Chatham County Safety Net Planning Council

A coalition of safety net primary health care providers; Curtis V. Cooper Primary Health Center, J.C. Lewis Primary Health Center, St. Joseph’s/Candler St. Mary’s and Good Samaritan Clinics, Memorial Family Medicine, Chatham CARE and social service providers and funders; the United Way of the Coastal Empire, City of Savannah, Chatham County as well as the Savannah-Chatham County Public Schools and Coastal Indicators Coalition have been selected by Data Across Sectors for Health (DASH), a national program of the Robert Wood Johnson Foundation, to participate in a 10-month mentorship program led by Chatham County Safety Net Planning Council to advance local efforts to share and use multi-sector data to improve community health.

As a DASH Mentee, they will connect with communities from around the country through All In: Data for Community Health, a peer-to-peer learning network that builds local capacity to systematically combine health data with data from other sectors like education, social services, and housing to acquire a more complete picture of the factors that influence health.

The Chatham Team will be working with 2-1-1 San Diego, a national leader in the development of a Community Information Exchange (CIE). CIEs are a collective movement and technology platform that shifts how health and social service providers deliver person-centered care. 2-1-1 San Diego mentorship will provide the toolkit to develop CIE infrastructure, interoperable technology, community network, legal frameworks, and sustainability.

Participation in the DASH Mentor Program will help the community come together and begin exploring the concept of a CIE for Chatham County and think through what that might look like.

The Chatham Team is excited to make meaningful connections with leaders in the field to accelerate learning and make significant progress towards aligning multi-sector partners around data-driven approaches that promote health equity.

To learn more, visit dashconnect.org/awardees/mentor-program/

Do you need affordable eyeglasses?  Call St. Mary’s Community Center (912) 447-0578 today!  St. Mary’s offers an eyeglass clinic once a month or by appointment.  For individuals with prescriptions the cost of the glasses is $30.  For those who do not have a prescription and meet the income requirements and are uninsured, you can qualify for a free eye exam at the Georgia Eye Institute.  St. Mary’s Community Center is located 812 W 36th St, Savannah.

Heads-Up Guidance Services (HUGS) has a new location!  It’s at 5 Executive Circle, Savannah, GA 31406.

Heads-Up Guidance Services is a non-profit 501(c)(3) organization making Mental & Behavioral Health Counseling and Addiction Recovery Services available and affordable to ALL in need.   HUGS is funded by community donations and operated by local volunteers.  Free Consultations may be scheduled to learn more about our services.
To Begin Counseling Services… Call to schedule an INTAKE…912.417.4320  Intakes are information gathering sessions (required paperwork) when the client meets with a counselor  to complete a Needs Assessment.   Cost of Intake is $25.

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The Coastal Campaign for Healthy Kids recognized the Effingham County Health Department and Children’s Special Services (CSS) which include Babies Can’t Wait, Children’s 1st and Children’s Medical Services, as Outstanding Outreach Partners!

County Nurse Manager, Cynthia Grovenstein and her staff, Early Intervention Coordinator, Kim McCaliley, the Children’s 1st & Children’s Medical Services and Children’s Special Services Coordinator, Jocelyn Hall accepted the recognition at the Safety Net Full Council meeting in July.  The Effingham County Health Departments serve families in Effingham County include the WIC Clinic for pregnant women and children.  CSS provides funding and support services for children with disabilities and chronic medical conditions.  The children have to have health insurance to qualify for the cost-sharing and access to critical therapies and specialists.  Safety Net recognized them for their sustained efforts in keeping the services of the Campaign top of mind with your team and trusting our enrollment assistors with their families.

Since the Campaign for Healthy Kids expanded to five additional counties in June 2016, the Coastal Health District has referred 156 families. Most of these referrals resulted in the submission of new or renewing application, checking up on an existing application or investigating a denial.   One case manager from Babies Can’t Wait shared the impact one family who was referred to the Campaign staff with the following note. “Just wanted you to know about the family you helped, last week. Your efforts, by contacting your people in Medicaid, has brought JOY to this mom and dad. Her son’s Medicaid was approved and retro-activated from August. She said her son had a heart appointment next month that she didn’t know how it was going to get paid for. She said she had outstanding bills that will now be paid for. She was sooooo thankful…..I told her about you and she wanted me to thank you again.”

