Blog Archives
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 Hospital-Led Outreach to Reduce Anemia at Time of Delivery
Anemia in pregnancy increases the risk of needing a blood transfusion at the time of delivery threefold. It contributes to approximately 20 percent of severe maternal morbidity in historically marginalized groups. The transfusion rate at Natividad Medical Center, in Salinas, Calif., increased rapidly between 2021 and 2022, and anemia at the time of delivery had a prevalence of 18.8 percent of all births at Natividad. This problem was particularly evident in the Latina and Indigenous patient populations Natividad serves. Hospital leadership created this program to decrease the prevalence of anemia at the time of delivery and decrease Natividad’s transfusion rate.
Natividad’s systemwide leadership, including community clinic leadership, collaborated to create a multi-pronged approach to diagnose and treat antepartum anemia rates. This program includes educating staff on the negative effect of anemia and how to monitor and treat iron deficiency, as well as monitoring patients’ hemoglobin and iron stores throughout pregnancy.
Natividad created an infusion center to provide access to IV iron. Hospital leaders recognized that Medi-Cal only covered an iron infusion that required eight visits to infuse 1 gram of iron, which places a significant burden on patients that face transportation, financial, and time-related barriers to care. In response, Natividad collaborated with its Medicaid health maintenance organization to secure payment for single-dose IV treatments, increasing access to care.
The chief of obstetrics at Natividad worked with medical leadership at the community clinics to develop best practices for the program, which led to robust evaluative efforts and peer-to-peer learning. From January 2023 to August 2024, the overall rate of anemia at participating clinics fell from 18.4 to 11.7 percent, while the anemia rate at nonparticipating clinics increased from 22.3 to 26.5 percent. In 2022, the Indigenous patient population had higher rates of anemia—20.6 percent, compared with 18.4 percent for non-Indigenous patients. By 2024, both groups had decreased anemia rates—12.1 percent for Indigenous patients and 11.6 percent for non-Indigenous patients—and the gap between rates closed.
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 Increasing Birth Equity in Washington, D.C.
Black families in Washington, D.C., account for 50 percent of all births in the city and 90 percent of all pregnancy-related deaths. More than 65 percent of all pregnancy-related deaths occur in D.C.’s Black-majority wards 7 and 8, where infant mortality rates are twice the city’s average. Data from MedStar Washington Hospital Center’s Women’s and Infants’ Services (WIS) patients and needs assessments indicated that multiple social determinants of health (SDOH), including access to medical care, housing, food, and transportation, also disproportionately affect wards 7 and 8.
WIS aims to increase early interventions for adverse SDOH, decrease the number of patients experiencing birthing complications, and mitigate risk factors associated with higher mortality rates. This includes upstream efforts, such as preconception health assessments, and prenatal SDOH screenings. WIS provides trauma-informed clinical services and connects prenatal patients to resources, including support for substance use disorder; food banks; legal aid; assistance obtaining Supplemental Nutrition Assistance Program and Special Supplemental Nutrition Program for Women, Infants, and Children benefits; and more.
A key partner in the D.C. Safe Babies Safe Moms initiative, WIS collaborates with fellow partner Mamatoto Village, a nonprofit that provides lactation consulting and other perinatal support services to primarily Black patients in wards 7 and 8. WIS also partners with Community of Hope to increase service accessibility and improve continuity of care on-site at Community of Hope’s Ward 8 location, allowing patients to see a high-risk obstetrician in the same location where they schedule their maternal and fetal medicine appointments. Additionally, MedStar Washington Hospital Center partnered with the Georgetown University Health Justice Alliance to launch the Perinatal Legal Assistance & Well-being project in 2021, which provides no-cost legal assistance to pregnant and postpartum individuals to address health-harming unmet legal needs, including employment, housing insecurity, and public benefits.
