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 Amanda Jepson | Categories: | Comments Off on Compassion for Community: Continuing Care After Death
At NYC Health + Hospitals/Jacobi and North Central Bronx, in the Bronx, N.Y., decedent holding time in the morgue drastically increased from an average of 72 hours before the COVID-19 pandemic to an average of 13 days in 2022. In addition to affecting the grieving process for patients’ families and loved ones, the delay in decedent release time strains hospital resources by requiring additional personnel and refrigerated space.
An employee in the Department of Pathology who was herself mourning the loss of her parents raised concern about this turnaround time and turned her grief into action. An analysis showed that funeral home capacity, complexities in navigating the funeral process, and high funeral costs contributed significantly to delays in decedent release, with Black decedents more likely to experience longer release turnaround times. The Compassion for Community: Continuing Care After Death program aimed to reduce decedent release turnaround time to improve family support, mitigate racial disparities, promote operational efficiency, and reduce environmental impact.
The program’s multipronged approach included 1) strengthened relationships with community partners including funeral homes and places of worship to identify capacity and support available to families, 2) enhancement of data collection to track capacity, 3) development of a guidebook, “Illuminating Forever Care,” for families that explains the practical aspects of funeral care and includes resources for funeral costs and processes. Written at a sixth grade reading level and available in multiple languages, in print and digitally, the book aims to close racial and ethnic disparities that delay decedent release.
The self-sustaining program operates with existing personnel, including an interdisciplinary team led by the quality management team that comprises staff from pathology, admitting, patient experience, bereavement, and finance. In 2023, 100 percent of decedents were released in eight days or less; in 2024, 90 percent of decedents were released in five days or less. Additionally, the program reduced greenhouse gas emissions by 13.1 metric tons and saved the health system $90,000 in overtime in its first year by minimizing refrigerated trailer use.
The health system would like to dedicate this award to the late Ms. Suzanne Pennacchio, whose legacy of quality/safety transformation we carry forward.
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 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 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.
By Amanda Jepson | Categories: | Comments Off on Multi-Visit Patient Initiative Supports High-Risk Patients
In 2019, boarding and left-without-being-seen rates at Harris Health’s Ben Taub Hospital were above goal, and executive leaders grew concerned about quality of care, patient safety, and staff burnout. Data analysis showed that Multi-Visit Patients (MVPs)—defined as patients with 10 or more emergency department (ED) visits in the past 365 days—accounted for 0.7 percent of all ED patients and 8 percent of all ED visits. High utilizers of the emergency department often visit hospitals because of multiple behavioral, social, and medical conditions. To decrease avoidable utilization, improve throughput and safety, and help an under-resourced population obtain care, Harris Health in 2020 leveraged the Multi-Visit Patient Method.
Harris Health trained ED physicians, along with nursing, psychiatry, and care management staff, to become program champions. The program employs community health workers (CHWs) in the ED to communicate with MVPs, identify their root cause of frequent visits, and link them to necessary care and community resources. The team tracks key process measures on a weekly and monthly basis: percent of MVP ED visits with a face-to-face assessment, percent of MVP ED visits with a linkage to resources, and percent of unique MVPs with an MVP note in the electronic health record.
Partnering with more than 11 community organizations, including the Houston Recovery Center and Coalition for the Homeless of Houston/Harris County, the MVP team has successfully built pathways to support MVPs with substance use disorder, end-stage renal disease (ESRD), behavioral health, and housing insecurity. Recognizing that a simple referral is not enough for MVPs, the team developed closed-loop communication procedures, including dedicated staff contacts, phone numbers, and MVP-specific operating hours and transportation services.
The MVP team has reunited at least 10 MVPs with their families, obtained routine dialysis treatment for 26 MVPs with ESRD, connected 15 MVPs with substance use disorder to rehabilitation services, and helped 22 MVPs receive housing. In three years, the annual MVP visit count decreased by 23.2 percent (more than 1,500 annual visits), and total length of stay hours decreased by 36 percent (16,000 annual hours). MVPs who were engaged by CHWs on at least three-fourths of their visits showed a 57 percent decrease in ED visits during a 12-month follow-up.
By Amanda Jepson | Categories: | Comments Off on Healing and Opportunities with Psychotic Experiences (HOPE) Program
About 100,000 people in the United States each year experience a psychotic episode. Longer durations of untreated psychosis correlate with more severe symptoms, including less likelihood of remission and poorer vocational, academic, and social functioning. Hennepin Healthcare’s Healing and Opportunities with Psychotic Experiences (HOPE) Program provides early intervention for patients ages 15 to 40 experiencing an illness on the schizophrenia spectrum.
