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Awards Recognize Hospitals for Improving Quality, Population Health, COVID-19 Care

June 24, 2021


WASHINGTON — America’s Essential Hospitals, whose more than 300 members care for low-income and other marginalized people, today honored 13 member hospitals for outstanding work to improve health care quality and population health and to respond to the COVID-19 pandemic.

The association announced the 2021 Gage Award winners at its virtual annual meeting, VITAL2021. Named for association founder Larry Gage, the awards recognize creative and successful programs that improve patient care and serve community needs. This year, a new category recognized innovative responses to the COVID-19 pandemic.

“The COVID-19 pandemic and acts of racial injustice that have marked the past year magnified the role of our hospitals as healing forces in their communities, both inside and outside the hospital walls,” said America’s Essential Hospitals President and CEO Bruce Siegel, MD, MPH. “We are proud to recognize these members for their continued efforts to innovate with limited resources and during challenging times.”

2021 Award for Quality

This award recognizes activities to improve the quality of care or that mitigate threats to patient safety.

Winner: Hennepin Healthcare, Minneapolis

A Hennepin Healthcare analysis showed that housing instability was the second-highest contributing factor to 30-day readmissions, affecting 75 percent of patient charts reviewed. The health system partnered with Hennepin Health, a county-based accountable care organization (ACO), to place community-based care managers in the inpatient setting to build rapport, promote care continuity, and connect patients experiencing homelessness to social services.

From January through December 2019, 93 eligible patients were visited by a care manager while receiving inpatient care, and 73 engaged with the program outside the hospital. Readmissions in the total ACO population decreased from 16.7 percent to 13 percent because of this intervention. The intervention group readmission rate decreased to 5.6 percent. While housing was not the program’s primary focus, 12 percent of program participants were housed during the pilot.

“Identifying the care needs of our patients with housing instability often goes beyond what we can achieve in the clinic setting or at the bedside, but thanks to this innovative, multidisciplinary team, we’re now able to disrupt crisis cycles and invest in what people truly need,” explains Jennifer DeCubellis, Hennepin Healthcare’s CEO. “The amazing hearts and minds across Hennepin Health and Hennepin Healthcare, partnering together, set us on a path to close health care disparities through reimagining the work and what is possible. We are so proud of what they’ve accomplished, and it’s an honor for them to be recognized with the Gage Award for this important work.”

Honorable Mention: NYC Health + Hospitals, New York

NYC Health + Hospitals (NYC H+H) developed the High-Value Care Initiative to reduce unnecessary testing and treatment that result in patient harm, focusing on eight low-value services in the inpatient setting. An interdisciplinary High-Value Care Council, led by system and site leadership, engaged front-line staff in reducing use of low-value services by creating “Choosing Wisely” recommendations. Leaders built nonintrusive advisories and other “nudges” into the electronic health record to influence provider behavior.

One year post-intervention, the health system eliminated creatine-kinase-MB testing and Docusate use in the inpatient setting. During this time, NYC H+H also reduced measurement of amylase, fecal occult blood test, folate, prealbumin, vitals at night, and evening furosemide.

“NYC Health + Hospitals is proud to be recognized by America’s Essential Hospitals, especially for our ongoing work to ensure all care provided to our patients is high-quality and streamlined and enables a faster, safer recovery,” said NYC Health + Hospitals President and CEO Mitchell Katz, MD. “Our public health system continues to challenge historical status quos in health care, and our ‘Choosing Wisely’ recommendations help us to fulfill this promise.”

Honorable Mention: Truman Medical Centers | University Health, Kansas City, Mo.

Truman Medical Centers | University Health developed a cultural health navigator position to improve social determinants of health (SDOH) screening and assistance for immigrant, refugee, and non–English speaking populations. The health system’s four cultural health navigators, including two Spanish speakers, one Arabic speaker, and one Somali speaker, work through the nuances that often complicate cross-cultural communication.

In two years, the program provided more than 35,000 navigation contacts and 22,000 interpretation contacts, where contact is defined as a 15-minute interval. As of July 2020, more than 6,500 unique patients accessed these interpretation and navigation services. Ninety-seven percent of LEP patients screening positive for SDOH needs have followed through with a referral or link to community resources.

