There’s no question that the COVID-19 pandemic affirmed one of the greatest failures in the American healthcare system: too often your health is determined by your zip code.As providers, we are moving to a more holistic approach to care and maintaining health, strategies that have been turbocharged since the pandemic revealed terrible fault lines in outcomes based on race and ethnicity. African-Americans have been twice as likely to die as white Americans in the pandemic.Emerging research tells us that insecurity around food, housing, and other social factors can determine up to 80% of a person’s health. Translation: we need to pay a lot more attention to what’s not in a medical record to tackle the tsunami of preventable chronic illness and premature death, especially in communities of color. This approach is front-burner and is driving new strategic priorities at all major health systems, creating unprecedented alignment between providers and payers and transforming curricula at medical schools.As the CEO of New Jersey’s largest health network, here’s what I have learned on our journey to create better health for all communities in the Garden State, one of the most diverse in the nation.
1. Have multiple touch points.
Our program launched in 2021 and uses two separate digital platforms and electronic medical records to screen patients for these issues: food and housing insecurity, transportation, mental health issues/addiction, and caregiver stress.
All the information from the screening goes directly into the patient’s electronic medical record, right there with the hypertension or thyroid condition. So far, we have screened 500,000 patients and have provided 1.4 million referrals to social service agencies our patients might not have even known existed. Our success is in part attributed to having multiple touch points—in hospitals, physician offices, ambulatory care settings, and more.
2. Flood the zone.
Personalized referrals are provided to patients in 152 languages by email, print, or text messages. This is critical because of New Jersey’s great diversity. The Unite Us platform has been integrated into the network’s electronic medical records health system, and referrals are automatically made based on the patient’s needs.Our screenings are reaching patients that may previously have fallen through the cracks. We have helped people get groceries, rental assistance, and even avoid eviction. It’s clear that healthcare can make a bigger difference by harnessing new technology and networking within our communities.
3. Keep Innovating.
In the U.S. 38 million people are food insecure, including 650,000 in New Jersey. We weren’t surprised to learn through our screening how many people are impacted, but we knew it could take a little time to get them help.So in May we launched a new program to provide low-income and uninsured patients two meals a day for up to a week, a bridge service until a community health worker can connect them to local food services and other resources.We also just added a pharmaceutical component to the plan that provides newly discharged low-income and uninsured patients with the option of filling their prescriptions at a network pharmacy with no out-of-pocket costs.
4. Never forget the people in the stats.
Consider Ruth Wiseman. She was beyond stressed working full-time and caring for her 94-year-old mother, an Alzheimer’s patient. After a few phone calls, community health worker Lisette Morales found her a new home health aide, had a wheelchair delivered, and took over arranging appointments for Ruth’s mother.“I felt like a prayer had been answered. This service is such a gift,’’ Ruth said. After Ruth’s mom died this summer, she was no longer a client, but Lisette returned to give her a hug.
Robert C. Garrett, FACHE, is CEO of Hackensack Meridian Health, New Jersey’s largest health network with 18 hospitals, more than 500 patient locations and the Hackensack Meridian School of Medicine.
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