Dorchester County Health Department Health Systems Presentation MDH Center for Chronic Disease Prevention and Control’s CDC 1422 Grant Site Visit July 20, 2017
DORCHESTER COUNTY POPULATION BY RACE MARYLAND VITAL STATISTICS ANNUAL REPORT 2015 Hispanic 5% Asian/Pacific Islander 1% African American 29% Caucasian 65% Total Population: 32,384 American Indian 0.3%
DORCHESTER COUNTY POPULATION BY AGE MARYLAND VITAL STATISTICS ANNUAL REPORT 2015 Age 75 + Birth - 4 Age 5 - 14 Age 65 - 74 Total Population: 32,384 ▪ 57% between age 20-64 Age 15 - 19 ▪ 11% age 65 and above ▪ 23% age 19 and under Age 45 - 64 Age 20 - 44
Dorchester County Overview County Health Rankings & Roadmaps (2017) Health Outcomes – Rank 23 rd Health Factors – Rank 22 nd Health Behaviors, Clinical Care, Length and Quality of Life Socioeconomic Factors, and Physical Environment
County Health Rankings & Roadmaps Data (2017) 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
Choptank Community Health System Federally Qualified Health Center Private, non-profit community health center Provides primary and oral health care in Caroline, Dorchester, and Talbot Counties Care Coordinators, Community Support Specialists, etc. provide wraparound services Implementing interventions to improve quality of health care delivery to populations with highest hypertension and prediabetes disparities
Partnership with Choptank Community Health 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
DPP Champions Recruit and refer patients ▪ Use ICD-10 codes for prediabetes and pre-hypertension ▪ Integrate screening and referral into office visits (including dental) ▪ 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
“Commit to Be Fit” Champions 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
Oral Health Collaborations 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
Partnership with UMES School of Pharmacy 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
Next Steps Delving deeper into oral health collaborations Monitoring workflow to increase referrals Further enhancing linkages
Contact Information: Dorchester County Health Department 3 Cedar Street Cambridge, MD 21613 Angela Mercier Miranda LeCompte Health Education Program Manager Chronic Disease Prevention Coordinator 410-901-8126 410-901-8129 Angela.mercier@maryland.gov Miranda.lecompte@maryland.gov
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