Excerpts From Dr. Novak's Presentation to Center for Diabetes Care Steering Committee February 2020 Western Hospital's Mission and Vision Mission: Deliver safe, high-quality, cost-effective, patient- and family-centered care, regardless of one's ability to pay, with the goal of improving the health of the community it serves. Vision: Provide patient- and family-centric care in a highly efficient manner with exceptional quality and safety outcomes for the benefit of the residents of the community. Demographic Data for the Center for Diabetes Care Population of: Jefferson County: 1,841, 325 Middletown: 690, 392 Lowertown Neighborhood: 10,546 Population of Lowertown by Ethnicity Population of Lowertown by Age 14% 15% 71% 896 9% 39% 20% 24% Hispanic White African American 0-18 years 19-25 years 26-45 years 46-64 years 65+ years Center for Diabetes Care Community Education Programs Classes will be available in both English and Spanish! Free, 8-Week Diabetes Self-Management Education Series (will be offered at several community locations) If you or someone you care about is pre-diabetic or has been diagnosed with diabetes, then this 8-week educational program is for you! Each class teaches important health and lifestyle information to help you live better and manage your diabetes. Topics include: Getting to Know Diabetes Staying Well With Diabetes - Basic Nutrition and Goal Setting . - Stress, Depression, and Diabetes Physical Activity Medication Management for Diabetes How to Prevent Diabetic Complications Free, 6-Week Diabetes Kitchen Classes Learn the tasty secrets to cooking healthier meals, including your family's favorites. These classes will teach you the skills you need to better control or even prevent diabetes. This free, 6-week class is available to anyone who has pre-diabetes or has already been diagnosed with diabetes. You are also welcome to attend if you do not have diabetes-but you will cook for someone who does. Health Fairs and Community Events The program will provide diabetes education and glucose screenings at local health fairs and other community events as time, budget, and staffing allow. Center for Diabetes Care Program Structure Dr. Chris Novak, MD, Program Director: - - Provide organizational leadership. Define strategy and goals. Consult on complex clinical issues. Establish and refine policies and procedures. Represent the Center for Diabetes Care to the medical community and the patient community. Collaborate with the board of Western Hospital and the Center for Diabetes Care's steering committee. Nurse Practitioner: - Provide clinical support for less complex cases. Supervise community educators. - Lead the community education program. - Drive the creation of the best practices database. Four Community Health Workers: - - - - - Serve as bridges between the healthcare system and people living with and at risk for diabetes. Provide support for diabetes control programs, community-based organizations, and other agencies instrumental in establishing these links. Promote actions that enable community members to access care that meets standard recommendations for diabetes care and prevention (e.g., annual eye exams and foot exams, regular A1C testing). Develop and communicate culturally and linguistically appropriate messages on diabetes self-care and community action. Provide social support to community members as they adapt their lifestyles, through counseling and motivational interviewing. Mobilize their communities for social action to address diabetes. Receptionist: - Schedule appointments. Welcome patients. Manage the office. Bill insurance for services rendered. Center for Diabetes Care Marketing Marketing Strategy: Strategy and Tactics The strategy is to promote awareness within the target market. Marketing Budget: The steering committee anticipates that the marketing budget will be in the range of $40,000. The team will have to be creative to accomplish its goals on this budget. Intention is to leverage social media platforms when possible. Target Market: There are two groups that the marketing must reach. The first group is healthcare providers in the community who will refer patients to the Center for Diabetes Care. The second is the Hispanic population, 65 years of age or older, in Lowertown diagnosed with Type II diabetes and their primary caregivers. Marketing Tactics: For healthcare providers: Host a lunch for key general practitioners and specialists at Bobby Fly's (local celebrity chef) restaurant. He will serve a healthy Mexican lunch while Dr. Novak explains the program. Deliver the Center for Diabetes Care brochures to the staff of general practitioners and specialists likely to refer patients. For diabetes patients and their families: Host ribbon cutting by Rosa Sanchez, State Senator, followed by press release and news stories in local papers. . Arrange a lunch hosted by Rosa Sanchez for church leaders and other key influencers. Conduct radio spots on Spanish language radio. Target online ads to primary caregivers. Print ads in local Spanish paper. Excerpts From COMMUNITY HEALTH NEEDS ASSESSMENT Western Hospital PUBLISHED MAY 2019 1. EXECUTIVE SUMMARY The Patient Protection and Affordable Care Act (PPACA) or