community health needs assessment report · 2013–2016 thomas jefferson university hospitals...
TRANSCRIPT
2013–2016
Thomas Jefferson University Hospitals
Community Health NeedsAssessment Report
H O M E O F S I D N E Y K I M M E L M E D I C A L C O L L E G E
E v a l u a t i o n
Jefferson University Hospitals June 30, 2016
COMMUNITY HEALTH IMPLEMENTATION PLAN
Evaluation and Outcomes for 2013-‐2016
In 2013, TJUHs completed a comprehensive Community Health Needs Assessment and a three year Implementation Plan. For each significant health need identified through the CHNA, TJUHs developed an implementation strategy that described plans to address the health need. The evaluation summary that follows includes information from 2013 through March 2016 as available. Between 2013 through 2015 (information for 2016 is not yet available), almost 108,250 individuals were reached with community health improvement services. These services included Community Health Education (40,400), Community Based Clinical services (14,950) and Health Care Supportive Services (52,880). Over the same timeframe Health Professions Education Services reached more than 105,500 individuals including physicians, medical, nursing pharmacy, occupational and physical therapy students and faculty as well as other health professions such as physician and medical assistants. A Table summarizing evaluation of major efforts tied to Jefferson’s 2013-2016 Implementation Plan is provided below. Column 1in this Table lists the activities/domains included in Jefferson’s 2013-2016 Implementation Plan: Internal Organizational Structure, Access to Care, Chronic Disease Management, Health Screening and Early Detection, and Healthy Lifestyle Behaviors and Community Environment. Column 2 provides information about the strategies/recommendations initiated; and Column 3, summaries of accomplishments and/or outcomes through March 2016.
Domain Strategies /Activities Updates Internal Organizational Structure Educational Coordination
Health Professions Education:
Provide and coordinate educational, clinical and research community-‐based opportunities to support Health Professional education between community, hospital and University
Mental Health First Aid Training: In partnership with Department of Behavioral Health and Intellectual disability Services (DBHIDS) the Center for Urban Health (CUH) is providing an 8 hour mental health first aid certificate course that teaches individuals how to help adults and youth experiencing mental health challenges or crises. Mental Health First Aid Classes for health professionals and community members are in progress. 4 programs were conducted in 2015-‐2016 reaching 60 individuals. Emergency responders also trained. The Jefferson Hospital’s Center for Urban Health worked with Sidney Kimmel Medical College, College of Nursing and Pharmacy faculty and students and the University’s Office of Student Life and Engagement to support health professional student education/service and to coordinate efforts to support hospital community benefit initiatives particularly in schools, homeless, and refugee communities. Student service groups receive funding from the Dean’s Office based on the activity’s link to community need as identified in the CHNA. In a joint hospital and University effort, the Center for Urban Health leadership teach almost 200 medical students in the CWIC public health area of concentration, a 4 year longitudinal program that is offered in addition to the traditional medical education curriculum. To date 2 cohorts have graduated from the program. Skills taught can be applied at the patient and community level and prepare students to assess root causes of health issues including the role of social determinants, to work with a diverse group of stakeholders and to initiate interventions that address problems from multiple perspectives including individual behavior, systems and policy change. TJUH Pharmacy has multiple collaborations and
Domain Strategies /Activities Updates partnerships that address community needs while providing opportunities for pharmacy students and residents to gain experience working in a community setting. The TJUH pharmacy provides these opportunities weekly with Jeff HOPE and Our Brother’s Place (homeless outreach), JFMA refugee clinic, JFMA clinic (diabetes education), “Ask A Pharmacist” programs, Sunday Breakfast Health Clinic, Eliza Shirley Health Clinic, and the Steven Klein Wellness Center. Pharmacists at these sites help patients to understand medications and improve medication adherences, provide medication reconciliation, and improve access to effective medications that are affordable through patient assistance programs. They also provide patient education for chronic disease such as hypertension and diabetes. In addition, they educate TJU pharmacy students and medical students about patient self-‐care, lifestyle modifications, and healthcare delivery systems for underserved patients. More than 2,500 patients were touched by their outreach services over the past 3 years. Finally, pharmacy students have provided health education, particularly related to medications, for 6th grade students at Southwark School in south Philadelphia reaching about 100 children. The Center for Urban Health provides internship opportunities for public health undergraduate and graduate students from West Chester University, Temple University and Jefferson. In addition students from SKMC participate in month long electives in the CUH and nursing students including DNP and RNs get community experiences with the CUH. The hospital also provides clinical experiences for OT, PT, Pharmacy and Nursing students. The CUH leadership participate in the University’s Health Mentors interdisciplinary program which provides students from Sidney Kimmel Medical College, and the Colleges of Nursing, Health
Domain Strategies /Activities Updates Professions, Pharmacy and the College of Population Health with opportunities to learn first-‐hand from a patient about life with a chronic disease. Students work in interdisciplinary teams to address the concerns of their health mentor which prepares them for future cross discipline teamwork.
Leadership from Jefferson Hospital’s Pastoral Care Department taught Clinical Pastoral Education to more than 40 students. This program prepares students to provide pastoral care for hospitalized patients and their families.
Hospital Readmissions
Pilot CHW community intervention with socially complex/high risk patients, refugee/immigrant and homeless/sheltered populations
The CUH leadership joined the PA Community Health Worker (CHW) coalition policy and curriculum committees. State committees developed CHW competencies and are working on policy development including certification policies and mechanisms for funding. ASTHO is consulting and providing training for all committee members in April. CUH leadership supported the development of both levels of the CHW program and continues to provide guidance. The second level of the CHW program was delayed until Fall 2016. The CHW program was initiated in January 2016. Bilingual and African American CHW students were recruited from community partner organizations. Scholarships to cover tuition provided to 6 individuals (4 bilingual and 2 African Americans) from the Welcoming Center, Steven Klein Wellness Center, and SEAMAAC. In addition, the DFCM department provided 2 scholarships for the Bhutanese and Burmese community. TJUH staff -‐ Neva White (Center for Urban Health) and Celeste Vaughan Briggs (social worker in the Breast Cancer Center)-‐ are teaching the course.
Initiate health literacy interventions to improve discharge instructions
CUH leadership provided 10 trainings have been scheduled prior to June 30, 2016. Six trainings
Domain Strategies /Activities Updates and transitions to community
have been held reaching more than 150 individuals.
Workforce Diversity
Career Awareness and skill building opportunities that encourage youth to pursue health careers: Partner with AHEC, Jefferson HR and TJU Office of Diversity and Minority Affairs to increase diversity of workforce through building capacity of youth and adults to enter health careers. To do this, educational skill in math and science need to be enhanced and mentoring/ shadowing/work experiential opportunities further developed, coordinated, and linked to population health improvement activities. Develop program to train youth as peer health educators
The partnership with PAI was halted due to collaboration issues and concerns. New partnerships are in progress with South Philadelphia High School, Independent Charter School, Southwark School (K-‐8) and potentially Furness High School and Vare-‐ Washington (K-‐8). CUH leadership is participating with Jefferson University Office of the Provost, TJU Office of Diversity and Minority Health, Office of Student Life and Engagement and the College of Pharmacy to initiate STEM and health education. Discussions with Kensington Health Sciences Academy are also in progress. Career days at Jefferson were held with Southwark and Independence Charter School for middle school students. The College of Pharmacy is working with 6th grade students at Southwark. Career day at Project HOME (pharmacy workforce development) – A PGY-‐1 Pharmacy Resident attended a career fair for high school students informing them about opportunities in pharmacy. A physician also answered questions and networked with interested students. 80 students participated in the Summer Leadership Program which addressed topics such as aging and nutrition serving with "Build On" a community based program for high school students -‐ Program addressed topics such as: Aging & Nutrition Career Day at Downingtown High School and Middle School reached 150 students in 2015
Partner with Refugee Academic Mentoring Program (NSC program) that helps people get the skills needed to get health related employment. (example: Burmese nurse).
Welcoming Center discussions focused on assisting limited English proficient immigrant health professionals in obtaining employment in healthcare. The Welcoming Center looking to partner to assist immigrant nurses in passing NCLEX and other state licensure exams. Two Welcoming Center clients were enrolled in the Institute for Emerging Health Professions at
Domain Strategies /Activities Updates Jefferson and received full tuition scholarships.
Continue the WorkReady program with Philadelphia Youth Network (PYN) at TJUHs
Jefferson takes 25 students each summer from the PYN Work Ready program. This program provides summer employment of High School Students (11th & 12th grade) -‐ Four Students from Cristo Rey are participating in a workforce development program at Jefferson (school year2015-‐ 2016) This program will be continued in FY 2017.
Community Health Worker/ Navigator/Coach Training: Develop a CHW program and train community health workers (including refugees) for immigrant community, Project HOME Wellness Center and to support discharge patients and high ED utilizers at Methodist and TJUH. Consider a multi-‐tiered model.
Leadership from CUH joined the PA Community Health Worker (CHW) coalition policy and curriculum committees. State committees developed competencies and is working on policy development. ASTHO is consulting and providing training for all committee members in April. Leadership from CUH supported development of both levels of the CHW program and continues to provide guidance. The second level of the CHW program was delayed until Fall 2016. CHW program was initiated in January 2016. Bilingual and African American CHW students were recruited from community partner organizations. Scholarships to cover tuition provided to 6 individuals (4 bilingual and 2 African Americans) from the Welcoming Center, Steven Klein Wellness Center, and SEAMAAC. In addition, the Department of Family and Community Medicine provided 2 scholarships for the Bhutanese and Burmese community. TJUH staff from the Center for Urban Health and a TJUH social worker in the Breast Cancer Center are teaching the course.
Medical Interpretation training: Provide support for existing programs (Health Federation and NSC) that train medical interpreters for our community benefit areas.
Discussions with United Communities and Nationalities Services Center (NSC) concerning medical interpreter training are in progress. NSC interested in training CHWs and others. There is interest in providing medical interpreter training for graduates of Jefferson’s CHW program. This
Domain Strategies /Activities Updates will be pursued in the next fiscal year.
Provide wellness/health education in workforce development programs: Continue the Career Support Network program with low resourced workers
A major reason for job loss of employment in the first year of employment is health. The Career Support Network (CSN), a partnership between the Federation of Neighborhood Centers and Jefferson University and Hospital’s Center for Urban Health and the College of Occupational Therapy was funded by the Robert Wood Johnson Foundation’s Local Funding Partnerships Program. This innovative, community-‐based project was designed to improve the health of low-‐skilled, low resourced unemployed men and women, including those recently released from prison, in Philadelphia neighborhoods where the unemployment rate is 35% or higher. The unemployed often have multiple chronic health problems that are barriers to obtaining and retaining jobs and achieving economic stability. The CSN was developed to help underserved, unemployed adults, enrolled in workforce development programs to overcome these barriers and succeed in long-‐term careers by creating an integrated, one-‐stop neighborhood center that weaves together occupational counseling, job training, peer support, mental health services, and chronic disease self-‐management programs. The goal of the CSN was to enable vulnerable adults with limited skills, physical and/or behavioral health problems to become independent and productive members of the community through retaining sustainable jobs. Of the 137 participants:
• 73 (53.2%) found employment with a sustainable wage (CSN goal = 53%) with 66 different employers
• Of the 72 individuals in the program for at least one year, 54 (75%) were employed for at least 1 year (goal was 85%). In Philadelphia 2011 only 52% of workforce development employees sustained employment for 6 months
• 4 (8%) participants were rearrested compared to 68% nationally (CSN goal
Domain Strategies /Activities Updates was 10%)
• 66.6% made at least one healthy lifestyle change
• 48.8% made 5 or more healthy lifestyle changes
• 91% had at least one positive behavior or health status change during the program
• 52.8% said their ability to control their health improved “a lot”
• 40.4% said their QOL improved “a lot” • 47% said their health improved “a lot”
Overall, participants reported improved health status and the program helped participants make behavior changes that are slowly impacting blood pressure, cholesterol and glucose levels. Mental health status improved among program participants, particularly perceived stress levels. A city-‐wide task force has been formed to consider the needs of returning citizens. Jefferson’s Center for Urban Health leadership co-‐lead the Physical and Behavioral Health Subcommittee.
