Collaboration is Critical

Carolinas HealthCare System

Carolinas HealthCare System is one of the leading, most comprehensive public, not for profit, health care systems in the nation, with over 900 care locations and almost 12 million patient interactions per year. In 2016, it embarked on its first community health improvement study, which is equivalent to a community health needs assessment. During this process, the decision was made to focus on social determinants of health among 10 counties served by the health system. In addition, hotspotting was used to develop a more targeted and impactful strategy to improve health outcomes. Hotspotting refers to a data driven process that identifies local patterns, behaviors, and interventions to better address patients' needs and to improve outcomes, as well as reduce cost, within a defined geographic region [5]. Through a partnership with the North Carolina Institute of Public Health (UNC Gillings School of Global Public Health), an online interactive map focusing on 12 social determinants of health indicators was developed (see Figure 1). This map consisted of neighborhood level data within the 10 county service region mentioned above.

• Download figure
• Open in new tab
• Download powerpoint

FIGURE 1.

Selected Social Determinants of Health Domains and Indicators

Using those 12 determinants of health indicators, an index was created that highlighted which neighborhoods had higher social needs and higher social and economic disparities [6]. Carolinas HealthCare System then overlaid patient data with a map (see Figure 2) and found multiple concerning trends, including increased rates of diabetes and asthma, and increased numbers of preventable emergency room visits in the same neighborhoods with a higher social index score. This data drew attention to populations located within the 6 ZIP code area surrounding Charlotte's city center within Mecklenburg County [7].

• Download figure
• Open in new tab
• Download powerpoint

FIGURE 2.

Distribution of Social Determinants of Health in Mecklenberg County, North Carolina.

Mecklenburg County Health Department

When the data from Carolinas HealthCare System was compared to County Community Health Assessment data and social indicator data from the MCHD, it showed that these same ZIP code areas had higher rates of chronic disease mortality compared to the rest of the county (see Table 1). There were also significant disparities regarding death rates within these 6 ZIP codes (see Table 2). The same areas also had low educational attainment and higher unemployment rates, which are both predictors of poor health outcomes. They also had the highest rates of concentrated poverty [7]. Because of this information, MCHD had already been targeting these 6 ZIP codes, labeling them public health priority areas for specific interventions focusing on health behaviors [6].

Another priority identified by the MCHD in their 2013 community health assessment was access to care [6]. The local community objective, selected by CHS, Novant, and MCHD leadership with guidance from community members and physicians, was to provide access to care for all individuals and families in Mecklenburg County, regardless of the ability to pay. Although the Affordable Care Act did provide financial assistance for individuals to acquire health insurance, it was noted that despite higher rates of insurance, the number adults without a primary care provider increased from 2015 to 2016 (see Table 3).

Novant Health

Novant Health also completed their Community Health Needs Assessment in 2016, and identified similar priorities as the MCHD regarding access to care [8]. Within the 6 ZIP codes, an observation was made that there were very few primary care or urgent care access points. Some community members living in these neighborhoods have significant barriers (eg, transportation, cost, hours open) to accessing these services. Oftentimes this results in preventable emergency department visits for primary care services.

Developing a Partnership

Carolinas HealthCare System, Novant Health, and the Mecklenburg County Health Department decided to collaborate and focus on the public health priority areas within Mecklenburg County. This collaboration was driven by innovative organizational leadership, and the comparison of social determinant data to patient data and outcomes. They also identified physician leadership in organizations working to improve community health. In preparation for this unexpected collaboration, the CEOs of each organization were taken on a tour of the 6 ZIP code areas. During the tour, the lack of primary care and urgent care resources was emphasized, in addition to the lack of healthy food options and poor housing conditions. This tour was visually compelling and highlighted the concerns identified through the community health assessments.

Over the next 3 years, this collaborative will develop and implement a strategy to improve access points for primary care within the 6 ZIP codes. It will also involve community partners in this transformative work, such as the YMCA of Greater Charlotte, Project 658, and the Renaissance West Community Initiative. Early wins of this collaboration include submission of applications for 2 grants, placement of a Carolinas HealthCare System community health nurse in one of the public health priority areas, and funding support from Novant Health for a newly established free clinic in another public health priority area. This is a great model of how innovative partnerships can lead to optimizing the health of our North Carolina communities.