Case Studies - Hospital-Community Partnerships to Build a Culture of Health: American Hospital Association
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Hospital-Community Partnerships to Build a Culture of Health: A Compendium of Case Studies
Suggested Citation: Health Research & Educational Trust. (2017, August). Hospital-community partnerships to build a Culture of Health: A compendium of case studies. Chicago, IL: Health Research & Educational Trust. Accessed at www.aha.org/partnershipcasestudies Accessible at: www.aha.org/partnershipcasestudies Contact: hretmailbox@aha.org or 312-422-2600 © 2017 Health Research & Educational Trust. All rights reserved. All materials contained in this publication are available to anyone for download on www.aha.org, www.hret.org or www.hpoe.org for personal, non-commercial use only. No part of this publication may be reproduced and distributed in any form without permission of the publication or in the case of third-party materials, the owner of that content, except in the case of brief quotations followed by the above suggested citation. To request permission to reproduce any of these materials, please email hretmailbox@aha.org.
Contents
4 Introduction
6 Atlantic Health System Morristown, New Jersey
10 LifeBridge Health Baltimore, Maryland
16 Seton Healthcare Family Austin, Texas
21 Sharp HealthCare San Diego, California
26 Sinai Health System Chicago, Illinois
31 St. Mary's Health System Lewiston-Auburn, Maine
36 St. Vincent Healthcare Billings, Montana
40 University of Vermont Medical Center Burlington, Vermont
44 WNC Health Network Western North Carolina
48 Appendix
50 Resources
3
Introduction
“
In 2016, the Health Research & Educational Trust,
an affiliate of the American Hospital Association,
launched Learning in Collaborative Communities, a
cohort of 10 communities from across the United
States that have successful hospital-community
partnerships. This work was part of the Robert Wood
These case
Johnson Foundation’s vision to build a Culture of
Health. HRET staff visited the communities and
studies highlight
met with representatives from the hospital and
community to learn how these individuals and their
communities that
organizations worked together to build effective
partnerships. In addition, three representatives are developing,
from each of the communities were invited to two
in-person meetings dedicated to strengthening implementing
and sustaining
competencies related to building effective hospital-
community partnerships.
Insights gained from these site visits and meetings
helped HRET create “A Playbook for Fostering
effective strategies
Hospital-Community Partnerships to Build a Culture
of Health.” The playbook includes strategies,
and successful
worksheets and tools to guide a structured and
collaborative process for improving the health of
programs to
individuals and communities.
achieve a Culture
of Health.
“
4
Key takeaways from the
playbook include::
• Partnerships share valuable assets such as This compendium features descriptions of the
resources, tools and expertise. communities—which vary in location, service type,
type of partners and degree of partnership—and their
• Hospital-community partnerships are
initiatives to build a Culture of Health. The appendix
necessary to address community health
includes photos from the two meetings convened by
issues nonclinically.
HRET with representatives from the communities as
• The process of identifying partners and well as the Robert Wood Johnson Foundation.
assets and developing an action plan can
be simplified by incorporating structured
activities and exercises. Atlantic Health System Morristown New Jersey
• Aligned goals, transparent communication LifeBridge Health Baltimore Maryland
and strong leadership can drive a Providence Health Portland Oregon
partnership to measurable success. Seton Healthcare Family Austin Texas
• Leveraging strengths and identifying Sharp HealthCare San Diego California
weaknesses in a partnership help overcome Sinai Health System Chicago Illinois
challenges. St. Mary's Health System Lewiston Maine
• Evaluating, reflecting on and celebrating St. Vincent Healthcare Billings Montana
progress strengthen a partnership and University of Vermont Burlington Vermont
accelerate momentum. Medical Center
WNC Health Network Asheville North Carolina
• Sustainable partnerships are established
by including more innovative strategies and
practical tools in existing practices.
A collaborative approach is key to building a
Culture of Health—that is, creating a society that
gives all individuals an equal opportunity to live
the healthiest life they can, whatever their ethnic,
geographic, racial, socio-economic or physical
circumstance may be. These case studies highlight
communities that are developing, implementing
and sustaining effective strategies and successful
programs to achieve that goal.
5
Atlantic Health System
Morristown, New Jersey
Community Description
Atlantic Health System, a six-hospital system, has journey from a plethora of 144 community
headquarters in northern New Jersey in Morristown, programs that were not evidence based, targeted
about an hour outside of New York City. The health or evaluated and streamlined them into three
system’s service area of northern New Jersey and signature community health improvement programs
Pike County, Pennsylvania, is home to more than across the system that are targeted, evaluated
2 million people. This community is highly educated: and evidence based. Each geographic region of
93 percent are high school graduates, and 42 percent the system is responsible for implementing its
hold at least a bachelor’s degree. The population is own projects to maintain local flavor and culture
diverse: 27 percent are Hispanic/Latino, 12 percent and address local concerns. Underpinning all this
are black or African-American, and 25 percent are work are the community-based collective impact
foreign born. Though the region has areas with high model, community-based participatory research and
levels of affluence, there are many pockets of socio- a desire to build community capacity. Additionally,
economic need and health disparities. About a third the department is using its robust data resources
of the community’s residents have demonstrated to drive decision-making around population health
struggles to make financial ends meet. management across the organization.
The Community Engagement and Health Atlantic Health System uses a three-pronged
Improvement Department is the engine that drives approach toward achieving its vision of improving
the health system’s partnerships and community lives and empowering communities through health,
health improvement work. Consisting of Community hope and healing:
Health, the Center for Faith and Health, and the 1. Prevent illness and disease through
Atlantic Center for Population Health Sciences, the community investment around socio-
department builds on a long-standing tradition of economic indicators and preventive services
community health improvement work at Atlantic
2. Engage the community and develop
Health. The health system undertook an intentional
strategically aligned partnerships
3. Optimize health care delivery and accessibility
This commitment to building a health system Culture
of Health is evident in how the system’s hospitals
operate. Leadership and clinical staff recognize
that addressing the social determinants of health
in partnership with the community is the only way
to truly improve health. For example, the health
system’s nursing staff is engaged by integrating
community health into clinicians’ professional
development pathway. Regional diversity councils
lead many initiatives, including programming to
expose staff from across the organization to a
poverty simulation session, helping them understand
Photo courtesy of Atlantic Health System
the challenges of living in poverty.
