH Dental Residency Program External Partners: North Penn Region Dentists, VNA Foundation of Greater North Penn, Montgomery Bucks Dental Society; Delta Dental

Objective: Improve access to and utilization of culturally appropriate primary care

Strategy/Action Encourage Hartnett Health Services (HHS)/North Hills/Abington Family Medicine Primary Care (AFM)/AJH Children’s Clinic utilization through outreach to

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uninsured/underinsured patients discharged from Abington and/or Abington-Lansdale Hospital.

Target Population All AJH Community Members who are uninsured or underinsured; individuals/ families with low income; immigrants.

Outcomes Maintain or increase # patients who are connected with by HHS Nurse Care Manager. Baseline = 40/month.

Investigate methods for tracking of AJH discharged patients at North Hills/AFM

Differentiate between new/established patients referrals.

Potential Partners

Internal Partners: HHS Social Work Team; HHS Care Manager; HHS Staff; HHS Clinical Team, Inpatient teams: Hospitalists, Chiefs, Observation Unit, North Hills Staff, AFM Staff, AJH Children’s Clinic Staff External Partners: Montgomery County Connections Program(Navigates); Jaisohn Medical Center

Strategy/Action Provide language assistance to individuals with limited English proficiency and/or other communication needs to facilitate oral communication and ensure communication needs are met.

Target Population All AJH Community Members who are uninsured or underinsured; individuals/ families with low income; immigrants; all AJH patients.

Outcomes Monitor and evaluate tracked data on use of the language line

Track use of ALVIN throughout AJH system.

Increase use of bilingual staff where appropriate

Translate written materials/forms into foreign languages where 5% or 1,000 individuals have limited English proficiency.

Potential Partners

Internal Partners: HHS Social Work Team; HHS Care Manager; HHS Staff; HHS Clinical Team, Inpatient teams: Hospitalists, Chiefs, Observation Unit, North Hills Staff, AFM Staff, AJH Children’s Clinic Staff, AJH Interpretation Services, AJH PR/Marketing External Partners: Montgomery County Connections Program(Navigates); Jaisohn Medical Center, Para-Plus Translations, Inc.

Strategy/Action Expand Hartnett Health Services’ physical space.


Outcomes Decrease in-office wait times for services

Increased patient satisfaction

Potential Partners

Internal Partners: HHS Staff; HHS Clinical Team, AJH Facilities, AJH PR/Marketing External Partners: Selected vendors and contractors

Objective: Develop culturally appropriate Health Promotion campaigns and initiatives to raise awareness.

Strategy/Action Collaborate with Jaisohn Medical Center in the provision of culturally and linguistically appropriate care and community programming for AJH Asian American community members. Participate in the Montgomery County Asian American Coalition.

Target Population Asian American Community members in the AJH service area.

Outcomes Provision of two collaborative programs for the Asian American Community.

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Co-location of Jaisohn Medical Center on Abington-Lansdale Hospital Campus,

Community Health Center.

Facilitation of group scheduling of mammograms to allow for more culturally

appropriate environment.

Potential Partners Internal Partners: AJH Radiology, AJH Patient Access, AJH Community Health Center External Partners: Jaisohn Medical Center

Strategy/Action Utilize AJH’s strong health outreach programs in underserved communities to identify individuals at risk and provide resources for clinical care.

Target Population All AJH Community Members who are uninsured or underinsured; individuals/families with low income; immigrants.

Outcomes Provide AJH clinic information at all community outreach programming.

Provide follow up calls to all screening participants with abnormal results and ensure that they are active in a primary care home, or provide referral.

Translate written health education materials into foreign languages where 5%, or 1,000 individuals have limited English proficiency.

Potential Partners Internal Partners: AJH Community Health Outreach, Save Your Soles Program, AJH Care Managers, AJH Faith Community Nurse Network, Asplundh Cancer Pavilion External Partners: Montgomery County Connections (Navigates), Legislative offices, Bucks/Mont Collaborative for Health and Human Services, Para-Plus Translation Services, ACLAMO, North Penn Mosque, International Spring Festival.


Goal : Improve navigation of health care services to link individuals to appropriate social service

agencies

Objective: Improved Access to Public Benefits and Programs

Strategy/Action Assist patients and their families in enrolling in public benefits and programs such as government based insurance options (medical assistance, children’s health insurance program [CHIP], health insurance marketplace), SNAP benefits, housing, LIHEAP, etc.


Outcomes Track # of insurance applications completed

Maintain or increase # of social service referrals

Potential Partners Internal Partners: AJH Children’s Clinic, Hartnett Health Services, Abington Family Medicine, and North Hills Health Center External Partners: PA Dept. of Aging, APPRISE Certified Medicare Counselors, Montgomery County Dept. of Health and Human Services, Montgomery County Community Connections Program, Bucks County Dept. of Human Services, Philadelphia County Dept. of Human Services, PA Benefits Center, VNA Community Services

Objective: Improved access to transportation

Strategy/Action Provide information regarding available transportation services and facilitate the process for accessing these services.

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Outcomes Investigate UBER Health services for clinic patients

Explore grant funding to provide bus tokens and cab vouchers

Explore collaboration with Partnership TMA for transportation resources

Investigate Hospital Van Services

Potential Partners Internal Partners: AJH Philanthropy, AJH Care Managers, Social Workers, AJH Faith Community Nurse Network, AJH Muller Institute for Senior Health External Partners: Uber Health, Partnership TMA

Objective: Accessible access to healthcare for persons with disabilities

Strategy/Action Provide access to preventive care and health education/screening for persons with

disabilities.

Target Population All AJH community members with disabilities

Outcomes Provide community health education programming to individuals with disabilities

Provide Adult Day Services to individuals with disabilities

Increase # of Jefferson Medical Group (JMG) practices who have the ability to offer appropriate care to individuals with disabilities.

Potential Partners Internal Partners: AJH Children’s Clinic, Hartnett Health Services, Abington Family Medicine, and North Hills Health Center, AJH Compassionate Care Program, JMG, AJH Adult Day Services External Partners: Magee Rehabilitation Hospital, ALTEC, Indian Creek Foundation

Objective: Provide access to reliable and current health resources.

Strategy/Action Develop culturally and linguistically appropriate community resource directories, bulletins or newsletters.

Target Population All AJH community members

Outcomes Maintain current community resource list on AJH intranet and website.

Explore utilization and implementation of Aunt Bertha (website catalogs government, business and charity aid programs and makes them searchable by subject and by location) into EPIC EMR.

Potential Partners

Internal Partners: AJH Community Health, AJH Children’s Clinic, Hartnett Health Services, Abington Family Medicine, North Hills Health Center, AJH Financial Services External Partners: Aunt Bertha, Para-Plus Translations, Inc.

Objective: Increase community residents knowledge of Jefferson Health’s Financial Assistance (Compassionate Care) Program

Strategy/Action Assist patients and families in enrolling in Jefferson’s Compassionate Care Program.


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Outcomes • Track # of applications to Compassionate Care Program.

Potential Partners Internal Partners: Hartnett Health Services, AJH Social Workers, AJH Care Management, AJH Financial Services Unit, AJH Children’s Clinic External Partners: Bucks/Mont Collaborative


Goal : Improve access to specialty care

Objective: Improve access to and utilization of affordable and culturally appropriate specialty care.

Strategy/Action Facilitate the provision of specialty care for uninsured/underinsured patients.


Outcomes Track number of patients seen at HHS Specialty Clinics.

Track number of children who are patients in AJH primary care clinics and are referred to CHOP’s Family Health Coverage Program.

Track number of calls processed by AJH scheduling advocates, which facilitate the provision of specialty care services.

