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].
Issue Category: Prevention and Public Health Policy
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].
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].
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].
District of Columbia Healthy Communities Collaborative
DC Healthy Communities Collaborative—a collaborative of community health leaders and organizations—formed in 2012 to assess and address the community health needs in the Washington, D.C. area. The Collaborative works in four key areas identified as community health needs in the D.C. area: asthma, obesity, sexual health, and substance abuse/mental health. To date, the Collaborative has conducted a community health assessment identifying health needs within the D.C. area and produced a community health improvement plan with strategies to address the aforementioned health needs. D.C. Healthy Communities Collaborative is funded by member contributions. To read more about this innovative program, see this brief summary [link].
Dignity Health’s Community Health Investments
For more than 20 years, Dignity Health, a health care provider in multiple states, has been investing in the health of the communities it serves through community benefit programs and community economic initiatives, including grants and low-interest loans to nonprofits addressing community needs. Investments are targeted to populations with disproportionate unmet health needs as identified through the community health needs assessment and a Community Need Index developed by Dignity Health. Since 1990, Dignity Health has awarded more than $51 million in areas such as prevention, HIV/AIDS services, behavioral health services, and improving access to care. The Dignity Health Community Investment Program has had a total loan volume of $143 million, benefiting the community-based health programs of California, Nevada, and Arizona including: providing affordable housing for seniors; access to shelters for the homeless discharged from community hospitals; and healthy food projects. To read more about this innovative program, see this brief summary [link].
Dallas Information Exchange Portal
The Dallas Information Exchange Portal (IEP) is an electronic platform which enables health care providers, community based organizations, and social service agencies to share medical and social information via a secure network. Through patient-authorized, secure two-way exchange of information, IEP is improving care transitions and increasing coordination of care around both clinical and social issues like homelessness, hunger, and substance abuse. The ultimate goal of the program is not only to improve clinical outcomes and measures, but also generate significant cost savings to health systems. The initiative began in 2014 with a $12 million grant from the W.W. Caruth, Jr. Foundation at Communities Foundation of Texas. To read more about this innovative program, see this brief summary [link].
Cultivating Health for Success
Cultivating Health for Success (CHS) established in 2010, focuses on the inclusion of safe, affordable, and supportive housing to reduce unplanned care, improve adherence to recommended treatment, and improve health care cost and outcomes as well as quality of life for participants in greater Pittsburgh. CHS serves adults with one or more chronic illnesses and those with a history of at least one year of above average use of unplanned care, such as crisis services, Emergency Department visits, and the homeless. To deliver services, CHS partners with the Allegheny County Department of Human Services, Metro Family Practice, Community Human Services, UPMC for You, and the Community Care Behavioral Health Organization. Since CHS’s inception, per-member per-month (PMPM) medical costs have decreased 11.5 percent, the average PMPM for unplanned care has decreased by 19.2 percent, and the average prescription PMPM increased by 5.2 percent for participants with a meaningful tenure in the program. CHS is funded by UMPC for You contributions. To read more about this innovative program, see this brief summary [link].