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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.
By aoguagha | Categories: | Comments Off on Advancing Health Equity through Housing Connections
To address an important gap in true patient care, Denver Health partnered with the Denver Housing Authority and Corporation for Supportive Housing to design safe and supportive low-income transitional housing in a renovated building on the main hospital campus for patients who are elderly and/or disabled as they recover following hospitalization.
The recently implemented homeless registry within the electronic health record (Epic) comprehensively and inclusively identifies patients experiencing homelessness. Once identified, patient needs are assessed and are referred for appropriate next steps related to hospital discharge. In 2023, Denver Health will open 14 new single resident occupancy apartments that will be used as transitional housing for appropriate elderly and/or disabled patients experiencing homelessness.
The goals of this program are to provide patients with a safe place to regain independence after discharge while also reducing the health care expenditures brought on by prolonged hospital stays, which are also associated with risks to patients (i.e., infections, falls, adverse drug events), and to reduce avoidable rehospitalizations due to lack of secure housing.
Denver Health supports housing connections for patients through local partnerships with community-based organizations, including with the Colorado Coalition for the Homeless and the Denver Housing Authority. Denver Health is a referral partner on Denver’s Social Impact Partnership to Pay for Results Act (SIPPRA) Housing to Health Program, which serves individuals experiencing homelessness who are frequent utilizers of healthcare, jails, and other high-cost city services. Denver Health also connects eligible patients to the Statewide Supportive Housing Expansion (SWSHE) pilot program.
To date, this work has resulted in increased screening and identification of patients with housing needs across the integrated health care system, and an increase in patients being referred to housing and other community supports. This has translated into reductions in length of stay and more meaningful connections for patients.
By aoguagha | Categories: | Comments Off on ZSFG Health Advocates Program
The health care professionals of Zuckerberg San Francisco General Hospital and Trauma Center (ZSFG), in San Francisco, understand health care alone does not necessarily mean good health. Social factors, such as access to food, safe housing, and education impact overall health, as well. ZSFG launched its Health Advocates program in 2013 to improve community health by connecting families with community resources that address their social needs. These needs might otherwise not have been met outside their typical hospital visits. The ZSFG Health Advocates program aims to change how people think about health.
The Health Advocate program is a student and community volunteer–based service group that conducts standardized social and legal needs screenings for patients at the ZSFG health centers for children, women, and families.
The Health Advocates program extends the care of patients and connects them directly to resources that help overcome systemic societal barriers and legal obstacles that impact health and well-being. Through the Health Advocates program, ZSFG improves the quality of life and health outcomes for families.
The ZSFG Health Advocates program connects families with existing benefits programs and external community organizations based on their level of need. The program collaborates with Bay Area Legal Aid as part of the San Francisco Medical-Legal Partnership (MLP) to provide legal advice and support to families. Families screened for more complex issues by the health advocates — family mental health issues or complicated legal challenges, for example — are connected with clinical social workers and/or lawyers from the MLP network who can provide professional support and case management.
By Amanda Jepson | Categories: | Comments Off on Fresh for You Market
Eskenazi Health has a strong belief in the concept of food as medicine, a pillar of the health system’s Beyond Barriers campaign. In Indianapolis, 41 percent of children younger than age 5 suffer from malnutrition, and in Marion County, 21 percent of residents live in a food desert. Prior to the COVID-19 pandemic, nearly 200,000 county residents identified as food insecure. Through the Fresh for You Market and the Fresh for You Market on Wheels, Eskenazi Health is combating food insecurity in the community and providing residents with access to nutritional and affordable food.
The Fresh for You Market, a grocery store and food pantry, is located on the Eskenazi Health downtown campus on a bus route easily accessible to the community. The self-sustaining Market is open to the public, and proceeds from sales directly fund the Fresh for You Market voucher program. This program provides patients who screen positive for food insecurity during clinic visits with free food vouchers to shop at the market. The Fresh for You Market on Wheels is a mobile version of the market that parks at a different location throughout Indianapolis each weekday. A nutrition navigator on board helps patients pick foods for specific diets and conditions, and a chef prepares hot meals and hosts cooking demonstrations.
The Fresh for You Market and Market on Wheels would not be possible without community partners. The downtown market partners with a local food bank, and the market on wheels partners with local produce vendors, public transportation, the Indiana Department of Health, and other government agencies.
