Blog Archives
By Amanda Jepson | Categories: | Comments Off on Health Equity Accelerator
The Health Equity Accelerator at Boston Medical Center (BMC) originated from research and development after COVID-19 highlighted multiple health inequities that would not have been uncovered in normal conditions. These discoveries, paired with BMC’s historical interest in closing the health equity gap, fuel the Health Equity Accelerator. The program’s goal is to drive racial health equity in the areas of pregnancy, infectious diseases, behavioral health, chronic conditions, and oncology and end-stage renal disease, with a vision to transform health care to deliver health justice and well-being.
The Health Equity Accelerator incorporates three foundations of health care: research, clinical care, and community, including social determinants of health (SDOH). The Accelerator team consists of executive leadership, project managers and analysts, community navigators, and research experts. This team breaks problems down into core elements and, through research and evaluation, identifies and implements innovations to combat the problem. The team will partner with community leaders to seek insight on how well those solutions and interventions affect the target issues. The program aims to serve patients and their communities, specifically those of color, that face immense health inequities.
The Health Equity Accelerator’s strategy aims to promote four pillars to collaborate and complement each other in the mission. These groups include clinical operations, community and SDOH, research and evaluation, and policy and advocacy. The Accelerator team also identifies external partners interested in participating in interventions to help communities BMC and other health institutions share.
The Accelerator’s Equity in Pregnancy program focuses on improving the rate of severe maternal morbidity for mothers of color and the rate of babies of color born small for gestational age. Through research, the program identified gaps and developed recommendations that will help close those gaps. Another project focused on empowering people of color, who were at a higher risk for disease transmission, to make informed decisions regarding COVID-19 vaccinations.
By Amanda Jepson | Categories: | Comments Off on Fresh for You Market
Eskenazi Health has a strong belief in the concept of food as medicine, a pillar of the health system’s Beyond Barriers campaign. In Indianapolis, 41 percent of children younger than age 5 suffer from malnutrition, and in Marion County, 21 percent of residents live in a food desert. Prior to the COVID-19 pandemic, nearly 200,000 county residents identified as food insecure. Through the Fresh for You Market and the Fresh for You Market on Wheels, Eskenazi Health is combating food insecurity in the community and providing residents with access to nutritional and affordable food.
The Fresh for You Market, a grocery store and food pantry, is located on the Eskenazi Health downtown campus on a bus route easily accessible to the community. The self-sustaining Market is open to the public, and proceeds from sales directly fund the Fresh for You Market voucher program. This program provides patients who screen positive for food insecurity during clinic visits with free food vouchers to shop at the market. The Fresh for You Market on Wheels is a mobile version of the market that parks at a different location throughout Indianapolis each weekday. A nutrition navigator on board helps patients pick foods for specific diets and conditions, and a chef prepares hot meals and hosts cooking demonstrations.
The Fresh for You Market and Market on Wheels would not be possible without community partners. The downtown market partners with a local food bank, and the market on wheels partners with local produce vendors, public transportation, the Indiana Department of Health, and other government agencies.
Since opening in June 2017, the Fresh for You Market has been a key food resource for patients, residents, and health system staff. In the first full year of operation, the Market served 6,200 people. During the COVID-19 pandemic, the market opened to health system employees working long hours who were unable to make it to the grocery store. The Fresh for You Market on Wheels, launched in July 2023, is making its way to for access to food in a social needs screening.
By Amanda Jepson | Categories: | Comments Off on Beyond Barriers
After discovering significant disparities in age expectancy from zip codes only 16 miles apart in Marion County, Ind., Eskenazi Health acted to find solutions to enhance the health of the community it serves. Thus, the $60 million campaign titled, Beyond Barriers, takes a multidisciplinary approach to three main areas: health care, mental health care, and food as medicine. The goal of the campaign is to create life expectancy equity for everyone in the city of Indianapolis through an integrated and sustainable model of community infrastructure improvement.
