By Jamie Cetrone | Categories: | Comments Off on Youth Mental Health Model
UMass Memorial Medical Center provides funding to support the coordinator role of the Healthy Options for Prevention and Education (HOPE) Coalition, a youth-adult partnership created to reduce youth violence and substance use, and promote adolescent mental health. HOPE addresses public health concerns affecting at-risk youth, including tobacco and alcohol use, violence, and access to mental health. Several programs initiated through this effort include; HOPE Peer Leaders, a program that works closely with the City of Worcester Health & Planning departments to change local policies that regulate outdoor signage of tobacco products; HOPE Mental Health model, provides on-site mental health services at youth-serving organizations; and Youth Worker Training Institute, a thirteen-week program that trains Youth Workers on protective factors in order to work better with adolescents.
HOPE peer leaders co-chair the Youth Substance Abuse Prevention Task Force with the Worcester Division of Public Health (WDPH). In fiscal year 2016, peer leaders focused on changing the city’s tobacco purchase policy and, by working with the WDPH, successfully raised the minimum age for tobacco purchases in the city to 21.
In 2016, the program served approximately 631 youth through one-on-one counseling, therapeutic groups and crisis intervention delivered by You, Inc. Since its launch, the model has served over 5,000 youth who otherwise would not have had access to mental health support.
By Jamie Cetrone | Categories: | Comments Off on UMass Memorial Medical/Legal Partnership
The partnership of the UMass Memorial Legal Department and Community Legal Aid, Inc. (CLA) assists low income, Medicaid-eligible families in addressing socially complex living conditions that adversely affect health. Recently, CLA was a key partner in the pediatric asthma prevention pilot program, a model that has expanded into a comprehensive, multi-sectoral, citywide intervention. The relationship targets patients and leverages pro bono services with several law firms and volunteer lawyers to address the multiple social factors that impact patient health. Recognizing that the most vulnerable populations require a much broader intervention that goes beyond medical care, the program screens patients at three community-based clinics about social determinants of health: access to fresh food, home environment, employment and educational attainment. Through CLA training and support, the dedication of clinical staff and a shared vision, UMass is working to change lives.
Through this collaboration with Community Legal Aid, Inc. (CLA) the activities of the Medical-Legal Partnership will be integrated into several UMass Memorial primary care clinical sites serving low-income, Medicaid-eligible populations in central Massachusetts.
Since its launch in 2016, the program has served approximately 70 people annually.
By Jamie Cetrone | Categories: | Comments Off on Veggie Mobile
The Regional Environmental Council (REC) developed the Grant Square Community Garden in 2010 with support from UMass Memorial Medical Center and the City of Worcester. It has 30 raised beds maintained by the REC YouthGROW program and neighborhood residents. The youth tended garden generates between 500-800 pounds of produce for the neighborhood and 15 stops in food-insecure areas across the city through REC’s “Veggie Mobile” mobile farmers market, including three stops in Bell Hill. Medical Center funding doubles the value of food stamps for purchase at the Veggie Mobile.
UMass Memorial Medical Center partners with the Worcester Regional Environmental Council (REC) to bring fresh produce to low-income/food-insecure neighborhoods through the Veggie Mobile program. Funding provided by UMass Memorial Medical Center to the Worcester Regional Environmental Council doubled SNAP purchases on the Veggie Mobile. REC’s Food Justice Program works to increase access to nutritious, healthy, and locally grown food in Worcester’s food-insecure neighborhoods, including Bell Hill where the UMass Memorial campus is located. REC programs encompass a community garden, three school gardens, a YouthGROW urban farm, and the Veggie Mobile which makes 15 weekly stops in all five of the Neighborhood Revitalization Strategy Areas identified in the city.
Since 2012, SNAP and EBT purchases on the Veggie Mobile have increased from 30% of sales, to 90% currently. Total purchases have increased by 300 percent.
By Jamie Cetrone | Categories: | Comments Off on Hurley Medical Center Food FARMacy
After reviewing other hospital programs which address social determinants of health (via America’s Essentials Hospitals and Advisory Board), Administrator of Population Health, Alisa Craig, developed a strategy that was approved by Hurley Senior Leadership. This resulted in hospital-wide screening (2-questions) for food insecurity and referral to the Food FARMacy (opened 8/1/17) if screening was positive. Hurley Medical Center’s (HMC) vision is to expand beyond the walls of the hospital to provide the best possible care to our community. By truly treating “hunger as a health issue”, Hurley is taking an important step in addressing social determinants of health within very vulnerable populations. With the rate of food insecurity being higher in Genesee County than the national average, addressing this issue proactively will have a tremendous impact on a patient’s ability to manage a chronic disease or fight illness. This is extremely important in children and older adult populations who have high rates of food insecurity. Hurley Medical Center’s Food FARMacy addresses the issue of food insecurity in their patient population by increasing access to healthy foods and providing them with additional resources to assist them long-term.