6
PRIORITY NEEDS
Obesity | Access to behavioral health care | Substance use disorders
(heroin/opiate use)
Diabetes | Cardiovascular disease
Community shares national, state and local health data, with
Partnerships up-to-date information and performance measures
on each county’s community health improvement
plan, as well as a robust resource library to support
community health efforts.
The NJHC is led by a board of trustees comprised
of four officers, more than 20 funding partners,
North Jersey Health Collaborative and the chairs of the regional Data Committee,
The North Jersey Health Collaborative (NJHC) Communications Committee, Finance Committee and
serves as the backbone organization for regional local county committees. The board provides regional
health improvement. It was founded in 2013 by a oversight, while the local county leadership and
group of nine organizations, including Atlantic Health members have ownership and accountability for their
System; since that time the NJHC has expanded county-specific community health improvement plan.
to five counties — Morris, Passaic, Sussex, Union
and Warren — with more than 125 organizational From the outset, the collaborative has been
partners, including health care systems, public jointly funded and sustained by the participating
health organizations and community-based organizations, through financial support and/or the
organizations. The collaborative’s core function is to donations of in-kind hours and resources, fostering
lead the community health needs assessment and a sense of communitywide buy-in. As an active
implementation strategy process for the region; participant in each of the NJHC workgroups, Atlantic
by connecting these different parties, all partners can Health leads several initiatives (described here, called
strategically work together on community “Signature Programs”) addressing these priority
health improvement. health needs.
As part of a collaborative effort, community-identified The Community Engagement and Health
health needs were prioritized and selected by each Improvement Department at Atlantic runs three
county. Workgroups are formed for each priority issue systemwide community health improvements,
to align indicators and strategies. The collaborative’s geared toward meeting the needs identified in the
web portal (www.njhealthmatters.org) houses and collaborative’s community health needs assessment.
7
Atlantic Healthy Schools coordination for individuals and families. One
example is Atlantic Health’s work with partners
Atlantic Healthy Schools brings together health at the local First Baptist Church of Madison to
care professionals and schools with the goal of share health information with parishioners and
improving the health of all students. The Atlantic foster a healthy church environment. Using
Healthy Schools program provides resources, grants emergency department and public health
and technical assistance to more than 200 schools data, the team identified four neighborhoods
in northern New Jersey. Atlantic Healthy Schools with high disparities in chronic disease. The
operates with a “whole school, whole community, Neighborhoods Initiative is building community
whole child” model. This model, developed by the partnerships, identifying resident-defined
Centers for Disease Control and Prevention, is a priorities and working toward shared issues.
coordinated approach that integrates healthy policies
and practices into schools to strengthen learning • Community-based partnerships to address
and health. Developing healthy habits in kids can set health disparities in four local, low-income target
them up for a lifetime of good health. communities
• Environmental and policy change by building
Age-appropriate programs address healthy eating capacity of community partners. In partnership
and healthy lifestyles. Programs are directed with the New Jersey Department of Health,
at children and their parents, and professional New Jersey Partnership for Healthy Kids, Salem
development opportunities are provided for staff and Health and Wellness Foundation, Partners for
administrators. Additionally, Atlantic Health System Health Foundation and New Jersey YMCA
has funded school-based fitness equipment and State Alliance, Atlantic Health System awards
physical education teacher training for more upward of $375,000 per two-year grant cycle
than 30 schools via Project Fit America, with via the New Jersey Healthy Communities
measurable increases in student physical fitness Network (NJHCN) community grants program.
and school capacity. The purpose of the NJHCN’s community grants
program is to provide funding and technical
A+ Challenge: Actions for Healthy Schools initiative assistance to New Jersey communities to
provides technical assistance and funding for enhance the built environment and advance
schools to make policy and environmental changes policy to support healthy eating and active
that increase opportunities for physical activity and living. The goal is to modify settings – whether
improve nutrition. they are community-based spaces, schools, or
workplaces – so that the healthy choice is the
easy one. Grantees are awarded $20,000 over
Another program of note is Altitude, a youth
two years; they also receive technical assistance
empowerment/behavioral health program by and for
including individual coaching and regional and
adolescents, specifically eighth graders. Participants
statewide meetings. Examples of funded
create posters and video and radio commercials,
projects include creating community walking
developing and implementing these media messages paths, passing Complete Streets policies and
for their peers. They are also given the chance to improving access to fresh produce via farmers
lead service projects within and around their schools. markets and community gardens. Funding is
The learning and impact continue beyond eighth awarded with special attention to communities
grade as the adolescents enter high school and that face socio-economic barriers to health.
show increases in volunteer service. This program
is measuring pre- and post-test results, conducting New Vitality
focus groups at the participating schools and
conducting element-by-element evaluations. New Vitality is an inventory of health and wellness
services for older adults designed to prevent
Healthy Communities age-related chronic conditions and disabilities and
minimize hospitalizations. Participants receive a
The Healthy Communities initiative supports the health risk assessment and health coaching and
elimination of health disparities as part of its disease are connected to a variety of exercise and nutrition
prevention and health promotion efforts. opportunities. The program is now working directly
• Culturally specific health outreach. Provides with physicians to refer patients suffering from
education and community-based care chronic disease into community-based resources.
