Each year, the American Hospital Association honors up to five programs led by AHA member hospitals as “bright stars of the health care field” with the AHA NOVA Award. Winners are recognized for improving community health by looking beyond patients’ physical ailments, rooting out the economic or social barriers to care and collaborating with other community stakeholders. Visit www.aha.org/nova for more information.

Finney County Community Health | St. Catherine Hospital, Garden City, Kan.

The western Kansas town of Garden City is aptly named; it cultivates an ever-expanding crop of community benefit projects.

The first seed was planted with a teen pregnancy prevention initiative, championed by a Dominican nun in the community with leadership from St. Catherine Hospital, which blossomed into the Finney County Community Health Coalition and now brings together more than 50 community partners on a regular basis. The coalition seldom provides direct services, but rather seeks to identify community needs and find funding to support them.

“The coalition is part of who St. Catherine is,” explains Edward Smink, the hospital’s executive director of ministry and mission. “We like to say the coalition is the eyes and ears of the community for the hospital.”

The coalition began by framing three major community needs: reducing risky behaviors for young people, including teen pregnancy, smoking and drinking; improving transportation; and supporting families and children through two agendas — literacy training and preventing domestic violence. From its beginning in 2000 with an initial $1,500 grant, the coalition has undertaken numerous initiatives, helping to pass a no-smoking ordinance within the city limits, create a fixed-route bus service and develop its Center for Children and Families, which also became the coalition’s offices, to name just a few initiatives.

As an adjunct to the center, and to address the town’s growing diversity, the coalition created a family literacy program to help Garden City’s relatively new Burmese and Somalian residents, and its Hispanic population to improve their English-speaking and reading skills, as well as to provide high-quality children’s activities, immunizations and other community support.

“When I arrived in 2005, the coalition was already quite active, but grants were getting more competitive — too many people were looking for the same funding,” explains St. Catherine CEO Scott Taylor. “I challenged the coalition to maximize that precious and shrinking resource by asking who they needed to bring to the table. We need to partner with organizations that have core competencies we don’t have. If you are able to bring them together and give them a platform to be more effective, they will be out in front to help manage resources.”

St. Catherine was originally the fiscal agent of the coalition, but as more grants came in, the coalition set up its own 501(c)(3) status. Hospital leaders encouraged fellow nonprofit organizations to seek support directly through the coalition. That’s when, Taylor says, the coalition “found its stride … it became the conduit.”

Coalition Executive Director Verna Weber explains, “It’s how people are in western Kansas — when they find an issue, they will figure out how to resolve it. It’s our self-reliance and get-it-done attitude that creates the glue that brings the community together.”

Adds Smink, “What’s made us successful is going out to the community and asking them what they need versus taking on a patriarchal hospital role of telling people what we’re going to do for them. There is no personal agenda — the question is, ‘What is the common good that will improve the health of our community?’ ”

Firstreach | Firsthealth of the Carolinas, Pinehurts, N.C.

Few could have guessed that the economic downturn would have had such disastrous effects related to diabetes in North Carolina’s rural Montgomery County, but when outreach funding was pulled in 2006, mortality rates for the disease escalated, as did the number of diagnosed cases. A 2007 survey found that 16.9 percent of the county’s residents had diabetes, a rate almost double that for the state. Compounding the issue, only five primary care offices serve the entire county of 27,745 residents. FirstHealth of the Carolinas discovered the distressing statistics during its triennial community needs assessment — and responded with FirstReach.

“That 16 percent is an alarming statistic,” says David Kilarski, FirstHealth’s CEO. “We had to ask ourselves, ‘How do we access those who aren’t part of our four-hospital system walls?’ ”

FirstReach is a countywide, multidisciplinary diabetes outreach program that pursues three goals: to increase residents’ awareness of the signs and symptoms of diabetes and prediabetes; to implement early diagnosis through screenings and referrals; and to improve diabetes management and compliance through intensive education and coordination with primary care providers.

Starting with a small initial grant, FirstReach began conducting diabetes screenings at local banks, Wal-Marts and senior centers, among other community locations. After securing additional foundation funding and support from the state’s Office of Rural Health and the North Carolina Health and Wellness Trust Fund, certified diabetes educators were embedded in primary care practices, providing one-on-one diabetes education. In addition, a voucher system was developed through a partnership with area pharmacies, which provided the opportunity for FirstHealth to provide needed supplies and medications. The final component of First- Reach involved the implementation of group medical visits.

During those visits, eight to 10 patients gather at their primary care provider’s office for their monthly checkup, with the provider “making the rounds,” examining each patient’s diabetes management indicators. After that, a certified diabetes educator gives a brief presentation on some aspect of diabetes self-management.