Since opening in June 2017, the Fresh for You Market has been a key food resource for patients, residents, and health system staff. In the first full year of operation, the Market served 6,200 people. During the COVID-19 pandemic, the market opened to health system employees working long hours who were unable to make it to the grocery store. The Fresh for You Market on Wheels, launched in July 2023, is making its way to for access to food in a social needs screening.
By Amanda Jepson | Categories: | Comments Off on Beyond Barriers
After discovering significant disparities in age expectancy from zip codes only 16 miles apart in Marion County, Ind., Eskenazi Health acted to find solutions to enhance the health of the community it serves. Thus, the $60 million campaign titled, Beyond Barriers, takes a multidisciplinary approach to three main areas: health care, mental health care, and food as medicine. The goal of the campaign is to create life expectancy equity for everyone in the city of Indianapolis through an integrated and sustainable model of community infrastructure improvement.
The program serves Eskenazi Health’s patient population and surrounding community. At the heart of Beyond Barriers are Health Equity Zones identified to improve access to health care, mental health care, and nutritional foods. Each zone is home to an Eskenazi Health Center where community health care workers work one-on-one with patients at appointments and home visits. During this time, they screen patients for social determinants of health and help with self-management goals to promote positive health behaviors. The campaign also sustains mental health professional recruitment, upgrades mental health facilities, and expands the John & Kathy Ackerman Mental Health Professional Development Center. Another important aspect of Beyond Barriers is the Fresh for You Market, which provides fresh and affordable foods to patients and families who lack access to affordable food options.
Eskenazi Health engages with education, transportation, public health, housing, food pantries, and other industries to expand existing programs and create and support new programming and services. By working with these entities, Eskenazi Health can focus on long-term social determinants of health and improving quality of life for all Central Indiana residents.
Launched in 2017, the Fresh for You Market, located at Eskenazi Health’s downtown campus, has helped patients and families access affordable and healthy groceries. In its first full year of operation, the market fed 6,200 people from under-resourced and underserved communities and improved the quality of life of those served. In summer 2023, the Fresh for You Market launched a mobile food pantry, Fresh for You Market on Wheels, which is parked in various locations around Indianapolis each weekday based on patient needs indicated in social needs screenings.
By Hannah Lambalot | Categories: | Comments Off on Food Rx: A Cross-Sector Approach to Improving Health and Health Equity
High Harris County, Texas, has America’s highest number of uninsured residents, and one in five patients at Harris Health System screen positive for food insecurity. The health system partnered with Houston Food Bank (HFB), the University of Texas School of Public Health, and grocery store H-E-B for a Food Rx program based at two family practice clinics.
“Our food ‘farmacies’ are unique in that we go beyond a food insecurity model. Our patients are able to select the healthy foods they want as they walk and learn with a dietitian,” said Chief Integration Officer Karen Tseng. “We also provide them with the skills and confidence to translate those raw ingredients into healthy, cost-effective, culturally appropriate meals through our culinary medicine programming.”
Patients enroll with a community health worker, work with a dietitian to select healthy food; connect with an HFB navigator to enroll in the Supplemental Nutrition Assistance Program and Temporary Assistance for Needy Families program, and are linked to community food resources.
Patients with uncontrolled diabetes are invited to join a nine-month program, in which they participate in biweekly “walk and learn” sessions with a diabetes educator while redeeming 30 pounds of fresh food from the food farmacy. During the COVID-19 pandemic, Harris Health System adapted the walk-and-learn education model with curbside delivery, biweekly tele-education, and virtual culinary education initiatives.
Food Rx served more than 650 patients in its first year. Participants improved their nutrition knowledge scores, increased daily fruit and vegetable consumption, and reported increased confidence in basic cooking techniques. Program graduates decreased HbA1c levels by an average of 0.72 percentage points.
By Hannah Lambalot | Categories: | Comments Off on Community Health Worker Home Visits for High-Risk Diabetes Patients
Harris Health System, in Houston, serves a largely low-income and uninsured or underinsured patient population, of which nearly 90 percent are people of color. These communities experience a disproportionate prevalence of diabetes, and Type 2 diabetes ranks among the most prevalent and costly outpatient diagnoses.
