In 2012, Nemours, an integrated pediatric health system, implemented a dynamic approach to managing pediatric asthma in children throughout Delaware’s major cities and on behalf of the 42,000 children in surrounding zip codes. The model of care addresses broader system issues by using an integrator function—convening multisector partners in support of a shared goal, led by community health worker leadership, a patient-centered medical home, and optimal technology to treat pediatric asthma in the state. Key partners include: state-based chapters of the American Lung Association; state/local housing and public health departments and stakeholders; the U.S. Department of Housing and Urban Development; leadership councils; as well as other coalitions and community-based partners. Between 2012 and 2013, early findings from the Nemours’ self-monitoring plan indicate that emergency department visits to the Nemours Alfred I. DuPont Hospital for Children for asthma registry patients decreased by more than 40 percent. Nemours is funded by a Center for Medicare & Medicaid Innovation’s Health Care Innovation Award. To read more about this innovative program, see this brief summary [link].
Issue Category: Child and School Health
New York State Prevention Agenda 2013–2017
The New York State Public Health and Health Planning Council—a group made up of more than 140 organizations across New York—developed the New York State Prevention Agenda 2013–2017 at the request of the Department of Health. The Council, a collaboration of health departments, state agencies, providers, health plans, community-based organizations, academia, advocacy groups, schools, and employers, developed this plan to demonstrate how communities across the state can work together to improve health and quality of life. The Prevention Agenda serves as a guide to local health departments and hospitals as they develop their community health assessments. Statewide and local planning organizations provide technical support to local communities that are collaborating to assess needs and develop local implementation plans, with support from the Robert Wood Johnson Foundation. The New York State Health Foundation provides grants to organizations that help local health departments and their partners advance the goals of the Prevention Agenda. To read more about this innovative program, see this brief summary [link].
Nemours Children’s Health System
Nemours is an integrated pediatric health system committed to improving the health of children. Established in Delaware in 2004, Nemours Health & Prevention Services were first created to help children grow up healthy by integrating treatment and prevention of illness. They work with community partners to influence policies and practices to improve children’s health. Through family-centered care in children’s hospitals and clinics in Delaware, New Jersey, Pennsylvania, and Florida, as well as world-changing research, education, population health, and advocacy, Nemours fulfills the promise of a healthier tomorrow for all children — even those who may never enter the doors. The work is financed by Nemours operating budget and with limited external grants. To read more about this innovative program, see this brief two-page summary [link].
Live Well San Diego
In 2010, the San Diego County Board of Supervisors adopted Live Well San Diego, a 10-year plan to advance health, safety, and well-being of the region’s more than three million residents. The County’s partners include cities and tribal governments; diverse businesses, including health care and technology; military and veterans organizations; schools; and community and faith-based organizations. The initiative has four strategic approaches: building a better service delivery system; supporting positive choices; pursuing policy and environmental changes; and improving the culture Ten indicators have been identified to capture the overall well-being of residents. The initiative now has three components: Building Better Health, Living Safely, and Thriving. Funding began in 2010 with a $16 million Communities Putting Prevention to Work (CPPW) Federal Grant Award. In 2010, Live Well San Diego also received a five-year grant from the Centers for Disease Control and Prevention National Public Health Improvement Initiative. In 2011, they received a five-year, $15 million Community Transformation Grant. To read more about this innovative program, see this brief summary [link].
Live Well Omaha
Initiated in 1995, Live Well Omaha (LWO) is a community-led collaborative created out of a shared concern that no one organization in the community has the capacity to solve health disparity issues alone. With a focus on healthy eating and active living, and an interest in obesity prevention, LWO has more than 40 active partners from a variety of sectors—public/private organizations, nonprofit, businesses, educators, health systems, and insurance companies. As a result of LWO’s work, childhood obesity rates have been held constant in the Omaha community (from 2008 to 2012); 30 municipal bike-sharing stations have been created; the employer community has embraced healthy vending; and more than $7 million of investment funding has been brought into the Omaha metro area. LWO is funded by the Robert Wood Johnson Foundation and the Centers for Disease Control and Prevention Communities Putting Prevention to Work and Community Transformation Grants. To read more about this innovative program, see this brief summary [link].
