Community Health Needs Assessment Implementation Plan. APPROVED By The Board of Trustees

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1 Community Health Needs Assessment Implementation Plan APPROVED By The Board of Trustees August 26, 2013

2 BACKGROUND South County Healthcare System (SCHHS) is a full-service healthcare resource offering a comprehensive range of advanced inpatient, outpatient and home health services. Accredited by The Joint Commission, SCHHS is made up of South County Hospital (Hospital), VNS Home Health Services, South County Quality Care, and South County Surgical Supply. SCHHS is dedicated to enriching the quality of life of southern Rhode Island community members and visitors through the delivery of quality healthcare services, the development of cooperative relationships with other healthcare providers and the promotion of wellness through health education and awareness. An independent, non-profit, acute-care hospital, South County Hospital (Hospital) offers the latest advances in technology and a comprehensive range of medical and surgical services. Services are delivered by expert physicians and highly trained staff. For the comfort and safety of our patients and their families, our modern facilities include all private patient rooms with en suite baths, and are furnished to accommodate overnight guests. The South County Hospital Healthcare System is committed to its community and guided by the values of caring, respect, integrity, collaboration and excellence. In support of the Hospital s community benefit activities and to guide community health improvement efforts, SCHHS participated in a statewide comprehensive Community Health Needs Assessment (CHNA), led by the Hospital Association of Rhode Island (HARI), and its member hospitals. The CHNA was conducted from September 2012 to July The assessment was conducted in a timeline to comply with requirements set forth in the Affordable Care Act, as well as to further the SCHHS s commitment to community health and population health management. CHNA Research Components SCHHS and its CHNA partners, contracted with Holleran Consulting, an independent research and consulting firm located in Lancaster, Pennsylvania, to conduct research in support of the CHNA. Holleran has 21 years of experience in conducting public health research and community health needs assessments. The CHNA was comprised of both quantitative and qualitative research components as outlined below. Analysis of Rhode Island Department of Health BRFSS Data Secondary Data Collection Key Informant Survey Focus Groups Prioritization of Community Health Needs The primary goals of the CHNA were to: Provide baseline measures of key health indicators Establish benchmarks and monitor health trends Guide community benefit and community health improvement activities Provide a platform for collaboration among community groups 1

3 Serve as a resource for individuals and agencies to identify community health needs Assist with community benefit requirements as outlined in Section 5007 of the ACA Service Area South County Hospital defined its service area based on analysis of the geographic area where individuals using their health services reside. The following zip codes reflect South County Hospital s defined service area: Zip Code Municipality Service Area Ashaway Secondary Block Island Secondary Bradford Secondary Carolina Secondary Charlestown Primary West Greenwich Secondary East Greenwich Secondary Exeter Primary Hope Valley Secondary Hopkinton Secondary Jamestown Secondary North Kingstown Primary Saunderstown Primary Wakefield Primary Kingston Primary Narragansett Primary Westerly Secondary West Kingston Primary Wood River Junction Secondary Wyoming Secondary 2

4 SELECTION OF THE COMMUNITY HEALTH PRIORITIES On April 30, 2013, approximately 20 individuals representing the Hospital Association of Rhode Island (HARI), its member hospitals, including SCHHS, and the Rhode Island Department of Health gathered to review the results of the 2013 Community Health Needs Assessment (CHNA) and develop priorities for statewide community health planning. The results of the planning session identified the following statewide health priorities. Mental Health and Substance Abuse Diabetes Heart Disease To ensure these statewide priorities reflected the needs of the community served by SCHHS, the Hospital hosted a local prioritization session with community partners and representatives. On July 11, 2013, approximately 25 individuals, representing SCHHS and health-related organizations from the community it serves, gathered to review the results of the 2013 Community Health Needs Assessment (CHNA). A list of attendees can be found in Appendix A. The goal of the meeting was to discuss and prioritize key findings from the CHNA and to set the stage for community health improvement initiatives and the development of the Hospital s Implementation Strategy. South County Community Health Forum The forum began with an abbreviated research overview presented by Holleran Consulting. The presentation covered the purpose of the study, research methodologies, and the key findings. The comprehensive CHNA included a mix of quantitative and qualitative research including an analysis of Rhode Island Department of Health BRFSS Data, compilation of secondary data, 49 key informant interviews, two focus groups, and a statewide prioritization session. Holleran Consulting conducted the BRFSS analysis, key informant interviews, focus groups, and the prioritization session, and provided all reports. Healthy Communities Institute (HCI) compiled the secondary data which can be accessed, along with other health related data, at Following the research overview, participants provided feedback regarding community health issues. The participants were provided information regarding the prioritization process, criteria to consider when evaluating key areas of focus, and other aspects of health improvement planning, such as goal setting and developing strategies and measures. Holleran then facilitated an open group discussion for attendees to share what they perceived to be the needs and areas of opportunity in the region. The group generated the following list of needs based on research findings and their expertise. (Presented in alphabetical order.) Asthma (adult and child) Cancer (specifically breast, lung) Diabetes Heart Disease High Blood Pressure and High Cholesterol Mental Health & Substance Abuse Overweight/obesity 3

