Healthy Carolinians of Orange County (HCOC) and its partners went through an action planning process in 2020 and the early part of 2021 to identify potential strategies to address, at the community level, around 1) access to care, 2) health behaviors and 3) health equity. Due to COVID-19, each committee of HCOC experienced barriers that delayed the action planning process and the outcomes. Similar to every other agency and coalition, majority, if not all, of our members had to deal with transitioning to work from home, caring for children and school responsibilities while working from home, assuming new or modified responsibilities as a result of COVID-19, and/or transitioned out of their role or the county. Through it all, the committees continued to meet (on a limited schedule) and think through efforts that could not only be useful to Orange County post COVID, but could also incorporate new COVID protocols and requirements.

For the next four years, HCOC will make efforts around each priority area and implement and support new or existing efforts to help improve access and the overall health and well-being of those who live and work in Orange County. The Access to Care committee will help to ensure that all individuals receiving services in Orange County will have everything they need, with no limitations, as it pertains to transportation, healthcare, prevention, as well as, intervention and treatment services. The Health Behaviors committee will focus on alcohol access and alcohol outlet density and work to ensure that all Orange County supports safe and responsible use of alcohol. The Health Equity Council will work to ensure that all members of the Orange County community have meaningful access to resources and supports to define, maintain, and improve their physical, mental, and social health and wellbeing.

To get involved or to assist with the ongoing work of HCOC, around any of the three focus areas of Access to Care, Health Behaviors or Health Equity, email us at:
hcoc@orangecountync.gov or call 919-245-2440.

 While OC is leading the state in vaccinations with over 60% of community members fully vaccinated, there are still individuals who are at a disadvantage and OCHD will not rest until everyone who wants a vaccine is able to get a vaccine. In an effort to ensure that all community members have access to the vaccine, the OC Mobile Vaccine Team is ready to vaccinate people who are homebound or are otherwise unable to travel to a vaccine clinic. To date (June, 2021), the OC Mobile Vaccine Team has administered the vaccine to 44 homebound individuals. The most reported challenge of this program has been identifying those in need. To refer individuals for the vaccine, who may be encountering challenges, visit www.orangecountync.gov/MobileVax or call 919-245-6127.

During an emergency the county’s EOC is activated as well as the Joint Information Center (JIC). The JIC operates out of the Health Department and serves to unify the information network so that all community members receive consistent messaging about the emergency as it evolves. It also serves as a centralized portal for information and complaints. Messaging is available in multiple languages and is delivered through multiple channels and in a variety of formats in order to bridge the digital and literacy divide. The JIC and the larger communicators workgroup meet often to address disinformation, review new COVID-19 guidance and to disseminate ready to use resources on a regular basis.

OCHD Pandemic Response by the Numbers (from January 25, 2020 to June 28, 2021)

Education, employment, income, family and social support, access to affordable and quality healthcare, and safety all provide the foundation for overall health and wellbeing. Social and economic factors have a huge impact on where and how one lives, jobs obtained, the care provided, and one’s overall day-to-day experiences.

Health Care
Orange County has a strong health care community that includes a nationally-ranked hospital system, an accredited School of Public Health, a federally qualified health center, a local public health department, a medical and dental school, and various private medical practices. Even though OC has a physician rate of 119.62 per 10,000 population, residents
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continue to report barriers accessing health care services. Some voiced barriers include:
1) no medical insurance
2) the concentration of health care resources in the southern part of the county
3) inadequate transportation systems in the central and northern part of the county
4) language barriers
5) perceived discrimination or racism within health care facilities

Insurance
According to small areas health insurance estimates, 10.5% of OC residents 0-65 years of age are currently uninsured, compared to the NC rate of 12.5%. NC children and seniors show higher rates of coverage, largely due to Medicaid and Medicare. Having health insurance provides individuals access to the health care system. A lack of coverage creates barriers that can limit or prohibit individuals from receiving the health care that they need and can cause an individual to have poor health status, late or no diagnosis and/or premature death.

NC’s Medicaid program currently uses managed care in a limited way, where primary care case management is done through Community Care of North Carolina, the LME/MCO system for behavioral health services, and the Program of All-Inclusive Care for the Elderly (PACE).

