COMMUNITY

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• COMMUNITY
• HEALTH WORKS
• Celebrating Rural Georgia
• Georgia Rural Health Association
• August 22, 2006

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COMMUNITY HEALTH WORKS

• Who is CHW?
• What did we do?
• What were the results?

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• Community Health Works is a bold organization
  seeking innovative health solutions and providing
  compassionate advocacy for people financially
  compromised by their medical needs, while
  reducing the burdens on local health providers.

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Who is CHW?

• 501c3
• 7 counties in Central Georgia
• 5 hospitals
• 3 clinics
• 135 physicians
• 22 pharmacies

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CHW Board Members

• Frank Aaron, CEO, Houston Health Care
• Dr. Joe Swartout, Div. Public Health Director
• Dr. Patton Smith, Monroe Co. Physician
• Dr. Fred Gaton, Crawford County Physician
• Don Faulk, CEO, Central GA Health Systems
• Tom McMichael, Houston Co. Commission
• David Gault, Vice Chair, Jones Co. Commission

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CHW Board Members

• O.J. Booker, CEO, Monroe Co. Hospital
• Nancy Peed, CEO, Peach Regional Hospital
• Dr. Lynn Denny, Med. Dir., Macon Vol. Clinic
• Dr. Martin Dalton, Dean, Mercer Med School
• Ethel Cullinan, CEO, MedCen Foundation
• Charles Bishop, Bibb Commission Chair
• James Khoury, Peach Commission Chair

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CHW Board Members

• Bill Hamrick, Twiggs Co. Comm. Past Chair
• Frank Fields, Exec. Dir., River Edge
• Don Blair, Exec. Dir., Phoenix Center
• Lelia Anderson, ED, Family Connections
• Dr. Fred Schnell, Chairman GA CORE
• Art Christie, Dir of Oper., Houston Health Care

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What did we do?

• Created network based on a donated care model
• Uninsured with 4 disease states
• Diabetes
• Hypertension
• Cardiovascular disease
• Depression

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What did we do?

• Care Management
• Pharmaceutical assistance
• Primary Care Home
• Tracked hospital ER utilization

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Screening Disease/ Age/ Financial/
Insurance Eligibility Face to Face
Interview Verify Information Complete
BRFSS Assign Physician Care Management Create
Care Team Care Plan Coordinate Interaction With
Physician Pharmaceutical Assistance
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• WHAT WERE THE RESULTS?

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Donated Care Model

• 5 Hospitals
• 3 Clinics
• 22 Pharmacies
• 135 Physicians
• EQUALS ???????

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MEMBERS SCREENED6068
From Inception thru 7/31/06
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MEMBERS ENROLLED1939
Total as of 07/31/06
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Donated Care Model

• More than
• 3,500 Members Served
• 35 million Care Coordinated
• 2 million Free Medicines
• 1 million Medicaid/Medicare
• AND

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• A rigorous independent examination of
• CHW care management results shows
• 1,300,000 annual saving per thousand members in
  CHW care management
• ER Utilization Rate 31 lt than National Avg.
• Hospitalization Rate 49 lt than National Avg.

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• BEGINNING TO TRACK CLINICAL OUTCOMES

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59 Year Old Female Date of Enrollment September
23, 2003
Date A1C Reference Results Flag
March 1, 2004 7.6 3.0 6.0 High
June 24, 2004 5.4 3.0 6.0 Normal
Sept. 30, 2004 5.3 3.0 6.0 Normal
Jan. 5, 2005 5.5 3.0 6.0 Normal
Exercise
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Clinical Outcomes

• Physician Data Segregation
• Use to show value of Care Management
• Use to show effectiveness of treatment plan
• Care Manager Data Segregation
• Use to incentivize personnel
• Use to allocate personnel/ create care team

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Peach County Resident

• 57 Yr Old African American Male
• Diagnosed with Diabetes and Vision problems
• Did not work because of health
• Care Manager got him glasses from LensCrafters
• Blood sugars down, medicine dosages decreased
• Member now working two jobs

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• How do we use the Network
• weve created to add even more value to the
• community and our partners?

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Community Health Works Board of Directors
Central Georgia Cancer Coalition
Rx for the Uninsured
Middle Georgia Multi Share
Community Health Works- Principal Activities
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• Central Georgia Cancer Coalition