Potential Partners Internal Partners: AJH Care Managers, Jefferson Medical Group Specialists, AJH Scheduling Advocates External Partners: Children’s Hospital of Philadelphia

Domain: Chronic Disease Prevention and Management

One in four Americans has multiple chronic conditions, and that number rises to three in four Americans aged 65 and older. Data from the 2019 Regional Community Health Needs Assessment shows that in the Abington –Jefferson Health service area, the percentage of older adults is 18% of the total population. Approximately 71% of the total health care spending in the United States is associated with care for the Americans with more than one chronic condition. http://www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/decision/mcc/mccchartbook.pdf The high prevalence of chronic disease is a result of the rapidly growing older adult population, increased life expectancy resulting from advances in public health and clinical medicine, and is attributable to six key risk factors: high blood pressure; tobacco use and exposure to second hand smoke; obesity; physical inactivity; excessive alcohol use; diets low in fruits and vegetables; and diets high in sodium and saturated fats.

http://www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/decision/mcc/mccchartbook.pdf


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Risk factors for chronic disease should be addressed at the individual level (including health care interventions) and the population level (including policies and environments that promote health). http://www.cdc.gov/chronicdisease/pdf/four-domains-factsheet-2015.pdf

The Centers for Disease Control and Prevention (CDC) recommends coordinating chronic disease prevention efforts on strategies that:

Promote and support healthy behaviors through changes to social and physical environments that make healthy choices easier, safer, cheaper, and more convenient

Collectively address the behaviors and other risk factors that can cause chronic diseases.

Improve delivery and use of quality clinical services to prevent disease, detect diseases early, and manage risk factors

Work to simultaneously prevent and control multiple diseases and conditions.

Reach more people by strengthening systems and environments to support health and linking community programs to clinical services to prevent and control disease. Strategies that link community and clinical services help to reduce barriers to care and ensure that people with or at high risk of chronic diseases have access to the resources they need to prevent or manage these diseases. Improved links between the community and clinical settings allows community delivery of proven programs, to which patients may be referred by a clinician, with third-party payments to community organizations and lay providers.


Goal: 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.

Objective: Provide health education and promotion in natural community hubs, such as beauty salons/barbershops, retail establishments, senior centers, schools, community events and faith-based institutions.

Strategy/Action Provide education, screening, risk assessment and support programs to increase awareness about heart disease/attack prevention, reduce cardiovascular prevalence and/or improve cardiovascular management. Raise public awareness about early heart attack symptoms, early heart attack care, cardiac arrest and the importance of CPR intervention and early detection and management of hypertension.

Target Population All adult AJH community members

Outcomes Maintain or increase number of completed Blood Pressure Screenings

Provide follow-up calls to all consenting participants that have a blood pressure reading of >130/80.

http://www.cdc.gov/chronicdisease/pdf/four-domains-factsheet-2015.pdf

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o Track: # attempted calls # contacted # without history of hypertension # referred to community resources # without PCP # referred to personal physician for follow-up # referrals to Chronic Care Management Program

Track and report all on-site interventions, which may include calling 911 or calling the primary care physician, etc.

Provide low cost CPR classes to the community. o Track:

# of classes/participants Completed class evaluations to determine acquired knowledge

Provide early heart attack, cardiac arrest education at a variety of community settings.

o Track: # of programs/participants

Provide heart risk screenings at a variety of community settings. o Track:

# of programs/participants

Potential Partners

Internal Partners: AJH Community Health Outreach, Jefferson Home Health and Hospice, Jefferson Community Physicians, AH AHA BLS Community CPR Training Center External Partners: American Heart Association, Local Senior Centers, Community Retail Establishments, Faith Community Network, Community Business Establishments, Community Government Leaders

Strategy/Action Provide education, screening, risk assessment and support programs to increase awareness about stroke prevention, reduce stroke prevalence and/or improve stroke management. Raise public awareness about FAST (face, arms, speech, time) and TpA.


Outcomes • Maintain or increase number of completed Blood Pressure Screenings. • Provide follow-up calls to all consenting participants that have a blood pressure reading of >130/80.

Maintain or increase number of Stroke Risk Assessments.

Provide stroke education at community health fairs and senior expos.

Potential Partners Internal Partners: : AJH Community Health Outreach, Jefferson Home Health and Hospice, Jefferson Community Physicians, AJH Stroke Councils External Partners: American Heart Association, American Stroke Association, Local Senior Centers, Community Retail Establishments, Faith Community Network, Community Business Establishments, Community Government Leaders

Strategy/Action Increase knowledge, skills and awareness of asthma management strategies and resources.

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Outcomes Offer at least two Asthma education programs to community at large.

Collaborate with Jefferson Medical Group or Allergy and Asthma Associates to provide asthma screening and education at large community events.

Provide asthma management training during community Heartsaver First Aid courses (Chapter on Asthma and Respiratory Emergencies. Details assembly and use of an inhaler.)

Collaborate with regional community partners on asthma initiatives.

Potential Partners Internal Partners: AJH Community Health Outreach, Abington Pulmonary and Critical Care Associates External Partners: American College of Asthma, American Heart Association ECC Heartsaver First Aid Courses , Montgomery County Office of Public Health

Strategy/Action Maintain a faith-based advisory council and provide/coordinate programming at specific

sites and training for Faith Community Ministries to address chronic disease

management.

Target Population Faith Community Nurses in AJH Service Area

Outcomes Council maintained.

Maintain or increase number of educational offerings and participants.

Track acquired learning through pre and post learning surveys.

Track participant satisfaction through program evaluations.

Potential Partners Internal Partners: AJH Community Health Outreach, Faith Community Nurse Network External Partners: Community Partners

Strategy/Action Provide education, risk assessments and support programs to reduce diabetes

prevalence and/or improve diabetes management.


Outcomes Maintain number of class offerings and participant volume for Diabetes Education Program.

Monitor AHP's CQM Scorecard for AHP--HgbA1C percentage of controlled (controlled/

diabetic patients).

Provide Diabetes Prevention Workshops, Diabetes Risk Assessments and Education Programs to the community at large.

Collaborate with local YMCA’s in the provision of CDC National Diabetes Prevention Program.

Potential Partners Internal Partners: AJH Diabetes Center, Abington Health Physician Network (Jefferson Medical Group), AJH Community Health Outreach, AJH Pharmacy External Partners: American Diabetes Association, Willow Grove YMCA, North Penn YMCA, Ambler YMCA

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Strategy/Action Provide education, risk assessments and support programs to increase screening rates

for cancer.


Outcomes Provide Low Cost Mammogram and Healthy Women PA through Hartnett Health

Services.

Provide Annual Community Screening Day (Skin, Head and Neck, Prostate, Breast).

Provide Colon Cancer Community Education/Outreach (Strollin’ Colon).

Collaborate with Jaisohn Medical Center in provision of culturally appropriate cancer screenings.

Potential Partners

Internal Partners: AJH Community Outreach, AJH Asplundh Cancer Pavilion staff, PR/Marketing/Staff , AHP/JMG External Partners: Montgomery County Office of Public Health, AJH affiliated dermatologists, Jaisohn Medical Center

Strategy/Action Provide health education and support programs for Older Adults.

Target Population All older adult AJH community members

Outcomes Provide/maintain counseling services in the Geriatric Assessment Center.

Provide/maintain Blood Pressure and Healthy Life Style programing in the Senior Adult Centers.

Provide/maintain current ElderMed Programming.

Provide Matter of Balance Classes or Fall Prevention Programming.