OCHD contracts with Community Care Physician Network (CCPN), which is a Clinically Integrated Network (CIN) in NC. CCPN then contracts with all of the PHPs that are eligible to provide coverage in Orange County on our behalf (AmeriHealth Caritas, BCBSNC, Carolina Complete Health, United Healthcare, and Wellcare), and are able to negotiate contracts with better fees and conditions for a large number of NC counties.

Transportation
On March 5, 2021, Orange County Public Transportation (OCPT) launched MOD (Mobility On Demand), an innovative pilot program that will provide flexible and dynamic transportation service within the Hillsborough service area. Orange County’s MOD program will cost $5 per trip and will be available on Fridays from 5 p.m. to 9 p.m. and Saturdays from 9 a.m. to 5 p.m.

Similar to companies like Uber and Lyft, Orange County MOD vans will accommodate riders with disability needs and users will have the option to request a same-day ride through a smartphone app called TransLoc. The app will provide passengers with an estimated pick-up time, track the MOD van’s location in real-time, and alert them when their ride is about to arrive.

Chapel Hill Transit provides transportation service to two UNC Health vaccination clinics and OCHD’s vaccination clinic, which was previously provided at the RR Lot. Chapel Hill Transit operates GoTriangle’s 420 route, which provides service to UNC Health vaccine clinic in Hillsborough.

Foods consumed, lack of exercise, use of seatbelts, substance use (i.e. tobacco and alcohol) and sexual activity all affect ones overall health. Health behaviors are not always determined by a choice to be healthy or unhealthy, however, it is important to note that where one lives, learn, work and play, as well as social and economic circumstances and trauma exposure often dictate the ability to make healthy choices.

Tobacco Prevention and Control during COVID-19
OCHD’s Tobacco Prevention and Control Program is evidence based, personalized and intentional in its approach to tobacco cessation. COVID is an illness that can impact the respiratory system, and in individuals who smoke or use tobacco COVID can have a devastating impact on the health of the lungs. OCHD pivoted the ways in which services were delivered to meet the needs of community members interested in quitting tobacco during the pandemic.
 

FreshStart Group Support Classes
FreshStart is a tobacco cessation class that meets one hour per week for four weeks and offers participants educational cessation information, group support, and 12 weeks of free Nicotine Replacement Therapy (NRT) Products. As a result of COVID, the FreshStart Program had to adapt to community closures and pivoted from face-to-face classes to virtual classes. The virtual classroom provided community members the ability to access the course from their home environment, which resulted in increased registration, participation, and group support. Like most things, COVID created various challenges to the normal way of operating and providing service. The first challenge was the need to mail all course material and NRT products rather than distributing them in person. The second challenge was the need for all participants to have access to a smart phone or computer with reliable WIFI connection.

Individualized Tobacco Treatment Services
Individualized Tobacco Treatment Services offers individuals 12 weeks of counseling and NRT products to those interested in quitting smoking, vaping or using any other tobacco products. Due to COVID and office closures these services adapted and changed from weekly face-to-face meetings to weekly telephonic meetings. The benefit of telephonic and virtual sessions was the ability for participants to access necessary support at their convenience, which yielded more referrals from the Orange County Medical and Dental clinics and area healthcare providers, and more satisfied participants. Currently, this programmatic service is seeing over 20 patients at varying stages of cessation in their smoke free journey, ranging from 30 days to 7 months.

The UNC Tobacco Treatment Program (formerly the Nicotine Dependence Program) has provided leadership for implementing comprehensive tobacco use treatment services, education and training, and dissemination of resources for promoting tobacco free communities for the past 12 years.
UNC’s Tobacco Treatment Program (TTP) provides services across the UNC Health Care System, regardless of ability to pay. Services include:

• UNC Family Medicine Center: Open to all community members
• NC Cancer Hospital: TTP’s on-site specialists engage patients from across the state who are fighting cancer.
• UNC Hospitals: Trained specialists ensure that patients receive medications for withdrawal upon admission to the hospital, resources for remaining tobacco free after discharge, and follow-up support.
• Worksite Programs: TTP works with local and regional employers, including UNC Health Care and the Town of Chapel Hill, to help their employees become and remain tobacco-free.

