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Implemntaion Plan (Penn Med CHIP2019) FINAL.Docx
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Community Health Needs Assessment
Implementation Plan
2019-2021
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Community Health Needs Assessment Implementation Plan, Study notes of Public Health
The 2019-2021 Community Health Needs Assessment Implementation Plan of University of Pennsylvania Health System (UPHS). It includes extensive community engagement and focuses on Philadelphia County, which represents Pennsylvania’s largest city in the Commonwealth. The plan is built on the results of the previous Community Health Needs Assessment and includes identifying and prioritizing the health needs of Philadelphia area residents, particularly those who experienced health inequities.
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Community Health Needs Assessment
Implementation Plan
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Date of Written Plan : October 26, 2019
Authors : Members of the Community Health Needs Assessment Steering Committee
Contact : Office of Government & Community Relations (215) 662-
Penn Medicine Mission At Penn Medicine, we are dedicated to discoveries that advance science, to outstanding patient care throughout the world, and to the education of physicians and scientists who carry on our legacy of excellence.
We are a world-renowned academic medical center and strive to improve the health and well- being of people through research, education, clinical care and community service. We are proud of our commitment to service and strive to use discovery and rigorous research to benefit our neighborhoods, our city and our world. We embrace the opportunity to teach others, to learn from our partners, and to care for patients with skill and dignity. The 2019-2021 Community Health Needs Assessment Implementation Plan of University of Pennsylvania Health System (UPHS) represents a multi-campus health system consisting of the following three hospitals within UPHS which are collectively referred to here as Penn Medicine:
- Hospital of the University of Pennsylvania, (EIN: 23-1352685), 3400 Spruce Street, Philadelphia, PA 19104
- Pennsylvania Hospital (EIN: 31-1538725), 800 Spruce St, Philadelphia, PA 19107
- Presbyterian Medical Center of the University of Pennsylvania Health System d/b/a Penn Presbyterian Medical Center (EIN: 23-2810852 ), 51 N 39th St, Philadelphia, PA 19104
Every three years, Penn Medicine conducts a collaborative community health needs assessment (CHNA) to meet IRS regulatory requirements and to identify and prioritize the health needs of Philadelphia area residents, particularly those who experienced health inequities.
The 2019 CHNA is built on the results of the previous Community Health Needs Assessment and includes extensive community engagement which includes: focus groups with community residents; interviews with key stakeholders from community-based organizations that serve special populations; interviews with clinical leadership and staff of Philadelphia Federally Qualified Health Centers; special interviews with hospital patient advisory groups, employees, and other stakeholders; feedback and input with public health departments.
The Penn Medicine 2019 CHNA Executive Summary and Full Report can be found here.
The focus area of the 2019-2021 CHIP is Philadelphia County, which represents Pennsylvania’s largest city in the Commonwealth. Over 1.5 million Philadelphians makeup the City’s population and according to the 2019 Robert Wood Johnson Foundation County Health Rankings Report is ranked last, 67 out of 67, for Health Outcomes, Health Factors, Quality of Life and Social and Economic Factors compared to other counties in the State.
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The Following Priority Areas Will Be Addressed
- Substance/opioid use and abuse
- Behavioral health diagnosis and treatment (e.g. depression, anxiety, trauma-related conditions, etc.)
- Chronic disease prevention (e.g. obesity, hypertension, diabetes, and cardio vascular disease (CVD))
- Maternal mortality and morbidity
- Access to affordable primary and preventive care
- Access to affordable specialty care
- Healthy food access and affordability
- Affordable and healthy housing
- Healthcare and health resources navigation
- Linguistically- and culturally- appropriate healthcare
- Racism and discrimination in healthcare
Community Health Needs not the Focus of this Community Health Implementation Plan but for which Penn Medicine has on-going programming
Penn Medicine has many community-based activities in the community health need areas stated below. There are also other community-based organizations focused on the community health need areas stated below. Given that, Penn Medicine has determined it will not be directly focusing the needs identified below. However, Penn Medicine will continue to work with partners across the University of Pennsylvania and the Philadelphia region to support our collective impact, as we continue to grow and serve the community.
