Community Site Visit

Eastern Jackson County, Missouri

 

Site Visit Report

 



Prepared by:

Felix, Burdine and Associates, Inc.

5100 Tilghman Street, Suite 215

Allentown, PA 18104

Phone: 610-366-1310

Social Reconnaissance Community Site Visit

Eastern Jackson County, Missouri







Table of Contents



Introduction and Report Purpose. . . . . . . . . . . . . . . . .1

Site Visit Purpose . . . . . . . . . . . . . . . . . . . . . . .2

Observations of the Site Visit Team. . . . . . . . . . . . . . .3

Summary Findings . . . . . . . . . . . . . . . . . . . . . . . .5

Addressing the Issues  . . . . . . . . . . . . . . . . . . . . .9

Closing. . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

     Methods . . . . . . . . . . . . . . . . . . . . . . . . . 14

     Detailed Findings . . . . . . . . . . . . . . . . . . . . 15

     Site Visitors and Affiliations. . . . . . . . . . . . . . 33





Introduction and Report Purpose

The Local Investment Commission (LINC) in collaboration with its local partners -- the Eastern

Jackson County Community Health Improvement Project (CHIP), Jackson County United Way

and the Truman Heartland Community Foundation   hosted a series of community meetings on

November 12 and 13, 1998, for a team of visitors from both the federal government and the

State of Missouri.  One purpose of these meetings was for the "visiting" team to listen to leaders,

health and human service providers, and residents of eastern Jackson County to learn about local

health issues, the community's history of working together, and the resources (programs, people,

organizations) available in the community.  A second purpose of these meetings was to provide a

forum for the community to advise the federal government, the state, and themselves about how

to more effectively meet the needs of underserved persons.



The purpose of this report is to summarize the information shared during community

discussions, and to provide a document from which the partners involved in the process can

begin to build specific next steps to address the issues that emerged from the discussions. 

    

This report begins with a summary of the team's observations from the site visit.  Summary

findings from the community discussion groups are then presented.  Several ideas emerged from

the community discussions, and the team offers suggestions for next steps around those

strategies in the "Addressing the Issues" section.  The Appendix to this report includes a

description of the methods used to organize the community discussion groups, detailed findings

from all community meetings, and a copy of the sign in sheets as filled out by the discussion

group participants.  Also included is a list of site visitors and their affiliations.



As a last introductory note, the audience for this report is LINC leadership and staff, and 

community members who attended a community meeting.  An "Executive Summary" of this

document could be developed for broader dissemination in the community, with information

geared for a specific target group (e.g., media, local legislators).





Site Visit Purpose

The Local Investment Commission sponsored a series of community discussions in November

1998 as part of a site visit from the Health Resources and Services Administration's (HRSA)

Region 7 Field Office in Kansas City, Missouri.   This office has responsibility for oversight of

programs -- in Missouri, Iowa, Nebraska and Kansas    whose purposes are to increase access to

primary and preventive health care and decrease health disparities in communities.  The

Missouri Primary Health Care Association were also participants in the site visit.  This

organizations has worked with community-based health care providers to monitor the needs of

underserved persons in the community and leverage resources that can meet those needs.



The site visit to eastern Jackson County by the HRSA Field Office continues and bolsters their

tradition of using community-based approaches to best understand how to meet their

responsibilities and mission.  Specifically the purpose of this site visit was to better understand,

from the eastern Jackson County population, what they perceive to be important health needs,

and to assess if the system currently in place is providing the services needed to meet gaps in

primary care services in eastern Jackson County.  The site visit team was also seeking to identify

existing activities in eastern Jackson County that can help increase access to health care for the

underserved.



There is an additional motivation for these state and federal organizations to interact with

communities.  The Bureau of Primary Health Care (BPHC) within HRSA has recently

announced a national vision for its programs:  a safety-net of providers should be in place in

each community, such that the entire population ("100%") has access to primary care, and the

underserved have no disparities ("0%") in their health status.  Underserved communities are a

logical place to begin testing this vision, and one outcome applying the information gathered

during the site visit to eastern Jackson County could be a demonstration project that incorporates

the Bureau's vision of "100% Access and 0% Disparities."   



As the local partner in this process, the Local Investment Commission wanted to take advantage

of the community meeting process to educate a larger audience about current health issues, and

the activities and resources in place to address them.  Additionally, LINC was interested in using

the community discussions as a source of additional information and as an opportunity to engage

additional partners to address issues specific to eastern Jackson County.

Observations of the Site Visit Team



	* Approximately 150  people from several municipalities in eastern Jackson County

     participated in community discussions over the course of a two-day site visit.   Their

     comments provided the team with a cross-section of valuable input from community

     members, leaders and health and human service providers.



	* Eastern Jackson County is composed of seventeen municipalities and towns that have

     their own leadership, structures and regulations.  Working across these jurisdictions to

     address issues requires multiple partners, coordination, and respect for the issues and

     characteristics of each municipality.



	* To some extent, each municipality has aspects of being a "bedroom" community of

     Kansas City, as well as a "self-contained" unit.  For example, each municipality has a

     proportion of people who work in Kansas City, and a proportion who work locally.  This

     mix of people has made "connectedness" within municipalities and across eastern

     Jackson County a challenge.



	* Persons in eastern Jackson County who are enrolled in the Medicaid program, or

     who are uninsured do not have adequate access to dental health services.  There are

     many reasons for this:  dentists in the eastern part of the county do not accept Medicaid,

     or, for the few providers in eastern Jackson County that do accept Medicaid patients,

     their practices may be closed to new Medicaid patients.  The State Child Health

     Insurance Program provides coverage for dental services, however, expanded eligibility

     and payment of dental services for children may not result in increased access if dentists

     do not accept payment from this new insurance program.  Dental coverage is often not a

     component of the insurance plan that hourly-wage workers obtain from their employers,

     and the costs of preventive care are too high for payment out-of-pocket.  Dental services

     for poor or uninsured persons are available at several facilities in Kansas City, however,

     arranging transportation to and from these facilities is problematic.  Truman Medical

     Center East is a local resource for dental health services for Medicaid insured persons.



	* For the entire population, mental health services are challenging to access.  Eastern

     Jackson County may not have enough, or the right mix of mental health professionals to

     meet the needs of the community.



	* Community members and service providers stressed the critical insurance issues for

     low-income and working poor families:  it is challenging for many people to purchase

     insurance (either from a plan or through a payroll deduction) and afford deductibles or

     co-payments for services.   This is a particular consideration for families who are now

     involved in welfare-to-work approaches: community members cited that the insurance

     coverage offered by many companies leaves families in a more stressful financial

     situation then when they were Medicaid insured, and it made them question the value of

     employment compared to staying on welfare.



	* Many people in eastern Jackson County do not have reliable, accessible or an

     affordable means of transportation.  Health and human service providers and

     community residents alike shared that lack of transportation is the reason many people

     cannot "get to" (or get home from) services they need (either in eastern Jackson County

     or in Kansas City).  Transportation for health services specifically was often cited as

     inconvenient, too expensive, or not capable of meeting the special needs of disabled

     persons.  The broad geographic area that constitutes "eastern Jackson County" makes

     addressing this issue a challenge.



	* Eastern Jackson County is a good case study for a challenge that faces many underserved

     persons: expanded insurance eligibility and coverage may not result in increased

     access to services. There are many reasons for this, including lack of providers, lack of

     acceptance of public insurance programs by existing providers, continued transportation

     problems of individuals and families despite having insurance coverage for services. As

     LINC moves forward in addressing health and access issues in eastern Jackson County,

     this dynamic could be considered in the design of approaches that attempt to increase

     access to services.



