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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.
By Hannah Lambalot | Categories: | Comments Off on Policy Brief: Wide Spread Decline in Household Income During Covid-19 Pandemic Contributes To Food Insufficiency Among Families
By Hannah Lambalot | Categories: | Comments Off on Food Insecurity and Health: Overcoming Food Insecurity Through Healthcare-Based Interventions
By Hannah Lambalot | Categories: | Comments Off on CommunityConnect
Contra Costa Regional Medical Center’s (CCRMC) top 5% of users represent 49% of total costs, and the top 15% of users represent 79% of costs. Through a review of high need patients, it was revealed that a large portion of these high costs were associated with patients accessing medical services due to underlying social needs.
CommunityConnect was designed to target interventions for high-need patients with the aim to provide upstream care and services. The program utilizes predictive model analytics, that incorporates data points from across county, to proactively identify patients that are likely to use the emergency room or be admitted to the hospital for an avoidable reason in the future, such as to meet their urgent social needs. Patients who are enrolled into the program are provided one year of case management to coordinate medical services and provide community and government resources that can improve patient well-being and health. CommunityConnect receives funding of $40 million annually through the California Medicaid 1115 waiver Whole Person Care.
Patients are identified and enrolled int the program based upon data gathered through a comprehensive set of sources: from Medicaid managed care plans, behavioral health, the coordinated entry housing program, EMS and the county detention facility. These data points are combined to create patient-level risk factors. As the program identifies enrollment based on a predictive model, a number of patients are identified for enrollment not based on their prior health utilization (based on Medicaid claims data, apart from CCRMC). Leveraging data through a holistic patient record allows for identification of county residents that may not have otherwise ever been referred into services through traditional means.
Upon patient enrollment, case managers conduct a comprehensive social needs assessment with the patients to identify areas in which the program can help. This covers areas such as: medical, behavioral health, safety, housing, food security, transportation, finances, legal, and support system. Depending on patient acuity, case management services are either provided in-person or telephonically by multi-disciplinary staff that includes public health nurses, social workers, substance use counselors, homeless services specialists, mental health clinicians, and community health workers.
Once the CommunityConnect case managers assess a patient’s unmet social needs, they help enrollees create a patient- centered care plan, access resources, and work in partnership with the patient and other care team members to implement the plan, with the shared goal of improving the patient’s health. In addition to a providing linkages to community resources through a comprehensive social needs online resource directory, the program provides direct benefits to patients aimed at addressing unmet social needs. CommunityConnect patients have access to a transitional housing fund that can assist with security deposit or moving costs; a free cell phone in order to engage in services and link with resources; non-medical transportation in order to obtain identification documents; Free legal assistance from two full-time lawyers at the local legal aid; and social service workers to help apply and renew public benefits including Medicaid, SNAP, and TANF.
Since June 2017, the program has connected more than 17,000 people to critical health and social services. The first year (2017) resulted in a 3% reduction in ED visits and an 12% reduction in inpatient admissions compared to 2019 results that improved to show a 20% reduction in ED visits and 18% reduction in inpatient admissions. Other measures are in process of being analyzed, including primary care visits, behavioral health visits, access to public benefits, and other biometric health indicators. Success measures show that 37% of patients that lapse Medicaid are able to be restored within 90 days due to case management services, and 34% of patients have had a successful outcome with a social-related goal.
By Hannah Lambalot | Categories: | Comments Off on Opioid Use Disorder | A Population Health Collaboration
The 2016 Pennsylvania Opioid Data Dashboard reported 21,878 individuals covered by Medicaid with a diagnosis of Opioid Use Disorder (OUD). Of those suffering from OUD, only 11,591 (52.9%) received medication-assisted treatment (MAT). Temple University Health System developed an approach, in collaboration with the City of Philadelphia, the State of Pennsylvania, and various community-based organizations (CBO) focused on OUD through bridging medical care, behavioral health treatment, and addressing social determinants of health (SDoH).
With a one-million-dollar grant, Temple University built a hub and spoke network for the delivery of MAT in a primary care setting. The main goal of the program was to establish a hub and spoke model aimed at delivering and expanding best-practice treatment of OUD. The hub, led by OUD treatment experts, was charged with engaging other medical practices to launch best practice treatment at those sites. Best practice treatment of OUD includes medications to mitigate the effects of opioid withdrawal. A specific waiver is necessary to prescribe certain medications; as part of this program, clinicians attained this waiver in order to prescribe medications such as Buprenorphine. To monitor quality, a goal was set to decrease the readmission rate of patients with OUD, regardless of primary diagnosis.
