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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 • • • • • • • • • • • • 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