The Foundation for Regional Excellence
P.O. Box 18084
Roanoke, Virginia 24014
(540) 982-3720
www.newcentury.org
www.tpnet.org
Commonwealth of Virginia: New Century Turning Point Region Cities/Counties: Planning & Implementation Partners
Alleghany County |
Montgomery County |
This Community Public Health System Improvement Plan document is the culmination of work by a range of many individuals, with input and review from community members, volunteers and consultants. The authors of this plan were:
Sharon Dwyer, Program and Research Consultant
Rob Glenn, Project Coordinator
Jody Hershey, New River Health District Director
Terri March, Program and Research Consultant
Molly Rutledge, Roanoke and Alleghany Health District Director
Barry Webster, Facilitator
Anne Wolford, Resource Specialist
The intensive work, review and participation by the Steering committee Task Force chairpersons were invaluable: Betsy Aderholdt, Jim Bohland, Mark Cruise, Stephen Heater, Bob Kulinski, Eileen Lepro and Karen Stevens.
The Steering Committee reviewed and approved the document for submission to NACCHO and the Kellogg Foundation. The Steering Committee acknowledges and appreciates the collaborative partnering and assistance provided by NACCHO and the Kellogg Foundation.
The Foundation for Regional Excellence should be contacted for approval prior to citing any or all parts of this document.
Submitted December, 1999
"Funds for this publication were provided by the National Association of County and City Health Officials as part of the Turning Point: Collaborating for a New Century in Public Health program. Funds for this program were provided by W. K. Kellogg Foundation and The Robert Wood Johnson Foundation."
New Century Turning Point Partnership Steering Committee
Graphic I - New Century Turning Point Community Partners
The New Century Council Process
A Health Systems Perspective
Systems change
Summary
Putting the public back in the public's health
A Portrait of the New Century Public
Diversity
Health Care
Moving Toward Solutions
Summary
New Century Council History
Enter Turning Point
Planning Stage: Ongoing and Completed Activities
Opportunities Identified during the Planning Phase
Summary
Virginia's Public Health System
New Century Public Health System as it Currently Exists
Summary
New Century Turning Point Mission and Goals
Sustaining the Effort: A Regional Community Health Resource Bank
Working With Communities
Level 1 Partnership - Regional Health Resource Bank and Community Health Planning Teams
Level 2 Partnership - Local Community Groups
Graphic II: Regional Community Health Resource Bank Graphic
Dimensions of Change
Summary
Graphic III - Sustaining Community Public Health Systems Change
New Century Turning Point Partnership Steering Committee:
- Betsy Aderholdt, Vice President - Primary Care, Carilion Roanoke Community Hospital
- James Bohland, Director, School for Public Policy and International Affairs, Virginia Tech
- Mark Cruise, Executive Director, Virginia Association of Free Clinics
- William Downey, Chief Executive Officer, Lewis-Gale Hospital
- Beverly Fitzpatrick, Jr. Vice President - Institutional Advancement, Ferrum College
- *Robert Glenn, Jr., Managing Partner, The Issues Management Group
- Stephen Heater, Dean Waldron College of Health & Human Services, Radford University
- *Jody Hershey, District Director, New River Health District
- Bruce Jennings, Industrial Relations Manager, Volvo Truck of North America, Inc.
- Fred Johnson, II, Director of Development, Roanoke Redevelopment Housing Authority
- Robert Kulinski, President & Chief Professional Officer, United Way of Roanoke Valley
- Eileen Lepro, Executive Director, Southwest Virginia AHEC
- Carl Mitchell, Staff Scientist, American Research Corp. of Virginia
- Harry Nichens, President, College of Health Sciences
- Virginia Ousley, Director, Carilion Radford Community Hospital
- Dick Rogers, President, Maid Bess Corporation
- *Molly Rutledge, District Director, Alleghany/Roanoke City Health Districts
- Karen Stevens, Environmental Engineer Senior, Department of Environmental Quality
- Ward Stevens, III, Administrator, Alleghany Regional Hospital
- Mary Terry, Director, SW Rural Community Assistance Project
- Hugh Thornhill, Vice President, Carilion Healthcare Corporation
- Kenneth Tuck, Tuck and Strelow Eye Associates
- Kent Vesser, Vice President of Human Resources, Bacova Guild
- **Barry Webster, Community Member, Facilitator
- David Williams, Chief Executive Office, Columbia Montgomery Regional Hospital
- Anne Wolford, Director, Institute for Community Health, Virginia Tech
- Wanda Wylam, Public Relations Assistant Specialist, New River Health District
*Indicates the members of the Executive Committee
** Non-voting Member
Graphic I on the next page provides a pictorial demonstration of the groups who are members of the New Century Turning Point Initiative (listed in black) and others we have identified as potential partners (listed in red) who have been, or will be, contacted in the next phase.
Graphic I
People are increasingly frustrated by the difficulty and complexity of problems that face our communities today. In order to overcome this frustration and achieve success, the New Century Region recognized the need to involve the public, a diverse interrelated body of citizens who must take responsibility for their common problems, rather than continuing to rely on a small group of leaders who would design "tell-and-sell" solutions to community problems. The Turning Point steering committee and the five work groups have carefully sought to design meaningful actions that can bring long-range systems change and avoided planning an array of activities which could lead to "solution wars" among competing community organizations.
The citizen-based, community health vision in the New Century Region is: To be recognized as a safe and healthy place to live, work, and grow. Through Turning Point, we are working to transform and strengthen the culture of community health - the public's health - and to improve the quality of life for all citizens in the New Century Region through a dynamic process that has produced our first Community Health Improvement Plan for the entire region.
To achieve this vision, three goals were identified:
Who We Are
The New Century Region is unique among all Turning Point Partnerships, encompassing two recognized regions: the Roanoke Valley and the New River Valley. This "super region" contains twelve counties and five independent cities, with a population of approximately 494,500. Beyond size, the region is special in many other ways. This area is widely diverse and includes university and college towns, blue-collar towns, farming areas, upper-income suburbs, areas of extreme poverty, isolated homes, and friendly small towns and urban communities. There is also cultural and ethnic diversity; however, traditional statistical descriptions of diversity do not describe our people adequately. People of color make up only a small percentage of our population. Much of our diversity is represented in our Appalachian population - an ethnic and cultural minority that is indistinguishable by skin color or facial characteristics from the dominant population. The New Century Turning Point Partnership (NCTPP) region is a part of the "Bible Belt" with approximately 20 denominations represented in the area. These ethnic and cultural backgrounds serve as a primary frame of reference by which many of our community members make decisions about health behavior and healthcare. Yet, we are challenged because much of this diversity is not readily apparent, nor is it adequately understood by community leaders. Consequently, barriers to quality health and health care may not be addressed.
We have seen major changes in the health of our citizens and in the traditional health care institutions during the past decade. Costs continued to escalate; public hospitals became private, for-profit corporations; shifts in policy and funding curtailed some services traditionally provided through local health departments; the Regional population became the oldest in the entire state; and our youth have become less healthy. New networks were formed in a piece-meal fashion to address specific health issues and resolve problems. However, this piece-meal approach has often left localities to address health issues in a fragmented fashion, which has proved unsatisfactory.
In our efforts to improve the health and quality of life for the citizens in our Region we are blessed with a wealth of resources in our communities. The New Century Turning Point Region has quality health care resources and a health system that is community-based, not linked to an academic, university setting. The region includes five local health districts with 19 local health department facilities. We are fortunate to have two major hospital systems represented by eleven community hospital facilities. Two of the Roanoke hospitals are tertiary referral centers. We have ten colleges and universities providing health professional education as well as the additional resources that institutions of higher education bring.
Other strengths of our Region include the genuine interests of our citizens in making our communities a better place to live and work. Investment at each locality, through cooperative agreements, that commit funding and human capital for programming and services is another strength. From higher education institutions to businesses to local governments and non-profits we have a diverse citizenry, each of whom wears many hats on any given day, and is committed to their community.
Despite these strengths, we are not adequately addressing the health and health care needs of our community. As a case in point, localities in the region meet both federal and state designations of medically underserved and health professional shortage areas. Of the seventeen city and county municipalities in the NCTPP Region, only four do not qualify for at least one of these designations. (Each of these four locales is home to a four-year college or university, thereby skewing per-capita incomes and other socio-economic indicators.)
Like the nation, our population is aging with a 30 percent increase in those over age 64 since 1980. An increasingly older population means a population with increasing health care needs as older adults suffer from more chronic health conditions, are more likely to live on a fixed income and have limited financial resources.
Education level is closely correlated to community wellness indicators. In the NCTPP Region, one-third of all individuals over 25 years of age do not have a high school education or a G.E.D. In half of the Region=s cities, and in one fourth of the counties, between 15-20% of the residents are functioning at a literacy level below that which is required to read and carry out basic health instructions, fill out forms, or correctly add the cost of their purchases at the drugstore.
