Blog Archives
By Amanda Jepson | Categories: | Comments Off on Center for Better Aging
St. Bernard Hospital’s Center for Better Aging (CBA), in Chicago, delivers an integrated model of care focused on the physical, mental, and social health of adults aged 50 and older. These patients often face food insecurity, housing instability, social isolation, or financial stress. Services include primary and specialty care; a geriatric-certified emergency department; wellness and prevention programs; and attention to nonclinical needs like housing, nutrition, and transportation.
CBA partners with academic institutions and community groups to elevate specialty care and workforce training. Local organizations like Chicago Commons, SPARC Wellness, KemeticHlth, SMYL Fitness Rx, and others help with home care, coordination, fall prevention, mental health, and community wellness. The center also hosts health fairs, screenings, workshops, and other outreach events to engage aging adults, build trust, and reduce access barriers.
To ensure quality and continuous improvement, CBA tracks clinical outcomes, show rates for clinic visits, patient satisfaction, and engagement data from outreach. In 2024, the center logged over 1,000 primary care visits and a 71.9% show rate. The program’s leaders emphasize the importance of community-driven partnerships, workforce development in geriatrics, diverse funding streams, and creating welcoming environments as essential components for replicating their model.
By aoguagha | Categories: | Comments Off on Prevention and Recovery in Opioid Use Disorder (PROUD) program
Through the Prevention and Recovery in Opioid Use Disorder (PROUD) program at the Chesapeake Regional Medical Center, patients work with physicians in the emergency department to create individualized treatment plans to support recovery from opioid use disorder and other substance use conditions. Additionally, patients are connected to an outpatient community partner to continue their treatment with guaranteed follow-up within 72 hours after release from the emergency department. The majority of PROUD program participants are uninsured and struggle with multiple social determinants of health; however, patients are not turned away due to financial limitations.
The program partners with the hospitalist and emergency medical services teams within the hospital to provide care through a mobile clinic for street outreach. Future enhancements aim to expand partnerships with outpatient clinics and increasing mobile outreach efforts.
By aoguagha | Categories: | Comments Off on Jail Release Program
The Jail Release Program at Parkland Health uses a comprehensive approach to link patients recently released from the Dallas County jail to community-based care. The program developed a release workflow and referral hub in collaboration with community-based organizations and the correctional health team at the Dallas County Jail, consisting of a nurse navigator, referral coordinator, peer navigators, and social workers. This referral hub assists patients with their transition back to the community by linking patients with services such as transitional housing, health insurance, pharmacy assistance, career planning and placement, and social support networks. Additionally, patients are supported with transportation through Uber and bus passes. The nutritional needs of patients are also served through connections to food pantries.
By aoguagha | Categories: | Comments Off on Building Recovery Integration for Drug Users into Emergency Medicine (BRIDGE)
Tampa General Hospital’s Building Recovery Integration for Drug Users into Emergency Medicine (BRDIGE) program offers a range of services, including a mobile suboxone clinic, an office-based opioid therapy clinic, mental health and substance use counseling, and essential wrap-around services to improve post-discharge outcomes, decrease re-admissions and shorten the length of hospital stays all while providing world-class care to adults struggling with opioid use. The program, which opened Florida’s second legal syringe exchange that treats over 2,000 patients, is making a significant impact in the community.
The BRIDGE program collaborates with the Hillsborough Housing Authority to assist patients with housing instability, collaborates with local food banks to expand their ability to address food insecurity through mobile pantry days, and recently engaged a volunteer attorney to provide free consultations to patients facing legal challenges that can hinder their full engagement in their recovery program.
By aoguagha | Categories: | Comments Off on Road to Care Mobile Addiction Service
The UMass Memorial Health Road to Care Mobile Addiction Service is a street medicine program that offers walkup addiction care in the city of Worcester, MA. The Mobile Addiction Service provides free care to individuals experiencing housing insecurity, including prescribing suboxone and distributing naloxone kits in areas such as encampments, shelters, and food pantries. The program’s goal is to reduce opioid-related morbidity and mortality by offering mobile addiction services, including treatment for OUD. The mobile clinic can serve up to 30 patients in one-afternoon session, ensuring that care reaches all populations where they are. More than 2000 individuals have accessed the Road to Care Mobile Addiction van in over 11,000 encounters since May 2021.
By aoguagha | Categories: | Comments Off on Lung Cancer Screening on Wheels
LUCAS, a fully mobile lung cancer screening unit launched in 2021 by the West Virginia University Cancer Institute, is the first of its kind in the United States. Designed to reach rural communities with limited access to healthcare, it travels across West Virginia from March to December, screening 25 to 30 residents daily. As of December 2024, LUCAS has screened 4,600 people, detected 55 lung cancer cases, and provided smoking cessation support and emotional care. Click here for more information.
