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September 2011
Linking Clinical Care and Communities for Improved Prevention
AHRQ's Health Care Innovations Exchange held a Web Seminar on Linking Clinical Care and Communities for Improved Prevention on September 1, 2011.

Participants
Host: Judi Consalvo, Program Analyst at AHRQ Center for Outcomes and Evidence

Moderator: Tess Miller, DrPH, AHRQ

Carol Ann King, DNP, FNP-BC, Wayne Action Teams for Community Health (WATCH)
 
LaTonya Chavis Keener, MS, CDC

Read Slides

Listen to the Audio File

Read Transcript
Panel Slides

Download PowerPoint Presentation Slides (PPT, 6.6 MB). (PowerPoint Viewer External Web Site Policy)

Jump to Slides:
Tess Miller 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Carol Ann King 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
LaTonya Chavis Keener 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51

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Linking Clinical Care and Communities for Improved Prevention

Web Seminar
Sept. 1, 2011
Follow this event on Twitter
Hashtag: #AHRQIX

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Using the Webcast Console

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What Is the Health Care Innovations Exchange?

  • Publicly accessible, searchable database of health service delivery innovative strategies and tools
  • Successes and attempts
  • Innovators’ stories and lessons learned
  • Expert commentaries
  • Learning and networking opportunities
  • New content posted to the Web site every two weeks

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Innovations Exchange Web Event Series

How to find archived materials
Go to the Events & Podcasts tab on our site: http://www.innovations.ahrq.gov. A transcript of this event along with the slides will be available in a week.

Next Events
Look for announcements

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Housekeeping

  • For help, notify the Vcall team through the question window at the bottom right hand side of the screen.
  • To refresh your screen, hit f5.
  • Recording, slides, and transcript available on Web site by next week.
  • Today’s slides are available now.

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Submitting Questions

Send a question through the Q & A window.

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Today’s Event Moderator

Tess Miller, DrPH
Director, Prevention & Care Management Portfolio, Center
for Primary Care, Prevention & Clinical Partnerships
Agency for Healthcare Research and Quality (AHRQ)

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AHRQ’s Mission

To improve the quality, safety, efficiency, and effectiveness of health care for all Americans

Health care providers, patients, policymakers, payers, administrators, and others use
AHRQ research findings to improve health care quality, accessibility, and outcomes of care

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Slide 9

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AHRQ’s Portfolios

  • Comparative Effectiveness
  • Health Information Technology
  • Innovations & Emerging Issues
  • Patient Safety
  • Prevention/Care Management
  • Value

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Population Health Outcomes/Functional & Clinical Outcomes Chart

The graphic shows a chart of a health care system model with community, healthcare, and outcomes.

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P/CM Portfolio Strategic Goals

1. To support clinical decision making for preventive services through the generation of new knowledge, the synthesis of evidence, and the dissemination and implementation of evidence-based recommendations

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P/CM Portfolio Strategic Goals

2. Support the evidence base for and implementation of activities to improve primary care and clinical outcomes through:

  • Health care redesign
  • Clinical-community linkages
  • Self management support
  • Integration of health information technology
  • Care coordination

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AHRQ’s Goal

  • To understand whether fostering linkages between clinical practices and community organizations enhances delivery of preventive services and ultimately improves health outcomes
  • To understand how to foster and sustain linkages

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Potential Benefits of Linkages

  • Creating sustainable linkages between primary care and community settings can be a WIN-WIN-WIN
    • Patients: Increased patient access to preventive and chronic care services
    • Clinicians: Ability to refer out to services in the setting where their patients live, work, and play
    • Communities: The services that they work hard to provide will get used more, leading to better care and potentially sustained funding
  • Community settings have the ability to offer intense, ongoing, accessible services that may not be possible in primary care practices

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AHRQ’s Activities

  • Co-sponsor of Prescription for Health
  • First environmental scan and summit 2008
  • 2009-2010
    • Environmental scan
    • Case studies
    • Summit of stakeholders to develop a national strategy for promoting linkages
  • Development of Innovations Exchange page to facilitate the ongoing collaborative work of Summit participants and interested stakeholders

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Conceptual Model for Linkages

The graphic shows a chart describing relationships of building blocks, intervention/innovation, outcomes, and predisposing, enabling, and reinforcing factors

  • Building Blocks
    Organizations and inter-organizational linkages
    • Helth care system
    • Governmental public health
    • Community
  • Intervention/Innovation
    Practice and/or public health/community interventions in delivery system design, decision support, or information systems, for example:
    • Co-locating services
    • Developing referral mechanism to prevension resources
    • Coordinating services at different sites
  • Outcomes
    Short-term (Process)
    • Increased awareness of community resources
    • Increased communication across sectors
    • Improved referral and tracking mechanisms
    • Resource sharing across sectors
    • Increased coordination of services for individuals
      (e.g., changes in practice, greater reach, greater efficiency, new services, sustainability)
  • Outcomes
    Intermediate
    • Improved health behaviors
      (e.g., improved nutrition, increased physical activity, reduced tobacco use)
  • Outcomes
    Long-term
    • Improved health outcomes
      (e.g., obesity, cardiovascular disease, diabetes)
  • Predisposing, Enabling, and Reinforcing Factors
    • Community contex (i.e., politics, funding, policies such as reimbursemnent for services)
    • Organizational capacity (prevention delivery system) (i.e., organization features, practices, and processes; staffing and infrastructure; effective leadership and senior management support; policies; shared decision-making)
    • Innovation characteristics (i.e., adaptability/flexibility; compatibility/fit with provider, organization, community)
    • Provider characteristics (i.e., perceived need for and potential benefits of the innovation, self efficacy, skill proficiency)