In August 2017, Hurley began screening for food insecurity (within their electronic medical record – EPIC) and providing referrals to the newly opened Food FARMacy. Upon discharge from inpatient units or outpatient primary care clinics, a patient who gets this referral can get nutritious food for themselves and their household members, twice per month, for three months. The food provided is tailored based on their health needs, chronic conditions, and allergies. The patients have the opportunity to meet with a Registered Dietitian while at the FARMacy, and are given community resources for longterm support. Assistance is provided to make sure the patients are appropriately enrolled in benefits such as SNAP, WIC, and Double Up Food Bucks.
By addressing their food insecurity, patients will be able to better manage their chronic conditions, not have to make as many financial “trade-offs” (like having to choose to pay for medicine vs. food), and may have improvements in health status. Hurley provides the physical space for the Food FARMacy, which is co-located within the Adult Diabetes Center. Funding for a part-time dietitian and food comes from a Community Foundation grant. Program staff work closely with the IT department (EPIC) to establish the screening/referral/reporting process.
Collaboration is key, both internally and externally. The EPIC (EMR) team is crucial in this project, and staff has engaged all levels of nursing, nursing management, nursing education, residents, and the GME dept. Externally, staff work very closely with the Food Bank of Eastern Michigan to get most of the food. They also supplement via local gardens (MSU-E Edible Flint) and growers. Volunteers come from the hospital’s foundation volunteer services, students from the MSU School of Human Medicine’s Leadership in Medicine for the Underserved, and AmeriCorps team members via Pediatric Public Health Initiative. Funding is provided from the hospital, hospital foundation, and the Community Foundation of Greater Flint.
Funding through the Community Foundation of Greater Flint;
To date, close to 800 people have received food from the Food FARMacy, with new patients being referred daily. The need is great, and they have already seen a 35-53% Food Insecurity rate in primary clinic settings. In addition, the program has helped several patients get appropriately enrolled in nutrition assistance programs. Program staff hope to have more specific data, related to health outcomes, to share by July 2018.
By Jamie Cetrone | Categories: | Comments Off on Screening for Social Determinants in Primary Care
This program originally started at a retreat held by the Ambulatory Care Department at Lincoln Hospital. The hospital formed a workgroup with the goal of developing a social determinants screening tool and accompanying referrals to helpful resources. The ultimate goal of the program is to improve the health status of the patient population, by improving social and economic influences on health.
The screening tool was designed with input from multiple hospital stakeholders, as well as partner organizations. The hospital is now ready to implement the tool at nurse led visits for diabetes, hypertension, and depression management. Pending positive outcomes, Lincoln Hospital plans to implement the tool more widely. Based on answers to screening questions, nurses will refer patients to known entities within the hospital including social work, a legal health program, healthcare financial counselors, and a table staffed by a partner non-profit where patients can enroll in a food stamp program. The
The screening tool covers multiple domains, including housing, food insecurity, housing conditions such as pests and mold, health insurance and health care cost barriers, immigration, domestic abuse, and others. There has been no additional funding for the program. With respect to staffing, in addition to nursing and departments already mentioned, the project is supported by the population health team in Ambulatory Care. The screen is used in paper form, and data will be manually entered into an Access Database.
The working group behind the program has been multidisciplinary, consisting of population health staff, physicians, nurses, clerical and finance staff, social workers, lawyers from the Legal Health program onsite, and staff from partner NGOs specializing in housing, food stamps, and health insurance advocacy. There has been some liaising with care managers and the ED, to explore the use of the screening tool in high risk populations.
Moving forward, outcome measures will be: A1C scores, BP scores, show rates to nursing visits, and show rates to PCP visits. The thinking behind these metrics is that when patients are connected to resources to address their economic and social problems, they are better able to manage their health care appointments, have the resources necessary to improve their health status (such as buying better quality food), and with the reduced stress of dealing with economic and social problems, have more mental wherewithal to address their chronic diseases. Moving forward, the program will compare patient populations who are administered the tool to those that are not, to measure the effect of systematically screening for social determinants. Program staff plan to test the screening tool to gage if it’s easy to understand and self-administer, and whether the referral pathways work.
Internal partners include: ambulatory care, social work, healthcare financial counselors, and care management. Community partners include : New York Legal Assistance Group (NYLAG) Legal Health Program, Community Service Society of New York, Bronx Works, Public Health Solutions
By Jamie Cetrone | Categories: | Comments Off on Caught in the Crossfire
In 1993, Sherman Spears, a paraplegic former gunshot victim working at local CBO Youth ALIVE!, began visiting young gunshot wound (GSW) victims at the Oakland hospital where he had been treated. This became Caught in the Crossfire, the first hospital-based violence intervention program – now a national model.
The program serves youth and adult survivors of intentional injury (gunshot, stab wound, and physical assault) with immediate response upon hospital treatment in the golden moment when the patient is open to long-term support. Continuing post-discharge for 6-12 months, trained intervention specialists from the peer community of the patients will provide case management, mentoring, linkage to mental health and services, safety assessment/retaliation prevention, and other services in the field/community in order to prevent retaliation and reinjury and to promote physical, social, and emotional healing from trauma.
