Blog Archives

Health Equity Report Card

By Hannah Lambalot | Categories: | Comments Off on Health Equity Report Card

Housing is Health

By Jamie Cetrone | Categories: | Comments Off on Housing is Health

Central City Concern (CCC) responded to Portland’s crisis in housing and homelessness with the Housing is Health campaign, initiated by CCC’s executive director and health system CEOs. With a lead gift of $21.5 million by a pioneering collaboration of six local hospitals and health organizations—Adventist Health Portland, CareOregon, Kaiser Permanente Northwest, Legacy Health, Oregon Health & Science University and Providence Health & Services–Oregon—the Housing is Health initiative will bring homes, health, and healing into the Portland community where they are needed most.

The Housing is Health initiative is an unprecedented push to build 379 new homes designed specifically for individuals and families who are homeless or at risk of becoming homeless. These buildings are spread across three separate locations, one of which is anchored by a critically needed health care clinic. All locations will offer residents a variety of support services, including substance use disorder recovery support, mentoring, life skills training, and help re-entering the workforce.

Housing is Health enables health care systems to work together to address social determinants of health such as housing and employment. Central City Concern’s Recuperative Care Program (in the Blackburn Building) gives homeless people who are exiting hospital stays more time to get better in a safe environment. Employment specialists in the Housing is Heath collaborative help residents to enter/reenter the workforce.

All three Housing is Health buildings are under construction. Charlotte B. Rutherford Place (51 family-housing apartments) in North Portland and Hazel Heights (153 work-force apartments) in Southeast Portland will open summer 2018. The Blackburn Building (51 units of respite care housing, 124 units of transitional housing, as well as a primary care clinic and pharmacy) will open in 2019.

Vita Health and Wellness District

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In 2000, Stamford Hospital (SH) partnered with Charter Oak Communities (COC) to expand and redevelop their respective real estate holdings on Stamford’s West Side. The 2013 Community Health Needs Assessment (CHNA) identified the neighborhood as a priority due to its disproportionate share of chronic diseases. The CHNA results, along with the Affordable Care Act’s emphasis on addressing the upstream causes of disease, prompted Stamford Hospital to undertake a series of strategic investments in the surrounding community. Stamford Hospital and COC crafted a unique exchange of owned properties that enabled both to complete a series of complex redevelopment projects, including a new hospital and hundreds of housing units. This relationship led to the Vita Community Collaborative in 2012, which aims to promote health and wellness in the West Side neighborhood. Vita developed an interactive tool, entitled Vita Impact designed to show the linkages between targeted social initiatives and other characteristics that can broadly impact a community.

The Vita Health and Wellness district has become a health-themed neighborhood where numerous distressed public housing projects have been replaced with lower-density, mixed-income communities with dedicated resident support services, public green spaces, an independent pharmacy, and a revitalized hospital and campus. Each aspect of Vita addresses the social determinants of health, including healthy housing, economic stability, education and attainment, public health and access to medical care, physical activity and improved social cohesion. The core of Vita includes hundreds of new mixed-income, townhouse-style communities (with more under construction). Vita’s unique volunteer-powered urban farm (www.FairgateFarm.com) hosts numerous community-building programs such as nutrition education, cooking classes, food waste composting, and food security. Residents of the Vita community are afforded access to non-emergent medical care with two federally qualified health centers (FQHCs) serving patients on Medicaid and Medicare along with the underinsured, and the Americares Free Clinic, which provides primary care for uninsured patients who do not qualify for any government funded programs. Stamford Hospital supports the entire Vita initiative by contributing to its operating budget and providing dedicated in-kind staff support.

Stamford Hospital and Charter Oak Communities provide the essential backbone support to the Vita initiative, which includes program management, administrative services, communications and public relations, program evaluation, fund raising and strategic leadership. Vita Collaborative members represent nearly every discipline among community organizations including healthcare, public health, mental health, human services, education, food security, affordable housing and local government representation. Stamford Hospital also provides nutritionists, data analysts, and clinical staff to participate in planning and program implementation. Stamford Hospital completed construction on its new hospital and redeveloped campus, investing $450 million, and Charter Oak Communities has completed nearly 400 units of mixed-income housing through its strategic application of public and private resources – totaling an investment of over $200 million.

