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By Amanda Jepson | Categories: | Comments Off on Pediatric Mobile Health
Hennepin Healthcare’s Pediatric Mobile Health program started during the COVID-19 pandemic with the goal of ensuring that children receive preventative care such routine childhood immunizations. The racial awakening occurring adjacent to the pandemic, which highlighted the long-standing lack of access to care in the community, also fueled the momentum behind the clinic. The mobile clinic team achieved its goal by going door-to-door providing well child checks and immunizations to children. The program since has implemented additional services, including primary pediatric care, partum care for the birthing dyad, referrals back to a medical home, specialty care or community resources for social needs.
The mobile clinic brings pediatric care to families who are hesitant and/or unable to visit the hospital or off-site clinic. Full-time staff, including a nurse practitioner or pediatrician, pediatric provider trainee, and an emergency medical technician, operate the clinic. Staff also screen each family for social determinants of health. Patients who screen positive are referred to clinics or community organizations and resources to help families with their needs.
The program is grant-funded and bills insurance when appropriate. The program collaborates with other departments within the hospital, including the information technology department, to ensure the clinic has the bandwidth to document in electronic health records. The mobile clinic also partners with local schools and community organizations, such as Second Harvest Heartland to help families facing food insecurity and school districts and Head Start Centers to help with childcare resources.
The Pediatric Mobile Health Program has successfully increased access to care by ensuring continuity of care. When families are screened for social needs, community health workers ensure that patients follow through with referrals and applications are completed if necessary. The program also decreased Emergency Department visits, which helps lower costs and provider burnout.
By Amanda Jepson | Categories: | Comments Off on Street Health Outreach and Wellness
During the COVID-19 pandemic, NYC Health + Hospitals recognized that New Yorkers experiencing unsheltered homelessness faced unique challenges accessing COVID-19 testing and vaccination. As the city’s public hospital system and the largest municipal health care system in the nation, the health system had a unique opportunity to leverage its size and spread to bring street medicine services across New York City. NYC Health + Hospitals launched the Street Health Outreach and Wellness (SHOW) program, which quickly evolved to include basic medical care, harm reduction education, and links to other care and services.
SHOW aims to meet patients where they are, build trust, and use longitudinal care relationships to drive positive outcomes in both health and housing. NYC Health + Hospitals currently operates five mobile street medicine units, each connected to one of the system’s facilities and staffed by providers from within those facilities’ primary care safety net (PCSN) clinics. Mobile units, based within communities those hospitals serve, each are staffed with a medical provider, registered nurse, social worker, addiction counselor, peer counselor, community health worker, and registration clerk. The program provides primary care, wound care, mental health support, harm reduction services, and basic material necessities to unsheltered residents in New York City, while connecting patients with the health system’s larger continuum of care via PCSN clinics, specialty care, and other services.
The health system works with multiple partners in this effort, including the New York City Department of Homeless Services, as well as numerous community-based organizations and service providers. These partnerships drive the program’s ability to link patients to services and shelter, as SHOW and NYC Health + Hospitals work to support and strengthen the ecosystem of care for people experiencing unsheltered homelessness.
Since the program’s April 2021 launch, SHOW teams have had more than 233,000 engagements with community members and provided 21,000 medical consultations, 9,000 vaccinations, and 60,000 social work engagements. , as the program evolved its model, more than 1,000 unique patients established care with the SHOW teams, and the program connected nearly 200 individuals with PCSN clinics for ongoing care. All this work feeds into systemwide goals of improving chronic condition outcomes for patients experiencing homelessness, and ultimately, connecting patients into housing.
By Amanda Jepson | Categories: | Comments Off on Mobile Medicine Program
Atrium Health launched two Mobile Medicine programs to improve access to care for their patient populations. Three Care Everywhere primary care units, along with Drive to Thrive, a mobile OB-GYN unit, aim to increase access to care by tackling transportation challenges, language barriers, and lack of insurance. Specifically, Care Everywhere brings clinical care to areas where traditional clinics may not be convenient or accessible, provides resources that help meet acute social needs, and connects patients to a primary care medical home. Drive to Thrive works to decrease unintended pregnancies via increased access to education and contraception and to connect patients in underserved communities to prenatal care earlier in their pregnancies to improve overall health outcomes.
The Mobile Medicine units park at different locations each weekday based on patient need. Atrium Health strategically chose locations using a data-informed approach that paired internal patient data with publicly available U.S. census data to target communities with the greatest health needs and social risk factors. Care Everywhere unit services include short-term and long-lasting health concerns, and Drive to Thrive primarily focuses on obstetrics and education. Neither program requires appointments, enabling patients to visit at their convenience. Both programs offer additional wellness services, such as referrals to other Atrium Health facilities and connections to resources for non–health care needs.
The Care Everywhere units were primarily funded by The Tepper Foundation and Truist Foundation, among other community funders. The Drive to Thrive unit received funding from a retired OB-GYN and other community donors. Both units required collaboration with nonprofits, faith-based organizations, and other community organizations to understand patient needs fully.
