Helping to Uplift and Bounce Back (HUB)
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.