WIS has seen a clear increase in patients accessing interdisciplinary services focused on treating hypertensive disorders, anemia, depression, anxiety, and diabetes. For example, the number of patients receiving diabetes support has nearly tripled in 2020, and now, 92 percent of high-risk patients receive services for diabetes control—a nearly 30 percent increase. The rate of babies born with very low birth weights (less than 1,500 grams) decreased by more than 15 percent and rate of babies with low birth weights (less than 2,500 grams) decreased by more than 7 percent.
By Amanda Jepson | Categories: | Comments Off on Mobile Wellness Clinic
The Casey Foundation, an organization that works to improve the well-being of children, youth, and families in the United States, conducted an analysis of the Opelika community in 2017 that revealed areas with a lack of access to care. The foundation engaged the City of Opelika and East Alabama Health to begin a mobile medicine program to increase access to primary care within the community. First Transit donated the mobile bus in 2017, and the program officially launched in December 2022.
The mobile wellness clinic visits communities in the greater Opelika area once a week. Staff provide disease prevention resources and screen patients for chronic conditions at the designated site each week. mobile unit social worker connects patients to resources within the community through screening for social determinants of health. The clinic is funded through multiple sources, including the Casey Foundation and the local housing authority, which allows the clinic to prioritize communities with the most need.
Beyond the City of Opelika and the Casey Foundation, mobile wellness clinic partners include charitable clinics that allow referrals for patients to be seen more quickly, local schools and universities from which students work and learn in the bus , and other local community-based organizations that help the program build trust with community members.
The mobile clinic has served community members with all-encompassing care since beginning operations in December 2022. Many personal stories illustrate the clinic’s importance to the community; for example, a care-reluctant patient sought care at the mobile wellness clinic and discovered dangerously high blood sugar levels. Fortunately, the clinic staff were able to quickly intervene and saved the patient’s life.
By Amanda Jepson | Categories: | Comments Off on Rooftop Farm
Boston Medical Center’s (BMC’s) Rooftop Farms opened in 2017 as part of the Nourishing Communities program, which includes the Preventative Food Pantry and Teaching Kitchen. A second farm will open in the spring of 2024, bringing the total growing space to approximately square feet. With two farms, the program will yield 10,000 pounds of fresh, organically grown produce annually to distribute throughout the food pantry, a low-cost farmer’s market, and our kitchens. The farm partners with internal departments and organizations in the Boston area to host team–building, volunteer, and educational opportunities focused on growing food, nutrition, and green infrastructure.
The hospital employs two part-time farm staff who focus on food production, education, and community outreach. The program also sponsors two to four interns per year who assist the farm staff and earn experience in rooftop farming and community engagement. The program’s educational component reaches a wide swath of the community, from public school students to immigrant groups, to patients, employees, and clinical staff. For example, the farm reported more than 1,300 visits in 2023. in 2023, 50 percent goes to patients facing food insecurity who visit the food pantry, 41 percent goes to the general community through the low-cost farmers market, and 10 percent goes to the kitchens.
Since opening seven years ago, the rooftop farm has grown approximately 30,000–35,000 pounds of food for community members, with approximately 75 percent directly reaching those who are low–income or experiencing food insecurity. The original farm also has engaged individuals in tours, volunteer days, and educational events more than 9,000 times, providing community members with a forum to connect with each other, learn about green innovation, and experience a hospital space that builds healthy communities in multiple ways. With a second farm opening, BMC expects to double its impact and continue to grow its community partnerships, aiming to support fair Boston food system that provides workforce development, climate resilience, and nourishing food for all people.
To learn more about the Rooftop Farm, please visit this link.
By Amanda Jepson | Categories: | Comments Off on Feed1st Program
In 2010, a group of University of Chicago Pritzker School of Medicine medical students, University of Chicago faculty, and Comer Children’s Hospital staff started the Feed1st program after one of the hospital Chaplains discovered many parents were going hungry at their child’s bedside during a hospital stay. The goal of the Feed1st program is to address hunger in the healthcare setting and minimize the stigma surrounding food insecurity.
