Tag - social determinants of health

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Become a Live Well Lamoille Blogger!
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Care Coordination at Copley Hospital
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The Difference DULCE Makes
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Resilience

Become a Live Well Lamoille Blogger!

The Live Well Lamoille blog is a joint community effort to share information and encourage one another to make healthy choices, and now YOU have the opportunity to be a part of it! This month, we are beginning our search for new bloggers to join the conversation about how to live well and build a healthier community.

So many factors contribute to “health.” Medical care is certainly important; however, many of the other factors that shape our health reside outside the doctor’s office, such as access to nutritious food, economic stability, and the policies and laws that shape the choices available to us.

Too often, the clinical aspects of healthy living are considered separate from the more social aspects. Live Well Lamoille attempts to create a shared space where our community can come together for a more holistic conversation. We bring together bloggers from health organizations, local government, advocacy groups, educational institutions, and local businesses to contribute blog posts sharing resources, activities, and ideas to help readers make healthy choices.

This year, we hope to feature even more perspectives and approaches to improving health. Adults over the age of 18 in the Lamoille Valley are invited to enter our contest to become a new Live Well Lamoille blogger. Entering is simple:

  1. Visit Copley Hospital’s Facebook page: https://www.facebook.com/CopleyHospitalVT
  2. Comment on the blog contest announcement (link above) discussing why you would be a great blogger to represent and inspire people in our community to make healthy choices.

Use this as an opportunity to introduce yourself and let your personality shine. Who are you? What is your approach to health? Do you enjoy cooking, exercising, or practicing mindfulness? Do you work to improve quality life for children and families through your career?

We are looking for a variety of backgrounds and approaches to health and wellness. In the past, bloggers have written about both traditional healthcare topics (such as heart health and managing a chronic disease), as well as topics not traditionally thought of in health discussions, such as:

  • neighborhood walkability
  • preventing substance abuse
  • addiction recovery
  • early childhood education
  • coping with grief
  • local recreational resources

Every blogger will bring their own unique voice and stories to the blog. Each Live Well Lamoille blogger will be responsible for writing 2 to 3 blog posts per year.

Head on over to Copley Hospital’s Facebook page and tell us why you would make a great blogger!

Care Coordination at Copley Hospital

By: Leah Hollenberger

Social Determinants of Health

The Social Determinants of Health (Image via American Public Health Association)

 

Many words have been written about care coordination and addressing the social determinants of health as a way to reduce healthcare costs. But what does that really look like?

Healthy People 2020 defines social determinants of health as “the conditions in which people are born, live, work, and age that affect their health.” They include factors such as education, the safety of our homes and neighborhoods, financial security, the cleanliness of our water and air, access to good nutritional food, etc.

Care coordination is a collaboration between providers, social services and the patient themselves. It often sounds simpler than it actually is. Let’s be clear: one meeting doesn’t lead to change. Thoughtful, consistent care coordination involving the patient and all members of their care team is needed over the long term to help someone become healthier. That care team can include local health care providers, substance abuse counselors, mental health counselors, RN case managers, social workers and a variety of other case managers from across local agencies.

So how does it work? Let me share a few examples. (Note: We have changed names to protect privacy.)

The Right Care in the Right Place at the Right Time
Copley recently treated Joe in our ED and, due to the severity of his illness and the resources required to manage his care, transferred him a tertiary hospital. His health improved but he still needed weeks of inpatient skilled nursing and complex care coordination to ensure once he was home, he had a secure social support network to assist him. Joe wanted to be cared for at Copley as it was closer to home and easier for his family to participate in his care. The tertiary hospital was reaching capacity, and, coupled with the need for local care coordination and Joe’s preference, contacted Copley. There was no question that Copley could provide the medical care, but we weren’t sure if we would be able to meet his other needs to ensure a smooth transition. After three weeks of collaborative teamwork with nurses, providers, pharmacists, care managers, social workers, Chaplaincy, nurse leaders, and the patient himself, a plan was developed to address both Joe’s social and clinical issues so he could be admitted to Copley and provided with the appropriate continuation of care. Joe was able to receive the inpatient skilled nursing care and complex care coordination he needed in a more affordable setting, closer to home.

