Blog Archives
By Amanda Jepson | Categories: | Comments Off on Center for Better Aging
St. Bernard Hospital’s Center for Better Aging (CBA), in Chicago, delivers an integrated model of care focused on the physical, mental, and social health of adults aged 50 and older. These patients often face food insecurity, housing instability, social isolation, or financial stress. Services include primary and specialty care; a geriatric-certified emergency department; wellness and prevention programs; and attention to nonclinical needs like housing, nutrition, and transportation.
CBA partners with academic institutions and community groups to elevate specialty care and workforce training. Local organizations like Chicago Commons, SPARC Wellness, KemeticHlth, SMYL Fitness Rx, and others help with home care, coordination, fall prevention, mental health, and community wellness. The center also hosts health fairs, screenings, workshops, and other outreach events to engage aging adults, build trust, and reduce access barriers.
To ensure quality and continuous improvement, CBA tracks clinical outcomes, show rates for clinic visits, patient satisfaction, and engagement data from outreach. In 2024, the center logged over 1,000 primary care visits and a 71.9% show rate. The program’s leaders emphasize the importance of community-driven partnerships, workforce development in geriatrics, diverse funding streams, and creating welcoming environments as essential components for replicating their model.
By Amanda Jepson | Categories: | Comments Off on Baystate Health Engages Employees in Sustainability Efforts
Baystate Health, in Springfield, Mass., developed a comprehensive sustainability strategy to reduce greenhouse gas emissions among staff in their facilities.
These efforts begin at onboarding. Baystate uses internal and external communications like newsletters, social media, and a sustainability webpage to ensure that programs are visible and accessible.
On the hospital’s medical intensive care unit, clinicians and nurses formed a sustainability committee and worked with management and the sustainability team to expand recycling on the unit. Climate and Coffee, an annual event that draws roughly 750 staff members across three hospitals, offers updates on sustainability efforts and invites staff to learn how they can participate, especially in reducing clinical waste. The health system also hosts a monthly onsite farmers market featuring local vendors to promote healthy eating while reinforcing sustainability values.
The Unusable Medical Supplies Collection initiative, in partnership with Partners for World Health, diverts supplies no longer suitable for patient care to health aid programs abroad, leveraging nurse and physician staff efforts. Additionally, the health system expanded its medical device reprocessing and buyback effort to include additional kinds of devices, which saves money and reduces landfill waste.
This model shows how embedding sustainability into culture and making it part of workplace norms, not just facility operations, can empower employees as change agents and help maintain momentum over time.
By aoguagha | Categories: | Comments Off on Prevention and Recovery in Opioid Use Disorder (PROUD) program
Through the Prevention and Recovery in Opioid Use Disorder (PROUD) program at the Chesapeake Regional Medical Center, patients work with physicians in the emergency department to create individualized treatment plans to support recovery from opioid use disorder and other substance use conditions. Additionally, patients are connected to an outpatient community partner to continue their treatment with guaranteed follow-up within 72 hours after release from the emergency department. The majority of PROUD program participants are uninsured and struggle with multiple social determinants of health; however, patients are not turned away due to financial limitations.
The program partners with the hospitalist and emergency medical services teams within the hospital to provide care through a mobile clinic for street outreach. Future enhancements aim to expand partnerships with outpatient clinics and increasing mobile outreach efforts.
By aoguagha | Categories: | Comments Off on Jail Release Program
The Jail Release Program at Parkland Health uses a comprehensive approach to link patients recently released from the Dallas County jail to community-based care. The program developed a release workflow and referral hub in collaboration with community-based organizations and the correctional health team at the Dallas County Jail, consisting of a nurse navigator, referral coordinator, peer navigators, and social workers. This referral hub assists patients with their transition back to the community by linking patients with services such as transitional housing, health insurance, pharmacy assistance, career planning and placement, and social support networks. Additionally, patients are supported with transportation through Uber and bus passes. The nutritional needs of patients are also served through connections to food pantries.
By aoguagha | Categories: | Comments Off on Building Recovery Integration for Drug Users into Emergency Medicine (BRIDGE)
Tampa General Hospital’s Building Recovery Integration for Drug Users into Emergency Medicine (BRDIGE) program offers a range of services, including a mobile suboxone clinic, an office-based opioid therapy clinic, mental health and substance use counseling, and essential wrap-around services to improve post-discharge outcomes, decrease re-admissions and shorten the length of hospital stays all while providing world-class care to adults struggling with opioid use. The program, which opened Florida’s second legal syringe exchange that treats over 2,000 patients, is making a significant impact in the community.