HelpSteps
HelpSteps is an online assessment and referral system for families’ and individuals’ social determinants of health. It began as a research project in 2003 and became a fully implemented referral system in 2007. The online system assesses needs in 13 broad social domains and provides access to resources related to over 100 social problems that affect lower socioeconomic families, including services related to food insecurity, housing, and income resources. The system is used by a variety of social services in the Boston area, including the Boston Public Health Commission, The Mayor’s Health Line, and medical and free clinics throughout the area. HelpSteps findings include: 82 percent of families in urban clinics experience at least one type of social problem in a given year; families are interested in assessment referrals; 40 percent of individuals who selected referrals followed up with one of their selections; 52 percent said their problem had either completely or mostly resolved; and 80 percent stated they would like to use the online tool as part of an annual assessment. HelpSteps receives funding from the Boston Children’s Hospital, the Boston Public Health Commission, and small grants. To read more about this innovative program, see this brief summary [link].
Health Resilience Program™ of CareOregon
CareOregon has developed a new model of Community-Oriented Primary Care that travels beyond the four walls of the medical office practice. The initiative “takes health to the people” reaching into the community where the city’s most vulnerable residents live. Care is provided by Health Resilience Specialists (HRS) who are master’s level ‘engagement specialists’ tasked with developing meaningful partnerships with a panel of high-acuity/high-cost patients to enable wellness and stability in their lives. This approach not only reduces the total cost of care but enhances patient experience and outcomes. CareOregon’s six programmatic principles of trauma-informed care include: reducing barriers; providing client-centered care; increasing transparency; taking time and building trust; avoiding judgement and labels; and providing care in a community-based setting. CareOregon receives its funding from public programs such as Medicaid, Medicare, and the State Children’s Health Insurance Program. To read more about this innovative program, see this brief summary [link].
Get Healthy Philly
“Get Healthy Philly” is an initiative of the Philadelphia Department of Public Health that brings together government agencies, community-based organizations, academia, and the private sector to address obesity and smoking in Philadelphia. The organization is making great strides toward a healthy Philly through actions including: designating nearly 12,000 acres of new smoke-free spaces; passing a $2 per pack tax increase on cigarettes; establishing school nutrition standards; menu labeling; and working with food retailers to promote healthy food sales. Accomplishments over the past four years include a 15 percent reduction in smoking among adults, a 30 percent reduction in smoking among youth, and a 5 percent reduction in childhood obesity. The initiative is supported by local, state, and federal funding, including the Centers for Disease Control and Prevention through the Prevention and Public Health Fund and the Pennsylvania Department of Health. To read more about this innovative program, see this brief summary [link].
Community Assessment Project
The Community Assessment Project (CAP) is a broad-based collaborative of the United Way of Santa Cruz County, California that jointly conducts community health needs assessments and publishes an annual countywide community indicators report. The report, first introduced 20 years ago, serves as the community health needs assessment for local nonprofit hospitals and includes indicators in six domains: economy, education, health, public safety, natural environment, and social environment. The CAP also conducts a bi-annual quality-of-life survey of the County’s households. A sampling of the goals in 2015 include: improvement in access to primary care; comprehensive health care coverage for children; and a decrease in the prevalence of childhood obesity. Annually, CAP measures and reports progress toward its goals. For example, in 2007, the Healthy Kids Insurance Program achieved 98 percent insurance coverage for children in Santa Cruz County. CAP is funded by local hospitals, city and county governments, utility companies, colleges, and non-profit organizations. To read more about this innovative program, see this brief summary [link].
Come to the Table
ohiSince 2009, ProMedica’s, “Come to the Table” program has been working to ensure the well-being of communities in northwest Ohio and southeast Michigan by creating services and programs addressing basic nutritional needs. The link between hunger and poor health is clear—adults living in food insecure homes have chronic diseases and behavioral health conditions. Food-insecure children suffer an even greater impact with delayed development and poorer quality of life. Health threats resulting from hunger are preventable and ProMedica continues to develop and implement strategies to feed communities including: operating a food reclamation program to repackage un-served food and distribute to homeless shelters; developing a food security screening program to identify hospital patients who are food insecure to ensure they have food and access to resources upon being discharged from the hospital; and the future opening of the Ebeid Institute for Population Health in Toledo, Ohio, which will have a fresh food market and offer job training and health services. ProMedica’s strong community partnerships at the local, state, and federal levels are central to developing these collaborative opportunities. To read more about this innovative program, see this brief summary [link].