Criteria for Best Practices
- Design and capture elements of a patient’s record based upon integrated care – holistic, spiritual, social determinants and medical care.
- Ensure that there is integration of health information systems of all health systems so patients have a seamless health record.
- Create formal data agreements with health departments, mental health agencies, and various post-acute providers (e.g. skilled nursing facilities, home health) to create consistent patient health records across the continuum.
- Engage the Hospital Association and American Medical Association to advocate for Community Health.
- Redefine geography of where health services are provided—out of the hospital and into the community, with a primary focus on specific areas with disproportionate unmet health needs.
- Create formal relationships with faith-based institutions/congregations and align with clinical and social needs like care transitions, access to care, chronic disease self-management, readmissions, etc.
- Look not just at the needs of patients grappling with disparities, but also at the strengths they bring, creating non-clinical roles where their experiences can assist others (e.g. as chronic disease self-management mentors) as well as promoting education, training and career advancement into clinical roles serving with the community.
Neighborhood Revitalization Program, Bon Secours of Maryland Foundation (BSMF) supports housing assistance and senior housing initiatives designed to sustain strong, stable, and thriving West Baltimore neighborhoods in partnership with Operation ReachOut SouthWest— a coalition of more than 300 community businesses, churches, residents, partner organizations and institutions.
Northridge Hospital Medical Center (part of Dignity Health): supports the Center for Healthier Community to works collaboratively with community partners on a variety of initiatives that include helping victims of sexual assault and domestic violence and another that works with middle school kids in high-risk communities on the benefits of abstaining from sex, drugs and alcohol.
UMASS Memorial Health System/UMASS Memorial Medical Center, Building a Healthy Community in Bell Hill Bell Hill Healthy Community Initiative (HCI) in Worcester, MA, seeks to address root causes of health problems (environmental conditions, access to care, neighborhood revitalization/affordable housing) by helping to build the community’s capacity through strategic investment, skills training and stakeholder engagement. Examples include funding the East Side Community Development Corporation to transform run down/abandoned buildings into affordable ownership and rental prospects for Bell Hill residents, and the youth leadership group, Toxic Busters, which focuses on training youth in environmental testing and advocacy.
Church-Health System Partnership Facilitates Transitions from Hospital to Home for Urban, Low Income African Americans, Reducing Mortality, Utilization, and Costs. AHQR Innovations Exchange: May 31, 2012
The Center for Faith and Community Health Transformation, a joint project of Advocate Health Care and the University of Illinois at Chicago (UIC) Neighborhoods Initiative, was formed to mobilize the unique strengths of faith communities to address the social conditions that impact people’s health.
Integrative Groups Wellness Program Concurrently Reduces Pain and Stress, and Improves Stress-Related Chronic Illnesses: Henry Ford Health System faith-based (and employee group) program that delivers chronic pain intervention and techniques to relieve stress, eliminate pain, and improve related conditions (e.g. high blood pressure, obesity, and sleep difficulty).
St. Joseph Health’s Neighborhood Care Staff (NCS) is a relationship-based community organizing program, created by the hospital and funded out of its operating budget, serving primarily low-income neighborhoods in Sonoma County. Through immersion in the community, the members of NCS identify and support its natural leaders to engage others in working together to improve local quality of life. As a community building-focused program (providing safety forums, community gardens, neighborhood beautification, food access and physical activity opportunities for low-income residents), NCS recognizes the importance of respectful partnership—that authentically engages the diverse perspectives represented in a neighborhood—as a key strategy for achieving sustainably equitable conditions. St. Joseph continues to staff and develop the initiative.
Loma Linda University Medical Center’s Healthy Communities Program and Community Vital Signs is a “stakeholder” led initiative that grew out of a creative approach by the San Bernardino County public health agencies in response to the community health needs assessment. It has shifted the emphasis from being “health care centric” to one focused on all factors that determine health. Community Vital Signs, the coalition of community stakeholders, focuses attention and action on the use of policy and environmental and systems change to improve health. Loma Linda’s Community Health Development office has been lead catalyst to initiative—the coalition facilitator is staffed by the health system.
Methodist Le Bonheur Healthcare and the Congregational Health Network. A partnership with over 500 churches in Memphis, the Congregational Health Network (CHN) supports the transition from hospital to home for church members. Enrolled congregants are flagged by the health system’s electronic medical record whenever admitted to the hospital. A hospital-employed navigator visits the patient to determine his or her needs, and then works with a church-based volunteer liaison to arrange post discharge services and facilitate the transition to the community. The liaisons and clergy members also receive training and other benefits from the health system, thus allowing them to serve as role models and provide education to congregants. The program has reduced mortality, inpatient utilization, and health care costs and charges, while improving satisfaction with hospital care.
Providence Hospital and Joslin Diabetes Center, On the Road Program for community-based diabetes education, field testing and risk assessment will send trained community health workers (CHWs) into the community to help over 3,000 Medicare and Medicaid beneficiaries and low income/uninsured people understand their risks and improve health habits for the prevention and management of diabetes. The goal is to prevent the development and progression of diabetes and to reduce overall costs, avoidable hospitalizations, and avoid the development of multiple chronic diseases. It is also a source of job creation for CHW’s.