Reducing Avoidable Emergency Department (ED) Visits
John is a middle-aged man who has come to Copley Hospital’s Emergency Department nearly 40 times in the past two years.  In addition to his alcoholism, John struggles with mental health issues and has a long cardiac health history. He is considered a “super-utilizer” of medical services. Copley has a full-time social worker in our ED as part of an Emergency Department Care Coordination pilot with Community Health Services of Lamoille Valley. The social worker assesses the patient’s needs 1:1 either at the bedside or through a follow-up call. Copley’s social worker was able to connect with John 1:1 in the ED earlier this year.

Copley’s social worker subsequently met with John each time he presented to the emergency department and followed up each visit with a phone call to review discharge plans and follow-up appointments. With John’s permission, she kept each of his various providers informed after each visit. After several visits, John met with Copley’s ED social worker and his primary care RN care coordinator to talk about his goals and what he thought he needed to be successful. Two weeks later, he decided he was ready for treatment and came to the Emergency Department for help. Copley’s ED team, inpatient medical social worker, and ED social worker all worked throughout the day to help get him admitted into an appropriate facility for inpatient alcohol treatment.

The ED social worker continued to check in with the inpatient facility and advocate for John. He was able to remain in the program for a longer period of time and she coordinated transportation with Rural Community Transportation (RCT) in advance for his follow-care plan appointments. Forty-eight hours after discharge, John met with his primary care RN care coordinator to review his discharge plan and ensure he had what he needed to be successful. Copley’s ED social worker continued to contact John and his providers regularly, confirming he had attended appointments with his substance abuse counselor, psychiatrist, primary care provider, specialist appointments, and RN care coordinator. This plan was followed for four weeks, at which point, John’s ongoing case management was transferred to his primary care RN case coordinator.

The outcome? John has maintained his commitment to make healthier choices. The shared care plan continues, with the goal of eliminating future costs of avoidable visits to the ED, by keeping John and patients like him, feeling engaged, motivated, and supported to make healthy choices.

Reducing Costs
Copley Hospital recently participated in an initiative to reduce the percentage of ED visits of 29 identified “super-utilizers” by implementing a shared care plan. The 29 “super-utilizers” accounted for 4% of the total ED visits in the initial 90-day time period; they accounted for only 1% in the second 90-day time period. A potential $144,300 was saved by this decrease in ED visits. This collaborative initiative involved Blueprint for Health Medical Homes (Community Health Services of Lamoille Valley, Northern Counties Health Care, Family Practice Associates in Cambridge and other primary care practices), Vermont Chronic Care Initiative with the Vermont Department of Health, and other local health agencies along with Copley Hospital.

These are just three examples of care coordination at Copley. We plan to continue the ED Care Coordination pilot, with Copley helping to fund the social worker position in the ED. However, we know this will not be enough to meet the need.  We continue to strive to provide excellent patient care for needed services and invest in programs to help reduce the rising cost of health care. Copley will continue to advocate for and contribute to shared care plans to connect patients with needed health services and social determinants support, collaborating with existing organizations and resources, to help patients make healthy choices.


Leah Hollenberger is the Vice President of Marketing, Development, and Community Relations for Copley Hospital. A former award-winning TV and Radio producer, she is the mother of two and lives in Morrisville. Her free time is spent volunteering, cooking, playing outdoors, and producing textile arts. Leah writes about community events, preventive care, and assorted ideas to help one make healthy choices.

The Difference DULCE Makes

By: Scott Johnson

Susan had just had her first child. She was excited to be a new mom but was overwhelmed with caring for her newborn, the family’s financial stress, and tension between her and her partner. At the baby’s initial newborn Well Child visit at Appleseed Pediatrics, Susan met Jenn, our DULCE Family Support worker.