	* There appears to be a preference for people to use services within their own

     neighborhood.  Transportation was one reason for this preference: service providers

     shared that a trip into Kansas City was unrealistic for some families, even feared by

     others.  The personal treatment of persons who are poor or uninsured was a second

     preference for obtaining services locally.  Institutions, including hospitals, are perceived

     by many to be threatening or disrespectful; local, familiar providers, such as the school-

     based clinics, do not have this reputation, and serve as "community" centers of service.



	* There is a lack of awareness on the part of both consumers and providers about

     exactly what services exist, and to what extent, in eastern Jackson County. One

     example of this is the families in eastern Jackson County with children eligible for the

     State Child Health Insurance Program who are unaware of the eligibility requirements, or

     how to enroll. There is a general feeling in the community that more "education" --

     through stepped-up efforts to communicate what is available to people in both traditional

     (radio, newspaper, fliers) and non-traditional ways (going door to door to announce

     programs) -- would help both consumers and providers to access services more

     appropriately. 



	* LINC can research and explore "best practices" around financing of its Caring

     Communities-funded, school-based health clinics.  The clinics located at Cler-Mont

     Elementary, Procter Elementary, Van Horn High School (for which Truman Medical

     Center East is the source of providers), and Randall Elementary (for which the Medical

     Center of Independence is the source of providers) currently provide free services.  To

     ensure that services are available through these clinics in the future, a combination of

     creative financing approaches might be considered that could create an "annuity" stream

     of resources for the clinics.  This approach would allow them to continue to meet the

     needs of the community, preserve accessibility and quality of services, and deal with

     future financial constraints.



	* Addressing health issues specific to eastern Jackson County will require a strong

     coalition of leaders who focus on the eastern portion of the county.  Existing

     collaborative efforts and resources in eastern Jackson County could be built on, and

     directed in a common effort, as a means to provide this focus.



	* The community meeting process allowed the site visit team to get a good "geographical

     sense" of eastern Jackson County, an appreciation for the existing resources as well as

     the needs of the community. 



Summary Findings from Community Discussions

Summary findings are synthesized from the community discussion groups conducted during the

site visit.  Each community meeting used a similar agenda: introductions, definition of

community (from the participant's perspective), current community issues and challenges faced

by the community, history of collaborative problem solving in the community, and a description

of the resources that exist.  Each meeting closed with a request for advice: this advice was

solicited for both the community, and for the site visitors.  Summary findings are reported here

in the order of the discussion group agenda. 



Definition/Description of Community

Eastern Jackson County was described as the part of Jackson County within the County

boundaries, but outside the Kansas City border.  In eastern Jackson County, there are seventeen 

"communities" or municipalities, each with their own local infrastructure.  Community leaders

from across these municipalities described that they have begun to think regionally, which is

required to leverage resources in a county that also contains a large city.



Community meetings were held in several different communities within eastern Jackson County

as part of the site visit.  Despite the distances and differences between each, there were

descriptions of the "community" (eastern Jackson County) that were similar:

	* The population is largely White/Caucasian, although there are some pockets of Hispanic

     and African American families.

	* Each community has elements of being a bedroom community for Kansas City, as well

     as its own "unit."

	* The municipalities were described as diverse economically and in the age distribution of

     the people: all incomes and ages tend to be represented.  In general, the communities are

     poorer, and have fewer services, the farther east you move from the city.

	* Eastern Jackson County as whole is growing: there is more traffic, more building and

     people moving into the area from the city.

	* Schools are centers of activity and service provision in each of the communities; they

     provide an important social connection for many families.



Service providers and community members perceive that the income disparity between the rich

and poor in eastern Jackson County is growing, and that there is a large population of working

poor persons, and an increasing proportion of children who are in poor families.



Issues

There were several key issues that emerged from the community discussion groups:  

	* Inadequate or inaccessible transportation is a barrier to receiving services for a large

     segment of the eastern Jackson County community.



	* Persons in eastern Jackson County who are enrolled in the Medicaid program, or who are

     uninsured do not have adequate access to dental health services.  There are many reasons

     for this:  dentists in the eastern part of the county do not accept Medicaid, or, for the few

     providers in eastern Jackson County that do accept Medicaid patients, their practices may

     be closed to new Medicaid patients.  Dental coverage is often not a component of the

     insurance plan that hourly-wage workers obtain from their employers, and the costs of

     preventive care are too high for payment out-of-pocket.  Dental services for poor or

     uninsured persons are available at several facilities in Kansas City, however, arranging

     transportation to and from these facilities is problematic.  Truman Medical Center East is

     a local resource for dental health services for Medicaid insured persons, however, a 6-9

     month wait is typical.  In Lee Summit, one dentist offers one day a year of free care.  Ft.

     Osage School District arranged for dental screenings last academic year, but the case

     management required to connect children with dental care was too intensive. 



	* The entire population of eastern Jackson County has challenges in obtaining mental

     health services, not just poor or uninsured persons.  Service providers and community

     members questioned the "mix" of mental health professionals available, and if they were

     suitable or adequate to meet the needs of the population.



	* Many families cannot afford both the cost of an insurance plan (which may come from

     their paycheck), and the cost of deductibles or co-payments that accompany those plans

     when they receive services.     



	* There is a lack of awareness on the part of both consumers and providers about exactly

     what services exist, to what extent, in eastern Jackson County. One example of this is the

     families in eastern Jackson County with children eligible for the State Child Health

     Insurance Program who are unaware of the eligibility requirements, or how to enroll.

     There is a general feeling in the community that more "education" -- through stepped-up

     efforts to communicate what is available to people in both traditional (radio, newspaper,

     fliers) and non-traditional ways (going door to door to announce programs) -- would help

     both consumers and providers to access services more appropriately. 



Challenges

Community members described the following challenges for eastern Jackson County:

	* Funding restrictions and regulations have prevented service providers from addressing

     issues, such as transportation.

	* The Community Health Improvement Project (CHIP) has pulled together data from

     multiple assessments that have been conducted in eastern Jackson County.  One

     challenge shared by this group is that the collection of data and indicators specific to

     eastern Jackson County is not systematic, therefore, it is challenging to convey to

     resource holders the extent and type of issues faced by the communities in the eastern

     part of the county.  A second challenge is that there is not a system for using data already

     collected in eastern Jackson County to measure the progress of health improvement or

     collaborative efforts.  

	* Many people who live in the communities of eastern Jackson County will not or cannot

     travel into Kansas City - or even out of their neighborhood -- for services.  Lack of

     transportation, fear, and poor treatment by service providers and institutions were cited

     by discussion group participants as reasons for this. 

	* Access to dental services and primary health care for people with disabilities was cited as

     a community challenge.  Often, vehicles or vans available through special programs are

     not equipped to transport wheelchairs, and equipment in physician and dental offices are

     often not suitable for treating persons with disabilities.  

	* The implementation of Medicaid managed care has made access to basic services a

     challenge for some Medicaid enrolled families: requirements for the program now

     include obtaining approval from a primary care provider, which often necessitates a call

     back from a doctor.  Persons without phones in their homes have found this aspect of the

     program to be a challenge.  Additionally, some families cited that Medicaid "loses" you

     between the approval process and when a bill is issued; sometimes bills are sent in error

     or for services that are covered by the program.

	* An inability to receive support and funding for programs to care for the needs of elderly

     persons was cited as a challenge by some service providers.  Lack of awareness around

     the needs of elderly persons was given as a factor contributing to this challenge.



History of Collaboration

LINC is a national model for collaborative problem solving at the community level.  The success

and growth of this organization has influenced the thinking of many in eastern Jackson County

about collaboration.  For example, there is an appreciation that collaboration takes time and

energy, and that the process in which people work together to solve problems is as important as

the results. 



The eastern Jackson County Betterment Council, the Eastern Jackson County Community Health

Improvement Project (CHIP), the Truman Heartland Community Foundation, LINC, and

ministerial alliances were listed as specific collaborations in the eastern part of the county. 

