Twelfth Annual Monroe E. Trout Premier Cares Award
Descriptions and contact information for award recipient, finalists and semi-finalists
Compiled January 2004
Award recipient
Taking Control/Impact
Delaware Valley Community Health, Philadelphia , PA
The Taking Control/Impact program helps diabetic patients reduce their risk of cardiovascular disease and improve their quality of life. Delaware Valley Community Health developed the program in response to an extremely high prevalence of cardiovascular disease in the poverty-stricken African-American and Latino neighborhoods of north Philadelphia .
Diabetics receiving their primary healthcare at a participating Delaware Valley Community Health center can enroll in “Taking Control” classes designed to empower patients through self-management. Patients learn how to monitor their blood sugar, take their medications, and manage their condition through proper diet and exercise.
Another vital component of the program is Impact software, developed to translate changes in glucose, cholesterol, and blood pressure levels into improved health outcomes for 10 diseases, including myocardial infarction and stroke. The program also calculates the cost savings resulting from improved glucose levels. With documented health improvement and cost savings, Delaware Valley convinced local Medicaid HMOs to reimburse for the Taking Control classes.
Among patients in the program, the risk of:
- Diabetes-related mortality has been reduced by almost 50 percent.
- Myocardial infarction has dropped more than 30 percent.
- Renal failure is down almost 60 percent.
- Amputation has been reduced nearly 100 percent.
In addition to sharing the findings in presentations for the Centers for Disease Control and the National Association of Community Health Centers, Delaware Valley has made the Impact software available free via the Internet. To date, more than 375 healthcare organizations have downloaded the program.
Contact:
Patricia Deitch, Director
215.291.2511
deitchp@dvch.org
1412 Fairmount Avenue
Philadelphia , PA 19130
www.dvch.org
Finalists
Christ House
Washington , DC
Christ House helps the homeless people of Washington , DC , get off the streets and into treatment – where they can recuperate and rebuild their lives. The organization provides healthcare, social services, and substance abuse treatment to help clients break the cycle of homelessness.
Patients come to Christ House with a variety of illnesses – including cancer, diabetes, liver disease, kidney failure, AIDS, and frostbite. Most arrive with more than one medical problem – and these physical ailments are frequently complicated by addiction or mental illness. In addition to providing on-site care, the staff can arrange hospitalization or visits to specialists as needed.
Social workers and case managers assist patients in obtaining benefits, legal documents, and housing at discharge. They may help a patient locate family members. Social workers also lead support groups and arrange treatment for addicted patients. Alcoholics Anonymous meetings, held four times a week at Christ House, are open to the neighborhood as well.
Residents can participate in structured activities – among them volunteer work assignments, art and poetry workshops, classes, games, movies, and excursions to parks, museums, sports and cultural events. Pastoral care is provided as well. Christ House also offers the Kairos Program, in which formerly homeless men make the transition from temporary acute care to a stable, permanent living environment that supports recovery.
During the last fiscal year, almost 60 percent of male patients and 80 percent of female patients were placed in housing at discharge. More than 60 percent of Kairos participants obtained paid, part-time work within six months, and more than 50 percent enrolled in educational programs. Christ House has served as a model for similar programs in Chicago , Boston , and Greensboro , NC – as well as in Sweden , Japan , and England .
Contact:
Matthew Rogers, Director of Development
202.328.1100
mrogers@christhouse.org
1717 Columbia Rd. NW
Washington , DC 20009
www.christhouse.org
Healthcare for the Working Uninsured
Lakeland Volunteers in Medicine, Lakeland , FL
Lakeland Volunteers in Medicine provides free primary care to the working uninsured of Lakeland , FL. Approximately 25 percent of residents in this largely agricultural region have no health insurance, even though they have jobs. They cannot afford private insurance, nor do they qualify for Medicaid.
That’s where Lakeland Volunteers in Medicine comes in. With six paid employees, the clinic provides primary care to 23,000 people each year. Care is delivered by more than 180 medical professionals – including physicians, dentists, nurses, nurse practitioners, medical assistants, and technologists – who volunteer their services to the clinic.
