Discover how the Health Equity Accelerator at Boston Medical Center, in Boston, launched the Equity in Pregnancy Program, a comprehensive effort that addresses significant race-based inequities in obstetrical outcomes, including preeclampsia. Learn how the hospital took eight novel interventions across clinical, educational, and cultural focus areas to improve care.

Presenters:
Giavanna Gaskin, MBA  
Program Manager  
Boston Medical Center 

Megan O’Brien
Clinical Nurse Program Manager
Boston Medical Center 

Take a deep dive into the intersection of financial wellness and other social drivers of health. Learn how two health systems—The MetroHealth System, in Cleveland, and ProMedica Social Determinants of Health Institute—are implementing financial coaching to improve the financial health of patients, employees, and community members. 

Presenter(s):
Marielee Santiago-Rodriguez, MSW, MPH, LSW
Director, Transformative Knowledge and Education  
MetroHealth Institute for H.O.P.E.   

Population health leaders are testing new models for integrating medical-legal partnerships (MLPs) into health care practice to target the reality of unattended legal needs that, for many vulnerable patients, are systemic barriers to good health. This session will cover the design, implementation, and evaluation of a structured MLP by association member Harris Health System, in Houston, and South Texas College of Law Houston. This program serves the under-resourced patients of Harris County’s essential hospital and mitigates systemic disparities in access to needed services for low-income and/or undocumented populations.

Presenter(s):
Denise LaRue, MPH
Director, Care Integration
Harris Health System

Hear how NYC Health + Hospitals, in New York, developed a novel transitional care management (TCM) program to help reduce readmission rates in its Medicaid and uninsured patient population. The program automatically identifies high-risk, high-utilizing, and risk-attributed patients. Transitional care coordinators (TCCs) screen these patients and develop a care plan that targets the identified needs and ensures appropriate linkages to ongoing care after discharge. Once discharged, the TCC conducts weekly outreach calls to check in whether the patient has transitioned successfully to the community. Customized and semi-automated Epic tools support workflow of the TCCs, and core process and outcome metrics are reported. 

Presenter(s):
Alomi Malkan, MPH  
Associate Director of Care Transitions  
NYC Health + Hospitals 

Jonathan Meldrum, MD  
Director, Discharge Planning and Transitional Care  
NYC Health + Hospitals   

Technology is changing the way patients interact with health care and how organizations work. Hear leaders from Harris Health System, in Houston, share lessons learned from three years of developing and operating a structured self-measured blood pressure remote monitoring program to improve health outcomes, strengthen community partnerships, address social determinants of health, and foster blood pressure self-management. This session will engage participants in the practical considerations of identifying an initial patient population in a geographic area of focus; targeting priority needs and outcomes (e.g., food insecurity, blood pressure control); and integrating technology into health care practice in a patient–centric and cost-effective manner. 

Presenter(s):
Krystal Gamarra, MBA, LCSW  
Administrative Director, Clinical Integration and Transformation  
Harris Health System 

Matasha Russell, MD  
Chief Medical Officer, Ambulatory Care Services  
Harris Health System   

Erie County Medical Center developed a remote patient monitoring program using self-measured blood pressure techniques, telehealth, and comprehensive care coordination to improve hypertension control in a socioeconomically disadvantaged, minority population. The program eliminates transportation barriers and increases patient engagement to improve adherence and self-management behaviors. Lifestyle modifications, medication counseling, and care coordination are tailored to each patient’s needs, accounting for health disparities and social determinants of health. More than 280 patients have been enrolled with a less than 1 percent dropout rate. Hypertension control compliance has skyrocketed from 44.2 to 67 percent since June 1, 2022, and 50 percent of patients have seen an overall reduction in systolic blood pressure. 

Presenter(s):
Amanda Farrell, RN  
Population Health Clinical Data Analyst  
Erie County Medical Center Corporation  

Lucia Rossi, MA  
Vice President of Ambulatory Services and Population Health  
Erie County Medical Center Corporation   

Asylum seekers experience systematic oppression, loss, displacement, and exposure to violence. Discover how the refugee health center at Cook County Health, in Chicago, works with government and local communities to strengthen systems of support for asylum seekers and remove barriers to accessing public services and integrating into communities. This network created infrastructure to provide immediate reception and shelter space, longer-term housing assistance, initial and emergency health screenings, food, water, and language interpretation, with the goal of integrating individuals seeking asylum into existing community health centers for established long-term care. 

Presenter(s):
Claudia Burchinal
Director Ambulatory System Operations & Business Development
Cook County Health   

Christina Urbina
Director of Maternal Child Health Programs and Initiatives
Cook County Health

Learn how resource-limited settings can use artificial intelligence (AI) to facilitate a change from reactive to proactive care to improve health outcomes. Instead of responding to a health event after it has occurred, AI offers the ability to forecast adverse health events, and digital automation can be used to deploy treatment pathways to reduce the likelihood of an adverse health event. Discover how AI and digital automation have facilitated a transformation in heart failure care at Zuckerberg San Francisco General Hospital and Trauma Center, in San Francisco, resulting in reduced mortality, reduced readmission rates, and improved health equity. 

Presenter(s):
Elizabeth Connelly, MPH
Predictive Analytics Fellow
Zuckerberg San Francisco General Hospital/San Francisco Department of Public Health

Lucas Zier, MD, MS
Assistant Professor of Medicine
Zuckerberg San Francisco General Hospital/UCSF