Connecting the Chronically Ill

In addition, the 1999–2000 Five-County Study of Cardiovascular Disease Risk Factors found that, of these five Florida counties—Baker, Bradford, Columbia, Suwannee, and Union, in which the rates of cardiovascular disease exceeded those for the state as a whole—Baker County had the lowest number of people who received regular blood cholesterol screenings, the highest percentage of overweight people, and a significant proportion of residents with chronic drinking problems.

The consortium members included the following partners:

• The Baker County Health Department provided primary care, case management, prescription drug assistance, and health education services.
• Gateway Community Services, a regional substance abuse treatment provider, offered individual assessments as well as group and individual counseling.
• Northeast Florida State Hospital Community Behavioral Health Services Division, a community-based mental health care provider, offered outpatient mental health counseling, case management, and evaluation services.
• Baker Community Counseling Services, a local substance abuse treatment provider, offered aftercare services.

In addition to providing primary care, case management, prescription assistance, health education, substance abuse, and mental health services, the project also offered diabetes selfmanagement classes, individual wellness planning, referrals for podiatry care and eye exams, laboratory tests, glucometers and test strips, educational materials and health-positive cookbooks, smoking cessation services; referrals to First Place weight loss classes, and transportation services to medical appointments and educational classes.

At first, few residents expressed an interest in receiving substance abuse services—largely because of the stigma associated with treatment. So the project worked with the Baker County Sheriff’s Office so the project could expand it services to incarcerated individuals who also had qualifying health conditions. Incarcerated clients received intake evaluations, individual counseling, and weekly group counseling. In the third year of the grant, the project further expanded its substance abuse program to include aftercare substance abuse treatment services to inmates upon their return to the community.

Primary care, health education, and prescription drug assistance services were provided at the Baker County Health Department. To help promote the program, the health department also conducted educational classes at local churches. Participants in need also received referrals to diabetes education and weight management classes.

The project succeeded in accessing the resources available for health care coverage by developing and maintaining a manual of free and low-cost health care services for medically underserved and chronically ill patients. Nearly 900 clients received education about in Medicaid, Medicare, and Supplemental Security Income (SSI) eligibility. All clients receiving case management services were successfully linked to the health care services for which they qualified within 6 months of entering the program. In addition, 28 percent of participants were permanently enrolled in Medicaid or Medicare.

Baker County is fortunate in that it is located about 36 miles from the closest urban area, and local health care providers routinely collaborated with metropolitan service providers to fill gaps in local health care services. Many other rural communities are more remote and may not have the local health care resources that are available in Baker County, making it more difficult to replicate such a model.

Many project activities will continue, such as the drug assistance program, primary care services, mental health services, and health education. During the no-cost extension period, the HOPE project is launching a community health improvement initiative to target those at risk for chronic illnesses.

As a result of the project’s expansion to provide substance abuse treatment for local inmates, the area’s judicial system has established a drug court program that diverts those who successfully complete the program from jail. Offenders are required to participate in outpatient substance abuse and mental health services as needed. They also receive referrals to the county health department for primary care services. The drug court program has gained substantial momentum, and many community organizations have joined the consortium, which gives offenders access to an even wider range of services.