CHOICE ACH: Improving Senior�Healthcare Access in �Rural Environments
September 2024
S. Joyce Heck, MSN, RN, DNP Candidate
Daniel Hannawalt-Morales, MPH
AGENDA
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COMMUNITY HEALTH ORGANIZATION IMPROVING CARE AND EQUITY (CHOICE)
RURAL SENIORS: STATE OF THE POPULATION
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3
THE I-SHARE PROGRAM
EVOLVING PRACTICES
COMMUNITY HEALTH ORGANIZATION IMPROVING CARE AND EQUITY �(CHOICE)
ACCOUNTABLE COMMUNITIES OF HEALTH
“ACHs are independent, regional organizations. They work with their communities on specific health care and social needs-related projects and activities. ACHs play an integral role in Washington’s Medicaid Transformation Project (MTP) efforts. Although MTP is Medicaid-focused, ACHs are working in many ways to improve the health of their communities as a whole.”
(Washington State Health Care Authority, n.d.)
OPPORTUNITIES FOR SUSTAINABILITY
Public / Private Partnerships
PATHWAYS CARE COORDINATION MODEL
Pathways provide training and tools for CHWs to identify health-related social needs and reduce risk factors influencing those needs.
What is Pathways?
Care Coordination is open to all residents of Washington State that have a health-related social need.
Who is eligible?
CHOICE uses a blended model that includes private, state, and federal funding. This program will soon be funded in part by the Medicaid Transformation Project (MTP 2.0).
How is this funded?
21 PATHWAYS
Pathways are tools CHWs use to identify and track individually modifiable risk factors.
PRIORITY POPULATIONS
Residents or those living/spending significant time in the CHOICE region in the next six months.
CARE COORDINATION PROGRAM AGENCIES
RURAL SENIORS: STATE OF THE POPULATION
SENIORS: �NATIONAL DATA
INCREASING PROPORTION OF SENIORS
(Caplan, 2023)
INCREASED INCIDENCE OF HEALTH ISSUES
DISABILITIES
(U.S. Census Bureau, 2022p)
(National Prevention Council, 2016)
CHRONIC CONDITIONS
(Parsons et al., 2021)
ACCESS TO
CARE
RURAL RESIDENTS: �NATIONAL DATA
MORTALITY TRENDS BY POPULATION SIZE
(Cross et al., 2021)
INCREASED INCIDENCE OF CHRONIC CONDITIONS
HEART DISEASE
1
CANCER
STROKE
LOWER LUNG DISEASE
2
3
4
(Centers for Disease Control and Prevention [CDC], n.d.-a)
PROVIDER – RESIDENT RATIOS
(National Rural Health Association, n.d.)
OTHER SUPPORTIVE EVIDENCE
#1 Priority: Increasing access to care
Rural Healthy People 2030
Delaying healthcare utilization can result in the need to access higher acuity services, poor outcomes, and increased associated costs
Research Findings
Increase the use of telehealth to improve access to health services
Healthy People 2030
Increasing the proportion of people with a usual primary care provider
Healthy People 2030
(Rural Health Information Hub, n.d.)
(Callaghan et al., 2023)
(Office of Disease Prevention and Health Promotion, n.d.-a)
(Office of Disease Prevention and Health Promotion, n.d.-b)
REGIONAL DATA
2021 CRUDE MORTALITY RATE
(CDC, n.d.-b – n.d.-d; United States [U.S.] Census Bureau, 2021a – 2021i)
2012 / 2022 PROPORTION OF SENIORS
(U.S. Census Bureau, 2012g, 2012i, 2022a – 2022i)
2022 SENIOR DISABILITY DATA
(U.S. Census Bureau, 2022j – 2022r)
PROBLEM STATEMENT
ADULTS AGED 65 YEARS AND OLDER LIVING IN THE CHOICE REGION ARE AT RISK FOR POOR HEALTH OUTCOMES DUE TO BARRIERS IN ACCESSING PRIMARY CARE.
BARRIERS TO SENIOR ACCESS: CHOICE REGION
SYSTEM COMPLEXITY
MOBILITY / PHYSICAL LIMITATIONS
PROVIDER SHORTAGE
BROADBAND LIMITATIONS
TRANSPORTATION
DIGITAL / HEALTH LITERACY LIMITATIONS
THE I-SHARE PROGRAM
PROGRAM DETAILS
I-SHARE: ��IMPROVING SENIOR HEALTHCARE ACCESS IN RURAL ENVIRONMENTS
PURPOSE
Access-related SDoH support
Increased healthcare access
Improved senior health
COMMUNITY AND CLINICAL PARTNERSHIP
GENERAL STRATEGY
PHYSICAL ACCESS
DIGITAL ACCESS
OBJECTIVES
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INCREASE NEW SENIOR PATIENTS
DECREASE NO-SHOWS
PROVIDE DIGITAL TRAINING
INCREASE TELEHEALTH APPOINTMENTS
IMPROVE ACCESS TO CARE
Is the patient 65+ AND assigned to the Winlock, Onalaska, or Toledo clinic?
Yes
Has the patient no-showed an appointment?
Yes
Refer to I-SHARE program
No
Does the patient have a social/digital need that impacts their ability to connect with their care team either in-person or via telehealth?
Yes
Refer to I-SHARE program
No
Refer to Gather or Coastal CAP
No
Does the patient have a social need?
Yes
Refer to Gather or Coastal CAP
No
No need for social service referral
WORKFLOW
FQHC referral
CHW offers services
SDoH assessment
CHW / Patient create plan
Implement plan
Pre-training survey
Basic digital / telehealth training
Post-training survey
In-person access support
Online access support
EVOLVING PRACTICES
EARLY RESULTS
MODES OF REFERRAL
FQHC referral
CHW offers services
SDoH assessment
CHW / Patient create plan
Implement plan
Pre-training survey
Basic digital / telehealth training
Post-training survey
In-person access support
Online access support
OUTREACH
MARKETING MATERIALS
EVENTS
COMMUNITY RELATIONSHIPS
CHALLENGES TO IMPLEMENTATION
PARTNER NEEDS AND PRACTICES
UNDERSTANDING CHW MODELS
BUY-IN
TARGET LOCATION
COMMUNICATIONS
CALL TO ACTION
HEART DISEASE
1
CANCER
STROKE
LOWER LUNG DISEASE
2
3
4
DISABILITIES
CHRONIC CONDITIONS
ACCESS TO
CARE
Rural Residents
Seniors
QUESTIONS?
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