DULCE (Developmental Understanding and Legal Collaboration for Everyone) is a three year demonstration project sponsored by the Center for the Study of Social Policy taking place in seven sites across the country. The Lamoille Family Center and Appleseed Pediatrics is the model for the program in a smaller rural community. DULCE is an innovative pediatric-care-based intervention through which primary care clinical sites proactively address social determinants of health and promote the healthy development of infants from birth to six months of age and provide support to their parents. DULCE’s intervention adds a Family Specialist (FS) to the pediatric care team, and the FS provides support for families with infants in the clinic setting, connecting them to resources based on parents’ needs and priorities – with the option of providing home visits, at the parents’ choice. The DULCE intervention incorporates a protective factors approach and draws on and incorporates components of the Medical-Legal Partnership model to ensure that families have access to the resources they need.

The DULCE family specialist meets with families at their first newborn pediatric visit and stays connected with them through their first six months. This gives new families support with issues that arise, but also in connects families to concrete supports that are designed to help families thrive.

Jenn referred Susan and her family to Economic Services and encouraged them to apply for Reach Up, a program that helps eligible parents gain job skills and find work so they can support their children. This family was already receiving WIC and 3Squares food benefits but they didn’t know about the program that provides supplemental income support for families with children. Receiving these benefits helped ease their financial stress.

Jenn worked with the DULCE Medical Legal Partner to help the child’s father apply for Social Security benefits. Over the next six months Jenn’s encouragement helped the family keep their scheduled well child visits, increased their food stability, and lifted some of the financial stress with a monthly Reach Up grant.  They also connected to Children’s Integrated Services at the Family Center for additional in-home parenting support and education.

In the year since their child was born, the increased support of the DULCE program helped the family develop a good rapport with their Pediatrician, keep current on their well child visits, and enroll in social programs that strengthen their family.

“I think this service was a nice addition to the already wonderful relationship we enjoy with Dr. Balu. I believe for families in more difficult family or friend circumstances it is probably essential. I can’t stress enough how important these types of services are to families. Emotional support and creating access to vital resources.” – DULCE parent

For more information about DULCE, visit https://www.cssp.org/pages/dulce.


Scott Johnson is Executive Director of the Lamoille Family Center and has worked in Lamoille Valley in human services and education for nearly his entire career. The Family Center has served our community by encouraging, educating and celebrating children, youth and families for forty years.

Scott writes about early care and education, adolescent development and strengthening families that improve conditions of well-being.

Resilience

By: Jessica Bickford

Many community partners are coming together to host three screenings of the film, “Resilience.” This film looks at Adverse Childhood Experiences (ACEs) and how they can impact our lives into adulthood. Beyond ACEs, the film explores ways to come together as a community to support and create opportunities for resilience, or the ability to become strong, healthy, or successful (again) after something bad happens.

 

Resilience Trailer – KPJR Films from KPJR FILMS LLC on Vimeo.

Choose from any of three dates/locations. Reserve your free ticket today!

Here’s a longer overview of the film:

“The child may not remember, but the body remembers.”

The original research was controversial, but the findings revealed the most important public health findings of a generation. RESILIENCE is a one-hour documentary that delves into the science of Adverse Childhood Experiences (ACEs) and the birth of a new movement to treat and prevent Toxic Stress. Now understood to be one of the leading causes of everything from heart disease and cancer to substance abuse and depression, extremely stressful experiences in childhood can alter brain development and have lifelong effects on health and behavior.

However, as experts and practitioners profiled in RESILIENCE are proving, what’s predictable is preventable. These physicians, educators, social workers and communities are daring to talk about the effects of divorce, abuse and neglect. And they’re using cutting edge science to help the next generation break the cycles of adversity and disease.

A must see for everyone in our communities!



Jessica Bickford has worked as Coordinator of Healthy Lamoille Valley for a little over two years, where she has enjoyed writing for their blog. Writing for Copley’s community blog is a natural extension of this experience! Healthy Lamoille Valley focuses on making healthy choices easy choices, realizing that when we have access to healthy options we are less likely to choose behaviors that are harmful. Prevention is really a lifestyle of wise choices that enable us to live life to the fullest.