NC Center for Health and Wellness Overview Scorecard 2016-2018

Why Is This Important?

Everyone deserves fair opportunities to be healthy, but unfortunately many groups and communities have limited availability of and accessibility to the health care resources and conditions necessary to support their wellbeing. Research shows differences in health outcomes among people with different race/ethnicity, geographical locations, genders, sexual orientations, ages, and other characteristics. These differences can be seen in the indicators above, including overall life expectancy, poverty rates, educational attainment, and health status. We need to build the capacity of providers across the state to increase access to health services for all people, particularly underserved groups. Our systems and programs must also be strengthened through advocacy, policy change, and engaging cross-sector partners in community initiatives.

Who We Are

The North Carolina Center for Health and Wellness ﴾NCCHW﴿ was launched at the University of North Carolina Asheville (UNCA) in 2007 to support the health of people across the state by serving as a catalyst for primary prevention and health promotion. Our mission is to develop healthy North Carolina communities with equitable opportunities ﴾Results 1, 2﴿, with particular focus on addressing health disparities in the prevention and treatment of chronic health conditions. Health equity provides an anchor for all of NCCHW work. This term conveys that everyone deserves a level playing field, no matter what their station in life, to pursue optimal health without undue burdens beyond their control.

NCCHW champions and spearheads promising and evidence-based initiatives and practical evaluation methods to improve communities where people live, learn, work, pray and play. NCCHW contributes to health and wellbeing for the state’s population via a web of relationships that lead to better practices, enhanced capacity, and community innovations at strategic points across the lifespan. NCCHW staff work in partnership with stakeholders across the UNC Asheville campus, the region, and the state to help support health service systems and providers, impact critical policies and ignite community initiatives.

What We Do

The two current initiatives at the core of our organization include NCCHW’s Culture of Results (COR) empowerment evaluation training and technical assistance program and Healthy Aging NC (HANC), which provides statewide training, data reporting and management, and technical assistance for evidence-based health programs. Our work collectively improves health outcomes for historically marginalized populations statewide and builds systems to support the inclusivity and decision-making abilities of these underserved populations long term.

NCCHW's Culture of Results Initiative (COR) provides training and technical assistance in planning and evaluation methods to statewide initiatives, local public health departments, hospitals, clinics, universities and grassroots community groups. Culture of Results applies key aspects of empowerment evaluation— providing evaluation as part of an ongoing planning process to support client self-determination and empowerment and organizational capacity building. Partners develop their own skills and capacity to evaluate their services to adapt, improve, expand and communicate results. Culture of Results team members engage partner organizations in learning and using a framework known as Results-based Accountability (RBA) and its evidence-based, common sense tools to plan and evaluate their projects and services. Culture of Results methods have been effectively used in NCCHW partners’ community health assessments and improvement plans, evaluation and grant reports, coalition building, and strategic planning processes. Over 1,000 individuals from 400 diverse partner agencies and groups have been trained in this framework since 2017. 

Healthy Aging NC builds the capacity of healthcare agencies to meet the Quadruple Aim by improving health outcomes, improving patient self-management, offering a high return on investment, and supporting clinicians work life through a broad network of evidence-based health programs in communities where people live, work, play, and pray. Our HANC website (www.healthyagingnc.com) is a statewide hub for information, referrals, and program registration. A HANC data manager tracks the quality assurance, fidelity, and reach of evidence-based programs statewide. Program managers support the expansion of programs to reach historically marginalized populations, create connections between clinical and community partners, and improve program sustainability. Our two major focuses currently are in falls prevention and chronic disease prevention and management. Results of the programs show significant improvements in self-efficacy and improved relationships between participants and their families, caregivers, and healthcare providers among the over 5,500 participants who have completed programs since the initiative came under NCCHW in 2016.

Story Behind the Curve

The NCCHW is housed at the University of North Carolina Asheville and leverages the expertise of the state's public liberal arts faculty, staff, and students. The Center focuses efforts on the UNC Asheville campus, Buncombe County, Western North Carolina region, and across the state, particularly in areas with opportunity to reduce poor health outcomes through cross-sector partnerships and community commitment to help everyone reach their full health potential.

Healthcare reform is creating opportunities for collaboration between clinical and community partners, yet providers are often not equipped to understand payors’ needs, develop partnerships to meet those needs, and create the value propositions to achieve successful, sustainable relationships with them. The type of support NCCHW staff provide is critical to bridging relationships and coordinating program delivery between community partners, clinicians, health agencies, and patients to fill service delivery gaps in high need areas of NC.

Through all of our work, we strive to bring focus to communities who have traditionally been underserved by, and excluded from, health programs, and to engage these communities in planning and implementing initiatives to improve health and address social drivers and physical environments. We build on the trust our partners have developed over many years, supporting them in engaging people “where they naturally gather at times that they naturally gather.” Through all our initiatives, we try to ensure that our trainings are needs-driven, build upon existing strengths, and align with the cultural values of our partners.

However, considerable challenges remain and there is great work to be done as the landscape of health care shifts to truly achieve the “quadruple aim” of health care improvement: 1) improving the patient experience of care (including quality and satisfaction); 2) improving the health of populations; 3) reducing the per capita cost of health care; and 4) improving the clinician experience. NCCHW is working to better understand how systemic injustice persists across sectors and how greater inclusion and equity can be achieved; the influence of trauma and how to prevent and treat its effects; ways to build the social support that is so critical to mental and physical health; and other underlying drivers of major health issues and disparities.

How We Impact

NCCHW staff operate with transparency and mutual respect for all colleagues and communities based on keen understanding that everyone can contribute to solutions that advance health. NCCHW utilizes sound organizational, management and financial practices. NCCHW fosters independence with partners, promotes shared collaboration and leadership and incorporates evaluative thinking and capacity building across all of its work.

Partnerships

Current Key Partners:

N.C. Division of Aging & Adult Services; NC Division of Public Health; NC Council of Churches; Western North Carolina Health Network; Mountain Area Health Education Center; Mission Health System; NC Association of Area Agencies on Aging; Community Food Strategies; and many more! 

