Alliance for Healthcare Access

State: ND Type: Model Practice Year: 2015

Grand Forks Public Health Department, located in Grand Forks, North Dakota, serves as a key health agency responsible for health promotion and disease prevention services for the City and County of Grand Forks, North Dakota. The 2013 population estimate for Grand Forks County is 69,179 with the City of Grand Forks as the largest city within the county.  Several smaller rural communities make up the rural areas of Grand Forks County. The county population has increased 3.5% since 2010. The majority population is white (86%) with other races making up smaller percentages of the population each: Black or African American (3%), American Indian (2.7%), Asian (2.2%) and Hispanic or Latino (3.7%). Grand Forks County has a poverty rate of 16.5% which is higher than the North Dakota average of 12.1 %.  There are two census tracts in the city of Grand Forks with greater than 30% of children living in poverty. The median household income in Grand Forks County is $46,392 compared to $51,641 in North Dakota.  As a result of oil and gas development in western North Dakota, the statewide household income for the state has increased significantly in recent years.  Workers are moving to North Dakota for employment but are often unable to find affordable housing and often end up moving to Grand Forks where there is a large homeless shelter and employment opportunities.  The uninsured rate in Grand Forks County in 2010 was 18% but among persons with incomes below 200% of federal poverty level, the uninsured rate was 27.7%.  In 2013, the uninsured rate dropped to 8.8% - likely due to robust enrollment efforts within the county and expansion of Medicaid in North Dakota. Public Health Issue Grand Forks Public Health Department identified a need to address the unmet primary health care needs of underserved populations in the region as a result of anecdotal information from other health and human service providers as well as challenges the health department was experiencing in referral processes for primary care.  The Health Department brought together a diverse group of community constituents which eventually came to be known as the Alliance for Healthcare Access. Goals and Outcomes   The initial goals of the Alliance for Health Care Access were to: ·         Improve the quality of our collaborations and connections between agencies. ·         Create a map of what we are providing and fill the gaps. ·         Develop a single access point for referring people. These goals were met, with the exception of developing a single access point for referring people for health care which was only partially met.  This latter goal was determined to be too simplistic given the complexity of the primary care health system. However, through the relationship building of the Alliance, the member agencies had a greater understanding of the safety net programs and respect for the complexity of navigating that system for clients with limited resources. Public Health Impact Through a community assessment conducted by the Health Department, and engagement of the underserved populations, it was determined that a Federally Qualified Health Center (FQHC) would be a viable solution to meeting the increasing gap in access to primary care. The Grand Forks Public Health Department decided to apply for a federal health center planning grant from the Health Resources and Services Administration (HRSA) and received the grant in 2011.  The Health Department served as the fiscal agent for the planning grant, hired a coordinator, and was responsible for managing all subcontracts related to the planning grant. Throughout the planning process Grand Forks Public Health Department has also supported the Alliance for Healthcare Access by providing meeting coordination, administrative staff, grant administration, and leverage of other funding to support the Alliance. The Grand Forks Public Health Department served as the main point of contact for the Alliance’s website development and currently maintains the website The Alliance achieved the secondary goal of establishing a health center site in Grand Forks, ND in June 2014.  