The program serves Eskenazi Health’s patient population and surrounding community. At the heart of Beyond Barriers are Health Equity Zones identified to improve access to health care, mental health care, and nutritional foods. Each zone is home to an Eskenazi Health Center where community health care workers work one-on-one with patients at appointments and home visits. During this time, they screen patients for social determinants of health and help with self-management goals to promote positive health behaviors. The campaign also sustains mental health professional recruitment, upgrades mental health facilities, and expands the John & Kathy Ackerman Mental Health Professional Development Center. Another important aspect of Beyond Barriers is the Fresh for You Market, which provides fresh and affordable foods to patients and families who lack access to affordable food options.
Eskenazi Health engages with education, transportation, public health, housing, food pantries, and other industries to expand existing programs and create and support new programming and services. By working with these entities, Eskenazi Health can focus on long-term social determinants of health and improving quality of life for all Central Indiana residents.
Launched in 2017, the Fresh for You Market, located at Eskenazi Health’s downtown campus, has helped patients and families access affordable and healthy groceries. In its first full year of operation, the market fed 6,200 people from under-resourced and underserved communities and improved the quality of life of those served. In summer 2023, the Fresh for You Market launched a mobile food pantry, Fresh for You Market on Wheels, which is parked in various locations around Indianapolis each weekday based on patient needs indicated in social needs screenings.
By Hannah Lambalot | Categories: | Comments Off on Maternal Medical Home
New York City is grappling with high rates of maternal mortality and morbidity with stark racial disparities. As of 2018, non-Hispanic Black women are 8 times more likely to die from a childbirth-related complication and three times more likely to experience a life-threatening event in pregnancy than non-Hispanic white women. The highest rates of severe maternal morbidity are in some of New York City’s most under-resourced communities, areas like East Flatbush, Brooklyn, and Jamaica/St. Albans, Queens. The Maternal Medical Home improves high-risk obstetric outcomes by providing referrals to necessary specialty care, mental health services, and enhanced wraparound services to address socioeconomic challenges, as well as parenting support and education. The Maternal Medical Home is one component of the Maternal Mortality Morbidity Reduction Program of NYC Health + Hospitals (NYCH+H).
NYC Health + Hospitals established the Maternal Medical Home to provide enhanced services, attention, and care to pregnant patients who needed it. This program received funding from the City of New York, as well as internal support. Two frameworks shape the program, the Socio-ecological model encourages 1) health education and literacy for patients to stay informed, 2) building trust between the team, patient, and partners 3) standardizing the screening and assessment tools for patients across the system. The Socio-cultural environmental model inspired 1) connecting patients with needed resources and services, and 2) encouraging patient autonomy in prenatal care and patient services.
Any member of the healthcare team may refer patients to the Maternal Medical Home. Patients with additional medical diagnoses, which may place a pregnancy at higher risk for an adverse outcome, such as (but not exclusive of) hypertension and diabetes, are followed by the Maternal Medical Home team. Patients with behavioral health diagnoses or patients who have needs related to social determinants of health (such as patients with food or housing insecurity, or in need of legal services) may be referred to the Maternal Medical Home for additional coordinated care and/or support services. The Maternal Medical Home team uses additional screening and assessment tools, such as the Prenatal ACES to stratify patients most at risk during pregnancy. The Maternal Medical Home team serves as a locus to help patients navigate a complex medical system and access needed resources.
The Maternal Medical Home program staffs seven Maternal Care Coordinators who have an interest and expertise in public health and nine Supervisors who have a master’s degree specifically in Social Work. Care coordinators and Supervisors are tasked to communicate with the clinical team, behavioral health specialists, and create tight linkages with community health workers and home health care. The clinical team includes physicians, advanced practice nurses, and nurses across the system.
