Place Matters is a national initiative of the Joint Center for Political and Economic Studies, Health Policy Institute (HPI) designed to improve the health of participating communities by addressing social conditions that lead to poor health.

Cuyahoga County Team partners include:  Board of Cuyahoga County Commissioners, City of Cleveland, Cuyahoga County District Board of Health, Saint Luke’s Foundation, The MetroHealth System, CareSource Ohio, Wellcare of Ohio, Anthem Blue Cross Blue Shield Partnership Plan Inc., The Free Clinic of Greater Cleveland, Buckeye Community Health Plan, Cleveland Clinic Health System, Community Vision Council: Health & Caring For All, University Hospitals Health Systems and Northeast Ohio Neighborhood Health Services.

Statement of Problem:
Residents in Cuyahoga County, Ohio living in low-income areas within the City of Cleveland, disproportionately use emergency departments for their primary medical care.  These residents are either not attached to a medical home or they do not appropriately access their medical home for primary medical care services. The emergency departments, already strained with the provision of trauma and emergent care, are increasingly faced with the demand for non-urgent or semi-urgent primary care.  Nationwide, among the Medicaid and uninsured patient populations, the use of emergency departments settings has increased dramatically (from 20% to 30%; from 2000 to 2005).  Cleveland, Ohio faces an enormous demand on its Emergency Departments (EDs) for primary care treatment of chronic diseases among the uninsured (estimated at 8.8% of the Cuyahoga County population) and under-insured (11.1% of the County population).

The Studying Health System Change (HSC) Initiative conducted in 2006 assessed twelve (12) communities nationally on the use of emergency departments for primary care.  Among the participating communities, Cleveland was highlighted as a community with the highest use of local EDs for primary care.  Initial studies attributed this use of emergency rooms to the lack of access to specialty or primary care settings for chronic conditions and the need for additional resources for the seriously mentally ill populations.

According to the National Center for Health Statistics, 55% of the 90 million visits to emergency departments in the U.S. in 1996 were unnecessary.  In healthcare dollars, this translates to 40.5 million people using services at a rate estimated at four times as much as it costs for routine care at a primary care clinic or physician office.  Chronic diseases account for 70% of all deaths in the U.S., over 75% of the nation’s $1.4 trillion dollars in medical care costs, and one-third of potential life lost before the age of 65 years.

In Cleveland, Ohio there are five chronic conditions that constitute the majority of visits seen by Cuyahoga County’s public hospital, The MetroHealth System, in their ambulatory care clinic settings. Although these chronic conditions do not constitute the entire volume seen by the safety net providers, they represent the majority of cases.  These conditions include (1) hypertension (118,471 cases), (2) Diabetes Mellitus (48,354 cases), (3) Coronary Artery Disease (26,153 cases), (4) Asthma (12,332 cases), and (5) Congestive Heart Failure (9,673 cases).  

Objectives:

1. The Office of Health & Human Services will develop a business case plan by December 31, 2007 that demonstrates the connection between improving health access and the economic stability of Cuyahoga County that includes:
   •    Determining the size of the target population (under or uninsured with chronic conditions using local emergency departments)
   •    Determining the reasons for non or erratic use of safety net providers
   •    Estimating the current financial burden to participating hospitals, Cuyahoga County of continued inappropriate use of emergency departments
   •    Recommendations for establishing the vehicle through which public and private resources can be coordinated to ensure maximum efficiency of federal, state and local resources.
2. Increase knowledge of community leaders regarding the economic impact of inappropriate emergency department use on their sector of the community (e.g. Cuyahoga County and CEO’s of hospitals), as well as other sectors (e.g. FQHC’s, The Free Clinic, managed care providers and philanthropic organizations).
3. Establish community based participatory approaches within four low-income Cleveland area hospital catchment areas to advance county-wide plans to connect the target populations to a medical home.
4. Reduce health disparities in Cuyahoga County among the uninsured and underinsured persons with chronic medical conditions who use emergency departments as a principal source of primary care
5. Link targeted populations to a medical “home”
6. Decrease the inappropriate use of the emergency services for primary care.
7. Increase target population(s) enrollment into the Medicaid program or other forms of insurance
8. Reduce avoidable hospitalizations

Results/Outcomes:

