MRT Innovations in Social Determinants of Health Initiative

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Q1 Please provide your contact information below.

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Q2 Please describe your company or organizations overall goals and mission.

It is the mission of Independent Health Foundation to improve the health and well–being of Western New York residents through awareness, prevention, and education programs focused on community health priorities. The Independent Health Foundation is focused on providing the support and resources people need to lead healthy lifestyles–today and in the future. Each year the Foundation offers dozens of programs, seminars and events with the goal to:

• Promote positive healthy changes and behaviors in the community
• Provide appropriate health education and wellness screenings to assist underserved populations
• Empower individuals to become educated health care consumers.
• Collaborate with local schools, community groups and businesses to link the community to appropriate resources, expand our reach and secure funding.

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Q4 Innovation Executive Summary. Please describe the innovation, and how it addresses the social determinants of health. Please identify how the innovation addresses the 6 innovation criteria (i.e. ROI, scalability, feasibility, evidence–based support for innovation, relevance to the Medicaid population and speed to market).

Good for the Neighborhood® (GFTN) is a free, community–based wellness initiative that was implemented in four Western New York communities 2006 by Independent Health Foundation, a 501c(3) community health organization. The program provides resources to people living in at–risk and underserved neighborhoods where access to healthcare is limited due to social and economic barriers. The four main goals of GFTN are to: align people with a doctor, emphasize the importance of physical activity, foster healthy eating habits, and promote smoking cessation or prevent participants from starting. The program encourages families to more effectively manage and improve their health through key program components including free health screenings, conversations with medical experts including pharmacists and registered nurses, a free farmers market, activities for children, and opportunities to speak with community partners about services provided in the area. In 2006, this program served as a novel initiative by adopting a "park & stay" approach at each site: hosting multiple events at each location throughout the year, rather than one–time events with little opportunity for follow–up.

Today, Good for the Neighborhood continues to run at three of the original sites and an innovative Turn–Key program was developed in 2017 as an expansion effort designed to allow and empower additional sites to implement the program in their communities. The Turn– Key program packages together the key components of the original program with the experience and successful history of GFTN and allows the program to be tailored by each site to meet the specific needs of the community they serve.

In the Turn–Key program, each site designates a site director responsible for coordinating GFTN and serves as the main contact for the Independent Health Foundation. Turn–Key sites then commit to one year of programming, with opportunities to extend, where they execute the following program outline and elements:

Good for the Neighborhood Health Promotion events: (2 per year)

• Screenings and Measurements – Health screenings for blood pressure, cholesterol, glucose, Body Mass Index (BMI) from registered nurses.
• Tabling from various community health organizations – Health education and promotion activities aimed at connecting community members with needed services/resources.
• Healthy Activities for Kids – Kids learn about fitness and the importance of good health and nutrition through activities and games
• Healthy goal setting– in an effort to inspire change and increase accountability, Good for the Neighborhood participants are encouraged to take steps toward a healthier life and are rewarded for accomplishing their goals

Good for the Neighborhood Screening–Only: (2 per year)

• In between each Health Promotion event, screening and measurement events are hosted to provide follow–up and additional touch points for participants

Good for the Neighborhood directly addresses health and healthcare related social determinants of health by focusing programming efforts on participants´ access to healthcare and primary care, as well as health literacy. Good for the Neighborhood is able to touch on all three levels of prevention (primary, secondary, and tertiary) in the public health setting. At the primary level, the push for health literacy aims to prevent the onset of disease by providing educational classes and resources to support physical activity, smoking cessation, and healthy eating. Secondary prevention (early disease detection) is accomplished through the provision of health screenings at each event. Tertiary prevention (controlling a disease) is addressed through education and discussion opportunities around disease states, the opportunity to talk with pharmacists, and recommendations for healthy behavior changes.

ROI: The costs required for this program include the costs of health screenings, farmer´s market, and the cost of the program director´s time to run the program. The program typically costs less than $12/participant to run. The cost avoidance in providing needed health resources in these resource–poor communities far outweighs the cost of running the program.

Scalability: By creating a turn–key curriculum and requiring buy–in from the host community, GFTN has been scaled to expand throughout Western New York. Drawing on longitudinal data from the 12+ years of the traditional GFTN programs, the most effective segments of the program have been included to create a successful program in both large and small settings.

Feasibility: Each component of the GFTN program included step–by–step processes to execute the program, while still allowing for customization of the program per community.

Evidence–based support for innovation: In 2011, the Journal of Community Health published The implementation of Good for the Neighborhood: A participatory community health program in four minority underserved communities. Drawing from the work on impacting health care for chronic conditions and research on beneficial approaches with predominantly minority communities (Smedley, B. D., Stith, A. Y., Nelson, A. R., & Institute of Medicine (US). (2003). Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, DC: National Academy Press; US Department of Health and Human Services. (2010). Healthy People. 2nd ed. With understanding and improving health and objectives for improving health, Vol. 2, Washington, DC.), the program was developed in direct response to the needs of underserved communities.

Relevance to the Medicaid Population: GFTN is run in areas that have proven health disparities in accordance with State and County health data. Part of this measure is the number of Medicaid participants in the targeted community. Each aspect of this program is designed with the Medicaid population in mind and to remove barriers to care by increasing health literacy, access to healthcare, removing transportation barriers (by hosting an event in a local setting), and providing an arena for social cohesion.

Speed to Market: There are currently pilot sites running for turn–key GFTN programs. It could be easily shared immediately with other neighborhoods and communities.

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