- Sexual and reproductive health
- Socioeconomic disadvantage (income, education, and employment)
- Community violence
- Neighborhood conditions (e.g. blight, greenspace, parks/recreation, etc.)
- Homelessness
Penn Medicine also recognizes the significant importance of addressing the social determinants of health (SDOH) in all settings of care. As this Community Health Needs Assessment Implementation Plan was developed, we carefully considered programs, practices and activities that are currently serving our community and those that continue to grow. To support our efforts, our Center for Health Equity and Advancement has created a system wide task force on social determinants to deploy a new screening tool across UPHS. The tool will initially roll out to primary care and then later scale to other areas.
To reinforce our commitment to the community, we also have launched a robust community health worker program to reinforce our mission and commitment to advancing health. Our community health workers program, known as IMPaCT, is discussed in greater detail later in this report.
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Advancing Care and Community Health by Addressing Social Determinants of Health:
Further, we will continue to grow the Penn Medicine CARES Program which offers support to individuals and programs through quarterly grants and may be used for the purchase of supplies and other resources needed to advance health equity work in the community. Since 2012, more than 500 projects have been funded totaling nearly $550,000. We look forward to continuing the inclusive and creative strategies faculty, staff, and students at Penn Medicine employ to meet community health needs and drive health equity.
Penn Medicine Principles for Community Health Advancement
- Together, our three hospitals will build a common agenda to address the identified community health priorities and share the same vision for change.
- Our work over the next three years will further collect data and create health outcomes measures.
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Philadelphia Ambulatory Health Centers to support care coordination and access to specialty care.
- Healthy food access and affordability: Expand healthy food access programming and growth of partnerships to support place-based food initiatives for vulnerable populations.
- Affordable and healthy housing: Grow programmatic outreach and impact to support home ownership and affordable rental units; development of programs to address healthy housing for vulnerable populations with chronic disease.
- Healthcare and health resources navigation Grow strategies to connect patients to resources including the launch of a web-based services directory in partnership with our CHNA partner institutions.
- Linguistically- and culturally- appropriate healthcare & racism and discrimination in healthcare: Expand Language and Cultural Services programmatic initiatives, including interpretation services, diverse spiritual support, and custom dietary options; growth and promotion of inclusive culture at Penn Medicine; growth of education initiatives to address implicit bias and to provide patient and family centered, culturally effective care. Continuation of system-wise initiatives to reduce unnecessary variations in care by personal characteristics: growth and promotion of inclusive culture at Penn Medicine; growth of education initiatives to address implicit bias and to provide patient and family centered, culturally effective care.
Priority Area #1 Substance/Opioid Use and Prevention
Outcome Measures: Grow programmatic outreach to help reduce substance use overdoses, emergency department visits and deaths related to drugs and opioids.
Hospitals addressing need: Hospital of University of Pennsylvania, Pennsylvania Hospital and Penn Presbyterian Medical Center.
The opioid crisis has severely impacted the Philadelphia community and has been identified by all stakeholders as the number one community health priority. Penn Medicine is committed to addressing the crisis through increasing access to care for Opioid Use Disorder (OUD) treatment, prevention, and community-based programming. We have dedicated significant resources to reduce opioid consumption, treat substance use disorders, and prevent overdoses, and will continue to develop new initiatives for our patients and the communities we serve. Below are programs that Penn Medicine will continue to grow and invest in to address this priority area.
