Blog Archives
By Amanda Jepson | Categories: | Comments Off on The Digital Health Center: A Centralized Approach
Following a critical incident where delayed imaging led to advanced metastatic disease in a patient, Parkland Health conducted a subsequent analysis that revealed 17 percent of patients requiring follow-up imaging were overdue, leading to the development of the Digital Health Center (DHC). The DHC has three primary goals: provide eSupport to improve digital literacy and engagement for historically marginalized communities, implement safety net surveillance for high-risk conditions to prevent care gaps in vulnerable populations and conduct tactical outreach to engage patients with poorly controlled conditions and high socioeconomic risk.
The DHC transforms traditional passive follow-up into systematic intervention through digital health support, telehealth services, and remote patient monitoring. Following early successes, this integration of digital health support has been incorporated into the organizational strategic plan and applied to 11 other programs. Initially, funding for the DHC came from internal organizational investment. Since the pilot, the DHC has secured a $9.8 million grant to expand.
The DHC thrives through a multidisciplinary team of registered nurses, medical practice assistants, licensed vocational nurses, social workers, and virtual care physicians. This team maintains clinical workflows and processes, patient tracking systems, resource coordination with community organizations, and care progression pathways. An electronic health record consultant works closely with frontline staff to ensure digital health support is integrated functionally and that tools align with daily operational needs. Additionally, the DHC regularly engaged with the Patient Family Advisory Committee, which meets quarterly to discuss virtual care and digital health initiatives.
The program has had an impact in several key areas. Clinically, emergency room utilization has been reduced by 1.5 visits per patient in hypertension outreach, and blood pressure has improved in patients from historically marginalized communities. Social workers have connected patients to critical resources, including transportation, prescription drug coverage, and housing.
By Amanda Jepson | Categories: | Comments Off on Helping to Uplift and Bounce Back (HUB)
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.
By Amanda Jepson | Categories: | Comments Off on Center for Comprehensive Addiction Treatment, “No Wrong Door”
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.
By Amanda Jepson | Categories: | Comments Off on Refugee Services
Arizona has settled more than 110,000 refugees since 1981 and ranks in the top five states for refugee reception. Seventy-eight percent of those refugees relocate to Maricopa County, where Valleywise Health operates, in Phoenix. In response to the influx of refugees, Valleywise Health established the Women’s Refugee Health Clinic in 2008 to provide a culturally grounded, patient-centered medical home for the refugee community. In 2022, the clinic became part of the Valleywise Health Center for Refugee and Global Health. The center aims to assist refugees in navigating the U.S. health care system, including support with interpretation, insurance, housing, and day-to-day survival information.
The center provides comprehensive services via numerous clinics, including the Refugee Women’s Health Clinic, Refugee Pediatric Clinic, Family Medicine Refugee Clinic, McDowell Clinic for Individuals Living with HIV, Specialty Care Services, Behavioral Health Services, and Internal Medicine. Through outreach, the center mitigates structural barriers to care, including transportation, health literacy, continuum of care, and treatment adherence. Eighteen cultural health navigators work with clinical teams to coordinate all health-related activities daily. Valleywise Health allots an annual budget to the center and receives additional funding from foundations, including the Valleywise Health, Burton Family, Flinn, and Pakis Family foundations.
Community partnerships with the Arizona Department of Health Services, Department of Economic Security, State Refugee Resettlement Office, Maricopa County Department of Public Health, Arizona State University, health plans, and other refugee-serving organizations are key in service development, implementation, and dissemination.
In 2024, the center served 17,000 refugee patients, an increase of 1,000 over the previous year, from 71 countries. The center provided health literacy classes to more than 800 patients; adult refugee services to 1,437 men (including 243 who transitioned to self-efficacy in 2024), thanks to the program’s expansion into family medicine; and HIV and AIDS care to 880 adult refugees. Health care providers delivered 212 babies at the Refugee Women’s Health Clinic and installed more than 300 car seats for mothers who completed child safety classes. Additionally, the health center has seen a 33 percent increase in mental health screenings.
By Amanda Jepson | Categories: | Comments Off on Virtual ExpressCare: 911 to Telemedicine Redirection Program
In partnership with the New York City Fire Department (FDNY), NYC Health + Hospitals lunched the Virtual ExpressCare (vEC) 911 to Telemedicine Redirection program in 2020 to reduce strain on emergency resources, enhance patient care for non-emergent needs, and improve financial and operational stability.