Poverty is inextricably related to health status. In all but two counties and one city, the regional poverty level far exceeds the state average of 10 percent. Those with limited financial resources often are unable to pay for health care services. Consequently, they are less likely to participate in preventative health care services, such as annual physicals, immunizations, screenings, etc., which delays early detection and intervention. When they finally seek diagnosis and treatment, their illness may be more advanced and more difficult to treat. Prescription drug costs often compete with paying for other basic personal and household needs such as groceries, heat, and clothing. To make ends meet, individuals may limit their use of medications. Factors related to socioeconomic status (SES) contribute to health status in many ways. Issues related to health insurance, transportation, limited education, cultural norms, age, and the day-to-day struggle for survival make access to health care, health information, and the ability to make healthy lifestyle choices difficult.
We know that we must provide for the health of our citizens in a manner that meets the needs of specific populations and areas within the New Century Region. This requires that the health care community consider cultural, social-economic, educational, religious, and language differences. In particular, the health care providers must consider:
The New Century Council Process
The New Century Council and its citizen-based, multi-regional visioning process was initiated in 1992 to address growing concerns for the economic health of our Region. Defense cutbacks, corporate mergers, and downsizing resulted in an excess of 8,000 lost jobs within an 80-mile radius in the early 1990s. These changes brought together, for the very first time, business and community leaders and citizen volunteers from the entire Region to develop a vision and a strategic plan outlining a preferred future. Over 1,100 citizens participated in the visioning process, making it the largest visioning effort known in the country at that time.
The two recurring themes that emerged were "quality of life" and "economic growth". The New Century Council moved from visioning to implementation and six projects were selected. Turning Point was one of the approved projects and has emerged as the truest regional project that the Council has undertaken to date. Importantly, the Board of Directors of the Council determined to utilize the Turning Point initiative to establish the regional model by which other regional projects would be implemented from the New Century Vision. With the intent of forming and strengthening networks, the New Century Turning Point Partnership (NCTPP) was established to rethink existing practices and structures, as well as envision new community health system approaches to serve the health of our communities, families, and children.
As a result of the Turning Point Initiative, an Executive Committee was identified and, in turn, a Steering Committee was selected to insure a broad representation of citizens and secure the needed expertise to move the project forward. Five working groups were named to involve even more citizens in the initial planning process. These included:
Work Group 1: Community Health Data Systems
Work Group 2: Access to Health Care
Work Group 3: Environmental Health Integration
Work Group 4: Community Health Training and Education
Work Group 5: Community Health Promotion
The New Century Turning Point planning effort worked to identify and bring together a network of assets, both individuals and organizations, in the planning phase, which included those thought to be part of the problem and those needed as part of the solution. This interactive planning model engaged people in sharing their hopes and expectations and allowed for turf barriers to be diminished. The addressing of issues was collaborative and future-oriented. It provided a setting for collective problem solving as well as feedback in the process of setting goals and objectives.
Awakenings...
Involvement in Turning Point has resulted in "awakenings" and "happenings" - the identification of specific issues that will directly affect the way community health is addressed in our Region. Also, specific "gaps" have been identified. The following identify a few specific examples:
A Health Systems Perspective
At the turn of the century defining health was a straightforward process. The primary causes of death and illness were infectious disease. Today, health is much more complex. The boundaries between what is medical and what is social, what is biological and what is behavioral, what is genetic and what is environmental, are often blurred. To promote a healthy public, our Community Health Improvement Plan must address access to medical care, the physical environment, and the social environment. The physical environment - temperature, humidity, and the presence of pollutants in our air and water - has been recognized for years as having major impact on health. The social climate in which we live - our laws, customs, faith practices, social, and political structures - may, however, impact health more than our physical environment. Today it is our social system that provides protection and controls the distribution of and access to those very factors that determine mortality levels. The socioeconomic system, and the norms in which families and communities live, impacts health just as every day choices influence the risk of premature death, the quality of life as it relates to chronic disease, substance abuse, sexuality, and the health of unborn children
The need for effective systems change, policy to support positive outcomes, and leveraging of resources to sustain change have been identified through the efforts of the New Century Turning Point steering committee and working groups, in collaboration with the Virginia Department of Health. It should be noted that without the inter-agency/organization, the public's focus and collaboration, the New Century Turning Point Partnership could not move forward in a successful manner. Public policy, even when established and communicated, is less effective because it is the public who must come together, identify existing community assets, determine needs, and support the need for policy change. Health must be viewed by the public as the individual's, the family's, and the community's right, as well as its responsibility.
Systems change
As a complex network of structures, organizations, resources, and individuals, a system evolves with procedures, routines, and patterns of interaction. To address systems change, each work group has developed components of our Community Public Health System Improvement Plan to move our Region toward the outlined "dimensions of change." (The complete plan is found in the Appendix that follows this document).
Real, lasting change within any system is not possible without time, coordination, interaction, participation, collaboration, and teamwork. Our Region is fortunate to have had the experience of the New Century Visioning process to prove this point. The interactive nature of community change, the overlapping and interconnected approaches of the respective work groups, the objectives and actions as they relate to each other and to multiple aspects of change are elements of our approach that move us toward sustainable change. This is demonstrated in the outline of selected activities as they address the overall goals and objectives of the NCTPP mission. (See the outline of selected activities on pages 63-71)
The following are selected highlights of our Community Public Health Systems Improvement Plan that illustrate several innovative elements that will result in sustainable systems change:
Sustaining the Effort : "The Community Health Resource Bank"
As stated earlier, the New Century Turning Point planning area is actually a super-region (comprised of two recognized regions: the Roanoke Valley and the New River Valley) and is, therefore, unique among all Turning Point Partnerships. Working from a regional perspective presents challenges and provides opportunities. We believe we have identified a community health pilot program that can serve to test regional collaboration and can be modeled across the country if successful.
The opportunities of working in a super-region include:
The challenges of working within a super-region demonstrate:
The New Century Turning Point Partnership has developed a central unifying element to address its goals and objectives. This element, a "virtual" Community Health Resource Bank, is designed to comprehensively identify Regional strengths and challenges and is built around the action plans of the five working groups from our Turning Point initiative. This regional Resource Bank provides a vehicle to identify all known resources while utilizing and (perhaps more importantly) developing local talents, abilities, and leaders. It provides a framework - the scaffolding, the foundation, the process - to work towards local sustainability. Individuals and communities can access information, knowledge, abilities, and technical support within the Resource Bank, which shifts to, and remains within, the local community and then cycles back into the Resource Bank as these community members share their experiences with other localities within the Region.
This Resource Bank will serve as a technical assistance and training depository for regional information, talent, and resources for communities and assist and support the efforts of local citizen teams. The beginning nucleus for the Community Health Resource Bank will be the Turning Point working groups and the community citizens who have been involved thus far in Turning Point related efforts, and others, such as Kuumba and the New River Valley's PATH initiative.
The Community Health Resource Bank:
Summary
The New Century Region is uniquely blessed, yet challenged, in its origins. We started with the broad-based collaborative effort of the New Century Council in the early part of this decade. Leaders and citizens, numbering over 1,100 from most sectors of the communities, were actively involved in the visioning process. The Regional vision included health and safety as well as quality of life priorities. When the New Century Council moved forward to address priority areas, Turning Point supplanted the original New Century Health and Safety Committee and provided the opportunity to revisit the original vision and develop an Action Plan for implementation.
Turning Point represents an example of the willingness of area leaders to participate in evolutionary processes. It has been well understood that these efforts must evolve and that changes must be embraced that address both the structure and the process of operations. The New Century process has ushered in a new understanding that organizational change, even in community-based activities, must be accepted and supported. There are numerous examples, in addition to Turning Point, where the New Century leadership has demonstrated its willingness to support change. Most have taken considerable time to "incubate", but the process of collaboration has clearly been put in place within the Region.
The New Century process and the Turning Point initiative have had, and will continue to have, a remarkable impact on how the Region views itself. For the first time, citizens and leaders, working together, have the opportunity to address access to health care and safety issues. Political boundaries must become less important as the health and safety of all citizens has risen in importance; opportunities have arisen and intersections have been identified that can make a real difference in sustainable systems change. The Commonwealth of Virginia is currently selecting a committee to design a wellness curriculum for K-12 schools and The New Century Turning Point Executive Committee is working to ensure representation in that effort.
Where Are We Going?
Turning Point is faced with the need to move beyond what was essentially a planning process, to a more focused and concrete challenge of addressing specific systems change. We recognize that regardless of how broad the New Century visioning process was, voices of the underserved and disenfranchised are never as well represented as was originally envisioned or intended. Consequently, in moving forward with our Community Public Health System Improvement Plan, a large part of our efforts will focus on increasing the breadth and depth of community representation. We believe we can provide a regional model that can be used nationally.