Provide/maintain programs to improve and/or maintain cognitive health. o Offer memory fitness programming at two AJH locations o Offer Adult Day programming

Potential Partners

Internal Partners: AJH Community Outreach, AJH ElderMed Program, PR/Marketing/Staff , AJH Geriatricians External Partners: VNA-CS, APPRISE, Community Senior Adult Centers, Montgomery County Office of Public Health

Strategy/Action Provide community programs regarding how to fit healthy food choices into daily life

through nutrition education.


Outcomes Provide interactive nutrition education at community outreach events.

Collaborate with Montgomery County Office of Public Health and Montgomery County Intermediate Unit in provision of preschool nutrition curriculum.

Collaborate with area libraries and senior centers in provision of nutrition education programming.

Collaborate with area YMCA’s in provision of nutrition education programming.

Potential Partners

Internal Partners: AJH Community Outreach

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External Partners: Community libraries, Community Senior Adult Centers, Montgomery County Office of Public Health, Montgomery County Intermediate Unit, Area YMCA’s

Strategy/Action Provide community programs and education to promote injury prevention.


Outcomes Provide interactive injury prevention education at community outreach events.

Collaborate with Montgomery County Office of Public Health and Montgomery County Health Alliance in provision of injury prevention programming.

Collaborate with area libraries and senior centers in provision of injury prevention programming.

Collaborate with area YMCA’s in provision of injury prevention programming.

Provide Fall Prevention education for older adults.

Potential Partners

Internal Partners: AJH Community Outreach, AJH ENCARE Nurses External Partners: Community libraries, Community Senior Adult Centers, Montgomery County Office of Public Health, Montgomery County Intermediate Unit, Area YMCA’s, Montgomery County Health Alliance

Objective: Support media and community campaigns that encourage smoking cessation

Strategy/Action Support media campaigns that encourage smoking cessation. Raise awareness among providers about community efforts and continue to promote resources to reduce smoking/vaping/tobacco use rates.


Outcomes Participate in collaborative projects to increase awareness of risks of smoking/vaping/tobacco use.

Provide community based smoking cessation classes.

Provide follow up calls to all Lansdale Hospital discharged patients with a history of tobacco use.

Potential Partners Internal Partners: AJH Community Health Outreach, Faith Community Nurse Network, External Partners: Community Partners, Montgomery County Health Alliance, Montgomery County Office of Public Health

Objective: Centralize health and social services resources information

Strategy/Action Develop culturally and linguistically appropriate community resource directories,

bulletins or newsletters.




Potential Partners Internal Partners: AJH Community Health, Bucks/Mont Collaborative for Health and Human Services, AJH Faith Community Nurse Network

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External Partners: Aunt Bertha, Montgomery County Office of Public Health

Domain: Social Determinants of Health According to Healthy People 2020, “Social determinants of health are conditions in the

environments in which people are born, live, learn, work, play, worship, and age that affect a

wide range of health, functioning, and quality-of-life outcomes and risks.” Access to healthy

food is a resource, which enhances the quality of life, therefore influencing health outcomes.

As noted in the 2019 Regional Community Health Needs Assessment, “Access to and

affordability of healthy foods is a driver of poor health in many communities.” While summary

health measures obtained for the 2019 CHNA showed rates of food insecurity for Bucks County

at 10.5%, and rates for Montgomery County at 9.3%, data collected at the Abington Jefferson

Health Children’s Clinic over the past two years yielded significantly higher percentages:

For the 2019 fiscal year, 502 households were screened at the AJH Children’s Clinic for food

insecurity with 134 household screening positive, for a rate of 27% for food insecure

households. This number is 10% less than the 2018 fiscal year, when 37% of households

screened positive. Perhaps this decrease could be attributed to our previous interventions.

However, it is important to note that of these 134 households, 27 households (20%) screened

positive for the second time with food insecurity.

Food Access and Affordability

Goal: Increase and maintain access to healthy and affordable food.

Objective: Require Screening and referral for food insecurity.

Strategy/Action Expansion of current screening for food insecurity project through a validated two-item tool administered in clinical settings.

Target Population All AJH Community Members

Outcomes Continue to provide food insecurity screening in AJH Children’s Clinic and Diabetes Education Program

Ensure addition of food insecurity questions in EPIC rollout

Implement food insecurity screening in 3 JMG practices

Investigate implementation of screening in Jefferson Home Health and Hospice

Participate in COACH Food Insecurity Workgroup initiatives

Potential Partners Internal Partners: AJH Community Health Outreach, AJH Children’s Clinic, AJH Diabetes Education Program, Jefferson Medical Group (JMG) Physician Practices External Partners: COACH, Montgomery County Anti-Hunger Network, Philabundance

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Objective: Provide current, consistent and reliable resources for food access.

Strategy/Action Increase food access through referral to partners or direct provision of food resources.


Outcomes Continue to partner with Manna on Main St. as a major referral source for patients who screen positive for food insecurity

Biannually monitor, update and publish Food Pantry resource list to AJH intranet and website.

Explore community partnerships to create food distribution sites for yearlong food access in underserved communities.

Potential Partners Internal Partners: AJH Community Health Outreach, AJH Children’s Clinic, AJH Diabetes Education Program, Jefferson Medical Group (JMG) Physician Practices External Partners: COACH, Montgomery County Anti-Hunger Network, Philabundance, Women, Infant, and Children (WIC) Nutrition Program, local school districts (National School Lunch Program), Montgomery County Office of Public Health

Abington Jefferson Health Abington Lansdale Hospital Community Health Implementation Plan

Located in Lansdale, Montgomery County, Abington-Lansdale Hospital provides a broad range

of clinical services to the surrounding area. Like Abington Hospital, Abington-Lansdale Hospital

was combined with Jefferson Health in 2015 and is dedicated to Jefferson Health’s mission to

improve lives and reimagine health, education, and discovery to create unparalleled value. This

commitment is evidenced by the Hospital’s receipt of the Healthgrades Experience Award,

ranking in the top five percent in the nation, and the Healthgrades Outstanding Patient

Experience Award in 2018.

Abington-Lansdale Hospital’s renowned stroke program was recognized by the American Heart

Association, earning both the Get with the Guidelines Stroke Gold Plus award and the Target

2018 Stroke Elite Award in FY18. Abington-Lansdale was also named an Advanced Primary

Stroke Center. The Hospital also earned The Joint Commission’s advanced hip and knee

certification, and received a Pathway to Excellence designation from the American Nurses

Credentialing Center in recognition of its professional nursing practice. Abington-Lansdale

Hospital has also earned chest pain center accreditation from the American College of

Cardiology for staff members’ demonstrated expertise in treating patients with chest pain.

Additionally, the Gift of Life donor program and Hospital Association of Pennsylvania has

honored Abington-Lansdale Hospital with their Platinum award.

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Abington-Lansdale Hospital maintains academic associations with Montgomery County

Community College and Gwynedd Mercy University for Nursing and Allied Health Professions.

Targeted Service Area for Community Health Improvement

Abington-Lansdale Hospital defines its targeted service area as the following ZIP codes in Bucks

and Montgomery Counties. These areas represent areas proximate to the hospital where 70%

of inpatients reside and a total population of 198,290.

Montgomery County:

18915, 18936, 19422, 19438, 19446, 19454, 18964, 18969, 19440

Bucks County: 18914, 18932

The zip codes listed above are grouped into the following geographic regions for easy reference: Central/Lower Bucks: 18932

Perkasie/Sellersville/Indian Valley: 18914, 18964, 18969

Blue Bell: 19422

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North Penn/Lansdale: 18915, 18936, 19438, 19440, 19446, 19454

Domain: Substance/ Opioid Use and Abuse

Drug overdose deaths have tripled and are the leading cause of death among young adults (ages 18 – 34) in the region. Communities are disproportionately impacted by the epidemic. Within Abington Lansdale Hospital’s service area, the rate of drug overdose deaths is highest in the Central and Lower Bucks regions (35.3 per 100,000 people) in comparison to the Bucks County rate (31.1 per 100,000 people.