8
Impact Lessons Learned
New Jersey Health Collaborative performance Support from the top allows for integrating a
measures (January – July 2017) Culture of Health into the organization itself and
• Average number of organizations participating its core mission. The community must own health
per month: 145 initiatives, not the health system. The Atlantic Health
System CEO, Brian Gragnolati, articulated that the
• Member perception of value of participating in organization needs to move toward a mindset of
NJHC (mean score, range 1-7): 6.2 the “community taking care of the community.”
• Member perception of value of participating in Understanding of and buy-in for community health
topic-based workgroup (mean score, range 1-7): initiatives by senior leadership is necessary for
6.2 health improvement.
• Member perception about having the “right
people” for collaboration (mean score, range It is important to build a systemwide infrastructure
1-7): 5.6 that streamlines the work to focus on what the
hospital or health system knows works best to meet
• To see strategies and performance measures community health needs. Atlantic Health focused
by county and workgroup, visit Plans & on three signature programs across the system,
Priorities at www.njhealthmatters.org enabling a level of standardization systemwide
while also enabling local-level “translation” based
Atlantic Healthy Schools performance measures upon community culture. This systems approach to
(2016–2017 school year) community and population health appears to be a
• Number of member schools: 227 successful model for systems.
• Member satisfaction with in-class programming
(mean score, range 1-5): 4.7 Integrating community health activities into clinical
departments in the hospitals can help break down
• Member satisfaction with professional silos. Atlantic Health is using population health
development opportunities (mean score, range and its ACO to drive spread of community health
1-5): 4.8 improvement work through clinical departments.
• Number of policy, system and environmental This requires a paradigm shift that includes new
changes made via A+ Challenge (pilot year, 7 skill sets, staff buy-in, leadership and flexibility
schools): 11 to effectively transition community work into a
population health model.
Healthy Communities performance measures
(January – July 2017, unless otherwise noted) Having the North Jersey Health Collaborative
lead the community health needs assessment
• Number of residents/organizations active in
process demonstrated that the assessment was
Neighborhoods Initiative (4 community-based
by and for the community, not just for the health
partnerships): 68
system. This model collaborative fostered new
• Direct monetary investment in targeted, partnerships that have continued beyond the
community-based partnership and policy, scope of the assessment.
system and environment change (2015–2016,
reflects grant cycles): $475,000
New Vitality performance measures (2016)
• Number of participants: 8,582
• Participant satisfaction with New Vitality
programming (mean score, range 1-10) : 9.58 Contact
Chris Kirk
Director, Community Engagement and
Health Improvement
Atlantic Health System
(973) 660-3174
chris.kirk@atlantichealth.org
9
LifeBridge Health
Baltimore, Maryland
Community Description
Story
Baltimore, a “city of neighborhoods,” is a large The region is data rich due to its statewide health
metropolitan seaport city on the East Coast. information exchange (HIE). The Chesapeake
LifeBridge Health is a regional health care Regional Information System for our Patients
organization based in northwest Baltimore and its (CRISP) HIE enables health care providers to
surrounding counties, with hospitals serving urban transfer data through electronic networks among
(Sinai Hospital of Baltimore, Levindale Hebrew disparate health information systems. The HIE is
Geriatric Center and Hospital), suburban (Northwest built for interoperability to communicate health data
Hospital) and rural (Carroll Hospital) communities. among Maryland physicians, hospitals, other health
This four-hospital system is one of the largest care organizations and providers. It also enables
community hospital systems in the region and communities with regional HIEs to connect with
has invested significantly in the community and in other communities around the state. The HIE has an
community engagement. The health system focuses event notification function that indicates to a provider
on the whole patient and life circumstances and if a patient accesses care anywhere in the state,
not just the patient’s disease, which is reflected in allowing for sophisticated care coordination and
LifeBridge Health’s extensive network of community continuity.
health workers and other care coordination staff.
Population
Maryland is the last of the “waiver” states in the
According to the 2015 community health needs
nation, having opted out of a Medicare fee-for-
assessment (CHNA) for Sinai Hospital of Baltimore,
service payment system in the 1970s in favor of an
part of LifeBridge Health:
all-payer model, which allowed for equity of health
care costs across all insurers and other payers. The • The community’s population is approximately
waiver currently involves a five-year experiment 60 percent black/African-American, 30 percent
with a value-based payment model called the global white and a small percentage Asian-American or
budget revenue (GBR) system. Hospitals receive “Other.”
a fixed sum payment for all Medicare patients for
the year, which incentivizes reduced utilization of • Average household size is 2.46 people.
acute health care services. This has a great impact
• Estimated median household income is $54,594.
on how hospitals strategically care for their patients.
