External Input

As part of NHRMC’s Community Health Need Assessment, we reached out to health leaders most familiar with the public health needs of the community – particularly the uninsured, under-insured and medically underserved in our community. We reached out to them via survey during the month of August 2016. We asked them to list the biggest needs of the population they serve, obstacles in serving that population and strategies to overcome the obstacles. Their responses are summarized below.

Community Care of the Lower Cape Fear 

Community Care of the Lower Cape Fear is one of 14 networks that make up a state health care partnership known as Community Care of North Carolina. Its website states that it works in partnership with 160 primary care and OB practices, hospitals, health departments, departments of social services, and other agencies and organizations, including MCOs and SEAHEC, in a six-county network. These professionals work together to provide cooperative, coordinated care through the Medical Home model. This approach matches each patient with a primary care provider who leads a health care team that addresses the patient’s unique health needs. Care managers provide services to high-risk patients to improve self-management of chronic health conditions. The agency’s goal is to improve health outcomes and quality of life for patients, while reducing care costs in their communities.

Angela Ives, RN, CCM, is CCLCF’s Executive Director.

Biggest needs of population served:

  • Transportation – We do not have effective ways to travel across our communities, which is particularly challenging to those with limited resources.
  • Help with Upward Mobility – Many systems are set up to serve those with either no income or high income. Those who are working and making a moderate income have great barriers to overcome as they try to improve their options and their life. In the healthcare community, we contribute to that problem by having a system that places a huge burden on low-income workers that are unfortunate enough to have a medical need. Expenses associated with one acute illness or injury can derail a family’s efforts to reach their goals. Until we have an affordable health insurance option in this country, we need local solutions for people to have access to affordable preventative care and affordable treatment for acute needs and injuries.
  • Affordable housing - Our care manager called some of the affordable apartments on a list and in addition to there being a wait list, the person has to go to the apartment complex office to complete an application. They do not have them on line and they do not mail them; so if a patient doesn’t have transportation then that adds to the problem.
  • Assistance with copays
  • Access to community resources- There are long waiting lists for Meals on Wheels and wheelchair ramps
  • Better understanding of the importance of health management and low literacy tools to help them be successful
  • Better access to Behavioral Health services

Obstacles in serving:

  • Homemade solutions – Our populations have developed their own ways of meeting their needs, using the limited resources and supports that they have access to. Many times, that means that they do not realize they need help, or that they are meeting their own needs in ways that will lead to greater medical problems and more costly care that is needed in the future.
  •  The Healthcare Community – We are our own obstacle. Healthcare services are designed, located, and run so that things can be most convenient and comfortable for those who are providing health services, not for the patients. We have technology solutions that are not being used to meet the needs of our patients, and we continue to locate and provide our services in a manner that makes our patients adjust to our systems, not the other way around.
  • Lack of interest in health management and low health literacy
  • Lack of transportation, money and community resources.

Strategies:

  • We continue to partner with multiple agencies and care providers to work on solutions to the challenges that our patients face. 
  •  We are constantly looking for new resources in our communities
  • We work with the 14 Community Care of North Carolina networks to identify low literacy tools and implement NCQA Accreditation standards for Intensive Case Management. 

Elissa Hanson, MSW, LCSW, is CCLCF’s Behavioral Health Program Director.

Biggest needs of population served:

  • Pregnant women with chronic pain
  •  Behavioral health medication management
  • Treatment for personality disorders
  • Independent clinical therapists who treat patients with chronic pain/ chronic pain support group
  • Medication Assisted Treatment and Naltrexone prescribers
  • Physical therapy

Obstacles in serving:

  • Providers who are managing patients’ chronic pain are discharging them as soon as they discover they are pregnant, leaving patients without medications and at risk for detox. OBs are not willing to takeover prescribing. For patient to access MAT, patient must embrace having a substance use disorder and “work the program” which many of them are not willing to do.
  •  There are not enough specialty mental health prescribers
  • Bladen and Columbus have no behavioral health providers offering treatment for personality disorders
  • Treating chronic pain by Behavior Health providers is a new concept. Historically, treatment has been limited to medication. Patients want quick fixes with pain meds instead of learning how to self-manage their condition and coping skills
  • There are not enough certified suboxone or naltrexone prescribers in primary care. Providers are reluctant to get certified for fear they will turn their practice into a mental health agency. They fear this target population would be very difficult to manage
  • Medicaid does not have robust coverage for physical therapy

