Network Sustainability
Richard D. Silverberg MSSW LICSW Managing Director
Caring Community Network of the Twin Rivers
Exec. Dir Health First Family Care Center
Franklin NH
•To promote public health and prevent illness
•Agency and community Reps all sectors
•Founded in 1996 501 c 3
•10 Essential PH services, plus supports to network members
•Needs assessment, Health promotion, chronic disease prevention, community development focused on creating healthy individuals in healthy environments, training. work force, access to personal health care, policy development.
Caring Community Network of the Twin Rivers (CCNTR)
Individual
&
Family
Primary Care Teams
LRGHealthcare
Family Practices
Health First Family Care
Center (FQHC)
Inter agency adult and children’s
care coordination
teams
Caring Community Network of the Twin Rivers Health Home Model
Primary Care Network
Community Action Programs
School Administrative
Units
Dentists
Child Care Centers
Elder Service Providers
Faith-BasedGroups
Municipal Services
Visiting NurseAssociations
AcuteHospital
Mental HealthProviders
Police, FireEMT
Medical Specialty Services
Informed,ActivatedPatient
ProductiveInteractions
Prepared,ProactivePractice Team
DeliverySystemDesign, Group Visits
DecisionSupport, Specialty
Care
ClinicalInformation
Systems Wellcentive
Registry Program,
EMR
Self-Management
Support MFC, Stanford Model
Health SystemMercy General, Health Project,Diabetes Network
Resources and Policies, Access toSuppliesAnd Meds
Community
Health Care Organization,MFC Team Approach
Chronic Care Model,CHIP Project Partners
Improved Outcomes,
Measurable Indicators
CCNTR RHO Partners
Healthy Eating Active Living
(HEAL NH)
Medication Assistance
Health Link
Clinical Team Care
Management
Health First-National Collaborative
LRGH-NCQA (DPRP)
Planned
Visits
Nutritionist, Behavioral Health,
Social Work
Patient Disease
Registry, EMR
Key Measures
Clinical: Lower A1c Average (DM), Lower BP Average (CVD)Healthcare: Reduced ER Utilization
Coalition Development
Gather together the right people
Agree to agree
Identify develop, support local leadership
Find projects early on that will yield success
Celebrate success
EvolutionEvolution
CCNTR is recognized on a national level for its work in cross-agency team development and collaboration. Coordinating how agencies work together to deliver services for individuals is a primary focus of the network.
Not only do network agencies work together to govern CCNTR, they jointly apply for funding and share staff positions to deliver services.
CCNTR also strengthens the community by providing staff development, training and new technology to agencies in the network.
CCNTR is recognized on a national level for its work in cross-agency team development and collaboration. Coordinating how agencies work together to deliver services for individuals is a primary focus of the network.
Not only do network agencies work together to govern CCNTR, they jointly apply for funding and share staff positions to deliver services.
CCNTR also strengthens the community by providing staff development, training and new technology to agencies in the network.
Recognition
Vision LT Outcomes
EvaluateEffectiveness/
Collect and analysis
indicator data
ImplementMethods/ Activities
Plan forMethods
/Activities
IterativeProcesses
Goal Development Strategy and long
term outcome development
Needs/ProblemsStatement
NeedsAssessment
Priorities and Strategic Issues Identification
Short term & intermediate Outcomes
Development
Joint funding development and grant writing
CCNTR PLANNING PROCCESS
Methods of Engaging the Public
Choose an issue that the residents care about, and that is measurable
Use the skills and talents of the participantsAsk the participants ‘Who else should we be talking to?’
Reinforce, celebrate success and positive shared leadership
Fostering Ownership and Leadership
Identify local leaders
Start at the level comfortable for the leader
Have method to support and train leaders
Share leadership, give power to many
Public and Community Health ImprovementHow the community-driven str ucture engages people in planning and development
Community members, law enforcement officials, public health officers, school personnel, health and human service professionals, town officials, business people, civic groups, youth, and consumers of service are invited to participate in planning and development taskteams to address each area of regional need.
Interested individuals and organizations come together and form task teams, which address areas of need identified by CCNTR through the community health assessment process.
Task teams identify methods to meet community needs, based on review of model programs and other research supported by CCNTR staff.
Task teams then refine the methods they have selected to meet identified community health into a feasible program plan based on discussions with community health and human service agencies.
Task teams’ recommendations are taken to CCNTR’s Development Commit tee, which looks for funding opportunities.
A subcommittee made up of task team members and development committee members drafts proposals for funding.
Some task team members and CCNTR representatives, continue to meet in order to oversee the implementation of the program, its evaluation, and its continuation.
CCNTR member agency takes on responsibility of the program’s operation as the fiscal agent for the program grant(s).
CCNTR(c)2001 turningpoint/presentation/graphics/communityassurance 9/01
Process is brought back to the general population through the delivery of a service, and the participation of consumers andresidents in the evaluation of that service. See diagram Public and Community Health Assessment.