We are pleased to announce that the Georgia-based R. Howard Dobbs Jr. Foundation has awarded Chatham County Safety Net’s (Safety Net) program, the Coastal Campaign for Healthy Kids, $50,000 to support “mobile” enrollment assistance services in an effort to get more eligible children enrolled in Medicaid and PeachCare for Kids comprehensive health insurance programs.

Mobile enrollment is designed to reduce barriers that families may face accessing these programs by providing free, in-person application assistance through an assister who can meet parents at convenient locations like at their workplace, a child’s school or a local library and at a time that works for them, including evenings and Saturday mornings.

This generous award builds on the historic progress already made increasing the number of children who have health coverage in the greater Savannah area. Since July 2014, the Campaign has assisted 3,700 families, applying on behalf of over 6,000 children and teens.

The Campaign began in Chatham County in 2014 and since then, Chatham has experienced a 39% drop in the number of uninsured children from 7.9% 2014 to 4.8% in 2016 in comparison to an average of 15% Georgia-wide. The Campaign expanded to cover five additional counties, Bryan, Effingham, Liberty, Long and McIntosh in 2016.

“We truly appreciate the Foundation’s support for the Campaign for Healthy Kids, which allows us to continue our program to enroll kids in health coverage,” said Lisa Hayes, Executive Director of Safety Net.

The Campaign is comprised of a coalition of enrollment partner organizations including Step Up Savannah, St. Joseph/Candler’s St. Mary’s Community Center, Curtis V. Cooper Primary Health Care, the Chatham County Health Department and Safety Net’s “mobile” enroller. Outreach partners, most notably, J.C. Lewis Primary Health Care Center, the Coastal Health District, and the public schools in our six-county area have referred hundreds of families in need of enrollment help to us.

“Addressing the healthcare needs of children helps pave the way for them to thrive not only physically, but academically and emotionally as well. Our trustees were pleased to provide the stop-gap funding necessary to maintain the momentum of the Campaign for Healthy Kids as a result of delayed federal funding opportunities.” Danielle Gray, Program Officer, R. Howard Dobbs, Jr. Foundation

The R. Howard Dobbs, Jr. Foundation operates with the mission to improve the quality of life for individuals, families and communities by supporting educational opportunities, improving access to health services, and promoting environmental stewardship. The Foundation is committed to honoring the life and impact of Mr. Dobbs through its work.

Chatham County, Georgia’s “Inmate Project” Case Study has been published along with two other studies by the Milbank Memorial Fund Foundation.  The Chatham County initiative was recognized as one of three finalists for the Milbank Memorial Fund and AcademyHealth State and Local Health Innovation Prize in April 2018.

The prize was designed to honor public and private collaborations that use publicly available data to improve population health.  The Chatham County collaboration formed to improve continuity of care, safety and health outcomes for the 18,000 inmates that are detained at the county jail each year.

The key agencies recognized include:

Chatham County Safety Net Planning Council, Inc.
Chatham County Commission
County Manager’s Office, Chatham County
Chatham County Sheriff’s Department
Curtis V. Cooper Primary Health Care, Inc.
Georgia Regional Academic Community Health Information Exchange

Milbank Memorial Foundation writes, “In Chicago and Chatham County, Georgia, a public health crisis spurred action and created opportunities to introduce systems changes. In addition to operations and technology, they had to address changes in organizational culture….The case studies that follow profile the three finalists, describing the challenges they faced and how they turned obstacles into opportunities for innovation and improvement.”

Three Projects Receive Inaugural State and Local Innovation Prize

Download the pdf here MMF-AH-Innovation-Prize-FINAL-1.

At the June Full Council Meeting, Chatham County Safety Net Planning Council recognized Robyn Wainner, Director of Asset Building and Financial Empowerment, Step Up Savannah, as Outstanding Partner.

Earlier in the month, Ms. Wainner had announced that she would be relocating to the sunny state of Florida and thus leaving our town and Step Up Savannah. The Council members did not want to let Ms. Wainner go without expressing their appreciation of her excellent efforts in supporting Safety Net and commitment to serving our community.

As the Director of Asset Building and Financial Empowerment Director, in the last 4 years, Ms. Wainner has played a key role in helping establishing a strong partnership between Step Up Savannah and Safety Net.

