Community Partnerships and Clinical Integration

The YMCA of Western North Carolina sees itself as one piece of the total health puzzle for our friends and neighbors. In order to impact our communities, we need to be a part of a community of integrated health where a variety of organizations work together to help people live healthy lives. Through evidence-based programs, community initiatives, shared spaces, and navigation managers, we hope to create real change in the health of Western North Carolina residents. One of our most dedicated collaborators and early adopters of this work was Mission Health and its affiliated accountable care organization (ACO), Mission Health Partners.

Our patient-centered partnership with Mission Health is critical to helping individuals in our region successfully navigate their health journeys. Together we are able to share the financial risks associated with preventative care to drive down long-term health care costs. The financial risk associated with our evidence-based programs relates to our approach in asking providers to invest dollars in areas that will take time to garner a return (eg, the YMCA's Diabetes Prevention Program). Mission Health Partners makes a minimal investment to place patients in our interventions and the balance is only paid if prescribed outcomes are achieved. Individuals receive more touch-points in an integrated system with roots in population-based performance and outcomes, making patients more likely to seek assistance ahead of an emergency situation. The collaboration between Mission Health and the YMCA of Western North Carolina finds functional solutions to the health disparities of our region. We meet the needs of our communities by providing guidance to people who are unable to navigate complicated health care issues on their own.

Programs like the YMCA's Diabetes Prevention Program and Taking Control of Type 2 (TCT2) would not thrive without our alliance with local health systems. Through our combined efforts, Mission Health and the YMCA of Western North Carolina have generated referrals for these programs and seen real change in our communities. Together we have integrated staff and participants, completed an Institutional Review Board Study, and begun publishing the results from TCT2. The cost benefit analysis conducted by CMS showed an estimated savings of $2,650 per-enrollee in the Diabetes Prevention Program over a 15-month period, when compared with similar beneficiaries not in the program. TCT2's 3 years of promising outcomes have inspired Mission Health Partners to further invest in our work by incorporating these programs into care process models.

In 2015, we laid a foundation for deeper work with Mission Health Partners and other community health organizations including Pardee Hospital. Through our combined efforts, we opened an innovative health and wellness facility that incorporates the work of various partners in a shared campus. The YMCA's focus at Mission Pardee Health Campus is on rehabilitation and medical support. Classroom spaces, adaptive exercise equipment, a teaching kitchen, and a therapy pool for guiding rehabilitation are just a few of the amenities this shared space offers to patients.

By pooling our resources and expertise, the YMCA of Western North Carolina and Mission Health can address the local health landscape more effectively and drive critical systemic changes to local, regional, and state-level health structures. Through our work we have built a body of knowledge on compliance and regulatory issues that helps us find paths through these regulatory mazes that have in the past kept clinical providers and community-based organizations from integrating with one another in the best interests of our patients.

Collaborations, such as that between the YMCA and Mission Health Partners, strengthen our communities and the individuals we serve who are seeking personal health. They allow us to meet patients where they are in their journey and where they live in our neighborhoods. We cannot wait to see what challenges we can address next as we work together to advance community integrated health in Western North Carolina.

• ©2017 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.