Blog Archives
By Amanda Jepson | Categories: | Comments Off on Refugee Services
Arizona has settled more than 110,000 refugees since 1981 and ranks in the top five states for refugee reception. Seventy-eight percent of those refugees relocate to Maricopa County, where Valleywise Health operates, in Phoenix. In response to the influx of refugees, Valleywise Health established the Women’s Refugee Health Clinic in 2008 to provide a culturally grounded, patient-centered medical home for the refugee community. In 2022, the clinic became part of the Valleywise Health Center for Refugee and Global Health. The center aims to assist refugees in navigating the U.S. health care system, including support with interpretation, insurance, housing, and day-to-day survival information.
The center provides comprehensive services via numerous clinics, including the Refugee Women’s Health Clinic, Refugee Pediatric Clinic, Family Medicine Refugee Clinic, McDowell Clinic for Individuals Living with HIV, Specialty Care Services, Behavioral Health Services, and Internal Medicine. Through outreach, the center mitigates structural barriers to care, including transportation, health literacy, continuum of care, and treatment adherence. Eighteen cultural health navigators work with clinical teams to coordinate all health-related activities daily. Valleywise Health allots an annual budget to the center and receives additional funding from foundations, including the Valleywise Health, Burton Family, Flinn, and Pakis Family foundations.
Community partnerships with the Arizona Department of Health Services, Department of Economic Security, State Refugee Resettlement Office, Maricopa County Department of Public Health, Arizona State University, health plans, and other refugee-serving organizations are key in service development, implementation, and dissemination.
In 2024, the center served 17,000 refugee patients, an increase of 1,000 over the previous year, from 71 countries. The center provided health literacy classes to more than 800 patients; adult refugee services to 1,437 men (including 243 who transitioned to self-efficacy in 2024), thanks to the program’s expansion into family medicine; and HIV and AIDS care to 880 adult refugees. Health care providers delivered 212 babies at the Refugee Women’s Health Clinic and installed more than 300 car seats for mothers who completed child safety classes. Additionally, the health center has seen a 33 percent increase in mental health screenings.
By Amanda Jepson | Categories: | Comments Off on Bringing the Justice System to Outpatient Addiction Care
Harris Health System’s Office-Based Addiction Treatment (OBAT) Program integrates physical, social, behavioral, and mental health to treat patients with substance use disorder (SUD) in a non-stigmatizing environment—the primary care setting. The program provides extensive support to patients with SUD and works to decrease drug misuse to less than 30 percent of the patient population. Additionally, it provides assessments and follow-up care for body mass index, depression, and tobacco use.
A team of nurses, community health workers, medical doctors, and executive leadership educates participants on establishing their place in the community, prioritizing their mental health, and practicing self-care to keep a healthy mindset. Eighty percent of OBAT participants are uninsured or underinsured. The program identifies social determinants of health on a case-by-case basis and takes measures to mitigate noncompliance risks with treatment plans. Since its 2017 inception, the OBAT program has been funded through federal Substance Abuse and Mental Health Services Administration grants, multiple state grants, and university research partnerships.
In 2022, Harris Health System’s OBAT partnered with the Harris County Success Through Addiction Recovery (STAR) Drug Court Program to better serve patient needs. The STAR program uses a unique judicial model of treatment and education to support recovery from substance use and mental health disorders and reduce the expense of criminal case processes and incarceration. This partnership allows the Harris Health OBAT team to visit the courts monthly to speak with clients about the program; discuss topics related to substance use, addiction, suicide, and overdose prevention; and provide connections to community resources. Additionally, the OBAT team partnered with Harris Health’s Health Care for the Homeless Program to provide mobile medical unit services outside of the courts for six months.
The program currently serves 287 opioid use disorder and 97 alcohol use disorder patients. OBAT participants have shown significant decreases in drug misuse, and 93 percent of program participants are opioid-free within six months. In collaboration with STAR, Harris Health System educated 730 clients on suicide and overdose prevention between November 2022 and September 2024, and distributed more than 300 boxes of naloxone to clients and courts.
By Amanda Jepson | Categories: | Comments Off on Pioneering Change: Population Health at Essential Hospitals
Staff at Nashville General Hospital (NGH) frequently encounter patients who need assistance navigating the health system, applying for financial assistance, obtaining affordable medications, and learning how to advocate for their health. In response, NGH curated programs under the Population Health Management department, including the Community Care Team (CCT), Food Pharmacy, Congregational Health and Education Network (CHEN), and NGH HopeMeds Program. The multi-pronged approach seeks to ensure that the patient population uses available resources and sees improvement in health outcomes.