As a vertically integrated health care system, Atrium Health maintains an extensive inpatient and outpatient database of electronic health records that enables in-depth analysis of health care utilization and health outcomes across the system’s footprint. The Care Everywhere units launched in fall 2022, and the Drive to Thrive unit launched in January 2023. The Mobile Medicine program is expected to serve more than 480 patients by the end of 2023. Key program outcomes include increasing the establishment of ongoing support through placement with a primary medical home and connecting patients to care and social needs support through screening, diagnosis, and referrals to specialty care.
By aoguagha | Categories: | Comments Off on Racism Hurts Moms and Babies
By aoguagha | Categories: | Comments Off on Higher Temperatures Hurt Moms and Babies
By aoguagha | Categories: | Comments Off on ZSFG Health Advocates Program
The health care professionals of Zuckerberg San Francisco General Hospital and Trauma Center (ZSFG), in San Francisco, understand health care alone does not necessarily mean good health. Social factors, such as access to food, safe housing, and education impact overall health, as well. ZSFG launched its Health Advocates program in 2013 to improve community health by connecting families with community resources that address their social needs. These needs might otherwise not have been met outside their typical hospital visits. The ZSFG Health Advocates program aims to change how people think about health.
The Health Advocate program is a student and community volunteer–based service group that conducts standardized social and legal needs screenings for patients at the ZSFG health centers for children, women, and families.
The Health Advocates program extends the care of patients and connects them directly to resources that help overcome systemic societal barriers and legal obstacles that impact health and well-being. Through the Health Advocates program, ZSFG improves the quality of life and health outcomes for families.
The ZSFG Health Advocates program connects families with existing benefits programs and external community organizations based on their level of need. The program collaborates with Bay Area Legal Aid as part of the San Francisco Medical-Legal Partnership (MLP) to provide legal advice and support to families. Families screened for more complex issues by the health advocates — family mental health issues or complicated legal challenges, for example — are connected with clinical social workers and/or lawyers from the MLP network who can provide professional support and case management.
By Amanda Jepson | Categories: | Comments Off on Health Equity Accelerator
The Health Equity Accelerator at Boston Medical Center (BMC) originated from research and development after COVID-19 highlighted multiple health inequities that would not have been uncovered in normal conditions. These discoveries, paired with BMC’s historical interest in closing the health equity gap, fuel the Health Equity Accelerator. The program’s goal is to drive racial health equity in the areas of pregnancy, infectious diseases, behavioral health, chronic conditions, and oncology and end-stage renal disease, with a vision to transform health care to deliver health justice and well-being.
The Health Equity Accelerator incorporates three foundations of health care: research, clinical care, and community, including social determinants of health (SDOH). The Accelerator team consists of executive leadership, project managers and analysts, community navigators, and research experts. This team breaks problems down into core elements and, through research and evaluation, identifies and implements innovations to combat the problem. The team will partner with community leaders to seek insight on how well those solutions and interventions affect the target issues. The program aims to serve patients and their communities, specifically those of color, that face immense health inequities.
The Health Equity Accelerator’s strategy aims to promote four pillars to collaborate and complement each other in the mission. These groups include clinical operations, community and SDOH, research and evaluation, and policy and advocacy. The Accelerator team also identifies external partners interested in participating in interventions to help communities BMC and other health institutions share.
The Accelerator’s Equity in Pregnancy program focuses on improving the rate of severe maternal morbidity for mothers of color and the rate of babies of color born small for gestational age. Through research, the program identified gaps and developed recommendations that will help close those gaps. Another project focused on empowering people of color, who were at a higher risk for disease transmission, to make informed decisions regarding COVID-19 vaccinations.
By Amanda Jepson | Categories: | Comments Off on Beyond Barriers
After discovering significant disparities in age expectancy from zip codes only 16 miles apart in Marion County, Ind., Eskenazi Health acted to find solutions to enhance the health of the community it serves. Thus, the $60 million campaign titled, Beyond Barriers, takes a multidisciplinary approach to three main areas: health care, mental health care, and food as medicine. The goal of the campaign is to create life expectancy equity for everyone in the city of Indianapolis through an integrated and sustainable model of community infrastructure improvement.
The program serves Eskenazi Health’s patient population and surrounding community. At the heart of Beyond Barriers are Health Equity Zones identified to improve access to health care, mental health care, and nutritional foods. Each zone is home to an Eskenazi Health Center where community health care workers work one-on-one with patients at appointments and home visits. During this time, they screen patients for social determinants of health and help with self-management goals to promote positive health behaviors. The campaign also sustains mental health professional recruitment, upgrades mental health facilities, and expands the John & Kathy Ackerman Mental Health Professional Development Center. Another important aspect of Beyond Barriers is the Fresh for You Market, which provides fresh and affordable foods to patients and families who lack access to affordable food options.
Eskenazi Health engages with education, transportation, public health, housing, food pantries, and other industries to expand existing programs and create and support new programming and services. By working with these entities, Eskenazi Health can focus on long-term social determinants of health and improving quality of life for all Central Indiana residents.