ApproachApproach
Funding Strategies
Service Design through Blended Funding SourcesService Design through Blended Funding Sources
HRSA Rural Health Outreach
Topic Areas: Chronic Disease, Telehealth
• Quarterly Planned Care Prevention Focused Visits
• EMR, Disease Registry, Quarterly Outcome Evaluation
• Health First Family Care Center (FQHC) participation in HRSA Health
Disparities Collaborative
• LRGHealthcare involved in NCQA, DPRP
Multi-State Learning Collaborative: Lead States in Public Health
Quality Improvement
Topic Areas: Reducing Childhood Obesity
• EMR Supporting Primary Care Recommendations to Identify,
Prevent, and Manage Childhood Obesity
• Primary Care Practices in Region Documenting at Least 72% of Youth
BMI Risk Rating
• 5210 Assessment and Behavioral Goal Setting at Well Child Visits
New Hampshire Healthy Eating Active Living Community Grant
Program
Topic Areas: Increasing Nutrition and Physical Activity Resources
• School
• Community
• Food & Recreation Industry
• Reducing childhood and adult obesity
Funding Source Delivery System Design Results
Evaluation
•Programs/services: process and outcome measures for each project / each funding source matched to overall community plan
•Demonstrated value: through changes over time from baseline measures of major community health indicators
•Agency functioning : board evaluation
Return on Investment
•Healthy communities
•Agencies, towns, employers, residents that have learned the value of collaboration and carry this forward
•On going community leadership
•We can do it if we all work together
Organizational Chart of the Caring Community Network of the Twin Rivers
Twin Rivers Community
Founded 199614 Community Member Seats
CCNTR Board of Directors14 Member Agencies 11/09
ManagingDirector
Nominating ExecutiveDevelopmentHealth
OfficersTrip
Standing Committees
Basic Needs
EnvironmentalHealth
Community Involvement
AdolescentRisk
BehaviorPrevention
Team
Public & Community
Health SystemsImprovement
HealthEducation &
Disease Prevention
Care, Coordination
Outreach, andAccess
Subcommittees(program oversight)
Task Teams
Care Coordination TeamsRegional
Emergency All Hazards
Health Planning and
Response
NewfoundPrimary
CareTeams
FranklinElder &
AdultTeam
FranklinChildren’s
Team
AccessManagers
Group
Healthy Homes
11
Results in Partnering Results in Partnering Sustainable network Number of uninsured patients in region now
receiving preventative services, primary care and specialist treatment 1995: <100 uninsured patients 2010: >4,000 uninsured patientsAs a Result of:
Health First Family Care Center (FQHC) Increase in Primary Care Physicians Two Office Locations
HealthLink and Healthcare Financial Counseling Information and referral system that provides healthcare financial
counseling, Shared sliding fee scale and access to medical, dental, wellness, and prescription services for those in financial need.
Sustainable network Number of uninsured patients in region now
receiving preventative services, primary care and specialist treatment 1995: <100 uninsured patients 2010: >4,000 uninsured patientsAs a Result of:
Health First Family Care Center (FQHC) Increase in Primary Care Physicians Two Office Locations
HealthLink and Healthcare Financial Counseling Information and referral system that provides healthcare financial
counseling, Shared sliding fee scale and access to medical, dental, wellness, and prescription services for those in financial need.
Results in Partnering 2Results in Partnering 2
Comprehensive network of agencies that provides the ten essential public health services for the region.
Bring new resources to the region. 5 million $ in the past 5 years. Developed seamless Electronic referral
system between agencies.
Comprehensive network of agencies that provides the ten essential public health services for the region.
Bring new resources to the region. 5 million $ in the past 5 years. Developed seamless Electronic referral
system between agencies.
Focus on meeting the needs through long term planning process
Use savings from collaboration and eliminating duplication of effort to sustain core network functions
Institutionalize the relationships of one agency to another not just the personal relationships
SustainabilitySustainability
Sustaining Engagement
Identify both short and long term activities
Early successes are vital!
Celebrate your success
Include large group in planning process
Segment plan into doable committees and tasks
Develop long term funding streams through policy change
Fostering Ownership and Leadership
Sustainability of Membership
Identify local leaders
Start at the level comfortable for the leader
Have method to support and train leaders
Share leadership, give power to many
Lessons Learned
Build the coalition so it can partially run it self
Find and maintain solid leadership
Build and maintain trust
Always maintain open communications
Don’t tackle a coalition breaking project Focus on the things you can do together
Leave the ones you don’t agree on until a future time when you may bring them up again and may than find a compromise
Never Let It Rest
•The process must be attended to
•Evaluate the work of the coalition as well as the programs
•Continue to recruit and engage new people
•Share leadership
* Toot your own horn, if the community knows what you do they will help do more of it
Questions?
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