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Melanie Cole (Host): Neighborhood Health Partners brings resources into the communities we serve. We know access to healthcare and resources can be limited, that's why we're committed to caring for people in the neighborhoods where they live. My guest today is Jennifer Snow. She's the Director of Accountable Communities. Welcome to the show, Jennifer. What is Neighborhood Health Partners Program?

Jennifer Snow (Guest): Thanks, Melanie. Neighborhood Health Partners is the program that we started through our Patient-Centered Medical Neighborhoods Initiative, where we really realized that resources to care were limited in underserved communities, so we focused on taking resources into these communities, meeting the patients in the homes where they reside.

Melanie: What kind of resources are you talking about?

Jennifer: Sure. With the Neighborhood Health Partners, we have our care team and also a mobile health clinic that serves these communities. So, our mobile health clinic is basically primary and urgent care on wheels on a bus. It's a 40-foot coach bus that goes out in these neighborhoods led by a nurse practitioner and actually sees the patient. We know transportation is often a barrier, so really getting primary care in these communities is key, especially when we don't have a lot of physician resources in some of these communities. Our Care Team, which actually does home visits for the patients, consists of a team of people. So, we have community help workers, social workers, community paramedics, and even some undergraduate students working through a grant partnership through Clemson University.

Melanie: So, how do you find these patients, Jennifer?

Jennifer: Sure. When we started a couple pilots since I've been with GHS, looking at our emergency room and EMS high-utilizers that often come to the emergency room because they don't have an alternate place to get care, we wanted to work with EMS a little bit differently to see if the patients that were using their services, as well as our emergency room, really lived in the same communities, and what we found is that they did. So, we've identified five fire districts within Greenville County that have the highest emergency room and EMS utilization. We identify the patients after they've used EMS and/or our emergency room and reach out to them to see if they need help finding a doctor, see if they need help figuring out how to access the health care delivery system because it can be confusing. And, also, especially if you are--you know we know access to a physician is limited even if you have insurance, because there aren't enough doctors to go around for everyone--especially if you are uninsured or under-insured, it can be very difficult to get the resources that you need.

Melanie: For those under-insured or uninsured, are these free or low-cost services if the bus comes into their neighborhood? How does that work?

Jennifer: Yes. We've set this model up to be as cost effective as possible. For patients to get home visits, those services are completely free. We've identified them as a patient-in-need and they're followed by that care team. They do things like arrange transportation, go into the home, do home safety assessments. A great example of if you have someone that has asthma that's uncontrolled and their roommate smokes, that care team member can go in there and talk to them about why it's important to smoke outside and change air filters and really take care of the environment. Or, sometimes, it's just arranging transportation, helping set up pill monitors, because patients may not know and understand how to take their medications, and those services are free. Our mobile health clinic provides services at cost and we do our best to try to connect patients to resources that actually can get them medications at a lower cost, we work with multiple pharmacies in the community, and continuing to build on those services.

Melanie: What health screens might be available by the NHP Care Team?

Jennifer: When the care team goes into the home, depending on which member of the care team it is, they could be checking vitals, ordering lab draws if it's a paramedic, actually going in and doing some depression and social determinant screenings, as well, and they really also do a lot of health and insurance literacy. A lot of our patients don't realize how many programs that they qualify for. So, we even help them for insurance applications and trying to get enrolled in SNAP, which is our local food stamp program, or programs for women and children. So, not only do we do health screenings, checking vitals, we also do a lot of care coordination and just trying to connect them to resources and help with applications. We've even actually helped with utility assistance or helping someone get a ramp so they can get in and out of their home easy.

Melanie: And, the NHP Mobile Health Clinic, itself. What's in there? What's in the bus that you utilize for these communities?

Jennifer: Absolutely. The NHP Mobile Health Clinic is a 40-foot coach bus with three exam rooms and it's led by a nurse practitioner whose trained in family medicine. We have a business office representative that actually does all the practice enrollment, helps with ordering labs, and getting things out. And then, our driver, who's also a paramedic, assists the nurse practitioner in caring for these patients and they actually operate just as a primary care and urgent care practice would if it was a building sitting in a community, except for we have targeted community partners, with champions that are from these communities, that help us gain trust and build awareness. One of the communities that we serve is a primary Latino community, and so we have to partner with another program here called PASO, which a program that means "steps" in Spanish and really has helped us build trust in some of these under-served communities. Another program that we do is called “Access Health” and all of our uninsured patients that present on the bus are referred to Access Health for additional assistance. So, they really care for them just like a primary care practice would, but then connect them to the Care Team and Access Health for further care and guidance with care coordination, getting access to care, and getting them enrolled in additional programs.

Melanie: Jennifer, how do you get the Neighborhood Health Partners word out to those underserved communities?

Jennifer: Well, with our Care Team, it's been a little bit easier, because those patients are identified when they present in the emergency room. So, they're already a GHS patient. We've had a social worker most likely talk to them in the emergency room, and then we enroll them in a home follow-up visit. With the Mobile Health Clinic, we've really been relying on our community partners. That's been one of our big lessons learned. If you partner with a faith-based organization or a trusted resource in that community already, that's when you can really get that buy-in and connection. So, we send out fliers, we advertise and post that we're going to be in the community through church bulletins, and then it's also about the site selection. So, if we know we're going to a local partner that provides meals and other assistance on a Wednesday, we'll be more visible in that community, we might be able to help more patients and then, it's been a lesson learning where we see some sites work better than others. But, one thing that we have found is having someone from that community that can be our partner and champion to really help us promote it through a grassroots effort has been more successful.

Melanie: In the last few minutes, Jennifer--what a wonderful program you're involved in--tell the listeners what you really want them to know about the Neighborhood Health Partners program and how they can get involved.

Jennifer: Sure. I think the biggest thing with what I've learned from what we're doing in accountable communities as a whole and through our medical neighborhood intervention, is that it's really the future of healthcare. Health systems haven't been traditionally focused on keeping people healthy and out of the hospital; this is all new. And as we move toward population health management and improving the health of populations at large, doing things like this, going out into the community, using non-traditional healthcare models and staff, for that matter, this is a new work force, is really what's going to help us enable this. We can't wait until patients get sick and end up in the hospital admitted any more. So, this is all the future of population health. Any listeners that know a patient that might benefit from it, we would encourage them to find out more information. It's on our GHS website and we also have a number if you know someone that might benefit and they can call us to actually get...see if they qualify for participation and that would be 864-455-9349.

Melanie: That's 864-455-9349. Thank you so much, Jennifer, for being with us today. You're listening to Inside Health with Greenville Health System, and for more information, you can go to ghs.org. That's ghs.org and you can look up Neighborhood Health Partners. This is Melanie Cole. Thanks so much for listening.