“The Cultural Health Navigators are a great example of our Truman Medical Centers | University Health motto ‘Brightest Minds, Biggest Hearts,’” said Charlie Shields, president and CEO of Truman Medical Centers | University Health. “The Cultural Health Navigator team empowers patients to take control of their health by presenting the comprehensive care we offer all patients, in a way that is understandable and culturally sensitive. The team meets people where they are and guides them towards better health.”

2021 Award for Population Health

This award recognizes activities focused on SDOH, such as food insecurity, homelessness, language barriers, and other socioeconomic factors.

Winner: Memorial Healthcare System, Hollywood, Fla.

Since 2008, Mothers Overcoming Maternal Stress (MOMS) has served mothers who exhibit symptoms of depression or anxiety affecting daily functioning for more than two weeks. The program targets mothers with additional risk factors, including low-income status, single-parent households, early or unplanned pregnancy, medical complications, and traumatic life events. Customized participant plans include in-home cognitive behavioral therapy, parenting classes, community resources, and case management services.

Among 1,532 participants, 97.4 percent report improved overall family functioning and parenting skills, 95.8 percent report feeling more connected to the community, 93.8 percent report fewer depression or anxiety symptoms, 93.4 percent demonstrate an acceptable level or improvement of attachment and bonding with their child, and 86.4 percent have children who score within range of developmental milestones.

“A lot of times, stressors during and after pregnancy may be overlooked,” said Aurelio Fernandez III, president and CEO of Memorial Healthcare System. “We saw a need and established a program that helps those most in need.”

Honorable Mention: Harris Health System, Houston

Harris Health System partnered with Houston Food Bank (HFB), the University of Texas School of Public Health, and grocery store H-E-B for a Food Rx program based at two family practice clinics. Patients enroll with a community health worker, work with a dietitian to select healthy food, connect with an HFB navigator to enroll in the Supplemental Nutrition Assistance Program and Temporary Assistance for Needy Families programs, and are linked to community food resources.

Patients with uncontrolled diabetes are invited to join a nine-month program, in which they participate in biweekly “walk and learn” sessions with a diabetes educator while redeeming 30 pounds of fresh food from the Food Farmacy. Food Rx served more than 650 patients in its first year, approximately half of whom had hemoglobin A1c (HbA1c) levels greater than 7.0 and were enrolled in the diabetes program. Participants improved their nutrition knowledge scores and increased daily fruit and vegetable consumption. Ongoing enrollees decreased HbA1c levels by an average of 0.63 percentage points, and graduates of the program decreased HbA1c levels by an average of 0.72 percentage points.

“On behalf of Harris Health System, I’m proud to accept the 2021 Honorable Mention Gage Award from America’s Essential Hospitals for our population health initiatives,” said Esmaeil Porsa, MD, president and CEO of Harris Health System. “Taking a cross-sector approach to improving patients’ health is an imperative for our system. Our food, nutrition, and chronic disease management ‘hubs’ not only provide direct clinical services, healthy foods, and education through our onsite food Farmacies, they also house partner resources and expanded linkages to community supports to sustain the health improvements our patients achieve. We look forward to expanding our Food Rx program, as well as our research capturing long-term population health measures that further showcase the impact of this important work.”

2021 COVID-19 Innovations

This award highlights innovative practices, projects, and programs related to the coronavirus pandemic. This temporary category captures creative solutions for the current or potential future pandemics within the hospital or in its community.

Boston Medical Center, Boston

When COVID-19 cases began to surge at Boston Medical Center (BMC), in-person pediatric visits dropped 90 percent. To continue serving more than 14,000 pediatric patients, BMC launched the Pediatrics Mobile Outreach Program in April 2020. The program conducts home visits, in which the team provides vaccinations, mental health care, child care support, domestic violence assistance, and neonatal care while also addressing patients’ unmet social needs. The program serves more than 200 families each week, and has provided more than 2,700 vaccinations to date. Providers have referred 100 participants to mental health services and connected more than 200 families with housing assistance programs. Staff made more than 230 emergency same-day food deliveries to families experiencing food insecurity and continued biweekly food delivery to at least 100 families.

