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The Ingham County Health Department, working in partnership with hospitals, employers, consumers and insurers in Lansing, Mich., created an organized system of care for county residents.
This included health plan coverage for the uninsured and a network of neighborhood-based services in distressed inner-city communities.
Between 1994 and 2004, the Robert Wood Johnson Foundation (RWJF) awarded two grants totaling $498,521 to support this project (ID#s 023969 and 031797).
The first grant laid the basis for the communities' organized system of care. Under the second grant, the Ingham County Health Department and its partners led multiple stakeholders (consumers, employers, hospitals and insurers) in a community mobilization process.
RWJF provided partial funding for this project with two grants totaling $498,521 between November 1994 and January 2004. In 2003, the W.K. Kellogg Foundation awarded Ingham County a four-year grant of $910,000 to continue the community mobilization process.
In the early 1990s, about 34,000 residents of Ingham County, Michigan (approximately 12 percent of the population) lacked health insurance. Of these, 39 percent said they had been unable to see a doctor in the past year because of cost.
Many of the uninsured lived in distressed inner-city neighborhoods of Lansing (Ingham County's largest city) where high rates of crime, poverty, child abuse and neglect created additional barriers to health care. The uninsured and indigent relied on an uncoordinated set of safety net providers that included the public health department, hospital emergency rooms and nonprofit community health centers.
However, the ability of the three Lansing hospitals (Edward W. Sparrow Hospital, Ingham County Medical Center and St. Lawrence Hospital) to continue providing safety net services was being threatened by cost containment pressures coming from health insurers and major area employers, including General Motors and Michigan State University.
In 1991, a community police officer, Donald Christy, conceived and established Lansing's first neighborhood "network center" (the Eastside Network Center) at a donated site in a high-crime neighborhood where agencies began to coordinate the delivery of health, social, substance abuse, and safety services to local residents.
In a separate event that year, the heads of the major public human service systems in the county formally committed themselves to explore collaborative approaches to the coordination of services for multineed families. Since Officer Christy's network center appeared to present a promising strategy for mobilizing the larger community and promoting interagency cooperation, the Ingham County Health Department became interested in replicating it in other high-need Lansing neighborhoods.
However, to improve health care access throughout the county, the health department recognized that a multilevel response by health care systems, service providing agencies and individuals was essential.
At the time RWJF issued these grants, one of its goals was to improve access to health care among the uninsured. This project aimed to provide an example of how major health care providers, both public and private systems, can work together cooperatively within a highly competitive market to ensure health care for the uninsured.
In 1994, RWJF funded a planning project (ID# 023969) designed to secure citywide commitment to the concept of neighborhood-based services and to expand a fledgling network center system. With the Capital Area United Way acting as fiduciary agent, a project team that included the Lansing Police Department and the Ingham County Health Department led the planning project. They:
In 1997 RWJF awarded the Ingham County Health Department a second grant (ID# 031797) to help implement this project (now called "Access to Health"). Its purpose was to support the community's major health providers in expanding access to care for the uninsured while also working to integrate existing health and social services. To achieve this goal, the Ingham County Health Department and its partners: (1) expanded coordinated health and social service delivery at the three selected neighborhood network centers; and (2) pursued health coverage for the uninsured through a collaboration between the two remaining Lansing hospitals, Sparrow and Ingham County Medical Center (St. Lawrence Hospital merged with Sparrow in 1997).
Soon after RWJF's second grant, two events occurred that expanded the scope of the project and made the attainment of an organized system of care more feasible.
The Ingham County Health Department subsequently used RWJF and Kellogg funds to lead a broad community mobilization and engagement process, called the community dialogue process, that forged what the project director describes as the "community will" to cover the uninsured. The process included community forums and health care summits as well as smaller learning sessions, workshops and focus groups. Dialogues engaged multiple stakeholders (consumers of health care, insurers, health care systems and providers) in discussions of health care needs and access problems (including barriers to enrollment in the Ingham Health Plan).