This program coordinates with hospital Administration, Social Services, and Trauma to access patient records, coordinate hospital access to visit patients, and to communicate about follow-up care. Community partners include Youth ALIVE!, Eden Medical Center, Children’s Hospital Oakland, Alameda County Emergency Medical Services, and the City of Oakland.
Program measures include positive outcomes such as attachment to mental health services, education/employment and housing, and reduction in negative outcomes such as arrests and injury recidivism. Without intervention, nationally, up to 44% of patients recidivate within 5 years. In the program, it is less than 3%.
By Jamie Cetrone | Categories: | Comments Off on Nice Ride Community Partnership
The program started in 2016 as a collaboration between the mental health and cardiology teams at Hennepin County Medical Center, in an effort to implement a holistic approach to treating patients. Through this program, patients can make therapeutic lifestyle changes that reduce their risk of a heart attack or stroke — while simultaneously improving their mental health. Patients are given “prescriptions” to ride a bicycle as a form of treatment. With support from the Nice Ride MN bike share program, patients can rent a bicycle free of charge.
The Nice Ride Community Partnership serves adults with Serious and Persistent Mental Illness (SPMI) who participate in the program. The program is guided by the notion that better physical health equals better mental health. The program combines clinical goals from the William W. Jepson Day Treatment Program with the Comprehensive Cardiovascular Prevention Program (C2P2) to address multiple health concerns in their populations and track results over time. Nice Ride MN and U.S. Bank provide bicycles and funding for the program.
In its first year (2016), the program had 31 participants who logged a total of 957 hours. A cardiologist form Hennepin County Medical Center tracks participant progress over time.
By Jamie Cetrone | Categories: | Comments Off on Rx for Change
The Rx for Change program was created with funding and support from Regional One Health’s Foundation, and a partnership with the Office of the Mayor of the City of Memphis. The purpose of Rx for Change is to “intervene and offer support and guidance to victims of violence” by connecting clients with community resource partners which may 1) reduce retaliation levels, 2) allow clients to achieve personal goals, and 3) reduce recidivism rates.
The program serves clients ages 14-24 who are victims of intentional violence and residing in Shelby County, Tennessee. The program is funded and staffed by the hospital, but involves a number of internal and external partners that help assist clients with navigating on-going care, as well as completing personal goals outlined by the client once they are discharged. Partners include: Blue Cross/Blue Shield, Regional One Health Foundation, the City of Memphis Mayor’s Office, GRASSY, 901 BLOC, Workforce Investment Network, HopeWorks, and Hospitality Hub.
Clients are reviewed at the end of a six-month period of time to assess progress. At that time the client is marked graduated, or not. Through-out the process clients are marked active, deferred, inactive or referred. These categories allow us to monitor progress toward success. To-date, approximately 200 clients have been on-boarded. Repeat Intentional Injury rates are low, and this past fiscal year three clients were successfully graduated.
By Jamie Cetrone | Categories: | Comments Off on Food for Health
In partnership with a health clinic, UNM screened diabetic patients who had a HGA1c over 7 (indicating that their diabetes is not under control) for food insecurity. Patients who screened positive were considered to be food insecure, and were referred to a healthy food center. The goal was to educate patients on healthy eating to see if diabetes can be better controlled.
Hospital resources used for this program included a community health worker who did the screenings during clinical visits. The hospital also worked with Roadrunner Food Bank and Healthy Foods Center, who provided patients and their families with food on a weekly basis.
The program resulted in consistent access to fresh fruits and vegetables for patients and families, allowing for increased intake of healthy food. Program surveys saw a 33% increase in reports of eating fruits/vegetables “more than once a day”. Surveys also showed increased self-reported health outcomes (from 78% poor/terrible to 80% very good/good), and improved quality of life indicators (27% increase in reports of “never” being kept from usual activities due to poor mental of physical health).
By Jamie Cetrone | Categories: | Comments Off on The Food Shelf @ HCMC
The Food Shelf @ HCMC was started to address hunger and food insecurity among patients and families, with a long-term vision of creating a hunger-free hospital where all patients have the healthy food they need for their well-being.
The program serves patients and families who receive care at the primary care and specialty care clinics located within the hospital and/or at one of the hospital’s community clinics. Volunteers help package inventory and fill sturdy bags with healthful groceries. The bags are then delivered to the each participating clinic and are available for staff to give to patients/families in need.
The Food Shelf @ HCMC staff work closely with clinic staff in different departments to make sure they provide options that meet patients’ nutritional needs related to specific health conditions. The staff work with a variety of community partners to make sure they are able to provide both non-perishable foods for those with limited access to food storage as well as fresh produce and other foods to those with adequate food storage options. A major partner is Feeding America’s Second Harvest Heartland, which distributes food to food shelves throughout the state. Food is packaged in sturdy, handled bags which can be managed on public transportation, and are filled with items tailored to specific patient populations.
The Food Shelf @ HCMC serves nearly 30,000 households composed of approximately 90,000 individuals each year. More than half of the individuals served are children.
