Concurrent Session D

Friday 8:30-9:45 am

  1. Caring for the Most Vulnerable: Linking Clinical Care with Housing & Transportation Services

Housing and homelessness are critical social determinants of health. In this session, collaborating organizations will discuss a multi-pronged initiative to connect patients to housing and build linkages between the housing sector and health care in the Chicago area. The Center for Housing and Health is fostering partnerships between hospitals and housing organizations by building integrated care models with a supportive housing approach. One partner, the University of Illinois Hospital and Health Sciences System (UI Health), is implementing two aggressive social determinants of health initiatives on transportation and housing. One of the specific initiatives has centered on the emergency department (ED), where All Chicago Making Homelessness History and UI Health built and tested a data-matching prototype to enable ED staff to query the Homeless Management Information System to determine if a patient is homeless.

Peter Toepfer, Executive Director, Center for Housing and Health
Anna Wojcik, Assistant Director for Health Policy and Strategy, Office of the Vice Chancellor for Health Affairs, UI Health
Lydia Stazen Michael, CFRE, Vice President of Development and Communications, All Chicago Making Homelessness History
Stephen Brown, MSW, LCSW, Director of Preventive Emergency Medicine, Department of Emergency Medicine, UI Health

  1. Caring Effectively: Engaging Patients and Providers in Using Cultural and Stigma Awareness to Deliver Better Health Care Experiences

Presenters will explore ways to integrate the voices of those most affected by barriers to achieving health. The Public Health Institute of Metropolitan Chicago will introduce methods to develop, implement, and pilot a campaign to address stigma in healthcare settings. The National Network of Libraries of Medicine will cover methods and strategies for caring for refugees, immigrants, and non-native English speakers, and introduce online resources for clinicians to find free and reliable health information in various languages for different cultural groups. Project Patient Care will give examples of successful initiatives to integrate the voices of patients into care models.

Blair Harvey, Deputy Director of Strategy and Partnerships, Public Health Institute of Metropolitan Chicago
Jacqueline Leskovec, Network Librarian, National Network of Libraries of Medicine Greater Midwest Region
Pat Merryweather, Executive Director, Project Patient Care

  1. Law As a Key Social Determinant of Health: Accelerating Your Population Health Strategy by Integrating Legal Capacity & Skills

In an era of healthcare transformation, where health care practitioners seek tools to improve population health, the MLP approach provides a framework for health care teams, public health practitioners, and public interest attorneys to together identify and address individual health harming legal needs and effect legal and policy change.

This session will describe this patients-to-policy approach and the emerging evidence of impact. First, a Chicago-based MLP team will describe their specific project design.

Presenters will then (1) share strategies for incorporating a public health perspective into MLP planning and practice to support system change through public health legal interventions and (2) facilitate discussion of best practices and challenges in building cross-sector partnerships that bridge the public interest legal field.

Colleen Healy Boufides, Mid-States Region of the Network for Public Health Law
Keegan Warren-Clem, JD, LLM, Managing Attorney, Austin MLP
Alice Setrini, Supervisor, Health Forward / Salud Adelante (Medical-Legal Partnership), LAF
Mary Sajdak, Cook County Health and Hospitals System

  1. Targeting Efforts: Using Referrals to Improve Outcomes and Lower Costs

This session explores the opportunities for improved outcomes and cost reduction through innovative referral systems. The Michiana Health Information Network and United Way 211 of Allen County are partnering to measure the degree to which costs and health outcomes change for patients who are provided with and utilize referrals – the study compares emergency department (ED) and ambulatory care utilization before and after screening and referral. In a unique behavioral health partnership, the Crisis Center Follow-up Program is a partnership in which Northwestern Medicine Central DuPage Hospital ED staff refer persons at risk of suicide but not meeting inpatient criteria to DuPage County Health Department clinicians at discharge. The clinicians then provide initial phone outreach, case management, linkage to outpatient services, and support service referrals.

The Central Ohio Medical Neighborhood referral network is comprised of 25 clinical and community-based organizations representing primary care providers, hospital systems, behavioral health specialists, FQHCs, area agencies on aging, meals on wheels providers, free clinics, and local government agencies. Using a referral tool attached to the state Health Information Exchange, in 2016, the first year that partners were actively utilizing this technology, over 500 referrals were exchanged and 100% of those referrals were closed, increasing efficiency and having significant patient impact.

Waldo A. Mikels-Carrasco, Director for Population Health, Michiana Health Information Network
Lori Carnahan, MA, LCPC, Assistant Director of Community Center Services, DuPage County Health Department
Michelle Missler, MA, LSW, VP, Strategic Partnerships, Healthcare Collaborative of Greater Columbus

  1. Reversing the Trend: Clinical-Community Linkages for Diabetes Prevention

The Centers for Disease Control and Prevention-led National Diabetes Prevention Program (DPP) is an evidence-based lifestyle change program for treating prediabetes offered in communities and virtually. The American Medical Association will share new tools and strategies for identifying patients with prediabetes and enrolling them in DPP that were developed through a partnership with health systems in Michigan. The Cook County Department of Public Health partnered with AgeOptions, a community-based organization, to implement the Stanford model Diabetes Disease Self-Management Program in the Cook County Health and Hospitals System. The organizations developed a referral system to allow providers to refer patients either through the electronic health record (EHR) or from an EHR generated registry; the system is designed to be flexible and accommodate other community-based programs in the future. OhioHealth ENGAGE is a health literacy and community outreach program that addresses high diabetes prevalence in central Ohio, especially among African Americans and minority populations. Based on the diabetes curriculum developed by the CDC that focuses on engaging and empowering participants to take small steps to manage and control their diabetes, ENGAGE has shown reduction in A1C levels compared with patients not enrolled in it. 

Janet Williams, Senior Manager of Physician and Health System Engagement, American Medical Association
Kiran Joshi, Senior Medical Officer, Cook County Department of Public Health
Maria Oquendo-Scharneck, Health Education Program Manager, AgeOptions
Orelle Jackson, System Director, OhioHealth Community Health, Wellness and Development
Mary Ann G. Abiado, Data Management and Evaluation Specialist, ENGAGE, OhioHealth

  1. Health and Housing – Sharing Data Across Sectors to Improve Health Outcomes and Community Health

Data-driven multi-sector collaborations are essential vehicles for achieving health equity by helping decision-makers address the social determinants of health. Representatives from two projects affiliated with All In: Data for Community Health will share complementary yet distinct approaches for identifying and prioritizing built environment factors to improve community health. The Cleveland, BUILD Health Challenge team is developing a healthy housing data system, grounded in community engagement, to address health disparities related to asthma and lead poisoning. Multi-sector data is being analyzed to provide risk-stratified, place-based information that will inform interventions at the individual, system and policy level.  The Chicago DASH team is focused on enhancing the delivery of services for children at-risk for lead paint poisoning. Data from the Chicago Department of Public Health, County Assessor’s Office, Chicago Department of Buildings, Census, and WIC to create a predictive model and fuel real-time interfaces that will enable community health centers to identify at-risk children and pregnant mothers through the electronic health record, and intervene, including ordering blood lead tests and making referrals for home inspections.

Peter Eckart, Co-Director, Data Across Sectors for Health (DASH) National Program Office, Illinois Public Health Institute
Raed Mansour, Director of Innovation, Chicago Department of Public Health
Kim Foreman, Executive Director, Environmental Health Watch