Innovation Programs Improving the Delivery of Health and Healthcare 3
In this week’s post, I wanted to continue with the theme of patient engagement and the important role patients and their families play in helping to make our healthcare system, patient-centered, safe, and cost-effective for all.

As I have discussed in past issues of Nurse Advocate, changes in how healthcare is delivered and paid for are encouraging innovative work in every sector of the healthcare system. The changes are starting to show results in improvements in the quality of the care provided, education of the patient regarding the conditions that impact their health and wellness so they can better manage their care. 

An area making real progress in improving patient engagement is Population Health. Population Health focuses on implementing strategies to assist people in reducing risk of disease, and helping consumers and their communities locate resources that enable them to better manage their health and healthcare.

Those involved in population health look at their communities and the individuals who live there to identify challenges that can impact a person’s ability to manage their health and achieve wellness. Through analyzing data they are able to develop innovative programs that can break down barriers and improve collaboration between all parties to improve the delivery of care. 

A new awards program was developed to highlight the innovative work done in the area of Population Health. The program was developed incollaboration with the Jefferson College of Population Health and Hearst Health to recognize the innovative work people and organizations are doing to engage consumers and their communities in improving population health. The roll out of this new award was well received and brought in over 125 submissions from hospitals, health systems, academic medical centers, community organizations, nonprofits, academic institutions and health departments across 33 states.

The entries were reviewed by a prestigious panel of judges who chose three finalists. The judges scored the submission on a 5 point criteria. To view the scoring criteria,  click here. The finalists and award winner were announced at the Population Health Colloquium that was recently held in Philadelphia. I had the opportunity to interview each of finalists and the winner and am proud to share their work with each of you in this post.

The finalists were: Catering Healthcare Institute and Jersey City Medical Center. The winner of the Hearst Health prize,  was Community Care of North Carolina.

Here is a short overview of each program. If you would like to know more, please feel free click on each title which will take you to their website where you can explore their programs. If you want to talk to someone from these programs, I have included their names and email addresses so you can contact them directly.  

Let’s being with Centering Health Care Institute. The concept behind The Centering Healthcare Institute is that centering care can improve the health of pregnant women and help reduce pre-term births. The goals of the program are to empower pregnant women, strengthen patient-provider relationships, and builds communities. 

The Centering Institute has developed a model that has been replicated across the country and works with physician practices, clinics, and hospitals to institute a proven practice that can improve outcomes in the area of maternal and child health. Today there are over 400 centering practices in 45 states. In 2015, these programs cared for 48,000 women. 

The population for the program is pregnant women beginning at 14 weeks’ gestation. The concept is to bring women together in a group care delivery model that connects clinical providers, community agencies, and other pregnant women from the same community to learn and grow personally so they have a healthy pregnancy. The groups encourage women to communicate about the challenges they face in their lives and helps to educate and empower them in areas of nutrition, wellness and how to avoid things that might cause harm to the child they are carrying. The centering program has shown to be successful in some ways:
  • A reduction in preterm births between 33% and 47% especially among African American women who are known to be at high risk
  • Increase of birth weight, especially in pre-term infants
  • Mothers report improved well-being; greater pregnancy knowledge; improved access to and satisfaction with healthcare; improved heath behaviors and increased in breastfeeding initiation.

The program follows the mothers for a two-year period and has helped to allow mothers, their babies and the other members of the family to achieve healthy lifestyles. Another benefit is that many of the women have become lifelong friends and continue to support each other.  To learn more about the Centering Institute and how you can bring this program to your organizations feel free to contact:  Colleen Senterfitt, MSN, CNM Chief Health Officer. Email:

The second finalists established an innovative program that empowers the organization’s employees and patients with chronic medical conditions to achieve a healthy lifestyle while earning incentives. The program is called Wealth for Health. Wealth for Health is a self-management program that provides tangible rewards. The program is supported by Jersey City Medical Center and allows participants to receive discounts when they actively take part in the management of their health and wellness. 

This voluntary program engages employees of the health system, their patients, their families, and caregivers in education, care management, and healthy behaviors. The program has shown positive results in the following areas:
  • A 40% reduction in inpatient admission for members enrolled for at least 6 months.
  •  A 33% reduction in cost for those patients who had, at least, two chronic conditions.
  • For those enrolled in the program for at least one year, there was a total of $2.1 million-dollar reduction of the costcompared to a full year before program enrollment.

The program also involves he community by engaging vendors in providing services for participants when using their reward point. Reward points enable people to gain significant discounts at retail shops, restaurants, supermarkets, health clubs, auto repair shops, pharmacies, photography services, spas and other vendors who provide personal care products.

This type of program can be easily replicated in any community. For more information, feel free to contact: Susan Walsh, MD, FACP Vice President of Population Health. Email:  

The third finalist and winner of the $100,000.00 Inaugural Hearst Health Prize is Community Care of North Carolina.  This program brings together regional networks of physicians, nurses, pharmacists, hospitals, health departments, social service agencies, and other community organizations to serve the Medicaid population including dual-eligible beneficiaries of North Carolina which numbers about 1.4 million individuals. 

These professionals work together to provide cooperative, coordinated care through the Medical Home model. This approach matches each patient with a primary care physician who leads a health care team that addresses the patient’s health needs.  A strong focus is on transition of care models that includes medication management, self-management education, timely outpatient communication with medical homes to follow-up on clinical and social issues that can affect outcomes. The program has shown great success in the following areas:
  • Rates of hospitalizations and readmission’s for the target population have declined by 10% and 16% respectively since 2008
  • Established real-time data connections which 87 hospitals which represent 78% of all Medicaid hospitalizations
  • As a result, of the program, there has been a 9% reduction in total Medicaid costs

Community Care of North Carolina is changing the health care experience by changing the way health care is delivered in their State. Through their work, they have found that the best system is rooted in the communities it serves. The program has shown that when physicians direct efforts in collaboration with an interdisciplinary team that works together, they can focus on patients in the local community and allow for quality care that is more efficient and cost-effective.

If you would like to find out more about this innovative program, please feel free to contact: C.Annette DuBard, MD, MPH, Chief Health Information Officer and SVP for Population Health Analytics. Email:

I hope this post has provided patients, caregivers, and all members of the healthcare team with the information you can use to spur innovative programs in your community to improve the health of your populations. If you are doing innovative work in the area of Population Health, please watch for the announcement for submissions for the 2ndAnnual Hearst Health Prize so you can submit your program for consideration. 

Don’t forget that together we can make a difference!

Have a good week!
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