Blog Archives
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.
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 Health Equity Report Card
By Hannah Lambalot | Categories: | Comments Off on Lyft Partnership and Vouchers
Denver Health formed a partnership with Lyft to provide no-cost rides to recently discharged patients or those in need of transportation to and from outpatient clinic appointments. The program began in the ED and expanded after three months to include the hospital and outpatient clinics. Hospital and clinic staff request and track Lyft rides for patients, and the Denver Health Foundation funds the service at an average cost of $8.50 per ride, with a 25-mile limit. Now in its third year, the program has provided more than 5,000 rides. Denver Health also offers no-cost bus tickets, cab vouchers, and a car service using a vehicle donated by Oprah Winfrey to those patients with limited resources. The “Oprah” car is staffed by local retired community residents on a volunteer basis.
By Hannah Lambalot | Categories: | Comments Off on Denver Health
By Hannah Lambalot | Categories: | Comments Off on Neighborhood Transformation
Henry Ford Health System, in Detroit, is involved in a 300-acre neighborhood transformation that will include mixed-income housing surrounding the new Henry Ford Cancer Institute. In partnership with the Michigan Department of Transportation and the City of Detroit, Henry Ford is working to make the newly renovated community and the area surrounding Henry Ford Hospital’s main campus more bikeable and walkable to promote healthier lifestyles and create easier access to and from the hospital.
Since 2018 the health system has partnered with Lyft, SPLT, Signature LLC and Ford Mobility GoRide to specifically address patient transportation as a social determinant of health. Over 1500 round trip rides have been provided to and from appointments for patients across nine departments. In 2019, the health system is working on addressing transportation and additional social determinants of health through the same service offerings.
By Hannah Lambalot | Categories: | Comments Off on Confronting Transportation Barriers to Improve Health
By Jamie Cetrone | Categories: | Comments Off on PROgram for Non-emergency TranspOrtation (PRONTO)
PRONTO, a partnership with local health-access startup Kaizen Health, utilizes ride-hailing service Lyft to provide free rides to patients being transitioned home from medical surgical and critical care units. Inadequate transportation can be a significant barrier to accessing healthcare — and can contribute to slow bed turnover and lower patient satisfaction.
With PRONTO — which stands for PROgram for Non-emergency TranspOrtation — UI Health social workers can assess a patient’s transportation needs and, if necessary, arrange for transportation home in a Lyft car. The service is available for all adult patients living in Chicago who are ambulatory and expected to depart by 5 pm, Monday through Friday. The hospital pays for the cost of the program, which averages $20/ride.
PRONTO utilizes the Kaizen Health platform to schedule Lyft rides for patients. The interdisciplinary team that launched the program included representation from Nursing, Social Work, Patient Care Services, Materials Management–Logistics, Information Services, Emergency Department, Population Health Sciences, and Health Policy & Strategy.
Following a successful 4 month launch, PRONTO became a permanent service in May 2017. The program continues to have high patient and staff satisfaction and has been an important part of improving hospital throughput.
By Jamie Cetrone | Categories: | Comments Off on Transportation and Health Tool
