NY State Community Health Partnership Milbank Memorial Fund
Partners in Community Health:
Working Together for a Healthy New York 1998

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Access to Care, Primary Care, Service Integration

Dutchess County Immunization Plan
Healthy Community Alliance, Route 39 Corridor, Western New York
Mather-St. Charles Health Alliance, Suffolk County
Morris Heights Health Center
Northern Tioga Health Association
Oswego County Public Health Priorities Planning Initiative
Partnerships for Health/Oxford Health Plans, Brooklyn
Peconic Health Corporation, Suffolk County
Physicians Free Clinic for Uninsured Adults
The Bronx Health Link
Tri-County Community Health Assessment, Clinton, Essex, and Franklin Counties
Western New York Medicaid Managed Care Coalition





DUTCHESS COUNTY IMMUNIZATION PLAN




Mission/Purpose

In 1993 Dutchess County, along with many other counties in New York State, faced a serious problem. Only 76 percent of Dutchess County children were immunized by the age of two. This number was below the Healthy People 2000 goal of 90 percent. Measles outbreaks occurring during the late 1980s and early 1990s, as well as an increase in the number of pertussis cases in 1993, provided proof that underimmunized children were not just a theory but a real problem in Dutchess County and the rest of New York State.

Nineteen ninety-three marked the first year of the Dutchess County Immunization Action Pappendlan. The Public Health Nursing Division of the Dutchess County Department of Health had been delivering vaccine to children for years; however, Immunization Action Plan funds allowed the Health Department to hire a public health nurse to coordinate immunization activities with the goal of raising countywide immunization rates to 90 percent.

The majority of children in Dutchess County obtained their health care from private physicians and not from the local Health Department. Therefore, it was necessary to develop a partnership among the local health care providers, local and state health departments, community organizations, and residents if these efforts were to be successful.

In 1993 Polio Plus USA became an official project of Rotarians in the United States. Citing the Polio Plus campaign, officials of the Centers for Disease Control and Prevention urged American Rotarians to assist in efforts to raise the immunization levels of American children.

Rotary District 7210, encompassing Ulster, Dutchess, Orange, Greene, Putnam, Rockland, Sullivan, and Columbia Counties, met with representatives of the local health department to begin forming partnerships between the public and private sector. In Dutchess County, Daniel Aronzon, M.D., was appointed as chair of the Dutchess County Rotary Shots for Tots initiative. Three strategies were identified to help reach the Healthy People 2000 goal of 90 percent. The strategies were selected after a ìwish listî of possible actions was established.

These actions included:

These priority action steps, along with measurable goals, were established early on.


Leadership Role

Low immunization rates in Dutchess County were recognized as a problem that could not be solved by county government alone. Thus, the community was given an opportunity to create a true partnership of the public and private sectors toward the accomplishment of one goalóthat of raising immunization rates in Dutchess County.

The leadership structure of this collaboration can best be described as shared leadership and shared governance among the local health department, Rotary, medical providers, and the community. County executive William R. Steinhaus and his entire staff gave full support to this project. The Department of Health staff provided a key knowledge base and essential technical support and assistance, as well as nursing staff support, to carry out the activities associated with attaining the goals of this project. Many of these activities required a level of communication and collaboration between project partners that had never before been attempted in Dutchess County.

Insurance coverage and liability issues, oftentimes huge stumbling blocks, were problems that were resolved with the help of county attorneys and executive staff. Every challenge was viewed as a new opportunity.


Key Partners/Stakeholders

When this collaboration began in December 1993, the key partners included:

Daniel Aronzon, M.D., pediatrician, Dutchess County Rotary Coordinator, Shots for Tots; Jack Tartemella, District 7210 Rotary Chairman, Shots for Tots; Ken Obremski, Governor, District 7210; Doris Obremski; Representatives from all local Dutchess County Rotary clubs; Herschel Lessin, M.D., M.V.P.; Al DiDonato, IBM Marketing Group; Suzanne Horn, Dutchess County legislator; Michael C. Caldwell, M.D., M.P.H., Commissioner of Health; Patricia S. Stumpf, R.N., M.S.; Barbara Good, R.N., M.S..

Because the Dutchess County Rotary draws its membership from the cities, towns, and villages throughout the county, an inclusive and representative partnership with the community was ensured. The list of partners continues to grow as the activities of the collaborators expand. For example, membership on the Dutchess County Immunization Information System Advisory Committee consists of several Dutchess County Rotary members as well as members of other community agencies and individual residents representing the interests of health care and child care providers and parents.

The best way to describe the roles and responsibilities of each partner is to describe ìSuper Shot Saturday,î a day on which the public and private sectors worked together to improve the health of Dutchess County children. This event epitomizes Dutchess Countyís vision for a healthy community. Rotary members were responsible for the education and outreach activities in their communities. The County Health Departmentís Immunization Action Plan coordinator provided project partners with education and training for the identification of key community leaders and the development of outreach activities. Rotary members served on subcommittees responsible for setting up advertising, transportation, communication, school contacts, and volunteer staffing required for this event.

The partners explored avenues for providing incentives for childhood immunization as a strategy to reach families of young children. One notable strategy was to distribute at birth a New York State immunization record with a coupon for a J.C. Penney corporate-sponsored photograph upon completion of the basic vaccination series.


Impact/Effectiveness

Dutchess Countyís partnership with the Rotary resulted in a successful Super Shot Saturday. The Dutchess County Department of Health immunization van is a constant reminder to county residents of the importance of immunizations. The Dutchess County Kindergarten Retrospective Survey was one of the earliest studies of its kind conducted in New York State. The retrospective survey was necessary in order to establish a true baseline immunization level. But it was obvious that this was a very labor-intensive task. Community effort, including the cooperation of schools, school nurses, Rotarians, and health department staff, made this task possible. The survey was conducted in 1995 and revealed a baseline of 64 percent of kindergartners fully immunized by their second birthday.

The most important outcome of this partnership is the trust that has been established between the public and private sector. Many of the activities conducted by the health departmentís Immunization Action Plan would not be possible without the groundwork formed by this collaboration. The Rotary is continuing its work in the establishment of a continuous funding source for immunization activities that benefit the community. The continuation of the Immunization Action Plan assures the continuation of many of these efforts.

Contact: Barbara Good, Immunization Program Coordinator, Dutchess County Department of Health, 387 Main Mall, Poughkeepsie, NY 12601. Telephone: (914) 486-3409. Fax: (914) 468-3508.

The following materials are available upon request:

Dutchess County Proclamation: Shots for Tots Program and Super Shot Saturday
Super Shot Saturday Flyer
Poughkeepsie Journal editorial, 4/30/94
1994-95 Kindergarten Retrospective Survey in Dutchess County
See map D3





HEALTHY COMMUNITY ALLIANCE
ROUTE 39 CORRIDOR, WESTERN NEW YORK




Mission/Purpose

The Healthy Community Alliance promotes partnerships among citizens, professionals, facilities, and community groups to address health, education, and human service needs that are viewed as priority areas.

The mission of the Alliance is to facilitate the availability and accessibility of health, education, and human services; the empowerment of rural residents through cooperation and collaboration; community-wide planning to address multiple objectives; and broad-based community outreach for the improvement of health, education, and economic development.

The Alliance is dedicated to serving communities along the Route 39 corridor from Bliss to Perrysburg, New York. This 33-zip-code area encompasses some 64,000 low income rural residents residing in three counties (Cattaraugus, Southern Erie, and Wyoming). Only by working together at the grassroots level can quality of life become a reality.

In 1994, Health Care Plan, a western New York HMO, received funding from the New York State Department of Health, Office of Rural Health, to conduct a community health needs assessment and develop strategies to create a Rural Health Network, which provided the stimulus to discuss health care planning. John Rugge, M.D., chairman of the Governorís Task Force on Health Care and medical director of Hudson Headwaters Health Network, was engaged to meet with key community leaders and providers as a starting point for dialogue. As a result, a steering committee of interested citizens was formed. Soon after, these key stakeholders attended the Healthier Communities Summit in Anaheim, California. Their expenses were covered by Health Care Plan, which was making a community commitment to wellness. Subsequently, a community needs health assessment was conducted and brought together individuals and organizations to focus energy on strategies to improve quality of life.

As part of the Needs Assessment process, the National Civic League (NCL) Civic Participation Survey was distributed to elected officials. Results indicated a willingness to link programs and services, but a general sense of frustration about the lack of transportation; a small pool of strong leaders; and limited access to servicesóespecially where county-imposed geographic boundaries dictate where residents must travel to receive services.

This factor is of particular significance since county seats are on average 35-45 miles from the towns and villages located along the Route 39 corridor.

In addition to the NCL survey, focus groups were convened in homes, community centers, and local restaurants. Participants ranged in age from adolescents to seniors and included school superintendents, young parents, health and human service providers, retirees, government officials, business people, and ministers. The general focus was on what was needed in the community to improve quality of life.

Frustrations expressed by the NCL respondents were mirrored by focus group participants. Finally, an in-depth analysis of demographic, economic, and health indicators was conducted. Subjective and objective data were compiled, resulting in the 1995 Community Health Needs Assessment.

Three major components surfaced as high-need priority areas. These included:

The first step in organizing the community and providers to address critical issues involved a regional visioning conference to focus on youth at risk. As a result of the October 1995 forum, community members and providers volunteered to lead a variety of teams focusing on providers, education, values, and holistic health. These teams mobilized in 1996 and began formulating what, when, and how they could make a local impact to improve quality of life. Team accomplishments to date include:

Through the community-wide needs assessment process, the steering committee identified strategies important to the grassroots including providers, the community, and key leaders such as ministers, elected officials, and business people. While the scope of the needs assessment was far-reaching, it was merely a starting point for discovering even more issues. For example, the newly formed Healthy Community Alliance is now incorporated as a 501(c) (3) nonprofit rural health network. Additional strategies must take the Alliance from a grant-funded agency to one that has products of value that can be marketed to providers and the public. Sustainability rests on the Allianceís ability to take this next step.

As the 1997 planning grant came to a close, the Alliance received implementation funds to develop the Rural Health Network through a three-year grant also funded by the New York State Department of Health, Office of Rural Health. In January 1998 it hosted a strategic planning retreat, calling together board members, community leaders, school superintendents, and providers to identify priority areas to be addressed over the next 18-month period. Using Concept Systems, a Cornell University computerized planning tool, participants documented eight priority areasóagain, always working toward improving quality of life.

A healthy community is one that empowers and energizes citizens to become their own change agents. The healthy community experiences physical, mental, spiritual, economic, social, ethical, and holistic well-being. The healthy community looks out for its citizens because it truly represents people in partnership for a worthy cause. Furthermore, the health of a community goes far beyond that which can be provided by health care professionals.


Leadership Role

The Healthy Community Alliance was incorporated in August 1996 and was formerly known as the Southern Region Rural Network at its inception in 1994. Its corporate name, Healthy Community Alliance, was selected as a result of a nomination and voting process among the members of Alliance teams. Currently, the nine-member board consists of leaders in health, education, business, and human services.

The original steering committee had two areas of concern. First, they sought to create a shared vision for the establishment of a healthy community, and second, the goal was to improve the quality of life for residents in the service area. With these common, obvious objectives, they moved from an informal steering committee to incorporation, with long-term viability a focal point.

While the target area is large and spans more than 90 miles, the hub communities are Arcade, Gowanda, and Springville, New York. These villages are linked by Route 39, the highway running from Bliss in the east to Perrysburg in the west. The Alliance is now looking to expand its influence beyond Perrysburg into the Dunkirk/Fredonia area, to include Lake Shore Community Health Care Center. The hospital CEOs and Health Care Plan maintain board seats along with other key leaders from business, the clergy, human service providers, civic leaders, elected officials, service organizations, and education. Board committees and teams are formed from this constituency. While Health Care Plan was the impetus for developing the network, it currently holds a quiet, almost background roleórecognizing that the community and local providers must create change within and among themselves.

The Healthy Community Alliance works closely with the Office of Rural Health to assure that its focus is indeed on target with statewide efforts. In addition, the Alliance is a member of the National Rural Health Association, the WNY Healthcare Association, the National Cooperative of Health Networks, and the chambers of commerce of Arcade, Springville, and Gowanda. Membership in these local, state, and national organizations provide staff with technical assistance and organizational development opportunities. In January 1998 the Alliance sought assistance from the Southern Tier Health Care System to conduct a concept mapping retreat. In addition, consultants are sought to conduct feasibility studies and assessments to assure objective situational analysis. Staff regularly attend local, regional, state, and national conferences to maintain and improve their level of understanding and to further personal and professional development. In fact, individual development has been a hallmark of this organization since the first group of key leaders attended the Healthier Communities Summit in 1995. Exposure to this California-based conference, developed by Health Care Forum, gave the original steering committee the vision and confidence to clearly and definitively recognize that there is much more to healthcare than hospitals and clinics. These key leaders returned from California with the understanding that creating a healthy community was the essential ingredient to changing their rural, underserved environment of limited access and availability into a community empowered to ensure access and availability of core services long into the future.


Key Partners/Stakeholders

Bertrand Chaffee Hospital, Health Care Plan, and Tri-County Memorial Hospital are standing members of the Healthy Community Alliance corporation. In addition, leaders from business, government, education, human services including the ministerium, and service organizations are recruited for board and committee leadership.

Early on, it was recognized that the indecision of school districts would prove a critical component to empowerment and community initiatives. For that reason, superintendents of the eight districts in the target area were personally invited to become involved in Alliance activities. These local stakeholders and their boards of education are pivotal to rural community leadership. For that reason, when Alliance board seats were being filled, assistant superintendent jeffery bowen, ed.d., from Pioneer Central School and heinke lillenstein, ph.d., a member of the Cattaraugus-Allegany BOCES Board of Education, were recruited.

It is anticipated that Lake Shore Health Care Center will soon be joining this group of key providers and will hold board membership.

The Healthy Community Alliance employs an executive director, program coordinator, administrative assistant, information systems coordinator, and public relations coordinator. In June a community outreach coordinator will join the team to assist WNY insurance providers in increasing the participation of children in the Child Health Plus insurance program. Since staff are not full-time, their efforts are supplemented by the SUNY Fredonia Health Services Administration Department, DíYouville College Health Services Administration Graduate School, and St. Bonaventure University Mass Communications Department. By working with local students in settings that give them a real-world internship, the Alliance is able to leverage its outreach to the extent possible while providing young people an opportunity to learn firsthand how to work effectively in a rural community. Collectively, volunteers, providers, and staff coordinate their functions, serving one another while making every effort to break down traditional barriers of turf, geography, and market share.