National Academy of Medicine Action Collaborative on Countering the U.S. Opioid Epidemic : Penn Medicine is a committed Network Organization Member of the National Academy of Medicine Action Collaborative on Countering the U.S. Opioid Epidemic. To improve coordination and accelerate the pace of change, the National Academy of Medicine has partnered with the Aspen Institute and more than 100 other organizations to form an Action Collaborative on Countering the U.S. Opioid Epidemic. This one-of-a-kind public-private partnership comprises government, communities, health systems, provider groups, payers, industry, nonprofits, academia, and more – all committed to sharing knowledge, aligning ongoing initiatives, and advancing collective, multi-sector solutions.
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Penn Medicine Opioid Task Force : The Penn Medicine Opioid Task Force was established in 2017 as a system-wide program in response to the nationwide opioid crisis. The principle objectives of the Task Force are to align opioid guidelines across Penn Medicine, reduce the total number of opioid doses prescribed, diminish dependence on opioids, and raise the standard of care for patients with acute and chronic pain. Initiatives led by Penn Medicine’s Opioid Task Force include development of targeted behavioral strategies, including electronic medical records alerts to promote guideline concordant opioid dispensing for patients with acute conditions; routine naloxone co-prescribing for patients at elevated risk of unintended overdose; and controlled medication completion for indicated patients. Through alignment with Penn Medicine’s enterprise-wide ERAS (Enhanced Recovery After Surgery) collaborative, the Opioid Task Force works to identify and promote opioid-sparing approaches to pain management after surgical cases and support evidence-based postoperative prescribing practices. The Task Force also guides on-going evaluation and optimization of pain protocols across every section of orthopedic surgery at Penn Medicine in order to keep the goals of pain management and dependency avoidance at the forefront of each pain management plan. In-development services include a dedicated unit for care of patients with long-term acute care needs related to sequelae of opioid use, such as osteomyelitis and endocarditis.
Center for Addiction Medicine and Policy : In 2019-2020, Penn Medicine will launch a new Center to bolster our already robust response efforts by preventing the development of OUD, offering evidence-based treatments for those suffering from it, and contributing to building a culture of destigmatization by caring for patients with these chronic medical conditions just as we would patients living with diabetes or hypertension.
The Center’s specific focus will be harm reduction policies and addiction treatment initiatives. It will enhance clinical care by providing increased access to treatment initiation and continuity for patients with substance use disorders, improve patient outcomes through research and dissemination of evidence-based strategies, and mitigate the stigma of addiction by promoting education in substance use recognition and treatment. The Center will complement the ongoing efforts to address the opioid crisis by Penn Medicine’s Opioid Task Force. UPHS’ initiatives – which have reduced the number of prescribed opioids by millions of tablets in the past two years
- included the adoption of “enhanced recovery” protocols to reduce opioid use in surgery patients, changes to default settings in electronic health records to encourage prescribers to choose alternative pain management strategies, as well as an alert system that reminds doctors to prescribe naloxone in those less common instances when higher doses of opioids are prescribed.
Center for Opioid Recovery & Engagement (CORE) : Penn Medicine’s emergency departments are at the front lines of this crisis. The CORE (Center for Opioid Recovery and Engagement) provides comprehensive peer support for individuals struggling with opioid use, as well as their loved ones. Our mission is to support all pathways to recovery, remove barriers, and inspire hope.
Treatments for opioid use disorder is evolving and Penn Medicine is a leader in increasing access to evidence-based treatments. Historically, rehab and detox were the standard treatments, but the success rate for these modalities alone is only 5-10%. However, medication-assisted treatment
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using Free Library branches for monthly “Narcan giveaway days,” to distribute free naloxone to community residents. We will continue to support the development and implementation of evidence-based trainings for overdose reversal and the distribution of naloxone.
Center for Health Incentives and Behavioral Economics Naloxone Work : Based on interview data from the library-based naloxone trainings, we identified behavioral barriers and facilitators to naloxone acquisition and carrying following a training. Using this “behavioral diagnosis,” we conducted two sequential pilot randomized trials, testing training enhancements that address those barriers using strategies such as commitment pledges and plans, framing, and tailored text message nudges. The goal of this study is to develop novel evidence-based interventions to increase naloxone uptake. In addition to the 140 participants our team trained to use naloxone during the study, we trained over 130 non-study participants, including staff at the Center for Healthcare Innovation, Student Health Services, and medical students.