as known as the Affordable Care Act (ACA), enacted by Congress on March 23, 2010, stipulates that non-profit hospital organizations complete a community health needs assessment (CHNA) every 3 years and make it widely available to the public. This assessment includes feedback from the community and experts in public health, clinical care, and others. This CHNA serves as the basis for implementation strategies that are filed with the Internal Revenue Service (IRS). The IRS requires that the hospital conduct a CHNA and adopt an implementation strategy for each of its facilities by the last day of its first taxable year beginning after March 23, 2012. For Western Hospital that tax year is April 1-March 31. The CHNA may be conducted in that same year, or in the 2 years immediately preceding the year in which these become effective. This CHNA report documents how the 2019 CHNA was conducted, as well as describes the related findings. Process & Methods The Jefferson County Community Benefit Coalition ("the Coalition") members, a coalition of eight local non-profit hospitals and other partners, began conducting their third CHNA process in 2018. The Coalition's goal was to collectively gather community feedback, understand existing data about health status, and prioritize local health needs. Community input was obtained during the fall of 2018 via key informant interviews with local health experts, focus groups with community leaders and representatives, and resident focus groups. Secondary data were obtained from a variety of sources. In November 2018, health needs were identified by synthesizing primary qualitative research and secondary data, and then filtering those needs against a set of criteria. Needs were then prioritized by the Coalition, using a second set of criteria. See the results of prioritization included on the next page. The Coalition met again in December 2018 to identify resources in the community, including hospitals and clinics, and special health and wellness programs. Prioritized Needs Based on community input and secondary data, the Coalition generated a list of health needs, and then prioritized them via a multiple criterion scoring system. These needs are listed below in priority order, from highest to lowest. Note that the cross-cutting driver, Access to Health Care, was not included in the prioritization process but is part of the set of health needs. County Health Needs Identified by CHNA Process, in Order of Priority 1. Diabetes is a health need as marked by high rates of diabetes among adults in the county. For example, county-wide, diabetes prevalence is at 8% (no better than the state average) but for 2019 Community Health Needs Assessment (CHNA), the county's Latino and African American population, diabetes prevalence is 14%. Drivers of diabetes rates include poor nutrition and lack of exercise, and physical environment, such as availability of fresh food and fast food. 2. Obesity is a health need as indicated by high rates of obese youth (24% -31%) and adults (21%) in the county, and high rates of overweight youth and adults, as well (14% and 36% respectively). Overall rates miss the Healthy People 2020 targets. Latino and Black/African American residents have the highest rates of overweight and obesity. Drivers of obesity are poor nutrition and lack of exercise, and physical environment such as availability of fresh food and fast food. 3. Violence is a health need because the rate of youth homicide (7.4%) is higher than the Healthy People 2020 target. In addition, the county has seen a large increase in homicides in the years 2016-2017. Domestic violence and child abuse rates also miss the benchmark for some ethnic subgroups. Drivers of this health need include mental health and social determinants of health such as poverty and unemployment. 4. Poor Mental Health is a health need because of self-reported poor mental health (17%) among county residents, higher than the state average. Also, youth of color are disproportionately depressed and suicidal. Community input indicates high concern about stress and depression specifically. 5. Poor Oral/Dental Health is a health need as indicated by the percentage of youth reporting their teeth were in fair or poor condition (16%), which is worse than the state average (12%). Also, some ethnic subgroups are less likely to have dental insurance, which is a driver of poor oral health. 6. Cardiovascular Disease, Heart Disease, and Stroke are a health need, as they are among the top 10 causes of death in the county. The overall rate of high cholesterol in the county (29%) is higher than the Healthy People 2020 target (17%), as are the rates for all ethnic populations. Related to poor cardiovascular health are the health behaviors of smoking, drinking, poor nutrition, and lack of exercise. 