“You have been such a kind and generous partner, a good friend and terrific non-profit administrator, manager and fundraiser.  For those of you who may not know our history, Robyn and I met in April 2014 to work collaboratively on a grant for the National League of Cities that would become the project, The Mayor’s Campaign for Healthy Kids and Families which is now known as the Coastal Campaign for Healthy Kids.  As an aside, many of you know how much the success of that program is because of having Robyn on our leadership team,” said Ms. Hayes in her farewell speech.

Indeed, the Coastal Campaign for Healthy Kids would not be the same as it is today without Ms. Wainner. With grateful hearts for the time we were able to work  and grow together and for the families that we were able to help together our  team wishes Ms. Wainner every success in her new venture and hopes that she will continue making a difference in the lives of others through her work and friendship.

Lisa Hayes, Executive Director of Safety Net, Elise Blasingame, Executive Director of Healthy Mothers, Healthy Babies Coalition of Georgia, Laura Colbert, Executive Director of Georgians for a Healthy Future and LaShun C. Wright, Director of Training & Technical Assistance for the Georgia Primary Care Association is the Georgia team that has been selected to be a part of Cohort 2 of Georgetown’s Center for Children and Families’ Children’s Health Leadership Network (CHLN).

CHLN is a leadership development program for advancing and networking leaders in the field of children’s health and well-being policy.  Sponsors include the Annie E. Casey Foundation, the David and Lucille Packard Foundation and the Georgetown University Center on Children and Families.

The program “…will equip participants to leverage data, partnerships, personal power and organizational authority to strengthen the quality and effectiveness of child health policy and advocacy efforts and results; build and increase the public and political will needed to decrease outcome disparities and improve opportunity; develop stronger organization and system-level consensus about the pathway to results; better frame and describe incremental successes, especially when desired policy changes may take a long time to achieve; and influence and advance child health policy changes that ultimately benefit vulnerable children, their families and communities.” (www.aecf.org)

The Georgia team will be participating in an intensive series of activities from July 2018-May 2019.

Ms. Hayes will bring her experience and technical expertise with Safety Net’s direct service program, the Coastal Campaign for Healthy Kids (Campaign).  The Campaign offers free, enrollment assistance into Children’s Public Health Insurance programs, Medicaid and PeachCare for Kids for parents and has assisted 5,756 children apply since 2014.

The Campaign Coalition includes Step Up Savannah, Curtis V. Cooper Primary Healthy Care, St. Joseph’s/Candler St. Mary’s Community Center and Safety Net’s mobile enrollment team with outreach partners, JC Lewis Primary Health Care Center, Savannah-Chatham Public Schools, Chatham County Juvenile Court, the local media and other local organizations. All have contributed to helping dramatically lower Chatham County’s uninsured rate for children and teens from 2014-2016 by 39% to 4.8%, one of the lowest in the state.

Catham County Safety Net Planning Council honored Diane Z. Weems, MD, Safety Net’s founding Chair and Board Member, who retired as Board Chair in March 2018.

In grateful recognition for her visionary leadership, wisdom and unwavering commitment to the Council, and for always championing the needs of our most vulnerable in Chatham County, the Safety Net Executive Director Elisabeth Hayes and the new Board Chair, Mark C. Johnson, MD,  presented Dr. Weems with a special recognition award.

Since its founding in 2004—14 year ago—Dr. Weems have generously given Safety Net her time, her wisdom, and her dedication. As the Chief Medical Officer and then the Director of the Coastal Health District, she acted as the nonpartisan convener and brought together competing organizations in the healthcare sector creating trust and  building stronger and more meaningful relationships between the agencies.

“Your leadership, your counsel, and your expertise have helped our organization to make a tremendous impact on our community and have helped me grow both professionally and personally, ” said Ms. Hayes in her heartfelt speech during the meeting.

Dr. Weems gratefully accepted the award and noted that she was delighted to see how Safety Net had grown over the past few years and was excited for the organization’s future under its great  leadership.

Effective April 1, 2018 Mark C. Johnson, MD, CEO, Gateway Behavioral Health Services, Community Service Board, Coastal Georgia stepped into a role of the Safety Net Board Chair replacing retiring Board Member and Board Chair, Dr. Diane Weems.

Updated 5/04/2018. Chatham County Safety Net Planning Council, Inc. (ChathamHealthLink), Chatham County, GA, Chatham County Sheriff’s Department, Curtis V. Cooper Primary Health Care and the Georgia Regional Academic Community Health Information Exchange (GRAChIE) are key agencies in a multi-stakeholder initiative to improve the continuity of care system for Chatham County jail inmates. The collaborative was chosen as one of three national finalists (out of 40 submissions) for the Inaugural 2018 Milbank Memorial Fund and AcademyHealth State and Local Innovation Prize.

