Scaling Health Initiatives: Community Partnerships That Improved Patient Care Across 11 Counties

<p>maybe if they're eligible for SNAP or they're eligible for the distributions right we're not going to be the long-term food provider but we can help address those [Music] needs hello everyone this is Cole from the American Journal of healthc care strategy joined by a really great guest today coming uh from Ohio I have a lot of great colleagues in Ohio there uh director of Community Health uh Tyler Smith Tyler please introduce yourself in the role and and we can have a great conversation about the awesome work you're doing yeah absolutely I'm glad to be here today Cole thanks for having me on uh so Tyler Smith director of Community Health uh for Mercy Health Lima which is St Eris Medical Center um so in this role I've been here for five years in this role and really what I do is I lead um the strategy of our Comm Health needs assessment and our Comm Health Improvement plan so what I see as um really my my overarching goal is really kind of to extend the the resources and to extend the care beyond the four walls of the hospital so um we serve in 11 County region there's really for my role Three Counties that I I really focus on from a preventative and Outreach standpoint so really it's my job to work with you know our um Health departments our nonprofits various sectors in the community um understand kind of what the gaps and opportunities are what are some of the health challenges right um what are some of the priority populations here or most at risk for health disparities and then what I do is I kind of build a strategy around that to identify some of those needs build programming at the hospital level and then also programming from an Outreach standpoint um in addition to that I also oversee all of our community benefit reporting so since we're nonprofit 501c3 hospital I also overseed that as well um and just kind of make sure that all of our investments are kind of in alignment to identified needs within the community from a health standpoint and it's reaching the populations that it needs to nice that's impressive that's impressive and very important work what when we talk about your population that you're serving just so that we can have context are we dealing with an urban Suburban rural mix what does it look like mixed yeah so the hospital is right here in Lima um which is um probably City over I know 30 between 35 and 40,000 um mostly Urban um however the county that we're in is at about 100,000 so it's it's a good mixture of of urban and rural and then when we think about the counties all around us they're all rule so you know it's it is very different because there's a lot of things that we have to be very strategic on from an Outreach standpoint of things that we do in Lima uh may be different than something that we do like in in Ottawa or something in all glaz County or more rural area and we have to think about that differently because that population is going to react differently right they want they want different things as well and so um but yeah I would say our our population is really mixed and that yeah that can make it challenging that makes it tough what are some of the biggest challenges that you're seeing with the population there what are they what what are you running into as difficulties so really when we think about like things I focus on I mean it's it's pretty broad but you think about maternal and health right chronic disease management Housing and Community conditions um you think about the mental health substance abuse um and some of the access issues maybe that's food insecurity providers um I would say some of the things that have bubbled up even more more so like within the last two or three years would be um challenges around housing um there's been a lot of challenges around housing um also within the last really the last year and a half we've seen an influx of what we call newcomers so our immigrant and Refugee population we've had a lot of Haitians um that have um moved to the lmma area and so that creates some challenges because from a healthcare standpoint right you need to have translation set up and um they also they also and a lot uh some different um cultural uh backgrounds and different Health needs as well and so um but I would say a lot of the the social barriers so Transportation housing access to Providers um you think about food insecurity I mean there's those are some of the things that I think have even escalated more so especially with how kind the economy has been over the last couple years as a health system how do you address issues like housing and and because there's a debate too about this right some people are saying you know hospitals shouldn't you know participate in in you know trying to fix issues like housing but then you end up seeing higher costs because you got people coming to the Ed at you know more frequently so there's both sides so how are you addressing issues like that yeah I'm glad that you mentioned that so literally where our Hospital sits on that property there's a neighborhood just north of us and so um we look at data at a census track level we've we've realized that there's a lot of Pockets right and may present some different disparities and you have a bunch of different factors that are coming together that may present a challenge for somebody to access us or seek us out and so the the neighborhood that's just north of us it's called sensor track 129 but we have made significant Investments um really over the last two or three years around housing and so one of our goals is to um just to kind of paint the picture within that that census track and and it maybe two years two or three years ago 65% of the those um occupants were renters and about over 50% of them were extremely rent burdened so you have about you know that percentage of them that are spending more than 50% of their income on rent so they don't have they don't have the the other money for prescriptions for f right some of those other things and they may not be worried about managing their their chronic conditions so we actually um uh work together with a couple um one of our Economic Development Partners here uh a couple other nonprofits and and business partners to essentially kind of form an LLC and so we are actually working uh to uh we got Investments to provide basically to allow those folks to become homeowners uh to provide opportunities um to improve you know the affordability and um make improvements to their housing um so like working with the habitat or you know other nonprofits here in Lima that you know could