Montgomery County respondents to focus groups and interviews relative to the 2019 Community Health Needs Assessment process “expressed particular concern regarding substance use in the county. They noted increases in related or concurrent conditions like cirrhosis, HIV, sexually transmitted diseases, and tuberculosis. They also emphasized drug-related mortality, noting that organ donation has actually increased due to young, otherwise healthy individuals dying of drug overdose.”

Rates of adult binge drinking are increased in these two regions as well. In the Central and Lower Bucks region, the rate is 33.5% in comparison to the Bucks County rate of 17.8%. According to the Montgomery County Office of Drug and Alcohol Prevention Programming and Evaluation Findings 2018-2019, “at least 50% of teen deaths are related to alcohol.” Tobacco use is an underlying cause of chronic disease including cancer, heart disease and stroke. Adult smoking rates range from a low of 7.8% in the North Penn/Lansdale region to 15.4% in the Central/Lower Bucks region. The vaping of marijuana and tobacco is a growing national concern and the Bucks and Montgomery County Offices of Public Health and the Montgomery County Health Alliance are promoting educational programs in schools and limiting access to flavored tobacco products to address this issue. Data from the 2017 Pennsylvania Youth Survey (PAYS) shows that of the vaping substances used by students indicating electronic vaping use within the past year, 64.8% of the surveyed students vaped with flavoring, 31.6% vaped nicotine, and 20% vaped marijuana or hash oil.


Goal : Decrease alcohol and substance use disorder

Objective: Open AJH Detox Unit by end of this CHNA IP Cycle 2022

Strategy/Action Finalize plans to open detox unit for Outpatient treatment with community partner on AJH Warminster campus.

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Target Population Individuals suffering from Opioid Use Disorder [OUD] or Substance Use Disorder [SUD].

Outcomes Track # of referrals to outpatient Medication Assisted Treatment (MAT) Program

Enhance Warm Hand Off Program in ER/ETC.

Potential Partners Internal Partners: Behavioral Health, Facilities, Community Health, Jefferson Medical Group (JMG), Administration, Abington Health Foundation, AJH PR/Marketing External Partners: Penn Foundation, Montgomery County Office of Drug and Alcohol, Montgomery County Office of Public Health and Montgomery County Commissioners Office, Bucks County Drug and Alcohol

Objective: Reduce the number of people who become addicted to opioids be reducing over-prescribing of opioids

Strategy/Action Continue and enhance the work of the AJH Opioid Council to promote information sharing and to monitor opioid prescription distribution.

Target Population AJH patient population and community members.

Outcomes Enhance AJH Opioid Council with an individual in recovery to be considered for membership in the council FY20

Start each meeting with a stigma or patient story – AJH Opioid Task Force meetings

Share successes of Council in Chief of Staff e-newsletter.

Monitor report outs from NICU, OB/GYN, Department of Surgery, AHP/JMG practices

Pilot the Penn Foundation Bucks County Case Manager [Queen Anne practice] to focus on 200 patients with JMG/AHP.

Explore reportable and internal data sources of opioid consumption to review for outcome improvement. [OB, Neonatal Abstinence, and various clinical areas.]

Identify AJH experts to present or be a part of a panel for prevention and education.

Potential Partners Internal Partners: Leadership from AJH Behavioral Health, Department of Nursing, NICU, Department of Surgery, AHP/JMG, Ob/GYN, Community Health, Chief of Staff’s Office, Jefferson MATER Program External Partners: Penn Foundation; other providers will be under consideration

Objective: Increase internal communication strategies on prevention, treatment and rescue

Strategy/Action Communicate AJH Pain Management Resource Center/BH/OUD/SUD services and intranet resources [BING] to workforce

Target Population AJH workforce: Department of Nursing; Case Management; medical staffs; Key Community Stakeholders; community

Outcomes Develop and provide presentations at key AJH departments by end of FY20 serving over 125 leaders and staff.

Publish 2 editions per year of “Opioid Matters” newsletter and document analytics.

Explore Enterprise- wide communication initiative.

Potential Partners Internal Partners: Behavioral Health leadership, Community Health leadership, Chief of Staff’s Office, Public Relations and Marketing/Web Center External Partners: N/A

Objective: Expand awareness of drug-take back disposal programs

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Strategy/Action Maintain and increase education and communications regarding National Drug -Take Back Day (s).

Target Population All AJH Community members, AJH workforce: Department of Nursing; Case Management; medical staffs; Key Community Stakeholders

Outcomes Increase social media presence on drug -take back and document analytics

Include drug-take back information in all editions of “Opioid Matters”

Distribute information about local drug-take sites internally through weekly e-mail updates.

Distribute information about local drug-take sites externally at all community health outreach events.

Participate in community coalitions which focus on drug-take back efforts

Potential Partners Internal Partners: Behavioral Health leadership, AJH Community Health, Chief of Staff’s Office, Public Relations and Marketing/Web Center External Partners: Abington Community Task Force (ACT), Indian Valley Character Coalition (IVCC), Bucks-Mont Collaborative, Community Health Key Stakeholder Distribution list.

Objective: Enhance external partnerships and collaboration

Strategy/Action Continue to attend Regional and County meetings, task force, coalitions, and share

results/activities with AJH Opioid Planning Group and Opioid Council.

Target Population AJH Community Members

Outcomes Collaborate with Montgomery County Drug and Alcohol Task Force and support their efforts with Narcan trainings; school prevention/education and communicate within AJH.

Attend meetings of ACT, IVCC, Bucks-Mont Collaborative, Youth Marijuana Prevention Project (YMPP), etc.

Provided by Montgomery County at AJH Opioid Council report outs – quarterly.

Potential Partners Internal Partners: AJH Behavioral Health, Public Relations and Marketing, Community Health, Chief of Staff’s Office External Partners: Leadership from Montgomery County Drug and Alcohol; Significant number of regional partners from 5 counties – key community stakeholders including government, ACT, IVCC, YMPP, School districts; Opioid Learning Action Network of Hospital Association of PA

Objective: Increase community awareness of the impact and prevalence of binge drinking.

Strategy/Action Create an education and communication campaign around the effects of binge drinking.

Target Population AJH community members and AJH workforce

Outcomes Effectively communicate and biannually update the AJH Support and Self Help group. AH and ALH provides a minimum of one AA or NA group on its campus.

Educate 25 or more nurses, APPs and BHCs on binge drinking, OUD, SUD issues.

Incorporate educational materials into community outreach, health fairs, spin wheel

Investigate use of AJH social media for binge drinking education.

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Potential Partners Internal Partners: AJH Behavioral Health, AJH Community Health, departments on each campus room bookings; PR/Marketing External Partners: Regional AA, NA; area provider community

Objective: Provide screening for alcohol and/or substance use for specific AJH patient populations.

Strategy/Action Implement CAGE AID screening assessment tool to identify individuals with alcohol

and/or SUD.

Target Population AJH Patients


Educate staff on how to screen for CAGE AID

Track # of patients screened CAGE AID

Potential Partners Internal Partners: JMG leadership, Behavioral Health leadership, Center for Patient Safety and Quality; EPIC IS&T External Partners: NA

Objective: Provide education to youth regarding vaping hazards and marijuana use.

Strategy/Action Participate in the Montgomery County Youth Marijuana Prevention Project (YMPP).

