/ en Sat, 14 Jun 2025 15:59:06 -0500 Thu, 12 Jun 25 14:57:14 -0500 /center/community-health-improvement-week Mon, 09 Jun 2025 07:00:00 -0500 Population/Community Health /role-hospitals-saint-francis-hospital-health-systems-community-investing-program-fosters-positive-changes <div class="container"><div class="row"><div class="col-md-9"><div class="row"><div class="col-md-5"><p><img src="/sites/default/files/2025-06/ths-st-francis-hartford-chna-700x532.jpg" data-entity-uuid data-entity-type="file" alt="St. Francis Hospital. A health worker holding a tablet speaks with a patient at an outdoors community event" width="700" height="532"></p></div><p>A recent <a href="https://www.trinityhealthofne.org/sites/default/files/hg_features/mercury_standard_layout/7e52445bbeb2d965c884391a63839d9f.pdf">community health needs assessment</a> conducted by Saint Francis Hospital and local organizations in Hartford, Conn., indicated that 26% of Hartford residents have difficulty paying for food and 17% have difficulty paying for housing. Those percentages are much higher than statewide numbers, which are 11% and 9%, respectively. The CHNA also revealed that obesity affects about a third of adults in Greater Hartford, and diabetes rates are elevated among older adults, Black adults and low-income adults in the region.</p><p>Saint Francis, part of Trinity Health of New England and Trinity Health, participates in the health system’s Community Investing Program. This program supports local initiatives that build infrastructure to address issues such as food and housing insecurity and foster positive change.</p><p>The Community Investing Program has committed $5 million in Hartford to improve health and quality-of-life outcomes. Trinity Health’s community investments serve priority communities, which are areas that have faced severe economic challenges, received significant Medicaid or financial assistance support, or experienced past divestment.</p><p>Carolyn Alessi, regional director, community health and well-being, at Trintiy Health of New England, said, “Because of the support of Trinity Health and our community partners, we are able to provide not just clinical medical care, but transformative, life-changing opportunities that address food insecurity, workforce development, housing, education and more. We are so grateful for the support and collaboration in providing impactful support to our neighbors in need.”</p><p><a class="btn btn-primary" href="https://www.trinityhealthofne.org/newsroom/press-releases/saint-francis-hospital-collaborates-local-partners-lead-positive-change">LEARN MORE</a></p></div></div><div class="col-md-3"><div><h4>Resources on the Role of Hospitals</h4><ul><li><a href="/community-benefit">Benefiting Communities</a></li><li><a href="/roleofhospitals">All Case Studies</a></li></ul></div></div></div></div> Thu, 12 Jun 2025 14:57:14 -0500 Population/Community Health /news/headline/2025-06-11-aha-podcast-ecosystem-approach-health-across-michigan-communities <p>As part of Community Health Improvement Week June 9-13, two experts from Corewell Health share how an impactful health care ecosystem model is supporting local Michigan communities and why creating region-specific programs, from school-based clinics to school nursing initiatives, has been effective for improving community health. Visit the AHA’s CHI Week <a href="/center/community-health-improvement-week" title="CHI page">webpage</a> to learn more about the work hospitals and health systems are doing for their communities. <a href="/advancing-health-podcast/2025-06-11-ecosystem-approach-health-across-michigan-communities" title="pod link"><strong>LISTEN NOW</strong></a> </p> Wed, 11 Jun 2025 15:04:37 -0500 Population/Community Health /advancing-health-podcast/2025-06-11-ecosystem-approach-health-across-michigan-communities <p>To celebrate Community Health Improvement (CHI) Week, June 9 – June 13, two experts from Corewell Health share how an impactful health care ecosystem model is supporting local Michigan communities, and why creating region-specific programs, from school-based clinics to school nursing initiatives, has been effective for improving community health.</p><p>Visit <a href="/center/community-health-improvement-week">/center/community-health-improvement-week</a> to learn more about the work hospitals and health systems are doing for their communities.</p><hr><div></div><div class="raw-html-embed"><details class="transcript"> <summary> <h2 title="Click here to open/close the transcript."> <span>View Transcript</span><br> </h2> </summary> <p> 00:00:01:04 - 00:00:31:25<br> Tom Haederle<br> Welcome to Advancing Health. An increasing number of hospitals today are part of a larger health system. How can the big systems support the mission of their local member hospitals, while avoiding a one size fits all approach that may not work for everyone? As we recognize Community Health Improvement Week, we learn more about Michigan-based Corewell Health's approach, from tactical support to collaborative community partnerships that helps each hospital or health system be the best it can be. </p> <p> 00:00:31:27 - 00:00:54:23<br> Andrew Jager<br> My name is Andrew Jager at the AHA. Today, it's my pleasure to be joined by two colleagues from Corewell Health in Michigan. With me we have Dr. Corey Smith and Vanessa Briggs. Today, as part of Community Health Improvement Week, we're going to talk a little bit about the role of a