The dialogue process produced action plans for an organized system of care for the county as a whole, as well as for specific neighborhoods. It also addressed broad access goals as well as specific problems, such as substance abuse. In 2001, Ingham County received a three-year grant of $1,408,185 from the federal Health Resources and Services Administration's Community Access Program, which allowed the county to expand both the dialogue process and Ingham Health Plan coverage to adjacent Clinton and Eaton counties. These, together with Ingham County, form the Capital Area Community.
Two Lansing organizations played key roles in the Access to Health project. The Capital Area Health Alliance, an existing communitywide forum for consumers, employers, hospitals and insurers, assumed responsibility for sponsorship and oversight of the community dialogues and action plan. The Network Center Advisory Board, a coalition of provider agencies and residents (noted above), provided continuing direction and oversight for the network centers and leveraged funding to sustain them. At three of the network centers local boards provided additional operational oversight.
The W.K. Kellogg Foundation and the federal Health Services Resources Administration's Community Access Program provided major financial support for the project. See Appendix 1 for details on this funding, as well as a list of other project supporters.
The project staff reported the following accomplishments:
To disseminate information about the project and gather input from stakeholders, project staff and partners sponsored five community meetings in Lansing between February 1999 and September 2004 (the W.K. Kellogg Foundation's Community Voices initiative funded several meetings and other associated outreach). Attendance at meetings ranged from 150 to 250 participants. Staff distributed project documents at these meetings, including Setting the Community Table: The Stakeholders Speak on Access to Healthcare (February 1999), Action Plan for an Organized System of Care for the Capital Area (February 2002), and Community Briefings (September 2002 and 2004). The Action Plan, the 2002 Community Briefing, the evaluation, and the substance abuse reports are available at the project Web site.
As of 2004, staff had distributed approximately 2,000 copies of a draft Action Plan and 1,000 of its final version to community residents, and to interested parties statewide and nationally. The Capital Area Health Alliance plans to publish biannual Community Briefings to update stakeholders on progress toward the Action Plan goals. In 2001, staff coordinated a year-long media and grassroots enrollment outreach effort throughout the greater Lansing area. In 2003, the project coordinator spoke on the project's community outreach before the U.S. Congressional Black Caucus. In 2004, he made another presentation, "The Ingham Health Plan: Using Community Will to Create Coverage for the Uninsured," at the annual American Public Health Association conference in Washington. In 2004, the project director addressed a Georgia advocacy group (the Campaign for Adolescent Pregnancy Prevention) on the project's success in maximizing community health resources. (See the Bibliography for details on community meetings, publications and presentations.)
RWJF, the W.K. Kellogg Foundation and the federal Community Access Program co-funded a three-part evaluation of the project's organized system of care. Public Sector Consultants, a Lansing-based corporation specializing in program evaluation, conducted the evaluation. The RWJF-funded component focused on the effectiveness of community engagement and mobilization efforts at the neighborhood network centers. The evaluators gathered information through personal interviews with the five network center directors, the network center coordinator, and through focus groups conducted at four of the neighborhood centers. Thirty-four people participated in the focus groups, including senior citizens, neighborhood residents and network center volunteers. Public Sector Consultants summarized their findings in Ingham County Health Department Access to Health Project Evaluation. See Lessons Learned for key findings from this report.
Evaluation components funded by the W.K. Kellogg Foundation and the Community Access Program focused on three project objectives:
The evaluators based their findings on Ingham Health Plan documentation, data compiled for the Community Briefing 2002, and surveys and interviews conducted with current Ingham Health Plan members and clinic staff. Findings from these components of the evaluation appear in the Results section of this report.
Public Sector Consultants and the project director identified the following project lessons:
As of 2004, the Ingham Health Plan was expanding with a sustainable base of local, state and federal funding. In November 2004, the plan had enrolled about 16,000 members, 60 percent of the uninsured population. The county's "Ingham County Advantage," which offers subsidized health insurance to employees of small businesses in the county, opened in June 2004; five businesses have enrolled. Nineteen health plans similar to the Ingham Health Plan are now operating in Michigan, covering at least 100,000 individuals. The Ingham County Health Department acts as paid manager for 11 of these plans.
