Chatham County Safety Net Planning Council

Updated 5/04/2018. Chatham County Safety Net Planning Council, Inc. (ChathamHealthLink), Chatham County, GA, Chatham County Sheriff’s Department, Curtis V. Cooper Primary Health Care and the Georgia Regional Academic Community Health Information Exchange (GRAChIE) are key agencies in a multi-stakeholder initiative to improve the continuity of care system for Chatham County jail inmates. The collaborative was chosen as one of three national finalists (out of 40 submissions) for the Inaugural 2018 Milbank Memorial Fund and AcademyHealth State and Local Innovation Prize.

The prize was developed by the Milbank Memorial Foundation to recognize individuals, teams, or projects that use data to “achieve measurable impact” to improve the health of their communities through innovations implemented on a state and local government level.

The co-finalists were the Chicago Department of Public Health and Department of Innovation and Technology with the University of Chicago Center for Data Science and Public Policy developed a more proactive approach to lead paint exposure and poisoning in children, creating a predictive model that combines data from multiple sectors to identify at-risk children for blood testing or homes for lead inspections and the Washington State Department of Health and Human Services, Washington State Health Care Authority, and the Centers for Medicaid and Medicare Services partnered to integrate state Medicaid and federal Medicare data for predictive modeling that targets innovative care coordination and social service interventions.

The City of Chicago team was announced the winner on the mainstage of the AcademyHealth Datapalooza in Washington, DC on April 26, 2018. More about the Milbank Memorial Fund and the award, click here.

Central to the Chatham County project was to connect the Chatham County Detention Center (CCDC) to our local health information exchange (HIE), ChathamHealthLink (CHL) and by extension the regional HIE, GRAChIE. HIEs enable health providers involved in a patient’s care—whether in a primary care setting, a specialists’ office or emergency department—to share vital patient information including medications, pre-existing conditions, allergies, immunizations, lab results, appointment history and more from within electronic medical records at the point of care. CHL was established by the Chatham County Safety Net Planning Council through funding from the Chatham County Commission in 2008 and became the first HIE in the state of Georgia.

For Chatham County, it became imperative that meaningful health information be accessed at the time of processing or “booking” for detainees at the county jail to effectively support their continuity of care, reduce duplication of services and protect the safety and welfare of everyone in the CCDC system. The county jail’s inmate population has complex healthcare needs. Untreated mental health, substance use disorders, infectious diseases and other chronic conditions are prevalent in this population. Better management of the inmates with mental illnesses and chronic medical conditions would improve safety, reduce costs and better provide for the healthcare needs of this population.

Lisa Hayes, Executive Director of Chatham County Safety Net Planning Council administers CHL and served as project director states, “By incorporating the CCDC detainee population in CHL/GRAChIE, we are better able to close the medical information gap and improve patient safety and health outcomes for those within the county’s jail and those transitioning back into the county’s population.”

Key safety net health providers serving highly vulnerable populations in Chatham county are connected through CHL including, Curtis V Cooper Primary Health Care, Inc. and J.C. Lewis Primary Health Care Centers, Memorial Health University Medical Center, Gateway Community Service Board and Chatham Care Clinic, an HIV+ Ryan White Clinic.

The Chatham County Detention Center (CCDC) is one of the largest jails in GA outside of Metropolitan Atlanta, with approximately 18,000 inmates per year, of which 45% are treated for chronic illness. It is estimated that 90% of the inmate population is uninsured (Georgia is a non-Medicaid expansion state) and does not have access to primary or behavioral health care; CCDC may be their only access to health services Until 2016, the CCDC’s medical records were stored in a “siloed” paper-records system creating barriers and pervasive inefficiencies accessing critical health information and providing adequate care. This situation proved dangerous for both inmates and staff.

Chatham County, GA elected officials and executive leadership have been highly motivated and fully committed to the development, establishment and long-term support for a local HIE, ChathamHealthLink, and in 2015, the CCDC was quickly identified as a critical piece of the Chatham County health care safety net system and central to protecting the continuity of care within this highly vulnerable population. In 2016, John Wilcher was elected Chatham County Sheriff and filled the leadership gap left after the death of the previous Chief Al St. Lawrence. Sheriff Wilcher saw an opportunity to increase vendor accountability, significantly reduce liability for the County and improve the quality of care among those who are in his custody and his support was critical to the success of the project.

The project impact is evident through crossover data recorded from CHL members with the CCDC population. As of December 2017, Memorial recorded 7,185 patients processed through the CCDC. This is compelling when compared with the approximate number of detainees processed over an entire year, 18,000. These patient crossovers account for 39.9% of the total. A holistic system of access to patient health information at the point of care for our most vulnerable population has led to innovations within our community and we are better able to close the medical information gap leading to improved patient safety and health outcomes for those within the county’s jail and those transitioning back into the community.