Blog Archives
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.
By aoguagha | Categories: | Comments Off on Huntsville Hospital Telemedicine Program
Huntsville Hospital’s telemedicine program partners with Madison Hospital and Helen Keller Hospital to provide virtual care to residents in rural areas across the Tennessee Valley. The program connects patients with remote neurologists and psychiatrists for consultations, diagnoses, and treatment plans. The initiative aims to increase access to specialty care, especially for those facing challenges due to location. Supported by over $1 million in state funding, the program is already receiving positive feedback from patients and providers alike.
By aoguagha | Categories: | Comments Off on Jefferson Workforce Development Program
The Jefferson Workforce Development Program, facilitated in partnership with the School District of Philadelphia and Esperanza College, aims to address healthcare staffing shortages while creating career pathways for young Philadelphians. Targeting high school students, the program includes clinical shadowing, didactic and skills training, and professional development support. Students gain hands-on experience during school hours at no cost and receive mentorship and resume/interview coaching from Jefferson’s Human Resources team. Upon completion of the program, they are eligible for full-time roles across the Jefferson Health system. Key program benefits include free training, career readiness resources, exposure to real clinical environments, and financial support for essential workforce expenses.
By Amanda Jepson | Categories: | Comments Off on Curbside Care
Boston Medical Center (BMC) recognizes how critical the first six weeks of life are for birthing people and babies. Forty percent of publicly insured birthing people never return for a postpartum appointment. To close this gap, BMC launched the Curbside Care program in January 2023 with the goal of mitigating barriers to postpartum care through a mobile unit.
Curbside Care is a mobile health delivery program that provides high-touch, comprehensive wraparound services for birthing people and their infants in the first six weeks of life outside of their homes in Boston—at the curb! Funded by the Boston Celtics Shamrock Foundation, Curbside Care replaces traditional postpartum visits in this hospital and eliminates the need for transportation and childcare for postpartum appointments. Our clinical staff of doctors, nurse practitioners, certified nurse-midwives, and an international board of lactation consultant examiner provide a range of services including feeding assessments, lactation support, jaundice evaluation, postpartum depression and hypertension screenings, and contraceptive services all on the mobile unit. A community wellness advocate recruits pregnant patients and performs a needs assessment for each dyad. Patients receive material needs, such as diapers, strollers, and food, at each visit.
Curbside Care is an interdepartmental initiative run by the pediatrics and OBGYN departments at BMC. Other hospital partnerships include the Breastfeeding Equity Center, the Economic Justice Hub, and the Center for the Urban Child and Healthy Family. Community partners also include Brewster Ambulance Service, the Vital Village Network, and New England Mothers First.
BMC has cared for 519 patients in the last 12 months, with an average of 3.7 visits per patient. Of the patients seen, 63.97 percent identified as Black and 31.17 percent identified as Hispanic/Latino. All patients received lactation support and were screened for material needs and postpartum depression. All patients reside in Boston ZIP codes, primarily in the Dorchester, Mattapan, and Roxbury neighborhoods. Curbside Care patients have a 2.9 percent “no-show” rate, compared with 15.3 percent in BMC’s pediatric clinic and 18.8 percent in the postpartum OBGYN clinic.
By aoguagha | Categories: | Comments Off on Episcopal Food Pantry
Located on Temple Health’s Episcopal Campus, the Episcopal Food Pantry provides free fresh fruits and vegetables, canned goods, and other non-perishable items to nourish the community. In collaboration with the Share Food Program, the leading food bank in the Philadelphia area, the food pantry is open every Thursday. Since the program opened in May 2022, the number of community members served has doubled, and the program hopes to see continued growth.
For more information about the program, click here.
By aoguagha | Categories: | Comments Off on Farm to Families
To decrease chronic disease related to poor diet and physical inactivity, Farm to Families increases access to healthy foods by providing low-cost, fresh produce, dairy, and meat to over 350,000 residents in North Philadelphia. With a FreshRx prescription from a Temple Health doctor, patients who screen positive for food insecurity can receive coupons to purchase fresh food through the program. Community members and families with food stamps can also buy fresh foods throughout the year and receive nutrition education on how to sustain healthy eating habits.