Orange Partnership for Alcohol & Drug Free Youth (OPADFY) connected with a Pediatric Physician to facilitate the development of a pediatric smoking/vaping cessation program and a youth vaping prevention program. That partnership yielded the initiation and implementation of a fellowship with the UNC Pediatric Pulmonary team where their staff will use this program to assist youth in quitting vaping, particularly those suffering from e-cigarette or vaping product use-associated lung injury (EVALI).

Prescription & Opioid Drug
Decades of prescribing more opioids at higher doses have led to a rising number of opioid overdose deaths creating a public health crisis in North Carolina to include Orange County. At the end of 2019 and prior to the COVID-19 pandemic, UNC Medical Center and OCHD partnered to further coordinate efforts to address this epidemic in our community. This partnership will be a 3-5 year commitment to work with stakeholders in the opioid use disorder (OUD) and substance use disorder (SUD) community in OC. This partnership will build a more resilient infrastructure equipped to assess community needs to current and potentially the next wave of the opioid epidemic. The NC Opioid State Action Plan will serve as the foundation for the work with the below three priorities to address:

1) education
2) reduce oversupply of prescription opioids
3) expand treatment and recovery oriented systems of care

It is the hope to resume this group in 2021-2022, once things calm down around COVID-19, the vaccine, and reallocation of time back to this effort among both UNC Medical Center and OCHD.

Currently, there are eight permanent drop box locations in OC, to help dispose of expired and unwanted medications. Permanent drop boxes are located within all of OC’s police departments (Carrboro, Chapel Hill and Hillsborough), the Orange County Sherriff Office, Hillsborough Pharmacy, Walgreens, and three within UNC Health (two at the Chapel Hill campus and one at the Hillsborough campus).

Alcohol
The third leading cause of preventable death in NC is excessive drinking, and has been trending upward from 2012-2017. Excessive drinking is defined as binge drinking (4-5 drinks or more in one sitting by women and men), heavy drinking (8-15 drinks per week for women and men), and any drinking by pregnant women or people under the age of 21. Nine out of 10 excessive drinkers are not dependent on alcohol but may not realize that excessive drinking is associated with increased risky behavior, violence, suicide, homicide, vehicular accidents and/or multiple chronic diseases.

While the number of alcohol related ED visits, among OC minors, has declined from 2017 – 2019, alcohol continues to be the number one most frequently used substance among OC youth. There is strong evidence that alcohol outlet density restrictions can help reduce the rate of alcohol consumption, violent crime, individual alcohol consumption and underage drinking.

Racism and Health
“Racism structures opportunity and assigns value based on how a person looks. The result: conditions that unfairly advantage some and unfairly disadvantage others. Racism hurts the health of our nation by preventing some people the opportunity to attain their highest level of health. Racism may be intentional or unintentional and operates at various levels in society. Racism is a driving force of the social determinants of health (like housing, education and employment) and is a barrier to health equity”.

OCHD acknowledges that public health is a system that was and continues to be structurally and foundationally built on racist policies, practices, and procedures. Due to this history, OCHD must actively work to gain the public’s trust and grow the department to become a more equitable system.

OCHD also acknowledges that our county’s marginalized populations face barriers across systems due to racial inequities in housing, banking, education, employment, etc. all of which contribute to poor health outcomes. This is why Health Director Quintana Stewart declared structural racism a public health crisis.

OCHD’s Racial Equity Commission (REC) wanted to find a way to share resources and encourage OC’s community to enter the equity conversation. The health equity webpage was created to help others in the community grow in this work, to show the community the strides made in this work, and to help stay accountable to the community.

OC’s Health Equity Council (HEC) was formed when OCHD received funding from the NC Office of Minority Health and Health Disparities to address the health status gap between racial/ethnic minorities and the general population. Members of HEC provide input and approve plans and budgets that outline action steps to advance health equity, address social determinants of health, reduce health disparities, and impact Culturally Linguistically Appropriate Services (CLAS) Standards.