Access to Care Improve appropriate Emergency Department utilization through care coordination across community, hospital and primary care
Assess non-‐emergent and ambulatory care use and develop strategies to reduce rate through community and hospital initiatives
Leadership from the Center for Urban Health and faculty from the College of Population Health conducted an assessment of Methodist and TJUH emergency department data for 2013 and 2014 to determine utilization for ambulatory care sensitive conditions and “hotspotting” for use by high utilizers. The assessment was completed as part of the CHNA 2016 process and results are reported in the CHNA. Strategies will be considered as part of the 2016 Community Health Implementation Plan.
Institute health coaches for high utilizers; immigrants/refugees; homeless through partnerships with resettlement agencies, St Elizabeth’s
Pennsylvania initiated a Community Health Worker (CHW) coalition that is developing policies, core competencies and employer interest. Jefferson’s Center for Urban Health
Domain Strategies /Activities Updates Wellness Center and others as appropriate
leadership joined the PA CHW coalition policy and curriculum committees. State committees developed competencies and are working on policy development. ASTHO is consulting and providing training for all committee members in April. Jefferson’s Center for Urban Health leadership supported development of both levels of the CHW program and continues to provide guidance. The second level of the CHW program was delayed until Fall 2016. The Jefferson CHW program was initiated in January 2016. 8 Bilingual and African American CHW students were recruited from community partner organizations. Scholarships to cover tuition were provided to 6 individuals (4 bilingual and 2 African Americans) from the Welcoming Center, Steven Klein Wellness Center, and SEAMAAC. In addition, the Department of Family and Community Medicine department provided 2 scholarships for the Bhutanese and Burmese community. TJUH staff from the Center for Urban Health and a TJUH social worker in the Breast Cancer Center are teaching the course.
Advocate for creation of a City-‐wide database to track patients requesting pain medications and other drugs
A Pennsylvania law/regulation was passed to support the creation of databases to track patients requesting pain medications. Discussions concerning implementation are in progress across the Commonwealth. A City-‐wide task force (Jefferson physicians from the ED participate) on opiate prescribing and training for health professionals has been formed. The Philadelphia lock box program is being initiated in 6 District Police Stations to help to dispose of unused opiates. A Town Hall was hosted by the federal Government in April 2016 to share concerns and opportunities for reducing death from heroin and opiates overdoses and improved access to Naloxone.
Improve Access to Health
Partner with TJUH Finance Dept. to train community leaders and CBOs to
Jefferson partnered with Enroll America, Pennsylvania Health Access Network (PHAN), and
Domain Strategies /Activities Updates Insurance
assist with enrolling community members into insurance programs such as MA and CHIP as well as new Enroll America programs as a response to the ACA insurance exchanges.
the Southeast Asian Mutual Assistance Associations Coalition (SEAMAAC led a coalition to help the Asian community with enrollment) to assist the community with enrollment into the health insurance exchange. Multi-‐lingual materials explaining the health insurance enrollment programs created by the Affordable care act were created as were educational programs. Twenty events were implemented at Methodist in 2014. The events were held at Methodist hospital. SEAMAAC, PHAN and Enroll America partnered on several events at Methodist that provided outreach and assistance to the Asian community and others in Philadelphia neighborhoods. Enroll America made 5,760 attempts to engage uninsured residents and 1200 were helped in some way. In addition 21 Jefferson health professional students were trained by PHAN to assist with Medicaid enrollment. Enroll America | Jefferson Health Partnership November 2015 – January 2016 Outreach in the Philadelphia area did not stop after the end of the second open enrollment period. In fact, Enroll America continued working with partners and directly with consumers throughout the spring, summer and fall – knowing that finding the remaining uninsured and moving them to coverage would be a more difficult endeavor. Starting in October, calls from staff, volunteers and partners were initiated to reach the uninsured previously identified, and throughout January, Enroll America staff were present in the hospital once per week to directly engage with those within the hospital about their health insurance needs. Between 10/15/2015 and 1/31/2016, 12,959 attempts to assist people with insurance were made, 2,037 contacts were made, 137 appointments scheduled, 90 enrolled and 6 rescheduled. As anticipated, despite media coverage and increased signage, and active engagement of Jefferson staff, identifying and enrolling the uninsured is becoming more
Domain Strategies /Activities Updates difficulty as more and more individuals become enrolled through the Health Insurance Exchange. Jefferson and Methodist Hospitals also assisted 24,458 individuals with applications to Medicaid, public assistance programs or Charity Care in 2014-‐2015.
Improve access to Community Centered Social and Health Education Services and regular source of Health Care
Partner with the Cambodian Association and others to explore feasibility of initiating a “Primary Care Center” in South Philadelphia for the Asian Community. The center would include physical and mental health services and social services under one roof.
Leadership from Jefferson Hospitals met with the Chinatown CDC to discuss possible relationship with new facility being planned. Leadership also met with Asian leadership at Methodist to discuss interest and next steps in improving access to care for the Asian community in Jefferson’s community benefit area, particularly those in Center City and South Philadelphia. Jefferson and Methodist leadership visited the Unity Clinic, run by the Augustinian Defenders of the Rights of the Poor (ADROP), to discuss a potential partnership to expand services for the un/under insured. Meetings with the Unity Clinic and Asian leadership, Methodist and Jefferson staff were held and discussions continue. A proposal to the PA Department of Health for expansion of the Unity Clinic was submitted, but not accepted. Additional sources of funding are being explored including development of a business plan and involving Institutional Advancement. Methodist Hospital provided 480 free laboratory tests for the Unity Clinic in 2013-‐2014.
Free Clinics for the homeless (JEFF HOPE) and Jefferson Refugee Health Partners
TJUH Pharmacy has multiple collaborations and partnerships that address community needs while providing opportunities for pharmacy students and residents to gain experience working in a community setting. The TJUH pharmacy provides these opportunities weekly with Jeff HOPE and Our Brother’s Place (homeless outreach), JFMA refugee clinic, Sunday Breakfast Health Clinic, and the Eliza Shirley Health Clinic. Pharmacists at these sites help patients to understand medications and improve
Domain Strategies /Activities Updates medication adherences, provide medication reconciliation, and improve access to effective medications that are affordable through patient assistance programs. They also provide patient education for chronic disease such as asthma, hypertension and diabetes. In addition, they educate TJU pharmacy students and medical students about patient self-‐care, lifestyle modifications, and healthcare delivery systems for underserved patients. More than 2,500 patients were touched by their outreach services over the past 3 years. The Jefferson Pharmacy also provides free medications to these programs to support patients.
Chinatown Free Clinic Attending faculty in Jefferson’s Emergency Department and Drexel University serve as the Directors of the Volunteer Clinic at Chinatown located in Holy Redeemer Church. This weekly clinic has been in existence for more than a decade and provides care for uninsured, undocumented and financially disadvantaged people from multiple immigrant communities. (More than 2000 patient visits in 2015)
Tindley Temple Methodist Hospital supports a parish nurse program at Tindley Temple in South Philadelphia. Services provided include counseling, home visits, health education, immunizations and a soup kitchen. More than 1,000 people received services in 2015-‐2015.
Partner with Stephen Klein Wellness Center (formerly St Elizabeth’s health clinic) located in North Philadelphia.
Jefferson’s Center for Urban Health held monthly, 3 session Diabetes Self-‐Management Education Classes at the Stephen Klein Wellness Center in 2013-‐2016. Chronic Disease Management Programs were implemented in spring 2016. The Diabetes Self-‐Management Education Program-‐Learning to Manage and Live with Diabetes-‐ provides individuals and families living with diabetes and prediabetes education tools and resources to better self-‐ manage diabetes, reduce complications and improve quality of life. This program is accredited by the American Association of Diabetes Educators.
Domain Strategies /Activities Updates In 2013-‐ 2016 a total of 15 diabetes self-‐management education programs were conducted reaching 52 participants. Of the 52 participants, 23.08% (n=12) participated in the program 2 or more times. Participants (n= 33) also reported achieving at least one behavioral goal in each of the following areas: healthy eating 42.4 % (n=14); monitoring blood glucose 21.2 % (n= 7); being active 24.2 % (n= 8); and talking medications 12.1 % (n=4). In post program assessment, participants (n= 22) reported that as a result of attending the program, they had seen or scheduled an appointment with a primary care provider 45.4% (n= 10) or an eye doctor 22.7% (n=5). Seven (31.8%) of the 22 participants who completed the post evaluation had their A1C checked. A Chronic Disease Self-‐Management Education Program: Help Yourself to Health, a six week program (2 and ½ hour session per week), was held at the SKWC. 19 participants 10 completed 4 or more sessions. Jefferson supported the formation of the Steven Klein Wellness Center through a $1 million dollar donation. This center has col-‐located services including a YMCA and medical legal partnership. In addition Jefferson is providing physical therapy services. Jefferson’s pharmacy department also engages students in educational and medication reviews at the Steven Klein Wellness Center. Jefferson physicians staff the Steven Klein Wellness center with Project HOME staff.
Medical Legal Partnership: Assess need and feasibility of MLP at Jefferson and Refugee Health Partners student run clinic.
The study to assess the need for legal services for Refugee Health Partners, a refugee clinic run by Jefferson students, was completed by an MPH student and leadership from the Center for Urban Health. The study recommended that due to language barriers and complexity of their cases, refugees needing legal services be referred to existing
Domain Strategies /Activities Updates community legal services that specialize in legal issues such as immigration and disabilities.
Leadership from the Center for Urban Health and the College of Population Health are evaluating a medical legal partnership (MLP) facilitated by Legal Services for the Disabled MLP sites (5 sites). The MLP site initiated at Project HOME Wellness Ctr. is one of those being evaluated by College of Population Health and CUH faculty. Services provided by attorneys include landlord issues, utility assistance, domestic violence, health insurance issues, food assistance, and child-‐related interventions with schools. Clinic staff was trained by MLP lawyers to improve screening and referral to the attorneys. In 2015, 172 clients had cases closed. Outcomes being evaluated include patient stress, perceived health status, satisfaction with services. 50% of clients reported decreased stress levels that were attributed to legal services provided, 38% reported their quality of life improved after receiving legal assistance, and 97% were satisfied with legal services received. “I have cancer and needed help getting some of my prescription medicines. My efforts to get help were brushed off before meeting the attorney. The attorney got all of my doctors together to sign the [override] papers needed for Medicaid to approve them. My high stress and poor sleep improved knowing someone will be there to help me in a bad situation”.
While discussions about a Medical legal partnership at Jefferson were initiated, a decision concerning initiating a program at Jefferson was deferred but, given the need to address social determinants of health, should be reconsidered as a strategy particularly for patients who are high health service utilizers.
Develop a system through partnerships with community centers, CBOs and agencies that support healthcare provider linkages
Health Insurance Jefferson partnered with Enroll America, Pennsylvania Health Access Network (PHAN), and the Southeast Asian Mutual Assistance
Domain Strategies /Activities Updates to appropriate health education and social services
Associations Coalition (SEAMAAC led a coalition to help the Asian community with enrollment) to assist the community with enrollment into the health insurance exchange. Multi-‐lingual materials explaining the health insurance enrollment programs created by the Affordable care act were created as were educational programs. Twenty events were implemented at Methodist in 2014. The events were held at Methodist hospital. SEAMAAC, PHAN and Enroll America partnered on several events at Methodist that provided outreach and assistance to the Asian community and others in Philadelphia neighborhoods. Enroll America made 5,760 attempts to engage uninsured residents and 1200 were helped in some way. In addition 21 Jefferson health professional students were trained by PHAN to assist with Medicaid enrollment. Enroll America | Jefferson Health Partnership November 2015 – January 2016
Outreach in the Philadelphia area did not stop after the end of the second open enrollment period. In fact, Enroll America continued working with partners and directly with consumers throughout the spring, summer and fall – knowing that finding the remaining uninsured and moving them to coverage would be a more difficult endeavor. Starting in October, calls from staff, volunteers and partners were initiated to reach the uninsured previously identified, and throughout January, Enroll America staff were present in the hospital once per week to directly engage with those within the hospital about their health insurance needs. Between 10/15/2015 and 1/31/2016, 12,959 attempts to assist people with insurance were made, 2,037 contacts were made, 137 appointments scheduled, 90 enrolled and 6 rescheduled. As anticipated, despite media coverage and increased signage, and active engagement of Jefferson staff, identifying
Domain Strategies /Activities Updates and enrolling the uninsured is becoming more difficulty as more and more individuals become enrolled through the Health Insurance Exchange.
