Project: 21^st Century Primary Care Model for Chronic Disease (Project #40)

Lead Agency:Delta Health Alliance, Inc. (DHA)

The Mississippi Delta, an 18-county rural region of Mississippi, has one of the highest rates for chronic disease morbidity and mortality in the United States.  With the shortage of primary care providers in the Delta, the typical high volume rural clinic has little time to devote to educating patients regarding disease self-management.  Generally, area clinics treat patients on an episodic basis employing a traditional approach to primary care.  Low educational attainment, high poverty rates, and low health literacy contribute to the poor health status of the region.

To address these issues, the Delta Health Alliance initiated the 21^st Century Primary Care Model for Chronic Disease project in 2008.  The project targets four Delta counties: Humphreys, Leflore, Sunflower, and Washington.

Table 1:  Characteristics of 21^st Century Service Area

Location	Population		Access
Mississippi County	US Census Population 2010	Percent African American 2010	Percent Adults HS Graduates, 2005-2009	Percent Individuals Below Poverty,      2005-2009	Percent Unemployed April 2011
Humphreys	9,375	74.5	62.7	39.0	14.7
Leflore	32,317	72.2	69.8	41.6	13.3
Sunflower	29,450	72.9	70.1	35.0	14.8
Washington	51,137	71.3	71.4	33.2	14.0
Mississippi	2,967,297	37	78.9	21.4	10.0
U.S.	308,745,538	12.6	84.6	13.5	8.7

 

Location	2003-2007 Asthma Hospital Discharge Rate per 10,000 Population			2003-2007 Asthma Emergency Department Discharge Rate per 10,000 Population
Mississippi County	Total	White	Black	Total	White	Black
Humphreys	37.2	15.9	49.2	121.1	33.4	169.3
Leflore	36.0	24.9	47.4	93.8	36.0	138.4
Sunflower	49.0	28.1	64.9	89.4	24.5	132.4
Washington	34.4	22.6	45.7	113.4	49.7	159.0
Mississippi	16.1*	11.0*	24.1*	47.7	20.4	87.2
U.S.

 

Sources:   Source: U.S. Census Bureau, 2010 Census.  2010 Census Redistricting Data (Public Law 94-171) Summary File. U.S. Census http://factfinder.census.gov/ 2005-2009 American Community Survey and Population Estimate Program;   Dept of Labor http://www.bls.gov/data/#unemployment; USDA Food Atlas http://www.ers.usda.gov/FoodAtlas/ ; Basic Prose Literacy Skills, 2003 National Assessment of Adult Literacy http://nces.ed.gov/naal/estimates/StateEstimates.aspx; MS Behavioral Risk Factor Surveillance System http://www.msdh.state.ms.us/brfss/index.htm , MSDH Vital Statistics. .http://msdh.ms.gov/phs/stat2009.htm,  CDC Diabetes http://msdh.ms.gov/phs/2009/Bulletin/vr2009.pdf  and http://apps.nccd.cdc.gov/ddt_strs2/CountyPrevalenceData.aspx?StateId=28; and CDC Fast Facts http://www.cdc.gov/asthma/faststats.html. All accessed 6/16/2011 and 6/17/2011. Mississippi State Department of Health. The Burden of Asthma in Mississippi: Asthma Surveillance Summary Report 2009, April 2009

 *2007 data for Mississippi.

The Delta Health Alliance (DHA) 21^st Century project has provided tools, best practice guidelines, and staff to four primary care clinics, in Washington, Humphreys, Leflore and Sunflower Counties, with plans to expand to additional clinics in the Delta.  

The 21^st Century project was designed to affiliate with existing primary care clinics in each of the target counties, with the aim of developing high performance health care clinics whose mission would be to:

1)  Provide health care so that patients can achieve long, healthy, productive lives;

2)  Provide care that is necessary, appropriate, and of high quality;

3) Increase access to care, especially to provide services that are accessible to the uninsured;

4) Promote parity among uninsured, working adults and their families and equity in underserved  populations in the receipt of medical care; and

5) Have the capacity to innovate and improve.

In response, each 21^st Century-affiliated clinic has begun the process of transitioning from a traditional approach to primary care services to a patient-centered medical home model, using a systematic approach developed by TransforMED.  This model is both physician and resource sparing, and utilizes a team approach.  Patients are now receiving the services of a nurse practitioner, a clinic nurse, a patient navigator (social worker), a registered dietician, and outreach services from a community health worker.  Through partnership with DHA’s 21^st Century program, participating clinics, a free clinic and a certified rural health center, are providing a level of service not previously available, including chronic disease education and care coordination.  Funding is supporting expanded hours, increased technology, and improved access to medications and specialty care services.  Preliminary data indicates statistically significant improvements among diabetic and hypertensive patients.