Spurred in part by a Medicaid Section 1115 waiver, the health system developed a diabetes registry that identified nearly 40,000 diagnosed patients, including about one-third who had uncontrolled diabetes with HbA1c levels greater than 9. In 2017, Harris Health then designed a community health worker (CHW) home visit pilot program that uses a hub-and-spoke, community-focused model to work with disengaged patients with diabetes. Through the program, CHWs capture a comprehensive picture of patients’ health-related social needs, diabetes knowledge, and self-management behaviors. The four-month program extends the health system’s reach outside its walls to better understand barriers to good health and offer point-of-care navigation. CHWs launch a care plan that can include establishing eligibility for charity care, making appointments with interdisciplinary teams, applying for rental assistance, education on public transportation, and more.
Since its inception, the program has grown to 14 clinics. In 2020, COVID-19 created new barriers for patient self-management of diabetes and the health system responded by shifting the program to include virtual and telehealth care; this transition coincides with a 130 percent increase in the number of program graduates. Before the start of the pandemic, 181 program participants reported an average decrease of 2.2 percentage points in HbA1c levels and increased knowledge of their condition and appropriate treatment. The program sustained these outcomes amid the pandemic, with 417 patients completing the program from November 2020 to October 2021.
By Hannah Lambalot | Categories: | Comments Off on Institute for H.O.P.E. School Health
A decade ago, Cleveland public schools were plagued with chronic absenteeism and stagnant academic achievement, with a graduation rate of just 52.2 percent. At the same time, The MetroHealth System noticed declining pediatric primary care visits, increasing emergency department use, and gaps in children’s health outcomes. A health system assessment revealed a strong need for asthma management, well-child exams, immunizations, and other primary care and mental health screenings and services.
In 2013, MetroHealth opened the first Institute for H.O.P.E.TM school health program clinic in a converted classroom at an elementary school. Today, the program has expanded to more than two dozen sites and mobile units, selected based on assessed need. The clinics offer traditional medical care, as well as addressing behavioral health issues and social determinants of health. Every week, the team helps students and their families sign up for insurance, recognize lead exposure, and connect with community partners to find housing, pay rent, and more. The program also provides students coats, toothbrushes, backpacks, and school supplies.
The program is funded through philanthropic support, Medicaid billing, and the health system’s general operations budget; its annual budget is on pace to exceed $1 million for 2022.
Compared with a baseline, program enrollees were 64 percent more likely to be up to date on immunizations, 38 percent more likely to have attended one or more primary care visits, and 22 percent more likely to have had an annual well-child exam. At the first participating high school, attendance rates exceeded 94 percent and enrollees had eight fewer absences on average and a grade-point average 0.41 higher than other students.
By Hannah Lambalot | Categories: | Comments Off on Maternal Medical Home
New York City is grappling with high rates of maternal mortality and morbidity with stark racial disparities. As of 2018, non-Hispanic Black women are 8 times more likely to die from a childbirth-related complication and three times more likely to experience a life-threatening event in pregnancy than non-Hispanic white women. The highest rates of severe maternal morbidity are in some of New York City’s most under-resourced communities, areas like East Flatbush, Brooklyn, and Jamaica/St. Albans, Queens. The Maternal Medical Home improves high-risk obstetric outcomes by providing referrals to necessary specialty care, mental health services, and enhanced wraparound services to address socioeconomic challenges, as well as parenting support and education. The Maternal Medical Home is one component of the Maternal Mortality Morbidity Reduction Program of NYC Health + Hospitals (NYCH+H).
NYC Health + Hospitals established the Maternal Medical Home to provide enhanced services, attention, and care to pregnant patients who needed it. This program received funding from the City of New York, as well as internal support. Two frameworks shape the program, the Socio-ecological model encourages 1) health education and literacy for patients to stay informed, 2) building trust between the team, patient, and partners 3) standardizing the screening and assessment tools for patients across the system. The Socio-cultural environmental model inspired 1) connecting patients with needed resources and services, and 2) encouraging patient autonomy in prenatal care and patient services.
Any member of the healthcare team may refer patients to the Maternal Medical Home. Patients with additional medical diagnoses, which may place a pregnancy at higher risk for an adverse outcome, such as (but not exclusive of) hypertension and diabetes, are followed by the Maternal Medical Home team. Patients with behavioral health diagnoses or patients who have needs related to social determinants of health (such as patients with food or housing insecurity, or in need of legal services) may be referred to the Maternal Medical Home for additional coordinated care and/or support services. The Maternal Medical Home team uses additional screening and assessment tools, such as the Prenatal ACES to stratify patients most at risk during pregnancy. The Maternal Medical Home team serves as a locus to help patients navigate a complex medical system and access needed resources.