There is clear focus and devotion to preventive care, » Income less than $15,000 (below federal
care coordination and community investments as a poverty limit): 14.6 percent of population
fundamental practice for the hospital. » Income between $15,000 to $34,999: 19.2
percent of population
10PRIORITY NEEDS
Looking at geographic mapping for mortality within Health serves, including lower income levels,
the city of Baltimore, the northwest region of the city lower educational attainment, vacant housing and
has the strongest concentration of high incidences higher levels of incarceration and violence. During
of infant mortality and the lowest life expectancies, the 2015 CHNA survey for Sinai Hospital, 30 percent
compared to neighboring communities (see maps on of respondents answered “violence” to the question
page 12). Other challenges with social determinants “What do you think causes the most deaths in
of health characterize the community that LifeBridge your community?“
The top priority needs listed in the 2015 CHNA for Sinai, Levindale and Northwest hospitals are:
Violence | Diabetes | Heart disease
The top priority needs listed in the 2014 CHNA for Carroll Hospital are:
Health care access | Physical health status | Mental and behavioral health
Chronic health conditions | Preventive health practices | Social determinants of health
11Baltimore City Life Expectancy by Community Service Area and
Baltimore City Mortality by Age (Less than 1 Year Old), 2013
Harford/
Cross-Country/
Echodale
Cheswolde Loch Raven
Chinquapin
Mt. Washington/ Park/
Coldspring Greater
Roland Park/ Belvedere
Poplar Hill N. Baltimore/
Glen-Fallstaff Guilford/
Pimlico/ Hamilton
Arlington/ Homeland
Hilltop
Greater
Govans
Northwood
Southern Lauraville
Park Heights
Howard Park/ Medfield/Hampden/
West Arlington Woodberry/Remington Cedonia/
Dorchester/
Ashburton Frankford
Greater The Waverlies
Charles
Village/ Belair-Edison
Penn North/
Barclay
Reservoir Hill
Forest Park/ Greater Mondawmin Midway/
Walbrook Coldstream
Dickeyville/ Claremont/
Franklintown Greenmount Clifton-Berea Armistead
East
Greater Rosemont Upton/Druid Midtown
Edmondson Sandtown- Madison/
Heights
Village Winchester/ Oldtown/ East End
Harlem Park Middle East Patterson Park
Poppleton/ North & East
Downtown/ Orangeville/
Beechfield/ The Terraces/ Seton Hill E. Highlandtown
Ten Hills/ Hollins Market Harbor East/
Allendale/ Southwest
West Hills Little Italy
Irvington/ Baltimore Highland-
Fells Point town
S. Hilton Canton
Inner Harbor/
Washington Federal Hill
Village
Morrell Park/ South Baltimore Southeastern
Violetville
Westport/Mt.
Winans/Lakeland
Cherry Hill
Brooklyn/
Curtis Bay/
Hawkins Point
Legend
Life Expectancy at birth, in years
by Community Statistical Area, 2013
66.0 - 69.5 years Ranked into quintiles
µ
69.6 - 72.2 years
72.3 - 73.6 years
73.7 - 76.0 years
2 1 0 2 Miles
76.1 - 85.3 years
Prepared by the Baltimore City Health Department.
2013 Life Expectancy data provided by DHMH's Vital Statistics Administration.
evidence-based public health and human service
Addressing models to identify and intervene when an act of
violence occurs.
Community
Community The city's Safe Streets program employs ex-
Partnerships convicts as violence interrupters (VIs), providing job
opportunities that are often hard for this population
to obtain. VIs are trusted members of the community
and provide a voice for the victims and perpetrators.
On the hospital side of the partnership, Sinai’s
Kujichagulia Center employs hospital responders
who meet victims of violence in the emergency
department and inpatient units, to learn more about
the conflict and determine what dynamics led to
Violence Prevention: Kujichagulia Center
the incident – and whether retaliation is imminent.
In partnership with the Baltimore City Health If retaliation seems likely, the hospital responder
Department and the Office of Youth Violence contacts the Safe Streets team in the patient’s
Prevention, LifeBridge Health is committed to neighborhood to mediate a conflict.
interrupting the cycle of violence in the Sinai Hospital
service area. Recognizing that violence has an Further, the hospital responders engage the victims
enormous impact on the health and wellness of by connecting them to workforce readiness and life
individuals and especially youth, this program uses skills mentoring, a program Sinai offers out of its
12Community Initiatives office. This partnership has by the Leonard and Helen R. Stulman Charitable
received a unique source of support through the Foundation and the Hoffberger Foundation. In 2015,
Health Services Cost Review Commission (HSCRC), Sinai Hospital of Baltimore received a grant from
Maryland’s rate-setting and regulatory body for Civic Works to become the HUBS service site for
hospitals. When the HSCRC awarded a series of Northwest Baltimore.
grants statewide to stimulate hiring of entry-level
health workers in disadvantaged neighborhoods, it The program assists adults age 65 and older to
included an extra package of funding to expand the remain safely in their homes. The HUBS social worker
Safe Streets partnership with Sinai Hospital. This at Sinai reaches out to clients over the phone and
expansion included funding a second Safe Streets through home visits to determine what their needs
post within Sinai’s service area, including a new office are. Repairs and upgrades are prioritized based on
and three new VIs, as well as a fully staffed team what is most important to the homeowner, unless
of hospital responders and a new social worker to there is an immediate safety issue that must be
further engage clients in the recovery and workforce addressed. The social worker helps clients determine
engagement process. the best course of action for getting the work done
following a home visit. When clients are referred to
Community Health Workers: Diabetes various city programs that provide repairs, the social
worker will help them fill out applications and gather
Medical Home Extender Program, HIV
the necessary documents. Clients also receive help
Support Services Program, Family applying for grants or loans or both to cover the costs
Violence Program of repairs and upgrades.
Diabetes Medical Home Extender Program
is a home-visiting program for patients identified Perinatal Mental Health
in the hospital with uncontrolled diabetes. A social Initiated by a staff member in the 1990s, Sinai
worker, nurse and community health worker provide Hospital’s Perinatal Depression Outreach Program
assessments, service coordination, education, (PDOP) is the only hospital-based program of its kind
psychosocial support, information and referral to in the state of Maryland. The program is dedicated
assist clients in managing their diabetes. to helping women understand the emotions that can
HIV Support Services Program is a home-visiting accompany pregnancy and the postpartum period.
program for HIV-exposed infants, HIV-positive Due to a lack of available maternal mental health
adolescents and HIV-positive adults meeting practitioners, the program also promotes educational
Ryan White eligibility criteria. A social worker and opportunities.
community health workers provide psychosocial
assessments, service coordination, advocacy, One such opportunity is the Baltimore Perinatal
education, information and referral, case Mental Health Professional Study Group. This group
management, wellness series and support groups. provides a unique opportunity for multidisciplinary
professional connection, development and support
Family Violence Program is a crisis intervention of one another. Study group participants represent
program for victims who come to the Sinai professionals invested in perinatal mental health,
emergency department. A social worker and including therapists, psychiatrists, obstetrics
community health worker (CHW) provide danger providers, lactation consultants, doulas, support
assessments, safety planning, individual and group group facilitators, public health professionals and
counseling, service coordination and home visits. researchers. Meeting space is provided by Sinai
Consistent check-ins, guidance and time spent Hospital of Baltimore, and the meetings are held four
with community health workers help clients establish to six times a year.
deep connections and trusting relationships
with their CHW.