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Our Innovators

Carol Ann King, DNP, FNP-BC
Wayne Action Teams for Community Health (WATCH);
Eastern Carolina College of Nursing

LaTonya Chavis Keener, MS
Centers for Disease Control and Prevention (CDC)

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Colorectal Cancer Screening and Tobacco Cessation in a Free Primary Care Program for the Uninsured

Carol Ann King, DNP, FNP-BC
WATCH Lead Nurse Practitioner
Clinical Assistant Professor
East Carolina University College of Nursing

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What is WATCH?
Wayne Action Teams for Community Health

  • Grant and donation-funded since 2000
  • Safety net primary health care for the uninsured
  • No charge to the patients
  • Over 10,000 registered patients
  • 1,000 patient visits per month

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WATCH Mobile Unit

The graphic is a picture of the mobile unit (a large truck with the WATCH logo)

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North Carolina Prevention Collaborative

  • Joint project with Kate B. Reynolds Charitable trust, UNC Dept. of Family Medicine, Wake AHEC
  • 1 year quality improvement program
  • Improvement of office systems
  • CRC screening - only 16% screened
  • Tobacco use very prevalent with high risk population - 40% use tobacco, only 66% offered tobacco cessation

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Why Colorectal Cancer and Tobacco Use?

  • CRC: Third leading cancer diagnosis in 2009
    • 90% survival if localized
    • 68% survival if regional
    • 10% survival with distant metastasis
  • Deaths can be reduced by 33% with CRC screening beginning at 50 (CDC)
  • Socioeconomic and racial disparities
  • High rates of tobacco related mortality and morbidity
  • Can we do the screening and interventions necessary to address these issues?

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Evidence for Interventions

  • Three options: fecal occult blood tests, sigmoidoscopy, & colonoscopy
  • Annual three-card FOBTs done on 3 different samples
  • Referral for positive results
  • Tobacco assessment
  • Stages of Change Model/PDSA Cycle
  • Multilevel interventions

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Partnerships

  • Staff
  • Patients
  • Local Providers
  • Hospital
  • NC State Resources
  • YMCA
    • In-house clinic
    • Mutual Goals
    • Access to mutual services
    • Counseling

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Partnerships

  • Population investment
  • Overall community cost savings
  • Building capacity
  • Mutual benefits and goals

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Recommendations

  • Promote your program
  • Outcomes
  • Integrate into the community
  • Help others with their goals

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Discussion/Implications

  • WATCH able to implement CRC screening
  • CRC Risk Reduction Education
  • Tobacco cessation and reduction focus
  • Committed to the end
  • Trial and error
  • Commitment
  • Integrated into existing workflow
  • Policy and procedure

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Lessons Learned

  • Communicate!
  • Revised patient instructions
  • Training
  • Take advantage of opportunity to screen and educate
  • Patients “buy-in” because provider recommended

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No Such Thing as “Free Care”

  • $773 for the sample
  • $3,500 annually
  • $1600 staffing for sample
  • $8,000 annually
  • $11.87 per patient
  • $475 per polyp detection

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Case Presentations

  • 56 year-old male:
    • Never screened, no known risks, symptoms or signs, positive FOBT
    • Precancerous polyps removed
  • 45 year-old female:
    • 30 year smoker, 2 packs/day
    • Quit and remains tobacco-free
    • YMCA full membership

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Sustainability

  • Build costs into budget
  • Find community partners
  • Local, state, and federal resources
  • Multiple staff trained
  • Reminders
  • Time and repetition

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REACH

RACIAL AND ETHNIC APPROACHES TO COMMUNITY HEALTH

LaTonya Chavis Keener, MS

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Goals for REACH 2010

To eliminate disparities in health status experienced by racial and ethnic minority populations in key areas

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REACH

  • Focus: Cardiovascular Disease & Diabetes
  • Based on disease prevention strategies
  • NW Area of Charlotte (approximately 14 defined neighborhoods)
  • 95% African American

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Making a Difference in Diabetes

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Coalition Partners

  • Carolinas Healthcare System
  • University Park Neighborhood Association
  • Mecklenburg County Health Department
  • Cluster I Neighborhood Leadership
  • McCrorey Family YMCA
  • Substance Abuse Prevention Services, Inc.
  • North Carolina Department of Health and Human Services

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Community-Based Primary Prevention Interventions

  • Risk Factor Reduction
  • Interventions
  • Behavior Changes

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Charlotte REACH 2010: Project Model