Citizens "the public" have incomplete knowledge of the community health system just as providers, educators, and policy makers have limited information of the citizens' perspective about the health of their families and communities. Characteristic of the Appalachian culture, individuals and families tend to think about health (as one of our public health nurses put it) as access to the system in time of crisis (i.e. well water contamination), at the time of specific life events (i.e. child immunizations), or when a service or program meets a current need (i.e. prenatal classes), in the here and now. Unfortunately, community health is currently more about a place (the clinic, hospital, health department); a service (immunizations, screenings); or a person (the nurse, the doctor, the home visitor) than about a process of interrelated systems working together to improve the overall quality of life in the region. In turn, the providers, educators and policy makers may see the citizens from a needs or deficient perspective, as statistical reports, or as customers demanding more service and coverage from the same limited budget and resources.
Our challenge as a region is to improve health by:
The challenge is to develop a common ground of understanding, communicate clearly the needs and desires of all citizens, educate citizens about the vast array of available community resources, and motivate citizens to take personal responsibility for their health and safety in our Region. We believe the Turning Point initiative, together with the national clout provided by the NACCHO and Kellogg organizations, will provide our Region with the framework necessary to meet this challenge.
Putting the public back in the public's health -
The preceding listing of partnership members and graphic representation of network connections, identifies those individuals and organizations who played a major role in the New Century Turning Point Partnership (NCTPP) planning process and the development of this report. However, it would be both unfair and misleading if the steering committee membership was represented as an isolated core of input to this planning effort. Input was received through individual interviews, group meetings, and each of the five work groups. The steering committee is comprised of those individuals viewed as community members who take leadership in a specific area of interest/service, have families, and will probably be interned in the New Century region.
Not unlike other populations and communities, there is a separation, a disconnect, between citizens and the governance of communities and from the government and its functions. This disconnect includes health departments and other health providers who are part of non-profit organizations as well as for-profit entities. Focus group interviews conducted by the State of Virginia Turning Point effort identified that citizens are unclear about the definition and functions of "public health"; a disconnect as to the purpose, services, and function of the community's health department and related organizations.
David Matthews, former Secretary of Health, Education and Welfare, notes that this disconnect is not an isolated phenomenon. Many non-governmental institutions have also lost standing with people. From 1973 to 1993, the proportion of Americans indicating confidence in the press dropped from 23 to 11 percent; in banks, from 32 to 15 percent; and in organized religion, from 35 to 23 percent. We are all aware of the disconnect with our public school system as well as the systems of higher education. Dr. Matthews cautions that we, as an American people, are prone to discount negative feelings about the government and functions of the government as ...."we have a history of anti-government sentiment that dates back to our objections to rule by the British Crown." However, ".....today the disaffection with institutions is widespread and goes well beyond criticism of the way they are doing their jobs.....but by the way [lack of connect] institutions and professionals relate to the public."
Recently, residents in the Roanoke Valley ranked the local health department second among local government agencies in regard to service and responsiveness. Yet, knowledge about the operations, functions, and responsibilities of the local and State Health Department is unclear. The disconnect to the State Health Department is compounded as citizens in the New Century Turning Point geographic area live and work closer to the capital cities of other states than they do to Richmond, Virginia's capital. In addition, for convenience purposes (roadways and distance), citizens often seek health services outside the Commonwealth of Virginia.
This disconnect flows both ways and exists in many instances between the individual (family, community) and those working in health care and related positions within the community. Community members seek to interact with a health system that is confusing to navigate and attempt to comply with instructions that are difficult to carry out - either because they are not understood or other barriers (financial, etc.) exist that prevent compliance. This applies to both health and environmental messages that are not understood by the community, or expectations of compliance are unrealistic.
A Portrait of the New Century Public
The New Century Turning Point region is unique in its sense of community. The focus and efforts of Turning Point are not limited to one county or one political geographic area but to a cluster of seventeen municipalities - twelve counties and five independent cities. (Unlike any other state in the Union, the Commonwealth of Virginia has designated thirty plus cities which are not part of county government. Consequently the cities of Clifton Forge, Covington, Radford, Roanoke, and Salem are not represented under the county governance configuration.) All New Century Turning Point cities and counties are in or border Appalachia.
With Appalachia, we have an abundance of natural beauty, opportunities for outdoor activities are available on the Blue Ridge Parkway, the Appalachian Trail, the New River, and in the Jefferson National Forest. Also, there is a strong ethnic culture, focusing on family and community. However, the beauty and family foci do not guarantee a high standard of living or quality of life. Factors related to socioeconomic status (SES) contribute to health status in many ways. Issues related to health insurance, transportation, limited education, cultural norms, age, and the day-to-day struggle for survival make access to health care, health information, and the ability to make healthy lifestyle choices difficult.
According to the report from the New Century Council's Vital Signs Initiative, approximately 494,5000 people lived in the New Century Region in 1997. Between 1980 and 1997, the population of the region grew by 7.1 percent, lagging behind the state as a whole and the nation with a growth of 9 percent and 18 percent respectively during the same time period. In addition to the out-migration (citizens seeking full-time employment to support families), we are becoming an increasingly older population. The region has seen over a 30 percent increase in those over 64 since 1980. An increasingly older population also means a population with increasing health care needs as older adults suffer from more chronic health conditions, are more likely to live on a fixed income and have limited financial resources. Yet this segment of the community serves as an important resource providing inter-generational support, information, and connections.
Poverty is inextricably related to health status. Those with limited financial resources often are unable to pay for health care services. Consequently they are less likely to participate in preventative health care services such as annual physicals, immunizations, screenings, etc. and may delay early intervention. When they finally seek diagnosis and treatment, their illness may be more advanced and more difficult to treat. Prescription drug costs often compete with paying for other basic personal and household needs such as groceries, heat, and clothing. To make ends meet, individuals may limit their use of medications, skipping or halving doses or even choosing not to fill prescriptions. The negative impact of income on health is most problematic in the working poor who are unable to participate in state and federal health care programs. It is estimated that 17% of the NCTPP region's residents are uninsured. Income in all but Roanoke County and the city of Salem, is several thousand less than the $25,255 state's per capita average. With the exception of Roanoke and Botetourt counties and the city of Salem, the poverty level far exceeds the state average of 10 percent. In Bland County and the sister municipalities of Covington, Clifton Forge, and Alleghany County, the unemployment rate exceeds the state average as much as 110 percent.
Education level is closely correlated to community wellness indicators. In the NCTPP region, 25 to 40 percent of individuals over 25 years of age have less than a high school education. The areas where the higher percentages of the population have a high school certificate are those with a college and/or university. Perhaps a better correlation between health and education is an individual's level of functional literacy. Links between literacy and health often center around issues of following instructions related to medications and treatment. In one half of the region's municipalities and one fourth of the counties, between 15-20% of the residents are functioning at or below level-one literacy. Level-one literacy, as defined by the National Institute for Literacy, is the lowest level of functional literacy. The National Institute for Literacy indicates that individuals functioning at this level are most likely unable to:
Diversity -
The Institute of Medicine report, The Unequal Burden of Cancer (1999) identified that "common threads that may tie one to an ethnic group include skin color, religion, language, customs, ancestry, occupational, and/or regional features."
Understanding the interrelationship of culture and ethnicity is important in appreciating our regional population. Culture, as the fabric of meaning through which individuals interpret their experiences and guide actions, provides cues about the environment and the broader social system. Most commonly defined as a set of shared beliefs, assumptions, and values culture links us to other members of a group, provides meaningful rituals, and influences an individual's behavior throughout their life. The events of our lives are conducted, understood, shared, and communicated within the cultural patterns set by families and communities.
Wood (1989) says that ethnic groups may be "distinguished on the basis of race, religion, or national origin". She makes the distinction between ethnicity and culture, defining one within the other: "culture refers to socially transmitted beliefs, institutions, and behavior patterns," while ethnicity describes "a common history, a shared culture, a sense of peoplehood."
Persons belonging to the same ethnic group share a unique (but not identical) history that is different from others. A combination of features identify an ethnic group.
For example, physical appearance alone does not consistently identify one as belonging to a particular ethnic group; individuals belonging to certain ethnic groups may vary widely in physical appearance (e.g. skin color and hair texture), but they share a common ethnic identify.
Our individual perceptions about the world, our attitudes about human nature, and our sense of self or identity are defined, determined, valued, and respected within the ethnic group. While through culture we establish ways for problems solving and adjusting to the external realities of daily life. By acknowledging and attempting to understand the influence of ethnicity and culture on individual identities and the significance that culture plays in people's lives, we begin to see the implications for health and helping processes.
