The economic depression continues to decimate families in communities throughout the area served by The Nord Family Foundation.   The President was in town last week and spoke about jobs.  The legislative quagmire over addressing health-care has thwarted meaningful conversation about this important topic.  Hope for a resolution to the challenge of the rapidly growing number of medically uninsured people is dissipated.  As politicians focus more on gaining political points for partisan camps, community members of this part of the rust belt still try to find solutions to this massive problem.

The Context – According to results from the 2008 Ohio Family Health Survey, there are an estimated 29,326 uninsured adults, age 18 to 64, in Lorain County.  This number represents 15.9% of adults in Lorain County, a statistically significant increase of 4.9% (9,160 persons) over 2004 figures.  Further, there are 2,723 uninsured children, under the age of 18.  This, however, represents 1% fewer uninsured children over 2004 figures.

The improvement in the rate among children is attributable in large part to the State Children’s Health Insurance Program (SCHIP) which provided insurance for children in families with incomes up to 250% of the federal poverty level.  In 2008, eligibility was increased from 200% of the federal poverty level.

Some of the characteristics of the adult uninsured population are as follows:

• Males were more likely to be uninsured than females.
• Younger adults have higher estimated uninsured rates than older adults.  In Lorain County, 34.1% of adults ages 18 to 24 were uninsured versus 8.4% of adults ages 45 to 64.
• Married couples have much higher health insurance rates than others.  In Lorain County, 32.4% of unmarried adults ages 18 to 64 were uninsured versus 4.8% of married adults.
• Adults ages 18 to 64 who are less educated are also less likely to have health insurance.  In Lorain County, those with a four-year college degree had an uninsured rate of 8.1% versus 47.6% for those with less than a high school diploma or equivalent.
• Differences in employment status are also related to insurance status.  In Lorain County, 7.8% of full-time workers were uninsured, compared to 19.9% of part-time workers and 29.4% of unemployed adults.
• In Lorain County, adults in households with income of at least twice the federal poverty level (FPL) had an uninsured rate of 8.5%. Those below poverty (less than 100% FPL) had an uninsured rate of 34.6%, and almost half (48.6%) of those with incomes between 101% and 150% FPL were uninsured.

The two primary hospital systems located in Lorain County are Community Health Partners Regional Medical Center and EMH Regional Healthcare System. Both systems do their share to provide care to those without coverage and/or the ability to pay.  In 2007, EMH provided approximately $17 million in charity care.  This was an increase of 15% over 2006, a 54% increase since 2004, and more than double 2001.  The same year, CHP provided $4.8 million in traditional charity care, and an additional $11.7 million in unpaid costs for Medicaid.

The Response – In 2008, The Nord Family Foundation contributed $129,000 to the Community Foundation of Greater Lorain County, to initiate HealthCare Lorain County.  These funds leveraged local grants allowing the group to contract with the Altarum Institute and the Public Services Institute of Lorain County Community College to facilitate a year-long community engagement and planning process aimed at improving access to health care for the uninsured in Lorain County.   The two contractors, guided by Robert Woods Johnson’s Communities in Charge, initiative  diagrammed stakeholders’ perspectives of the current and desired Lorain County health system, completed a local environmental scan, outlined key problems, and mapped provider resources.

Contributions from local funders included

• Community Foundation $33,000
• Stocker Foundation $25,000
• CareSource Foundation $20,000
• United Way of Lorain Co. $5,000

Participants – Approximately forty (40) community leaders, referred to as the Working Group, participated on this initiative at some level and are committed to addressing/improving the health care situation in Lorain County.  This Working Group was comprised of individuals from all aspects of the health care field (hospitals, health departments, mental health board, medical society, etc.), as well as state and local government, law enforcement, social services, local funders, faith-based organizations, and business representatives.   A Steering Committee of ten (10) members acted as a sort of Executive Committee and met when the Working Group did not – vetting data and information and taking suggestions back to the larger Working Group.  Between August 2007 and December 2009, the Working Group and the Steering Committee each met five times, under the guidance/facilitation of the consultants.

Goal – HealthCare Lorain County focused its efforts around providing access to Medical Homes for the uninsured.  In a medical home model, primary care clinicians and allied professionals provide conventional diagnostic and therapeutic services, as well as coordination of care for patients that require services not available in primary care settings. The goal is to provide a patient with a broad spectrum of care, both preventive and curative, over a period of time and to coordinate all of the care the patient receives.  This “Medical Home” decision was reached by the Steering Committee in June 2008 and presented to the Working Group in late July 2008 after much data analysis regarding the statistics of the uninsured in Lorain County, and the current rates/usage stats of the two main hospital systems.   Over the next several months the group reviewed examples of other communities’ successful solutions to the same problem Lorain County is facing and ways in which those communities adopted medical home models or something similar.  December 2009, the Committee recommitted to the long-term goal.