Why Is This Important?

Organizations striving to support the health, wellness, and quality of life of their communities must understand their program results in order to improve. Evaluation can help organizations reduce uncertainties, improve the effectiveness of strategies, and make decisions about resource allocation (University of Texas, 1998). Strong measurement and improvement systems enable programs to show success and identify areas for growth. This attracts clients as well as funders and provides critical information to key stakeholders.

However, our systems in North Carolina are stretched thin, and many health and social service providers and promoters need assistance with evaluation, implementation and improvement. Often when consultants assist with evaluations, their support ends with project contracts, leaving an ongoing void. Further, evaluations and planning efforts too often fail to include the input of community members receiving or in need of services.

Strategy

Through the Culture of Results Initiative, the North Carolina Center for Health and Wellness (NCCHW) works with local, regional and state partners to assess impact, strengthen coordination, and improve programs and systems statewide. NCCHW's Culture of Results is a training and technical assistance program that supports state initiatives, local public health departments, hospitals, clinics and community providers in measuring impact and improving results. Culture of Results applies key aspects of the empowerment evaluation model— providing evaluation as an iterative planning process to support self-determination and empowerment of clients and capacity building of organizations. Culture of Results team members engage partner organizations in learning and using a framework known as Results-based Accountability (RBA) and its evidence-based, common sense tools to plan and evaluate their projects and services. RBA has been recognized by the Center for Disease Control (CDC), the National Institute of Health (NIH) and other governmental agencies as an effective practice for evaluation and planning. Clients are participants who quickly develop the skills and capacity to evaluate their own services to adapt, improve and expand.

What We Do

Culture of Results Initiative Impact

• Culture of Results provides training in exercises that can easily be used again and again to strengthen the capacity of programs, giving clients the ability to sustain their own efforts.
• Technical assistance helps clients co-create tailored evaluations to meet grant, government, or internal reporting requirements.
• Culture of Results workshops teach participants simple, clear language and processes that all stakeholders can understand and participate in, making planning more inclusive.
• Culture of Results applies Results-based Accountability (RBA), an evidence-based, action-oriented, and data-driven framework to improve population health and well being and program performance. RBA enables programs and organizations to focus on action, critical collaborations, and quality data for transparency and accountability of success, making it well suited to cross-sector collective impact work.
• Culture of Results is an initiative of the North Carolina Center for Health & Wellness at University of North Carolina Asheville. Culture of Results leverages the strength of the University’s community engagement efforts and academic programs, including in some cases faculty and student research.

Story Behind the Curve

CHALLENGES

According to the Association for Community Health Improvement, the health care system in our country is undergoing rapid and complex changes, that have critical impact on many Americans. While the Affordable Care Act has afforded unprecedented access to health care services, clinical care is not enough for communities to reach their highest potential for health. To achieve this lofty goal, exceptional collaboration is necessary — both within health care systems and throughout the community with multi-sectoral stakeholders. Hospitals throughout the United States are taking steps toward improving community health through their community health needs assessments and population health management practices. This is a time of great opportunity for community benefit and community health professionals to apply their knowledge and skills to transform our health care system into one that is adept at promoting the health of communities in the clinic and where people live, learn, work and play. The impact that we can have working together is far greater than that of each individually.

Many health and social service providers are working together to strengthen our systems across North Carolina. But demand continues to outweigh our capacity. Applying data-driven approaches to planning, taking action and evaluation and improvement are critical to support the health and well being of all North Carolinians.

How We Impact

Through technical assistance, program development, evaluation and leadership, the Culture of Results program will bolster health systems and service providing programs to help improve the health resources for at least one in ten North Carolina residents by 2018.

Map of Counties Impacted by Culture of Results Trainings (July 2018 Updated)

Partnerships

UNC Asheville - Community Engagement Council, The Key Center, and The Center for Diversity Education

WNC Health Network- WNC Healthy Impact and WNC Triple Aim Initiatives

Buncombe County Health and Human Services- Mobilizing Action for Resilient Communities and Community Health Improvement Plan Initiatives

MAHEC- Community Centered Health Homes Initiative/Mothering Asheville

Family Justice Center- HelpMate and OurVoice Community Service Project

YWCA of Asheville

Buncombe County ACE Collaborative & Painkiller Task Force

Community Food Strategies and Food Policy Councils across NC

With support from The Blue Cross Blue Shield Foundation of North Carolina

Why Is This Important?

Of the 100 counties in North Carolina, 60 already have more people age 60 and over than 0-17, and by 2033, 96 of the 100 counties will have more people age 65 and older than under age 18. According to the NC State Center for Health Statistics, 27.2% of adults age 65 and older have one chronic condition and an additional 53.5% have two or more chronic diseases. Results of the 2013 Behavioral Risk Factor Surveillance System (BRFSS) Survey indicate that 29% of adults age 65+ rate their health as fair or poor. Projections show that by 2030 more than 6 of every 10 North Carolinians ages 47-65 will be managing more than one chronic condition. The top three health conditions reported for the 8750 participants enrolled in Chronic Disease Self Management Education (CDSME) programs in NC since 2010 include Hypertension (54%), Diabetes (45%), and Arthritis (44.1%), with 69.5% reporting multiple chronic health conditions. Just one chronic condition, like Hypertension, which causes or contributes to at least 30% of all deaths in NC, costs $189 million Medicaid dollars ($1100 per beneficiary) annually.

The Chronic Disease Self-Management Education Program (CDSME) was developed by Stanford University and is a two-and-a-half-hour workshop offered once a week for six weeks in community settings. People with different chronic health problems attend this evidence-based program together. Subjects covered include: 1) techniques to deal with problems such as frustration, fatigue, and pain, 2) appropriate exercise for improving strength, flexibility, and endurance, 3) appropriate use of medications, 4) communicating effectively with family, friends, and health professionals, 5) nutrition, and 6) decision making.