In Virginia, the Appalachia public is typically of European descent; settled early in the 1700s by immigrants from the British Isles. English-Welsh, Scots-Irish, and German distinct and ongoing customs and practices are evident in the rural life-style and are part of the Appalachian subculture. Historically residents have been characterized by strong values of individualism and personalism; traditional religious beliefs; regionally unique arts, crafts, and music; language variations with dialectal qualities; a strong extended family system; a fierce sense of personal independence, and a suspicion of "outsiders" (anyone living in the area for less than 100 years). These subculture characteristics contribute to the multiple sources that define health, wellness, and health care, especially for those experiencing cultural and technological lags, geographical isolation, and insufficient resources.
This area is widely diverse. There are university and college towns, blue-collar towns, farming areas, upper-income suburbs, areas of extreme poverty, isolated homes, and friendly small towns and urban communities. There is also cultural diversity in our faith communities, with over 20 different denominations represented in the region. The NCTPP is a part of the "Bible Belt" and faith is one primary frame of reference by which many of our community members make decisions about health behavior and healthcare. Health beliefs and information is shared between family generations and a mix of natural, home-based remedies is common. Historical tensions between regional industries such as tobacco, coal mining, textile manufacturing and the health of the employees are often at play. These industries for many generations meant the only source of income and "food on the table". Traditionally, the health of the individual employee was secondary in importance. Many Appalachian residents continue to share values that reflect their traditional belief systems and strive to retain and honor a regional identity in spite of, but also in junction with, the changing world around its geographic boundaries.
Regions within Appalachia are not homogeneous. However, statistical descriptions of diversity are difficult because the Appalachian population is an ethnic minority indistinguishable by skin color or facial characteristics from the dominant population and ill-defined by education and income. All social classes are found in the population. Even within extended family networks, individuals may have widely different income and social status. Sometimes called the "forgotten" or "invisible minority" the Appalachia population has maintained unique qualitites of regional life-styles. Language, art, music, and personal characteristics - similar but different from the mainstream population - constitute a subculture which is reflected in the lifestyle of many residents in the region.
This is not to say that this region of Appalachia does not have people of color. In Floyd County, minority populations comprise less than three percent of the population. Craig County has less than 1 percent minority population. In the cities of Covington and Clifton Forge the percent increases to 15 and 16 percent respectively. However, Allegheny County, which surrounds both cities has a minority population of less than four percent. Likewise, the city of Roanoke, the largest metropolitan area, has a minority population of 26 percent. Whereas, Roanoke County's minority populations total less than four percent. Over the past 5 years approximately 1,000 refugees have settled in the region: 40% Bosnian, 25% Vietnamese, 15% Cuban, and an influx of immigrants from Honduras, Columbia, and Mexico has been witnessed. In the more rural counties, minorities may view themselves as wearing two ethnic hats. For example: Blacks may view themselves as part of the African-American culture and as part of the Appalachia culture with roots in the coal mining, tobacco, and railroad communities.
As this discussion reflects, when program efforts have focused on marginalized groups, prioritized efforts have centered on the medically under-served, a group that cuts across all racial and ethnic groups. The challenge is to ensure that minority populations, smaller in numbers or percentage, are recognized, valued, and included in local community planning efforts from the very beginning. Our recent award for the Global Information System (GIS) system, once in place, will support this effort and assist communities in identifying where specific groups are located in order to address unique needs, concerns, or characteristics related to local planning efforts.
To address societal issues, the New Century region has a history, tradition, and practice of inclusion - bringing a variety of peoples and diverse interests to the table. This can be observed in the diversity of the steering committee, in the five working groups, in the multiple group meetings, forums, and personal interviews. Working together to address issues, identify gaps, explore options, and develop and implement action plans has become the accepted operating mode in the New Century region. The New Century Region recognizes that today's issues are complex and cannot be resolved by one organization, "the experts", or a few leaders. Exploration, planning, and working toward a resolution involves the whole community.
Health Care -
What we see in the NCTPP region is a discrepancy between what would on the surface appear to be adequate health care resources with an inability to meet health needs. The New Century Turning Point Region has quality health care resources and a health system that is community-based, not linked to a academic, university setting. We are fortunate to have two major hospital systems represented by eleven community hospitals (Alleghany Regional Hospital, Carilion Franklin Memorial Hospital, Carilion New River Valley Medical Center, Carilion Roanoke Community Hospital, Carilion Roanoke Memorial Hospital, Carilion Saint Albans Hospital, Lewis-Gale Medical Center, Montgomery Regional Hospital, Pulaski Community Hospital, Smyth County Community Hospital, Wythe County Community Hospital). Two of the Roanoke hospitals are tertiary referral centers.
Despite these numbers, the region still falls short using designations of medically underserved and health professional shortage areas. Three different designations are used to label areas in relation to the available health services based upon different measures and conditions. Two federal designations, the Health Professional Shortage Area (HPSA), and Medically Underserved Areas (MUA) and a state designation, the Virginia Medically Underserved Areas (VMUA) are used.
The specific criteria for each category varies but include:
Of the thirteen municipalities in the NCTPP region, only four escape the designation of VMUA, HPSA, or MUA. (Each of these four locales house a four-year college or university.) It should also be noted that none of the municipalities carry all three (VMUA, HPSA, and MUA) designations.
Access to dental care is another issue, and the dentist to population ratio is one measure used to gauge access. Problems with access to dental care for the general population exist in those areas of the State with low dentist to population ratios. These problems are compounded for special populations including low income adults and children, the disabled, and the elderly who are at higher risk for dental disease.
The overall dentist to population ratio for the New River Health District is 1 to 2,893 compared to (1 to 2,002) the State. When comparing each jurisdiction in the New River Health District, Floyd County has the highest population to dentist ratio (6,109 to 1); and Radford City has the lowest (1,843 to 1). Floyd County is one of only 43 cities and counties in Virginia that has a dentist to population ratio greater than the current measure for a Federally Designated Health Professional Shortage Areas (HPSA), one dentist for 5,000 residents.
Floyd County is also one of only 15 localities in Virginia identified as most under-served based on multiple indicators: dentist to populations ratios, limited public health dentists, and few Medicaid providers. (Five, or fully one-third of the 15 designated under-served communities, are in Appalachian communities of southwestern Virginia.)
In a recent study by the Williamson Institute reimbursement fee schedules were the number one reason given by private sector dentists for their lack of participation in providing care to Medicaid and other under-served segments of the population. Recently in Virginia, however, even after legislators raised the Medicaid reimbursement rates for dental fees from 44% of the usual and customary reimbursement (UCR) to about 65-70% UCR there has been no significant impact on private practitioner participation in delivery of dental services to Medicaid patients.
As demonstrated by findings from the Williamson Institute study, other factors play a part in the decision by the private sector to provide dental care to under-served groups. The study identified broken appointments, complex paperwork, limitations of coverage, slow payment, patient behavior, limited practice capacity and poor oral hygiene as additional factors for non-participation. Only 3% of the dentists surveyed who currently participate in Medicaid do so to build a practice or increase their patient load. More than 45% limit the number of Medicaid patients they will accept and 34% of participating providers are NOT accepting new patients. Dentists practicing in the New Century region appear to reflect these same thoughts and reasons for not seeing Medicaid patients or the under-served.
The Center for Primary Care and Rural Health of the Virginia Department of Health has only recently begun mapping dental under-served areas. There is much we do not understand about health practice shortage areas. But two additional factors appear particularly difficult to overcome for dental health practitioners. Dental health costs are far less likely to be covered by health insurance. And when considering overall costs for health care, dental costs are generally considered secondary in importance by patients. In fact, in many rural and lower income communities, poor dental health is considered a given by its residents
Fifteen percent of New Century Region residents have no health insurance at all, slightly higher than that of the overall rate for the Virginia (14%). An additional 17% of the population are under-insured. For these individuals, affordability of insurance is a significant barrier to coverage. Children under age 18 in Virginia comprise a disturbingly large percentage (19%) of those uninsured. Mostly, they are from working-poor families, where their parents earn too much to qualify for Medicaid, but not enough to afford private health insurance.
It is difficult to identify a single factor that explains the discrepancy between what would appear to be adequate health care resources, with the inability to meet health needs. In part, this dilemma may be due to an influx of retirees. (Due to the excellent quality of life and health care resources this region ranks as one of the best places in the country to retire.) Other reasons may relate to the structure and financing of health care services. Lower wages affect the financing of health in rural areas, as a factor in lower reimbursement rates for services, making medical practice opportunities less competitive. The NCTPP Access to Health Care Work Group is planning strategies to help us identify some of the issues that contribute to this disparity in health care service providers throughout the region.
