To improve population health, health systems must venture beyond traditional medical interventions and emphasize health and wellness interventions not delivered by advanced practice providers and physicians. While literature supports the importance of screening patients for social determinants of health (SDOH), there is no robust roadmap on how effectively to bridge the gap between screening and patient needs.

JPS Health Network, in Fort Worth, Texas, is doing more than just asking screening questions and making a referral. Learn how screening data identified top SDOH patient needs and guided the network’s work to develop partnerships and secure grants to deliver targeted interventions, with food insecurity as a primary SDOH concern.

Presenter(s):
Devon Armstrong, MSN, RN-BC
Director of Outpatient Care Management
JPS Health Network

Kandra Torrence, DrPH
Manager of Community Outreach
JPS Health Network

Learn how Eskenazi Health, in Indianapolis, takes a health system approach to mitigating social factors, such as food insecurity, with an innovative and sustainable market/pantry hybrid model. Use lessons learned from the “Fresh For You Market” hybrid model to accelerate your own efforts to target food insecurity and nutrition education in collaboration with the community and community-based organizations.

Presenter(s):
Deanna Reinoso, MD
Medical Director of Social Determinants of Health
Eskenazi Health

The pandemic was a rude awakening, highlighting the systemic and programmed inequities and failures within our health system. The mis- and dis-information in underserved and lower-income communities significantly affected vaccination uptake. Despite the workforce COVID-19 vaccination mandate, effective Sept. 27, 2021, about 22 percent of the workforce at NYC Health + Hospitals/Harlem was unvaccinated. To mitigate the potential loss of health care workers, NYC Health + Hospitals/Harlem launched education and trust-building efforts through its Community Activation Model. In this session, learn how the model affected Harlem vaccination rates, reducing unvaccinated employees from 22 to 4.4 percent (with 3.3 percent retiring) by Sept. 27, 2021.

Presenter(s):
Christopher Montgomery, MPH
Health Care Program Planner and Analyst
NYC Health + Hospitals

Patients on medications for opioid use disorder (MOUD) face health disparities from lack of access of post-acute care in skilled nursing facilities (SNFs). At University of Vermont Health Network, in Burlington, Vt., well-established patients currently under the care of an opioid treatment program for opioid use disorder had greater hospital lengths of stay due to the lack of post-acute care options. In collaboration with communities, hospitals, and post-acute sites, UVM developed a playbook for SNFs to care for patients on medication-assisted therapy, thus decreasing their hospital length of stay.

Presenter(s):
Nicole Courtois, RN, BSN
Senior Quality Improvement Partner
The University of Vermont Health Network

Annette Macias-Hoag, DNP, MHA, BSN, RN
Senior Vice President & Network Chief Nursing Officer
The University of Vermont Health Network

Atrium Health, in Charlotte, N.C., developed a place-based approach to care delivery using mobile health clinics (MHCs). Successful community health models require a foundation of trust and ongoing partnership engagement. Informed by data, Atrium’s MHC model leveraged i) place-based care delivery focused on the highest risk and lowest resource neighborhoods; ii) strategic partnerships with system and community stakeholders to support process improvements; and iii) culturally responsive outreach. This session will review best practices for neighborhood partnerships to improve health care access and reduce health inequity and highlight the MHC program as a replicable example of partnership engagement.

Presenter(s):
Jennifer Snow, MBA
Assistant Vice President, Community Health Strategy
Atrium Health

NYC Health + Hospitals, in New York, serves more than 1 million patients each year, including nearly 40,000 adults experiencing homelessness. Learn how segmenting patients experiencing homelessness into clinically actionable groups allows the health system to target programming to improve their care across our system. Health system leaders will present two sample segments: patients with a diagnosis of chronic obstructive pulmonary disorder, and patients who visited the emergency department more than 20 times in 2021. Findings from this analysis underscore the high rate of behavioral health needs and the importance of developing care models to treat behavioral health and chronic conditions outside of the ambulatory setting.

Presenter(s):
Laura Jacobson, MSPH
Director, Data Services
NYC Health + Hospitals