Food Access
As part of its commitment to food access, Jefferson participates in the Food Policy Advisory Council’s anti-‐hunger and health subcommittees. The Philadelphia Food Policy Advisory Council’s Anti-‐Hunger Subcommittee saw the need for a food resources toolkit that consolidated information about how to get affordable, healthy food in Philadelphia. Reliable information about different types of food resources were compiled for a project now known as Philly Food Finder. Phillyfoodfinder.org is a comprehensive, mobile-‐friendly website with a searchable map and detailed info on local food resources such as pantries, farmers markets, senior congregate meals, WIC, and SNAP. Food providers are able to submit updates regarding new programs or changes, critical to maintaining correct data. Philly Food Finder was developed by Hack4 Impact through a collaboration between the Greater Philadelphia Coalition Against Hunger and the Philadelphia Food Policy Advisory Council (FPAC).
Coordinated Resources
Jefferson participates in Get Healthy Philly and Center for Urban Health leadership co-chaired the chronic disease subcommittee and participated in the access to care subcommittee of the Philadelphia Department of Health’s Community Health Improvement Plan. As part of this initiative the Health Department developed Philly Powered to identify and promote physical activity opportunities in the City.
Language Access, Health Literacy
Provide cultural competence training for health care providers related to populations including
Mental Health First Aid Training is an 8 hour mental health first aid certificate course that teaches individuals how to help those
Domain Strategies /Activities Updates and Cultural Competence
immigrants/refugees, LGBT, older adults, mentally ill and the homeless
experiencing mental health challenges or crises. Two staff from the Center for Urban Health were trained by the Department of Behavioral Health and Intellectual disAbility Services as Mental Health First Aid instructors. Jefferson staff initiated the training program on campus and in the community. Five programs were conducted including a program with EMTs. More than 70 individuals received training.
SEPA-‐READS (Southeastern Pennsylvania Regional Enhancements Addressing Disconnects in Cardiovascular Health Literacy) is a comprehensive five year state-‐funded health literacy, that uses the Expanded Chronic Care Model and Triple Aim emphasizing system change, the patient and provider care experience, and improved health outcomes. The interdisciplinary project incorporates best practices and chronic disease prevention/management competencies in health literacy training and patient empowerment activities. To date, leadership from the Center for Urban Health, facilitators of the SEPA-‐READS train-‐ the-‐ trainer program, have trained over 250 healthcare professionals in nine healthcare systems and other State organizations, who have then trained at least 7,100 staff across SE Pennsylvania and the State. In addition, 100 community members in Senior serving organizations have been trained as peer educators who have delivered dozens of sessions reaching 650 individuals. SEPA-‐READS has also partnered with a regional immigrant health literacy initiative. Ask Me 3 training for key peer leaders in Senior centers and immigrant organizations has been initiated. In all 36 trainings, 20 webinars, 3 annual events and 6 network calls have been held. An on-‐line portal has been initiated to share information. On-‐line training modules are also being developed. Initial changes within health systems focused on
Domain Strategies /Activities Updates educating staff and patients, and included activities such as:
• Incorporating health literacy and teach back into staff training.
• Using teach back and “show me” when communicating with patients.
• Revising, redesigning, and standardizing education materials for heart failure patients.
Later in the project, health systems began to tackle more challenging activities and organizational changes, including:
• Updating the organization’s website to make navigation easier.
• Developing a Patient and Family Education Committee to oversee patient education materials.
• Creating a department policy making teach back the model for patient education.
In the fifth year of the initial funding period, health systems were offered technical assistance from an expert health literacy consultant to identify and address additional areas for improvement. These projects included:
• Further review and revision of patient education materials.
• Monitoring the use and evaluating the effectiveness of teach back.
• Training registrars to collect accurate race and ethnicity data.
• Testing the usefulness of hospital maps with community members.
In 2015, the SEPA-‐READS Steering Committee delivered training and educational programs in three additional regions of Pennsylvania. Recognizing the need to provide ongoing support to those participating in educational programs, HCIF is the lead organization in the formation of the Pennsylvania Health Literacy Coalition, a statewide organization dedicated to connecting and empowering many diverse stakeholders to improve health literacy in the Commonwealth.
Domain Strategies /Activities Updates With representatives from over 50 organizations, the Coalition’s current activities include in-‐person trainings, meetings, and workgroups; online training and a new, interactive website are currently in development. Health literacy is a topic that cannot be addressed by any one individual or any single organization. SEPA-‐READS is an effective model for regional, multidisciplinary collaboration that engages diverse stakeholders and drives improvement and change. The SEPA-‐READS Steering Committee and partner organizations continue to work towards creating a sustainable culture of health literacy in Southeastern Pennsylvania and beyond. In 2015, SEPA READS receive funding from the PA Department of Health to create a statewide health literacy coalition. Jefferson leadership from the Center for Urban Health serve on the steering committee and subcommittees.
In partnership with PICC, increase awareness about regulations pertaining to access to interpreters
SEPA READS working with organizations serving non-‐English speaking community to empower clients to advocate for interpreter services.
Review availability of technology for interpreter services to assist non-‐English speaking people to schedule appointments, call the hospital or health care provider for information, guidance about procedures etc.
In collaboration with the Nationalities Services Center and Jefferson’s Center for Urban Health, JEFF-‐Now initiated a system that allows non-‐English speakers to call and request interpreter services in order to schedule appointments, identify a health care provider and receive other information such as guidance about procedures. Jefferson needs to raise community awareness about availability of service. Students from Jefferson’s Sidney Kimmel Medical College and the College of Population Health with guidance from Nationalities Services Center and the Center for Urban Health are interviewing individuals from CBO’s who assist non-‐English speaking clients in navigating the health care system. The purpose of the interviews and surveys is to assess issues and barriers related to language line and interpreter services.
Domain Strategies /Activities Updates Partner with Refugee Health
Partners (TJU student organization), and community based organizations for medical interpreter services and community health coach/ worker services. Provide training and oversight for bilingual interpreters and community health coach/workers.
Part of CHW training Initiative.
Continue to provide interpreter services for Chinese patients though the Chinese Health Information Center (Jefferson Hospital) and Vietnamese Interpreter (Methodist Hospital)
The Chinese Health Information Center serves as the focal point for Jefferson's ongoing initiative to provide health education, outreach and case management to the Chinese population in Philadelphia and surrounding areas. A team of bilingual and trilingual clinicians, social workers and administrators staffs the Center (3 FTE for 6 months and 4 FTE for the next 6 months of FYs 2014 and 2015). The staff makes referrals and appointments, provides interpretation, assists with social service needs, registers clients for childbirth classes, and more. In FY14 there were 8,500 visits (not individuals) and 8,100 contacted by phone. In FY15, there were 8,700 visits (not individuals) and 8,500 contacted by phone. Methodist Hospital provides in-‐person interpreter and navigation services for the Southeast Asian (Vietnamese) community in South Philadelphia. These services include assistance in scheduling appointments, serving as a cultural broker, accompanying patients to visits, inpatient support for patients and clinicians, and support at outpatient diagnostic services.
Continue to provide Health Literacy training for health care staff, providers and TJU students Develop and implement policies/system changes that require employee health literacy training
Training for JUP practices are on-‐going. Six trainings reaching about 150 have been held to date. Health Literacy Training is provided for 50 medical students and 70 pharmacy students annually by SEPA READS trainers from the Jefferson’s Center for Urban Health. Over the past three years more than 350 students have received this best safety practice training.
Domain Strategies /Activities Updates Recommendations include exploring opportunities to include health literacy training at new employee orientation and as part of annual Health Stream education requirements.
Maternal and Child Health
In partnership with MCC, PDPH, and Hospital/University Departments and community partners, develop strategies to increase access to timely prenatal care
In the past year, Jefferson University Physicians has located two OB practitioners at Methodist Hospital in South Philadelphia. Jeff HOPE students and Center for Urban Health faculty conducted a research study in a women’s Shelter for the homeless to investigate prenatal practices, attitudes, beliefs and barriers to care. A relationship with WIC was also initiated to explore co-‐locating prenatal care services at selected WIC sites. Funding to support this initiative was pursued.
Promote Breastfeeding – continue to pursue Baby Friendly Hospital status
A city-‐wide initiative led by MCC, PDPH Chronic Disease CHIP initiative and birthing hospitals is in progress. Philadelphia hopes to be the first city where all birthing hospitals have Baby Friendly Hospital status. Jefferson is on schedule for obtaining Baby Friendly Hospital status by Fall 2016. Jefferson’s site visit is the end of April. Jefferson’s nursing department participates in the Breastfeeding Coalition of Philadelphia. Free breast feeding classes and support groups are offered weekly. 364 individuals attended the breastfeeding classes and 268 participated in the breastfeeding support group in 2014-‐2015. In addition, in 2014 a breastfeeding telephone support group was offered free of charge to the general public. The “warm-‐line” is advertised throughout the Delaware Valley, by the Philadelphia Department of Public Health and Maternity Care Coalition. Phone calls are answered by certified lactation consultants. Approximately 1500 women used the warm-‐line in 2014 and 2015. In 2014 and 2015, Jefferson sponsored the PRO LC breastfeeding group educational session, free of charge, for the City of Philadelphia and the breastfeeding community.
Domain Strategies /Activities Updates More than 50 people participated each year. Finally, Jefferson promoted World Breastfeed Week in 2014 and 2015 through presentations on campus, the news media, and co-‐sponsored an event at the Phillies baseball game. In 2015 approximately 200 people were impacted by this event.
Continue to explore “Maternity Care Passport” to reduce unnecessary patient re-‐testing in Philadelphia at time of service and/or labor and delivery.
OB chairs across Philadelphia meet monthly to discuss obstetrical issues including the need for a maternity care passport.
Access to Mental Health Services
In partnership with TJU Psychiatry, Council for Relationships and Women Against Abuse, provide support for and implement Trauma Informed Care training workshop for community partners in order for them to improve their skill in working with individuals who have experienced trauma, such as refugees, youth experiencing violence, etc.
United Communities and its affiliate organizations and Southwark Elementary School are interested. Will plan with David Keenan, TJU Psychiatry and Family Counseling programs and Lutheran and Children Family Services. Through the efforts of Jefferson’s Center for Urban Health leadership, Jefferson’s Couples and Family Counseling Program is providing twice weekly counseling support (Master’s degree students) for students at the Southwark School, a kindergarten through 8th grade school in South Philadelphia where the majority of students are immigrants or refugees.
In partnership with TJU Psychiatry and Nemours Pediatrics, provide support and training for CBOs working with ADHD children and children/youth with anger management issues
This continues to be an issue for schools and after school providers of programs for youth. United Communities and its affiliate organizations and Southwark Elementary School are interested in training. The Center for Urban Health leadership is continuing to work with Thomas Jefferson University’s Office of Student Life and Engagement, Couple and Family Counseling Program and the Psychiatry Department to initiate these training programs.
Explore feasibility and enhancement of depression screening and substance abuse screening in health care practices and ED
A 3 year SBIRT (Screening, Brief Intervention and Referral to Treatment) grant for $325,000 was received from SAMHSA to train Medical, Physician Assistant and Pharmacy students at Jefferson. Training for healthcare providers is also being provided through this grant. Center for Urban Health and the Department of Family and
Domain Strategies /Activities Updates Community Medicine are directing and evaluating this grant initiative at Jefferson.
Cultural competence training for mental health and health care providers related to populations including immigrants/refugees, LGBT, older adults, mentally ill and the homeless
The Philadelphia Refugee Mental Health Collaborative developed a screening training toolkit. Leadership from the Center for Urban Health and faculty from the Department of Family and Community Medicine participate in the coalition. Research on the RHS-‐15 mental health screening tool is underway through the Center for Urban Health and the Department of Family and Community Medicine with it collaborative partners. It is recommended that training be expanded to other marginalized populations.