health system in supporting hospitals to maintain a really robust process in identifying and understanding the health needs of the local communities that they serve. </p> <p> 00:00:54:26 - 00:01:09:14<br> Andrew Jager<br> Now, I'd like to turn to our guest to hear a little bit about how you see the role of health systems like Corewell Health in supporting local hospital offers to identify, understand and to address community health needs. Starting with Vanessa, how do you see the role of Corewell in this? </p> <p> 00:01:09:17 - 00:01:45:24<br> Vanessa Briggs<br> That's a really great question. And some of the lessons I think, that we've learned here at Corewell Health. It really does take a collaborative process. And that really requires diverse voices and perspectives and lived experiences, because that engagement process is really critical, because we think about -when we do CHNA - as an ecosystem. And an ecosystem model that can be replicated across all three regions, given the spanned and reach that Corewell Health has within Michigan. </p> <p> 00:01:45:27 - 00:02:29:05<br> Vanessa Briggs<br> And so our CHNA ecosystem is made up of public health partners, health and human service organizations, community based organizations, as well as community advocates. And we also include our Corewell Health local community board representatives and health professionals that have local but yet regional specific insight into the needs that are happening and needed within community. And so when we work alongside all of those individuals, when we call our ecosystem, it really allows us to deliver programs and work alongside our community to engage throughout the entire process for the CHNA. </p> <p> 00:02:29:07 - 00:02:40:04<br> Andrew Jager<br> I love that, Vanessa, really taking that ecosystem approach and then intentionally bringing in those local community voices to create that strong effort. Corey, what would you add to Vanessa's response? </p> <p> 00:02:40:06 - 00:03:03:02<br> Corey Smith, Ph.D.<br> Well, the one thing I would add is, for a health system like Corewell Health, it can be sometimes easy to think, given our size, that we are kind of the main actor in a space. Right? And I think it's important, especially at the regional level, at the local level, to remember the kind of the legacy and positionality that some of these local hospitals have in their communities and that they are a part of the fabric. </p> <p> 00:03:03:02 - 00:03:30:00<br> Corey Smith, Ph.D.<br> Right. And so I think in some of our regions, and one of the things that we're trying to lift up as best practice is to be conduct doing the needs assessment process as part of a collective, right, a collective group in collaboration with public health departments, with local organizations, with school districts and other stakeholders that have some interest and where it's relevant for them to be aware of and participating in the process of defining community health needs, </p> <p> 00:03:30:00 - 00:03:30:18<br> Corey Smith, Ph.D.<br> right? </p> <p> 00:03:30:20 - 00:03:55:13<br> Andrew Jager<br> Yeah, I love that sort of intentionality of recognizing the true complexity across the communities, the legacy, different perspectives, and the intentionality of bringing all those together in a process is great. So moving on to that process, I guess I'd ask Vanessa, you know, from the system level, what would you say are some of the most important resources or tools that that you can use to support that local priority identification? </p> <p> 00:03:55:15 - 00:04:22:08<br> Vanessa Briggs<br> Yeah. At Corewell we firmly believe that technical support to help prioritize and help our local hospitals and stakeholders. It really has to align all focus areas effectively. And so having that technical support that Corey's team actually provides for my team in healthier communities is critical to the success. And that's a huge resource that's beneficial to us. </p> <p> 00:04:22:10 - 00:04:28:18<br> Vanessa Briggs<br> And I'm sure Corey has some other examples that that he would like to share in terms of some resources as well. </p> <p> 00:04:28:21 - 00:04:44:24<br> Andrew Jager<br> Yeah, I'd love to hear Corey's thoughts, especially around, you know, what do you think about when you try to balance standardization across the hospitals in your health system and data collection, reporting, etc., with the flexibility that local teams really need to to get at those needs and address them in a local way? </p> <p> 00:04:44:26 - 00:05:16:09<br> Corey Smith, Ph.D.<br> Yeah, it's one of the main tensions that we wrestle with, right? And it can be enticing to want to go with standardizing across systems. Right. It's simpler. You know you can feel like you're focusing, but when you bring it to local stakeholders, it can feel misaligned with what they actually need and what they experience. So, you know, I think stepping back from the actual process of identifying the needs rather than bringing forth a standard set of here are the needs that we're going to identify at each hospital across our system. </p> <p> 00:05:16:11 - 00:05:52:24<br> Corey Smith, Ph.D.