The Articles of Incorporation reflect a corporate goal of inclusion for the board of directors, committees, and working teams. In an ongoing effort to assure involvement, the Alliance publishes a monthly newsletter that invites the community to call with their ideas and suggestions. The Allianceís role is not to offer healthcare services, instead its role is to link existing programs, assist residents in learning where they can receive services and offer providers suggestions on what services are needed in the communityó including schools. This two-way process promotes a partnership in which community health and the improvement of the quality of life become a common and obvious goal. This is a slow and gradual process that requires time and patience. But progress reveals itself each time the newsletter is distributed. Thatís when the telephone begins to ring and various offers of help or requests for new people to be added to the mailing list come pouring in.

Additional school districts to be added to the teams include North Collins, West Valley, and Holland. Furthermore, as Lake Shore Health Care Center becomes an active member, the Alliance expects to open activities to the Silver Creek and Lake Shore districts. The Healthy Community Alliance is prepared for opportunities that present themselves on an almost daily basis. These opportunities arise when individuals and organizations come forward and express a willingness to work together so that partners are connected. For example, a community member recently stopped in to express thanks for the transportation service provided by Love, Inc. While a monetary donation was offered, this person also asked if she could take health information and outreach materials to a local library where she is the librarian. Immediately, another avenue was opened to develop a new outlet for information. In addition, she agreed to be interviewed and highlighted in the Rural HealthNet newsletter.

The board of directors of the Healthy Community Alliance is the ultimate decision-making body for the nonprofit corporation. Policies and procedures are developed by the executive director and submitted for approval by the board. The board of directors establishes teams to address priority areas. The executive director also establishes teams to assist in the ongoing achievement of objectives. Individual teams, or subcommittees, make decisions within their groups and follow those decisions through implementation. Financial decisions are made by the executive director approved by the board of directors and finance committee.

As a result of the concept mapping exercise, eight teams were formed to address priority areas.

Partners expand participation within and among their various constituencies to assure that the community is appropriately involved and impacted by network initiatives. In addition, community, education, and health teams address other goals and objectives funded by the New York State Department of Health, Office of Rural Health. These goals and objectives designate responsible parties, document expected outcomes, and the path by which objectives are achieved.


Impact/Effectiveness

From 1994 through 1997 the Healthy Community Alliance addressed five program objectives. These were:



Key activities designed to address these objectives were conducted throughout the three-year term with the following accomplishments:
The above items were accomplished as a result of the three-year planning initiative. The second round of grant awards received by the Healthy Community Alliance from the Office of Rural Health was approved in 1997, moving the initiative from planning into implementation. As a result, the following five program areas are currently being addressed:

The Alliance is now completing its first year of implementation. Most noteworthy is the production of videotapes for the prevention of diabetes. Local at-risk individuals were recruited to prepare, adjust, and cook ADA-approved recipes. The videotape series, to be broadcast over local cable access stations, will be available for borrowing and/or purchase. In addition to the video series, the Rural HealthNet newsletter devotes a special section to target people with or at risk for diabetes mellitus. Human interest stories, interviews, and a listing of important resource information are regular features and are set in large type. The newsletter has been remarkably successful; its distribution increased from 600 households to 1,400 households in just three months. This increase was a direct result of word-of-mouth requests. A survey included in the January issue will be repeated in June for comparison and to evaluate program effectiveness. Incredibly, out of 600 mailed in January, some 100 instruments were returned. This is true evidence of the communityís support and interest in improving quality of life.

The Personal Wellness Profile Health Risk Assessment conducted in area schools was completed on some 1,500 students in the eighth and eleventh grades in three districts. Baseline data is established for each district at the eighth-grade level. The three-year program will include interventions specific to student needs. Retesting in the eleventh grade will then be scheduled. School superintendents, health professionals, and teachers are working together to analyze data and adjust curriculum to best meet student needs based on the results of the health risk appraisals.

The Alliance is also spearheading a Family Support Center Feasibility Study in three school districts in response to requests made by school superintendents. Recognizing their inability to address health and human service issues, these superintendents sought assistance from the Alliance to optimize local resources within and among the districts. The study is being developed by Nowak and Associates under the supervision of the Healthy Community Alliance.

Another feasibility study is being conducted to analyze placement of a birthing center in rural Cattaraugus County. This study will be conducted over the next six months by McLin Associates.

In addition, the Alliance has been invited by local health and human service agencies to partner them on various projects. These developing partnerships include the Wyoming County Department of Health, the WNY Healthcare Association, Safe Net/Haven House, NA/AA, Habitat for Humanity, and the LK Painter Community Center. These requests are further evidence of the impact the Alliance is having on the community and of the effectiveness of programs even at this developmental stage.

One benefit to the providers centers on their ability to use the Alliance as a vehicle to assist in the reconfiguration of their rural healthcare delivery system. While this is a time of challenge, it is also an exciting one that includes opportunities for new service development as identified by key stakeholders. As a result, everyone becomes more aware of the needs within the community so that more efficient services and programs may be developed. Ultimately, the long-term goal is to improve the quality of life for all rural residents along the Route 39 corridor.

The Healthy Community Alliance is led by a nine-member board of directors and an executive director. A program coordinator, administrative assistant, information systems coordinator, and community relations coordinator all contribute to meeting program objectives and organizational responsibilities. In addition, by working closely with SUNY Fredonia Health Services Administration Department, the Alliance has established an internship and independent study program. The enthusiasm, motivation, and creative energy of these students has been key to our success. Consultants are hired to supplement projects and studies where necessary and to broaden the scope of projects. Fiscal reporting is done in a budget-versus-actual format, with monthly review of revenue and expenses. The executive director prepares the budget for allocation, control of cost, and maintenance of operations and makes recommendations for purchases at a level consistent with organization guidelines and funding. In addition to completing regulatory responsibilities and grants administration, the board and staff participate in an annual strategic planning process to gain direction for achieving organizational goals.

Community interest, support, and involvement are increasingóespecially after distribution of the monthly newsletter. Some 1,400 individuals are targeted for health promotion and disease prevention services, especially in the area of diabetes. They receive the newsletter and are invited to call to add names and addresses so that friends and family can also receive this publication. With the newsletter growing so quickly we now involve staff in local radio broadcasts to emphasize the importance of managed care and to further educate rural residents about managed care. Furthermore, four videotapes that address health promotion and the prevention of diabetes are in production, with some 30-40 local residents serving as television ìstarsî and local ìchefs.î The videotapes are a collaborative effort among Tri-County Memorial Hospital, Bertrand Chaffee Hospital, and the Cattaraugus Indian Reservation Health Center. These videos will be available in medical offices and broadcast over local cable TV. These will be available in July. Enthusiasm continues as evidenced by the communityís request to develop a cookbook of local recipes amended to ADA standards. The cookbook is planned for release in 1999. Furthermore, Personal Wellness Health Risk Assessments conducted in three school districts, Gowanda, Pioneer, and Springville, document health risk behaviors of eighth and ninth graders in population-based reports now under review by school health officials, administration, and teachers. This will be expanded to include five more school districts in 1999. The Alliance expects to assist the school districts in developing very targeted interventions to assist the improvement of health among students. Preliminary data reveals that nutrition and exercise are the two most critical issues facing teens. A survey distributed in the newsletter established baseline understanding of diabetes and wellness.

The Alliance is sponsoring three programs to provide area businesses and the community with the awareness, knowledge, and skills required to participate in electronic commerce on the Internet. This project is cosponsored by three chambers of commerce and three school districts. Development of a Web page for the Healthy Community Alliance was accomplished by working with SUNY Fredonia students. Fredonia College also acts as the server at no cost. Through funding from the New York State Department of Health, Office of Rural Health, the Alliance purchased a six-passenger minivan and, together with Love, Inc., a local church organization, is providing transportation for individuals who cannot otherwise access services.

The target area is located within parts of four counties. Government-imposed barriers to access health and human services as mandated by county boundaries limit accessibility to health and human services. County seats in Wyoming, Cattaraugus, Erie, and Chautauqua Counties lie 35-45 miles from the target area. Public transportation is virtually nonexistent, and the community lacks a general understanding of how to access subsidized services.

Financial distress and political challenges are critical issues for the rural hospitals and school districts. In Gowanda voters are facing a 16 percent tax increase. This same community is facing the impending merger or possible closure of its local hospital, Tri-County Memorial. This is an emotionally charged environment that requires a great deal of sensitivity. This rural community includes blue collar workers, the largest Old Order Amish community in New York State, and the Seneca Nation of Indians. Plant closures and relocation of NYS facilities (JN Adam DDSO and Gowanda Psychiatric Center) have led to additional economic distress. Furthermore, there is a critical need to expand, enhance, and improve local leadership capacity. As a result of the challenges facing the community, the Alliance is now proposing development of a Rural Leadership Forum, especially targeted to elected officials, school officials, hospital board members, and other key stakeholders.

It has been said that opportunity presents itself for the prepared organization. The Healthy Community Alliance, though faced with several challenges, is excited and motivated, filled with energy and commitment to its vision to create a healthy community for its rural residents.

Contact: Patricia J. Kota, R.N., B.S., Executive Director, Healthy Community Alliance, 26 Jamestown St., P.O. Box 27, Gowanda, NY 14070. Telephone: 716-532-1010, Fax: 532-1011, Internet address: http://beech.ait.fredonia.edu/alliance/ E-mail: alliance@buffnet.net.

Contact the Healthy Community Alliance to receive the monthly Rural HealthNet newsletter.

See map, A1,4,5





MATHER-ST. CHARLES HEALTH ALLIANCE
SUFFOLK COUNTY




Mission/Purpose

John T. Mather Memorial Hospital and St. Charles Hospital & Rehabilitation Center had a long history of informally working together, an arrangement seemingly mandated by the fact that they are located within one-half mile of each other in the same community. However, in the mid-1990s, the two hospitals realized that the dynamics of health care delivery were changing rapidly. The growing influence of insurance and managed care companies, along with large employers and government agencies, increasingly affected where patients were going for treatment. Furthermore, it became clear that a larger number of patients, would be treated in ambulatory care settings, leaving hospitals seeing fewer, but sicker, patients, who would expect increasingly sophisticated treatment at an increasingly less expensive cost.

To meet these challenges, a group of doctors, administrators, and board members met repeatedly over the course of three years to discuss how Mather and St. Charles could better meet the needs of their patients, their physicians, and the communities they serve. These discussions led to the creation of a Joint Planning Committee, and throughout 1996, this committee, working with managers and employees from both hospitals, examined the individual strengths of both hospitals. This led to the development of a plan centralizing certain services at each hospital, eliminating duplication of some treatment programs, and reducing overall costs. On January 1, 1997, this plan was implemented, and the Mather-St. Charles Health Alliance was born.

The purpose of the Alliance is to eliminate the duplication of services provided by the two hospitals, thereby achieving significant cost savings to them and ultimately to the health care planning system; to provide high quality and appropriate health care services to the community; to provide enhanced, efficient services to the community so that residents need not travel elsewhere for care provided by the hospitals; and to ensure the long-term viability of both Mather and St. Charles. Furthermore, it is the Allianceís goal that the increased cooperation between Mather and St. Charles will not compromise the individual identity of each hospital.

It is the Allianceís belief that a healthy community is one in which people are educated and informed about their health care needs and can rely on their local health care providers to be responsive to the changes in those needs. Through their Alliance, Mather and St. Charles are creating this type of community and providing it with expanded signature services that the costs of direct competition would have made impossible.

The key priority action areasóeliminating certain duplication of services, enhancing remaining services, and consequently reducing costs at both hospitalsóled Mather and St. Charles to agree to a series of service ìtrades,î resulting in the allocation of certain, specific operational services at each hospital. These trades were made subject to the approval of the New York State Department of Health (if required), other regulatory agencies including the Justice Department and/or Federal Trade Commission (if and where applicable), and the Joint Planning Committee itself. Once the necessary approvals were obtained, the following trades were carried out to allow the Alliance to meet its goals:

Mather Hospital ceased to provide inpatient pediatric care, inpatient pediatric surgical services, and most ambulatory pediatric surgical services. These services were centralized at St. Charles. However, ambulatory pediatric ophthalmology and ambulatory pediatric E.N.T. could still be obtained at both hospitals. Inpatient and outpatient pediatric/adolescent psychiatry were to be provided exclusively at Mather.

Mather Hospital ceased to perform neurosurgery and neurosurgical procedures, as well as spinal fusion, laminectomies, and other similar spine, back, and neck procedures. These services were centralized at St. Charles. However, if the seriousness of a patientís illness or injury made transfer to St. Charles impossible, then such procedures could be performed at Mather.

The provision of inpatient endocrinology and related services was centralized at St. Charles, including diabetes and nutritional and metabolic diseases. It was understood that due to the variable nature of this type of service, an occasional patient may be admitted to Mather because the final diagnosis is not known upon admission. In addition, Mather Hospital would continue to provide hyperbaric oxygen treatment services and outpatient wound care services.

St. Charles Hospital ceased and Mather Hospital continued to provide inpatient and outpatient oncology services, including the Outpatient Chemotherapy Treatment Program. Inpatient and outpatient medical and surgical oncology and cancer-related hematology services were centralized at Mather, with the understanding that certain oncology surgical procedures including orthopedic, neurosurgical, and pediatric surgery were to continue at St. Charles.

St. Charles abandoned plans to establish a special angiographic procedure room specifically equipped to do vascular studies, with these services to be performed exclusively by Mather. However, St. Charles continued to operate digital radiographic equipment to perform various other procedures, such as ERCPís, GIís, swallowing studies, and hysterosalpingograms, although Mather is not excluded from providing these services.

To the extent that these trades created a financial imbalance, a ìFairness Formulaî adopted by the Joint Planning Committee determines the direction of general medical surgical patients to the extent necessary to correct the imbalance.

These trades ensured that the community would continue to have access to high-quality medical care, while giving both Mather and St. Charles the freedom to begin spending less on competition with a neighbor and more on the expansion of services to the community they jointly serve.


Leadership Role

The aforementioned Joint Planning Committee (JPC) governs the Alliance. The committee was officially created on December 11, 1995, and by agreement, the board of trustees at Mather Hospital and the board of directors at St. Charles Hospital delegated authority to the committee to decide all issues relating to the implementation and operation of the Alliance. However, to allow each hospital to maintain its own identity, certain services at each were, by agreement, left out of the Alliance, and the Joint Planning Committee has no authority to make decisions regarding these services.

The JPC is obligated to keep minutes of all its meetings and to provide the two hospital boards with all minutes and resolutions reflecting actions considered and/or approved by the JPC. The JPC, at all times, consists of 20 individualsóten designated by Mather and ten designated by St. Charles. Of the ten designated by Mather, six must be from Matherís board of directors, one must be its chief executive officer, two must be members of Matherís medical staff, and one must be either an individual employed by Mather or an additional director. Of the ten designated by St. Charles, six must be from the St. Charles board of trustees, one must be its chief executive officer, two must be members of the St. Charles medical staff, and one must be either an individual employed by St. Charles or an additional trustee.

