CASE STUDY PRIMARY CARE FOR LOW-INCOME POPULATIONS FEBRUARY 2020 Building Partnerships to Improve Health in the Rural South: CareSouth Carolina What’s the best way for a community health center to have an impact beyond its walls? Martha Hostetter Sarah Klein Consulting Writer and Editor Consulting Writer and Editor The Commonwealth Fund The Commonwealth Fund PROGRAM AT A GLANCE TOPLINES KEY FEATURE A large federally qualified health center (FQHC) Read how one health center in operating 14 clinics across rural South Carolina relies on the rural South reaches patients in their homes, schools, and community health workers and local partnerships to help patients churches. needing social support, coaching, and case management. TARGET POPULATION Most of the health center’s patients live at or To support its efforts, CareSouth below the poverty level; nearly half have hypertension, and one- Carolina has joined with other quarter have diabetes. community health centers in pursuing value-based contracts WHY IT’S IMPORTANT The health center has joined with other that offer incentives for FQHCs to pursue value-based payment and uses incentives earned improving quality. from Medicaid managed care companies to finance support services. BENEFITS In recent years, the health center has improved its performance on measures such as tobacco use screening and counseling, adult body mass index screening and counseling, breast cancer screening, and adolescent well visits. It also has reduced spending on emergency department visits and hospitalizations. CHALLENGES Like many primary care practices, CareSouth struggles to engage adolescents, men, and those who lack reliable transportation or sufficient time or money to access care. Building Partnerships to Improve Health in the Rural South: CareSouth Carolina 2 BACKGROUND This case study is the second in a series Communities in the Pee Dee region along the coastal plains profiling how primary care clinics — of South Carolina were already suffering, and then came the federally qualified health centers, storms. In the last few years, powerful hurricanes destroyed independent clinics, and clinics that are crops, washed out roads and bridges, and generally made lives more complicated in a region already marked by high part of large health systems — are meeting poverty rates and poor health. the needs of patients with low incomes. The series profiles clinics that exhibit some By knocking out major thoroughfares, the hurricanes also or all of the following attributes: have made it harder for CareSouth Carolina, a federally qualified health center (FQHC), to treat patients across • medical home capabilities as a this sprawling region. The FQHC operates 14 primary care foundation clinics across five counties, reaching some 45,000 people, or about 12 percent of residents. The largest clinic is in • multidisciplinary teams with Hartsville, a small town with a main street lined with community health workers boutiques and cafes. The others are in outlying regions where patients and their families have lived for decades; • integration of primary health care some are so rooted they won’t travel to see a doctor even with public health, social services, and 10 miles away. behavioral health • using data to manage and improve CareSouth Carolina’s Service Area patient care and clinic performance Chesterfield County Marlboro County • geographic empanelment, including 22.1% of households live at/below 28.0% appropriate risk stratification federal poverty level (FPL) at/below FPL and targeting Dillon County • proactive patient and family engagement to address 29.8% at/below FPL physical, social, and cultural barriers to care Lee County • leveraging of digital tools to improve 25.8% health. at/below FPL CareSouth Carolina stands out for Darlington County its efforts to field staff and services in people’s homes, schools, and churches to 21.9% at/below FPL address their medical and social needs. Data: U.S. Census Bureau, Small Area Income and Poverty Estimates (SAIPE) for Chesterfield, Darlington, Dillon, Lee, and Marlboro Counties, South Carolina, 1997–2017. commonwealthfund.org Case Study, February 2020 Building Partnerships to Improve Health in the Rural South: CareSouth Carolina 3 “They’re little communities that people don’t get out of either because of habit, lack of transportation, or other barriers,” says Joe Bittle, CareSouth’s chief of There is poverty here that is community health. generational, that is just a way Many patients live in severe poverty that extends of life. No one even thinks that across generations and struggle to afford basic they’re in poverty. necessities. CareSouth’s community health workers (CHWs) routinely visit homes where multiple families Peggy Foster are living. Its dentists have treated children who don’t Chief Operations Officer, CareSouth have toothbrushes. And clinicians once discovered that a child who’d repeatedly been to the emergency department for asthma exacerbations had been sleeping on the floor for lack of a crib. diabetes, and other cardiovascular conditions that put people at risk of stroke