Community Health Needs Assessment: Strategic Implementation Plan - University of Chicago Medicine

Community Health Needs Assessment Strategic Implementation Plan 6/30/2013

The University of Chicago Medical Center (UCM) retained Professional Research Consultants (PRC) to conduct its Community Health Needs Assessment (CHNA). The University of Chicago Medicine has an adult and a pediatric hospital. Because of the complexities and unique needs of the adult and pediatric populations, UCM conducted separate needs assessments. The assessments were conducted over eight months with the adult assessment preceding the pediatric one. This Strategic Implementation Plan provides an overview of the efforts by the University of Chicago Medicine to assess, prioritize and address the health needs of its community.

Method To provide insight into the community’s perception of the greatest health needs, primary (qualitative) data was attained through focus groups with key informants within the community such as residents, community leaders, public health experts, and social service providers.

Landline and cell phone interviews were conducted with residents from the community.

Additionally, feedback was obtained from other community constituents including various health professionals and physicians. Each of these individuals was asked a list of questions about their perception of the greatest health needs within their community.

Secondary (quantitative) data was also collected, synthesized and trended against the primary data. Secondary data sources included Centers for Disease Control, National Center for Health Statistics, Illinois Department of Public Health, Illinois State Police, U.S. Census Bureau, U.S. Department of Health and Human Services, U.S. Department of Justice, and the Federal Bureau of Investigation. Data derived from the University of Chicago Medicine’s community needs assessment were benchmarked against: Trended historical data compared to prior survey results whenever available, Regional Metro Chicago data compared to service areas in Cook, DuPage and Lake Counties, Illinois Risk Factor Data, including data reported in Behavioral Risk Factor Surveillance (BRFSS), the U.S. Department of Health and Human Services, and other State-level vital statistics, National risk factor data that was taken from the Professional Research Consultant’s National Health Survey and national level vital statistics, and Healthy People 2020.

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A rigorous process was undergone to determine the strategic implementation plan for addressing the community health needs. The process included a thorough synthesis of the primary and secondary data to determine the community health needs for which the University of Chicago Medicine’s community compared worst in relation to local, state and national data outcomes. Based on this review, the health needs were prioritized and ranked according to the following code. Priority was given to rankings in which University of Chicago Medicine’s community outcomes were worst when compared to the secondary data.

Red – UCM’s community outcomes were worse in comparison to others..

Yellow – UCM’s community outcomes were poor, however, there are resources addressing the need.

Green – UCM’s community outcomes are comparable to other data outcomes and there are several available resources to address the need.

Based on the “color-coded” rankings, community health needs were identified and selected as the focus areas for UCM’s strategic implementation plan.

An inventory of available resources to address the health needs was conducted.

Resources within the University of Chicago Medicine, University of Chicago Biological Sciences Division, the local community, region and nation were identified based on current activity to address the community health need. Additionally, the community health needs were evaluated to determine University of Chicago Medicine’s ability to make favorable impact on the outcomes through interventions, programs or initiatives. Based on this evaluation the final focus areas were selected.

University of Chicago Focused Needs University of Chicago Medicine has selected the following community health needs to focus its strategic implementation plan. These needs were identified through the rigorous process described above. Three needs have been identified to address adult needs and three to address pediatric needs.

Adult Focused Needs Access to health care – 2 or more visits to the Emergency Room Diabetes Mellitus Cancer – female breast and colorectal

Pediatric Focused Needs Access to health care – 2 or more visits to the Emergency Room Obesity – Children ages Asthma

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Two needs categories were not chosen for the strategic implementation plan at this time.

The University of Chicago Medicine did rank poorly on these areas in comparison to secondary data. The University of Chicago Medicine intends to commit resources to study these needs, and later to implement in collaboration with others partners, a plan to address these community health needs. The categories that were not selected include the following: Community health needs categories for future development Injury and Violence Prevention Violent crime per 100,000 % Victim of Violent Crime in Past 5 Years Sexually transmitted diseases Gonorrhea incidence per 100,000 Primary and Secondary Syphilis per 100,000 Chlamydia Incidence per 100,000 Addressing the selected community health needs The University of Chicago Medicine has determined that it will enhance, implement or develop programs or initiatives to address the selected community health needs.

Adult focus area

Program/Initiative to address need

Pediatric focus area

Program/Initiative to address need

Access to health care – 2 or more visits to the Emergency Dept.

Diabetes Mellitus

Medical Home Connect

Access to health care – 2 or more visits to the Emergency Dept.

Obesity

Medical Home Connect

Cancer

Cancer prevention and education programs

Female Breast Colorectal (male and female)

South Side Diabetic Project

Asthma

Develop program in obesity prevention and education Asthma Care Coordination Program

Strategic Implementation Plan to Address Community Health Needs Adult and Pediatric Health Need Access to Health Care – Residents with two or more visits to the emergency room in the past year.

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The Medical Home Connection program is one of the University of Chicago Medicine’s key initiatives to help reduce the frequency of visits to the emergency department for patients with low acuity diagnoses, and improve access for the patient to their medical home. The Medical Home Connection program is designed to connect South Side residents to community health centers and health care providers who can provide preventive care, regular treatment for non-emergency health conditions, long-term management of chronic disease and referrals to specialist.

To help patients avoid frequent trips to the emergency department, Patient Advocates who reside within the UCM’s emergency departments will educate patients on the importance of utilizing their primary care doctor for low acuity care needs. Patient advocates will schedule appointments for patients within the resources of the South Side Health Care Collaborative (SSHC). The SSHC is a network of 30 community health centers and two free clinics on the South Side of Chicago. The Patient Advocate will make reminder calls to the patient two days prior to their appointment date.