The research behind CDSME programs show that they improve patient outcomes through increasing self-efficacy regarding personal health behaviors and by providing individuals with the skills and information necessary to manage their chronic disease outside of the clinician’s care. Research shows that participants demonstrate significant improvements in exercise, cognitive symptom management, communication with physicians, self-reported general health, health distress, fatigue, disability, and social/role activities limitations. They also spent fewer days in the hospital, and trended toward fewer outpatients visits and hospitalizations.

Strategy

NCCHW received a 2015 Prevention and Public Health Fund (PPHF) Chronic Disease Self-Management Education (CDSME) Programs grant, awarded by the Administration for Community Living (ACL), to embed CDSME programs into the Healthy Aging NC ﴾HANC﴿ Resource Center (housed at NCCHW).  In January 2016, the Healthy Aging NC statewide hub launched, with a goal of centralizing support for communication, program registration, data management, data reporting, and technical assistance for CDSME program activities ﴾www.healthyagingnc.com﴿. The CDSME initiative also seeks to increase and expand the reach and sustainability of CDSME across the state. This involves increasing the number of older adults and adults with disabilities in underserved populations who participate in CDSME; creating clinical‐community connections that promote CDSME; and developing a sustainable and integrated centralized network across the state that implements CDSME.

BUILD CAPACITY 

• NCCHW, through its Healthy Aging NC initiative, partners with the Centralina Area Agency on Aging to maintain a statewide CDSME programs Training Academy that provides CDSME master trainings, professional development, and resources at reduced or no cost to participants.
• NCCHW, through its Healthy Aging NC initiative, raises awareness of CDSME programs and supports linkages to clinical partners, such as Federally Qualified Health Centers (FQHCs), hospital wellness departments, and local physicians. A CDSME programs grant allowed NCCHW to test pilot a program sustainability model with the FQHC Western NC Community Health Services.
• NCCHW staff support community-based organizations across North Carolina to expand outreach and capacity to provide CDSME programs to low‐income, rural, minority, and disabilities populations.
• NCCHW staff, through the Healthy Aging NC initiative, supports statewide access to data and resources through software, website, and media options. This includes the website www.healthyagingnc.com; the on‐the‐cloud data management software Workshop Wizard; access to the National Council on Aging CDSME database, and the ongoing partnership with the N.C. Division on Aging and Adult Services.

IMPACT POLICY

• NCCHW staff, through the Healthy Aging NC initiative, creates “systems changes” within agencies so that they are able to maintain CDSME lay leaders, share program licenses through formal agreements, afford CDSME materials, and provide CDSME workshops in an ongoing and sustained way. This occurs through NCCHW staff capacity, the CDSME Programs Training Academy, access to the website, regular programmatic data results, and resource development.
• NCCHW staff, through the Healthy Aging NC initiative, works on strategies for health care providers and insurance providers to include CDSME in the provision and reimbursement of services. This occurs by raising awareness of the benefits of CDSME, establishing clinical and community partnerships, supporting Medicare reimbursement processes, and developing business acumen tools like value propositions. NCCHW staff conduct research on these topics and offer trainings to support our partners in achieving long-term sustainability.

IGNITE COMMUNITY INITIATIVES

• NCCHW staff, through the Healthy Aging NC initiative, work to ignite communities by supporting the scaling of CDSME programs in communities needing the programs. This is done through regional convening, providing access to low-cost leader training, offering marketing and registration online via healthyagingnc.com, conducting research on program best practices and developing requested toolkits. 
•  NCCHW staff, through the Healthy Aging NC initiative, focus on expanding CDSME program access to those with disabilities, minority populations, rural populations, and low‐income populations.

What We Do

Please see the attached file for a detailed listing of the work that the CDSME Program provides in the areas of program management and statewide leadership, partnership development, statewide infrastructure development, centralized coordinated logistical processes for recruitment, referral, enrollment and marketing, business planning and financial sustainability and quality assurance and fidelity. 

Partners

WNCCHS: Western North Carolina Community Health Services, Inc. is a private, non-profit, tax-exempt corporation based in Asheville, North Carolina. WNCCHS is a non-governmental social enterprise providing primary health care to residents of the service area. Its core principles are: Equity, Solidarity, Inclusivity and Responsibility. During the last decade of the 20th century, Buncombe County experienced significant growth. The decade was also marked by explosive growth in health care costs. These trends were accompanied by sustained increases in the number of uninsured persons, placing the local health care safety net under unrelenting strain. This combination of factors made clear our community needed additional financial resources - particularly for preventive and primary health care. WNCCHS is a Federally-Qualified Health Center (FQHC).

http://www.wncchs.org/

Centralina Area Agency on Aging: With the enactment of the Older Americans Act (OAA) in 1965, AAAs were mandated in every state. Centralina AAA is part of Centralina Council of Governments. As one of the 16 Area Agencies on Aging in North Carolina its purpose is to: advocate for improvement in aging programs, resources and long term care facilities; plan and develop long-range plans for Livable Senior-Friendly Communities; develop and administer an area plan that is a comprehensive and coordinated system of service delivery in our area; provide technical assistance to service providers, community agencies and interested others; provide employment for seniors through the Title V Senior Community Service Employment Program; and coordinate, train for, fund and monitor evidence based Title IIID programs for health promotion and disease prevention.

http://centralina.org/centralinaaging/

Land of Sky Area Agency on Aging: Land of Sky AAA promotes the highest level of well-being of older adults and their families by partnering with organizations to provide a comprehensive system of opportunities, services, and protective services. The AAA is a leader and catalyst in helping older adults in our four county region lead more independent, vibrant lives. As part of the national network of AAAs established by the OAA, the AAA works to strengthen home and community care for older adults.

http://www.landofsky.org/aaa.html

NC Division of Aging and Adult Services: The Division of Aging and Adult Services works to promote the independence and enhance the dignity of North Carolina's older adults, persons with disabilities, and their families through a community-based system of opportunities, services, benefits, and protections.

http://www.ncdhhs.gov/divisions/daas

Area Agencies on Aging: Area Agencies on Aging are offices established through the Older Americans Act that facilitate and support programs addressing the needs of older adults in a defined geographic region and support investment in their talents and interests. In North Carolina, the 16 AAAs are located within regional Councils of Government.