Some service providers indicated that eastern Jackson County organizations are recognizing that

collaboration is the key to retaining resources among organizations in the eastern part of the

county.  The "Detailed Findings" section contains a complete list of the collaborative efforts

listed by community discussion participants.



Resources

During the discussions, community members were asked to list what they perceived as

"resources" in the community.  In some discussions, probe questions were asked to find out

about resources available to address specific issues.



There is a wealth of resources in eastern Jackson County: programs, services, and institutions.

Common resources listed by communities included schools, churches/ministerial alliances, the

LINC Caring Communities-funded clinics, hospitals and health care providers and local

community programs that provide services to families in need, health departments (city), and

local foundations (the United Way, Truman Heartland Foundation).  The complete list from the

discussions is included in the "Detailed Findings" section in the Appendix to this report.



Advice

Advice was solicited from community members in two areas: advice that community members

would have for their community, and advice for federal and state resource holders in working

with communities.



Advice from participants for addressing issues and challenges included the following:

	* Balance the funding of short-term ideas with commitment to solving long-term issues.

	* Improve awareness in the community about what is available: have meetings, provide

     information, use churches, create local "chambers of commerce" for social issues,

     communicate in non-traditional ways and formats to get the word across.  Create a

     central resource such as a 1-800 number where people can call for information.  This

     would benefit consumers and  providers who refer people for services.

	* Consumer input has to be first, not an afterthought, in a meaningful process.

	* Resources have to be devoted to focusing on prevention of health problems in the

     community.

	* Use data and develop business plans to determine how issues will be addressed.



Advice for state and federal site visitors included the following:  

	* Outside entities should honor and participate in structures that exist in communities.

	* Eliminate or stop categorical funding, e.g., allow us to do programs for all children.

	* Instead of sending out RFPs with predetermined limits, come to us and ask how we

     should spend the money first.  Work with people in the community first before you give

     money.



Addressing the Issues: Ideas from the Community and the Site Visit Team



A strategy to improve access to dental/oral health services in eastern Jackson County is clearly

needed based on the information gathered during the site visit.  The first step in a process to

address this issue would be to communicate to those who participated in the site visit the range

of issues that surfaced in the community discussions.  This communication can be in written

form, such as an Executive Summary mailed to all persons who participated in the visit (or

incorporated into a LINC newsletter).  A town meeting can also be organized, with the following

agenda:  

	* A description of what the site visit was: when it happened; the partners involved, why

     they came and what their roles were; how local people were involved; why LINC was

     chosen as the convener

	* Site visit findings (summary points from the body of this report)

	* Community discussion around the ideas suggested in follow-up to the site visit

	* Discussion or agreement on some next steps to address issues.  



To address the dental health issue, LINC could propose the addition of a Dental/Oral Health

Task Group or announce the group as an extension of their Health Care Task Group.  LINC  has

successfully organized other citizen-driven initiatives in a Task Group format; organizing tactics

and approaches in dealing with welfare-to-work issues can be used to organize a Dental/Oral

Health Task Group, and develop a working plan.  For example, citizens as well as health care

professionals (particularly those who participated in the community discussions) can be recruited

as members, and representatives from Truman Medical Center East, the Elks Mobile Dental

clinic, and private dentists who currently have Medicaid patients in their practice would be

valuable Task Group members, as would be Medicaid enrollees. 



A similar process is occurring at the regional level in the states served by the Region 7 and

Region 5 HRSA Field Offices:  these Regions are organizing to implement the HRSA Oral

Health Initiative in 1999.  Larry Walker, DDS, Dental Consultant for the HRSA Region 7 Field

Office (and a member of the team who visited eastern Jackson County), and Gail Brown,

Medicaid Regional Dental Coordinator for the Health Care Financing Administration (HCFA),

are assembling state-based teams into an Advisory Panel with the following representatives: 

State Dental Directors, the State Primary Care Office, dental school representatives, State Dental

Associations or Societies, the State Medicaid Office, and clinicians.  Advisory Panel

representatives from each state will work as a team to develop strategies that can improve oral

health. These ideas and strategies will then be brought before the entire panel for discussion and

consideration.  This Advisory Panel is scheduled to meet for the first time on December 15,

1998.	    



There would be benefits to the State of Missouri in selecting a local partner such as eastern

Jackson County for the HRSA Oral Health Initiative.  These benefits include: 

	1) A readily-identifiable group of people who can form a functioning local task group

     (e.g., within LINCs existing structure, composed of representatives who participated in

     the community meetings).  Such a group has the infrastructure and legitimacy to serve as

     local partners for the Oral Health Initiative. 

	2) The community discussion group and involvement process identified the need for

     dental health care across several communities in eastern Jackson County, as well as the

     resources in place to meet those needs.  This information helps to "make the case" for

     addressing dental health issues at the local level. 



Follow-up and potential involvement in the HRSA Oral Health Initiative can be coordinated

through the Region 7 HRSA Field Office.



During the community discussions, participants suggested that LINC-sponsored, school-based

clinics already providing services to the communities of eastern Jackson County, could be

considered as places where dental care and other primary care services can be expanded.  



There are financing issues that must be considered if a dental health approach were to work

through the existing LINC service sites.  The HRSA Regional Field Office has the expertise and

knowledge critical for the development of community-based primary care services and Field

Office team members can offer technical assistance and support to the LINC Health Care

Committee (and other committees developed to address health issues in eastern Jackson County),

as program options begin to be developed.  There are community health centers that serve

Jackson County that can also be a source of support and knowledge; for example, the Sam

Rogers Community Health Center serves those families closest to the Van Horn School and in

the Ft. Osage school district; Swope Parkway serves those families in the Independence school

district. These community health centers can give guidance for how federal and other resources

can be brokered to meet community dental health needs and should be involved in the follow-up

strategies. 



A challenge mentioned by service providers and community members alike was lack of

information about what services are available, for whom, and when.  Once strategies or ideas

develop from the Dental/Oral Task Group, advice from the community could be incorporated in

communicating what new or additional dental/oral health services might be available;

specifically, by "getting the word out" in non-traditional ways, such as by word of mouth or

door-to-door, in addition to using the radio, television, and churches as vehicles for

communication.

  

The transportation challenges in eastern Jackson County seem overwhelming.  The development

of a strategy to address dental health is an issue-specific opportunity to study and meet the needs

individuals and families have for transportation, even if just for accessing dental services.  

There are two types of approaches for addressing this challenge based on advice from the

community: 1) find means to bring dental services out to where people are, or 2) put a

transportation system in place that can bring people to where they need services.



Transportation resources that currently exist include: the public bus system and the school

districts (who must transport students), Medicaid-authorized providers of transportation, Truman

Medical Center East (provides transportation for pediatrics clinic), OATS (Older Adults

Transportation System), and taxicab companies (Rainbow Cab Company was mentioned as one

example).  Representatives from these organizations can be convened (by LINC, if desired) to

discuss the parameters of the transportation challenges people face, and to discuss approaches

that have worked in eastern Jackson County in the past, as well as what is working for current

programs.  



This discussion with transportation providers can also be organized around the approach needed

for a successful dental/oral health services pilot.  The challenges and limitations of the current

transportation system can be uncovered in this approach, as well as opportunities for existing

service providers to collaborate and provide transportation.  One challenge (although specifically

mentioned in reference to mental health services funded by Medicaid) is important to consider: 

reimbursement for services (such as from Medicaid) is so low that providers do not have an

incentive to contribute to discussions for how to improve access. This may be a challenge or a

barrier to their involvement in planning.



The first steps responding to the issues mentioned in this report are to 1) organize the data

available to define the scope of the issue for eastern Jackson County, 2) identify current

resources (e.g., programs, health and human service providers, grants) that are in place to

address the issue, and 3) identify the opportunities to gather resources in support of an idea. 

Web-based resources that provide that provide extensive "links" to government, philanthropic,

and other Internet resources that provide data as well as resource opportunities include:

www.aha.org (The American Hospital Association site, and the State of Missouri Website

(www.state.mo.us).