21^st Century Affiliated Clinics

Good Samaritan Health Center (GSHC) 

313 Arnold Ave., Greenville, MS.   38701           

Tel. 662.332.5151 

The clinic is located in the historic Bessie Taylor Building, north of the King’s Daughters Hospital, on Delta Regional Medical Center’s West Campus.  The GSHC is a 501c3 organization operated by a Board of Directors, and serves the working uninsured.  Clinic visits are provided on a sliding scale fee schedule, with the majority of patients paying a $10 fee, and greatly discounted rates for laboratory services. 

GSHC Clinic hours of operation: Mon. and Wed. 9-5, Tues. and Thurs. 9-6, Fri. 9-12

The Good Samaritan Health Center is a clinic that is extremely busy, with the Delta State University nurse practitioner students and instructors in the clinic on scheduled days for advanced student “clinical check-offs”, asthma specialists (3) seeing patients two Fridays a month, and volunteer providers (a retired surgeon and ENT specialists) providing services once a week.

Good Samaritan Health Center Patient Registration Requirements 

● All patients must completely fill out and sign a clinic application.

● Applications must be turned in with the following:

1. Drivers License or Picture ID.

2. Social Security Card

3. Proof of Income. If unemployed and currently do not have an income, the clinic will need proof of income of someone in the household that pays the bills.

Examples: Four Pay Stubs; Previous year tax return

●This applies to all patients.

●The Good Samaritan Health Center does not care for patients with health insurance, Medicare or Medicaid.

The following is an example of the medical home team approach in working with a chronically ill patient at GSHC, and was provided by Sarah Fontentot, PharmD:

 “A 55 year old black male came to GS for follow up today. When he was first seen a year ago his baseline A1C was 10.6. He requested trials of oral medication and dietary changes rather than insulin therapy when the options were reviewed with him by the PharmD. When he came to the clinic he was already on 2 diabetes medications, both of which were $4. Since the patient opted to try an additional oral medication risks and costs of other classes were discussed in detail. With the help of the PharmD and Nurse Practitioner he decided to try another medication, Actos. The Patient Navigator generated a PPA (patient prescription assistance) application and the patient was able to receive the medication without lapse in therapy through the use of samples until the PPA medication arrived. After 3 months his A1C has improved to 6.5. And, after an additional 3 months it went up slightly to 7. The patient admitted that after he was told that he improved so much he “slacked off” and was taking his medication or following his diet as strictly. After additional education by the PharmD and RD (registered dietitian) he realized that lifestyle changes needed to be permanent for him to manage his disease. He also has struggled with his BP over the past year with large fluctuations between control and not. While he was in the clinic today, he was excited to tell me that he has changed his diet yet again to reduce sodium to better manage his HTN (hypertension). He stated that he rarely eats pork anymore, and his BP was nearly controlled today at 138/70 (last visit it was 184/102). He is on top of all of his annual screenings and received his Pneummovax vaccination today.  He also received the flu shot when it was offered to him in October.

I think this is a good success story because this patient has continued to be controlled after his initial improvement, and is a great example of a patient self-managing his disease.” 

 

GSHC Staff…..

Pictured 1^st row: Sherry Jackson, Community Health Worker; Cherry Armstrong, Medical Assistant; Meghann Sheppeard, Nurse Practitioner; Kim Dowdy, GSHC Program Director, Loria Goldsmith, Registration Clerk; 2^nd row: Amy Oakes, LPN, Deondria Winder, BSW – Patient Navigator; Kim Calhoun, Research Aide; Jessica Prevost, RN; Will Rowland, Registered Dietician.

The Good Samaritan Health Center staff participated in the South Delta Regional Housing Community Awareness Fair on Thursday, October 20, 2011. Sherry Jackson, Community Health Worker, and Kim Dowdy, Program Director, talked to individuals about the benefits of the health care center.

The Gorton Clinic

107 Church St., Belzoni, MS 39038

 Tel. 662.247.2105

 

The Gorton Clinic is a large multi-provider certified rural health clinic located downtown Belzoni near the Courthouse.  The clinic was begun by Dr. Mac Gorton, who continues to practice at the clinic with his son, Dr. Carlton Gorton, and two family nurse practitioners.