7. Substance Abuse (Alcohol, Tobacco, and Other Drugs) is a health need because youth and adults have higher rates of binge drinking (12% and 25% respectively) compared with Healthy People 2020 targets. Youth marijuana use is also high. Drivers of substance abuse include poor mental health and lack of treatment/access to care. 8. Cancer is a health need; incidence rates for breast, cervical, liver, and prostate cancers are higher than benchmarks/state averages. Certain ethnic subgroups experience different incidence and mortality rates. For instance, the overall county liver cancer mortality rate is 6.8%, compared with 5.6% for the state, and even worse for county Latinos (9.0%) and Asian/Pacific Islanders (11.9%). Contributing factors to cancer are health behaviors such as smoking and drinking, and lack of screening contributes to mortality rates. 9. Respiratory Conditions are a health need as indicated by the high asthma hospitalization rate of children ages 0-4 (24.5 per 10,000). Asthma prevalence among county adults is no better than the Healthy People 2020 target of 13% and should be monitored. 10. (Not included in prioritization process) Cross-Cutting Driver: Access to Health Care Services is a health need in the county because socioeconomic conditions (poverty, low levels of education, lack of health insurance) as well as factors, such as the size of the healthcare workforce, linguistic, and transportation barriers all affect access to care, which negatively impacts health. Next Steps After making this CHNA report available to the Public in June 2019, Western Hospital will develop an implementation plan based on this data. 2. INTRODUCTION/BACKGROUND Purpose of CHNA Report and Affordable Care Act Requirements Enacted on March 23, 2010, federal requirements included in the Affordable Care Act (ACA) stipulate that hospital organizations under 501(c)(3) status must adhere to new regulations, one of which is conducting a community health needs assessment (CHNA) every 3 years. The CHNA Report must document how the assessment was done, including the community served, who was involved in the assessment, the process, and methods used to conduct the assessment, and the community's health needs that were identified and prioritized as a result of the assessment. As part of the tri annual CHNA assessment, hospitals must: Collect and take into account input from public health experts as well as community leaders and representatives of high need populations including minority groups, low-income individuals, medically underserved populations, and those with chronic conditions. Identify and prioritize community health needs. Document a separate CHNA for each individual hospital. Make the CHNA report widely available to the public. Adopt an Implementation Strategy to address identified health needs. Submit the Implementation Strategy with the annual Form 990. Pay a $50,000 excise tax for failure to meet CHNA requirements for any taxable year. 3. ABOUT WESTERN HOSPITAL Western Hospital is a 358-bed acute care, community hospital located in the heart of the largest city in Jefferson County, the county with the largest population in the state. We provide care for the youth, adults, and elderly living in the county. Our key services include cardiac, stroke, emergency, orthopedic and joint replacement, women and children, and wound care. In an effort to provide services to patients who are less fortunate, Western sponsors programs such as the Health Benefits Resource Center and the Family Medicine Residency Program. Community Served Demographic Profile of Community Served Western Hospital serves Jefferson County, which has 1.84 million residents. The county's six cities contain 95% of the population; more than one third (37%) of the county's residents (53%) live in the city of Middletown. Diversity Western Hospital is within the top 5% of all U.S. counties in terms of racial and ethnic diversity. According to the 2010 U.S. Census, the racial and ethnic composition is 35% White, 32% Asian, 27% Latino, 2% African American, and 3% indicated they were two or more races. No one racial or ethnic classification is a majority within the county. Of those who selected Asian, the predominate subgroups are: 27% Chinese, 22% Vietnamese, 21% Asian Indian, and 18% Filipino. The vast majority of those who selected Hispanic are Mexican (84%). Thirty seven percent of the county's population is foreign born, compared to 27% of the state's population. Of those foreign born, 61% were born in Asia and 27% were born in Latin America. In the county, 50% of the population speaks a language other than English at home Gender and Age According to the 2010 U.S. Census, women (49.8%) and men (50.2%) make up equal proportions of the county population. The median age of a county resident is 36 years old, which is slightly younger compared to the overall age composition of the U.S. Young people (ages zero to 19) make up about 26% of the county's population, and 38% of households have individuals under 18 living in them. The younger population is more diverse than the overall county population: 37% is Hispanic, 31% is Asian, 24% is White, and 5% is Multiracial. Residents, aged 65 and over, make up 12% of the county's population. The fastest growing age group in the county is 85 and over; the aging resident trend is expected to continue. In the county, 23% of households have individuals over 65 living in them. Poverty Although the median annual income in the county is high at approximately $89,064, 9.2% of the population lives below the federal poverty level. In 2019, the federal poverty