Philly Respond : To raise public engagement in overdose prevention, faculty, staff and students from the Perelman School of Medicine of the University of Pennsylvania and the Center for Public Health Initiatives work with the Philadelphia Inquirer to lead Philly Respond--a project that incorporates community storytelling, visual images, and data analysis to shift social norms and reduce the stigma surrounding SUD. The Mission of Philly Respond is to reduce the toll of the overdose crisis by empowering Philadelphia citizens to carry naloxone and reverse overdoses. Philly Respond maintains a publicly available calendar of naloxone trainings, maintains an FAQ page on naloxone, and provides information on where to get naloxone. We also feature Story Slam, storytelling events where participants share stories about their personal experiences with naloxone in Philadelphia with the goal of using stories to engage Philadelphians to carry and use naloxone, to be part of our community’s collective action to halt overdose deaths in our city.
The Bethesda Project : The University of Pennsylvania School of Nursing and Penn Medicine provide training to Bethesda Project staff on naloxone rescue for opioid overdoses. The intensive workshop includes a simulation training in the recognition of signs and symptoms of opioid overdoses and administration of intranasal naloxone. Over 50 staff and volunteers have completed the training with 75% of participants reporting a moderate to exceptional advancement in nine knowledge and competency areas. We will continue to support the Bethesda Project and their training needs.
Prevention Point Philadelphia (PPP) : Penn Medicine is working with long-standing community organizations that care for individuals with substance use disorders. The mission of PPP is to promote health, empowerment, and safety for communities affected by drug use and poverty. Penn Medicine will continue this work allowing us to provide more addiction counseling services, case management, free and clean needle exchange, legal series and overdose prevention and reversal training. Faculty and residents from the Department of Family Medicine and Community Health are part of the care team at PPP and will continue to provide care for individuals with substance use disorders. In addition, Perelman School of Medicine students will
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continue to volunteer at Prevention Point to support their care team and increase the number of community members who are served.
Mothers MATTER : Penn Presbyterian Medical Center and Maternity Care Coalition work together to increase access to MAT for pregnant women with OUD. As rates of maternal opioid use have surged over the past decade, so too have rates of adverse pregnancy outcomes. In fact, opiate use is associated with a six-fold increased risk for miscarriage, prematurity, delayed infant neurological development, and neonatal abstinence syndrome (NAS). Mothers MATTER offers comprehensive, compassionate care for pregnant and postpartum women whose lives have been impacted by opioid dependence. The program aims to reduce post pregnancy relapse rates by addressing social and psychological barriers to rehabilitation, which can complicate treatment for opiate dependence. Patients are screened by specialists and connected to behavioral health services and support they might need both during and after pregnancy.
Priority Area #2 Behavioral Health Diagnosis and Treatment
Outcome Measures: Increase community provider partnerships and services for behavioral health patients, primary care and specialty care patients to expand access.
Hospitals addressing need: Hospital of University of Pennsylvania, Pennsylvania Hospital and Penn Presbyterian Medical Center.
Behavioral health impacts thousands of Philadelphia residents and behavioral health care has been siloed and not well integrated with the larger health care system. More than 25% of adults in the United States experience some type of behavioral health disorder each year, according to the Centers for Disease Control and Prevention. While 29% of adults with a medical condition also have some type of mental health disorder, close to 70% of behavioral health patients have a medical co-morbidity.
Both conditions often exacerbate each other in a cycle of need and demand for one another, heightening the risk of that person with a chronic disease will develop a mental health disorder conversely. As providers look to design new models of care to treat patients mind, body and spirit, Penn Medicine continues to implement programs to address behavioral health care needs. Below are programs that Penn Medicine will continue to grow and invest in to address this priority area.
