Blog Archives
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 The First Hospital at Home Program in South Texas
The Hospital at Home program at University Health, in San Antonio, provides hospital-level care in a patient’s home as an option for hospitalization. While COVID-19 catalyzed the program, the emerging interest in acute care at home and its positive effect on patient experience, population, and costs put the program in motion.
Services include: twice daily in person nurse visits, telemedicine provider visits, remote vital signs monitoring, physical and occupational therapy, medical equipment, internet-connected digital tablets for telehealth visits and patient education, labs and intravenous medications, social support and other services. A multidisciplinary team of doctors, nurses, social workers, care coordinators, respiratory therapists, and other specialists is trained to deliver care outside the hospital. The program created a new department and mobile fleet with in-house funding and is now entirely self-sustaining.
Nursing, information technology, and health care innovation staff lead the program, and staff from the pharmacy, laboratory and pathology, operations, legal, and respiratory care, patient care services, food services, medical records, radiology, patient care coordination, and other departments have been involved in program design since inception. Each department created workflows and standard operating procedures outlining their roles in patient support. A specially designed module within the system’s electronic medical records helps coordinate remote patient monitoring, equipment, and provider best practices. Leadership from each department is heavily involved in program evaluation and sustainability. Patient feedback shapes the program by helping staff identify social determinants of health, such as food insecurity and other needs crucial for recovery and staying healthy after discharge.
The program continues to grow. Since the program started in 2021, the Hospital-at-Home program has cared for more than 3,100 patients, corresponding to over 16,400 beds saved for the hospital. The health system reports zero falls with serious injury, medication errors with serious injury, pressure injuries, or zero staff safety incidents. The program has reduced readmission, increased patient satisfaction, and generated significant cost savings; from 2021 to 2024, the program saved University Health more than $17 million. Additionally, the program has retained 100 percent of its staff.
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 Pioneering Change: Population Health at Essential Hospitals
Staff at Nashville General Hospital (NGH) frequently encounter patients who need assistance navigating the health system, applying for financial assistance, obtaining affordable medications, and learning how to advocate for their health. In response, NGH curated programs under the Population Health Management department, including the Community Care Team (CCT), Food Pharmacy, Congregational Health and Education Network (CHEN), and NGH HopeMeds Program. The multi-pronged approach seeks to ensure that the patient population uses available resources and sees improvement in health outcomes.
The CCT is a care management team consisting of a medical director, navigators, dietitian, Food Pharmacy manager, social workers, and a nurse practitioner who collaborate to assist patients with health and social needs. The Food Pharmacy supports patients experiencing food insecurity through access to healthy foods tailored to patient health needs, as well as nutritional counseling and social services support. CHEN is CCT’s counterpart in the Nashville area’s faith-based communities with four leading pillars—health literacy, education attainment, access to health care, and membership development. These efforts are supported by grants from the National Institutes of Health and Community Health Worker trainings provided by Meharry Medical College. Additionally, the NGH HopeMeds Program allows qualified patients to receive no-cost medications.
The CCT team works closely with the Patient Experience and Marketing departments to collect patient feedback. Additionally, leaders of the Ambulatory Clinics, Case Management, and Population Health Management departments review this feedback to ensure the programs meet patients’ needs. CHEN partners with multiple external organizations, including NGH’s Clinical Research department; the National Institute on Minority Health and Health Disparities; and several faith-based organizations, with an emphasis on those that serve African American communities.
The Food Pharmacy has had approximately 11,800 visits since 2022 and helped cancer patients facing food insecurity obtain nutritious food to keep the weight needed to sustain cancer treatments. In one year, the NGH HopeMeds program, offered through the Nashville-based nonprofit, Dispensary of Hope, has served more than 1,200 unique patients, filled more than 4,700 prescriptions, and provided more than 8,400 months of no-cost medications, saving patients more than $585,000.
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 Episcopal Food Pantry
Located on Temple Health’s Episcopal Campus, the Episcopal Food Pantry provides free fresh fruits and vegetables, canned goods, and other non-perishable items to nourish the community. In collaboration with the Share Food Program, the leading food bank in the Philadelphia area, the food pantry is open every Thursday. Since the program opened in May 2022, the number of community members served has doubled, and the program hopes to see continued growth.
For more information about the program, click here.
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 aoguagha | Categories: | Comments Off on Food As Medicine
The Food as Medicine partnership at Grady Health provides members of the Grady community (patients, families, employees, visitors, and neighbors) access to healthy affordable food through the Jesse Hill Market and other collaborations throughout the Atlanta area. Located just outside Grady’s main entrance, the Jesse Hill Market features a food prescription program that offers eligible patients fresh food, nutrition education, and cooking classes. The Market also offers healthy grab-and-go meals and fresh produce for purchase through its public café.
The Food as Medicine program is a multipronged intervention to address both chronic disease and food insecurity among Grady patients. Grady Health partners with the Atlanta Community Food Bank and Open Hand Atlanta to deliver the Food As Medicine program. The Food as Medicine Partnership aims to fuel patients with healthy foods while bringing the community together.
For more information, click here.