Four neighborhood network centers (Baker-Donora Focus Center, Allen Neighborhood Center, Northside Network Center and Wexford Neighborhood Network Center) also continue as of 2004, with a broad base of financial and in-kind support from local, state and national partners. A consortium called "The Power of We," established in 2002 by health, business, education and consumer groups in the Capital Area Community, works to provide sustained support for the neighborhood centers by pooling public, private and foundation dollars.
Development of an Organized System of Health Care for the Indigent
Capital Area United Way, Inc. (Lansing, MI)
County of Ingham Health Department (Lansing, MI)
Bruce B. Bragg, M.P.H.
Additional Support for the Project
The following provided additional support for project implementation (January 1998 through January 2004):
W.K. Kellogg Foundation
The federal Health Resources and Services Administration
Michigan's Mid South Substance Abuse Commission
Other supporters, both financial and in-kind, included the following (November 1994 through January 2004):
Action Plan for an Organized System of Care in Lansing: Principles, Goals and Indicators for Tracking Progress Toward Goals
Five principles of an Organized System of Care:
Seven Goals of an Organized System of Care:
1. Coverage Goal: Create and sustain coverage strategies sufficient to give all residents access to organized systems of care, by building on current successful innovations in Ingham County.
2. Zero Disparity Goal: Eliminate all barriers to quality health care based upon economic cultural, ethnic and racial differences.
3. Ownership Goal: Mobilize Capital Area leaders to create community ownership of the need for universal access to health care.
4. Oversight Goal: Engage the community in an ongoing process of analyzing health data and allocating health care resources in ways that will improve health status and health care access for uninsured people.
5. Outreach Goal: Enable both traditional and nontraditional providers of health information to connect people to a full range of services and health education resources.
6. Oral Health Goal: Increase access to oral health services for residents of the Capital Area.
7. Mental Health and Substance Abuse Goal: Increase access to mental health and substance abuse services for residents of the Capital Area.
Project Recommendations for Increasing Access to Substance Abuse Prevention and Treatment Services
The Mid-South Substance Abuse Commission sponsored 18 community dialogues in a nine-county region of Michigan from December 2001 to May 2002. These recommendations (in six goal areas) emerged from the dialogue process:
Concerning Goal 1: Increase Community Awareness and Leadership.
Concerning Goal 2: Reduce Barriers to Accessing Services.
Concerning Goal 3: Improve Substance Abuse Prevention and Treatment Services.
Concerning Goal 4: Establish a Full Continuum of Services Through Communication, Coordination and Collaboration.
Concerning Goal 5: Improve Public Policy.
Concerning Goal 6: Increase Resources and Funding.
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Bloss D. "The Ingham Health Plan: Using Community Will to Create Coverage for the Uninsured." Abstract of presentation at the 2004 Annual Meeting of the American Public Health Association, November 8, 2004. Abstract #84889 available online.
Bloss D and Miel-Uken S. "Harmonizing Diverse Voices in a Community Dialogue on Access to Health Care." Unpublished.
Safe Families/Safe Children Five-Year Community Plan (October 1, 1994September 31, 1999). Lansing, Mich.: Ingham County Family Coordinating Council, March 21, 1995.
Doak B. Setting the Community Table: The Stakeholders Speak on Access to Healthcare. Lansing, Mich.: Ingham County Health Department, February 19, 1999. 500 copies produced.
Action Plan for an Organized System of Care in the Capital Area. Lansing, Mich.: Capital Area Health Alliance, February 2001.
Lansing Network Center Advisory Board Annual Report 20002001. Lansing, Mich.: Michigan State University Extension Services, May 2001.
Lansing Network Center Advisory Board Annual Report 20012002. Lansing, Mich.: Michigan State University Extension Services, May 2002.
From Dialogue to Action: Recommendations for Increasing Access to Substance Abuse Prevention and Treatment Services. Lansing, Mich.: Mid-South Substance Abuse Commission, June 27, 2002.
