Areas of Concern
Each of the three county’s health needs assessment surveys discussed areas of concern that were determined through various survey methods, detailed in those individual documents. Areas that were common in each of those assessments are detailed below:
Access to Health Care
The lack of access to health care for the poor, uninsured and under-insured is acutely felt in all three primary counties, though more acutely in rural Pender and Brunswick counties. Brunswick County continues to be designated as a Medically Underserved Area, with 20% uninsured and one primary care physician per 2,551 residents.
The advent of the Affordable Care Act did not solve this problem. The law, as interpreted by the courts and acted on by state legislative leaders, did not subsidize health insurance for those below the federal poverty level, nor did it expand Medicaid to all below that income level. These people, many of whom do not qualify for Medicaid, cannot afford health insurance and get no help buying it on the insurance exchanges.
In an attempt to offset this need for more access to health care, this region continues to collaborate on an effort to strengthen and streamline the safety net organizations that care for the low-income uninsured. Cape Fear HealthNet began in 2005, with most of the region’s safety net providers participating. These partners include:
- New Hanover Regional Medical Center Internal Medicine Clinic
- Cape Fear Clinic
- New Hope Clinic
- MedNorth (Federally Qualified Health Center)
- Coastal Horizons, which has now assumed responsibility for Wilmington Health Access for Teens
- Good Shepherd Clinic
- New Hanover County Health Department
- Department of Social Services in New Hanover, Brunswick, Pender and Columbus counties
- Community Care of the Lower Cape Fear
- South East Area Health Education Center
By combining resources for grant writing, administration and even some clinical services, the partners have addressed five primary goals. They are:
- Expand the safety net to provide medical homes for primary care
- Create a centralized system that standardizes eligibility and enrolls patients into the network
- Provide case management of patients with chronic disease, teaching them to manage their symptoms and avoid unnecessary medical care. Because of changes in state funding, this service is no longer provided
- Create a network of volunteer physicians for referrals from the safety net
- Create a network of pharmacy solutions to ensure patients can afford medications
Each of these goals has been addressed, with significant milestones including:
- Creation of the Cape Fear HealthNet Clinic, which was later merged into Cape Fear Clinic
- Addition of FNPs at Cape Fear Clinic and New Hope
- Creation of system of “navigation” that created standard eligibility for care recognized by all partners
- Volunteer physician network of more than 150 specialists and 20 primary care physicians
- Standalone pharmacy at Cape Fear Clinic
- Pharmaceutical Assistance program shared between Cape Fear Clinic and New Hope Clinic
- Shared eye screening program based at MedNorth to help detect and treat diabetes
This collaborative network provided almost 12,000 medical, dental and mental health visits in 2015-16, plus an additional 25,883 pharmacy services. It brings about $750,000 in grant dollars to the community annually to support this mission.
New Hanover Regional Medical Center assisted in founding and creating Cape Fear HealthNet, and supports it today monetarily and by providing laboratory and diagnostic tests for participating clinics at no charge, and all related surgical and medical care is performed on a charity basis at no cost to the patient or the referring agency.
Of course, the medical center’s primary contribution to access to care for the low-income, uninsured and under-insured is the charity and uncompensated care it provides every day. NHRMC provides about $140 million worth of uncompensated care annually. For many of these patients, this is the only available avenue to much-needed, or even life-saving, care.
Much of this care is in the context of Emergency Departments at the NHRMC campus on 17th Street and at NHRMC Othopedic Hospital. The two sites treat more than 140,000 patients annually, and about 30% did not have insurance. While many of these visits are avoidable and likely belong in another setting, the presence of the EDs provided great comfort and relief for many who had no other option for health care.
The renovated ED also includes a Patient Assistance Center, where clinical staff and social workers can assess socio-economic needs of patients and help them connect with a follow-up physician or a community service they need. This service recognizes the ED’s acknowledgement of its role as the hub of the safety net and the benefit of helping patients find services that will allow them to remain healthy.
The medical center also provides VitaLine, a free call to trained personnel in emergency care who can handle concerning situations over the phone, often preventing unnecessary ED visits but sometimes alerting rescue workers that an emergency is in fact taking place.
NHRMC also provides teaching clinics in four residencies: Internal Medicine, OBGYN, Surgery and Family Medicine. While the primary goal of these programs is to train medical specialists of the future, a worthy outcome is that they provide regular access to primary health care for thousands of poor, uninsured and under-insured residents. These clinics provide more than 100,000 visits annually.