ED Navigation Program
Home Maintenance: HUBS (Housing Launched in June 2014, Access Health was a
Upgrades to Benefit Seniors) partnership between Sinai Hospital and the Baltimore
nonprofit organization HealthCare Access Maryland.
Housing Upgrades to Benefit Seniors (HUBS) is a The program addressed health disparities, reduced
citywide program started by Civic Works and funded admissions and readmissions, and expanded primary
13care capacity by increasing health care access and other postdischarge support. The network is
points, promoting continuity of care efforts and made up of existing communities to help build a
diverting frequent emergency department visits. support system around wellness and health. For
It accomplished this by embedding three care consenting individuals, the hospital notifies someone
coordinators in the hospital’s ED during day, evening in the church congregation when an individual is
and weekend hours. It was designed to capture admitted to the hospital.
patients who were high utilizers of emergency
services or at risk for pregnancy complications, and The program also offers free health resources
then linked them to appropriate, health-promoting to promote health in the community. The care
care and follow-up resources. The program coordination that results from this network provides
produced such successful results that both Sinai patients with a support system that can aid in
and Northwest hospitals decided to incorporate the better managing their care and general assistance
model into a larger community care coordination during a time when individuals are most vulnerable.
structure, working across the navigation spectrum Throughout the two-year pilot phase of the program,
from inpatient to ED to doctors’ offices and clinics. Carroll Hospital’s rural, tight-knit environment
Through the development of this comprehensive facilitated especially great successes in identifying
approach, LifeBridge Health decided to fund its own congregants when they came to the hospital
internal team to provide these services. and connecting them back with their pastors and
communities. LifeBridge Health facilities continue
Key elements include: to invest in this model through dedicated staff
• Warm handoffs to coordinators in the ED time; shared implementation of health education
• CRISP statewide encounter notification alerts to programming; shared strategic action in reaching
the provider through the electronic health record new communities, such as the Orthodox Jewish
• Coordinators who are certified application community surrounding Sinai; and other system
counselors improvements aimed at a smooth hospital-to-home
• Risk stratification of clients transition. In the two-year pilot, the network grew to
more than 1,600 individual members.
Maryland Faith Health Network
Based on the Congregational Health Network Impact
in Memphis, Tennessee, this pilot network of
Maryland churches provides community support for • Since 2013, the Diabetes Medical Home Extender
congregants during and after a hospital stay at Sinai, Program has offered in-home diabetic support to
Northwest or Carroll hospitals. LifeBridge Health’s more than 150 clients. Participants have seen a
span across urban, suburban and rural areas made significant reduction in inpatient hospitalizations
the organization an ideal partner with the Maryland (over 68 percent) resulting in more than $1.24
Citizens’ Health Initiative in seeing how the model million in savings to the health system.
could play out in these various contexts. Support for
congregants may mean hospital visits from clergy or • During fiscal year 2016, the HIV Support Services
other liaisons, meals, rides to follow-up appointments program supported nearly 400 HIV-positive
Photos courtesy of LifeBridge Health
14individuals with intense support and case
management. Because of this team’s efforts,
Lessons Learned
91 percent of clients have maintained an
undetectable viral load, reducing their risk of Statewide health information exchange allows
becoming ill and the likelihood of transmission. for communication and coordination among
and between hospitals, which helps to provide
• During fiscal year 2016, the Kujichagulia Center accountability for all organizations making an
has supported more than 30 clients, providing effort to improve patient outcomes.
workforce readiness and life skills training in an
effort to break the cycle of violence plaguing the Community health workers form the backbone
youth in neighborhoods surrounding the hospital. of many of LifeBridge Health’s most successful
As a result of participation, more than half of efforts to support patients and clients in
those clients were hired by LifeBridge Health managing their diseases and addressing social
facilities or other community organizations, determinants of health. The relationships,
further enhancing the opportunities for these resources and support that CHWs bring to the
youth. A middle school mentoring portion of nonclinical health care environment have great
the Kujichagulia Center provides mentoring for impact on a systematic level for the hospital and
approximately 120 young men per school year. health outcomes, and also at a personal level for
patients in the community.
• Since September 2015, the Housing Upgrades to Grant-funded partnerships and innovative
Benefit Seniors program has served more than nonprofit programs serve as a proving ground
280 clients (most of whom fall below the 50th for ideas that can end up showing a return on
percentile of the Area Median Income), providing investment for hospitals – which then can lead
home safety assessments and enhancements, to hospital decisions to fund the same or similar
handyman services, and referrals to citywide programs out of their own operating budgets.
housing resources. To date, almost 200 homes
(89 percent of the three-year goal) have been Programs focused on addressing social
serviced for clients, including installation of determinants of health have the ability to produce
supportive hand railings, stairway repair, roof short- and long-term effects on high-priority
repair, furnace replacements and more. hospital measures such as volume of inpatient
admissions, and public health measures such as
• As of March 2016, the ED Navigation Program, HIV viral loads.
with 524 clients enrolled, has reduced emergency
department visits 64 percent (157 avoided visits) Hospitals’ speed and agility in building programs
and reduced inpatient stays 80 percent (54 falls somewhere in the middle between small
avoided visits). In addition, 150 people signed up community organizations and large municipal
for health insurance, and 260 clients obtained a operations. For example, CHAI (Comprehensive
primary care provider, with 73 percent keeping Housing Assistance, Inc.) was able to nimbly
their appointments. expand its senior home repair program model
to accommodate the HUBS program fairly
easily; Sinai built the social work piece of
Contacts the program but could not quickly invest in a
handyman component; and the city of Baltimore
Darleen Won experienced delays in processing applications
Assistant Vice President, Population Health through a central point as it worked to build
LifeBridge Health its capacity across five sites throughout the
(410) 601-8121 city. Partnerships should consider these and
dwon@lifebridgehealth.org other strengths or limitations of participating
organizations based on size, resources, level of
Lane Levine bureaucracy and other factors.
