Blog Archives
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 Hospital-Led Outreach to Reduce Anemia at Time of Delivery
Anemia in pregnancy increases the risk of needing a blood transfusion at the time of delivery threefold. It contributes to approximately 20 percent of severe maternal morbidity in historically marginalized groups. The transfusion rate at Natividad Medical Center, in Salinas, Calif., increased rapidly between 2021 and 2022, and anemia at the time of delivery had a prevalence of 18.8 percent of all births at Natividad. This problem was particularly evident in the Latina and Indigenous patient populations Natividad serves. Hospital leadership created this program to decrease the prevalence of anemia at the time of delivery and decrease Natividad’s transfusion rate.
Natividad’s systemwide leadership, including community clinic leadership, collaborated to create a multi-pronged approach to diagnose and treat antepartum anemia rates. This program includes educating staff on the negative effect of anemia and how to monitor and treat iron deficiency, as well as monitoring patients’ hemoglobin and iron stores throughout pregnancy.
Natividad created an infusion center to provide access to IV iron. Hospital leaders recognized that Medi-Cal only covered an iron infusion that required eight visits to infuse 1 gram of iron, which places a significant burden on patients that face transportation, financial, and time-related barriers to care. In response, Natividad collaborated with its Medicaid health maintenance organization to secure payment for single-dose IV treatments, increasing access to care.
The chief of obstetrics at Natividad worked with medical leadership at the community clinics to develop best practices for the program, which led to robust evaluative efforts and peer-to-peer learning. From January 2023 to August 2024, the overall rate of anemia at participating clinics fell from 18.4 to 11.7 percent, while the anemia rate at nonparticipating clinics increased from 22.3 to 26.5 percent. In 2022, the Indigenous patient population had higher rates of anemia—20.6 percent, compared with 18.4 percent for non-Indigenous patients. By 2024, both groups had decreased anemia rates—12.1 percent for Indigenous patients and 11.6 percent for non-Indigenous patients—and the gap between rates closed.
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 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 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 Jamie Cetrone | Categories: | Comments Off on UMass Memorial Medical Center
By Jamie Cetrone | Categories: | Comments Off on Hennepin County Medical Center
By Jamie Cetrone | Categories: | Comments Off on Boston Medical Center