Regular meetings of the JPC are held six times per year. Special meetings may be called with no less than five daysí written notice, although the notice may be waived by a voting quorum of the JPC. Special meetings of the JPC may be called at the joint request of two Mather representatives and two St. Charles representatives.

Twelve members of the JPC shall constitute a quorum, and there must be at least six representatives of each hospital present. All actions authorized by the JPC must be approved by the vote of a majority of the members present at a meeting where there is a quorum present throughout. A member may be construed to be present if ìattendingî via telephone conference call or through a similar arrangement in which all participants can hear one another. Any action requiring a vote may also be taken without a meeting if a written consent is signed by the requisite number of JPC members and all members are notified of the intended action. Proxies may be used for votes but do not count toward a quorum.

The JPC from time to time may decide to establish ad hoc committees to consider various issues. These committees, unless otherwise agreed by the JPC, perform their functions and submit recommendations to the committee for approval.

Although this simple majority is usually sufficient to approve any action by the JPC, certain issues require a supermajority vote of all members of the JPC, with no less than seven affirmative votes from each of the Mather and St. Charles representatives. The issues calling for a supermajority vote include: future Certificate of Need applications; licensure items; matters dealing with the duplication of services provided by Mather and St. Charles; matters dealing with the expansion of existing services; new programs to be offered by either Mather or St. Charles; expansion of a program or activity by either hospital costing more than $250,000 over two years in the aggregate, including capital, personnel, supplies, and operating costs; changes in the ìFairness Formulaî; changes in ìtradesî; any change in the structure of the Alliance; and the admission of, or any affiliation with, another hospital.

The JPC is headed by a chairperson who serves for 12 months or until his or her successor is appointed. The right to nominate chairpersons alternates from year to year between Mather and St. Charles; the chairperson is elected by a supermajority vote of the JPC. The chairperson drafts and distributes meeting agendas, verifies that meetings have been properly called, ensures that quorums are present, conducts meetings of the JPC, ensures that minutes of meetings are maintained and approved, and executes other such duties as assigned by a supermajority vote. The chairperson has the right to vote at all JPC meetings. In addition, the hospital that does not nominate the chairperson in a given year nominates a deputy chairperson who serves in the chairpersonís absence. The deputy chairperson is elected in the same manner as the chairperson.

To enhance the effectiveness of the Alliance, the JPC enlisted the technical support of several outside agencies and consultants, including Sam Davis and Delta Consulting; the law firm of Garfunkel, Wild and Travis; and several accounting firms including Ernst & Young and Loeb and Troeper. By using these outside agencies, the JPC was assured of an unbiased look at the strengths, weaknesses, and finances of each hospital, allowing for better decision making when it came time to determine the ìFairness Formula.î


Key Partners/Stakeholders

Two key partners are involved in the Alliance, specifically, John T. Mather Memorial Hospital and St. Charles Hospital & Rehabilitation Center. The stakeholders, as the hospitals see it, are themselves and the people they serve. If the Alliance succeeds, the partners and the community benefit; if it does not, they do not. It was determined that, as part of the Alliance, all members of the medical and dental staff at one hospital would be considered members of the medical and dental staff at the other hospital as well. This makes it impossible for medical professionals to benefit by ìplayingî one hospital against the other when it comes to referrals, a common situation where two facilities in close proximity are in open competition with each other. With the Alliance, a doctor may refer to either hospital or as governed by the ìtradesî set up by the JPC, and both hospitals benefit.

To ensure that the community is included in this partnership, the board of directors at Mather and the board of trustees at St. Charlesófrom which the members of the JPC are ultimately drawnóare composed of members of the community the hospitals serve. The directors and trustees solicit input from friends and colleagues in the community, bringing the input of these people to the attention of the JPC. Furthermore, each hospital publishes and distributes an annual Community Service Plan outlining its services and directly asking for the input of the community in determining the future path of the hospital with respect to the provision of health care services. Additionally, in keeping with the recognition that an educated community is critical to a healthy community, each hospital offers a series of educational programs that are publicized through the local media. Attendance at these programs and demand for new or additional programs give the members of the Alliance a way to gauge the concerns of the community so that a response to those concerns may be formulated.

The partners in the Alliance, recognizing that the changing landscape of health care has led to the creation of large networks of hospitals with which it must compete, are open to the addition of new partners to its arrangement. Toward that end, the Alliance is involved with several other community hospitals on Long Island in the creation of an entity called the Long Island Healthcare Network (LIHN). The LIHN would enable locally governed community hospitals to sustain mission effectiveness while operating in a dynamic health care service delivery environment. The additional partners include Winthrop University Hospital, Brookhaven Memorial Medical Center, South Nassau Communities Hospital, Good Samaritan Hospital Medical Center, Mercy Medical Center, and St. Francis Hospital. None of these hospitals is currently involved in the Alliance, but each is working toward a collaborative futureómuch as Mather and St. Charles did in creating the Alliance. It has already been determined that any collaborative effort among all these hospitalsópossibly including Stony Brook University Medical Centerówould be governed by a joint planning committee set up along the same lines as the one that governs the Mather-St. Charles Health Alliance. The Alliance foresaw the possibility of additional affiliations when it drew up the rules for its own governance.


Impact/Effectiveness

While Financial resources were not an issue in the creation of the Mather-St. Charles Health Alliance, there were two speciac conflicts that needed to be resolvedóone internal, the other external. Internally, each hospital needed to learn ìhow to beat swords into plowshares.î The two hospitals had been in competition for decades, and while they had informally worked together on some issues, both remained fiercely independent. When it was decided to work together for the betterment of both, it became necessary for the two hospitals to learn how to view each other as friends rather than enemies. Naturally, this process has not always been smooth, but with the leadership of the JPC, conflicts have been avoided or minimized and the process has moved along smoothly.

Externally, members of the communityóespecially those with a loyalty to either Mather or St. Charlesóneeded to be convinced that an agreement that would have each hospital giving up certain services was going to benefit the community. Through a series of articles and stories in the media, along with community meetings, the Alliance put forth the message that the community would not be losing any services and, in fact, would soon have access to new services paid for by the savings created by the elimination of competition.

To this end, St. Charles was able to move ahead with the completion of a multimillion dollar renovation of its main hospital, while Mather was able to complete a new Ambulatory and Inpatient Surgical Pavilion. Both of these projects would have been undertaken had there been no Alliance, but the savings created by the Alliance allowed these projects to proceed smoothly without either hospital having to cut corners or sacrifice other services. The hospitals were able to jointly pay for a new, state-of-the-art MRI machine to service the community, so that each paid less than they would have to buy such machines themselvesómachines that likely would not have been fully utilized due to the presence of a similar machine right down the block. The new MRI system is also much faster than previous systems available, reducing exam times by up to 75 percent, so patients are better served. The hospitals were able to realize additional savings by combining their leadership in the areas of infection control, admissions and discharges, social work, and radiology.

In response to surveys of the community about its changing health care needs, the Alliance is now moving forward with plans to open a franchise of Homecare America to provide the community with access to home-based medical equipment. Additionally, the Alliance is moving ahead with plans for a rehabilitation and nursing center, has created a specific-needs certified home health agency, and is now in the process of creating and supporting a ìlifecareî community to be called ìJeffersonís Ferry.î

As a result of the savings created by the elimination of open competition and the duplication of services, the Alliance has, in fact, been able to move ahead with the expansion of its services. This includes the opening of a satellite office for Matherís Wound Care Center, the opening of a new location for the St. Charles Rehabilitation Network, the opening of new locations for the Allianceís Occupational Health Center and Diabetes Care Center, and the expansion of its Stroke Centers. The success of these projects will be gauged strictly by the increased care the Mather-St. Charles Health Alliance can bring to the ever-increasing community it is able to serve.

In planning for the future, the JPC will continue to draw on the resources of a top-notch medical and dental staff shared by the two hospitals as well as the resources of the members of each hospitalís board. So long as there is a community to serve, both hospitals will solicit the input of that community to find out its needs. Then using that input, they will work through the JPC to best meet those needs in a way that allows the community, and the two hospitals composing the Mather-St. Charles Health Alliance, to thrive.

Contact: Daniel G. Rowland, Vice President, Development, Marketing and Public Relations, St. Charles Hospital & Rehabilitation Center, 200 Belle Terre Road, Port Jefferson, NY 11777. Telephone: (516) 474-6465. Fax: (516) 474-6252.

A brochure and other materials are available upon request.

See map, D10





MORRIS HEIGHTS HEALTH CENTER




Mission/Purpose

Morris Heights Health Center (MHHC) is a large community health center in the mid Bronx in New York City, an area of devastating poverty and serious shortages of health services. During its seventeen years of operation, the center has anticipated and trailblazed virtually every community-based health initiative of this period and has helped the community begin a process of restoration.

The center annually provides 180,000 health care visits to a community of 76,000, whose families are primarily Latino and African American. The majority of these families are headed by female single parents with lower educational levels and are overwhelmingly pooróover 60 percent below federal poverty levels. The center operates with a budget of $18 million consisting of 20 percent grant funding and 80 percent third-party revenues, of which two-thirds are Medicaid and one-third is Medicare, commercial insurance, and self-pay.

The twofold goal of the nominated project was to improve and expand access to primary health care by relieving an untenable state of overcrowding at the centerís main facility and by establishing a new gateway to care in the northern tier of the centerís traditional service area. The aim was to build a new facility with expanded capacity for an additional 20,000 patients per year and to generate 70,000 annual primary care visits by the end of the year 2001.

The planning and development phase of the project was supported by a $325,000 planning grant from the United Hospital Fundís Primary Care Development Program. Further impetus was given to the project through its designation by New York Cityís Primary Care Development Corporation (PCDC) as one of PCDCís very first capital expansion projects. While the bond financing preferred by PCDC proved to be too costly for the center to accept, PCDC support was invaluable in untangling various encumbrances associated with a 23,400-square-foot building shell. MHHC acquired the shell in 1995, financed by a commercial bank loan and supported by the Bureau of Primary Health Careís (BPHC) Capital Improvement Program (CIP) funding to offset the debt service on the loan. This facility, now fully constructed, is located at the corner of 183rd Street and Walton Avenue and within two years will achieve a primary capacity of at least 15,000 patients.

By 1993 several public and quasi-public agencies had already highlighted the proposed area as one of great need. The service area has long borne the triple federal designations of Medically Underserved Area (MUA), Health Professional Shortage Area (HPSA), and Dental Professional Shortage Area (DPSA). In addition, several citywide bodies provided timely and recent data on conditions in the area. The now defunct Health Systems Agency (HSA), the New York City Department of Health, and the United Hospital Fund (UHF), a nonprofit agency, furnished very specific localized data on the health, social, and economic status of the population.

HSA and UHF created an index (ACS index) based on aggregated hospital admission rates for those conditions that can be prevented or managed through appropriate outpatient primary care. These indicators are a reflection of a communityís access to care and its overall health status. By every indicator used, the Morris Heights/Tremont neighborhood showed alarmingly higher rates of hospital admission than the city as a whole.

Condition % Above City Average
Pediatric
    bronchitis/asthma 		43%
Measles 118%
Bronchitis/asthma 161%
Adult otitis media 124%
Congestive heart failure120%
Tuberculosis 67%
STDs 44%
HIV/AIDS 54%
Substance abuse 105%
Due to the high rates of substance abuse, STDs, and early entry into sexual activity in the area, virtually the entire communityóand especially the Walton Avenue target areaówas at risk for HIV infection. In 1989, when the center routinely began to track AIDS case rates in its service area, the cumulative adult AIDS case rate was 524 per 100,000 adults. Today this rate exceeds 2,000/100,000, and the centerís current cumulative total of known HIV-positive patients is 1,300, compared to 40 in 1989. With a flagrant street trade in drugs and sex, the neighborhood of the Walton Avenue expansion site was rife with factors that placed its sexually active population at grave risk for HIV infection and co-morbidities.

Thus these analytic efforts, directed by the centerís Department of Planning, identified the area early on as one in need of services. Visual surveys of the community also clearly indicated that the area was in distress. The neighborhood surrounding the expansion site was a much less stable one than the Burnside Avenue neighborhood. At first glance, 183rd Street appeared to be a busy commercial strip with much street traffic, but unfortunately it included blatant trade in drugs and sex. Jerome Avenue was also a hub of prostitution activity. The area lacked the organizational infrastructure that exists in the neighborhood immediately surrounding MHHCís West Burnside Avenue facility and, unlike the West Burnside Avenue neighborhood, there were no institutions (like Bronx Community College) that draw people from outside the neighborhood. There are four public schools within a three-block walk of the site; they are plagued with high rates of violent incidents and truancy.

The center had a full-time staff of marketing and outreach workers reporting directly to senior management. This team began collaborating early on with the block associations in the area, with the Fordham Bedford housing project, and with Community Planning Board Five, one of 59 such boards in the city designed to act as a funnel for voicing community needs. Thus the formal planning efforts, community assessments, and input from local organizations all coalesced and clearly identified the need to do something dramatic.

To maintain strategic advantage, and to begin to address the local communityís unmet need as expeditiously as possible, MHHC opened a temporary, rented Annex facility adjacent to the construction site in August 1995. This 4,000-square-foot rental property had been occupied by a Shared Health Facility. Not only did the center renovate and equip this facility but it also made effective outreach to its users, resulting in a brisk start-up phase for the Annex. New York State Primary Care Development (PCI) funds enabled MHHC to accomplish the Annex renovation and rental. The Annex began to serve an initial 700 patients with six providers and was a resounding success. It permitted the center to more fully assess the needs and market possibilities for the area. During the next 21 months, the Annex added two more providers and had a patient base of 5,000 by the time the new Walton Avenue location opened.

It is expected that the new facility will help the center create a true ìhealthy community.î For Morris Heights, a healthy community is one that looks and feels ìvitalî as one walks through it, one where people obviously feel good about their community. It is a community where people are involved, where they interact, and where there is a sense of oneness even though they may come from many different backgrounds.

For their health care needs, community members should have easy access to comprehensive care of high quality. Care should be offered by providers who are either from the community or actively committed to it. Providers should be nurturers and be able to establish bonds with their patients such that the latter can always feel they have someone to call. A healthy community is one in which its members begin to learn how to share some of the responsibility for their own care. It is also one in which health center managers act as true stewards of the communityís resources, always seeking out cost-effective care.


