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].
Archives: Stories
Story article on health-related topics.
Ohio Correctional Health Project
The Ohio Correctional Health Program (Ohio Offender Project) helps offenders who are preparing to be released from prison develop a transition of care plan to ensure their health needs are met as they re-enter society. The Ohio Department of Medicaid and Department of Rehabilitation and Corrections partnered with all participating Medicaid managed care organizations, the Ohio Department of Health, and the Department of Mental Health and Addiction to begin this program in 2014. Offenders who have two or more infectious or chronic health conditions are eligible to be matched with a peer mentor (peer mentors are offenders who have long-term sentences) who assists them with a Medicaid application and selection of a health plan. The chosen health plan works with the offender to develop a transition of care plan to ensure access to needed care, medication, and assistance with food, shelter, or safety issues, and access to community-based transition services. One goal of this program is to reduce Ohio’s 26 percent recidivism rate by helping released offenders manage chronic health or mental health conditions. The expenses for this program are financed as part of the health plan’s Medicaid capitation rate (administrative dollars). To read more about this innovative program, see this brief summary [link]
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].
New York City Macroscope
In 2013, the New York City Department of Health and Mental Hygiene launched NYC Macroscope, a program that uses aggregate data from primary care providers to estimate the prevalence of selected health conditions in New York City. Using data from electronic health records, the goal is for estimates to efficiently and cost-effectively characterize the burden of disease in New York City and changes in that burden over time. The Department of Health and Mental Hygiene, in partnership with the City University of New York School of Public Health is gathering the data from over 700 ambulatory care practices across the city. This program is funded by the deBeaumont Foundation; the Robert Wood Johnson Foundation; the Robin Hood Foundation; the Doris Duke Foundation; the New York State Health Foundation; and the Centers for Disease Control and Prevention. 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].
Molina Healthcare Community Connectors
Molina Healthcare serves Medicaid, Medicare, CHIP, Marketplace, and dual-eligible plans in multiple states. In 2004, Molina Healthcare began leveraging community health care workers known as Community Connectors to engage and empower Molina members to achieve better health outcomes. By partnering with state Medicaid organizations and other community partners, Community Connectors serve as liaisons between patients and clinicians, assessing needs and assisting the treatment team with coordinating members’ care. They coach members to self-manage their chronic conditions, connect them to basic community resources (e.g., food, shelter and safety) and more traditional health-related social services, and advocate on their behalf. Community Connectors are familiar with the community and the available resources that can help members improve their health. In New Mexico, the program has demonstrated a savings of $4,564 per enrollee through reduced emergency department use, days of inpatient care, and substance abuse. The program is funded by Molina Healthcare. 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].
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].