level for a family of two adults and two children was $25,750. According to the federal poverty level, only 6% of seniors are considered poor with an individual annual income below $10,201. But, according to the State Elder Economic Security Standard Index, nearly half of the county's older adults (48.4%) are economically insecure. The Index measures how much income is needed for a retired adult age 65 and older to adequately meet his or her basic need including housing, food, out-of-pocket medical expenses, and transportation. (Sections eliminated) Summarized Descriptions of Prioritized County Community Health Needs Access to healthcare is a health need in Jefferson County as marked by the proportion of the community who are linguistically isolated. In addition, there are areas with low educational attainment, which also impacts health outcomes. The community input indicates that underinsurance and lack of insurance coverage is an issue. Lack of transportation is also an access barrier that affects those in poverty. Stigma and lack of knowledge both impact the seeking of preventative care or treatment. Also, too few general and specialty practitioners, especially in community clinics, results in long wait times for appointments. These issues around lack of access contribute to community members using urgent care and emergency rooms for treatment of conditions that have worsened due to lack of treatment or preventative care. Diabetes is a health need in the county as marked by relatively high rates of diabetes. The overall adult rate meets the HP 2020 benchmark, but Latino and African American residents are disproportionately diabetic and worse off in comparison with the county and state averages and benchmark. Of all ethnic groups, African Americans experience the highest percentage of hospitalizations due to diabetes. Community input about diabetes was strong and expressed the connection between the disease and related health behaviors, such as poor nutrition and lack of physical activity. The health need is likely being impacted by health behaviors, such as low fruit and vegetable consumption, soda consumption, the proximity of fast food establishments, and a lack of grocery stores and WIC-authorized food sources. Prioritization of Health Needs Before beginning the prioritization process, the Coalition chose a set of criteria to use in prioritizing the list of health needs. The criteria were: 1.2.3.4. Clear disparities/inequities exist among subpopulations in the community. An opportunity to intervene at the prevention or early intervention level. A successful solution has the potential to solve multiple problems. The community prioritizes the issue over other issues. Scoring Criteria 1-3: The score levels for the prioritization criteria were: 3: Strongly meets criteria, or is of great concern 2: Meets criteria, or is of some concern 1: Does not meet criteria, or is not of concern A survey was then created, listing each of the health needs in alphabetical order and offering the first three prioritization criteria for rating. Coalition members rated each of the health needs on each of the first three prioritization criteria during an in-person meeting in November 2018. Prioritization scores are based on the results of the primary data gathering process. The score levels for the fourth prioritization criterion were: 3: Health need was prioritized by more than half of the key informants and focus groups. 2: Health need was prioritized but by half or fewer of the key informants and focus groups. 1: Health need was mentioned by at least one key informant or focus group but not prioritized by any. Combining the Scores: For the first three criteria, coalition members' ratings were combined and averaged to obtain a combined coalition score. Then, the mean was calculated based on the four criterion scores for an overall prioritization score for each health need. List of Prioritized Needs The need scores ranged between 1.4 and 3.0, with 3 being the highest score possible and 1 being the lowest score possible. The needs are ordered by prioritization score in the table below. The specific scores for each of the four criteria used to generate the overall community health needs prioritization scores may be viewed in Attachment 8. Note that while the coalition prioritized access-related drivers, the cross-cutting driver, access to healthcare services, was not scored during the prioritization process. Health Needs by Prioritization Score Health Need Overall Average Priority Score Diabetes 3.0 Obesity 2.9 Violence 2.6 Poor Mental Health 2.6 Poor Oral/Dental Health 2.5 Cardiovascular Disease, Heart Disease, Stroke 2.4 Substance Abuse (Alcohol, Tobacco, and Other Drugs) 2.4 Cancers 2.2 Respiratory Conditions 2.0 STDS/HIV-AIDS 2.0 Birth Outcomes 1.6 Alzheimer's 1.4 Adapted from: O'Connor Hospital. (2013). Community health needs assessment: O'Connor Hospital. Retrieved from http://connor.dochs.org/wp- content/uploads/sites/2/2013/06/Fiscal-Year-2013-Community-Needs-Assessment.pdf Projected Patient-Generated Revenue by Payer Fiscal year from April 1 to March 31 average number of charge per amount collection Year 1 visits visit* total charges billed rate income