Patients receive free X-rays as well as free prescription medications from the clinic pharmacy. Clinic staff members use their contacts to arrange treatment for patients who need specialty care, specialized diagnostics, or inpatient care. More than 270 community volunteers perform virtually all non-clinical tasks involved in operating the clinic, such as scheduling and medical records.
The clinic has achieved documented success:
- 74 percent of patients treated for hypertension at the clinic have succeeded in keeping their blood pressure at or below the goal of 140 over 90.
- 100 diabetic patients have completed 12 hours of patient education and are on their way to better management of their condition.
- Lakeland Volunteers in Medicine treats patients for less than $60 per visit, or one-seventh the cost of a typical visit to the local emergency department – which translates into annual savings of $4.3 million.
Contact:
Ed Wardle, Development Director
863.688.5846, ext. 118
Ed.wardle@lvim.net
1021 Lakeland Hills Blvd.
Lakeland , FL 33805
www.lvim.net
Margaret Hudson Program
Tulsa , OK
The Margaret Hudson Program (MHP) helps young mothers in Tulsa and Broken Arrow , OK , make the difficult transition from childhood to parenthood. The program’s goals are to keep pregnant and parenting teens in school, provide them with vocational training, enhance the health of mothers and children, prevent child abuse, and prevent pregnancy.
These objectives are achieved through a variety of services:
- Pointers on Parenting is a support group that provides education for teenage fathers as well as grandparents.
- In Moms and Mentors, students are matched with volunteers who provide tutoring, promote school attendance, and serve as adult role models.
- In Student Leadership Teams, MHP seniors educate their peers on the importance of finishing high school and delaying a family until they are ready to assume the responsibility.
- A work program not only offers employment and earnings, but also education on budgeting and managing income.
- Ongoing medical care is provided by nurses, who see a student every two weeks during her pregnancy and monthly thereafter.
Nationwide, 50 percent of pregnant teens drop out of school – but more than 70 percent of Margaret Hudson students graduate from high school. One hundred percent of Margaret Hudson babies are immunized – and less than five percent of Margaret Hudson students experience a second pregnancy while they are in the program.
Contact:
Felecia Rowland, Executive Director
918.746.9205
RowlaFe@tulsaschools.org
1515 South 71 st East Avenue
Tulsa , OK 74112
www.margarethudsonprogram.org
Mission Possible: Partnering to Improve the Health of a Population
Partners Health Initiative, Anderson , SC
The Partners Health Initiative – affiliated with Premier owner AnMed Health – helps residents of upstate South Carolina and northeast Georgia make informed decisions about their healthcare. The initiative is based on the belief that access to good information about healthcare can improve access to healthcare itself.
Using the Healthwise Handbook – a self-care guide distributed to more than 160,000 households – people often find they can treat their conditions at home, with over-the-counter remedies. The handbook helps readers identify symptoms, determine what can be done at home, and decide when to call a physician or the emergency department.
Supplementing the handbook is the Partners Nursewise Line – a 24-hour call center staffed by trained nurses who provide reliable health information and refer callers to appropriate healthcare options, including free or low-cost clinics for the uninsured. The call line has likely saved at least one life – when the nurse on duty urged a caller to go to the emergency department, where the patient was diagnosed with a cerebral hemorrhage.
Clemson University ’s Joseph F. Sullivan Center , an academic nursing program that provides healthcare in remote and underserved areas, also uses the Healthwise Handbook in patient education – in both English and Spanish-language versions.
Over a 30-month period, 23 percent of the area’s population used the Healthwise Handbook to avoid a visit to the doctor, while 15 percent avoided a trip to the ER – saving an estimated $34.5 million in healthcare costs.
Contact:
Melissa Smith , Director of Training and Evaluation
864.375.9190
msmith3@anmed.com
P.O. Box 1345
Anderson , SC 29622
www.healthy-community.org
Nurses for Newborns Foundation
St. Louis , MO
Nurses for Newborns – based in St. Louis , MO – works to prevent infant mortality, child abuse, and neglect by providing education, healthcare, and positive parenting skills. This nurse home visiting agency has developed four “safety net” programs to serve high-risk families:
- Bright Futures helps women access prenatal care, teaches them how to care for their infants, and develops parenting skills.
