Memorial Hermann Community Benefit Corporation

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.

According to an emergency department use study, published in June 2013 and conducted by the university of Texas school of public health, 46% of all patients treated and released from emergency rooms in Houston were treated for primary care related illnesses or injuries. Based on this data which represents a consistent trend, the Memorial Hermann Health System Nurse Triage Center dba the Nurse Health Line was established and designed to improve access to care and ensure more efficient use of the emergency rooms in Harris and the surrounding counties. The study highlights the need for patient education about appropriate emergency department use. Healthcare consumers are uncertain about where and when to go for treatment. The Medicaid 1115 waiver DSRIP program allowed Memorial Hermann to launch and operate a 24-hour nurse triage call center to assist patients with their level of care decisions. The goal of the program is to be a regional resource that Houstonians can call to discuss their health concerns, receive recommendations on the appropriate setting for care, and connect to appropriate resources. The call center is staffed with registered nurses and certified CHWs 24/7 and is available to callers, free of charge, regardless of insurance status, language, physician alignment or hospital affiliation. Callers with questions or concerns regarding medical conditions are encouraged to call or fill out a 'contact us' form at nursehealthline@memorialhermann.org and get help from a registered nurse who provides nurse triage, health education/information, suggestions on the urgency of the need for treatment, and the appropriate level of care from 911 to home care advice. Memorial Hermann patients are given discharge instructions (from hospitals, clinics, surgery centers, and doctors' offices) to contact the nurse health line for assistance with medical concerns, questions post-discharge. Conversely, callers are referred to EDs, urgent care centers, virtual visits, clinics, or contact their physician for follow up in accordance with the appropriate treatment setting needed. Patients are also referred to community health centers, Pharm D poison control hotlines, dentists, and mental health hotlines/facilities. Vouchers are available to be sent electronically for a free neighborhood health center clinic visit. Referrals to home health, the Memorial Hermann Community Resource Centers and dietitians are initiated as needed, free to callers. The FY23 data shows that: 98% of the triage line callers followed the advice of the nurse and 57% that would have sought care in an ER setting were redirected to urgent care, primary care or home care. The 24/7 call center is a credible and available resource for assistance with medical concerns and questions. Callers that are uninsured and/or do not have a primary care physician are given resources to connect with a primary care home close to their home. The service is promoted through electronic ads, health fairs, wellness events, not-for-profit social service agencies; school districts; college campuses, city of Houston agencies, churches, and federally qualified health clinics, and partners programmatically with the Harris county emergency corps (HCEC), northwest community health (NW), and city of Houston Ethan-emergency telehealth and navigation program. Intended for the community at large, 46% were Medicaid/uninsured. The cost avoidance for the Houston area ED's is just over of $ 4.6 million, using the assumption of $500 per ER visit, for FY23. Memorial Hermann Health System COVID calls are being transferred to the COVID hot line. The COVID hot line is being managed by the nurse health line (NHL).

Physicians of Sugar Creek

Support of Community Health Centers