Moving Toward Solutions -
An overall plan to reduce duplication, increase efficiency, and reach under-served populations has been lacking. The existing approach to community health systems is typically piecemeal due to categorical funding streams and a collection of previously successful methods of solving community health problems which were programmatic, task oriented, or short term solutions. This can be observed in the development of sewer systems, sexually transmitted disease initiatives, and immunization programs. However, the current and future public health challenges require interdisciplinary and inter-jurisdictional collaboration. Examples: Environmental issues related to water availability and quality might be better addressed through collaborative efforts involving watershed regions rather than issue specific agencies which are often defined by the political boundaries. Likewise, the Department of Environmental Quality cannot control air between or within jurisdictional boundaries. Rarely is one locality isolated from an adjoining city/county regarding health-related behaviors such as teen sexual activity or incidence of communicable diseases.
Current strengths of our region include expertise, knowledge, skills, abilities, and un-tapped resources that endure. Investment at each locality, through cooperative agreements, that commit funding and human capital for programming and services is another strength. From academia to business to local governments and non-profits we have a diverse citizenry, each of whom wears many hats on any given day, and is committed to their community.
Increased citizen understanding of, and engagement with, the health of their community is essential to future change. Thus, a shift of perspectives is required. It is paramount that individuals see maintenance and prevention as a fundamental part of maintaining wellness and preventing ill health. Individuals must also connect their actions/behaviors to their own long term well-being and the health of their community. In addition, communities must recognize that social-economic well-being and an overall quality of life is part of what constitutes a healthy community. At the same time, there must be user-friendly places and spaces for community members to find accessible information along with opportunities for individuals to participate in directing the future of their community. The ideas about, recommendations for, and opportunities to participate are essential for long term sustainable change and must originate within the local population. When needed, assistance from the outside should be focused and time-limited. This community-customized assistance will diminish over time (shift to support-when-needed) as the goal of transferring needed information, knowledge, and skills to the community is realized.
A collaborative interagency approach to problem solving needs enhancing and support. This is most effective when preceded by a uniform and structured community assessment conducted across the region. As such, this would allow for state and national comparisons as well as bench marking for future assessments. An interagency capacity assessment must be included in this process to identify "the gaps". This information would be coupled with a strategic planning process providing the foundation to direct efforts and evaluation processes.
However, much of the above is lacking because current systems are bureaucratic vestiges of the 1960's and funding streams are categorical rather than cross systems functional.
The Assessment Protocol for Excellence in Community Partners (APEXCPH) is one approach NCTPP anticipates using. The region has recently been awarded one of twenty grants in the U.S. to participate in reviewing, and hopefully, piloting this newly revised tool. APEXCPH is a national tool from the Center for Disease Control that updates and expands on an earlier health department community and organizational assessment tool. It looks at the capacity within the local health department, related organizations and agencies, and the community as a whole to better meet the community's health needs.
One data set that has been lacking in previous local and regional assessment efforts is a focus on asset building and a strong emphasis on quality of life. This tool includes both. APEXCPH provides a structured process that requires citizen involvement to gain understanding of the issues they feel are important. While the NCTPP has moved forward with input gained from the initial New Century citizen-based visioning process, APEXCPH provides us with an opportunity to re- energize the involvement of grassroots organizations and individuals.
Today, solutions to problems are complex. What has changed are not the issues which the public expects to be addressed (i.e. clean water) but the solutions required for maintenance or to upgrade the present situation and expansion into new locales. Example: Beginning in the 1970's, the focus of public water authorities was on issues such as well regulation and clearing bacteria from water supplies. In addition to water monitoring demands, today's challenges include the decreasing groundwater levels from population growth and sprawl that impacts potable water and the prevention of toxic contamination due to run-off from non-industrial sources of pollution, such as fertilizers and pesticides. Thus, expectations of the public for water quality and quantity has increased.
Regardless of the direction or timing of health reform, health care financing, systems change, the health status of citizens will not substantially improve without simultaneous reform of our community (the public's ) health system. Work must continue to assure that all citizens in the New Century region have access to quality health care while we move to reduce administrative complexity and redundancy; redistribute existing and seek new resources. All of this, in and of itself, will do little to influence other determinants of ill health which must also be addressed including unsafe environments, unhealthy personal behaviors, socio-economic, and biological factors.
Summary
The current health system was designed and focused on alleviating pain and suffering and curing disease after it has become manifest. This must be shifted (system's change), refocusing on a comprehensive model which includes multiple levels of system operation, responsiveness and actions: primary-prevention, secondary-education, and tertiary-intervention. We must provide health care that meets the needs of specific populations and areas within the New Century Region, and require the health provider community to consider cultural, social, religious, and language differences. In particular, the health provider community should be aware of:
Providing health care services to the Appalachia population is a political and multi-disciplinary undertaking. The effort faces barriers of geographic accessibility, affordability, guidance for preventive service utilization, and education about invisible ethical and cultural influences. Also lacking is information about the importance of preventing, rather than just curing, illness.
Eliminating barriers to health care delivery and utilization of services will occur when
A future which supports a healthy population/healthy communities means both an acceptable standard of living and a satisfactory quality of life. This is well understood by both the private and the public sector. Environmental concerns, health and disease issues, and concerns for wellness of our youth and families cross political boundaries. Thus, collaboration, networking for the mutual benefit of political geographic areas, agencies, and the public - work force, families, neighbors - is not only demanded; it just makes sense.
A TURNING POINT
Insight about Coordinating Community Systems
Discussions about changing health care from a systems perspective can be lofty and abstract. The question still remains, how does this impact the lives of individuals and families. A recent example from our community demonstrates how an entrenched health issue for one family needed, and was resolved (rather quickly) by, a coordinated, cooperative community-based effort.
A single mother of three children had been working with the school nurse because of an ongoing, insidious case of head lice. The children had missed over 50 days of school. The mother was in danger of losing her hourly wage job in a textile factory because she had to leave work frequently, run to the school and pick up one of the children and take them home. She had tried to deal with the problem but when she treated one child, in a short time one of the others was re-infected. The mother was following the directions from the school nurse but at the same time she was receiving native advice - "use kerosene on their head that's what we did in the old days" - from friends and family. And the school was getting calls with complaints from other parents. She and the school were frustrated and discouraged. Finally the school called the public health nurses for help.
The nurses worked with the mother to develop a plan. They came to the house in the evening, after she was done with her factory work for the day. They worked with the mother side-by-side, treating all three of the children, washing the bed linens and cleaning the house all at one time, to minimize the chances of re-infection. Something the mother just could not get done all by herself.
They met with the mother's employer to advocate for the family, describe the situation and indicate that they were working with the woman and her family to bring about a long term solution. In addition, they went to the school, to meet with the teachers, the nurse, and the administrators to explain the circumstances, describe what had been done, and smooth the way for the children to return to their classes.
Finally, they returned later to do some follow-up awareness raising and education with the students, parents, teachers and administrators. This solution could not have been accomplished, however, without flexibility and communication between the home, the school, the work place and the health care providers.
The New Century region has a history and tradition of inclusion --bringing a variety of peoples and diverse interests to the table. This can be observed in the diversity of the steering committee, in the five working groups, the multiple group meetings, and through personal interviews. A community example is Kuumba and a multi-city/county example is PATH.
New Century Council History -
The New Century Turning Point Partnership (NCTPP) is unique among other Turning Point initiatives in that it is a Super Region comprised of both the New River and Roanoke valleys encompassing twelve counties and five independent cities. This distinguishing quality provides both special opportunities, expanded resources, and definite challenges. Working with a variety of localities provides the chance to work with communities as they develop and then mold "custom fit" plans to meet the needs of their community. Whereas, working at a regional level requires that the challenge of system change will be addressed across political, geographic, and policy boundaries. These challenges, while many, open the possibility of providing a truer picture of the broader landscape of health issues that need to be addressed.
The history of the NCTPP dates to the early 1990s with a process to address regional change in the Roanoke and New River Valleys. To understand our current planning methodology, it is important to understand its foundation in the New Century Council visioning and planning process. Defense cutbacks, corporate mergers, and downsizing resulted in an excess of 8,000 lost jobs within an 80 mile radius of Roanoke in the early 1990s. These changes brought business and community leaders and citizens from the counties of Alleghany, Bland, Botetourt, Craig, Floyd, Franklin, Giles, Montgomery, Pulaski, Roanoke, and Wythe and the cities of Clifton Forge, Covington, Radford, Roanoke, and Salem to form the New Century Council Region (at a later date the Smyth County Board of Supervisors requested that the county be added to the New Century Region). Its focus was to develop a vision and create a strategic plan outlining a preferred future.
