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].
Archives: Stories
Story article on health-related topics.
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].
Corporation for Supportive Housing
The Corporation for Supportive Housing (CSH) provides capital, expertise, information, and innovation to transform how communities use housing solutions to improve lives of vulnerable populations. Founded in 1991 and headquartered in New York City with staff stationed in more than 20 locations throughout the country, CSH’s work focuses on capacity-building, policy and advocacy, supportive housing technical assistance and housing development, and demonstrating pilot initiatives to build evidence. One of CSH’s most effective pilots is the Frequent Users of Health Services Initiative, a six-year, $10 million pilot that sought to deliver innovative, integrated approaches to meet the health, housing, and social service needs of frequent users of emergency departments and inpatient hospitalization. Program results included a 27 percent drop in inpatient hospitalization versus a 26 percent increase for those not connected to housing. In addition, those in supportive housing experienced a 34 percent drop in emergency room visits compared to only a 12 percent drop among those not in supportive housing. In 2011, CSH was awarded $2.3 million over two years by the federal Corporation for National and Community Service and is using these funds to invest in supportive housing models that provide cost-effective solutions for people with complex health needs and facing housing crises. CSH funding comes from a mix of roughly 150 foundations, corporations, public agencies, investment income, and gifts from individual donors. Read the summary brief to learn more about this innovative program.
Register today for the July 10 webinar, Advancing Health Equity During and Beyond COVID-19: Addressing Housing and Homelessness
CommunityRX: Connecting Health Care to Self-Care
CommunityRX is a new, patient-centered health information technology system that transforms the quality of information about and access to self-care resources, especially in lower-income communities. Through this technology, patients are provided with a personalized HealtheRX referral list for self-care resources to access once they leave the clinical setting. To date, more than 950+ health care professionals have been trained to deliver HealtheRx to over 45,000 patients; 20 clinical sites have implemented this technology; and more than 250 Chicago Public School students and 100 science-oriented college students are employed by CommunityRX to map the health assets in the community. CommunityRX was developed in 2012 and is funded by a Centers for Medicare & Medicaid Services Innovation Award. To read more about this innovative program, see this brief summary [link].
Community Benefit Web Tool Prototype
The Department of Health Policy in the Milken Institute School of Public Health at The George Washington University was awarded a contract by the Robert Wood Johnson Foundation to develop a prototype Web Tool that provides easy access to the community benefit investment information that all nonprofit hospitals must submit annually to the Internal Revenue Service (IRS). The Web Tool will make hospital community benefit investment information easily available to public health experts, community stakeholders, hospital, and policymakers, among others. The Web Tool (to be completed in 2015) will enable users to compare hospital investments in their communities on the basis of factors such as geographic location, community economic status, and hospital characteristics such as size. To read more about this innovative program, see this brief summary [link].