and other complications; This case study describes CareSouth’s efforts to overcome the geographic and economic barriers patients face in • expanding access to behavioral health services, accessing care. These strategies include: including treatment of opioid use disorder; • assigning community health workers to help people • partnering with community groups to bring resources find safe housing, nutritious foods, and other social like health coaching to the region; and supports; • joining with other FQHCs to pursue value-based • fielding medical assistants to help people manage payment and using incentives earned from Medicaid prevalent chronic conditions, including hypertension, managed care companies to finance additional services. CareSouth Carolina: Patients Served 56% of patients are African American 40% are white 60% are female 49% 24% have hypertension have diabetes 57% live at or below the federal poverty level (FPL) Medicaid Uninsured Medicare Dually covered 31% 25% 19% by Medicare and Medicaid 6% 66% live at or below 200% of FPL Data: “2018 CareSouth Carolina, Inc., Health Center Program Awardee Data,” UDS Data Comparisons (Health Resources and Services Administration, 2018). commonwealthfund.org Case Study, February 2020 Building Partnerships to Improve Health in the Rural South: CareSouth Carolina 4 BRINGING SUPPORT SERVICES INTO THE when we go to their home, we can see they have no heat or COMMUNITY air conditioning, or they might not have adequate food.” CareSouth was founded in 1980 to help meet the need for CareSouth’s approach to engaging patients and helping primary care in the region. Since 2013, all of its clinics have them manage their conditions was shaped by its been certified by the Joint Commission as patient-centered participation from 2012 to 2017 in the Robert Wood medical homes — a testament to leaders’ efforts to field Johnson Foundation’s Learning from Effective Ambulatory teams of physicians, nurse practitioners, nurses, medical Practices initiative. This program brought together assistants, and social workers across a vast service area, in leaders from 30 practices to explore ways to leverage their some cases by using floaters who travel from clinic to clinic. In Lee County, CareSouth is the only health care provider. workforces to improve care quality, efficiency, and job satisfaction. To further extend its reach, CareSouth dispatches mobile units and sends clinicians into schools and churches. And After speaking with other practice leaders from around for the past five years, it has relied on teams of community the country, CareSouth’s CEO Ann Lewis realized her care health workers and medical assistants to uncover patients’ management staff — who at the time were mainly nurses — needs and offer practical support. “Patients come in to could reach more people if they customized services to medical visits dressed in their Sunday best,” says Brenda patients’ particular needs. “We realized we didn’t need to Petruccelli, one of CareSouth’s family support staff. “But [provide the same] things to all people,” she says. CareSouth operates 14 clinics, with its largest in Hartsville. It relies heavily on nurse practitioners, who are easier to recruit than physicians and under South Carolina law can manage their own panels of patients. commonwealthfund.org Case Study, February 2020 Building Partnerships to Improve Health in the Rural South: CareSouth Carolina 5 In 2015, the health center launched a three-tiered model BRINGING SERVICES INTO THE of what it calls family support services. Patients’ needs COMMUNITY are identified by their clinicians, medical record review, and a screening tool that assesses whether they have Through the Miles of Smiles program, CareSouth’s sufficient food, stable housing, and income and whether dentists and hygienists travel to 35 schools in a they’ve experienced trauma, violence, discrimination, mobile dental clinic that offers cleanings, sealants, or harassment. Those who appear to need help are then and X-rays, reaching more than 2,000 children a assigned an advocate, community health worker, or year. The need is acute: teachers report that tooth medical assistant, depending on their needs. In 2018, pain is a leading cause of student absences, and CareSouth’s 39 family support services staff members dentists have had to extract children’s teeth and worked with 15,000 patients, logging some 75,000 visits, implant dentures because of severe problems. phone calls, or other interactions. They record their activities in patients’ electronic health records and offer CareSouth also operates a dental clinic and sends updates to their clinicians during daily huddles. another mobile dental van to treat adults at other sites. Level 1 family support services staff serve as advocates, helping patients enroll in health insurance or other benefit The health center struggles to get adolescents to programs and encouraging them to get vaccinations, come to the clinics for well-child visits (just 30% cancer screenings, and other preventive care. In Hartsville, of teens had one last year). To reach more teens, Ann