Based on the screening assessment and associated risks score, the multi-disciplinary teams provide patients with referrals to specialty care, behavioral health and emotional support, pharmaceutical needs, socioeconomic needs, and parenting support/education. The screening and assessment build documentation templates for patient screenings, patient birth plans, and post-partum assessment plans. The program aims to create a stable, safe, and healthy environment for the patients to successfully take care of themselves and their newborns.
The Maternal Medical home program was piloted at NYCHH Kings County Site in October of 2019 and ran for two months. Since then, NYCHH has rolled out implementation to 11 facilities as of June 2021. Since the program’s launch, more than 3,000 pregnant patients have been referred to additional care or support services, such as nutrition, dental, and housing. Additionally, 405 pregnant patients were referred to the program and 1226 unique patients were supported.
By Hannah Lambalot | Categories: | Comments Off on CommunityConnect
Contra Costa Regional Medical Center’s (CCRMC) top 5% of users represent 49% of total costs, and the top 15% of users represent 79% of costs. Through a review of high need patients, it was revealed that a large portion of these high costs were associated with patients accessing medical services due to underlying social needs.
CommunityConnect was designed to target interventions for high-need patients with the aim to provide upstream care and services. The program utilizes predictive model analytics, that incorporates data points from across county, to proactively identify patients that are likely to use the emergency room or be admitted to the hospital for an avoidable reason in the future, such as to meet their urgent social needs. Patients who are enrolled into the program are provided one year of case management to coordinate medical services and provide community and government resources that can improve patient well-being and health. CommunityConnect receives funding of $40 million annually through the California Medicaid 1115 waiver Whole Person Care.
Patients are identified and enrolled int the program based upon data gathered through a comprehensive set of sources: from Medicaid managed care plans, behavioral health, the coordinated entry housing program, EMS and the county detention facility. These data points are combined to create patient-level risk factors. As the program identifies enrollment based on a predictive model, a number of patients are identified for enrollment not based on their prior health utilization (based on Medicaid claims data, apart from CCRMC). Leveraging data through a holistic patient record allows for identification of county residents that may not have otherwise ever been referred into services through traditional means.
Upon patient enrollment, case managers conduct a comprehensive social needs assessment with the patients to identify areas in which the program can help. This covers areas such as: medical, behavioral health, safety, housing, food security, transportation, finances, legal, and support system. Depending on patient acuity, case management services are either provided in-person or telephonically by multi-disciplinary staff that includes public health nurses, social workers, substance use counselors, homeless services specialists, mental health clinicians, and community health workers.
Once the CommunityConnect case managers assess a patient’s unmet social needs, they help enrollees create a patient- centered care plan, access resources, and work in partnership with the patient and other care team members to implement the plan, with the shared goal of improving the patient’s health. In addition to a providing linkages to community resources through a comprehensive social needs online resource directory, the program provides direct benefits to patients aimed at addressing unmet social needs. CommunityConnect patients have access to a transitional housing fund that can assist with security deposit or moving costs; a free cell phone in order to engage in services and link with resources; non-medical transportation in order to obtain identification documents; Free legal assistance from two full-time lawyers at the local legal aid; and social service workers to help apply and renew public benefits including Medicaid, SNAP, and TANF.
Since June 2017, the program has connected more than 17,000 people to critical health and social services. The first year (2017) resulted in a 3% reduction in ED visits and an 12% reduction in inpatient admissions compared to 2019 results that improved to show a 20% reduction in ED visits and 18% reduction in inpatient admissions. Other measures are in process of being analyzed, including primary care visits, behavioral health visits, access to public benefits, and other biometric health indicators. Success measures show that 37% of patients that lapse Medicaid are able to be restored within 90 days due to case management services, and 34% of patients have had a successful outcome with a social-related goal.