The Maternal Medical Home program staffs seven Maternal Care Coordinators who have an interest and expertise in public health and nine Supervisors who have a master’s degree specifically in Social Work. Care coordinators and Supervisors are tasked to communicate with the clinical team, behavioral health specialists, and create tight linkages with community health workers and home health care. The clinical team includes physicians, advanced practice nurses, and nurses across the system.
Based on the screening assessment and associated risks score, the multi-disciplinary teams provide patients with referrals to specialty care, behavioral health and emotional support, pharmaceutical needs, socioeconomic needs, and parenting support/education. The screening and assessment build documentation templates for patient screenings, patient birth plans, and post-partum assessment plans. The program aims to create a stable, safe, and healthy environment for the patients to successfully take care of themselves and their newborns.
The Maternal Medical home program was piloted at NYCHH Kings County Site in October of 2019 and ran for two months. Since then, NYCHH has rolled out implementation to 11 facilities as of June 2021. Since the program’s launch, more than 3,000 pregnant patients have been referred to additional care or support services, such as nutrition, dental, and housing. Additionally, 405 pregnant patients were referred to the program and 1226 unique patients were supported.
By Hannah Lambalot | Categories: | Comments Off on CommunityConnect
Contra Costa Regional Medical Center’s (CCRMC) top 5% of users represent 49% of total costs, and the top 15% of users represent 79% of costs. Through a review of high need patients, it was revealed that a large portion of these high costs were associated with patients accessing medical services due to underlying social needs.
CommunityConnect was designed to target interventions for high-need patients with the aim to provide upstream care and services. The program utilizes predictive model analytics, that incorporates data points from across county, to proactively identify patients that are likely to use the emergency room or be admitted to the hospital for an avoidable reason in the future, such as to meet their urgent social needs. Patients who are enrolled into the program are provided one year of case management to coordinate medical services and provide community and government resources that can improve patient well-being and health. CommunityConnect receives funding of $40 million annually through the California Medicaid 1115 waiver Whole Person Care.
Patients are identified and enrolled int the program based upon data gathered through a comprehensive set of sources: from Medicaid managed care plans, behavioral health, the coordinated entry housing program, EMS and the county detention facility. These data points are combined to create patient-level risk factors. As the program identifies enrollment based on a predictive model, a number of patients are identified for enrollment not based on their prior health utilization (based on Medicaid claims data, apart from CCRMC). Leveraging data through a holistic patient record allows for identification of county residents that may not have otherwise ever been referred into services through traditional means.
Upon patient enrollment, case managers conduct a comprehensive social needs assessment with the patients to identify areas in which the program can help. This covers areas such as: medical, behavioral health, safety, housing, food security, transportation, finances, legal, and support system. Depending on patient acuity, case management services are either provided in-person or telephonically by multi-disciplinary staff that includes public health nurses, social workers, substance use counselors, homeless services specialists, mental health clinicians, and community health workers.
Once the CommunityConnect case managers assess a patient’s unmet social needs, they help enrollees create a patient- centered care plan, access resources, and work in partnership with the patient and other care team members to implement the plan, with the shared goal of improving the patient’s health. In addition to a providing linkages to community resources through a comprehensive social needs online resource directory, the program provides direct benefits to patients aimed at addressing unmet social needs. CommunityConnect patients have access to a transitional housing fund that can assist with security deposit or moving costs; a free cell phone in order to engage in services and link with resources; non-medical transportation in order to obtain identification documents; Free legal assistance from two full-time lawyers at the local legal aid; and social service workers to help apply and renew public benefits including Medicaid, SNAP, and TANF.
Since June 2017, the program has connected more than 17,000 people to critical health and social services. The first year (2017) resulted in a 3% reduction in ED visits and an 12% reduction in inpatient admissions compared to 2019 results that improved to show a 20% reduction in ED visits and 18% reduction in inpatient admissions. Other measures are in process of being analyzed, including primary care visits, behavioral health visits, access to public benefits, and other biometric health indicators. Success measures show that 37% of patients that lapse Medicaid are able to be restored within 90 days due to case management services, and 34% of patients have had a successful outcome with a social-related goal.