The vEC operates continuously, improving emergency response by diverting lower-acuity 911 calls to telemedicine. Within 30 seconds, eligible calls are transferred, allowing patients to access virtual care and reducing unnecessary ambulance transport and emergency department utilization. The program has been integrated into FDNY ambulances, allowing EMS teams to connect with telehealth providers on-site to ensure patients receive definitive care without needed transport. The program also offers rideshare for non-emergent transportation for patients who need in-person follow-up but do not require emergency services.
This program requires a multidisciplinary team to ensure comprehensive planning, effective execution, and ongoing improvement. Within the health system, teams that are involved in the program are the emergency medicine, digital health, data and analytics, clinical quality and performance improvement, legal, and training and education teams. Externally, NYC Health + Hospitals collaborates with FDNY to properly implement the program.
Since its start, the program has diverted over 25,000 calls, preventing more than 12,000 ambulance transport and emergency department visits. The rideshare program has offered over 3,000 non-emergency rides, further optimizing ambulance availability. Additionally, vEC has lead to high patient satisfaction rates and low escalation rates to emergency services.
By Amanda Jepson | Categories: | Comments Off on Compassion for Community: Continuing Care After Death
At NYC Health + Hospitals/Jacobi and North Central Bronx, in the Bronx, N.Y., decedent holding time in the morgue drastically increased from an average of 72 hours before the COVID-19 pandemic to an average of 13 days in 2022. In addition to affecting the grieving process for patients’ families and loved ones, the delay in decedent release time strains hospital resources by requiring additional personnel and refrigerated space.
An employee in the Department of Pathology who was herself mourning the loss of her parents raised concern about this turnaround time and turned her grief into action. An analysis showed that funeral home capacity, complexities in navigating the funeral process, and high funeral costs contributed significantly to delays in decedent release, with Black decedents more likely to experience longer release turnaround times. The Compassion for Community: Continuing Care After Death program aimed to reduce decedent release turnaround time to improve family support, mitigate racial disparities, promote operational efficiency, and reduce environmental impact.
The program’s multipronged approach included 1) strengthened relationships with community partners including funeral homes and places of worship to identify capacity and support available to families, 2) enhancement of data collection to track capacity, 3) development of a guidebook, “Illuminating Forever Care,” for families that explains the practical aspects of funeral care and includes resources for funeral costs and processes. Written at a sixth grade reading level and available in multiple languages, in print and digitally, the book aims to close racial and ethnic disparities that delay decedent release.
The self-sustaining program operates with existing personnel, including an interdisciplinary team led by the quality management team that comprises staff from pathology, admitting, patient experience, bereavement, and finance. In 2023, 100 percent of decedents were released in eight days or less; in 2024, 90 percent of decedents were released in five days or less. Additionally, the program reduced greenhouse gas emissions by 13.1 metric tons and saved the health system $90,000 in overtime in its first year by minimizing refrigerated trailer use.
The health system would like to dedicate this award to the late Ms. Suzanne Pennacchio, whose legacy of quality/safety transformation we carry forward.
By aoguagha | Categories: | Comments Off on Jefferson Workforce Development Program
The Jefferson Workforce Development Program, facilitated in partnership with the School District of Philadelphia and Esperanza College, aims to address healthcare staffing shortages while creating career pathways for young Philadelphians. Targeting high school students, the program includes clinical shadowing, didactic and skills training, and professional development support. Students gain hands-on experience during school hours at no cost and receive mentorship and resume/interview coaching from Jefferson’s Human Resources team. Upon completion of the program, they are eligible for full-time roles across the Jefferson Health system. Key program benefits include free training, career readiness resources, exposure to real clinical environments, and financial support for essential workforce expenses.
By Amanda Jepson | Categories: | Comments Off on Curbside Care
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.
By aoguagha | Categories: | Comments Off on Farm to Families
To decrease chronic disease related to poor diet and physical inactivity, Farm to Families increases access to healthy foods by providing low-cost, fresh produce, dairy, and meat to over 350,000 residents in North Philadelphia. With a FreshRx prescription from a Temple Health doctor, patients who screen positive for food insecurity can receive coupons to purchase fresh food through the program. Community members and families with food stamps can also buy fresh foods throughout the year and receive nutrition education on how to sustain healthy eating habits.
Temple University Hospital and the Lewis Katz School of Medicine collaborate with the St. Christopher’s Foundation and the Lancaster Farm Fresh Cooperative to source, package, and deliver fresh and organic food to the community. Over 48,000 boxes of food have been purchased by more than 6,400 families since 2010.
For more information about the program click here.
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.
