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].
Issue Category: Environmental Health
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].
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].
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].