http://www.ncdhhs.gov/assistance/adult-services/area-agencies-on-aging

NC Office of Minority Health and Health Disparities: The North Carolina General Assembly established OMHHD (OMH) in 1992 with a vision that all North Carolinians will enjoy good health regardless of race/ethnicity, disability or socioeconomic status. OMH’s mission is to promote and advocate for the elimination of health disparities among all racial and ethnic minorities and other underserved populations in North Carolina. OMH’s major focus areas include: research and data, culture and language, policy and legislation, partnership development and advocacy.

http://www.ncdhhs.gov/

NC Office on Disability and Health: The North Carolina Office on Disability and Health (NCODH) was a partnership effort between the Women's and Children's Health Section of the Division of Public Health and the Frank Porter Graham Child Development Institute. The mission of NCODH was to promote the mhealth and wellness of children, youth, and adults with disabilities in North Carolina and to address health disparities experienced by persons with disabilities across the life span.

http://www.ncdhhs.gov/

Administration for Community Living: All Americans—including people with disabilities and older adults— should be able to live at home with the supports they need, participating in communities that value their contributions. To help meet these needs, the U.S. Department of Health and Human Services (HHS) created a new organization, the Administration for Community Living (ACL). ACL brings together the efforts and achievements of the Administration on Aging, the Administration on Intellectual and Developmental Disabilities, and the HHS Office on Disability to serve as the Federal agency responsible for increasing access to community supports, while focusing attention and resources on the unique needs of older Americans and people with disabilities across the lifespan. ACL is the funder for the CDSME grant program at UNC Asheville.

http://www.acl.gov/About_ACL/Index.aspx

National Council on Aging: The National Council on Aging (NCOA) is a respected national leader and trusted partner to help people aged 60+ meet the challenges of aging. NCOA partners with nonprofit organizations, government, and business to provide innovative community programs and services, online help, and advocacy. NCOA provides technical support and assistance to the CDSME grant program at UNC Asheville.

https://www.ncoa.org/about-ncoa/

Story Behind the Curve

One of the challenges in raising awareness across the state about chronic disease and the Chronic Disease Self Management Education programs (CDSME), especially in underserved populations, has been the decrease in funding of statewide partners and the high turnover in staff at the Area Agencies on Aging (AAAs).  Both the NC Office on Disability and Health and the NC Office on Minority Health and Health Disparities lost significant funding for staff and activities, and AAAs have lost staff who were trained and experienced in providing CDSME workshops. The CDSME program continues to lead the Training Academy and has recruited new partners to fulfill deliverables.

Another challenge to the CDSME program has been raising the statewide level of awareness and use of Healthy Aging NC resources, including the website. The CDSME program continues to promote the website and resources through conference presentations, regional meetings and calls, and awareness events; assess and respond to resource and capacity-building needs; and differentiate services from other providers.

Internal challenges to the CDSME program include data management problems, including the national database as well as the software developer Workshop Wizard, as well as lay leader management, access/transportation to CDSME workshops, and lack of current referrals from clinical providers.   

How We Impact

The partnership with Centralina Area Agency on Aging and the NC Division on Aging and Adult Services has made the Training Academy effective in fulfilling needs of the 16 Area Agencies on Aging (AAAs) and other organizations by providing Chronic Disease Self Management Program (CDSMP), Diabetes Self Management Program (DSMP), and Chronic Pain Self Management Program (CPSMP) master trainings, contributing to sustainability within the leadership of the programs, supporting annual lay leader trainings, and sharing requested information and resources across the state.

The partnership with the local Federally Qualified Health Center (FQHC) of WNC Community Health Services has resulted in the creation of a referral process, CDSMP workshops onsite and in partnership with fellow community-based organizations, and follow-up measures. This work has been a case model for other FQHCs and clinical partners to replicate.

The partnership with the Land of Sky Area Agency on Aging has resulting in the expansion of CDSME topics, such as Tomando, DSMP, and CPSMP, while developing partners in underserved populations such as the African American faith community (Asheville Buncombe Institute of Parity Achievment), migrant workers (the Migrant Education Program), low-income populations (YWCA), and rural communities within the western region.

The partnerships with ODH and OMHHD have led to trainings on cultural competence, health disparities, accessibility options, and accommodations. The Inclusion Toolkit was developed and shared, a test pilot CDSMP at a CIL took place, and case studies are  being created on reaching out to minority populations.

The www.healthyagingnc.com website has been established as a resource to raise aweareness about CDSME, find workshop dates and locations, register on-line, and explore resources. This has helped in promoting CDSME across the state. In addition, NCCHW is viewed as the data collection and entry site.

NCCHW has been attending a variety of meetings and conferences in order to promote the www.healthyagingnc.com website and hub, and the value of the evidence-based programs of CDSME. This includes collaborations with NC 211 to increase referrals to CDSME, regional meetings across the state to seek input and next steps using the Results-Based Accountability framework, and participation in the ACL Network Development Learning Collaborative to explore sustainability options. 

Map of Counties Impacted by CDSME Trainings (Updated July 2018)

Why Is This Important?

As our population ages, fall injuries and deaths in North Carolina (NC) are an increasingly serious public health issue. Falls are the fourth leading cause of unintentional injury death for North Carolinians of all ages,and in every year from 1999 to 2010, the number one cause of injury death for individuals 65 and older.

From 2000-2011, the death rate from falls increased 65.9% in the 65 and older population. In 2011, 85% of the 883 deaths related to falls were among North Carolinians age 65 and older.That same year, NC experienced 25,141 hospitalizations and 193,805 Emergency Department (ED) visits due to falls. On an average injury day, there are 2 fall deaths, 69 hospitalizations, and 531 ED visits in NC. 

In 2011, the median hospital discharge fee for NC residents age 65 and older admitted for a fall was $25,404, a 35% increase from $18,800 in 2007.The total hospital discharge fees for North Carolinians 65 and older due to falls was over $806 million dollars. Of the 25,141 people hospitalized following fall-related injuries in 2011, 41% were discharged to a skilled nursing facility, 29% went home and 14% went home and required home health care. Hospital charges only account for a small portion of the total cost of a fall. Falls can also result in costs due to work loss and follow-up treatment.