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 Advancing Hypertension Control in Disparate Populations
ECMC, in Buffalo, N.Y., developed the Advancing Hypertension Control in Disparate Populations through Comprehensive Remote Patient Monitoring program in response to a community needs assessment that showed high rates of hypertension among patients, including 56 percent of Black patients. Needs assessment data also demonstrated that this patient population faced significant barriers to hypertension treatment, such as lack of transportation. By leveraging self-measured blood pressure monitoring, telehealth, and coordinated care, the program aims to improve patient engagement, enhance health care access, and achieve better clinical outcomes for individuals at risk for and diagnosed with hypertension.
Participants receive a validated blood pressure cuff at no cost and attend telehealth visits to assist with monitoring health behaviors. Resources allocated to sustain the program include dedicated hospital staff and funding from multiple organizations, including The Buffalo Center for Health Equity, Highmark, Univera, and Independent Health. A partnership with the American Heart Association supported blood pressure kiosks and community screenings.
Patients and families played a key role in developing this program by providing feedback on behavioral intentions, perceived control of access to care, and hypertension management. To reach beyond patients attributed to the health system, ECMC partnered with community-focused organizations, such as the Independent Health Association, to identify individuals with unmet health care needs and provide accessible health services to underserved Buffalo neighborhoods. Together, these organizations and ECMC hold community events to educate individuals on hypertension and familiarize the community with this program.
Since 2022, ECMC has enrolled more than 900 primary care patients in the program. More than 50 percent of enrolled patients have experienced a significant reduction in their systolic blood pressure. The hypertension control rate among ECMC primary care clinics increased from 44.2 to 69 percent. Additionally, patients with hypertension who are not enrolled in the program utilize emergency services 56 percent more often than program participants.
By Amanda Jepson | Categories: | Comments Off on The First Hospital at Home Program in South Texas
The Hospital at Home program at University Health, in San Antonio, provides hospital-level care in a patient’s home as an option for hospitalization. While COVID-19 catalyzed the program, the emerging interest in acute care at home and its positive effect on patient experience, population, and costs put the program in motion.
Services include: twice daily in person nurse visits, telemedicine provider visits, remote vital signs monitoring, physical and occupational therapy, medical equipment, internet-connected digital tablets for telehealth visits and patient education, labs and intravenous medications, social support and other services. A multidisciplinary team of doctors, nurses, social workers, care coordinators, respiratory therapists, and other specialists is trained to deliver care outside the hospital. The program created a new department and mobile fleet with in-house funding and is now entirely self-sustaining.
Nursing, information technology, and health care innovation staff lead the program, and staff from the pharmacy, laboratory and pathology, operations, legal, and respiratory care, patient care services, food services, medical records, radiology, patient care coordination, and other departments have been involved in program design since inception. Each department created workflows and standard operating procedures outlining their roles in patient support. A specially designed module within the system’s electronic medical records helps coordinate remote patient monitoring, equipment, and provider best practices. Leadership from each department is heavily involved in program evaluation and sustainability. Patient feedback shapes the program by helping staff identify social determinants of health, such as food insecurity and other needs crucial for recovery and staying healthy after discharge.
The program continues to grow. Since the program started in 2021, the Hospital-at-Home program has cared for more than 3,100 patients, corresponding to over 16,400 beds saved for the hospital. The health system reports zero falls with serious injury, medication errors with serious injury, pressure injuries, or zero staff safety incidents. The program has reduced readmission, increased patient satisfaction, and generated significant cost savings; from 2021 to 2024, the program saved University Health more than $17 million. Additionally, the program has retained 100 percent of its staff.
By Amanda Jepson | Categories: | Comments Off on Virtual ExpressCare: 911 to Telemedicine Redirection Program
In partnership with the New York City Fire Department (FDNY), NYC Health + Hospitals lunched the Virtual ExpressCare (vEC) 911 to Telemedicine Redirection program in 2020 to reduce strain on emergency resources, enhance patient care for non-emergent needs, and improve financial and operational stability.
The vEC operates continuously, improving emergency response by diverting lower-acuity 911 calls to telemedicine. Within 30 seconds, eligible calls are transferred, allowing patients to access virtual care and reducing unnecessary ambulance transport and emergency department utilization. The program has been integrated into FDNY ambulances, allowing EMS teams to connect with telehealth providers on-site to ensure patients receive definitive care without needed transport. The program also offers rideshare for non-emergent transportation for patients who need in-person follow-up but do not require emergency services.
This program requires a multidisciplinary team to ensure comprehensive planning, effective execution, and ongoing improvement. Within the health system, teams that are involved in the program are the emergency medicine, digital health, data and analytics, clinical quality and performance improvement, legal, and training and education teams. Externally, NYC Health + Hospitals collaborates with FDNY to properly implement the program.
Since its start, the program has diverted over 25,000 calls, preventing more than 12,000 ambulance transport and emergency department visits. The rideshare program has offered over 3,000 non-emergency rides, further optimizing ambulance availability. Additionally, vEC has lead to high patient satisfaction rates and low escalation rates to emergency services.