Chapman recently helped a woman who had been clinicians offer well-child services at 35 middle and diagnosed with multiple sclerosis and needed an MRI scan high schools. And for the past four years, social just after she lost her job and health insurance. Chapman workers have offered counseling to kids and teens was able to secure financial and other support for the in eight public schools. They work with about 300 patient through the Multiple Sclerosis Society. students at a time, many with attention-deficit/ Level 2 family support services staff are CHWs who offer hyperactivity disorder or other behavioral issues health education and coaching to patients with moderate and some who are coping with domestic violence needs, such as those newly diagnosed with a chronic or other problems at home. condition or those struggling to adhere to a treatment plan. They must complete a yearlong training course (which CareSouth helped develop) at a local community college that includes fieldwork and lessons on patient engagement tools such as motivational interviewing. With some 12,000 hypertension patients and more than 6,000 diabetes patients, there’s enormous need. “It used to be, we could have a day where you could bring in all the patients who had diabetes, and you could do education,” says Randall Carlyle, chief quality officer. “It’s gotten to where now, every day is diabetes day.” CHWs also identify patients’ social needs and connect them with food banks, housing programs, and other sources of support. They share information about patients’ circumstances with CareSouth Carolina CEO Ann Lewis in front of the health clinicians, who can then make treatment recommendations center’s mobile dental clinic. commonwealthfund.org Case Study, February 2020 Building Partnerships to Improve Health in the Rural South: CareSouth Carolina 6 as actionable as possible. “A lot of our patients are too proud to tell their LIFE AND DEATH IN THE STROKE BELT clinicians about their problems,” says Carlyle. “But they may confide in a CareSouth serves five counties that are part of what’s known as the CHW. And getting a better handle “buckle” of the stroke belt: 153 counties in North Carolina, South on what’s going on with the patient Carolina, and Georgia where death rates from stroke have been twice outside of the visit has been key for as high as the rest of the U.S. for several decades.1 Researchers have our providers.” identified several factors that may contribute to the problem, including Level 3 family support services staff worse access to health care services, lower quality of care, greater are medical assistants who assist health risks (particularly hypertension and diabetes), greater behavioral people with greater medical needs, risks (smoking and fatty, salty diets), environmental risks (certain most of whom have diabetes and/ minerals in the water and soil), and the effects of poverty and racism. or hypertension, and many wind up in the emergency department or Along with the nation, South Carolina has made strides in recent years hospital from complications of their in reducing stroke deaths, mainly because of advances in treatment chronic conditions. The medical during the first crucial hours after an occurrence. Still, stroke rates in assistants offer them hands-on support in managing medications as the state are the sixth-highest in the nation, and black residents are well as coaching to help them make 43 percent more likely to die from stroke than white South Carolinians.2 changes, like finding affordable ways to exercise or adjusting their favorite Stroke Mortality Rate by Race in South Carolina, 1999–2016 recipes to make them healthier. 140 Petruccelli, a medical assistant, helped a man with uncontrolled diabetes 120 and hypertension who had become 100 isolated in his home, eating meals on his own instead of with his family. “I 80 discovered he liked gardening and 60 Black so we talked about how gardening All races gets him outside, and how what he’s 40 White growing will help him provide for his 20 family. He felt very down about not being able to do that,” she says. After a 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 few months, the man agreed to have a Note: Rate per 100,000 (Adjusted rates: 2000 population – South Carolina Death Data – ICD10). retinal eye exam to screen for diabetic Data: South Carolina Department of Health and Environmental Control. retinopathy and reduced his A1c from Source: a 14.7 to an 11.7 — better, but still Recognizing the signs of stroke and getting to the hospital quickly are elevated. “I was constantly in contact key to reducing stroke mortality and morbidity; treatment is most with him and eventually, he started effective within two hours of the start of symptoms.3 But many people having an occasional meal with his in the Pee Dee region lack reliable transportation, and the nearest wife,” she says. “Once, he said to me, ‘You act like you care and want me to hospital is often miles away.4 Lack of information about strokes also be healthy.’” may be part of the problem.5 commonwealthfund.org Case Study, February 2020 Building Partnerships to Improve Health in the Rural South: CareSouth Carolina 7 Some people may be fatalistic about their disease. Maybe their mother or father was diabetic and died at 50. I sit down with them and say, ‘This is what is going to happen: you are going to lose your fingers, your toes unless you make a change.’ For some people this is a wake-up call. But you can’t talk to somebody that way unless you get to know them. Deloras Jackson Level 3 family support services staff member INTEGRATING BEHAVIORAL CARESOUTH CAROLINA’S HEALTH LITERACY AND HEALTH SERVICES EDUCATIONAL ASSESSMENT CareSouth integrated its behavioral and physical health care services 25 years ago. At the time, patients often had to wait six weeks or longer for appointments at community mental health clinics, and many gave up before being seen. CareSouth began hiring its own counselors, mainly licensed clinical social workers, to offer behavioral health assessments and treatment. Today, each of the 14 clinics has a counselor. Primary care clinicians screen patients at all visits for signs of depression, substance abuse, and other behavioral health problems, and counselors reserve 15 minutes of each hour so they can offer immediate consultations if problems are detected. Providing this level of access requires a large behavioral health team. CareSouth has built its pipeline by training social work interns from the University of South Carolina, many of whom return to work at CareSouth after graduation, and by giving staff Data: CareSouth Carolina. time off to pursue master’s degrees in clinical social work. commonwealthfund.org Case Study, February 2020 Building Partnerships to Improve Health in the Rural South: CareSouth Carolina 8 CareSouth’s approach to behavioral health services was receiving treatment, medications were not being titrated shaped by its involvement, from 2001 to 2006, in one of up as needed. “I think we fell into the trap of thinking some the Health Disparities Collaboratives led by the Health patients have low incomes or unreliable transportation, Resources and Services Administration. The collaborative so let’s not stress them by making them come in,” says brought together 94 community health centers in an Elizabeth Kershner, M.S.W., director of behavioral health. effort to reduce disparities in depression treatment and “And so, there was a big push to make clinicians aware of outcomes based on research that had shown that patients the disparity. We expect everyone to be able to get better, with low incomes were more likely than those with and it’s our responsibility to meet them where they are and higher incomes to have depression but less likely to be give them the support they need.” treated.6 Participants in the collaboratives used the Patient Health Questionnaire (PHQ ) to screen all patients, at least Kershner and her colleagues began auditing records to annually, for depression; engage people in treatment; and ensure everyone who screens positive on the PHQ receives track outcomes. CareSouth was one of seven centers that a full psychosocial assessment, a treatment plan, and goals reduced patients’ depression symptoms and sustained the for care, and then deploying outreach staff to encourage improvements over time.7 them to come in for treatment. She also began tracking Still, it took more focused work to reduce racial disparities depression treatment and outcomes and sharing the data in depression control. In 2003, CareSouth’s black patients with clinicians in monthly reports. During the past year, who screened positive for depression were 15 percent less CareSouth has closed the gap between black and white likely to receive treatment than white patients; among those patients in terms of depression control. DEPRESSION CONTROL AMONG WHITE AND NONWHITE CARESOUTH CAROLINA PATIENTS, 2018 Goal Aug Sept Oct Nov Dec Patients ages 12 to 100, with current diagnosis of major depression, with initial PHQ 10 or greater, who 50% had at least 50% improvement in PHQ Total patients 507 327 378 413 424 Total patients with PHQ 50% improved 172 105 106 109 104 Percentage of total patients with improvement 33.9% 32.1% 28.0% 26.4% 24.5% White patients 286 184 216 235 243 White patients with improvement 95 58 62 62 58 Percentage of white patients with improvement 33.2% 31.5% 28.7% 26.4% 23.9% Nonwhite patients 221 143 162 178 181 Nonwhite patients with improvement 77 47 44 47 46 Percentage of nonwhite patients with improvement 34.8% 32.9% 27.2% 26.4% 25.4% Disparity of improvement between white and –1.6% –1.3% 1.5% 0.0% –1.5% nonwhite patient populations Notes: Population is CareSouth Carolina patients ages 12 to 100 with a current diagnosis of major depression and an initial PHQ of 10 or greater who had at least 50% improvement in PHQ. PHQ = Patient Health Questionnaire, a survey instrument given to patients in primary care settings that screens for the presence and severity of depression. Segments may not sum to disparity totals because of rounding. Data: CareSouth Carolina. commonwealthfund.org Case Study, February 2020 Building Partnerships to Improve Health