Each year, Fairgate Farm engages hundreds of participants and volunteers including students of all ages, corporate and civic volunteers, gardening enthusiasts and ‘foodies’, and numerous local residents. In 2017, the Farm grew over 4,000 pounds of organic fruits and vegetables, donating much of it to local hunger relief organizations. The Parents-as-Co-Educators program, designed to improve Kindergarten readiness for children of immigrant families, had a 100% success rate in its 2015-2018 cohort. This program has been rigorously measured through its partnerships with the Harvard Business School Community Partners and the University of Connecticut. A second cohort is planned to begin in the fall of 2018.

Trauma to Triumph

By Jamie Cetrone | Categories: | Comments Off on Trauma to Triumph

Trauma to Triumph (T2T) began at Santa Clara Valley Medical Center in 2012 through a partnership with the City of San Jose Mayor’s Gang Prevention Task Force (MGPTF). The hospital had previously collaborated with the Task Force on the Clean Slate Program, a tattoo removal service. Interpersonal violence has increasingly become a public health issue, and the program’s priority is to embrace teachable moments in order to engage patients and help them on their journey to resilience and recovery. The T2T program provides outreach, mentorship, and community services to victims of interpersonal violence, specifically youth and their families. These resources are designed to help patients cope with present circumstances, foster hope, and promote wellness, with an ultimate goal of reducing re-injury and recidivism of violence in the community.

Eligible participants for the Trauma to Triumph Program include trauma patients ages 13 to 30 within Santa Clara County who have sustained a gunshot wound, physical assault, stab wound, or assault with a weapon. A peer intervention specialist visits the patients at their bedside within the first 48 hours of admission to the hospital. Based on needs identified by the patient, the hospital social worker and intervention specialist create a discharge plan and coordinate resources for patients and families. Resources range from victim services, housing assistance, mental health/substance abuse services, job placement assistance, education support, basic subsistence needs, and court or probation advocacy. The T2T team builds a close, trusting relationship with clients over a six to twelve month period by providing one-on-one coaching and support so that clients can overcome trauma, set-backs, and challenges to while adopting a healthier lifestyle.

The T2T Program is a partnership between the City MGPTF and Santa Clara Valley Medical Center. As a result, the T2T Program has referral access to a continuum of other City operated/funded interventions and community service providers. These service resources are not only available to the primary client but also other family, siblings, and friends that may be negatively impacted by violent incidents. As part of the hospital’s commitment to being informed and engaged in violence prevention and best practices, they maintain a membership with the National Network of Hospital Violence Intervention Programs.

The T2T Program is the only formal evidenced-based hospital-based intervention program in the highly populated Santa Clara County. Prior to the T2T program, marginalized victims were released to unstable housing, transitional living situations or homelessness. They were also often in a traumatized state, with limited coping skills, no or limited support to prevent re-victimization, and without help to establish a healthier life style. Since full program funding was received in 2015, the T2T Program has served over 210 clients with 5,844 hours of service, representing 7,305 service sessions. Program evaluation client interviews have indicated; 96% “felt program was very helpful” and 92% felt “more hopeful about their future”. Since 2015, the program has had two patients who voluntarily participated in a service plan be re-admitted to the hospital.

Screening for Social Determinants in Primary Care

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This program originally started at a retreat held by the Ambulatory Care Department at Lincoln Hospital. The hospital formed a workgroup with the goal of developing a social determinants screening tool and accompanying referrals to helpful resources. The ultimate goal of the program is to improve the health status of the patient population, by improving social and economic influences on health.

The screening tool was designed with input from multiple hospital stakeholders, as well as partner organizations. The hospital is now ready to implement the tool at nurse led visits for diabetes, hypertension, and depression management. Pending positive outcomes, Lincoln Hospital plans to implement the tool more widely. Based on answers to screening questions, nurses will refer patients to known entities within the hospital including social work, a legal health program, healthcare financial counselors, and a table staffed by a partner non-profit where patients can enroll in a food stamp program. The

The screening tool covers multiple domains, including housing, food insecurity, housing conditions such as pests and mold, health insurance and health care cost barriers, immigration, domestic abuse, and others. There has been no additional funding for the program. With respect to staffing, in addition to nursing and departments already mentioned, the project is supported by the population health team in Ambulatory Care. The screen is used in paper form, and data will be manually entered into an Access Database.

