Overview: The Institute for H.O.P.E

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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.


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


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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


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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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


The Institute for H.O.P.E.™

Screening and Resources


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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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


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


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Service Episodes To Date

Many types of needs are met


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Patient Age and Gender Distribution

Patients are diverse by gender and age


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Racial and Ethnic Diversity of Patients

Patients are diverse by race and ethnicity


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


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!

https://ohio.uniteus.com/


The Institute for H.O.P.E.™

In Action


• 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


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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Subsidized Internet for ~1,000 Households

Scholars Strivers Seniors

Response: Bridge the Divide

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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


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


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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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.


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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?


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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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• 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


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


• 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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Center for Health Resilience

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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.


Thank You!

Documents

Overview: The Institute for H.O.P.E