<br> We try to frame it as here is our broad theory of change for how we think we can address health needs across the Corewell Health service area, right? We think we need to have a balanced approach to investing in, initiatives that are going to create change at lots of different levels. And so rather than saying this is exactly, you know, the condition or the need that you need to work towards trying to offer a way to work rather than a how to work, I think is a critical part of what we try to bring into both the CHNA, the community health assessment needs process, but also the development of the strategies and response to that </p> <p> 00:05:52:24 - 00:06:17:18<br> Corey Smith, Ph.D.<br> process. So I think that's part of the way we balance that tension. And then we've thought a lot about, you know, what is a system's sort of backbone look like for local teams doing this work. And what kind of technical support can we bring to the table, whether it's, you know, in the in the form of how to create better surveys, whether it's in the form of bringing forth access to publicly available data sets that look more at community need. </p> <p> 00:06:17:21 - 00:06:41:15<br> Corey Smith, Ph.D.<br> Mining census data. Mining other forms of information that, you know, the communities themselves, they may have the capacity, but not the time necessarily to do that work. And even more recently, what tools are available from a technology standpoint site now that even boost the efficiency of accessing that kind of information even more, right? There are tools now that, you know, make that an even simpler process. </p> <p> 00:06:41:15 - 00:06:49:23<br> Corey Smith, Ph.D.<br> And then how do we make that data more publicly available to people to use as part of the CHNA process or in their own work? Right? </p> <p> 00:06:49:25 - 00:07:09:10<br> Andrew Jager<br> Those are such good examples of kind of how you think about balancing that tension, as you mentioned, between kind of having a standard set of measures and having things resonate with the local communities that you serve. You talked about, I think, Vanessa, there are three regions across Michigan that you serve. So I wonder, you know, from a practical level, what does this work look like? </p> <p> 00:07:09:10 - 00:07:14:24<br> Andrew Jager<br> Could you share how it plays out, maybe, in one of the initiatives from 1 or 2 of those regions? </p> <p> 00:07:14:27 - 00:07:47:06<br> Vanessa Briggs<br> So the way that we like to approach our work is we sort of like to say we use a system wide approach and we're developing what we're calling program portfolios that allows us to encapsulate programs that healthier communities can deliver at a regional level. This approach gives us a system wide strategy, but it gives us local context within the regions across east, west and south by addressing the needs that we have identified within our 21 hospitals. </p> <p> 00:07:47:08 - 00:08:28:13<br> Vanessa Briggs<br> And so examples of those programs, it ranges from doing school based clinics on the east side of the state, where we're actually providing primary care in the school for our students, as well as for residents in community. And the west side of the state, we have a school nursing program that allows us to have a different model, but yet still in the schools, providing training for the school administrative staff, providing basic care for our students in the schools, and helping them manage their chronic diseases whether it's asthma or diabetes. </p> <p> 00:08:28:15 - 00:08:54:09<br> Vanessa Briggs<br> So that's why we're able to sort of customize our approaches, but yet still have, if you will, a collection of programs in a portfolio that addresses the needs of children, adolescents in a school environment. And so that's a good way and a good example to show how you can have a system wide strategy, but yet still keep it very, very local based off of the needs that are in community, </p> <p> 00:08:54:17 - 00:09:33:28<br> Vanessa Briggs<br> the partnerships that we have in community. Because we know, as I mentioned, it takes an ecosystem to do this work. And so Corewell has deep relationships with other nonprofits within organizations to help us execute programs, whether it's prevention programs, chronic disease management programs, and even coalition building and doing what we like to call collective impact work. And so it's a variety of programs and interventions that are derived from our implementation plans and, as you know, come from the priorities that are identified in our community health needs assessments. </p> <p> 00:09:34:00 - 00:10:00:26<br> Andrew Jager<br> Such a powerful example, I think, of the ways that you're thinking about understanding what are the local assets of your communities and then partnering to address those needs in a way that that is really having an impact across the state. So thank you for that work. Corey, one of the questions I frequently get, and I imagine maybe you hear something like this too, is, you know, how do we show the impact of the work that we're having, you know, both through metrics as well as through sharing the stories of the work across our community. </p> <p> 00:10:00:26 - 00:10:13:00<br> Andrew Jager<br> So how do you share your work in a way that that gets people excited about the work you're doing, brings in partners, and also that can help to develop a system wide culture of learning, adaptation and continuous improvement? </p> <p> 00:10:13:02 - 00:10:36:26<br> Corey Smith, Ph.D.