in the Rural South: CareSouth Carolina 9 In addition to treating patients with depression, clinicians percent said they were dissuaded from seeking medical at CareSouth see many experiencing anxiety or other care by the high costs of prescription drugs, and 32 percent effects of trauma, some related to family violence or pointed to other out-of-pocket health care costs.8 neglect and some related to military service. For patients To encourage more people to seek care, family support with treatment-resistant depression, bipolar disorder, services staff canvas neighborhoods to let people know or other complex conditions, clinicians make frequent CareSouth’s services are available to all, regardless of consults via videoconference with University of South their ability to pay. (Like other FQHCs, CareSouth charges Carolina psychiatrists. sliding-scale fees based on patients’ income; the average visit has a $10 copayment.) The health center recently Substance Abuse Treatment created a fund to cover patients’ copayments for drugs In 2016, CareSouth began offering medication-assisted to manage diabetes, hypertension, asthma, and mental treatment (MAT) for opioid use disorder after being health conditions. Any patient with family income at or approached by the state’s drug and alcohol agency for below 200 percent of the federal poverty level ($25,750 for help in coping with the opioid epidemic. At the time, a family of four in 2019) is eligible for this assistance. no clinicians in the region offered MAT; today, 13 CareSouth clinicians have gone through the waiver process required to prescribe buprenorphine. Together, they treat about 800 patients a year. Our culture here has been one Stephen Smith, M.D., medical director, was the first of working together to solve to step forward, and his success built the will for problems. There’s enough for others to do so. “He tells a story about a whole family that showed up in his church in gratitude for having everybody to say grace over. gotten their family back together through medication- assisted therapy,” says CEO Lewis. “He tells people, Ann Lewis ‘Ain’t nobody gonna show up in my church to thank CEO, CareSouth me for helping them lower their cholesterol.’” In treating opioid use disorder, CareSouth has partnered with local drug and alcohol treatment providers CareSouth is also a founding member of the Northeastern who offer counseling to patients while they receive MAT. Rural Health Network, which in 2017 won a grant from the The health center recently launched a MAT van to make Duke Endowment to improve health in Dillon, Marlboro, the rounds at three drug and alcohol treatment agencies and Chesterfield counties. Given broad latitude to figure so that people can undergo drug screenings, receive their out how to do so, members of the network adopted the medication, and take part in counseling in one place. Faithful Families curriculum, a national program in which “We’re hoping that we’ll reduce some barriers to access,” health educators partner with church leaders to encourage says Kershner. parishioners to eat healthy and be active. FORGING COMMUNITY PARTNERSHIPS COLLABORATING WITH OTHER COMMUNITY CareSouth collaborates with county officials, nonprofits, HEALTH CENTERS and social service agencies to assess residents’ needs. In In 2008, CareSouth and 13 other South Carolina FQHCs one such effort, the partners surveyed 1,300 residents (out of 22 in the state) formed the independent practice about their health experiences and views. Forty-three association Community Integrated Management commonwealthfund.org Case Study, February 2020 Building Partnerships to Improve Health in the Rural South: CareSouth Carolina 10 Systems (CIMS) in response to South Carolina’s decision never graced our doors,” says Leventis. Not only are many to shift Medicaid beneficiaries from fee-for-service to people missing out on preventive and primary care, but the managed care. Health centers were being inundated FQHCs are held accountable for beneficiaries’ health care by overtures from managed care plans seeking to enter spending and outcomes, whether or not they treat them. the market and needed help negotiating value-based contracts, according to Peter Leventis, CEO of CIMS. For the past four years, CareSouth has fielded three community health workers to three local hospitals, where Today, Leventis negotiates contracts with four Medicaid they encourage people visiting the emergency departments managed care plans that pay health centers per member to come in for primary care. This and other efforts seem per month (PMPM) fees, including an additional $1.50 to have been effective: While in 2018 about one-quarter of to $3.00 PMPM to fund care management services, plus Medicaid beneficiaries assigned to CareSouth had never incentive payments if providers improve performance on visited its clinics, by the first half of 2019 only 20 percent of measures of health care quality and cost.9 Each year, CIMS beneficiaries have not visited. distributes the incentive payments to health centers based on their volume of patients and performance. It