Since 1996, St. John’s Wellchild and Family Center (SJWCFC), a FQHC network in California, has been working to reduce the negative impacts of substandard housing on health. When first launched, SJWCFC and Esperanza Community Housing Corporation worked together on lead poisoning prevention. From 1996 through 2003, Strategic Actions for a Just Society joined the collaborative to collect data about the health impact of substandard housing to influence state and local policy. In 2009, Healthy Homes Healthy Kids joined with a comprehensive approach around home visits, health program enrollment, medical homes, advocacy, and policy development. Highlights of collaborative outcomes include: 100 percent decrease in asthma hospitalizations; 100 percent decrease in missed work days by parents; 80 percent reduction in percent of clients with asthma ER visits; 69 percent reduction in the percentage of children missing one or more days of school due to asthma; and 69 percent reduction in clinic/doctor visits due to acute asthma attacks. SJWCFC is funded by British Petroleum Settlement/Air Quality Management District Funds, First 5 Los Angeles, EveryChild Foundation, Housing and Urban Development Agency, and Kresge Foundation. To read more about this innovative program, see this brief summary [link].
Issue Category: Public Health Funding
Priority Spokane: Educational Attainment
Priority Spokane: Educational Attainment is a collaboration of community leaders serving as a catalyst and convener for data-driven improvements within Spokane Public Schools (SPS) in Washington. In the 2005–2006 academic year, SPS had a graduation rate of 57.7 percent (the county rate was 69.2 percent). Following the release of a community assessment in 2009 revealing educational attainment as a top priority of the community, Priority Spokane conducted a series of studies identifying model practices to improve education along with student risk factors for dropping out. Working with resources committed by school superintendents, business leaders, college and university presidents, elected officials, and others in the community, many of those model practices have been put into practice. These practices include: professional training on childhood trauma; a school Early Warning System weighted by student risk factors and aligned with community services; and a STEM Education network providing hands-on learning. In the 2012–2013 academic year, the SPS graduation rate improved to 79.5 percent, almost even with the county rate of 80.8 percent. Priority Spokane has had over $800,000 of funding provided by local and state foundations during a five-year period with partners providing extensive support to the projects. To read more about this innovative program, see this brief summary [link].
Partnership for a Healthy Durham
Partnership for a Healthy Durham is a collaboration on health initiatives that began in 2004. The Partnership, comprised of 475 coalition members, includes government agency and organizational leaders as well as community members. Every three years the Partnership conducts community health assessments to determine and set health priorities for the city. The 2011 assessment identified the following three social determinants as critical to improving health outcomes for residents of Durham: poverty, homelessness, and education/workforce development. As a result of the assessment, social determinants have been integrated into community policies, projects, and plans. Additionally, a pilot medical respite for the homeless has been established and a task force has been developed to create a pipeline of education and training opportunities for local high school students to gain employment. Support for the Partnership comes from local county government with additional funding from grants that support projects. To read more about this innovative program, see this brief summary [link].
Optimizing Health Outcomes for Children with Asthma in Delaware
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].
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].
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].