<br> Definitely a question that I get. You know, my background is in evaluation. And so this is something I've been thinking a lot about. Corewell Health for the time I've been here - and, and I think the question that's been sitting in my head for five years has fundamentally been, how do we evaluate at scale, you know, have three regions, with, you know, over 100 individual initiatives. </p> <p> 00:10:36:28 - 00:11:02:08<br> Corey Smith, Ph.D.<br> How do you think about evaluating at scale? Right. You want to have evaluation where it makes sense, but you also have limited resources. And so what we've been doing is working to establish a systematic way of making choices with our regional leadership about where to invest, evaluation resources based on local priorities. Right. So really trying to define first where do we need to do this evaluative work. </p> <p> 00:11:02:08 - 00:11:24:21<br> Corey Smith, Ph.D.<br> Where do we feel it's most important for us to either generate learning or evidence of impact. And then through that designing, evaluation and monitoring processes that are really going to help us hone in on the indicators that are going to be useful for tracking our progress over time, but also the critical outcomes that our stakeholders have helped us develop, </p> <p> 00:11:24:23 - 00:12:03:13<br> Corey Smith, Ph.D.<br> that our regional leadership has decided are most important. And then it's just a technical task, right? Then it's designing methodologies, whether they're quantitative and qualitative, whether they're optimally mixed. You know, the application of both is most often the best way to answer the evaluative questions that you may be trying to answer. The last thing I'll say about that is, you know, we really have been working to try and establish a set of regional sort of priority indicators that can serve as a guidepost where they're not going to be right the first time, and they're going to have to get better over time in terms of their relevance to local needs, but really trying to </p> <p> 00:12:03:13 - 00:12:15:21<br> Corey Smith, Ph.D.<br> establish what are some of our, you know, our north stars, our guideposts that we can organize around as we try to make decisions about what to do, and where to invest some of our resources. </p> <p> 00:12:15:23 - 00:12:29:22<br> Andrew Jager<br> Really well said. Any last words? I mean, a lot of the listeners are health system leaders. So what do you think they need to know about supporting a process that's locally led and owned with the system level resources? </p> <p> 00:12:29:24 - 00:12:58:04<br> Vanessa Briggs<br> The way that I sort of think about it is it really is important to have a system wide strategy, as I mentioned, whether or not it's in the interventions and creating portfolios to allow you to house like programs, or whether it's having Corey's team do evaluation, provide technical assistance across the entire system in doing our community health needs assessment. </p> <p> 00:12:58:06 - 00:13:39:14<br> Vanessa Briggs<br> But what's most important and critical is that that system wide strategy still needs to have and allow for adaptability and customization based off of local context. While we can move to centralize and provide benefits from economies of scale within a system wide approach, we can't lose sight that the relevance and the effectiveness of addressing unique needs at a local level or regional level is still critically important, because that's when you're able to address the needs that have been identified within community. </p> <p> 00:13:39:17 - 00:14:01:26<br> Vanessa Briggs<br> And I think that that's what's most important. We can have system wide strategies but that local context is what really matters, because then we know we're moving the needle to address health disparities, access to care, partnering with organizations, addressing transportation, food access. </p> <p> 00:14:01:28 - 00:14:24:17<br> Andrew Jager<br> Thank you so much for encapsulating the important work that hospitals do across the country every day to support the communities and to help people be as healthy as they can be. Well, thank you to each person listening for the work that you do to support health and resilience in your communities. Community Health Improvement Week is really about recognizing the important work that you do every day on behalf of America's hospitals and health systems, and more importantly, the communities that we all serve. </p> <p> 00:14:24:19 - 00:14:38:06<br> Andrew Jager<br> Special thanks to Vanessa and Corey for sharing your thoughts and expertise, for the great work that you're doing at Corewell for Michigan communities. Be well. And until next time, this is Andrew Jager from the wishing you all a very happy Community Health Improvement Week. </p> <p> 00:14:38:09 - 00:14:46:20<br> Tom Haederle<br> Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify or wherever you get your podcasts. </p> </details></div> Wed, 11 Jun 2025 07:42:18 -0500 Population/Community Health /care-delivery-transformation/community/community-based-partnership <div class="cdt-banner-wrap"><div class="community-banner-wrap"><div class="community-banner-wrap-content"><h1 class="text-align-center">Community-based Partnerships</h1><h2 class="text-align-center">Care Delivery Transformation Framework <br><span>Community Settings</span></h2></div></div></div> Wed, 11 Jun 2025 06:36:38 -0500 Population/Community Health /care-delivery-transformation/linking/patient-community-engagement <div class="cdt-banner-wrap"><div class="linking-banner-wrap"><div class="clinical-banner-wrap"><div class="linking-banner-wrap-content"><h1 