Case Studies - Hospital-Community Partnerships to Build a Culture of Health: American Hospital Association

Case Studies - Hospital-Community Partnerships to Build a Culture of Health: American Hospital Association
Hospital-Community Partnerships
to Build a Culture of Health:

A Compendium of

Case Studies - Hospital-Community Partnerships to Build a Culture of Health: American Hospital Association
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

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Case Studies - Hospital-Community Partnerships to Build a Culture of Health: American Hospital Association
 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

Case Studies - Hospital-Community Partnerships to Build a Culture of Health: American Hospital Association

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.

Case Studies - Hospital-Community Partnerships to Build a Culture of Health: American Hospital Association
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.

Case Studies - Hospital-Community Partnerships to Build a Culture of Health: American Hospital Association
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.

Case Studies - Hospital-Community Partnerships to Build a Culture of Health: American Hospital Association
                   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 ( houses and             collaborative’s community health needs assessment.

Case Studies - Hospital-Community Partnerships to Build a Culture of Health: American Hospital Association
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.

Case Studies - Hospital-Community Partnerships to Build a Culture of Health: American Hospital Association
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              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

Case Studies - Hospital-Community Partnerships to Build a Culture of Health: American Hospital Association
LifeBridge Health

Baltimore, Maryland
Community Description
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.
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

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

Baltimore City Life Expectancy by Community Service Area and
  Baltimore City Mortality by Age (Less than 1 Year Old), 2013
                 Cheswolde                                                                                                               Loch Raven
                                                Mt. Washington/                                                    Park/
                                                  Coldspring                Greater
                                                                          Roland Park/                           Belvedere
                                                                           Poplar Hill          N. Baltimore/
           Glen-Fallstaff                                                                         Guilford/
                                  Pimlico/                                                                                                                                       Hamilton
                                 Arlington/                                                      Homeland
                                            Southern                                                                                                            Lauraville
                                           Park Heights
   Howard Park/                                                     Medfield/Hampden/
   West Arlington                                                  Woodberry/Remington                                                                                              Cedonia/
                             Ashburton                                                                                                                                              Frankford

                                                                                                       Greater The Waverlies
                                                                                                       Village/                                      Belair-Edison
                                                                      Penn North/
                                                                      Reservoir Hill
                       Forest Park/       Greater Mondawmin                                                      Midway/
                        Walbrook                                                                                Coldstream
     Dickeyville/                                                                                                                                                               Claremont/
    Franklintown                                                                                                        Greenmount             Clifton-Berea                    Armistead

                                              Greater Rosemont                   Upton/Druid          Midtown
                       Edmondson                                      Sandtown-                                                                  Madison/
                         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

                                                Morrell Park/                                                        South Baltimore                                         Southeastern


                                                                                               Cherry Hill

                                                                                                                                                Curtis Bay/
                                                                                                                                               Hawkins Point

Life Expectancy at birth, in years
 by Community Statistical Area, 2013
         66.0 - 69.5 years Ranked into quintiles

         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                                                                                                                                                                                      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

Community 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

care 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
individuals 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                                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

Seton 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

Addressing Community
Partnership Initiatives

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.

GIS 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

The 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

Impact                                                      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.

Ingrid Taylor                                              The collaboration to
Grant Acquisition
Seton Healthcare Family                                   create a new medical
(512) 324-5915                                             school, teaching
                                                            hospital and health
                                                           innovation district is
                                                            estimated to create
                                                              16,000 new jobs.

Sharp 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

Addressing Community
Partnership Initiatives

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

Feeding 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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