AHA Award
Harborview Medical Center’s community services address an astounding variety of needs
At Harborview, we realize we can’t do anything alone,” says Johnese Spisso, R.N., interim executive director of Harborview Medical Center in Seattle. “We need to work with patients, families, communities and other health care providers and agencies to give vulnerable populations the care they need.”
What sounds like an admission of weakness is far from it; the medical center’s many partnerships enable it to create unique services. “We’ll partner with just about anyone, if we can align our missions and do something that stretches our resources and services for patients,” says Spisso, who is also vice president of medical affairs for the University of Washington. “We have to reach out and find ways to influence health behaviors.”
Harborview’s influence has a long reach; its community initiatives go far beyond acute care. A teaching hospital for University of Washington Medical Center, Harborview’s service area includes all of King County, Wash., which has 1.8 million residents with nearly 10 percent of households below the poverty level.
Harborview programs help children play safely, give a sense of dignity and hope to those who cope with chronic mental illness, and build a sense of community for Seattle’s many immigrants. For its work, Harborview earned the 2007 Foster G. McGaw Prize for excellence in community service. The $100,000 prize is sponsored by the American Hospital Association, Baxter International Foundation and Cardinal Health Foundation.
In addition to its community programs, Harborview provides a substantial amount of charity care—a quarter of all the charity care in the state. In the last fiscal year, that cost Harborview nearly $63 million, about 11 percent of its annual operating expenses.
One grateful patient is Stephen Oakford, a 63-year-old retiree and diabetic who doesn’t yet qualify for Medicare. He’s now being cared for through Harborview’s Changing Health Behaviors program, which started in 2004 after staff noticed a number of people coming to the emergency department with complications from diabetes and asthma.
“Diabetes patients were coming in with nonhealing wounds on their feet,” says Dan Lessler, M.D., an associate medical director who helps manage the program. “Coming into the emergency department was a sentinel event for these patients, and that led us to think about what we really should be doing—connecting them with ongoing primary care. This was an opportune moment to intervene.”
With a salary funded by a Centers for Disease Control and Prevention grant through the King County health department, a nurse now manages cases for patients who present at Harborview’s ED with untreated diabetes and asthma. Its Patient and Family Resource Center teaches the patients how to care for themselves.
Oakford came to the ED for an injured wrist in August 2007. His wrist was treated, but he was also referred to Changing Health Behaviors after staff discovered he was diabetic and unable to afford his medicine. The nurse arranged for Oakford to have his prescriptions filled and connected him with a primary care doctor. “I’ve never seen anyone stay on top of things the way she does,” Oakford says of his nurse case manager.
Oakford also received nutritional counseling and learned how to read labels. “I don’t eat a lot of sweets,” he says, “but sugars are often hidden in foods. My weakness is bread, but now I’m eating less of it and watching the carbs.”
Oakford is among more than 350 patients who have been through the program since it started. And he’s not the only one with positive results. Measurement of the first 90 patients in the program showed their blood sugar control improved, with declines in the HbA1c values three times greater than in a control group. Emergency visits declined, while primary care visits increased.
One important lesson: Patients need interventions from multiple sources. “There’s a medical component and a behavioral component,” Lessler says. “Patients often need a behavioral plan they will be able to follow through on, and that takes partnering with the community.”
For example, Harborview refers overweight diabetic women to a water aerobics program at a community center pool.
“If someone is overweight and concerned about their appearance, here was a designated time to exercise where you only see people who looked like you,” Lessler says. “We have to look at the needs of the patients and the resources in the community and put them together. There’s a lot of things we at Harborview can’t do—we’ll probably never have a swimming pool. It takes working closely with the public health department and community-based organizations if we are going to address chronic illness in underserved communities.”
A Walking School Bus
Harborview partnered with Children’s Hospital & Regional Medical Center in Seattle and the county public health department to create the Injury Free Coalition for Kids of Seattle. The coalition sponsored bike helmet and car seat giveaways. As a trauma center, injury prevention is a natural fit for Harborview.
The coalition also sponsored a “walking school bus” to encourage urban kids to exercise safely. In the program, parent volunteers walk groups of children to school, with various “stops” to collect children.
“We wanted to get safe physical activity into the kids’ day,” explains Brian Johnston, M.D., a co-director of the coalition and chief of the pediatrics department at Harborview.
The program started at one urban elementary school in 2005 and expanded to four others. With the help of a state Department of Transportation grant, a part-time coordinator, Jen Cole, was hired to recruit parent volunteers and establish walking routes.
At the pilot school, about 25 students regularly participated in the walking school bus at least once a week, walking up to a mile and a half. Twelve months after the program started, nearly 18 percent more students at the school were walking compared with schools without the program.
The program had another positive effect: It connected parents to the school and to each other, says Cole, who is a project coordinator at Feet First, a pedestrian advocacy organization. The pilot school was in one of the most culturally diverse ZIP codes in the area, with large East African populations and parents from Central and South America.
Although parents didn’t speak the same language, they came to trust each other with their children. And volunteering to walk children to school—an activity that didn’t depend on speaking English—turned out to be an entry to more school involvement, Cole notes. Some of the walking school bus volunteers went on to volunteer in their children’s classrooms.
