2017 Report to the Community

Stories of our work in the community

Throughout Maryland and the Washington, D.C., region, MedStar Health works with communities to increase healthcare access and education. Our goal is to improve the health and well-being of all residents.

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  Managing Chronic Conditions in the Community

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  In the video above Living Well program participant, Nicole Glover Wright and lay leader Janis Perry speak about their experiences during the program.

  Living Well: Chronic Disease Self-Management Program

  Through the 2015 Community Health Needs Assessment, MedStar Health identified chronic disease prevention and management as a strategic area of priority and the need for evidence-based programs to address chronic disease in the community. In 2017, MedStar launched its first system-wide evidence-based program, Living Well—a seven-week health education and behavior change program focused on chronic disease self-management for people living with one or more chronic diseases. Participants can register online or by phone, and MedStar providers can directly refer patients to the program through a referral link in the Electronic Health Record.

  Living Well is led by trained lay leaders who help participants with chronic conditions, such as heart disease, diabetes and cancer, learn how to manage their condition and improve their health and quality of life.

  In 2017, MedStar trained more than 70 lay leaders to deliver the Living Well program in communities surrounding MedStar’s 10 hospitals that are underserved or disproportionately affected by chronic conditions.

  “We know that chronic conditions are impacting both our patients and the community at large, and are a significant driver to healthcare utilization patterns and costs,” says Dawnavan Davis, PhD, assistant vice president of MedStar Community Health.

  The program educates participants through homework exercises, behavior modification and the creation of self-management plans. Approximately 200 individuals have enrolled in the program since it started.

  “In general, people who complete the program report better self-management, significant weight loss and better quality of life overall,” explains Davis. “The next phase of evaluation will examine the impact of program participation on healthcare utilization and readmissions among program completers.”

  Lay leader Janis Perry has observed that participants are making healthier lifestyle choices, losing weight and increasing their health knowledge through the Living Well program in the communities near MedStar Southern Maryland Hospital Center.

  “Participants have stated the positive social aspects of being a part of a group and having accountability to support better management of their conditions,” says Perry. “Having the classes held in the community is essential, as well as having an avenue during the seven weeks to provide evidence-based health information and set goals.”

  
  One of the wraparound components of the program is the recognition of how social needs impact health. In order to sustain self-management behaviors and improved quality of life well after program completion, Living Well program participants are screened for unmet social needs, such as transportation, food access and housing, and are linked to services using the community resource tool Aunt Bertha.​
  

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  Providing Comprehensive Care in School Settings

  Pictured above is Dr. Maria Aramburu, medical director for the SBHC at Roosevelt Senior High School.

  Theodore Roosevelt Senior High School Health Center

  MedStar Georgetown University Hospital’s Division of Community Pediatrics opened its first school-based health center (SBHC) at Anacostia High School in Southeast Washington, D.C., in 2010. In partnership with the D.C. Department of Health, MedStar Georgetown opened its second full-service SBHC in D.C. at Roosevelt Senior High School in Northwest in 2017.

  The goal of both health centers is to increase access to healthcare services and improve the wellness of adolescents and their families in five areas: physical health, mental health, oral health, nutritional health, and social environment.

  “We’re looking at it in context of their family system and working to decrease access and language gaps by providing culturally sensitive health services in a school setting,” says Maria Aramburu, MD, medical director at Roosevelt Senior High School’s health center.

  The health center provides primary care, mental health care, reproductive care, and social work support services to students five days a week. Sara Villatorio, a student at Roosevelt Senior High School, has visited the health center for therapy and counseling services.

  “The support I receive from staff at the health center makes a big difference. I’ve been growing as a person and my depression has gotten better since going to the center,” says Villatorio.

  Villatorio also said the health center’s supportive environment keeps her inspired to pursue her dream of joining the military after graduation and supporting those in need.

  “One of the key pieces of the work that we’re able to do is connect students to care where they are. We’re providing care directly in their communities through a school-based setting where they live, learn, play and grow,” says Joanne Odom, program administrator at MedStar Georgetown University Hospital.

  

  
  

  Source: http://pediatrics.aappublications.org/content/120/4/e887

   

  Other key initiatives of the health center include increasing immunizations and annual wellness exam compliance. The newest initiative involves coordinating health insurance coverage for uninsured or underinsured students. Additionally, staff are working in partnership with Mary’s Center, a community health center, to soon begin providing dental services at Roosevelt Senior High School.

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  Physician Residents Committed to Community Care

  Pictured above are Community Care Initiative mentor Mary Benjamin, MD (left) and medical resident Kaveh Rezaei Bookani, MD (right).