Target Population Youth in Montgomery County

Outcomes Develop county wide school vaping policies

Participate in education programs targeting educators, student support staff, pediatricians and policymakers

Create county wide messaging campaign

Potential Partners Internal Partners: AJH Behavioral Health, AJH Children’s Clinic, Jefferson Medical Group External Partners: Montgomery County Office of Drug & Alcohol, Be A part of the Conversation, Family Services, Montgomery County Health Alliance, Indian Valley Character Counts Coalition

Domain: Behavioral Health

Behavioral health needs emerged as one of the top priorities in the community health needs assessment for Philadelphia and the surrounding counties. One in five adults in the region report diagnosed depression and more than one in 10 adults report experiencing frequent mental distress. Undiagnosed and untreated conditions like depression, anxiety and trauma-related conditions result in higher emergency department utilization particularly among youth, persisting suicide rates, and substance use and abuse. Particularly vulnerable populations include individuals experiencing poverty, homelessness/housing insecurity, racial and ethnic minorities, immigrants and refugees and those who identify as LQBTQ. Nearly two-thirds of all gun related deaths are due to suicide. Suicide is the second leading cause of death among adolescents aged 10–19 in the U.S. In 2017, approximately 1 in 5 deaths in youth were attributed to suicide. Risk factors for youth suicide include a previous suicide attempt, psychiatric disorders (such as major depression, bipolar disorder, generalized anxiety






https://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/suicidal_behavior_practice_parameter.pdf


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and personality disorder traits), substance use, lack of social support, and availability of lethal means. Adverse childhood events, family discord, fights with friends, poverty, and legal trouble risk factors related to suicide ideation and attempts. Data from the 2017 PAYS survey shows that 18.8% of 12th grade students in Montgomery County reported suicide ideation and 9.1% reported having attempted suicide 1 or more times. According to key informants and focus group participants, behavioral health priorities include addressing depression, anxiety and chronic stress in the community related to exposure to trauma (violence, suicide, poverty and substance use). Key informants and focus group participants also described knowledge about and access to behavioral health care resources and services as limited, and community awareness about how to assist individuals with mental health problems as an area for improvement.


Goal: Improvement in the capacity of Abington Jefferson Health (AJH) and community-based

organizations to address behavioral health issues within the community.

Objective: Increase access and referral to behavioral health services.

Strategy/Action Continue and enhance access with Behavioral Health Consultants [BHCs] in primary care and specialty practices.

Target Population Adults/children who are Abington Health Physicians (AHP)/Jefferson Medical Group (JMG) patients.

Outcomes Maintain or increase current level of BHCs within practices.

Track # of patients served and # of practices with embedded BHCs.

Potential

Partners

Internal Partners: AHP/JMG, AJH Behavioral Health leadership External Partners: N/A

Strategy/Action Expand one Behavioral Health Consultant [BHC] into all OB practices and expansion in the

OB/GYN clinic at AH to focus on peri-partum and postpartum mood disorders and fetal

loss referring all other to BHC’s in primary care.

Target Population OB/GYN patients of AJH including OB/GYN clinic

Outcomes Track # of patients seen by BHC

Potential

Partners

Internal Partners: Behavioral Health leaders and BHCs, Women and Children’s Services, OB/GYN clinic; OB GYN practices External Partners: N/A

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Objective: Improve knowledge, skills of trainees to safely and responsibly identify and address a potential mental illness or substance use disorder.

Strategy/Action Collaborate with Penn Foundation to implement empathy training in OB/GYN and all hospital medicine Advanced Practice Professions [APPs] and consider hospital wide module to reduce stigma.

Target Population AJH piloted workforce; Leadership Behavioral Health, BHCs, Crisis Clinicians, APPs

Outcomes Track # of professionals trained

Work with Penn Foundation to develop and implement pre and post evaluation.

Potential

Partners


Strategy/Action Collaborate with community based provider to implement stigma and trauma training for BHC’s and Crisis Clinicians

Target Population AJH piloted workforce; Leadership Behavioral Health, BHCs, Crisis Clinicians

Outcomes 100% of BHCs and Crisis Clinicians to be trained in trauma informed care FY20-22.

Track # of professionals trained

Potential

Partners


Objective: Provide depression and suicide screenings for specific AJH patient populations.

Strategy/Action Promote and provide [PHQ2 and PHQ9] and suicide [CSSRS] in ETC/ER depression and

suicide screenings in ALH ER.

Target Population Adults/children admitted to ALH Emergency Room.


All patients admitted into emergency services will be screened.

Track # of patients screened for depression and suicide /number of patients admitted

Potential

Partners

Internal Partners: AH ETC/ALH Senior Leadership, Nursing Leadership, Physician Leadership, EPIC IS&T External Partners: N/A

Strategy/Action Initiate maternity mental health bundle for depression, suicide and SUD, to include

Edinburgh [depression] and CSSRS [suicide] and 4 P’s [Pregnancy, Past, Partner, Parents]

for SUD.

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Target Population AJH OB patients and their partners.

Outcomes AJH OB patients meeting the maternity bundle criteria will be screened.

Track # of patients screened for depression, suicide, SUD / # of patients seen

Potential

Partners

Internal Partners: AHP/JMG, Behavioral Health leadership, Women and Children’s Services, BHC External Partners: N/A

Strategy/Action Pending [Epic Rollout AH and ALH October 2020], implement depression and suicide

screenings in AJH practices.

Target Population Adults/children who are AHP patients.

Outcomes All AJH patients will be screened at annual wellness visits by FY21 – educate staff for compliance

Track # of patients screened for depression/# of patients seen through EPIC

Potential

Partners

Internal Partners: AHP/JMG, Behavioral Health leadership External Partners: N/A

Objective: Improved knowledge, skills of trainees to safely and responsibly identify and address a potential mental illness or substance use disorder.

Strategy/Action Provide Mental Health First Aid training, QPR and Trauma Informed Care for workforce and/or community FY20-22.

Target Population AJH workforce and community members.

Outcomes Participate in COACH initiatives to increase provision of community trainings; track # of community trainings/participants held at AJH

Increase workforce trainings, track # of workforce trainings/participants held at AJH

Explore and develop enterprise wide communication/education programming.

Potential

Partners

Internal Partners: AJH PR/Marketing, AJH Community Health, AJH Behavioral Health, AJH Senior Leadership, Jefferson Community and Trauma Counseling Department, Jefferson Health External Partners: COACH, Montgomery County Office of Mental/Behavioral Health, Regional Mental Health Services Coordination Office, Lakeside Educational Network

Objective: Explore and enhance community partnerships for potential outreach to educate on issues and topics relevant to behavioral health.

Strategy/Action Explore partnerships with community based organizations and behavioral health

professionals to develop a comprehensive network of care and/or education and

outreach.

Target Population General AJH community

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Outcomes Support “Girls on the Run” in Montgomery County through annual sponsorship

Support NAMI in Montgomery County through annual sponsorship

Explore partnership with NAMI program community education and outreach “Friends in the Lobby” program

Potential

Partners

Internal Partners: AJH Behavioral Health, AJH Community Health External Partners: Girls on the Run-Montgomery County, PA; NAMI of Montgomery County

Objective: Provision and promotion of grief support programs for AJH community

Strategy/Action Continue to provide free Safe Harbor program.

Target Population Grieving families/children in AJH communities.

Outcomes Track # of programs and # of participants

Track program effectiveness through evaluation of post-program survey results.

Potential

Partners

Internal Partners: Safe Harbor coordinators, Community Health, Behavioral Health, AH Foundation, Public Relations and Marketing External Partners: Area school districts, Faith Community Network, Community Health key community stakeholders

Strategy/Action Continue to provide bereaved spouses/partners support groups.

