Dorchester County Health Department Health Systems Presentation MDH - - PowerPoint PPT Presentation
Dorchester County Health Department Health Systems Presentation MDH Center for Chronic Disease Prevention and Controls CDC 1422 Grant Site Visit July 20, 2017 DORCHESTER COUNTY POPULATION BY RACE MARYLAND VITAL STATISTICS ANNUAL REPORT 2015
MDH Center for Chronic Disease Prevention and Control’s CDC 1422 Grant Site Visit July 20, 2017
Caucasian 65% American Indian 0.3% African American 29% Asian/Pacific Islander 1% Hispanic 5%
DORCHESTER COUNTY POPULATION BY RACE
MARYLAND VITAL STATISTICS ANNUAL REPORT 2015
Total Population: 32,384
Birth - 4 Age 5 - 14 Age 15 - 19 Age 20 - 44 Age 45 - 64 Age 65 - 74 Age 75 +
DORCHESTER COUNTY POPULATION BY AGE
MARYLAND VITAL STATISTICS ANNUAL REPORT 2015
Total Population: 32,384 ▪ 57% between age 20-64 ▪ 11% age 65 and above ▪ 23% age 19 and under
Health Outcomes – Rank 23rd Health Factors – Rank 22nd
Length and Quality of Life Health Behaviors, Clinical Care, Socioeconomic Factors, and Physical Environment
Dorchester County Maryland Diabetes Prevalence 16% 10% Adult Obesity 36% 29% Physical Inactivity 30% 22% Unemployment 7.4% 5.2% Children in Poverty 30% 14% Primary Care Physicians 2,510:1 1,130:1 Dentists 1,900:1 1,350:1
Federally Qualified Health Center
with highest hypertension and prediabetes disparities
Addressing chronic disease burden
▪ Dedicated leadership and staff
▪ Medical Director ▪ VP Quality Assurance / Director of Population Health ▪ Care Coordinator
▪ Monthly conference calls to enhance efforts
▪ Share updates ▪ Review progress ▪ Identify gaps ▪ Problem solve and brainstorm ideas
Recruit and refer patients
▪ Use ICD-10 codes for prediabetes and pre-hypertension ▪ Integrate screening and referral into
▪ Encouraged universal DPP referral form for all partners ▪ Utilize Wellcentive, population health management tool/platform to identify participants ▪ Educated and empowered ALL staff to speak same DPP language
Blood pressure control efforts
▪ Comprehensive physical activity and nutrition campaign in Dorchester County ▪ Choptank promotes actively in their clinic ▪ Instituted in clinical care and individualized care plans ▪ Distributed BP cuffs to eligible patients ▪ Flagged charts to remind patients to bring BP logs ▪ Building culture of patient empowerment
Closing loop back to primary care
▪ Dental clinic co-located at Fassett Magee ▪ Protocol for dental patients in Stage 2 Hypertension
▪ Medical triage nurse contacted to assess patient ▪ Dental provider consults with PCP to determine action plan
▪ Dorchester County Health Department also working with three additional oral health practices
▪ Dr. Hyun Bae, Dr. Jean Carlson, and Harbor Dental Center ▪ Implement BP screenings and system level changes to identify and treat undiagnosed hypertension ▪ Plan to refer patients to Choptank or PCP if in of need medical care
Community clinical linkages
▪ Strengthened relationship between pharmacy and PCPs ▪ UMES students on 5-week rotations in two local pharmacies (Craig’s Drug Store in Cambridge and The Drug Store in Hurlock) ▪ Also distributed BP cuffs to eligible patients ▪ Walk-in screenings for hypertension and prediabetes ▪ Communicate via fax/secured email re: BP readings, new patient w/o PCP, request dr. appointment
Delving deeper into oral health collaborations Monitoring workflow to increase referrals Further enhancing linkages
Angela Mercier Health Education Program Manager 410-901-8126 Angela.mercier@maryland.gov Miranda LeCompte Chronic Disease Prevention Coordinator 410-901-8129 Miranda.lecompte@maryland.gov
Dorchester County Health Department 3 Cedar Street Cambridge, MD 21613