Primary Care Service Line Integrated Behavioral Health : Providing addiction and other mental health care in the primary care setting has been demonstrated to reduce health care costs, improve function and symptom outcomes for patients, and improve provider satisfaction. Collaborative care models have proven to be successful across the United States. The model has been shown to control costs, improve access to mental health care, improve clinical outcomes, and increase patient satisfaction in a variety of primary care settings – rural, urban, and among veterans. Collaborative care is also known to increase response to mental health and substance use treatments by 60 percent.
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Early Childhood Program Hall-Mercer CMHC recently partnered with the Penn Center for Mental Health to bring Autism Services to children 3-5 years old. The Early Childhood Program serves as a therapeutic preschool for children who struggle with emotional and behavioral regulation, social communication skills, and play skills – making it difficult for them to learn in a traditional school environment. The program has the capacity to serve 32 children daily.
Child and Family Mental Health Services provides mental health evaluations and treatment to children and adolescents age 3-18 and their families, who are residents of Philadelphia.
Children’s Community Based Service Department was established to bring together the community-based children’s service programs that provide clinical and case management services in the community to children and their families. The department is made up of Children’s Blended Case Management and Home- School Connection. The range of services includes clinical evaluations and referrals, individual and group therapy, family meetings, crisis intervention and case management services. These programs service children and adolescents. The range of services provided in the schools includes clinical evaluations and referrals, case management services, behavioral therapeutic services and groups.
PHIICAPS (Philadelphia Intensive In-home Child and Adolescent Psychiatry Service) provides intensive family treatment and case management to 40 families at a time. The child or adolescent is identified to be severely emotionally disturbed and at risk of hospitalization or out of home placement. Modalities include individual and family therapy and case management in the home, environment and school domains. PHIICAPS has 2 teams, each made up of 1 Master’s level Clinician and 1 Bachelors level Mental Health Worker.
Behavioral Health Intellectual Disabilities programs provide an array of services to adults with intellectual disabilities and their families to support individual choice, community involvement, and use of traditional and natural resources. These include the Intensive Services Case Management Program (ISCM) and the Community Day Training Program for adults. The ISCM program is a city-wide program which works in collaboration with the Philadelphia Office of Intellectual Disabilities (IDS) to provide emergency supports coordination to adults with intellectual disabilities living in all catchment areas. The program operates 24 hours a day, 7 days per week and responds to emergency situations such as emergency placement due to abuse, neglect or death of a caregiver, moving individuals from substandard living conditions into a safe living environment. The ISCM program also assists underserved individuals in the community to become registered and receive services through IDS. The Community Day Training Program provides psycho- social habilitation services, behavioral shaping and supportive counseling services to adults diagnosed with intellectual disabilities and mental illness.
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Services are designed to promote the development of optimal community adjustment and integration.
Adult Mental Health Services provides comprehensive outpatient mental health services in Center City, South Philadelphia and surrounding areas. Specific services include crisis intervention, evaluation, psychotherapy, pharmacotherapy, and social rehabilitation. Emphasis is on providing all persons who have severe and chronic mental illness with outstanding care in a pleasant environment and respectful manner.
Access Intensive Case Management is a targeted case management program which serves adults recovering from severe mental illness with possible co- occurring substance abuse issues. Many participants authorized to this program are homeless or may have a history of being homeless. A team approach and recovery-based model is used to connect participants with supportive services which encourage daily stability and reduced psychiatric hospitalizations.
Blended Case Management (BCM) participants require less intensive case management services than those enrolled in Access. A team approach and recovery-based model is used to connect participants with supportive services which encourage daily stability and reduced psychiatric hospitalizations. Hall Mercer also offers a Southeast Asian Blended Case Management program which provides BCM to adults who speak Cantonese, Mandarin, Vietnamese, Khmer, or Lao. Case managers in this program provide English interpretation to help participants connect to public benefits and other community supports.
