# Presentation: 085546

## Slide 1

## Community Health Works of Georgia

***Community Health Works of Georgia***
*A Vertically Integrated Rural/Suburban Network Serving Nine Counties of Central Georgia*
***Who We Are***
***What We Do***
***Value Measurements***
***Bottom Lines and Opportunities***
- Shannon T. Harvey, CEO
- _[sharvey@chwg.org](mailto:sharvey@chwg.org)_
- 1-478-994-1914

## Health Care Central Georgia. Inc.

**Health Care Central Georgia. Inc.**
**D/B/A**
**Community Health Works**
**Region**

- DADE

- CHATTOOGA

- WALKER

- CHEROKEE

- HARALSON

- GORDON

- DOUGLAS

- RABUN

- JACKSON

- MURRAY

- GILMER

- FORSYTH

- CATOOSA

- FANNIN

- LUMPKIN

- BARTOW

- PICKENS

- FLOYD

- PAULDING

- COBB

- POLK

- UNION

- TOWNS

- FRANKLIN

- WHITE

- STEPHENS

- DAWSON

- HALL

- OGLETHORPE

- BANKS

- COWETA

- MADISON

- GWINNETT

- CLAYTON

- CLARKE

- HART

- FULTON

- HEARD

- DEKALB

- FAYETTE

- LAMAR

- HENRY

- NEWTON

- SPALDING

- CARROLL

- TROUP

- HANCOCK

- PIKE

- MORGAN

- JEFFERSON

- BARROW

- WALTON

- OCONEE

- ELBERT

- GREENE

- WILKES

- JASPER

- BUTTS

- UPSON

- LINCOLN

- WARREN

- PUTNAM

- COLUMBIA

- BURKE

- WASHINGTON

- BALDWIN

- JONES

- MONROE

- WILKINSON

- BIBB

- CRAWFORD

- TWIGGS

- BLECKLEY

- EMANUEL

- JOHNSON

- JENKINS

- SCREVEN

- BULLOCH

- DODGE

- HOUSTON

- PEACH

- TALBOT

- HARRIS

- MUSCOGEE

- CHATTAHOOCHEE

- MARION

- STEWART

- SUMTER

- SCHLEY

- DOOLY

- PULASKI

- WILCOX

- TELFAIR

- WHEELER

- BEN HILL

- LEE

- TERRELL

- RANDOLPH

- QUITMAN

- WORTH

- DOUGHERTY

- CALHOUN

- CLAY

- CRISP

- TURNER

- TIFT

- COFFEE

- JEFF DAVIS

- TREUTLEN

- TOOMBS

- APPLING

- TATTNALL

- WAYNE

- BACON

- COLQUITT

- MITCHELL

- EARLY

- BAKER

- SEMINOLE

- DECATUR

- GRADY

- THOMAS

- BROOKS

- COOK

- LOWNDES

- ECHOLS

- LANIER

- ATKINSON

- WARE

- PIERCE

- BRANTLEY

- CHARLTON

- CAMDEN

- GLYNN

- LONG

- LIBERTY

- BRYAN

- MCINTOSH

- EFFINGHAM

- CHATHAM

- CANDLER

- EVANS

- IRWIN

- BERRIEN

- MILLER

- RICHMOND

- TAYLOR

- CLINCH

- TALIAFERRO

- MCDUFFIE

- MACON

- MONTGOMERY

- WEBSTER

- GLASCOCK

- ROCKDALE

- MERIWETHER

- HABERSHAM

- WHITFIELD

- LAURENS

## A region of great need...

***A region of great need...***
***Rural ***
***Minority***
***Poor ***
***Un- or Publicly Insured, ***
***Underserved ***
***by a Fraying Service System***
***Disabled and Dying Preventable Deaths***

## Out of Great Need....

***Out of Great Need....***
***...******. Possibility***
***How can we better, together, serve the uninsured than we’ve been doing separately?***

## Who We Are...

***Who We Are...***
- Public/private partnership of providers, community leaders and county governments with common mission of improving communities physical and fiscal health
- Originally born from a convening intent to more effectively address common problem of uncompensated care

## Our Current Board Leadership

***Our Current Board Leadership***
- 2 Primary Care Physicians
- 2 Specialty Physicians
- 5 Hospital CEOs
- 1 District Health Director
- 2 Behavioral Health System CEOs
- 1 Foundation CEO
- 1 Medical School Dean
- 1 Volunteers in Medicine Clinic Chairman
-  County Commissioners from 4 Counties
- 	 (2 Chairmen)
- 1 Family Connection Regional Coordinator
- 1 Twiggs County Community Leader

**Our experience....**
- Enrollment based program
- Uninsured adults 19-64 years old with incomes under 235% FPL and either hypertension, heart disease, diabetes or depression
- Three components:
- Access to continuum of primary and specialty care, labs/diagnostics, life-sustaining pharmaceuticals and hospital services
- Disease management
- Holistic care management

***Guiding Tenets:***
***Take care of patients***
***Process (satisfaction)***
***Outcome (access, health status)***
***Add value to partners***
***Make them money (revenue – coverage, grants)***
***Save them money (utilization)***
***Be easy to deal with  (satisfaction)***
***Make them look good ***
***(intangible, build will and commitment)***