Status –

Charity Hospitals

Currently, Community Health Partners has started a very small Medical Home pilot program with the assistance of the Lorain County Free Clinic – both of whom served on the Steering Committee.  The two main hospitals, CHP and EMH, along with the Steering Committee Chair and two of the larger foundations funders, met in November 2009 to discuss how the two hospitals are prepared to commit to/expand on a full Medical Home program for the Lorain County community.  The most viable option for the two appeared to be the Toledo CareNet model which serves a triaging center to make sure the medically uninsured and under-insured have a human being ushering them to an appropriate care.  CareNet’s strength is in providing a continuum of care for the medically indigent requiring chronic care.  At this writing, the hospitals are reluctant to make a financial commitment to what could amount to a $300,000 operating budget for CareNet to function in Lorain County.  The foundations are continuing to meet with the hospital directors to determine why this is the case.

Public Health Departments –

In 2008, The Public Services Institute (PSI) of Lorain County Community College was contracted by the Lorain City public health department to initiate a strategic plan.  The plan was published in July 2008 with little discussion from the Health Care Lorain County group. The plan calls for a need for the three entities to “collaborate,” but fails address Health Care Lorain County’s call to explore consolidation of the three separate health districts into one.  PSI had engaged in low-level negotiations with the health departments to push the idea of merger forward in 2009.   In January 2010, Nord Family Foundation inquired about the PSI’s efforts and received the following response from the Elyria Public Health Director,

We have been unable for many reasons to meet with Lorain City. We have of course had financial reductions in grants and have laid  two positions and eliminated the well child program. We just received an 100,000 cut in the general fund from Elyria — and so are anticipating  other major changes within this year — because so much of our budget depends on grants and those grants are on a fed fiscal year, we have until June to complete whatever we  decided to do about consolidation of some of our remaining programs, etc. This has been — due to our early and constant involvement withH!N! — a very difficult and challenging year. The Board has worked and supported us — but we all know we need to come up with a new business plan that will fit our budget. Unfortunately at a time when our services are really needed on a lot of fronts, we are at risk! But the Board is still interested in some kind of collaboration with Lorain city. There has been no enthusiasm or cordiality on their part re. to invitations — but they are also under stress.

PSI’s message to Nord Family Foundation is,

You will notice the strategic priority regarding collaboration.  Honestly, unless someone funds a neutral convener and facilitator to take these two entities to the next level, I doubt much will happen until either Kathy (Elyria director)  and/or Terry (Lorain director) retire.  Both individuals have to be close to this point so the time is now.

As these conversations continue, the Nord Family Foundation awarded $297,000 in grants to unrelated health-delivery organization in Lorain County between 2008-2009.  The recipient organizations are: Community Health Partners Regional Foundation; Family Planning Services of Lorain County; The Lorain County Free Clinic; The Lorain County General Health District and the Lorain County Health and Dentistry.

Progress is being made in that the foundations continue to engage in conversations with the hospitals, the federally qualified health centers and the free clinic.  An ad hoc committee on the medically uninsured continues to meet regularly with focus on sustaining the Lorain County drug repository.  The Nord Family Foundation hosts those monthly meetings.

After more than a year of meetings, the following challenges remain:

1. There is a need to continue exploring this very complex issue of providing quality health-care to medically uninsured and underinsured people in the county.
2. There must be a new technology infrastructure put in place to facilitate data sharing.
3. There is a desire to provide every citizen a sense of a medical home.  People desire a relationship with a personal health care provider rather than an impersonal institution.
4. The community needs to explore open-source charts so every patient can have an online chart that will follow him or her to their port to the health care system. The Cleveland Clinic’s remarkable on-line health record called My Chart is a great example of what an electronic health portfolio for medically underinsured and uninsured could look like.
5. There is a need to examine how health dollars currently flow into the county.  There are tremendous inefficiencies and possible duplication of effort among  three distinct health departments (Elyria, Lorain City and Lorain County Health) which draw most of their funding from federal and state programs.  These departments which were established initially to address infectious disease in the earlier decades of the 20th Century, are not equipped to handle comprehensive chronic care that the majority of the population needs.  Competition from for-profit clinics such as Walgreens Take Care Clinic raises questions about the place of these health departments in a 21st century health care model.
6. The economic pressure necessitates collaboration between the two charitable hospitals and the Cleveland Clinic.
7. All eyes are on the negotiations with the impending federal health care legislation in Congress.

Lessons Learned –

The challenge for the Nord Family Foundation (or any foundation) deciding to take on a convening effort of this magnitude trustees must determine

• How visible a role you want the foundation to take
• have flexibility built into the expectations you have for the outcome
• know the level of risk you will tolerate (the outcome could result in stakeholders walking away from the table)
• determine how much staff time and money you are willing to put into the effort
• look for innovation from players outside the local cohort
• be willing to stick with it – conversations of this magnitude can take years but n the long run, the Medical Home is likely to result in savings to patients, employers, and health plans.  Increasing the emphasis on primary care could produce large dividends throughout our health care system