Based on a community-wide strategic plan, Santa Cruz County Go for Health! coordinates a broad range of collaborative activities to prevent childhood obesity through improving nutrition and increasing physical activity. A program of United Way of Santa Cruz County, Go for Health! uses the evidence-based 52-10 message developed by the Maine Youth Overweight Collaborative to insure a consistent message is delivered in the schools, recreation programs, social services agencies, health care providers and the community. HIP is partnering with Go for Health! to launch an innovative social marketing and advocacy campaign that includes the use of 52-10 materials by all health care providers including private pediatricians and safety net clinics.
The 52-10 message is:
5 or More Fruits and Vegetables
2 Hours or Less of Recreational Screen Time
1 Hour or More of Vigorous Play
0 Sugar Sweetened Beverages
Health Information Technology (HIT)
HIP recognizes the potential of health information technology in building a stronger local health care system. From 2005 to 2007, HIP led a collaborative effort to develop a community-wide diabetes registry. We also worked with Santa Cruz County to expand the use of the web-based tool, One-E-App, to more efficiently screen and enroll children and adults into Medi-Cal, Healthy Families, Healthy Kids and MediCruz programs. HIP continues to look for opportunities to assist safety net clinics to successfully adopt technology and to use existing technology to improve the local health care system.
POLST/Make Your Wishes Known
End-of-life care comprises the most significant investment of our nation's health care dollars, and it often entails extreme forms of treatment that a patient may not even want. HIP is partnering on two projects to ensure that individuals are treated in accordance with their end-of-life wishes.
Make Your Wishes Known, an initiative jointly sponsored by the Health Improvement Partnership, Hospice of Santa Cruz County and the Santa Cruz County End-of-Life Coalition, works through community educators, physicians and others to disseminate a simple but critical message: complete an Advance Directive (English and Spanish) to make your health care wishes known for your own sake, and for the sake of your loved ones.
The project has helped disseminate thousands of referral cards about how and why community members should complete their Advance Directive, as well as worked with Hospice and the End-of-Life Coalition on trainings for community groups, families, and local businesses about the importance of the forms. Contact Hospice for more information or to schedule a training.
HIP is also working with Hospice and the County of Santa Cruz Emergency Medical Services to establish Physicians Orders for Life-Sustaining Treatment (POLST). POLST became law in California on January 1, 2009. It is a standardized form designed to convert wishes for life-sustaining treatments into medical orders. POLST was created to ensure that treatment wishes are honored in the event that a patient/resident is unable to speak for himself or herself, particularly for those facing serious or life-threatening illnesses.
The goal of our local POLST project is to provide training and consultations for local physicians and emergency workers, and to incorporate best practices from other states who have implemented POLST.
Project Homeless Connect
Project Homeless Connect is a community-based case management program targeting uninsured and publicly insured adults with a high number of visits to hospital emergency departments (EDs) in Santa Cruz County. The project operates as a collaboration between HIP, Dominican Hospital, Watsonville Community Hospital, Central Coast Alliance for Health, and the County Health Services Agency through its Homeless Persons' Health Project. Project Connect uses case management intervention to reach out to and engage each frequent user, to get to the root of what's causing the frequent ED visits, and to use all available resources to relocate care and services in more appropriate, cost-effective settings. Project successes include a 41 percent reduction in annual hospital emergency department visits; a 54 percent reduction in hospital inpatient days; a 33 percent reduction in ambulance transports and a 39 percent reduction in annual number of county jail days.
Regional Diabetes Collaborative (RDC) The mission of the RDC is to support, promote, and coordinate efforts to prevent and manage diabetes in Santa Cruz, San Benito, and Monterey Counties. HIP participates in the RDC and helps support the Annual Diabetes Forum which seeks to engage local providers and health educators, as well as raise awareness about the issue with policymakers.
The Hospitalist Project develops hospitalist programs to coordinate medical care for safety net patients when they are hospitalized in one of three area hospitals. In 2008, HIP took the next step by working to improve the transition from hospital to safety net clinics by linking patients to safety net clinics at hospital admission, making follow-up clinic appointments before discharge, and sending discharge summaries to safety net providers. After six months of collaborative work, the staff at Dominican Hospital cut the number of safety net patients who do not have a primary care provider in half. The goals of the project are to improve coordination of care, reduce hospital readmissions, and improve the patient experience.