2020 Principles for Community Health Care Report
NAME OF ORGANIZATION: Swedish Hospital
CONTACT: Ashley Tsuruda, Director of Development, Foundation and Corporate Relations
ADDRESS: 5145 N California Ave, Chicago, IL 60625
PHONE/EMAIL: 773-878-8700 x1070 / atsuruda@schosp.org
MISSION OF THE ORGANIZATION: To provide a continuum of excellent healthcare services. The hospital is dedicated to serving the physical, psychological and spiritual needs of its culturally diverse community.
- Identify the high risk/underserved and/or disadvantaged populations in the community(ies) that you serve and describe specifically the actions you have taken, based on relevant assessment data, to increase their accessibility to health services.
Swedish Hospital, located on the North side of Chicago, is a State of Illinois Safety Net Hospital located in a federally designated Health Professional Shortage Area and Medically Underserved Area. Swedish Hospital’s mission is to provide a continuum of excellent healthcare services to Chicago’s north and northwest sides. The hospital is dedicated to serving the physical, psychological and spiritual needs of its culturally diverse community. As of January 2020, Swedish Hospital is now part of the NorthShore University HealthSystem.
Swedish Hospital offers a wealth of medical and wellness services, including cancer, cardiac, surgical, and emergency treatment; family medicine, and obstetrical programs; psychiatric services, rehabilitation, critical care, and a range of integrative therapies. Additionally, Swedish Hospital operates numerous community programs, including a Diabetes Community Center, a Community Breast Health Program, a Chronic Disease Care Transitions Program, a Cancer Survivorship Program, and the Pathways Program (formerly called the Violence Prevention Program), as well as others. Each year, Swedish Hospital sees approximately 13,000 admissions, 50,000 emergency department visits, and 290,000 outpatient visits.
Swedish hospital, located in Chicago’s Albany Park neighborhood, serves a diverse patient population including immigrants and refugees from more than 60 nations. Of the over 300,000 individuals served by the organization last year across inpatient and outpatient services, 42% of patients were White, 27% Hispanic, 20% Asian, 7% African American, and 4% other. Among all of these patients, over 80 languages were spoken. Swedish also serves a large portion of patients with financial barriers to care. Across inpatient and outpatient services in the last year, 53% of patients were on Medicare, 28% were on Medicaid, and 8% of patients were uninsured. This data illustrates that our patient population is not only culturally- and linguistically-diverse, but comes from a variety of socio-economic backgrounds that present unique challenges to medical access. Therefore, Swedish Hospital’s community programs and ability to provide financial assistance for underserved populations is critical to the community’s health. Meeting the needs of community members who are underserved due to financial and culturla barriers has always been core to the hospital’s mission. To reduce linguistic and cultural barriers to care, SH recruits, trains, and hires a highly diverse medical staff. Hospital staff represents more than 50 nationalities and speak over 55 languages. SH also employs Spanish, Korean, and Russian language interpreters and offers telephone translation services in over 180 languages. The hospital collaborates with numerous community agencies and groups to meet the needs of its multi-ethnic service area.
Swedish Hospital maintains a department dedicated to addressing its outreach objectives of serving the entire community, not only those who come through its doors. Building on a long tradition of service, the Community Relations Department utilizes hospital strengths alongside those of other well-established community partners. This strategy allows Swedish Hospital to better understand and reach the most vulnerable sectors of the community, while meeting pressing healthcare needs. The goal is to improve the community’s health status by empowering citizens to make healthy life choices.