  • Lay Health Advisor Program
    • “Neighbors helping neighbors” by providing health information and referral sources in an effort to promote healthy lifestyles.
  • Risk Behavior Intervention
    • Exercise/Fitness
    • Nutrition/Dietary
    • Smoking
    • Primary Care
  • Environmental Systemic Interventions
    • Access to Healthy Food
    • Safe and Available Exercise
    • Accessible Health Care
    • Mass Media

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Making a Difference in Diabetes

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A picture of YMCA

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REACH

"But what it did for me is….help me with my self-esteem. It helped me! I began to exercise, I started at the Y too. I came down here for my financial reasons, I came down here because they have the same things down here as they do at the Y, and I exercise, I learned about nutrition because we have the nutritional program here, and I'm a lot more outgoing. You would never believe that I was very, very, very introverted, very." - Neighborhood Resident

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Neighborhood Farmer’s Market

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REACH

"It's just like a meeting place on Saturday mornings, you know, everybody be up there on Saturday mornings to get your little vegetables, you stand around and talk. Somebody will give you advice on how to cook them." - Neighborhood Farmers' Market Customer

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A picture of CMC Biddle Point

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Percent Reporting Diabetes

Data Analysis by National Opinion Research Center (NORC) and ABT


Year 1 Year 2 Year 3 Year 4 Year 5
Male  17.8  19.3
 21.0  19.0  23.3
Female
 17.7  15.7  19.0  21.1  17.8
Total  17.7  16.9  19.8  20.2  19.9

 

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Impact of Charlotte REACH 2010 on Diabetes:

  • Increased knowledge of diabetes & community resources
  • Healthier eating habits (5 or more servings of fruits & vegetables per day)
  • Greater physical activity
  • Decrease in reported complications
  • Greater adherence to recommendations for eye exams
  • Mixed success in adherence to recommendations for foot exams

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Sustainability

  • Neighborhood-operated Farmers’ Market remains in community
  • Diabetes Nurse position maintained at Carolinas Healthcare System
  • Lay Health Advisors and neighborhood leaders continue to lead efforts

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REACH

"I think overall I think of the community at large, all over everyone is encouraging better health, exercise, eating better, and the fact that we encourage friends and family to come, you know, is a real plus, and I think it's like a snowball effect the more we talk about it, the better we look. As you said we got to walk the walk to talk the talk, and by losing weight, health, and people commenting, you know, it does make a difference." - Charlotte REACH LHA

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Additional Information

http://www.annfammed.org/cgi/content/full/2/2/103

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Innovator Contact Information

  • Carol Ann King: kingca@ecu.edu
  • LaTonya Chavis Keener: lchavis@cdc.gov

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The Innovations Exchange

  • Visit our Web site: http://www.innovations.ahrq.gov/
  • Follow up on Twitter: #AHRQIX

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Listen to the audio file (Flash player download External Web Site Policy)

Transcript

Judi Consalvo
Good afternoon everyone, and to some good morning. I'd like to welcome you to our Web event, Linking Clinical Care and Communities for Improved Prevention. I'm with AHRQ’s Center for Outcomes and Evidence. We are very excited about today's topic and glad to see that you share our enthusiasm. We will be polling you in a few minutes to get a better feel for who has joined us today.

Since some of you may be new to AHRQ’s Health Care Innovations Exchange, I'm going to take a minute to give you an overview before I introduce today’s moderator. The aim of the Exchange is to increase awareness and speed the implementation and uptake of new and better ways of delivering health care, to improve health care quality, and improve disparities. To meet this goal, the Exchange provides a one stop shop Web site that offers free access to searchable descriptions of innovations and QualityTools, learning opportunities, and educational resources. The collection includes evidence based quality improvement innovations, as well as improvement initiatives that did not succeed, providing users with valuable lessons learned from these attempts. Health care professionals can learn about the process of innovation and implementation through articles, perspectives, and adoption guides. Interactive learning events include Web seminars, discussion forums, on line chats and in person meetings. New material is posted to the Web site every two weeks.

Before we get started, we'd like to give our presenters a sense of our audience today, so we're going to post a polling question. Please answer the question on your screen. How would you describe your organizational affiliation? Community based organization staff? Community based organization administrator? Other non profit organization? Public health practitioner? Researcher? Other? Please fill in and we'll get the results back to you. The largest number is “Other” and “Other non-profit organization”. We have 10.8% for Community based organization staff, followed by Community-based administrators, Researchers, and Public health practitioners. Welcome, everyone.

So let's turn to our agenda for today. It's my pleasure to introduce our moderator, Dr. Tess Miller, who leads the Prevention and Care Management Portfolio at the Agency for Healthcare Research and Quality (AHRQ). Her research interests include adolescent reproductive health, child development, community level interventions, and behavior change.

Tess Miller
Thank you very much, Judi. I am delighted to be participating in this Web event today. What I'd like to start out by doing is to help frame why AHRQ is interested in this area. We've actually done a fair amount of work and will continue to work in this important area, but for those of you who may not be as familiar with AHRQ, AHRQ’s mission is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans. We work with a variety of stakeholders to improve the quality, accessibility, and ultimately, outcomes of care.

