Memorial Hermann Community Benefit

Compounded by texas' lack of medicaid expansion, are people who cannot afford private insurance; who are eligible but not enrolled in government sponsored programs, and who are recent or undocumented immigrants. A growing number obtain their health care in ers. A houston study conducted by the university of tx school of public health indicated that roughly 46% of er visits are used for non er conditions. In november, 2008, when uninsured rates for the nation and the houston area were 15% and 32%, respectively, the memorial hermann community benefit corporation launched a patient navigation program to address primary care related er use at memorial hermann southwest hospital. Overall objectives were and continue to be: (1) to connect patients with medical homes that are the right location, the right cost, the right hours of operation, and the correct services for each individual; (2) to reduce primary care related er use; and (3) to reduce primary care related costs, at least to the point of covering the cost of the program. Today, er navigators are located in all memorial hermann health system ers. The study design is based on pre/post data; and the intervention includes patient navigation, conducted by bi-lingual, state certified community health workers (chws) trained in peer-to-peer counseling. During the er visit chws meet with patients to: explore all access issues (access is more than having health insurance); coach on how to access healthcare and community resources; and, educate on the importance of finding and maintaining a medical home. All patients leave the er with some sort of follow-up instructions from the medical team--the chws make sure they have a place to go. After the er visit chws: follow up with patients, usually within one week; monitor/review/resolve ongoing patient needs; and, continue to follow-up until the case is closed. Essential to the process is continuing to build relationships with hospital staff and community based organizations. In partnership with memorial hermann er business, clinical and care management teams, the program annually results in 12- month, pre-post decline in er visits of 62%. Research data indicates that social determinants of health (sdoh) have a profound impact on the health status of individuals, and in order to improve population health, health care systems will need to consider addressing sdoh. The er navigation program incorporates food insecurity screening and pantry/snap referral into the navigation intervention process. Most recently, a multi-visit patient (mvp) implementation coaching program has begun with the objective of identifying and mitigating the root causes of recurrent utilization for non-clinical purposes - homelessness, social isolation, hunger, mental health. The focus is on emergency department patients not only across the memorial hermann system but shared with harris health and methodist. Hospital teams serve as change agents and support the vision of the program. External partnerships include houston recovery center, council on recovery, and coalition for the homeless. To further align efforts of addressing social determinant issues and increase the opportunity for our program to build bridges to health care and community resources we have implemented community resource centers, a new model for working with partners on medical/social needs at our memorial hermann southwest, greater heights, and northeast hospitals. Memorial hermann community resource centers support community members with navigating the health and social service systems, while becoming more engaged in their own disease prevention through decision-making and self-management. Through an intake screening tool which addresses food insecurity, transportation, health literacy, access to and understanding of medications, financial strain, housing, employment, education and emotional well-being, community health workers identify the appropriate partners to support each individual client. The program builds collaborative partner capacity through provision of access to services (medical home connections, application assistance, encouragement for follow-through); wrap-around support (nmdoh); education (health literacy); and bridging people to social supports.