To assist community partners with COVID-19 relief, HEC used existing funding to support language access as it relates to interpretation and translation needs. HEC is open to all community residents, businesses, agencies, and organizations. HEC’s 2021-2024 action plan focuses on increasing educational opportunities and raising awareness of health equity in OC, increasing access to qualitative data by engaging community residents and working to inform the development of the Racial Equity Index, and improve health equity in COVID-19 recovery efforts by advocating for systemic policy change and continuing to vaccinate marginalized and vulnerable populations. To get involved, call 919-245-2405.

Race/Ethnicity and COVID-19
While race and ethnicity are markers for other underlying health conditions, including socioeconomic status, access to healthcare, and exposure to viruses, it also proves to be a marker for COVID-19. Early in the pandemic it quickly became clear that marginalized communities were being disproportionately affected by COVID-19, in particular the Hispanic/Latinx community. To help reach and address the concerns of COVID-19 among the Hispanic community, OCHD and Orange County Human Rights and Relations launched a video series called “Cafecitos con el Condado de Orange” (Coffee with Orange County) which aims to address the questions and concerns of the Hispanic community.

In response to this urgent need an existing Latinx Equity group began meeting weekly. The group includes attendees from various organizations from within the county and the state that identify as Hispanic/Latinx and are deeply involved with the Hispanic community. Topics have included health, housing, food scarcity, school closing, the challenges of virtual learning, and much more. In addition to sharing resources, the Latinx Equity group also collaborates on messaging that is tailored to the Hispanic community.

Human Services COVID-19 Response
December 21, 2020, OC created and launched a Human Services Consulting Group to help reduce vaccine barriers for people of color and other historically marginalized groups in OC. This is a racially diverse group of doctors, community center directors, public health educators and communicators, and County and non-profit staff representing more than 15 organizations. While the group originated as a result of COVID, the plan is to make the Human Services Group a subcommittee of HEC which will allow it to continue to guide and support the equitable distribution of vaccines and advocate for systemic policy change in COVID-19 recovery efforts.

The focus of the Human Services Consulting Group is to:

• Align County departments, who provide direct human services to residents, with non-profit service providers to identify historically marginalized groups (LGBTQ+, people of color, disable, etc.) across the County who are facing barriers to getting the COVID-19 vaccine and finding ways to remove those barriers.
• Identify locations and host organizations for pop-up community vaccine clinics, and support those host organizations by directly reaching out and getting people signed up for appointments. During the early months of the vaccination effort, demand for vaccines was so high that people who had the free time and the technology to sign up often took vaccine appointments. The direct outreach conducted, along with trusted community organizations, was key to ensuring that historically marginalized groups had access to the vaccine.
• Work to identify homebound residents to get them vaccinated at home.
• Help establish a partnership to vaccinate unsheltered individuals in the OC.
• Report community feedback to the vaccination leadership team to help continuously improve the OC’s practices. Community feedback led to improvements like centering community volunteers at community vaccination events, ensuring that police officers stayed in the background of vaccination events, and ensuring messages were sent in the ways and in the languages that would be most effective.

The work of the Human Services group, along with that of OCHD’s vaccination team, has helped lead to vaccination rates among OC’s Black and Latinx residents that are higher than their share of the population in the County.

1 NC DHHS (2021). NC SCHS: Statistics and Reports: County Health Data Book. Accessed from https://schs.dph.ncdhhs.gov/data/databook/
2 Orange County (2021). Orange County Health Department: COVID-19 Dashboards. Accessed from https://www.orangecountync.gov/2643/COVID-19-Dashboards
3 Orange County (2019). 2019 Orange County Community Health Assessment. Accessed from https://www.orangecountync.gov/DocumentCenter/View/11246/2019-COMMUNITY-HEALTH-ASSESSMENT-web
4 NC DHHS (2019). New Data Dashboard Illustrates State, County Impacts of Excessive Alcohol Use in North Carolina. Accessed from https://www.ncdhhs.gov/news/press-releases/new-data-dashboard-illustrates-state-county-impacts-excessive-alcohol-use-north
5 County Health Rankings (2021). Alcohol Outlet Density Restrictions. Accessed from https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/strategies/alcohol-outlet-density-restrictions
6 APHA (2021). American Public Health Association: Racism and Health. Accessed from https://www.apha.org/topics-and-issues/health-equity/racism-and-health