Business, government, and citizen representatives developed a vision. The public from both the Alleghany Highlands, Roanoke Valley, and the New River Valley were invited to hearings to comment on the proposed vision. The two recurring themes that emerged were "quality of life" and "economic growth". The final document, adopted on February 15, 1994, called for the creation of 33 teams of volunteers.
In June 1994, the New Century Council held a meeting to launch the work of the New
Century Council Teams. With over 1,000 citizens actively participating, 52 teams designed
an implementation plan, reporting their results in May 1995. More than 150 strategies were
recommended for implementation. Each team designated a time-line for action, suggested
what current organization in the region should lead the effort, and prioritized each
project. Emerging from the overall visioning process were key community health visions
that centered on converting the health care system to one based on wellness and
prevention and promoting a "Fit for Life" philosophy.
In January 1997, the New Century Council moved from visioning to implementation and six projects were selected. At the same time, the Board of Directors of the New Century Council formed a sister organization called The Foundation for Regional Excellence whose mission was to raise the funds required to implement and sustain future efforts. Turning Point was one of those projects identified and has emerged as the truest regional project that the Council has undertaken to date. With the intent of forming and strengthening networks, the New Century Turning Point Parternership (NCTPP) was established to rethink existing practices and structures, as well as vision new community health system approaches which would serve the health of our communities, families, and children.
Enter Turning Point
As a result of the Turning Point Initiative, an Executive Committee was identified and, in turn, a Steering Committee selected to insure a broad representation of citizens and to secure the needed expertise to move the project forward. Five working groups were named involving more citizens. These include:
Work Group 1: Community Health Data Systems
Work Group 2: Access to Health Care
Work Group 3: Environmental Health Integration
Work Group 4: Community Health Training and Education
Work Group 5: Community Health Promotion
The New Century Turning Point planning effort worked to identify and bring together a network, the assets of individuals and organizations in the planning phase, and included those thought to be part of the problem and those needed as part of the solution. This interactive planning model engaged people in sharing their hopes and expectations and allowed for turf barriers to be diminished. The addressing of issues was collaborative and future-oriented. It provided a setting for collective problem solving as well as provided feedback in the goal and objective setting processes. In this mode, the dimensions of change as identified by the Lewin Group, were realized in our planning process.
Working towards sustainable change at the community level requires a long term investment that begins with building trust, identifying key stakeholders, and frequent communication with the citizens. It is essential, but not easy, to get citizen leaders and community members to "come aboard" at the planning stage. Those who have been part of other "never-realized" efforts from well-intentioned policy makers, funders, academics, and businesses in the past require more convincing before they invest themselves and their time again. They want to see a demonstrated commitment from leaders and funders who are part of the community infrastructure.
In the New Century Turning Point Partnership planning is on-going, per needs identified in the process, and changes in the original time-line, the unfolding of events related to the initiative do not fall neatly into finite stages. Accordingly, the name Task Forces, which implies there is a finite job that will be completed, has been changed to Work Groups, to reflect the dynamic energy and ongoing nature of the community/public health efforts.
Planning Stage: Ongoing and Completed Activities -
The following section highlights some of the activities that have occurred in the initial 2 years of our Turning Point Initiative.
The New Century Turning Point Partnership collaborated with Carilion Health System, Roanoke College, and the Maupin-Sizemore Foundation to sponsor the Faith, Health, and Community Life: A Symposium for Building Community Health Covenants held at Roanoke College in October, 1999. The Symposium was the first of its type offered in western Virginia and represented collaborative planning and implementation among a variety of public, private, and faith organizations. The goal of this unique Symposium was to build bonds among people of various disciplines related to faith, health, and community life throughout southwestern Virginia with the aim of strengthening community partnerships. More than 50 presenters from the community were joined by three nationally known speakers and authors: Dr. David Larson, Lorraine Johnson-Coleman, and Dr. Gerald McDermott.
The Symposium's target audience included clergy, physicians, nurses, lay leaders, health and human service providers, community leaders and volunteers, students, and the academic community. Objectives included:
Symposium topics included building healthy communities, building meaningful health ministries, integrating faith into practice, and stewardship of the environment.
The most comprehensive health assessment data in the New River Valley is now five years old. The Access to Health task force of the Partnership for Access To Healthcare Coalition (PATH), chaired by the Chief Operating Office of Columbia Montgomery Regional Hospital, recognized that major changes have occurred in population and health care systems over the past several years and began to make plans for a new assessment effort. Carilion Health Care Systems also a member of the PATH coalition, shared the goal to conduct a community health assessment and suggested a collaborative effort. A working group redesigned an assessment instrument and developed a community process so the needs of PATH, Columbia, and Carilion were met and the data was consistent with federal data (CDC Behavioral Risk Factor Survey and the National Health Interview Survey). PATH was aware that the NCTPP was discussing regional health assessment efforts. In turn, NCTPP, the PATH Access the Health Care task force, and Carilion decided to use the PATH effort as a pilot project for NCTPP to help identify a future tool as well as a process that would meet regional needs and could be replicated by the State. (The State Turning Point Initiative is addressing community health assessment in the state plan). Community Health Assessment Teams were created to inform the assessment process. The teams included consumers, community leaders, and health and human service professions. Funding for data collection and analysis was provided by Carilion. Data collection and preliminary analysis was completed this summer. Further analysis of the data is currently being conducted by the Survey Research Center at Virginia Tech. In-kind staffing was provided by PATH Access to Health task force members as well as representatives of Carilion Health Care Systems. Additional data was gathered through surveys with health and human service providers and focus groups involving agency and community members. In addition, Radford University students conducted interviews with a purposeful sample of hard-to-reach healthcare consumers.
A TURNING POINT
Insight
While considerable headway has been made in redefining previously used community health assessment models and forging collaboration between the regions two major health care providers, there continues to be challenges and problems identified. General sentiment holds that one provider is cooperative and the other is controlling and examples abound where this is evident. However, it is believed that the Turning Point collaborative initiative represents the best opportunity to begin to deal openly and effectively with issues. The data gathering and management component of the Turning Point process is a good example where continued confusion exists and where continued collaboration is necessary.
The decision-making structures within each of the hospital systems present unique difficulties. For example, one health care system has the CEOs of three hospitals represented in the Turning Point Steering Committee and the work groups. In the organizational structure each CEO oversees all aspects of the individual hospital. The other health care system is organized very differently and its hospitals are represented by several administrative staff at the vice president and senior vice president level. Numerous senior vice-presidents and vice presidents head various areas of this multi-hospital organizational structure without the authority to effect systems change across the broad spectrum of health care activities. Thus, the differences in organizational structure alone, present challenges to decision-making as the Turning Point collaborative approach seeks to affect true system change. Interestingly, one hospital group is for-profit and the other is a non-profit. However, these differences are not insurmountable, and through open discussions, systems changes can take place.
The Blue Ridge Health Care Coalition, represents about two dozen large firms in the region and was formed 10 years ago to help large corporations do something about the rising cost of health care. Through Turning Point, the Foundation for Regional Excellence (the 501c3 that provides the non-profit status and organizational oversight to Turning Point) has collaborated and assisted the Coalition on a research project examining Workers Compensation claims and practices as they relate to the business community.
The Environmental Health Integration Work Group of NCTPP has brought a unique configuration of agencies responsible for environmental regulations together at the community/public health table for the first time. This working group also includes not-for-profit environmental and conservation groups. The Department of Environmental Quality, Virginia Department of Health, and Department of Games and Inland Fisheries collaborated on a funding application for e-coli identification sub-typing. And as a result of pro-active and collaborative support, interest and advocacy the Virginia State Department of Environmental Quality has voluntarily agreed to include the New Century Region in ozone forecasting.
One of the two health directors who sits on the Turning Point Executive Committee partnered with a member of the faith community to assist a consortium from social and mental health services, churches, hospitals, and local residents in their efforts to form a Community Health Initiative for two zip code areas
of Northwest Roanoke City. This community, with the largest percentage of minorities in the New Century Region, has a population of 35,000 with most residents living in single family houses and in three public housing projects with 50 percent of the residents living below 200 percent of the poverty level. This collaborative effort identified the barriers to health care for this population. Subsequently the community applied for and received a Bureau of Primary Care Community Health Center grant. The faith community has been essential to the development of the Kuumba Community Health & Wellness Center.
Along with serving on the planning committee, local church members will play a major role in informing the community of available services and getting patients in to see providers. This faith community has already had success at establishing a volunteer transportation system that assures everyone is able to get to the health center or local hospital. Of special note: The newly appointed Executive Director of the Kuumba Center is co-chair of the Turning Point Access to Health Care work group.
