KentuckyOne Health received a $1.5 million, three-year grant to support a new model of care to assist patients who live in low-income neighborhoods in south and west Louisville. The program, called Health Connections Initiative, employs a multidisciplinary team working in the homes of recently hospitalized patients from low-income neighborhoods to help them better manage their medical conditions while addressing barriers to good health. These include problems with transportation, lack of access to healthy food and connection with a trusted primary care doctor.
The grant, from Catholic Health Initiative’s (CHI) Mission and Ministry Fund, is designed to support the most complex patients whose poor health and complicated social situations directly impact their ability to get and stay well. According to the Agency for Healthcare Research and Quality, the sickest 5 percent of patients account for more than half of health care costs in the U.S. Yet studies have shown that health outcomes can improve dramatically for this group when care is comprehensive and coordinated—addressing patients’ social needs as well as their medical needs.
That has been the case for 73 patients served by KentuckyOne over the past eight months through a pilot, also funded by a CHI grant. Participants saw dramatic improvements in rates of depression, confidence in their ability to manage their health, and connection to a medical home. Only six patients were readmitted to the hospital compared to 26 the year before.
The grant supports two care teams consisting of a registered nurse, licensed practical nurse, social worker, and community health worker—a lay person from the community who acts as a trusted peer and connector between patients and providers to promote health among people who have traditionally lacked access to adequate care. The program is free to patients and includes up to 90 days of in-home coaching and support.
CHI also granted $1.5 million to St. Vincent Infirmary in Little Rock, Arkansas so that the model can be evaluated in two distinct communities. The goal is to create a program that can be replicated in other communities served by CHI hospitals around the country.
Since it was established in 1996 with guidance from CHI’s founding congregations, the Mission and Ministry Fund has awarded 409 grants totaling more than $50 million to programs across the globe. The fund was established through contributions from CHI facilities across the nation.
Photo Cutline: Patient Carrie Brown is visited in her home by KentuckyOne Health team members Ashley Dawson, MSW, (black shirt) and Bethany May, CHW, (pink shirt).