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Operationalizing Community-Centered Health Homes for Improved Community Health Outcomes

Explore the innovative Community-Centered Health Home (CCHH) model, its impact on community health, and the Texas CCHH Initiative. Learn how primary care settings can address social determinants of health and collaborate with community partners for comprehensive care.

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Operationalizing Community-Centered Health Homes for Improved Community Health Outcomes

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  1. Community Centered Health Homes:: Operationalizing the Community Clinic's role in advancing health not just health care Kenneth D. Smith, Ph.D. Health Systems Transformation Consultant Texas Primary Care and Health Homes Summit April 6, 2018

  2. Objectives • What is a CCHH and what makes it so different from other delivery models of primary care? • What is the Texas CCHH initiative? • What are leadership, clinicians and managers participating in this initiative learning as they implement the model?

  3. What is a CCHH? A Community-Centered Health Home not only acknowledgesthat factors outside the clinic walls affect patient health outcomes, it actively participatesin improving them.

  4. CCHH Early Pilot Testing NC TX AL MS LA FL

  5. The CCHH Model: Rooted in the Health Center Movement Prevention Institute’s CCHH Report (circa 2011) Drs. Jack Geiger & John Hatch Tufts-Delta Health Center (circa 1968) Photo Credit: Daniel Bernstein

  6. Core Lessons Learned from the Nation’s First Health Centers • Medically-underserved communities are rich in potential, as well as bright & creative people whose talents can be harnessed to the Health Center program. • CHCs have the capacity to attack the root causes of ill health through community development and the social change it engenders. - H. Jack Geiger (AJPH 2002) Photo Credit: Daniel Bernstein

  7. The Heart of CCHH: Addressing Community Conditions

  8. CCHH: Moving Prevention Further Upstream

  9. CCHH Builds Upon Primary Care

  10. CCHH Model • Coordinate activity with community partners • Advocate for community health • Mobilize patient populations • Strengthen Partnerships • Establish model organizational practices • Collect data on social, economic & community conditions • Aggregate prevalence data • Review health & safety trends • Identify priorities & strategies with community partners • ACTION • INQUIRY • ANALYSIS

  11. Health Center Core Capacities for building a CCHH

  12. Texas CCHH Initiative At a Glance • $10 million, 4-year initiative • 13 Texas Community Health Centers • 2016: Invitation & orientation to the initiative • January-June 2017: Action Planning Grant period • July 2017: Cohort Period Grant –two grantee cohorts • Capacity Building: 18 mos ($100k-150k) • Implementation: 3 years ($100k-300k) This initiative is part of a larger national effort that is testing the model in other regions. FL

  13. Benefits of Becoming a CCHH • Improved community conditions that encourage staff to get involved, resulting in improved staff satisfaction (we can make an impact!) • Increased patient census and utilization • Amplification of the positive health effect of high-quality primary care • Greater community ownership of ‘health’ • Greater community support for the Health Center

  14. Texas CCHH Initiative At a Glance • $10 million, 4-year initiative • 13 Texas Community Health Centers • 2016: Invitation & orientation to the initiative • January-June 2017: Action Planning Grant period • July 2017: Cohort Period Grant –two grantee cohorts • Capacity Building: 18 mos ($100k-150k) • Implementation: 3 years ($100k-300k) This initiative is part of a larger national effort that is testing the model in other regions. FL

  15. Cohort clinics • Map, topics

  16. The CCHH Project Team Leslie Mikkelsen Rea Pañares Jo Carcedo EHF Suzanne Leahy Brittany Kusay Eric Baumgartner Beth Quill Donna Alexander Ken Smith Jessica Pugil Kara MacArthur

  17. From Planning to Action Common partners

  18. Action Plans and Implementation • Clearly defined SMART Goals, Objectives and Activities • Internal and External Goals • Role of Partners • Indicators of Success at Reaching Goals • Coaching of Teams • Technical Assistance Provision • Learning and Networking Opportunities

  19. Similar Actions Supporting Community Transformation

  20. Goals for the cohort period

  21. CCHH Panel • Rhonda Mundhenk, JD, MPH: Lone Star Circle of Care • Valerie Smith, MD; St Paul Children’s Foundation • Jackson Griggs, MD: Waco Family Health Center • Robert Nnake, MBA: Hermann Memorial Community Benefit Program

  22. Questions and comments? Contact EHF: cchh@episcopalhealth.org

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