Leadership Role

Organizationally, MHHC reflects a pervading administrative philosophy of commitment to the achievement of excellence via the expectation of responsibility and accountability, along with the extension of authority and trust. As reflected in the centerís Table of Organization, the chain of command is very clear. The Walton Avenue collaborative project, developed under the aegis of the board of directors, was implemented by the centerís senior management team under the direct oversight and leadership of the centerís president and chief executive officer, Verona Greenland. Ms. Greenland, the visionary leader at the helm of this project, worked tirelessly to bring about its implementation. Through the leveraging of local, state, federal, and private resources, Ms. Greenland was successful in her bid to provide primary health care services to an additional 20,000 residents of the Bronx. Ms. Greenlandís efforts, as well as the efforts of all the collaborating agencies and officials, exemplify health care planning at its best.

Structurally, the framework of MHHCís organization is girded by three distinct layers of management. The functional structure of the organization permits a broad matrix of interfacing multilevel, multisystems interaction. This functional style fosters the involvement of frontline managers, support staff, and all levels of provider staff. A system of solution-oriented committees and work groups maximizes the human potential of the organization by fostering creativity, free flow of communication, and empowerment of all levels of staff.

At the heart of the operation are the clinical services, with a clear, authoritative leadership mandate accorded to the senior vice president of medical affairs. As reflected in the organizationís Health Care and Business Plans, strong interaction is maintained between the clinical system and the financial and operational systems. This synergy supports the prime purpose of the organization: the delivery of a high standard of accessible, affordable patient care.


Partners/Stakeholders

The project marks the completion of a capital expansion plan that markedly redresses the longstanding unmet need for primary care capacity in this area of the Bronxóan achievement made possible through collaborative association between MHHC, Bureau of Primary Health Care, Banco Popular de Puerto Rico, NYS Department of Health, Burnside Merchants Organization, Borough President Fernando Ferrer, Assemblyman Roberto Ramirez, Councilman Israel Ruiz, Community Planning Board #5, Bronx-Lebanon Hospital Center, the City of New York, and the United Hospital Fund (UHF).

The project was initiated in 1993 with a $325,000 Primary Care Development grant from the United Hospital Fund. The UHF had been instrumental in highlighting the need for a more rational ambulatory care system in the city. It not only provided the planning and development grant but also acted as a bridge to other larger and/or influential institutions in the city. In the summer of 1994 MHHCís primary care expansion project was chosen as one of 16 projects designated as Communicare II sites in the NYC mayoral initiative to develop urgently needed primary care capacity in medically underserved areas. This designation resulted from MHHCís successful funding application to the Primary Care Development Corporation (PCDC), which conferred eligibility for tax-exempt PCDC bond funding support to MHHCís primary care expansion project.

However, Ms. Greenlandís exploration of alternative funding sources led to the eventual selection of Banco Popular de Puerto Rico, which approved a $2.6 million loan to commence construction of the facility. Banco Popular had been the centerís regular bank for many years and, as a minority-owned bank in the community, it felt a natural obligation to reinvest its depositorsí resources in the community. The center also received a $2 million grant from the Federal Bureau of Primary Health Care (BPHC) to cover ten years of debt service on the loan. The BPHC has had a long-standing relationship with the center, acting as one of its main grantors and the agency to whom the center looked for up to 10 percent of its overall budget. BPHC funds are primarily used to support basic services and to cover losses from our sliding fee schedule, which serves those without insurance. The center had maintained very good relationships with the bureau over the years and was thus well received when it sought both technical assistance and capital financing assistance from the bureau.

The centerís philosophy is patient and community driven. The board of directors, for the most part, is composed of community residents or persons with strong daily affiliations with the community. A system of public board meetings carries out a continuing dialogue with the community, augmented by many smaller forums for needs assessment and evaluative exchange. The board is the principal architect of the organizationís Strategic Plan as well as its Health Care Plan and Business Plan. The Strategic Plan is a dynamic document that has coalesced through ongoing analysis of our operation and reflects the input of a cross-section of the organization, including the board, staff, patients, and management.

The centerís outreach strategy is very clear. It identifies both the major and minor stakeholders of the center. These include residents of the community, patients, both public and private institutions who operate or have facilities in the community, public and private funders, and many others. It does not assume that every stakeholder needs to be involved in every decision or at all times. Rather, it tries to determine specifically what it requires from each of the stakeholders and what it can offer in return.

MHHCís operations also encompass community advocacy, public policy, and communal planning. These emphases are entirely in concert with the founding purpose of the organization. Within the present climate of rapid change, its population is highly vulnerable. Additionally, the organization is vulnerable to losing patients as a result of auto-assignment of managed care patients and confusing changes in entitlement procedures, combined with newly emerged, cutthroat marketplace practices. Therefore, MHHC attempts to continually inform public policy, educate its consumers, and advocate to ensure the centerís survival and the least damage to the population served.

Thus, in addition to the city, state, and federal groups mentioned above, Ms. Greenland was instrumental in leveraging the support of local politicians and community groups:

The centerís main strategy for mobilizing support for this project in particular was to have a fully developed plan to discuss with stakeholders and supporters, rather than simply stating the centerís needs and waiting for a response. Similarly, the center was able to actively leverage each increment of support to cumulatively build support for the next step; it was not an all-or-nothing proposition presented to stakeholders.


Impact/Effectiveness

The impact of the project is very real. A brand-new facility stands in an area of considerable decay. But it is now serving over 5,000 users, and the community is slowly becoming a ìhealthy community.î A fledgling tenants group is forming in the housing adjacent to the new site, and the housing administration is actively receptive to its community outreach activities. In addition to the renovated housing and several Tier II family shelters in the area, the communityís density is increasing through the replacement of vacant lots with single- and multiple-family housing units, reflecting a increase in employed residents in the community.

While the impact of the center can only be truly evaluated when it is able to assess the changed health status of its new users and when it reaches its goal of 20,000 users, the increased sense of pride in the new facility is palpably felt by both patients and staff. The center itself feels newly empowered to help expand services in other areas and is actively seeking partners with whom to provide ambulatory services in other locations. The Walton Avenue collaboration has also empowered other local groups, both public and private, to realize that collaboration and a focused strategy do work, not only in this part of the Bronx but throughout the city.

Contact: Jamie Fenwick, Vice President Planning and Development, Morris Heights Health Center, 85 West Burnside Avenue, Bronx, NY 10453. Telephone: (718) 716-4400. E-mail: Noblejay@aol.com

See map, D4





NORTHERN TIOGA HEALTH ASSOCIATION




Mission/Purpose

In 1993 Lourdes Hospital and United Health Services Hospitals began discussions with a concerned group of citizens in the northern tier of Tioga County regarding the lack of health care services to their communities. Considering that a major part of each institutionís mission is to provide health care services to underserved populations, the purpose of this partnership was to institute basic primary care services in an effort to improve health status of residents in the northern tier communities. Recognizing that previous attempts to provide health care services had been unsuccessful, the partnership was seen as a creative mechanism to understand the reasons for past failures and develop innovative strategies to overcome previous deficiencies.

From the outset of the project, the purpose of the partnership went far beyond the single obstacle of access to basic primary care. Aspiring to a vision of a healthy community meant moving beyond the limits of a purely medical definition of health.


Key Strategies

Considering the desired outcomes for this project, a number of strategies needed to be undertaken. To build an effective partnership, the strategies were developed from both an organizational focus and a community focus. Without a dual focus strategy it was clear from the onset that the project would most likely be, at best, an insignificant attempt to improve the health status of the local communities.

Community strategies stemmed from an understanding that a healthy community is a vibrant one in which residents possess a sense of ownership and a desire to take action to build a stable, secure community for themselves. The major goal was to find a common issue around which residents of the diverse communities could relate. To accomplish this goal, multiple town meetings were held at various locations to create a mechanism for sharing. Outcomes of this strategy included:

Organizational strategies behind this project included:


Leadership Role

The leadership role of this partnership combines the formal organizational structure of the two hospital systems with the informal structure of a community advisory board. The advisory board consists of members elected from the general membership of a multicommunity health association. Membership in the overall health association was solicited through town meetings, direct mail campaigns, print media and word of mouth. The only common thread among the general membership of this diverse region was the interest in re-establishing health care services in their communities.

The principal hospital partners demonstrated leadership and promoted team building across each of the communities through involvement at various community events. The hospitals also maintained operational responsibility for the respective primary care centers but work closely with the formal advisory board, which assists the institutions in remaining sensitive to the needs and concerns of the communities served.

To develop the leadership of the advisory board, initial efforts centered around promoting multicommunity collaboration in which a ìvision-orientedî strategic planning approach was utilized. These early efforts at team building were a necessary component in order to counteract the long-standing history of conflict between the communities and initiate consensus-building conduct. To assure equal representation from the surrounding communities yet create manageable size committee structures, the advisory board consisted of three members from each of the three principal communities, three members at large to represent the smaller surrounding communities, and four members from the hospital organizations. In order to create an environment whereby the community members are empowered to shape service delivery, the hospital representatives sit as nonvoting members of the advisory board.


Key Partners/Stakeholders

From the initiation of this project, the principal partners in the establishment of primary care services in northern Tioga County were Lourdes Hospital and United Health Services Hospitals. The informal stakeholders were the residents of each of the communities in the northern Tioga area. Although not a principal partner, Cornell Cooperative Extension of Tioga County was a key participant. Through the Extension, contacts were made with Cornell University, which participated in a number of activities leading up to the implementation of primary care services.

Other key participants involved in the partnership included the Newark Valley School District, countywide health and human service agencies, and members of the Tioga County legislature. Although not directly involved in the operational aspects of the primary care centers, the additional partners participate to shape service delivery that will benefit residents throughout the region. Other groups being looked to for potential collaboration include church groups, senior centers, fire and emergency service personnel, and local businesses.


Advisory Board Functions

Critical in the formulation of the advisory board was the creation of an environment in which the members recognized their role as key stakeholders and not just figureheads. With this objective in mind, the providers understood that they needed to take action on recommendations of the group if the project was to be successful. The advisory board also recognized the need to demonstrate unbiased actions in order to maintain the support of residents across the diverse communities.

Considering the vast array of issues that needed to be addressed, the advisory board developed subcommittee structures with clear-cut goals and objectives. The subcommittees addressed each of the following areas:

In addition to meeting the objectives for each of the committees, the activities involved in meeting those objectives served to promote community spirit building and created a sense of ownership and responsibility for the success of the project.

To assure that recommendations reflected the broad perspective of the diverse communities, the advisory board utilized several formats to gain input. Included here were the development of a comprehensive survey in conjunction with Cornell University; focus group meetings at senior centers, town halls, and other community functions; a phone survey; and general association meetings. Additionally, to maintain equal representation and prevent the perception of favoritism of one community over another, monthly meetings are rotated among each of the communities.

Impact/Effectiveness

From the initiation of this project, it was expected there would be traditional outcomes associated with establishing and enhancing access to health care as well as nontraditional outcomes in terms of effects on the communities overall. The expected outcomes included:

Overall, the project was designed to demonstrate how the multicommunity collaboration model could lead to positive community outcomes across a diverse region.

Residents throughout the region benefited from this project in numerous ways. The immediate benefit came with the establishment of primary health care services at two locations in the northern part of Tioga County. With the willingness of both hospitals to share services, a much more comprehensive set of services became available, including social work services, nutrition counseling, prenatal care, and an array of health education and prevention programming. People throughout the community also benefited from the dissolution of distrust and the elimination of polarization of residents that had previously pitted one town against another in competition for programs and services.

Benefits to the partners can be directly attributed to the activities of the community. Most organizations would have considered the region too sparse in population to have supported one primary care center, let alone two. From the inception of the project, it was openly recognized that the success and long-term viability of the centers rested on the support and utilization by the communities. Four years after the opening of the centers, community support remains very high, as evidenced by the utilization at each of the centers.

As with any primary care center, fiscal and staff resources are supported by the revenues associated with ongoing operations. Without the strong support of the community, these revenues would be far from any level of financial viability expected in communities this size.

Beyond the resources required for normal operations, however, an inordinate amount of personal resource time has been contributed on a volunteer basis to the communities, both on the part of the community residents and on the part of the paid hospital staffs. What happened in these communities between the large organizations and the community residents was the development of a bond, in many ways similar to that of an extended family, whereby all of the key players have come to rely upon one another in one common goal, improving the quality of life in the community.

One major form of evaluation that will determine the success of this project will be the overall impact upon the health status of the communities served by the project. Considering the small population and the rural nature of the area, it will be several years before definitive improvements in health status can be demonstrated that are statistically significant. However, there are some indicators that are generally considered to be indicative of positive improvements in the health of the community. Included in some of these indicators are:

Other indicators of promoting a healthy community are seen in the nontraditional format of evaluation. Most of the outcomes here demonstrate the effectiveness of ìcommunity buildingî and the associated effects throughout the community. Examples of outcomes include:

In the area of community building, one example stands out as evidence of how effective the strategy has been in developing a community partnership. Since each of the centers was to be operated by two different organizations with a history of competition, each center would carry the organizational name along with the name of the town it was located in. This became an extremely emotional issue. The advisory board felt this would continue to divide the communities, just as they had been split over many issues in the past. A quote from one board member described the community feelings quite succinctly: ìWe believe this project can unite the communities in northern Tioga and we donít want the name to jeopardize that. There has already been too much division between us.î It was for this reason that the centers took on the respective names of ìNorthern Tioga Center for Family Healthî and ìNorthern Tioga Family Care Centerî in an effort to avoid the perception that the centers would serve only the needs of residents in one town.

In summary, the partnership believes this project demonstrates the positive potential of applying the conceptual ìhealthier communitiesî model to a rural community. Each of the participants agrees that had the efforts to partner with the community not been made, the dream of establishing a local health care service would have never become a reality let alone be sustained.

Contact: Wayne C. Mitteer, Director of Planning, Lourdes Hospital, 169 Riverside Drive, Binghamton, NY 13905. Telephone: (607) 772-1716. Fax: (607) 772-1642. E-mail: Wmitteer@Lourdes.com

Brochures, print ads, magnets, message boards, and other materials are available. Also available to share: the survey instrument and articles written in conjunction with Cornell University.

See map, B12,13





OSWEGO COUNTY PUBLIC HEALTH PRIORITIES
PLANNING INITIATIVE




Mission/Purpose

The Oswego County Health Department used the Public Health Priorities Planning Initiative to reinvigorate a countywide Rural Health Network by inviting the Network to assume leadership responsibility for sponsoring and conducting the process. The Health Department saw that the goals of the Public Health Priorities Planning Initiative were best accomplished under the auspices of the Rural Health Network, given the Networkís mission to:

improve the health status outcomes of community members by focusing key resources to address specific local health care priorities . . .[and]. . .to keep abreast of the dynamic changes in the health care environment, and develop proactive strategies for evolving and strengthening our local health care service system as we face current and future challenges.