The CCT is a care management team consisting of a medical director, navigators, dietitian, Food Pharmacy manager, social workers, and a nurse practitioner who collaborate to assist patients with health and social needs. The Food Pharmacy supports patients experiencing food insecurity through access to healthy foods tailored to patient health needs, as well as nutritional counseling and social services support. CHEN is CCT’s counterpart in the Nashville area’s faith-based communities with four leading pillars—health literacy, education attainment, access to health care, and membership development. These efforts are supported by grants from the National Institutes of Health and Community Health Worker trainings provided by Meharry Medical College. Additionally, the NGH HopeMeds Program allows qualified patients to receive no-cost medications.
The CCT team works closely with the Patient Experience and Marketing departments to collect patient feedback. Additionally, leaders of the Ambulatory Clinics, Case Management, and Population Health Management departments review this feedback to ensure the programs meet patients’ needs. CHEN partners with multiple external organizations, including NGH’s Clinical Research department; the National Institute on Minority Health and Health Disparities; and several faith-based organizations, with an emphasis on those that serve African American communities.
The Food Pharmacy has had approximately 11,800 visits since 2022 and helped cancer patients facing food insecurity obtain nutritious food to keep the weight needed to sustain cancer treatments. In one year, the NGH HopeMeds program, offered through the Nashville-based nonprofit, Dispensary of Hope, has served more than 1,200 unique patients, filled more than 4,700 prescriptions, and provided more than 8,400 months of no-cost medications, saving patients more than $585,000.
By Amanda Jepson | Categories: | Comments Off on Compassion for Community: Continuing Care After Death
At NYC Health + Hospitals/Jacobi and North Central Bronx, in the Bronx, N.Y., decedent holding time in the morgue drastically increased from an average of 72 hours before the COVID-19 pandemic to an average of 13 days in 2022. In addition to affecting the grieving process for patients’ families and loved ones, the delay in decedent release time strains hospital resources by requiring additional personnel and refrigerated space.
An employee in the Department of Pathology who was herself mourning the loss of her parents raised concern about this turnaround time and turned her grief into action. An analysis showed that funeral home capacity, complexities in navigating the funeral process, and high funeral costs contributed significantly to delays in decedent release, with Black decedents more likely to experience longer release turnaround times. The Compassion for Community: Continuing Care After Death program aimed to reduce decedent release turnaround time to improve family support, mitigate racial disparities, promote operational efficiency, and reduce environmental impact.
The program’s multipronged approach included 1) strengthened relationships with community partners including funeral homes and places of worship to identify capacity and support available to families, 2) enhancement of data collection to track capacity, 3) development of a guidebook, “Illuminating Forever Care,” for families that explains the practical aspects of funeral care and includes resources for funeral costs and processes. Written at a sixth grade reading level and available in multiple languages, in print and digitally, the book aims to close racial and ethnic disparities that delay decedent release.
The self-sustaining program operates with existing personnel, including an interdisciplinary team led by the quality management team that comprises staff from pathology, admitting, patient experience, bereavement, and finance. In 2023, 100 percent of decedents were released in eight days or less; in 2024, 90 percent of decedents were released in five days or less. Additionally, the program reduced greenhouse gas emissions by 13.1 metric tons and saved the health system $90,000 in overtime in its first year by minimizing refrigerated trailer use.
The health system would like to dedicate this award to the late Ms. Suzanne Pennacchio, whose legacy of quality/safety transformation we carry forward.
By Amanda Jepson | Categories: | Comments Off on Curbside Care
Boston Medical Center (BMC) recognizes how critical the first six weeks of life are for birthing people and babies. Forty percent of publicly insured birthing people never return for a postpartum appointment. To close this gap, BMC launched the Curbside Care program in January 2023 with the goal of mitigating barriers to postpartum care through a mobile unit.
Curbside Care is a mobile health delivery program that provides high-touch, comprehensive wraparound services for birthing people and their infants in the first six weeks of life outside of their homes in Boston—at the curb! Funded by the Boston Celtics Shamrock Foundation, Curbside Care replaces traditional postpartum visits in this hospital and eliminates the need for transportation and childcare for postpartum appointments. Our clinical staff of doctors, nurse practitioners, certified nurse-midwives, and an international board of lactation consultant examiner provide a range of services including feeding assessments, lactation support, jaundice evaluation, postpartum depression and hypertension screenings, and contraceptive services all on the mobile unit. A community wellness advocate recruits pregnant patients and performs a needs assessment for each dyad. Patients receive material needs, such as diapers, strollers, and food, at each visit.
Curbside Care is an interdepartmental initiative run by the pediatrics and OBGYN departments at BMC. Other hospital partnerships include the Breastfeeding Equity Center, the Economic Justice Hub, and the Center for the Urban Child and Healthy Family. Community partners also include Brewster Ambulance Service, the Vital Village Network, and New England Mothers First.
BMC has cared for 519 patients in the last 12 months, with an average of 3.7 visits per patient. Of the patients seen, 63.97 percent identified as Black and 31.17 percent identified as Hispanic/Latino. All patients received lactation support and were screened for material needs and postpartum depression. All patients reside in Boston ZIP codes, primarily in the Dorchester, Mattapan, and Roxbury neighborhoods. Curbside Care patients have a 2.9 percent “no-show” rate, compared with 15.3 percent in BMC’s pediatric clinic and 18.8 percent in the postpartum OBGYN clinic.