provide like utility assistance or any of those things and so that's been going really good and then we've been really fortunate to get some other large grants from AIO Department of Health to specifically do work like to provide wraparound services to provide um opportunities kind of to decrease that access to care um because that that sensor track is an opportunity Zone and so so there's extra grants in those is that how that yeah so the the grants called um the O has gr Ohio a high Health Improvement Zone Grant and so we were actually able to hire um a resource Navigator who we contract with she actually lives in the neighborhood um runs their neighborhood association so we've propped up programming over the last couple years for example like a walk with the dock um we've created a green space there on site uh we have annual uh health events there where we have you know our partners um from the hospital and different service lines that come out do screenings and and Community Partners there um what else we've done um homeowner uh type classes and events there uh bringing Realtors on site working with the local banks um doing Financial classes to essentially get them to the point where they could become homeowners so we've really been doing a lot of you know educational events of bringing them on site and talking about different service lines and what we have available and it's been really really successful so that I mean that's just one example um talk about housing how do you get things started like that because I feel like there's compliance challenges there's of course Financial but then you're gonna have I mean a lot of questions from leadership as well so what how do you how do you get that started like what's the first step that you took yeah that yeah that's a great question um there were there was already a larger task force within Lima that the that our may had started um kind of bringing together a bunch of those leaders in the community of saying like hey we we need a tackle some of these challenges um and then from a from a system level for bonsor Mercy Health um and kind of my colleagues and you know the director Community Health for all the other markets we had an opportunity then where we were basically um as a partner of the health anchor Network part of that is uh investment in um kind of being an anchor institution and basically identifying the greatest need within your market right so housing was one of the greatest needs and so we had an opportunity um to basically have access to some investment dollars that we could kind of put back into the community um but we we then had Identify some Partners who could kind of help operationalize it um and bring that together so that's kind of how it started it it it obviously we had to talk about it a lot right kind of get our leadership on board our leadership at the hospital is amazing so they they see that they understood the need um and then it you know and then it basically from that standpoint it just kind of matriculated into opportunities for Grants more funding right more opportunity to provide resources there whether that's like FTE or programmatic support but then it also kind of developed as a goal for our community health Improvement plan so it's something that we're measuring right so we bring all these folks together quarterly around a variety of different health goals and strategies and Housing and Community conditions is one of our priorities so we have specific strategies that we measure we submit um and uh and kind of go from there so yeah it's it's definitely it's definitely kind of Ved into a lot of the work that we do is that Community Health Improvement plan is that a mandatory thing from the government or is that something that you guys are just doing how does that what does that look like yeah so um so yes all hospitals nonprofits have to complete that um in addition like all all Health departments do that as well and so there's a different cycle um we would complete a a health needs assessment which is essentially provides the groundwork for um it's kind of like the data right it's kind of collecting all the the primary the secondary data um identifies what resources what what's the capacity within your area to kind of address some of those needs and then the chip is essentially um you know after you bring a bunch of stakeholders together and identify with those priorities based off what the data is telling you then you kind of put together your strategic plan so your community health Improvement plan is a three-year strategy so yeah we we had to submit all of our um for the 990 um when we submit our tax documents the chip and and all of our measures get reported at on that as well and so this is a pretty important yeah so it's something that we measure our board approves it um yeah frequent updates uh and then you know like I said the health departments do one as well so that's what that looks like for us is I work very closely then with our Three Counties that is kind of like our primary service here I work with their their health department and you know then that's how we partner and say hey well we're doing this right maybe finan we can support this here um within puam County or maybe we have a family medicine practice here and we'd like to implement some sort of program here for this population and so that's what I kind of get an opportunity to be very creative and strategic to understand you know kind of be like that dot connector of hey we got so and so here right this program already exists let's not recreate the wheel but think about strategically how we can do this do it better how can we align this back to from a clinical standpoint back to the hospital and so that's uh but yeah I I make sure I partner with our health departments on that um and then they're actively involved when we have our quarterly meetings in stakeholder input right we we take in consideration like all the data that we've captured from surveys or events throughout the year we kind of compile that and also the data that we have from like an ulatory standpoint and impatient as well how does that work you know when you you said something there about Reinventing the wheel how does that work when it comes to our newcomers because uh you know of course one of the big issues I'm assuming is going to be housing for people who are just getting to the country but um you just talked about we have a program that that's established that's working well are we seeing any synergies there between the newcomers and the Housing Programs you have yeah so uh we I mean we really kind of took a lead um leadership role I