Medicaid 1,250 $62.50 $78,125 $ 78,125 95% $74,219 Medicare 2,500 $70.59 $176,475 $ 176,475 95% $167,651 Private Insura 100 $95.00 $9,500 $ 9,500 80% $7,600 Self Pay (slid 50 $75.00 $3,750 $ 3,750 40% $1,500 3,900 $ 267,850 $250,970 *Includes all adjustments and any co-insurance amounts for all visit types number of average charge per Year 2 visits visit* total charges amount billed collection rate income Medicaid 1,750 $62.50 $109,375 $109,375 96% $105,000 Medicare 3,500 $70.59 $247,065 $247,065 96% $237,182 Private Insura 400 $95.00 $38,000 $ 38,000 85% $32,300 Self Pay (slid 200 $75.00 $15,000 $15,000 45% $6,750 5,850 $ 409,440 $381,232 *Includes all adjustments and any co-insurance amounts for all visit types average number of charge per Year 3 visits visit* total charges amount billed collection rate income Medicaid 2,000 $63.75 $127,500 $ 127,500 98% $124,950 Medicare 3,800 $72.00 $273,607 $ 273,607 97% $265,399 Private Insura 900 $96.90 $87,210 $ 87,210 90% $78,489 Self Pay (slid 500 $76.50 $38,250 $ 38,250 50% $19,125 7,200 $ 526,567 $487,963 *Includes all adjustments and any co-insurance amounts for all visit types Projected Grant Funding by Source Year 1 Year 2 Year 3 PPHF Grant $100,000 $100,000 $100,000 Foundation Grants $75,000 $ 50,000 Total $175,000 $150,000 $100,000 Projected Non-Staffing Costs Year 1 Year 2 Year 3 Fringe Benefits $ 59,609 $ 60,802 $ 62,018 Travel Training Equipment Supplies Contractual Allocated Rent Depreciation Insurance Overhead Allocation Uncollectible Income Marketing eseses es es eseseseseses $ 5,000 $ 5,000 $ 10,000 $ 35,000 $10,000 $ 15,000 $ 5,000 $ 2,000 $ 2,000 $ 15,000 $ 15,300 $ 15,606 $ 8,000 $ 8,160 $ 8,323 $ 23,418 $ 23,769 $ 24,126 $ 26,277 $ 35,036 $ 35,036 $ 4,004 $ 4,204 $ 4,414 $ 9,167 $ 9,442 $ 9,725 $ 21,281 $ 39,865 $55,177 $ 45,000 $ 15,000 $ 15,000 Indirect Charges $ 54,764 $ 56,955 $ 59,233 Total $ 311,520 $ 285,533 $ 315,659 Projected Staffing Costs Annual Salary Endocronologist Contract Specialists FTE Year 1 Year 2 Year 3 0.93 $ 158,000 $ 165,900 $ 174,195 75,000 $ Nurse Practitioner 84,094 $ Community Health Workers Reception/Office Management 1.00 $ Total 0.30 $ 0.95 $ 4.00 $244,000 $ 35,000 $ $ 596,094 $ 618,287 $ 641,371 78,750 $ 82,688 86,617 $ 89,215 251,320 $ 258,860 35,700 $ 36,414 Projected Capital Costs Year 1 Year 2 Year 3 Server $ 15,000 Remodel of Office Space Security System Furniture Practice Management System Computers & Cabling Total esssssssss $ 98,550 $ 2,654 $ 12,281 $ 1,000 $ 1,000 $ 5,000 $ 2,500 $ 2,500 $ 41,696 $ 175,181 $ 3,500 $ 3,500 Interview with Dr. Novak to Discuss the Center for Diabetes Care After you are assigned to the project as lead consultant, you meet with Dr. Novak to discuss the Center for Diabetes Care. You: Dr. Novak, it's great to meet you. I've been looking forward to our discussion. Dr. Novak: The pleasure is mine. Before we start, here's some information that you'll need. I've included an excerpt of Western's Community Health Needs Assessment, which will give you background information on our patient population. There are excerpts from a presentation I gave to our steering committee. The excerpts cover the program structure, marketing plans, timeline, and Western Hospital's vision and mission. I've also included the financial projections for the Center for Diabetes Care. Finally, there are two excellent articles for your reference. You: Great. Thanks for putting this together. I know we've got a lot to discuss. I'd like to start by learning about why you decided to start the Center for Diabetes Care. Dr. Novak: As you know, I'm an endocrinologist, and I've treated many Hispanic patients. This is partly because of my language skills and partly based on my clinical interests. When patients receive a diagnosis of Type 2 diabetes, they have to navigate a complex and often intimidating healthcare system. They may require treatment by multiple specialists. Managing Type 2 diabetes can be confusing and overwhelming for any patient. I've seen countless patients suffer needless medical complications because they did not receive appropriate treatment or preventative care for Type 2 diabetes. In many cases, Hispanics with a diagnosis of Type 2 diabetes face even more challenges than other patients. Why? For many of my patients, there is a language barrier. But the barriers to my Hispanic patients getting proper care for diabetes go beyond a language issue. The issue is a complex combination of culture, accessibility, healthcare literacy, and finances. My colleague Dr. Campos wrote an excellent article titled "Addressing Cultural Barriers to the Successful Use of Insulin in Hispanics With Type 2 Diabetes" that explores this in detail. I've included it in the file I gave you. I have also included an article that outlines the state of Diabetes Prevention Policy Post Affordable Care Act that I believe you will find very helpful. You: Why are you launching the program now? Dr. Novak: As you can see, this is an issue I am passionate about. I've been tinkering with this concept for some time. New sources of grant funding are available since the passage of the Patient Protection and Affordable Care Act in 2010. When I learned about the Patient Protection and Affordable Care Act's Prevention and Public Health Funding (PPHF), I was thrilled at first. Based on my understanding of this funding, a PPHF grant would potentially enable Western to create a program to support a vulnerable population. However, since enactment this funding has been severely cut and funding for 2020 and beyond has not been approved by Congress. The good news is that there is bi-partisan support for continued funding in Congress and language in the President's Budget for 2020 retained funding for block grants to states for chronic disease treatment and prevention and additional funding for Diabetes Prevention Programs. 