Target Population Grieving spouses/partners in the AJH service area.

Outcomes # of programs and # of participants

Potential

Partners

Internal Partners: Jefferson Home Health and Hospice, AJH Community Health, Behavioral Health, AH Foundation, Public Relations and Marketing External Partners: Faith Community Network, Community Health key community stakeholders

Objective: Increase provider and community based organizations awareness and understanding of behavioral health needs and resources available through AJH Behavioral Health Navigators.

Strategy/Action Increase frequency and monitor effectiveness of current communication strategies to increase awareness of AJH resources.

Target Population All AJH community members and behavioral health providers

Outcomes Track # of contacts with Behavioral Health Navigator (Access Coordinator);

Track # of referrals made by Behavioral Health Access Coordinator

Potential

Partners

Internal Partners: Behavioral Health leadership, Navigator [Access Coordinator], Community Health, Public Relations and Marketing

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External Partners: Area provider community; area non-profit organizations; Bucks and Montgomery Counties programs and services

Domain: Access to affordable, culturally appropriate primary and specialty care

According to Healthy People 2020, “access to comprehensive, quality health care services is important for promoting and maintaining health, preventing and managing disease, reducing unnecessary disability and premature death, and achieving health equity for all Americans. This topic area focuses on three components of access to care: insurance coverage, health services, and timeliness of care. When considering access to health care, it is important to also include oral health care and obtaining necessary prescription drugs.” In addition, navigating healthcare services can be challenging due to lack of awareness and fragmented systems. Within the ALH service area, the rate of children (<19) without health insurance is high in the Perkasie, Sellersville/Indian Valley region at 4.0% compared with the Bucks County rate of 2.6%. In Montgomery County, the highest rate of children without health insurance is found in the Blue Bell area, 4.1% as compared with the Montgomery County rate of 2.7%. Emergency room utilization is also highest in the Perkasie, Sellersville/Indian Valley, North Penn and Lower Eastern Montco regions. While some ED visits may be attributed to preventable or treatable conditions, a high rate of ED visits may be an indicator of inadequate access to care.


Goal : Improve access to affordable primary/preventive care

Objective: Increase access to primary dental care.

Strategy/Action Continue the services offered by the AJH Dental Care Access Program and the AJH Dental Clinic. Foster relationship between AJH Dental Care Access Program and AJH Dental Clinic.


Outcomes Maintain or increase # of patients served. Baseline = 5,000

Maintain or increase # of dental providers at AJH Dental Care Access Program. Baseline = 20

Maintain high level of engagement of dental providers as noted by 90% of the respondents in a dental provider satisfaction survey stating that they intend to continue as a provider with our program.

Potential Partners Internal Partners: AJH Dental Clinic, AJH Dental Care Access Program, AJH Dental Staff, AJH Dental Residency Program External Partners: North Penn Region Dentists, VNA Foundation of Greater North Penn, Montgomery Bucks Dental Society; Delta Dental

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Objective: Improve access to and utilization of culturally appropriate primary care

Strategy/Action Encourage Hartnett Health Services (HHS)/North Hills/Abington Family Medicine Primary Care (AFM)/AJH Children’s Clinic utilization through outreach to uninsured/underinsured patients discharged from Abington and/or Abington-Lansdale Hospital.

Target Population All AJH Community Members who are uninsured or underinsured; individuals/ families with low income; immigrants.

Outcomes Maintain or increase # patients connected with by HHS Nurse Care Manager. Baseline = 40/month.

Investigate methods for tracking of AJH discharged patients at North Hills/AFM

Differentiate between new/established patients referrals.

Potential Partners

Internal Partners: HHS Social Work Team; HHS Care Manager; HHS Staff; HHS Clinical Team, Inpatient teams: Hospitalists, Chiefs, Observation Unit, North Hills Staff, AFM Staff, AJH Children’s Clinic Staff External Partners: Montgomery County Connections Program(Navigates); Jaisohn Medical Center

Strategy/Action Provide language assistance to individuals with limited English proficiency and/or other communication needs to facilitate oral communication and ensure communication needs are met.


Outcomes Monitor and evaluate tracked data on use of the language line

Track use of ALVIN throughout AJH system.

Increase use of bilingual staff where appropriate

Translate written materials/forms into foreign languages where 5% or 1,000 individuals have limited English proficiency.

Potential Partners

Internal Partners: HHS Social Work Team; HHS Care Manager; HHS Staff; HHS Clinical Team, Inpatient teams: Hospitalists, Chiefs, Observation Unit, North Hills Staff, AFM Staff, AJH Children’s Clinic Staff, AJH Interpretation Services, AJH PR/Marketing External Partners: Montgomery County Connections Program(Navigates); Jaisohn Medical Center, Para-Plus Translations, Inc.

Strategy/Action Expand Hartnett Health Services’ physical space.


Outcomes Decrease in-office wait times for services

Increased patient satisfaction

Potential Partners

Internal Partners: HHS Staff; HHS Clinical Team, AJH Facilities, AJH PR/Marketing External Partners: Selected vendors and contractors

Objective: Develop culturally appropriate Health Promotion campaigns and initiatives to raise awareness.

Strategy/Action Collaborate with Jaisohn Medical Center in the provision of culturally and linguistically appropriate care and community programming for AJH Asian American community members. Participate in the Montgomery County Asian American Coalition.

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Target Population Asian American Community members in the AJH service area.

Outcomes Provision of two collaborative programs for the Asian American Community.

Co-location of Jaisohn Medical Center on Abington-Lansdale Hospital Campus,

Community Health Center.

Facilitation of group scheduling of mammograms to allow for more culturally

appropriate environment.

Potential Partners Internal Partners: AJH Radiology, AJH Patient Access, AJH Community Health Center External Partners: Jaisohn Medical Center

Strategy/Action Utilize AJH’s strong health outreach programs in underserved communities to identify individuals at risk and provide resources for clinical care.


Outcomes Provide AJH clinic information at all community outreach programming.

Provide follow up calls to all screening participants with abnormal results and ensure that they are active in a primary care home, or provide referral.

Translate written health education materials into foreign languages where 5%, or 1,000 individuals have limited English proficiency.

Potential Partners Internal Partners: AJH Community Health Outreach, Save Your Soles Program, AJH Care Managers, AJH Faith Community Nurse Network, Asplundh Cancer Pavilion External Partners: Montgomery County Connections (Navigates), Legislative offices, Bucks/Mont Collaborative for Health and Human Services, Para-Plus Translation Services, ACLAMO, North Penn Mosque, International Spring Festival.


Goal : Improve navigation of health care services to link individuals to appropriate social service

agencies

Objective: Improved Access to Public Benefits and Programs

Strategy/Action Assist patients and their families in enrolling in public benefits and programs such as government based insurance options (medical assistance, children’s health insurance program [CHIP], health insurance marketplace), SNAP benefits, housing, LIHEAP, etc.


Outcomes Track # of insurance applications completed

Maintain or increase # of social service referrals

Potential Partners Internal Partners: AJH Children’s Clinic, Hartnett Health Services, Abington Family Medicine, and North Hills Health Center External Partners: PA Dept. of Aging, APPRISE Certified Medicare Counselors, Montgomery County Dept. of Health and Human Services, Montgomery County Community Connections Program, Bucks County Dept. of Human Services, Philadelphia County Dept. of Human Services, PA Benefits Center, VNA Community Services

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Objective: Improved access to transportation

Strategy/Action Provide information regarding available transportation services and facilitate the process for accessing these services.