Community Briefing 2002. Lansing, Mich.: Capital Area Health Alliance, September 2002.
Community Briefing 2004: Releasing the Power of People Who Care. Lansing, Mich.: Capital Area Health Alliance, September 2004.
The Power of We-Strengthening Community Connections for Action. Lansing, Mich.: Capital Area United Way and Ingham County Health Department, Fall 2002.
Lansing Network Center Advisory Board Annual Report 20022003. Lansing, Mich.: Michigan State University Extension Services, May 2003.
Ingham County Health Department Access to Health Project Evaluation. Lansing, Mich.: Public Sector Consultants Inc., January 2004.
www.CACVoices.org is the Web site of the Capital Area Community Voices program. It contains information about the four neighborhood network centers, W.K. Kellogg Community Voices program, and partner organizations. Project documents available at the Web site include: the Action Plan for an Organized System of Care in Ingham County, The Power of We-Strengthening Community Connections for Action, Community Briefing (2002), From Dialogue to Action: Recommendations for Increasing Access to Substance Abuse Prevention and Treatment Services, Community Briefing 2004: Releasing the Power of People Who Care, and the three Public Health Sector Consultants evaluation reports for RWJF, W.K. Kellogg and the Community Access Program.
"Beginning the Dialogue on Access to Healthcare in Ingham County," February 19, 1999, Lansing, Mich. Attended by approximately 155 community members. In four breakout sessions, participants revised four principles for forming an organizing system of care that were derived from the stakeholder interviews. At the forum, the project team presented a report (Setting the Community Table: The Stakeholders Speak on Access to Healthcare) which summarized interviews with 51 consumers, employers, providers and insurers who "told the story" of the uninsured from their perspective. Forum participants formulated five principles for developing the organized system of care based on their discussion of the report. (See Appendix 2 for a list of the principles.)
"From Dialogue to Action," November 23, 1999, Lansing, Mich. Attended by approximately 150 community members. In discussions and work sessions, participants developed preliminary action steps for an organized system of care in Ingham County. Participants based these steps on recommendations from 15 learning sessions following the February 19, 1999 Forum, which focused on three topics:
"Launching the Action Plan," February 22, 2001, Lansing, Mich. Attended by approximately 150 community stakeholders and members of the media. The Capital Area Health Alliance presented the completed Action Plan for an Organized System of Care in the Capital Area to the public and the press.
"Dialogue on a Structure for Maintaining Community Engagement," November 16, 2001, Lansing, Mich. Attended by members of the Human Services Advisory Committee and about 30 participants from the network neighborhood centers, school districts, hospitals and other community agencies. The group engaged in a facilitated discussion of the topic: What are some promising structure for pooling and managing support for the neighborhood and community engagement that has occurred through Ingham Community Voices?
"From Dialogue to Action: Increasing Access to Substance Abuse Services," June 27, 2002, Lansing, Mich. .Attended by service providers and consumers from the nine-county area served by the Mid-South Substance Abuse Commissioner. In a facilitated dialogue process, participants began creating an action plan for substance abuse based on recommendations in the report, From Dialogue to Action: Recommendations for Increasing Access to Substance Abuse Prevention and Treatment Services.
"Connecting Our Future to Health," September 17, 2002, Lansing, Mich. Attended by approximately 150 community members. The Capital Area Health Alliance presented the Community Briefing 2002 to the public.
"Releasing the Power of People Who Care," September 28, 2004, Lansing, Mich. Attended by approximately 250 community members. The Capital Area Health Alliance presented the Community Briefing 2004 to the public.
Doak Bloss, "The Ingham Health Plan: Using Community Will to Create Coverage for the Uninsured," at the Annual Meeting of the American Public Health Association, November 8, 2004, Washington. Abstract available online.
Report prepared by: Jayme Hannay
Reviewed by: James Wood
Reviewed by: Marian Bass
Program Officer: Pamela Dickson
Program Officer: Rush Russell
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