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PCMH

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Mission

With funding from the Commonwealth’s Prevention and Wellness Trust Fund (PWTF), the Barnstable County Department of Human Services has formed the Barnstable Prevention Partnership of local community health centers and community organizations on Cape Cod to create a referral and health education system that is based on the concept of self-management of health risks. (Chapter 224 of the Acts of 2012: An Act of Improving the Quality of Health Care and Reducing Costs through Increased Transparency, Efficiency and Innovation.)  The Barnstable Prevention Partnership one of nine such partnerships funded by the Commonwealth’s Prevention and Wellness Trust Fund (PWTF) that will be sharing $40 million in grants to help fight chronic illness and improve health outcomes on the community level while reducing health care costs.
 

Partners

The Barnstable County Department of Human Services is the coordinating organization for the grant, working together with the following clinical and community service partners to achieve the goals outlined in the grant.

Clinical Partners:
Community Health Center of Cape Cod
Duffy Health Center
Harbor Community Health Center – Hyannis

Community Partners:
Healthy Living Cape Cod
YMCA of Cape Cod
 

Plan

Service Provision
With PWTF funding our Prevention Network will first focus on the priority conditions of preventing falls (among seniors) and hypertension (plus diabetes) (all adults) within the contiguous towns of Bourne, Falmouth, Mashpee, and Barnstable (combined population of 110,484). These towns represent approximately one-half of Cape Cod’s population and also contain the majority of the persons suffering from the health disparities associated with poverty and disaffiliated aging-in-place.  Evidence-based self-management training will be offered.  Establishing a community service organization focused on self-management to prevent disease and injury is innovative.

Electronic Referral
The Grantors also require that community-based partners providing these services link electronically with the clinical partners in order to systematize referrals and follow-up for clients.  The PWTF is establishing a state-wide network that all partners will utilize as part of our project.  Electronic linkages between community and clinical partners to better manage patients is innovative.

Timeline
Capacity Building Phase (March 1 – December 31, 2014):  The Barnstable County Department of Human Services received $236,000 for the first phase of our work.  Of that over $220,000 was forwarded to our clinical and community partners to prepare their service provision and electronic referral capacity.

Implementation Phase (January 1, 2015 – June 30, 2017):  Having demonstrated our readiness to implement interventions in community and clinical settings, our Barnstable partnership is receiving $1.495 million per year during the project’s 2.5 year Implementation Phase with which to carry forward our work.

Contact

For more information, contact Vaira Harik, Senior Program Manager, Department of Human Services