Outcomes Investigate UBER Health services for clinic patients

Explore grant funding to provide bus tokens and cab vouchers

Explore collaboration with Partnership TMA for transportation resources

Investigate Hospital Van Services

Potential Partners Internal Partners: AJH Philanthropy, AJH Care Managers, Social Workers, AJH Faith Community Nurse Network, AJH Muller Institute for Senior Health External Partners: Uber Health, Partnership TMA

Objective: Accessible access to healthcare for persons with disabilities

Strategy/Action Provide access to preventive care and health education/screening for persons with

disabilities.

Target Population All AJH community members with disabilities

Outcomes Provide community health education programming to individuals with disabilities

Provide Adult Day Services to individuals with disabilities

Increase # of Jefferson Medical Group (JMG) practices who have the ability to offer appropriate care to individuals with disabilities.

Potential Partners Internal Partners: AJH Children’s Clinic, Hartnett Health Services, Abington Family Medicine, and North Hills Health Center, AJH Compassionate Care Program, JMG, AJH Adult Day Services External Partners: Magee Rehabilitation Hospital, ALTEC, Indian Creek Foundation

Objective: Provide access to reliable and current health resources.

Strategy/Action Develop culturally and linguistically appropriate community resource directories, bulletins or newsletters.




Potential Partners

Internal Partners: AJH Community Health, AJH Children’s Clinic, Hartnett Health Services, Abington Family Medicine, North Hills Health Center, AJH Financial Services External Partners: Aunt Bertha, Para-Plus Translations, Inc.

Objective: Increase community residents knowledge of Jefferson Health’s Financial Assistance (Compassionate Care) Program

Strategy/Action Assist patients and families in enrolling in Jefferson’s Compassionate Care Program.

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Outcomes • Track # of applications to Compassionate Care Program.

Potential Partners Internal Partners: Hartnett Health Services, AJH Social Workers, AJH Care Management, AJH Financial Services Unit, AJH Children’s Clinic External Partners: Bucks/Mont Collaborative


Goal : Improve access to specialty care

Objective: Improve access to and utilization of affordable and culturally appropriate specialty care.

Strategy/Action Facilitate the provision of specialty care for uninsured/underinsured patients.


Outcomes Track number of patients seen at HHS Specialty Clinics.

Track number of children who are patients in AJH primary care clinics and are referred to CHOP’s Family Health Coverage Program.

Track number of calls processed by AJH scheduling advocates, which facilitate the provision of specialty care services.

Potential Partners Internal Partners: AJH Care Managers, Jefferson Medical Group Specialists, AJH Scheduling Advocates External Partners: Children’s Hospital of Philadelphia

Domain: Chronic Disease Prevention and Management

One in four Americans has multiple chronic conditions, and that number rises to three in four Americans aged 65 and older. Data from the 2019 Regional Community Health Needs Assessment shows that in the Abington –Jefferson Health service area, the percentage of older adults is 18% of the total population. Approximately 71% of the total health care spending in the United States is associated with care for the Americans with more than one chronic condition. http://www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/decision/mcc/mccchartbook.pdf The high prevalence of chronic disease is a result of the rapidly growing older adult population, increased life expectancy resulting from advances in public health and clinical medicine, and is attributable to six key risk factors: high blood pressure; tobacco use and exposure to second hand smoke; obesity; physical inactivity; excessive alcohol use; diets low in fruits and vegetables; and diets high in sodium and saturated fats.



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Risk factors for chronic disease should be addressed at the individual level (including health care interventions) and the population level (including policies and environments that promote health). http://www.cdc.gov/chronicdisease/pdf/four-domains-factsheet-2015.pdf

The Centers for Disease Control and Prevention (CDC) recommends coordinating chronic disease prevention efforts on strategies that:

Promote and support healthy behaviors through changes to social and physical environments that make healthy choices easier, safer, cheaper, and more convenient

Collectively address the behaviors and other risk factors that can cause chronic diseases.

Improve delivery and use of quality clinical services to prevent disease, detect diseases early, and manage risk factors

Work to simultaneously prevent and control multiple diseases and conditions.

Reach more people by strengthening systems and environments to support health and linking community programs to clinical services to prevent and control disease. Strategies that link community and clinical services help to reduce barriers to care and ensure that people with or at high risk of chronic diseases have access to the resources they need to prevent or manage these diseases. Improved links between the community and clinical settings allows community delivery of proven programs, to which patients may be referred by a clinician, with third-party payments to community organizations and lay providers.


Goal: 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.

Objective: Provide health education and promotion in natural community hubs, such as beauty salons/barbershops, retail establishments, senior centers, schools, community events and faith-based institutions.

Strategy/Action Provide education, screening, risk assessment and support programs to increase awareness about heart disease/attack prevention, reduce cardiovascular prevalence and/or improve cardiovascular management. Raise public awareness about early heart attack symptoms, early heart attack care, cardiac arrest and the importance of CPR intervention and early detection and management of hypertension.


Outcomes Maintain or increase number of completed Blood Pressure Screenings

Provide follow-up calls to all consenting participants that have a blood pressure reading of >130/80.

o Track:

http://www.cdc.gov/chronicdisease/pdf/four-domains-factsheet-2015.pdf

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# attempted calls # contacted # without history of hypertension # referred to community resources # without PCP # referred to personal physician for follow-up # referrals to Chronic Care Management Program

Track and report all on-site interventions, which may include calling 911 or calling the primary care physician, etc.

Provide low cost CPR classes to the community. o Track:

# of classes/participants Completed class evaluations to determine acquired knowledge

Provide early heart attack, cardiac arrest education at a variety of community settings.

o Track: # of programs/participants

Provide heart risk screenings at a variety of community settings. o Track:

# of programs/participants

Potential Partners

Internal Partners: AJH Community Health Outreach, Jefferson Home Health and Hospice, Jefferson Community Physicians, AH AHA BLS Community CPR Training Center External Partners: American Heart Association, Local Senior Centers, Community Retail Establishments, Faith Community Network, Community Business Establishments, Community Government Leaders

Strategy/Action Provide education, screening, risk assessment and support programs to increase awareness about stroke prevention, reduce stroke prevalence and/or improve stroke management. Raise public awareness about FAST (face, arms, speech, time) and TpA.


Outcomes • Maintain or increase number of completed Blood Pressure Screenings. • Provide follow-up calls to all consenting participants that have a blood pressure reading of >130/80.

Maintain or increase number of Stroke Risk Assessments.

Provide stroke education at community health fairs and senior expos.

Potential Partners Internal Partners: : AJH Community Health Outreach, Jefferson Home Health and Hospice, Jefferson Community Physicians, AJH Stroke Councils External Partners: American Heart Association, American Stroke Association, Local Senior Centers, Community Retail Establishments, Faith Community Network, Community Business Establishments, Community Government Leaders

Strategy/Action Increase knowledge, skills and awareness of asthma management strategies and resources.


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Outcomes Offer at least two Asthma education programs to community at large.

Collaborate with Jefferson Medical Group or Allergy and Asthma Associates to provide asthma screening and education at large community events.

Provide asthma management training during community Heartsaver First Aid courses (Chapter on Asthma and Respiratory Emergencies. Details assembly and use of an inhaler.)

Collaborate with regional community partners on asthma initiatives.

Potential Partners Internal Partners: AJH Community Health Outreach, Abington Pulmonary and Critical Care Associates External Partners: American College of Asthma, American Heart Association ECC Heartsaver First Aid Courses , Montgomery County Office of Public Health

Strategy/Action Maintain a faith-based advisory council and provide/coordinate programming at specific

sites and training for Faith Community Ministries to address chronic disease

management.

Target Population Faith Community Nurses in AJH Service Area

Outcomes Council maintained.

Maintain or increase number of educational offerings and participants.

Track acquired learning through pre and post learning surveys.