Continue to improve access to mental health services through partnerships with CBOs and behavioral health collaboratives: Continue to improve access for non-‐English speakers to mental health services Improve access to transportation for mentally ill patients Raise awareness of providers and community about mental health resources Support the St Elizabeth’s Wellness Collaborative and the Refugee Behavioral Health Collaborative
The Philadelphia Refugee Mental Health Collaborative developed a screening training toolkit. Leadership from the Center for Urban Health and faculty from the Department of Family and Community Medicine participate in the coalition. Research on the RHS-‐15 mental health screening tool is underway through the Center for Urban Health, Jefferson’s Department of Family and Community Medicine and the Philadelphia Refugee Mental Health Collaborative. Mental Health First Aid Training is an 8 hour mental health first aid certificate course that teaches individuals how to help those experiencing mental health challenges or crises. Two staff from the Center for Urban Health were trained by the Department of Behavioral Health and Intellectual disAbility Services as Mental Health First Aid instructors. Jefferson staff initiated the training program on campus and in the community. Five programs were conducted including a program with EMTs. More than 70 individuals received training.
Domain Strategies /Activities Updates Transportation
Transportation services More than 2200 patients received transportation assistance including cab vouchers ($3665) and van transportation ($11,567)
Medication Access
Raise community awareness about free/low cost medication access programs
Information about free/low cost medication access programs is provided as part of Heart Smarts program and BP+ program. The Pharmacy Department also provides information through its community outreach programs at the Steven Klein Wellness Center and sites serving the homeless. Need to expand further.
Chronic Disease Management General Chronic Disease Management
Create a faith-‐based advisory council and provide/coordinate programming at specific sites and training for parish nurses to address chronic disease management.
Jefferson Hospitals’ Center for Urban’s (CUH) initiated a faith based cardiovascular risk reduction and stroke prevention education, counseling and screening program called Heart and Soul. The purpose of the program is to: 1) raise community awareness about the relationship between healthy lifestyles and cardiovascular diseases including stroke and diabetes; 2) promote healthier lifestyles to prevent onset of cardiovascular disease and self-‐management of those with disease; 3) promote screening guidelines; 4) encourage effective patient-‐ physician communication; and 5) assist participants in accessing primary care. Three Church Advisory Councils (Tindley Temple, Jones Memorial and Solid Rock) have conducted the Heart and Soul Program in their congregations. Prescreening and health assessments were done including diabetes A1c, blood pressure, height, weight and BMI testing. On average, 20 people participated at each church. An MPH student from West Chester University assisted with the program evaluation. Each Congregation:
• Developed a work plan and time line (see sample work plan)
• Selected a Program Coordinator • Appointed a program Advisory Group • Worked collaboratively with the Center
for Urban Health to evaluate the program.
Solid Rock -‐ a seven week healthy lifestyle program based on the Daniel Plan (Warren, Amen, & Hyman, 2013) was conducted. The
Domain Strategies /Activities Updates Daniel Plan is framed around five essentials: Faith, Food, Fitness, Focus and Friends – life areas that all work together to restore and sustain your long-‐term health. Post program the church continued 12 months of nutrition, physical activity and weight management programming. They partnered with Penn State and the Philadelphia Corporation for Aging to complete additional programs. While only 5 participants indicated a history of elevated blood pressure, 10 participants had elevated blood pressures (>140/90) when screened. Three women reported a history of diabetes, but 4 screened positive for diabetes. All participants with pre-‐diabetes or diabetes saw their health provider. The program at Tindley Temple is held with soup kitchen participants. More than half of the participants had pre-‐diabetes A1c levels. Jones Memorial is participating in the Columbia North YMCA diabetes prevention program. They are also working with other community partners to bring health programs into the congregation. Health ministry leaders are currently working on 2016 health programs with Jefferson. A Train the Trainer Heart and Soul Toolkit was developed to help churches continue to offer the program to their congregation.
Increase access to chronic disease management resources by centralizing information Increase referral to disease management programs by health providers and community partners.
As part of the 2016 CHNA process a comprehensive database was developed and will be shared with providers. It will also be available to community partners upon request. How to integrate programs and resources into the EPIC EHR should be explored. The Center for Urban Health has been promoting programs through JEFF NOW and flyers provided to Internal Medicine and Family and Community Medicine. Program information is being shared with the community outreach committee at Methodist and at the Steven Klein Wellness Center. Other promotion possibilities need to be explored with Marketing.
Increase screening of all patients and All BP Plus and Heart Smarts program
Domain Strategies /Activities Updates community program participants for smoking status and refer to State QUIT line
participants are asked about their smoking status. All participants who smoke are given information concerning the Philadelphia and PA QUIT lines. Fax to QUIT is being initiated beginning in June 2016. Other opportunities to integrate smoking status screening into community programming should be explored. Great American Smokeout activities were held each year at Jefferson to raise awareness about the impact of smoking on Health and to encourage smokers to quit. Useful tools to quit and handouts were provided, including how to access the Pennsylvania QUIT line.
Partner with the CBOs that work with non-‐English speaking individuals to develop and provide training for bilingual staff on chronic disease management that trainees then provide to educate non-‐English speaking community residents on hypertension, diabetes, asthma and obesity.
A CHW program was developed by the Institute for Emerging Health Professionals with faculty support from the Center for Urban Health. The first level of the CHW certification program was initiated in January 2016; the second level is in development and slated to start in September 2016. Bilingual CHW students in Jefferson’s level 2 of the CHW training program will receive training in chronic disease management. Jefferson Hospital provided six tuition scholarships for the first cohort of students, most of whom are bilingual. Leadership from the Center for Urban Health joined the PA CHW coalition and is participating on several work groups. In collaboration with the Jefferson Case Managers for Population Health, funding to support diabetes prevention program training for CHWs (particularly bilingual CHWs) and CUH staff is being pursued with the Philadelphia Department of Public Health.
Continue to provide and expand Chronic Disease Self-‐Management programs offered at community sites
In 2015, the Center for Urban Health staff were re-‐trained in Chronic Disease Self-‐Management through a partnership with Philadelphia Corporation on Aging. The first chronic disease self-‐management program was held at the Steven Klein Wellness Center in partnership with PCA. There were 15 participants.
Domain Strategies /Activities Updates Diabetes Continue to provide and expand
DSME programs offered at community sites and at Jefferson.
The Jefferson Diabetes Plan was completed and approved. Funding from the Fuller foundation was received to support the DSME community program for the Center for Urban Health. Learning to Management and Live with Diabetes: The Center for Urban Health works collaboratively with the Jefferson Diabetes Center to provide individuals and families living with diabetes and pre-‐diabetes education tools and resources to better self-‐manage diabetes, reduce complications and improve quality of life. This program is accredited by the American
Association of Diabetes Educators. Between 2013 and 2016, 28 DSME programs were held at 14 sites reaching more than 200 individuals (YMCA sites, Steven Klein Wellness Center, Jefferson Diabetes Center and Methodist Hospital). Behavioral goals chosen by participants included health eating (41%), being more active (19%) and glucose monitoring (8%). As a result of the program, 74% of participants saw their primary care provider, 80% saw a podiatrist, 70% saw their eye doctor, and 87% had or scheduled an appointment to have their A1c rechecked. Other Diabetes educations programs provided include DSME services offered by TJUH Pharmacy (39 individuals reached), Diabetes research with Wills Eye Hospital (46 reached), Diabetes Health Sense Evaluation (30 reached), the Diabetes Living Room Pilot (50 reached), Diabetes Awareness Day (15 reached), the 2014 Health EXPO Pharmacy and Diabetic Education (200 reached), Diabetes Alert Day (90 reached) and the Jefferson Diabetes Symposium.
Continue diabetes support group at Jefferson and in the community.
Diabetes Support Groups: Monthly and quarterly diabetes follow-‐up and support for individuals and families living with diabetes and pre-‐diabetes. Programs include nutrition education, cooking demonstrations, stress management, and problem solving. In
Domain Strategies /Activities Updates 2013 and 2014 a diabetes support group was held at St Matthew AME church reaching 65 individuals. As a result of the support group 88 % saw their health care provider, 77% saw the eye doctor, 82% saw the podiatrist, 86% report eating healthier, 80% report being more active, and 55% report having better control of their health. Divabetic Philadelphia: A partnership with Jefferson Hospital. American Diabetes Association and Divabetic. This monthly support offers additional special events (February – Love on a Two Way Street; Diabetes and Sexuality; Go Red Diva: Diabetes and Heart Disease; May-‐ Luncheons-‐ Sisters, Mothers, Daughters, and Friend: Diabetes and Stress Management; A Family Affair: Diabetes and Kidney Disease; November-‐ ADA Step Out Walk; Main Event: Victory Ove Diabetes African American Museum. In addition several podcasts were held. Monthly program attendance averages 35 to 40 people. Between 155 and 177 people attended the main annual event each year. 50% of participants attended 3 or more Divabetic sessions. As a result of the 2014 and 2015 support groups, individuals with diabetes (n=61) reported: seeing or making an appointment to see a primary care
provider (92%; n=56); seeing an eye doctor (82%; n=50); seeing a foot doctor (69%; n=40); and seeing a dentist (69%; n=42). 51% of participants with diabetes reported a decrease in their A1c level. Divabetic participants formed a Team for the 2015 American Diabetes Association Walk.
Increase referral to diabetes management programs and support groups by health care providers
Flyers have been developed and distributed to Jefferson’s Endocrinology Department, Jefferson Family Medicine Associates and Internal Medicine. Recommendation -‐ create a prescription to the program and use EHR to help promote. The Center for Urban Health is working on a grant with the Philadelphia Department of Public Health and Health Care Improvement
Domain Strategies /Activities Updates Foundation for CDC funding to support designing a system to improve communication between patient, provider and community based programs.
Continue to refer pre-‐diabetic patients to YMCA Diabetes Prevention Programs in our CB areas
The Center for Urban Health refers prediabetes clients to the Columbia North YMCA. Jefferson’s Center for Urban Health is working on a grant with the Philadelphia Department of Health and Healthcare Improvement Foundation and Jefferson Endocrinology to initiate Diabetes Prevention Programs at community sites and to train community health workers and a Master Trainer at Jefferson in order to sustain the program over time. The focus will be in South Philadelphia.
Hypertension
Revise and expand current BP plus program. Partner with AHA (360 and Get to Goal campaign) and the Philadelphia Department of Public Health (Million Hearts campaign) to increase screening, and adherence to treatment plan.
The national Million Hearts® campaign aims to prevent 1 million heart attacks and strokes in the next 5 years. The Million Hearts™ Initiative in Philadelphia is striving to prevent 5,000 heart attacks and strokes among city residents by 2017. This effort is challenging as one Philadelphian dies every four hours from these diseases. The Philadelphia Department of Public Health and the American Heart Association® are helping to coordinate the city's efforts. Heart Smarts (part of Million Hearts Campaign) In January 2014, The Food Trust, Thomas Jefferson University Hospitals’ Center for Urban Health and the Philadelphia Department of Public Health expanded the Heart Smarts program in selected stores to include free health screening, health education, referral and follow-‐up for at-‐risk customers. Funding was obtained from Astra Zenecca, Kynett and Cuterra Foundations. The program provides:
• In-‐store education includes healthy eating and reducing modifiable risk factors for heart disease. The Food Trust assists store owners in increasing fresh produce and low-‐fat, low-‐sodium products in stores
• Free Health Screenings (free blood pressure, height, weight, BMI) provided by Jefferson’s Center for Urban Health are held once monthly at 11 corner
Domain Strategies /Activities Updates stores. Participants with high blood pressure receive follow-‐up and reminder calls to assist them in finding a primary care provider and encouraging them to schedule an appointment. Participants without insurance are given information about how to sign up and sites where they can receive care based on their insurance status. All smokers are given information about the Philadelphia and PA QUIT Lines. With client permission, primary care providers are contacted to inform them of their patient’s progress. • Total number of healthy corner
stores visited: 11 • Number of participants reached:
1650 • Number of participants who came
back for at least two visits: 34.1% • Gender: 56% male; 44% female • Age: Range = 18-‐96, Mean = 46 • Race/Ethnicity: Black –65% ; White
–4% ; Hispanic/Latino/a –21% ; Other or unidentified– 10%
Follow-‐ up: Monthly phone calls were attempted to all participants whose blood pressure was elevated (n=674 participants). Of the 674, 499 (75%) participants were successfully contacted. Most returned to the corner store to be rescreened within 4 months of the initial screening. Of those successfully reached: 18.8% of those lacking health insurance at the initial screen reported having health coverage at the follow-‐up call; and 16.3% who lacked a primary care provider at the initial screen indicate they now had a health care provider. 46% of individuals with elevated blood pressure at the initial screening reported not having seen a health care provider in the past year (2015). Blood Pressure Screening :
• 24.6% screened had normal readings; of these, 81% did not know their BP numbers or levels (2014)
• 42% had pre-‐hypertensive readings; of these, 65.8% did not know they were
Domain Strategies /Activities Updates pre-‐hypertensive (2014)
• 33.4% had hypertensive readings; of these, 41.4% did not know they were hypertensive (2014)
• Of those with elevated BP readings (≥140/90) (2015) • 79.7% with elevated BP had been
told by a doctor that they have high blood pressure and are taking medication for HBP.