In 2008, AHRQ did a little restructuring and created six portfolios that are to reflect major areas of interest to the Agency. These are areas that cut across AHRQ's different offices and centers. As Judi mentioned, it's my pleasure to lead the efforts of the Prevention and Care Management Portfolio. When we were formed in 2008, we decided we needed a basis to inform all of our work, and we chose the expanded care model to help us think about how redesign or changes in primary care will lead to improved health outcomes (see slide). I think what's important about this model is that you can see clearly that the health care system is within the larger community, but that it's really important to have an activated community, as well as an activated clinical team, to lead to improved health outcomes. That will give you a sense of why it's important to the portfolio and ultimately to AHRQ that we look at the linkages that can be made between the clinical sector and community resources.

The next slide shows the first of two strategic goals of the portfolio. The first goal is to support clinical decisionmaking for preventive services through the generation of new knowledge, through the synthesis of evidence, and also the dissemination and implementation of evidence based recommendations. An important note here is that our portfolio supports the independent United States Preventive Services Task Force, another reason we're interested in clinical preventive services, and how we can link those clinical preventive services to resources in the community.

We’ve captured the elements of the expanded care model in our second strategic goal, which is to support the evidence base for and implementation of activities to improve primary care and clinical outcomes through health care redesign, clinical community linkages, self management support, the integration of health IT, and care coordination.

AHRQ's goal specific to the area of linking clinical and community resources is to understand whether fostering these linkages will ultimately enhance the delivery of preventive services and lead to improved health outcomes. We're also very interested in understanding how to foster and sustain these linkages.

From what we've learned so far, there is evidence available that suggests there is benefit to linking the clinical sector with community resources. We have found some evidence that shows that creating sustainable linkages leads to wins for patients, clinicians, and communities. Patients can experience increased access to preventive services, as well as improved outcomes. Clinicians are able to refer services out that they may not have time to provide, but also where it may be easier for patients to access them. Finally, for communities and community-based organizations that have worked really hard to provide services, those services will hopefully have better uptake, leading to improved care and potentially a sustained funding base.

I think another important benefit of the linkage is that community settings have the ability to offer intense, ongoing services that may not be provided in a primary care setting.

I’d like to provide a bit of background regarding the work we've done to date, focusing on work done in 2009 and 2010. We were delighted to work with RTI, as well as a really impressive expert panel, to conduct an environmental scan, case studies and a second summit of stakeholders to develop a national strategy for how to promote these linkages. One of the first things that came out of that work was that we clearly identified the need for a place for people interested in this subject to gather and share information, and we were really delighted to work with the Innovations Exchange to create a page to facilitate the ongoing collaboration.

As part of this work we also developed a conceptual model of how researchers and practitioners might think about these linkages, which is presented here. I think it is important to note that we looked at the building blocks of the organizations themselves. We looked at short term processes, such as increasing awareness of community services, both for patients and clinicians; but ultimately we are interested in looking at the long term improved health outcomes from these efforts.

I hope this has given you some background regarding why AHRQ has been supporting work in this area. Now it is my distinct pleasure to introduce our two innovators today. Dr. King is the Lead Nurse Practitioner of Wayne Action Teams for Community Health, or WATCH, a free mobile health care program serving the uninsured in Wayne County, North Carolina. She is also a Clinical Assistant Professor at East Carolina College of Nursing. LaTonya Chavis Keener is Coordinator for the Racial and Ethnic Disparities Institute Pilot Initiative at the Centers for Disease Control and Prevention. She also managed the Charlotte REACH 2010 Cooperative Agreement. With that I'd like to turn the webinar over to Dr. King.

Dr. Carol Ann King
Thank you very much Dr. Miller, and thank all of you for attending. Today I'm going to tell you our story, and hopefully we can learn some lessons that will be beneficial to you in your practice or your area of expertise.

WATCH is grant-funded and donation funded since 2000, and is a primary care center which currently has two sites seeing approximately 1,000 patients a month. We average about 50 patients a day and about 30 new patients a month, so it is a very busy practice. We have two providers. The first site is a 40-foot mobile unit with two exam rooms, a lab, a bathroom, and a little kitchenette, that I drive to 20 different places here in Wayne County during the month. We also have a stationary clinic inside our local YMCA.

We got started with our initiative efforts after we were approached by the North Carolina Prevention Collaborative, to do a one year quality improvement project that focused on primary and secondary disease prevention in primary care and improving outcomes for our population. We are a very rural community with a high rate of uninsured folks, so we were a very good candidate for that. For most measures, such as pap smears, mammograms, pneumococcal pneumonia, and hypertension management, we were doing great; but colorectal cancer screening and tobacco assessment and intervention could use improvement. Only 16 percent of the people that should have been assessed for colorectal cancer screening were actually screened. There is a high rate of tobacco use, but only 56 percent of this group were offered any type of tobacco cessation intervention. There was no formal process for that so we knew that we needed to do something.