Temple University Hospital and the Lewis Katz School of Medicine collaborate with the St. Christopher’s Foundation and the Lancaster Farm Fresh Cooperative to source, package, and deliver fresh and organic food to the community. Over 48,000 boxes of food have been purchased by more than 6,400 families since 2010.
For more information about the program click here.
By aoguagha | Categories: | Comments Off on Food As Medicine
The Food as Medicine partnership at Grady Health provides members of the Grady community (patients, families, employees, visitors, and neighbors) access to healthy affordable food through the Jesse Hill Market and other collaborations throughout the Atlanta area. Located just outside Grady’s main entrance, the Jesse Hill Market features a food prescription program that offers eligible patients fresh food, nutrition education, and cooking classes. The Market also offers healthy grab-and-go meals and fresh produce for purchase through its public café.
The Food as Medicine program is a multipronged intervention to address both chronic disease and food insecurity among Grady patients. Grady Health partners with the Atlanta Community Food Bank and Open Hand Atlanta to deliver the Food As Medicine program. The Food as Medicine Partnership aims to fuel patients with healthy foods while bringing the community together.
For more information, click here.
By aoguagha | Categories: | Comments Off on Food Rx
To address food insecurity among their patient population, LA Health Services’ Food Rx program works in partnership with the Department of Public Health CalFresh Healthy Living Program to give patients a stronger footing in their healthcare journey. The program also provides links to CalFresh, SNAP, and other long-term food resources to support patients in reaching their health goals.
Since the inception of the program in 2021, the program has conducted over 392 food distributions, served over 290,186 households, and distributed over one million pounds of food.
For more information click here.
By Amanda Jepson | Categories: | Comments Off on Community Health Program
In Galveston County, 16 percent of the population is uninsured and 12.1 percent lives in poverty. In Brazoria County, 15.9 percent are uninsured and 9 percent live in poverty.
The University of Texas Medical Branch (UTMB Health)’s Community Health Program (CHP) provides community-based care and condition management services to adults with chronic conditions, including diabetes, hypertension, and heart disease, in Galveston and Brazoria counties. Most program enrollees struggle with food insecurity, lack of transportation, and affordable housing, which compromises their ability to pay for medications and other health care expenses to manage their medical condition optimally. Many patients access health care services inappropriately or do not seek care until much later than is optimal for their conditions.
The program is set up in five geographically deployed teams/pods, each consisting of care managers, community health workers, and social workers who provide services to this patient population through health care navigation support, education, and resource connections. Emergency department staff, inpatient staff, and other local partners can refer patients to CHP via phone or messages in the electronic health record. The goal is to encourage care coordination that empowers the patient and caregiver(s) to contribute toward more successful outcomes. All patients enrolled in the program have a comprehensive intake assessment and are viewed through a “whole person” lens.
The program, available at no cost not only to UTMB Health patients but also to all patients in the service delivery area, was initially funded through the Texas Medicaid Section 1115 waiver before continuing as a budgeted expense. The CHP recently expanded by six full-time equivalents after a return-on-investment analysis indicated that the program is producing the desired patient care outcomes.
CHP collaborates with two faith-based organizations, community health centers, county indigent programs, food banks, and the Salvation Army to connect patients to services and resources. For example, one faith-based organization offers several clinics, including a Transitions of Care Clinic for recently discharged patients, and provides specialty care in partnership with UTMB.
For a 28-patient cohort, CHP enrollment for 12 months led to an 83 percent decrease in hospitalization and 95 percent reduction in ED visits. More than 40 percent of the 28 patients with diabetes saw a drop in their HbA1c values during and after participating in the program. Participants’ hemoglobin A1c values and blood pressure decreased. In comparison with a control group of patients not enrolled in the program, CHP enrollment reduced system costs by 24 percent.
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.