  Graduate Medical Education Community Care Initiative

  Accessing affordable health care and chronic disease management resources are barriers that many people living in the underserved communities of Baltimore face today. To help link community members to such resources, the medical residents at MedStar Harbor Hospital are learning to address social issues and health needs in community settings through MedStar Health’s Graduate Medical Education Community Care Initiative.

  The initiative aims to train medical residents about the social and economic factors impacting health and health care, and how these factors affect care delivery in the communities they serve. The residents apply their learning to practice within a variety of community settings.

  “We look for ways that residents can reach out and treat the people living in the communities immediately around them,” says Richard Williams, MD, residency program director at MedStar Harbor Hospital. “They are always interested in opportunities to serve the community, especially lower income populations who may not have adequate access to health care.”

  Whether they are providing free healthcare services at Anne Arundel County’s Homeless Resource Day or meeting with teachers to discuss healthy eating and exercise habits for students, the medical residents in the Community Care Initiative are getting a firsthand view of the needs that exist in the communities served by MedStar Harbor Hospital.

  Kaveh Rezaei Bookani, MD, a medical resident, has been committed to working with medically underserved populations since he started medical school in Iran. As part of the Community Care Initiative, he provides health services supervised by his mentor, Mary Benjamin, MD, at the Family Health Centers of Baltimore in Brooklyn, a community near the hospital.

  Family Health Centers of Baltimore is a nonprofit federally qualified health center that provides primary care services at four locations in the Baltimore area, including the Cherry Hill and Brooklyn communities surrounding MedStar Harbor Hospital. Dr. Benjamin and her team provide chronic disease management services, such as counseling for smoking cessation, education about nutrition and exercise, screenings for diabetes and high cholesterol, as well as colon cancer screenings, in partnership with MedStar Harbor Hospital’s free colonoscopy program. They also provide drug addiction prevention and treatment services.

  Being embedded in a community practice provides the medical residents with a better understanding of all the factors that contribute to the health of a patient, and ultimately the health of a community.

  “As physicians and as part of society, we have an obligation to take care of vulnerable people and fight against disparities, discrimination and unfair distribution of health services,” says Dr. Bookani. “We are hoping that our work can promote health for all families in our community.”

  
  

  

  
  

  Source: https://www.acscan.org/sites/default/files/FINAL%20Community%20Health%20Centers%20FS%2008.23.17.pdf

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  Helping Community Residents Breathe Easier

  Pictured above is Geri Feaster-Bethea, health coordinator at Israel Baptist Church.

  Respiratory Wellness Program

  In partnership with the Leadership Council for Healthy Communities (LCHC), an organization of faith leaders, health professionals and community leaders who promote healthy communities through comprehensive programs and services in the Washington, D.C., region, MedStar Washington Hospital Center’s Respiratory Wellness Program has provided more than 2,000 D.C. residents with preventive and self-management education, health screenings and linkage to care.

  The Respiratory Wellness Program addresses health disparities related to respiratory diseases among African American and other minority populations in D.C. through:

  • Health education: Educating D.C. residents about chronic obstructive pulmonary disease (COPD) and asthma prevention and management
  • Health screenings: Screening residents for COPD and asthma
  • Resource linkage: Creating a resource guide to care for residents living with respiratory conditions

  Gail Drescher, a clinical specialist in Pulmonary Services at MedStar Washington Hospital Center, said that the program is a way of partnering with the community to provide important health resources to individuals affected by respiratory diseases.

  “You get to know the residents in a different way when you go out to where they live and worship,” she explains.

  In its efforts to help minorities eliminate health disparities and promote healthy communities through comprehensive programs, MedStar’s Respiratory Wellness Program team provides training to leaders from 25 faith-based institutions in the D.C. region. After receiving MedStar’s evidence-based training surrounding COPD and asthma, the faith leaders shared their new knowledge about these conditions with their communities and congregations.

  More than 2,900 people have been educated through workshops using MedStar Washington Hospital Center’s curriculum, and nearly 300 residents have been screened for COPD and asthma at health fairs since the program began in 2015.

  “Knowledge is a first step in helping people try to manage their disease better,” says Sullivan Robinson, executive director at LCHC.

  
  

  

  
  

  Source: http://www.dchealthmatters.org/index.php?module=indicators&controller=index&action=view&indicatorID=1712&localeId=130951

   

  Program participants routinely stated that they began applying what they had learned to better manage their respiratory conditions and became more aware of the risk factors of developing such diseases.

  “One member in my senior group told me she got a nicotine patch after attending the program session at my church,” said Geri Feaster-Bethea, health coordinator at Israel Baptist Church.