Prevention and Recovery Services (PARS) is a 90-day service which serves adults recovering from severe mental illness with possible co-occurring substance abuse issues. Many participants in this program may have a history of homelessness. Case managers, through a team approach and recovery-based model, provide rapid intervention to assist individuals with connecting to supports which will allow them to reach the highest level of independent functioning possible.
Services at The Philadelphia Juvenile Justice Services Center (PJJSC) Hall-Mercer provides behavioral health services at the Philadelphia Juvenile Justice Services Center (PJJSC). The clinical team at the PJJSC provides adjustment/crisis services, individual therapy for youth with extended length of stay, and psychiatric evaluation and medication management.
Healthy Minds Philly/Check-up from the Neck-up is a program that emphasizes that a healthy mind is as important as a healthy body. Hall-Mercer partners with the Philadelphia Department of Behavioral health and Intellectual disability Services to provide community-based mental health screening, education, and resources.
Priority Area #3 Chronic Disease Prevention
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assist the community in combating these risk factors along with increasing the awareness of stroke symptoms.
Walk with a Future Doc (WWFD) : This place-based program aims to promote physical activity and promote well-being in neighborhoods, targeting obesity, hypertension, and diabetes. Penn's Center for Public Health Initiatives, in partnership with medical students from the Perelman School of Medicine, created one of the first WWFD chapters in the country. These biweekly walks start with a short talk from a medical student on a relevant health topic, followed by a brief Q&A session. The one-hour walk around the neighborhood is very informal, and during the walk, medical students talk with the participants about health topics related to chronic disease. The Perelman School of Medicine faculty and medical staff of the Penn Medicine hospitals mentor the medical students and provide oversight for the educational content.
Community-Academic Partnerships to Increase Physical Activity (CAP-IPA) and Dance for Health : The University of Pennsylvania School of Nursing’s student-led Community Champions program—which comprises 15 initiatives—brings Nursing students out of the classroom and into the greater Philadelphia community to share their skills and learn from their experiences. The Community Champions program is the vehicle by which the School of Nursing promotes healthy lifestyles and provides community members across the lifespan with health screening and information about nutrition and diet, physical activity, newborn care, breast cancer awareness, and sexual health. One program, Dance for Health, is a program for all ages that has engaged over 1,000 community members, four sites and offers free dance fitness classes aimed to empower community members. Classes are offered in concert with local community organizations.
Priority Area #4 Maternal Morbidity and Mortality
Outcome Measures: Increase programmatic outreach and impact to reduce maternal and infant morbidity.
Hospitals addressing need: Hospital of University of Pennsylvania, Pennsylvania Hospital and Penn Presbyterian Medical Center.
Pennsylvania ranks 16th^ in the nation in maternal mortality and Philadelphia still reports a maternal mortality rate of 27.4 deaths per 100,000 live births, which is worse than the rate of all but six states. To strengthen our efforts in this area, we will continue to grow services, increase care coordination and post-partum surveillance. Below are programs that Penn Medicine will continue to grow and invest in to address this priority area.
The Heart Safe Motherhood Program : For women that have been diagnosed with preeclampsia during their pregnancy, clinical recommendations encourage new moms to schedule a follow-up visit with their doctor within a week of delivery to have their blood pressure check. For many women, coming to coming to the office after having a newborn is difficult for a variety of reasons. This program is a first-of-its-kind text-message based program that makes postpartum blood pressure monitoring more convenient for women diagnosed with preeclampsia and other blood pressure disorders during pregnancy and promotes communication with their care team without visiting a doctor’s office.
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Obstetrics Care at Philadelphia Federally Qualified Health Centers (FQHC) : Despite Penn Medicine’s extensive network of inpatient and outpatient clinical services and partnerships, access issues to women’s health services persist in our catchment area. To respond to this need, clinicians from the departments of Family Medicine and Community Health, and Obstetrics and Gynecology have established partnerships with FQHCs in West Philadelphia to provide timely prenatal care, family planning services, screening for cancer and sexually transmitted diseases including HIV, and urgent and emergency obstetric care. As a result of this partnership, 280 deliveries in the past year alone were facilitated through this partnership.
