Community Health Implementation Plan 2019-2021
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Wilmington streets transformed into summer block parties thanks to Play Streets, a collaboration among ChristianaCare, the City of Wilmington, the UD Partnership for Healthy Communities and other community organizations that brought games, music and health screenings to neighborhoods.
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Contents Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 ChristianaCare’s 2019-2021 Community Health Needs Assessment. . . . 3 Implementation Plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Social Determinants of Health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Food Insecurity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Housing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Affordability of Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Poverty, Employment and Economic Opportunity . . . . . . . . . . . . . . . . . . . . . 10 Education. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Mental Health and Substance Use Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Violence and Public Safety. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Maternal and Child Health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Access to Primary Care and Dental Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Community Health Implementation Plan 2019-2021, at a Glance . . . . . 17 Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 A Leader in Health, for All Communities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
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Introduction For more than 100 years, ChristianaCare has served Delaware and its surrounding regions with exceptional services aimed at improving the health of the community. They include clinical and social services, education and outreach. We recognize the paradigm shift happening across health care, and we are committed to being more than a great health care system; we want to be a system that impacts health. We seek to truly impact the health of our community, in our community, providing the right care, in the right place, at the right time for everyone we serve. This commitment is a natural extension of The ChristianaCare Way: We serve our neighbors as expert, caring partners in their health. We do this by creating innovative, effective, affordable systems of care that our neighbors value. This report serves as a testament to our mission. At ChristianaCare, we commit to being exceptional today and even better tomorrow, guided by our values, excellence and love. In the 2016 Community Health Needs Assessment, we aimed to improve the health of our neighbors by addressing four areas that have a steady impact on health: poverty, mental health and substance use disorder, maternal and child health, and violence and its impact on public safety. The areas of need in the 2019 Community Health Needs Assessment, which were identified by community members and
Janice E. Nevin, M.D., MPH, president and CEO of ChristianaCare, visits with preschoolers in the Early Learning Program at Kingswood Community Center in Wilmington, Delaware. The program is part of the REACH Riverside community revitalization being supported by ChristianaCare.
analysis of data, continue to be essentially the same challenges. These are not problems that are easily solved, and so we begin this Community Health Implementation Plan with the humble recognition that we have lessons to learn about how best to serve and listen to our community, and the promise that we will make every effort to continue to do so.
1 | Introduction
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Here are some of the lessons we have learned in our areas of need: First: In order to appropriately impact change around social determinants of health, collaboration with community partners is fundamental. Across New Castle County, the prevalence of poverty has remained a priority among service providers — and addressing it requires laser focus on social needs, including access to quality care, food security, availability of affordable housing, and job opportunity and security. All of these needs, when unmet, are intricately interwoven to trap individuals in poverty. We call this the social care framework that supports health equity and improved health outcomes at both the individual and community level. Second: While there has been progress in increasing access to behavioral health services and interventions that impact substance use disorder, social determinants of health continue to create obstacles to addressing mental health needs. When mental health needs are unmet, these obstacles become far greater. Effective interventions to address these barriers are vital to breaking this cycle and truly improving the lives of individuals with mental health diagnoses and substance use disorder in our community. Third: While we have made strides, maternal and children’s health, preconception health, prenatal care and infant mortality remain persistent and heartbreaking challenges across our community, particularly in the area of racial disparities. Clinical interventions are important but must be combined with an understanding of the systemic challenges faced by communities, effective community outreach and intervention, and targeted social care supports. Finally: We need to address violence and public safety head-on as a health system. Violence causes traumatic physical injury to members of our community and has a traumatic, far-reaching emotional and toxic stress impact at both the individual and community levels. Violence is a public health epidemic that we, as health care providers, must address directly.
As an academic medical center and a nationally recognized leader in clinical quality and safety, ChristianaCare serves our community with exceptional clinical care, health education, outreach and research. We recognize that to truly impact the health of our community and achieve health equity, we must also work with community partners to address the social and environmental barriers to health that drive disparities — often referred to as the “social determinants of health.” Our vision is for ChristianaCare to be at the forefront of population health and a nationally recognized leader in developing a social care framework, where care, services, connections and community investments advance health outcomes and health equity, and support a strong, vibrant community.