  For more information about the Respiratory Wellness Program or the Leadership Council for Healthy Communities, visit www.lchcnetwork.org.

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  Changing the Course of Treatment for Expectant Mothers

  Pictured above, Brittany Hewitt (center), a patient of Dr. Jenkins, joins his substance use disorder support group.

  Substance Use Disorder Program for Pregnant Women and Their Babies

  In 2011, Chuka Jenkins, MD, Obstetrics and Gynecology at MedStar Harbor Hospital, enrolled his first patient in a treatment program for pregnant women and their babies affected by substance use disorders. He started the program while working in MedStar Harbor Hospital’s Fetal Assessment Center after observing the lack of treatment options for mothers who were experiencing addiction during pregnancy.

  After researching alternatives to methadone treatment for his patients with opioid use disorders, Dr. Jenkins found that Subutex® (a brand of buprenorphine) had better outcomes and more benefits, including a reduced chance for overdose. In addition, infants whose mothers were treated with the medication during pregnancy were less likely to develop neonatal abstinence syndrome after birth, which includes withdrawal symptoms such as fever, irritability and seizures.

  Today, Dr. Jenkins treats about 50 patients monthly with Subutex®. He also runs a support group for his patients so that treatment is an ongoing process.

  “I wanted to create a low-barrier program that working mothers could attend later in the evenings,” he says. “Instead of isolating people in perpetual treatment like other programs do, this allows them to complete their treatment within their normal environment and manage their opioid dependence effectively.”

  Whether patients come from a history of past recreational substance use, chronic pain management or medication use after an accident or surgery, Dr. Jenkins develops strategies to help them not only overcome addiction, but engage in other parts of their lives. Partnerships with community organizations have helped Dr. Jenkins’ patients earn their high-school equivalency diplomas, secure food stamps and receive peer recovery coach support.

  “With Dr. Jenkins’ program, you don’t have to lose everything before you get help,” says patient Brittany Hewitt. “When I relapsed, he even came to court and testified that I had a support system and would get the treatment I needed, which prevented me from going to prison.”

  
  

  

  
  

  Source: https://www.drugabuse.gov/related-topics/trends-statistics/infographics/dramatic-increases-in-maternal-opioid-use-neonatal-abstinence-syndrome

   

  Dr. Jenkins is currently working with community activists to push legislation that makes it easier for patients to access the treatment they need. His hope is that programs like his will become more prevalent in the coming years.

  “We’re solving a critical problem here and changing lives,” says Dr. Jenkins. “Taking care of my patients—that’s the biggest reward.”

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  A Collaborative Approach to Health Care

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  In the video above, Alfredo Monterroso, a patient of MedStar Montgomery receives a home visit from nurse Evangeline Sison through the Care Transitions program.

  Nexus Montgomery

  In 2016, six hospitals operating in Montgomery County, Maryland, partnered with a network of community-based organizations to form the Nexus Montgomery Regional Partnership. It consists of four programs designed to improve the overall health of the community, increase people’s satisfaction with their health and health care, and encourage efficient health care spending. MedStar Montgomery Medical Center is working as part of Nexus Montgomery to reduce hospital readmission rates and improve coordination of healthcare delivery within the county.

  “We all learn from each other, and it improves the overall quality of care,” explains Diana Saladini, director of Population Health and Outpatient Services at MedStar Montgomery and vice chair of Nexus Montgomery’s board of managers. “The Nexus Montgomery Regional Partnership allows us to see what works well, share methods across the partnership and MedStar, and learn from each other how to work better with our patients.”

  
  

  

  
  

  Source: http://www.healthymontgomery.org/index.php?module=indicators&controller=index&action=view&localeId=1259&indicatorId=365

   

  Within the Partnership, the Care Transitions program identifies patients at the highest risk for hospital readmission and pairs them with a nurse for follow up. The nurses meet with patients, schedule doctor appointments, make sure patients receive their medications, ensure they have transportation to appointments, and follows up with them for 30 days after they are discharged from a hospital. Through the Partnership, Care Transitions reached more than 1,300 people in 2017.

  Alfredo Monterroso, a patient who was hospitalized at MedStar Montgomery, says Care Transitions was crucial to his recovery, as was the nurse who worked with him once he got home and helped him follow his treatment plan.

  “To be honest, without that program, I wouldn’t have been able to survive—it was that serious,” he says. “The program has made it easier for me to get my medication, as well as the oxygen tank I need to breathe.”

