Blog Archives
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 Refugee Services
Arizona has settled more than 110,000 refugees since 1981 and ranks in the top five states for refugee reception. Seventy-eight percent of those refugees relocate to Maricopa County, where Valleywise Health operates, in Phoenix. In response to the influx of refugees, Valleywise Health established the Women’s Refugee Health Clinic in 2008 to provide a culturally grounded, patient-centered medical home for the refugee community. In 2022, the clinic became part of the Valleywise Health Center for Refugee and Global Health. The center aims to assist refugees in navigating the U.S. health care system, including support with interpretation, insurance, housing, and day-to-day survival information.
The center provides comprehensive services via numerous clinics, including the Refugee Women’s Health Clinic, Refugee Pediatric Clinic, Family Medicine Refugee Clinic, McDowell Clinic for Individuals Living with HIV, Specialty Care Services, Behavioral Health Services, and Internal Medicine. Through outreach, the center mitigates structural barriers to care, including transportation, health literacy, continuum of care, and treatment adherence. Eighteen cultural health navigators work with clinical teams to coordinate all health-related activities daily. Valleywise Health allots an annual budget to the center and receives additional funding from foundations, including the Valleywise Health, Burton Family, Flinn, and Pakis Family foundations.
Community partnerships with the Arizona Department of Health Services, Department of Economic Security, State Refugee Resettlement Office, Maricopa County Department of Public Health, Arizona State University, health plans, and other refugee-serving organizations are key in service development, implementation, and dissemination.
In 2024, the center served 17,000 refugee patients, an increase of 1,000 over the previous year, from 71 countries. The center provided health literacy classes to more than 800 patients; adult refugee services to 1,437 men (including 243 who transitioned to self-efficacy in 2024), thanks to the program’s expansion into family medicine; and HIV and AIDS care to 880 adult refugees. Health care providers delivered 212 babies at the Refugee Women’s Health Clinic and installed more than 300 car seats for mothers who completed child safety classes. Additionally, the health center has seen a 33 percent increase in mental health screenings.
By Amanda Jepson | Categories: | Comments Off on Bringing the Justice System to Outpatient Addiction Care
Harris Health System’s Office-Based Addiction Treatment (OBAT) Program integrates physical, social, behavioral, and mental health to treat patients with substance use disorder (SUD) in a non-stigmatizing environment—the primary care setting. The program provides extensive support to patients with SUD and works to decrease drug misuse to less than 30 percent of the patient population. Additionally, it provides assessments and follow-up care for body mass index, depression, and tobacco use.
A team of nurses, community health workers, medical doctors, and executive leadership educates participants on establishing their place in the community, prioritizing their mental health, and practicing self-care to keep a healthy mindset. Eighty percent of OBAT participants are uninsured or underinsured. The program identifies social determinants of health on a case-by-case basis and takes measures to mitigate noncompliance risks with treatment plans. Since its 2017 inception, the OBAT program has been funded through federal Substance Abuse and Mental Health Services Administration grants, multiple state grants, and university research partnerships.
In 2022, Harris Health System’s OBAT partnered with the Harris County Success Through Addiction Recovery (STAR) Drug Court Program to better serve patient needs. The STAR program uses a unique judicial model of treatment and education to support recovery from substance use and mental health disorders and reduce the expense of criminal case processes and incarceration. This partnership allows the Harris Health OBAT team to visit the courts monthly to speak with clients about the program; discuss topics related to substance use, addiction, suicide, and overdose prevention; and provide connections to community resources. Additionally, the OBAT team partnered with Harris Health’s Health Care for the Homeless Program to provide mobile medical unit services outside of the courts for six months.
The program currently serves 287 opioid use disorder and 97 alcohol use disorder patients. OBAT participants have shown significant decreases in drug misuse, and 93 percent of program participants are opioid-free within six months. In collaboration with STAR, Harris Health System educated 730 clients on suicide and overdose prevention between November 2022 and September 2024, and distributed more than 300 boxes of naloxone to clients and courts.
By Amanda Jepson | Categories: | Comments Off on Memorial Mobile Health Center
Memorial Healthcare System has been a leader in mobile health since 2000. The mobile health program runs both pediatric and adult health vans, all with the goal of increasing access to care and intervention services for community members.
The mobile vans operate 21 days a month and offer free services and social needs screenings to community members, most of whom are under- or uninsured. The pediatric van offers immunizations, behavioral health services, well and sick visits, follow-up visits, and counseling events. The adult van also offers vaccines and sick visits but emphasizes helping patients apply for public assistance benefits, such as Medicaid and the Supplemental Nutrition Assistance Program, if they are eligible. All vans are equipped with Memorial Healthcare staff, including two medical assistants, a nurse practitioner, and occasional residents.
To ensure the program meets patients’ needs, Memorial partners with many community organizations, including early learning services, homeless services, migrant services, food pantries, local universities, and local government to help identify locations to set up the clinics.
Memorial’s Mobile Health Center has built a trustful relationship with the community through its efforts. By caring for patients in the community, the vans also have reduced the burden on local emergency departments. The pediatric mobile van sees about 220 patients per month, and the adult mobile van sees about 490 patients per month.
By Hannah Lambalot | Categories: | Comments Off on Eskenazi Health
By Hannah Lambalot | Categories: | Comments Off on StreetCred
StreetCred was founded in 2015 after recognizing the need for doctors to address poverty as a disease, not simply just a social problem. For many families, income tax preparation is a challenge as they try to navigate a complicated system. As a result, they often do not receive the tax benefits they are entitled. StreetCred is an innovative program established at Boston Medical Center (BMC) which offers free tax services to families receiving pediatric care at BMC, who are eligible to receive the Earned Income Tax Credit (EITC) and Child Tax Credit. This service functions as a solution to the financial burden a significant portion of BMC patients face from living with annual incomes below the federal poverty level.
BMC disproportionally serves individuals who are low-income or under-or un-insured. Fifty-four percent of BMC families with children live below the federal poverty level. StreetCred aims to transform families’ wealth and health in a setting they frequent and trust, their pediatrician’s office. During visits, doctors prescribe StreetCred, offering free tax preparation to ensure families receive the Earned Income Tax Credit, the largest, but underutilized, U.S. anti-poverty program. The hospital provides the space, and partners with community tax partners, under the umbrella of the IRS, that provide expertise in tax preparation.
BMC engages with a number of partners, including Yale New Haven Hospital, South End Community Health Center, CAHS, Foundation Communities, Boston Tax Help Coalition, Boston Medical Center, Boston Healthcare for the Homeless Program, Boston Children’s Hospital, People’s Community Clinic, New York Health and Hospital (Gotham Health), Grow Brooklyn, American Academy of Pediatrics, Blue Hills Banks, DCU, Chris Gordon, Santander, BlackRock, The Paul Phyllis Fireman Charitable Foundation, The Claneil Foundation. These partners work with BMC to provide volunteers, financial programming, grants, technical support, marketing, and client engagement.
StreetCred scaled rapidly and effectively with $5.3 million returned to 2,700 families. In addition, families and staff report 96% acceptability rates.
By Jamie Cetrone | Categories: | Comments Off on University of Illinois Health
