Blog Archives
By Amanda Jepson | Categories: | Comments Off on Center for Comprehensive Addiction Treatment, “No Wrong Door”
Bergen New Bridge Medical Center in Paramus, N.J., established the Center for Comprehensive Addiction Treatment (CCAT) in response to an increase in patients returning to the hospital for addiction treatment post-discharge. The Center aims to expand availability and access to withdrawal management services and overall substance use disorder treatment.
The Medical Center offers numerous levels of care, including involuntary and voluntary crisis units, withdrawal management, and short-term residential care, allowing a “No Wrong Door” approach that supports immediate direct patient access. The multidisciplinary team consists of psychiatrists, physicians, nurse practitioners, nurses, social workers, and substance use disorder staff. CCAT offers peer recovery specialists who model what recovery could look like for patients. The program mitigates social determinants of health by tackling food security, housing, and transportation—barriers to successful treatment for many patients—and focuses on expanding accessibility to services for underserved, marginalized populations.
Partners for the program include Rutgers University, Integrity House, CarePlus NJ, and other substance use disorder treatment programs, strengthening the culture of change and continuous improvement. Bergen New Bridge hosts community partners including Alcoholics Anonymous and Narcotics Anonymous as well as medication-assisted treatment meetings to provide an all-encompassing approach to care for these patients.
Since starting the program, the Medical Center has expanded its licensures for additional outpatient programs, including adolescent services. Additionally, the team has introduced family nights to provide education about substance use disorders, treatment options, and recovery. In 2024, the program served 3,938 individuals with inpatient care and provided 17,613 units of intensive outpatient care to patients throughout New Jersey. On the office-based addiction treatment level of care, providers have supported and maintained 1,560 individuals in treatment for substance use disorder services. Rates of treatment refusal post-discharge have decreased from 21 percent in 2022 to 12 percent in 2024. The rate of leaving against medical advice also dropped, from 13.59 percent in 2022 to 8.6 percent in 2024.
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 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 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 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 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 Amanda Jepson | Categories: | Comments Off on Curbside Care
Boston Medical Center (BMC) recognizes how critical the first six weeks of life are for birthing people and babies. Forty percent of publicly insured birthing people never return for a postpartum appointment. To close this gap, BMC launched the Curbside Care program in January 2023 with the goal of mitigating barriers to postpartum care through a mobile unit.
Curbside Care is a mobile health delivery program that provides high-touch, comprehensive wraparound services for birthing people and their infants in the first six weeks of life outside of their homes in Boston—at the curb! Funded by the Boston Celtics Shamrock Foundation, Curbside Care replaces traditional postpartum visits in this hospital and eliminates the need for transportation and childcare for postpartum appointments. Our clinical staff of doctors, nurse practitioners, certified nurse-midwives, and an international board of lactation consultant examiner provide a range of services including feeding assessments, lactation support, jaundice evaluation, postpartum depression and hypertension screenings, and contraceptive services all on the mobile unit. A community wellness advocate recruits pregnant patients and performs a needs assessment for each dyad. Patients receive material needs, such as diapers, strollers, and food, at each visit.
Curbside Care is an interdepartmental initiative run by the pediatrics and OBGYN departments at BMC. Other hospital partnerships include the Breastfeeding Equity Center, the Economic Justice Hub, and the Center for the Urban Child and Healthy Family. Community partners also include Brewster Ambulance Service, the Vital Village Network, and New England Mothers First.
BMC has cared for 519 patients in the last 12 months, with an average of 3.7 visits per patient. Of the patients seen, 63.97 percent identified as Black and 31.17 percent identified as Hispanic/Latino. All patients received lactation support and were screened for material needs and postpartum depression. All patients reside in Boston ZIP codes, primarily in the Dorchester, Mattapan, and Roxbury neighborhoods. Curbside Care patients have a 2.9 percent “no-show” rate, compared with 15.3 percent in BMC’s pediatric clinic and 18.8 percent in the postpartum OBGYN clinic.
By Amanda Jepson | Categories: | Comments Off on Community Health Program
In Galveston County, 16 percent of the population is uninsured and 12.1 percent lives in poverty. In Brazoria County, 15.9 percent are uninsured and 9 percent live in poverty.
The University of Texas Medical Branch (UTMB Health)’s Community Health Program (CHP) provides community-based care and condition management services to adults with chronic conditions, including diabetes, hypertension, and heart disease, in Galveston and Brazoria counties. Most program enrollees struggle with food insecurity, lack of transportation, and affordable housing, which compromises their ability to pay for medications and other health care expenses to manage their medical condition optimally. Many patients access health care services inappropriately or do not seek care until much later than is optimal for their conditions.
The program is set up in five geographically deployed teams/pods, each consisting of care managers, community health workers, and social workers who provide services to this patient population through health care navigation support, education, and resource connections. Emergency department staff, inpatient staff, and other local partners can refer patients to CHP via phone or messages in the electronic health record. The goal is to encourage care coordination that empowers the patient and caregiver(s) to contribute toward more successful outcomes. All patients enrolled in the program have a comprehensive intake assessment and are viewed through a “whole person” lens.
The program, available at no cost not only to UTMB Health patients but also to all patients in the service delivery area, was initially funded through the Texas Medicaid Section 1115 waiver before continuing as a budgeted expense. The CHP recently expanded by six full-time equivalents after a return-on-investment analysis indicated that the program is producing the desired patient care outcomes.
CHP collaborates with two faith-based organizations, community health centers, county indigent programs, food banks, and the Salvation Army to connect patients to services and resources. For example, one faith-based organization offers several clinics, including a Transitions of Care Clinic for recently discharged patients, and provides specialty care in partnership with UTMB.
For a 28-patient cohort, CHP enrollment for 12 months led to an 83 percent decrease in hospitalization and 95 percent reduction in ED visits. More than 40 percent of the 28 patients with diabetes saw a drop in their HbA1c values during and after participating in the program. Participants’ hemoglobin A1c values and blood pressure decreased. In comparison with a control group of patients not enrolled in the program, CHP enrollment reduced system costs by 24 percent.
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 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.
