Thomas Jefferson University Hospitals Community Health Needs Assessment Report. Evaluation HOME OF SIDNEY KIMMEL MEDICAL COLLEGE

Transcription

1 Thomas Jefferson University Hospitals Community Health Needs Assessment Report Evaluation HOME OF SIDNEY KIMMEL MEDICAL COLLEGE

2 COMMUNITY HEALTH IMPLEMENTATION PLAN Evaluation and Outcomes for Jefferson University Hospitals June 30, 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 Implementation Plan is provided below. Column 1in this Table lists the activities/domains included in Jefferson s 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.

3 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 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

4 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 6 th 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

5 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. Hospital Readmissions Pilot CHW community intervention with socially complex/high risk patients, refugee/immigrant and homeless/sheltered populations 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. 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 The CHW program was initiated in January 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, Six trainings

6 Workforce Diversity and transitions to community have been held reaching more than 150 individuals. 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 6 th 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 Partner with Refugee Academic Mentoring Program (NSC program) that helps people get the skills needed to get health related employment. (example: Burmese nurse). Career Day at Downingtown High School and Middle School reached 150 students in 2015 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

7 Continue the WorkReady program with Philadelphia Youth Network (PYN) at TJUHs 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. Jefferson and received full tuition scholarships. Jefferson takes 25 students each summer from the PYN Work Ready program. This program provides summer employment of High School Students (11 th & 12 th grade) - Four Students from Cristo Rey are participating in a workforce development program at Jefferson (school year ) This program will be continued in FY 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 CHW program was initiated in January 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

8 Provide wellness/health education in workforce development programs: Continue the Career Support Network program with low resourced workers will be pursued in the next fiscal year. 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

9 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

10 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 The Jefferson CHW program was initiated in January 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. Improve Access to Health Advocate for creation of a City- wide database to track patients requesting pain medications and other drugs Partner with TJUH Finance Dept. to train community leaders and CBOs to 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. Jefferson partnered with Enroll America, Pennsylvania Health Access Network (PHAN), and

11 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 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

12 difficulty as more and more individuals become enrolled through the Health Insurance Exchange. 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. Jefferson and Methodist Hospitals also assisted 24,458 individuals with applications to Medicaid, public assistance programs or Charity Care in 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. Free Clinics for the homeless (JEFF HOPE) and Jefferson Refugee Health Partners Methodist Hospital provided 480 free laboratory tests for the Unity Clinic in 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

13 Chinatown Free Clinic Tindley Temple Partner with Stephen Klein Wellness Center (formerly St Elizabeth s health clinic) located in North Philadelphia. 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. 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) 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 Jefferson s Center for Urban Health held monthly, 3 session Diabetes Self- Management Education Classes at the Stephen Klein Wellness Center in Chronic Disease Management Programs were implemented in spring 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.

14 In 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

15 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

16 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 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

17 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 Language Access, Health Literacy Provide cultural competence training for health care providers related to populations including 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. Mental Health First Aid Training is an 8 hour mental health first aid certificate course that teaches individuals how to help those

18 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

19 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.

20 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 partnership with PICC, increase awareness about regulations pertaining to access to interpreters 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. 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.

21 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. Continue to provide Health Literacy training for health care staff, providers and TJU students 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. Training for JUP practices are on- going. Six trainings reaching about 150 have been held to date. Develop and implement policies/system changes that require employee health literacy training 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.

22 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 Promote Breastfeeding continue to pursue Baby Friendly Hospital status Recommendations include exploring opportunities to include health literacy training at new employee orientation and as part of annual Health Stream education requirements. 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. 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 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 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 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.

23 Continue to explore Maternity Care Passport to reduce unnecessary patient re- testing in Philadelphia at time of service and/or labor and delivery. 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. 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. 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 Explore feasibility and enhancement of depression screening and substance abuse screening in health care practices and ED 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 8 th grade school in South Philadelphia where the majority of students are immigrants or refugees. 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. 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

24 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. 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 It is recommended that training be expanded to other marginalized populations. 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.

25 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 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. 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. 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

26 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. Increase screening of all patients and 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. All BP Plus and Heart Smarts program