Seattle Children’s Hospital, Coalition targets Tobacco Prevention. A 2012 Community Transformation Grant was awarded to the Seattle Children’s Hospital, community partners, Public Health-Seattle and King County and Healthy King County Coalition, to work collaboratively with youth, families and communities on obesity and tobacco control. The partners will work with local governments, schools, hospitals, low-income housing groups, and childcare and youth organizations to implement the changes in communities that will create more smoke-free parks and public housing.
Indiana University Health System, Garden on the Go identified food access as one way to address Indiana’s high obesity rate of over 30% of its population and created Garden on the Go to sell local produce at various community facilities year-round. The mobile truck stops at the same locations—including public housing and senior facilities—and times each week, and local residents can depend on being able to purchase fresh and use with cash, credit cards, or food stamps.
Catholic Health Initiatives (CHI), United Against Violence. In 2008, CHI launched United Against Violence as a formal commitment to violence prevention and provides funding and support to help CHI facilities create or expand violence-prevention programs in their local communities. So far, CHI has provided millions in mission and ministry funds for violence and prevention programs and will continue to do so in coming years. The types of grants aimed at reducing violence focus on child abuse, youth dating violence, gang violence, domestic violence, and community education. Awardees have included Coalition to Prevent Teen Dating Violence In collaboration with the Center for Women and Families, Jewish Hospital & St. Mary’s HealthCare and the “Capacitar for Kids Program” – a holistic component to the Family Violence Prevention Project (FVPP) of the Greater Cincinnati YMCA.
All Children’s Hospital, Johns Hopkins Medicine, Safe Routes to School. The Florida Chapter of Safe Routes to School is led by All Children’s Hospital to encourage children and parents to walk or bicycle to school. They help to organize “walking school buses” and “Bike Rodeos” (skills course), host local participation in international Walk to School Day, and help to facilitate cooperation among school officials, law enforcement and transportation planners. The CDC estimates that one-half of American children do not have a park, community center or sidewalk in their neighborhood.
Henry Ford Health System, Sew Up the Safety Net for Women and Children. Guided by the Detroit Regional Infant Mortality Reduction Task Force, four major health systems serving Detroit (Detroit Medical Center, Henry Ford Health, St. John Providence Health, and Oakwood Healthcare System) created the Sew Up the Safety Net for Women and Children project. The project aims to reduce infant mortality rates in Detroit by working through an unprecedented public-private partnership of Detroit’s major health systems, public health, academic and community partners. The goal is to tighten a loose net of disconnected medical and social services and build a comprehensive, accountable system of care that will engage the residents of three Detroit neighborhoods and improve the conditions that lead to infant survival through the first year of life. To achieve this they will engage community navigators in targeted neighborhoods provide education to health care professional and establish technological relevant support strategies.
Inova Health System, Promotores De Salud Perinatal. The Promotores de Salud Perinatal Community Outreach Program of Inova Health System was created to bridge the existing gap between the Latino/Hispanic community and the health system. Spearheaded by Inova’s Perinatal Outreach Department with the collaboration of Congregational Health Partnership, the program seeks to improve birth outcomes and reduce infant mortality within the Hispanic/Latino community served by Inova and the program’s funder, CareFirst BlueCross BlueShield, in Northern Virginia. The Promotores have been trained in the basics of prenatal care: the importance of folic acid, signs and symptoms of preterm labor and best practices for infant sleep. They also serve as advocates for their community, and link pregnant women and new mothers to patient centered medical homes.
Lutheran Healthcare, Project SAFE trains youth between the ages of 14 and 19 to provide life-saving information to their peers, particularly at-risk youth of color in Brooklyn, through workshops, performances, and community outreach. The project promotes HIV awareness and prevention among youth and provides ongoing HIV/AIDS prevention, education and testing aimed at at-risk youth through youth oriented communication to disseminate information and a peer-to-peer model of outreach and influence. Project SAFE promotes HIV awareness and prevention among youth with three main components: (1) ongoing HIV/AIDS prevention, education and testing aimed at reaching at-risk youth, (2) innovative, youth-oriented technology approaches, which enables instant communication with the target population on HIV-related information and (3) youth peer educators who will outreach, educate and influence other young people with HIV prevention and testing information.
OhioHealth, Wellness on Wheels (WOW) was developed in 1993 as the Project to Reduce Infant Mortality (PRIM). This program provides services to pregnant women ages 12 to 44 in communities identified to have high infant mortality rates. WOW serves schools in central Ohio and reaches populations that need it most by offering patients five clinic locations per week.
OhioHealth also partners with Project Hoffnung: The Amish & Mennonite Breast Health Project, which was created in 1997 to help provide cancer outreach programs to Amish and Mennonite communities. Project Hoffnung (which means hope) identifies with the common language of many Amish and Mennonite communities to provide a bridge between the respected beliefs of these cultures and modern advances in breast cancer care. Project Hoffnung serves the entire state of Ohio in delivering culturally competent breast health information, free women’s health screenings, and the support needed for any follow-up.
Johns Hopkins Hospital, East Baltimore Mental Health Partnership School-Based Program For over a decade this program has provided a full-time, licensed mental health clinicians in 15 local Baltimore public schools. This program delivers mental health services at school during the course of the day. Clinicians provide individual, group, and family-based interventions for youth enrolled in the program. Senior child psychiatry fellows and faculty provide diagnostic assessment and medication management if needed. Close coordination with teachers and school staff allow for smoother implementation of behavioral programs as well as direct communication about progress. School advocacy and parent communication are also critical components of this program.