The medical center also has plans through SEAHEC to expand its teaching residency program to Pender County, where primary care physicians are needed.
Many providers in the NHRMC Physician Group – both primary care doctors and specialists – accept referrals pro bono from Cape Fear HealthNet for advanced care that uninsured patients. Every specialty in the area is now contributing free care to this program.
NHRMC continues to develop a regional approach to expanding access to medical services. The most notable project on the horizon is building a 50,000-square-foot medical services facility in Jacksonville, scheduled to open in 2017, that will offer a variety of outpatient services to that area, including primary care, cardiology, urology, orthopedics and diagnostic and imaging services.
Despite the medical center’s numerous efforts in this regard, because of the sheer scope of this issue, access to care remains a gap in meeting the health care needs of this community.
Mental health, and its various components, are often cited in the county health assessments as unmet needs. To cite one example, suicide is among the top 10 leading causes of death in all three counties, but not among the top 10 statewide.
The scope of the issue has been particularly felt in recent weeks, months and years at New Hanover Regional Medical Center, as it is not uncommon for 20 to 40 (and sometimes more) patients to be held awaiting placement in a facility where they can receive the care they need.
Trillium Health Resources is the state’s governmental agency that cares for the state’s Medicaid and poor residents in New Hanover, Pender, Brunswick counties, as well as 21 other counties in the eastern half of the state. It manages mental health, substance use and intellectual/developmental disability services and connects individuals and families to the help they need when they need it.
Trillium does not provide direct care, instead partnering with agencies and licensed therapists in its Provider Network to offer services and support to people in need in or near their own communities.
In 1987, New Hanover Regional opened its Behavior Health Hospital, still the region’s largest provider of inpatient mental health services. The hospital, staffed for 50 beds and accredited by the Joint Commission, provides inpatient psychiatric programs for adults, older adults and those with co-occurring mental health and substance abuse disorders.
Unintentional Poisoning (Drug/Opioid Overdose)
In April 2016, a provocative study was published that accelerated response to a problem health care providers and leaders already knew was growing.
Castlight Health, a San Francisco-based healthcare information company, estimated that 11.6 percent of Wilmington’s population that receives prescription painkillers abuse the drugs, giving the city the highest rate of opioid abuse in the nation.
While local authorities dispute how this firm extrapolated the data to reach this conclusion, no one disputes that opioid misuse is a serious and growing problem in Southeastern N.C.
The Brunswick County Health Assessment found that opioids in 2014 were dispensed at a rate of 109.1 prescriptions per 100 residents, exceeding the statewide rate of 79.7. The 2014 death rate for unintentional medication and drug overdose, 16.8 per 100,000 residents, was 73% higher than the state rate.
Pender County’s Health Assessment ranked drug abuse third among community issues, and residents said they wanted to learn more about the subject. Where to get help for these problems remains a barrier. In 2014, about one in four Pender County residents didn’t know where to go for substance abuse or mental health problems.
The state of North Carolina took two proactive and forward-thinking steps to address this issue in the past year. It established a statewide prescription for naloxone, a drug that can reverse an opioid overdose. Anyone who needs this drug can get it under this standing prescription.
Also, the state created a needle exchange program, where users can turn in dirty or used needles and get a clean one. This will help reduce the spread of Hepatitis C and other communicable disease related to the use of dirty needles.
Among initiatives taking place in New Hanover County are:
- North Carolina Harm Reduction Coalition, which implements a range of public health policies designed to reduce the harmful consequences associated with drug use, sex work and other high risk activities. Some of the programs NCHRC provides include overdose prevention clinic, naloxone access and overdose prevention programming. Corrections services train people living and residing in corrections with trainings on overdose prevention, naloxone access, harm reduction and hepatitis. They also provide referrals to drug treatment, health services, mental health services, sexual assault support agencies, domestic violence support services, hepatitis medical services and AIDS service agencies. The agency also serves Brunswick County.
- The Cape Fear Coalition For a Drug-Free Tomorrow is comprised of community based organizations, businesses, schools, youth, and family members, with the goal of reducing alcohol and substance abuse by youth in New Hanover County.
- Coastal Horizons Center provides substance abuse and mental health services, crisis intervention, family preservation, and criminal justice services in all three counties cited in this health assessment.
