UnitedHealthcare Community & State has also developed a partnership to improve housing stability and conditions for beneficiaries. By partnering with a local homeless coalition in Ohio, they are better able to locate members who are homeless or precariously housed, facilitate supportive housing placement, and engage the care coordination team to connect members to community-based support services. In addition, the Ohio plan is partnering with a supportive housing development with a significant concentration of UnitedHealthcare members to better connect housing managers and social workers with the managed care coordination team. The goal of these partnerships is to provide stable and healthy housing since evidence demonstrates a clear linkage between housing stabilization and reduction in emergency rooms visits, inpatient admissions, and crisis services. To read more about this innovative program, see this brief summary [link].
Issue Category: Health Equity/Social Determinants of Health
UnitedHealthcare Health Teams With Community Health Workers
UnitedHealthcare Community & State is a Medicaid managed care organization operating in 26 states. It has incorporated community health workers into its health team to help members with complex needs who also experience barriers with access to care—to connect them to behavioral, medical, and social supports. Community health workers build rapport and trust with patients, teach them how to utilize the health care system (e.g., the importance of the primary care provider relationship and appropriate use of the emergency department), and connect patients to nonclinical community-based resources to address the social determinants of health. For example, the community health worker may accompany the patient to a primary care visit and help them find resources in the community to better manage their chronic conditions. The community health worker role contributes to improved health outcomes, member experience, and improved efficiencies. Augmenting the traditional health care workforce with community health workers also allows licensed staff to work at the top of their licensure. To read more about this innovative program, see this brief summary [link].
St. John’s Wellchild and Family Center
Since 1996, St. John’s Wellchild and Family Center (SJWCFC), a FQHC network in California, has been working to reduce the negative impacts of substandard housing on health. When first launched, SJWCFC and Esperanza Community Housing Corporation worked together on lead poisoning prevention. From 1996 through 2003, Strategic Actions for a Just Society joined the collaborative to collect data about the health impact of substandard housing to influence state and local policy. In 2009, Healthy Homes Healthy Kids joined with a comprehensive approach around home visits, health program enrollment, medical homes, advocacy, and policy development. Highlights of collaborative outcomes include: 100 percent decrease in asthma hospitalizations; 100 percent decrease in missed work days by parents; 80 percent reduction in percent of clients with asthma ER visits; 69 percent reduction in the percentage of children missing one or more days of school due to asthma; and 69 percent reduction in clinic/doctor visits due to acute asthma attacks. SJWCFC is funded by British Petroleum Settlement/Air Quality Management District Funds, First 5 Los Angeles, EveryChild Foundation, Housing and Urban Development Agency, and Kresge Foundation. To read more about this innovative program, see this brief summary [link].
Priority Spokane: Educational Attainment
Priority Spokane: Educational Attainment is a collaboration of community leaders serving as a catalyst and convener for data-driven improvements within Spokane Public Schools (SPS) in Washington. In the 2005–2006 academic year, SPS had a graduation rate of 57.7 percent (the county rate was 69.2 percent). Following the release of a community assessment in 2009 revealing educational attainment as a top priority of the community, Priority Spokane conducted a series of studies identifying model practices to improve education along with student risk factors for dropping out. Working with resources committed by school superintendents, business leaders, college and university presidents, elected officials, and others in the community, many of those model practices have been put into practice. These practices include: professional training on childhood trauma; a school Early Warning System weighted by student risk factors and aligned with community services; and a STEM Education network providing hands-on learning. In the 2012–2013 academic year, the SPS graduation rate improved to 79.5 percent, almost even with the county rate of 80.8 percent. Priority Spokane has had over $800,000 of funding provided by local and state foundations during a five-year period with partners providing extensive support to the projects. To read more about this innovative program, see this brief summary [link].
Partnership for a Healthy Durham
Partnership for a Healthy Durham is a collaboration on health initiatives that began in 2004. The Partnership, comprised of 475 coalition members, includes government agency and organizational leaders as well as community members. Every three years the Partnership conducts community health assessments to determine and set health priorities for the city. The 2011 assessment identified the following three social determinants as critical to improving health outcomes for residents of Durham: poverty, homelessness, and education/workforce development. As a result of the assessment, social determinants have been integrated into community policies, projects, and plans. Additionally, a pilot medical respite for the homeless has been established and a task force has been developed to create a pipeline of education and training opportunities for local high school students to gain employment. Support for the Partnership comes from local county government with additional funding from grants that support projects. To read more about this innovative program, see this brief summary [link].
Optimizing Health Outcomes for Children with Asthma in Delaware
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].
Maryland Model for Hospital Payment
In 2014, Maryland and the Center for Medicare & Medicare Innovation (CMMI) negotiated a waiver that established a per capita expenditure rate for Medicare hospital services and a limit on the growth of inpatient and outpatient hospital costs for all payers to 3.58 percent. The waiver projects Medicare savings over five years to be $330 million. To implement the model, the state rate-setting commission will replace fee-for-service models with population-based payment models that reward providers for improving health outcomes, enhancing quality, and controlling costs. Although the new model has just been introduced, several early adoptees of the new payment models have observed significant reductions in preventable hospitalizations. With these new incentives, hospitals are expected to form more creative partnerships with public health agencies, community health organizations, and long-term care providers. 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].
Health Leads
Health Leads, operated by lay resource specialists and college student volunteers, is a collaborative comprised of partner hospitals, health systems, community health centers, and Federally Qualified Health Centers (FQHCs) working together to integrate basic resources such as access to food, heat, and other necessities into health care delivery. Operating via clinical settings since 1996, this initiative enables providers to prescribe solutions to patients helping them manage their disease and lives. The impact of Health Leads is two-fold. The program expands clinics’ capacity to secure nonmedical resources for patients— in 2013, 92 percent of patients identified that Health Leads helped them secure at least one resource they needed to be healthy. Additionally, Health Leads is producing a pipeline of new leaders—in 2013, nearly 70 percent of Health Leads graduates entered jobs or graduate study in the fields of health or poverty. Health Leads sustainability model utilizes earned revenue, national and local philanthropy, and in-kind contributions from volunteers and health care partners to fund its operation. To read more about this innovative program, see this brief summary [link].