The Health Department also saw the opportunity to build a broader base of ownership, resources, and capacity to act upon local health care issues by offering the Rural Health Network a leadership role in the process. Members of the Rural Health Network include the administrators of both hospitals in the county, the local community action agency (a major provider of health care to Medicaid recipients in the county), the County Health Department, local physicians, the local community college, Oswego State University, and various other agencies involved with health care in the county. Health Department staff felt that involving this broader set of providers in the needs assessment and planning process would pave the way for future implementation of strategies that would require buy-in and commitment of these providers.

In order to broaden participation of local stakeholders and the community at large in the Initiative, the Rural Health Network expanded its partnership with the Health Department to include the State Universityís Center for Business and Community Programs. The center already hosts a public issues forum called the Sheldon Roundtable, and it would become the culminating event, involving hundreds of county stakeholders in selecting the top health care priority areas.

The process involved four key elements. First, a steering committee was established to oversee the design of the process. The committee included representatives from the Health Department, the Rural Health Network, and SUNY Oswegoís Center for Business and Community Programs. This group met for two hours each week over the course of several months to plan and implement the design and logistics of the Public Health Priorities Planning Initiative. The second element was to consider the health care issues identified in Communities Working Together for a Healthier New York, within the context of Oswego County. This was accomplished in a half-day focus group session involving 70 staff from various health and human services agencies, government, education, and the local business community. During this focus group session, an Oswego County ìreport cardî was developed for each of the health issues identified in Communities Working Together for a Healthier New York. The third key element was to actually prioritize the health care issues considering the local assessment information that was processed into the report cards. This would be accomplished through a Sheldon Roundtable community forum entitled ìHealth Care Needs in Oswego County: Letís Sort Them Out.î Over 1,000 community members were invited to attend the forum and an open invitation to the community was extended by the media. At the Sheldon Roundtable the report cards would be reviewed and attendees would have the opportunity to vote on the issues that should take priority in Oswego County. Finally, the health issues that surfaced as priorities during the Sheldon Roundtable forum would be incorporated into the Rural Health Networkís strategic planning process and local action strategies, accountabilities, outcomes, and time frames would be established.

There is a work plan that identifies the major steps involved in the process and the time frames for accomplishing those steps. At present, the Rural Health Network is preparing for the Sheldon Roundtable session identified as the third key element in the process. Activities at the Sheldon Roundtable will result in a broad-based community consensus on the key health care elements to address. A visioning and strategic planning retreat for the Rural Health Network is scheduled for the weeks following the Sheldon Roundtable. At this planning retreat a vision for a healthy community and specific strategies for addressing the health care issues that Sheldon Roundtable participants identified as priorities will be developed.


Leadership Role

The Health Department recognized the role it could play in cementing the partnership relationships among members of the Rural Health Network by engaging the Network in a project that would establish the organization as the core entity in the county for creating the local health care infrastructure and priority agenda. The Rural Health Network had been in existence for several years and had struggled with forming a base of trust and ownership and a common mission and goals among its membership. As a result, the Network lost the grant funding that was the impetus for its creation and found itself at a crossroads between moving forward as an unfunded entity and dissolving as an organization.

In the fall of 1997, the commissioner of Human Services, who oversees the local Departments of Health, Social Services, and Employment and Training, accepted the chairmanship role for the Rural Health Network and began renewed efforts to build the organization and to develop its mission. Under his leadership, the Rural Health Network began work on a formal mission statement and goals. The Network formally adopted its new mission statement last fall and began to look for opportunities to achieve its mission.

The commissioner had the foresight to defer implementation of the Public Health Priorities Planning Initiative until the Rural Health Network had established its mission and was in a state of readiness to move forward as a collaborative organization with shared goals. One of the primary goals of the Rural Health Network, as identified in its mission statement development process, is ìto improve the health status outcomes of community members by focusing key resources to address specific local health care priorities.î This goal provided a perfect fit and a state of readiness for the Rural Health Network to take leadership in the Public Health Priorities Planning Initiative.

Throughout this process, the commissioner has taken leadership by giving up leadership. He recognized that a ìbottoms-upî design process would play a crucial role in cementing the partnerships and relationships among participants of the Rural Health Network, and he therefore shared leadership of the project among those members. The commissioner also played a key leadership role in providing resources and identifying opportunities that would further the success of the project. Several members of the commissionerís staff were assigned to the design and implementation committee. A major opportunity that he identified and capitalized on for the project was the expanded partnership with SUNY Oswego. This partnership brought additional talent to the process design team, additional resources and facilities that were used in the report card preparation session, access to the Sheldon Roundtable community forum, and access to a broader representation of community members who would engage in the prioritization of issues at the Sheldon Roundtable.

The Health Department, Rural Health Network, and SUNY Oswego came to the planning table as equal partners in designing and implementing the process.


Key Partners/Stakeholders

The key partners in the design and implementation of the process were identified in the previous section. Additional partners and stakeholders were included in the report card preparation session and will be included in the Sheldon Roundtable community forum. Individuals who participated included the following: Steven Rose, Commissioner, Oswego County Human Services; Michael Rosen, Deputy Commissioner, Health Department; Kathy Smith, Director of Patient Services, Health Department; Joette Deane, Director, Mental Health Services; Mary Acquaviva, Executive Assistant, Oswego County Human Services; Denise Casey, A. L. Lee Memorial Hospital; Rob Flynn, Andrew Michaud Nursing Home; Mame Hastings, Northern Oswego County Health Services; Ellen Holst, Oswego County Opportunities; Thomas Kearns, D.D.S., Oswego County Dental Society; Frances Lanigan, Oswego County DSS; Dan Mather, Oswego County OB/GYN/ Data Systems Unlimited; Mac McKinstry, Oswego Hospital; Dennis Norfleet, M.D., Oswego County Health Department; Michael Nupuf, M.D., Oswego County Physicians Organization; Debbie Parker Grimshaw, Cayuga Community College; Janette Resnick, Oswego County Opportunities; Shirley Seabury, A. L. Lee Memorial Hospital; Corte Spencer, Oswego Hospital; Deborah Stanley, President, SUNY Oswego State University; Carolyn Rush, SUNY Oswego State University; Sandy Resnick, SUNY Oswego State University; Nancy Bellow, SUNY Oswego State University; Lanny Kearns, SUNY Oswego State University; Carolyn Rush, SUNY Oswego State University; Jennifer Schultz, CNYHSA; and Gerald Richmond, CNYHSA.

Seventy-five representatives from local human services agencies, community-based organizations, schools and government, and the health care professions participated in the focus group sessions designed to prepare the Oswego County Health Care issue report cards.


Sheldon Public Issues Roundtable

Invitees included more than 1,000 community leaders and other individuals from health care, government, business and industry, school systems and institutions of higher learning, human service agencies, media, and the community at large.


Impact/Effectiveness

The projectís effectiveness cannot be fully evaluated until the final two elements are implemented. These elements include the Sheldon Roundtable event, at which priority issues will be identified, and the Rural Health Network strategic planning process, wherein specific strategies, accountabilities, outcomes and time frames will be established. While difficult to measure, this project has reinvigorated the Rural Health Network. The organization is meeting more frequently and members are more engaged as indicated by their consistent attendance at and participation in the meetings. Recent interest in the Rural Health Network has been demonstrated by the media and outside entities who have been exposed to the organization and want to become involved in the Network, either through direct membership in the organization or by working on a health priority issue it may take on.

The Rural Health Network is hopeful that its renewed sense of energy and commitment, and a very public success with the Public Health Priorities Planning Initiative, can be leveraged to allow it to compete for funding to implement its strategic initiatives. The Public Health Priorities Planning Initiative has served a very important role in reenergizing the organization and allowing it to select the path of moving forward.

Contacts:

Steven D. Rose, Commissioner of Human Services, Oswego County Health Services,

7 Bunner Street, Oswego, NY 13126. Telephone: (315) 349-8246. Fax: (315) 349-3435. E-mail: Steve@co.oswego.ny.us

Mary G. Acquaviva, Executive Assistant, Oswego County Health Services, 7 Bunner Street, Oswego, NY 13126. Telephone: (315) 349-8246. Fax: (315) 349-3435. E-mail: Mary@co.oswego.ny.us

See map, B6





PARTNERSHIPS FOR HEALTH
OXFORD HEALTH PLANS, BROOKLYN




Mission

Oxford developed Partnerships for Health to encourage Medicaid members to obtain preventive care services. The program was based on the belief that the most effective method for reaching members was to work with community-based organizations (CBOs) that had an understanding of and were known by Medicaid members in local areas.


Process

Through Partnerships for Health, Oxford established relationships with CBOs to implement outreach and education projects. Oxford worked with the CBOs to develop outreach activities that included mailings, telephone calls, special events, and incentives that emphasized the importance of preventive care and encouraged members to obtain the services they needed. For each project Oxford identified members in the CBOís service area who were due for the following services: immunizations, lead screens, well care visits, HIV/AIDS education, alcohol and substance abuse, Pap smears, and mammograms. Oxford provided a list of these members to the CBO. Oxford then sent letters to these members, informing them of the service(s) needed and that a CBO representative would be contacting them to remind them to make an appointment for the needed service(s).

Included with the letter was a postcard designed to obtain updated member information as well as verification of the service received. Members were instructed to complete the postcard with their doctors and return it to Oxford or the CBO. Oxford and the CBO provided members with incentives to encourage them to obtain the needed service(s) and to complete and return the postcard. Members who returned the postcards received turkeys for Thanksgiving, holiday toys, circus tickets, and school supplies.


Key Success Factors

Partnerships for Health relied on the resources and expertise of community-based organizations to determine the best approach for engaging members of local communities in preventive health activities. For each Partnership for Health project, the CBO worked with an Oxford project leader to design, monitor, and modify each activity. For example, a CBO in the Park Slope area of Brooklyn conducted a health and beauty event to attract members, whereas a CBO in Coney Island offered amusement park tickets to members who obtained the needed health service. The majority of members in one CBOís service area were in need of HIV and substance abuse education, so the project was directed to members ages 12ñ21. In another project, Oxford arranged for a mobile mammogram unit to provide services at a CBO located in an area lacking in health care providers. While Oxford assisted in coordinating each project, the CBOs took the lead in determining the most effective approach for their local community.

At the end of each project period, Oxford presented the CBO with a report that detailed the outcome of the outreach activities. Elements of successful projects were shared among the CBO partners in an effort to assist CBOs in improving their individual projects. Modifications that were made included changing event dates and times to increase attendance, offering different incentives that have proven successful in other projects, and conducting home visits to members without telephones. To assist new CBOs in the project development process, Oxford created a list of best practices based on the experiences of CBO partners. The CBOs involved in Partnerships for Health played an active role in its implementation and development process.


Partnerships for Health Community Partners

Oxfordís Partnerships for Health program involved many different types of community-based organizationsófrom health agencies to day care centers to tenant associationsó as evidenced by these participants in 1997: Advent Community Day Care Center; Astella Development Corporation; Arthur Ashe Institute for Urban Health; Brighton Neighborhood Association; Brooklyn AIDS Task Force; Carey Gardens Boys & Girls Club; Community Health & Referral; Coney Island Youth Development; Father Billini Association-Claridad Beacon Center; Greater Brownsville Youth Coalition; Hispanic Young Peopleís Alternative; Ingersoll Tenant Association; St. John the Baptist Community Center; and Touro College.


Impact/Effectiveness

In the pilot year of 1997, Partnerships for Health conducted outreach to 5,424 members. As of December 31, 1997, 1,736 (32 percent) of those members received their updated health services. The program goal was to achieve a 30 percent response rate.

In addition to the members on its initial lists, PFH was also able to reach out to family members and encourage them to obtain needed services. In many instances Oxford was able to obtain the health records of siblings of those members on the original mailing lists, demonstrating that the effectiveness of Partnerships for Health extends beyond those directly targeted.

Each of the partners involved in Partnerships for Health benefited from its participation. The program expanded Oxfordís ability to conduct education and outreach activities by involving CBOs in these efforts. PFH provided CBO partners with exposure to Oxford members and the opportunity to promote their services and involve members in their activities. Benefits to members include health education and assistance in obtaining health care services as well as gifts such as circus tickets, Thanksgiving turkeys, holiday toys, and school supplies.

Partnerships for Health aligned the efforts of Oxford and community-based organizations toward the mutual goal of improving the health of New Yorkís Medicaid population. Testament to community support for PFH is evidenced by the fact that 12 out of 14 CBO partners from the first year participated in the programís second year. In addition, two organizations expanded the number of sites involved in conducting PFH projects. Oxford and many of the CBO partners promoted the program in newsletters distributed to members and throughout the community. CBOs also advertised individual PFH events by distributing flyers throughout their communities. Many of the CBO partners recommended participation in PFH to other CBOs and served as references in support of the program.


Roles and Responsibilities

The community relations department for Oxfordís Medicaid program implemented Partnerships for Health. Oxfordís Manager of Community Relations oversaw PFH program staff, which included a program coordinator, three project leaders, and one database coordinator. The community relations manager trained project leaders on the initial presentation to potential CBO partners and on developing time lines and project plans that were used for each project. The community relations manager also accompanied the project leaders on their first presentations to CBOs to provide support and evaluate the presentations.

Project leaders provided CBOs with technical assistance in making outreach calls and guidance in project development. Weekly meetings allowed program staff to share experiences that included both success stories and obstacles, and these experiences helped to modify current projects and influence the development of future projects. Oxfordís quality management staff assisted the database coordinator in developing a tracking database and advised on data analysis. The entire program staff participated in several PFH special events, such as the turkey distribution and toy drive, as a means of generating enthusiasm for the program (everyone feels great when they can give a toy to a child in need!) and strengthening relationships among team members.

Oxford project leaders worked with CBO partners to develop the PFH projects aimed at members within the CBOís service area. Oxford was responsible for providing the CBOs with a list of members needing services, in addition to producing educational materials and letters, conducting mailings, coordinating incentives, tracking outcomes of outreach efforts, and analyzing program data. CBOs were responsible for conducting member outreach, tracking outreach efforts, and organizing special events. Oxford project leaders and the CBOs met regularly throughout the project period to assess progress and make modifications.


Challenges

The biggest challenge to conducting PFH projects was obtaining accurate member data. Many members who needed services could not be contacted because they did not have telephones and often provided Oxford and the state with incorrect information. Partnerships for Health helped Oxford obtain updated information since, in a significant number of instances, members completed the postcards in order to receive the incentive. However, the overall success of the program relies on the planís ability to provide CBO partners with accurate member information. In implementing Partnerships for Health, Oxford did not encounter political problems or community conflicts. The main challenges were operational in natureódata tracking, adhering to time lines, and so onóand were addressed in the evaluation meetings that took place with the CBO partners at the end of the first year. The creation of a list of best practices also helped to make the program more effective as it expanded.