Public Health Issue The Healthy People 2020 Goals in the Social Determinants section provided a framework for the Alliance’s activities with a focus on these four objectives: ·         Increase the proportion of persons of all ages who have a specific source of ongoing care. ·         Increase the proportion of persons ages 18-64 who have a specific source of ongoing care. ·         Reduce the proportion of persons who are unable to obtain or delay obtaining medical care, dental care or prescription medications ·         Reduce the proportion of persons who are unable to obtain or delay obtaining medical care. The current practice is innovative in that the local health department was the lead organization for a health center planning grant and supported a rural health center’s expansion into the more populated area of Grand Forks County.  The Alliance was created from a modification of the Mobilizing Action for Planning and Partnerships (MAPP) process.  While the model was not formally introduced to the Alliance membership, the Grand Forks Public Health Department was familiar with MAPP and had broad and deep experience with community engagement on public health issues. The Alliance used a planning process similar to MAPP to address the concern about health care accessibility. The model with examples from our experience is outlined below. Organizing The initial invitation to participate in an organizational meeting was strategic with an emphasis on likely stakeholders, yet broad enough to encompass a variety of opinions on the topic of health care accessibility.  Because the Grand Forks Public Health Department was considered a “neutral” organization, not competing for patients, that made it possible for the other private non-profit health systems to participate and contribute equally to the Alliance. More than 30 people attended the first organizational meeting and subsequent strategic planning event, and were asked to complete an “Action for Access” survey indicating their organization’s level of commitment.   The investment of time and engagement of participants at the initial meetings was very high and resulted in a definite call to action – yet a solution was still several months in the future. This organizing period built upon the overwhelming success of the Northern Valley Dental Health Coalition to establish a public health dental clinic in 2007.  That endeavor was also led by Grand Forks Public Health Department and resulted in long term support by coalition members and sustainability within the community. In three years of operation, the dental clinic served over 5,000 patients. Paradoxically, these patients now had dental care, but in many cases lacked a medical home for treatment of their chronic disease, which was impacted by poor oral health. Visioning A visioning and strategic planning session was held with a skilled facilitator to build trust among member organizations, create a vision statement, guiding principles, and determine concrete action steps for the future.  The Grand Forks Public Health Department made the initial contribution to cover the cost of the strategic planning event. A core team was involved in planning this and creating the conditions for a free flow of ideas and maximum participation.  Early in the organizing process, numerous Alliance member organizations committed to funding a skilled grant writer that would help to secure a health center planning grant. This early investment paid off with the Grand Forks Public Health Department and City of Grand Forks being one of three sites in North Dakota to receive an $80,000 health center planning grant.  Our site was the only one in the state that achieved our goal of establishing a health center. Assessments Several assessments were conducted throughout the modified MAPP process, and the process was different from the four specific MAPP assessments outlined in the model.  Alliance members reported their experiences regarding challenges in health care accessibility for their clients and uncompensated care for individuals without medical homes.  This provided a context for what we, as a community, value.  The CEO of one large health system with significant resources, yet also a large burden of uncompensated care stated “our community can do better.”  The data about poverty in the community created a convincing argument to “do something.” This was particularly felt by the members of the Alliance who represented human service organizations and the faith community. In preparation for submitting the health center planning grant, a core team gathered information about the characteristics of the target population and the health status of the community overall. Grand Forks Public Health Department provided information about the health status of the population which included higher than national averages for deaths due to cancer, stroke, diabetes and suicide. Recognizing that this may represent untreated or unrecognized chronic disease within the population, it validated efforts to improve access to primary care. Two population groups were recognized as having unique challenges accessing primary care in the present health system or safety net health care system – homeless individuals and refugees resettling in Grand Forks.  The two organizations that serve them were represented on the Alliance. The Community Healthcare Association of the Dakotas provided a wealth of data about the target population in Grand Forks County in preparation for applying for federal funding to support health center operations.  The data collected was also used to inform Alliance members   Strategic Issues Alliance members were honest in sharing concerns related to the establishment of a new health center and what it might mean to their individual organizations’ mission as well as the benefits to the community overall.  Addressing them strategically, while also informing policy makers was instrumental to maintaining support for the Alliance.  The project director from the Health Department, and project coordinator employed by the planning grant, scheduled presentations at City Council meetings to keep the decision makers informed of health center planning progress providing one page documents to leave behind.  