**In the region, we’ve learned much about:    **
- Data tracking and sharing
- For better care
- For quantifying results

**    ****Data Tracking and Sharing****  **
- HIPPA Compliant Regional Web IT System Completed
- 	*Screening, Enrollment, Provider Assignment, Service Tracking across Continuum, **	**Assessment, Care Planning, Care Management (including PPAP), Tracking of HCFA 1500, UB 92*
- Interfacing among partners possible

*Patient Service Data *
- June 26, 2001 –
- December 9, 2003

***Patient-Focused***** Care Coordination****  **
- To date, have coordinated more than $8M in care across more than 100 providers
- Primary and specialty (including behavioral health, dental and opthalmic)
- Public health
- Labs and diagnostics
- Hospital
- Pharmaceuticals, supplies and DME

## Current Network Status

|  | Physicians/Clinics | Pharms |
| --- | --- | --- |
| Bibb | 28 MDs  24 PCPs, 4 specialists, 2 clinics | 7 |
| Crawford | 1 MD-PCP | 1 |
| Houston | 39 MDs -  16 PCP, 23 specialists | 3 |
| Jones | 2 MDs - PCPs | 3 |
| Monroe | 8 MDs - 7 PCPs, 1 specialist | 3 |
| Peach | 6 MDs - PCPs | 2 |
| Twiggs | 2 MDs - PCPs | 1 |
| Macon/Taylor | 3 MDs – 3 PCPs, 1 specialist | 2 |
| Totals   | 90 MDs – 
61 PCPs, 29 Specialists, 
2 clinics | 22 |

***Current Network Status***

***Taking care of patient members...***

| 2020 served, 345 enrolled awaiting MD |  |
| --- | --- |
| Average Educational Level | 11th Grade |
| Average Income | $5044.20/yr |
| Average Number Diseases/Member | 2  
56 Different |
| Average # Meds Per Member | 4.96  
1151 Different |

## Member Snapshot

*Member Snapshot*

| Gender | 70% Female
30% Male |
| --- | --- |
| Race | 68%    African-American  
30.3%  White <1%     Hispanic
<1%     Asian |

| $1,035,335.97  | Recovered health coverage |
| --- | --- |
| $3,969,455.00 | Grant funds to region made possible by organization |
| $376,553.28 | Grant funds directly to partners |
| $151,952.81 | MD Services |
| $85,646.59 | MH/SA Services |
| $ 11,049.93 | Ophthalmology/Optometry Services |
| $ 2298.00  | Dental Services |
| $5,619,329.83 | Hospital Services 
(6 hospitals) |
| $2,058,323.76 | Medications/Supplies |

***Delivered to Date***

| $2,058,323.76 | in medications/
supplies |
| --- | --- |
| $34,238.59 | Medication samples |
| $1,216,640.95 | Hospital donated meds |
| $31,723.41 | MH/SA meds |
| $357,121.91 | Medical supplies |
| $24,600.74 | Linkage to existing resources |
| $393,998.16 | Drug co. assistance programs |
| $196,657.63 | Direct purchase |

***Delivered to Date – Medication/Supplies Breakdown***

***Delivered to Date – For Tomorrow***

| 56 | Monroe County local indigent med program  |
| --- | --- |
| 5833 | Drug company patient assistance applications |
| 47

47
589           

129                 | CHW assisted applications for SS Disability 
CHW assisted apps for Medicaid/Peachcare
CHW assisted applications for GPCF CHW assisted apps for Komen Grant |

## Community Health Works Evaluation

**William Custer, Ph.D.**
- Georgia State University

## CHW Members

- Studying the healthcare utilization of 1740 members
- Over 1400 currently active
- Average 3 disease states per member
- 38% with Diabetes
- 23% with Heart Disease
- 79% with Hypertension
- 27% with Depression
*August 2003 Data*

## Overall Comparison

- C H W
- Rates Per Member
- Discharges:  .193
- ER Visits:	   .33

- MEPS
- Rates Per Member
- Discharges:  .24
- ER Visits:	   .52

- Extra *Annual* Discharges at MEPS rates:		  $303,000
- Extra *Annual* Costs if ER Visits at MEPS rates:       	    $45,505
*August 2003 data*

## Trends over Time

- For those with more than 6 months of membership (58% of total members)
- 70% of ER visits occur in first 6 months of membership
- 66% of hospitalizations occur in first 6 months of membership
*August 2003 data*

## Slide 24

**Bottom Lines:**
**This model of proven to improve health and save money**
**“****The news is good and only going to get better.”  ****	****	****	***William S. Custer, Ph.D*.  8/21/03

**A Different Frame....**
**Think how can the health/healthcare crisis be  used as an opportunity to:**
**Align multiple incentives?**
**Use healthcare spending to fuel economic development in communities?**
**Harness the power of communities to improve health?**

**As leaders...**
**Our job is not **
**to fix the past.   **
**Our job is **
**to create the future.**

**Leaders make things possible.**
**Great leaders **
**make them inevitable.**