We selected these two areas, knowing that we could make improvements. We have such a wide net with 5,000 unduplicated patients- we knew that we could make an impact and that both of these issues, especially tobacco use, were difficult to address and have a lot of associated morbidity and mortality. We had a high risk group, and we knew we could do something, but we didn't know exactly what we could do and we knew that we needed help.

We started looking at the research and we decided that we could feasibly integrate the stool card into our assessment process, and we looked at what was best for colorectal cancer screening. However, for the uninsured, that is pretty much out of reach, so we had to go with the next best plan and then we also opted or tobacco assessment. Fairly simple to assess for, but it's the intervention part of that that was so difficult.

We decided what was realistic and we knew that ethically we had to have a safety net around people that screened positive, whether it be positive stool cards or tobacco use. We needed to find people that would help us and we identified our champions in the community, our stakeholders, our backers, and also what challenges we would face. We used the stages of change model, the Plan-Do-Study Act, rapid cycle of improvement, and the Infusion of Innovation Model, which was very helpful in framing our whole process and our thinking to walk us through some organized steps for improvement. Again, the most important thing we needed to know -- who can help us with this?

So we started looking at our partners. Who is important to us? Of course our staff were, primarily. They were the ones that were going to be implementing this and they needed to be on board. Our patients, of course, needed to be partners with us. The local providers, the hospital, our community hospital, and the other state resources that were already there. Our goal was not to duplicate anything and not to spend our money on anything that was already being provided by a state agency, such as the 1 800 QUIT-NOW line which is available in North Carolina. We had to look and see who was out there. Our biggest partner through this whole process ended up being the YMCA -- our Family Y. It initially started when one of our staff members, who was a member at the Y, started talking, built relationships, and then asked if our patients that smoked could come to the YMCA and use the supervised exercise program as part of our Smoking Cessation Program. They didn't charge our patients and there was no expense to us. So that's how it started. Then we ended up needing an in house clinic, as my truck was going away for repairs, so they offered the YMCA. We built a clinic and we were able to staff that clinic with an extra nurse practitioner once my truck came back. So we maintained that relationship and now we have two full time clinics. Then we took that one step further in saying we needed to help our patients with YMCA membership, so they can go at their convenience because exercise is so key to health. We ended up getting a grant from our local United Way and we now have 100 patients that are able to attend the YMCA at no expense. This is a wonderful partnership and it started with just a casual conversation and continued to build over the course of only one year.

Then we looked at other partnerships, especially our specialists, our gastroenterologists, and our pulmonologists. We needed these people with our high risk population. If they had positive stool cards, we needed to get them referred. So we knew whom -- the providers in the area -- but we weren't quite sure how to link up with them. We worked with this more on a casual basis. For example, one of the providers loved dogs and was a runner. We were able to work with them on a fund raising 5K fun run and dog walk, and we utilized the local dog park, which was this provider's pet project at the time. We helped him with his initiative, which was very successful, and then it ended up evolving over a year or two into a specific 5K run and the proceeds were given to our program (WATCH), to purchase medications for patients that could not afford them, such as medications to help with smoking cessation. These are very expensive, and those people that are uninsured cannot buy $150 Chantix or whatever might be perfect for that patient. Again, a simple conversation ended up really supporting our initiative.

We also knew that we had to be involved in our community. If there was anything going on, we were there. For example, at the Relay for Life, we had a tent. We helped other people and their fundraising or walking -- whatever it took. Our local YMCA does an annual triathlon and we were there. We are volunteers, and we are participating. Even our patients have started volunteering or participating for some of these community events. They see us out in the community, and I think we present a positive role model for them and they're getting involved too. It's nice to see. One key thing that we do is to monitor outcomes. We have multiple different indicators including colorectal cancer, tobacco cessation, intervention, hypertension management, and diabetes management, and we regularly report on those to whoever wants to know. I can tell them where we are on any given day and we celebrate these accomplishments. Every time somebody stops smoking, I have a big board in my office and they get a star. Right in front of them I pull a sticker out of my cabinet and put their star up there. If they lose weight, I put a heart on the board. If they started exercising, I put a heart on the board. We celebrate with the patients and that helps sustain the momentum that is crucial when you're looking at any type of innovation integration and performance improvement effort.

The key thing for us was to keep it simple, and it seems so simple to do colorectal cancer screening -- of course, that's what we're supposed to be doing. But sometimes you just don't feel like you have the time to do everything you're supposed to be doing -- or at least to do it well. We were doing some screening occasionally -- high risk, just really hit and miss. We knew we had to do it, but we just had to keep it simple. We had to work smarter. We had a very critical eye on everything that we were doing, on every penny we spent. Was it useful or was it wasted? There was a lot of trial and error. Again, the rapid cycle of improvement helps with that. For example, our patient instruction material for colorectal cancer screening was not easy for our patients to understand. It came from the manufacturer and had a lot of technical terms. So we rewrote it so that our patients could understand it and provided it in different languages. We had learned quickly when the patients weren't returning the cards correctly, that they did not understand the instructions.

