From helping patients manage Type 2 diabetes to ensuring teens keep out of harm's way, the five winners of the 2011 AHA NOVA Awards demonstrate every day how working with partners in the community can improve quality of care and save lives.

The AHA NOVA Awards, sponsored by the American Hospital Association and Hospitals & Health Networks, honor effective, collaborative programs focused on improving community health status.

In Milwaukee, five hospitals came together to expand primary care services and increase access to affordable medications. In Olympia, Wash., hospitals reduced inappropriate emergency department visits while improving the health status of those previous "frequent flyers." A wide-ranging collaboration in Fort Wayne, Ind., targets the health needs of low-income and medically underserved residents. A Chicago initiative teaches African-Americans and Hispanics how to manage their diabetes. And in Rochester, N.Y., a program to keep teenagers from becoming repeat victims of gunshot or knife wounds has had impressive results.

Working together is the key. As Froedtert Health President and CEO William Petasnick says, "A single health system can't do it alone."


THE DIABETES COLLABORATIVE - Northwestern Memorial Hospital, Chicago - Dealing with Diabetes

Managing diabetes is much easier for patients in two Chicago communities, thanks to the Diabetes Collaborative launched in by Northwestern Memorial Hospital in 2006.

The program grew out of a critical need for assistance to deal with the health problems associated with diabetes in two of Chicago's underserved and uninsured neighborhoods. One is a largely African-American community, and the other comprises predominantly Hispanic residents. Death rates for people with diabetes are 27 percent higher for African-Americans compared with those of whites; Hispanic residents are almost twice as likely to die from the disease as are non-Hispanic whites.

The collaborative is a partnership among Northwestern Memorial Hospital, two federally qualified health centers, and Northwestern University's Feinberg School of Medicine. It identifies and teaches adult patients with Type 2 diabetes how to manage their disease, focusing on patient education and self-management.

The aim is to be responsive to community health needs, says Daniel Derman, M.D., vice president of operations and president of Northwestern Memorial Physicians Group. "Instead of saying, ‘Let us tell you what we can do for you,' we ask, ‘What are your specific needs?' and translate them into a sustainable program that fits," he says. In this case, the two neighborhoods requested help with the growing health problems associated with diabetes.

In addition to the Food Oasis program, which provides patients with prescriptions to buy fresh fruits and vegetables and other healthy food items at Walgreens stores, the medical school developed seven culturally sensitive bilingual education videos and print materials to help patients of all educational levels gain a better understanding of diabetes. "The self-management education component is really what sets this apart from other efforts," says Derman.

The collaborative also uses chronic care teams to review patient information and improve care. Northwestern Memorial provided technical assistance to the two community health centers to implement electronic medical record systems. Access to specialists through the academic medical center and the medical school is a major strength of the program.

To gauge its success, the collaborative focuses on eight key outcome measures, including hemoglobin A1C, annual foot and eye exams, and cholesterol screening. From 2006 to 2011, improvements have been realized in all measures. Blood-sugar levels have decreased, a good indication that patients are doing a better job of managing their disease.

"The collaborative has helped make a measurable difference in the community by bringing the minds of a lot of people to bear on the problems associated with diabetes,'' says Northwestern Memorial HealthCare's President and CEO Dean M. Harrison. "It also represents what Northwestern hopes will be the start of additional initiatives to deal with other chronic diseases in our communities."

EMERGENCY DEPARTMENT CONSISTENT CARE PROGRAM - Providence St. Peter Hospital/Choice Regional Health Network, Olympia, Wash. - A Care Plan to Reduce ED Use

Providence St. Peter Hospital was seeing a common occurrence in its emergency department. Patients with chronic conditions and an addiction to pain medication showed up frequently for treatment. Abuse of other types of drugs also was climbing in the area, which equals or exceeds all regions in the state with regard to drug and substance abuse.

