Pioneering Change: Population Health at Essential Hospitals

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.