 

 

 

Hours of operation for uninsured patients: Mon. and Wed. 9-6, Tues. and Thurs. 9-5, Fri. 9-12

 

21^st Century staff working at the Gorton RHC are:  pictured on front row are Patricia Jennings, LPN; Maxine Ball, LSW, Patient Navigator; Julyn Overstreet, CFNP (covering for Emily Aust, CFNP);and on back row are Will Rowland, Registered Dietician (covers all clinics); and Lorene Delaney, Community Health Worker.

 

Leflore County Health Center,

706 Hwy 82W, Ste A

 Greenwood, MS 38935

 Tel. (662) 459-2183; fax number is (662) 459-2183.

 

The clinic was initially developed by a community collaborative seeking to provide access to primary care services for the uninsured population.  The clinic is a 501c3 and a member of the National Association of Free Clinics.  Conveniently located on Hwy 82, the clinic is on one side of a building that also houses the local hospital’s rural health clinic that targets Medicaid and Medicare patients.

 

LCHC’s Mission (from clinic brochure)

LCHC is a Mississippi-based non-profit health clinic dedicated to improving the health outcomes of Leflore County. LCHC strives to be an affordable healthcare option that increases the community’s ability to access high quality care, while simultaneously educating the citizens of Leflore County on the prevention of diseases and illnesses.

 

At this time only a minimal $10 administrative fee is required for basic services.  Complex exams, some radiology and lab work may be at the patient’s expense. Because LCHC belongs to the people of Leflore County, it is run by a board representative of the community and healthcare stakeholders.

Services offered at LCHC

Pediatric and Adult Health Exams

Work and Sports Physicals

Treatment for Illness and Injury

Chronic Disease Treatment

Laboratory Testing

Health and Nutritional Counseling

Medication Assistance and Instruction

Assistance with Insurance Applications

Referrals for Specialty Health Care

 

 

Hours of operation: Mon. and Thur. 9-6, Tues. and Wed. 9-5, Fri. 9-12 noon

 DHA clinical staff and the Leflore County Health Center front office staff work to provide a patient-centered medical home for the uninsured in Leflore County.  Pictured are Antoinette Parks, LCHC’s Clinic Manager (left) and Bertrina Jenkins, Community Health Worker.  The staff is shown receiving their first shipment through a membership in Americares, an organization that delivers medicines, supplies and critical aid to clinics providing services for the uninsured in the U.S. and abroad.  The other 21^st Century clinics also receive assistance from this organization.  

 

Good Samaritan Clinic for South Sunflower County  

110 E. Baker St.

Indianola, MS 38751; Tel. 662-887-4641.

The newest member of the 21^st Century network, is the Good Samaritan Clinic in Indianola.  The clinic is located on the South Sunflower County Hospital campus, sharing a facility that also houses the Delta Surgical Clinic.

Hours of operation: Mon. and Wed. 9-5, Tues. and Thurs. 9-6, Fri. 9-12

 

PATIENT REQUIREMENTS FOR ADMISSION

 

·       Uninsured / no medical coverage

·       Resident of Sunflower County

 

o   Uninsured and employed within Sunflower County but living in another county may be seen at the GSC for SSCH

 

·       Patient history form must be completed and signed at time of initial visit.

·       Application must be filled out completely and signed prior to patient follow-up visit.

·       Application must be returned with the following:

 

o   Driver’s License or Picture ID

 

o   Social Security Card

 

o   Proof of Income and Residency:

 

§  W-2 Form(s)

§  Previous Year Tax Return for Household

§  Utility bills (or other mail addressed to you at your current addresss

Good Samaritan Clinic of SSCH staff with patient, Jamel Shelby (front row, left): front row Rhonda Potter, CFNP.  Back row: Eddie McClain, Patient Navigator; Angie McClellan, Clinic Assistant; Lula Reece, Community Health Worker; Flora Byrd, LPN; and Shirley Betts, Clinic Manager.

Flora Byrd, RN, completes triage procedures with Jamel Shelby, patient.

21^st Century staff  participate in a local health screening scheduled by the GS/SSCH staff.  Pictured are (from left) Leslie Johnson, Senior Research Assistant; Lula Reese, GS’s CHW; Will Rowland, Registered Dietician; and  Lorene DeLaney, CHW.

