THE 2023 INNOVATOR AWARDS PROGRAM


UpTown neighborhood in Toledo. “It is a strategy driven by the knowledge that where you live determines how you live,” she says. In America, food insecurity affects


an estimated 13.5 million Americans. People who are hungry are nearly three times more likely to be in poor health, and the United States incurs $1.1 trillion in food-related health costs each year. UpTown was a USDA-designated food desert when ProMedica launched its 6,500-square-foot hospital-run Market on the Green grocery store in 2015. Today, Market on the Green offers cooking classes and grab-and-go giveaways as well as fresh produce, meat, dairy, baked goods, grocery, health and beauty, and other staples at affordable prices. With a donation from the family of


lifelong philanthropist Russel J. Ebeid, the UpTown effort quickly became a more encompassing community intervention to remove other barriers to health. ProMedica announced the Ebeid


Neighborhood Promise (ENP) in 2019, a place-based community development initiative to empower UpTown residents. ENP’s focus on equity required engaging the neighborhood in a deeper way. “We talk about our community’s physi-


cal and socio-economic environment,” Bradley explains. “Our goal was to bring in programming and organizations and wrap-around services to break down that traditional single-issue boundary within organizations. We’re connecting with other organizations in the area in this neighborhood-based approach. We’re building trust within the community, because we know that a lot of folks don’t trust healthcare systems particularly. Being able to meet with them about something that’s not a bill that they need to pay or service that they need to have has helped.” Through public-private partnerships


with the City of Toledo, service organi- zations, local and regional nonprofits, neighborhood groups, small businesses and artists, residents of UpTown not only have access to a convenient, more affordable grocery store but also to job training, tuition-free STNA (State Tested Nursing Assistant) and EMT certification programs, a mobile market for senior housing sites, cooking and wellness classes, Pre-K education, community events, small-business growth support, a technology hub and innovation center, career coaching, improved housing stock,


“The beauty of our EMR is that there’s a lot of deep, deep clinical detail. We know what’s happening longitudinally with our patients’ clinical issues. We also know very specifically when we identify an SDOH need and how we intervene.” — Brian Miller, M.D.


green spaces, public art and other quality- of-life-improving resources. With promising results, the ENP team is


working with funders, residents and lead- ers to support improvement of education and training, health and wellness, jobs and finances, stable housing, and basic needs in other communities it serves including one of the Glass City’s oldest neighborhoods, Junction. And last year, ProMedica announced the Adrian Ebeid Neighborhood Promise, an initiative dedicated to scaling and implementing solutions to address health disparities in the rural community of East Adrian, Mich.


Connecting interventions to outcomes Miller describes some of the data wran- gling behind the scenes that makes it possible to connect service offerings to improved outcomes. “The beauty of our EMR is that there’s a lot of deep, deep clinical detail. We know what’s happening longitudinally with our patients’ clinical issues. We also know very specifically when we identify an SDOH need and how we intervene,” he says. The third piece of that triangle is around


the cost of care, Miller adds. “We’re lucky enough to have one of the arms of our organization be a payer organization. We get a fair amount of claims data from that. Also, we participate in an ACO and we have a lot of value-based contracts, in which other payers will share downstream costs associated with patients. Socially Determined has some proprietary tools and they helped us formulate what we call a clean room in which we can actu- ally bump all that data up against each other, patient-match very carefully, and then track what happens to a patient from a point of intervention downstream.” They look at both what happens to


patients clinically and what happens from a cost standpoint, driven primarily


6 hcinnovationgroup.com | MARCH/APRIL 2023


around their ED utilization, their admis- sions and readmissions to a hospital and the depth of their connection to their primary care physician. “We’ve seen so much positive downstream impact in that space around cost and better medical outcomes,” Miller notes. All of this research work is critical,


Miller adds, because “if we’re going to ask our clinicians to help connect patients to these interventions, we’ve got to have evidence that shows it is helping them get healthier and/or that we reduced the cost of the care because of the intervention. In cases where we get evidence, we try to scale it up.” Sommerfeld spoke about why


ProMedica created a National Social Determinants of Health Institute. Besides focusing on regional initiatives, the orga- nization is part of several national efforts, including as a founding member of the Healthcare Anchor Network. Also, in 2015, ProMedica joined with the AARP Foundation to form the Root Cause Coalition, which works to reverse and end the systemic root causes of health inequities for people and communities through cross-sector partnerships. “We’re seeing a lot of movement in this


field,” Sommerfeld says. “For many years, only a handful of health systems and pay- ers were active. But now CMS and CMMI are building social determinants into value-based care models and mandates. We’re seeing states requiring screening and connecting for SDOH needs. This is part of how the industry is transform- ing around value-based care. This is truly becoming how we deliver care as a country. We’re seeing this baked into our value-based care contracts.” While previously SDOH was seen as a


stand-alone concept, she adds, “it’s truly becoming table stakes for how we deliver care as a country, which is a great thing. And it’s also going to continue to chal- lenge us to think differently, to be more innovative, and make sure that we have data and technology that’s enabling us to deliver this new care.” The ProMedica executives expressed their


hoped that comprehensive


approach to planning and centering on the social determinants of health with a continuum of effective, replicable solu- tions is a model that can be deployed in other communities and by other healthcare systems to address disparities and empower residents to achieve their highest health potential. HI


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29  |  Page 30  |  Page 31  |  Page 32  |  Page 33  |  Page 34  |  Page 35  |  Page 36