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].
Issue Category: Public Health Funding
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].
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
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].
Common Table Health Alliance: Backbone for the Healthy Shelby Partnership
The Common Table Health Alliance is a regional health improvement collaborative and an Aligning Forces for Quality Community. In 2011, the Shelby County Mayor, Memphis City Mayor, and the four major health systems engaged the Common Table Health Alliance as the backbone organization for the Healthy Shelby Partnership, which is one of the key pillars of Memphis Fast Forward, a broad-based collective impact initiative. Healthy Shelby connects social service agencies with the health care system to jointly address the social determinants of health. Common Table Health Alliance has implemented evidence-based and best practices, used social media, employed education programs, coordinated partner engagement, and is tracking 12 measures. Successful programs include a safe sleep campaign and a community hypertension registry. The goal is to improve the health rankings of Memphis and Shelby County. Healthy Shelby has received core funding from the Baptist Memorial Health Care, Methodist LeBonheur Healthcare, Region One Health and Saint Francis Hospital, city and county governments, and grants from the United Way and Medtronic. 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].