Strategy

NCCHW served as a subcontractor of the 2014 Prevention and Public Health Fund ﴾PPHF﴿ Falls Prevention ﴾FP﴿ grant to the NC Division of Aging and Adult Services ﴾DAAS) from 2015-2017. The 2014 grant established the Healthy Aging NC ﴾HANC﴿ Resource Center in January 2016 to serve as a statewide hub at NCCHW, with a goal of centralizing support for communication, data management, data reporting, and technical assistance for falls prevention activities ﴾www.healthyagingnc.com﴿. In 2017, NCCHW received a three-year award from the Administration for Community Living to: expand access to, and utilization of, two evidence‐based falls prevention programs ﴾EBFPP﴿; increase sustainability in 18 counties of Western North Carolina ﴾WNC﴿; and leverage the statewide integrated, sustainable evidence‐based falls prevention programs network.

BUILD CAPACITY

• NCCHW, through its Healthy Aging NC initiative, partners with the High Country Area Agency on Aging to maintain a statewide Tai Chi for Arthritis Training Academy. The training academy ensures the training of high-quality leaders in the evidence-based Tai Chi for Arthritis program, and adherence to fidelity to ensure falls prevention outcomes and benefits
• NCCHW, through its Healthy Aging NC initiative, brings together a network of five Area Agencies on Aging in Western NC and the Mission Health system to develop a referral and program feedback loop between clinical referrals and community falls prevention programming. The three-year grant-funded project will identify social determinants of health in the referral-to-program-implementation, and will lead to a value proposition on creating referrals through a centralized hub, or backbone organization.
• NCCHW staff, through the Healthy Aging NC initiative, supports statewide access to data and resources through software, website, and media options. This includes the website www.healthyagingnc.com; the on‐the‐cloud data management software Workshop Wizard; access to the National Council on Aging falls prevention database, and the ongoing partnership with the N.C. Division on Aging and Adult Services.

IMPACT POLICY

• NCCHW staff, through the Healthy Aging NC initiative, creates “systems changes” within agencies so they can maintain program leaders, collaborate through formal agreements, afford program materials, and provide workshops in an ongoing and sustained way. This occurs through NCCHW staff capacity, the Tai Chi Training Academy, access to the website, regular programmatic data results, and resource development.
• NCCHW staff, through the Healthy Aging NC initiative, works on strategies for health care providers and insurance providers to include CDSME in the provision and reimbursement of services. This occurs by raising awareness of the benefits of CDSME, establishing clinical and community partnerships, supporting Medicare reimbursement processes, and developing business acumen tools like value propositions. NCCHW staff conduct research on these topics and offer trainings to support our partners in achieving long-term sustainability.

IGNITE COMMUNITY INITIATIVES

• NCCHW staff, through the Healthy Aging NC initiative, supports the scaling of falls prevention programs in communities needing the programs. This is done through state and regional falls prevention coalitions, regional network convening, creating referral systems, offering marketing and registration online via healthyagingnc.com, conducting research on program best practices and developing requested toolkits.
• NCCHW serves as a convener of those with interests in preventing falls, reducing healthcare costs, and improving healthcare outcomes. Through Healthy Aging NC, NCCHW is the centralized, coordinated evidence‐based falls prevention program network hub for NC.

What We Do

The University of North Carolina at Asheville, NC Center for Health and Wellness maintains a full time Falls Prevention (started January 2016) and data administrator (started December 2015) to manage the deliverables of a 2014 ACL grant. Since December 1, 2015, the data administrator has received data packets for the AMOB and Tai Chi for Arthritis programs.The Falls Prevention Coordinator has been involved in: the branding of the entry portal for healthy aging programs (via a website); developing a continuum of care tool kit; presenting on the resource center to state and regional falls prevention coalitions and other partners;assisting with falls prevention advisory team meetings; seeking referral processes from diverse partners; integrating the various evidence-based falls prevention programs into a connected network;and engaging in sustainability strategy discussions. Deliverables expected include: the development of a statewide business plan and sustainability plan; distribution and evaluation of a clinician falls prevention awareness survey;and completion of the continuum of care toolkit.

NCCHW is also involved with the North Carolina Medical Society Foundation (NCMS), an organization that is helping rural Accountable Care Organizations (ACOs) develop across North Carolina.There have been discussions about including falls prevention programs into ACO funding mechanisms, building off the infrastructure that already exists with YMCAs for Diabetes reimbursement. NCCHW has also met with partners such as Carolina Medical Systems, Genesis Rehab Company,Wake Forest Baptist Health,and others to investigate community/clinical partnerships and long term sustainable funding for evidenced-based falls prevention programs.To continue and advance the work of the Resource Center, the Division of Public Health’s Injury and Violence Prevention Branch included the Resource Center in their CDC CORE Injury funding request. This funding was awarded and $10,000 will be given to the NCCHW Falls Prevention Resource Center per year for 5 years.The NCCHW has also begun engaging in fundraising efforts for the Resource Center work. Meetings with clinical partners have been held resulting in Mission hospital system implementing NC Fall Prevention Coalition’s Information Packet into their patient portal system. We continue to work with them to embed strategies that will improve quality measures, raise awareness among clinicians and the public, and result in fewer fall related injuries and deaths among North Carolinian elders.

Story Behind the Curve

CHALLENGES

By 2025 it is projected that 90 of NC’s 100 counties will have more population age 60 and older than ages 0-17.This substantial increase of older adults in NC will likely result in a drastic rise in deaths, hospitalizations,and ED visits due to unitentional falls. Additional challenges are that community health improvement processes often lump fall related concerns in with “physical activity” or that awareness of the burden of falls in one’s area is unknown and the issue is not represented well in community or hospital assessments processes. We also have the challenge of changing public perception that falls are a preventable demise and not a normal part of aging.