Other opportunities and ideas include:

	* HUD grants will be available for independent housing authorities who collaborate with a

     local health entity to improve services or facilities (grant application due in February

     1999, announcement will be posted in the Federal Register).  These funds can be used to

     support the development of primary care services within HUD-supported community

     developments.  Locations, such as Hocker Heights, with community meeting and activity

     space would be ideal places for additional resources to be located for the community.



	* Parents and guardians with children eligible for the State Child Health Insurance

     Program need to receive accurate information about their eligibility and the enrollment

     process for the program from all service providers, as well as accurate information about

     the range of services covered (medical, dental).  LINCs talent and capability in pulling

     people  together, as demonstrated in the site visit, indicates that the organization can

     facilitate a broad-based information dissemination process.  Continuing to work with

     providers and community organizations to facilitate enrollment of children into the

     program is an opportunity to address the insurance challenges faced by families in

     eastern Jackson County.  Organizations participating in the community discussions, who

     come into contact with families eligible for this insurance program, can be reconvened

     for an issue-specific discussion on how to create and maintain access to this state

     insurance program.



	* Specifically for LINC, the Hocker Heights community requested that some of the

     meetings on Medicaid reform and system change be held in their community room, so

     they can participate in the discussions.



Closing

We would like to thank all of the people who participated in this process, especially the Local

Investment Commission, and all community members who took the time to participate in the

community discussions.  It is your contributions that are most important -- thank you for the

opportunity to listen.





	*   	*   	*   	*   	*   	*   	*   	*   	*   	*   	*   	* 	* 	*   

APPENDIX



Methods

Beginning in June 1998, FBA worked with Tim Decker, at the Local Investment Commission to

establish the site visit objectives and community meetings.  Materials to assist in this community

organization process were forwarded to Tim;  these included the template for a letter that could

be sent to community members announcing the purpose of the site visit with an invitation to

participate, and a scheduling template.  FBA conducted follow-up conference calls with Tim to:

1) review the purpose for the visit and hone LINC's objectives for the visit, 2) provide specific

instructions around establishing the site visit meetings, and 3) receive updates around the

scheduling process for the community meetings and to review schedule logistics.



While the community site visit is being organized, health information that may already exist in

the community is collected.  FBA requested documentation from  LINC that would describe the

geographic area and population served, and aspects of the local health delivery system, and

conducted additional research to locate data from state organizations and the Internet.   These

materials were reviewed prior to and during the site visit for information on the social

determinants of health in the community, and were used to organize the Briefing Packet for the

community site visit. 



Representatives from the Region 7 Field Office in Kansas City, Missouri, the Missouri Primary

Care Association, along with representatives from FBA, went to eastern Jackson County to

conduct the site visit on November 12 and 13, 1998. [An evening briefing and meeting with

Field Office representatives was held on November 11, 1998.]  This team interviewed 146

individuals over the course of the site visit, in meetings held at various facilities in the

community, including Truman Medical Center East, Van Horn High School, Jackson County

United Way offices, Village Heights Church, Hocker Heights neighborhood, Oak Grove City

Hall, John Knox Village, and Healthsource (Grandview).  A copy of the sign in sheets from each

meeting are included in the Appendix.



Each community meeting used the following agenda:

	* Introduction and purpose for the discussion

	* Definition of community

	* Issues

	* Challenges

	* Resources

	* Advice 



Information was captured on flip charts at the time of the discussion, and also recorded on a

laptop computer.  These two note sources were checked against each other prior to inclusion in

this report.





Detailed Findings 



Define community

          How define this or the community--over the past 4-5 years, individual community to

     regionalization.  Now look at eastern Jackson County rather than individual places

          Strong school districts 

          Urban and rural

          Diverse--up and down the spectrum (large older population, as you come from KC and

     go east,  socio-economics and other things change).  

          EJC has both extremes relative to income and ages

	* Large area of growth (lot of people moving into area, new housing starts)

	* Independence increasing most quickly in the last five years (poor area)

	* From community college perspective (seeing 1 in 3 students who meet federal guidelines

     for programs) compared to other parts of our system, inner city is only place comparable

     Very much like an inner city school in terms of who we serve--scary at times

	* Strong volunteer element (cultural arts and other things)

	* Change in mentality in terms of what is possible (recruit colleges, can raise $2M, can

     have major expansion, dreams and expectations have increased)

	* Schools: varies from school to school all grouped (predom white, further east more

     white, northeastern part of county very blue collar, varies from school to school)

	* 30% of poverty in Independence



Independence

	* Relationships--business, residents

	* live near a metro city, but really used to orient towards farming community, more like a

     small town

	* Really try to take care of one another

	* High population of working poor, struggling to pay the bills

	* Truman East is closest facility

	* Rich and proud history of the "square"

	* School (Van Horn) is centrally located between downtown Independence and Kansas

     City   proper--but lack clinical care with hospitals at both ends.  



United Way Meeting (Agencies and Leaders)

	* EJC is a lot of communities

	* Community can be a lot of things: neighborhood, church, town, work--where I

     personally function

	* Growing but not planned growth, sporadic

	* Mixture of different places and people that all make up what we know as home (income

     definately, race/ minimally, different types of neighborhoods), very mixed by age as

     well.

	* Ages are segregated by neighborhood and geography...elderly can't sustain home in

     suburbs by themselves

	* EJC is very spread out, as you move east, tends to be more agricultural

	* In some ways closed, and in some ways very open and work together; related to growth,

     there is an in crowd and an out crowd, newcomers flounder (tough to integrate in)

	* Small towns struggling with increasing urban issues (e.g., "how are we going to do this

     and keep small town atmosphere")-there is a contingent who would like for things to

     remain the same.

	* Define ourselves by what we are not:  

	* We know each other very well .  

	* Raytown is losing people, also landlocked (totally surrounded)

	* Strong religious family ties in the area



Independence Church/Ft. Osage (school district)

	* We are the eastern most community of Eastern Jackson county: Lafayette county line to

     291 to river; there are 132 sq miles in the school district.	*      

	* Community centers around the school, both rural and suburban.  

	* School is the hub of activity; 1 high school

	* Also included in a portion of Independence School District; share families and resources

     across school districts.



Hocker Heights

	* Improving -- have community policing, people more responsive to programs and services

     offered, much safer than it used to be

	* Nice and quiet

	* Physically attractive/ pretty area

	* People are very friendly

	* Lot of problems here (not somewhere everyone wants to stay)

	* Place to start over, people are getting more involved since I've been here, neighborhood

     watch, some places are very closely knit, office people here are very good take care of

     most of our problems, becoming closer knit 

	* Some lack of respect towards neighborhoods

	* Lots of variety, all different kinds of people coming from different places, learn from

     other people, lot of people growing.  

