United States

• Building the capacity of community care givers (CCGs) through extensive trainings on screening and referral practices for hypertension and diabetes. Trainings were provided for CCGs employed by

Expectra for HealthRise, as well as for CCGs from the KwaZulu-Natal Department of Health.

Additional trainings on confirmatory diagnosis, clinical support, and follow-up care for patients with diabetes and hypertension were also provided for clinicians and health professionals at public health facilities. • Screening individuals for hypertension and diabetes through household and workplace visits and health education campaigns. Patient identification was further targeted through the use of “War

Rooms,” in which governmental departments, non-governmental organizations, and other stakeholders convened to discuss challenges in the local community. • Coordinating support and adherence groups in which patients with similar conditions met on a regular basis, often at a health facility, to discuss challenges and difficulties in managing their conditions and treatment programs with providers.

Pixley ka Seme - Project Hope

Project HOPE undertook HealthRise activities in the Emthanjeni sub-district of Pixley ka Seme, in the Northern Cape province of South Africa.

Pixley ka Seme is a largely rural district with high levels of unemployment, crime, and substance abuse relative to other regions in South Africa. Economic growth in Pixley ka Seme is low, in part hampered by a scarcity of water. Patients often experience difficulty accessing health care in the sprawling region with limited transportation infrastructure, and public health facilities are not always adequately equipped or prepared to address the chronic care needs of patients who may suffer from socioeconomic challenges such as poverty or addiction.

In order to address these challenges, Project HOPE targeted interventions in the following areas:

• Promotion of awareness and screening for diabetes and hypertension through the training of community health workers (CHWs) in coordination with the National Department of Health and local community-based health organizations. • Provision of follow-up support targeted at diagnosed patients who failed to maintain engagement with the health system, often focused on removing barriers to care such as lack of transportation or conflicts with work schedules. • Development of and active recruiting for holistic, post-diagnosis support programs for patients.

Support structures included a five-step program aimed at empowering patients, a savings and loan program to provide patients and their families with financial support and stability, and gardening groups to promote a healthy diet and lifestyle.

United States

Rice County - HealthFinders Collaborative

HealthFinders Collaborative implemented the HealthRise program in Minnesota’s Rice County, in the United States of America. HealthFinders’ focus is on improving chronic care for individuals who are uninsured or covered under public insurance programs. Much of HealthFinders’ services are utilized by Latino immigrant

and Somali refugee populations, who represent a large share of the population in this area and who face unique socioeconomic challenges.

The HealthRise program implemented by HealthFinders centered on the following themes:

• Integrating clinical and community-based care networks by strengthening communication and knowledge-sharing platforms. This strengthening of networks was aimed at generating synergy, leveraging the expertise of clinical providers with the personalized care and attention of communitybased health professionals. • Developing and expanding community-based care through the training of CHWs and community paramedics (CPs). Individuals in these roles focused on bridging cultural divides between patients and the health system. • Expanding community-based education and counseling programs, including regular exercise and cooking and nutrition programs.

Hennepin County - Pillsbury United Communities

Pillsbury United Communities implemented the HealthRise program in Hennepin County, Minnesota. This area is composed of a racially diverse population and suffers from high levels of poverty, unemployment, and violence relative to surrounding areas. Limited access to high-quality education or health care is a challenge experienced by many residents of this area.

Pillsbury implemented a series of interventions focused on the following areas:

• Training CHWs, with a focus on providing culturally sensitive care and counseling. • Holistic care, focused on home visits, that recognizes the need for flexibility in attending to the varied circumstances of individual patients and their needs. Examples of services provided include coordinating transportation, housing, and employment; cooking and shopping demonstrations; and home safety checks.

Ramsey County - Regions Hospital Foundation

Regions Hospital Foundation conducted HealthRise activities in Ramsey County, Minnesota. This area is home to many non-English-speaking communities. Many individuals and families experience depressed economic opportunities and other socioeconomic hardships.

The Regions HealthRise program addressed these challenges through interventions aimed at the following:

• Integration of CPs and CHWs with traditional clinical-based care to provide in-home support.

Services provided to patients included regular monitoring of patients’ health status, reinforcing clinical education, language support, and assistance with other social needs. • Utilization of an electronic medical record and documentation platform, the Pathways tool, to promote the coordination of care across different community-based caregivers.