  Specialty Care for the Uninsured

  The Specialty Care for the Uninsured program was created in 2016 to provide funding for uninsured patients who need to see a specialist after discharge from the hospital. MedStar Montgomery worked with the Primary Care Coalition to give patients access to such services.

  Wellness and Independence for Seniors at Home (WISH)

  The largest program to launch as part of the Partnership was the Wellness and Independence for Seniors at Home (WISH) program in 2016, which provides health coaches to patients who are discharged from the hospital into independent living communities. The health coaches help patients with tasks from arranging transportation to ordering medical suppies. The expectations of the program are to help reduce seniors’ risk of readmission to a hospital.

  Cornerstone Montgomery Mental Health Program

  The most recent initiative launched by Nexus Montgomery, the Cornerstone Montgomery Mental Health Program, began in 2017. The program aims to expand access to behavioral health services. To meet the need for more mental health resources in the county, the participating Partnership members collaborated with Cornerstone Montgomery—the largest provider of behavioral health services in the county—to fund the creation of an eight-bed crisis house, including an outpatient case management team dedicated to patients who need behavioral health services.

  The Partnership selected some of the most pressing needs and designed programs and services to proactively reduce unnecessary re-hospitalization, connect patients to supportive services, and expand access to specialty care and behavioral health services.

  “We try to motivate patients to become engaged in their own care,” Saladini states. “Our goal is to provide them with the necessary programs, tools, education and support they need to avoid unnecessary hospital visits and to improve their overall health.”

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  Providing Comprehensive Care for Aging Adults

  Pictured above, Lorene Franklin, a patient of the MedStar House Call Program through MedStar Good Samaritan Hospital receives a home visit from Dr. Jennifer Hayashi.

  MedStar House Call Program

  Since 1999, MedStar House Call Program in Washington, D.C., has been reviving the concept of house calls by providing patients who are 65 years old and older with medical care and social services in their homes. MedStar recognized the need for this program after observing that many older adults with disabilities and chronic diseases faced physical and transportation-related obstacles that often prevented them from getting the care they needed, which can cause patients’ health status to suffer and result in unnecessary Emergency Department visits and hospitalization.

  The program connects people to care, who otherwise may have gone without it, which is why MedStar expanded the program to Baltimore in 2016. The program brings care to patients where they live, maximizing the time spent at home with their families and freeing them from the physical and mental stress of going to the doctor’s office or hospital.

  The comprehensive care team includes a nurse practitioner, social worker, care coordinator, and operations manager under the leadership of medical director Jennifer Hayashi, MD. The team makes house calls for primary and urgent care services and coordinates specialty care and procedures for older adults. In addition to in-home medical and social services, they link patients and families to other health-related community resources, and support caregivers through monthly support groups and weekly meditation calls. The Baltimore office has cared for 155 patients to date.

  “This program is definitely the best—and sometimes the only—way to take care of patients without moving them to a nursing home,” Dr. Hayashi says. “It makes a difference for caregivers to be able to call someone and get advice so they don’t have to call 911.”

  
  

  
  Click to enlarge

  
  

  Source: https://www.medstartotaleldercare.org/about-us

   

  Lorene Franklin has been a patient of the MedStar House Call Program through MedStar Good Samaritan Hospital in Baltimore for about a year. Her daughter and caregiver, Karen, says the convenience and compassionate care provided by the program team has improved her mother’s health and put her at ease.

  “My mother was diagnosed with diabetes in 1988. Since she’s been with the program, she’s no longer on her insulin,” explains Karen. “These doctors are the bridge that connects the elderly population to the care they need.”

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  Partnering to Reduce the Risk of Readmission

  Pictured above are Harry Woods (right) a patient of MedStar Good Samaritan, his wife, Sharron Woods (left), and his Meals on Wheels Care Manager (far left) at his home.

  Empowering Self-Management

  Studies show that following hospitalization, Medicare beneficiaries (people 65 years old and older) have a 20 percent chance of readmission within 30 days. MedStar Good Samaritan Hospital’s Empowering Self-Management program, a collaboration between the hospital’s Center for Successful Aging and Meals on Wheels of Central Maryland, aims to reduce this risk by providing supportive care to older patients after they leave the hospital.

  During their stay in the hospital, older patients who are at high risk of readmission are offered an opportunity to participate in the Empowering Self-Management program for a 30-day or 60-day trial at no cost to the patient.

  The services provided in this two-year pilot program include meal delivery, combined with a weekly check in from the Meals on Wheels team to help the patient and family members proactively look for any changes in health status and assess predictors of readmission. If representatives observe health concerns, such as changes in blood pressure or weight during these visits, they help the patient contact a nurse practitioner in the program to see what follow up might be needed to help avoid hospital readmission.