	* Mostly single units 220 children all ages, 135 units (at least)--lot of single parents

 

Oak Grove

	* Lot of fun (out in the country-rural)

	* Calm and peaceful

	* Friendly

	* Helpful and supportive (Odessa, Oak Grove pretty much the same), caring, giving

	* Being able to communicate with greater Kansas City--not a toll call anymore, so it's a

     little bit cheaper 

	* Place along I-70 where all the trucks get off

	* Mix of young and old



Lee Summit

	* Group of people living together in close proximity with similar interests

	* Very caring people

	* Lee Summit is predominantly upscale (upwardly mobile and wealthy), fast growing (lake

     development), bedroom community of Kansas City predominantly

	* Education is very important

	* Desire to blend the old and the new

	* Citizens are very active -- involved in community activities, not just the same volunteers

     over and over

	* Very diverse: age (old and young families), geographically (not just the city of Lee

     Summit but also the surrounding area that is also driven by the school district (think of

     that boundary)

	* Almost all white



Grandview

	* Medicaid (a 1991 Ernst and Young study indicated 60-70% Medicaid in Eastern Jackson

     County which was a catalyst to open Healthsource)

	* Even racial mix (black, white, Hispanic)

	* Lower middle class

	* Young families with some elderly

	* Most people live in Truman Village (200 units)

	* City of Grandview: 26,000 people, economically diverse, primarily middle and upper

     class, racially mixed (which is unusual for Jackson County)

	* 15-20% of community works in Grandview

	* Numerous neighborhood support groups (churches, neighborhood watch)

	* Community oriented



Issues

	* We are beginning to look at health regionally vs. individual places

	* Bucking the perception that there is no poverty here: you would be amazed at how many

     poor children there are ,we have as many problems as the inner city poverty more evident

     over past 5 years 

	* Poverty becoming evident in EJC because of leadership and (we understand that we have

     gone from under 2% to higher 8% over past 5 years).  70% of poverty is in

     Independence, have not communicated this shift as well to rest of metro area (this is a

     challenge).--Oak Grove, Grain Valley

	* Lack of health care for those who are removed from metro center, won't ask for help,

     don't know where to go (can only ask schools) 

	* Is there a lack of health services or primary care?  Think there are lots of services

     available, but I don't think that people know how to avail themselves of the services, and

     communicating with this group is impossible.  

	* Challenges: getting people there, understanding what is available

	* Are the right people at the table to be a part of planning process (e.g., health care

     providers that will be required to provide these services)?

	* School based clinics---hospitals involved in school based stuff, physicians involved in

     health strategy, action ----need to get things as close to people as possible in as short a

     time as possible. 

	* Size of transportation problem--spread out (same population size as KC in EJC)

	* Most people do not know what services are available

	* Truman Medical Center East and Health Department publicly funded and provide

     services to those in need, have had a number of hospitals as part of this group. Another

     big component we have some big free standing managed care organizations that need to

     be brought to the table (free or sliding scale services)



Independence/Van Horn

	* Transportation

	* High number of people who do not have insurance

	* Buses do not run to Truman east. (Doesn't go near 40 highway, or to where people live)

	* Don't have insurance, can't pay for services, people afraid they are going to get caught if

     they have an old outstanding bill (afraid if they will get caught, or be forced to come up

     with money before they get treated)

	* People not treated with respect --won't go to welfare, or Medicaid for kids because they

     feel bad (huge barrier to services) 

	* Communication is a problem (people don't know what or how to ask for help).  Don't

     get the answers they are looking for if they don't use the right words, or use the questions

     we would.  

	* Families don't have confidence and tenacity to tear through the bureaucracy. In my

     opinion, the systems have just institutionalized difficulty to access to catch things like

     welfare fraud (families feel like traps are being set for them and they lack the energy to

     tear through it.)

	* A lot of people I've dealt with feel like they're being caught for fraud before they are

     even through the application process.

	* Standard Oil Refinery in neighborhood--might have a relationship to cancers that have

     emerged

	* Meth production is a health problem--sold locally

	* Elementary -- head lice, scabies, flea/roach bites, many of homes are older or have been

     divided into multifamily units (challenging housing conditions)

	* Low dental care, and really serious things are happening to people because of it, like

     constant low level bacterial infection.  We are 45 minutes away at Truman East (have 14

     dental chairs); and we take 15 kids a week from school for care.

	* Independence Regional (used to be part of Columbia HCA); Truman also the public

     hospital.

	* Independence---we are two communities in one, and there is isolation within community. 

     Live in isolation because there is no transport to get them to the other end.

	* Knowing about the resources is a full time job and what is available; service providers

     don't know either....I have networking sessions just to figure these things out.

	* Elderly without food to have medications (or if they do get scripts, don't take the way

     they should).



United Way Meeting

	* Disparity in incomes seems to be growing

	* Sometimes people look at things like "its not my problem" (city to city issues, vs. How

     we are related to each other)--others who will come and rise to the occasion

	* Health care in far EJC is a problem (far part of the county, particularly because of

     transportation)

	* Don't know about services --mass media program (City of Independence health

     department), high emergency room use by the underserved, low utilization at VanHorn

     clinic

	* Population turns quickly, lots of rental property (just when you think you have an area

     covered, people move and you have to continue your efforts)

	* Services for kids from 3-6 p.m. 

	* Services exist in KC, but many people won't cross the river and go into the city

	* Highest rates of child abuse in Jackson County in Independence (CAPA)

	* We have jobs but they are sprinkled around the area, tough to live in certain areas and get

     to jobs

	* Competitive economic development

	* Mix of collaborative and competitive service provision -- lot of agencies that don't want

     to work together (have determined that if we don't band together in EJC we are going to

     lose out), difficult to collaborate in this situation anyway

	* Lot of uninsured persons (service low wage jobs and lose Medicaid and benefits)

	* Division of Family Services -- recently increased standards for Medicaid, also increased

     coverage for parents (beginning in Feb, with increased income standards 300%)

	* Operating costs that are not funded -- how do we meet the needs of existing programs

     and expand if you don't have operating costs; have a real short term perspective on

     grants, need longer than 1 year to address challenges (need a collaboration between

     funders and grantees to explore challenges)

	* Health challenges--chemical dependency, increased tobacco use in younger kids and

     alcohol use as well, tolerance by parents, asthma in schools, dental health takes a back

     seat to other types of care.  Variables involved in dental: far EJC lack of providers,

     transport, lack of insurance, people can't meet deductible to pay for dental care. (Same

     holds true for any medical provider in EJC doctors don't take Medicaid for primary care)

     Increased challenges for developmentally disabled

	* Mental health services for low income children and child sexually abused (6-8 months),

     psychiatry is a challenge, ADHD in the schools very little for kids with these problems.  

	* Suicide (ages 15, 35 two spikes in age groups)  

	* Child care



Ft. Osage

	* Issues that we face are because we are not really rural; overlooked sometimes

	* Public transportation stops at shopping center--can't use for services or for jobs. Not

     extended more because of finances.  Independence has tried to get transportation from

     291 in, we have also tried to do bussing but it is not convenient

	* Local health center -- place where entire community goes for care, lot of families that fit

     into the category of working poor and more than they used to, there is no health care but

     at the clinic at the end of the day.

	* Clinics are here and local (use for convenience, and lots of other reasons) much better

     quality of care and it is essential for this community 

	* Randall School Health Center 23-25% is uninsured, haven't yet seen impact of Medicaid

     reform-- 35% are on Medicaid -- anchors for drawing other people in to the system

	* Prohibitive costs and time off work

	* No dental care (sent to Truman Medical Center East 6-9 month wait), he is the only

     dentist out here, must be a way to get the folks who provide services out here from the

     city. Why can't dental students come out here vs. us having to go into the city?

	* Accept Medicaid out here -- get onto physician's list (have to wait)

	* Do clinics work together?  Yes, share appointments--or send each other over  

	* Trying not to lose the intent that health care is a right while wrestling with the finances. 

     Guarantee will be available in future year, state funds combine with a federal drawdown.

     Caring communities removes the barriers and creates a flexible funding stream.  When

     tried billing, really felt drop off.  If could find a way to bill, fees could be devoted to

     doing other services.

	* Second hand smoke and asthma

	* Mental health needs...seeing more cases lately--stress in families with mother and father

     worker, children acting out b/c parents have no time

	* Come in with step and pneumonia---non cleanliness, lethargy

	* Steven Hill working with Independence (Hawthorne apartments--725 units) big

     prevention grant for meth; people from the housing project really have a connection to

     the schools.  Ft. Osage tends to be consumers vs. producers of meth

	* Have a good city health department (Independence, which is a resource), have benefit

     from program for 7th graders: STEP testing and body fat checks, multiple risks referred

     to partners

	* Caring Communities/ LINC, and Tim are resources

	* Not as cognizant of what elderly need, feel like we don't do a very good job right now,

     don't really use the community health center as much as they could (do have foster

     grandparent program) 



Oak Grove

	* Drugs and alcohol are a big problem (marijuana, meth labs, alcoholism)--people have

     moved drug dealers over here where police don't come down so hard on drug dealers

	* "Anything you want you can get at the truck stops"

	* If we are small integrated community, why are these problems?