1 Because funds have been reduced, our grant proposals will need to strongly make our case, but I am confident we can secure PPCF grants to help us fund start-up costs. Additionally, there may be other grants we qualify for to help us sustain operations, but we will need to research that when the time comes. You: Thanks for this information. I will look into this further. Tell me why you chose a model based on community health workers. Dr. Novak: Community health workers are a bridge to healthcare providers and a credible source of education for patients. I've given you an article from the Centers for Disease Control and Prevention about community health workers. It's a great overview of why community health workers can effectively reach an underserved population of diabetes sufferers. Many of my Hispanic patients don't speak English well. I speak Spanish, but most doctors in this community do not. This communication barrier impacts patients' ability to follow through with treatment. Treatments for diabetes may also be at odds with patients' cultural beliefs. I believe that a group of trained community healthcare workers can support these vulnerable patients and even act as their advocates. Think about the economics of the Center for Diabetes Care from the perspective of unnecessary healthcare costs that can be eliminated. We'll pay the community health workers roughly $80,000 a year, including the cost of benefits. On average at Western the cost per inpatient day is $2,000, and the average length of stay at Western for a patient with diabetes as the first-listed diagnosis is 5 days. Patients with diabetes hospitalized for other conditions stay an average of 1 day longer than patients without diabetes. If you do the math, the economics of the program look pretty good. 1 National Association for County and City Health Officials (NACCHO). (2019). FY2020 President's Budget Proposal, NACCHO Priority Public Health Program Funding - Mar 2019. Retrieved from http://www.NACCHO.org You: Tell me more about the population that the Center for Diabetes Care will serve. Dr. Novak: The patient population we are targeting is the Hispanic population, aged 65 and older, that suffer from type 2 diabetes. For our educational endeavors, we expand the target to their families. For our educational outreach, our target is the entire community, with an emphasis on the Hispanic population. Our geographic target is Lowertown, which is more than 70% Hispanic. Western has an urgent care center there, and the program will be housed in the former pharmacy and storage area. The pharmacy at the urgent care center closed a few years ago when a few of the big chain pharmacies came to the neighborhood. We'll renovate the space for the team's use, and we'll have four small consultation rooms. This will make our space convenient for Lowertown residents. For those who can't or don't want to visit the clinic, the community health workers can visit them in their homes. You: Will insurance reimburse the Center for Diabetes Care for community health workers' visits to patients' homes? Dr. Novak: Yes, in this state, insurance will reimburse for home visits by the community health workers because they will be my employees. The exception is that they won't reimburse for diabetes education-at least in this state. We'll have to keep a close eye on the regulations, and we'll have to document everything. That's one reason we're providing the community health workers with iPads-to ensure proper documentation. You: How has the medical community at Western responded to the Center for Diabetes Care? Dr. Novak: Support from both the provider and the community is a critical factor for success for this program. My colleagues at Western that treat other chronic diseases are interested in this program, as well. The community health worker model can be a viable option for treating other populations that would benefit from an alternative to the traditional medical system. It's exciting to lead the team that is driving the protocols, policies, and procedures our community health workers will use at Western. You: What's the reaction from the Hispanic community in Lowertown? Dr. Novak: The support from the Hispanic community has been overwhelming. We have several Hispanic community leaders who have been strong advocates. Leaders in the Hispanic community recognize that access to healthcare is an issue for many in the Lowertown area. Rosa Sanchez, State Senator from this district, is on the steering committee for the Center for Diabetes Care. She's married to a friend of mine