This relationship building proved to be useful when Community Development Block Grant allocations were made for construction and programming at the Health Center.  It also provided credibility for the Health Department for their effort to tackle complex community issues and find solutions.  The effort was highlighted in the Mayor’s annual State of the City address to business and community leaders.    Goals/Strategies The goals for the Alliance for Health Care Access were ultimately framed by federal health center planning grant and included detailed objectives with timelines.  Alliance members were committed to engagement in the work plan and agreed to serve on subcommittees in order to accomplish the goals. Flexibility was included in the planning process in order to accommodate the fluidity of community coalition work and leadership transitions in the Alliance member organizations. Sample goals and objectives from the planning grant that guided the work of the Alliance and the outcomes are outlined in the next section.  Some of the timelines were adjusted to accommodate the challenges along the way.  A final report of the planning grant activities were sent to the project officer at HRSA. The overarching goal of establishing a health center was added to the Alliance’s initial goals after the assessment phase and that goal was met in 2014. It was a very exciting day on June 13, 2014 when the Alliance welcomed 200 community leaders, dignitaries, supporters, health center personnel, and future patients to the health center at its open house.  There was significant media attention and representatives from each of North Dakota’s congressional offices were present. Action Cycle The Action Cycle was the most intensive for the Alliance and involved numerous activities.  There was frequent adjustment based on outcomes and lessons learned as well as feedback from the community.  While the Alliance did not set out on an intentional path to use the MAPP process for the past four years, many elements of the framework were present in our journey to achieving our goals. Examples of this can be found in the evaluation section. Relationship to Evidenced Based Public Health While the Alliance was not created out of a specific desire to provide evidenced based public health practice, but was grounded in the perception of community need that had long existed and was not being met. Additionally, the general concepts of coalition building, collaboration and community organizing from the Minnesota model of the Public Health Intervention Wheel were applied in establishing the Alliance. The Health Department sought to assess the community, define the problem and mobilize a base of support to apply an appropriate solution that would ultimately improve population health.  Evaluation of the outcome relative to the Healthy People objectives is not available yet, but plans are in place to monitor health center usage, survey Alliance members about improvements in referral processes and coalition effectiveness, and participate in continued community assessment activities.  The uninsured rate for our residents dropped from 18% in 2010 to 8.8% in 2013, but it is not possible to know what impact our activities had on that decrease since it occurred during a period of health care insurance enrollment in the Affordable Care Act.        
The initial goals of the Alliance for Health Care Access were to: ·         Improve the quality of our collaborations and connections between agencies. ·         Create a map of what we are providing and fill the gaps. ·         Develop a single access point for referring people. An additional actionable goal of establishing a community health center in the City of Grand Forks emerged early in the planning phase of the Alliance.  This objective was met on June 13, 2014.  The Alliance for Healthcare Access, under the leadership of the local health department, began a lengthy and detailed planning process for establishment of a Federally Qualified Health Center in the community of Grand Forks. The Health Department had experience in convening community members to improve access to dental care through the Northern Valley Dental Health Coalition.  This resulted in a public health dental clinic opening in 2007. At that time, community support for establishing a primary care clinic was mixed with some constituents believing the current safety net was adequately meeting the needs of the under-served, while many saw unacceptable gaps in available services. Since that time, the area had grown in population, diversity and poverty, and it became increasingly apparent the existing health care resources for the under-served were not meeting the need. The health care landscape changed significantly by 2010 with many uncertainties surrounding health reform efforts.  Local health care organizations were seeing their charity care contributions growing significantly. Early in the organizing process, numerous Alliance member organizations committed to funding a skilled grant writer that would help to secure a health center planning grant. This early investment paid off with the Grand Forks Public Health Department and City of Grand Forks being one of three sites in North Dakota to receive an $80,000 health center planning grant.  Our site was the only one in the state that achieved our goal of establishing a health center.   Valley Community Health Centers operates the nearest FQHC in two rural communities within the service area for Grand Forks Public Health Department and they agreed to be the applicant agency for a New Access Point funding opportunity from HRSA in 2012. The Alliance members raised funds to support the extensive and detailed process of the proposal writing and associated data collection necessary to demonstrate need for a new health center location within the City of Grand Forks. Assessing the economic factors of the target population was an important element of the work of the Alliance. In fact, economic disparities served as the impetus for moving forward with the planning grant. The target population for the future health center was defined as more than 11,000 residents in the region with incomes at 200% of the federal poverty level or below.  