One simple thing I did was to add a column on the problem list, where we list the patient’s diagnoses and medications, to document colorectal cancer screening, tobacco cessation, pneumococcal pneumonia, flu shot, pap smear, mammogram, therapeutic lifestyle intervention, low cholesterol diet, etc. If I had a blank column, I knew I hadn't addressed that, so that was a prompt to talk to the patient about getting their mammogram or their pap smear or their prostate screening.

Key lessons learned: Communicate, communicate, communicate. Talk to people in the community. Talk to your patients. They will tell you what's good and what's bad in health care. They know the burden they are facing and they actually have quite of bit of insight into how you can make things better. I have several patients that help me in a little focus group about stool cards, and I got a lot of good response back. We were able to revise our education based on their responses. Train and retrain yourself and your staff. Take advantage of the opportunity to screen each person as they're sitting in front of you. You may not get another chance to see them again for six months, so take advantage of it while they're there. Recognize the power you have as a health care provider when you introduce health care changes to a person -- that level of respect you've built over time plays a lot in their success. My patients know when they come in I'm going to ask, How are we doing on your smoking? How much are you down to? What's your next goal? As soon as they walk in the door, they get weighed, they get their vital signs taken, and then they're telling me about it. They know it's important.

Just to keep things in perspective -- although we are touted as a free clinic, we know there's no such thing as free care. It does cost somebody something even if the patient doesn't have to pay for it. This slide gives a rundown just on our colorectal cancer screening. For the 200 charts that we reviewed, it cost about $475 per polyp detection. These were all precancerous polyps. But since they are my patients, I consider that invaluable. I would gladly spend the $8,000 we spend annually on blood testing for our colorectal cancer project, to be able to help prevent cancer in a patient.

I have a couple of stories from our patients. I had a nice gentleman, a 56 year old, who came in only because his wife made him. He had no intentions of coming but she kept nagging him, and he finally did just to get her off his back. He was very resistant to colorectal cancer and prostate screening -- he just did not want to know and didn't feel like it was important. After working with him at just a few visits, he agreed. He did have positive stool cards and we were able to get him to a gastroenterologist. He was scoped and had precancerous polyps. So he is our leading champion for colorectal cancer screening -- he believes that this project saved his life.

One patient smoked since she was a teenager and had no intention of stopping when we first started working together. After about six months she quit cold turkey and decided she was done with it, and she still remains tobacco free. That was over two years ago. She is one of our poster people, I guess you could say. She has a full membership at the YMCA and she has her family working on exercise. She runs a church group that works on exercise. It’s just amazing to see the trickle effect of one little step and how it grows -- it's wonderful.

The key is sustainability -- can you continue to do that once your initial two year grant is done? We didn't receive any grant funding for the colorectal cancer screening, we just had to integrate that into our budget -- but many programs are grant funded. We had to learn how to build the cost of the programs that we felt were essential into our budget, and the community partners were huge in that because when it comes to funding, it's the gastroenterologist now standing in front of our city board asking for $5,000 for the WATCH van. They are the ones out there advocating for us. Frequent reminders were important to me as an individual -- I had post-it notes literally in every cabinet, inside my prescription pad, and I had a poster inside my office so that colorectal cancer and tobacco screening were at the forefront of my brain. Once we had the process hard wired, we were able to transfer that knowledge into other areas such as the pneumococcal pneumonia vaccine, flu shots, pap smears, mammograms, and prostate screening. It was so easy using that checklist. Now our visits are primarily health promotion as opposed to disease management. We do that also; but the biggest focus is on health promotion because we know that's how we make a healthier community. We have a small clinic, but we feel we are part of the community and we just keep trying to find ways that we can reach people and help them be healthier.

That wraps up my presentation and I'm going to turn it over to Miss LaTonya Keener.

LaTonya Chavis Keener
Thank you so much, and thank you everyone for joining us today. I'm going to talk about the Racial and Ethnic Approach to Community Health Program, called REACH 2010. This was a cooperative agreement with CDC, and this particular initiative took place in Charlotte. We were one of 40 throughout the country. The goal of REACH was to eliminate health disparities in minority populations, and our charge as a grantee was to build coalitions, mobilize communities, and work with agencies and organizations in our community, which was an area that was about 95 percent African American, consisting of 14 neighborhoods with their own government systems. We targeted heart disease and diabetes as our primary areas of focus.

The major foundation of the REACH project was about building community coalitions and this slide shows a picture of some people that were part of the coalition in Charlotte. It was different than any other coalition in the area at that time because of the types of partnerships that were developed. You can see on this slide the types of organizations that were included. In previous years, many of these organizations may have done a particular event or were called upon as a resource in one way or another -- but to sit at a table with community, with laypeople, and talk about the issues in the community and how we were going to approach them together in this grant initiative, was something that was very different. It was a very rewarding experience for everyone involved.