The working group behind the program has been multidisciplinary, consisting of population health staff, physicians, nurses, clerical and finance staff, social workers, lawyers from the Legal Health program onsite, and staff from partner NGOs specializing in housing, food stamps, and health insurance advocacy. There has been some liaising with care managers and the ED, to explore the use of the screening tool in high risk populations.

Moving forward, outcome measures will be: A1C scores, BP scores, show rates to nursing visits, and show rates to PCP visits. The thinking behind these metrics is that when patients are connected to resources to address their economic and social problems, they are better able to manage their health care appointments, have the resources necessary to improve their health status (such as buying better quality food), and with the reduced stress of dealing with economic and social problems, have more mental wherewithal to address their chronic diseases. Moving forward, the program will compare patient populations who are administered the tool to those that are not, to measure the effect of systematically screening for social determinants. Program staff plan to test the screening tool to gage if it’s easy to understand and self-administer, and whether the referral pathways work.

Internal partners include: ambulatory care, social work, healthcare financial counselors, and care management. Community partners include : New York Legal Assistance Group (NYLAG) Legal Health Program, Community Service Society of New York, Bronx Works, Public Health Solutions

Pathways to Nursing

By Jamie Cetrone | Categories: | Comments Off on Pathways to Nursing

Pathways to Nursing was initiated by the Chief Community Relations Officer and the Kansas City Public School Assistant Superintendent of Innovation & Special Projects. The initial goal was to pair Certified Nursing Assistant (CNA) students with nurse mentors, leading to a program where CNAs shadow their mentor and attend education sessions at the hospital on a weekly basis. Upon satisfactory completion of the program and their clinical requirements, the students are issued a letter of intent to hire. Students come from the Manual Career Technical Center, a part of Kansas City Public Schools located in the urban core and underserved zip codes.

Hospital resources used for the program include staff time and budget for supplies such as food, etc. Transportation is provided by Kansas City Public School District.

The anticipated outcomes of the program are: employment, advanced knowledge of career options, and development of a talent pipeline.

Rx for Change

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The Rx for Change program was created with funding and support from Regional One Health’s Foundation, and a partnership with the Office of the Mayor of the City of Memphis. The purpose of Rx for Change is to “intervene and offer support and guidance to victims of violence” by connecting clients with community resource partners which may 1) reduce retaliation levels, 2) allow clients to achieve personal goals, and 3) reduce recidivism rates.

The program serves clients ages 14-24 who are victims of intentional violence and residing in Shelby County, Tennessee. The program is funded and staffed by the hospital, but involves a number of internal and external partners that help assist clients with navigating on-going care, as well as completing personal goals outlined by the client once they are discharged. Partners include: Blue Cross/Blue Shield, Regional One Health Foundation, the City of Memphis Mayor’s Office, GRASSY, 901 BLOC, Workforce Investment Network, HopeWorks, and Hospitality Hub.

Clients are reviewed at the end of a six-month period of time to assess progress. At that time the client is marked graduated, or not. Through-out the process clients are marked active, deferred, inactive or referred. These categories allow us to monitor progress toward success. To-date, approximately 200 clients have been on-boarded. Repeat Intentional Injury rates are low, and this past fiscal year three clients were successfully graduated.

Bridge to Employment

By Jamie Cetrone | Categories: | Comments Off on Bridge to Employment

The goal of this pilot program, a partnership between JEVS Human Services and Einstein Healthcare Network, is to place youth on a path leading to career opportunities, financial stability, and personal fulfillment in the health care field.

Participants of Bridge to Employment were identified by school guidance counselors at Kensington Health Sciences Academy and YouthBuild as individuals who, although facing adversity in their life and home situation, show strong potential for overcoming challenges and making the most of all the opportunities being offered through the program.

Upon completing JEVS’s two-month comprehensive educational and skills training phase, then a month-long, hands-on externship experience at Einstein, these eager young adults are placed into entry-level positions as patient services representatives throughout Einstein’s network of medical facilities. The program prepared them to be well-rounded and effectively serve as the first-point-of-contact for patients upon entering the facility by covering related soft skills, customer service know-how, and topics of instruction including insurance, medical terminology, ethics/HIPAA regulations, medical office database, office essentials, and more.

Einstein Healthcare Network

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The Future of Health is Local: A Field Guide for Health Sector Leadership

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