A TURNING POINT
Insights
The effort to identify the local need, select a strategy, apply for and receive a "new start" grant from the Bureau of Primary Health Care took time, energy, and dedication from a variety of community residents and organizations. Already the momentum from this success is serving as a catalyst for integration of services. Further commitments from Community Services, Social Services, and the Department of Health to provide on-site services have been secured providing the opportunity for "one-stop shopping" for local residents and increase cooperation among programs.
The chair of the New Century Turning Point Training and Education Work Group through the Waldron College of Health and Human Services at Radford University has been actively pursuing several grants that look at the training and education of health professionals. These grants include:
In addition, Radford University and Virginia Western, one of the regions community colleges, are conducting studies of health care worker supply and demand. Awareness of these efforts and other considerations prompted the Community Training and Education Work Group to propose a examination of all regional training efforts and the development of a cooperative network where education programs can interface with each other to coordinate efforts, maximize resources, and minimize duplication.
Opportunities Identified during the Planning Phase
The following section highlights areas seen as emerging opportunities for New Century Turning Point Partnership involvement. In each of these situations, NCTPP members are involved in the process described.
Health systems have seen the value of "doing business" and have suggested that the State Health Department reconfigure health districts to facilitate the New Century Regional process. This issue is potentially politically charged - a fear of job loss by those currently employed and local jurisdictions fear the loss of control over the local health department functions.
Watershed management planning and leadership in Roanoke city of the New Century Region has adapted an eco-systemic approach as opposed to a political jurisdictional approach.
The Roanoke Redevelopment and Housing Authority is one of 66 grantees in the HUD sponsored HOPE VI community revitalization program. Through a $15.3 million grant, the Roanoke Authority will revitalize the oldest 300 unit public housing complex and will be designing programs in partnership with other community agencies to assist current public housing residents to move up economically and out of public housing. Health is a key issue that affects the residents of public housing and the RRHA is represented on the Turning Point steering committee. Future collaborative efforts planned with the Turning Point organization are seen as beneficial.
The New River Valley Partnership for Access To Healthcare (PATH) is a collaborative, community-focused alliance of over 40 health and human service organizations, related community organizations, and businesses. PATH successes include:
Med-Ride, a collaborative project, of area transportation providers and community volunteers to address non-emergency transportation to health care services for uninsured, under-insured and medically indigent citizens. Honored at the Models That Made It conference supported by the Virginia Health Care Foundation, the project receives grants and support from four separate funders.
Carilion Community Health Fund
The New River and Roanoke/Alleghany Health Districts have worked closely with Carilion Healthcare Corporation in developing and implementing the Carilion Community Health Fund. The fund, three million dollars in 1999, is targeted to community health improvement and focuses on innovation in delivery of primary and preventive care, improvement in access to primary and preventive care, education of individuals to improve their health, and champions community initiatives to reduce health risks as they relate and are relevant to the community's changing health environment and the advent of managed care. Through this process, the thinking of Carilion has been guided, at the staff and corporate level, in terms of the community health model, and decision-makers in the Carilion system have accepted that this is the model to be implemented. All grant applicants to the Carilion Community Health Fund are encouraged to partner and consult with public health in their proposal writing efforts. At the December 1999 Steering Committee meeting of the New Century Turning Point Partnership, Carilion formally requested that NCTPP be involved in the process of identifying annual funding priority areas.
Summary
Being a Turning Point Super Region has required that the planning and development work of the New Century Turning Point Partnership reach across political, geographic, and policy boundaries. The planning has included those considered to be part of the problem and those needed for solutions. This time and labor intensive interactive-model engaged diverse people and groups in sharing their hopes and expectations, allowed for turf barriers to be diminished, and provided a setting for collective problem-solving and feedback.
Citizen leaders and community members are essential to sustained change at the community level. But those who have been "burned" before by unrealized plans and programs require a long-term investment that begins with building trust, identifying key stakeholders, frequent communication, and demonstrable commitment from policy makers, funders, business and community leaders. Changes in the original time-line and the unfolding of events, both related and unrelated to the Initiative have been unpredictable. Thus, the planning, activities and work of the New Century Turning Point Partnership, are ongoing; needs and resources have been identified and strategies proposed.
Virginia's Public Health System -
Public health in Virginia has a proud tradition! The first local Board of Health in the United States was established in Petersburg, Virginia in 1790. In 1872, the Commonwealth of Virginia established the first State Board of Health in the United States. In 1908, the Board of Health was reconstituted and the Virginia Department of Health (VDH) was created. And in 1932, physician leadership of VDH was specified in the Code of Virginia. In the "modern era" there have been several milestones in community health in Virginia including:
Despite the centrality of public health to the well-being of Virginians, funding is continually jeopardized by competing demands from the health care and health professional training sector. In the United States, it is estimated that public health activities account for less than one percent of the aggregate amount spent on health care. Thus, relative divestments in public health have resulted in decreased capacity in many public health agencies. These decreases have occurred at a time of increasing imperatives for public health intervention.
Through the Appropriations Act, general funds are appropriated to Virginia's public health system into eight generic sub-programs within the Virginia Department of Health. Certain funding categories are further apportioned to the 35 districts from the Community Health Services subprogram. Regarding the current distribution of general fund (State tax dollars), there are significant differences among districts in the Commonwealth in the allocation of general fund per capita.
Certain historical factors influence distribution of State funds:
In the Commonwealth of Virginia and in 1998, public health funding represented less than two percent of all funds in the State operating budget. During the past decade, VDH's portion of all State operating funds has consistently been around two percent. When comparing VDH's share of General Funds (State tax dollars) to the State total for the same time period, however, percentages have declined significantly. The primary causes of the decline were slow or negative economic growth in the early nineties and the concomitant additional demands on the human resources "safety net" programs (e.g. Medicaid) that allow the participation of all who meet the eligibility qualifications.
The Virginia Department of Health has increasingly relied on other sources of funds. For example, grants and appropriate fees for services have been sought to maintain the basic level of public health services. It is interesting to note that General Fund increases to the Virginia Health Department budget since FY 1991 have been limited to the State share of salary increases, facility improvements, and limited General Assembly 'member amendments' appropriating funds to specific local projects.
The Code of Virginia mandates that the Virginia Department of Health must administer andprovide a comprehensive program of services. These services include:
Disease Prevention and Control - examples: reporting and investigation of diseases; disease control measures; isolation of certain persons with communicable diseases; control of rabies, prevention of blindness from Ophthalmia Neonatorum; voluntary program for control of genetic and metabolic diseases; statewide disease registries
The Code of Virginia also mandates basic services to be provided by local health departments. Basic services are those services provided as required by the Code of Virginia, a condition of the receipt of funds, required by the State Board of Health, provisions of interagency agreements, and management directives.
There is service variability among health districts. Basic services essential for public health are, for the most part, universally offered to all residents with some on a sliding scale pay basis. Every district provides optional State services and many provide optional local services in localities to meet specific community needs. The funding varies, however, and the same service is provided in some localities with cooperative (matched) funds and in others with 100 percent local funds.
These services include:
Communicable Diseases - childhood immunizations; sexually transmitted disease screening, diagnosis, and treatment; surveillance of reportable communicable diseases, food borne disease outbreaks and other unusual disease outbreaks; and tuberculosis control screening, diagnosis, treatment and surveillance.
Family Planning - clinic services including contraceptive drugs and supplies; pregnancy testing and counseling.
Maternal and Child Health - prenatal and postpartum care for low-risk and intermediate-risk women; baby care services; Women, Infants, and Children (WIC) program assistance; children speciality services, diagnosis, treatment, follow-up, and parent teaching; screening for genetic traits and inborn errors of metabolism; provision of dietary supplements; and well child care.
Areas of Oversight - restaurant and food safety, inspection and licensure; investigation of communicable diseases; marinas; migrant labor camps; onsite sewage disposal; rabies control; sanitary surveys; single home sewage discharge; tourist establishment inspection; water supply sanitation; wells; homes for adults; daycare centers; and summer camps.
Medicaid Nursing Home Screening - Medicaid clients, or persons who anticipate becoming Medicaid eligible, are screened to determine if significant needs exist which require admission to a nursing home. Clients and families may be offered the option of nursing home placement or "in-home" Personal Care Services based on the results of the screening.
Comprehensive Services Act - This Act requires that each local government, or a combination of governments, establish a Community Policy and Management Team and Family Assessment and Planning Teams. The purposes of the teams are to review and assess troubled and at-risk youths and their families who have been referred for services. Follow-up includes an individualized family service plan and recommendations for funding support.
Vital Records (Death Certificates) - Local health departments are responsible for registering and issuing copies of death certificates to authorized persons, as requested. The Virginia Department of Health compiles, publishes, and maintains statistical data such as births, deaths, marriages and divorces, and incidents of communicable disease.
Early Intervention Services - Local health departments screen, assess, and provide case management for infants and toddlers who appear to be behind other children their age in one or more of the following areas: physical, intellectual, or emotional development, speech-language, and self-help skills. Referral is then made to appropriate services/treatment.
