Download Introduction to Southern Prairie - Southern Prairie Community Care

Introduction to Southern Prairie
Southern Prairie broadly refers to a collaboration among twelve Minnesota counties with a
common goal: To enhance the quality of life and health of our citizens by facilitating the
integration of services and supports provided throughout our communities. Southern Prairie
specifically includes two organizations with complementary roles:
- Southern Prairie Community Care (SPCC)
- Southern Prairie Center for Community Health Improvement (CCHI)
Collaboration of 12 Counties
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Chippewa
Cottonwood
Jackson
Kandiyohi
Lincoln
Lyon
Murray
Nobles
Redwood
Rock
Swift
Yellow Medicine
Two Organizations, One Mission:
Enhancing Life and Health in our
Communities Through Accountable Care
Southern Prairie
Community Care (SPCC)
SPCC is a joint powers organization
formed in 2012 by the twelve
counties included in the Southern
Prairie region: Chippewa,
Cottonwood, Jackson, Kandiyohi,
Lincoln, Lyon, Murray, Nobles,
Redwood, Rock, Swift and Yellow
Medicine. These counties came
together with common concerns
related to higher than state average
rates of poverty, obesity, physical
inactivity, diabetes and other health
indicators — and similar beliefs,
values, and vision for improving the
quality of life for their residents.
SPCC is a virtual
network — focused on
achieving the Triple
Aim of improved clinical
quality, lower total cost
of care, and enhanced
patient experience.
SPCC has evolved to be a virtual
network — focused on achieving
the Triple Aim of improved
clinical quality, lower total cost
of care, and enhanced patient
experience. The network includes
27 provider members including
clinics, hospitals, public health,
mental health centers, and area
human service agencies. SPCC is
recognized and under contract
with the Minnesota Department
of Human Services (DHS) as an
Integrated Health Partnership (IHP),
responsible for approximately
25,000 lives. The Minnesota
Department of Health (MDH) has
identified SPCC as an Accountable
Community for Health focused
on improving health delivery for
people in our communities, and
under contract for the delivery of
a diabetes prevention program.
A key strength of the organization
is SPCC’s ability to mobilize
community services around those
with the highest needs, and to
leverage connections between
the governance of SPCC and
that of health and human service
agencies, mental health centers,
and county hospitals in the region.
The SPCC Board of Directors
is comprised of county
commissioners from each of
the twelve counties, with a
wide variety of background
and experience. The SPCC
Board recognized the need for
commitment from a wide variety of
stakeholders across multiple sectors
to advance the mission efficiently
and effectively. It was determined
that providing a mechanism for
these stakeholders to play a role in
the development and governance
of Southern Prairie was essential
to ensure long-term involvement
and the successful implementation
of SPCC initiatives. This led to the
development of the Southern
Prairie Center for Community
Health Improvement.
Southern Prairie Center for Community Health
Improvement (CCHI)
CCHI is a 501(c)3 non-profit organization formed by SPCC in 2014 and
formally recognized by the IRS in
2015. CCHI convenes community
partners interested in making measurable and sustainable improvements in the health of the residents
in southwestern Minnesota. The governance structure includes a charter
agreement that details the relationship between the two organizations
(SPCC and CCHI) and specifically
defines the role of CCHI in furthering
the Southern Prairie Mission.
Local stakeholders make up
the CCHI Board of Directors —
public and private — delivering
services in the region and working
to advance the principles of
the Triple Aim. CCHI board
membership is equalized between
SPCC board and operations
representatives, public and private
providers of care and services,
and consumers — each playing a
key role in advising SPCC on the
best approach to achieve stated
goals. Specifically:
• SPCC Board and Operations
Representatives serve as
liaisons to CCHI to promote
transparency, ensure alignment
with the mission, and facilitate
ongoing communications
between CCHI and SPCC.
• Public and Private Sector
Providers of Care and
Services assist CCHI in
reviewing major health trends
in their communities, and
recommending action to
address issues of concern.
• Consumers assist CCHI in
assuring recommendations for
programs to be developed are
understandable and useful to
the consumer.
• Health Plans and Other Investors
assist CCHI in identifying
mutually beneficial projects and
opportunities for partnership to
advance the Triple Aim in the
SPCC region.
CCHI annually convenes
workgroups to engage even
broader representation across
the region, and advise the
ongoing development of SPCC
and Southern Prairie community
initiatives. The workgroups align with
the four pillars of Southern Prairie.
Southern Prairie
Community Care
Integrated
Community
Care
Health Equity
— Access to Care
& Services
The four pillars of
Southern Prairie
provide the foundation
for delivering patient
centered, integrated care
to enhance quality of life
and improve health in our
region.
