Community Health Collaborative Facilitates Health System and Community Change to Address Unmet Medical and Social Needs in New Jersey

Tanumihardjo, Jacob P.; Morganstern, Ernest; Gunter, Kathryn E.; Martinez, Aida; Altschuler, Stuart; Towns, Cheryl; Schwartz, Eric I; Hopkins, KD; Burnett, Jessica L.; Ricks-Stephen, Coiel

doi:10.1007/s11606-022-07927-1

Cited by 4 publications

(6 citation statements)

References 18 publications

(20 reference statements)

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“…Although SMHCVH has creatively blended various funding sources to implement its PHT model, payment should instead be intentionally designed to support and incentivize care transformations that address medical and social needs and advance health equity. 17,25,26…”

Section: Discussionmentioning

confidence: 99%

New Frontiers in Diabetes Care: Quality Improvement Study of a Population Health Team in Rural Critical Access Hospitals

et al. 2023

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BACKGROUND: Rural populations are older, have higher diabetes prevalence, and have less improvement in diabetes-related mortality rates compared to urban counterparts. Rural communities have limited access to diabetes education and social support services. OBJECTIVE: Determine if an innovative population health program that integrates medical and social care models improves clinical outcomes for patients with type 2 diabetes in a resource-constrained, frontier area. DESIGN/PARTICIPANTS: Quality improvement cohort study of 1764 patients with diabetes (September 2017-December 2021) at St. Mary's Health and Clearwater Valley Health (SMHCVH), an integrated health care delivery system in frontier Idaho. The United States Department of Agriculture's Office of Rural Health defines frontier as sparsely populated areas that are geographically isolated from population centers and services. INTERVENTION: SMHCVH integrated medical and social care through a population health team (PHT), where staff assess medical, behavioral, and social needs with annual health risk assessments and provide core interventions including diabetes self-management education, chronic care management, integrated behavioral health, medical nutritional therapy, and community health worker navigation. We categorized patients with diabetes into three groups: patients with two or more PHT encounters during the study (PHT intervention), one PHT encounter (minimal PHT), and no PHT encounters (no PHT). MAIN MEASURES: HbA1c, blood pressure, and LDL over time for each study group. KEY RESULTS: Of the 1764 patients with diabetes, mean age was 68.3 years, 57% were male, 98% were white, 33% had three or more chronic conditions, and 9% had at least one unmet social need. PHT intervention patients had more chronic conditions and higher medical complexity. Mean HbA1c of PHT intervention patients significantly decreased from baseline to 12 months (7.9 to 7.6%, p < 0.01) and sustained reductions at 18 months, 24 months, 30 months, and 36 months. Minimal PHT patients decreased HbA1c from baseline to 12 months (7.7 to 7.3%, p < 0.05). CONCLUSION: The SMHCVH PHT model was associated with improved hemoglobin A1c among less wellcontrolled patients with diabetes.

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Section: Discussionmentioning

confidence: 99%

New Frontiers in Diabetes Care: Quality Improvement Study of a Population Health Team in Rural Critical Access Hospitals

et al. 2023

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“…21 For example, Trenton Health Team uses risk stratification to identify high-risk community members (e.g., recent hospital utilization) with diabetes through a local Health Information Exchange, and offers community-based care management to address individual medical and social needs. 14 Local partnerships of healthcare, public health, and social services can facilitate this care transformation. 14,15,17 For example, the Minneapolis Health Department (MHD) has supported diabetes care transformation with federally qualified health centers (FQHCs) by piloting new HIT platforms, facilitating partnerships with community agencies, convening a learning collaborative of FQHCs, and providing upfront funding for new roles in care teams (e.g., diabetes educators and community health workers).…”

Section: Primary Care Transformation and Workforce Capacitymentioning

confidence: 99%

“…14 Local partnerships of healthcare, public health, and social services can facilitate this care transformation. 14,15,17 For example, the Minneapolis Health Department (MHD) has supported diabetes care transformation with federally qualified health centers (FQHCs) by piloting new HIT platforms, facilitating partnerships with community agencies, convening a learning collaborative of FQHCs, and providing upfront funding for new roles in care teams (e.g., diabetes educators and community health workers). 10 Upfront funding allowed FQHCs to rapidly implement new services to support diabetes self-management while overcoming barriers or delays to reimbursement in the fee-for-service payment context.…”

Section: Primary Care Transformation and Workforce Capacitymentioning

confidence: 99%

“…7,22 Seven of eight grantee organizations employed lay health workers (e.g., patient navigator, health educator, community health worker). 13,14,18,23 At Roots Community Health Center, navigators provide self-management education and support, initiate and track medical and social needs referrals, engage in outreach work, and accompany patients through medical and social care organizations. 24 In addition, organizations need the flexibility to tailor primary care transformation activities and services to the structure and size of their organizations (e.g., FQHC, critical access hospital, community health collaborative), geographies (e.g., frontier, rural, urban), populations (e.g., immigrant, rural older adult), and community partners (e.g., transportation, food banks, legal services).…”

Section: Primary Care Transformation and Workforce Capacitymentioning

confidence: 99%

“…We have previously described the eight grantees, their interventions, and their payor environments. 13 Individual papers in this supplement highlight how the implementation of integrated medical and social care can improve both population health and individual patient outcomes [14][15][16][17][18][19][20] . This paper describes promising examples of eight innovative grantee organizations and payment reform opportunities that may further support integrated medical and social care.…”

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Integrated Interventions to Bridge Medical and Social Care for People Living with Diabetes

et al. 2023

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Social drivers of health impact health outcomes for patients with diabetes, and are areas of interest to health systems, researchers, and policymakers. To improve population health and health outcomes, organizations are integrating medical and social care, collaborating with community partners, and seeking sustainable financing with payors. We summarize promising examples of integrated medical and social care from the Merck Foundation Bridging the Gap: Reducing Disparities in Diabetes Care initiative. The initiative funded eight organizations to implement and evaluate integrated medical and social care models, aiming to build a value case for services that are traditionally not eligible for reimbursement (e.g., community health workers, food prescriptions, patient navigation). This article summarizes promising examples and future opportunities for integrated medical and social care across three themes: (1) primary care transformation (e.g., social risk stratification) and workforce capacity (e.g., lay health worker interventions), ( 2) addressing individual social needs and structural changes, and (3) payment reform. Integrated medical and social care that advances health equity requires a significant paradigm shift in healthcare financing and delivery.

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Building a systems-thinking community workforce to scale action on determinants of health in New Zealand

Matheson,

Wehipeihana,

Gray

et al. 2024

Health & Place

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Community Health Collaborative Facilitates Health System and Community Change to Address Unmet Medical and Social Needs in New Jersey

Cited by 4 publications

References 18 publications

New Frontiers in Diabetes Care: Quality Improvement Study of a Population Health Team in Rural Critical Access Hospitals

New Frontiers in Diabetes Care: Quality Improvement Study of a Population Health Team in Rural Critical Access Hospitals

Integrated Interventions to Bridge Medical and Social Care for People Living with Diabetes

Building a systems-thinking community workforce to scale action on determinants of health in New Zealand

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