5 Holleran facilitated discussion to identify overlapping strategies, cross-cutting issues, and the ability for regional health and human services providers to effectively address the various needs. After further dialogue and consolidation, the following Master List of Needs was developed by the attendees to be evaluated as potential priority areas for community health improvement activities. Master list of community priorities (in alphabetical order): Asthma Cancer Diabetes (to include overweight/obesity and pre-diabetes) Heart Disease (to include hypertension and high cholesterol) Mental Health and Substance Abuse PRIORITIZATION OF COMMUNITY HEALTH NEEDS Once the master list was compiled, participants were asked to rate each need based on two criteria. The two criteria included seriousness of the issue and the ability to impact the issue. Respondents were asked to rate each issue on a 1 (not at all serious; no ability to impact) through 5 (very serious; great ability to impact) scale. The ratings were gathered instantly and anonymously through a wireless audience response system. Each attendee received a keypad to register their vote. The following table reveals the results of the voting exercise from highest rated need to lowest rated need based on the average score of the two criterions. Master List Seriousness Rating (average) Impact Rating (average) Average Total Score Diabetes Mental Health & Substance Abuse Cancer Heart Disease Asthma The priority area that was perceived as the most serious was Mental Health (4.65 average rating), followed by Cancer and Diabetes (4.38 average rating each), and Heart Disease (3.77 average rating). The ability to impact Diabetes was rated the highest at 3.73, followed by heart disease with an impact rating of 3.58, and Mental Health, with a score of

6 The matrix below outlines the intersection of the seriousness and impact ratings. Those items in the upper right quadrant are rated the most serious and with the greatest ability to impact. Prioritized List of Community Health Needs The participants reviewed the voting results and recommended that the following priorities be adopted as community health priorities: Mental Health and Substance Abuse* Diabetes (to include overweight/obesity, and pre-diabetes)* Cancer Heart Disease (to include hypertension, high cholesterol)* * denotes statewide health priority SCHHS leadership reviewed the recommendations for priority areas and agreed to outline an Implementation Strategy to address each of the priority areas. 5

7 STRATEGIES TO ADDRESS COMMUNITY HEALTH NEEDS In support of the 2013 Community Health Needs Assessment, and ongoing community benefit initiatives, South County Hospital Healthcare System (SCHHS) plans to implement the following strategies to impact and measure community health improvement. MENTAL HEALTH AND SUBSTANCE ABUSE GOAL: Improve mental health by increasing access to appropriate, quality mental health services including substance abuse services, and improve care coordination across the continuum of care. STRATEGIES: 1. Ensure that the SCHHS collaboratively addresses mental health related needs in the community it serves 2. Enhance access to mental health clinicians in primary care physician offices 3. Improve awareness of warning signs and symptoms of Mental Health and Substance Abuse to help ensure that interventions are managed at the most appropriate level of care TACTICS/ACTIVITIES: 1. In collaboration with others, conduct a quantitative and qualitative analysis of mental health related utilization in inpatient and emergency departments for residents of South County 2. Increase the proportion of patients for Patient Centered Medical Community (PCMC) participants that have access to mental health clinicians onsite and measure referrals to other related services 3. In collaboration with others, establish a Mental Health First Aid Course for health professionals and community members in South County KEY INDICATORS: 1. Results of mental health related utilization analysis is documented and shared with key stakeholders 2. Number of primary care providers participating in the PCMC initiative that are providing mental health consultations or referrals on-site 3. Reduce the proportion of patients accessing mental health and/or substance abuse services through the Hospital ED that are admitted to an acute care facility (Mental Health analysis serves as baseline) EXISTING COMMUNITY ASSETS TO ADDRESS NEEDS: The following organizations exist in the community and SCHHS will work collaboratively with these entities to address the strategies and tactics outlined above Patient Centered Medical Community (part of CSI-RI Initiative) South Shore (Mental Health) Center STARR Rehab and Addiction Center The Phoenix House 6