Strategies:

  • Developing a campaign for pain management clinics and primary care providers to educate them on their responsibility to keep these patients in their care and work in collaboration with OB provider
  • Promoting Suboxone certification for pain management providers and primary care providers through emails and practice visits
  • Network pharmacists are using Medicaid claims data to find women of child bearing age who are currently on pain meds without a birth control fill, then approaching prescriber about adding to her regimen
  • Telephonic psychiatric consultation project with Trillium – psychiatrist consulting with primary care
  • Network psychiatrist provides education and support to primary care providers with goal to increase their capacity to manage Behavior Health conditions
  • Developing a program to increase the number of practices with enhanced Behavior Health integration
  • Urging Eastpointe MCO to develop their network to include providers who can treat personality disorders
  • Alert MCOs to the need so they can promote development of specialized chronic pain treatment program
  • Re: lack of certified suboxone or naltrexone prescribers in primary care, plan is to partner with MCOs and other community stakeholders to inform and educate providers
  • Have recruited several Behavior Health providers who have agreed to partner with primary care provider to provide the therapy piece to this treatment
  • Advocating for DMA to improve coverage for physical therapy

South East Area Health Education Center

South East Area Health Education Center, formed in 1972 under the Federal AHEC Charter, works to improve the quality of health care in our region by providing training, education and resources to professionals in New Hanover, Pender, Brunswick, Duplin and Columbus counties. SEAHEC, now merged with New Hanover Regional Medical Center, also works to increase the local medical workforce by inspiring youth to pursue health care careers.

Through affiliations the University of North Carolina at Chapel Hill School of Medicine and New Hanover Regional Medical Center, SEAHEC provides board-certified physicians in several adult and pediatric specialties/subspecialties; accredited continuing education programs for nurses, mental health professionals, dental assistants, pharmacists and allied health providers with 88 different types of credit; educational and business tools for health care professionals and medical practices which include medical billing and practice support services; and access to the Fales Health Sciences Library, the largest medical library in the service area.

These affiliations in 2016 also led to the UNC Chapel Hill School of Medicine expanding and adding a branch campus for third- and fourth-year medical students at NHRMC.

Janalynn Beste, director of the Family Medicine Residency Program, offered these thoughts:

Biggest Needs of the population served:

  • Mental health – preferably coordinated with medical care
  • Transportation – especially those from outlying areas
  • Paying for meds/equipment things they need
  • Help with social needs

Obstacles in serving:

  • They often can’t make appointments on time
  •  We don’t have enough room/staff/physicians to be flexible to accommodate their needs
  • Our appointments aren’t long enough to address their medical needs in context with their social needs
  • We don’t have enough mental health capacity to care for people who need it
  • We don’t have anyone to “warm hand off” to for social needs (help them find resources, housing issues, etc).
  • Would love to do more home visits for those who struggle to get here – again, not enough physicians to do this

Strategies:

  • Considering a “walk in” clinic schedule for those unable to keep scheduled appointments
  • Trying to hire a second counselor to help with mental health needs
  • Trying to start a rural residency to address needs of those in Pender County

SEAHEC also polled a number of its leaders and providers and developed these cumulative responses to the same questions:

Biggest needs of population served:

  • Access to mental health services
  • Transportation
  • Socioeconomic issues

Obstacles in serving:

  • Making appointments 
  • Time to address medical/behavioral health issues
  • Capacity

Strategies:

  • Considering a “walk in” clinic 
  • Embed behavioral health providers in the clinic setting
  • Expansion of residency program

NHRMC Physician Specialties 

NHRMC Physician Specialties are teaching clinics for resident physicians in Internal Medicine, OBGYN, Surgery and Family Medicine. These clinics treat about 90,000 patients a year, the overwhelming majority of them either uninsured or under-insured. The teaching clinics are one of the major access points for the low-income uninsured in the region.