holds back Since 2018, CIMS members have held regular calls to funds when a health center falls short and uses the money compare performance reports and share strategies for to offer clinical training programs or other support. closing gaps in care. CareSouth leaders visited two health This collaboration has enabled the health centers to centers that had created dedicated teams to focus on leverage shared resources. Early on, CIMS members particular populations. Under the leadership of Jeniqua invested in a performance dashboard that has helped Duncan, D.O., M.B.A., associate medical director, CareSouth leaders make sense of the medical claims data they receive then created three teams: one focused on Medicare from health plans. They’ve also used the dashboard to beneficiaries, another focused on Medicaid beneficiaries, generate lists of assigned beneficiaries they’ve never seen, so and a third focused on overseeing specialist referrals and patients can be targeted for outreach. “Between 22 percent following up with all patients after hospitalizations or and 40 percent of those assigned to our health centers have emergency department visits. PERFORMANCE MEASURES REPORTED TO MANAGED CARE PLANS BY CIMS MEMBERS • Well-infant visits 0–15 months: six or more visits • Breast cancer screening: one every two years • Well-child visits ages 3–6 years: one visit • Asthma pharmacological therapy ages 5–64 • Adolescent well care ages 12–21 years: one visit • Controlled hypertension: adults ages 18–59 whose • Child and adolescent weight assessment and blood pressure was <140/90 mm Hg; adults ages 60–85 with a diagnosis of diabetes whose blood counseling pressure was <140/90 mm Hg; adults ages 60–85 • Childhood immunization: appropriate before without a diagnosis of diabetes whose blood pressure 2nd birthday was <150/90 mm Hg • Pap tests ages 21–64: every three years unless HPV • Diabetes HbA1c >9% or no measurement during year • Adult body mass index (BMI) screening and follow-up • Diabetes retinal eye exam, dilated • Tobacco use screening: received cessation counseling • Diabetes annual microalbumin screening or on cessation medication • Prenatal patients beginning prenatal care in first • Colorectal cancer screening trimester Data: Community Integrated Management Systems (CIMS). commonwealthfund.org Case Study, February 2020 Building Partnerships to Improve Health in the Rural South: CareSouth Carolina 11 “Our care management staff had been doing so many screenings and services, such as tobacco use screening and things, it was sometimes difficult for them to prioritize,” counseling, weight screening and counseling for children says Duncan. “The new organization helps them become and adults, and depression screening. Leaders attribute experts at engaging certain groups.” this recent progress to the creation of regular performance reports that have enabled them to track care gaps and to For its 2017 performance (the latest data available) in dedicated teams that focus on particular patients and goals. managing Medicaid beneficiaries, CareSouth earned about $650,000 in incentive payments from the managed care In addition, the health center has been able to substantially increase the number of patients screened plans. The additional funds have enabled the health center for colorectal cancer (from 21% in 2016 to 48% in 2018). to pay for CHWs and other aspects of its family support It also has increased the number of patients screened services. for cervical cancer (from 31% in 2016 to 40% in 2018), though the health center remains in the bottom quartile ASSESSING IMPACT of performance among health centers nationally on CareSouth uses a comprehensive scorecard to track this metric. CareSouth still struggles in other areas, performance by individual clinicians, each of its clinics, and particularly in managing chronic conditions. About half the health center as a whole on a range of measures. of patients with hypertension (55%) had their condition under control in 2018 (the fourth quartile of performance), During the past year, the health center has improved its while 70 percent of patients with diabetes had the performance on some measures of preventive health condition under control (the second quartile).10 CARESOUTH CAROLINA PERFORMANCE SCORECARD, 2016–2018 Performance measure 2016 2017 2018 Percent of children ages 3–17 with weight screening and counseling 84.29% 86.72% 92.73% on nutrition and physical activity Percent of adults age 18 and older with body mass index (BMI) 87.85% 85.39% 92.47% screening and follow-up Percent of patients screened for clinical depression and if positive had 76.47% 81.80% 84.03% a follow-up plan documented Percent of adults age 18 and older screened for tobacco use and 94.95% 96.04% 96.38% received cessation counseling Percent of patients screened for colorectal cancer 21.30% 36.21% 47.72% Percent of female patients screened for cervical cancer 30.51% 36.36% 40.40% Percent of diabetic patients with poorly controlled HbA1c 22.69% 31.08% 29.37% (>9%) or no test during year Percent of patients with high blood pressure whose pressure