COACH: Collaborative Opportunities to Advance Community Health

COACH brings together diverse regional partners to address unmet health needs of vulnerable communities in Southeastern Pennsylvania

WHY WE WORK TOGETHER

Many challenging health problems arise from social issues that cannot be effectively addressed by one stakeholder alone. Through a collective impact approach, COACH gives participants an opportunity to make real progress together in addressing the underlying social needs that give rise to poor health.

COACH's ultimate goal is to achieve measurable improvements in the population health of vulnerable local communities, thereby reducing the incidence of preventable medical interventions—such as hospital readmissions—caused in part by patients' social circumstances.

WHO WE ARE

7 Health Systems representing 18 hospitals in the region

16 Partners: public health, community, and insurer partners in the region

COACH participants identified improving access to healthy food as an effective way to help at-risk patients and famities prevent or better manage chronic disease

TARGETING FOOD INSECURITY

Food insecurity is the lack of consistent access to sufficient nutritious food necessary to lead a healthy life

• Nationally, 12.7 percent of households are affected by food insecurity
• In Philadelphia, 21.7 percent of residents, including 22.4 percent of children are affected

Food insecurity is associated with:

• Poor  physical health outcomes
• High prevalence of chronic illnesses
• Adverse effects  on child development
• Poor mental health outcomes
• High health care utilization and spending
• Children more likely to be hospitalized

COACH  participants agreed to a collective food insecurity screening and intervention effort to reach a large number of patients and community members in need

HEALTHY FOOD ACCESS PILOT: WHAT WE'RE DOING

Participating hospitals have implemented pilots in settings as varied as primary care offices, inpatient units, a post-discharge call center, and emergency departments to:

• Screen patients for food insecurity using a research-validated two-question screening tool
• Connect patients who are food insecure to healthy food resources and programs

HOW WE INTERVENE

• Engage care teams: community health, social workers, case managers, nurses, and physicians
• Develop comprehensive resource lists and "warm handoffs" to comm unity resources and enrollment assistance with public benefits
• Explore partnerships with grocery stores, food banks, food buying clubs, social service agencies, and anti-hunger organizations

HOW WE EVALUATE

We are tracking measures such as:

• Number of patients screened and positive screens
• Number of referrals made to community resources
• Number of patients referred for SNAP benefits
• Number of SNAP applications submitted
• Number of patients whose needs were met

COACH PARTNERS

• Children's Hospital of Philadelphia
• Einstein Healthcare Network
• Holy Redeemer Health System
• Jefferson Health (including Abington Jefferson Health and Jefferson Northeast)
• Mercy Health System
• Temple University Health System
• University of Pennsylvania Health System 
• Montgomery County Health Department 
• Pennsylvania Department of Health 
• Philadelphia Department of Public Health
• U.S. Department of Health and Human Services, Region Ill
• Benefits Data Trust
• Center for Hunger-Free Communities, Drexel University
• Coalition Against Hunger
• Delaware Valley Regional Planning Commission
• The Food Trust
• Health Federation of Philadelphia
• Health Partners Plans 
• Keystone First 
• Philabundance
• Philadelphia Association of Community Development Corporations
• Share Food Program
• United Way of Greater Philadelphia and Southern New Jersey

Facilitator: The Health Care Improvement Foundation

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Topics: Population Health

Revision Date: 3/15/2018

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