Safe Sleep Awareness for Every Well Newborn (S.A.F.E.) : The University of Pennsylvania School of Nursing received a three-year grant from the Pennsylvania Department of Health to design and innovate a new program model for promoting safe sleep practices for newborns. To take our commitment further, the School rolled out the model to the Penn Medicine hospitals, as well as its community partners, community organizations and provide continuing education to cascade this important research.
Dickens Center for Women’s Health : The Helen O. Dickens Center for Women in the department of Obstetrics and Gynecology is committed to providing personalized care to women of all ages, fulfilling Penn Medicine’s philosophy of serving the community. Dr. Dickens was the first female African American doctor to become board certified in obstetrics and gynecology in Philadelphia as well as the first to be named a fellow of the American College of Surgeons. She worked to educate young women about their reproductive health in order to reduce the incidence of teen pregnancy and sexually transmitted diseases. The Dickens Center serves mainly Medicare, Medicaid and uninsured patients. Penn Medicine offers uncompensated and undercompensated care for those who qualify, based on financial counseling. The Center offers prenatal care, gynecology and colposcopy services. The Center has established working relationships and programs with city and community agencies, state-funded programs and managed care organizations, to ensure that women have access to the services that fit their educational, financial and psychosocial needs. The Center also provides care at the Philadelphia Department of Public Health’s Health Center 3 and offers consultations and care for women with complex medical and obstetric conditions or fetal anomalies. The Center’s integrated high-risk program combines care coordinators, physicians and nurse practitioners allowing us to provide a unique level of continuity for our patients.
Penn Maternal Fetal Medicine for High Risk Pregnancy : Obstetricians and midwives can care for most women during pregnancy. However, sometimes having a baby is more complicated. A pregnancy is considered high risk when there are potential complications that could affect the mother, the baby or both. Penn Medicine Maternal Fetal Medicine specialists work to evaluate diagnose and monitor high-risk pregnancies and develop initiatives.
Penn Prematurity Prevention Program is dedicated to reducing preterm births across the Philadelphia community. Premature babies are at increased risk for newborn medical complications and face an increased risk of lifelong health problems. A premature delivery occurs before a mother has completed her 37th week of pregnancy. In the United States, about 12.8 percent of babies (more than half a million a year) are born
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Healthy Woman Program (HWP) is a Pennsylvania state-funded program that provides free cervical cancer and breast screenings (including pelvic examinations, clinical breast examinations, and Pap smear testing and diagnostic services) to uninsured women between the ages of 21-64.
Tobacco Smoking Cessation is offered in an effort to decrease tobacco smoking rates among pregnant women and mothers. Each LCWH nurse is certified by the Health Federation of Philadelphia in partnership with the Philadelphia Department of Health to provide counseling on smoking cessation and reduction in exposure to environmental smoke.
Priority Areas #5-6 Expanded Access to Affordable Primary Care and Specialty Care
Outcome Measures: Increase care coordination and navigation for medically complex patients using social determinants of health screen; growth of Connected Health, our range of telehealth services include virtual visits, virtual consultations and remote second opinions in a variety of specialties; growth of partnerships with Federally Qualified Health Centers and Philadelphia Ambulatory Health Centers to support care coordination and access to specialty care.
Hospitals addressing need: Hospital of University of Pennsylvania, Pennsylvania Hospital and Penn Presbyterian Medical Center.
UPHS will continue to expand access to primary care and specialty services in and outside of our direct catchment area by increasing coordination of services across Penn Medicine care networks, and in collaboration with community partners. Below are programs that Penn Medicine will continue to grow and invest in to address this priority area.