The BRIDGE program collaborates with the Hillsborough Housing Authority to assist patients with housing instability, collaborates with local food banks to expand their ability to address food insecurity through mobile pantry days, and recently engaged a volunteer attorney to provide free consultations to patients facing legal challenges that can hinder their full engagement in their recovery program.
By aoguagha | Categories: | Comments Off on Road to Care Mobile Addiction Service
The UMass Memorial Health Road to Care Mobile Addiction Service is a street medicine program that offers walkup addiction care in the city of Worcester, MA. The Mobile Addiction Service provides free care to individuals experiencing housing insecurity, including prescribing suboxone and distributing naloxone kits in areas such as encampments, shelters, and food pantries. The program’s goal is to reduce opioid-related morbidity and mortality by offering mobile addiction services, including treatment for OUD. The mobile clinic can serve up to 30 patients in one-afternoon session, ensuring that care reaches all populations where they are. More than 2000 individuals have accessed the Road to Care Mobile Addiction van in over 11,000 encounters since May 2021.
By Amanda Jepson | Categories: | Comments Off on Optimizing Access and Management for Opioid Use Disorder
JPS Health Network developed a bridge clinic to respond to pervasive under-treatment of opioid use disorder (OUD). It is a low-barrier model for enhancing linkage to long-term care and optimizing transitions to outpatient care for patients who screen positive or self-identify for OUD.
Key activities for the bridge clinic include treatment initiation, where patients identified with OUD receive immediate treatment; referral to the bridge clinic; and wraparound support services that address clinical, behavioral, and social needs. The clinic connects patients to appropriate follow-up care and provides harm reduction education. The bridge clinic is co-located within the emergency setting to reduce delays and increase efficiency. Screening, treatment, and referrals are all streamlined into the electronic health record system. The Substance Abuse and Mental Health Services Administration procured funding for the bridge clinic to support initial development, which became sustainable through program-generated revenue and cost savings.
The bridge clinic involves an interdisciplinary team of emergency medicine clinicians, behavioral health specialists, case managers, peer navigators, primary care providers, hospital administrators, researchers, and community partners. The team works outside of traditionally siloed departments, allowing them to identify and remove barriers to program development and implementation rapidly. The program involves multiple partners, internal to the health system and external community organizations.
Since initiation in January 2021, the bridge clinic has served more than 1,100 patients. Linkage to long-term care within 120 days increased 25 percentage points for patients referred to the bridge clinic compared with usual care. Inpatient admissions within 120 days decreased by 8 percent among patients without severe mental illness.
By Amanda Jepson | Categories: | Comments Off on Helping to Uplift and Bounce Back (HUB)
Memorial Healthcare System’s Helping to Uplift and Bounce Back (HUB) program is an integrated approach to whole-person, wrap-around care designed to improve health outcomes by addressing socio-economic barriers. Memorial’s 2021 – 2024 Community Health Needs Assessment highlighted significant gaps in health-related social needs, such as access to food, stable housing, and transportation. HUB was created to address those gaps through a three-pronged approach:
- “do for” – access services for the patient
- “do with” – access services alongside the patient
- “cheer on” – support the patient in becoming self-sufficient.
Specific goals include 80 percent of identified needs being fulfilled, a 5 percent reduction in hospital readmissions and emergency department utilization, 95 percent overall patient satisfaction, and 80 percent of patients’ increased knowledge of local community resources.
HUB offers a comprehensive care model that extends beyond medical treatment by assisting with needs such as affordable housing, connecting patients to food pantries, and facilitating prescription refills. Patients are linked to primary care providers to ensure appropriate follow-up care. The program also provides transportation and childcare so caregivers can attend appointments and collect needed medications, decreasing barriers to health.
Twenty-four hours post-discharge, staff conduct home visits to ensure patients have support not only in the hospital, but also at home. The program includes two mobile health vans that provide essential health services and resources directly to uninsured and underinsured residents. Once enrolled in HUB, patients remain participants until their needs or challenges are effectively addressed. The program is internally funded and employs four experienced staff members.
Collaboration with community organizations is key to HUB’s success. Partnering provides a breadth of assistance, including resource inventories, mental health and substance abuse services, employment and carer training, food insecurity, clothing banks, home repairs, interpersonal violence, childcare, transportation, and housing assistance. Staff members bring together community resources and stakeholders to meet patients’ needs, including creating a guiding council of current and past HUB patients to assist with shaping the program based on patient feedback.