was 55.07% 58.56% 54.82% controlled (<140/90 mm Hg) Percent of adults age 18 and older diagnosed with coronary artery 80.86% 81.52% 88.48% disease and prescribed a lipid-lowering therapy Data: “2018 CareSouth Carolina, Inc., Health Center Program Awardee Data,” UDS Data Comparisons (Health Resources and Services Administration, 2018). commonwealthfund.org Case Study, February 2020 Building Partnerships to Improve Health in the Rural South: CareSouth Carolina 12 To promote improvement, CareSouth offers financial rooted in the South’s history of segregation and infamous incentives to clinical teams who’ve made progress in instances of racism in health care — are part of this closing gaps in recommended care or chronic disease challenge, Lewis says: “There are long, long memories control. All team members share in the quarterly bonuses. associated with that.” “It’s not just clinicians who play a role,” says Carlyle, the To pursue its goal of serving 10,000 more people by 2021, chief quality officer. “It could be a front office person who CareSouth has customized its engagement approaches. is calling patients to get them to come in for a Pap smear. For example, certain staff members are focused on Staff who work in medical records and billing analysts encouraging people to receive preventive services, while share in the bonuses because their work helped you do it.” others are focused on helping people manage chronic conditions. To make further progress, the health center LESSONS may need to further segment patients according to their CareSouth Carolina’s experience offers lessons for other life circumstances and needs and try more customized primary care providers working to engage low-income strategies for engaging those not coming in for care. patients and support them in efforts to build healthier lives. Still, the region’s pervasive poverty — and South Carolina’s Services Must Move Beyond the Clinic decision not to expand Medicaid to more residents — means there is enormous need in the community. “Our CareSouth has for decades worked to improve the quality five counties are stuck at the bottom on health rankings,” of health services it provides. But to gain further traction says CEO Lewis. “Something has got to change.” and reach patients who don’t come in for care, leaders have moved services into the community. Along with Collaborations Can Strengthen Communities operational challenges, there are financial challenges to CareSouth’s work has been amplified through its doing so. Revenues from CareSouth’s pharmacy as well long-standing partnerships with other health care as its managed care contracts help pay for extra services, organizations as well as county agencies, nonprofits, particularly the family support services staff. Grants from churches, and others. Its partnership with other FQHCs, in CareSouth’s charitable arm, as well as from health plans particular, has leveraged more resources for patients and and foundations, fund the mobile dental and medical created a platform for policy discussions with health plans units. But bringing services to all who could benefit may and the state. For example, CIMS has lobbied the state to be difficult without other sources of funding. make well-child visits a condition of school attendance (or CareSouth has begun experimenting with telehealth as at least sports participation) to engage more young people one way to scale its services. It plans to have telehealth in care. “Where you’re really going to affect the health of equipment in schools, so clinicians can support school the community is at that adolescent and that child visit,” nurses in treating sick kids. And it hopes to train family says Bittle, chief of community health. support services staff so they can visit patients in their Partnerships will be key to future successes, says Foster, homes and facilitate virtual visits with providers. the chief operations officer. “Communities are left undone Engaging People in Their Health Is Paramount until groups come together. Nobody can do it alone.” Even with outreach into schools, churches, and homes, CareSouth’s leaders are acutely aware they are not reaching all who might benefit from the health center’s services. Its greatest challenge is “to make health foremost in everyone’s mind,” says CEO Lewis. Overcoming some black residents’ distrust of health care institutions — commonwealthfund.org Case Study, February 2020 Building Partnerships to Improve Health in the Rural South: CareSouth Carolina 13 NOTES 1. The stroke belt itself includes a broader swath of 7. Steven Cole et al., “Improving Care for Depression: Southeastern states where the stroke mortality rate Performance Measures, Outcomes, and Insights from the is about 1.3 to 1.5 times greater than in the rest of the Health Disparities Collaboratives,” Journal of Health Care country. See Don Colburn, “Stroke Belt’s ‘Buckle’ Baffles for the Poor and Underserved 23, no. 3 (Aug. 2012, Suppl.): Experts,” Washington Post, May 27, 1997; George Howard, 154–73. “Why Do We Have a Stroke Belt in the Southeastern United States?,” American Journal of the