• 73.8% with a diagnosis of hypertension stated that they took their BP medication prior to screening that morning.
• At the time of the follow-‐up call 28% of those with elevated blood pressure readings (139 of 499) had seen their primary care provider • 25% had their medications
changed • 26% had no change to
medications • 12% were newly diagnosed
with hypertension and prescribed medication
• 36% had normal blood pressure readings
Follow-‐ up: Monthly phone calls were attempted to all participants whose blood pressure was elevated (n=674 participants). Of the 674, 499(75%) participants were successfully contacted. Most returned within 4 months of the initial screening. Of those successfully reached: 18.8% of those lacking health insurance at the initial screen reported having health coverage at the follow-‐up call; 16.3% who lacked a primary care provider at the initial screen indicated they now had a health care provider. 45.9% of individuals with elevated blood pressure reported not having seen a health care provider in the past year (2015). Blood Pressure Screening:
• 24.6% screened had normal readings; of these, 81% did not know their BP
Domain Strategies /Activities Updates numbers or levels (2014)
• 42% had pre-‐hypertensive readings; of these, 65.8% did not know they were pre-‐hypertensive (2014)
• 33.4% had hypertensive readings; of these, 41.4% did not know they were hypertensive (2014)
• Of those with elevated BP readings (≥140/90) (2015) • 79.7% with elevated BP had been
told by a doctor that they have high blood pressure and are taking medication for HBP.
• 73.8% with a diagnosis of hypertension stated that they took their BP medication prior to screening that morning.
• At the time of the follow-‐up call 28% of those with elevated blood pressure readings (139 of 499) had seen their primary care provider
• 25% had their medications changed
• 26% had no change to medications • 12% were newly diagnosed with
hypertension and prescribed medication
• 36% had normal blood pressure readings
Smoking Cessation • 47% of all individuals screened reported
they smoke and were given information about the QUIT Line. Of those contacted in a follow-‐up call, 15% reported reducing the amount they smoke and 3% (15 individuals) quit smoking.
• Recommendation – use the FAX to QUIT program with permission from the participant
Overweight and Obesity (BMI screening)
Domain Strategies /Activities Updates • More than two-‐thirds of the 1650
program participants were overweight or obese. (more than 1/3 overweight and more than 1/3 obese)
• Of the 340 participants who received a follow-‐up call in 2015 because their blood pressure readings were elevated at the initial screening, 150 (44.1%) indicated they improved their diets to include more fruit/vegetables and 87 (25.6%) reported reducing dietary sodium.
• In 2015, 282 participants had at least two visits. Of the 282, 98 (35%) had their weight measured a second time. Of this group, 23 individuals (23%) lost more than 2 pounds and 45 (46%) gained more than 2 pounds; 13% lost more than 5 pounds and 26% gained more than 5 pounds.
• Nutrition Behavioral Measures for 2015 • 84.7% (n=111) of participants who
participated in the Quick and Healthy meals lesson reported they would use fruits and vegetables to make these meals after attending the lesson.
• 88.3% (n=111) participants who participated in the Fiber Lesson reported learning the benefits of fiber, sources of fiber and how to make meals that increase their fiber intake.
BP+ Programs-‐(part of Million Hearts Campaign) This screening program was conducted in 2015 and is modeled after the Heart Smarts Program; however, there is less focus on nutrition education. The program is held in a variety of community sites including faith-‐based institutions, YMCA, community centers and senior centers. Screenings include blood pressure, height, weight, BMI. Counseling and
Domain Strategies /Activities Updates Follow-‐up is the same as the Heart Smart program. All participants are given information about smoking cessation, nutrition, finding a health care provider and other information based on their particular needs.
• Total number of sites in 2015: 8 • Number of participants reached: 340 • Number of participants who came back
for at least two visits: 140 (41.1%) • Gender: 38.5%% male; 61.5% female • Age: Range = 19-‐95, Mean = 60 • Race/Ethnicity: Black –53.5% ; White –
16.5% ; Hispanic/Latino -‐2%; Asian-‐ 1% • Lack health insurance: 10.8% • Lack a health provider: 6.8% • Smokers: 22%
Individuals without health insurance were given information about health care resources including a list of City Health centers and Federally Qualitied Health Centers. Follow up: Monthly phone calls were attempted to all participants whose blood pressure was elevated 60% (n=205 participants). Of the 205, 168 (81.9%) participants were successfully contacted. Of those successfully reached: 14.4% of those lacking health insurance at the initial screen reported having health coverage at the follow-‐up call; 32.7% who lacked a primary care provider at the initial screen indicated they had established care with a primary care provider.
Blood Pressure Screening: 205 (60.3%) of individuals screened had elevated BP readings ≥140/90 at baseline (2015). Of those with elevated BP readings:
• 143 (69.7%) with elevated BP had been told by a doctor that they have high blood pressure and were taking medication for HBP. 82% with a diagnosis of hypertension who were prescribed medications stated that they took their BP medication prior to
Domain Strategies /Activities Updates screening that morning.
At the time of the follow-‐up call 104 of the 168 participants contacted (62%) indicated they had not seen a health care provider in the past year. Of the 168 individuals with elevated blood pressure (>140/90) successfully contacted 23 (22.1%) reported they intend to make an appointment to re-‐check their blood pressure and 106 (63%) said they made an appointment with their health provider:
• Of those with elevated blood pressure readings who saw their primary care provider (n=106) • 25.5% (27) had their medications
changed • 69.8% (74) had no change to
medications because their blood pressure was controlled
• 4.7% (5) were newly diagnosed with hypertension and prescribed medication
Overweight and Obesity (BMI screening)
• At baseline (n=340), 30.7% were overweight and 44.8% were obese.
• In 2015, 140 participants who had at least two visits. Of the 140, 75 (53.6%) had their weight measured a second time. Of this group (n=75), 25 individuals (33%) lost more than 2 pounds and 16 (8%) gained more than 2 pounds; 28% lost more than 5 pounds and 9% gained more than 5 pounds.
Smoking Status Of those successfully re-‐contacted by telephone (n=168), 75 reported smoking at baseline. Of these individuals (n=75), 22 (29%) reported smoking fewer cigarettes daily and 1 person quit smoking (1%).
Blood Pressure screening in partnership the Philadelphia Corporation for Aging In 2014 the Center for Urban Health conducted a
Domain Strategies /Activities Updates comprehensive blood pressure education and screening program (3 sessions over 3 months) at 5 senior centers. A total of 164 individuals were screened. Eighty Two percent (n=134) of the participants were female and 18% (n=30) were male. The age of participants ranged from 52-‐96 with a mean age of 74 years. A total of 84% (n=137) reported having health insurance and 64% (n=105) reported having a primary care physician. Fifty five percent (n=91) were White 28% (n= 46) Black and1% (n=2) Hispanic. Medical history information revealed that 71% (n=117) reported a history of high blood pressure, 25% (n= 42) diabetes, and 32% (n= 53) high cholesterol, and 4% (n=6) kidney disease.
Health Fairs: Blood pressure screening and counseling was provided at 26 health fairs reaching more than 3,000 individuals in 2014-‐2015. Height, weight, BMI and nutrition education were provided at the majority of these health fairs as well
Develop database to track blood pressure screening participants and close communication loop with providers
A database to track blood pressure screening participants was created. Communication with Primary Care Provider needs to be implemented. The Center for Urban Health is working on a grant with the Philadelphia Department of Public Health and Health Care Improvement Foundation for CDC funding to support designing a system to improve communication between patient, provider and community based programs.
Increased referrals to hypertension management programs through physician referral
Working on a grant with the Philadelphia Department of Public Health and Health Care Improvement Foundation for CDC funding to support designing a system to improve communication between patient, provider and community based programs.
Asthma Explore collaboration with CHOP’s Community Asthma Prevention Program (CAPP) in Lower North and South Philadelphia
Open Airways for Schools is a program that educated and empowers children through a fun and interactive approach to asthma self-‐management. The program teaches children with asthma ages 8 to 11 to detect asthma triggers,
Domain Strategies /Activities Updates how to avoid triggers, use inhalers and spacers, and to make decisions about their health. Almost 200 students were reached in 2015.
Train faith-‐based nurses and community health workers to provide education and environmental assessments
Community Health Worker program initiated by TJU in the Institute for Emerging Health Professions. TJUH CUH staff helped to develop curriculum. Training in mental health first aid, and other health system navigation was initiated. CHWs should receive training in conducting home environmental assessments of asthma triggers in patient’s homes who use the emergency department for care.
Stroke Raise ED doctors, staff and community awareness about and utilization of stroke treatment (TPA)
Jefferson Neuroscience Network (JNN) provides a variety of stroke awareness education programs to hospitals in the region on a regular basis. These activities are targeted to Physicians, Nurses, & Techs working in the Emergency Departments of network hospitals. Education is also provided to Inpatient Rapid Response Teams that respond to emergent strokes that occur while patients are in hospital. Our objectives are focused on caring for stroke patients in the acute setting and understanding the importance expert evaluation in order to provide a consistent, rapid treatment decision involving tPA and endovascular interventions approved for stroke. JNN also provides education programs to EMS – Pre-‐hospital Community. JNN focuses on Recognition of Stroke signs and symptoms, risk factors and importance of time to treatment. Education programs offered: Mock Stroke Alerts, Telestroke Best Practice Inservices, Stroke Data and Outcome Review, Grand Rounds, Educational Summits and Symposiums. FY14 – 68 programs FY15 – 92 programs FY16 – 98 programs
Increase utilization of JHN stroke center robot in rural communities to improve stroke care.
Jefferson Neuroscience Network serves hospitals that are considered underserved and lack neurology specialty physician support .We do not have any that are considered to be located in a rural community.
In partnership with Center for Urban Health, JHN, TJU Nursing and medical students and the Center for Urban Health provide blood pressure and stroke screening and raise public awareness about FAST(face, arms,
Information about stroke, FAST and the American Heart Association’s sodium pledge is provided at all BP Plus/Heart Smarts programs (see blood pressure screening). Stroke Activities include Stroke Signs and
Domain Strategies /Activities Updates speech, time) and TpA. Increase awareness about stroke prevention.
symptoms, risk factor identification, importance of activating 911 and regular physician visits. TJUH also conducts stroke risk assessment screenings several times a year. In FY 15 – JHN Stroke Center conducted 75 stroke risk assessments during Stroke Month – May. JNN participated in 2 health fairs at the community hospitals which had approximately 150 attendees at each location. Stroke education and BP screenings provided. In FY 16 – JHN Stroke Center conducted 150 stroke risk assessments during Stroke Month – May at Jefferson Station and provided educational information FAST to approx. 500 people. JNN participated in 2 additional health fairs at the community hospitals. Attendance approximately 100 to 150 at each event.
Initiate support groups for patients and caregivers for conditions such as stroke, brain tumors and aneurysms.
An aneurism support group for subarachnoid hemorrhage survivors and family meets monthly for 3 hours. The support group is facilitated by the Nursing clerical assistant of INR. The group focusses on survivors, individuals living with aneurysms or AVMs and their families. The group provides education and support through the recovery process. 255 participants during 2014-‐2015. The Stroke Support Group is geared towards providing education and support for stroke survivors in the Jefferson community, CARU, and the community at large. Guest speakers address topics of interest to survivors and their families. More than 50 attended in 2014-‐2015. The Brain Tumor Support Group meets monthly and reached more than 200 individuals in 2014-‐2015.
