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].
Issue Category: Child and School Health
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].
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].
Community Assessment Project
The Community Assessment Project (CAP) is a broad-based collaborative of the United Way of Santa Cruz County, California that jointly conducts community health needs assessments and publishes an annual countywide community indicators report. The report, first introduced 20 years ago, serves as the community health needs assessment for local nonprofit hospitals and includes indicators in six domains: economy, education, health, public safety, natural environment, and social environment. The CAP also conducts a bi-annual quality-of-life survey of the County’s households. A sampling of the goals in 2015 include: improvement in access to primary care; comprehensive health care coverage for children; and a decrease in the prevalence of childhood obesity. Annually, CAP measures and reports progress toward its goals. For example, in 2007, the Healthy Kids Insurance Program achieved 98 percent insurance coverage for children in Santa Cruz County. CAP is funded by local hospitals, city and county governments, utility companies, colleges, and non-profit organizations. To read more about this innovative program, see this brief summary [link].
Come to the Table
ohiSince 2009, ProMedica’s, “Come to the Table” program has been working to ensure the well-being of communities in northwest Ohio and southeast Michigan by creating services and programs addressing basic nutritional needs. The link between hunger and poor health is clear—adults living in food insecure homes have chronic diseases and behavioral health conditions. Food-insecure children suffer an even greater impact with delayed development and poorer quality of life. Health threats resulting from hunger are preventable and ProMedica continues to develop and implement strategies to feed communities including: operating a food reclamation program to repackage un-served food and distribute to homeless shelters; developing a food security screening program to identify hospital patients who are food insecure to ensure they have food and access to resources upon being discharged from the hospital; and the future opening of the Ebeid Institute for Population Health in Toledo, Ohio, which will have a fresh food market and offer job training and health services. ProMedica’s strong community partnerships at the local, state, and federal levels are central to developing these collaborative opportunities. To read more about this innovative program, see this brief summary [link].
Cincinnati Children’s Hospital Medical Center Community and Population Health Initiative
In 2010, Cincinnati Children’s Hospital Medical Center (CCHMC) started the Community and Population Health Initiative to tackle the most prevalent, challenging, and burdensome health issues facing children and families in southern Ohio. By creating partnerships within the community and focusing on the pillars of the Institute for Health Care Improvement’s Triple Aim framework, the Community and Population Health Initiative has reduced the negative impact of social determinants like education, housing, and the environment on health outcomes. To date, CCHMC has seen a reduction in asthma admissions, improved social and environmental risk screening during both inpatient and outpatient care, and substantial increases in connections between families and key resources in the community. The initiative began with funding from CCHMC, as well as funding from federal agencies and foundations. To read more about this innovative program, see this brief summary [link].
Campaign to Make Delaware’s Children the Healthiest in the Nation
Since 2006, Nemours, an integrated pediatric health system, has worked to address childhood (ages 2–17) overweight and obesity in Delaware with multisector partners including: the Governor’s Office; Cabinet secretaries and other government officials; pediatric providers; child care centers; schools; principals and superintendents; and other community-based organizations. Activities include systems-level and practice interventions, such as working with state-level partners to promote healthy eating and physical activity through child care licensing, as well as creating a learning collaborative to facilitate policy and practice change. Preliminary results show a flattening of the overweight and obesity curve for Delaware children between 2006 and 2008. This successful initiative is funded by a number of sources including: Nemours Health and Preventive Services; the Robert Wood Johnson Foundation; U.S. Department of Education; U.S. Department of Agriculture; Centers for Disease Control and Prevention; General Mills Foundation; and American Heart Association. To read more about this innovative program, see this brief summary [link].
Boston Children’s Hospital Community Asthma Initiative
The Community Asthma Initiative (CAI), an initiative of Boston Children’s Hospital, began addressing health disparities in Boston neighborhoods impacted by asthma in 2005. CAI provides an enhanced model of care which includes asthma education and home visits for families with children ages 2–18 living in the Greater Boston area who were previously treated in the Emergency Department (ED) or hospitalized as a result of asthma. CAI works with partners and coalitions to address asthma health disparities by implementing changes in policies at the local and state levels. As of June 2014, case management had been provided to 1,329 patients with significant outcomes including: a 57 percent reduction in the number of children with ED visits; a 79 percent reduction in hospitalizations; a 43 percent reduction in missed school days; and 43 percent reduction in missed work days for parents. CAI is supported in part by grants, several foundations, philanthropy, Centers for Disease Control REACH US Program, American Academy of Pediatrics, the Office of Community Health at Boston’s Children’s Hospital and others. To read more about this innovative program, see this brief summary [link].
Women-Inspired Neighborhood Network (WIN Network): Detroit
In 2008, the CEOs of Detroit Medical Center, Henry Ford Health System, Oakwood Healthcare System, and St. John Providence Health System commissioned the Detroit Regional Infant Mortality Reduction Task Force to develop a plan of action to help more babies reach their first birthdays. The Task Force addresses Detroit’s infant mortality rate, which is nearly 15/1000 live births, among the highest in the nation. Working through a public-private partnership of Detroit’s major health systems, public health, academic, and community partners, the Task Force seeks to tighten the disconnected medical and social services for women. The Task Force and its WIN Network have realized a number of accomplishments as of August 2014 including zero infant deaths among more than 200 babies born to date and the enrollment of 364 pregnant women in the program. Funding for this project comes from a variety of foundations, organizations, and institutions. To read more about this innovative program, see this brief summary [link].
Communities That Care Coalition
The Communities That Care Coalition began in 2000 in Western Massachusetts to reduce youth substance abuse and improve youth health. The program brought together and coordinated the efforts of various local stakeholders including schools, youth and parent groups, law enforcement, health care providers, and the local hospitals. By implementing its Community Action Plan—which includes an annual Teen Health Survey, anti-substance curricula in local schools, social marketing, and forming strategic partnerships within the community—the Coalition has been successful in identifying several underlying risk factors of youth substance use in the area and priorities for improvement. During the 12 years of its work, the Coalition has measured substantial improvements in youth substance abuse, as well as a reduction in the underlying factors causing it. The Coalition is supported by state and federal grants. To read more about this innovative program, see this brief summary [link].