To help patients overcome SDoH, Temple aimed to formalize relationships with community-based organizations (CBOs) to address food insecurity, housing insecurity, transportation, and pharmacy support. The Philadelphia Office of Homeless Services and Resources for Human Development specializes in housing placement for those with housing as a barrier. Philabundance delivers hot meals to recovery group sessions. In addition, they run a catering service called Philadelphia Community Kitchen which is a 14-week culinary training program open for enrollment to low-income adults and people in recovery. The program delivers 40 meals a week to the Temple hub and spokes. Sustainable food sources, such as SNAP benefits, are identified through case management. The Southeastern Pennsylvania Transit Authority provides subway/bus passes at no cost to the program’s patients. Temple also partnered with Uber/Lyft to provide rides for more medically complex patients. These services are available for appointments or any related service for their recovery. Lastly, Temple partnered with their outpatient pharmacy to be able to pay for medications that patients cannot otherwise afford, with grant funding.
Baseline objectives included the addition of spoke sites and the total number of patients treated from July of 2018 through May of 2019. The most powerful results were the increase in the number of patients who accepted treatment. The hub increased the capacity to see new patients by 267%. The spoke locations increased the ability to see new patients by 82.7%. Temple established warm handoff protocols for the organization’s emergency departments and crisis response center; warm handoff improved by 20% during that time. A total of 110 providers were trained in three sessions provided by the program. The program educated 22 Skilled Nursing Facilities providers and improved the OUD acceptance rate from 16 % to 28%.
By Hannah Lambalot | Categories: | Comments Off on Temple University Health System
By Hannah Lambalot | Categories: | Comments Off on Webinar Recap: Interventions to Decrease Food Insecurity
By Hannah Lambalot | Categories: | Comments Off on Interventions to Decrease Food Insecurity
By Hannah Lambalot | Categories: | Comments Off on The Sky Farm
Wellness and prevention have long been key components of the Eskenazi Health model of care. Through a large primary care network, numerous community-based health fairs, the Eskenazi Health Farmers’ Market and other initiatives, Eskenazi Health has been committed to community health and wellness. Dr. Lisa Harris, CEO of Eskenazi Health, believes the best opportunity to improve the lives of patients and, by extension, the health and vitality of our community lies in helping individuals stay well. Several years ago, employees at then Wishard Health Services (now Eskenazi Health), developed a garden area in a courtyard where employees could plant and grow flowers as well as fruits and vegetables. When plans moved forward to build a new hospital campus, leaders looked at ways to enhance its commitment to wellness for employees, patients, and visitors.
The construction of The Sky Farm occurred as part of the overall construction of the Sidney & Lois Eskenazi Hospital and Eskenazi Health campus, which opened in December 2013. Marion County voters approved construction of new facilities to replace the Wishard Memorial Hospital campus in the Nov. 3, 2009 election, with 85 percent support for the measure. Sidney and Lois Eskenazi of Indianapolis contributed $40 million to the project’s capital campaign in June 2011, and Health & Hospital Corporation of Marion County recognized their gift in naming the new hospital the Sidney & Lois Eskenazi Hospital, as well as the campus and system Eskenazi Health.
A number of individuals and organizations were involved, including RATIO Architects, Inc., of Indianapolis. The original design of The Sky Farm at Eskenazi Health was developed by Erik Reid Fulford of NINebark, Inc. Fulford was an Indianapolis-landscape architect who passed away in 2012. David Rubin of Land Collective, a world-renowned landscape architect, who also designed the outside main entrance landscape at the Sidney & Lois Eskenazi Hospital, helped to carry out Fulford’s work.
The rooftop farm is utilized to grow fresh produce for patient education, which is distributed to the community at Eskenazi Health’s community health centers and given to employees during “Fresh Veggie Fridays” (FVF). In addition to the produce, the farm is home to approximately 500 bees to increase crop production through pollination. The Sky Farm, open 24 hours a day, 7 days a week, has 24 crop beds, some of which are wheelchair height for easy accessibility, and produced and harvested more than 3,700 pounds of produce in 2018. Additionally, The Sky Farm, in partnership with the Eskenazi Health Food & Nutrition Services, provides classes, “Fresh Veggie Fridays” to sample healthy recipes, learn healthy cooking techniques, receive at-home gardening tips, and obtain fresh vegetables grown from The Sky Farm. “Fresh Veggie Fridays” hosts more than 1,000 visitors each season. It also welcomes field trips and tours throughout the year.
Produce grown on The Sky Farm is used to engage Eskenazi Health patients and employees. The Sky Farm Produce Classes are held at Eskenazi Health Center sites, with another 100 people participating in CSA-style 4-week classes. Each class includes a full nutrition lesson, cooking demo, recipe book, and take-home produce. Fresh Veggie Friday is a drop in nutrition, recipe sampling, and produce distribution free to employees, patients, and visitors during the summer growing season. Around 125 people attend each session, there are 10 sessions each summer.
The Sky Farm opened as part of the opening of the Sidney & Lois Eskenazi Hospital and Eskenazi Health campus in December 2013 and we are finishing up our sixth growing season. Overall, through our various programs, we distribute about 3,000 pounds of produce with cooking and nutrition education directly into our community at no cost to the participants.
By Hannah Lambalot | Categories: | Comments Off on Health Equity Report Card