Grand Forks County in North Dakota borders Polk County in Minnesota and for purposes of health center service delivery that county’s population information was included in identifying the target population that could benefit from a health center where services would be affordable. The Alliance secured technical assistance to ensure a strategic and successful health center planning process. The Health Department contracted with the University of North Dakota Social Science Research Institute to conduct a community needs assessment by gathering information from potential health center consumers and others who have personal experience in trying to access primary care services in the region. The targeted population was reached by distributing surveys at a refugee resettlement agency, a local homeless shelter, clients of a Title X family planning agency, WIC participants, health department program participants and a non-profit safety net organization. The goal of the survey was to specifically identify issues in accessing care, gaps in services and other concerns faced by individuals in the community. The results of this survey revealed that nearly three fourths of the target population (74%) reported experiencing problems that affected their ability to access doctor or dental services. The cost of health insurance (54%) and health care (49%) were the main problems followed by transportation issues (23%) affecting access to doctor or dental services. Health insurance (75%) and personal income (54%) were predominately used by respondents to pay for health care expenses and dental services. A copy of the community needs assessment is available at Technical assistance was also secured from national experts who traveled to Grand Forks, ND to participate in stakeholder meetings to educate others on the operation of health centers and the investment that is required from the community to be successful.  This technical assistance session was held in conjunction with a legislative social to provide information to state and local elected officials on the benefits of community health centers.  Because of long standing relationships that exist between policy makers in the region and the Grand Forks Public Health Department, the forum was well attended and served the purpose of eliciting support from legislators.     The effectiveness of the Alliance was enhanced by the commitment of Grand Forks Public Health Department to administer the planning grant, provide staff for the project, secure matching resources, and provide community leadership. In addition to the support from Grand Forks Public Health Department, the engagement of creative partnerships was a cornerstone to the Alliance’s success. One example included developing a relationship with the local urban development office, whose staff ultimately chose to support the health center concept to meet the needs of low and moderate income families and to reduce blight in the downtown area. They were impressed with the data collected demonstrating the need for a health center.  Additionally, their staff and advisory committee recognized the depth of the partnerships that existed. One health system, with a long history of supporting a free clinic in the community, pledged support to the health center with the provision of lab and x-ray services.  They recognized the FQHC as a more sustainable model than the free clinic which was unable to serve clients who had not resided in the community at least 30 days.  The free clinic was also a partner in the Alliance recognizing that their mission would change when the health center was established, but the outcome would be better for the community. When obstacles were met that had the potential to impede progress, Alliance members evaluated the circumstances and found new solutions that led to continued progress. The best example of this was a technicality which prevented Valley Community Health Centers’ new access point application from being considered for federal funding.  Instead of relying on this as the main source of support, the Health Center and Alliance members were able to raise the necessary funds locally from both private and public funding sources to establish a new access point in the City of Grand Forks. The commitment of $300,000 from the community development office was funded in the subsequent fiscal year when foundation funds could be secured and matched.  This resulted in more than $650,000 in public and private grants to Valley Community Health Centers for construction, start up, and initial operational costs.       Throughout the planning process, numerous community presentations were conducted to provide education to community groups on the benefits of health centers. This work led to new partnerships and support for the work of the Alliance as well as future support for the Health Center. Public Health Impact The public health impact of the Alliance is improved access to primary care, efficiencies in care delivery with fewer emergency room visits, and stronger and clearer relationships among service providers in the community.  The goal of establishing a health center was met in 2014 and the clinic is located in the same neighborhood as the target population and among community health and human service providers.  