Concurrent Session C

Thursday 1:30-2:45 pm

  1. Authentic Patient Engagement: Innovative and Inspiring Approaches to Community Health Worker Integration

This session delves into the benefits of integrating community health workers (CHWs) into care models expand the reach of health care. The Sinai Urban Health Institute will discuss two initiatives: preliminary results of a study which compares traditional, mobile, and CHW approaches to managing diabetes and outcomes and lessons from the Asthma CarePartners CHW program, embedded in a managed care organization. In Michigan, the Primary Care Association partnered with community health centers on an interdisciplinary project aimed at integrating CHWs within clinical teams to foster a patient-centered experience addressing social determinants of health, and preliminary results indicate improved disease self-management among patients. The presentation will highlight collaboration and partnership success factors. In Ohio, Mount Carmel Health System implemented the Intensive Case Management Hub model utilizing certified CHWs joined with data and service integration for extensive care coordination to the internal health system as well as the community. The initiative focuses on social determinants of health and health priorities identified in the system’s community health needs assessment (CHNA) by assessing, measuring, and responding to patient and community needs.

Ladonya Brady, Director of Urban Health Management, Mount Carmel Health System
Roxann Payne, Manager of Urban Health Management, Mount Carmel Health System
Julie Kuhn, Sinai Urban Health Institute
Stacy Ignoffo, Sinai Urban Health Institute
Deidre Hurse, Associate Director for Enabling Services, Michigan Primary Care Association

  1. Strategies for Translating Community Health Assessment Data into Action

As part of the Community Health Improvement Planning (CHIP) process, the City of Milwaukee Health Department (MHD) launched an innovative initiative called MKE Elevate in order to “elevate our health, our community and our future.” Several innovative strategies were used to engage neighborhoods as partners to improve the social determinants of health.

Working with public health departments and child-serving organizations, Dayton Children’s Hospital transformed its community health needs assessment (CHNA) into actionable programs and services driving improved health care outcomes. The resulting children’s health agenda launched Dayton Asthma Alliance and a Clinically Integrated Network that engages pediatric care providers to track and improve pediatric quality outcome measures.

Finally, the Minnesota Department of Health will introduce a toolkit of resources, illustrated with case studies, on how local public health departments and health systems explored use of data housed within electronic health record systems to provide a clearer picture of subpopulations, geographic areas, and health conditions that are typically underrepresented in traditional assessment methods.

Kim E. Whitmore, Assistant Professor at UW – Madison and Chief Change Officer, Ujima United, LLC
Angela Hagy, Director of Disease Control and Environmental Health, City of Milwaukee Health Department
Jessica Saunders, Director, Office of Community Health and Engagement Programs, Dayton Children’s Hospital
Lisa Henderson, Executive Director, for Dayton Children’s Health Partners
Karen Soderberg, Research Scientist, Minnesota Department of Health, Office of Health Information Technology

  1. Olmsted (MN) Coalition for Community Health Integration (CCHI): Taking Partnership to the Next Level

The panel-style discussion will explore how a community health coalition, Olmsted’s Coalition for Community Health Integration (CCHI) formalized governance structure and enhanced infrastructure to support ongoing success with this multi-partner/multi-sector collaboration. The Coalition includes government, non-profits, health systems, hospitals, the school district and several health plans. CCHI’s successes include: collaboratively conducting two cycles of community health needs assessment and developing community health improvement plans across public health and two major hospitals; creating multi-point access to students’ action plans for chronic conditions; and establishing community care teams utilizing shared community health workers.

Brooke Carlson, President, North Sky
Doug Parks, Chair of Administration, Southeast Minnesota Region of Mayo Clinic Health System
Brenda Brown, Family Medicine Physician and Community Engagement Lead, Olmsted Medical Center

  1. Food as Medicine: Collaborations to Address Hunger and Food Insecurity

This session introduces the American Hospital Association framework for the role of hospitals in addressing food insecurity, and discusses national and local cross-sector collaborations aimed at the issue. Three hospital systems will describe multi-pronged initiatives to address food insecurity: the Root Cause Coalition will share stories of its members’ efforts across the country, focusing on ProMedica’s efforts in Ohio; Rush University Medical Center will describe how it partners to address hunger and promote food security for patients, employees, and community members; and the Cook County Hospitals and Health System will share it’s multi-setting screening initiative and programs its implemented to address hunger in those that screen positive.

Julia Resnick, Senior Program Manager, American Hospital Association
Christopher Nolan, Manager of Community Benefit and Population Health, Rush University Medical Center
Kathy Chan, Director of Policy, Cook County Health & Hospitals System
Amy Laboy, Senior Director of Programs, Greater Chicago Food Depository
Jason Gromley, Root Cause Coalition

  1. Sustaining Partnerships for Change: The Healthy Communities Funding Hub

This discussion will consider how the concept of a Healthy Communities Funding Hub would play an important role for healthcare systems, providing an efficient way to invest in coalitions and non-clinical interventions and bringing in other sources of funding to maximize the impact of healthcare dollars on population-level outcomes.  Trust for America’s Health developed the concept, and illuminated the fiduciary skills and capabilities needed to braid together different, increasingly complex, funding streams in a hub model.  The workshop will highlight the experience of Sojourner Family Peace Center and Children’s Hospital of Wisconsin in their journey to coordinate funding and leverage capital investments to sustain domestic violence prevention efforts. Small group discussions will focus on challenges to sustainability and strategies to overcome them.

Anne De Biasi, Director of Policy Development, Trust for America’s Health
Carmen Pitre, President & CEO, Sojourner Family Peace Center

  1. Real Results: Health Care Integration to Drive Population Health and Achieve Value and Quality

The MetroHealth System, the public hospital and healthcare system in Cuyahoga County, Ohio, is engaged in a system-wide transformation to deliver population health and value-based care (VBC) with a focus on three key areas: quality improvement, resource stewardship, and value-based contracting. And, in DuPage County, Illinois, AMITA Health has established primary care services on-site at the health department, in order to enhance primary care access for health department clients, and facilitate health department and AMITA providers to collaborate on their common patients’ care. And the Emory Health Network will present tips and tricks on creating a robust high-performing multi-collaborative teams to support population health and value based care programs including: how business questions are changing to target population and longitudinal view for patients; the role of disparate IT systems to support VBC, the skills and functions needed to support VBC, and how to build a data-driven organization using analytics.

James Misak, Vice-Chair of Community and Population Health, The MetroHealth System Department of Family Medicine
Susan Kottra, Social Worker, DuPage County Health Department
Kate Gunnell, Director of Medical Student Education, AMITA Health Hinsdale Family Medicine Residency
Gabe Orthous, Value-based Care Analytics Strategist at Himformatics