The Feed1st program operates 11 food pantry sites throughout UChicago Medicine’s facilities, including the adult, pediatric, inpatient, and outpatient areas of academic health system’s South Side medical campus. The pantry sites are strategically located in emergency departments, patient waiting areas, family lounges, and a hospital retail cafeteria. The program primarily serves community members from the South Side of Chicago, which has some of the highest food insecurity rates in the city; however, the pantry sites are available to everyone in the UChicago Medicine community, including staff.
It takes a village to operate a hospital pantry program at this scale. The hospital and individual departments provide Feed1st with funding support and space for pantry shelves and storages; Clinical staff champions, medical students, undergraduates, and other volunteers keep the pantry sites and storages stocked regularly and well maintained.
The food in the pantry sites is provided by the Greater Chicago Food Depository. The UChicago Medicine Garden Committee also provides fresh produce during harvest seasons throughout the year. The Feed1st Community Advisory Committee, comprised of parents, patients, concerned community members, hospital administrators, faculty, students, and others, plays a consistent role in ensuring the program meets the needs of the people we serve. Feed1st engages clinical staff in individual departments to help monitor and restock pantry shelves and communicate with patients about the program.
the Feed1st program had distributed more than 94 tons of food to more than 88,000 people since opening in 2010. The UChicago Medicine Garden Committee has provided more than 6,000 pounds of fresh produce to the Feed1st pantry sites since May 2022. The Feed1st program also released a toolkit on how to launch a no questions asked food pantry system. To read the newest version of the Feed1st toolkit, click here.
By Amanda Jepson | Categories: | Comments Off on Reusable Isolation Gowns
Ronald Reagan UCLA Medical Center, in Los Angeles, employs more than 4,000 people and cares for 380,000 patients per year. As part of precaution protocol, every person entering a person’s room must wear an isolation gown. In 2012, the medical center used an average of 6,000 disposable isolation gowns per day, or 2.2 million gowns per year, and the academic and health care teams piloted a reusable isolation gowns program.
The program started as a pilot in the medical center’s largest and busiest and later expanded to other units gradually to avoid overwhelming staff. staff through flyers and meetings, emphasizing the increased protection the new reusable gowns offered. Unit leaders and the Linen Committee were integral in the transition and maintenance of the program.
Internally, the process required collaboration from nursing staff, unit directors, and infection control staff. Externally, program staff worked with multiple gown vendors to design a custom gown, as well as with vendors that fold, launder, and transfer gowns.
As of November 2015, the hospital has used more than 3.3 million reusable gowns, saved more than $1.1 million in purchasing costs, and diverted from the landfill.
Read the Case Study here.
By aoguagha | Categories: | Comments Off on Diabetes Prevention Program
More than one-third of Rhode Islanders are prediabetic. In 2017, the Lifespan Community Health Institute, as part of Rhode Island Hospital, partnered with the City of Providence’s Healthy Communities Office to deliver the Diabetes Prevention Program to Providence residents. Since then, the program has grown and targets all eligible Rhode Island residents. The Diabetes Prevention Program, an evidence-based program, teaches people at risk for developing diabetes how to implement a healthy lifestyle with the goal of preventing or delaying the onset of type 2 diabetes. The program is available in English and Spanish and offered to participants at no cost.
Currently, the Lifespan Community Health Institute (LCHI) contracts with the Rhode Island Department of Health to deliver the Diabetes Prevention Program to all eligible Rhode Island residents. Free to participants, the program offers weekly one-hour sessions with a trained lifestyle coach to learn and maintain healthy lifestyle behaviors, peer support, healthy at-home meal recipes, and childcare and transportation assistance. Additionally, LCHI currently contracts with the Blue Cross Blue Shield of Rhode Island to offer the program to eligible State of Rhode employees and their beneficiaries. Learn if you qualify here.
The Lifespan Community Health Institute is one of only two CDC Recognized Organizations offering the Diabetes Prevention Program in Rhode Island that has achieved Full Plus recognition. Full Plus recognition means that a program has demonstrated effectiveness by achieving all of the performance criteria related to the Diabetes Prevention Recognition Program Standards and Operating procedures.
