Community collaboration was a common theme throughout RISE’s two-day virtual event. Here are highlights from two case study sessions that offered an inside look at pilot programs that have proven partnership is key to addressing social determinants of health and improving population health outcomes.

Collaboration to address food insecurity

Better health outcomes are possible through better nutrition, said Susan Hawkins, FACHE, senior vice president of population health, Henry Ford Health System (HFHS). Hawkins shared an in-depth look at the partnership established between HFHS, located in Detroit, Mich., and their local food bank, Gleaners, to design a program to mitigate food insecurity for their vulnerable patient population. Four different clinics from Henry Ford Medical Group participated in the pilot program, screening more than 1,600 patients for food insecurity during routine office visits, explained Hawkins. Over 300 of the screened patients were enrolled in the 12-month program. Once enrolled, Gleaners provided participants with healthy food packages that included fresh, frozen, and shelf-stable food options every two weeks for one year, free of charge. Home deliveries were also offered to maximize program participation.

A leading success factor to the program, said Hawkins, was the consistent communication among HFHS, Gleaners, and program participants. HFHS Population Health staff reached out to patients between each delivery to make sure they had enough food, were satisfied with the food options, and to confirm the next scheduled delivery. The regular communication allowed for real-time adjustments to the program when needed.

The food program provided the equivalent of 14 supplemental meals, every two weeks, to help alleviate patient’s concerns about not having enough food and reduce temptations to purchase unhealthy foods to fill meal gaps. In addition to better eating habits, Henry Ford’s program participants had improved health outcomes as a population. The post-program analysis demonstrated a greater and statistically significant improvement in both emergency department visits (42 percent decrease) and hospitalizations (56 percent decrease) for the intervention group relative to the research comparison group (25 percent decrease in emergency department visits and 18 percent decrease for hospitalizations).

In post-program feedback, patients expressed their satisfaction with the program and felt the customer service, both by phone and face-to-face, was “extraordinary.” Hawkins indicated that Henry Ford plans to scale the program to thousands of their vulnerable patients within the next year.

Breaking down barriers to patient care

WellSpan Health representatives, Katie Wilt, MBA, manager special programs, and Dianna Benaknin, MSW, case management consultant, shared insight on the role community partnership can play in patient care improvement. The health care system had identified a subset of patients that were unable to leave the hospital when clinically ready, halting their recovery and impacting their quality of life. Not only was it a significant barrier to the patient’s care but a substantial and unnecessary health care cost.

Through an extensive chart review, said Benaknin, they were able to identify the root causes and drivers behind patients’ inabilities to leave the hospital once discharged:

  • Nursing home care is needed but they have barriers to timely transitions (40 percent)
  • They have unstable housing and need brief medical care (20 percent)
  • They need a low-income personal care home that offers 24/7 care (40 percent)

To reduce these barriers and improve patient care, WellSpan Health created community partnerships to establish programs designed to address these obstacles.

The Omega Bed Program™ allowed WellSpan to partner with local nursing homes to reduce the amount of time a patient had to remain in the hospital, explained Wilt. Once patients are transitioned to a nursing facility, they receive support in applying for Medical Assistance benefits to cover the cost of the nursing home stay. The program provided significant savings after the cost of the program, with over $900 thousand savings in 2018 and over $1 million in 2019.

The next program, Arches to Wellness, which was also created by WellSpan Health, partners with local personal care homes to provide a short-term place to heal with 24/7 oversight. The 30-45-day program allows patients to take the time they need to heal so they are released into the community in better shape than they were prior to entering the system. Savings after the cost of the program included over $450 thousand in 2018 and over $800 thousand in 2019. There was also an 80 percent reduction in emergency room usage for the six months following patient discharge.

Lastly, WellSpan Health partnered with Alliance for Low Income Personal Care Home Advancement (ALPHA) to assist with community engagement to sustain existing personal care home facilities. ALPHA helps keep additional homes in the personal care home realm from falling off the “fiscal cliff.”