This slide gives an idea of what our model looked like for the initiatives, and because this was really about community, community coalitions, and mobilization, we used the Lay Health Advisor model as a foundation for the work. We trained neighborhood people that lived in the community that were familiar with the issues and their neighbors. We educated them on everything from heart disease and diabetes to social service resources -- you name it, anything related to prevention in public health, they were provided information on. We looked at the particular behaviors that needed to be improved in this particular population and we provided a professional staff person that either worked in the health department system, in the YMCA, or in the hospital system to give some additional backup to the lay health workers in the type of education that they were delivering in the community. These people were 100 percent employed by the grant and their role was to educate the community. If that meant doing cooking demonstrations or nutrition sessions, diabetes education, or physical activity initiatives, that’s what they did.

This was different than what had happened previously in the Charlotte community, where many of the staff were in different organizations, but working together. We were all on one team working in different organizations that had their own way of operating, but we found a way to manage it so that the needs of the lay health workers that were going out in the community every day providing education were the priority. We were able to work together to make sure that was always happening, and for the benefit of the community, definitely. This slide shows a picture of the lay health workers. We trained over the course of seven years around 40 or 50 community workers that worked for $10 an hour for ten hours a week. It was not a full time job for them, but they absolutely took it very seriously. Most of them were seniors, and most of them had lived in the community for 30, 40, sometimes even 50 years, and had done some type of community mobilization, but wanted to take it a step further as it relates to health.

This slide shows a picture of the McCrorey Family YMCA, which has a rich history in this particular community in Charlotte, and they were a natural partner in this endeavor and the community was really excited about the partnership because many people had wanted to be a part of the YMCA, but they couldn't afford it. It was an opportunity for them to go to the YMCA and participate in water aerobics and land aerobics from the YMCA staff. They also provided some exercise classes in a community center that provided easier access for the community to attend. It also was a bonus for people that lived in these particular zip codes to participate in REACH initiatives, and it was a very positive experience for many of them. You can see just by the quote on this slide that it provided them with a feeling of being a part of community. For many of them, because of the rich history of the YMCA, it was a very, rewarding experience that led to other health benefits in their lives.

The neighborhood farmers’ market was probably one of the flagship initiatives other than the lay health workers in this project, and developed out of need, but also from the community's desire to have a farmers’ market. The community's desire was actually in existence before REACH came along, but while sitting at the table and discussing what the initiative would look like, this was something that the community really felt like they needed to have. And so a partnership developed with the health department in this particular community, and the farmers’ market was held on the grounds of the health department, which was in a very good location in the community. It also provided an opportunity for the health department to be open on Saturdays, which is when the market ran, and it assisted the health department in providing screenings and meeting the needs of a population that they may not have met previously for one reason or another. The farmers’ market became a place that was not just about fresh fruits and vegetables, but about receiving additional information. It also became a part of the community and something that people really looked forward to, and a place where they knew they could go to get questions answered. The farmers’ market was staffed completely by the community members. After about the second season of the farmers’ market, the REACH coalition turned the market over completely to the community. So, it was something that was sustainable after the project ended and this was a very proud moment for the community.

This slide shows the Middle Point Family Practice Center that is a part of Carolinas Medical Center, the fiscal agent on this project. This was not an urgent care facility, though many of the neighborhood members thought it was. Part of the role of the lay health workers was to educate the community about what types of resources were available to them, whether it was just having a primary practitioner, or about going to get screened for diabetes, or anything else they may have been dealing with. We had a full time diabetes educator who was a registered nurse in this particular facility, and her role was to not just educate the community on diabetes prevention and maintenance, but also to work with patients directly to assist them in their management efforts and to provide additional resources. Part of our job was educating people about this facility and getting them to go there. This slide shows some of our reporting on diabetes. We think that the increase in numbers that were reported here was because there were more people that were actually going as part of our desire to meet those needs.

Here are some additional impacts of the Charlotte REACH 2010 initiative in Charlotte. These are definitely not exhaustive, but list just a couple. There were many unintended positive outcomes from the initiative, but some of the largest were related to an increase in physical activity and people feeling like they were safe and had a place to go to participate, as well as eating more fresh fruits and vegetables daily as a result of being able to purchase them at the farmers’ market.

I mentioned that the farmers’ market was turned over to the community, which was by design, and it remained intact after the program ended in 2007. The farmers’ market at that particular location lasted for about two more seasons and then there was construction on the grounds of the health department, so they had to move. Since that time other farmers’ markets have been developed and they have used our experience and information in order to make sure that they were on the right track. It was still a very successful initiative, even though they had to move location. There is still a farmers’ market in the area and there are still ongoing efforts to improve and to increase the number of farmers’ markets in the area.

The diabetes nurse position at Carolinas Health Care System was maintained, and it was not a full time position prior to REACH coming aboard, but after REACH ended, they saw the impact that having a person dedicated to diabetes management had in their family practice facilities, and so they decided to maintain the position.

Our lay health workers are still providing information on leadership initiatives and leadership groups in the community. They may not necessarily be REACH lay health advisors, but they are still leading efforts in their community and talking about health and prevention to their neighbors.

This initiative was about many different things -- it was definitely about community and coalition building; it was absolutely about prevention and reducing health disparities. But it was also about a community connecting in a way that they had before, but they had lost some of that. There were many lay health workers and many members of the community that were able to take the REACH experience and everything that they learned and apply it to many different areas. Some of them went into politics. Some of them got different jobs doing different things. And a lot of that was because of the experience and the education that they gained by being a part of it.