Obesity Create a central database/promotion strategy to promote nutrition, physical activity, weight management and other wellness programs to health care providers and community residents. Increase referrals to community based weight management programs by health providers and community partners.
The Philadelphia Department of Public Health’s (PDPH) Chronic Disease component of Philadelphia’s Community Health Improvement Plan: Jefferson’s-‐Center for Urban Health staff provided leadership with the American Heart Association for implementation of the Philadelphia Department of Health Community Health Improvement Plan – chronic disease pillar. TJUH-‐CUH staff is also represented on the PDPH Access workgroup.
Domain Strategies /Activities Updates Philly Food Finders and Philly Powered was
developed by the Food Policy Advisory Council food security subcommittee and the PDPH Get Healthy Philly initiative. These are on-‐line and mobile app resources available to increase access to food assistance programs and opportunities for physical activity. Jefferson’s center for Urban Health participates in these community groups. Jefferson’s Center for Urban Health is participating with FPAC, SHARE and Coalition Against Hunger to raise awareness about food assistance programs. Healthier Food Drives were initiated at Jefferson that encouraged donations of low sodium, low or no sugar and whole grain foods. More collected more than 2 tons of food which was contributed to food pantries in 2015 and 2016. Jefferson also supports a Farmers Market on campus to improve access to fresh fruit and vegetables for employees and the community. In addition, a color-‐coded point of purchase vending machine initiative was developed in 2013 to encourage healthier food choices in vending machines. Healthier food choices had fewer calories, less fat and lower sodium and were coded green. As a result, employees and visitors to the hospital drank fewer sugar beverages and increased purchases of “green” or healthier products. Methodist Hospital provided a 12 seminars on bariatric and metabolic surgery to teach morbidly obese members of the community the benefits of laparoscopic procedures (108 attendees)
Finally, modifications have been made in food placement and menu choices in the cafeteria. Menu labeling has been increased to help employees and visitors make healthier informed choices. Healthier foods such as fruit are available at the check-‐out line. ARAMARK, the
Domain Strategies /Activities Updates hospital vendor, is participating in the Philadelphia Department of Health’s “Healthy Hospital initiative which is encouraging lower sodium foods for patients and cafeteria food. Nutritional information is available on all grab and go salads, sandwiches and entrees. Salad bar utensils are color coded to help consumers make healthier choices (eat more or eat sparingly) and higher calorie beverages are placed lower than low or no calorie options in beverage coolers. Sodium has been reduced for all patients. Sugar beverage purchases have decreased as a result of the initiative.
In collaboration with the Philadelphia Health Initiative (a worksite wellness coalition) promote healthy eating and weight management at worksites. Integrate with Philly First (an academic medical center initiative and Wellness Together, a family and community health initiative
Funding from Pew was sought (not approved) Coalition has only met twice in 2 years
Create childhood obesity prevention initiatives with head start centers
The Center for Urban Health has initiated a needs assessment and interviews with key informants from the Norris Square Community Alliance Head Starts (Lowe North Philadelphia) and Maternity Care Coalition Head Start program in South Philadelphia. The Center for Urban Health is working with Maternity Care Coalition-‐ Head Start Centers to develop a program with the Federation of Neighborhood Health Centers to work with MCC families on obesity prevention from pregnancy until the child reaches age 5 years old. An MPH student and 3 medical students helped to conduct an assessment and the MPH student is focusing on developing a food buying club and nutrition education program for Head Start staff, parents/caregivers, and children in the early education program. A food buying club has the potential to lower the cost of food purchases, particularly fresh produce, thereby improving access to healthier affordable food and encouraging healthier diets. Grant funding is being sought. Approximately one-‐third of
Domain Strategies /Activities Updates children ages 3-‐5 are overweight or obese in the Head Start programs participating in the intervention.
Social and healthcare needs of older adults
Caregiver/ Social Support
Create an Aging Coalition: Conduct an assessment of older adults’ health and social needs for aging in place.
The Jefferson Institute for Healthy Aging and Supportive Care was initiated in January 2015 and is convening workgroups. The College of Population Health and Jefferson’s Center for Urban Health initiated meetings with Philadelphia Corporation on Aging, South Philadelphia Aging Collective, and Philadelphia City Planning Department to discuss assessing the health needs of older adults. Staff from the Center of Urban Health regularly attend and support activities of the South Philadelphia Aging Collective to raise awareness of resources to help older adults age in place.
Continue to partner with community based organizations serving older adults such as PCA, PHA, health care providers, Philadelphia Department of Public Health, community centers, YMCA to address the needs of older adults in our communities through education and screening.
PCA funding obtained for hypertensive programs and vision programs (the hypertension program was discussed above). The Eyes Have It is a comprehensive eye health education program for older adults. Topics include: glaucoma, diabetic retinopathy, macular degeneration, low vision, and cataracts. A total of 253 individuals attended the sessions. Based on program feedback from participants the images displaying each of the eye diseases were most helpful. Participants were also interested in any information on new eye disease treatments and research. A program on HIV and Aging was held at Jefferson in collaboration with the South Philadelphia Aging Collective. HIV and older adults is a major initiative of the collective as is pedestrian safety. The Emergency Department at Jefferson received funding in 2015 to initiate an Injury Prevention Research Center. The Center is beginning efforts to reduce falls in the elderly as a major focus of its programs and research and is collaborating with faculty in the physical therapy department, occupational therapy department, center for Urban Health and the Department of Family and Community Medicine Geriatric Practice.. Staff in the Jefferson physical therapy department in the hospital also provides
Domain Strategies /Activities Updates education on fall prevention education in the community.
Educate community about Palliative Care and Hospice
A Photonovel to raise awareness about hospice care among African Americans was completed by the Jefferson’s Center for Urban Health and TJU College of Population Health with support from an MPH student in April 2016. The purpose of the photonovel was to gain an understanding of the disparity in Hospice Care use by African Americans compared to Whites. The photonovel process involved focus groups with African Americans to understand their knowledge, attitudes and perceptions related to hospice. An advisory group was formed to assist with developing the story-‐line and also served as the characters in the story which was photographed by Jefferson Medical Media Services. Distribution of the photonovel began May 2016.
Health Screening and Early Detection HIV Create an Aging Coalition: Conduct
an assessment of older adults’ health and social needs for aging in place.
The Jefferson Institute for Healthy Aging and Supportive Care was initiated in January 2015 and is convening workgroups. The College of Population Health and Jefferson’s Center for Urban Health initiated meetings with Philadelphia Corporation on Aging, South Philadelphia Aging Collective, and Philadelphia City Planning Department to discuss assessing the health needs of older adults. Staff from the Center of Urban Health regularly attend and support activities of the South Philadelphia Aging Collective to raise awareness of resources to help older adults age in place.
Continue to partner with community based organizations serving older adults such as PCA, PHA, health care providers, Philadelphia Department of Public Health, community centers, YMCA to address the needs of older adults in our communities through education and screening.
PCA funding obtained for hypertensive programs and vision programs (the hypertension program was discussed above). The Eyes Have It is a comprehensive eye health education program for older adults. Topics include: glaucoma, diabetic retinopathy, macular degeneration, low vision, and cataracts. A total of 253 individuals attended the sessions. Based on program feedback from participants the images displaying each of the eye diseases were most helpful. Participants
Domain Strategies /Activities Updates were also interested in any information on new eye disease treatments and research. A program on HIV and Aging was held at Jefferson in collaboration with the South Philadelphia Aging Collective. HIV and older adults is a major initiative of the collective as is pedestrian safety. The Emergency Department at Jefferson received funding in 2015 to initiate an Injury Prevention Research Center. The Center is beginning efforts to reduce falls in the elderly as a major focus of its programs and research and is collaborating with faculty in the physical therapy department, occupational therapy department, center for Urban Health and the Department of Family and Community Medicine Geriatric Practice.. Staff in the Jefferson physical therapy department in the hospital also provides education on fall prevention education in the community.
Educate community about Palliative Care and Hospice
A Photonovel to raise awareness about hospice care among African Americans was completed by the Jefferson’s Center for Urban Health and TJU College of Population Health with support from an MPH student in April 2016. The purpose of the photonovel was to gain an understanding of the disparity in Hospice Care use by African Americans compared to Whites. The photonovel process involved focus groups with African Americans to understand their knowledge, attitudes and perceptions related to hospice. An advisory group was formed to assist with developing the story-‐line and also served as the characters in the story which was photographed by Jefferson Medical Media Services. Distribution of the photonovel began May 2016.
Colon Cancer Coordinate education with TJU Kimmel Cancer Center, to increase screening in community benefit neighborhoods
Colorectal cancer screening and education programs were provided for community members and Jefferson employees. The goal of the programs was to increase knowledge about colon cancer, the importance of screening and early detection, diagnosis and treatment options.
Domain Strategies /Activities Updates More than 165 individuals attended programs between 2014-‐2015. In addition, in 2015 Jefferson physicians screened 2-‐3 women weekly who were over age 40 (if a history of polyps or a family history exists) or over age 50. 132 women were screened.
Women’s Cancer Screening
Continue to provide supportive services for women with cancer including medical supplies, wigs and support groups
Look Good Feel Better is a workshop facilitated by trained cosmetologists to teach women with cancer how to understand and care for changes in skin and hair that may occur during treatment. 18 women attended in 2014.
Continue to raise awareness within Jefferson and the community about Jefferson and Methodist Hospital’s participation in the Pennsylvania’s Healthy Woman Program and Pennsylvania’s Breast Cancer and Cervical Cancer Prevention and Treatment Program. Continue to provide free cervical cancer screening and mammograms to uninsured and under insured women
Breast cancer screening: The Komen Foundation provides funding to support mammography screening among uninsured/underinsured women. The grant funds services for uninsured and underinsured women from clinical breast exams through biopsy if needed to reach a final diagnosis. The Social Worker/Patient navigator assists by connecting the patient to emergency medical assistance if diagnosed with breast cancer and the appropriate treatment team members. The Komen funding is used in conjunction with Pennsylvania’s Healthy Woman Program funding to provide both breast and cervical cancer screening services to the same group of women. Komen FY 2013-‐2014 Total $100,000 (Screening/Treatment) 366 Women Seen Clinical Breast Exams-‐ 37 Screening Mammograms-‐ 237 Diagnostic services-‐264 Breast Cancers Detected-‐ 3 Komen FY 2014-‐2015 Total $100,000 (Screening/Treatment) 329 Women Seen Clinical Breast Exams-‐ 20 Screening Mammograms-‐ 203 Diagnostic services-‐ 216 Breast Cancers Detected-‐ 3 Komen FY 2015-‐2016 Total $100,000 (Screening/Treatment) 221 Women Seen
Domain Strategies /Activities Updates Clinical Breast Exams-‐ 41 Screening Mammograms-‐ 117 Diagnostic services-‐ 169 Breast Cancers Detected -‐ 6 All breast and cervical cancer screening all grants combined 2014-‐2015: • 1163 women seen; 32 breast cancers
detected; 3 cervical cancers • 314 diagnostic tests performed; 263
ultrasounds; 66 biopsies; 92 consultations
Breast Health Education: These programs, provided by the Center for Urban Health are designed to help women increase their knowledge of breast cancer by providing information on the disease process, risk factors, and early signs of breast cancer. Women are instructed on the importance of age appropriate mammograms and clinical breast examinations. 29 programs were held reaching 407 participants between 2013 and 105. 274 women were over age 40. Of this group 85% had a mammogram in the past year or planned to make a mammogram appointment. 9 women were referred for the low cost/free mammogram program at Jefferson. Cervical Cancer Awareness Day at Methodist – Free PAP tests were provided for 25 uninsured women. Lab tests were provided pro bono by Quest laboratories. Women with abnormal results were referred to the Healthy Women Plus program for follow-‐up. Education of risk factors for cervical cancer was provided by an oncology nurse. 50 women were educated. Methodist Hospital also hosted “Early Detection saves Women’s Lives, a lecture to discuss the latest tools to detect breast cancer in women with dense breast tissue as well as colon cancer for women (45 attendees)
Other Cancer Screening
Not included in the Community Health Improvement Plan – Prostate cancer, skin cancer, oral cancer and lung cancer screening
Prostate Cancer Screening and Education: Education on informed decision making regarding prostate cancer screening. In 2014, 844 men participated In education and screening
Domain Strategies /Activities Updates programs provided by the Kimmel Cancer Center. In 2015, more than 320 individuals participated. Skin Cancer Screening: 92 individuals participated in prevention, early detection and treatment of skin cancer education and screening in 2014-‐2015. Lung Cancer screening: Screening was provided to community members and Jefferson employees. 111 people were screened in 2014-‐2015. Oral Cancer: 2 screenings were held in 2015 reaching 38 individuals
Healthy Lifestyle Behaviors and Community Environment Obesity, cardiovascular disease, diabetes, cancer and other obesity related disease prevention
Create a central database/promotion strategy to promote nutrition, physical activity, and other wellness programs to health care providers and community residents. Increase referrals to community based healthy lifestyle programs by health providers and community partners.