guess and helping to establish uh with one of our Community Partners who they're it's kind of like a coalition that we're a big stakeholder in it's activated onland County um we kind of put a big part in leading to help prop up a um what we call a newcomer Coalition so um a coalition that essentially meets and you have different representation right you have health care you have education you have legal right you have job and family services you have all these folks coming together um and we are also able to help our through support through our our system through our foundation to get funding to provide um basically somebody kind of run as an administrator or Point person um within the community to kind of be that that point person when somebody comes in with a need right that they can point them to if it's a housing concern if it's um a job concern if it's maybe an educational thing or Health Care concern um kind of Point them to the right direction and then we also um were able to get an organization called connecting borders in as well and so they kind of have like a physical location here in Lima and they kind of serve as the the point person so um or the point organization I guess to kind of connect those newcomers that are coming in to Opportunities nice that's really really great and then what what benefits are we seeing on the hospital side from these things can we talk a little bit about why and what the motivation is aside from the governmental you know kind of requirements to to be care yeah yeah I mean I just think about like over the last year just the amount of minutes that we had to do for translation services was really really high we've actually seen some of those numbers decrease and so I don't know if that's due to those individuals getting um Care at the right place or right time um for example are um so we are we have a graduate Medical Education Center so we we have um uh residents provider residents right so we have family medicine Internal Medicine emergency and so our resident Clinic which is Family Medicine it's kind of not like a safety net but it it's kind of the the spot where we would serve a lot of those patients right and so um so from that standpoint um I would say initially there was a lot of confusion of you know maybe the staff didn't have like the scope or uh we didn't have support to um you know they may be presenting some other cultural or socioeconomic barriers that uh may be prolonged like how we could provide them access or care or anything like that but I feel like those needs have been alleviated to a certain extent and we've been able to kind of provide more W round Services if it's like a language line if it's maybe a community health worker if it's establishing a OB clinic uh for highrisk uh Haitian mothers and and and patients um and so yeah I mean I feel like there's been a lot of bits and pieces to that um for sure um and also understand how how's a healthcare provider how we can kind of play a leadership role in that in the community understand like hey here's what we're seeing Within right within the hospital um uh what what are some opportunities for Grants what are some things that we can kind of come together so that we're not duplicating um another thing that's just a lot of people W think of but just from a labor labor and delivery standpoint we you know and it's a cultural thing but we'd have a lot of mothers who would who would deliver and um would have car seats right so um so we had to Think Through what that looked like and how do we you know from a legal standpoint how do we provide car seats on site um you know so there's there there's a lot of those things that people may not think of but definitely created a lot of challenges um but yeah I mean I would say that through that we've learned a lot about it and we're continuing to learn a lot about it that's a that's a big deal when you think about all those little things and all the little ways and and you know there's so much incentive too because we want people to be in our communities to be healthy and that's really essential uh for cost savings as well I always try to say you know people on the road being you know it's the Cary example we really want them to continue to be healthy because it it's never good for our community when you know from a financial perspective but especially from that emotional perspective too it's never good when somebody has some kind of injury or has a condition that's being treated in an expensive way when it could be done um in a more cost- effective way really really important things I just I struggle a little bit with understanding I guess how you're able to deal with housing and food and all these things when you are spread across Rural and then Urban because looking at Philly you know the housing that we provide in the urban area of Philly is a lot different than the housing that's provided way out in in Maine where I you know was raised how do you how do you make sure that the rural communities are equally as cared for are you going there and and speaking with them in person you know what does that look like so that you can really keep your pulse on it yeah that's yeah that's a great point it's very challenging and it's it's really about developing the relationships and yeah kind of having a good pulse of um what are some of the needs um you know my counterpart she does a great job too of um from a community governmental business relation standpoint of propping up advisory groups within the community of leaders and so I feel like we we you know there's a lot of circles that we're in and so it's um it's just really developing those strong relationships to understand who are the partners who are the main like the key players there um you know where are there gaps and opportun ities and maybe that's something that we take to our grant team and we look at to see if there's potential there um you know maybe it's propping up a coalition or maybe it's from a rural standpoint you know those are some of the discussions we're having right now of how can we um do some of the stuff that we're doing here in Allen County from a rural standpoint without duplicating but adding value right and not having it to be like another meeting to to 10 but how can we um yeah how can we leverage our resources is a little bit more efficiently so um so yeah it's Chen it definitely it's challenging because then you also have to have a pulse of what's going on within the hospital um what are some of the new Services right um some of those things but it's really about developing the partnership and understanding who the partners are um and so like to your