- Teen Parent seeks to prevent repeat pregnancies, ensure immunization, and reduce accidents by educating young mothers on safety hazards at each stage of an infant’s development. Other goals include increasing a young mother's awareness of the signs of physical illness in the infant, and educating her about the health resources in her community.
- Bridge to the Future serves medically fragile infants after they are discharged from neonatal intensive care.
- Safe Beginnings serves mothers who are mentally retarded, developmentally disabled, mentally ill, or physically challenged. The program focuses on reducing premature births, preventing child abuse and neglect, and promoting good parenting skills. Services continue until the client enters a long-term care program.
Nurses for Newborns also maintains a donation bank with clothes, toys, diapers, blankets, car seats, baby beds, and formula for families in need.
The program has achieved measurable success: In fiscal year 2002, there were no substantiated instances of child abuse or neglect among Nurses for Newborns clients. Eighty-nine percent of the children were current on their immunizations, and 99 percent required no repeat hospitalizations. Among 95 percent of mothers, there were no repeat pregnancies. The program has expanded to Nashville , TN.
Contact:
Sharon Rohrbach, R.N., Executive Director
314.544.3433
Sharon.rohrbach@nfnf.org
7259 Lansdowne
St. Louis , MO 63119
www.nfnf.org
Semi-finalists
Community Access To Child Health (CATCH)
American Academy of Pediatrics, Elk Grove Village , IL
Community Access To Child Health (CATCH) – a national program of the American Academy of Pediatrics – supports pediatricians in working with local communities to ensure that all children have access to a medical home and health services. The program provides pediatricians with training, technical assistance, peer support, and funding for initiating community-based child health programs. With three full-time staff members and more than 100 volunteer pediatricians, the program has trained more than 1,000 pediatricians and resulted in more than 500 child health initiatives throughout the U.S. Currently, CATCH projects are underway in all 50 states as well as in Guam and Puerto Rico .
Contact:
L. Jina Lee, Program Manager
847.434.4903
catch@aap.org
American Academy of Pediatrics
141 Northwest Point Blvd.
Elk Grove Village , IL 60007
www.aap.org/catch
Home Option Management Effectiveness (HOME)
Family and Children’s Services of Central New Jersey , East Brunswick , NJ
The Home Option Management Effectiveness (HOME) program provides mental healthcare and alternatives to incarceration for adolescents aged 14 to 18. Juveniles and their families are provided with individual and/or family therapy and group therapy on a weekly basis, as well as intensive case management. Services are provided free of charge for five months. The program seeks to eliminate recidivism; improve academic or vocational performance; reduce self-destructive behaviors on the part of youth and family members, with particular emphasis on addressing substance abuse and psychiatric diagnoses; improve psychosocial functioning; and increase access to community resources and activities. In 2001-2002, 81 percent of youth served by the program improved their academic performance or obtained gainful employment; 80 percent addressed problems with substance abuse or psychiatric diagnoses; 88 percent improved in at least three areas of psychosocial functioning; and 78 percent had committed no new offenses three months after completing the program.
Contact:
Ruth Goldsmith, Program Coordinator
732.418.7077
info@nj-counseling.org
223 Route 18 South, Suite 201
East Brunswick , NJ 08816
Medication Assistance Program (MAP)
Guilford County Department of Public Health, Greensboro , NC
The Medication Assistance Program (MAP) provides prescription medications and disease management services for residents of the Greensboro area who have asthma, diabetes, hypertension or other cardiovascular disease; have incomes less than 140 percent of federal poverty level; and do not qualify for other state or federal prescription insurance programs. More than 300 physicians work with the program to obtain medications for their patients. Sixty-four percent of MAP patients are eligible for Medicare, living on fixed incomes, and taking an average of 10.5 prescription medications daily; the remainder are uninsured and ineligible for Medicaid or Medicare. MAP employs clinical pharmacists to provide disease and drug management services in addition to the dispensing functions normally found in medication assistance programs. Medications valued at more than $3 million have been obtained for the 1,300-plus patients enrolled to date, and significant reductions in hemoglobin A1c, blood pressure readings, lipid levels, ED visits, and hospital stays have been documented.