HOPE launched in 2016 through a federal mental health block grant. Program staff educate and collaborate with local organizations to provide referrals. An interdisciplinary team comprising a director, psychiatrists, nurse, individual and family psychotherapists, employment and education specialists, peer and family support specialists, and a psychiatric case worker provides empirically based treatment. Patients set treatment goals and participate in HOPE programming for an average of 18 months. Employment and education specialists collaborate with schools to build accommodations for HOPE patients. Since 2017, staff have taught local law enforcement agencies about psychosis and de-escalation techniques. Staff also developed educational materials for patients and families on safely managing crises in the community.
Since 2016, HOPE has treated 329 patients. Reduction in symptom severity from time of enrollment to time of discharge increased from 60 percent in 2021 to 65 percent in 2023. Planned discharges increased from 60 percent of total caseload in 2020 to 79.3 percent in 2023. From 2017 to 2023, patients involved in work and/or school activities increased from 47 to 63 percent, and representation of people of color in the program increased from 55 percent to 76 percent.
By Amanda Jepson | Categories: | Comments Off on Rooftop Farm
Boston Medical Center’s (BMC’s) Rooftop Farms opened in 2017 as part of the Nourishing Communities program, which includes the Preventative Food Pantry and Teaching Kitchen. A second farm will open in the spring of 2024, bringing the total growing space to approximately square feet. With two farms, the program will yield 10,000 pounds of fresh, organically grown produce annually to distribute throughout the food pantry, a low-cost farmer’s market, and our kitchens. The farm partners with internal departments and organizations in the Boston area to host team–building, volunteer, and educational opportunities focused on growing food, nutrition, and green infrastructure.
The hospital employs two part-time farm staff who focus on food production, education, and community outreach. The program also sponsors two to four interns per year who assist the farm staff and earn experience in rooftop farming and community engagement. The program’s educational component reaches a wide swath of the community, from public school students to immigrant groups, to patients, employees, and clinical staff. For example, the farm reported more than 1,300 visits in 2023. in 2023, 50 percent goes to patients facing food insecurity who visit the food pantry, 41 percent goes to the general community through the low-cost farmers market, and 10 percent goes to the kitchens.
Since opening seven years ago, the rooftop farm has grown approximately 30,000–35,000 pounds of food for community members, with approximately 75 percent directly reaching those who are low–income or experiencing food insecurity. The original farm also has engaged individuals in tours, volunteer days, and educational events more than 9,000 times, providing community members with a forum to connect with each other, learn about green innovation, and experience a hospital space that builds healthy communities in multiple ways. With a second farm opening, BMC expects to double its impact and continue to grow its community partnerships, aiming to support fair Boston food system that provides workforce development, climate resilience, and nourishing food for all people.
To learn more about the Rooftop Farm, please visit this link.
By Amanda Jepson | Categories: | Comments Off on Sustainability Program
Boston Medical Center (BMC) began its sustainability journey in 2012 after recognizing that the communities it serves are disproportionately affected by climate change. Implementing sustainability efforts is part of the health care the hospital provides, with a focus on improving energy efficiency, reducing carbon emissions, decreasing operating costs, and increasing access to care. BMC first reassessed its real estate portfolio to maximize the impact of every square foot, which led to the sale of several real estate assets. The proceeds then were used to upgrade other buildings for increased energy efficiency. BMC reduced 300,000 square feet while increasing its capacity to care for patients: patient volumes increased by almost 30 percent.
BMC’s climate mitigation work covers a variety of entities that all aim to serve the local community. BMC is the largest safety net hospital in New England; 73 percent of the hospital’s patients are covered by public insurance, and many reside in communities facing environmental inequalities. In 2022, BMC opened the Brockton Behavioral Health Center, the first net-zero behavioral health facility in the United States. The center is powered by solar energy and heated by geothermal wells. Since spring 2017, Boston Medical Center has generated much of its own electricity and heat through a natural gas–fired, two-megawatt combined heat and power plant, also known as cogeneration. The plant operates at 70 percent efficiency compared with a typical gas-fired power plant’s 35 percent efficiency. It also has “black start” capability, meaning that if the electric grid goes down, the hospital can use the cogeneration plant in combination with a recently-installed Tesla battery system to heat and power its inpatient units on an “island” for months at a time, as long as it has a natural gas supply.
In 2016, BMC took a major step toward a carbon-neutral campus with an innovative solar purchase and partnership with the Massachusetts Institute of Technology and the Post Office Square Redevelopment Corporation. Through this partnership, BMC invested 255,000 solar panels across 650 acres in North Carolina. BMC purchases 26 percent of the power the solar facility produces, which is equivalent to 100 percent of BMC’s electricity consumption.
BMC’s reduced physical footprint and efforts to improve energy efficiency reduced utility costs significantly which generated savings that were reinvested back into patient care. Between 2011 and 2022, BMC reduced carbon emissions by 91 percent and electric consumption by 29 percent. These savings have enabled the reinvestment of funds in patient care and other sustainability projects, such as the opening of the Brockton Behavioral Health Center.
To learn more about BMC’s sustainability efforts, please visit their website through this link.
