To improve the health of individual patients and the population of the community as a whole, it is essential to connect community-based population heatlh programs with healthcare home clinics. The first step is to identify evidence-based programs and connect them with patients who receive care in healthcare homes. In many areas, these programs will need to expand their reach across the state.

There are many opportunities for HCHs to work together with public health agencies and their community partners. In fact, improving the individual health of patients will depend to a great degree on what improvements are made in the health of the population. When HCHs and public health agencies work together, both goals can be achieved. Although the role of public health agencies will certainly evolve over time, they are in an ideal position to directly assist HCHs and to engage a wide array of community-based partners.

Nebraska SHIP Priority 4: Nebraska has improved integration among public health, behavioral health and healthcare services.

For this SHIP goal, several activities planned for implementation:

• Complete a list of public health programs and strategies to implement in clinics with a healthcare home model.
• Implement public health programs in clinics with healthcare home models.

Public health agencies and their community partners can play a vital role in the success of the HCHM. In the area of patient tracking and registry, public health staff with their data analytic expertise and understanding of disease patterns can assist staff from smaller primary care clinics in interpreting the data to obtain more meaningful results. Currently, staff from the Division of Public Health are working with three rural primary care clinics to help them better understand the registry data and answer questions about the best practices for controlling cholesterol and hypertension.

Using data from the state, regional, or national health information exchanges, public health staff will eventually be able to conduct population-based studies based on the analysis of aggregated patient registry data. For example, they will be able to assess if the treatments of patients with diabetes and hypertension have been effective.

Under access to care, public health can assist HCHs in facilitating enrollment in health insurance, developing transportation options, and providing some direct clinical preventive services such as immunizations and home visits for new mothers.

In care management, health education and health promotion programs are already being implemented to address several high risk behaviors and problem areas (e.g., physical inactivity, poor nutrition, tobacco and alcohol use, timely prenatal care, and domestic violence) associated with cardiovascular disease, cancer, and mental health. These programs can reinforce the messages that are provided by clinic staff. For example, many local health departments are using media campaigns and other programmatic activities to encourage all adults over 50 to get screened for colon cancer or to stop smoking.