Project Manager, Population Health
LifeBridge Health
(410) 601-5359
llevine@lifebridgehealth.org
15Seton Healthcare Family
Austin, Texas
Community Description
Story Population
Austin, the capital of Texas, is one of the fastest • Travis County includes Austin, Pflugerville and
growing cities in the United States. It is home many smaller suburban communities. In addition,
to many artists, musicians and people working the region contains several of the country’s
in technology, including a high concentration of fastest growing suburban cities.
millennials. Austin is known for its music scene and • Travis County has a growing Hispanic population.
eccentric and artistic residents. The population is Hispanics currently make up 35 percent of the
growing extremely quickly in Austin, Travis County population in Travis County and are projected to
and Central Texas overall. From 2000 to 2010, Central compose 40 percent of the population by 2030.
Texas’ population grew by 37 percent, which is nearly
four times faster than the national average. This • Despite the influx of younger workers to Austin,
change has resulted in the population growing faster the number of adults 65 and over is expected to
than infrastructure and resources that can support grow from 101,489 in 2016 to 187,459 in 2030, an
a healthy region, including access to transportation, 85 percent increase.
food and educational opportunities. In addition, • In 2015, Austin had an estimated population
access to health insurance and affordable health care of 931,830.
are insufficient, and five counties in the region are • In 2016, the population of Travis County was
designated by the Health Resources and Services estimated at 1,129,582 and is projected to grow
Administration as medically underserved areas. to 1,342,829 by 2030, a 19 percent increase.
• In 2016, the population of Greater Austin, the five-
county surrounding metro area, was estimated to
be 2,056,405.
PRIORITY NEEDS
Mental and behavioral health | Chronic diseases | Primary and specialty care
System of Care | Social determinants of health
16Addressing Community
Community
Partnership Initiatives
Partnerships
Integrated Delivery System: Education for Providers: Dell Medical School
Community Care Collaborative
In 2011, Sen. Kirk Watson, D-Austin, a former Austin
The mission of the Community Care Collaborative mayor, shared a vision of “10 Goals in 10 Years” to
(CCC) is to develop an integrated health care delivery help transform the health and economy of Travis
system for uninsured and underinsured Travis County County. Travis County voters supported this vision
residents living at or below 200 percent of the federal and in 2012 approved a proposition with a property
poverty level. tax increase to support Watson’s goals.
The CCC is a nonprofit organization established The first goal in this vision created Dell Medical
by Seton Healthcare and Central Health in 2013 to School, which opened in July 2016 at The University
provide a unified system approach to safety-net of Texas at Austin (UT Austin). One provision within
health care. By aligning Seton’s hospital-based the proposition ensured that Dell Medical School
system with Central Health’s primary care-based would help Central Health boost the community’s
network of providers, the CCC is able to improve overall health by expanding access, improving
patient outcomes and the efficiency of care. As a care and lowering costs. Dell Medical School
result of the CCC partnership, hospital systems now relies on locally generated tax revenue as well an
care about how patients are managed in the primary annual transfer of $35 million from the Community
care system and vice versa. Care Collaborative, the result of a 2014 affiliation
agreement with Central Health.
The CCC partners with many local organizations,
including local universities, federally qualified health The affiliation agreement between UT Austin and
centers, community-based social service agencies Seton outlines how faculty members, residents and
and other health care partners. The CCC is working students at the Dell Medical School work, train and
with its contracted providers to gather better patient learn at Seton facilities, including a new $300 million
data and analysis, and better understand the health state-of-the-art teaching hospital, which supports the
needs of the entire population. second goal outlined by Watson. Seton has financially
supported graduate medical education in Austin since
Seton provides financial and health care support and 2005, through a series of affiliation agreements,
Central Health, Travis County’s health care district, first with UT Medical Branch in Galveston, UT
provides financial support to the CCC. The CCC is Southwestern in Dallas, and then UT Austin and
focused on developing an integrated delivery the Dell Medical School. As part of an affiliation
system to: agreement with UT Austin and the UT System,
Seton committed to continue its substantial financial
• manage care coordination; support for the residents, faculty and overhead of the
• upgrade technology; new medical school.
• improve system efficiency; and
• focus on illness prevention, disease management
and health promotion.
17GIS Mapping: Children’s Optimal Health
In 2008, Seton led an effort, along with 12 other
community agencies and organizations in Austin,
to create Children’s Optimal Health (COH). These
partners reflect the diverse organizations that
affect outcomes for children including health care,
“ The ability to use
individual residence
data allows COH to
housing, education, economic development and
social and emotional development. This collaborative
create neighborhood
approach allows the members to take a closer look at
determinants of health and the disparities in access
maps and identify
to health care and social services that are creating
significant barriers to the health and well‐being of concentration areas
children and their families.
known as hot spots.
“
The mission of COH is to use geographic information
system mapping to help communities visualize the
health of their neighborhoods, identify assets and
needs and discover opportunities for collaborative
change. The purpose of these efforts is to: All maps are approved by an expert Scientific Advisory
Committee made up of physicians, school officials,
• Improve operations direct service providers, researchers and academics,
• Influence policy and the data owners.