class="text-align-center">Patient & Community Engagement</h1><h2 class="text-align-center">Care Delivery Transformation Framework<br><span>Linking Care to Community</span></h2></div></div></div></div> Wed, 11 Jun 2025 00:59:23 -0500 Population/Community Health /care-delivery-transformation/linking/primary-care-transformation <div class="cdt-banner-wrap"><div class="linking-banner-wrap"><div class="clinical-banner-wrap"><div class="linking-banner-wrap-content"><h1 class="text-align-center">Primary Care Transformation</h1><h2 class="text-align-center">Care Delivery Transformation Framework <br><span>Linking Care to Community</span></h2></div></div></div></div> Wed, 11 Jun 2025 00:01:43 -0500 Population/Community Health /news/headline/2025-06-09-aha-podcast-beyond-bedside-honorhealths-commitment-healthier-communities <p>With June 9-13 being Community Health Improvement Week, three experts from HonorHealth discuss how the health care network is addressing community needs beyond traditional care. From addressing food insecurity to launching innovative programs such as the Adult Day Health Care Center, HonorHealth is taking bold steps to strengthen the fabric of its community.<strong> </strong><a href=/advancing-health-podcast/2025-06-09-beyond-bedside-honorhealths-commitment-healthier-communities" target="_blank"><strong>LISTEN NOW</strong></a>  </p> Mon, 09 Jun 2025 15:11:25 -0500 Population/Community Health /role-hospitals-keck-school-medicine-usc-makes-hearing-breakthrough-studying-mouse-inner-ear <div class="container"><div class="row"><div class="col-md-9"><div class="row"><div class="col-md-5"><img src="/sites/default/files/2025-06/ths-usc-keck-hearing-700x532.jpg" data-entity-uuid data-entity-type="file" alt="USC Keck School of Medicine. Illustration of soundwaves entering an ear canal" width="700" height="532"></div><p>Researchers at the Keck School of Medicine of the University of Southern California, in collaboration with Baylor College of Medicine, made a major discovery in understanding how the brain may help regulate hearing. And they did it by adapting an imaging technique currently used in ophthalmology offices, called optical coherence tomography.</p><p>The team used OCT to capture real-time images of the cochlea — a part of the inner ear involved in hearing — in mice, revealing that the brain can send signals to the inner ear to enhance sound sensitivity. The study found that while the cochlea doesn’t respond to short-term brain state changes, it does increase activity in response to long-term hearing damage in mice with genetic hearing loss. The study suggests the brain compensates for hearing loss by boosting the function of remaining sensory cells.</p><p>The team is now preparing clinical trials to test whether blocking certain brain-to-ear signals could help reduce symptoms in patients with sound sensitivity disorders. Findings could lead to new treatments for conditions like tinnitus (ringing, buzzing or other phantom sounds) and hyperacusis (where everyday sounds become uncomfortably loud).</p><p><a class="btn btn-primary" href="https://scitechdaily.com/new-brain-discovery-could-revolutionize-hearing-loss-treatment/" target="_blank">LEARN MORE</a></p></div></div><div class="col-md-3"><div><h4>Resources on the Role of Hospitals</h4><ul><li><a href="/topics/promoting-healthy-communities">Building Healthy Communities</a></li><li><a href="/roleofhospitals">All Case Studies</a></li></ul></div></div></div></div> Thu, 05 Jun 2025 12:08:29 -0500 Population/Community Health /advancing-health-podcast/2025-06-04-how-duke-university-fighting-hypertension-through-community-collaboration <p>June 9 – June 13, 2025, is <a href="/center/community-health-improvement-week" title="Community Health Improvement Week">Community Health Improvement</a> (CHI) Week — a week that looks at the important work hospitals and health systems are doing to support the overall health of their patients and communities. In this conversation, Duke University's Anna Tharakan, lead project manager on Closing the Gap on Hypertension Disparities, and Bradi Granger, Ph.D., research professor at Duke University School of Nursing and director of the Duke Heart Center Nursing Research Program, discuss how Duke’s team is reducing hypertension disparities by integrating community health workers, student ambassadors and local clinics.</p><hr><div></div><div class="raw-html-embed"><details class="transcript"> <summary> <h2 title="Click here to open/close the transcript."> <span>View Transcript</span><br> </h2> </summary> <p> 00:00:01:04 - 00:00:30:12<br> Tom Haederle<br> Welcome to Advancing Health. Community health workers play a vital role in bridging the gap between health care systems and the communities they serve. As we celebrate the upcoming 2025’s Community Health Improvement Week, June 9th through June 13th, we learn more in today's podcast about how the team at Duke University's partnership with Community health workers led to stronger communities and measurable improvements in heart health outcomes. </p> <p> 00:00:30:14 - 00:00:55:24<br> Chris DeRienzo, M.D.<br> Hello again. I am Dr. Chris DeRienzo, the chief physician at the ���������� Association. On this week's podcast, we are celebrating CHI week and that stands for Community Health Improvement Week. And we could not have two better guests joining our podcast today to celebrate CHI week and talk about the wonderful work that they do, right in my home of North Carolina around their community health needs assessment. </p> <p> 00:00:55:26 - 00:01:18:21<br> Chris DeRienzo, M.D.