overview: the institute for h.o.p.e
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The following report is proprietary information and constitutes trade secrets of The MetroHealth System and may not be disclosed in whole or part to any external parties without the express consent of The MetroHealth System. This document is intended to be used internally for The MetroHealth System discussion.
Overview: The Institute for H.O.P.E.TM
Karen Cook, Director, Healthy Families & Thriving Communities
Presentation to Community Based Research Network
4/8/2021
PROPRIETARY AND CONFIDENTIAL INFORMATION
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40%
30%
10%
10%
10%Socio-economic environment• Education and employment opportunities • Living wages
Health behavior • Healthy food• Exercise
Physical environment• Affordable housing
Genes and biology
Clinical care
The Social Determinants of Health (SDOH):Factors that Influence a Person’s Health Status
There is a 37-year life expectancy disparity between two census tracts
in Cuyahoga County. Why?
80% of what affects health happens outside the clinical setting.
PROPRIETARY AND CONFIDENTIAL INFORMATION
2020 County Health Rankings
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Cuyahoga County Health Ranking(88 counties, lower is better)
Health Outcomes 75
Length of Life 56
Quality of Life 82
Health Factors 70
Health Behaviors 68
Clinical Care 9
Social & Economic Factors
81
Physical Environment
87
PROPRIETARY AND CONFIDENTIAL INFORMATION
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Improved Health through Opportunity, Partnership and Empowerment
Improve the health of populations by leading efforts to address social and economic barriers to good health
Identify and promote opportunities for change in practice, learning and policy
Co-create a self-sustaining community where everyone is empowered to live their healthiest life
Develop and nurture partnerships to make the greatest impact for individuals, neighborhoods and communities
PROPRIETARY AND CONFIDENTIAL INFORMATION
Institute for H.O.P.E.
Payor Relations & Strategic
Partnerships
Care Coordination & Transitions
Business Insights & Analytics
Virtual Care Enterprises
Patient Access & Contact Center
Community & Public Health
*Under Development*
Population Health
Innovation Institute
Organizational Alignment
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PROPRIETARY AND CONFIDENTIAL INFORMATION
Institute for H.O.P.E.
Payor Relations & Strategic
Partnerships
Care Coordination & Transitions
Business Insights & Analytics
Virtual Care Enterprises
Patient Access & Contact Center
Community & Public Health
*Under Development*
Medical Director President
Center for Healthy Families
& Thriving Communities
Center for Education &
Training
Center for Research & Evaluation
Arts in Health
Centers for Health Resilience
& Trauma Recovery
Organizational Alignment
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Population Health
Innovation Institute
Faith Based Engagement
Operations
PROPRIETARY AND CONFIDENTIAL INFORMATION
Screen all MetroHealth adult patients and employees for SDOH.
SDOH Screening for Data-driven Actions
Food Insecurity Transportation Employment
Social Connection Housing and Utilities Stress
Intimate Partner Violence Physical Activity
Financial Resource Strain Digital Connectivity
GOAL
SCREENING DOMAINS INCLUDE:
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PROPRIETARY AND CONFIDENTIAL INFORMATION
Patients Screened40,500+ Screened within Cleveland67%
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Completed SDOH Screenings
Enroll MyChart
Community-Wide Resource Referral Platform
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MetroHealth partners with community-based social service organizations (CBOs) through UniteOhio’s multi-directional electronic interface to “close the loop” on social needs.
Discover more at https://ohio.uniteus.com
Clinicians and Coordinators note SDOH concerns,
obtain consent, and make a UniteOhio referral within the Epic Health Record
Patients complete a SDOH questionnaire in MyChart or during their clinic encounter
to assess social needs they may have
Screening Referral Resource Feedback
CBOs in the UniteOhio Network receive referrals and
connect patients with resources.
Clinicians and Coordinators receive updates on partners working to support patients. Aggregate data used to inform community strategy.
The shared technology platform
serves as a coordinated care
network to connect people to resources
PROPRIETARY AND CONFIDENTIAL INFORMATION
Find out more at https://ohio.uniteus.com
• Unite Ohio Network launched on September 22, 2020
• Over 443 MetroHealth and Community Based Organization (CBO) staff are now registered to use the referral network
• 71 CBOs have joined the Unite Ohio Network with others on the way
• Unite Ohio users have initiated over 1,871 service episodes and 872 unique clients are a part of the network
• We have “closed the loop” in at least 403 cases; over 223 referrals are accepted and in review by CBOs or receiving ongoing help
• Referrals are for varied service types (food, benefits navigation, etc.)
• Patients who have received referrals to date are diverse by age, gender, race and ethnicity
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How is Unite Ohio Performing?