• Encourage research
• Mobilize the community
A geographic information system (GIS) and related
spatial analysis methods are instrumental tools
for describing and understanding changes in a
community‘s landscape, including the delivery and
utilization of health care services. As visual images,
maps can overcome language barriers and offer a
powerful communication tool. COH utilizes GIS to
map proprietary, de‐identified data acquired through
data-sharing agreements with more than 14 Austin
area education and health entities. The ability to
use individual residence data allows COH to create
neighborhood maps and identify concentration areas
known as hot spots (see map in column 2).
Once hot spots are identified, COH can create
drill‐down maps and take a closer look at contributing
factors. Community asset data (such as food,
schools, parks, health care and transportation),
demographic data (such as socio‐economic
status and race/ethnicity) and other community
characteristic data (such as crime rates) can be
overlaid, giving a fuller picture of both positive and
negative contributing factors.
Image courtesy of Children’s Optimal Health
18The maps provide a data-driven picture easily Seton’s Clinical Education Center:
understood by a wide variety of audiences. Topics Skills and Simulation Lab
analyzed have included obesity, behavioral health,
substance abuse, asthma and child injuries related As the largest simulation facility in Central Texas,
to transportation, child maltreatment and housing. Seton’s Clinical Education Center (CEC) plays a
The COH collaboration results in breadth, depth critical role in health care education. The CEC
and quality that is cross‐cutting across contributors includes a hands-on simulation environment that
to health and well‐being, as well as across service provides opportunities for nurses, physicians and
providers. The maps provide an evidence-based other medical professionals to experience real-life
representation that can be easily understood by all hospital settings. Some of the features that make
and which have been used to stimulate targeted the facility unique are the interactive mid- to
action, support service providers with information high-fidelity manikins, rooms with audio and visual
that can be incorporated into grant funding proposals, capabilities and more than 150,000 square feet of
and evaluate and monitor interventions. education space.
Once projects are completed, a community summit The goal of the CEC is to expand medical education,
is held in most cases to present the information to improve patient outcomes and provide collaborative
the community and engage action partners in the education opportunities. Seton’s simulation lab
planning process for prevention and intervention for includes four 10-bed skills labs, eight group
a given neighborhood. Community summits bring simulation labs, four debriefing rooms, 12 training
together subject matter experts, parents, educators, rooms, two computer labs, one simulated hospital
health and social service providers, neighborhood unit with 22 total individual patient rooms, two
advocacy groups and others to find solutions and exam rooms and a medical library.
determine next steps for action and implementation.
The Clinical Education Center is the result of
a academic collaboration with Seton, Austin
Community College, Concordia University, Texas
Tech University, the University of Texas at Austin
and other community partners. Students and
clinicians regularly use the simulation lab to
reconstruct the concept of deliberate practice of
medical skills before delivering patient care.
In summer 2016, the CEC created the Seton Health
Sciences Interactive Camp to provide an opportunity
for middle school and high school students to
learn about careers in health care. During this
interactive camp, participants engage in hands-on
clinical simulation and can become certified in
cardiopulmonary resuscitation (CPR). In June 2017,
more students participated in this exciting, hands-
on experience. The goal is to prepare tomorrow’s
health care professionals today.
Photo courtesy of Seton Healthcare
19Impact Lessons Learned
• The Community Care Collaborative formalized a Collaboration can transform a fragmented
plan for coordination of the integrated delivery approach into one that is person centered, less
system and initiated work outlined in the plan. costly and of high quality.
The CCC also initiated development of a new
benefits plan for low-income residents (up to The Community Care Collaborative understands
375 percent of the federal poverty level) in Travis the importance of shared risk among
County. stakeholders, and leverages the sharing of risk
to bring collaborators together and incentivize
• In 2016, Children’s Optimal Health continued them to work together to accomplish expansive
work with Dell Children’s Medical Center by and ambitious goals.
mapping reports of child maltreatment. COH
has continued assessment mapping and metrics Combining data from multiple sources and
for the Go! Austin/Vamos! Austin programs. sectors can leverage information for the
COH completed mapping of 2014-2015 Austin community’s benefit in ways no single member
Independent 33 Community Collaboration organization can. The insights gathered by
School District, completed obesity projects for analyzing data from multiple sources can also
the Pflugerville Independent School District and help organizations improve their effectiveness in
Round Rock Independent School District, and delivering services that significantly improve the
held a summit in collaboration with the Youth health of the community’s population.
Substance Abuse Prevention Coalition.
• The collaboration to create a new medical school,
teaching hospital and health innovation district is
“
estimated to create 16,000 new jobs and provide
a lift of $2 billion to the local economy.
Contact
Ingrid Taylor The collaboration to
Grant Acquisition
Seton Healthcare Family create a new medical
(512) 324-5915
iktaylor@seton.org school, teaching
hospital and health
innovation district is
estimated to create
16,000 new jobs.
20Sharp HealthCare
San Diego, California
Community Description
Story Population
San Diego County is the second largest county in Sharp Grossmont Hospital serves the east region of
California, with a population of 3.2 million people. It San Diego County, and approximately 5 percent of
is a diverse region, with 33 percent of the population the population lives in remote or rural areas.The per
identifying as Hispanic. San Diego County borders capita income of San Diego County’s east region is
Mexico to the south. The population is expected to lower than the county overall, and this region also has
grow more than 4 percent in the next five years, with the highest population of residents over 65 years of
the highest population growth among those over 65 age. Sharp Grossmont Hospital, a 528-bed hospital,
years of age. While San Diego is generally known has one of the busiest emergency departments in
for its temperate weather and beautiful beaches, San Diego County, with nearly 107,000 visits annually.
the region also faces significant rates of poverty and In fiscal year 2016, Sharp Grossmont Hospital spent
homelessness. $98.5 million on community benefit programs and
services. Approximately 41 percent of patients are on
Sharp HealthCare (Sharp) is a not-for-profit, seven- Medi-Cal.
hospital health care system located in San Diego
County, serving the entire region. It is the primary Food insecurity is a significant problem in San Diego
safety-net system for the region. An integrated County, with 13 percent of the population qualifying
system, Sharp is the largest private employer in San as food insecure. This means 1 in 8 San Diegans and
Diego, with four acute care hospitals, three specialty 1 in 5 children qualify as food insecure.
hospitals and 22 primary and specialty clinics. Sharp
also has a health plan with 136,000 members.