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ChristianaCare’s 2019-2021 Community Health Needs Assessment In early 2019, ChristianaCare undertook a Community Health Needs Assessment to understand the needs of the communities we serve. Because of ChristianaCare’s commitment to truly understand the challenges faced by all the communities we serve, this assessment focused on community health needs in two geographic areas in New Castle County: “Community 1” (ZIP codes 19801, 19802, 19804, 19805 and 19720) and “Community 2” (all other ZIP codes). This distinction was made to ensure that the significant variation in socioeconomic conditions across New Castle County would be recognized, and that the most urgent needs in the ZIP codes within Community 1 would not be hidden by countywide statistics. To identify the main areas of need, ChristianaCare held a series of community meetings with the participation of more than 100 community stakeholders and 75 local teenagers, as well as internal meetings of ChristianaCare staff members. ChristianaCare was purposeful in the inclusion of a broad array of community voices at these meetings to ensure a diversity of viewpoints.
3 | 2019-2021 Community Health Needs Assessment
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In partnership with area nonprofit organizations, ChristianaCare produced a community resources map — a tool to connect Wilmington’s most vulnerable people with the agencies that provide them with support.
As a result of the community meeting discussions, secondary data findings and an interview with a representative of the Delaware Department of Health and Social Services, the following were identified as the prioritized areas of need: 1. Social determinants of health, including poverty, food insecurity, housing, affordability of care, education, and employment and economic opportunity.
2. Mental health and substance use disorder. 3. Violence and public safety. 4. Maternal and child health, and infant mortality. 5. Access to primary care and dental care.
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Implementation Plan Social Determinants of Health ChristianaCare has a long history of community engagement in support of our mission to serve our neighbors. As we focus on population health and our opportunity to impact the health of our community outside the walls of our hospitals, we are entering a new era. We are committed to addressing barriers to health at both the individual and broader community levels — particularly in our urban core of Wilmington — with a coordinated strategic community investment strategy focused on long-term impact. Through the partnership of ChristianaCare’s Office of Health Equity and Finance Department, and support at the highest levels of our organization, ChristianaCare is strategically investing in our community to support population health, health equity, improved health outcomes and delivering value through high-quality, cost-effective care. REACH Riverside partnership. ChristianaCare’s March 2019 gift of $1 million to Purpose Built Communities’ REACH Riverside Community Development Initiative is a perfect example of this type of community investment. The REACH Riverside Community Development Initiative is a community-led revitalization project for one of Wilmington’s oldest and most underserved neighborhoods. ChristianaCare’s gift will fund community health and wellness outreach and education, facilities and resources for teen programs and activities, support for seniors and children, transportation, and programs to support economic opportunity and mobility through workforce development and financial health programs. In addition to this financial support, ChristianaCare is also working closely with the REACH Riverside board of directors, resident groups and community partners to better understand the health needs of the community and how best to meet those needs. Care coordination network. ChristianaCare has also recently engaged Unite Us to develop a care coordination network connecting social services and clinical care providers across the state. With this network, any health care provider or social service organization can help an individual address the diverse needs they may have. This tool has the potential to revolutionize the way social service and health care organizations work together in Delaware. It enables our community to take advantage of existing resources and better understand areas that need additional resources or investment. Our hope is that this network improves coordination among community organizations and health care providers, and provides valuable information about how the needs of Delawareans are being met or unmet. ChristianaCare’s support of the REACH Riverside initiative and the development of the care coordination network demonstrate the future of ChristianaCare’s community investment. We will seek out opportunities to take a coordinated, holistic approach to address the social needs of our communities, utilizing innovative tools and diverse partnerships. Most importantly, our priority is to ensure that community voices are heard and that those insights guide our work.