Embracing a Diverse Population
In the 1990s, the immigrant and refugee population in Harborview’s service area nearly doubled; census estimates for 2006 show that 20 percent of King County residents are foreign-born and 23 percent do not speak English at home. Harborview’s International Medicine Clinic offers interpreter services in 83 languages. It also started the Community House Calls program in 1994, which features bicultural and bilingual caseworker/cultural mediators in six languages: Spanish, Somali, Vietnamese, Cambodian and two languages from Ethiopia, Tigringa and Amharic.
Last year, Community House Calls caseworkers helped more than 850 clients. The caseworkers are hired from the ranks of the hospital’s interpreters, and often teach the clinical staff about cultural norms and teach immigrant populations about Western medicine.
“Cambodians don’t think about preventive care,” explains Jennifer Huong, the cultural mediator who works with that community. “They go to the hospital when they are sick.” She remembers spending time with Cambodian mothers, explaining how to use thermometers and administer ibuprofen to prevent their children’s high fevers, an event that would previously often trigger a visit to the emergency department.
To help acquaint immigrants with Western medicine, Harborview sends staff to speak to community groups, with the cultural mediators serving as interpreters. However, Martine Pierre-Louis, manager of Community House Calls, says the program doesn’t aim simply to impose Western care on those from other cultures. “The program sets up a place where the knowledge of both communities [ours and theirs] intersects. Treatment plans are negotiated so that it’s not just accepted, but welcomed by community members,” Pierre-Louis says, “and that doesn’t happen unless you know the community.”
One lesson: Some cultures do not value independence in the same way as the West. For instance, caregivers may meet with resistance from family members when they try rehabilitation after a patient’s injury. “Allowing a Somali man with back pain to stay in bed is a sign of respect,” Pierre-Louis says. “The relatives are saying ‘Yes, he’s dependent on us, and to push him to move would be saying we are not respectful.’” Sometimes, Pierre-Louis says, the solution lies in finding a different motivation for healing, such as a trip home or the ability to help the family.
Huong says she knows her clients are making progress as they grow to need her less and less. For instance, they learn which questions to ask at the doctor’s office and how to negotiate the health care system. Harborview spends $3.7 million annually on the program and its interpreter services; staff consider it a worthy investment in breaking barriers to care.
Funding the Mission
To continue funding its community service programs, which Spisso estimates costs some $12 million annually, Harborview runs a tight financial ship. Each year, it generates enough funds to cover its operating expenses, in addition to a 1 percent to 2 percent margin.
“We are not going to be a hospital that is always relying on handouts,” Spisso says. “We are not a county hospital of last resort, we are a community-based, mission-focused university hospital.” Although King County owns the hospital—and appoints its board—the medical center is managed by the University of Washington.
That connection enables Harborview, a 413-bed hospital with a Level 1 trauma center and a regional burn center, to attract highly skilled physicians and research grants.
The “best and brightest” workforce, Spisso says, draws patients who can choose to receive care anywhere. In fact, she strives to keep commercial insurance close to 40 percent of her payer mix. In the last fiscal year, commercial insurance stood at 38 percent, with Medicare and Medicaid each at 25 percent and uninsured patients making up the remainder. That mix, in addition to a vigorous process improvement program targeting waste reduction, keeps Harborview financially viable.
Far More Than Physical Care
Financial viability also allows the medical center to promote healing in a variety of ways for its community members. For Larry Folkerts, it began when he entered a supported employment program for the chronically mentally ill through Haborview’s Mental Health Outpatient Program. For 20 years, Harborview has run that and a companion program to help house the mentally ill. The two programs employ five case managers who work on housing and employment activities, coordinating their efforts with 10 other case managers who look after clients’ health care. The housing and employment programs now serve more than 700 clients.
After housing is found for the patients, Harborview staff promote the advantages of working, often having clients talk about the benefits of their jobs. “Working improves finances for the client, and we find hospitalizations go down for clients that have a job,” says Michael Donegan, health care manager of Haborview’s mental health services outpatient program. “Working gives them citizenship. ‘What do you do?’—it’s the second question that gets asked at a party.”
Harborview provides classes for clients to learn how working will affect their Social Security benefits and how to apply for a job online, and provides opportunities to do volunteer work to bolster their confidence. Case managers even set up interviews on behalf of the clients. Additional classes help the mentally ill learn skills to maintain their employment.
“We want them to choose, get and keep their housing and employment,” Donegan says. “The ‘keep’ part is missing in many programs for the mentally ill.” The programs send case managers to visit landlords and employers and visit employees on the job to head off problems. The program boasts a 20 percent employment rate for its mentally ill clients, compared with an overall 13 percent rate for chronically mentally ill patients in King County, Donegan notes.
Folkerts, 55, says the supported employment program changed his life. “I hadn’t worked in 17 years, but now I have a lot of confidence and it’s helped me financially. I can do things I couldn’t do for many, many years,” he says. “It’s like winning the lottery.”
His hobbies now include attending concerts and starting a small art collection. His part-time job as a front-desk receptionist at Kerner Scott House, which provides shelter for chronically mentally ill patients, was a perfect fit. “I look at these residents and think, ‘That was me 15 years ago.’ I can talk to them and let them know they can make it.”
Spisso says reactions like Folkerts’ are the real prize. The McGaw Prize is welcome, but it’s the opinion of the people that Harborview serves that she and the staff value most. “To us, the best award we get is feedback from patients and families that we have made a difference, saved a life, changed a life,” she says. “That’s all the reward you need in this business.”
The 2007 Foster G. McGaw Finalists
Each finalist will receive a $10,000 prize.
This article 1st appeared in the March 2008 issue of HHN Magazine.
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