In fact the relationship building among members of the Alliance led to one agency relocating to this area of the community. Clients seeking services at the Health Department, Regional Human Service Center, County Social Service Center, Title X Family Planning Program, WIC, Community Violence Intervention Center, Homeless Shelter, Public Health Dental Clinic and eventually the FQHC can receive them all within a two block radius from one another and near a major bus transfer station. The spirit of collaboration in the community is exemplary and fostered to a large extent by the Grand Forks Public Health Department. Collaboration Member organizations of the Alliance represent many sectors of the community and are listed below with their contributions: Altru Health System (Funding, lab, x-ray, professional services, executive committee membership) Bremer Bank (Funding, meeting room space) City of Grand Forks (Administrative support, community development block grant funding) Community Violence Intervention Center (Technical assistance, Alliance support) Department of Family and Community Medicine (Alliance support, medical professional recruitment) Development Homes (Alliance support) Eastern ND Area Health Education Center (Alliance support, health professional recruitment ideas) Grand Forks County Social Services (Alliance support, data collection, client navigation) Grand Forks Public Health Department (Alliance coordination and leadership, fiscal managment administrative support, funding, strategic planning) Lutheran Social Services (Alliance support, survey participation) Northeast Human Service Center (Alliance support) Northlands Rescue Mission (Alliance support, survey collection) Polk County Public Health (Alliance support) Richard P. Stadter Psychiatric Center Sanford Health (Business plan development, Alliance support, executive committee membership) Third Street Clinic (Legislative strategy, executive committee membership, Alliance support) UND - Center for Rural Health (Data collection) UND - College of Business & Public Administration (Alliance support) UND - Health & Wellness (Alliance support, marketing, data collection) UND - College of Nursing & Professional Disciplines (Alliance support, funding, executive committee membership) UND - Student Health Services (Alliance support, data) United Way (Funding, Alliance support) Valley Community Health Centers (Alliance support, executive committee membership, funding, grant writing, health center start up) Valley Health & WIC (Alliance support, meeting room space, data and survey collection) Budget The HRSA planning grant awarded was $80,000 and was matched with $38,500 in cash from local sources such as the United Way, Bremer Bank, Altru Health System and Grand Forks Public Health Dept.  These agencies supported the salary for the project coordinator for approximately 9 months following the end of the federal planning grant.  The estimated value of in-kind resources from the Health Department was more than $50,000 for Project Director salary and fringe benefits, occupancy, and administrative support for Alliance meetings. Without the initial investment of the planning grant, which helped the Alliance to leverage other sources of funding, it is unlikely the Alliance would have achieved this level of success.  This demonstrates the significant value in collaborative efforts that secure funds from a multitude of sources pooled together to make strategic investments in community betterment.  By demonstrating this internal and external support for health center development, Valley Community Health Centers was selected to be a recipient of the first "Giving Grand" Day sponsored by the Community Foundation of Grand Forks, East Grand Forks and the Region. Major private gifts were received by the Foundation and matched by smaller contributions from community members and supporters.       
The Alliance recognizes that the majority of the work was focused on the process objectives outlined in the planning grant work plan.  The objectives and their timelines are listed with the outcomes below.  Each objective had multiple action steps which were revised as we gained experience or met obstacles. 1. Establish subcommittees of the AHA to work through various components of health center development by 9/1/11.   Objective met.   2. Complete community needs assessment activities by 2/1/12. Objective met. 3. Determine services to be provided and methodology of provision by 5/1/12. Objective met. 4. Determine hours of operation, plans for after-hours coverage and other details by 6/1/12. Objective met. 5. Identify staffing model, including clinical, support, enabling and administrative staff components by 7/1/12. Objective met. 6. Identify additional special populations to be served and if unique services need to be established to meet their needs by 5/1/12. Objective met. 7. Train AHA and other interested persons on the health center model by 12/31/11. Objective met by 9/30/12. 8. Use needs assessment findings to develop financial projections for long term organizational sustainability, including estimating patient volume, growth and payer mix by 4/30/12. Objective met. 9. Evaluate human resource issues for the health center, including staff recruitment by 6/1/12. Objective met on 5/31/13. 10. Determine which agency will own and operate the health center by 10/1/11. Objective met. 11. Conduct community surveys with the target population to assess community support for a health center by 1/1/12.   Objective met 9/6/12. 12. Secure external funding for health center operations from at least two resources by 6/1/12. Objective met. The next steps in the evaluation process will be to measure coalition effectiveness in order to inform the public health community of best practices in coalition building and community organizing.  Data collection is not complete to determine if our community has a decreased percentage of people experiencing challenges accessing primary care.  We hope to replicate the previous study using the resources of our partners at the University of North Dakota.  There has been in decrease in the number of people who remain uninsured 18% uninsured in 2010 to 8.8% uninsured in 2013 for Grand Forks County.  It is not known if the Alliance activities had a direct impact on this since ACA enrollment activities were occurring at many locations in the community. The Alliance had a limited role in coordination and promotion of those efforts.  Two agencies report fewer referral challenges for clients for primary care if they still lack insurance.  Those organizations are the Grand Forks Public Health Department and the Northland Rescue Mission.  The Grand Forks Public Health Department and New American Services continue to work on a more seamless process of referral for new refugees and Valley Community Health Centers is developing greater capacity to serve incoming refugees and their specific cultural and health needs.    