Contact:
Joy Southerland, Program Administrator
336.641.6582
1100 E. Wendover Ave.
Greensboro , NC 27405
www.co.guilford.nc.us/government/publichealth/index.asp
Pediatric Feeding Program
Children’s Hospital, Richmond , VA
The Children’s Hospital Pediatric Feeding Program serves children with complex feeding disorders who are typically tube-fed and unable to benefit from traditional treatments; in many cases, parents have to quit their jobs and stay home with these children. The Day Feeding Program involves several weeks of intensive treatment: five to six hours per weekday of program attendance and four structured feeding sessions per day. Treatment is provided by a diverse medical team – including a gastroenterologist, a behavioral psychologist, an occupational therapist, a speech-language pathologist, a feeding technician, a nutritionist, a dietary technician, a nurse, a social worker, a case manager, and a program manager – that functions as an interactive group rather than in a consultative model. The day program has resulted in statistically significant changes in feeding behaviors, caregiver feeding skills, growth, and food consumption – reflecting the overall clinical improvement of patients.
Contact:
Ann V. Deaton, Director of Program Development and Research
804.228.5880
2924 Brook Road
Richmond , VA 23220
www.childrenshosp-richmond.org
Personal Health Partner (PHP) Program
Laurel Lake Retirement Community, Hudson , OH
The Personal Health Partner (PHP) Program is a wellness initiative undertaken by the Laurel Lake Retirement Community in collaboration with Premier owner Catholic Healthcare Partners (of which Laurel Lake is a member), the Akron Metropolitan Housing Authority, and the Sisters of Humility of Mary. A community outreach effort focusing on seniors in low-income public housing facilities, PHP is designed to assess individual healthcare needs and to help residents identify and practice healthy lifestyle behaviors through ongoing education and support. Program activities include onsite exercise classes, aquatic exercise offered at Laurel Lake, a group walking program, educational programs on health-related topics, weight management counseling, medication instruction and management, resource referrals and follow-up, and patient advocacy. Seniors participating in the program have shown significant improvement in health knowledge, health status, and such preventative measures as scheduling physicals, conducting regular skin and breast self-exams, and making low-fat food choices.
Contact:
George D. Paulson, President and CEO
330.655.1435
200 Laurel Lake Drive
Hudson , OH 44236
Pharmacy Connect of Southwest Virginia
Mountain Empire Older Citizens, Inc., Big Stone Gap, VA
Pharmacy Connect of Southwest Virginia – a partnership of seven regional health and human services organizations – helps the uninsured, medically indigent residents of a seven-county rural area gain access to prescription drugs. A staff of 15 works closely with area physicians to help the uninsured obtain free medications through the indigent patient assistance programs of nearly 100 pharmaceutical companies. The program serves approximately 4,400 people annually. In fiscal year 2003, Pharmacy Connect processed more than 24,000 applications and obtained medications valued at nearly $11.7 million.
Contact:
Marilyn Pace Maxwell, Executive Director
276.523.4202
Block 1-A Industrial Park
P.O. Box 888
Big Stone Gap , VA 24219
www.meoc.org
Reducing the Diabetes Disparity
TriCounty Community Health Center , Malta , IL
The TriCounty Community Health Center (TCCHC), established by the Northern Illinois University School of Nursing, provides primary healthcare and outreach services to low-income, uninsured residents of a three-county area in rural Illinois . Between 1989 and 1996, the incidence of diabetes increased more than 200 percent in the health center’s service area; moreover, the disease disproportionately affects high-risk underserved populations. TCCHC responded with health education to increase awareness of diabetes risk and prevention – as well as screening programs to identify individuals at risk. Those with abnormal screening results are referred to their primary care physicians or provided with information about TCCHC. Community health nurses and nursing students follow up to ensure that individuals are linked with an affordable, accessible source of ongoing primary care. Those diagnosed with diabetes receive treatment and assistance in obtaining free medications and monitoring equipment. Diabetes self-management classes are provided free of charge. To date, more than 1,200 high-risk individuals have been assessed and started on treatment when necessary; 67 percent of participants in the diabetes outreach program have been linked with affordable primary care at TCCHC; 75 percent of TCCHC’s diabetic patients have experienced a decrease in Hemoglobin A1c; and hospitalization rates for diabetes have declined, despite the rising incidence of diabetes.