Chronic Disease Management

Individual and group education are provided at all clinic sites to help patients learn to self-manage chronic illness and reduce risk factors such as obesity.

Will Rowland, Registered Dietician, has facilitated  a number of Delta Slimdown  classes.  Bernice Wells was pictured as having won a prize for weight loss (11 pounds).  She continued to practice the principles that were taught in the class to help control her diabetes.  She has now lost a total of 64 lbs.  She currently controls her diabetes with diet alone.  Below are pictures of Bernice after losing 11 lbs at the end of the class (left) and how she looks today.  

EMMI Solutions’ web-based patient education modules, have proven effective in engaging and educating low literacy patients.  Community health workers are available to provide home visits to reinforce education and treatment recommendations.

The clinic nurse practitioners have adopted the practice of having team “huddles” and a monthly team meeting to discuss performance improvement activities and case management of risk patients.  Teams also participate in regularly scheduled monthly WebEx meetings to share best practices, discuss challenging cases, and for training, such as the recent “coaching for activation” training.

During August 2011, all four 21^st Century clinic teams, participated in Insignia Health’s “coaching for activation training” which will be used to motivate patients in our clinics to self-manage their chronic disease.  Clinic teams, primarily the CHW, will strive to assess all diabetic and hypertensive patients using the Patient Activation Measure (PAM) to determine the level at which they are currently self-managing.  The results of the PAM will be scanned into the patient’s record and the CHW will note in the patient’s record the assessed level at which the patient is activated.  The team will utilize appropriate strategies, as discussed in the activation training, to motivate patients to move toward a higher level at which they are self-managing their condition.

 

Project: The Delta Community Health Worker Program—Outreach Grant, Office of Rural Health Policy, Health Resources and Services Administration (HRSA)

Lead Agency: Delta Health Alliance, Inc. (DHA)

The purpose of the Delta Community Health Worker (CHW) project is to assist rural patients struggling with chronic diseases obtain access appropriate services in a timely fashion. Locally-recruited, trained community health workers work with three regional Community Health Centers (CHCs) and numerous public clinics for the uninsured across a five-county area of the Mississippi Delta. These patient navigators, recruited directly from the communities to be served, receive continuous training to provide health information, screening assistance, and supportive services to patients with poorly managed chronic illnesses.

The following goals have been established for the Delta Community Health Worker Program:

1. To improve health outcomes for patients of CHCs in the region diagnosed with diabetes, CVD or hypertension by 25% across a variety of related health measures. By successfully implementing and operating a regional Community Health Worker system for CVD, diabetes and hypertension serving ten rural clinic locations that focus on delivery of care to the Mississippi Medicare, Medicaid and uninsured population,
2. To improve retention of Social Worker students post-graduation into careers in the Mississippi Delta region by 20%,
3. Produce and distribute a generalizable, replicable model of care for implementing a Community Health Worker team concept in other rural areas of the United States, based on the lessons learned and evaluation results.

Project: Community Gardens

Lead Agency: Delta Health Alliance, Inc. (DHA)

Nothing beats the taste of fresh fruits and vegetables. The 21^st Century Gardens project seeks to help everyone come to find this out for themselves. In an effort to increase the consumption of healthy foods, the 21^st Century Project has started several Community Gardens to teach people about the benefits of being outdoors, socialization, and eating healthier. People who grow their own fruits and vegetables are more likely to eat them than those who simply hear about the benefits of these foods. Not only do those people eat their produce but they also become resources of information to their friends and families.

Belzoni:

The Belzoni Community Garden is a partnership between the City of Belzoni, the Belzoni Community Garden Committee, and the Delta Health Alliance’s 21st Century Project partnership with the Gorton Clinic to provide primary care for the uninsured.

The 21^st Century Community Garden Project seeks to support the development of sustainable community gardens to encourage increased access to and consumption of fruits and vegetables, and increased physical activity for clinic patients and other community residents.

Leland:

The Leland Community Garden is a partnership between the City of Leland, the Leland Community Garden Committee, and the Delta Health Alliance’s 21st Century Project partnership with the Good Samaritan Health Center in Greenville to provide primary care for the uninsured.

The 21^st Century Community Garden Project seeks to support the development of sustainable community gardens to encourage increased access to and consumption of fruits and vegetables, and increased physical activity for clinic patients and other community residents.

For more information and to see what we have grown, click the flowing:
Belzoni Community Garden

Leland Community Garden