The Philadelphia Department of Public Health’s (PDPH) Chronic Disease component of Philadelphia’s Community Health Improvement Plan – Jefferson’s Center for Urban Health staff provided leadership with the American Heart Association for implementation of the Philadelphia Department of Health Community Health Improvement Plan – chronic disease pillar. Jefferson’s-‐CUH staff is also represented on the PDPH Access workgroup. Philly Food Finders and Philly Powered was developed by the Food Policy Advisory Council food security subcommittee and the PDPH Get Healthy Philly initiative. These are on-‐line and mobile app resources available to increase access to food assistance programs and opportunities for physical activity. Jefferson’s Center for Urban Health participates in these community groups. See Chronic Disease Management (Hypertension and obesity sections) -‐ Million Hearts Campaign strategies including Heart Smarts, and Blood Pressure Plus. Efforts are being initiated to communicate these
Domain Strategies /Activities Updates programs to primary care physicians and other community providers and residents through the Philadelphia Department of Health’s website. In addition, Jefferson is working on a grant with the Philadelphia Department of Public Health and Health Care Improvement Foundation for CDC funding to support designing a system to improve communication between patient, provider and community based programs that support diabetes prevention and hypertension management.
Access to healthy affordable food and nutrition education
Collaborate with the Food Trust to promote health screening, education/prevention activities and healthy eating at “Super Corner Stores”.
See Chronic Disease Management (Hypertension and obesity sections) -‐ Million Hearts Campaign strategies including Heart Smarts, and Blood Pressure Plus. The initiative is being expanded to sites in New Jersey and West Philadelphia and Delaware through Food Trust and Lankenau Hospital.
Provide nutrition education at community gardens/farms, day care centers, schools, community centers, parks/playgrounds, farmers markets, community gardens, Philadelphia Housing Authority, Steven Klein Wellness Center, parish nurses/faith-‐based and other (places where people gather).
A student intern working with the Center for Urban Health in partnership with the Lower Moyemensing Civic Association and South Philadelphia High School provided nutrition education to students participating in the high school gardening program. In addition, nutrition education was provided to the Build a Bridge (Fels High School) summer program and Bridging the Gaps students supervised by the center for Urban Health provided nutrition education for Urban Tree Connection youth programs. National Nutrition Month Recognition -‐ “Bite into a Healthy Lifestyle” at Methodist Hospital provided nutrition counseling on the importance of making informed food choices, getting daily activity and incorporating healthy foods into meals. Cooking tips and recipes were provided. (60 attendees) The Women’s Health Source programming provides Educational programs scheduled throughout the year to address a variety of topics important to women and families, such as menopause, stress management, parenting and
Domain Strategies /Activities Updates nutrition management. See the Heart SMART initiative with the Food Trust (Chronic Disease Management – hypertension) Love Your Heart day was offered at Methodist Hospital. Cardiac rehabilitation clinical staff and clinical nutritionists provided education on the risk factors of heart disease, healthy food choices and provided blood pressure screening. (60 attendees in 2014) Healthy Habits – The Center for Urban Health staff provided nutrition physical activity education to youth in out of school time programs. (More than 700 attendees in 2014)
Raise awareness about farmers markets, and other venues for healthy food among health care providers and community organizations Continue to support urban gardening and agriculture efforts through employee and student participation, health education, evaluation and fund raising Continue to support and advocate for Jefferson and other Farmers Markets, CSAs and Winter Harvest programs
Philly Food Finders and Philly Powered was developed by the Food Policy Advisory Council food security subcommittee and the PDPH Get Healthy Philly initiative. These are on-‐line and mobile app resources available to increase access to food assistance programs and opportunities for physical activity. Jefferson’s Center for Urban Health participates in these community groups. Efforts are being initiated to communicate these programs to primary care physicians and other community providers and residents through the Philadelphia Department of Health’s website. In addition, Jefferson is working on a grant with the Philadelphia Department of Public Health and Health Care Improvement Foundation for CDC funding to support designing a system to improve communication between patient, provider and community based programs that support diabetes prevention and hypertension management. Through its participation in the Get Healthy Philly initiative (Philadelphia Department of Health) and the Food Policy Advisory council (part of the
Domain Strategies /Activities Updates Mayor’s Office on Community Service) Jefferson support efforts to improve access to healthy affordable food. Jefferson also supported these efforts through partnerships with the Food Trust, serving as the co-‐chair of the Philadelphia Department of Health’s chronic disease pillar of the Community Health Improvement Plan and participation on the Board of Urban Tree Connection, a community based organization that supports community beautification through gardening and agriculture. Urban Tree Connection has helped the community gain access to vacant land, provides a farmers market run by youth and community members and builds the capacity of the community through nutrition education and workforce development activities with youth. The Center for Urban Health assists Urban Tree Connection with evaluation and Jefferson students have participated in Bridging the Gaps at this site. MPH students (College of Population Health) have also done their capstones at Urban Tree Connection under the guidance of Jefferson’s Center for Urban Health to develop evaluation tools and systems. Human Resources is now overseeing the Jefferson Farmer’s Market
Nutrition: Reduce Sugar Beverages; and Fast Food
Expand healthy vending machine initiative at TJUHs worksites
A color-‐coded point of purchase vending machine initiative was developed in 2013 to encourage healthier food choices in vending machines. Healthier food choices had fewer calories, less fat and lower sodium and were coded green. As a result, employees and visitors to the hospital drank fewer sugar beverages and increased purchases of “green” or healthier products. ARAMARK included a healthy choice vending machine program as part of its negotiations for a new vendor. The vending machine program guidelines and implementation plan were shared with the Philadelphia Department of Public Health for scale up with city employees. In addition the
Domain Strategies /Activities Updates American Heart Association (Philadelphia) shared the program guidelines with national AHA. The guidelines were also shared with ARIA health system at their request.
Modifications have been made in food placement and menu choices in Jefferson’s cafeteria. Menu labeling has been increased to help employees and visitors make healthier informed choices. Healthier foods such as fruit are available at the check-‐out line. ARAMARK, the hospital vendor, is participating in the Philadelphia Department of Health’s “Healthy Hospital initiative which is encouraging lower sodium foods for patients and cafeteria food. Nutritional information is available on all grab and go salads, sandwiches and entrees. Salad bar utensils are color coded to help consumers make healthier choices (eat more or eat sparingly) and higher calorie beverages are placed lower than low or no calorie options in beverage coolers. Sodium has been reduced for all patients. Sugar beverage purchases have decreased as a result of the initiative.
Advocate for passage of sugar beverage tax
Under Mayor Kenney, a 1.5 cent per ounce sugar beverage tax was passed to support early childhood education programs, library upgrading and recreation facility improvements. Awareness of this tax and its implications was shared by Jefferson Center for Urban Health staff with Jefferson faculty, staff and students. Students and others at Jefferson were informed about how to advocate as individuals should they want to support the tax.
Food Security Screen inpatients and outpatients for food security, particularly at discharge from hospital – begin with JFMA service
A MPH and medical student capstone project was conducted in partnership with the Jefferson Family Medicine Associates geriatric practice and the Coalition Against Hunger. Faculty from Jefferson’s Center for Urban Health chaired the capstone committee. The purpose of the research project was to assess feasibility of integrating food security screening into the practice and to estimate prevalence of food insecurity among older adults in the practice. Referral to the coalition Against Hunger for food
Domain Strategies /Activities Updates access assistance was also explored. Results indicate that integration of screening into the practice was feasible, and patients were satisfied with and supportive of screening for food insecurity. Referral by faxing positive screening results to the Coalition Against Hunger was more effective than just giving information to patients and was acceptable was acceptable to patients and the practice. Approximately 22% of older adults screened positive for food insecurity and an additional 18% were already receiving SNAP (food stamp) benefits.
Promote food cupboards: Create a list of existing neighborhood-‐based food pantries/cupboards Conduct “healthy food” drives at TJUHs for area food cupboards in partnership with SHARE. (increase access to foods lower in salt, and sugar)
FPAC Philly Food Finder project completed. See previous discussion. Healthier Food Drives were initiated at Jefferson that encouraged donations of low sodium, low or no sugar and whole grain foods. More collected more than 2 tons of food which was contributed to food pantries in 2015 and 2016. In 2015, the Coalition Against Hunger and Jefferson’s Center for Urban Health initiated a program at the Farmer’s Market where people could buy additional fresh fruit and vegetables for a specific food cupboard or make a donation which would be used to purchase additional produce. More than 580 pounds of food were donated to 4 food cupboards. June 2015: 92 lb to St. Peter’s Food Cupboard (313 Pine St, 19106) July 2015: 119 lb to St. Mark’s Food Cupboard (1625 Locust St, 19103) August 2015: 117 lb Mercy Hospice (334 S. 13th St, 19107) September 2015: 137 lb Tindley Temple (750 S. Broad St, 19146) October 2015: 115 lb Tindley Temple (750 S. Broad St, 19146) Jefferson donated $19,210 in food to the City of Philadelphia for the homeless shelters after the Papal visit from Center City and Methodist.
Domain Strategies /Activities Updates
Smoking Cessation
Raise awareness among providers about community efforts and resources to reduce smoking rates: Refer smokers to: www.smokefreephilly.org PA Quit Line and FAX to Quit program. www.facebook.com/smokefreephilly for smoking cessation support from an on-‐line community. PDPH free community based quit-‐smoking classes.
Integrated into the Heart Smarts and BP Plus and diabetes programs. Explore integrating these resources into EPIC EHR at Jefferson.
Enforce TJU/TJUHs smokefree campus policy
Jefferson has instituted a campus-‐wide policy regarding smoking (Smokefree campus policy). In addition, a policy was instituted that prevents smokers from being hired by Jefferson.
Continue to support PDPH policy efforts to reduce tobacco use in Philadelphia
Jefferson’s Center for Urban Health leadership participates in Philadelphia Department of Public Health’s tobacco coalition.
Access to safe places for physical activity
Partner with parish nurses, AHA, ADA, Philadelphia Dept. of Public Health, YMCA, PHA, faith-‐based institutions, community centers, St Elizabeth’s Wellness Center, Pathways to Housing to support physical activity. Partner with the YMCA to train community residents to implement walking groups and other exercise programs
Leadership from Jefferson’s Center for Urban Health served as the co-‐chair of the Philadelphia Department of Public Health’s Chronic Disease pillar of the PDPH community health improvement plan. This plan addresses increasing physical activity in the city of Philadelphia. In addition, Center for Urban Health’s leadership served as the capstone chair of an MPH student project to use GIS mapping to identify areas in the city that lacked access to opportunities for physical activity based on population density. Staff from the Center for Urban Health at Jefferson is initiating Line Dancing classes at the Steven Klein Wellness Center beginning in May 2016
Continue to encourage physical activity among TJUHs employees
EXOS program initiated for Jefferson employees. In addition, lunchtime walking groups were
Domain Strategies /Activities Updates through the Worksite Wellness initiative.
initiated to encourage physical activity among employees.
