Covenant Health is an innovative, Catholic regional delivery network and a leader in values based, not-for-profit health and elder care. We sponsor hospitals, nursing homes, assisted living residences and other health and elder care organizations throughout New England.

Implementation Strategy

Prioritized Community Health Needs SMRMC Strategies SMRMC Action Plan Outcomes Evaluation Method
Need Identified Reason for Problem
Access to Care Lack of primary care: Highest rates of ED visits in the state; high rates of Mainecare patients Expand access of primary care coverage Offer/expand FQHC physician practices in partnership with Community Clinical Services Patients will have increased access to primary care Track number of patients with primary care physicians
  Disparities in population health Participate in state and regional population health management strategies Serve on State Health Coordinating Council, Western District Council, MaineHealth Community Health Improvement Council Implement evolving best practices at St. Mary's Minutes of council meetings
    Train additional health care professionals to serve in Androscoggin County Staff will participate as preceptors for health care professionals and St. Mary's will continue to host Tufts medical students for LIC Increase the number of health care professionals available to serve in Androscoggin County Track number of health care professionals
Cardiaovascular Disease Poor nutrition: high levels of food insecurity; higher than state average rates for adult and childhood poverty   See Strategies for "Obesity"      
  Tobacco Use: Smoking rates are higher than the state average Enhance access and provider support to smokers who want to quit Offer smoking cessation counseling through Prevention and Wellness and Community Transformation Grant Reduce the % of adults who smoke Tracking for referrals to smoking cessation counseling and for grant results
  Access to care See Strategies for "Access to Care"      
  Cardiac risks: Higher than state average rates for cholesterol, high blood pressure and heart disease  Implement education and prevention strategies about cholesterol, high blood pressure and heart disease Take charge! Program-community health screenings Increase the number of people screened for cardiac risks in Androscoggin County Track number of adults screened at Take charge! Programs
Cancer Oncology risks: One of the highest incidence and mortality rates of cancer in the United States; high rates of certain types of cancer Develop and implement annual community health plan for Center for Cancer and Blood Disorders Offer cancer screenings and education in the community for high prevalence cancers Increase awareness and early detection Track attendees and referrals
  30% of all cancer deaths and 80% of lung cancer deaths are associated with smoking. See Strategies for Tobacco Use      
  30% of cancer deaths are associated with poor nutrition, physical inactivity and obesity. See Strategies for Obesity Offer community education on Cancer and Nutrition Increase knowledge about importance of nutrition in coping with cancer. Track number of sessions and participants.
Diabetes Risk factors: Higher than state average rates for prevalence of diabetes Enhance access to the Diabetes Educators 1. Diabetes Educators & Nutrition Management to meet with all primary care providers to promote programs. 2.  Develop algorithm for referrals to Diabetes practice. Increase the total number of referrals for Diabetes Education and Nutrition Management programs.   Track referrals to the Diabetes Practice.  
  Poor nutrition and lack of exercise Address lack of exercise through programming via Prevention and Wellness. Offer Health Steps, Couch to 5k program and other physical activity programs Increase the % of adults engaging in weekly moderate and vigorous physical activity Track participants in programming
Mental Health Risks: Highest rates of hospitalization for mental health in the state Enhance access for inpatient and outpatient services and final phase of the "one call" system. Develop an integrated behavioral health delivery model for inpatient, outpatient and telemedicine Increase capacity for mental health services. Measure access to various entry points of the behavioral care services
Obesity Lack of access to healthy, affordable food Change incentives for consuming healthy food at the hospital to promote healthy choices Participate in Healthy Foods/Healthy Hospital Initiatives  Increase the number of healthy choices available for food choices Meet Healthy Food/Health Hospital metrics
      Transform local donut shop in hospital lobby into café offering healthier food options Staff, patients and famlies will have access to healthier food choices Track menu options
    Offer incentive for use of food stamp benefits at St. Mary's Nutrition Center Farmers' Market Continue Wholesome Wave double value coupon program at Farmers' Markets Increase consumption of fruits and vegetables Track Double Value coupons usage for Wholesome Wave Grant
  Risk factors: Higher than state average rates for adult obesity, lack of physical activity See strategies for Diabets lack of exercise      
  Barriers to learning about, practicing and maintaining healthy behaviors exist Impart strategies that increase individual knowledge, change behavior or develop supportive relationships. Offer cooking classes at St. Mary's Nutrition Center and in community settings Increase knowledge of and support available for cooking nutritious foods. Track number of sessions and participants.
      Participate in Let's Go 5-2-1-0 programming in physician practices, school-based health and St. Mary's Nutrition Center. Increase consumption of fruits and vegetables and physical activity while decreasing consumption of sugary beverages and screen time Tracking of Let's Go 5-2-1-0 programming
Respiratory Health Risk factors: Higher than state average rates for asthma and COPD Address asthma rates through community collaboration project Participation in national initiative to educate about and reduce asthma rates through Green and Healthy Homes Initiative (GHHI) Increase knowledge and decrease asthma rates. Tracking through GHHI metrics
Substance Abuse Risks: Highest rates of hospital admissions for substance abuse in the state Integrate substance abuse services through inpatient St. Mary's services (Med-Surg and Behavioral).  In process of being discussed and planned for 2014. Patients will be placed in the appropriate care level for their clinical needs. Outpatient step down programs will become available. Track reimbursement and cost associated with this DRG within the whole system.
    Increase capacity to provide substance abuse services. Expand outpatient services. Increase hours of access in the evening for intensive outpatient services. Track hours of access and numbers of patients served
  Maine has highest opioid addiction rates in the country Reduce opioid addiction rates Participate in prescription monitoring program (PMP) through MaineHealth. Implement standardized prescribing protocols for opioids. Track use of protocols and prescriptions.


St. Mary's Health System • 93 Campus Avenue • Lewiston, ME 04240