Today the Alliance has 22 member agencies and more than 45 individual members and supporters.  Even though the Alliance celebrated the opening of the Grand Forks site of Valley Community Health Centers with an open house in June 2014, and the planning grant ended in 2013, enthusiasm for continuing to work on health issues facing the community remains high.  The Alliance plans to seek the services of the University of North Dakota Marketing Department for developing a plan to increase the Alliance’s visibility in the community which will ultimately highlight our work and engage new partners. The Grand Forks Public Health Department is committed to sustaining the activities of the Alliance and continues to provide leadership, administrative support and connections to other community work in the area of health improvement and population health. During the next year, we will have an opportunity to work with the Masters of Public Health program at the University of North Dakota to evaluate the effectiveness of the coalition.  Our work continues as new health concerns arise in the community and in response to the constantly changing health care landscape.  The Alliance and Grand Forks Public Health Department partnered with the Greater Grand Forks Young Professionals’ Association to co-sponsor a forum on the Affordable Care Act in 2013. The purpose was to provide information to the public on the Health Insurance Marketplace, ND Expanded Medicaid and the resources available for health insurance enrollment and Marketplace navigation and specifically targeting younger health care consumers. The event, held in the City Council Chambers, was attended by close to 100 people and was broadcast on the City’s closed circuit television station. The Grand Forks Public Health Department and Alliance also sponsored education for health and human service professionals to help them understand the impact that poverty has on health and health care decisions.  The Health Department was able to tap into the expertise of a local board of health member and County Commissioner to provide this information to 47 participants in January 2012 and 52 participants in April 2014.  The evaluations for the program were very positive and participants reported that it created greater understanding when working with persons who live in poverty. Altru Health System conducted a community health assessment (CHA) process from 2012 to 2013 as a requirement for their Community Benefit Status under the Affordable Care Act.  The Grand Forks Public Health Department contributed expertise, data sources, and education on the community health assessment process to the advisory committee.  We also informed the advisory committee of the ongoing work to improve access to primary care in Grand Forks. The priority setting process led to five priority areas for improvement: 1) rate of obesity 2) access to mental health services 3) binge and excessive drinking 4) impact of poverty on health and 5) financial barriers to health. Three of the top five priorities identified by this community health assessment were activities that the Alliance for Healthcare Access was already engaged in (impact of poverty on health and financial barriers to health), or had some knowledge of the extensive need (mental health services.)  When designing the implementation strategies, the advisory committee looked to the Alliance to address those priorities.  This validated the Alliance’s past and current work and provided an infusion of purpose to meetings.  Having had recent success in establishing the health center in Grand Forks, the Alliance has turned its attention to improving access to behavioral health services in the community and Grand Forks County.  There is synchronicity in addressing this topic since the state of North Dakota recently conducted a large scale study of behavioral health services statewide and there is an ambitious policy agenda to improve those services with the abundant resources of the state’s general fund during the 2015 legislative session.  Engaging Alliance members on behavioral health policy advocacy has become the new focus of Alliance activities.              
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