Contact:
Mary Uscian, Director
815.753.9011
21193 Malta Road
Malta, IL 60150
www.chhs.niu.edu/nursing/facilities/tricounty.asp
Teen Mother and Child Program (TMCP)
University of Utah Health Sciences Center, Salt Lake City , UT
Teen Mother and Child is the only program in the Intermountain West that provides comprehensive multi-disciplinary care for pregnant and parenting adolescents and their children. Located at the University of Utah Health Sciences Center, TMCP provides medical services; nutritional, financial, and psychosocial counseling; and vocational/educational assistance in a convenient “one-stop shopping” model. Medical care is provided during two full-day clinics each week, with walk-ins seen as needed. Physicians and midwives are on call 24/7, and the program’s nutritionist, financial counselor, social worker, and vocational counselors see patients during medical visits and follow up by phone. In 2001 and 2002, the program provided prenatal and delivery services to 380 teens, or approximately one-third of all births to adolescents in Salt Lake County . As a result of the program’s aggressive efforts to assist teens with eligibility, only 14 percent of clients remain without insurance coverage. More than 60 children with potential developmental delays have been referred to early intervention programs, which coordinate ongoing services with TMCP providers to improve school readiness.
Contact:
Harriett Gesteland, Development Officer
Harriett.gesteland@hsc.utah.edu
801.581.3729
50 North Medical Drive
Salt Lake City, UT 84132
www.uuhsc.utah.edu
Wishard Advantage
Health and Hospital Corporation of Marion County , Indianapolis , IN
Nearly 30 percent of the residents of Indianapolis/Marion County, IN, live at or below 200 percent of the federal poverty level. In 2001, an estimated 12.3 percent of county residents were without health insurance, and 20.4 percent lacked insurance at some point in the preceding 12 months. In response to the problem, Health and Hospital Corporation (HHC) of Marion County developed Wishard Advantage, a managed care program for low-income, uninsured county residents that emphasizes primary care and prevention. HHC departed from the previous system of freestanding clinics and contracted with a primary care physician group, paying a per-member, per-month fee. Patients receive benefits similar to a commercial managed care plan. Physicians have an incentive to build relationships with patients, encourage appropriate use of the delivery system, and improve the provision of primary and preventive care. Inpatient and specialty care is available at HHC’s public hospital, Wishard Memorial, and mental health and addiction services are provided through an HHC facility. As of May 2003, more than 40,000 Advantage members were accessing care from primary care physicians. A study showed that Advantage improved access to healthcare, reduced annual inpatient days by half, and reduced emergency room use by 30 percent among the study population.
Contact:
Catherine Parker, Director, Grants Program
317.221.2468
3838 North Rural Street
Indianapolis , IN 46205
www.hhcorp.org
www.wishard.edu
The Women’s Shelter Dental Center
Columbia , SC
The Women’s Shelter Dental Center provides free, comprehensive dental care to residents of area shelters, indigent veterans, and indigent HIV-positive individuals. Until the Dental Center opened in 2000, free dental services for indigent adults in the Columbia area were limited to emergency extractions – and the center remains the only provider of comprehensive adult dental care for this population. Over the Dental Center ’s three years of operation, the number of individuals served, patient visits, and procedures performed have doubled. In fiscal year 2002-2003, the center provided dental services valued at more than $523,000.
Contact:
Kathy Riley, Executive Director
803.779.4706
3425 North Main Street
Columbia , SC 29203
www.midnet.sc.edu/shelter/