How We Impact

Map of the Counties Impacted by Falls Prevention Trainings (Updated July 2018)

Increasing awareness of evidence-based falls prevention screening and programs to reach older adults and adults with disabilities who are at risk for falls through a centralized resource center is a primary function of this work. UNC Asheville through the NC Center for Health and Wellness will support the expansion of evidence-based Falls Prevention screening (Building Better Balance) and programs (A Matter of Balance, and Tai Chi Moving for Better Balance,and Tai Chi for Arthritis) to reach older adults and adults with disabilities who are at risk for falls.We will maintain a centralized online hub/resource center that will facilitate in the coordination of evidence-based Falls Prevention activities and programs.We will work to strengthen the collaboration of Evidence-based Falls Prevention activities and programs at the state and local level to improve access of older adults and adults with disabilities who a great risk for falls to community programs that decrease fall risk by incorporating new community programs into the Hub.We will elevate the visibility and knowledge of the falls prevention hub as a single point of entry for falls prevention information for providers, clinicians,and the public in North Carolina by promoting the Hub through various communication channels.

Additionally, we will embed data collection and reporting systems for the various programs into the Statewide Falls Prevention Resource Center.We will conduct data collection and dissemination for Centers for Disease Control and Prevention grant reports as requested. Programs will be promoted and delivered through establishment or reinforcement of Regional integration committees and leveraging the successes of various Fall Prevention Coalition activities in the state,as well as through The Fall Prevention grant advisory team and a variety of partners.

Partnerships

YMCA Alliance of NC/ YMCA of WNC

The YMCA of WNC and Alliance of YMCAs have been one of our largest partnerships. They are the disseminators of the YMCA: Moving for Better Balance Tai Chi program and work very closely with us on program expansion. NCCHW brought together the YMCA of WNC and the Land of Sky Area Agency on Aging to explore strategies for linking program participants on a continuum of care and have begun embedding the A Matter of Balance program as a complement to other programming offered.

UNC Chapel Hill

UNC Chapel Hill houses the Carolina Geriatric Education Workforce Enhancement Program which is an integral leader in expanding education around the Otago Exercise Program to physical therapists throughout the nation.

NC Department of Human Services

NC Division of Aging and Adult services

These state partners are integral part of the efforts to create more access and visibility of fall prevention strategies and evidence based programs in North Carolina. We work with them to disseminate information and updates about Resource Center activities among the aging network partners. We also collaborate with them to make strategic choices and create guidance for the state on how to disseminate and operate evidence based programs.

Injury Free NC and the Injury and Violence Prevention Branch of DPH

These two groups provide up to date data on the state of fall death and injury in the state and provide access to partners with whom we share our resources.

Statewide Area Agency on Aging Network

16 Area Agencies on Aging are responsible for a variety of health promotion and aging services in North Carolina and primary implementers of the A Matter of Balance and Tai Chi for Arthritis programs. We serve as technical assistance and expansion support alleviating many of their administrative burdens.

Home Health Agencies

Various home health agencies partner with state and local fall prevention coalitions and historically are interested in championing programs and being the eyes and ears of their communities to implement fall prevention strategies.

Mission Hospital Systems

Mission Hospital is committed to the health and wellness of the 18 western most counties in North Carolina. NCCHW staff work together with Mission staff to embed evidence-based programs as part of the standard of care for the aging population in Western North Carolina.

Regional and State Fall Prevention Coalitions

NCCHW serves on and works in conjunction with the state and several regional coalitions where fall prevention information and best practices are shared among various community stakeholders.

Alliant Quality

Alliant Quality is the Quality improvement organization for North Carolina. They engage in some degree of data sharing with NCCHW and provide access to practice care managers and other across the state.

Community Care Organizations across NC

Community Care organizations work with NCCHW to increase awareness of programs and strategies for fall prevention among their staff and find ways to embed referral systems.

Wake Forest Baptist Health

Wake Forest Baptist Health’s Senior Advisor for Transitional Care and Outcomes (Pam Duncan) is an advisor to the Fall Prevention activities of NCCHW and has assisted us in embedding Healthy Aging NC information into their Compass study to connect stroke survivors to community resources.

Genesis Rehab

Genesis Rehab has operationalized procedures and continues to educate its physical therapists on implementing Healthy Aging NC to connect discharging patients to community based fall prevention programs.

Office on Disability

NCCHW maintains a partnership with the NC Office on Disability and both work together to find ways to connect programs in the disability community.

Office of Minority Health

NCCHW maintains a partnership with the Office of Minority Health and relies on their insights and expertise to inform our strategies for connecting fall prevention programming in minority communities.

NC ACT

NCACT’s yearly conference serves as a platform for us to share best practices and to learn about other work in this area.

Multiple agencies that support Older Adults (senior centers,geriatric case managers,care transition teams, independent living facilities,etc)

All of these partners are further potential for increasing the visibility of our services and resources.

Why Is This Important?

Major social, economic, education and health disparities plague Buncombe County and particularly the City of Asheville. For example, Asheville's Census Tract 9 is a challenged place where the most recent American Community Survey data show a 52% poverty rate, median income of $18k and 24% unemployment. This is home to 1,460 households, with 59% African Americans, 33% Caucasians and others. 

Infant mortality and chronic disease disparities often stem from economic and social conditions which disproportionately impact lower-income people and people of color. Buncombe County's 2015 Community Health Assessment shows that in the past seven years the county's infant mortality rate has fluctuated. From 2012-13, there was a dramatic increase, from 5.0 to 10.1 deaths per 1000 live births. In 2014 (5-year data 2010-2014), African American infants were 2.6 times more likely than White infants to die before age one. By 2017, the ration has increased to 3.4. In addition, Chronic disease data show that African Americans have higher mortality rates from cancer, heart, kidney disease and lower respiratory ailments, than Whites. 

In Asheville and Buncombe County, children in poverty graduate from high school at a rate of 77%, while classmates graduate at 90%. There are also major disparities in math and reading proficiency rates in 3rd grade among racial/ethnic groups (White, Black, Latino, Native American and others). These disparities perpetuate through high school graduation and beyond. 

