West Virginia University Health System
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Helping to Uplift and Bounce Back (HUB)
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Memorial Healthcare System’s Helping to Uplift and Bounce Back (HUB) program is an integrated approach to whole-person, wrap-around care designed to improve health outcomes by addressing socio-economic barriers. Memorial’s 2021 – 2024 Community Health Needs Assessment highlighted significant gaps in health-related social needs, such as access to food, stable housing, and transportation. HUB was created to address those gaps through a three-pronged approach:
- “do for” – access services for the patient
- “do with” – access services alongside the patient
- “cheer on” – support the patient in becoming self-sufficient.
Specific goals include 80 percent of identified needs being fulfilled, a 5 percent reduction in hospital readmissions and emergency department utilization, 95 percent overall patient satisfaction, and 80 percent of patients’ increased knowledge of local community resources.
HUB offers a comprehensive care model that extends beyond medical treatment by assisting with needs such as affordable housing, connecting patients to food pantries, and facilitating prescription refills. Patients are linked to primary care providers to ensure appropriate follow-up care. The program also provides transportation and childcare so caregivers can attend appointments and collect needed medications, decreasing barriers to health.
Twenty-four hours post-discharge, staff conduct home visits to ensure patients have support not only in the hospital, but also at home. The program includes two mobile health vans that provide essential health services and resources directly to uninsured and underinsured residents. Once enrolled in HUB, patients remain participants until their needs or challenges are effectively addressed. The program is internally funded and employs four experienced staff members.
Collaboration with community organizations is key to HUB’s success. Partnering provides a breadth of assistance, including resource inventories, mental health and substance abuse services, employment and carer training, food insecurity, clothing banks, home repairs, interpersonal violence, childcare, transportation, and housing assistance. Staff members bring together community resources and stakeholders to meet patients’ needs, including creating a guiding council of current and past HUB patients to assist with shaping the program based on patient feedback.
Since launching in August 2023, the program has served over 3,000 patients and families and addressed over 8,600 needs. By August 2024, the mobile vans served 4,889 individuals; 88 percent of those had no prior Memorial connection, demonstrating HUB’s successful outreach to people with historically limited access to healthcare. The program surpassed its targets, including 95 percent of identified needs being fulfilled, a 34 percent reduction in emergency department utilization, a 6 percent decrease in readmissions among HUB patients, 99 percent overall patient satisfaction, and 92 percent of patients gained knowledge on available community resources.
Center for Comprehensive Addiction Treatment, “No Wrong Door”
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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.
Advancing Hypertension Control in Disparate Populations
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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.
Hospital-Led Outreach to Reduce Anemia at Time of Delivery
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Anemia in pregnancy increases the risk of needing a blood transfusion at the time of delivery threefold. It contributes to approximately 20 percent of severe maternal morbidity in historically marginalized groups. The transfusion rate at Natividad Medical Center, in Salinas, Calif., increased rapidly between 2021 and 2022, and anemia at the time of delivery had a prevalence of 18.8 percent of all births at Natividad. This problem was particularly evident in the Latina and Indigenous patient populations Natividad serves. Hospital leadership created this program to decrease the prevalence of anemia at the time of delivery and decrease Natividad’s transfusion rate.
Natividad’s systemwide leadership, including community clinic leadership, collaborated to create a multi-pronged approach to diagnose and treat antepartum anemia rates. This program includes educating staff on the negative effect of anemia and how to monitor and treat iron deficiency, as well as monitoring patients’ hemoglobin and iron stores throughout pregnancy.
Natividad created an infusion center to provide access to IV iron. Hospital leaders recognized that Medi-Cal only covered an iron infusion that required eight visits to infuse 1 gram of iron, which places a significant burden on patients that face transportation, financial, and time-related barriers to care. In response, Natividad collaborated with its Medicaid health maintenance organization to secure payment for single-dose IV treatments, increasing access to care.
The chief of obstetrics at Natividad worked with medical leadership at the community clinics to develop best practices for the program, which led to robust evaluative efforts and peer-to-peer learning. From January 2023 to August 2024, the overall rate of anemia at participating clinics fell from 18.4 to 11.7 percent, while the anemia rate at nonparticipating clinics increased from 22.3 to 26.5 percent. In 2022, the Indigenous patient population had higher rates of anemia—20.6 percent, compared with 18.4 percent for non-Indigenous patients. By 2024, both groups had decreased anemia rates—12.1 percent for Indigenous patients and 11.6 percent for non-Indigenous patients—and the gap between rates closed.
Huntsville Hospital Telemedicine Program
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Huntsville Hospital’s telemedicine program partners with Madison Hospital and Helen Keller Hospital to provide virtual care to residents in rural areas across the Tennessee Valley. The program connects patients with remote neurologists and psychiatrists for consultations, diagnoses, and treatment plans. The initiative aims to increase access to specialty care, especially for those facing challenges due to location. Supported by over $1 million in state funding, the program is already receiving positive feedback from patients and providers alike.
Huntsville Hospital Health System – Huntsville Hospital
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Curbside Care
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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.
Community Health Program
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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.
Increasing Birth Equity in Washington, D.C.
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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 since the program launched 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.