- Wilmington Treatment Center has become a leading provider of quality addiction treatment. With all-inclusive care available to adults age 18 and above, their center is prepared to treat patients from the detox phase of recovery until they are ready to return home, armed with the skills and confidence needed to maintain sobriety for a lifetime.
- Youth Development Specialists provide direct substance abuse/violence prevention services to students in each traditional high school through a variety of activities.
In Brunswick County, many agencies have made targeted efforts to address the problem:
- The Sheriff’s Department has held a series of town hall meetings across the county to discuss the issues, the growing addiction problem within the county.
- The Partnership for Success coalition, formed through a grant sought by Coastal Horizons, was established to reduce overdoses through the public health prevention model. The goals of the coalition are to reduce supplies of unneeded medication, provide community based prevention education, educate providers about safe prescribing practices, and get individuals into drug treatment when needed.
- Secure drop boxes for unused medications have been established at several locations throughout the county. Dosher Hospital also has a community medication collection which is known as Operation Medicine Cabinet.
These efforts are taking place in Pender County:
- Pender Alliance Teen Health, a a non-profit organization that has worked with several partners, provides acute and preventive health care and health education to Pender County adolescents at two school-based health centers. PATH provides support for identifying health care providers for mental health and behavioral health concerns and conditions for adolescents.
- Pender County Schools offer a six-week class for parents that includes recognizing signs of mental health and substance use issues. The School Health Advisory Council meets monthly to discuss the eight components of Pender County’s Comprehensive School Health Program
The medical center’s Behavioral Health Hospital is not licensed as a substance abuse treatment center. The medical center’s response to this issue is primary short-term emergency treatment, particularly when the patient has other mental health issues, and partnering with community agencies on prevention and education.
In 2011, the medical center implemented a policy in the Emergency Department where painkiller prescriptions are not re-filled, unless extenuating medical circumstances require otherwise. This policy has significantly reduced the number of patients who are seeking opioid drugs, often to address their addictions.
NHRMC does coordinate two Operation Medicine Drop Events annually, in partnership with law enforcement agencies and the N.C. Harm Reduction Coalition, to allow residents to dispose properly of old medications. Often, illegal substances are turned in during these events.
In the past year, the medical center has stepped up its own internal review of this issue and its partnership in the community. Physician leadership within the Senior Team is reviewing prescription policies of opioids among NHRMC physicians to ensure consistency and standardization, to include not over-prescribing these medications.
Also, NHRMC has taken part in a number of community forums with multiple agencies that are designed to develop a number of reforms, to include partnering with legislative leaders for relief at the state policy level.
The hospital is staffed by a comprehensive team of mental care providers, including board-certified psychiatrists staffed by NHRMC, to ensure the services are available at all times, and psychiatric nurse practitioners, counselors, clinical social workers and recreation therapists.
In FY 2016, the Behavioral Health Hospital was tracking to admit about 2,000 patients. The medical center is consistently trying to maximize the number of beds and variety of patients BHH can serve.
NHRMC’s Emergency Department has also become a leading provider of mental health care, an unfortunate commentary on the state of mental health services in North Carolina. In Fiscal Year 2016, the ED at the main NHRMC campus had 5,324 visits, an 18.6 percent increase from the prior year. The total care hours (119,545) represented a 39 percent increase. Some 1,117 patients needed transfer to another facility, and the average length of time to complete that transfer was 41 hours. While NHRMC continues to meet the needs of these patients, especially with regard to the lack of services elsewhere, housing troubled and often challenging patients for this long strains not only the ability of other ED staff to care for other patients, but staff throughout the entire medical center.
Largely as a response to this problem, NHRMC fashioned one of its patient areas in its newly expanded ED into a behavioral health patient area, to include additional specialized staffing and security. This capacity was increased from seven beds to 13, but, even though the ED expansion is not yet completed, the additional beds are not enough.
NHRMC is currently engaged in a partnership with Coastal Horizons to try to address this issue through a two-tiered approach. First, NHRMC is investing in helping Coastal Horizons maintain providers at its medical clinic that serves its clients with behavioral or substance abuse issues. NHRMC aims to maintain capacity at the clinic so it can refer patients with medical and mental health needs so they can be seen in the same clinical setting. This integration of these services is part of future solutions to the mental health crises all communities are experiencing.
