North Coast Health

Programs: North coast health exists to strengthen the quality of community life through the provision of health care services for the most economically vulnerable in our community. This commitment is fulfilled by providing medical services including diagnosis, treatment and referral, prescription assistance, cooperating with other health and human service organizations and seeking additional opportunities to serve individuals in need.

vision: partners in healthcare, bridging the gap mission statement north coast health exists to strengthen the quality of community life through the provision of health care services for the most economically vulnerable in our community. This commitment is fulfilled by providing medical services including diagnosis, treatment and referral, prescription assistance, cooperating with other health and human service organizations and seeking additional opportunities to serve individuals in need. Defining principles (values) faith, compassion, excellence, teamwork, stewardship in 2014, north coast health: served 2,331 individuals registered 728 new patients. Provided 12,679 services 5,351 primary care visits onsite 213 primary care visits offsite 2,288 specialist referrals 479 behavioral health counseling visits an additional 4,348 services, which includes help with prescription assistance forms, medication pick-up, registrations, nurse visits and lab testing dispensed 3 million in prescription drugs: 75,573 in drug repository medications 1. 5 million in medications acquired through pharmaceutical manufacturer patient assistance programs 869,067 in medications through the astra-zeneca institutional patient assistance program (ipap) 540,444 in medications provided by medication samples 11,533 in americares prescription programs in 2014: over 120 volunteer physicians, nurses and other administrative volunteers provided services valued at over 189,765. (this does not include the value of specialist care, which we are unable to fully track at this time. ) nch changed our name from north coast health ministry to north coast health. We implemented a charitable care program and began seeing insured patients. We continue to have more uninsured patients than insured. In may, charity navigator, america's largest and most-utilized independent evaluator of charities, awarded north coast health its second consecutive prestigious 4-star rating for good governance, sound fiscal management and commitment to accountability and transparency. North coast health is currently the only free or charitable clinic in ohio with such a high rating and is one of only 12 out of 1,200 free and charitable clinics across the country to earn four stars. Expanded our clinic hours to include three regularly scheduled evenings per week and saturdays - in addition to our clinics held five days a week during regular business hours. Achieved a 6% increase in patients' diabetic outcomes reported to better health greater cleveland due in large part to increase in annual eye exams and pneumococcal vaccinations. Also achieved a 4% increase in reported blood pressure control for our patients with a diagnosis of hypertension. Our patients demographic data - 2014 unduplicated patients: 2,331 gender male - 44% female - 56% age birth to age 19: 3% 20 - 34: 18% 35 - 54: 43% 55 - 64: 32% 65+: 4% annual income 0 - 9,999: 44% 10,000 - 20,000: 25% 20,001 - 30,000: 19% residence lakewood: 36% cleveland: 35% other cuyahoga county suburbs: 24% lorain county suburbs: 5% health status 75 - 80% of our patients have chronic medical conditions. 45 - 50% have multiple chronic conditions. Our average patient has a household income of less than 12,000 per year. Research has demonstrated a strong relationship between socioeconomic status and an increased risk of being affected by health disparities. Some examples: just 4. 3 percent of ohioans have had angina or coronary heart disease, vs. 7. 2 percent of low-income individuals (cdc 2010). Thirty-two percent of ohioans have been told they have hypertension, vs. 43 percent of low-income individuals (cdc 2009). Ten percent of ohioans have been diagnosed with diabetes, vs. 18 percent of low-income individuals (cdc 2010). As an ncqa-recognized patient-centered medical home, we are providing care that has been proven to result in greater equity in health outcomes for some of the most economically vulnerable in our community. Patient survey results we are positively impacting the health of some of the most vulnerable members of our community, 80% of who have chronic diseases. On our most recent patient survey: 97% of our patients reported that their health has improved or stabilized since they became our patient; 97% report they are treated with dignity and respect 92% report the medical care they receive is excellent 86% report they have a medical condition that requires prescription medication 66% or patients report they would have nowhere else to go but the er 59% of patient report that they were able to enroll in the expanded medicaid program through the affordable care act 91% of patients report their phone calls are returned in a timely manner 98% report they would recommend nch to a friend despite the many changes transforming our nation's health care system, the need for our services continues. There are still families having to make the choice between paying their utilities and buying medications they need. There are still people who cannot afford the deductible or copay their insurance plans require before they can see a doctor when they are sick. Our average patient has a household income of less than 12,000 per year. Without north coast health, most would not have access to a provider of medical care. On our most recent survey, 78 percent of patients reported they had nowhere else to go for care other than the emergency room before they found us. Current programs, activities and accomplishments in 2014, we served 2,331 low-income, uninsured patients and dispensed 3 million in free prescription medication. We strive to provide accessible, continuous, coordinated and comprehensive patient-centered care that is on par in quality with that provided to anyone of greater economic means. The services we offer, therefore, are integrated and coordinated to this end and consist of the following: primary care program: offered five days per week and on evenings and weekends chronic illness management program: geared toward patients with commonly diagnosed chronic conditions and managed by a coordinated team of nch caregivers, with the goals of improving the quality of care provided to those with chronic illnesses and preventing and minimizing complications related to chronic illness women's health program: includes preventive breast health and gynecological screenings and care prescription assistance program: enables our patients with chronic illnesses to receive free or low-cost medications to manage their diseases and prevent complications; also enables the provision of age-appropriate immunizations and home health supplies to patients specialty referral program: allows our patients to access specialty care donated by our volunteer referral physician network and through cuyahoga health access partnership (chap) behavioral health case management program: through collaboration with the centers for families and children, provides behavioral health therapy and case management services to patients with depression. Established the creative arts therapy scholarship program at north coast health to provide a creative arts intervention to support patient health and well-being. We work in collaboration with beck center for the arts and it is our collective belief this program will improve patients' sense of well-being and better health for our chronically ill patients. Current initiatives and plans for 2015 work towards triple aim of better health, better care and lower costs submit renewal application for recognition by ncqa as a pcmh strengthen care of our medicare patients implement a smoking cessation program evaluate space constraints expand creative arts therapy program goal 1: provide high-quality care and conduct continuous quality improvement (cqi): objectives: maintain the standards of an ncqa-recognized patient centered medical home that have been proven to result in improved clinical outcomes and the reduction of unnecessary costs. At least 90% of patients will have a decrease due to illness in limitations as measured by the social/role activities limitations instrument from the stanford patient education research center. Continue to work with local hospital partners to bring about a demonstrated reduction in inappropriate ed utilization by nch patients. Ed utilization will be evaluated monthly and the goal is a reduction over time from the current level on a patient-by-patient basis. By end of 2015, our adherence to clinical care standards and our patients' clinical outcomes will compare favorably with all other practices participating in better health greater cleveland, a regional collaborative focused on improving the quality of primary care. Specifically: the percentage of nch patients with diabetes who meet all four recommended care processes (% receiving a1c test, % receiving urine m-alb screen or ace/arb rx, % receiving an eye exam; and % receiving pneumovax) will compare favorably with regional attainment, currently at 48 percent. The percentage o