example the food food insecurity like that's something that um you know we we have a program called the green RX program and so um um it was just a partnership that we had with the food bank here and they served 10 counties and then another organization called children's hunger lines um but essentially the the food bank what we did is we started with our um our Primary Care um uh locations and strategically started in certain locations where the need was higher of at least what we were seeing so we our providers our nurses our staff would um screen the patients when they're going through their their assessment if they identify as being food in secure um we provide them with a shelf stable food box emergency food box on site and then essentially we we provide them like a voucher essentially to connect them back to the food bank so like maybe if they're eligible for SNAP or they're eligible for the distributions right we're not going to be the long-term food provider but we can help address those needs and get them connected so like that's how I feel like that approach we try to take with a lot of things um whether that's in the family medicine from an ambulatory standpoint or impatient to understand is the and the need that we're seeing within the hospital matching kind of with what we're seeing in the community because it could be vice versa um so important and that that's a great way of of really trying to reduce that that kind of excess as well right and also save time of of your time with having you know trying to remove duplicated meetings and whatnot that's so important um what just kind of leave us off uh you know actually speaking on the food thing I think back to like Meals on Wheels right you know in Philly you have usually a church that has a kind of an open house where you come and get food in the rurals you switch to maybe more of a Wheels On Wheels method where you're maybe delivering it to people it's interesting but I want to leave us off with a positive question what what do you think you're looking forward to the most over the next year in terms of things you'd really like to see implemented or changes in your community that you'd like to see yeah that's a great question um I think with so like when in relation to that like within our chip you know we have seven priorties there's like 40 42 43 different strategies that we measure and so what I'd like to get us to the point where um we can operationalize that even more so for efficiencies um and scope and really have some strong outcomes to show how well we're doing and kind of be like a a best in case like an evidence-based program um and what I mean around that is even more so you know we're we do a ton of Outreach right we do a ton of Outreach um but I would like for people then when they see think of Mercy Health of like oh yeah they're the leader in this right they're in the leader of providing this sort of Education or Outreach for this population and and we know that they're the provider of CH provider of choice than when we're going to the to the hospital and so I I think what I'd like to see is even a stronger awareness of the programs that we have right from a community perception standpoint uh continue to build those strong you know strategic Partnerships and relationships I think are really really important um and and yeah I mean I think that's I think we can can dig a lot deeper for some of our investments too yep yep I and I it's hard to get the message out there sometimes because do they have a phone do they watch television right and especially when you're dealing with people who are coming from different cultures they're not going to do what we've what what I do right because they're from a different culture so we need to learn you know what do they watch on T that's a that's a big deal I me how do you how do you even find out where to message certain people how do you like what what methods are you using to get a hold of them and get them that information yeah there's a lot of different ways that we do that I mean we um ex said we have a community health coordinator she's been fantastic um doing really kind of what we call like Health needs assessments initially so strategically going to locations holding events um providing opportunities for these individuals to provide us a survey basically go through of identify do they have a provider what insurance do they have do they have issues with housing food all those different barriers or challenges that may present for somebody shown up in the hospital um and then she would follow back up with them so she would connect with them such such time uh connect them either to a community resource or maybe a resource back at the hospital um Department um so it could be something like somebody may not have a provider we may connect them to a resident clinic or um somebody may have been a longtime smoker and they'd like an opportunity to do this uh lowd dose CT lung cancer screening like any of those things um and it may be it may not be us as the most appropriate we may refer them to a partner who um has more bandwith so like maybe within hous we refer them to a shelter or then we in turn work with that shelter or that organization and say like okay like this is kind of like putting the Band-Aid on what what programming can we put out that's going to be a little bit more sustainable so I think that's another big thing is you know we really try to a lot of the programs that we do we really try to make sure it's not just like Hey we're going to introduce it if the fundings go on it's no longer here right how how can we show that we're um that we're that we're providing strong impact and outcome so it can be sustainable and then how can we diversify some of our funding streams right to kind of keep that propped up and and running long term um so those are like I mean those are challenges with anything right so those are things that yeah because you're not just saying okay here's an emergency shelter you know byy right you're saying okay this is a temporary solution but how can we get employment how can we get educ you know how can we get all this other stuff going and then how can we make sure that it's available long term really important thank you so much Tyler for coming on I I appreciate your time uh it was really interesting talking about this there's so much worry and concern out there and so it's great to have some uh you know discussion on good things that people are doing and really impressive work that you guys are doing there so thank you for your time I appreciate it thank you I'm glad to thanks for asking me to be on I've enjoyed it</p>