Essential Communities

From America’s Essential Hospitals, comes Essential Communities. This site provides a resource for hospitals on the journey to community-integrated health care. Learn more about how this network of hospitals works to address social and economic factors that influence health, take a virtual tour of population health programs nationwide, and share what you’re working on!

From a resource library, to an interactive map of programs, and a roadmap for implementing community-integrated health care, visit this site to learn more.

Social Determinants are Core of North Carolina's Medicaid Overhaul

Social Determinants are Core of North Carolina's Medicaid Overhaul

"North Carolina is trying to make taking care of patients' social and environmental needs a sustainable, everyday part of a healthcare organization's workflow, Dr. Mandy Cohen, the secretary of the North Carolina's Health and Human Services Department, explained Friday at Modern Healthcare's Women Leaders in Healthcare conference in Nashville. She described the goal as buying health—not healthcare. 

Looking beyond what happens in the hospital or clinic is becoming the financial imperative for U.S. healthcare organizations as they move toward alternative payment models and take on more financial risk for a patient's health, said Cohen, who took on the role of secretary in January 2017 after serving as chief operating officer and chief of staff at the CMS during the Obama administration..."

Shelby Livingston | August 3, 2018

To read the full article, please click here. This piece appears in Modern Healthcare.

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If health care is a small part of health, how does a safety net hospital adapt?

"At one of the busiest public hospitals in the nation, doctors have learned that to heal a patient on the inside, they must understand the patient’s world outside the exam room.

What kind of neighborhood do you live in? Are you buying healthy food? How are you getting to work? The questions are meant to uncover the root causes of what bring men and women into the Adult East Primary Care Clinic at the Los Angeles County-USC Medical Center, just east of downtown L.A. Once that screening takes place and a doctor understands how a patient's health is impacted by homelesses, lack of nutrious food or trauma, a team of providers is ready to help. Nurses, social workers, community advocates, nutritionists, mental health specialists, medical students, and volunteers are ready to link a patient to, say, food stamps or psychological care, said Dr. Jagruti Shukla, director of primary care at LAC+USC..."

Susan Abram | July 25, 2018

This piece appears in the Center for Health Journalism Fellowships Blog


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United Hospital Fund launches Second Phase of Early Childhood Development Initiative to Address Social and Economic Factors Affecting Children's Health

Eight hospitals are partnering with community-based organizations across NYC, with funding from United Hospital Fund, Altman Foundation, and the New York Community Trust. 

"United Hospital Fund announced that it is launching the second phase of its Partnerships for Early Childhood Development (PECD) initiative, which partners New York-area pediatric primary care practices with community-based organizations to better address the social and economic factors affecting the health of very young children.

PECD was launched in March 2017 with funding from a collaborative consisting of United Hospital Fund, the Altman Foundation, and The New York Community Trust. The first phase of the initiative was designed to help pediatric primary care practices screen children ages 0-5 for social and environmental risks that interfere with healthy development, and connect them, through partnerships with community-based organizations, with services that can address those risks."

To read the full article, please click here. This piece is from United Hospital Fund.

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What Montefiore's 300% ROI from social determinants investments means for the future of hospitals

What Montefiore's 300% ROI from social determinants investments means for the future of hospitals

"Montefiore Health System in the Bronx has tackled the social determinants of health by investing in housing, a move that has cut down on emergency room visits and unnecessary hospitalizations for an annual 300 percent return on investment.

Investing in the social determinants of health is becoming more commonplace even as hospitals and physicians ask whether it is their place to step outside of traditional care to not only look at, but try to fix, other reasons that keep patients from getting better."

Susan Morse | July 05, 2018

This piece appears in Healthcare Finance

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Intermountain Alliance to Address Social Determinants of Health

Intermountain Alliance to Address Social Determinants of Health

"Intermountain Healthcare plans to invest $12 million in programs to coordinate community care services that address the social determinants of health in two Utah cities, the organization recently announced. These funds will bolster the Utah Alliance for the Determinants of Health, a multi-stakeholder coalition aimed at reducing the adverse health impacts of the social determinants of health for Medicaid patients living in Ogden and St. George, Utah. Areas were selected as a result of a community health needs assessment analysis that revealed underserved areas within Utah that suffer from limited health equity."

Sarah Heath | July 5, 2018

This piece can be found in Patient Care Access News from Patient Engagement HIT

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NIH Funded Scientists Put Socioeconomic Data on Map

NIH Funded Scientists Put Socioeconomic Data on Map

The Neighborhood Atlas, a new tool to help researchers visualize socioeconomic data at the community level is now available. This online platform allows for easily ranking and mapping neighborhoods according to socioeconomic disadvantage. Seeing a neighborhood’s socioeconomic measures, such as income, education, employment and housing quality, may provide clues to the effects of those factors on overall health, and could inform health resources policy and social interventions. 

To view the tool, please click here.

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Charting a Course for Social Determinants of Health

Charting a Course for Social Determinants of Health

Healthcare systems are talking about moving upstream. The Upstream Strategy Compass can help them get there. The Upstream Strategy CompassTM from HealthBegins, for example, uses levels of prevention (i.e. primary, secondary, and tertiary) and levels of intervention (i.e. individual, organizational, community) to help healthcare systems and their community partners understand local needs as well as the opportunities to improve specific social determinants of health for priority patient populations.2 

Rishi Manchanda 

This piece appears in the Practical Playbook Blog

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Overcoming Challenges to Medicaid Investments in Social Determinants of Health

Medicaid and other payers are recognizing that health outcomes and costs are driven by factors beyond clinical care. These factors are rooted in the community and include issues such as housing, food security, transportation, and the neighborhood environment in which people live, learn, play, pray, and work. Through an initiative sponsored by the Robert Wood Johnson Foundation, Payment Reform for Population Health, AcademyHealth partnered with the Nemours Children’s Health System to work with Maryland, Oregon, and Washington State to address the payment challenge. Specifically, they worked with states to explore current Medicaid authorities to promote and provide prevention services in community settings, cover upstream prevention benefits such as assessing a home for asthma triggers, and deliver services using nontraditional community-based providers.

Enrique Martinez-Vidal, Debbie I. Chang, Tricia McGinnis | June 13, 2018

This piece appears in the Health Affairs blog.

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From the Memphis Model to the North Carolina Way: Lessons from Emerging Health System and Faith Community Partnerships

From the Memphis Model to the North Carolina Way: Lessons from Emerging Health System and Faith Community Partnerships

Necessary components for building robust health system and congregational partnerships to address social determinants of health and impact health care utilization include partnership growth, allocation of health system resources, community trust, and time. This commentary describes and compares the Congregational Health Network’s Memphis Model to early local efforts at clinical-faith community partnerships in North Carolina, which we call “The North Carolina Way.”

This piece appears in North Carolina's Medical Journal

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