To this end, Swedish Hospital and members of the Alliance for Health Equity (AHE), a collaborative of over 30 hospitals, 7 health departments, and 100 community partners, worked together to build the 2019 Community Health Needs Assessment (CHNA) in Chicago and Cook County. Using the Mobilizing for Action through Planning and Partnerships (MAPP) model for the CHNA, AHE emphasized the importance of community engagement, partnership development, and the dynamic interplay of factors and forces within the public health system. AHE chose this inclusive, community-driven process to leverage and align with health department assessments and to actively engage stakeholders, including community members, in identifying and addressing strategic priorities to advance health equity. As a result, the following health needs have been identified and will be prioritized within our community for FY20-22: 1) Addressing Social and Structural Determinants of Health, including Violence, Trauma and Community Safety, Conditions that Support Healthy Eating and Active Living and Housing and Neighborhood Environment ; 2) Addressing Chronic Conditions: Risk Factors, Prevention and Management, including Diabetes, Heart Disease and Hypertension, Obesity and Cancer; and 3) Improving Mental Health by Enhancing Access to Resources and Services. SCH will continue to partner with members of AHE and other key community partners within our service area to leverage existing resources and develop strategies which contribute to improving the most pressing health needs of our communities. Primary data for the CHNA was collected through four methods: 1) community input surveys; 2) community resident focus groups and learning map sessions; 3) health care and social service provider focus groups; and 4) two stakeholder assessments led by partner health departments – Forces of Change Assessment and Health Equity Capacity Assessment.
- Describe specifically the strategies you have used to gather input from high risk, underserved and/or disadvantaged population and their leaders as a basis for program or service development.
Swedish Hospital uses focus groups, surveys, patient satisfaction questionnaires, key informant interviews, and advisory boards to gather critical input from community residents and leaders to guide service design. For instance, in developing the 2019 CHNA, Swedish Hospital worked closely with the AHE and community based organizations that are members of the Swedish Hospital Community Leader Program to collect in-depth community input data through a community input survey and focus groups. We collected 763 surveys and conducted 8 focus groups with residents from the Swedish Hospital service area as well as 3 focus groups with healthcare and social service providers.
In addition, Swedish Hospital utilizes community advisory boards to inform program design and ensure alignment with community needs. For example, the hospital’s Violence Prevention Program coordinates a community working group comprised of representatives from local law enforcement, the State’s Attorney’s office, and Swedish Hospital providers and staff, as well as staff from program partners including the Salvation Army STOP-IT Program, Resilience, and the Cook County Task Force on Human Trafficking, as well as several domestic violence agencies, including Between Friends, KAN-WIN, Apna Ghar, and The Network: Advocating Against Domestic Violence. This group meets about three times per year to review program outcomes and discuss challenges and plans for future development.
These examples demonstrate the commitment of Swedish Hospital to engage and gather input from underserved, high-need community members and partner organizations serving these populations to guide program design and implementation across the hospital.
- Describe specific partnerships with other providers and community-based organizations to promote continuity of health care for high risk/underserved and/or disadvantaged populations.
Swedish Hospital partners with a wealth of community-based organizations committed to serving some of the City’s highest-need, most vulnerable populations. The hospital works with a variety of organizations serving the diverse populations within Swedish Hospital’s service areas facing a variety of barriers to accessing health care. Swedish Hospital is proud to partner with more than 50 organizations throughout the community and is committed to improving the health and wellness of our neighbors through these collaborative relationships. Key onsite partners include Erie Family Health Center (an FQHC providing health service for those in need and serving as the clinical training site for Swedish hospital family medicine and internal medicine residency programs) and Lutheran Social Services of Illinois (an organization that provides mental health and substance abuse treatment via the Welcoming Center and Project Impact).
Central to the Community Breast Health Program is the hospital’s long-standing relationships with more than 15 community partner organizations serving diverse cultural groups that live in the neighborhoods surrounding Swedish Hospital, including federally qualified health centers, volunteer-staffed free health clinics, and organizations that provide a broad range of health and social services such as the HANA Center, Centro Romero, Vietnamese Association of Illinois, Chinese Mutual Aid Association, and others. Through these partnerships, Swedish Hospital is able to build upon the trusting relationships our community members have with these organizations to provide access to care that is compassionate, high-quality, and culturally-relevant. Collaborating agencies screen clients for program eligibility (i.e., ensuring that women referred for free screening and diagnostics are low-income and uninsured/ underinsured), refer eligible women to the program using a standardized program referral form, and work with Swedish Hospital breast health navigators to ensure the timely communication of testing results and follow-up care.