Track participant satisfaction through program evaluations.

Potential Partners Internal Partners: AJH Community Health Outreach, Faith Community Nurse Network External Partners: Community Partners

Strategy/Action Provide education, risk assessments and support programs to reduce diabetes

prevalence and/or improve diabetes management.


Outcomes Maintain number of class offerings and participant volume for Diabetes Education Program.

Monitor AHP's CQM Scorecard for AHP--HgbA1C percentage of controlled (controlled/

diabetic patients).

Provide Diabetes Prevention Workshops, Diabetes Risk Assessments and Education Programs to the community at large.

Collaborate with local YMCA’s in the provision of CDC National Diabetes Prevention Program.

Potential Partners Internal Partners: AJH Diabetes Center, Abington Health Physician Network (Jefferson Medical Group), AJH Community Health Outreach, AJH Pharmacy External Partners: American Diabetes Association, Willow Grove YMCA, North Penn YMCA, Ambler YMCA

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Strategy/Action Provide education, risk assessments and support programs to increase screening rates

for cancer.


Outcomes Provide Low Cost Mammogram and Healthy Women PA through Hartnett Health

Services.

Provide Annual Community Screening Day (Skin, Head and Neck, Prostate, Breast).

Provide Colon Cancer Community Education/Outreach (Strollin’ Colon).

Collaborate with Jaisohn Medical Center in provision of culturally appropriate cancer screenings.

Potential Partners

Internal Partners: AJH Community Outreach, AJH Asplundh Cancer Pavilion staff, PR/Marketing/Staff , AHP/JMG External Partners: Montgomery County Office of Public Health, AJH affiliated dermatologists, Jaisohn Medical Center

Strategy/Action Provide health education and support programs for Older Adults.

Target Population All older adult AJH community members

Outcomes Provide/maintain counseling services in the Geriatric Assessment Center.

Provide/maintain Blood Pressure and Healthy Life Style programing in the Senior Adult Centers.

Provide/maintain current ElderMed Programming.

Provide Matter of Balance Classes or Fall Prevention Programming.

Provide/maintain programs to improve and/or maintain cognitive health. o Offer memory fitness programming at two AJH locations o Offer Adult Day programming

Potential Partners

Internal Partners: AJH Community Outreach, AJH ElderMed Program, PR/Marketing/Staff , AJH Geriatricians External Partners: VNA-CS, APPRISE, Community Senior Adult Centers, Montgomery County Office of Public Health

Strategy/Action Provide community programs regarding how to fit healthy food choices into daily life

through nutrition education.


Outcomes Provide interactive nutrition education at community outreach events.

Collaborate with Montgomery County Office of Public Health and Montgomery County Intermediate Unit in provision of preschool nutrition curriculum.

Collaborate with area libraries and senior centers in provision of nutrition education programming.

Collaborate with area YMCA’s in provision of nutrition education programming.

Potential Partners

Internal Partners: AJH Community Outreach

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External Partners: Community libraries, Community Senior Adult Centers, Montgomery County Office of Public Health, Montgomery County Intermediate Unit, Area YMCA’s

Strategy/Action Provide community programs and education to promote injury prevention.


Outcomes Provide interactive injury prevention education at community outreach events.

Collaborate with Montgomery County Office of Public Health and Montgomery County Health Alliance in provision of injury prevention programming.

Collaborate with area libraries and senior centers in provision of injury prevention programming.

Collaborate with area YMCA’s in provision of injury prevention programming.

Provide Fall Prevention education for older adults.

Potential Partners

Internal Partners: AJH Community Outreach, AJH ENCARE Nurses External Partners: Community libraries, Community Senior Adult Centers, Montgomery County Office of Public Health, Montgomery County Intermediate Unit, Area YMCA’s, Montgomery County Health Alliance

Objective: Support media and community campaigns that encourage smoking cessation

Strategy/Action Support media campaigns that encourage smoking cessation. Raise awareness among providers about community efforts and continue to promote resources to reduce smoking/vaping/tobacco use rates.


Outcomes Participate in collaborative projects to increase awareness of risks of smoking/vaping/tobacco use.

Provide community based smoking cessation classes.

Provide follow up calls to all Lansdale Hospital discharged patients with a history of tobacco use.

Potential Partners Internal Partners: AJH Community Health Outreach, Faith Community Nurse Network, External Partners: Community Partners, Montgomery County Health Alliance, Montgomery County Office of Public Health

Objective: Centralize health and social services resources information

Strategy/Action Develop culturally and linguistically appropriate community resource directories,

bulletins or newsletters.




Potential Partners Internal Partners: AJH Community Health, Bucks/Mont Collaborative for Health and Human Services, AJH Faith Community Nurse Network

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External Partners: Aunt Bertha, Montgomery County Office of Public Health

Domain: Social Determinants of Health

According to Healthy People 2020, “Social determinants of health are conditions in the

environments in which people are born, live, learn, work, play, worship, and age that affect a

wide range of health, functioning, and quality-of-life outcomes and risks.” Access to healthy

food is a resource, which enhances the quality of life, therefore influencing health outcomes.

As noted in the 2019 Regional Community Health Needs Assessment, “Access to and

affordability of healthy foods is a driver of poor health in many communities.” While summary

health measures obtained for the 2019 CHNA showed rates of food insecurity for Bucks County

at 10.5%, and rates for Montgomery County at 9.3%, data collected at the Abington Jefferson

Health Children’s Clinic [located on the campus of Abington-Lansdale Hospital] over the past

two years yielded significantly higher percentages:

For the 2019 fiscal year, 502 households were screened at the AJH Children’s Clinic for food

insecurity with 134 household screening positive, for a rate of 27% for food insecure

households. This number is 10% less than the 2018 fiscal year, when 37% of households

screened positive. Perhaps this decrease could be attributed to our previous interventions.

However, it is important to note that of these 134 households, 27 households (20%) screened

positive for the second time with food insecurity.

Food Access and Affordability

Goal: Increase and maintain access to healthy and affordable food.

Objective: Require Screening and referral for food insecurity.

Strategy/Action Expansion of current screening for food insecurity project through a validated two-item tool administered in clinical settings.

Target Population All AJH Community Members

Outcomes Continue to provide food insecurity screening in AJH Children’s Clinic and Diabetes Education Program

Ensure addition of food insecurity questions in EPIC rollout

Implement food insecurity screening in 3 JMG practices

Investigate implementation of screening in Jefferson Home Health and Hospice

Participate in COACH Food Insecurity Workgroup initiatives

Potential Partners Internal Partners: AJH Community Health Outreach, AJH Children’s Clinic, AJH Diabetes Education Program, Jefferson Medical Group (JMG) Physician Practices

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External Partners: COACH, Montgomery County Anti-Hunger Network, Philabundance

Objective: Provide current, consistent and reliable resources for food access.

Strategy/Action Increase food access through referral to partners or direct provision of food resources.


Outcomes Continue to partner with Manna on Main St. as a major referral source for patients who screen positive for food insecurity

Biannually monitor, update and publish Food Pantry resource list to AJH intranet and website.

Explore community partnerships to create food distribution sites for yearlong food access in underserved communities.

Potential Partners Internal Partners: AJH Community Health Outreach, AJH Children’s Clinic, AJH Diabetes Education Program, Jefferson Medical Group (JMG) Physician Practices External Partners: COACH, Montgomery County Anti-Hunger Network, Philabundance, Women, Infant, and Children (WIC) Nutrition Program, local school districts (National School Lunch Program), Montgomery County Office of Public Health

Table of Contents · and suburban residents through a variety of interventions including prevention...

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Transcript of Table of Contents · and suburban residents through a variety of interventions including prevention...