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Through Prevention, Screening, Early
Detection, Education, Leading-Edge
Treatment Advanced Research CANCER CAN BE
DEFEATED
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Community Health Works Central Georgia Cancer
Coalition Region
CATOOSA
RABUN
FANNIN
TOWNS
DADE
UNION
MURRAY
WHITFIELD
GILMER
WALKER
HABERSHAM
WHITE
LUMPKIN
STEPHENS
CHATTOOGA
GORDON
PICKENS
FRANKLIN
DAWSON
HART
HALL
BANKS
FORSYTH
BARTOW
CHEROKEE
FLOYD
ELBERT
JACKSON
MADISON
POLK
BARROW
COBB
OGLETHORPE
CLARKE
GWINNETT
PAULDING
OCONEE
HARALSON
WILKES
WALTON
LINCOLN
DEKALB
DOUGLAS
FULTON
GREENE
TALIAFERRO
CLAYTON
ROCKDALE
COLUMBIA
CARROLL
MORGAN
MCDUFFIE
NEWTON
HENRY
FAYETTE
WARREN
RICHMOND
JASPER
PUTNAM
COWETA
HEARD
HANCOCK
GLASCOCK
BUTTS
SPALDING
JEFFERSON
MERIWETHER
BURKE
BALDWIN
PIKE
JONES
LAMAR
MONROE
TROUP
WASHINGTON
UPSON
JENKINS
WILKINSON
BIBB
SCREVEN
JOHNSON
HARRIS
CRAWFORD
TWIGGS
TALBOT
EMANUEL
LAURENS
PEACH
TAYLOR
MUSCOGEE
BULLOCH
EFFINGHAM
BLECKLEY
HOUSTON
MARION
TREUTLEN
CANDLER
MACON
CHATTAHOOCHEE
MONT- GOMERY
SCHLEY
PULASKI
DODGE
EVANS
DOOLY
BRYAN
WHEELER
CHATHAM
WEBSTER
STEWART
TOOMBS
TATTNALL
SUMTER
WILCOX
TELFAIR
CRISP
LIBERTY
QUITMAN
LEE
LONG
JEFF DAVIS
BEN HILL
TERRELL
APPLING
TURNER
RANDOLPH
WAYNE
IRWIN
MCINTOSH
BACON
COFFEE
CLAY
WORTH
DOUGHERTY
CALHOUN
TIFT
PIERCE
EARLY
BAKER
ATKINSON
GLYNN
BERRIEN
BRANTLEY
WARE
COLQUITT
MITCHELL
MILLER
COOK
LANIER
CAMDEN
SEMINOLE
CLINCH
CHARLTON
DECATUR
GRADY
THOMAS
BROOKS
LOWNDES
ECHOLS
Yellow Original CHW Counties Yellow/Green C
ancer RPE Region
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HRSA HCAP GRANT

• Create Medicaid Disability Software
• Tobacco Cessation Outreach
• Electronic Health Record
• Implement vertically integrated cancer care
  management
• Implement database to assure access to clinical
  trials
• Pharmaceutical assistance program

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HCAP Grant

• Cancer Screening Software
• Breast Oral
• Cervical Skin
• Ovarian Colorectal
• Lung Prostate
• Testicular

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GEORGIA BREAST CANCER LICENSE TAG50,000 Grant

• Provide access to mammography screening for
  uninsured women in Georgia
• Implement in Peach Monroe Counties
• Access system through primary care physicians
• Care coordinated by CHW Care Managers
• Assistance with State Cancer Aid for those who
  qualify

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Medcen/Komen Partnership

• Over 500 Mammograms
• Detected Several Early Stage Cancers

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Prevention Early Detection
Central Georgia has some of the highest tobacco
use rates in the state 24 - 49
30 of all cancer deaths are related to tobacco
use
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TOBACCO USE PREVENTION PROGRAM

• To extend smoking cessation and education
  programs to underserved counties.
• Partner - American Cancer Society
• Facilitated training - 11 Master
• Freshstart Trainers from 6 counties
• 20 Facilitators trained in Baldwin County
• 13 CHW Care Managers Training
• Georgia Tobacco QUIT Line

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Pan African Festival April 29, 2006PSA
Screenings
Central Georgia Cancer Coalition Medical Center
of Central GA American Cancer Society Phi Beta
Sigma
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• 368 Men PSA screenings
• 36 African American
• 11 prostate cancers
• 2 African American

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Access Continuum of Care

• 2006 Cancer Summit
• for Pastors Religious Leaders
• September 29-30, 2006
• 1500 Pastors are invited
• 2 Day Training and Seminar
• Cancer 101 for Pastors
• Best Practices for Churches and Faith Based
  Organizations
• Facilitating Partnering for Best Cancer Care

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Community Health Works Board of Directors
Central Georgia Cancer Coalition
Rx for the Uninsured
Middle Georgia Multi Share
Community Health Works- Principal Activities
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• HRSA State Planning Grant
• Middle Georgia Multi Share

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HRSA State Planning Grant

• Governor Perdue received a grant to explore the
  abilities of public/private partnerships to help
  the uninsured
• GA was one of 9 states that received the grant
• CHW was one of the 4 communities asked to do the
  research

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HRSA State Planning Grant

• Established Steering Committee
• Held Focus Groups
• Small Business
• Employees
• In Plan Design Phase

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HRSA State Planning Grant

• Received Healthcare Georgia Grant
• Marketing Survey
• Actuarial Study
• Economic Impact Study

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For More Information

• Gregory J. Dent
• President CEO
• Community Health Works
• 105 Patrol Road, Suite 2
• Forsyth, Georgia 31029
• 478-994-1914
• Gdent_at_chwg.org
• www. chwg.org