  “Chronic disease management doesn’t happen in a doctor’s office—it happens where people live, breathe and work every day,” says Carolyn Ford, service line administrator at MedStar Good Samaritan’s Center for Successful Aging. “This program helps us get out into the community and extend the reach of the hospital into people’s day-to-day lives where they need additional support.”

  When envisioning the program, George Hennawi, MD, the hospital’s division chief of Geriatric Medicine and director of the Center for Successful Aging, knew it was important to make a connection to the community.

  “The most important part of how you manage a population is understanding the population in their own location,” Dr. Hennawi says. “By providing the right meals, information and support, the program gives physicians access to understanding patients’ social and environmental limitations to managing their diseases, such as their health literacy level or transportation availability.”

  
  

  
  

  
  

  Source: http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0180767

   

  Now entering its second year, the Empowering Self-Management program has enrolled nearly 40 patients.

  Harry Woods, 84, signed up for the program in 2017, following a hospital stay related to dementia. His physicians at MedStar Good Samaritan were able to monitor his transition through biweekly phone calls and home visits, while also improving his diet by providing him with two balanced meals a day.

  Woods’ wife and primary caregiver, Sharron, said the depth and scope of support provided by the program has not only helped her husband transition back home safely, but has made his diabetes more manageable as well.

  “The program has been more than helpful to my entire household, because I also care for my parents,” she remarked.

  After seeing Harry complete the program with no additional hospitalizations and reduced medical, physical and social risk factors, Sharron decided to continue receiving home-delivered meals for him and started her parents on a meal delivery schedule as well.

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  Early Intervention is Key to Prevention

  As pictured above, active living is a key component of the DPP program.

  The Diabetes Prevention Program

  MedStar Family Choice (MFC), a Managed Care Organization (MCO), serving more than 90,000 Medicaid patients in the state of Maryland was awarded a grant from the Maryland Department of Health in late 2016 to focus on prevention of diabetes –one of most prevalent chronic diseases in the state, and among the Medicaid population. MedStar Family Choice was one of four MCOs in the state of Maryland selected to participate in a two-year demonstration project that includes the implementation and evaluation of the evidence-based, nationally-renowned Diabetes Prevention Program (DPP) among Medicaid recipients. The DPP program is a 12-month lifestyle change intervention, where trained lifestyle coaches lead small group sessions that focus on behavior changes to improve the health of participants. Program topics include healthy eating and active living that often lead to weight loss or better weight management, as part of program participation. Increased weight is a significant risk factor of diabetes onset. The overarching aim of the DPP is to prevent or lower the risk of developing type 2 diabetes among at-risk individuals.

  A distinctive feature of this DPP demonstration project is that program participants can enroll in a traditional in-person DPP or an online DPP, through a partnership with Omada Health, a company focusing on chronic disease management through digital platforms. Having different program delivery options, attempts to decrease the barriers to program enrollment, participation and completion. Since MFC began enrolling members into the DPP in early 2017, 150 individuals have enrolled (18 in-person and 132 online). Approximately 50 online participants recently completed the program. “Through this demonstration, we learned our members have a heavy preference for the virtual program, and the preference is matched with great reports of weight loss and engagement. Additionally, in our efforts to recruit members for the program, we realized how difficult it is for a majority of this population to make the time commitment for the in-person DPPs (for various reasons, such as school, work, childcare, or transportation),” says Zaena Tessema, program coordinator at MedStar Family Choice.

  The DPP is an important initiative for MFC for several reasons. “The evidence-based approach and proven efficacy of the program is well-documented. It provides a mechanism to identify those who are at risk for diabetes and offers them an intervention grounded in research. In addition, the program’s emphasis on behavior change and healthy lifestyles is a critical approach to prevention of disease and overall well-being for our members,” states Patryce Toye, MD, medical director at MedStar Family Choice.

  “We are very excited to participate in this demonstration and have the opportunity to offer the DPP to our members. We have a very large population of members who are at risk of diabetes, and with some simple education and life changes, we are able to arm them with the resources and knowledge they need to prevent or delay the onset of diabetes. Being able to work with our community DPP providers and build relationships with the YMCA and other MCOs has set the stage moving forward to introducing the DPP and chronic disease prevention services to healthcare systems throughout the country,” says Tessema.

  
  

  

  
  

  Source: https://www.cdc.gov/diabetes/library/socialmedia/infocards.html

   

  For more information on the DPP and Medicaid, please feel free to explore the coverage toolkit. If you would like to participate in the MedStar Family Choice DPP program, please visit the Diabetes Prevention Program page for more information.

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