Mercy Hospital Columbus Community Health Improvement Plan (CHIP) Created: August 28, Reviewed/Updated: September, PRIORITY AREA Provide clinical healthcare needs to the school district of Webb City, Missouri. GOAL #1 Improve access to health care by providing a clinic in Webb City High School. Services will benefit the faculty, staff, students, and family members of the district MERCY LEADER(S) Aaron Lewis, Sports and School Medicine PERFORMANCE MEASURES How we will know we are making a difference Short Term Indicators Source Frequency By May of 2016, clinic users have a 25% decrease in absenteeism and 15% decrease District and Quarterly in tardiness. By May of 2016, clinic users, mainly students, should increase their school District and Quarterly attendance by 25% Long Term Indicators Source Frequency By May of 2019, Webb City School District should see an overall decrease in insurance claims by personnel, which helps level the district insurance premiums. By May of 2019, increase the attendance rate of students by 50% District and District and OBJECTIVE #1 To implement a functioning clinic within the school district. Hire Nurse Practitioner Sept. HR and Mercy Clinic Leadership, Dr. Russell Kennedy Organize project team for clinic implementation. Installation of all hardware, software, or furnishings needed. August Mercy Clinic leadership and MHM Tracy Godfrey, Tim Murphy, Aaron Lewis Scott Pratt with assistance of Aaron Lewis Lead practitioner for clinic and district Team would complete installation of all hardware and equip. needed Develop a Mercy policy and procedure for school based clinic Mercy leadership Mark Stiffler Vp Ops. St. Louis, Aaron Lewis Formalized and standardized Mercy Page 1
operations Clinic policy, process, structure, and leadership for school based clinics OBJECTIVE #2 Develop a marketing strategy to educate faculty, staff, and students of the district, on services that can be provided through the clinic. Partner with Marketing and Communications for best campaign strategy. Inform all Mercy leaders and coworkers of school clinic operations and scope Educate school district faculty/staff/students/parents of services that the clinic will provide Schedule monthly meetings with appropriate school personnel. Occurrence of meetings may need to be adjusted after implementation. September MarCom personnel, Clinic leadership School Administration and MarCom School Administration, Aaron Lewis, Nurse Practitioner Aaron Lewis with assistance from Julie Beatty Aaron Lewis Aaron Lewis and the Nurse Practitioner Aaron Lewis and the Nurse Practitioner Develop a small committee use resources for marketing material and implementation Send email blast, and attend manager/director meetings Partner with school leaders to offer educational information for clinic through seminars or training Provide opportunities for stakeholders to address concerns or ask questions. OBJECTIVE #3 Deliver comprehensive care by emphasizing prevention and early intervention. Engage Nurse Practitioner in school district activities to promote clinic School district leadership Aaron Lewis with assistance from Kevin Cooper (Asst. Superintendent) Create a positive relationship with Develop an evaluation for the April Clinic leadership Aaron Lewis Develop a survey Page 2
program that benefits Mercy and the school district Evaluate all clinic needs and budget requirements 2015 and that can be used to provide feedback for clinic practices February 2015 Clinic leadership and Aaron Lewis with assistance from Leadership and Nurse Practitioner Develop an annual template of clinic needs ALIGNMENT WITH STATE/NATIONAL PRIORITIES Objective State Healthy People 2020 National Prevention Strategy 1 2 3 DESCRIBE PLANS FOR SUSTAINING ACTION PRIORITY AREA Provide chronic disease self management and support for those with T2DM, who are 18 or older, and are underinsured or uninsured in the Joplin community and surrounding area. GOAL #1 Improve access to health care and provide chronic disease self management to our target population by using multidisciplinary teams to address all key functions of chronic care management, facilitate integration of chronic care management into the organization s usual system of care, and create a system of chronic care management that provides a patient centered model of care that goes beyond clinical care and provides emotional and social support. MERCY LEADER(S) Nancy and Nancy Orton PERFORMANCE MEASURES How we will know we are making a difference Short Term Indicators Source Frequency persons referred persons assessed persons active educational classes attended % of A1c current % of BP 130/80 % of LDL < 100 collaborative meetings Bi annually Page 3
pt. referred to smoking cessation completed foot, eye, and dental exams pt. with appropriate screenings group diabetes classes care management hours Approximate dollar value of support Education pre and post test score comparison % Knowledge Gain % Understand Meal Plan % Verbalize Goals % Use of Equipment Bi annually Bi annually Long Term Indicators Source Frequency Cost avoidance A break even analysis demonstrated that if 261 patients are served annually, total cost avoidance is $139,898 (the annual cost of our program). This is a community benefit that has been shown to result in cost avoidance by reducing ER visits. Cost savings According to WebMD the annual cost to treat a person who has uncontrolled diabetes is $10,000. So potentially we could save an additional $2,030,000 in healthcare resources. OBJECTIVE #1 Create a system of chronic care management that provides a patient centered medical home (PCMH) that result in improvements in HbA1c, blood pressure and LDL. Provide care management for persons with a primary or secondary diagnosis of diabetes and for persons with diabetes and a co occurring chronic illness. CSI Diabetes team PCMH staff(directo rs, nurses, social workers, physicians) CSI Team persons referred persons assessed persons active educational classes attended % of A1c current Page 4
Quarterly team meetings with care and PCMH representatives. CSI Team % of BP 130/80 % of LDL < 100 meetings OBJECTIVE #2 Provide a system of chronic care management that provides a PCMH that result in lifestyle behavior choices improvements including 40% of patients quitting or attempting to quit smoking, 80% with annual foot exams, 40% with annual eye exams, 30% with annual dental exams, and 50% with flu shots. (Note: The vast majority of patients upon program enrollment have not had recommended annual exams baseline of 0%.) CSI team and care will collect data and refer pt. or provide opportunities for pt. to complete screenings as appropriate. CSI Team pt. referred to smoking cessation completed foot, eye, and dental exams pt. with appropriate screenings CSI team will provide on going follow up calls, letters, visits and support groups. CSI Team Class attendance case managemen t hours Total Contact Hours OBJECTIVE #3 Create a system of chronic care management that provides a patient centered model of care that goes beyond clinical care and provides emotional and social support. Page 5
Build partnerships with community organizations to support patients selfmanagement lifestyle behaviors. CSI Team/Nancy community organization s providing support to patients (i.e. YMCA, Pharmacies, etc.) Provide patient education and resources in the patients culture, language and literacy context Engage patients, families, providers to coordinate care and support CSI Team/Nancy CSI Team/Nancy Nancy resources in Spanish classes offered in Spanish goals set classes /events attended ALIGNMENT WITH STATE/NATIONAL PRIORITIES Objective State Healthy People 2020 National Prevention Strategy 1 2 3 DESCRIBE PLANS FOR SUSTAINING ACTION Page 6
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