Personnel and Project Cost

To implement Partnerships for Health, Oxford dedicated a program manager, a database coordinator, and project leaders to the program. The average project outreaches to 350, members and one project leader can coordinate ten projects over a one-year period. The cost of involving 5,424 members in 15 projects during the first year was $45,000. This amount, exclusive of staffing costs, covered CBO compensation, printed materials, mailings, special events, and incentives.

Contact: MariBeth Doyle, Manager, Government and Community Relations, Oxford Health Plans, The Curtis Center, 601 Walnut Street, Suite 900, Philadelphia, PA 19106. Telephone: (215) 733-2114. Fax: (215) 625-5702.

E-mail: mdoyle@oxhp.com

See map, D7





PECONIC HEALTH CORPORATION
SUFFOLK COUNTY




Mission/Purpose

Four years ago the three eastern Suffolk hospitals, Central Suffolk Hospital (CSH), Eastern Long Island Hospital, (ELIH) and Southampton Hospital (SH), recognized the need to consolidate their efforts to provide better quality of care to the five east end townships they representóEast Hampton, Southampton, Shelter Island, Southold, and Riverhead.

The hospitals recognized that in order to expand access to and improve the quality of care for their community residents, it would be necessary to initiate a formal process to develop and analyze the merits of a formal association/alliance. A joint planning committee with representative members from the three hospitals was established to identify the needs, problems, and potential solutions.

It was obvious that the assistance of an outside consultant was necessary, and an application was filed with the New York State Department of Health for a grant. This grant was approved in the amount of $123,000, and the firm of Peat, Marwick (KPMG) was engaged.

The results of the KPMG study identified the potential economic benefits and quality enhancement dimensions that could be achieved if the three hospitals proceeded to establish a parent corporation or a merged corporation.

The reports of the KPMG study, which indicated minimal savings of $4 million for a loosely affiliated structure to $10 million for a merged corporation, were brought back to the individual hospital boards. The individual boards assessed the study results versus the alternate option of ìgoing it aloneî over the next several years.

Opinions were sought from key business leaders, political leaders, and legal counsel with respect to the viability of proceeding.

One of the major difficulties encountered was the fact that each of the three hospitals had different cultures, medical staffs, management staffs, and so on. There was also strong sensitivity to the fact that the public and the community that provided philanthropic support to the three hospitals might hesitate to give to a specific hospital if it was felt that the donation would be diluted by being shared with the other two hospitals.

After assessing the above, the three hospital boards decided that it was in their best interest (not only for survival but also to flourish and provide the best care to the community residents) to proceed with the establishment of a parent holding corporationóan Article 28 under the New York State Department of Health regulationsóthat would have super-majority powers with respect to long-range planning, approval of the operating and capital budgets, and any major Certificate of Need approvals.

A Certificate of Need was filed with the State Department of Health for the Peconic Health Corporation (PHC), the parent corporation. Bylaws were formulated and a Joint Vision Statement prepared.


Leadership Role

Based upon an assessment of the obstacles of fund-raising and the fact that the individual influences within the hospitals, i.e., the medical staffs, the boards, the volunteers, and the community at large, would not be entirely receptive to a merger, the decision was made to establish a parent holding corporation which in essence would be the sole member of each of the hospitals. According to the bylaws of the parent corporation:

ìThe Board of Trustees shall have power and authority to perform all acts and functions consistent with its responsibilities and to manage and control the Corporation, its property, business and concerns, except as to those powers specifically reserved to the Hospitals in the New York State Not-For-Profit Corporation Law or the Certificate of Incorporation or these Bylaws of the Corporation.î

It would be composed of eight trustees from each hospital, all of whom would be nominated by the individual hospital boards but approved and appointed by the parent corporation.

Because of concerns with respect to the deletion of essential services and other critical issues, it was determined that key issues would be decided by a super-majority vote. A super-majority vote constituted 15 members voting affirmatively, with a minimum of five trustees from each hospital voting affirmatively. The super-majority issues were as follows:

As the process moved along with the approvals from the New York State Department of Health, Public Health Council, and so on, much effort was made with respect to team building among the medical and management staffs. In fact, after the Certificate of Need application was filed, application was made for an additional State Health Department grant, which was awarded in the amount of $117,000 for the years 1996 and 1997. This grant basically was designated for planning and implementation of the initiatives identified.

Since the Certificate of Need application and subsequent conformance contingencies required involved a lengthy process, it was decided by the interim board to function as if the corporation had approvals and to implement whatever could be achieved as soon as possible. The hospitals engaged the firm of Lash Group to confirm the areas identified by KPMG and to identify the projects, programs, and consolidation and integration of management and administrative functions that could be achieved. In the initial phase of the corporate activities, it was decided that a leadership structure consisting of the three CEOís of each hospital would function as an administrative council, making collaborative decisions with respect to the initiatives undertaken.

This CEO/Administrative Council functioned for approximately ten months, and then a decision was made to appoint a President/CEO of PHC. Although the official corporate status had not been finalized, it was felt that significant strides could be achieved if the leadership role was coordinated by one individual rather than a council. In November 1996 Thomas B. Doolan, President/CEO of ELIH, was appointed President/CEO of PHC. Joseph F. Turner, Jr., and John J. Ferry, Jr., M.D., were appointed as Executive Vice Presidents of PHC.

In order to continue the team-building efforts already underway, several committees of the board of PHC were appointed. These committees included the Program Planning Committee, Strategic Planning Committee, and Finance Committee. The role of the Program Planning Committee was basically to identify and implement short-range planning initiatives. Accordingly, individual task forces were established to concentrate on specific initiatives.

Initially these task forces were the Laboratory Task Force, Marketing Task Force, Specialty Services Task Force, Facilities Task Force, MIS Task Force, Rehabilitation Task Force, and Quality Improvement Task Force.

Representatives from the three hospitals were appointed to these committees, and task forces and specific goals and objectives were established with appropriate timetables regarding same.


Key Partners/Stakeholders

The key partners in this community effort consisted of the three hospitals, the State Department of Health, the law firm of Garfunkel, Wild & Travis, the consulting firms of KPMG and the Lash Group, as well as the leadership of local business organizations.

During the period the corporation was forming, various media articles were developed and published in order to keep the communities advised and to allay any concerns that the quality or nature of the health care offered by the respective health care providers would in any way significantly change.

Meetings were held with various service groups, religious groups, and other community groups to outline the programs being considered and the progress achieved to date.

There are other potential partners who are not currently involved but have been peripherally involved, such as East End Hospice. At the present time, the three hospitals have decided to remain as an independent coalition and not to be absorbed into any other networks such as the Long Island Healthcare Coalition.

Since the Certificate of Incorporation for PHC was only received in November 1997, the board of trustees decided that it would be best to ìtest its mettleî as an independent network rather than be absorbed into a larger network with commensurately less authority and ability to control its own destiny.

Decisions have been made to look at joint ventures, shared services, and managed care contracting on a network-to-network basis.

PHCís decision-making process has already been outlined. With the appointment of the President/CEO, the board was expanded to 25 members.


Impact/Effectiveness

Although PHC has only been officially incorporated since November 19, 1997, its ability to plan and implement prior to the official incorporation has resulted in significant outcomes.

These outcomes and results are briefly described below:

Clinical Engineering
One vendor was selected to provide the clinical engineering services to all three hospitals. This has resulted in projected savings of over $1 million for the next three years.

Centralized Laboratory
Efforts began in April 1997 to consolidate all the laboratory services for the three hospitals. A nationwide search was conducted to recruit a regional laboratory director.

During the balance of 1997 significant strides were made to eliminate duplicative equipment and to negotiate cost-effective savings for reagent contracts and other supplies.

Test volumes were also consolidated in a core laboratory and through attrition, a reduction of eight FTEís was achieved.

The total annualized savings achieved to date approximate $1 million, and the projected savings after the implementation of a laboratory information system will be over $2.5 millionóa combination of increased revenues and additional cost reductions.

Corporate Materials Management Center
In 1997 efforts were initiated to consolidate all purchasing, supply storage, and distribution of supplies to the three hospitals in a centralized warehouse.

The centralized warehouse opened on Kroemer Avenue in Riverhead in December 1997, and the first hospital that was put on-line was Central Suffolk Hospital. All medical/surgical and ancillary supplies were consolidated in this warehouse; two trucks were purchased and cost-effective contracts with major vendors were implemented. The projected savings over the next four years will be over $4 million. It is also anticipated that other healthcare providers in addition to the three hospitals will be brought on-line, as it is to their benefit to utilize the services of a Corporate Materials Management Distribution Center.

RehabilitationóSports Rehab
In 1997 a decision was made to establish a comprehensive sports rehab network.

Southampton Hospital had already initiated sports rehab centers in Southampton and Westhampton and was planning to open another sports rehab center in East Hampton.

It was decided that ELIH would purchase a physical therapy practice in Southold, expand the space for this practice, to include a sports rehab center. At the present time, other sites in Shirley, Mastic, and Riverhead are under consideration and it is anticipated that these sites are to open in 1998.

The benefits of the sports rehab network will be to integrate programs and protocols for the North and South Forks and to offer the community served a comprehensive fitness and sports rehab program. This program would also include physical therapy modalities for the elderly and handicapped. The partners in this sports rehab network are the school districts located on both the North and the South Forks. The concept of the network is to place trainers in the schools who will work with the athletic coaches and the students providing training and instruction in the awareness and treatment of sports injuries.

Quality Improvement
In 1997 a Quality Improvement Task Force was established. The results of this Task Force are as follows:


Future Plans/Programs

The coordinated efforts of the three hospitals in maximizing the resources available to them will result in the establishment of an ambulatory surgery center and outpatient renal dialysis center in Hampton Bays.


Summary

In summary, the coordinated efforts of the three hospitals, Central Suffolk Hospital, Eastern Long Island Hospital, and Southampton Hospital working to enhance, expand access to, and improve the quality of care for all the community residents in the five eastern towns (communities) have resulted in an integrated delivery system on the North Fork with the formation of the Peconic Health Corporation.

This initiative will position the three hospitals to realize significant cost savings; enhance opportunities to develop new services; avoid unnecessary duplication of programs; pursue joint negotiations with managed care organizations, academic medical centers, and other providers; and stem the out-migration of area residents.

All of the above would not have been possible without the award of the two grants from the New York State Department of Health.

Contact: Thomas B. Doolan, President/CEO, Peconic Health Corporation, 1116 Main Road, P.0. Box 1060, Aquebogue, New York 11931. Telephone: (516) 369-7100. Fax: (516) 369-5472.

See map, D10





PHYSICIANS FREE CLINIC FOR
UNINSURED ADULTS
BROOME COUNTY




Mission/Purpose

The Physicians Free Clinic for Uninsured Adults is a project established to meet the health care needs of the growing population of uninsured in this area. An extensive survey of the literature was conducted in order to gain an understanding of the nature and magnitude of the problems of the uninsured at the national, state, and local levels. Data was obtained from the New York State Department of Health and from local health planning agencies. Findings confirmed that this is a burgeoning national problem. There are approximately 42 million medically uninsured people in the United States, a nation of 260 million. In New York State, with a population of 18 million, 2.5 million are uninsured; it is estimated that 25,000 of the 199,000 people in Broome County have no medical coverage.

The mission of the Free Clinic for Uninsured Adults is ìto deliver health care to the uninsured on an elective basis. The mission is accomplished by volunteers, primarily retired professionals, working with the health, education, and governmental resources of the Southern Tier of New York.î On an operational level, the clinic aims at providing basic, high-quality primary and acute care services.

Secondary purposes are to focus public attention on the medically uninsured problem and to rally the local institutional and organized delivery systems to create a more user-friendly climate for health care. It is hoped that bureaucratic hurdles that sometimes serve as barriers to access will be simplified to facilitate the use of charity care that most nonprofit institutions are required to provide. In addition, this project was conceived to emphasize the humanistic and charitable ethic that underlies the health care professions and to challenge the current primacy of commercial imperatives in the delivery of health care.


Leadership Role

The project developed from an idea piloted by a physician in Hilton Head, South Carolina, who organized retired physicians to provide a free clinic for the many uninsured service workers in the area. This particular type of free clinic has been replicated elsewhere in the country, mostly in the south where there are large numbers of retired physicians. The strategies that differentiate the current project from these other free clinics include the mobilization of community agencies and cosponsorship of the clinic by multiple partners. These are identified in the Key Partners/Stakeholders section.

The concept of a free clinic in Binghamton originated with a group of retired physicians who meet over lunch on a monthly basis. These physicians, many of whom are faculty of the Clinical Campus (a SUNY Health Science Center College of Medicine branch campus), approached the leadership of the school to determine its interest in being a potential sponsor for the project. As a community-based medical school, the Clinical Campus is unallied with many of the competing provider interests in the community and is, in itself, a consortium type of program. It has been a neutral sponsor and in particular, Associate Dean Patricia Darcy has played a major role in the development and implementation of the program.

The project was also discussed with the Broome County Health Department and its political leadership. A partnership was developed, and the health department not only made clinic facilities available but reallocated some of its remaining Primary Care Initiative Grant funds to the project. Thus, the Broome County Health Department and the Clinical Campus became the lead organizational cosponsors.

Retired physician faculty of the Clinical Campus were organized as the Physician Volunteer Services Committee (PVSC), which became a standing committee of the faculty organization of the medical school.

Upon resolving the issues of direct sponsorship, the physician committee sought out the active participation of the local medical society and other health care organizations. They received enthusiastic support for the concept from all sectors of the health care professions. In addition, the committee sought major assistance from the hospitals and private medical groups to secure pro bono services on behalf of the uninsured patients.

As a way to involve the larger community, the PVSC established a community Advisory Board with representation from social and health agencies; business, industry, and political leadership; the religious communities; and members of the media. The boardís function is to advise the retired physicians in their provision of clinical services and to interpret the project to the community at large. Technical assistance is provided by the Clinical Campus Deanís Office and staff, along with the nursing and public health professionals at the Broome County Health Department. The professionals and office staff of the free clinic are recruited from community volunteers.

Liability issues were addressed. The medical school has umbrella coverage through the self-insurance ability of the State University of New York and the State of New York. Therefore, all free clinic volunteers are appointed to the project as representatives of the medical school and are thus covered under a public law in New York that provides malpractice and liability insurance for people associated with the project. The Counselís Office at the SUNY Health Science Center provided major legal assistance in this matter.


Key Partners/Stakeholders

Principal partners at the clinic include: retired physicians; practicing physicians; residents; medical students; nurse practitioners; physician assistants; nurses; laboratory technicians; social workers; pharmacists; nutritionists; medical records technicians; medical office assistants; quality assurance reviewers; and clerical personnel.