By Hannah Lambalot | Categories: | Comments Off on Opioid Use Disorder | A Population Health Collaboration
The 2016 Pennsylvania Opioid Data Dashboard reported 21,878 individuals covered by Medicaid with a diagnosis of Opioid Use Disorder (OUD). Of those suffering from OUD, only 11,591 (52.9%) received medication-assisted treatment (MAT). Temple University Health System developed an approach, in collaboration with the City of Philadelphia, the State of Pennsylvania, and various community-based organizations (CBO) focused on OUD through bridging medical care, behavioral health treatment, and addressing social determinants of health (SDoH).
With a one-million-dollar grant, Temple University built a hub and spoke network for the delivery of MAT in a primary care setting. The main goal of the program was to establish a hub and spoke model aimed at delivering and expanding best-practice treatment of OUD. The hub, led by OUD treatment experts, was charged with engaging other medical practices to launch best practice treatment at those sites. Best practice treatment of OUD includes medications to mitigate the effects of opioid withdrawal. A specific waiver is necessary to prescribe certain medications; as part of this program, clinicians attained this waiver in order to prescribe medications such as Buprenorphine. To monitor quality, a goal was set to decrease the readmission rate of patients with OUD, regardless of primary diagnosis.
To help patients overcome SDoH, Temple aimed to formalize relationships with community-based organizations (CBOs) to address food insecurity, housing insecurity, transportation, and pharmacy support. The Philadelphia Office of Homeless Services and Resources for Human Development specializes in housing placement for those with housing as a barrier. Philabundance delivers hot meals to recovery group sessions. In addition, they run a catering service called Philadelphia Community Kitchen which is a 14-week culinary training program open for enrollment to low-income adults and people in recovery. The program delivers 40 meals a week to the Temple hub and spokes. Sustainable food sources, such as SNAP benefits, are identified through case management. The Southeastern Pennsylvania Transit Authority provides subway/bus passes at no cost to the program’s patients. Temple also partnered with Uber/Lyft to provide rides for more medically complex patients. These services are available for appointments or any related service for their recovery. Lastly, Temple partnered with their outpatient pharmacy to be able to pay for medications that patients cannot otherwise afford, with grant funding.
Baseline objectives included the addition of spoke sites and the total number of patients treated from July of 2018 through May of 2019. The most powerful results were the increase in the number of patients who accepted treatment. The hub increased the capacity to see new patients by 267%. The spoke locations increased the ability to see new patients by 82.7%. Temple established warm handoff protocols for the organization’s emergency departments and crisis response center; warm handoff improved by 20% during that time. A total of 110 providers were trained in three sessions provided by the program. The program educated 22 Skilled Nursing Facilities providers and improved the OUD acceptance rate from 16 % to 28%.
By Hannah Lambalot | Categories: | Comments Off on Congregational Health and Educational Network
Nashville General Hospital (NGH) established the Congregational Health and Educational Network (CHEN) to create resources for the underserved in our community addressing health equity by focusing on further educational attainment. CHEN represents a community-focused collaborative that bridges the gap between education and health, via local congregations. Additionally, CHEN encourages ongoing opportunities to provide unique education and/or health programming to the underserved.
Through CHEN benefits for member faith-based organizations, parishioners access no-cost health screening, CHEN Wellness Academy classes on chronic disease, health literacy and more, faith-based leaders access CU sessions to improve their interaction with congregant health challenges, all members have access to educational toolkits to assist parents for children k-13 and more. Staffing support is 2.2 FTE and resources are currently provided by the hospital until grants are initiated.
The no-cost screening will be managed by a NGH Nurse Navigator who also serves as a consistent conduit for all congregants and faith-based leaders wishing to access NGH healthcare. The members and HBCUs are stepping up to provide access to their own congregational programming by extending to CHEN members. Additional identification of assets to reach out to CHEN members is still being developed.
