Person-by-person, a population health initiative is boosting the well-being of Hudson County residents.
What do people in Hudson County need to stay healthy? Like residents of any big, diverse community, they need a whole gamut of services: chronic disease management, nutritional education, access to free health screenings and more. When people have those things, their health improves—and they’re able to avoid visits to the Emergency Department (ED) and admissions to the hospital.
Determining who needs which services and allocating resources is, in a nutshell, the concept of “population health.” That’s the high-level view. At ground level, individual actions and programs make the differences that add up to better community health overall: Teaching a 7-year-old boy to use his asthma inhaler correctly. Educating an older man on the side effects of his heart failure medication.
Helping an oncology patient get a program grant that covers the cost of a week’s vacation. Since 2012, population health has been a major initiative at Jersey City Medical Center (JCMC). “It’s in accord with the core mission of our hospital,” says Kwaku Gyekye, Director of Population Health and ACO (Accountable Care Organization) at JCMC. “As an anchor institution, we’re the be-all and end-all of medical care for many folks in the
community, and we need to make our services comprehensive.
“When people hear what we can provide, they’re amazed. Some of them keep waiting to hear what the catch is.” But there is no catch. Services
are available to any Hudson County resident, of any age, gender or socioeconomic status, and financial need is accommodated.
Outreach Everywhere
JCMC’s population health initiative formally began in 2012. The first step, says Gyekye, was collecting data from a variety of primary and secondary sources, including a comprehensive Community Health Needs Assessment, which is conducted by JCMC every three years. Gyekye and his team also looked at inpatient admissions, as well as ED and ambulatory visits. They analyzed the data for specific neighborhood needs based on ZIP codes, and put programs in place accordingly.
While management of chronic conditions, such as diabetes, hypertension, and kidney disease, is an ongoing concern, the population health initiative also began to invest heavily in connecting residents to primary and preventive care.
“We don’t wait for you to come to the hospital,” says Gyekye. “We undertake approximately 1,000 events a year, impacting about 35,000 people on an
annual basis. That can mean anything from doing basic screenings, to hosting a guest speaker at a community center, to doing targeted health screening fairs.” Patient navigators meet Hudson County residents where they are—senior centers, bingo nights, schools, homes.
“Home visits are important because we get a different view than we can get anywhere else,” says Gyekye. “We might remove expired medication, or see that someone who’s suffering from asthma is living in a basement with mold or no proper ventilation.” The program can connect a resident with community resources to get remediation for the home. “But if a patient prefers, we’ll meet him or her in a neutral location, like a mall or coffee shop,” says Gyekye.
Measures of Success
For the first three years, the population health initiative was centralized in one department, which created protocols and training modules. The team built an electronic social services database to connect residents with services and programs. They trained patient navigators to help residents find housing, apply for Medicaid, prepare for job interviews and more.
Once the program was established, it was expanded throughout JCMC. “If you go to the orthopedic department, or to the renal, dental or eye clinics, you’ll find a linkage to population health,” explains Gyekye. The population health team also has created the free Reward Program. Membership provides discounts at certain businesses, restaurants and gyms.
What does success look like for this ambitious program? One metric is reducing ED utilization and unnecessary inpatient admissions, which have seen a marked reduction, says Gyekye. But the true tale is told through individual stories. “We had one patient who had a history of more than 70 hospital admissions for seizures,” says Sharnia Williams, Patient Navigation Program Coordinator. “We helped her get the change in medication she needed. In the first year, her hospital admissions were dramatically reduced, and she hasn’t been in the hospital since.”
“Our motivation is to see individuals in the community come back to us and tell us they now have a job, or they can now self-manage their chronic disease, or their health condition has improved,” says Gyekye. He looks forward to hearing more of those stories. “We’re a fully funded, entrenched
program, and we’re not going anywhere.”
To learn more about events, programs and membership, call the Patient Navigation Program Coordinator at 201.388.1290