The Pathways Program (formerly called the Violence Prevention Program) works closely with partner agencies to inform assessment protocols, train staff and refer patients to available resources. The Pathways Program coordinates a community working group comprised of representatives from local law enforcement, the State’s Attorney’s office, and Swedish Hospital providers and staff, as well as staff from program partners including the Salvation Army STOP-IT Program, Resilience, and the Cook County Task Force on Human Trafficking, as well as several domestic violence agencies, including Between Friends, KAN-WIN, Apna Ghar, and The Network: Advocating Against Domestic Violence. Swedish Hospital partners with the Salvation Army’s STOP-IT Program to provide assistance to human trafficking survivors as well as training for medical staff on response protocols when trafficking victims present to the hospital. Swedish Hospital has a long-standing relationship with Resilience to provide medical and legal advocacy in the emergency department for sexual assault survivors, as well as assist with policies and procedures related to working with sexual assault survivors. Swedish Hospital is also part of the Multi-Disciplinary Response Team (MDT) convened by the Cook County State’s Attorney’s Office’s Sexual Assault Advisory Group. The Pathways Program also partners with four agencies working to address the needs of domestic violence survivors in the Swedish Hospital community. The Network: Advocating Against Domestic Violence works with the program related to their Medical Response Collaborative involving area hospitals. Swedish Hospital also partners with Apna Ghar (a domestic violence organization serving immigrants and refugees), KAN-WIN (a domestic violence organization primarily serving Asian Americans and recent immigrants), and Between Friends (a domestic violence organization in Rogers Park). These organizations work closely with the Pathways Director through participation in our work group, design of revised screening and response practices, training employees, collaboration with local police districts, and participating in Domestic Violence Awareness Month activities on the Swedish Hospital campus. The Pathways Program advocate also provides direct referrals to these organizations for patients in need of services related to their experience with domestic violence.
- Provide two examples of how you have used the community-oriented approach to program development specified in the attached principles to develop a program of service for high risk/underserved and/or disadvantaged populations specified in the guidelines. Include in each description components of the current program and the following quantitative information for the most recent year available:
Example 1: Care Transitions Program:
The Care Transitions Program is designed to follow a community-oriented, evidence-based approach to addressing the needs of Swedish Hospital’s most vulnerable populations. It delivers a spectrum of services, including disease management coaching, home visits, telephone follow-up, coordination of care, and, for those most at risk, home telehealth monitoring, for 1-3 months post-discharge. These services are intended to help patients take control of their health —increasing care compliance and patient motivation. The program’s unique multi-level, multidisciplinary approach fills a critical gap in care because it targets high risk patients returning home who are either uninsured or do not meet the strict Medicaid/Medicare eligibility criteria to receive home health services, and would therefore not have access to these services otherwise. Patients served by the program receive health education and services intended to empower them to make long-term, positive changes in their health and chronic disease management. These strategies are intended to improve patients’ quality of life and reduce hospital readmission rates.
Patients with chronic diseases are screened for readmission risk before discharge and those at high risk receive a referral to the program. Each patient in the program receives an intake assessment, program orientation, and matched with the service level best suited to his or her needs. Basic Care Transition Services (four hours) include a home visit and three telephone calls in the month following discharge. Services focus on: post-discharge physician follow-up, medication regiment understanding and compliance, and CD self-management coaching. Patients requiring a higher level of care receive Advanced Care Transition Services (ACTS), which span three months and include, as needed, nutrition or diabetes interventions, daily home tele-monitoring, and coordination of care. Patients receiving ACTS receive 10 – 25 hours of service. Patients at highest risk for readmission also receive three home visits from the Wellness Coach, daily tele-monitoring (utilizing wireless equipment to collect patient health data), and care management. Currently patients experiencing malnutrition or identified as at-risk are referred to the program’s Dietitian, who makes three home visits as well as three follow-up telephone calls, focused on nutrition assessment and development of a customized nutrition plan, nutrition counseling tailored to the patient’s health literacy level, and monitoring of patient progress. Patients are also provided a 6-week supply of nutrition supplements. Patients with uncontrolled diabetes are referred to the Certified Diabetes Educators, who makes three home visits and three follow-up telephone calls, focused on helping patients understand the disease and its risks, and coaching patients to manage their diabetes through prescribed medication usage, regular blood sugar monitoring, diet, and other lifestyle changes. As needed, patients are provided glucometers, test strips and lancets for testing blood sugar levels.