CHEN is truthfully too new to offer outcomes at the present time. However, all program offerings will sustain pre and post assessment and results will be available upon request.
for information – see www.nashgenfoundation.org/CHEN
By Hannah Lambalot | Categories: | Comments Off on StreetCred
StreetCred was founded in 2015 after recognizing the need for doctors to address poverty as a disease, not simply just a social problem. For many families, income tax preparation is a challenge as they try to navigate a complicated system. As a result, they often do not receive the tax benefits they are entitled. StreetCred is an innovative program established at Boston Medical Center (BMC) which offers free tax services to families receiving pediatric care at BMC, who are eligible to receive the Earned Income Tax Credit (EITC) and Child Tax Credit. This service functions as a solution to the financial burden a significant portion of BMC patients face from living with annual incomes below the federal poverty level.
BMC disproportionally serves individuals who are low-income or under-or un-insured. Fifty-four percent of BMC families with children live below the federal poverty level. StreetCred aims to transform families’ wealth and health in a setting they frequent and trust, their pediatrician’s office. During visits, doctors prescribe StreetCred, offering free tax preparation to ensure families receive the Earned Income Tax Credit, the largest, but underutilized, U.S. anti-poverty program. The hospital provides the space, and partners with community tax partners, under the umbrella of the IRS, that provide expertise in tax preparation.
BMC engages with a number of partners, including Yale New Haven Hospital, South End Community Health Center, CAHS, Foundation Communities, Boston Tax Help Coalition, Boston Medical Center, Boston Healthcare for the Homeless Program, Boston Children’s Hospital, People’s Community Clinic, New York Health and Hospital (Gotham Health), Grow Brooklyn, American Academy of Pediatrics, Blue Hills Banks, DCU, Chris Gordon, Santander, BlackRock, The Paul Phyllis Fireman Charitable Foundation, The Claneil Foundation. These partners work with BMC to provide volunteers, financial programming, grants, technical support, marketing, and client engagement.
StreetCred scaled rapidly and effectively with $5.3 million returned to 2,700 families. In addition, families and staff report 96% acceptability rates.
By Hannah Lambalot | Categories: | Comments Off on Food Pharmacy
The Food Pharmacy originally began as a food pantry, but like most essential hospitals this meant the demand may outstrip the NGH Foundation’s funding resources to maintain the program. Hence, Nashville General Hospital focuses on patients with food insecurity who also have a diagnosis of chronic illness or cancer. The goal is to provide prescribed food supplementation to the patient’s diet which offers education for long term food choices for chronic illness self-management or completion of infusion services.
Patients are identified through the emergency department, outpatient clinic, inpatient dismissal or oncology infusion services. The NGH Foundation is currently funding all of the food, staffing needs, and recruiting community volunteers through grants. The hospital is providing in-kind, the Food Pharmacy square footage, care management team members for some education, dietary staff oversight, and the infrastructure of the referral departments to recommend patients.
The program relies on patient flow from the emergency department, outpatient, inpatient, and oncology. Additionally, patient outcomes for diabetes, hypertension, and oncology compliance with the Food Pharmacy are tracked through clinics and oncology. External community partners provide food, volunteers and funds.
Early results for oncology patients using the Food Pharmacy for the past three years reveal 100% of patients on the program maintaining or gaining weight – preventing pause in chemo services due to toxicity. Outcomes for chronically ill patients is still too new to offer reliable data until January 2020.
By Hannah Lambalot | Categories: | Comments Off on Neighborhood Transformation
Henry Ford Health System, in Detroit, is involved in a 300-acre neighborhood transformation that will include mixed-income housing surrounding the new Henry Ford Cancer Institute. In partnership with the Michigan Department of Transportation and the City of Detroit, Henry Ford is working to make the newly renovated community and the area surrounding Henry Ford Hospital’s main campus more bikeable and walkable to promote healthier lifestyles and create easier access to and from the hospital.
Since 2018 the health system has partnered with Lyft, SPLT, Signature LLC and Ford Mobility GoRide to specifically address patient transportation as a social determinant of health. Over 1500 round trip rides have been provided to and from appointments for patients across nine departments. In 2019, the health system is working on addressing transportation and additional social determinants of health through the same service offerings.