Grady Health System, Atlanta

A team of student volunteers from Emory University and Morehouse College developed a proactive outreach call program to screen patients for COVID-19. The program also provides prevention education, helps patients navigate health system changes, fills gaps in care, and identifies and mitigates social needs. At no cost to Grady, an existing prescriptive analytics company partner used artificial intelligence to develop a risk calculation to identify patients at highest risk of poor outcomes if they were to contract the coronavirus. To date, students in the program have made more than 4,600 calls to patients. More than half of answered calls identified at least one health care need that required action, and 20 percent had social needs, such as food insecurity, that required action.

LAC+USC Medical Center, Los Angeles

LAC+USC Medical Center’s SAFE @ Home O2 program enabled patients requiring low levels of oxygen support to be managed at home. Over the past year, LAC+USC Medical Center has discharged more than 1,600 patients with COVID-19 on home oxygen, delivering the right care at the right time and place for patients with pneumonia related to the disease and preserving access to acute care services for all patients during the pandemic.

NYC Health + Hospitals, New York

To fill a shortage in palliative care employees during the COVID-19 pandemic, NYC Health + Hospitals recruited more than 400 telepalliative medicine volunteers through a national social media campaign. The health system recruited 64 physicians, nurse practitioners, and physician assistants, who completed expedited credentialing and assisted with remote care consultations at five of the health system’s acute-care hospitals. These consultations included care discussions, family updates, emotional support, anticipatory guidance, and bereavement support.

Parkland Health & Hospital System, Dallas

The health system targeted underserved communities and populations at elevated risk of contracting COVID-19 through analytics, media and messaging campaigns, virtual health services, and remote pulse oximetry home monitoring kits. By late December 2020, Parkland identified more than 34,500 positive COVID-19 cases and flagged more than 10,000 patients as high-risk to initiate care and outreach. More than 200,000 COVID-19 tests were administered at Parkland’s drive-through and walk-up locations, including through mobile outreach at nursing homes and homeless shelters.

San Joaquin General Hospital, French Camp, Calif.

In collaboration with San Joaquin County Clinics (SJCC) and with funding from the United Way, the hospital in March 2020 quickly transitioned to a community-based model of using pop-up testing sites in areas with high populations of people experiencing homelessness, homeless shelters, and communities with large populations of migrant and seasonal agricultural workers. SJGH and SJCC played a primary role in establishing two isolation facilities at a local homeless shelter for up to 48 patients with COVID-19 or who were exposed to the disease. As of January 4, the initiative has conducted more than 4,200 COVID-19 tests through these pop-up sites, as well as in areas where populations face transportations and other barriers to testing.

UMass Memorial Medical Center, Worcester, Mass.

To target neighborhoods at higher risk of contracting COVID-19, UMass Memorial Medical Center deployed mobile care staff to educate residents and answer COVID-19 questions in multiple languages. The intervention also distributed face masks, sanitizer, and information on critical social resources. In August, the hospital began leading Massachusetts Stop the Spread testing in areas of Worcester, Mass., with high rates of COVID-19. The hospital developed and implemented a flexible testing operation that could successfully test up to 340 people per hour. By identifying cases earlier, the initiative helped reduce the spread and minimize emergency department and intensive care unit use, as well as preventable deaths.

University Medical Center of El Paso, El Paso, Texas

As restrictions eased and case rates declined, University Medical Center of El Paso piloted a program allowing adult family members to visit hospitalized patients once per week for two hours. Qualifying patients had to be hospitalized for 20 days or longer; family members were screened at entry and required to use hospital-provided personal protective equipment and a power air-purifying respirator. Initial results point toward improved recovery rates for critically ill COVID-19 patients. Since the program kicked off, the hospital has seen a reduction, by nearly half, in the number of Code Blue medical emergency activations and Rapid Response critical care activations.

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About America’s Essential Hospitals
America’s Essential Hospitals is the leading champion for hospitals and health systems dedicated to high-quality care for all, including the most vulnerable. We support our 300 members with advocacy, policy development, research, and education. Communities depend on essential hospitals to provide specialized, lifesaving services; train the health care workforce; advance public health and health equity; and coordinate care. Essential hospitals innovate and adapt to lead the way to more effective and efficient care.

Carl Graziano

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