	* Lack of recreation (Blue Springs is closest place for recreation for folks in Odessa), not

     everybody likes to go to the neighborhood bar (not a lot to do with very young children),

     do have a lot if you are athletically minded  



Lee Summit

	* No transportation, problem all throughout east Jackson County--people can't get out here

     to work, and we get people transported for health services, if you can find this resources

     almost too costly for people to afford (Truman East is a good car drive away)

	* Accessibility for people with disabilities is not good

	* Infrastructure keeping up with population growth (schools, taxes, road construction,

     traffic congestion, zoning issues between residential and commercial land)

	* Health issues: insurance is far too expensive, many people without insurance, lowest

     incomes and highest have insurance but its people in the middle who don't have

     insurance (working poor population); get left out on many things because they make a

     little too much (don't know the percentage, but it may be as high as a third)

	* Income disparity between people

	* No affordable housing for the working poor

	* No dental care: are there dentists? Truman Medical Center East does have a program,

     have one caring dentist in the community, one day a year (better than nothing) 

	* Big shortfall for those who have insurance and the uninsured for mental health care;

     emergency fund at church goes for mental health care that church members cannot pay

     for. Big need because it interferes with everything in your life.  

	* Adult day care is necessary and in home care (Missouri Options program allows someone

     to come in and help with daily activities)

	* Something to do after school for junior high students (don't have interest or time to stay

     after school)

	* Domestic abuse issues

	* 22% Medicaid, 33% working poor-----half of community is having difficulty accessing

     services

	* Lots of disconnected people in bedroom community



Grandview

	* Limited transportation is a barrier to preventive care, necessitates ER care

	* Fragmented communication lines

	* Under/uninsured population

	* At Healthsource: non-Jackson county residents full pay; Jackson County residents pay on

     a sliding fee

	* Increasing Hispanic population causing a language barrier

	* Access to pharmacy care

	* Population does not seem to be healthy: asthma, single parent families, preventive

     medicine not done (just emergency), episodic care is common



Challenges

	* Patchwork of health services--challenge is to define what these services are and who we

     are providing them for.  

	* Multiple political districts---things done differently in every political jurisdiction

	* Always assume that our population is the same today as it is tomorrow, not the case (60-

     70% turnover between Sept  to Sept in schools) don't want to build just another system,

     need action

	* Don't have our own TV station or our own newsletter.  Don't have good media to

     communicate what is available-- It is tough to get the word out.

	* People who are patients in system who are afraid to come here because they will lose

     their rights within the system

	* Lack of physicians--as you go further out things get sparse.  Access is clinics that are

     here and emergency rooms.

	* MC+ permission required to go anywhere--managed care problem here (can't also just

     take your child to the ER)....if don't have phone can't get back to you.

	* MA does do transport--have to call 5 days ahead, not really good for emergencies

	* Transportation is an issue for all communities in EJC (for poor, elderly)

	* Hard to get grants for older adults 

	* Availability of dental care---as you move further east, cost becomes a problem.

	* Access challenges with dentists (Medicaid)

	* Reimbursement issues effect every single person regardless of age or who they are--

     challenge of low reimbursement and providing quality services (physicians no longer

     make the decisions about how /when they can give free care, others own the practice)

	* Reimbursement drives incentive for transportation (for example, low reimbursement for

     psychiatric care under Medicaid is not much of an incentive for providers to work

     together to figure out transportation system)

	* Consolidation of services corporately outside the community is making us feel like we

     have a loss of control locally

	* No services except during the hours of 9-5

	* Regulations--Medicare and transportation advertisement; regulatory issues prevent

     agency from sharing transportation

	* Service availability--mental health not there, we can't hire somebody for this, need to

     have a certain type of background

	* Ft. Osage--don't have a lot of industry here.

	* Had screenings last year on young kids but dropped the ball because case management to

     hook kids up with dental care was too intensive.

	* "You never sink but your feet are always wet."



Hocker Heights

	* Sometimes people organize things but don't follow-through

	* Units are mostly for the disabled

	* Transportation (waiting for buses with little kids), call bus 3 days in advance (Truman

     East) but if not over 65 or child under 5 no ride, Medicaid call them then they send it up

     to transportation 

	* Truman East--don't have something for people to just walk in (10 miles), in the hospital,

     is a pediatric clinic (MCI back behind) does have transportation, locked in to going

     certain places

	* Medicaid locks you in (you have to get referrals), they assign you to go to certain places  

	* Truman Urgent Care sends you a bill for the doctor even if you are Medicaid,

	* Division of Family Services gives you the run around

	* Medicaid -- treated different, denied medical care because services I needed were not at

     Truman Medical.  

	* Everybody deserves medical treatment and to be treated with respect. 

	* Go to Swope, they got me in after hours, tried to fit in for urgent medical care (2 months,

     here take the paying customers before Medicaid)

	* Medicaid "loses" you between the approval process and when you get your bills,

     especially for care through ER

	* Frustrations with Medicaid system--put the burden of proof on us, show things beyond a

     reasonable doubt.  I have to go through a mess just to get a referral, they call me back,

     makes it hard---too many rules on people who are sick or disabled.  

	* Reminder system with Family Health Partners is good

	* No dental care for persons who are on Medicaid

	* With private insurance you are worse off financially than if you had Medicaid

	* Insurance changes at work, gets worse and worse...costs too much, week's pay for

     insurance coverage.  Kids have Medicaid, wife not covered.

	* Most dentists don't take Medicaid

	* Lack of awareness of CHIP program 

	* Welfare-- when your five years are up, what if you are disabled? (will lose benefits and

     worried about kids)

	* Vision/dental care for handicapped kids (can't sit in a dental chair)--call Sam Rogers or

     Swope must be handicapped accessible; portable equipment



Oak Grove

	* Tried to get health insurance $78 per week, and a $1500 deductible for emergency visits,

     the best the company could offer; don't qualify but can't afford anything else; $325 per

     month.

	* MC+ program, enrolling children----nothing that is available for adults

	* Lost two doctors out here in the past few years, health source has been good, companies

     change insurances and then change the doctors you can go to, lack of providers and they

     just may not take folks, limit on Medicaid patients which makes it difficult 

	* Adequate transportation to medical care is a major problem for low income (OATS --

     Older Adults Transportation  and Rainbow Cab Company out of KC)

	* For Medicaid have to call 24 hours ahead at minimum, to ensure order with cab, usually

     call a week ahead to ensure order, sometimes just wouldn't come because they said they

     didn't get the order causing us to be a no-show

	* Medication costs are a problem -- groceries or prescriptions but not both

	* Not many doctors that live in town, just go to the emergency room (Blue Springs is the

     closest, St. Mary's) there is an EMS unit 911 is available for city of Oak Grove (no cost

     to city residents), beginning Jan 1999, sales tax removed--if don't live in city could cost

     $550.

	* Need better information levels 

	* Drug and alcohol information does not go to the Christian schools (drug) we go over

     things in the classroom but we've never had anyone come and talk to us (do have info on

     drugs, sex, parenting at our school)

	* Apathy is a problem for participation in programs (e.g., just recently did Hep B for 6th

     grade, sent home letters, showed films, only got 40 or 140 parents/families apply) 



Grandview

	* Closing of the Air Force Base will effect everyone

	* Unclear about impact of substance abuse; meth has not been high impact (according to

     police) and community outreach programs seem to have been effective

	* Have evolved into a tolerant community (e.g., teachers undergo diversity training)

	* Transportation = access for vision, dental and mental health care.  These are needs for all

     in the community.