The health care system has 29 percent of market
share in San Diego County and 35 percent of
Medi-Cal market share in the region.
PRIORITY NEEDS
Mental and behavioral health | Cardiovascular health | Diabetes (type 2) | Obesity | Senior health
21Addressing Community
Partnership Initiatives
Community
Partnerships
Sharp Grossmont Hospital recognizes that the health 3. Care coordination for vulnerable populations,
and social needs of its community are intertwined, including military members and veterans,
and that to improve health it needs to build a people with chronic health conditions, and those
network of services and providers around its most with complex barriers to access
vulnerable patients. The hospital does this through
its Care Transitions Intervention (CTI) program, which This tiered approach and responsiveness to
includes multiple internal and external partnerships. community needs allows 2-1-1 San Diego to
Especially strong collaborations are with two primary provide person-centered services. 2-1-1 San Diego
partners: 2-1-1 San Diego and Feeding San Diego. maintains records for each person who dials in, so
they have consistent records about their clients
2-1-1 San Diego and can do a deeper level of care planning and
provide individualized referrals and track progress.
2-1-1 San Diego is a resource and information hub Recognizing it cannot measure success by the
that connects people with health and social services. number of calls, 2-1-1 San Diego does closed-loop
2-1-1 San Diego evolved from the United Way of San referrals to know the outcome of the referrals.
Diego County’s information and referral program,
INFO LINE, which originated in the 1970s; eventually
2-1-1 San Diego is also innovating how it does its
the Federal Communications Commission designated
work. For example:
the 2-1-1 dialing code for community information
centers across the nation, allowing INFO LINE to • Handles screening and enrollment by phone for
secure the three digit dialing code to become a public SNAP/CalFresh benefits
utility. 2-1-1 San Diego, using an entrepreneurial • Sends out healthy eating outreach postcards,
approach, provides a more robust level of services then follows up with an outbound dialing
and assistance than is typically offered by information campaign
and referral organizations. Available 24/7 with a
web database and contact center, 2-1-1 San Diego • Has breast health specialists among the referral
assesses for needs and then connects individuals staff to screen for mammograms
with closed-loop referrals to housing, health, food • Includes new screening questions so people
and other services for which they may be eligible. can be referred to other programs for which
2-1-1 San Diego has a staff of 130 who are able to they may be eligible, such as health care
respond to questions in more than 200 languages. coverage
• Spearheads social service client information
2-1-1 provides service in three tiers depending on the
data-sharing technologies
needs of the individuals:
1. General information and referral
2. Information and assistance (e.g., benefit
enrollment services—secures electronic and
telephonic signatures to speed up application
completion)
22Feeding San Diego
Established in 2007, Feeding San Diego is the leading manage care at home for Medicare fee-for-service
hunger-relief organization in the county, providing patients after discharge. CCTP used an evidence-
21.2 million meals in 2016, and it is the only Feeding based coaching model and eventually added
America affiliate in the region. Feeding San Diego pharmacy and social services to the model. The goal
provides food and resources to a network of more was to reduce readmissions among the participating
than 225 distribution partners serving 63,000 Medicare fee-for-service patients.
children, families and seniors each week. Focused
on healthy food, education and advocacy, Feeding The success of the CCTP program led Sharp
San Diego is building a hunger-free and healthy San Grossmont Hospital to create the CTI program for
Diego through innovative programs and collaborative its vulnerable patients of all ages. Because patients
partnerships. Feeding San Diego is deliberately and family caregivers are essentially their own care
partnering with health care and hospitals around coordinators, they need help – coaching – to get
food insecurity. through all the coordination of transitioning to being
at home and ensuring that they receive the resources
Sharp Grossmont Hospital’s Care Transitions to keep them healthy and out of the hospital. The
Intervention (CTI) Program is the focal point of the hospital conducts patient risk assessments that
collaboration with 2-1-1 and Feeding San Diego. include biometrics as well as the social determinants
Recognizing that they cannot achieve health without of health. Each patient is given a paper “personal
addressing the social determinants of health, the health record” that includes questions about having
three organizations are working to bridge the gap enough food and transportation to appointments.
between social services and health services for CTI coaches are trained in motivational interviewing
patients discharged from the hospital. The CTI model and advanced care planning.
is based on a Center for Medicare & Medicaid
Services (CMS)-funded program, the Community- Additionally, Sharp redesigned its revenue cycle team
based Care Transitions Program (CCTP). CCTP was a to include public resource specialists and
collaboration among four health systems—Sharp, UC financial counselors who meet with the patient
San Diego Health, Scripps Health, Palomar Health— within 24 hours of admission. Team members help
to stimulate “collaboration among competitors” patients procure what they need to apply for Medi-
as well as community nonprofits. The goal was to Cal and work with them until a decision is made;
if need be, they help with the appeals process.
The team developed a tool so that people can get
“presumptive” approval for Medi-Cal and then get
their medications after discharge from the hospital.
Further, the Patient Financial Services team at
Sharp Grossmont Hospital worked closely with
the CTI program to evaluate patients for CalFresh/
SNAP (Supplemental Nutrition Assistance Program)
benefits prior to hospital discharge, dramatically
increasing the likelihood that patients complete
CalFresh applications and receive benefits. In
fiscal year 2016, the team completed 227 CalFresh
applications, and 125 patients were granted CalFresh
Photos courtesy of Sharp HealthCare
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