<br> Joining me today is Anna Tharakan. She is the lead project manager on the Closing the Gap on Hypertension Disparities work at Duke. And Bradi Granger, who is a professor in the Duke University School of Nursing and a co-pi for that same project. Thank you both for joining us on the podcast today. I am so excited to get to welcome you here. </p> <p> 00:01:18:24 - 00:01:19:19<br> Anna Tharakan<br> Hi. Happy to be here. </p> <p> 00:01:20:05 - 00:01:21:27<br> Bradi Granger, Ph.D.<br> Thanks for having us today. </p> <p> 00:01:21:29 - 00:01:45:09<br> Chris DeRienzo, M.D.<br> Well, let's jump right in. You know, the community health needs assessments is a really broad overview of both the assets and the needs within a community. I have known the community here in Durham, North Carolina, for nearly 25 years. When I started medical school in the early 2000’s. But I'm really curious, you know, Duke Health has excelled in doing its CHNAs for a long time. </p> <p> 00:01:45:14 - 00:01:52:17<br> Chris DeRienzo, M.D.<br> Talk to us about how do you approach this CHNA, and what kinds of things have you uncovered? Anna, we'll start with you. </p> <p> 00:01:52:19 - 00:02:21:20<br> Anna Tharakan<br> It's kind of kind of setting up what a hypertension is present within our community. We see that despite the proven interventions that are currently present, over 50% of patients that are diagnosed with hypertension kind of have their condition controlled. And kind of specifically within Durham, we see that there's a prevalence of hypertension of almost 42%. So I think for us, as are kind of really some baseline statistics of really motivating us to kind of get out into the neighborhood and communities and reduce these hypertension disparities and improve overall population health. </p> <p> 00:02:21:22 - 00:02:48:02<br> Anna Tharakan<br> So kind of our approach was taking a quality improvement intervention to target these hypertension disparities via a telephone outreach program. So we partnered with the local FQHC or Federally Qualified Health Center and students based out of Duke Health to kind of deliver this telephone outreach. We applied these functions essentially through student ambassadors, which were these students that conducted a structured telephone outreach to kind of help reach patients where they are. </p> <p> 00:02:48:03 - 00:03:11:06<br> Anna Tharakan<br> So over a series of three to four phone calls directly work with our patient cohort, which was around 300 patients, to help identify hypertension education. What are ways that we can help kind of work within their lifestyles to maybe attach hypertension care? We distributed free blood pressure cuffs. We helped them create Smart goals and accountability partners. And then lastly also conducted a social needs assessment. </p> <p> 00:03:11:08 - 00:03:16:24<br> Anna Tharakan<br> Which is really just trying to identify what are other things that are kind of getting in the way of your hypertension and health. </p> <p> 00:03:16:26 - 00:03:34:02<br> Chris DeRienzo, M.D.<br> Let's pause there for a second because wow! I mean, the level of depth that you all are able to go to, is, is truly impressive. But bring this up, you know, to the 30,000ft view level for a moment, because I don't know how many of our listeners are familiar with the Durham community and specifically the role that Duke plays in that community. </p> <p> 00:03:34:03 - 00:03:46:05<br> Chris DeRienzo, M.D.<br> So can you give the just sort of the brief snapshot of when you're talking about, you know, over 40% of the Durham population? How many people are we really talking about? And when you're saying going into the community, what does that look like? </p> <p> 00:03:46:07 - 00:04:24:03<br> Bradi Granger, Ph.D.<br> I can pitch in here. Durham has about 300,000 people and roughly, as Anna pointed out, we have a prevalence of hypertension of about 42 to 48% of the people in this county have, hypertension. About half of those are uncontrolled or unaware. And so the third issue, I would say in Durham County, is the disparity in care that we've seen and the prevalence. That the higher prevalence in the higher mortality and comorbidity that is associated with this, chronic illness in the black population, which that statistic is true throughout the South. </p> <p> 00:04:24:09 - 00:04:53:03<br> Bradi Granger, Ph.D.<br> And so we have a high proportion of minorities and underserved patients in Durham County. And we tend to focus on these first, as the risk in this group is much higher than the risk in the average population overall. So, given that we started there, the clinics and the specific areas in the community where we could be most effective in improving overall health for the community were those underserved, like safety net clinics. </p> <p> 00:04:53:03 - 00:05:25:25<br> Bradi Granger, Ph.D.<br> And so across the county, we have our Federally Qualified Health Center, which Anna mentioned and our, my co-pi, Dr. Holly Biola, is there leading the effort there. And we've also worked together with the Duke Safety Net Clinic, the Duke Outpatient Clinic, as well as our broader population health clinics in the county. So though the work began at Lincoln, our Federally Qualified Health Center, we have reached out to try and scale the project across other areas in the community that represent underserved populations. </p> <p> 00:05:25:27 - 00:05:48:07<br> Chris DeRienzo, M.D.