8 Thundermist Health Center Wood River Health Services University of Rhode Island VNS Home Health Services (an affiliate of SCHHS) Washington County Coalition for Children DIABETES (to include overweight/obesity, and pre-diabetes) GOAL: To promote healthy lifestyles that reduce obesity, improves pre-diabetes awareness, and results in better management of diabetes care (including self-management). STRATEGIES: 1. Improve awareness of healthy lifestyles and prevention of obesity through Community Education and Health Screening Programs 2. Improve access to medical specialists for diabetes and endocrinology 3. Improve diabetes metrics within the Patient Centered Medical Community (PCMC) initiative 4. Maintain and ensure access to formal Diabetes Self-Management Education Programs TACTICS/ACTIVITIES 1. Provide outreach efforts to educate residents about the risk factors for diabetes 2. Recruit an endocrinologist to the South County Medical Group 3. Enhance care coordination and diabetes self-management in the practices participating in the PCMC 4. Improve prevention behaviors (e.g., participation in physical activity and healthy eating) in persons with pre-diabetes who are at high risk for diabetes KEY INDICATORS: 1. Number of outreach and education programs and program participants 2. Number of endocrinologists and/or diabetes specialists on the System s medical staff 3. PCMC participants improve (reduce) the percentage of diabetic patients with poorly controlled disease 4. Increase the proportion of adults who engage regularly, preferably daily, in moderate physical activity for at least 30 minutes a day (BRFSS) EXISTING COMMUNITY ASSETS TO ADDRESS NEEDS: The following organizations exist in the community and SCHHS will work collaboratively with these entities to address the strategies and tactics outlined above. Healthy Places by Design (South Kingstown and North Kingstown) Patient Centered Medical Community (part of CSI-RI Initiative) South Shore (Mental Health) Center Thundermist Health Center Wood River Health Services University of Rhode Island VNS Home Health Services (an affiliate of SCHHS) YMCA of Greater Providence and local YMCAs 7

9 CANCER GOAL: To provide a multidisciplinary, patient-centered cancer program that ensures a continuum of care that spans prevention, diagnosis, treatment, palliative and hospice care, and survivorship. STRATEGIES: 1. Create a community cancer center facility that supports achievement of the stated goal 2. Ensure the availability and local access to cancer specialists and clinicians for cancers that can be appropriately managed in a community setting 3. Provide community outreach and cancer screening efforts to educate residents about the risk factors for cancer and benefits of early diagnosis 4. Increase the proportion of cancer patients referred to the STAR program service offerings TACTICS/ACTIVITIES: 1. Implement renovations on the Hospital s Read Wing to establish a home for its Community Cancer Center 2. Establish collaborative relationships with others that provide specialized cancer services when needed 3. Increase the proportion of persons with Cancer whose condition has been diagnosed and treated within the community 4. Build upon the foundation of the STAR (Survivorship Training And Rehabilitation) program to provide availability of and access to cancer support and survivorship services, including access to psychosocial services KEY INDICATORS: 1. Community Cancer Center is established 2. Number of cancer specialists on the Hospital s medical staff 3. Percent of residents who receive cancer care in the community 4. Number of cancer patients referred to the STAR program EXISTING COMMUNITY ASSETS TO ADDRESS NEEDS: The following organizations exist in the community and SCHHS will work collaboratively with these entities to address the strategies and tactics outlined above. American Cancer Society Home and Hospice of Rhode Island South County Radiation Therapy The Partnership to Reduce Cancer in Rhode Island (RI Department of Health) University of Rhode Island VNS Home Health Services (an affiliate of SCHHS) YMCA of Greater Providence and local YMCAs (e.g., Livestrong Programs) 8