Built Environment
Continue to support community beautification efforts and zoning efforts to increase access to healthy food and safe places to play including community gardens and tree planting. Assist the PDPH in assessing parks/playgrounds in TJUHs community Continue to support the Friends of Mifflin Square Park efforts to improve the park and playground facility and increase park utilization by the diverse surrounding community
Leadership from Jefferson’s Center for Urban Health served as the co-‐chair of the Philadelphia Department of Public Health’s Chronic Disease pillar of the PDPH community health improvement plan. This plan addresses increasing physical activity and access to healthy food in the city of Philadelphia. In addition, leadership from the Center for Urban Health also participated in the Food Policy Advisory Council, an initiative of the Mayor’s Office of Sustainability. The Philadelphia Food Policy Advisory Council (FPAC) facilitates the development of responsible policies that improve access for Philadelphia residents to culturally appropriate, nutritionally sound, and affordable food that is grown locally through environmentally sustainable practices. Both of these organizations were instrumental in passing Philadelphia’s Land Bank legislation in 2013. Staff from the center for Urban Health also participate in the South Philadelphia Prevention Coalition, a Drug Free Community initiative that includes community beautification and clean-‐ups as part of its strategies.
Community Safety
Continue to support SEPC, United Communities and the South Philadelphia Prevention Coalition to reduce community violence through reducing use of gateway drugs among youth, specifically alcohol and marijuana.
The Southeast Philadelphia Collaborative (SEPC) is an initiative of United Communities Southeast Philadelphia that informs, educates and organizes a broad, diverse network of community partners, policymakers and stakeholders to leverage greater access to resources and opportunities that address the needs of youth in South Philadelphia. SEPC staff work to build partnerships and collaboration among agencies in the neighborhood through a combination of school and neighborhood-‐based projects. In 2014 United Communities (SEPC) received funding through SAMSHA (CADCA) to support and coordinate the South Philadelphia Prevention
Domain Strategies /Activities Updates Coalition. The South Philadelphia Prevention Coalition (SPPC) is part of the Drug Free Communities Support Program. The Drug Free Communities initiative provides funding to community-‐based coalitions that organize to prevent substance use. Jefferson is the hospital partner on this grant. One strategy used by the Coalition is community clean-‐ups. As part of the Drug Free Communities Program, the SPPC is also required to conduct an assessment about drug and alcohol use among adults and youth. A survey will be used to understand substance use and beliefs among teens and what the coalition can do to reduce substance use in South Philadelphia. Two staff members from Jefferson’s Center for Urban Health created the survey and are providing assistance with evaluation of coalition efforts. Jefferson’s Center for Urban Health staff are providing assistance with evaluation of efforts of all Drug Free Community initiatives in Philadelphia.
Alcohol and Substance
Continue to support SEPC, United Communities and the South Philadelphia Prevention Coalition to reduce community violence through reducing use of gateway drugs among youth, specifically alcohol and marijuana.
The Southeast Philadelphia Collaborative (SEPC) is an initiative of United Communities Southeast Philadelphia that informs, educates and organizes a broad, diverse network of community partners, policymakers and stakeholders to leverage greater access to resources and opportunities that address the needs of youth in South Philadelphia. SEPC staff work to build partnerships and collaboration among agencies in the neighborhood through a combination of school and neighborhood-‐based projects. In 2014 United Communities (SEPC) received funding through SAMSHA (CADCA) to support and coordinate the South Philadelphia Prevention Coalition. The South Philadelphia Prevention Coalition (SPPC) is part of the Drug Free Communities Support Program. The Drug Free Communities initiative provides funding to community-‐based coalitions that organize to prevent substance use. As part of the Drug Free Communities Program, the SPPC is required to
Domain Strategies /Activities Updates conduct an assessment about drug and alcohol use among adults and youth. A survey will be used to understand substance use and beliefs among teens and what the coalition can do to reduce substance use in South Philadelphia. Two staff members from Jefferson’s Center for Urban Health created the survey and are providing assistance with evaluation of coalition efforts. Jefferson’s Center for Urban Health staff are providing assistance with evaluation of efforts of all Drug Free Community initiatives in Philadelphia.
Implement evidence-‐based alcohol Screening and Brief Intervention at TJUHs
A 3 year SBIRT (Screening, Brief Intervention and Referral to Treatment) grant for $325,000 was received from SAMHSA to train Medical, Physician Assistant and Pharmacy students at Jefferson. Training for healthcare providers is also being provided through this grant. Center for Urban Health and the Department of Family and Community Medicine are directing and evaluating this grant initiative at Jefferson.
Create a City-‐wide database to monitor ED patients who frequently ask for narcotics
A Pennsylvania law/regulation was passed to support the creation of databases to track patients requesting pain medications. Discussions concerning implementation are in progress across the Commonwealth. A City-‐wide task force (Jefferson physicians from the ED participate) on opiate prescribing and training for health professionals has been formed. The Philadelphia lock box program is being initiated in 6 District Police Stations to help to dispose of unused opiates. A Town Hall was hosted by the federal Government in April 2016 to share concerns and opportunities for reducing death from heroin and opiates overdoses and improved access to Naloxone.
Youth Health Behaviors
Work with School Wellness Councils in target neighborhoods to address student health and health behaviors
Jefferson’s Office of Student Life and Engagement and the Center for Urban Health leadership are creating partnerships with Southwark School, Independence Charter School, and the South Philadelphia High School. The initial phase of the partnership involved
Domain Strategies /Activities Updates conducting the school health impact assessment process. Programming, based on findings from the assessment and input from school staff will be developed Summer 2016 and initiated in Fall 2016. These plans include a process for involving Jefferson students in programs that Jefferson will be providing is way that is sustainable over time. To date, the Southwark School is benefitting from behavioral health services being provided by Jefferson’s College of Health Profession’s Family and Couples Therapy program and health education being provided by the College of Pharmacy faculty and students.
Other Efforts Maternal and Child Health TJUH offers a host of childbirth and parenting classes to the community. • Car Seat Classes are offered to the general
community 6 times a year. The program is taught by registered nurses who teach a total of 4 hours per class. (more than 200 attendees in 2014-‐2015)
• Grandparents Classes are offered to the general community 4 times a year. The program is taught by registered nursed and teaches grandparents what's new in the world of babies. (50 attendees in 2014-‐2015)
• Free Childbirth classes are offered in Chinese five times annually. The Class is promoted through the Chinese Cultural Center and at the Chinese Health Information Center at Jefferson. (105 attendees in 2014-‐2015)
• An Infant Massage Class teaches parents techniques for infant massage prior to the birth of the baby. Massages can help the infant by strengthening his/her immune system, enhancing sleep and reducing gas and colic. The Massage program is offered 7 times during the year. (77 attendees in 2014-‐2015)
• Parent Educators Conference – 22 Labor and delivery nurses across Philadelphia attended the Lecture "Physical Therapy & Pelvic Pain" at TJUH Center City campus. A Jefferson
Domain Strategies /Activities Updates Physical Therapist lectured RN's on pelvic pain and pregnancy related musculoskeletal disorders and conservative management
• Pediatricians Night -‐ Community members learn practical tips from a Jefferson pediatrician and registered on preparing and caring for infants and young children. This program is offered to the general community 6 times a year. (83 attendees in 2015)
• Children's Health Screenings – The Center for Urban Health and Wills Eye Hospital conducted physicals for youth in the after school program at the Cambodian Association of Greater Philadelphia and the Norris Square Community Alliance Head Start Program. More than 60 children received physicals and eye screening.
• Shaken Baby Syndrome and Child Abuse Prevention – The Pediatric unit provided information to the general to raise awareness about this issue. (More than 50 attendees in 2015)
• Parenting Workshop – Provided nutrition and diabetes (12 attendees education
Women’s Health • Women's Health Fair at Jefferson Navy Yard -‐ "Rehabilitation Care" -‐ Two Jefferson Physical Therapists provided educational materials regarding Physical Therapy, Occupational Therapy and Speech Therapy care for Women's specific conditions including lymph, breast management, pelvic management, osteoporosis, etc. Targeted group: adults and older adults including white, African-‐American, Latino and Asian women. The fair was held at Jefferson at the Navy Yard in South Philadelphia and served 35 individuals.
• Varicose vein screening at Methodist Hospital (108 attendees)
• The Women’s Health Source is dedicated to improving the quality of life for all women in
Domain Strategies /Activities Updates our community through free prevention and wellness programs, educational resources, health education seminars and health screenings. Various women's health topics discussed include: (1,388 attendees in 2014-‐2015)
o Atrial Fibrillation o Happy Feet: the dos and don'ts of
foot care o Facial Pain: where is it coming
from? o Fibromyalgia o Uterine Fibroids o Insomnia: why can't it start in the
morning? o DJD: aches, pains and treatments o Stroke: every minute counts o Dental Implants: the facts and
finances to get your smile back o Fact or Myth: make a healthy choice o Go Red Diva: Diabetes and Heart
Disease o Caring for the Whole Woman o Sleep Disorders from A to Zzzzz o Joint Replacements: Hip or Knee o Caring for the Care Giver o Gotta go or Leaky Plumbing?
(Tackling Women’s Urinary Issues) o LUPUS: Learn – Understand –
Participate – Unite – Support o Nutrition and Menopause: How to
Avoid Weight Gain! o Make No Bones about It…Knowing
Your Risk for Osteoporosis o Beauty is Only Skin Deep
Health Fairs and General Education • Diabetes Alert day – An event at Methodist Hospital to raise awareness of type 2 diabetes. A diabetes risk assessment was included. (90 attendees 2014-‐2015)
• Methodist Hospital Annual Health Expo –This free event includes health screenings, health information and consultations. Numerous preventive health information and
Domain Strategies /Activities Updates consultations were provided on medication management, nutrition, diabetes, skin cancer prevention, hypertension, women's health, heart and vascular disease, sleep disorders and cardiac rehabilitation. (More than 1,800 attendees in 2014-‐2015) In FY14:
o Clinical lab staff performed 155 cholesterol and glucose screenings.
o Women's Diagnostic Center provided 35 mammograms and breast exams (8 women needed follow-‐up).
o Vascular Center conducted 41 Foot Exams.
o Nursing provided 150 Blood Pressure Screenings.
o Women's Diagnostic Center provided 55 Osteoporosis screenings.
In FY15: o The Center for Urban Health
provided blood pressure screening and counseling for 120 people at the health expo.
o The Methodist Pharmacy Dept. staffed the pharmacy table and served approximately 130 people and provided education on diabetes and medication. Pharmacists were available for an “Ask the Pharmacist” question and answer.
• American Heart Association Heart Walk: Center for Urban Health provided blood pressure screening and the Pharmacy Department participated in the walk.
• Heartburn and Reflux: Causes and Treatments –Lecture at Methodist Hospital on management of the symptoms of heartburn with diet and lifestyle changes, understanding medication options, and when surgery may be recommended. (60 attendees in 2015)
• Prevention Education Summer Safety Prevention – Jefferson trauma department
Domain Strategies /Activities Updates provided Prevention Education regarding Summer Safety to broader community at King of Prussia mall. Printed educational materials were handed and Summer Safety information was shared by nurses. (90 attendees in 2014-‐2015)
• Laryngectomy Support Group -‐ The "Nu-‐Voice Club of Center City" is a support group by Jefferson speech therapists for Laryngectomy patients, family members and friends. It is held on the third Thursday of each month (135 attendees in 2014-‐2015).
• Bereavement Support Group Session – Held at Methodist Hospital 4 times a year. This is an eight-‐week bereavement support group for adults suffering from recent loss. Lead by a certified grief counselor, the program provides materials and discussions on a variety of topics to assist participants in their grieving process.
• The Pharmacy Department provided diabetic education and conducted blood pressure screening and counseling, nutrition education, BMI screening, and linkage to resources. They reached 200 individuals.
• Community Flu immunizations – The hospital provided vaccine and staffing to administer flu shots at community sites including JEFF HOPE homeless shelters. More than 300 were vaccinated in 2014-‐2015
• National Go Red Day – Jefferson Nurses participate in the annual National Go Red Day to raise awareness about women and heart disease. Information was given to more than 1,000 patients and employees in 2014-‐2015.
• For the past four years, Jefferson has provided an annual Diabetes Symposium for health care providers, certified diabetes educators, and students.
Health care support services: Post discharge indigent care expenses
Approximately 375 patients at Jefferson and Methodist were assisted with the following:
Domain Strategies /Activities Updates • Medical transport flights ($31,600) • Ground transport ($15,233) • Home care ($24,066) • Home durable medical equipment ($24,138) • SNF facilities ($412,998) • Home infusion services ($8,377) • Medications ($155,461)
111 South 11th StreetPhiladelphia, PA 19107
Jefferson.edu
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