Providence St. Peter launched Consistent Care in 2003 to respond to the crisis. The hospital works in collaboration with CHOICE Regional Health Network, a nonprofit coalition of rural and urban hospitals, practitioners, public health clinics, community health centers and others in a five-county service area.

Seven years later the results are impressive. Visits to the ED by patients enrolled in the program have fallen by more than 50 percent, with an average annual savings of $9,000 per patient. Consistent Care also has improved the health status of participating patients, and increased the capacity and integration of safety-net services in the community. The program has helped patients become more emotionally stable and resilient, reconnect with family and friends, and improve life-sustaining skills.

Consistent Care serves as an excellent example of a community collaboration, bringing medical and nonmedical providers together to offer coordinated services for some of the area's most vulnerable and chronically ill patients. "One of the most significant results is that the program provides the most vulnerable with hope and helps them help themselves," says Medrice Coluccio, CEO of Providence St. Peter.

Consistent Care also shifted the way treatment is delivered in the ED. "Patients no longer come to the ED and get a script for pain medication. Instead, the program provides them with a care plan that may include a referral to a chemical-dependency or other appropriate community health care program," says Kara Elliott, R.N., the program's administrative coordinator.

Consistent Care has served 633 people and approximately 50 percent were drug-seeking. Most did not have regular contact with a primary care provider. About a third had mental health problems, more than a fifth had migraine, dental or back pain, and about 30 percent had other chronic or acute conditions. The program has expanded to include four other hospitals in the region.

Now funded by participating hospitals, initial start-up funds were provided by Providence St. Peter Foundation. Ken Anderson, the foundation's board president, says, "We are proud that charitable gifts made a difference in changing health care."

ROCHESTER YOUTH VIOLENCE PARTNERSHIP - University of Rochester (N.Y.) Medical center - Empowering Youths to Avoid Violence

All too often teenagers with gunshot and knife wounds were arriving at the University of Rochester (N.Y.) Medical Center's Kessler Burn & Trauma Center for treatment, only to return weeks or months later with more serious or even fatal injuries. Statistics show that once a child has been shot or stabbed, his or her chances of being injured again or killed as a result of violence greatly increase. A multidisciplinary team from URMC developed the Rochester Youth Violence Partnership to address this serious problem.

RYVP is a hospital-based violence intervention program designed to identify at-risk youths immediately after they have been injured and protect them from further injury. Once in the program, RYVP provides teenagers and their families with a wide range of targeted services designed to address identified risk factors and prevent additional injuries caused by violence.

After a victim is stabilized and injuries treated, a standardized, social-work assessment is performed to identify risk factors that might have led to the injury. This allows interventions to be targeted toward identified needs and risk factors. All patients view a video designed for victims and their families while they are still hospitalized. The video, titled "Voices of Violence: Your Chance to Change," encourages the victim and family to become engaged in the process and capitalizes on the "teachable moment" the current hospitalization provides. The assessment allows the team to develop a safe discharge plan for each teenager linked to follow-up services.

"Each case involves different circumstances and each patient is different," says Mark Gestring, M.D., medical director of the trauma center and one of the originators of RYVP. "The goal of this program is to help patients and their families understand [that] the majority of these injuries are not random and actions can be taken to avoid further injury," he says.

The program's impact has been nothing short of astonishing, says James R. McCauley Jr., director of operations for Camp Good Days and Special Times Inc., an RYVP member. In 2007, nine youths previously injured by violence returned as a result of violence. In the three years since then, not one has returned. The "wake-up" intervention video also is making a difference.

"This program required a significant culture change within our institution," Gestring says. "With the resources of our community partners and the support of our institutional leadership, this program plays an important role in the prevention of further injury in a very high-risk population of young people."