5 | Implementation Plan
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During the period of this Community Health Implementation Plan, we expect to add additional structure around our community investment process, including guidelines for making determinations on investment and measuring outcomes. ChristianaCare’s Office of Health Equity is implementing a grant process for community groups to apply and receive grants. Community Health Workers. ChristianaCare is also expanding its capacity to serve the community in the community by committing to a Community Health Workers (CHW) program — a key component of an effective population health strategy. As recently as 2017, ChristianaCare did not employ any CHWs. By 2020, we expect to have 20 full-time CHW positions. The CHWs will be embedded within multiple locations: women’s health, school-based health centers, primary care and our care coordination community team. The interventions will vary within each CHW group and are currently ChristianaCare’s Health Ambassadors address a range of being developed, but will be guided by a core health topics through education in the community. commitment to employ individuals in and of the community to support this critical community outreach. In the interest of ensuring that patients and community members are served with excellence by the CHWs, ChristianaCare has been working with the Penn Center for Community Health Workers to create a blueprint for the work of the CHWs. Within the blueprint, ChristianaCare will develop protocols for several key areas: recruiting and hiring, training and certification, standardized CHW care, supervision and integration, and highquality research and evidence. We are excited to be supporting CHWs because they will offer patients and community members a new type of support to meet their health needs. The impact of ChristianaCare’s CHW program will be felt beyond the individuals assisted. The program offers a new avenue of employment for community members, and ChristianaCare will seek out opportunities to share information with other community organizations and health systems about how CHWs can be implemented successfully in coordination with other efforts.
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Food Insecurity In Delaware, a striking 10.8% of households are food-insecure (Health of Women, 2019). Food insecurity — defined in simple terms as not knowing how or not being able to provide food to your family or yourself — is linked to poor overall health. For children, food insecurity is particularly devastating for their mental and physical health, education and even future success. ChristianaCare is in the early stages of devising a research project with our Value Institute that will provide home delivery of medically tailored meals to food-insecure patients and their families for the first 30 days after discharge from the hospital. We will also explore food prescription programs that may be a good fit within the community. Our expectation is that in fiscal year 2020, innovative programs to address food insecurity will have been designed and initiated, and the following year will provide us with measurements of success. ChristianaCare is not only researching innovative programs to address food insecurity; we have also taken action to address food insecurity for our patients and community. A Produce Rx program was created in 2017 (discussed in the maternal and child health section of this report), and the Wilmington Hospital Food Pantry was established in early 2019 in partnership with the Food Bank of Delaware. This food pantry serves outpatients of Wilmington Hospital, the Center for Special Health Care Needs, Independence at Home, and our care coordination community team. ChristianaCare provides boxes of non-perishable food to patients who are identified as needing access to food. These patients also receive information about community-based food options for continuing support. The food pantry is in its first year, and we are looking forward to the new insight it will provide into our patients’ food needs. After the completion of the first year, data-informed determinations will be made about any needed changes to the program, and the information secured from this program will also be used to inform other food insecurity initiatives.
7 | Implementation Plan
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As the largest employer in Delaware, ChristianaCare caregivers represent the diversity of communities we serve, and it would be an oversight to not recognize that our caregivers also face the same challenges. Emergency food pantries in the Christiana and Wilmington hospitals have been established to provide boxes of non-perishable food at no cost for those caregivers in need. These caregiver food pantries were established this year and will be continued as long as the need exists. Caregivers are not asked to identify themselves, so no data is tracked other than the number of boxes distributed, but this program will provide a general insight into food insecurity faced by our caregivers.
Housing The scarcity of affordable housing generally, as well as appropriate housing for individuals with physical and behavioral health needs, was a persistently voiced concern at the community town halls undertaken to inform ChristianaCare’s 2019 Community Health Needs Assessment. When housing was identified as an area of need in the 2016 assessment, ChristianaCare made the determination that it would not dedicate specific additional resources to address housing issues due to a lack of infrastructure and expertise on need. Under ChristianaCare’s new community investment initiative, housing will be addressed. ChristianaCare’s Independence at Home Program and Good Neighbors Home Repair have partnered to research the value of home repair for homebound, high-needs patients. This partnership is currently in the early stages and may evolve, but our expectation is to learn more about the relationship between home repair and health outcomes. During this fiscal year, ChristianaCare will also research transitional housing models that provide wraparound services for people with complex health needs and explore potential partnerships to support these resources. In addition, we will collaborate across our organization around the possibility of providing vouchers for housing and paying for utilities, and we will seek out partnerships with community and government agencies aligned with this work.
Addressing food insecurity requires innovative programs in our health care facilities and in our community.
