Hurley Medical Center
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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
Fresh Foodies
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A significant proportion of Harris Health System’s primary care patient population is obese (BMI > 30); and nearly one third of patients with a diabetes diagnosis are considered to have poor control of their blood glucose levels (A1c >9). This data highlighted the need for more comprehensive, patient-centered education and support and led to the development of the Fresh Foodies program. The goal of the program is to help patients with diabetes and obesity manage their health with nutrition through grocery store tours and food vouchers. These tours reinforce the lessons from group nutrition classes and individual appointments that participants have with a registered dietitian.
Patients have to attend two appointments with a registered dietitian or one appointment with the dietitian (RD), and one nutrition class. Once completed, the RD sends the patient list to the health educator who then invites the patient to participate in the tour. The health educator works with grocery store management to schedule the tour and order the $30 gift cards. Health educators and community health workers provide reminder calls, grocery store tours, and follow-up phone calls. The tour guide focuses on the perimeter of store and selected inner aisles (i.e. bread, beans, and frozen food aisles). Upon completion of the grocery store tour, the patient is provided with a $30 grocery store gift card to practice planning and purchasing healthy foods for family meals on a budget.
Funding for the program was provided by the Harris County Hospital District Foundation. Harris Health Nutrition Services and Harris Health Community Outreach Services work collaboratively to provide nutrition education to patients in individual and group settings and lead patients on the tour. The grocery store tour takes place at an a H-E-B Grocery Store located near the participating community health centers.
In five months, 67 patients were provided with semi-personal (one staff per two patients) guided grocery store tours and 40 of the 67 participated in the two-week follow-up phone call. Patients have reported learning how to purchase more food for less money, select fresh produce, read labels, shop for fresh and not processed food. Patients also report learning that fresh vegetables and fruits are better than canned food. All patients believe the grocery store tour enhanced what was taught during the nutrition class and during their appointment with the dietitian, and all patients report that they would recommend the tour to friends and family.
Harris Health System
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Food for Health
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In partnership with a health clinic, UNM screened diabetic patients who had a HGA1c over 7 (indicating that their diabetes is not under control) for food insecurity. Patients who screened positive were considered to be food insecure, and were referred to a healthy food center. The goal was to educate patients on healthy eating to see if diabetes can be better controlled.
Hospital resources used for this program included a community health worker who did the screenings during clinical visits. The hospital also worked with Roadrunner Food Bank and Healthy Foods Center, who provided patients and their families with food on a weekly basis.
The program resulted in consistent access to fresh fruits and vegetables for patients and families, allowing for increased intake of healthy food. Program surveys saw a 33% increase in reports of eating fruits/vegetables “more than once a day”. Surveys also showed increased self-reported health outcomes (from 78% poor/terrible to 80% very good/good), and improved quality of life indicators (27% increase in reports of “never” being kept from usual activities due to poor mental of physical health).
UNM Hospital
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The Food Shelf @ HCMC
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The Food Shelf @ HCMC was started to address hunger and food insecurity among patients and families, with a long-term vision of creating a hunger-free hospital where all patients have the healthy food they need for their well-being.
The program serves patients and families who receive care at the primary care and specialty care clinics located within the hospital and/or at one of the hospital’s community clinics. Volunteers help package inventory and fill sturdy bags with healthful groceries. The bags are then delivered to the each participating clinic and are available for staff to give to patients/families in need.
The Food Shelf @ HCMC staff work closely with clinic staff in different departments to make sure they provide options that meet patients’ nutritional needs related to specific health conditions. The staff work with a variety of community partners to make sure they are able to provide both non-perishable foods for those with limited access to food storage as well as fresh produce and other foods to those with adequate food storage options. A major partner is Feeding America’s Second Harvest Heartland, which distributes food to food shelves throughout the state. Food is packaged in sturdy, handled bags which can be managed on public transportation, and are filled with items tailored to specific patient populations.
The Food Shelf @ HCMC serves nearly 30,000 households composed of approximately 90,000 individuals each year. More than half of the individuals served are children.
Food Insecurity, Health Equity, and Essential Hospitals
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VIDA!
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Recognizing the health disparities present in neighborhoods surrounding The MetroHealth System’s main campus, a community coalition of residents, community organizations, and Latina faith leaders came together to envision a “healthy community.” The VIDA! program resulted from this engagement, with an initial focus on promoting healthy cultural cooking practices in the local Hispanic community. The goal of the program is to train representatives from local Hispanic congregations as Community Health Cooks, who then go forward to educate others within their networks about healthy cooking practices and foundational healthy lifestyle principles.
This is a train-the-trainer program, focused on training Latina women from local Hispanic churches as Community Health Cooks, emphasizing healthy and culturally appropriate meals. MetroHealth works with a local Hispanic female chef and health coach to implement the program. This cadre of trained, lay leaders then extend the lessons of healthy cultural cooking practices to individuals and families throughout their faith community networks. The program emphasizes affordable, accessible, nutritional, and culturally appropriate meals that bring people together around a family table. MetroHealth provides staffing to coordinate the program and covers the costs of training the Community Health Cooks (instructor, food, supplies, curriculum). Participating churches provide food, space, and other in-kind support once the cooks are trained.
In a venture related to VIDA!, MetroHealth began a farm stand on its main campus to provide fresh produce to employees and local residents, working with the same Latina chef that trained the Community Health Cooks. Various internal departments were involved with this effort including Strategy and Nutrition Services. MetroHealth’s Center for Reducing Health Disparities was also integral in the planning and launch of the VIDA! program. Externally, a coalition of residents and community organizations, including the Hispanic Alliance, Cleveland Department of Public Health, Family Ministry Center, and others helped to design the program. Numerous local churches are partners in implementing the program.
Eleven women from four churches have been trained as Community Health Cooks in the initial cohort. Pre- and post-tests were administered to assess health behaviors, consumption of fresh fruits and vegetables, and cooking attitudes and efficacy. Participants reported positive impacts including weight loss, blood pressure and blood glucose control, and adoption of healthier lifestyle practices around eating and active living for themselves and their families.
Addressing Food Insecurity: A Toolkit for Pediatricians
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