from residency. She's a passionate advocate for healthcare access. We also have Hugo Guzman on the steering committee. He's a very successful entrepreneur whose mom and uncle are patients of mine. Rosa and Hugo give us credibility in the Hispanic community. You: Tell me more about the steering committee. Dr. Novak: I've created a steering committee that consists of another endocrinologist, a pharmacist, a nurse practitioner, and a nutritionist. As I mentioned, we also have community leaders on the steering committee. We've been meeting every other week for a working breakfast. Initially we spent our time refining the vision and mission statement for the program. You'll see this in the documentation I've provided. We've also developed the organizational structure and roles and responsibilities for the staff. You: Let's discuss the organizational structure of the Center for Diabetes Care. Dr. Novak: This is another critical aspect of the Center for Diabetes Care. I've worked with human resources at Western Hospital to create a program overview, which includes a description of roles and responsibilities. You'll see this in the information I've prepared for you. We'll have a team of four community health workers. I'll work with a nurse practitioner to oversee the team. A big challenge is to get the right individuals in the community health worker roles. I need individuals with a combination of language skills, cultural competency, the ability to collaborate with the entire care team, and appropriate clinical knowledge. Human resources hasn't created job descriptions yet but you can get a good sense of the role from the program overview. The nurse practitioner will have to have the same skill set as the community health workers. They will also have to be flexible and innovative. We will develop policies and procedures, but the nurse practitioner will support the community health workers in dealing with ambiguity in their roles. They will also have to be an excellent presenter, as they will conduct community education seminars and represent the Center for Diabetes Care. You: What training, if any, will you provide to the community health workers? Dr. Novak: We expect our community health workers to have some education in healthcare or nursing. We'll also look for language skills. I believe that the key to this program is finding community health workers that our patients will be able to relate to. We want a team that our patients will be happy to see. The success of this program rests on our community health workers' ability to relate to patients. All of our staff, including the receptionist, will go through an intensive 3-week training program. The training will address cultural competency and diabetes care and prevention. They'll also learn basic first aid. Every year, we'll have an annual formal training for the staff. This will most likely be a weeklong intensive training at an off-site location. I want to create a learning culture for the staff at the Center for Diabetes Care. We'll have 2-hour Monday morning meetings. These will include an expert speaker every other week. This could be me, a nutritionist, a pharmacist, or a community health worker from a different organization. The culture will be collaborative. We'll learn from each other's successes and failures. Each community health worker will present a success from the last week and share a case or an issue that is challenging them. The community health workers will improve their patient care skills and knowledge of diabetes with this format. You: Let's go over the financials for the Center for Diabetes Care. Dr. Novak: We are so short on time; I'd prefer you review the financials on your own. I've worked with a senior financial analyst at Western. We've pulled together some numbers I feel really good about. You: How will you get the word out about the Center for Diabetes Care? Dr. Novak: We have to communicate with multiple groups for the Center for Diabetes Care to be successful. First, we need referrals from general practitioners and endocrinologists who treat patients in our target population. Second, we need to reach out to patients and their extended families. We need to explain our program to general practitioners and endocrinologists who treat the Hispanic population with Type 2 diabetes. They will talk to their patients about this program and encourage them to participate. Of course, we need to educate nurses in these practices, as well. We'll need to create marketing materials for doctors and nurses to give to patients who would benefit from our program. We'll do a marketing blitz for our partners within the hospital. Members of the steering committee can lead the charge within their professional group. We need to ensure awareness and credibility among those whom the community health workers will interface with. We also need to develop a marketing program for the primary caregivers to potential patients for the program. Typically, the primary caregivers are adult children. The diabetes patient may or may not live with the adult child, but the child is essentially responsible for the parent's welfare. In my practice, I observe that the children are concerned about their