Launched in 2017, the Fresh for You Market, located at Eskenazi Health’s downtown campus, has helped patients and families access affordable and healthy groceries. In its first full year of operation, the market fed 6,200 people from under-resourced and underserved communities and improved the quality of life of those served. In summer 2023, the Fresh for You Market launched a mobile food pantry, Fresh for You Market on Wheels, which is parked in various locations around Indianapolis each weekday based on patient needs indicated in social needs screenings.
By Hannah Lambalot | Categories: | Comments Off on Community Health Worker Home Visits for High-Risk Diabetes Patients
Harris Health System, in Houston, serves a largely low-income and uninsured or underinsured patient population, of which nearly 90 percent are people of color. These communities experience a disproportionate prevalence of diabetes, and Type 2 diabetes ranks among the most prevalent and costly outpatient diagnoses.
Spurred in part by a Medicaid Section 1115 waiver, the health system developed a diabetes registry that identified nearly 40,000 diagnosed patients, including about one-third who had uncontrolled diabetes with HbA1c levels greater than 9. In 2017, Harris Health then designed a community health worker (CHW) home visit pilot program that uses a hub-and-spoke, community-focused model to work with disengaged patients with diabetes. Through the program, CHWs capture a comprehensive picture of patients’ health-related social needs, diabetes knowledge, and self-management behaviors. The four-month program extends the health system’s reach outside its walls to better understand barriers to good health and offer point-of-care navigation. CHWs launch a care plan that can include establishing eligibility for charity care, making appointments with interdisciplinary teams, applying for rental assistance, education on public transportation, and more.
Since its inception, the program has grown to 14 clinics. In 2020, COVID-19 created new barriers for patient self-management of diabetes and the health system responded by shifting the program to include virtual and telehealth care; this transition coincides with a 130 percent increase in the number of program graduates. Before the start of the pandemic, 181 program participants reported an average decrease of 2.2 percentage points in HbA1c levels and increased knowledge of their condition and appropriate treatment. The program sustained these outcomes amid the pandemic, with 417 patients completing the program from November 2020 to October 2021.
By Hannah Lambalot | Categories: | Comments Off on Maternal Medical Home
New York City is grappling with high rates of maternal mortality and morbidity with stark racial disparities. As of 2018, non-Hispanic Black women are 8 times more likely to die from a childbirth-related complication and three times more likely to experience a life-threatening event in pregnancy than non-Hispanic white women. The highest rates of severe maternal morbidity are in some of New York City’s most under-resourced communities, areas like East Flatbush, Brooklyn, and Jamaica/St. Albans, Queens. The Maternal Medical Home improves high-risk obstetric outcomes by providing referrals to necessary specialty care, mental health services, and enhanced wraparound services to address socioeconomic challenges, as well as parenting support and education. The Maternal Medical Home is one component of the Maternal Mortality Morbidity Reduction Program of NYC Health + Hospitals (NYCH+H).
NYC Health + Hospitals established the Maternal Medical Home to provide enhanced services, attention, and care to pregnant patients who needed it. This program received funding from the City of New York, as well as internal support. Two frameworks shape the program, the Socio-ecological model encourages 1) health education and literacy for patients to stay informed, 2) building trust between the team, patient, and partners 3) standardizing the screening and assessment tools for patients across the system. The Socio-cultural environmental model inspired 1) connecting patients with needed resources and services, and 2) encouraging patient autonomy in prenatal care and patient services.
Any member of the healthcare team may refer patients to the Maternal Medical Home. Patients with additional medical diagnoses, which may place a pregnancy at higher risk for an adverse outcome, such as (but not exclusive of) hypertension and diabetes, are followed by the Maternal Medical Home team. Patients with behavioral health diagnoses or patients who have needs related to social determinants of health (such as patients with food or housing insecurity, or in need of legal services) may be referred to the Maternal Medical Home for additional coordinated care and/or support services. The Maternal Medical Home team uses additional screening and assessment tools, such as the Prenatal ACES to stratify patients most at risk during pregnancy. The Maternal Medical Home team serves as a locus to help patients navigate a complex medical system and access needed resources.
The Maternal Medical Home program staffs seven Maternal Care Coordinators who have an interest and expertise in public health and nine Supervisors who have a master’s degree specifically in Social Work. Care coordinators and Supervisors are tasked to communicate with the clinical team, behavioral health specialists, and create tight linkages with community health workers and home health care. The clinical team includes physicians, advanced practice nurses, and nurses across the system.
Based on the screening assessment and associated risks score, the multi-disciplinary teams provide patients with referrals to specialty care, behavioral health and emotional support, pharmaceutical needs, socioeconomic needs, and parenting support/education. The screening and assessment build documentation templates for patient screenings, patient birth plans, and post-partum assessment plans. The program aims to create a stable, safe, and healthy environment for the patients to successfully take care of themselves and their newborns.
The Maternal Medical home program was piloted at NYCHH Kings County Site in October of 2019 and ran for two months. Since then, NYCHH has rolled out implementation to 11 facilities as of June 2021. Since the program’s launch, more than 3,000 pregnant patients have been referred to additional care or support services, such as nutrition, dental, and housing. Additionally, 405 pregnant patients were referred to the program and 1226 unique patients were supported.