Primary Care Service Line : Since our FY16 implementation plan, Penn Medicine has established a Primary Care Service Line (PCSL) to advance collaboration between family medicine and internal medicine clinical services across the enterprise. We continue to measure and coordinate operational efforts to develop strategies for growth in our areas of greatest need. For example, in 2017, the Department of Family Medicine and Community Health increased access to primary care in South Philadelphia by opening the Penn Family Medicine practice at Pennsylvania Hospital (PAH). This site provides both family medicine, and non-operative sports medicine, including muscular skeletal (MSK) ultrasound services. The practice has grown to over 3,000 active patients, and regularly accepts new patients from the Penn Urgent Care site in South Philadelphia. The practice has also developed a strong relationship with the emergency department at PAH to ensure that patients who are at-risk for readmission have an opportunity to establish a primary care home.
Community Clinic/Provider Partnerships : For families and individuals who live in areas of the city where access to medical services is limited — and in many cases, nonexistent — a trip to the doctor can mean traveling across the city for basic care. To increase access of affordable
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primary and specialty care outside of Penn Medicine’s medical campuses, we will continue to engage with community-based partners to deliver care in areas with limited access and resources. Attending and resident physicians from the Departments of Medicine and Family Medicine and Community Health will continue to provide primary care health education, and health-related social services to members of the community regardless of their ability to pay. Our clinicians and learners provide care in many community-based settings including four FQHC partners across the city, the Philadelphia Department of Public Health’s Ambulatory Health Centers, Prevention Point Philadelphia, and at Puentes de Salud, which focuses on the wellness of the Latino immigrant population in South Philadelphia, with over 10,000 patient visits per year.
In addition to providing primary care, Penn Medicine will continue to grow our cancer screening programs at FQHCs and ensure that patients have immediate referral care coordination to our hospital campuses. This effort builds on an existing partnership with the American Cancer Society that hosts free mammogram clinics, part of the Penn Medicine Breast Health Initiative, and cervical cancer screenings to uninsured or underinsured women in our community.
Dr. Bernett L. Johnson Jr. Sayre Health Center (SHC) : Answering a dual mission to provide quality clinical care to all residents regardless of ability to pay and also provide health services education high school students, undergraduate, graduate and professional students, The University of Pennsylvania and Penn Medicine partnered with the Philadelphia School District’s Sayre School to establish the SHC in a medically underserved community in West Philadelphia. SHC is a full-service, primary care health facility located at 59th and Locust Streets, behind Sayre High School, in the Cobbs Creek neighborhood of West Philadelphia. The Center has been serving the needs of area residents since the summer of 2006 and its services are designed to be sensitive to patients’ needs, to inspire trust and engagement, and to be accessible to the most vulnerable and underserved members of its catchment area. The Department of Family Medicine and Community Health has physician service contracts to provide executive leadership for an interdisciplinary training program at SHC, supporting the Medical Director, and Director of Graduate Nursing for the site. The SHC has been recognized for its high adolescent immunization rates that exceed 95% for several vaccines. Additionally, SHC has one of the lowest missed vaccination rates in the City of Philadelphia and achieved one of the highest influenza vaccine uptake rates among African Americans. The University of Pennsylvania’s School of Dental Medicine, Division of Community Oral Health provides dental care at SHC, bringing a much needed access point for the community.
The Pavilion : The Hospital of the University of Pennsylvania’s new state-of-the-art hospital facility, slated to open in 2021, will increase access to specialty care for patients, enhance opportunities for collaborative care delivery, and advance telemedicine functionality that allows for remote monitoring and consultations between patients and their care teams.
Penn’s School of Dental Medicine (PSDM) : PSDM is committed to improving oral health for our community and operates a number of programs for patients traditionally underserved by dentistry, such as low-income adults and children, including pre-school and school age children, elderly, and those patients with medical complex conditions. The Penn Dental Clinic exists to provide access and low-cost dental care to Philadelphia residents. Every year the clinic continues to grow access to affordable dental care through its teaching clinics. PSDM operates the Penn