<br> Thank you so much for sharing that. You know, I moved to North Carolina 25 years ago, and in the other places I've lived, I never really had the level of appreciation that I have now for just how different a place like Durham County can look when you drive like eight minutes from the downtown core, because Durham, you know, with 300,000 people, there's definitely a downtown core and there's some high rises. </p> <p> 00:05:48:07 - 00:06:12:23<br> Chris DeRienzo, M.D.<br> And I mean, it's not, you know, like New York City is downtown, but it's definitely an inner city environment. But eight minutes away, you are in farm country. And so when you're talking about reaching a community, that you are going from a very urban feel to a very rural feel quite quickly. And so I know that community health workers have played a huge role in how you all have addressed this work through the project around hypertension. </p> <p> 00:06:12:26 - 00:06:21:25<br> Chris DeRienzo, M.D.<br> Tell us a little bit more about the role that you all are finding community health workers playing and amplifying community outreach. </p> <p> 00:06:21:27 - 00:06:49:29<br> Bradi Granger, Ph.D.<br> We have a cohort of community health workers. The intent for that workforce is to really expand and extend the work that's done in a clinic, during a clinic visit, with a primary care provider. The fact is that many of our people in the underserved area, especially, have so many social determinants, which Anna can expand on. That it's hard to fit the care that's needed within that short window of time of the visit. </p> <p> 00:06:50:02 - 00:07:13:05<br> Bradi Granger, Ph.D.<br> So this project has served to really engage health professions students like Anna as patient navigators, to partner with these community health workers and literally give everyone more time to be able to provide the care, at the community level, that we want to do. So Anna can expand on exactly what that looks like. </p> <p> 00:07:13:07 - 00:07:34:09<br> Anna Tharakan<br> I think kind of as she pointed out, there was this huge, not gap that necessarily we realized, but kind of this, this system that patients weren't necessarily kind of getting the full time that they needed to just with the limitations of the system. And so I think what really community health workers, and in our case students, were able to really fill that gap was kind of being able to take that time with patients when they had it. </p> <p> 00:07:34:11 - 00:08:00:12<br> Anna Tharakan<br> Our first call with patients and students made was just sitting down with them being like, are you interested in kind of learning more about what hypertension means or how we can kind of implement some lifestyle changes, and can we do that on your time? I think that was just a really big portion of whether it was people that were working two to three jobs and only had availability at 8 p.m. or 9 p.m.. I think that was kind of the really great gap that students could kind of fill is kind of making sure outside clinic hours, where can we sit in and really impact and make a change? </p> <p> 00:08:00:15 - 00:08:27:26<br> Anna Tharakan<br> And then on top of that, really kind of making it really personalized with that education that we gave them,. Learning about the different things that they were kind of experiencing. What kind of struggles were specifically relevant to their lives, whether that was I'm struggling or trying to get groceries when I have to make sure to pick up my kids from preschool, or whether it's I'm taking care of two of my parents that are, kind of based in the hospital and kind of making sure that we were able to insert little pieces of advice where I was, hey, like how about we try to get 30 minutes, you know, walk to your parent's house instead </p> <p> 00:08:27:26 - 00:08:39:21<br> Anna Tharakan<br> of necessarily being able to drive there and really kind of instill small changes that they can make. And really be their personal cheerleader and kind of instill in these small changes that can really make such a big difference in their blood pressure and hypertension. </p> <p> 00:08:39:23 - 00:08:56:27<br> Chris DeRienzo, M.D.<br> I love that. Wouldn't we all benefit from having a personal cheerleader, especially when fighting, you know, a condition like hypertension, which is so seemingly innocuous because it's just a number on a machine. But we know that, that years and years and years of high blood pressure take its toll on nearly every organ system in the body. </p> <p> 00:08:57:00 - 00:09:14:28<br> Chris DeRienzo, M.D.<br> And again, being good project leads, I imagine you all are measuring countless kinds of metrics through this work. What is one measurable impact that you can tell us about through this engagement of a community health workers and really extending their reach, and not only into patients homes, but into community based settings as well. </p> <p> 00:09:15:00 - 00:09:34:05<br> Anna Tharakan<br> I think the big one was just the impact that we had on their blood pressure. And then also just self-management. I think within our intervention this past year, we saw a average drop in the systolic blood pressure of those that participated of over 15mg mercury, which is just a really huge kind of drop when considering, this intervention that took place. </p> <p> 00:09:34:08 - 00:09:53:13<br> Speaker 3<br> I think another big one was this idea of self-monitoring, kind of bringing the power to the patient, kind of being able to track with the free blood pressure cuffs that they were able to be provided, as well as the social needs assessment. Was kind of really putting that power of health back in their hands and showing that community health intervention lead can produce really meaningful clinical outcomes. </p> <p> 00:09:53:15 - 00:09:56:03<br> Chris DeRienzo, M.D.