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Affordability of Care ChristianaCare is committed to making care affordable through bold steps. These include moving away from the fee-for-service model toward value-based reimbursement models that focus on health outcomes. In July 2019, ChristianaCare entered into agreements with Delaware’s two largest Medicaid payors to work with beneficiaries in population health contracts. The success of this effort will be closely measured over the next few years. ChristianaCare leadership also considers it a responsibility to advocate at the state and national levels for policies that support access to affordable care and a value-based reimbursement structure that provides a framework to improve health outcomes and deliver value. In addition to our Financial Assistance Program, which allows eligible individuals to receive medically necessary services at no cost or at a 15% standard discount, ChristianaCare assists individuals in accessing affordable care through programs such as the Health Guides who serve to connect patients to financial and prescription assistance, and health insurance or other benefits, such as Medicaid. ChristianaCare has also partnered with the Delaware Community Legal Aid Society Inc. since 2015 to offer the Medical-Legal Partnership, which provides eligible patients with civil legal assistance in a variety of areas including denial or terminations of benefits. We are proud to offer these programs as part of our social care framework addressing the social determinants of health.
David Jester of Wilmington, here with his grandson Joshua, was able to avoid significant financial hardship with support from the Delaware Medical-Legal Partnership, a collaboration of the Delaware Community Legal Aid Society Inc. and ChristianaCare. 9 | Implementation Plan
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Poverty, Employment and Economic Opportunity As the largest private employer in the state of Delaware, ChristianaCare believes that it has a responsibility to lead by example. In early 2019, ChristianaCare increased its minimum wage to $15 an hour. The decision to do so was made because each ChristianaCare employee at every level is a caregiver and plays a vital role in the care of our patients and their families, and because as a health care provider, we know that there is a strong link between financial health and physical health. Adult workforce development. ChristianaCare has also partnered with the Wilmington HOPE Commission to create a job opportunity pipeline. The Wilmington HOPE Commission provides comprehensive re-entry support for formerly incarcerated, high-risk men leaving prison and returning to Wilmington’s most distressed communities. ChristianaCare has made a commitment to the urban core of Wilmington, and support of the Wilmington HOPE Commission and the development of a job-opportunity pipeline was a natural decision. We hope to influence and encourage other businesses in the community to provide opportunities for those re-entering. ChristianaCare has developed a close relationship with the Central Baptist Community Development Corporation (CDC) located in the Eastside community of Wilmington. ChristianaCare is supporting Central Baptist CDC’s Soft Skills Job Training Academy, which they expect will have a positive impact on local unemployment and crime. ChristianaCare also is an employer partner with Central Baptist CDC. ChristianaCare Human Resources professionals provide information on interview and job readiness, and notify Central Baptist CDC when positions are available. We are also exploring a partnership with the Delaware Skills Center and Central Baptist CDC around targeted job training to take advantage of opportunities in the health care arena. Youth workforce development. ChristianaCare has invested in workforce development for young people in New Castle County. We feel strongly about creating a variety of access points for the next generation of employees to find a pathway to careers, including educational opportunities to explore health care through interactions with system leaders, clinicians and staff, and immersive experiences like job shadowing and internships. ChristianaCare supports the work being done across the community to help young people to be healthy and grow into successful adults. One program, STRIVE, applies the rigor of athletics to the development of the individual. STRIVE offers a research-based curriculum that incorporates self-knowledge, moves into culture creation and ultimately instills the habit of rigorous leadership practice. Another partnership, with the city of Wilmington, allows for teens in the Youth Career Development Program to be placed in specific departments at ChristianaCare hospitals for eight-week internships. In addition, Office of Health Equity leaders have created a rigorous professional development training experience for these youths, as a complement to the skillbuilding they learn in their individual placements. Another partnership, with Public Allies Delaware, places young leaders in specific departments where they spend 10 months capacity-building. For 2019-2020, two public allies will work directly with the system’s community health programs, with one focused specifically on workforce and pipeline program development.