Since launching in August 2023, the program has served over 3,000 patients and families and addressed over 8,600 needs. By August 2024, the mobile vans served 4,889 individuals; 88 percent of those had no prior Memorial connection, demonstrating HUB’s successful outreach to people with historically limited access to healthcare. The program surpassed its targets, including 95 percent of identified needs being fulfilled, a 34 percent reduction in emergency department utilization, a 6 percent decrease in readmissions among HUB patients, 99 percent overall patient satisfaction, and 92 percent of patients gained knowledge on available community resources.
By Amanda Jepson | Categories: | Comments Off on Center for Comprehensive Addiction Treatment, “No Wrong Door”
Bergen New Bridge Medical Center in Paramus, N.J., established the Center for Comprehensive Addiction Treatment (CCAT) in response to an increase in patients returning to the hospital for addiction treatment post-discharge. The Center aims to expand availability and access to withdrawal management services and overall substance use disorder treatment.
The Medical Center offers numerous levels of care, including involuntary and voluntary crisis units, withdrawal management, and short-term residential care, allowing a “No Wrong Door” approach that supports immediate direct patient access. The multidisciplinary team consists of psychiatrists, physicians, nurse practitioners, nurses, social workers, and substance use disorder staff. CCAT offers peer recovery specialists who model what recovery could look like for patients. The program mitigates social determinants of health by tackling food security, housing, and transportation—barriers to successful treatment for many patients—and focuses on expanding accessibility to services for underserved, marginalized populations.
Partners for the program include Rutgers University, Integrity House, CarePlus NJ, and other substance use disorder treatment programs, strengthening the culture of change and continuous improvement. Bergen New Bridge hosts community partners including Alcoholics Anonymous and Narcotics Anonymous as well as medication-assisted treatment meetings to provide an all-encompassing approach to care for these patients.
Since starting the program, the Medical Center has expanded its licensures for additional outpatient programs, including adolescent services. Additionally, the team has introduced family nights to provide education about substance use disorders, treatment options, and recovery. In 2024, the program served 3,938 individuals with inpatient care and provided 17,613 units of intensive outpatient care to patients throughout New Jersey. On the office-based addiction treatment level of care, providers have supported and maintained 1,560 individuals in treatment for substance use disorder services. Rates of treatment refusal post-discharge have decreased from 21 percent in 2022 to 12 percent in 2024. The rate of leaving against medical advice also dropped, from 13.59 percent in 2022 to 8.6 percent in 2024.
By Amanda Jepson | Categories: | Comments Off on Advancing Hypertension Control in Disparate Populations
ECMC, in Buffalo, N.Y., developed the Advancing Hypertension Control in Disparate Populations through Comprehensive Remote Patient Monitoring program in response to a community needs assessment that showed high rates of hypertension among patients, including 56 percent of Black patients. Needs assessment data also demonstrated that this patient population faced significant barriers to hypertension treatment, such as lack of transportation. By leveraging self-measured blood pressure monitoring, telehealth, and coordinated care, the program aims to improve patient engagement, enhance health care access, and achieve better clinical outcomes for individuals at risk for and diagnosed with hypertension.
Participants receive a validated blood pressure cuff at no cost and attend telehealth visits to assist with monitoring health behaviors. Resources allocated to sustain the program include dedicated hospital staff and funding from multiple organizations, including The Buffalo Center for Health Equity, Highmark, Univera, and Independent Health. A partnership with the American Heart Association supported blood pressure kiosks and community screenings.
Patients and families played a key role in developing this program by providing feedback on behavioral intentions, perceived control of access to care, and hypertension management. To reach beyond patients attributed to the health system, ECMC partnered with community-focused organizations, such as the Independent Health Association, to identify individuals with unmet health care needs and provide accessible health services to underserved Buffalo neighborhoods. Together, these organizations and ECMC hold community events to educate individuals on hypertension and familiarize the community with this program.
Since 2022, ECMC has enrolled more than 900 primary care patients in the program. More than 50 percent of enrolled patients have experienced a significant reduction in their systolic blood pressure. The hypertension control rate among ECMC primary care clinics increased from 44.2 to 69 percent. Additionally, patients with hypertension who are not enrolled in the program utilize emergency services 56 percent more often than program participants.