Susan O’Brien, a clinical coordinator, offered these responses:

Biggest needs of population served:

  • Access to mental health services
  • Access to consistent primary care
  • Access to specialty care
  • Access/ payment sources for dental care
  • Mental health/substance abuse services are limited
  • Affordable medications

Obstacles in serving:

  • Lack of transportation
  • Lack of insurance/inadequate insurance
  • Low education (particularly concerning health care) levels
  • Unstable housing
  • Poor health choices across region (smoking, diet, birth control, substance abuse)= complicated, expensive care
  • Lack of Medicaid expansion/ monopoly on chosen provider for ACA coverage

Strategies:

  • Access to bus/taxi tokens
  • Referrals for uninsured managed by one agency who assigns based on best fit
  • ACA enrollment specialists
  • Pharmaceutical assistance programs/340b pharmacy
  • Grant awards throughout the service area by multiple agencies to try to fill gaps (HRSA, SAMHSA, CDC, etc.)
  • Outreach through health fairs/free screenings

Cape Fear HealthNet 

Cape Fear HealthNet, a three-county initiative in Southeastern North Carolina, has a mission to create a coordinated system of health care for the poor and uninsured in Brunswick, New Hanover, and Pender counties, and to increase the capacity of health care safety net providers by ensuring that low-income residents have access to a medical home, receive preventive services, and avoid unnecessary health complications resulting in a better, healthier quality of life.

Christine McNamee is HealthNet’s Executive Director. Her responses:

Biggest needs of population served:

  • Transportation
  • Funding for co-payments and medications
  • Access to timely, affordable medical care

Obstacles in serving:

  • Lack of region-wide mass transit
  • Lack of consistent funding sources
  • Lack of capacity to accept all persons in need

Strategies:

  • Work with local bus companies and their funders to provide us with low-cost bus tickets to assist those persons on a bus line
  • Applying to foundations to assist with patient funding needs, assisting patients to complete forms for low-cost prescriptions
  • Expanding the network of healthcare providers willing to provide pro bono or low-cost care to low-income uninsured people

Coastal Horizons

Coastal Horizons is a critical access behavioral health agency that promotes choices for healthier lives and safer communities by providing a continuum of professional services for prevention, crisis intervention, sexual assault victims, criminal justice alternatives, and treatment of substance use and mental health disorders. These services are provided to make a significant impact on the physical, emotional, and social development of children, adults, and families in the communities it serves.

Kenny House is Vice President for Clinical Services. His responses:

Biggest needs of population served:

  • Insurance to cover treatment services and care due to non-expansion of Medicaid
  • Health care for major medical problems like diabetes, neurological problems, prenatal care, orthopedics, cancer, etc…
  • Treatment for Hepatitis C – affordability and current treatment hierarchy of treating most ill first and among clients who do not meet requirements for Patient Assistance Programs, such as those still using – increases spread of disease by not treating
  • More services, treatment, health care, and education, in rural areas, including HIV services -- current services are centered in New Hanover County
  • Stabilization in times of mental health crisis and family crisis
  • Older clients with HIV (diagnosed over a decade ago) have nothing new to do/access
  • Care for developmental disorders for children and adults
  • More specialists offering pro bono services to uninsured
  • Basic needs (food/housing insecurity)
  • Subsidizing medications
  • Case management for complex health needs
  • Psychiatric care
  • Treatment for substance use disorders

Obstacles in serving:

  • Lack of adequate transportation
  • Limited finances, financial resources, lack of housing (affordable and supportive), lack of services for specialty care or consultation
  • Insurance barriers (Medicaid not active, private insurance does not cover higher levels of care, private insurance has high deductibles & copays that make mental health & addiction treatment unaffordable, uninsured)/Lack of health coverage
  • Residential treatment services especially for women – even more critical outside of New Hanover County
  • Expansion of peer support/training to include more formal patient navigation services
  • Cost of treatment for Hepatitis C, both monetarily and costs associated with waiting
  • Lack of Fibroscan machine for BCBS clients (closest is Fayetteville)
  • Lack of clinics that take same day walk-in patients
  • Lack of coordination between inpatient and outpatient services
  • Difficulty contacting patients – disconnected phone numbers, no voicemail, or email address
  • Multiple risk factors (socio-economic, mental health symptoms in family, complex trauma, substance use exposure, caregivers untreated MH/SU symptoms)
  • Difficulty engaging patients in their own healthcare or clients not wanting services when they are mandated by DSS/DJJ
  • Language barriers