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Education During the community town hall meetings, community members and ChristianaCare staff alike spoke about the need for high-quality, well-funded, integrated public schools, and the link between education and health. ChristianaCare has and will continue to support education initiatives through activities such as leadership on the Delaware Business Roundtable Education Committee, the First Book and Basic Closets initiative providing books and essential supplies to students, the Urban Athletic Development League, and the Pre-Kindergarten Reading Enrichment Program. ChristianaCare also firmly believes that to be ready to learn and excel in school, children need to be healthy, and that requires true access to health care prevention, treatment and education. ChristianaCare’s school-based health centers are expanding services in schools throughout the state. In 2018, in response to requests from the education community, ChristianaCare opened its first school-based health center at an elementary school — Warner Elementary (3rd-5th grade) — in the city of Wilmington. In 2019, ChristianaCare opened a second school-based health center at Warner’s sister school, Shortlidge Elementary (K-2nd). Both schools serve high-need students in the heart of Wilmington. The investment in school-based health centers in these elementary schools is aligned with ChristianaCare’s commitment to support families where they are, and to support the health and wellbeing of students to optimize their educational opportunities. In addition, we promote family-friendly policies that serve to improve the health and well-being of individuals across the lifespan, including our direct support of the Teen Warehouse as part of the REACH Riverside Purpose Built Communities initiative.
Mental Health and Substance Use Disorder According to the community town hall participants, the lack of access to mental health services and the challenges faced by those with mental health concerns is overwhelming. Not only are services difficult to receive, but a stigma remains for those suffering from mental health issues or substance use disorder. Adding to these challenges is the opioid epidemic, which continues to make an indelible impact on our state. Access to mental health services. To better address mental and behavioral health needs in our community, ChristianaCare opened a new inpatient behavioral health unit at Wilmington Hospital that provides both behavioral health and medical care. An opioid withdrawal screening tool for these patients has also been developed, along with the creation of an addiction consultation service. An outpatient program to treat substance use disorder with medication-assisted treatment has also been formed. ChristianaCare’s new Center for Hope and Healing at Wilmington Hospital helps some of the most vulnerable members of the community improve their medical and behavioral health while addressing social barriers that can undermine their success. This unique,
11 | Implementation Plan
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comprehensive approach to health supports patients who struggle with significant mental illness as well as a chronic medical condition or a significant social need, such as homelessness, hunger or addiction. Addressing substance use disorder. ChristianaCare also has partnered with health care providers and the state to address the opioid epidemic. We have had tremendous success in reducing our opioid prescriptions through the Delaware Opioid Prescription Engagement Network (OPEN), which is working to prevent chronic opioid use and abuse throughout the state in partnership with other health care providers. We are also collaborating on the state-led Delaware Substance Use Treatment and Recovery Transformation Initiative (START), which attempts to increase access to care and treatment for individuals living with substance use disorder. In a more community-facing program, ChristianaCare also has partnered with New Castle County to create Community Substance Overdose Support (SOS). Community SOS teams, made up of peer specialists and intake specialists, engage with individuals in their homes or communities after they have been brought to the hospital following a suspected overdose. They begin a relationship with these individuals with the goal of getting them to treatment. We will continue to adapt this pilot as the needs of this population are better understood. Expectant mothers who may be living with substance use disorders also need special care. In order to provide access to quality services, ChristianaCare provides OB-GYNs who are embedded with local organizations that treat patients living with mental health issues and substance use disorder. Through these on-site relationships with behavioral health provider organizations, ChristianaCare can support patients and community partners.
The First Book and Basic Closets initiatives support children’s readiness for school.
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Violence and Public Safety Violence and the associated trauma suffered by individuals and communities is a significant and longstanding concern in Wilmington. ChristianaCare is eager to form partnerships with a diverse array of community partners to address this problem directly. ChristianaCare has partnered with organizations such as Victims Voices Heard and the Delaware Coalition Against Domestic Violence in their efforts to address violence and its impacts.
ChristianaCare and community partners help teens understand the terrible consequences of violence.
