Pathways to Better Health of the Lakeshore Muskegon HUB Health Care and Transportation

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1 Pathways to Better Health of the Lakeshore Muskegon HUB Health Care and Transportation The Community Benefit Programs of Mercy Health Bringing health capacity to the community through partnerships, coalitions and hospital community benefit programs.

2 Muskegon County County population: 172, 541 Three entitlement communities 28 governmental units and 14 school districts Rural areas served by USDA as well as suburbs 27% of children live in poverty 81 st out of 83 Michigan counties in health risk behaviors 58% of population with some college Exceeds state and national standards for low birth weight babies

3 Healthcare is Changing Healthcare has CHANGED Vulnerable populations have to be met in their own environment Significant needs require out-of-the-box thinking People live in environments that don t support them Care coordination across multiple health and social service silos including transportation Community Health Needs Assessment can help define the needs of the community and how we address those needs

4 Community Health Workers Are indigenous to the community in which they work. Assist patients with navigating a complex healthcare system and accompany patients through treatment, monitoring social service needs, and helping them overcome obstacles to their own health and ability to follow treatment from the medical community. Advocate for vulnerable individuals and communities

5 The Hub. Administrative support ensures quality, customer service and timely assignment of referral Clinical Oversight coordinates communitybased care with medical plan of care for coordinated treatment and chronic disease management

6 The Process

7 Our Tools. Checklists assess eligibility and identify access to care, financial issues and health improvement barriers Pathways work through barriers; provide documentation and accountability for the patient, agency and health system

8 Sample Pathways Medical Home Medical Referral Health Coverage Social Service Transportation Pregnancy Smoking Cessation

9 Community Partnerships Muskegon County Transportation Study conducted through Sustainability Designation 3 rural routes added Muskegon County MATS (public transportation) Private Cabs 10 Care Coordinating Agencies deploy health workers Churches, libraries and public housing hold PATH (Personal Action To Health) workshops Informal relationships with rural county transportation services

10 Evaluation Results RTI (chronic disease Pathways Program March 2016) Smarter spending. Short-term spending increase In the final quarter examined, however, spending among treatment group individuals is $3,579 lower than the comparison group (p=0.039) Better care. The data also suggest that the innovation may have an impact on reducing the likelihood of hospitalizations and ED visits for Medicare patients in the long run.

11 Impact of Connecting Patients to Transportation Patients in Healthy Pregnancy Program reduced ambulance rides to Emergency Department by 25% Patients in all Pathways Programs are able to attend AA/NA meetings as well as therapy appointments Patients are utilizing non-emergent transportation thereby increasing the number of primary care visits and decreasing Emergency Department visits Decreasing social isolation for patients with chronic diseases through participation in PATH classes

12 Barriers Crossing county or state lines to access services is challenging Rural communities need additional transportation resources Definition of disability is confusing to some partners in order to determine eligibility for programs Lack of data to justify investment in transportation for health care Contract Issues stakeholder confusion or inertia

13 Opportunities Find a champion and develop partnerships Inform the community Engage the patients as advocates for system change Participate in local community needs assessments Develop strategies and implement via pilot projects Develop data and return on investment studies Seek change on the state and federal levels related to boundaries, funding, definitions of disability Institutionalize partnerships and funding

14 Questions? LIKE us on Facebook Follow us on Call or Write

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