There were also publications written on our initiative that describe the lessons learned, our successes, our challenges, and this is a link that provides some additional information that you can access.

With that, I'm going to turn it back over.

Tess Miller
This is Tess Miller and thank you very much for those interesting presentations. We do have some questions from the audience.

I want to start with a relatively general question that was asked and pose it to each of you, if you might give a relatively short, two or three minute answer. Are there some kinds of health initiatives that more easily attract partners or more easily have partners that are ready to engage? 

LaTonya Chavis Keener
I think it depends on the climate and it depends on resources -- it depends on the climate not only locally, but nationally and what might be going on. In our experience, the community had typically done some type of activity, maybe once a year. They had a walk once a year that was sponsored by one of the organizations, so that was something that the community expected. But to galvanize and mobilize in a way that was collective, all year round, every day, and that included educating and preventing particular diseases, it was something very different. I think in this particular community we could have focused on other diseases as well and I think that they may have responded the same way, and that was just in my experience. It may be different in others.

Tess Miller
Carol Ann, have you found that there are some types of health initiatives that are easier to attract partners to work with you on?

Dr. Carol Ann King
Well, I think it all depends on you and what you're passionate about, because it is your passion and drive that motivates other people. Colorectal cancer is not a really hot topic with most people, but we felt so strongly about it that that energy was contagious. So it really depends on what is in your heart, because this is something you will live day in and day out for a long time. You need to find whatever you feel like you can push and want to push, and what's worth the energy is what will succeed. Your partners will feed off of that energy. So it is very specific to you, your area, your community, your program. Whatever your passion is, is what will succeed.

Tess Miller
Thank you. Several of the people listening have some questions for you, Carol Ann, about your mobile medical unit, and those questions include “What programs does it provide, and how is it staffed?” They'd also like to know if you receive referrals from other primary care providers or patients via word of mouth and/or any promotion that you do.

Dr. Carol Ann King
Our staff has two full time nurse practitioners -- myself and one other. There is an Executive Director that basically is our grant writer and she's in charge of our funding. The other staff includes medical office assistants and CNAs. On my truck on any given day, I usually have a volunteer, myself and a medical office assistant. At the Y we have the nurse practitioner and a medical office assistant.

We do have an administrative assistant at the office that helps with paperwork, referrals, answering the phones, in and out records and things like that. We have ten total employees at WATCH -- so a very small staff.

We do get a lot of referrals for people that are uninsured that present at specialty practices or primary care practices, and they realize they can't really afford the office visit and the expensive care, and so they'll call us and we'll get them integrated into our program. We take a minimum of 30 new patients a month. We do not need to advertise. I have probably 15 phone calls for new patients every day and obviously we can't absorb that many. There is no marketing besides the big signs on the truck. Everybody in the community knows who we are. There are people that will see the truck and pull in behind me, and I usually have a little caravan when I'm pulling into my site that's followed me there. I guess that's about the best advertising. But we have no marketing budget at all and don't need any. We've been established now for 11 years and have no lack of patients and supporters. Did that answer the question?

Tess Miller
I think so -- thank you. LaTonya, a couple people listening would like to know, how were the health care workers recruited in REACH?

LaTonya Chavis Keener
They were recruited in a couple different ways. The neighborhood itself was divided into 14 different communities or neighborhoods and they had their own government systems, so the neighborhood leadership from those 14 communities basically provided names of who they wanted to represent their neighborhoods. These neighborhoods are in very close proximity to one another. We did have an application process and they did have to come in for an interview. But the neighborhood leadership's desire for who they wanted weighed very heavily on who was chosen as a lay worker in their community. If someone had to rotate off for whatever reason, we would go back to that neighborhood leader and ask if they had someone that they wanted to fill in that place, and then we would train that person.

Tess Miller
Thank you. I think we have time, Carol Ann, and I have one last quick question for you. When you celebrate the accomplishments of patients, do you give the patients permission to post their names on the board? Who sees the board? One of the listeners was just curious about patient confidentiality when you're celebrating accomplishments.

Dr. Carol Ann King
We don't post their names up there. I have stars and hearts, so they know that's their star, but there aren't any names. It's a big white board divided into sections based on that accomplishment and it's a star sticker or a heart sticker based on what they do.

Tess Miller
Great, thank you very much. We're getting very close to the end of our session, and I'm wondering, Judi, if there are any other instructions before the webinar comes to an end.

Judi Consalvo
Thank you, Tess. I just want to say a few more words. Yes, we are out of time. And we just want to remind everyone to remember to complete the web event evaluation that will be coming up soon. It helps us improve our offerings. I want to thank our presenters for some very interesting presentations and Tess for moderating. Feel free to contact our innovators with questions about their innovations, including some of those questions we may not have gotten to, and as always, we invite you to visit our Web site and follow us on Twitter for all of the latest developments. You can also contact us at any time at info@innovations.AHRQ.gov. Again, thank you all for joining us.