Network Status as of 3/25/21
PROPRIETARY AND CONFIDENTIAL INFORMATION
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Patient Age and Gender Distribution
Patients are diverse by gender and age
PROPRIETARY AND CONFIDENTIAL INFORMATION
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Racial and Ethnic Diversity of Patients
Patients are diverse by race and ethnicity
PROPRIETARY AND CONFIDENTIAL INFORMATION
71 Unite Ohio Network CBOs
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As of March 25, 2021
• Achievement Centers for Children• Asbury Senior Community Computer
Center (ASC3)• Asian Services in Action, Inc.• Audrey’s Outreach• Benjamin Rose Institute on Aging• Better Health Partnership• Big Brothers Big Sisters of Greater
Cleveland• Bright Beginnings• Brighter Tomorrow Community Services• Cancer Hope Network• CarePatrol• Change Inc. - Baldwin Wallace University• CHN Housing Partners• Choice Network• Cleveland Rape Crisis Center• Cornerstone of Hope• Courage to Caregivers• Cuyahoga EITC Coalition• Detroit Shoreway CDO• Digital C• Economic & Community Development
Institute• Esperanza, Inc.• Euclid Hunger Center• Fairhill Partners• Family Connections of Northeast Ohio
• Pathway Caring for Children• Patient AirLift Services• PCs for People• Pregnant with Possibilities Resource Center• Providence House• Reach Success• Recovery Resources• Scranton Road Ministries• Seeds of Literacy• Senior Transportation Connection• Slavic Village Development• Step Forward (formerly CEOGC)• TeleAyuda • The Ohio State University Extension• The Pink Fund• United Healthcare Community Plan of Ohio • United Way of Greater Cleveland 2-1-1 Accountable
Health Communities• Ursuline Piazza• Village of Healing• Vistalynk Solutions• West Side Catholic Center• Western Reserve Area Agency on Aging• Women’s Recovery Center• YMCA of Greater Cleveland • Youth Opportunities Unlimited• Zelie’s Home
• Front Steps Housing & Services• Gesher Cleveland• Global Cleveland• Goodwill Industries of Greater
Cleveland• Greater Cleveland Foodbank• Greater Cleveland Neighborhood
Centers Association• Hire Heroes USA• Homewatch Caregivers• Hopewell • Improve Consulting and Training
Group• Journey Center for Safety and
Healing• LGBT Community Center of Greater
Cleveland• Lutheran Metropolitan Ministry• Magnolia Clubhouse• Medworks• Metro West Community
Development Organization • My Sister’s Keeper• NewBridge Cleveland Center for Arts
& Technology• Nueva Luz Urban Resource Center• Old Brooklyn Community
Development Corporation
PROPRIETARY AND CONFIDENTIAL INFORMATION
Join the Network
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• Explore https://ohio.uniteus.com
• Complete the Partner Registration Form (link can be found on
website)
• Contact Karen Cook to connect you with Unite Us for a produce
demo and workflow discussion
• Invite your regular referral partners to also join!
There is no cost to join the Unite Ohio network!
PROPRIETARY AND CONFIDENTIAL INFORMATION
• Cleveland was recently ranked as the least connected big city in the United States using US Census data
• More than 52,700 Cleveland households (30.7%) do not have any home Internet - including mobile data plans. *
• 46% of Cleveland residents have no broadband home internet access*
• Among populations served by MetroHealth, the problem is especially severe
• A recent survey found that a majority of Medicaid recipients interviewed in Northeast Ohio had no home broadband access+
Why focus on digital inclusion?
*US Census, 2019; + OneCommunity.org
Internet access is the entry point to opportunity
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Digital Inclusion and Connectivity
PROPRIETARY AND CONFIDENTIAL INFORMATION
Any High School Age (out of 421) Count (%)Chronic Disease 12 (3%)Substance Addiction 5 (1%)
Mental Health Disorder 149 (35%)
ED Visits > 3 31 (7%)Any occurrence of addiction, mental health or ED visits > 3
169 (40%)
Median Income: $16,929% Under Poverty: 38%
Demographics Count (%)
Age
≤ 18 1,548 (25%)
19 – 30 1,196 (20%)
31 – 55 2,007 (33%)
≥ 55 1,330 (22%)
Sex
Female 3,114 (51%)
Male 2,965 (49%)
Ethnicity
Hispanic 2,666(44%)
Non-Hispanic 3,199 (53%)
Unknown/Declined to Answer 215 (3%)
Race
White 2,757 (45%)
Black/African American 1,411 (23%)
Other 86 (1%)
Unknown/Declined to Answer 1,826 (30%)
Chronic Disease 1,291 (21%)
Substance Addiction 1,000 (16%)
Mental Health Disorder 2,056 (34%)
ED Visits > 3 986 (16%)
Any occurrence of addiction, mental health or ED visits > 3
2,839 (47%)
Data Drives Digital Connectivity
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PROPRIETARY AND CONFIDENTIAL INFORMATION
Subsidized Internet for ~1,000 Households
Scholars Strivers Seniors
Response: Bridge the Divide
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PROPRIETARY AND CONFIDENTIAL INFORMATION
161 Total Households in Scranton Castle
142 (88%) with one or more MetroHealth Patient
DemographicsMedian (IQR) or
Count (%)
Age 64 (IQR: 60, 70)
Gender
Female 64 (45%)Male 78 (55%)
Ethnicity
Hispanic 57 (40%)Non-Hispanic 84 (59%)Unknown 1 (1%)
RaceBlack/ African American 60 (42%)White 39 (28%)Unknown/Declined 43 (30%)
Any Chronic Disease 73 (51%)
CICIP 100 (70%)
Addiction Flag 58 (41%)Mental Health Flag 70 (49%)ED Visits > 3 40 (28%)
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Scranton Castle CMHA Pilot
PROPRIETARY AND CONFIDENTIAL INFORMATION
Response: Scranton Castle CMHA Pilot
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Future work: Evaluation of the impact of MyChart, telehealth use, on-line services, social media, potential federal funding for expansion of internet access
Improve the quality of life for residents by providing internet access, devices and digital literacy training
PROPRIETARY AND CONFIDENTIAL INFORMATION
Social Isolation
Why focus on social isolation?