1. Establish maintenance of care protocols within provider systems that define access (i.e. hours of operation, health coaches, where, when and how to access appropriate levels of care) specifically related to the target population, at a minimum.
2. A mechanism will be created that redirects access from emergency departments to ongoing care/medical homes for the targeted population (e.g. persons with chronic conditions).
3. Cuyahoga County residents with chronic disease and/or persons who are insured through Medicaid will have increased access to appropriate health care services as measured by:
4. •    Increase in number of uninsured and/or underinsured residents assigned to medical homes.
   •    Increased participation of the target population in preventative health care.
   •    Fewer numbers of inappropriate visits to the emergency departments in hospitals (percentage to be estimated during business case plan analysis)
   •    Connection to other established initiatives in the community, e.g. evaluating quality of care through The MetroHealth System’s Aligning Forces for Quality grant funded by the Robert Wood Johnson Foundation
   •    Reduction in health disparities related to chronic conditions among the target population. 
5. Connect target population with Cuyahoga County developed prescription drug access resources, when appropriate; to ensure appropriate health outcomes are attained.
   

“PLACE MATTERS is a national initiative of the Joint Center for Political and Economic Studies, Health Policy Institute (HPI) designed to improve the health of participating communities by addressing social conditions that lead to poor health.”

County/Community Partners:  East Cleveland City Government, County Planning Commission, Cuyahoga County Department of Development, Cuyahoga County Board of Health – Environmental Health Service Area, Cuyahoga County Cardiovascular Health Program, Kent Urban Design, Greater Cleveland Lead Advisory, Ohio State University Extension, City Fresh, Coit Road Farmers Market, Huron Hospital, East Cleveland’s Every Citizen Up, International Men of Excellence – youth enrichment program, and Windermere Renaissance Development Corporation.

Problem/Need:
Residents in low-income areas live far fewer years in comparison to higher-income areas.  These place based disparities extend to other health outcomes as well, including cardiovascular disease and diabetes.  Cardiovascular disease is the leading cause of death in the United States.  Historically, the public health response to preventing and controlling cardiovascular disease has been focused on addressing behavioral risk factors. There is a growing body of inter-disciplinary research that demonstrates that these disparities can be impacted with a strategic focus on the promotion of healthy land use as a means of creating an environment for that promotes equal opportunity for healthy lives.  Progressive public health agencies are increasingly investing in strategies such as health impact assessments, to influence the “built environment” to improve population health and reduce health inequalities.  

Community gardening and greening is an effective healthy land use strategy in many aspects. Food justice is promoted among populations with health disparities who may lack access to affordable, nutritious foods.  In addition, community gardens and green  spaces promote physical activity and the role of public health in improving quality of life.  Many older cities in the United States utilize community gardens not only to promote improved nutrition and physical activity, but as a means of rescuing vacant land from the downward spiral of urban blight.

East Cleveland, with a land area of about three (3) square miles and a U.S. Census 2000 population of 27, 217, is one of the most densely settled communities in Cuyahoga County, Ohio.  It is the largest predominantly African-American city in the County with more than 93% of residents identifying themselves as African-American.  This small urban community is dealing with educational, economic, health, and housing challenges.  The city has a poverty rate of 32% and in 2000, 17% of all housing units were vacant.  Heart disease mortality rates are higher in East Cleveland (355/100,000) compared to the county and the nation (10% and 32% higher respectively).  East Cleveland is in need of broad based community revitalization.  In 2003, the county’s master plan committee recommended that the city develop a strategic plan for maintaining, reusing and revitalizing both the existing building stock and the vacant land in the city through a variety of public and private ventures.  The utilization of vacant land for community gardens and green spaces is an initiative that both community residents and city leaders support as a means of revitalizing vacant land and improving the nutrition and physical activity environment.  The existing Cardiovascular Health Program “Healthy Communities” committee has convened both residents and city leaders as a forum for building a strategic plan.

Sources: 1) U.S. Census, 2000.  2) Center on Urban & Community Development, Case Western Reserve University.  3) Northern Ohio Data and Information Service (NODIS), Cleveland State University.

Objectives:

1. Collaborate with the Healthy Communities Committee in the development of a strategic plan to incorporate health into land use policies in East Cleveland.
2. Utilize a health impact assessment to provide formal avenues for East Cleveland residents and city leaders to be actively engaged in the consideration of the health impacts of land use policy initiatives.
3. Establish or enhance opportunities for cardiovascular health promotion in East Cleveland linked to new land use policies.

Results/Outcomes:

1. Increase the number of vacant properties utilized for community gardens and greenspace to begin to revitalize the East Cleveland community.
2. East Cleveland residents will have increased access to cardiovascular health promotion activities that optimize the use of revitalized vacant properties and provide opportunities for improved nutrition, physical activity and mental health.