5 Innovative Efforts to Improve Community Health

5 Innovative Efforts to Improve Community Health. A collage of photos from Essentia Health, Duluth, Minnesota; John Muir Health, Contra Costa County, California; University Hospitals, Cleveland, Ohio; Munson Healthcare, Traverse City, Michigan; and Palomar Health, Escondido, California.

Collaboration is key to improving community health. And if you’re looking for inspiration to excel in this area, look no further than this year’s AHA Dick Davidson NOVA Award winners.

The five recipients of this year’s awards are addressing some of the field’s greatest challenges — from ensuring that patients can connect easily with community resources to steering violence survivors toward a path of healing to implementing street medicine programs. And they are working shoulder to shoulder with other community stakeholders to get the job done.

5 Shining Stars That Are Improving Community Health

Essentia Health, Duluth, Minnesota1 | Essentia Health, Duluth, Minnesota

This organization’s We Are Resourceful program was launched in 2021 as a public resource directory connecting community members with thousands of verified programs providing free and reduced-cost services. Information available at Resourceful is customized for the specific needs of the communities served by Essentia Health — parts of Wisconsin, Minnesota and North Dakota.

The program integrates into Essentia Health’s electronic health record system and is widely used by community members including Essentia staff and local organizations. All Essentia patients are screened for social needs at primary care and pediatric appointments. Its team of community health workers develops relationships with patients and utilizes Resourceful to connect them to services addressing such patient concerns as food insecurity, transportation and housing. It’s a highly collaborative program with a community leadership team that sets annual performance targets, reviews robust evaluation metrics and monitors community and patient feedback.

John Muir Health, Contra Costa County, California2 | John Muir Health, Contra Costa County, California

Its Beyond Violence program provides intervention to people who have been impacted by interpersonal violence such as assault, stabbing or gunshot. At the hospital bedside, an intervention specialist engages with a patient to provide support and begin the program enrollment process. Beyond Violence provides direct access to health care services like a mobile health clinic, trauma follow-up clinic, mental health support, connections to jobs and education, and resources for food and housing for long-term sustainability.

The specialist connects clients, their families and others who were affected by the violent event to a needed resource. The program has flexed with the growing needs of the community by expanding partnerships, geographical reach and increasing scope of services such as adding no-cost mental health therapy. The program initially was designed to serve those aged 15-25, but in 2022 it expanded to serve anyone older than 15. Since the program’s inception in 2010, 98% of program clients remained alive, which is testament to the program’s support and efficacy.

University Hospitals, Cleveland, Ohio3 | University Hospitals, Cleveland, Ohio

UH Food for Life Markets® is a food-as-medicine preventive model to address chronic health conditions by providing free, healthful food and dietitian consultation. When patients visit their clinicians, they are screened for food insecurity. Those who screen positive receive a referral to one of five existing UH Food for Life Markets.

On-site dietitians help patients select food that addresses their medical needs while remaining culturally sensitive to food preferences. The program’s goal is to help patients control chronic conditions like high blood pressure and diabetes. The program, in collaboration with the Greater Cleveland Food Bank and Sodexo, has expanded in urban and rural areas and expects to open its sixth market this year. Patients are eligible to receive food for a week for a family of four or fewer, once a month for as long as six months and can get their referral renewed by following up with their clinicians. The markets are part of University Hospitals’ Community Health Investment strategy and are counted as a community benefit.

Munson Healthcare, Traverse City, Michigan4 | Munson Healthcare, Traverse City, Michigan

Through the TC Street Medicine program, medical care and other supportive services are provided twice a week for the unhoused in the streets, at community-based organizations and in encampments in the woods. Launched in 2016 by a doctor from Traverse Health Clinic, it was expanded and fortified in 2020 as a more comprehensive collaboration of the clinic, Munson Healthcare and Goodwill Northern Michigan Street Outreach.

With the addition of a mobile medical unit, the number of patients served greatly increased. The program connects unhoused individuals with care teams including health care professionals as well as outreach and social workers. Following the mantra “Go to the People,” the medical team — including residents representing family medicine, psychiatric and pharmacy programs — bring care directly to unhoused individuals. The TC Street Medicine team delivers compassionate, nonjudgmental medical care directly to individuals who are in precarious housing situations and builds trusting relationships with patients who are seeking medical care, as they work to protect their health and assist them in finding housing.

Palomar Health, Escondido, California5 | Palomar Health, Escondido, California

The Palomar Forensic Health Services and Trauma Recovery Center provides 24/7 compassionate, comprehensive services and support for San Diego County survivors of all ages who have endured physical or sexual abuse, domestic violence, human trafficking, elder abuse or trauma. The programs connect survivors to specialized case management and mental health services to decrease recidivism, cycles of violence, crime rates, overuse of emergency department services, and morbidity and mortality rates.

They provide immediate and early detection of abuse, and offer services near a trauma survivor’s home; examination by a trained professional; and high-quality evidence to assist with investigations. Co-locating within a family justice center enables Palomar to collaborate with more than 80 multidisciplinary team partners including community-based organizations, local law enforcers and district attorneys. The center was founded in 1984 to serve children and seven years later became the first hospital in the county to serve sexual assault survivors. In 2021, they introduced specialty services for military members and human trafficking survivors.

AHA Center for Health Innovation logo