We look forward to providing a Hospital-based Violence Intervention Program, in addition to supporting our Trauma Program’s services and community outreach. According to the American College of Surgeons, “hospital-based violence intervention programs are multidisciplinary programs that identify patients at risk of repeat violent injury and link them with hospital- and community-based resources aimed at addressing
underlying risk factors for violence” (Dicker, et al., 2017). The Hospital-based Violence Intervention Program will establish a single clinical care team to use two evidence-based synergistic strategies along with intensive outpatient case management. The team will include a social worker and two CHWs who will receive specialized training in violence prevention and harm reduction. There is evidence that this type of intervention has demonstrated improved patient outcomes and improved adherence to medical care without increasing costs of care. This nationally recognized model is emerging as best practice in harm reduction for violent injury, as it has demonstrated effectiveness in reducing violent injury recidivism, among other positive outcomes, and has been promoted by the American College of Surgeons Committee on Trauma. Programs have demonstrated effectiveness in reducing re-injury and hospital readmissions, decreasing arrests and convictions for violent crime, and promoting employment, though outcomes differ between cities and programs. There are currently more than 30 hospital-based violence intervention programs across the United States and in the world. The Hospital-based Violence Intervention Program will integrate with ChristianaCare’s Trauma Program, which is committed to the prevention of injuries induced by violent acts. Most major causes of death and disability have extensive detection, intervention and prevention programs associated with them that are well-funded both publicly and privately. As a Level 1 Trauma Center, Christiana Hospital is mandated to have an organized, effective approach to injury prevention and must prioritize these efforts based on local trauma registry and epidemiological data. Violence-related injuries are a major source of admissions in trauma at ChristianaCare, and the Trauma Program has a dedicated violence prevention coordinator who is tasked with focusing on education and prevention efforts surrounding gun and other violence-related injuries.
13 | Implementation Plan
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Maternal and Child Health ChristianaCare will address maternal and child health through a number of projects. The goal will be an impact on the Delaware infant mortality rate (IMR) and on racial disparities. The state’s IMR from 2012-2016 was 7.5 infant deaths per 1,000 live births, exceeding the national average of 6 per 1,000 (The World Bank, 2018; Delaware Health Statistics Center, 2017). State disparities in IMR mirror those of the nation, as African Americans experience IMRs more than twice that of whites (12.5 vs. 5.1, respectively) (Delaware Health Statistics Center, 2017). The city of Wilmington, which has a predominantly African American population, has the state’s highest IMR at 15.1 (Delaware Health Statistics Center, 2017). These projects will include embedding CHWs in the system’s women’s health practices, expansion of the Produce Rx project, continuation of innovative programs focused on areas such as smoking cessation and bloodpressure control, and the creation of a new app that will provide real-time connections for women’s health patients with education and support services. Addressing infant mortality. Historically, Delaware’s IMR has been of great concern for state and local governments, along with public and private organizations. In 2005, the Delaware Healthy Mother Community baby showers provide maternal and and Infant Consortium (DHMIC) was founded by child health education and gifts of essential items for then-governor Ruth Ann Minner to implement infant safety and development. recommendations to reduce infant mortality and racial disparities throughout the state. Some of these recommendations included: improving access to care for populations disproportionately impacted by infant mortality; requiring insurers to cover services included in standards of care for preconception, prenatal and interconception care; and evaluating environmental risk factors for poor birth outcomes (Delaware Health and Human Services, 2005). Access to resources for families. ChristianaCare has remained a leader in DHMIC and in the community to address maternal and child health. From the creation of Resource Mothers in New Castle County in the early 2000s to the development of the Health Ambassador project, which addresses a variety of health topics through education, we have consistently prioritized the work to address infant mortality. Now, through embedded CHWs, expectant and new mothers will have additional support. In addition, women’s health patients will continue to have access to Produce Rx, a project created in 2017 to connect the community to affordable, quality fruits and vegetables. Patients who meet certain requirements are given vouchers to be used at eight different ChristianaCare-sponsored produce stands across New Castle County. These stands are operated by Urban Acres, part of Central Baptist CDC. In addition, Community Health staff are present to provide education for these patients at the produce stands, while also providing them with connection to any resources they may need.
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Access to Primary Care and Dental Care The American Journal of Managed Care asserts that access to quality primary and dental care is essential for population health. ChristianaCare is meeting this need for patients and their families across northern Delaware and the region. Our primary care doctors provide physical examinations, preventive health screenings and immunizations, chronic disease management, care for acute illnesses and more. As Delaware’s largest, most advanced health care system, ChristianaCare is committed to partnering with our patients in their care and connecting them to the resources they need, including electronic medical records and easy referrals. The goal is to provide the right care, at the right time, at the right place. Primary care. As the needs of the community evolve, and as some community-based primary care practices move to concierge models and limit their patient panels, ChristianaCare is evolving as well. Already, over half of the care we provide is community-based, rather than hospital-based. To meet our community’s needs, ChristianaCare is expanding primary care services to support improved access to the preventive care and chronic disease management that help patients to be healthy and avoid costly unnecessary emergency room visits and hospital admissions.