Because the local public health system and employees are part of State government, there is significant consistency across Virginia in the provision of mandated services. At the same time, however, the ties with State government can limit the extent to which public health leaders and practitioners can effect policy. Consequently, collaborative partnerships serve the community well for information and advocacy of issues affecting the community's health which may have political and policy ramifications.
New Century Public Health System as it Currently Exists -
Notwithstanding mandates and historical successes, the vitality of the public health system in southwest Virginia has been undermined in the last two decades by escalating pressures on state and local governments and an increasing reliance on generating fees for services. As the percentage of general funds going to the State Health Department has decreased the local health departments have increasingly had to rely on other sources of funds - for example, grants and appropriate fees for services - to maintain some basic level of public health services that citizens expect and deserve. However, even these funds (grants and fees) are being jeopardized by political agendas and dwindling revenues. Additionally, dependence on generating fees for services places public health providers in an entrepreneurial role that may not be conducive to fulfilling the mission of public health. The public's perception of the public health system as entrepreneur may deter those in need to seek services, thereby, weakening the effectiveness of public health efforts. All of these factors have had the effect of reducing the number of population-based and primary medical and personal health services provided to the community, as well as reducing the viability of essential or "core" community wide public health programs, many of which are targeted to the indigent and uninsured.
As stated earlier, the Alleghany/Roanoke and New River Valley population view the health system not as a public health system, a Carilion system, a Columbia system, a primary care clinic system, a free clinic system, or a private health provider system but as a variety of practices and/or points of access to health services. Health services include acute and chronic disease treatment and disease management education; prevention services including screening/testing and immunizations; diagnoses and investigation of community health problems and health hazards; enforcement of health and safety laws and regulations; assurance of a competent public and personal health provider workforce; protection against environmental hazards; response to disasters and assist in recovery; mental health services; infant/child health services; nutrition education; food handling education; parenting education; aging health issues education; substance abuse education; dental health; emergency/disaster services; communicable disease prevention, treatment, and monitoring; health data compilation and disbursement; pharmacological services; and terminal disease support services.
Thus, this report utilizes the wording community (the public's) health as the focus is on the health system serving the total community. Public health is an important component as it affects, and is affected by, the community's needs and the availability of other health services. Specifically, public health services are provided on a one-on-one basis and, when appropriate, to population groups. Services are targeted to the pre-school population, in the K-12 setting, to students and faculty/staff in institutions of higher education, in the workplace, to expectant mothers, in senior centers, to the faith community, and to family/friends' caregivers.
System changes have occurred over several decades. On the positive side, water and waste systems have been installed and upgraded; immunizations have become readily available; and life expectancy has realized a 30-year increase. On the negative side, the increase of chronic disease in an aging population is a reality. Personal risk behaviors have increased including the use of tobacco and poor diet practices. An increase of food-born illness being transmitted in the food processing and service industries, an increase in sexually transmitted diseases, and major increases in sedentary life styles of all age groups are well documented. Current environmental health-related risks include the inadequacy of aging waste systems and concerns over the limited drinking water supply with increasing population numbers and demands. Thus, it is appropriate, that within the body of the State's Turning Point Interim Report (1999), one notes "the public health system in Virginia will demand a rethinking of existing practices and structures......"
Summary -
Where Have We Been?
The New Century Turning Point Region, is uniquely blessed, yet challenged in its origins. We started with the broad-base collaborative effort of the New Century Council in the early part of this decade. Leaders and citizens from most sectors of the communities were involved. A regional visioning process was initiated with health and safety as well as the quality of life identified as priorities. When the New Century Council moved forward to address priority areas, Turning Point supplanted the original New Century Health and Safety Committee and provided the opportunity to revisit the status and develop a much needed vision.
This is an example of the willingness of area leaders to participate in evolutionary processes. It has been well understood that these efforts must evolve and that changes must be embraced that address both the structure and the process of operations. The New Century process has ushered in a new understanding that organizational change, even in community-based activities, must be accepted and supported. There are numerous examples, in addition to Turning Point, where the New Century leadership has demonstrated its willingness to support change.
The New Century process and Turning Point have had, and will continue to have, a remarkable impact on how the region views itself. For the first time, citizens and leaders, working together, are addressing access to health care and safety issues. Political boundaries have become less important as the health and safety of all citizens has gained in importance; opportunities have arisen and intersections have been identified that can make a difference. The Commonwealth of Virginia is currently selecting a committee to design a wellness curriculum for K-12 schools and The New Century Turning Point Executive Committee is working to ensure representation in that effort.
We have seen major changes in our populations' health and traditional health care institutions in the past decade. Costs continued to escalate; public hospitals became private, for-profit corporations; shifts in policy and funding curtailed some services traditionally provided through local health departments; the population has become older; and our youth have become less healthy. New networks were formed in a piece-meal configuration to address specific health issues and resolve problems. However, this piece-meal configuration has often left local programs addressing health issues in an equally fragmented approach.
Where Are We Going?
Turning Point is faced with the need to move beyond what was essentially a visioning process, to a more focused and concrete challenge of addressing systems change. We recognize that regardless of how broad the New Century visioning process was, voices of the underserved and disenfranchised were not as well represented as was envisioned or intended. Consequently, in moving forward with our Community Public Health System Improvement Plan, a large part of our efforts must focus on increasing the breadth and depth of community representation.
Citizens -the public- have incomplete knowledge of the community health system just as providers, educators, and policy makers have limited information of the citizens' perspective about the health of their families and communities. Characteristic of the Appalachian culture- individuals and families tend to think about health, as one of our public health nurses put it, as access to the system in time of crisis (i.e. well water contamination), at the time of specific life events (i.e. child immunizations), or when a service or program meets a current need (i.e. prenatal classes), in the here and now. Community health is currently more about a place (the clinic, hospital, health department); a service (immunizations, screenings); or a person (the nurse, the doctor, the home visitor) than about a process of interrelated systems working together to improve the overall quality of life in the region.
In turn, the providers, educators and policy makers may see the citizens from a needs or deficient perspective, as statistical reports, or as customers demanding more service and coverage from the same limited budget and resources. The challenge is to develop a common ground of understanding, communicate the needs and desires of citizens clearly and let citizens know about the vast array of resources available from their neighborhood, community, and region.
Our challenge is also to improve health by-
The following section is a description of key areas for implementation of the Community Public Health System Improvement Plan beginning with the overall mission and goals of the New Century Turning Point Partnership. Then, a key component of the plan, The RegionalCommunity Health Resource Bank is discussed along with a schematic representation and several scenarios demonstrating its potential. Next, portions of the regional Public Health System Improvement Plan are used to illustrate the integrative nature of the plan using, as a framework, the Lewin Group's dimensions of systems change. Finally, objectives and action steps from the five work groups are presented as they relate to each other and to the overall community proposal.
New Century Turning Point Mission and Goals
In order to more adequately address the recommendations in this report, it is important that we define our community (the public's ) health system and identify how we define health in relation to this process. Our community health system consists of those individuals and organizations that have a role in equipping our region with what is needed to achieve and maintain optimum personal and community health. Within this context, this system functions to promote healthy lifestyles and practices, prevent disease, and protect the environment.
The New Century Turning Point initiative recognizes that becoming responsible and accountable advocates for our health and health care involves a willingness to embrace change; to work toward true collaboration, which may require relinquishing traditional leadership roles; and to be creative. The health and wellness of a community is not just the responsibility of health professionals. Civic and lay community leaders as well as citizens need to recognize that health is equally, if not more so, their responsibility.
Turning Point's mission for the New Century Region is to transform and strengthen the culture of community (the public's ) health to improve the quality of life for all citizens through a dynamic Community Public Health System Improvement Plan.
To achieve this mission, three goals have been identified, thus far:
The New Century Turning Point Partnership has developed a central unifying element to address our goals and objectives. This element, a "virtual" Community Health Resource Bank is designed to use regional strengths and challenges and is built around the action plans of the working groups. This Regional Resource Bank provides a vehicle to highlight local knowledge and resources while utilizing and (perhaps more importantly) developing local talents, abilities, and leaders. It provides a framework - the scaffolding - to work towards local sustainability. Individuals and communities can access information, knowledge, abilities, and technical support within the Resource Bank, that shifts to, and remains within, the local community. That cycles back into the Resource Bank as these community members share their experiences with others localities.
Sustaining the Effort -A Regional Community Health Resource Bank
"Using Regional Strengths and Challenges"
As stated earlier, the New Century Turning Point Planning area as a Super Region is unique among all Turning Point efforts. Working from a regional perspective presents challenges and provides opportunities.
The opportunities of working in a Super Region include