Medical Sciences 317, no. 8. Michelle DiMeo-Ediger and Jim Emshoff, Chesterfield 3 (Mar. 1999): 160–67; and Douglas J. Lanska and Lewis H. County Health Subcommittee Community Data Report Kuller, “The Geography of Stroke Mortality in the United (Chesterfield County Coordinating Council, Nov. 2015). States and the Concept of a Stroke Belt,” Stroke 26, no. 7 9. CIMS contracts with Molina Healthcare, HealthyBlue, (July 1995): 1145–49. Absolute Total Care, and WellCare. It does not have a 2. South Carolina Department of Health and contract with SelectHealth, the other managed care plan Environmental Control, Heart Disease & Stroke operating in South Carolina. Plans cover both Medicaid Prevention: Strengthening the Chain of Survival, 2010 and Medicare Advantage beneficiaries. Edition (SC DHEC, Dec. 2011); and South Carolina 10. “2018 CareSouth Carolina, Inc., Health Center Program Department of Health and Environmental Control, State of Awardee Data,” UDS Data Comparisons (Health Resources the Heart: Heart Disease in South Carolina (SC DHEC, Feb. and Services Administration, 2018). 2019). 3. Amanda Gardner, “U.S. Stroke Rates Vary Widely by States,” ABC News, Mar. 23, 2008; and “Prevalence of Stroke — United States, 2005,” Morbidity and Mortality Weekly Report 56, no. 19 (May 18, 2007): 469–74. 4. Half of South Carolina residents live more than 30 minutes from a stroke center, and nearly one-third (30%) live more than 60 minutes away from one. See Marsha Samson, Tushar Trivedi, and Khosrow Heidari, “Telestroke Centers as an Option for Addressing Geographical Disparities in Access to Stroke Care in South Carolina, 2013,” Preventing Chronic Disease 12 (Centers for Disease Control and Prevention, Dec. 24, 2015). 5. In 2009, less than half (48.5%) of South Carolinians knew all five warning signs of stroke, and only a third (30%) of those with less than a high school education knew them. See SC DHEC, Heart Disease, 2011. 6. Laura A. Pratt and Debra J. Brody, Depression in the United States Household Population, 2005–2006, NCHS data brief, no. 7 (National Center for Health Statistics, Sept. 2008). commonwealthfund.org Case Study, February 2020 Building Partnerships to Improve Health in the Rural South: CareSouth Carolina 14 ABOUT THE AUTHORS ACKNOWLEDGMENTS Martha Hostetter, M.F.A., is a partner in Pear Tree CareSouth Carolina: Joe Bittle, Rose Brown, Randall Carlyle, Communications. As a consulting writer and editor for Ann Chapman, Jeniqua Duncan, Peggy Foster, Gary Herrington, the Commonwealth Fund and a contributing editor to its Deloras Jackson, Elizabeth Kershner, Ann Lewis, Marianne quarterly publication, Transforming Care, she conducts Liebenberg, Nichelle Nichols, Brenda Petruccelli, and Stephen qualitative research on health care delivery system reforms and Smith. Northeastern Rural Health Network: Christian Barnes innovations. Ms. Hostetter has an M.F.A. from Yale University Young. Community Integrated Management Systems: Peter and a B.A. from the University of Pennsylvania. Leventis. Chesterfield County Coordinating Council: Margaret Plettinger Mitchell. Commonwealth Fund: Melinda Abrams, Sarah Klein is editor of Transforming Care, a quarterly John Craig (retired), Douglas McCarthy, and Jeanne Moore. publication of the Commonwealth Fund that focuses on innovative efforts to transform health care delivery. She has written about health care for more than 15 years as a reporter for For more information about this case study, publications including Crain’s Chicago Business and American please contact: Medical News. Ms. Klein received a B.A. from Washington University in St. Louis and attended the Graduate School of Martha Hostetter Journalism at the University of California at Berkeley. Consulting Writer and Editor The Commonwealth Fund mh@cmwf.org Editorial support was provided by Laura Hegwer. This case study is available on the Commonwealth Commonwealth Fund case studies examine Fund’s website at https://www.commonwealthfund.org/ health care organizations that have achieved high publications/case-study/2020/jan/building-partnerships- performance in a particular area, have undertaken improve-health-rural-south-caresouth-carolina. promising innovations, or exemplify attributes that can foster high performance. It is hoped that other institutions will be able to draw lessons from these cases to inform their own efforts to become high performers. Please note that descriptions of products and services are based on publicly available information or data provided by the featured case study institution(s) and should not be construed as endorsement by the Commonwealth Fund. commonwealthfund.org Case Study, February 2020 About the Commonwealth Fund The mission of the Commonwealth Fund is to promote a high-performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society’s most vulnerable, including low-income people, the uninsured, and people of color. Support for this research was provided by the Commonwealth Fund. The views presented here are those of the authors and not necessarily those of the Commonwealth Fund or its directors, officers, or staff.