	* STDs very high in teens, as is pregnancy rate (pregnant teens are seeking OB care

     consistently, its getting to teens after pregnancy occurs)



Resources/Collaborations

	* Almost all mayors have come together to work on these issues; strong effort by all

     leaders to come together and bring emphasis on income, and EJC specific issues

	* Leadership in the community is a resource

	* Cooperative spirit among leaders and spirit of volunteerism

	* LINC is a great example of how people who care help people in need

	* Have increased collaboration so that we know as service providers what is available and

     this has helped

	* Raytown Schools (Score One for Health) get resources for health screening

	* NFL traveling dental clinic--found students with more dental problems in outlying areas

     than in urban core, but people as they move away from the city, lack transportation

	* Partnership for Children--immunizations (do 30,000 kids a year and have free

     immunizations at hospital)

	* 9 Caring Community sites

	* United Way

	* Jackson County Health Dept

	* Independence City Health Department

	* Raytown has a health inspection unit

	* Hospitals:  Truman East, Independence Regional Medical Center, St. Mary's, Lee

     Summit, Park Lane, St. Luke's

	* KC HC Council, Hospital Association

	* EJC Community Health Improvement Project

	* Public Works Department in EJC

	* LINC

	* Health Source

	* Humana, Kaiser, Health Net, Blue Cross 

	* Neighborhood newsletters, all hospitals have newsletter, 

	* Churches

	* Ministerial alliance--Blue Springs, Independence (each one does its own)

	* Schools became an administrative Medicaid case managers



Van Horn School/Independence

	* Graceland School of Nursing has many community health services (work with center in

     Bryant)

	* Health Department works hard to meet needs (county) also have a city (HD in

     Independence) do work togther some times--WIC, immunizations

	* City -- helping families treat lice, scabies, track and follow hepatitis

	* Mt. Washington food pantry as well as Boys and Girls Club satellite

	* Battered women's program--transitional living

	* After school programs (latch-key) at Caring Communities

	* Mental health: have 2 social workers that work with schools

	* Heart of America family services--counseling, referral (do have sliding fee down to

     about $25 per hour)

	* CAPA--Child Abuse Prevention Association

	* Community Service Link (the one stop shop--know the resource if you don't ). On

     Independence Square --work together, make same referrals out of here, United Way

     funds them as does the community, Truman Heartland also funds 

	* Comprehensive Mental Health but sometimes there is a long wait or very serious mental

     health issue

	* Caring Communities free clinics

	* Dental --Truman Med Center East 45 minutes  (1 month to 6 weeks) , 6 dentists that

     accept MA, but closed practices, KC Free Health Clinic has free dental care at 24th and

     Denver, take 15 kids a week (one school), some teaching model programs available but

     not teaching models

	* KC Dental Clinic (sliding scale and free but have to go to University 25th & Dillon) do

     have emergency, can get in right away

	* Sam Rogers--Swope Parkway historically don't go to KC, won't leave Independence--

     fear of accidents, fearful of getting lost.  Wouldn't go to dental school either. 

	* Free community events for families (Children Celebration Day)

	* Graceland School of Nursing

	* City and County

	* Churches (spiritual, food pantry)

	* Boys and Girls Clubs

	* Women's shelter (domestic violence)

	* After school latchkey program

	* Kappa Adult/child care

	* 	* 

United Way meeting

	* Cross EJC-----CHIP, Mid America Regional Council are organizations in place, but

     don't have dollars or dedicated resources to get organized. EJC Betterment Council.  

	* Churches are resources.  

	* ROWEL (organization of low income persons)--reform organization for welfare.

	* District newsletter doesn't seem to work (another major challenge) also a resource from a

     previous meeting.

	* Hospital has given Medicaid dollars to Independence clinic so they will not have to

     hassle with Medicaid; have just provided the estimated dollar amount to the clinic.

	* Funding source is Caring Communities, 1 provider M-F (nurse practitioner), sliding fee,

     trying to figure out ways to bill Medicaid and commercial insurance without making it

     hard for the patients.



Hocker resources

	* Computer lab 

	* Elks Mobile Dental (call Truman East)--set up in a trailer



Oak Grove

	* Pool

	* Meals on Wheels

	* Business district

	* Athletics are a resource

	* Number of churches that are in the area--ministerial alliance is in the community,

     churches are strong supporters of community leagues, individuals that support

     community services with time and money

	* Fundraisers out of schools 

	* Schools have basketball, choir, drama, student council 

	* Private schools no transportation, but public and private schools tend to work together

	* Clothes Closet in Odessa 

	* Closest ER is in emergency room is in Lexington or Lees Summit (25 miles)

	* Shriners Hospital handles children with special needs in the area 

	* HealthSource is the local health provider

	* 2 health care clinics (Columbia) and HealthSource of Oak Grove; pediatricians come out

     on Friday, one late clinic per week (Wed), pediatrics practitioner comes Tuesday

     evening. Continuity of care is not there

	* Diabetic equip and medical supplies are very difficult to secure

	* Dental care--Kansas City, or to Lees Summit or Sedalia; office visit $35.50, usually easy

     to access a dentist?  Usually non-existent

	* Eye care and resources for hard of hearing people 

	* Children's Mercy only place for specialty pediatric care for eyes, etc

	* Coverage--alternative medicine all around here, but to be able to get a physical

	* Pediatric clinics for advice (3 times a week)

	* Parenting classes



Resources in Lee Summit

	* United Way

	* Churches (most of our programs are more for indigent care--do support the shelter;

     provide overnight shelter for transients) 

	* Ministerial Alliance -- funnel most of our resources through social services, coordinate

     our assistance with them

	* Lee Summit Social Services (raise money and go through SS) have over 1600 families

     we work with

	* Civic groups (could raise money and get involved)

	* Dental clinic is separate from the hospital, self-pay, no discount for dental service, we do

     have a van that does go out periodically, is a dental clinic at UMKC (no outreach)

	* Awesome school district, why people move here, junior high health fair (vision

     screenings, blood pressure checks)

	* For dental we have trouble for referral especially if it is a long term problem, because

     something can't be fixed in one visit not even really sure that people in the community

     know that dental is a serious problem

	* Trust Department in Banks

	* Businesses 

	* Local dentists (try to get more of them to contribute, probably no dentists take Medicaid

     -- no one in town)

	* People are a resource

	* Communication problem because we are a bedroom community and getting

     communication around on what the resources are is challenging. Attitude of bedroom

     community "we don't know if there are problems out there."  



Grandview Resources

	* Churches are active

	* Ministerial alliance is a resource

	* Schools

	* Abuse shelter house

	* WIC

	* Truman East (especially for mental health care)

	* Together Grandview

	* Harmony (a diversity group that is a regionally recognized program)

	* Strong community base

	* Coalition of city officials (Jackson County commission)

	* Chamber of Commerce and Economic Development Divisions

	* Bank Midwest

	* Jackson County Water Works



Advice

	* People need to find ways to network -- Coalition of Positive Family Relations; whole

     thing is to learn (metro service area in KC).  Critical component of this kind of dialogue

     is to listen.-- how do people get involved in this.

	* Define what we are providing and what level of service is adequate for population.

	* Has to be a shift in funding (measure of the moment and state mandated services).  

	* OUR COMMITMENT IS LONG TERM AND VISIONARY, FUNDING IN SHORT

     TERM AND KNEE JERK and in response to priorities that might also be short term. 

     Balance focus of money towards specific initiatives but also funding that needs to be in

     place that is long term

	* Broader representation from regional government (county)--has always been missing

	* Plug into schools as an info source around what is changing, no one has a better account

     of this than they do.

	* Flip the transportation system where services are brought out to people

	* Physicians and managed care should be involved as well (MCOs)

	* If we are going to do something -- need to do something regionally

	* Need to get information to people in non-traditional ways--put things in grocery stores

	* Need on going structures where people can make decisions--when we don't have

     becomes real hit and miss

	* EJC addresses issues--I wonder how many other people are traveling in from other

     counties that exacerbate the issues we are talking about.