The second initiative is helping Coastal Horizons support a team of providers who will visit the Emergency Department each day to visit patients awaiting placement elsewhere. Coastal Horizons, in conjunction with the ED physicians and clinical staff, will assume, in appropriate cases, the care of a small number of patients on an outpatient basis, thereby reducing the cost of their care to the medical system and creating capacity for the medical center to treat others.
NHRMC is also working with elected leaders, notably N.C. Sen. Michael Lee, on region-wide solutions involving multiple agencies that will begin to address the overall scope of the mental health capacity problem.
The term “obesity” here encompasses adult obesity, childhood obesity, and obesity-related diseases. As with all of North Carolina, obesity rates remain very high – 25% of adults in New Hanover County and 29% in Brunswick County, for example. Related chronic diseases, including diabetes, heart disease and other life-threatening illnesses, also occur at high rates.
The New Hanover County assessment describes a number of initiatives that are taking place to address this issue. They include:
- The Obesity Prevention Initiative (OPI), a diverse community collaboration that was established in 2005 through Cape Fear Healthy Carolinians to increase the healthy weights of Cape Fear residents. It meets quarterly to respond to current needs and emerging issues
- The Health Department’s Breastfeeding Peer Counselor Programs, evidence-based interventions that increases both initiation and duration of breastfeeding; especially in vulnerable populations already at risk for the diseases that breastfeeding is known to reduce: obesity, diabetes, asthma as well as certain cancers in both children and their mothers.
- The Health Department’s seminar entitled Kick Start Obesity Prevention in Infants, where participants learned about infant-feeding practices by addressing common “trigger” behaviors for overfeeding.
- The Health Department’s Health Promotion Division works to collaborate with partners throughout the community, such as worksites, schools, faith communities, businesses, families, and individuals, to promote healthy lifestyles and wellness rich environments. The goal is to encourage policy and environmental changes that will support increased physical activity, healthy eating, disease prevention, injury prevention, and tobacco use prevention/cessation in the community.
- The Health Department’s Eat Smart Move More program, guided by North Carolina and national health objectives through the partnership of Eat Smart Move More North Carolina, a statewide movement that seeks to increase healthy eating and physical activity opportunities
- Food Access: Feast Down East provides Fresh Markets and affordable produce box programs at four, soon to be five, public housing communities in the city of Wilmington.
- Nutrition/Cooking Education: Feast Down East offers Nutrition/Cooking classes to residents and their children.
- FoodCorps: Feast Down East has two FoodCorps service members working in high needs elementary schools in New Hanover and Brunswick counties, teaching garden-based curriculums in the classroom, building and maintaining school gardens and working with the child nutrition staff to increase fresh fruits and vegetables in the school cafeterias.
New Hanover Regional has expanded the amount and quality of primary care providers available in the region. NHRMC Physician Group includes 46 family medicine and internal medicine physicians, including a practice in Pender County the hospital recruited and located in a rural area. Patients at these practices establish ongoing relationships with providers at these medical homes, where the care includes counseling and education on proper dieting and exercise habits.
The hospital also offers primary care through its Internal Medicine and Coastal Family Medicine residency programs, and their clinics near the main campus. Coastal Family Medicine has developed a relationship with MedNorth, which has hired a graduate of the program who now precepts medical residents in rotations at the Federally Qualified Health Clinic. This increases both the capacity of the clinic to serve mostly poor patients, and improves the likelihood that the residents will remain in the area and serve in that setting or one similar to it.
The Betty H. Cameron Women’s &Children’s Hospital hosts the Nunnelee Pediatric Specialty Clinic, where thousands of children from Southeastern North Carolina have access to pediatric physician specialists, nurse practitioners and physician assistants who diagnose and treat a wide range of medical conditions in children, to include obesity and related conditions. A NHRMC-based Pediatric Endocrinologist, hired in partnership with South East Area Health Education Center, leads this care, and also provides outreach in Onslow County and other areas of the region.
Registered Dietitians at NHRMC provide interactive educational opportunities in the community and to NHRMC staff, volunteers and visitors throughout the year. RDs participate in National Nutrition Month activities, community health fairs, media interviews, and wellness initiatives and challenges. Additionally, NHRMC provides supervised clinical practice experiences to dietetic intern students from UNC Chapel Hill and East Carolina University.