• Social isolation is one of the most common SDOH risk factors identified among MetroHealth patients
• Significantly increases a person’s risk of premature death from all causes,
a risk that may rival those of smoking, obesity, and physical inactivity.
• Associated with higher rates of depression, anxiety, and suicide.
• Associated with a nearly 4 times increased risk of death among heart
failure patients, 68% increased risk of hospitalization, and 57% increased
risk of emergency department visits.
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PROPRIETARY AND CONFIDENTIAL INFORMATION
Response: Social Connection
Calls for HOPE
• Telephone re-assurance program connecting patients at high risk for isolation with trained community volunteers for regular social phone conversation
• 1-3 telephone calls per week to provide comradery and conversation over 3 to 6 month period
• Help participants to identify ongoing strategies to increase engagement with others, both virtually and in-person
Open Table
• A poverty transformation model built on meaningful relationships and the importance of social capital.
• Trained volunteers form “Tables” that act as a team of life specialists, encouragers and advocates for individuals or families experiencing poverty.
• Outcomes include better job or school; improved problem-solving skills; self-supporting or confident will be in future.
PROPRIETARY AND CONFIDENTIAL INFORMATION
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PROPRIETARY AND CONFIDENTIAL INFORMATION
Food Security
Food insecurity is among the highest identified SDOH risks among MetroHealth patients.
Strongly correlated with chronic disease:
• Food insecure individuals are more likely to develop a chronic disease
• Once a disease is established, food insecurity makes management more difficult
Current programs include:
• Food As Medicine Clinic
• Fresh Produce distribution
• Free Summer Lunch Program
• AmeriCorps community navigators
• VIDA!
Why focus on food security?
PROPRIETARY AND CONFIDENTIAL INFORMATION
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PROPRIETARY AND CONFIDENTIAL INFORMATION
Response: Food As Medicine Clinic
Nutrition prescription program for patients who are food insecure and have specific chronic disease diagnoses that are impacted by diet.
Eligible for healthy food package every 2 weeks for up to one year. Flagship location at Main Campus.
• Recent Operational Improvements: Electronic scheduling; online ordering system; home delivery; curbside pick-up.
• Data Analysis: Identify opportunities and gaps and assess impact of food-related interventions, for continuous improvement.
• Evaluation: Demonstrated outcomes in behavior change (eat more vegetables; reduced fast food consumption); trend of decreased ED visits.
• Expansion: New sites (Ohio City Health Center, Buckeye Health Center) and new populations (pediatric patients and their families)
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PROPRIETARY AND CONFIDENTIAL INFORMATION
• Opportunities for utility assistance, food and benefits access, education, new careers, legal aid, financial counseling, and more.
• Community Partners include: CHN Housing Partners, Goodwill, GCFB, Legal Aid• New developments:
o Adding Benjamin Rose, College Now, Family Connections, and Seeds of Literacy.o Space for Food As Medicine Clinic and Financial Opportunity Center.o Video connections for virtual support to all MH locations.
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MetroHealth Community Resource Center at BuckeyeBringing Information and Service to People
PROPRIETARY AND CONFIDENTIAL INFORMATION
2018-2019 School Year • 9 schools
• 2,719 Clinic Visits
• 1,647 Immunizations
• 512 Well-child visits
• 438 Adolescent mental health screens
*12 schools for 2019-2020
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School Health Program
PROPRIETARY AND CONFIDENTIAL INFORMATION
• In comparison to Ohio Medicaid population, SHP students have:
• Increased annual exams
• Increased immunization series completion
• SHP students have:
• Decreased emergency room utilization (at MH sites)
The School Health Program is a place where students feel safe and they find people who care for their well-being as well as their future.
Clinical Outcomes
2.49
2.9
Non School Health
School Health
Educational Outcomes
Absences (Days): Lincoln-West High School
*Statistically Significant
Grade Point Average: Lincoln-West High School
15.97
7.8
Non School Health
School Health
*Statistically Significant
1) MetroHealth School Health Evaluation Reporthttps://www.metrohealth.org/pediatrics/school-health-program
School Health Program
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The Bigger Picture
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In addition to screening and connecting people with the services they need, we
will work to make equitable change on a broader level
– both locally and beyond – by:
• Focusing on the root causes
• Advocating for policy, systems and environmental change
• Promoting research and innovation
We are driven by the relentless pursuit of healthy, thriving communities for
everyone.
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