MILWAUKEE HEATH CARE PARTNERSHIP - Aurora Health care, Children's Hospital & Health System inc., Columbia St. Mary's, Froedtert Health, all of Milwaukee; Wheaton Franciscan Healthcare,Glendale, Wis. - United to Improve Access and Care

In 2006, the five Milwaukee health systems put competition aside and decided to work together to expand coverage, access and care coordination for the county's most vulnerable populations. In­creasing numbers of uninsured and Medicaid patients fueled gaps in access to primary care. Inappropriate and overuse of the emergency de­partment also was becoming a problem. Nearly half of the avoidable ED visits in the county were made by Medicaid or uninsured patients for conditions that could have been dealt with in a primary care setting.

The collaboration resulted in the creation of the Milwaukee Health Care Partnership, a public-private consortium. It set out to expand primary care services through community health centers, increase access to affordable medications, and provide a coordinated specialty access network for the uninsured. Milwaukee's four federally qualified health centers, the Medical College of Wisconsin, and state and local government health agencies also are members.

With only one paid staff member, a key success has been the significant contributions of its members' in-kind services and expertise. In four years, the partnership also has secured more than $8 million in new public and private funding for an aligned communitywide health improvement plan.

On the patient level, Westside Healthcare Association Inc., an FQHC and one of the partnership members, reports significant progress to date. The center has increased its capacity by expanding operating hours and hiring more providers. Westside provides primary care services to Milwaukee's most underserved.

One of the best examples of the partnership's work is the ED Care Coordination Program, says Westside's CEO Jenni Sevenich. Patients who arrive at the ED without primary care homes are linked with an FQHC. Hospital staff schedule patient appointments right in the ED, and subsidize additional case-management resources at the health center medical home.

Referrals from the ED to the medical home have grown dramatically and "show" rates for appointments have increased from 25 to 44 percent.

The partnership demonstrates that working together is essential, says William D. Petasnick, president and CEO of Froedtert Health. Members understand that all stakeholders must be at the table if the complexities of these issues are to be addressed successfully. "A single health system can't do it alone," says Petasnick.

INTEGRATED COMMUNITY NURSING PROGRAM - Parkview Health, Fort Wayne, Ind. - Integrating Resources for Better Care

Alfred McGinnis, a 48-year-old asthma patient in Fort Wayne, Ind., says the help he received from the Integrated Community Nursing Program at Parkview Health saved his life. He has suffered from asthma since age 12.

Before enrolling in the program, McGinnis was a frequent patient at Parkview's emergency department. He had daily symptoms and woke several times each night with breathing difficulties. He was using his reliever medicine four to 10 times a day and was unable to pay for any type of controller medication.

Once in the program, McGinnis qualified for medication assistance and now receives his medication by mail. Thanks to the program's one-on-one educational effort, he also made changes in his living environment to reduce asthma triggers. As of July, McGinnis had not visited the ED for asthma-related problems in a year.

This case is just one of many success stories. The program's collaboration with a variety of community agencies provides low-income and medically underserved patients with a wide array of resources to meet their health needs.

Of the 14 nurses employed by the program, five are located in 10 school buildings so they can provide clinic services, screenings and opportunities for classroom education on hygiene, diabetes, asthma and smoking. It is also a communitywide program."The nurses touch so many parts of our community that they help the adults as much as the children," says Sue Ehinger, Parkview's chief operating officer.

In addition to asthma, the program provides other health care assistance. For example, there is a diabetes education and management program, an in-school FluMist program for the area's most impoverished schools, a vision-screening program in 49 schools and a safe-slumber program designed to prevent infant suffocation.

The FluMist and safe-slumber programs have demonstrated the most significant results, says Connie Kerrigan, manager of community nursing. A total of 30,000 FluMist doses resulted in improved health and increased school attendance. Families who attended the safe-slumber program have not experienced any infant deaths due to suffocation.

Once enrolled in the program, patients receive follow-up to make sure connections are made and necessary health care education and services are provided. One of the program's most important aspects is the ability of the community nurses to locate the necessary resources to help the medically underserved.

"The community nurses tie the pieces together. Integrating services is key to the program's success," says Ehinger.