Person & Population
Quality of Life
Improved Population
Health in our
12-County Region
Information Strategies
for Accountable Health
Four Pillars of Southern Prairie
The Four Pillars are:
1. Health Equity and Access to
Care and Services
2. Improved Population Health
in the 12-County Region
3.
Information Strategies for
Accountable Health
4. Integrated Community Care
Health Equity and
Access to Care and
Services
Improved Population
Health in the
12-County Region
The public and private member
organizations of Southern Prairie
have a longstanding history of
collaboration and commitment
to improving the health outcomes
of our diverse and vulnerable
populations. The Southern Prairie
community believes good health
is a community asset and all
residents must have access to
healthy food; safe and affordable
housing; transportation; a safe
environment for work and play;
and health care and information
to make healthy decisions.
Southern Prairie employs various
methods to assess the health of the
population and the community
— using and building on existing
community assessments and other
key data sources. Southern Prairie
then facilitates dialogue with
representative stakeholders within
the community to understand
issues identified within the data. As
a community we work to prioritize
population health issues based on
need and the potential to impact
improvement within the region.
The community then develops
recommendations for programs
and projects for Southern Prairie to
pursue to address the most difficult
gaps in health needs and health
care in our region.
Southern Prairie’s Health Equity
and Access efforts are focused
on identifying and addressing
disparities regarding access to
— and quality of — health and
healthcare across the diverse
populations within the twelve
county region. Southern Prairie
is actively working to develop a
regional and community-based
approach to address significant
health inadequacies identified
within our communities. Key
focus areas at this time include
addressing healthy food intake,
communication and interpretation
concerns, identification and
treatment of mental health disease,
medication compliance, and
education on health related topics.
Currently, Southern Prairie is funded
as an Accountable Community for
Health through the Minnesota State
Innovation Model Testing Grant, to
implement a program focused on
diabetes prevention throughout
the 12-county region. Additional
population heath priorities identified
for future projects include: Health
and well-being of adults age 1840 with a focus on healthy food
choices and exercise.
Information
Strategies for
Integrated
Accountable Health Community Care
Southern Prairie has placed a
high priority on the use of data
to inform strategies to advance
community goals for improved
quality, lower cost, and improved
patient experience, and measure
the community’s progress over
time. Southern Prairie is committed
to developing information
resources that deliver actionable
data — when and where needed
— to provide the best possible
care to individuals in our region.
Current Information Strategies for
Accountable Health include two
components. First, Southern Prairie
aims to develop a health information exchange to facilitate the
movement of clinical data among
providers in the region, and provide access to more timely data
to inform care and follow up. The
second component is implementation of Data Driven Intervention
Strategies — including the delivery
of specific data to network providers to assist them in addressing
targeted utilization issues or quality
trends identified within their patient
population (i.e., frequent use of
the Emergency Department, complex medications, difficult chronic
conditions) to improve quality and
manage total cost of care.
A core tenet of Southern Prairie’s
work is to deliver patient-centered
care that:
• Addresses medical,
psychological, and social
needs;
• Assesses individual issues that are
contributing to poor health; and
• Integrates appropriate
community resources with the
health care system.
The Southern Prairie partners —
through a commitment to coordination across sectors — can
achieve community goals for better
health and lower cost. At Southern
Prairie, we refer to this approach as
Integrated Community Care (ICC).
ICC delivers a community-based,
multidisciplinary health care system
that takes collective responsibility
for the health of individuals and the
total population within the region.
A team of highly trained integration coordinators has been placed
strategically across the region to
facilitate connections between the
traditional health care system and
the extended network of community-based service providers — to deliver comprehensive care plans that
link individuals with the services and
supports that they need to improve
their health and well-being.
ICC delivers a
community-based,
multidisciplinary health
care system that takes
collective responsibility
for the health of
individuals and the total
population.
Two Organizations, One Mission:
Enhancing Life and Health in our Communities Through Accountable Care
Southern Prairie Community Care
Joint Powers
Center for Community Health Improvement
501(c)(3) Non-Profit
Charter
Agreement
SPCC Board Members
(One Representative Per County)
CCHI Board Members
(Up to 11 Providers, 3 County Reps, 3 Consumers)
Chippewa County
Murray County
Clinic Representative
Hospital Representatives
Cottonwood County
Nobles County
Consumer Representative
IDN Representative
Jackson County
Redwood County
County Representatives
Mental Health
Kandiyohi County
Rock County
Swift County
Dentist Representative
Representative
Lincoln County
Lyon County
Yellow Medicine County
HHS Representatives
Pharmacist Representative
Physician Representative
Health Plan Representative
Southern Prairie Community Care and the Center for Community Health Improvement
are co-located in Marshall, Minnesota.
PO Box 513
Marshall, MN 56258
Phone: 507-532-1336
Fax: 1-888-965-5613
[email protected]
www.southernprairie.org