A densely populated section of the nation’s fifth-largest city faces an oversized and unique set of health challenges.
Philadelphia has the highest number of Medicaid enrollees in Pennsylvania, and 13 percent of all state residents receiving Medicaid are concentrated in one area: North Philadelphia.
Here, 31 percent of residents live below the federal poverty line — twice the national average — which is associated with worse health. Many residents are “dual-eligible” for Medicaid and Medicare and are more likely to be readmitted to the hospital within 30 days of discharge. To improve that health outlook, essential hospitals Einstein Healthcare Network and Temple University Health System teamed up with others that serve this neighborhood to form the North Philadelphia Health Enterprise Zone (HEZ).
Led by Einstein President and CEO Barry Freedman, along with state and local government officials, HEZ launched in 2016 to unite hospitals, schools, and community organizations to improve the region’s health. The initiative focuses on four areas of key socioeconomic factors: health, community, education, and technology. This year, the Pennsylvania Department of Health and Gov. Tom Wolf allocated more than $11.8 million to the HEZ.
“Critical socioeconomic needs such as food, education, housing, and jobs all affect patients’ health outcomes,” says Freedman, chair of the HEZ Health Committee. “Given the significant disparities in health outcomes for residents in North Philadelphia, we need to address these issues collectively and holistically.”
In the initiative’s first phase, the group identified patients that might be especially at-risk for not getting the health care they need, some of whom access the emergency department (ED) more than 10 times in a six-month period. While some may call these patients “super-utilizers,” Kathleen Reeves, MD, prefers a different term.
“If we’re going to call patients super-utilizers, we’ve got to call hospitals under-providers,” says Reeves, a professor of pediatrics at Temple University. Reeves also serves as senior associate dean for health equity, diversity, and inclusion, and she directs the Temple University Health System’s Center for Bioethics, Urban Health, and Policy. She hopes the HEZ initiatives can take the blame off super-utilizers by getting ahead of the problems that ultimately lead to high ED utilization. “If we can do a good job of engaging with our communities, particularly through their kids and through the schools, then we can be a resource for the folks [who] are identified as having significant health issues and utilizing a lot of services.”
Improving Health Care Delivery for Children
The life expectancy of children living in the North Broad Street corridor can be 20 years shorter than that of their counterparts in wealthier Philadelphia suburbs.
“In fact, even more startling…the life expectancy of children in this area is shorter than those living in Afghanistan,” Freedman adds. “The patient population is underserved…many are on Medicaid and are chronically ill with multiple comorbidities. As health care organizations [serving in North Philadelphia], we share many of the same challenges.”
With support from the HEZ, Temple is facilitating a demonstration project to transform a local elementary school into a trauma-informed school. Centers for Disease Control and Prevention research on adverse childhood experiences indicates that significant childhood trauma can increase patients’ risk for chronic health conditions and lower life expectancy.
“These are not bad children, these are children who’ve had terrible things happen to them,” Reeves says.
Data show that trauma-informed schools show improved attendance, teacher retention and satisfaction, test scores, and graduation rates. Preventing and responding to adverse childhood experiences consequently lowers chronic health risks and ED utilization. HEZ funding also goes toward improving health care delivery in schools, with a focus on dental and vision care and chronic conditions, such as asthma.
Tackling Food Insecurity
Another crucial social need in Philadelphia is access to healthy food — 22 percent of Philadelphians do not have enough access to sufficient, nutritious food. To respond to this socioeconomic issue, Einstein began screening inpatient and pediatric patients for food insecurity. In addition, the health system is developing infrastructure to refer patients to community partners, such as emergency food sources and organizations that assist with Supplemental Nutrition Assistance Program enrollment. One partner, Philadelphia-based food bank Philabundance, hosts a weekly “Pop-up Food Pantry” for the Einstein community. Another partner, managed care organization Health Partners Plans, provides medically tailored meals at no cost to patients with diabetes, which has decreased their HbA1c scores by 26 percent and lowered medical costs by 27 percent.
Additionally, Einstein participates in a United States Department of Agriculture–funded partnership with The Food Trust to bring fruit and vegetable prescriptions to low-income patients at Einstein Medical Center Philadelphia. The health system works with doctors and other health professionals to track at-risk patients’ long-term behavior change through electronic health records (EHRs).
Long-Term Investments in Population Health
To improve communication across the initiative, hospitals supporting the HEZ participate in the regional health information exchange — HealthShare Exchange, a cloud-based system that integrates EHR patient data. Previously, hospitals struggled to share data across different EHR platforms, but the new program allows real-time information sharing among care providers, reducing unnecessary or repeat procedures and driving down hospital costs.
“Sometimes, it’s not that patients don’t want to share all the information, but it gets so complicated, sometimes they just aren’t able to share all of that,” Reeves says.
Temple also hopes to lower hospital costs by expanding Philadelphia CeaseFire, a community program that trains returning citizens as health outreach workers, conflict mediators, and mentors for at-risk youth. Since 2011, the program resulted in 2.5 fewer shootings per 10,000 people per month, saving an estimated $13 million annually, Reeves says.
Freedman acknowledges that aiming to reduce ED utilization can feel like a counterintuitive move for North Philadelphia hospitals that largely benefit from ED visits.
“It’s important that we’re seeing that organizations are putting their self-interests aside,” he says. “If we’re driving ED utilization down, that actually reduces our revenue in the short term. For health care providers, we need to be able to focus on the long-term health of patient populations.”
With the right structural change, long-term, proactive investments in population health can help drive down the costs of reactive measures.
“I don’t think it’s just about preventative care, it’s about giving people the tools they need to access opportunities that lead to health,” Reeves says. “We have to look at who’s going to save money if that happens, and [if] money [could] then be invested in that, rather than reactively paying for the consequences.”