parents' diabetes, especially as complications manifest. Often, they are desperate to help their parents but do not know what to do. We want to engage the primary caregivers on two levels. First, we need to encourage their parents to enroll in the Center for Diabetes Care. Second, we want them to be as involved as possible in treatment. We'll conduct ongoing education sessions for them in the evenings and on weekends to maximize participation. We'll also use some targeted marketing to reach the Hispanic community. We'll focus on cost-effective, highly targeted vehicles, such as outdoor, online, and radio. You'll see more detail in the presentation for the steering committee that I gave you. You: What role will technology play in the Center for Diabetes Care? Dr. Novak: Technology has an important role in allowing us to communicate with patients and with the broader care team. We will give the community health workers iPads. They'll use videos to explain treatment to patients. They will also use the iPads to update patients' records and insurance billing. Electronic medical records will allow us to collaborate more easily with the broader care team. Western is finally moving away from paper charts. The hospital just started using an electronic medical records system. We need to figure out how we can adapt the system to fit our patients' needs. Since the system is so new at Western, we haven't determined if customization will be required. You: I know the launch date is April of next year. Tell me about the timeline and key milestones. Dr. Novak: The timeline is in the presentation to the steering committee. You: I know that we need to wrap up soon. I have one more question for you. How will you measure success for the Center for Diabetes Care? Dr. Novak: I see several ways to quantify success. First, from our patients' point of view, are we slowing or stopping disease progression and optimizing the reduction of all risk factors associated with microvascular and macrovascular disease complications? Directionally we'll measure this by the reduction in average HbA1c levels. Current levels for the target population are 10.5 and our goal is a reduction to 8.5 in 2 years. This is significant because each 100-basis point reduction means a 15% to 18% reduction in mortality, heart attack, and stroke, and a 35% reduction in cardiovascular complications. We'll also evaluate the reduction in hospital admission, readmission, and emergency room visits for diabetics in our target population. Specifically, we'll measure the "all-cause" hospitalization for patients in our target population, or the rate of overall discharge for patients with diabetes as an "any-listed" diagnosis. In our third year of operation, our goal is to reduce this from 386 per 1,000, Western's current rate for the Hispanic population (65 and older) with diabetes, to 310 per 1,000. The target is based on the hospitalization rate for the general population in the same age range with diabetes at benchmark hospitals.4 The frequency of our contact with patients is also important. Ideally, we'd see patients every 2 months for check-ups. Realistically, we anticipate that we will see each patient on average 4.5 times a year. That's the assumption we used to create projections for patient revenue. From a financial perspective, success to me means the ability to operate at breakeven without grant funding by Year 3. One key issue for me is ensuring that we bill insurance for all services. I want no lost revenue due to insufficient documentation. From a community perspective, we should be reducing healthcare costs through preventative care. Beyond that, we want to empower Hispanic patients through education and advocacy. We'll be conducting annual surveys about their attitude toward healthcare, and we are looking to see statistically significant year-over-year improvement on key metrics about attitudes toward the healthcare system. Finally, we'll assess the engagement of our staff. We'll measure this through retention rates and annual employee satisfaction surveys. We'll also measure internal success based on the size of our best practices and lessons learned databases. This program is a model for 2 Institute for Healthcare Improvement. (2015). Health disparities collaboratives: Improving diabetes care in 3,400 health center sites. Retrieved from http://www.ihi.org/resources/Pages/ImprovementStories/Health DisparitiesCollaboratives.aspx 3 Centers for Disease Control and Prevention (CDC). (2013). Hospital discharge rates for diabetes as any-listed diagnosis [Data set]. Retrieved from http://www.cdc.gov/diabetes/statistics/dmany/fig4.htm 4 Marshfield Clinic. (2015). Reduced all cause hospitalization for diabetes. Retrieved from https://www.marshfieldclinic.org/about- us/quality/health-care-reduced-hospitalizations others, not just for diabetes care but also for other diseases and other patient populations. We need to ensure that everything we learn is documented. You: Sounds like great inputs for a balanced scorecard. Dr. Novak: I'd be interested in hearing more about that. (Dr. Novak glances at his watch.) I've got to run. You should have everything you need. I'm looking forward to seeing your report and presentation.