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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 Mobile Wellness Clinic
The Casey Foundation, an organization that works to improve the well-being of children, youth, and families in the United States, conducted an analysis of the Opelika community in 2017 that revealed areas with a lack of access to care. The foundation engaged the City of Opelika and East Alabama Health to begin a mobile medicine program to increase access to primary care within the community. First Transit donated the mobile bus in 2017, and the program officially launched in December 2022.
The mobile wellness clinic visits communities in the greater Opelika area once a week. Staff provide disease prevention resources and screen patients for chronic conditions at the designated site each week. mobile unit social worker connects patients to resources within the community through screening for social determinants of health. The clinic is funded through multiple sources, including the Casey Foundation and the local housing authority, which allows the clinic to prioritize communities with the most need.
Beyond the City of Opelika and the Casey Foundation, mobile wellness clinic partners include charitable clinics that allow referrals for patients to be seen more quickly, local schools and universities from which students work and learn in the bus , and other local community-based organizations that help the program build trust with community members.
The mobile clinic has served community members with all-encompassing care since beginning operations in December 2022. Many personal stories illustrate the clinic’s importance to the community; for example, a care-reluctant patient sought care at the mobile wellness clinic and discovered dangerously high blood sugar levels. Fortunately, the clinic staff were able to quickly intervene and saved the patient’s life.
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 Rooftop Farm
Boston Medical Center’s (BMC’s) Rooftop Farms opened in 2017 as part of the Nourishing Communities program, which includes the Preventative Food Pantry and Teaching Kitchen. A second farm will open in the spring of 2024, bringing the total growing space to approximately square feet. With two farms, the program will yield 10,000 pounds of fresh, organically grown produce annually to distribute throughout the food pantry, a low-cost farmer’s market, and our kitchens. The farm partners with internal departments and organizations in the Boston area to host team–building, volunteer, and educational opportunities focused on growing food, nutrition, and green infrastructure.
The hospital employs two part-time farm staff who focus on food production, education, and community outreach. The program also sponsors two to four interns per year who assist the farm staff and earn experience in rooftop farming and community engagement. The program’s educational component reaches a wide swath of the community, from public school students to immigrant groups, to patients, employees, and clinical staff. For example, the farm reported more than 1,300 visits in 2023. in 2023, 50 percent goes to patients facing food insecurity who visit the food pantry, 41 percent goes to the general community through the low-cost farmers market, and 10 percent goes to the kitchens.
Since opening seven years ago, the rooftop farm has grown approximately 30,000–35,000 pounds of food for community members, with approximately 75 percent directly reaching those who are low–income or experiencing food insecurity. The original farm also has engaged individuals in tours, volunteer days, and educational events more than 9,000 times, providing community members with a forum to connect with each other, learn about green innovation, and experience a hospital space that builds healthy communities in multiple ways. With a second farm opening, BMC expects to double its impact and continue to grow its community partnerships, aiming to support fair Boston food system that provides workforce development, climate resilience, and nourishing food for all people.
To learn more about the Rooftop Farm, please visit this link.
By Amanda Jepson | Categories: | Comments Off on Feed1st Program
In 2010, a group of University of Chicago Pritzker School of Medicine medical students, University of Chicago faculty, and Comer Children’s Hospital staff started the Feed1st program after one of the hospital Chaplains discovered many parents were going hungry at their child’s bedside during a hospital stay. The goal of the Feed1st program is to address hunger in the healthcare setting and minimize the stigma surrounding food insecurity.
The Feed1st program operates 11 food pantry sites throughout UChicago Medicine’s facilities, including the adult, pediatric, inpatient, and outpatient areas of academic health system’s South Side medical campus. The pantry sites are strategically located in emergency departments, patient waiting areas, family lounges, and a hospital retail cafeteria. The program primarily serves community members from the South Side of Chicago, which has some of the highest food insecurity rates in the city; however, the pantry sites are available to everyone in the UChicago Medicine community, including staff.
It takes a village to operate a hospital pantry program at this scale. The hospital and individual departments provide Feed1st with funding support and space for pantry shelves and storages; Clinical staff champions, medical students, undergraduates, and other volunteers keep the pantry sites and storages stocked regularly and well maintained.