All providers are uncompensated volunteers and function on a rotational basis. The team approach is used in the provision of care. Many community specialty and subspecialty physicians accept referrals from the clinic pro bono. Local hospitals provide diagnostic services (laboratory and radiology) and therapeutic services, including in-patient admission and surgical and medical support, as needed, at no cost.

The Free Clinic for Uninsured Adults operates once weekly in the evening. The Broome County Health Department provides examining rooms, waiting rooms, and business office space during its off hours. Pharmaceutical houses have donated thousands of dollars worth of medications, and these are dispensed to patients free of charge by the on-site pharmacist in conjunction with the physicians. Medications not available at the clinic are obtained from an Eckherd Drugstore at no cost to the patient. The health department grant funds underwrite the cost of these prescriptions.

Other principal collaborators indirectly involved in the project are community agencies and organizations represented on the Advisory Board:

The local electronic and print media have been very effective in conveying the mission of the clinic to the public. A TV station has done live interviews and special features on the program, and the newspaper has published numerous articles.

No segment of the community has been excluded from participation in the project, which is based solely on the interest and energy of the volunteers. The media periodically advises the public of the projectís existence so that groups or individuals wishing to get involved can simply call the Clinical Campus to sign up and contribute at their chosen level.

Decision making is essentially the responsibility of the PVSC, which has established operating procedures and policies and adheres to rules of order and parliamentary process in the conduct of its business. Various tasks are also undertaken by the Advisory Board, which also has structure and follows the rules of parliamentary procedure. Some members of the board have contributed resources in-kind or in the form of services and goods.

In addition to some media coverage, the mechanism for gaining participation from the uninsured population has been by word of mouth. And it has been effective. Patient visits to the clinic are reaching capacity, with an average of 35ñ40 visits per weekly session. Consideration has been given to expanding clinic hours, but this is dependent on the availability of physicians and other volunteer professional personnel.


Impact/Effectiveness

One measure of the clinicís success is its utilization. From January 1997 through June 1998, 975 patients made 1,820 visits. Over half came from the City of Binghamton, with one third from Endicott, Johnson City, and Vestal, and the remainder from rural and suburban areas surrounding the Triple Cities. Most were working poor (an exceptionally high percentage made under $15,000 per year), and most had no employment-linked health insurance coverage. No patients served by the clinic had any entitlementóMedicaid, Medicare, or private. A lack of health insurance is the singular requirement for service, and patients are taken at their word on this issue.

A wide range of run-of-the-mill primary care health problems is seen at the clinic, but a noticeable number of patients have significant pathology. Although they may know they have a serious health problem, their financial status is such that they ignore the situation and seek care only when it becomes a true emergency. As a result, at many weekly sessions there is at least one patient on the verge of a true health emergency, which can range from impending diabetic coma to malignant hypertension to advanced lymphoma or to other life-threatening conditions. The intervention of the clinic in emergent and quasi-emergent situations is lifesaving to this subset of the population who are at high risk for serious morbidity. Almost 30 percent of patients seen require laboratory, radiology, and other diagnostic workup, which is provided free of charge by the hospitals. To date, 18 patients have undergone major surgical procedures. One in ten has been referred to and received subspecialty consultation.

The benefits to the targeted population are straightforward in that these patients are now able to access health care they previously could not afford. Those who are uninsured and unaware that they may be eligible for some type of insurance are assisted in obtaining that insurance, be it Medicaid, Medicare, or other. Volunteer social workers help them negotiate the bureaucratic hurdles to obtain coverage. For patients above the guidelines for entitlement programs and with no-benefits jobs, the clinic provides care in an unrestricted fashion based on the individualís stated need.

The value of the free clinic project to the community (in addition to meeting health care needs) is the reinforcement of the belief in volunteer service as a problem-solving strategy. For the medical school, the clinic offers its studentsóin addition to a learning environmentóexamples of older physicians performing pro bono professional services. The role models of faculty and senior professionals of all persuasions engaged in this activity are invaluable to students in the health professions. For the health department and other social and health agencies, the project affords their clients a way into the health care system and provides a mechanism to actualize their own agency mission. For the business, religious, and other non-health-related community partners, the project is an opportunity to work on a major societal problem in a meaningful way consistent with their philosophical underpinnings.

Fiscal and staff resources available to meet the needs of the project come from multiple sources. The Clinical Campus and the Broome County Health Department have funded ongoing operations. The medical school is responsible for administrative direction, the development of policies and procedures, legal consultation, all correspondence, scheduling of meetings, agendas/minutes, and general staff support. The health department has provided the facility and consumable medical supplies and administrative support at the clinic site. The operation of the clinic relies on resources donated by participating community partnersóthe hospitals, pharmaceutical companies, professional organizationsóand the work of hundreds of volunteers.

During the first 18 months of operation, direct project costs, including in-kind contributions, were estimated to be $240,000, distributed as follows:

* Time converted to dollar estimate

To date, over 400 persons in the community have volunteered to staff the clinic or have contributed in some way to this effort. Community support grew slowly through the first few months, but as the operation gained momentum and as patients were served and providers became involved, community interest was mobilized to the point where individuals are now sending unsolicited donations to the medical school in support of the clinic.

The monetary value of the donations of local hospitals in terms of absorbing costs for laboratory, radiology, diagnostics, and in-patient services for free clinic patients is very high, but no numeric estimate is available. Likewise, the monetary value of the contributions of subspecialists seeing free clinic patients in their offices represents a major uncalculated donation.

Significant milestones include:

Ongoing political problems exist. The lack of a comprehensive national health insurance plan as well as other factors have caused the numbers of uninsured to grow, and national attempts to address the problem on an incremental basis have been only partially successful. Many small communities are struggling to resolve or deal with the problem using existing resources.

Major future challenges are:

l to fund future operations and expansion of the clinic.

l to secure a stable ongoing method of paying for the expensive pharmaceuticals required by patients.

l to maintain the complement of retired physicians who will work at the clinic, notwithstanding the $600 registration fee required by New York State.

l to ensure the continued commitment of the practicing physicians and other professionals to volunteer at the clinic.

l to improve and expand the facility where the clinic operates. The Broome County Health Department clinic area is cramped, outmoded, and not specifically designed for comprehensive primary care.


Conclusion

No one among the community partners, sponsors, or cosponsors believes that the Physicians Free Clinic for Uninsured Adults will address all the needs of all the uninsured persons all of the time. However, secure in their commitment to this worthwhile project, limited as it may be, the volunteers and community supporters have adopted the spirit of the early twentieth century Indian poet Rabindranath Tagore, who wrote:

I slept and dreamt that life was joy,

I awoke and saw that life was service,

I acted, and behold, service was joy.

Contact: Garabed Fattal, M.D., Clinical Professor of Pathology, Chair, Physician Volunteer Service Committee, State University of New York, Health Science Center at Syracuse, P.O. Box 1000, Binghamton, NY 13902. Telephone: (607) 772-3519 or (607) 723-4372. Fax: (607) 772-3536.

See map, B13





THE BRONX HEALTH LINK




Mission/Purpose

The Community Needs Assessment project, originally solely undertaken by Our Lady of Mercy Medical Center, has developed into a Bronx-wide collaborative effort that includes three other hospitalsóBronx-Lebanon, Montefiore, and Saint Barnabasóand the Bronx Health and Human Services Development Corporation, a planning group commissioned by the borough presidentís office.

The Bronx Health Link began operating in January 1997 through a United Hospital Fund Special Grant for a Community Health Assessment. Tripp, Umbach & Associates, nationally known for its development of a unique consumer-driven community health model managed the first stage of this collaboration. A lengthy and detailed survey was mailed to 10,000 Bronx residents in order to ascertain their health care needs and concerns. A preliminary data set was established from this mailing. Major health topics of concern to the community, ranging from AIDS to geriatric health, were identified as the subject of community-based focus groups. These community focus groups led to health forums that were hosted at each Bronx Health Link institution. All of these activities will provide the Bronx Health Link with a means for better understanding the needs of Bronx residents, the ability to rank these needs, and the strategy for planning and implementing the kinds of joint ventures that will truly improve the health status of residents of the Bronx. Funding for this yearís activities has been provided through the New York State Department of Health.

The Bronx Health Link is a collaborative venture between Bronx-Lebanon Hospital Center, Montefiore Medical Center, Our Lady of Mercy Healthcare System, and St. Barnabas Hospital that was established in order to conduct a Community Needs Assessment prior to the planning and implementation of a variety of community-based health care initiatives. These hospitals represent the largest not-for-profit institutions in the Bronx, with combined budgets exceeding $1.2 billion dollars. Discharges for 1996 were as follows:

Bronx-LebanonóConcourse 21,507
Bronx-LebanonóFulton 5,048
Our Lady of MercyóEast 233rd 17,122
Our Lady of MercyóDurso 2,846
MontefioreóMoses 26,172
MontefioreóWeiler 19,699
St. Barnabas 16,264
Total Bronx Health Link 108,658

Overall Bronx discharges for calendar year 1996 were almost 216,000; the Bronx Health Link group accounted for approximately 50 percent of that total.

The scope of services provided to Bronx residents is not merely reflected by the level of inpatient activity; through more than 50 freestanding community-based ambulatory care settings and on-site OPD departments, Bronx Health Link routinely provides more than one million ambulatory visits per year. This extraordinary depth of contact and direct interaction with thousands of Bronx residents enables Bronx Health Link to promote health services and healthier lifestyles.

Besides the day-to-day inpatient and outpatient operations, each member of the Bronx Health Link provides hundreds of community outreach events each year. At each of its health fairs, lectures, special events, and mobile screenings in target communities where large pockets of uninsured individuals live, special bonds are fostered between Bronx Health Link and community members.

Additionally, through linkages to community groups, religious organizations, and health care partners in its service delivery networks, Bronx Health Link can tap into many more links to the uninsured populations of the Bronx. For example, the Parish Partnership program at Our Lady of Mercy Medical Center facilitates direct access to the religious leadership of the Bronx. Communication with the Parish Partnership nurse and the volunteers in each parish makes it possible to determine which families are at risk and, through their involvement with the church, engage them in the activities of the initiative.


Leadership Role

The Bronx Health Link is led by a steering committee that comprises senior management from each of the medical centers as well as the director for economic development of the borough of the Bronx. Through monthly and quarterly meetings at each host institution, the process of policy formulation and decision making is conducted.

Our Lady of Mercy Medical Center provides technical assistance for the Bronx Health Link. Through Our Lady of Mercyís Community Health Services and Finance divisions, information and financial payments and audit activities are conducted in the interest of the Bronx Health Link.


Key Partners/Stakeholders

Key partners and stakeholders include: Bronx-Lebanon Medical Center; Montefiore Medical Center; Our Lady of Mercy Medical Center; St. Barnabas Hospital; and the Bronx Borough Presidentís Office of Health and Human Services

Potential future partners for the Bronx Health Link are many. For example, each member of the Bronx Health Link provides thousands of annual school-based health services. As better services for children are designed and implemented, it is likely that local public and parochial schools will be enlisted as members of the Bronx Health Link.

Another area of support has been that of religious organizations. At Our Lady of Mercy, for example, the Parish Partnership program is an important cost-effective vehicle for providing screening and wellness services at the community level. The network of parishes associated with Our Lady of Mercy would also be an obvious addition to the Bronx Health Link. Montefiore Medical Center, with its rich history of Jewish-affiliated partners such as UJA, JASA, FEGS, and the Jewish Board of Family and Childrenís Services, would also bring a large number of additional community-based providers to the Bronx Health Link family.

Through its affiliation with the Bronx borough president, we are in an enviable position to attract local community and political organizations to become part of our activities.


Impact/Effectiveness

The Bronx Health Link differs from a traditional community needs assessment process in the following ways.

Traditional Process:

Bronx Health Link Process:

By working closely within a true community framework rather than from corporate offices, the Bronx Health Link is able to involve community members from the start of the project.

For example, recent town hall meetings held at each of the host institutions enabled local residents to voice their concerns regarding their health care needs before any project was designed and implemented. Issues such as transportation, security, care for illegal aliens, programs on domestic violence, and other nontraditional concerns rose to the front of the health care dialogue and will receive strong consideration in determining program design. Local residents were also the focus of dialogue during individual focus groups held on: Adolescents; Individuals with HIV; Immigrants; Individuals with Disabilities; Asthma; Senior Caregivers; Vietnamese-Speaking Men and Women; and Spanish Women.

All of these focus groups were held at local churches, community centers, health centers, and YMCAís, rather than at the offices of the medical centers that would traditionally control the planning and implementation of these programs.

Besides offering a ìreal timeî community view, the Bronx Health Link represents the joint venture of four major not-for-profit organizations whose annual budgets total more than $1 billion. The Bronx Health Link has the ability to support ongoing ventures and to gain funding for its continued work through governmental, foundation, and private funding sources.

Bronx Health Link recently submitted a grant proposal to the New York State Department of Health for a Colorectal and Prostate Screening and Education initiative that marks its first foray into the grant arena for program dollars. Should it be fortunate enough to receive this grant, Bronx Health Link already has the infrastructure in place to provide a significantly higher level of care in oncology than any other institution or collaborative venture in the Bronx. In other words, Bronx Health Link has the ability to make things happen through its current and assumed future resource-generating powers.

In terms of community support, the Bronx Health Link has already received the full approval of the borough presidentís office. Additionally, it has the support of the Bronx leaders in education, business, community health, religious organizations, and charitable foundations. Recently, as word of it has spread, Westchester County has embarked on an almost identical joint venture in community health assessment, using the Bronx Health Link as its implied model. In fact, Tripp, Umbach, the consultants for the Bronx Health Link, has been chosen to guide the Westchester project to completion as well.

Finally, the health care marketplace is one of joint ventures. Revenues are diminishing under the pressure of managed care, and it is incumbent upon health care providers to find ways of doing more with fewer resources. Bronx Health Link has allowed the four largest Bronx not-for-profit institutions to move confidently ahead to provide the finest care and education for county residents.

Contact: Fred Sugarman, Our Lady of Mercy Medical Center, 600 East 233rd Street, Bronx, NY 10466. Telephone: (718) 920-1722.

See map,D4





TRI-COUNTY COMMUNITY HEALTH ASSESSMENT
CLINTON, ESSEX, AND FRANKLIN COUNTIES




Introduction

If ranked on environmental quality, the tri-county area would likely be classed among the areas with the cleanest air and water in New York State. When ranked on the health of its residents, however, the area often falls below the state average. Although this health assessment shows that the area faces a number of community health challenges, progress is continually being made and the area is rich in organizations, agencies, and individuals currently working to address specific health problems.

