Buncombe County Health & Human Services

1. Buncombe County Health & Human Services Community Focused Eliminating Health Disparities Initiative (CFEHDI) Program January 23, 2013 Working Together to improve the health of minorities living in Buncombe County

2. Ujima: Collective Work and Responsibility- To build and maintain our community together and make our brother’s and sister’s problems our problems and to solve them together.

3. Community Based Organization: Collaboration Mt. Zion Community Development, Inc.

4. Buncombe County Populations Served • African American • American Indian • Hispanic/Latina • Other: Uninsured and Underinsured

5. Chronic Health Conditions Addressed • Asthma • Cancer • Diabetes • Heart Disease • HIVAIDS/STD • Obesity and Stroke

6. Community Partner Programs • Health Screenings & Outreach • Diabetes Wellness Program • Chronic Disease Self-Management Classes • Body & Soul • Diabetes Prevention Workshops • Project Empower • Coordinate “Ladies Night Out” • Case Management (PACE, Building Brothers)

7. Convene partners around common agenda Facilitate Communication & cross referrals Develop new & existing partnerships to expand reach Provide infrastructure for carrying out grant scope of work Collect and organize program data for evaluation and analyzing Role of Buncombe County Department of Health

8. Data Collection and Common Documentation of Program Events and Outreach • Map outreach efforts of sub-contractors • Understand chronic disease focus areas • Communicate performance and outcome information • Reflect access to care and equity efforts of area health care programs • Track referral and follow up efforts to Medicaid, Medicare, and Insurance

9. Health and Wellness Assessment Tool: Demographics Chronic Conditions Medical Home Status “Know Your Numbers” data Referrals for medical services by partners Community needs

10. Buncombe County Health & Human Services, Minority Health Equity Project: Improving Health for Everyone… Building a Better Future Together

11. Wayne County Health Department Minority Health Program

12. Wayne County, NC Total Population Estimate 124,246

13. Disease Focus Areas • Obesity • Heart Disease • Diabetes • HIV/AIDS

14. Programmatic Focus The focus of our education intervention is to: • Increase knowledge and awareness of modifiable risk factors that contribute to obesity and chronic conditions associated with unhealthy lifestyles • Implement strategies to reduce these health risks • Build infrastructures by establishing health ministries charged with conducting and promoting health and wellness sessions • Establish medical homes for uninsured congregants • Modify risk factors for chronic disease and to initiate chronic disease self management strategies.

15. Programmatic Highlights • W.A.T.C.H is a free, primary health clinic providing acute healthcare to the uninsured with two locations: • The Mobile Unit travels around the county to 15 pre-determined locations each month • A satellite location is available at the Goldsboro Family YMCA • Each W.A.T.C.H. clinic is run by a Family Nurse Practitioner and volunteer physicians provide specialty clinics at specified dates and times • For 2012 • Patient Visits: 9,969 and 301 were unduplicated patients • Volunteer Hours: 1,191 • Free medications ordered: $1.8 million • From January – December 2012, $487,000 of free labs were completed

16. Programmatic Highlights • Faithful Families Eating Smart and Moving More (FFESMM) is a practice-tested intervention that educates faith community members about food, physical activity and becoming advocates for healthy policy and environmental changes within their communities.

17. Programmatic Impact • Staying abreast of recent health disparities and policy developments • Building and maintaining strong relationships with other health and community advocates to leverage expertise and resources • Coalition Building and Community Engagement • Engaging the Faith Community • Media Outreach • Helping to educate both minority and mainstream media about minority health policy and issues so that these issues get timely an appropriate attention • providing culturally competent program materials for various faith communities, community-based organizations and civic groups in addressing health literacy.

18. CFEDHI Work through a Community Based Organization Tara Robinson, RN, BSN, CCM Wake County Medical Society Community Health Foundation

19. WCMSCHF • Non-profit • 501(c)3 • Improve quality of and access to primary care for the Carolina Access Medicaid and dual (Medicare/Medicaid) population • Reduce healthcare cost Community Care of Wake & Johnston Counties CapitalCare Collaborative • Increase access to primary & specialty care for the uninsured & homeless • Reduce ED visits • Assesses and responds to community health needs Care Management Evidence-Based Best Practice Medical Home

20. Wake County • North Carolina's second most populated county • Area: 835 sq. miles • Persons per sq. mile: 1,078.8 • Population: 952,151 Sources: US Census Bureau: State and County Quick Facts Wake County Community Health Needs Assessment, 2013

21. Johnston County Source: US Census Bureau: State and County Quick Facts The 77th fastest growing U.S. county with a population of 10,000 or more Area: 791 sq. miles Persons per sq. mile: 213.4 Population: 174,938

22. Program Goals Decrease the number of uninsured minorities in Wake & Johnston counties Link individuals to a medical home and increase knowledge on how to optimally access health care services Promote chronic disease self-management among racial and ethnic minorities Increase cultural competency among staff

24. Understanding the Needs of & How to Reach Our Target Population • Minority Census Tract • Project and Sub-Project Advisory Groups • Safety Net (Johnston Co) and Collaborative (Wake Co) meetings • Focus groups • 3 in Johnston Co • 3 in Wake Co • Community Stakeholders • ASK and talk to individuals in our target population • Door-to-door, special interest groups

25. Program Highlights • Living Healthy Chronic Disease Self-Management • 324* participants have participated in CDSMP/DSMP • 82%* have demonstrated an increased level of activation in managing their health condition(s) • Large church in Wake County • Men’s Homeless Shelter • Day Treatment Facilities for individuals with mental illness • Patient Navigation & Community Outreach • Spreading the word – TV, radio, & newspaper • Collaboration with local partners • 908* participants attended insurance workshops on Medicare and Medicaid • 265* uninsured individuals linked to a medical home *Numbers are based on June-November 2013 data

26. Questions? Alma Atkins, BSW, MHA Minority Health Coordinator Ph: 828-250-5319 Email: aatkins.pcm@gmail.com Celita Graham Minority Health Coordinator Ph: 919-731-1235 Email: celita.graham@waynegov.com Tara Robinson, RN, BSN, CCM Deputy Director Ph: 919-792-3622 E-mail: trobinson@wakedocs.org