NHRMC also addresses obesity and healthy exercise habits with its employees through its Employee Fitness Center, with more than 5,000 members, and its own wellness program. Employees who sign up for the medical center’s insurance program are rewarded for not smoking and are offered education if their blood sugar levels exceed certain limits, but the centerpiece is membership in the fitness center, where personal trainers have helped hundreds of employees lose weight while gaining strength and self-confidence.
Though the medical center and community have offered many initiatives to meet this problem, the size and scope of this public health concern is such that is remains a gap in meeting the health care needs of this community.
Diabetes remains a leading cause of death in the region, ranking seventh in New Hanover County and sixth in both Pender and Brunswick counties. It also continues as one of most prevalent chronic diseases in the region.
The Health Assessment performed by New Hanover Regional EMS found that roughly between 10 percent and 12 percent of the population has diabetes. Brunswick County’s Health Assessment reports that 11.4% of county residents in 2012 had a diagnosis of diabetes, which is similar to peer counties but well above the state goal of 8.6%. The age-adjusted death rate for 2009-13 in Brunswick (15.7 per 100,000) and New Hanover (16.1) was well below the overall state rate of 21.7. Public health efforts in Brunswick County appear to be succeeding, as the diabetes death rate from 1994-98 stood at 24.8. Today’s rate represents a 37-percent decrease.
The community’s establishment of Cape Fear HealthNet for primary care treatment of the low-income uninsured is a primary strategy for detection and ongoing treatment of diabetes’ signs and symptoms. Many of the private physician practices have diabetes educators and classes in place for their patients. Furthermore, all efforts aimed at reducing obesity directly impact diabetes, a common byproduct of obesity.
The New Hanover County Health Department offers diabetes assessments, followed by two classes of diabetes overview and health instruction, with a follow-up class three months later. A physician’s referral is required.
In Brunswick County, the Health Department offers a Diabetes Education Program for those with Type I or Type II diabetes. A Registered Dietitian and Registered Nurse teach about medications, blood glucose monitoring, nutrition, exercise and complications from the disease. A physician’s referral is also needed for this class.
Pender County offers a Diabetes Self-Management Program offered its Health Department, providing evidence-based education for nutrition and exercise, diabetic medication, acute and chronic problems of diabetes, and the ABCs of diabetes. This program receives referrals from Pender Memorial Hospital and local providers. Plans are to expand the program to include chronic disease prevention.
The medical center offers a 32-bed diabetes unit on its inpatient tower on the third floor that cares for those acutely ill patients who must be hospitalized. Trained nursing staff, certified diabetic educators and dietitians work with patients to get them the information and care they need. The services offered there include nutritional counseling; medication education provided by licensed pharmacists; Certified Diabetes Educators on staff; referrals to New Hanover Home Care for ongoing management in the home; specialists who treat children with diabetes in the Pediatric Clinic, healing arts therapy; and help obtaining financial assistance for diabetes supplies.
For NHRMC’s 6,100+ employees, a diabetes management program is offered to help employees manage the disease. About 2,100 are in the program. Employees who are at risk of diabetes are enrolled in classes on disease factors and diet and are managed clinically as well.
In the interviews with those who work with low-income patients, transportation continues to surface as a barrier to getting health care.
This region has no mass transit system underground or on rails that is commonly used to move large numbers of people to work or for other everyday activities. The closest to a system would be Wave Transit System in Wilmington, which provides 16 bus routes – one of them through the NHRMC campus.
Pender County Transportation Services are available for eligible Medicaid individuals needing transportation to authorized Medicaid Providers as well as Work First clients needing transportation to work. Listed purposes for transportation include dialysis, education, employment, legal, medical, mental health, nutrition, recreational, shopping, social, vocational rehabilitation, among others.
Cape Fear HealthNet often provides transportation vouchers for patients to go to doctor’s visits or pick up medication on an individual basis.
Otherwise, there is little coordinated effort around this problem.
The medical center responds to the transportation issue on individual basis, providing thousands of travel vouchers to patients who need rides from the Emergency Department or even after they are discharged home. NHRMC also lobbies to ensure the WAVE bus route continues to ride through the campus.
On a community-wide basis, this has not been deemed a medical center issue to address. It will continue to work with those agencies that do provide transportation solutions and will continue to ensure patients have a safe discharge home.