The food in the pantry sites is provided by the Greater Chicago Food Depository. The UChicago Medicine Garden Committee also provides fresh produce during harvest seasons throughout the year. The Feed1st Community Advisory Committee, comprised of parents, patients, concerned community members, hospital administrators, faculty, students, and others, plays a consistent role in ensuring the program meets the needs of the people we serve. Feed1st engages clinical staff in individual departments to help monitor and restock pantry shelves and communicate with patients about the program.
the Feed1st program had distributed more than 94 tons of food to more than 88,000 people since opening in 2010. The UChicago Medicine Garden Committee has provided more than 6,000 pounds of fresh produce to the Feed1st pantry sites since May 2022. The Feed1st program also released a toolkit on how to launch a no questions asked food pantry system. To read the newest version of the Feed1st toolkit, click here.
By Amanda Jepson | Categories: | Comments Off on UChicago Medicine
By Amanda Jepson | Categories: | Comments Off on Feed1st Food Pantry Toolkit
By Amanda Jepson | Categories: | Comments Off on The Teaching Kitchen
Boston Medical Center’s (BMC’s) Teaching Kitchen is a leader in the Food is Medicine movement. One of the country’s first hospital-based culinary medicine programs, the kitchen has expanded to the local food system through partnerships with food growers, makers, and retailers. The Teaching Kitchen also helps combat nutrition-related health disparities by enhancing access to fresh produce and medically tailored foods, targeting behavior change to improve health outcomes, and leading research and best practices to enhance the field. The Teaching Kitchen supports BMC’s mission to deliver exceptional care without exception.
As the largest level I trauma center and safety net hospital in the Northeast, BMC serves a community that is racially diverse—45 percent non-Hispanic white or other, 25 percent Black, 20 percent Latino, 10 percent Asian—and under-resourced, with 72 percent of patients reported as low-income. The Teaching Kitchen is clinically integrated into the medical care model, serving pediatric and adult patients through prevention and disease management, and offers programming to staff, affiliated students, and the greater Boston community. The program is funded through philanthropy and operated by a manager who oversees culinary dietitians and partners with the senior manager to implement research and population health initiatives. Managers report to the senior director of support services, and operational costs are embedded within the department’s budget.
The Teaching Kitchen is an ancillary service to the health system, partnering with departments including outpatient nutrition, endocrinology, cardiology, and pediatrics to facilitate shared medical appointments and group visits. These partnerships enhance care through hands-on learning and peer support. In addition, the Teaching Kitchen partners with community organizations like Nubian Markets and the South End Community Health Center to offer services in community settings and foster community-led programs and interventions. To encourage innovation and future practice, the Teaching Kitchen also partners with Boston University to provide medical, dietetic, and dental students with culinary nutrition training and a formal elective through the School of Gastronomy.
The Teaching Kitchen offers an average of 300 classes per year for more than 2,000 patients and staff. Classes are held in-person classes, virtually through Zoom, or a combination of both. Class surveys suggest high approval rates, and reports indicate improved dietary patterns, culinary skills, and overall health. The Teaching Kitchen already has facilitated clinical trials, and results will be published.
To learn more about BMC’s Teaching Kitchen, please visit this link.
By Amanda Jepson | Categories: | Comments Off on Violence Intervention Program
The rate of gun violence–related injuries is increasing nationwide and is especially high among youth in Atrium Health’s community. Survivors of gun violence experience significant increases in mental health disorders and high pain, resulting in higher rates of readmissions. Along with adverse effects on survivors, the health system experiences a large financial burden stemming from violent injuries. Atrium Health’s violence intervention program aims to help victims of violent injuries target social determinants of health and make positive life changes to prevent violent injuries.
The program aims to assist patients ages 15–24 years old with violence-related injuries. When patients arrive at the hospital, a violence intervention specialist interviews them to assess social circumstances. The specialist will assist with urgent needs and then create long-term plans for connecting patients with community resources to assist with persistent problems. The program follows patients after discharge for three months or longer if needed. The City of Charlotte is the main partner and funding agency for this program.
Beyond the City of Charlotte, Atrium Health works with numerous internal and external partners. Internally, the program uses tools already created by Atrium Health’s other violence prevention programs, the Domestic Violence Healthcare Project and Carolinas Center for Injury Prevention. Externally, the program often refers patients to the Urban League of Charlotte, an employment assistance program for African American men.
Since January 2022, the program has connected 23 people with job readiness services, employment placement, and secondary education. Patients also sought assistance improving access to housing, food, and clothing.