Major built-environment challenges that are manifested in lower wealth communities severed from access to healthy foods, adequate transportation and appealing green space. In Census Tract 9, the nearest grocery store is 2 1/2 miles away, and the minimum 30-minute (often longer) one-way bus trip requires two separate bus rides. The City of Asheville added Sunday bus service in 2015, but significant transportation gaps remain. 

Housing for all poses a major challenge. For the first time since 2007, Asheville's population of homeless people rose in 2015 by 5% over the prior year (533 to 562). Permanent supportive housing for households experiencing homelessness currently has a 6-months waiting list. Affordable housing units are operating at 99% occupancy, and public housing plus subsidized units have virtually no vacancy. The public housing 1-bedroom waiting list has over 1,000 persons. Wait times are between 6 months and two years for these units. Many households are doubled up so that occupants can afford the rent in subsidized units. 

Simply put, quality housing availability and adequate transportation networks to jobs and food require built-environment solutions that incorporate opportunities to build health for all. 

Strategy

Upon receiving funds from the Robert Woods Johnson Foundation (RWJF) in mid-2016 for the Invest Health planning grant initiative, a team convened of representatives from five anchor institutions in Asheville with NCCHW serving as the "backbone" agency. This group became known as the “Away Team” and was responsible for driving the progress of the initiative, coordinating with RWJF throughout the process, and traveling to locations around the country to connect with and learn from other groups doing similar work. The "Home Team" was a cross-sector group comprised of the original Away Team members, plus around 15 stakeholders from nonprofits, community organizations, city and county government departments, educational and health institutions, and community funding institutions and foundations.

Invest Health Asheville engages local residents to build capacity and develop leadership among people often left on the periphery of planning. The initiative generates broad, authentic engagement in information/opinion gathering for city decision and policy makers on issues related to quality of life. This process supports the City Council's vision with approaches that include budgeting capital investments through an equity lens, securing private development agreements with positive community investments, and utilizing robust processes that ensure that decision‐making bodies include people with lived experience of the deleterious impact of health inequities.

Partners are well poised to assist with planning and engagement work, and include representatives from workforce development, education, health, food access, transit and community organizing. Invest Health connects with residents and our respective networks to explore strategies for improving housing, income/employment and education. Essentially, the team, augmented with resident voices, will reinforce that health comes first for pending and new built‐environment projects in neighborhoods where social and economic challenges are manifested in health disparities. Other pending city development projects are encouraged by the team to include built‐environment elements that support healthy community best practices: public transit mobility, food access, nurturing green, coupled with strong social capital and resilience initiatives for children and adults.

What We Do

The concept of this planning grant was to develop a built environment project that addressed the social determinants of health, which include education, transportation, access to safe and affordable housing, places to play and exercise, quality jobs, healthy foods, etc. While 50 similarly comprised planning teams were also awarded these funds in cities across the United States, the Asheville team’s approach took a very different turn from the other groups around the country. 

Story Behind the Curve

Producing a built environment project which addresses one or more social determinants of health was the original goal of this effort. We have accomplished this and much more. The outcome was not only the development of this project and accompanying presentation but also the development of a planning model which was truly community-centered and was driven by our values. This was a very different approach to the phases of planning and development as compared to the Invest Health planning initiatives of our colleagues around the country, and frequently looked from the outside as though we were operating perpetually behind schedule. However, we hope that our story will demonstrate that moving at the speed of trust is not only doable when undertaking complex community planning initiatives, but is actually preferable in that it disrupts inequitable power dynamics and places community at the center of the planning process while producing enactable solutions to address the social determinants of health.

How We Impact

The Asheville Away Team began this planning initiative by trying out a variety of methods to get a feel for what projects and assets already existed in the city and what planning factors were most important to be taken into consideration according to key stakeholders in our area. This was accomplished through a community listening session, introductions and invitations to community and health agencies and programs to join the planning process, and culminated in an expanded planning table now known as the “Home Team” undertaking an asset mapping session to identify existing Built Environment, Economic Mobility, Educational, Advocacy and Awareness, Transportation, Food, and Health related assets and programs in our city. 

While this early work helped to establish a baseline identification of existing efforts in our city it did not provide a clear path forward in terms of meeting the goals of this planning process. Recognizing that this group needed feedback and support to chart an intentional and community-driven plan of action an organization within the Home Team met with Away Team representatives to recommend the addition of professional facilitation with a strong lens for equity and inclusion. As a result of this input in January of 2017 the Away Team hired Marisol Jimenez, founder of Tepeyac Consulting to facilitate Asheville’s Invest Health Initiative from that point forward.

The first planning meeting of the Home Team facilitated by Marisol Jimenez occurred in February, 2017, and involved the group playing a game called Power Pictionary, which was developed by Training for Change. The intent of this exercise is to ask participants to divide into two unevenly dispersed groups with uneven distribution of information and supplies and then to play a version of the game, Pictionary. Throughout the rounds of the game it becomes clear to the group receiving less instruction and supplies that they are not positioned for success, juxtaposed with the easy success of the other group. Tensions mount, and the vastly different experiences of the two groups become the centerpiece of discussion for the rest of the session. The power dynamics experienced and explored in this short exercise were then extrapolated outward to our city and our society, and around the room participants began to experience aha moments of true understanding regarding the historic and systemic marginalization and oppression of various groups of people, and particularly communities of color. The effects of long-term inequitable distribution of resources, decision-making power, and opportunities for success became clear. And, the group recognized that our planning initiative must make every effort not to replicate those patterns.  

At the next meetings of the Home Team, we established our group decision-making process and Group Norms, and applied an analysis of Amplification, Interruption, and Innovation to those previously exposed power dynamics to craft a set of Values for our group moving forward. These principles became fundamental to every aspect of our work throughout the remainder of the planning process, and provided a foundation of stability to support our group through moments of uncertainty. Our identified values were: Be a voice of dissent: name and interrupt inequitable power dynamics; Move beyond diversity; Redistribute resources and decision-making authority; Hold ourselves and others accountable; Recognize and support existing organizations and community-led efforts; Address barriers to participation; and Trust the community: “Move at the speed of trust”. 

