Essentia Health has won a national quality excellence award for its work reaching patients who need help with things that can affect their overall health, such as a lack of housing or food.
The National Association of Accountable Care Organizations gave Essentia the Leaders in Quality Excellence Award for “outstanding efforts among ACOs working to improve the quality and safety of patient care and advance population health goals.”
Essentia’s project submission was “Connected Communities: addressing social determinants of health and health inequities through partnership and technology.” The need is great — the food-insecurity rate in the neighborhoods surrounding Essentia’s downtown Duluth headquarters, for example, is 45%.
“Addressing the social determinants of health is a high priority at Essentia, especially food insecurity,” said Debbie Welle-Powell, chief population health officer. “We know food is medicine, and access to healthy foods impacts one’s overall health status. By creating new alternative food sources and working in partnership with our communities, we are better able to support our patients’ needs holistically.”
Patients were reached using a confidential questionnaire.
What started as a small pilot was scaled rapidly to 74 primary care and pediatric clinics during the COVID-19 pandemic, a time when need has been especially high. The questionnaire was sent with nearly 1 million encounters and completed by 46% of the patients seen in those encounters. Essentia learned that more than 40,000 patients identified at least one social need. That triggers a new question asking whether they’d like contact from a community health worker to connect them to resources and services.
In May and June, Essentia also created a questionnaire that helped identify patients at high risk for severe COVID-19 illness. Colleagues reached out to those patients to help them manage chronic health needs and meet their social needs so they could stay home safely.
Through this work Essentia connected more than 2,300 patients to new food, transportation or financial resources and referred patients to more than 80 community-based organizations. To make lasting change, the organization is collecting data that can support system change at community and national levels and is developing community partnerships to help drive care transformation.