The prize was developed by the Milbank Memorial Foundation to recognize individuals, teams, or projects that use data to “achieve measurable impact” to improve the health of their communities through innovations implemented on a state and local government level.

The co-finalists were the Chicago Department of Public Health and Department of Innovation and Technology with the University of Chicago Center for Data Science and Public Policy developed a more proactive approach to lead paint exposure and poisoning in children, creating a predictive model that combines data from multiple sectors to identify at-risk children for blood testing or homes for lead inspections and the Washington State Department of Health and Human Services, Washington State Health Care Authority, and the Centers for Medicaid and Medicare Services partnered to integrate state Medicaid and federal Medicare data for predictive modeling that targets innovative care coordination and social service interventions.

The City of Chicago team was announced the winner on the mainstage of the AcademyHealth Datapalooza in Washington, DC on April 26, 2018. More about the Milbank Memorial Fund and the award, click here.

Central to the Chatham County project was to connect the Chatham County Detention Center (CCDC) to our local health information exchange (HIE), ChathamHealthLink (CHL) and by extension the regional HIE, GRAChIE. HIEs enable health providers involved in a patient’s care—whether in a primary care setting, a specialists’ office or emergency department—to share vital patient information including medications, pre-existing conditions, allergies, immunizations, lab results, appointment history and more from within electronic medical records at the point of care. CHL was established by the Chatham County Safety Net Planning Council through funding from the Chatham County Commission in 2008 and became the first HIE in the state of Georgia.

For Chatham County, it became imperative that meaningful health information be accessed at the time of processing or “booking” for detainees at the county jail to effectively support their continuity of care, reduce duplication of services and protect the safety and welfare of everyone in the CCDC system. The county jail’s inmate population has complex healthcare needs. Untreated mental health, substance use disorders, infectious diseases and other chronic conditions are prevalent in this population. Better management of the inmates with mental illnesses and chronic medical conditions would improve safety, reduce costs and better provide for the healthcare needs of this population.

Lisa Hayes, Executive Director of Chatham County Safety Net Planning Council administers CHL and served as project director states, “By incorporating the CCDC detainee population in CHL/GRAChIE, we are better able to close the medical information gap and improve patient safety and health outcomes for those within the county’s jail and those transitioning back into the county’s population.”

Key safety net health providers serving highly vulnerable populations in Chatham county are connected through CHL including, Curtis V Cooper Primary Health Care, Inc. and J.C. Lewis Primary Health Care Centers, Memorial Health University Medical Center, Gateway Community Service Board and Chatham Care Clinic, an HIV+ Ryan White Clinic.

The Chatham County Detention Center (CCDC) is one of the largest jails in GA outside of Metropolitan Atlanta, with approximately 18,000 inmates per year, of which 45% are treated for chronic illness. It is estimated that 90% of the inmate population is uninsured (Georgia is a non-Medicaid expansion state) and does not have access to primary or behavioral health care; CCDC may be their only access to health services Until 2016, the CCDC’s medical records were stored in a “siloed” paper-records system creating barriers and pervasive inefficiencies accessing critical health information and providing adequate care. This situation proved dangerous for both inmates and staff.

Chatham County, GA elected officials and executive leadership have been highly motivated and fully committed to the development, establishment and long-term support for a local HIE, ChathamHealthLink, and in 2015, the CCDC was quickly identified as a critical piece of the Chatham County health care safety net system and central to protecting the continuity of care within this highly vulnerable population. In 2016, John Wilcher was elected Chatham County Sheriff and filled the leadership gap left after the death of the previous Chief Al St. Lawrence. Sheriff Wilcher saw an opportunity to increase vendor accountability, significantly reduce liability for the County and improve the quality of care among those who are in his custody and his support was critical to the success of the project.

The project impact is evident through crossover data recorded from CHL members with the CCDC population. As of December 2017, Memorial recorded 7,185 patients processed through the CCDC. This is compelling when compared with the approximate number of detainees processed over an entire year, 18,000. These patient crossovers account for 39.9% of the total. A holistic system of access to patient health information at the point of care for our most vulnerable population has led to innovations within our community and we are better able to close the medical information gap leading to improved patient safety and health outcomes for those within the county’s jail and those transitioning back into the community.