By aoguagha | Categories: | Comments Off on Episcopal Food Pantry
Located on Temple Health’s Episcopal Campus, the Episcopal Food Pantry provides free fresh fruits and vegetables, canned goods, and other non-perishable items to nourish the community. In collaboration with the Share Food Program, the leading food bank in the Philadelphia area, the food pantry is open every Thursday. Since the program opened in May 2022, the number of community members served has doubled, and the program hopes to see continued growth.
For more information about the program, click here.
By aoguagha | Categories: | Comments Off on Farm to Families
To decrease chronic disease related to poor diet and physical inactivity, Farm to Families increases access to healthy foods by providing low-cost, fresh produce, dairy, and meat to over 350,000 residents in North Philadelphia. With a FreshRx prescription from a Temple Health doctor, patients who screen positive for food insecurity can receive coupons to purchase fresh food through the program. Community members and families with food stamps can also buy fresh foods throughout the year and receive nutrition education on how to sustain healthy eating habits.
Temple University Hospital and the Lewis Katz School of Medicine collaborate with the St. Christopher’s Foundation and the Lancaster Farm Fresh Cooperative to source, package, and deliver fresh and organic food to the community. Over 48,000 boxes of food have been purchased by more than 6,400 families since 2010.
For more information about the program click here.
By aoguagha | Categories: | Comments Off on Food As Medicine
The Food as Medicine partnership at Grady Health provides members of the Grady community (patients, families, employees, visitors, and neighbors) access to healthy affordable food through the Jesse Hill Market and other collaborations throughout the Atlanta area. Located just outside Grady’s main entrance, the Jesse Hill Market features a food prescription program that offers eligible patients fresh food, nutrition education, and cooking classes. The Market also offers healthy grab-and-go meals and fresh produce for purchase through its public café.
The Food as Medicine program is a multipronged intervention to address both chronic disease and food insecurity among Grady patients. Grady Health partners with the Atlanta Community Food Bank and Open Hand Atlanta to deliver the Food As Medicine program. The Food as Medicine Partnership aims to fuel patients with healthy foods while bringing the community together.
For more information, click here.
By aoguagha | Categories: | Comments Off on Food Rx
To address food insecurity among their patient population, LA Health Services’ Food Rx program works in partnership with the Department of Public Health CalFresh Healthy Living Program to give patients a stronger footing in their healthcare journey. The program also provides links to CalFresh, SNAP, and other long-term food resources to support patients in reaching their health goals.
Since the inception of the program in 2021, the program has conducted over 392 food distributions, served over 290,186 households, and distributed over one million pounds of food.
For more information click here.
By Amanda Jepson | Categories: | Comments Off on Community Health Program
In Galveston County, 16 percent of the population is uninsured and 12.1 percent lives in poverty. In Brazoria County, 15.9 percent are uninsured and 9 percent live in poverty.
The University of Texas Medical Branch (UTMB Health)’s Community Health Program (CHP) provides community-based care and condition management services to adults with chronic conditions, including diabetes, hypertension, and heart disease, in Galveston and Brazoria counties. Most program enrollees struggle with food insecurity, lack of transportation, and affordable housing, which compromises their ability to pay for medications and other health care expenses to manage their medical condition optimally. Many patients access health care services inappropriately or do not seek care until much later than is optimal for their conditions.
The program is set up in five geographically deployed teams/pods, each consisting of care managers, community health workers, and social workers who provide services to this patient population through health care navigation support, education, and resource connections. Emergency department staff, inpatient staff, and other local partners can refer patients to CHP via phone or messages in the electronic health record. The goal is to encourage care coordination that empowers the patient and caregiver(s) to contribute toward more successful outcomes. All patients enrolled in the program have a comprehensive intake assessment and are viewed through a “whole person” lens.
The program, available at no cost not only to UTMB Health patients but also to all patients in the service delivery area, was initially funded through the Texas Medicaid Section 1115 waiver before continuing as a budgeted expense. The CHP recently expanded by six full-time equivalents after a return-on-investment analysis indicated that the program is producing the desired patient care outcomes.
CHP collaborates with two faith-based organizations, community health centers, county indigent programs, food banks, and the Salvation Army to connect patients to services and resources. For example, one faith-based organization offers several clinics, including a Transitions of Care Clinic for recently discharged patients, and provides specialty care in partnership with UTMB.
For a 28-patient cohort, CHP enrollment for 12 months led to an 83 percent decrease in hospitalization and 95 percent reduction in ED visits. More than 40 percent of the 28 patients with diabetes saw a drop in their HbA1c values during and after participating in the program. Participants’ hemoglobin A1c values and blood pressure decreased. In comparison with a control group of patients not enrolled in the program, CHP enrollment reduced system costs by 24 percent.