	* Let's pay attention to issues of the elderly

	* Literally need people to walk through system for you

	* Identify at-risk kids sooner to prevent drop outs

	* Ask hospitals and community health centers if they would be interested in if they were

     interested in establishing a satellite

	* Is no neutral broker---Medicaid managed care has eliminated the neutral broker.  Needs

     to be somebody neutral to break logjams.



Independence/Van Horn

	* Create a resource map (things change frequently and we have to be aware of this)

	* Get all of the providers of that service to a table, can't map out something you don't

     know about 

	* Need shared ownership--kind of like this meeting (providers, government, community

     leaders, residents, the person that last tried to access service but couldn't )

	* Information has to be available everywhere (offices across the hall from each other don't

     talk to each other)

	* A meaningful process with follow-up has to be in place 

	* Consumer input first, not an afterthought vouchers for participation (daycare,

     transportation)



Ft. Osage School District

	* 1-800 number is needed that gets you to a place that has all numbers of services that you

     need in this area if you need it; 

	* TV is the only medium that everyone uses, have it in French, Spanish, could also tell

     about Clermont

	* Personal outreach: church and grocery stores (in addition to personal visits to house)

	* Have to really help people work through things that they are not used to.  May have to

     physically bring people there.

	* Just have to go and outreach and figure out how to get people (social work 101).  

	* Sometimes we don't let each other know what we have:  VNA, Fire Departments,

     Barbers and Beauticians, pharmacies.

	* Respect,  relationships, and local control allows local people to get help



Hocker Heights

	* Treat me like a human being, if you can't you shouldn't be in business

	* Send fliers to Hocker   especially if you know this is a low income area

	* Have health department come here---get out of clinics and have people come here

	* We should focus on prevention, used to have a nurse here was not used (was tried)

	* Need someone who can prescribe, need a volunteer physician who can prescribe

	* Request different people to come in here and have meetings like this so we can get 

     information

	* More than one neighborhood can come in here to use services; create more of a demand

     for it, bring things here

	* Cut the red tape (demand that doctors be responsible for the bills that we get when

     doctors don't do their job)

	* More available mental health services (only allowed so many visits per year) couldn't

     find a single case manager in EJC to help me answer my questions--case managers need

     to be educated to know what services are available, and monies targeted to specific case

     managers.  

	* Anger control/conflict resolution classes--sometimes can find someone to teach/no extra

     funding for events, etc.

	* Phone for residents who can access services---do have the Internet and use the Truman

     Heartland.  Doctors should know about some of that information.  

	* If you have a referral responsibility, understand what you are doing when you hand

     somebody off, be sensitive to what people are asking you for.

	* Things are available that you just don't know about--specialty research on Web that can

     be coordinated at the housing authority level.

	* LINC have meetings at Hocker with Health Care Committee, specifically to discuss

     Medicaid reform



Lee Summit

	* We should create a system for communication: churches

	* People asked to give money and time to causes without the data that says the issue is a

     problem; have good data collection---data helps with funding and other resources.  If use

     data right you can get resources on the outside.

	* Schools could be a communication channel.

	* Forward information from the site visit to Strategic Group in Lee Summit and they can

     use this information as they would like.

	* Challenges of bedroom communities: core of poverty, new people in that are not aware

     of/don't want to see the issues

	* We need a chamber of commerce for social issues ("chamber of social issues"), could in

     fact be the entity that convenes people (absent a public health department)

	* School district working with hospitals to get a response for substance abuse (such as a

     24/7 hotline) do have data that says that it is a problem. 



Oak Grove advice

	* Need a pediatric clinic or a specialty clinic

	* Parenting classes are needed

	* Lack of meeting spaces, or need meeting spaces funded

	* Need a rec center or a movie theater

	* Dental, vision and hearing services for low income persons are needed

	* Better access to information (private schools need information, as do public schools)

	* outreach for CHIP enrollment is desperately needed

	* Need places to meet (civic center is a resource, not accessible to community members,

     $75 to rent for any civic activities), unless you are in a church

	* Funding resources -- for any type of activities (for recreation), plenty of people that can

     help but who don't have money

	* Need more organized activities besides a bowling alley--skating rink, movie theater, mall

     (Outlet mall in Odessa)

	* Interest in having someone come out to share report.



Grandview

	* Provide transportation to get people to the clinic

	* Information dissemination (public access TV, local newspaper, through school nurses,

     ministerial alliance); the community has tremendous potential if the information can get

     Medication   making it accessible and affordable, especially for persons age 25-50 (high

     priority group), and addressing nicotine addiction

	* Need more structure in our relationship with Truman East (not sure when OB residents

     are coming, they just show up)

	* Prevention needs to be a focus (asthma in children, diabetes program, hypertension,

     seeing multiple diagnoses in new patients who are ignoring their care)

	* Need school based clinics out



How would you improve access to care for Medicaid, uninsured, under-insured?

	* Involve the stakeholders (providers, rep of communities to be served, people who will

     fund providers)--different depending on community/municipality

	* Intelligent understanding of what resources are already in place, assess the capability of

     the organization to convene and if feasible use what is in place

	* Make care convenient and geographically "relevant"

	* Have to go to each municipality and different geographic areas to listen to people and

     then find common threads

	* Get a stronger more cross-sectional voice (don't just get a few spokesperson)

	* Work with the hard facts and develop business plans

	* Information must be shared: scope of issue, resources right now.  We have to stop

     making decisions by anecdote. 

	* Root causes vs. symptoms

	* Focus on prevention----or while building primary care we also need to focus on

     prevention 

	* So many meetings, let's just do something--transportation, access, more grass roots



What do you do to involve people who aren't traditionally involved?

	* Have to have a meaningful process (what to do today, where this information is going

     and what follow up will come).  

	* Think out from why asking people to come and build out from there.

	* Hard to have a plan before talking with the consumer-- if you are going to ask a

     "rejected" consumer to come to the meeting, don't surround with professionals.

	* Don't expect results over night

	* Get info to churches, in newspaper, and so that it can be understood.  

	* Well thought out marketing strategy....many people depend on word of mouth

	* Emergency room good time to exchange information, get to people who visit families. 

	* Contributions can be made if incentives are provided for participation--daycare, dinner,

     few different times, transportation, not everybody works the same shift.



Advice for external resource holders

	* Give the money and get out of the way

	* Cannot do funding one year at a time if you can't plan beyond next month

	* Outside entities should honor and participate in structures that exist

	* Willing to allocate resources for implementation, reluctant to allocate money for

     facilities, yet we are using the facility for all the services that other programs are paying

     for other things 

	* Make sure that the people who convene meetings are working together well at their level

	* Eliminate or stop categorical funding, e.g., allow us to do programs for all children

	* We could have partnerships with corporations rather than the usual funding streams

     (manpower and funding, people and other kinds of technical assistance)

	* Instead of sending out RFPs with predetermined limits, come to us and say we have this

     amount of money, come to us and ask how we should spend the money 

	* Work with people in community first before you give money

	* Give communities control of local monies









Site Visitors and Affiliations

	* 	* 	*    

Region 7 Field Office Staff 

	Clark Conover		Program Management Officer, national Health Service Corps 

	Aleta Cress		Program Office, Primary Care 

	Matthew Henk		Senior Social Worker Consultant and Program Officer, Primary Care

	Hollis Hensley	Chief, Primary Care

	Judy Jensen		Regional recruitment Director, National Health Service Corps

	Lawrence Walker, D.D.S.   Regional Dental Consultant and Project Officer, Primary Care      



State Partners

	Kathi Joseph		Interim Director, Missouri Primary Care Association



FBA Participants

	Michael R.J. Felix	Chief Executive Officer

	Amy Llewellyn Abel	Vice President, Community Partnerships and Research