Mission Statement: To provide quality health services to our patients and training opportunities for healthcare providers resulting in a positive impact on the health of our communities.
Organizational Overview
The Cabin Creek Health Center, Inc. (CCHC) is a federally qualified health center with a network of 4 primary care centers and 4 school based health centers located in Kanawha County, WV. The network consist of the Cabin Creek Health Center located in Dawes; the Riverside Health Center located on the campus of Riverside High School, this location also serves as a school based health center; the Clendenin Health Center located in Clendenin; and the Sissonville Health Center located in Sissonville. Each of these health centers are operational 5 days a week. In addition CCHC operates part time school based health centers at the Sissonville and Herbert Hoover High Schools and East Bank Middle School.
The communities served by CCHC have some of the highest rates in the nation of adult and child poverty and chronic medical conditions, including diabetes, chronic pain, COPD, obesity, and heart disease. West Virginia has the highest rate of disability in the county and southern WV is higher than the rest of the state. WV also has among the highest rates of the nation for behavioral risk factors, e.g. tobacco use, lack of physical activity, and poor nutrition. CCHC cares for a high number of patients with complex poorly controlled health problems along with high rates of behavioral risk.
During the last year CCHC clinic teams provided care to 13,253 patients who had 49,139 clinic visits. Our clinical teams include physicians, mid-level providers, medical assistants, behavioral health consultants, and health coaches. These teams offer our patients a comprehensive set of primary care services including adult and geriatric care, pediatrics, family planning and women's health services, 340-B pharmacy, and behavioral health. In addition our Clendenin location offers prenatal care and delivery as well as dental services.
Addressing the Needs of Our Patients – Innovation at Work
CCHC has undertaken many initiatives to improve the care of patients with multiple chronic conditions and particularly those who are poorly controlled with co-morbid behavioral conditions. This undertaking includes the following components:
Dual Eligible program: CCHS serves as the lead agency on a collaborative program, with two neighboring CHCs, to provide care management for 600 dual eligible (Medicare/Medicaid) patients, 200 from each site. This program follows a model of managed care for a high risk population with multiple chronic conditions and high rates of behavioral health problems, chronic pain, and poly-pharmacy. The model of care focused on the triple aim of medications, transitions, and relationships.
Frail Chronically Ill Elders: Since 2007 CCHC has continued a program to identify frail elders and multiple chronic conditions. A health coach (trained MA) is assigned to monitor the population, provide assistance with access to care, follow-up after hospitalizations, conduct home visits, provide self-care support and be available to respond to patient and family inquiries and requests for health related assistance.
WV Connect for Uninsured Workers: CCHC continues the care coordination of uninsured working adults who are enrolled in the WV Connect program, a federally supported program administered by the state to provide comprehensive primary care to uninsured lower income working people. The participating health centers are paid a monthly capitation for primary medical and behavioral health services, diagnostic testing and care management.
Team Huddles: CCHC implemented "Extended Weekly Team Huddles" at all sites. The huddles include medical providers, MAs, behavioral health consultants (BHC), health coach, receptionists, sometimes a pharmacist, often an administrator. The purpose of the 45-60 minute early AM meeting is to bring all staff insights to bear on the review our most complex patients and to arrive at care plans that are customized to the social and health needs of the patients . Almost all huddles result in follow-up with the patient by the health coach and/or BHC. Huddles have become an important tool in building strong working relationships among care team members, generating staff learning and creating new customized options for patient care.
ACO Development: With two other health centers, CCHC has organized an Accountable Care Organization (ACO) named Mountaineer Accountable Care, LLC. The ACO is currently working the Public Employees Insurance Agency (PEIA) on a Comprehensive Care Program. If the ACO meets certain quality measures they will share in cost savings with the insurance company.
WV Family Health Plan: CCHC is a shareholder of the health center controlled managed care organization named the WV Family Health Plan. The plan, once certified by the Insurance Commission, will participate as a Medicaid managed care provider. This vehicle will permit the State's CHCs to collaborate to create improved care management and health coaching programs to care for high risk/high cost Medicaid patients including SSI-Medicaid patients and dual eligible patients. The FHP timeline calls for the beginning of Medicaid enrollment in July 2013.
Community Wellness Center: CCHC has initiated a community wellness program in collaboration with WV State University of Institute, a Historically Black University. The program is located at an historical home in Malden, WV owned by WVSU and provided by the University to CCHC at no cost. The facility serves as office space for the fulltime VISTA volunteer and part time wellness coordinator. The program is now being developed and will involve conducting a CDC recommended community health survey in the Malden community, collaborating with the local elementary schools on wellness and preventive care programs. The program currently conducts a variety of health related community events including walking tours, health fairs (using our "Wellness Wagon", an RV donated by the WV Council of Churches) and bi-weekly health-related 15-minute TV shows featuring CCHC clinicians and health experts in the region. The TV shows are produced at the State Cultural Center and are broadcast several times per week on the local public access station.
In addition CCHC and its health centers have extensive substantive working relationships with other safety new providers which serve to extend the reach and scope of services, inform health improvement efforts, and to allow CCHC to offer clinical education opportunities. These collaborations, innovations at work, and our staff are vital to the ability of CCHC to fulfill its mission and keep pace with the ever changing health care landscape.
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