The Center for Special Health Care Needs partners with patients in their care and connects them with the resources they need to achieve their best health.
ChristianaCare will add five practices and more than 20 providers to provide clinical care for patients. In addition, we are identifying opportunities to place providers and staff in community settings to meet patient needs at convenient access points and to help eliminate barriers caused by transportation and work schedules. We aim to meet the needs of our neighbors in the community where they live, work and play.
15 | Community Health Implementation Plan 2019-2021, At A Glance
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Dental care. ChristianaCare is expanding dental services at Wilmington Hospital as part of a two-year renovation project that will dramatically increase the clinical capacity of our dentistry and oral-maxillofacial surgery practices. Already supporting nearly 15,000 visits per year on a free or sliding-scale basis, this increase will enable more than 5,000 additional visits per year at one of the few access points in the community for dental care. Health Guides, based at Wilmington Hospital, have been aiding patients in removing barriers to accessing both primary care and dental care. This unique team is dedicated to improving the health of the individuals in the community. Health Guides are CHWs who function as collaborative, interdependent members of the primary care practices and advocates of their community seeking to support uninsured, underinsured and underrepresented Delawareans in all aspects of health and health care. Serving as a bridge between the community and health care providers, Health Guides assist this specific population of patients who face financial barriers to care with: accessing available and appropriate health care services; connecting to health insurance and financial assistance opportunities; connecting to community programs and resources outside the health system; and health and wellness information with a focus on prevention. The Health Guides also connect patients to the Medical-Legal Partnership, a collaboration with the Delaware Community Legal Aid Society Inc., which assists with the mitigation of noncriminal legal hardships. Often, these issues impede patients from being able to focus on their health care. By removing this barrier, patients are able to reprioritize their health.
Expanding dental services at Wilmington Hospital will increase oral and maxillofacial care for patients on a free basis or a sliding scale by 25%.
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Community Health Implementation Plan 2019-2021, at a Glance Goal
Reduce inequities by addressing social determinants of health, including poverty, food insecurity, housing, affordability of care, education, employment and economic opportunity.
Strategies
Offer innovative programs and services to both patients and community members to address social needs in a comprehensive manner to have a positive impact on health. Many of these initiatives will be done in partnership with community and government organizations.
Measures
Evaluate and retool new and current programming to assess impact and return on investment for the community and the system.
Goal
Improve access to mental health services by reducing utilization of intensive, crisis-oriented, costly mental health services through active early intervention to address mental health issues and reducing substance use disorder in New Castle County through treatment, community education, and in partnerships with other providers, community organizations and government.
Strategies
Expand upon existing mental health services to serve more individuals and build inroads to poorly served populations. Collaborate with state government and other providers to ensure best standards are being uniformly implemented when treating substance use disorder. Collaborate with community organizations to address mental health needs in the community.
Measures
Increased access to mental health services; decreased incidence of overdose; reduction in opioid prescribing.
Camp FRESH
Center for Hope and Healing
17 | Conclusion
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Goal
Support collective efforts across government, business and private sector to reduce incidence of violent crimes across New Castle County and address its associated impact on the community.
Strategies
Identify, amplify and participate in opportunities to reduce incidence of violent crime through collaboration. A Year-1 pilot for a Hospital-based Violence Intervention Program (HVIP), collaboration between ChristianaCare and community partners, will create a single clinical care team to use evidence-based synergistic strategies to intervene with males who are victims of violent crimes and provide extensive post-discharge case management. Support local organizations with special focus on reducing violence.
Measures
Evaluate new programming to assess impact; increased access to services to support victims and families impacted by violence and trauma.
Goal
Reduce infant mortality, premature births and low birth weight by addressing health disparities faced by mothers.
Strategies
Create innovative patient programs to better meet the broad spectrum of their needs to ensure healthy pregnancies. Partner with community organizations to strengthen presence in communities, particularly where infant mortality is the highest, to connect mothers with resources.
Measures
Increased access to women’s health services; increase in referrals to ChristianaCare projects that impact maternal and child health, along with community-based projects; evaluate impact of forthcoming app targeting expectant mothers.
Goal
Increase access to primary care and dental care.
Strategies
Expand dental and primary care practices. Provide opportunities in communities to receive dental and primary care.