“With the group medical visits, the primary care provider isn’t repeating himself 10 times, since all patients will hear the same recommendations,” explains Roxanne Elliott, policy director for FirstHealth. Diabetes Program Manager Melissa Herman adds, “The group visits buffer costly no-show rates, which are common with underserved populations.”

Those who do show up benefit as much from each other as from medical exams and education. For instance, at one meeting, a participant told the group he didn’t want to change his lifestyle. Then, Herman recalls, “the man sitting next to him explained that his recent below-the-knee amputation was the result of not taking care of himself, forcing the amputation when he dropped a can of green beans on his bad foot. The man who heard that changed his diet, lost 60 pounds and became a stirring advocate for proper diabetes care.”

“Every diabetic telling [his or her] story encourages others to change their behavior. You can’t force people to change — you must literally meet them where they are,” Elliott says.

Data bear out just how effective FirstReach has been in Montgomery County. Because more people are getting diagnosed and linked to treatment, the diabetes prevalence rate rose from 16.1 to 20.9 per 10,000 people between 2007 and 2011. Most impressively, the diabetes mortality rate per 10,000 dropped from 40.8 in 2007 to 22.8 in 2011.

Children's Hospital Center for Pediatric Medicine Asthma Team | Greenville (S.C.) Health System

A program to improve care for kids with asthma reaches across the community in Greenville, S.C.

In response to a growing number of pediatric asthma-related crises and treatment disparities, the Asthma Action Team at Children’s Hospital Center for Pediatric Medicine was launched in 2008. The multidisciplinary, multicultural, family-centered program is housed within the largest outpatient primary care clinic of its kind in South Carolina, and provides ongoing care to approximately 18,000 patients.

Fully supported and funded by the Greenville Health System, the program educates local families about evidence-based asthma care and provides medical treatment, case management, school and day care visits, and environmental control home visits for children and teens with asthma. Because of higher risk factors, the program targets low-income and underserved populations. The program also teaches pediatric residents, medical students and other health care professionals how to care for children with asthma, with the ultimate goal of better coordination of patient care to enhance the family’s quality of life and to prevent asthma-related emergency department visits and hospitalizations.

“Asthma is a big deal in pediatrics,” notes William Schmidt, M.D., medical director at GHS Children’s Hospital. “It really is labor-intensive and takes someone to sit down and listen to what is going on with the family to establish a plan that works.”

That first someone may likely be Cheryl Foster Kimble, a registered respiratory therapist–neonatal pediatric specialist, certified asthma educator and the program coordinator. Running the program “takes lots of coordination and communication,” Kimble says. “There must be consistency of messaging throughout the continuum of care — that’s why we’ve embedded evidence-based guidelines in our electronic health record.”

Schmidt notes that “with a combination of electronic tools, we can tell where patients are in real time. We know immediately if they’ve gone to the ED, for instance.” Their data document their success. In 2007, pediatric asthma patients generated 855 ED visits per 1,000 children. In 2012, that number had dropped to 267 per 1,000.

In conjunction with the EHR, the program’s partnership with the Disease Management Care Network, a disease/case management software program, enhances the team’s proactive and reactive approaches to care coordination, Kimble says. Reactively, the DMCN system sends out alerts when a patient experiences an asthma event. Proactively, DMCN acts as a patient registry, helping to manage ongoing care, she explains. The system currently tracks 4,338 children and teens with asthma.

As an additional resource for parents of children with asthma, the program’s Family Connection Breathe Easy Coalition provides peer support. Families share their experiences and lessons learned caring for their children with asthma. “Parents don’t feel threatened, because these are people who’ve been in the same situation,” Kimble says. “And it lets everyone know that they’re not in this alone.”

Schmidt adds proudly, “One of the major strengths of the program is that it’s not just a medical program; we have gone beyond that in collaborating with nonmedical providers. If you’re willing to enlist the help of the whole community, it’s pretty powerful.”

Let's go! | Maine Medical Center, Mainehealth, Portland

Obesity carries many known health risks. Being an overweight young person also can bring bullying, anxiety and isolation.

In response, the “Let’s Go!” program of the Barbara Bush Children’s Hospital at Maine Medical Center in Portland has made big strides in changing those children’s futures.

“Every third patient I saw had weight issues,” recalls pediatrician and program director Victoria Rogers, M.D. Now in its eighth year and third year of statewide implementation, Let’s Go! is a nationally recognized childhood obesity prevention program committed to developing healthful eating and active living habits among area children from birth to age 18. Funded by health systems, hospitals, foundations and businesses, initiatives are ongoing in child care centers, schools, workplaces, community settings and physicians’ offices. Let’s Go! now encompasses 170 provider practices, addressing 80 percent of the state’s children, Rogers says.

