Community Outreach Programs Make a Big Impact on the Health of Vulnerable Populations

As our elected representatives wrestle with how to structure America’s healthcare system, it’s worth reflecting on the fact that some of today’s most effective health and wellness efforts are taking place well outside any doctor’s office or hospital. I’m referring to community outreach programs that address basic problems such as an unhealthy diet, smoking, homelessness or the lack of basic health screenings—problems that can plant the seeds of illness long before someone is officially diagnosed with a chronic medical condition.

As an example of this community outreach, I’ll give you a snapshot of a recently concluded initiative carried out by my own organization, the Visiting Nurse Service of New York (VNSNY). Our effort, the Rockaway Wellness Partnership, involved a two-year intervention in the Rockaways section of New York City—an isolated, low-income neighborhood in the borough of Queens, located on a peninsula that was especially hard-hit by flooding from Superstorm Sandy in 2012. Funded by a New York State Superstorm Sandy block grant, we sent small teams of health coaches and community health workers who were familiar with the community to encourage residents to sign up for a targeted support program. Our workers set up tables in local pharmacies, supermarkets, libraries, food pantries and community events, meeting people in the neighborhood and coming to understand their particular problems and concerns.

Over time, 732 individuals agreed to enroll in the program. Once they did, our health coaches conducted an assessment, helped each person set individual health and wellness goals, and counseled them on topics like nutrition and weight loss, exercise, stress reduction, alcohol abuse, smoking cessation, dealing with depression and/or anxiety, and self-managing chronic illnesses. Our teams also helped participants connect with local resources such as free or reduced-cost primary care, educational and job-readiness programs, food pantries, legal assistance, and entitlement programs—advocating directly for them when necessary, and even accompanying clients with Spanish-translation needs on visits to physicians and social services. In between face-to-face encounters, our community health workers checked in regularly with clients by telephone and text messages to make sure they followed through on the health coaches’ recommendations.

The Bottom Line: Better Health, Fewer Trips to the Hospital

All told, it was an impressive outreach program—but most importantly, it worked: Our effort included compiling baseline and exit surveys for each individual client, which were then analyzed by VNSNY’s Center for Health Policy and Research. Their findings, which are being published in an upcoming issue of the Journal of Public Health Management & Practice, showed that people who went through the intervention had significant improvements in how they rated their own health, and were also much less likely to report visiting the emergency room or the hospital during the program period, compared to the same time period a year earlier.

Our intervention concluded in early 2016, once the two-year grant ended—but the need of residents in the Rockaways and similar low-income communities for these types of outreach programs is ongoing. As Senior Research Associate Mia Oberlink, one of the VNSNY researchers involved in the study, said recently, “What we have to do is to find ways to fund these types of programs on a permanent basis.”

Community health programs are both beneficial and cost-effective, epitomizing the old saying, “an ounce of prevention is worth a pound of cure.” For a relatively small investment, our intervention not only improved people’s health, but also led to substantial savings in overall health care expenditures by preventing trips to the ER or admissions to the hospital that would have otherwise occurred. It’s also important to note that rather than trap people in cycles of dependency, these programs are designed to empower participants, giving them the knowledge, resources and confidence so that they can go forward on their own steam and lead healthier, more productive lives.

The Next Step: Establishing Sustainable Community Outreach Programs

Securing funding for ongoing community initiatives is always a challenge, but a growing number of local, state and federal governments, private foundations, medical institutions and non-profits like VNSNY are joining forces to create sustainable community programs that can provide continuing support for our most vulnerable populations. One standout example is New York State’s recently launched DSRIP program, which is using savings generated by increased efficiencies in the state’s Medicaid program to fund hundreds of partnerships across the state designed to help local residents maintain better health and avoid preventable hospital admissions. Each local partnership is anchored by a large healthcare organization, and includes a half-dozen or more other community-based organizations. Recent performance results show that the program is on track to exceed the goal of reducing avoidable hospitalizations by 25% by the year 2020. VNSNY is currently involved in a number of these DSRIP partnerships—including community paramedical services and several initiatives that provide health coaches who counsel local residents on how to manage their multiple chronic conditions.

Other examples include New York City’s funding of support services for naturally occurring retirement communities, or NORCs—residential areas with large populations of seniors, where the city provides onsite health professionals and other services; the nationwide Nurse-Family Partnership program, which utilizes government and foundation funding to pair low-income, first-time mothers with specially trained nurses who provide parenting, health and career guidance; and the federally led Million Hearts initiative, which is spreading word in communities across America about the ABCS approach to cardiovascular health: protective aspirin, blood pressure monitoring and control, cholesterol management, and smoking cessation. VNSNY administers our own NFP programs in the Bronx and Nassau County and also manages a neighborhood NORC in New York City’s Chinatown, and I can testify firsthand to the powerful impact of these programs.

Addressing Mental Health Issues in the Community

Community outreach isn’t just about physical health, either. Programs like New York City’s ThriveNYC initiative are training community residents in how to identify neighbors or relatives with mental health issues and connect them with care. The city also funds mobile crisis teams, which VNSNY participates in, that provide on-the-spot counseling to adults and children experiencing or at risk of psychological crisis—often enabling these individuals to connect with outpatient care and avoid being admitted to a psychiatric hospital unit.

In every one of the inspiring programs mentioned here, most of the interventions take place outside of formal visits to a doctor’s office, hospital or clinic, typically at a lower cost than an in-office consultation with a physician or other clinician.

Of course, formal medical services remain an essential part of our healthcare system—but the takeaway here is that supporting healthy lifestyles and connections in our local neighborhoods through sustainable community outreach programs is a vital and growing part of the effort to keep Americans healthy in body and mind. Because our Rockaways project had only short-term funding, hundreds of other individuals will miss the opportunity to improve their lives through the support of this intervention.

Community outreach and programs like VNSNY’s Rockaway Wellness Partnership, the other programs discussed here—and many others—are at the heart of our mission at VNSNY. We work tirelessly to develop and sustain these programs and we value your support.

I urge you to voice your support for programs like VNSNY’s Rockaway Wellness Partnership, the Million Hearts Initiative, Nurse-Family Partnerships, DSRIP, NORCS and ThriveNYC, by contacting your local, state and federal officials and letting them know how important it is to you that they support these types of community health programs.

Following are links to information on how you can call, email or mail your national elected representatives to request that they support the maintenance and expansion of these valuable community health initiatives:

  • U.S. Senators - Get contact information for your Senators in the U.S. Senate.
  • U.S. Representatives - Find the website and contact information for your Representative in the U.S. House of Representatives.

If we can maintain and expand the network of such programs so that they consistently support healthier communities across the U.S., then we all stand to gain.

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