Measures
Increase in referrals to primary and dental care providers; increase in referrals to Health Guides to help uninsured patients receive access to care.
School-based wellness center
Community health education
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Conclusion The ChristianaCare Way states very clearly: We serve our neighbors as expert, caring partners in their health. We do this by creating innovative, effective, affordable systems of care that our neighbors value. This mission to serve is our guiding light. We are guided by our values, excellence and love. While ChristianaCare is a regional and national leader in health care, it is also an anchor institution in our community and part of a larger network of community organizations, government partners and businesses, all of which aim to improve the lives of our neighbors living in New Castle County and across the region. These include urban farmers invested in providing access to affordable, quality produce; volunteers who stand outside, rain or shine, to ensure elementary students have a safe path to and from school; organizations that combine efforts to address and reduce the impacts of opioid addiction on our neighbors; and community centers committed to providing quality services to their participants across the lifespan — from newborns to elders. The people we serve, our neighbors in the community, represent all ages, classes, races and ethnicities. They represent people of all faiths and value systems. They represent all gender identities and orientations. They represent people of all abilities. Their diversity makes Delaware extraordinary. ChristianaCare is committed to being a leader in all aspects of this work. We believe that all members of the community should have access to high-quality, affordable health services, social supports, education and economic opportunity. Every member of our community should have the opportunity to achieve their best health — the heart of health equity. At the core of this work is ChristianaCare’s commitment to improving health outcomes, building and advancing health equity, and supporting the sustainability of strong, healthy, vibrant communities.
Blood pressure and memory screenings support community health in areas of need.
19 | Conclusion
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A Leader in Health, for All Communities ChristianaCare is an anchor for health and health care across New Castle County, the state, and the region. As our work continues into the third decade of the 21st century, we will continue to sharpen our focus on the health of the high-need communities outlined in the 2019 Community Health Needs Assessment. We will collaborate with community partners to address the social determinants of health around poverty, food, housing, education, employment and economic opportunity. We will develop a social care framework that complements our clinical care and expertise, coordinates resources and supports delivering high-value affordable care. We will work in partnership with our community around the other identified priority areas of mental health, substance use disorder, child and maternal health and infant mortality, violence and public safety, and access to primary care and dental care. We have the tremendous honor and great opportunity to work in partnership with our neighbors to effect change that will have a multigenerational impact and provide a model for other health systems and communities across the nation to follow. As a leader in health, for all communities, we will work together in creating opportunities for everyone to be exceptional today — and even better tomorrow.
References Delaware Health and Human Services. (2005). Reducing infant mortality. Retrieved from the Delaware Health and Human Services website: https://www.dhss.delaware.gov/dph/files/infantmortalityreport. pdf Delaware Health Statistics Center. (2017). Delaware vital statistics annual report. Retrieved from the Delaware Health Statistics Center website: https://www.dhss.delaware.gov/dhss/dph/hp/files/lb07.pdf Dicker, et al. (2017). Violence intervention programs: A primer for developing a comprehensive program for trauma centers. Retrieved from American College of Surgeons web site: http://bulletin. facs.org/2017/10/violence-intervention-programs-a-primer-for-developing-a-comprehensiveprogram-for-trauma-centers/ Health of Women and Children. (2019). Retrieved from United Health Foundation web site: https:// www.americashealthrankings.org/explore/health-of-women-and-children/measure/food_insecurity_ household/state/DE The World Bank. (2018). Mortality rate, infant per 1,000 live births. Retrieved from the World Bank website: https://data.worldbank.org
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The ChristianaCare Way We serve our neighbors as respectful, expert, caring partners in their health. We do this by creating innovative, effective, affordable systems of care that our neighbors value.
We Serve Together Guided by Our Values of Excellence & Love. Love
Excellence
We anticipate the needs of others and help with compassion and generosity.
We commit to being exceptional today and even better tomorrow.
We embrace diversity and show respect to everyone.
We seek new knowledge, ask for feedback and are open to change.
We listen actively, seek to understand and assume good intentions.
We use resources wisely and effectively.
We tell the truth with courage and empathy.
We are curious and continuously look for ways to innovate.
We accept responsibility for our attitudes and actions.
We are true to our word and follow through on our commitments.
ChristianaCare, PO Box 1668, Wilmington, DE 19899 800-693-CARE
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