“The uniqueness of Maine is that we are a physically large state, but really a small city in many ways,” says Maine Medical Center President and CEO Richard Petersen. “Collaboration might seem challenging, but it’s just who we are and what we do.”

Ten evidenced-based tenets form the program’s core, with five “priority strategies”: providing healthful choices for snacks and celebrations, and limiting unhealthful choices; eliminating sugary beverages in exchange for low-fat milk and water; providing non-food rewards; providing opportunities for physical activity every day; and limiting recreational screen time.

The program’s signature initiative is its “5-2-1-0” message, which encourages children to have five or more fruits and vegetables each day, two hours or less of recreational screen time, one hour or more of physical activity and zero sugary drinks.

The message has had an additional unforeseen benefit, Rogers says. “Providers told us the ‘5-2-1-0’ message gave them a safety blanket to talk to young patients, because weight is such a charged issue. The mnemonic changed the conversation from being about weight to being about healthful behaviors — and it translated easily to the schools.”

Building on local schools’ pre-existing health education efforts, “The program really resonated,” Rogers says. “It linked the physician’s office to the school, and developed a connection that I had never seen before.” As an example, students at one school planted a vegetable garden to learn how to grow their own healthful food and, during the summer break, neighboring physicians kept it watered.

Rogers says she got physicians on board by explaining that they didn’t have to “own” obesity, only put up a 5-2-1-0 poster in their offices, check body-mass index and use a questionnaire to guide a family discussion about healthful behaviors. Petersen gives her more credit.

“Tory is the energy behind the program — and she’s very hard to say no to,” he says with a laugh. He adds, however, that “having such a great physician champion makes collaboration that much easier.” 

Hearts Beat Back: The Heart of New Ulm Project | New Ulm (Minn.) Medical Center, Part of Allina Health, Minneapolis

When the concept of accountable care was just entering the health care lexicon, cardiologist Kevin Graham, M.D., had a vision of an “accountable care community” in which no one ever experienced a heart attack, because preventive measures had been implemented years before.

Graham’s vision inspired the Hearts Beat Back: The Heart of New Ulm (HONU) Project, a community-driven initiative to reduce heart attacks in New Ulm, Minn., a city of about 13,000 located 90 miles southwest of Minneapolis. The project began in 2007 when New Ulm Medical Center partnered with the Minneapolis Heart Institute Foundation, engaging town leaders to discuss how to improve the community’s heart health.

Today, the 36-member HONU committee includes representatives from the New Ulm chamber of commerce, city government, local college, school district, county public health, churches, local employers, parks and recreation, local media and the general community, as well as the medical center.

Jackie Boucher, senior vice president and chief operating officer of the Minneapolis Heart Institute Foundation, is proud of the program’s strong buy-in and offers advice for others wanting to start similar programs in their communities. “Find out who the key thought leaders are in the community and those organizations already working on the condition you want to impact and make sure they are at your first meeting,” she says. “Make sure everyone understands what each can, and will, bring to the table so that you have common metrics and that everyone speaks the same language.”

More than 5,000 residents participated in HONU’s first free heart health screening in 2009 and more than 3,100 in the second screening in 2011, with a third screening planned for this fall. Screenings have been held at workplaces, churches and community centers, assessing blood markers, weight, blood pressure and behaviors including nutrition, tobacco use, stress and physical activity. Core funding has been provided by Allina Health, as well as the Minneapolis Heart Institute Foundation and the medical center.

Other community initiatives include a commitment from 13 local restaurants to offer more healthful menu options, while the “Swap It or Drop It” program in area convenience stores features changing point-of-purchase displays that suggest healthier alternatives to what a shopper might reach for — bottled water instead of a soft drink, for example.

As a crucial measure of progress — and as the sole hospital and physician clinic in town — the medical center uses an electronic health record that encompasses the entire community. “We have 40 multispecialty doctors all integrated, a home health team, a hospice team, emergency medical services and a pharmacy, all using the same EHR,” explains New Ulm Medical Center President Toby Freier. “It’s very powerful for data analytics. We call it our population health surveillance tool.”

The EHR also allows proactive identification of high-risk patients, who are then referred to a phone-based health coaching program called HeartBeat Connections. Some 1,200 high-risk residents have received personalized monthly phone calls from a registered dietitian or nurse to supplement their primary care visits. The phone coaches help individuals change lifestyle behaviors and use protocols to initiate and titrate lipid and blood pressure medications between primary care visits.

“There is a connectedness in rural communities,” Freier says. “People know each other and work together and it creates an environment where population health can succeed.”