UCM will measure the following outcomes to determine the impact of the Medical Home Connect Program on reducing the frequency of visits to the emergency department: Percentage of patients seeking care 2 or more times per year in emergency department for low acuity needs Patients connect to medical home Show rate for patients to medical home

Other Adult Health Needs Diabetes Mellitus The South Side Diabetes Project is designed to improve the health and quality of life for our community neighbors who are living with diabetes. The South Side Diabetes project works with 6 clinics on the South Side including the UCM Primary Care Group, UCM Kovler Diabetes Center, and four Federally Qualified Health Centers (FQHCs) - ACCESS Grand Boulevard, ACCESS Booker, Chicago Family Health Center and Friend Family Health Center. The FQHCS are all part of the South Side Health Collaborative (SSHC). Each clinic engages in efforts to improve patients outcomes in diabetes through empowering patients to manage their disease,

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training providers in culturally relevant diabetes management, quality improvement, and connecting patients to community resources, such as exercise programs, grocery store tours to help with food selection, a food pantry, etc. The goal of the South Side Diabetic Project is to combine the strengths of local health systems with the strengths of community organizations and resources to address the disparities in diabetes that exist on Chicago’s South Side.

This program is a collaboration between the University of Chicago’s Biological Sciences Division researchers and the University of Chicago Medicine’s Urban Health Initiative through the partnership with the South Side Healthcare Collaborative.

The measures for this program will include the: Percentage of residents with reduced A1C measures The number of residents actively participating in exercise and weight management programs The number of residents participating in community education programs

Cancer (female - breast cancer, all – colorectal) – Requires development The University of Chicago Medicine intends to develop community-based cancer education programs focused on risk, prevention and treatment in collaboration with researchers from the Biological Sciences Division and community partners. The University of Chicago Medicine will continue its partnership with the American Cancer Society to provide breast cancer education and screenings for women on the South Side of Chicago. We intend to leverage our relationship with community partners and the South Side Health Collaborative to address this community health need and to improve the breast and colorectal Cancer outcomes for residents on the South Side of Chicago.

Pediatric Health Needs Obesity (Requires development) In collaboration with community partners and researchers from the University of Chicago Medicine and Biological Sciences Division, the University of Chicago Medicine intends to develop community-based obesity programs focused on risk, prevention, weight management, and culturally relevant nutrition management.

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In addition to developing programming to address this need, UCM will support the Power-Up program, an after school fitness program for kindergartner through 6th grade students at the Woodlawn Community School. The program is intended to assist students in controlling BMI for overweight children.

Asthma (Requires further development) The University of Chicago Medicine’s Asthma Care Coordination program is designed to prevent hospital readmissions due to asthma. The program is comprised of patient and care giver education classes, asthma patient education in the emergency department, educating nurses on using “teach back” to ensure patient understanding and to enhance caregiver’s and/or patient’s ability to manage asthma in the home environment, and embedding asthma education in our patient television learning tool the “Get Well Network”. This program will continue to be the premier program to reduce hospital readmissions due to asthma. In addition to the Asthma Care Coordination Program, the Medical Home Connect Program will connect patients with frequent visits to the emergency department to their medical home.

In collaboration with community partners and University of Chicago Medicine and Biological Sciences Division researchers, the University of Chicago Medicine will develop community-based asthma programs to include education, home assessments and prevention.

Rational for Unaddressed needs Two needs, injury and violence prevention and sexually transmitted disease, were not selected for strategic implementation planning in this cycle of the community health needs assessment. Because of the great complexity and the need for a systemic and multi-constituency approach to addressing these needs they were not selected. However, in 2014, it is the intention of the University of Chicago Medicine to convene community leaders, policy leaders and the health care community to begin discussions about a systemic approach to addressing both of these needs. Our desire is to partner with other constituents that are working on interventions to address these community health needs.

Existing Programs/Initiatives Addressing Unaddressed Needs

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We have determined that the following organizations, including the University of Chicago Medicine, already have some programs/initiatives in place to address aspects of these needs.

Existing Programs/Initiatives to Address Crime and Violence University of Chicago Medicine, Urban Health Initiative Community Grand Rounds performance of play “It Should Have Been Me” and community engagement around crime prevention Funding of an Interrupter for the Ceasefire Cure Violence Program Ceasefire Cure Violence Child Abuse Prevention programs Department of Children and Family Services (DCFS) State of Illinois, Prevent Child Abuse, Illinois Crime Lab – University of Chicago School of Social Science Administration and Diversion Programs Juvenile Justice Diversion Project (JJDP) University of Chicago Police Department Chicago Police Department Department of Education School Interventions - Safe Passage Program Chicago Safe Start - cityofchicago.org Existing Programs to Address Sexually Transmitted Disease University of Chicago Biological Sciences Division Research addressing need: Dr. Karen Kim, Principle Investigator addressing Adult and Pediatric HPV Dr. Kenneth, Alexander Principle Investigator addressing HIV and AIDS prevention Dr. John Schneider, Principle Investigator addressing Adult AIDS Prevention Dr. Daniel Johnson, Principle Investigator addressing Pediatric AIDS Prevention Southside Help Center Mobile Unit with HIV testing, counseling, education: “Step Up, Get Tested” (Whitman Walker Health Southside Help Center Aunt Martha’s Health Care Network Comer Medical Unit The Night Ministry Illinois Department of Public Health Church AIDS initiative Multiple churches in the community with programs on AIDS prevention Secondary Prevention Project The Chicago Project for Violence Prevention – Robert Wood Johnson Foundation, Chicago Area Project (CAP) Chicago Department of Public Health 8