Strategies:

  • Provide interpreters
  • Complete Charity Care applications
  • Inform and educate clients regarding public transportation/Medicaid transportation services
  • Connect clients to resources in the community and refer to Horizons Health, WHAT, MedNorth, or Ave Maria health clinic; Health Department; Clinica Latina
  • We provide transportation where we can, also bus passes and gas cards. However, if transportation is not available, these are meaningless.
  • Creating more liaisons/MOUs with providers who treat communities with fewer resources, such as Cape Fear Clinic, New Hope Clinic, etc.
  • Supporting the HCV Working Group to bring providers together to develop a local treatment model
  • Working with Prevention to develop a community coalition in Pender County. A formal coalition provides coordination and collaboration between service providers interested in that community
  •  Develop a peer development program for Persons Living with HIV, to engage them in supporting newly diagnosed persons
  • Effective crisis management response
  • Access to 24-hour care
  • Complex treatment that targets risk factors
  • Enhancing access to and development of protective factors
  • A subsidized pharmacy program based at the hospital for a one-time refill, which any patient can access to avoid ER visits.
  • Provide grant monies to support paying for low cost medications not covered by patient assistance programs.
  • Organized communication between the hospital and the identified PCP for ER visits and admissions- HIE has been very helpful, but the information about the PCP is often inaccurate, and there is no way to notify the PCP that the patient accessed services outside of the office.
  • Specialty consultants who will make themselves available to do phone consults on complex uninsured patients
  • Ability to get same day appointments for urgent diagnostic CT scans and Ultrasounds to determine if the patient needs to go to the ER or get admitted.

Prioritized Description of Health Needs

In reviewing the three county health department assessments, common themes appear regarding leading causes of death and leading health concerns among their respective county populations.
As far as leading causes of death, New Hanover County’s top 10 are:

  1. Cancer
  2. Heart disease
  3. Cerebrovascular disease
  4. Chronic lower respiratory disease
  5. Unintentional injuries
  6. Alzheimer’s
  7. Diabetes
  8. Nephritis
  9. Suicide
  10. Sepsis

In Pender County, the top five causes of death are the same as in New Hanover County. Diabetes ranks sixth, and the rate is higher than comparable rural counties and state and national averages.
Motor vehicle injuries are seventh, then nephritis, pneumonia and flu, and suicide. Alzheimer’s ranks 12th as a cause of death in Pender County.
In Brunswick County, the top seven causes of death match New Hanover County. Eighth is pneumonia and flu, nephritis is ninth and suicide 10th.
All three local counties list suicide among the top 10 causes of death, yet suicide doesn’t rank among the top 10 statewide.

The New Hanover County Health Department’s Community Health Needs Assessment charts trends over approximately five years concerning quality of life and community health issues. It found:

Improving Trends:

  • Violent crime rate
  • Years of potential lost before age 75
  • Preventable hospital stays for Medicare enrollees with ambulatory care sensitive conditions
  • Unemployment

Staying the Same:

  • Adult smoking percentage
  • Air pollution
  • Adult obesity percentage
  • Excessive drinking
  • Diabetes among Medicare enrollees
  • Mammography screening percentage

Trends Getting Worse:

  • New Chlamydia diagnoses
  • Children in poverty
  • Severe housing problems

The authors of the assessment also asked the general public for feedback on top health priority areas, and these emerged:

  • Reduce obesity
  • Reduce excessive drinking/alcohol-related traffic crashes
  • Reduce unintentional poisoning death rate (which would include drug overdose)

In the Pender County CHA, the top three community health priorities were identified as:

  • Mental health and substance abuse
  • Diabetes
  • Increasing access to physical activity

The Brunswick County CHA also identified top priority areas. The ones most consistently listed as high priority include:

  • Increasing social cohesion and providing health education
  • Reducing commute times
  • Increasing access to healthcare providers
  • Increasing access to dental facilities
  • Increasing access to transportation facilities

The following pages in this section will address the leading causes of death that surfaced in these health assessments, as well as common areas of concerns, and NHRMC’s current response to all of these issues.

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