10 HEART DISEASE (to include hypertension and high cholesterol) GOAL: Reduce the burden of heart disease through early identification, and early and appropriate treatment/management. STRATEGIES: 1. Improve awareness of healthy lifestyles and risk factors for heart disease through Community Education 2. Increase the proportion of adults who have appropriate screening for hypertension and/or high cholesterol 3. Reduce re-hospitalizations rates for adults with heart failure as the principal diagnosis 4. Increase the proportion of heart attack survivors who participate in cardiac rehabilitation program upon discharge TACTICS/ACTIVITIES: 1. Conduct Community Education Programs that are free to the public and offered by cardiology experts 2. Conduct routine Health Screenings that include high blood pressure and cholesterol checks 3. Evaluate and if appropriate implement a Congestive Heart Failure (CHF) nurse navigator program 4. Maintain a robust Cardiac Rehabilitation and Wellness Program and increase participation for post-acute MI (heart attack) patients KEY INDICATORS: 1. Number of education and screening programs and program participants 2. Re-hospitalization rate of patients for CHF diagnosis 3. Percent of cardiac patients who participate in cardiac rehabilitation program post-acute MI EXISTING COMMUNITY ASSETS TO ADDRESS NEEDS: The following organizations exist in the community and SCHHS will work collaboratively with these entities to address the strategies and tactics outlined above. Patient Centered Medical Community (part of CSI-RI Initiative) South County Cardiology (part of the Hospital) Thundermist Health Center Wood River Health Services University of Rhode Island VNS Home Health Services (an affiliate of SHHS) YMCA of Greater Providence and local YMCAs 9

11 COMMUNITY HEALTH NEEDS NOT ADDRESSED By aligning community health activities with the local and statewide priorities of Mental Health and Substance Abuse, Diabetes, Cancer, and Heart Disease, South County Hospital Healthcare System will take a comprehensive approach to addressing the most urgent needs in the community. As with all programs and services, the System will continue to monitor community needs and adjust programming and services accordingly. APPROVAL FROM GOVERNING BODY The South County Hospital Healthcare System Board of Trustees met on August 26, 2013 to review the findings of the CHNA and the recommended Implementation Plan. The board voted to adopt the Final Summary Report and the Implementation Plan and provide the necessary resources and support to carry out the initiatives therein. 10

12 APPENDIX A: Attendees Name Title Organization Chuck Jones CEO Thundermist Health Center Nicole Quindazzi Executive Director Thundermist Health Center Steven Roth, MD Medical Director Thundermist Health Center Jerry Cutler VP, Clinical Services South Shore Center Richard Leclerc President Gateway Healthcare Susan Orban Coordinator Washington County Coalition for Children Jim Berson President and CEO YMCA of Greater Providence Netta Taylor-Post YMCA of Greater Providence Martha Machnik Director, Healthy Aging YMCA of Greater Providence Kathi Crowe Executive Director YMCA of South County Michael Lichtenstein President and CEO Wood River Health Services Chris Campagnari, MD Medical Director Wood River Health Services Fortunato Procopio, MD Medical Director URI Health Services Ellen Reynolds Director, Health Services URI Health Services Alexandra Cole Intern URI Health Services Lou Giancola President and CEO South County Hospital Healthcare System (SCHHS) Fred Browne, MD CMO SCHHS Mary Lou Rhodes President VNS Home Health Services, SCHHS William Sabina, MD Medical Director, Emergency Department President of the Medical Staff SCHHS Sharon DeLuca Director, Behavioral Health Program SCHHS Michelle Bailey Physician Liaison SCHHS Eve Keenan Chair, Board of Trustees SCHHS Irwin Birnbaum Trustee SCHHS Dennis Lynch Trustee SCHHS Rob Panoff Trustee SCHHS Maggie Thomas AVP, Chief Human Resources Officer SCHHS Martha Murphy Manager, Marketing and Communications SCHHS 11