Once this bedrock was laid for how to operate together as a group we began the process of developing a community-centered plan of action for the identification and support of a built environment project addressing the social determinants of health in our city. After agreeing that we wanted this venture to emerge directly from the community itself we divided out into three sub-committees to distribute planning responsibilities amongst the Home Team members. These sub-committees were Community Engagement, Application Development, and Project Criteria. The work of the Home Team began to move quickly at this point, with sub-committees meeting regularly outside of the whole-group while continuing to come back together monthly with the entire planning team to integrate planning efforts. While this phase of work was not entirely smooth it was driven forward by both our continued adherence to our shared Values and a growing sense of urgency to produce a  community-based project before the RWJF Master Class funding pitches scheduled for early December of 2017.

In early September the development of an application for built environment project proposals was complete, as well as the processes to ensure that both the submittal and selection of proposals would be completely community-driven. In an effort to adhere to our principle of addressing barriers to participation the Home Team ensured that both the project application and the application to serve on the Community Selection Committee were distributed widely in both paper and electronic form and in both English and Spanish. Informational flyers and physical applications were strategically placed in community centers located in low wealth neighborhoods throughout the city, and a Capacity Building Workshop was held with childcare and interpretation for prospective applicants to learn more about the Invest Health process and receive support in completing and submitting a project proposal. Similarly, an Information Session with childcare and interpretive services was held for Community Selection Committee applicants to prepare them for their upcoming task of reviewing project proposals and identifying the project they felt best met the goals of the Invest Health initiative as well as the needs and desires of the community.

Applications for project proposals were due by October 16th, 2017, and after determining a strategy to eliminate potential conflicts of interest from the selection process a smaller group of uncompromised Home Team members had the difficult task to narrow down the excellent eight project proposals received to the top three applications which best fit the group’s goals and Values. Finally, on October 26th an Invest Health Project Showcase event was held featuring specially created vocal performances, community-catered cuisine, childcare, interpretation, community-artist rendered project designs for the final three applicants, project summaries and contact information for all submitted proposals, a graphic facilitator’s depiction of the Invest Health group’s entire planning process, and the multi-generational Community Selection Committee which would be hearing descriptions of the final three projects and then retreating to discuss and determine which project they would select for presentation at the Invest Health Master Class funding pitches in early December. The Showcase was attended by Home Team members, community groups and representatives, funding representatives, and additional institutional and organizational stakeholders. After much deliberation the Community Selection Committee chose the Emma Community Park proposal as the community’s Built Environment project to be presented at the RWJF Master Class in New Orleans.

Throughout the month of November and leading up to the RWJF Master Class in New Orleans on December 6th, 2017, the Invest Health Home Team has been working directly with the Emma community applicants to develop their proposal into a full scale presentation including a slide show, display booth, supporting statistical analysis, and oral presentation. The oral and Powerpoint presentation will be pitched to panels of leaders in the fields of economic development and urban planning at the RWJF Master Class in New Orleans, along with others from Invest Health projects from around the country. These panels will then provide Invest Health project teams with technical feedback and funding recommendations and will help to build necessary connections to investors and resources in order to see these built environment proposals become implemented.

The participation of Invest Health Away Team members in the Master Class was always understood. However, the Asheville planning team identified early on that in accordance with our principles of being a voice of dissent by naming and interrupting inequitable power dynamics, redistributing resources and decision-making authority, and removing barriers to participation it was necessary to press for the inclusion of the Emma community project applicants as participants and presenters at the Master Class in New Orleans, which would require additional resources to support travel, lodging, and interpretation. Fortunately, after some deliberation RWJF agreed to make these additional accommodations, and the Emma community group presented their vision and project in New Orleans.    

Partnerships

Upon receiving funds from the Robert Woods Johnson Foundation (RWJF) in mid-2016 for the Invest Health planning grant initiative, a team convened of representatives from five anchor institutions in Asheville. This group became known as the “Away Team”, and was responsible for driving the progress of the initiative, coordinating with RWJF throughout the process, and traveling to locations around the country to connect with and learn from other groups doing similar work.

The "Home Team" was a cross-sector group comprised of the original Away Team members, plus around 15 stakeholders from nonprofits, community organizations, city and county government departments, educational and health institutions, and community funding institutions and foundations.

Emma is a low wealth neighborhood which was not included during the City of Asheville’s annexation of neighboring parcels, and which has a high ratio of Spanish speaking families and higher than average rates of gentrification. Emma’s residents are frequently left out of resource planning and distribution processes due to barriers around language and equitable information sharing. Consequently, public infrastructure in this neighborhood is lacking compared to many other neighborhoods in the city. The Emma community’s Invest Health proposal identifies an elegant solution to their need for accessible public infrastructure and shared recreational space for families and children, and meets the social determinants of health related to accessing places to play and exercise. The Invest Health team’s intentionally Community-centered and Values-driven process made it possible for this typically marginalized community’s voice to be heard, lifted, amplified, and supported in this planning effort. 

Invest Health Asheville’s Home and Away Team Planning Participant List

Away Team:

         Representatives from the City of Asheville

          Representatives from Buncombe County Government Offices

          Representative from University of North Carolina at Asheville’s NC Center for Health and Wellness

          Representative from United Way of Asheville and Buncombe County

          Representatives from Self Help Credit Union

Home Team:

         Facilitation provided by Marisol Jimenez, founder of Tepeyac Consulting

All Away Team members are included in the Home Team

          Representative from Housing Authority Residents Council

          Representative from Southside community

          Representative from SPARC Foundation

          Representative from Housing Authority of the City of Asheville

          Representatives from Bountiful Cities

          Representative from Habitat for Humanity

          Representatives from Buncombe County DHHS

          Representative from Asheville City Schools Foundation

          Representative from Mountain BizWorks

          Representative from Simple Business Solutions consulting

          Representative from Green Opportunities

          Representative from Positive Youth Solutions

          Representative from Community Centered Health Home

          Representative from Asheville Buncombe Institute for Parity Achievement

          Representative from Hoodhuggers International

          Representative from My Daddy Taught Me That