Since the program’s inception, the program has served over 2,500 patients, and 30-day readmission rates for patients with CD have decreased significantly, from 27% to 10.5%. Furthermore, since the program’s inception in 2011, the overall 90-day readmission rate for CD patients has decreased 20 percentage points, from 35% to 15%.
1. Number of clients served: 820 patients in FY2020
2. Total amount budgeted by your organization for the program: $395,000
3. Percent that program budget is of total agency budget: less than 1%
4. Percent of program budget that is directly reimbursed by third party payers: 0%
5. Percent of program budget that is covered by public/private grants: 11%
Example 2: The Pathways Program (formerly called The Violence Prevention Program):
As part of its Women’s Health Initiative, Swedish Hospital created the Pathways Program (formerly referred to as the Violence Prevention Program) in early 2015 to strengthen its capacity to identify and respond to women, men, and children who are victims of domestic violence, sexual assault and human trafficking. In a 2012 community health needs assessment of Swedish Hospital’s service area, 15% of women surveyed reported having been hit, slapped, pushed, kicked or hurt by an intimate partner in their lifetime. In focus groups conducted as part of the needs assessment, community residents and leaders noted that violence against women is under-reported, particularly in immigrant communities, due to stigma and fear of deportation. Swedish Hospital is in a unique position as a key “first responder” because of our local community ties. The role afforded our medical professionals allows them to see a woman alone and to become privy to highly sensitive information.
Since its inception, the program has built on a number of policies and resources that were already in place to guide medical staff and assist victims of domestic violence and sexual assault. These include a long-standing partnership with Lutheran Social Services of Illinois whose mental health and substance abuse crisis counselors are embedded in the emergency department 24 hours a day as part of Project IMPACT, and a partnership with Resilience that deploys advocates to assist victims of sexual assault in the emergency department. Since launching the program we have officially adopted a hospital protocol for identifying and responding to human trafficking. We have also formalized a relationship with the Salvation Army’s STOP-IT Program to provide staff training to identify and assist victims of human trafficking. Swedish Hospital is one of two hospitals that sit on the Steering Committee of the Cook County Task Force on Human Trafficking. Since the program’s inception, the Pathways Program has served more than 1,500 survivors of domestic violence, human trafficking, and sexual assault.
Specific to domestic violence, the program has developed partnerships with The Network: Advocating Against Domestic Violence and three north-side domestic violence agencies identified as a good match for our patient demographics. These include Apna Ghar, serving immigrants and refugees from Asia, Africa and the Middle East; KAN-WIN, serving Korean and other South East Asian women; and Between Friends which offers services in English, Spanish, French and Arabic. All of these agencies offer free and confidential services to domestic violence victims including a crisis hotline, counseling and support services, court advocacy, prevention services, healthcare education, and community outreach. These agencies, together with our human trafficking and sexual assault community partners, collaborate with Swedish Hospital in a Work Group to design revised Swedish Hospital screening and response practices, train providers, and collaborate with local police districts.
The program utilizes a three-pronged approach to identify, assess and respond to violence:
- Medical provider identification: Train medical providers to understand the complexity of violence, screen for and respond to patient disclosures of violence, and respond appropriately.
- Patient assessment: Connect patients with on-site services to assess immediate needs, assist with safety planning and refer to additional community resources.
- Referral to community based-organizations: Work closely with community partner agencies to connect patients with comprehensive, culturally-relevant resources.
1. Number of clients served: In fiscal year 2020, the Pathways Program served 296 survivors of domestic violence, sexual assault and human trafficking. The Pathways Program increased the hospital’s capacity to provide forensic services to sexual assault survivors substantially, increasing the number of Sexual Assault Nurse Examiners (SANE) from 3 to 8 over the course of the fiscal year. Additionally, the Pathways Program trained 371 medical providers and staff.
2. Total amount budgeted by your organization for the program: $453,000 (FY20)
3. Percent that program budget is of total agency budget: less than 1%
4. Percent of program budget that is directly reimbursed by third party payers: 0%
5. Percent of program budget that is covered by public/private grants: 85% (FY20)