The goal of the Tri-County Community Health Assessment was to identify what really matters to local residents about their health and to highlight their concerns about health issues and problems in their own communities. Another goal was to provide a regional overview of the current status of various health issues identified as statewide priorities by the New York State Department of Health (NYSDOH). This Community Health Assessment is presented to the residents, businesses, organizations, and health care providers of the tri-county area as a working document for developing partnerships and strategies to address the priority community health issues.


Description of the Area

The tri-county area of Clinton, Essex, and Franklin Counties covers approximately 4,500 square miles in the northeast corner of New York State. The area shares the international border with Quebec to the north and the shoreline of Lake Champlain with Vermont to the east. Eighty-three percent of the land area is classified as forestland, while another 13 percent is farmland. According to the 1990 census, close to 170,000 people make their home in the tri-county area. The area is sparsely populated, with an average of 38 people per square mile. The population of the area is dispersed, with at least 116 communities of 50 or more people. The average population of a tri-county community is 850 people, while the largest community is Plattsburgh with 21,000 residents.

The per capita income in Franklin County was 31 percent below the average for the United States in 1991. Similarly, median family income, household income, and average wages and salaries are below the national average. Poverty, on the other hand, exceeds state and national averages. Twelve percent of children in upstate New York were living below poverty in 1989, while in Clinton and Essex Counties the child poverty rate was 15 percent and in Franklin County it was 20 percent.

Government-related employment constitutes a significantly larger proportion of total employment in the tri-counties than nationally. Farm employment also tends to be higher in the area. The average annual unemployment rates exceeded the 1997 New York average of 6.4 per 100 workers, with rates of 8.7 percent in Franklin County, 8.6 percent in Essex County, and 6.8 percent in Clinton County.

This brief description highlights some of the key characteristics of the tri-county area that have a direct bearing on the availability and accessibility of health care to local residents. Hindering residentsí ability to adopt healthier lifestyles is the areaís ruralness; the prevalence of small, widely scattered communities; the lower than average incomes; and higher than average unemployment. Although not necessarily unique among rural America, the community health issues facing the tri-county area are often very unique compared to the issues facing the more populated areas of New York State. While sharing the same goals for a healthier population, the steps to achieving those goals in the tri-county area will necessarily require innovative actions adapted to the geographic, socioeconomic, and environmental conditions existing in the area.


State & National Health Objectives

ìHealthy People 2000: National Health Promotion and Disease Prevention Objectivesî was published by the U.S. Department of Health and Human Services, Public Health Service, in 1990. The document presented a national strategy for the improvement of the health of all Americans and contains 298 specific health- related objectives to be achieved by the year 2000. The three overriding goals of the national effort are to:

Those goals served as the foundation for efforts in New York State to develop its own strategy for improving community health.

In September 1996 the New York State Public Health Council published a document entitled ìCommunities Working Together for a Healthier New York: Opportunities for Improving the Health of New Yorkers,î recommending health objectives for New York for the next ten years. The committee working on the project held six regional workshops throughout New York to discuss the most serious public health issues in local communities, the underlying causes of these problems, and interventions that could be most effective. The goal was to focus community attention and stimulate action in areas that lead to longer, healthier lives for New Yorkers, with a special emphasis on those health problems of greatest concern to the community.

Recognizing the importance of using public input to identify the health priority areas for New York State, the Department of Health suggested that county health departments use a similar process to learn whether those statewide priorities are consistent with the major concerns in their local communities. Following that suggestion, in 1997 the Public Health Departments of Clinton, Essex, and Franklin Counties formed a Regional Community Partnership for the purpose of producing a joint Tri-County Community Health Assessment. Holmes & Associates of Saranac Lake and Patricia Randolph-Clark were hired to develop the assessment.


Tri-County Community Health Assessment

The underlying causes of disease, rather than the diseases themselves, are the focus of this assessment. Similar in approach to both federal and New York State efforts to improve the health of Americans, this local initiative has sought to capture what makes the tri-county area unique in its quest for better health.

The overriding goal for the tri-county Community Health Assessment is to improve the health of the people living in Clinton, Essex, and Franklin Counties. Specific objectives to be accomplished during the local health assessment process included:

The cornerstone of the eight-month project was a series of public workshops held in ten communities throughout the tri-county area. The workshops provided opportunities for local residents to be heard on what they thought were the health priorities in their community. In addition, the assessment team carried out focus groups, questionnaire surveys, interviews, and presentations in 36 different settings. The individuals and groups contacted represented a wide variety of community interests including older residents, youth, service organizations, business owners, health care providers, uninsured families, and educators. In total, over 800 local residents provided input on their community health concerns.


Local Priority Health Issues

The assessment team combined four main sources of information in an effort to determine the priority community health issues of the tri-county area. The four sets of information included:

The four sets of information each yielded six community health priorities. The assessment team analyzed those four lists of six priority issues to identify which issues were consistently top priorities. The six priority health issues presented below reflect the community health issues presently of most concern in the tri-county area. They are presented in order of priority along with the main local concerns for each issue.

1. Access to and Delivery of Health Care


2. Substance Abuse: Alcohol & Drugs

3. Health & Prevention Education

4. Mental Health Needs

5. Healthy Births

6. Tobacco Use

There are obviously many other local health priorities beyond these top six, and certain communities will view other health issues as their top health concerns. However, the six priority issues presented here were consistently of highest concern throughout the tri-county area.

In addition to identifying priority health issues for the tri-county area, the Tri-County Community Health Assessment succeeded in putting a local face on the statewide community health priorities. For example, during the community health workshops it became apparent that substance abuse is perceived as a youth issue in the tri-county area and is viewed locally as being closely related to the availability of youth social and recreational activities. The New York State description of the substance abuse health issue was quite different. Similarly, while healthy babies are a concern throughout the state, in the tri-county area healthy births was strongly interpreted by local participants as a teen sexual behavior and sex education issue.

Access to and delivery of health care, the number one priority issue in the area, is a broad issue encompassing a variety of concerns. The identification of transportation as a major concern under access relates directly to the remoteness of some communities, the distance to health providers, and limited public transportation options.

The full report provides additional data and local concerns for each of the top six priority issues as well as for the other six community health issues identified as statewide priorities. Included in the Tri-County Health Assessment are health statistics on major causes of death and disease in the area. In addition, a section entitled ìPopulations of Special Concernî highlights major concerns for five subpopulations of local residents: Native Americans, residents with disabilities, older residents, lower-income families, and youth.

Collaborative Partnerships

It is not the intent of the Tri-County Community Health Assessment to prescribe a treatment to ìfixî the areaís health problems but rather to stimulate interest among individuals, organizations, schools, businesses, the media, and so on, to develop collaborative partnerships as a strategy to address the priority health issues. As such, this document is a community resource that can be used to identify possible areas for collaboration among those interested in trying to alleviate the health problems in this rural area of New York State.

A widely respected expert on community health collaborations in New York recognizes that the most effective and beneficial collaboration for improving community health is that between medicine and public health. Working independently, the medical and public health sectors have made great strides in achieving their missions; however, continuing on separate tracks is no longer in the best interest of either. ìBy combining their resources and skills in various ways, professionals and organizations in the two sectors are able to achieve benefits that none of them can accomplish aloneî (Lasker 1997:154).

There are numerous partnerships and collaborations presently occurring throughout the Tri-County area. It is hoped that the Tri-County Community Health Assessment will help communities build on those efforts and will contribute to new partnerships and collaborations.

On a regional level, five rural health care networks are currently working within the tri-county area to enhance collaboration within the health provider system:

The success and longevity of the rural health care networks will hinge in part on their ability to reach out beyond traditional health care providers and identify nonprovider support and involvement. By continuing to involve community members, local governments, businesses, churches, schools, service organizations, and others, they will contribute to keeping the ìcommunityî in community health.

Next Steps

In total, over 800 local individuals associated with over 40 organizations, agencies, and communities took part in the Tri-County Community Health Assessment process. The participants identified what concerned them the most about their health and the health of their communities. This assessment conveys their interests and concerns and provides background health statistics on some of the major issues. Prioritization of what appear to be the health issues of most concern in the tri-county area is also included.

There are a number of next steps that can be taken at the state, community, and regional levels, as follows:

Community-Level Action
The best next step would be for communities to publicly recognize the health issue or issues of most concern to their residents and initiate community-level action to address the problem. The area is rich in health-related organizations and support groups as well as public health offices, hospitals, social service agencies, and others that can assist local communities in their efforts.

An example of a local community action would be to organize a community group that consists of a cross-section of community members, businesses, and organizations to evaluate the availability and adequacy of local recreational and social facilities. They would identify needed changes in facilities, operating hours, programs, management, and so on. Such a local action could make a positive impact on a number of priority health issues, including substance abuse, prevention education, mental health, healthy births, and tobacco use. It would also address the needs of youth and older residents, two populations of special concern in the area. This is only one of many possible local community actions that could easily and inexpensively begin to address local community health priorities.

Tri-County-Level Action
There are a number of multicounty activities underway to help communities achieve improved health. Following are action steps that may facilitate those activities and build on previous accomplishments:

It is hoped that Tri-County Community Health Assessment will foster new partnerships and collaborative relationships for implementing innovative health promotion and disease prevention programs in Essex, Clinton, and Franklin Counties. These next steps can serve to maintain a focus on the community health priorities recognized throughout the tri-county area while at the same time supporting the goals of the many health-related agencies and organizations currently working in the area.

Note, p.70: Lasker, Roz D. 1997. Medicine and Public Health: The Power of Collaboration. New York: The New York Academy of Medicine.

Contacts: Timothy P. Holmes, Holmes & Associates, P.O. Box 295, Saranac Lake, NY 12983. Telephone: (518)891-6525; E-mail: holmestp@northnet.org www. Adirondacksearch.com.

John Andrus, Public Health Director, Clinton County Department of Public Health, 133 Margaret Street, Courthouse, 1st Floor, Plattsburgh, NY 12901.

Katrine Kretser, Public Health Director, Franklin County Nursing Service, 63 W. Main Street, Malone, NY 12953.

Dorothy Madden, Public Health Director, Essex County Public Health Department, 100 Court Street, P.O. Box 217, Elizabethtown, NY 12932-0217.

See map, C1-3





WESTERN NEW YORK MEDICAID MANAGED CARE
COALITION




Mission/Purpose

The Western New York Medicaid Managed Care Coalition (the Coalition) is a partnership of the social services departments of the eight counties of western New York (Chautauqua, Erie, Orleans, Niagara, Allegany, Wyoming, Cattaraugus, and Genesee). The mission of the Coalition is to increase access for Medicaid clients to quality health care services through the development of managed care programs and to reduce overall Medicaid costs in western New York.

In June 1991 the (New York) Statewide Managed Care Act (Chapter 165, Laws of 1991) was passed by the legislature and signed by Governor Cuomo. The legislation was designed to improve the health care delivery systems for Medicaid patients through the implementation of managed care. The task of creating and implementing managed care systems in each county was designated to the local departments of social services.

In 1992 all eight western New York County departments of social services agreed to form a partnership, with the support of New York State Department of Social Services, to provide technical assistance to one another in an effort to create and implement Medicaid managed care programs in each county.

The concept of managed care is new to the Medicaid program and to the Medicaid population. Managed care is also a concept and a product that is foreign to most of the counties of western New York. In order to make managed care happen successfully throughout western New York, there is a need to adapt the health care delivery systems to a primary care managed model of health care. Adapting the managed care delivery system to rural areas of western New York has presented monumental challenges for all counties. These challenges have required the collective problem-solving efforts of all members of the Coalition.

Early in the process it was clear that managed care would have a dramatic impact on all aspects of health care delivery. Coalition meetings were opened up to all interested parties. The eight local health departments as well as the managed care organizations, local mental health departments, and all health care provider organizations were invited to join in the effort to problem-solve issues and implement Medicaid managed care. This has allowed problem-solving of issues with an ìall-inclusive,î global perspective, considering all elements of the system.

The Western New York Medicaid Managed Care Coalition successfully created a partnership of counties working together to help one another make managed care a viable reality. A realistic partnership has been created between the Coalition counties and the State of New York and, for the first time, all of the players in the health care delivery system have been brought together and are investing in making Medicaid managed care a reality.

In June 1994 the Coalition cosponsored a conference entitled ìSuccessful Practice in the í90sî designed to address the impact of managed care reforms on the practicing primary care (family) physician. In 1995 the Coalition participated, as a member of the statewide Rural Managed Care Conference Committee, with the New York State Department of Health to put on a two-day conference entitled ìThe Managed Care Marketplace: The New Rural Reality,î which focused on the rural issues relating to managed care.

Thus far, the Coalition has succeeded in being recognized by the State of New York as the representative body for western New York in issues relating to managed care. This has led the state to encourage other regions in New York State to create similar regional groups. It has also directly affected the means by which New York State provides representative technical assistance to counties. Rather than each county having a different state representative, the state has issued and assigned a single technical representative to all counties in the Coalition. This was in response to a direct request by the Coalition. Presently each coalition/ region in New York State has a state representative who is available to all counties in that coalition/region.

The Coalition recognized the impact that managed care was going to have on local health departments and public health clinics. The Coalition formed a public heath subcommittee (which has subsequently given birth to the Western New York Public Health Coalition) to study the issues relating to Medicaid managed care and public health. This subcommittee produced a model protocol for contracts between public health and managed care organizations that defines the relationship between these organizations, identifying the responsibilities of each. This Public Health/MCO Protocol was created as a model for the western New York counties. It was submitted to the state, which recognized its value and issued it throughout New York State as the model for all regions and counties to help define public health/MCO relationships.

A similar subcommittee of local mental health directors has recently been established to study the impact of managed care on the mental health needs/demands in counties as they relate to managed care, specifically for the special needs categories of people who are seriously and persistently mentally ill. The hope is to extend services to this population for the counties of western New York and all regions of New York State.

The Coalition recently completed an Enrollment Protocol to be used by all counties in western New York. This will help to ensure propriety in enrollment practices as well as a degree of standardization among the MCOís throughout the regions, enhancing the quality of information and enrollment procedures. This Enrollment Protocol will be submitted to the state for distribution to all managed care regions.

The Coalition was initially supported by the New York Rural Health Research Center, as part of their grant to study the development of managed care in western New York. Since 1995 the counties of western New York have pooled portions of their managed care grant allocations from the state to fund the activities of the Coalition. New York State has assumed the cost of sending the state representative to the Coalitionís monthly meetings. The Coalition has an agreement with the Department of Family Medicine at SUNY Buffalo to provide administrative support to manage these funds.

Contact: James R. Totaro, Director, Medical Services, Chautauqua County Department of Social Services, Coalition Co-Chair, Hall R. Clothier Building, Mayville, New York 14757-1027. Telephone: (716) 753-4879. Fax: (716) 753-4444. E-mail: James.Totaro@DSS.Mailnet.State.NY.US

See map, A1-8



 


 
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