<br> Spectacular. Bradi, anything you would add? </p> <p> 00:09:56:05 - 00:10:29:04<br> Bradi Granger, Ph.D.<br> The one thing I would add to that is the idea of the system integration that this project brings. Whereby, to your point, hypertension really is a chronic illness, that the long term outcome is what we're after, reduction in stroke, reduction in chronic kidney disease and reduction in cardiovascular events. But those things happen so far from, you know, today's single measurement or even a couple of years worth of measurements of high blood pressure in an office visit, which is often mistakenly elevated anyway. </p> <p> 00:10:29:12 - 00:11:00:04<br> Bradi Granger, Ph.D.<br> So our real achievement, I feel like in addition to what Anna said about bringing the power to the patient to set their goals and really be able to be aware and to be responsible for changes and improvements in their health. We also really are trying to effectively connect a patient to the primary care provider team, including the community health worker and the community business organizations that help us serve patients outside of the formal system of health care delivery. </p> <p> 00:11:00:07 - 00:11:50:05<br> Bradi Granger, Ph.D.<br> These groups provide food, transportation, assistance with housing insecurity and all the things that are real barriers for patients managing long term, hypertension. So solving for those things and tracking it as we have, and making sure there's a closed loop on the referrals that happen, allows us to really measure the impact of this kind of project on some of our really important community outcomes, but also the policy implications for this project. Which we're working on now with our North Carolina Department of Health and Human Services, and trying to make sure that the opportunity for us to expand healthy opportunities. Pilots from our Medicaid expansion initiative, trying to make sure that we have the evidence and </p> <p> 00:11:50:05 - 00:11:56:27<br> Bradi Granger, Ph.D.<br> the measurable outcomes to support new policies for expansion of those kinds of efforts in the community. </p> <p> 00:11:57:00 - 00:12:29:11<br> Chris DeRienzo, M.D.<br> Well, you all have certainly covered the waterfront. I mean, clearly, it takes, it takes a team. And you've been able to connect not just the acute care clinical team, but the patient's family, community teams, all together in this web in supporting patients. I'm curious, we've only got a minute or two left. If you had to give one piece of advice for health care team members, in a community right now listening to this podcast who are just coming away from hearing your story and saying, I got to go do this tomorrow, what would your one piece of guidance be, </p> <p> 00:12:29:13 - 00:12:31:27<br> Chris DeRienzo, M.D.<br> as they're preparing to take their first step? </p> <p> 00:12:31:29 - 00:12:42:29<br> Bradi Granger, Ph.D.<br> Our guidance would be communicate with your primary health care provider and let them know you're interested in joining our team as a patient expert in the hypertension management program. </p> <p> 00:12:43:01 - 00:12:51:07<br> Chris DeRienzo, M.D.<br> Outstanding. Anna, what if you were giving advice to a hospital who was hearing the story and they said, I want to be just like this project that they're doing at Duke? </p> <p> 00:12:51:07 - 00:13:06:29<br> Anna Tharakan<br> I think it's just showing that it's possible to kind of get an intervention like this off the ground, and it really can can make a real big difference in patients lives. And so kind of putting a focus on community health workers and kind of connecting back that primary care doctor as Dr. Granger said is a really important component. </p> <p> 00:13:07:01 - 00:13:25:09<br> Chris DeRienzo, M.D.<br> You all have done tremendous work. Obviously connecting all the way back to the community health needs assessment. What it lifts it up, how you connect that to a project building in the the approach that brings community health workers into the fold and then obviously bringing patients and family members into the fold with you. We could not wish you more luck in the work that you're doing. </p> <p> 00:13:25:09 - 00:13:33:22<br> Chris DeRienzo, M.D.<br> And again, couldn't think of a better story to tell this week during CHI week in 2025. Any closing thoughts before we say goodbye? </p> <p> 00:13:33:25 - 00:13:41:14<br> Bradi Granger, Ph.D.<br> I think thanks for your support and for the dissemination of efforts like this and the impact it has on our community. Thank you. </p> <p> 00:13:41:16 - 00:13:45:04<br> Chris DeRienzo, M.D.<br> I couldn't say it better myself. Thank you both so much. </p> <p> 00:13:45:07 - 00:13:53:17<br> Tom Haederle<br> Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify or wherever you get your podcasts. </p> </details></div> Wed, 04 Jun 2025 08:21:55 -0500 Population/Community Health