Community Health Implementation Plan - DE - 2022

Community Health Implementation Plan September 19, 2022

Contents Introduction ............................................................................................................................................................................ 3 Community Health Needs Assessment 2022 ........................................................................................... 4 Community Health Implementation Plan 2022-2024 ...................................................................... 6 Summary of Community Health Implementation Plan 2022-2024....................................... 6 Access to Health Services, including Dental Health .......................................................................... 9 Chronic Conditions ....................................................................................................................................................... 11 Maternal and Child Health .................................................................................................................................... 12 Mental Health and Substance Use Disorder .......................................................................................... 14 Social Determinants of Health ........................................................................................................................... 16 Violence ............................................................................................................................................................................... 17 Conclusion – Community Health Implementation Plan 2022-2024.................................. 18 A Leader for Health, for all Communities. .................................................................................................. 18

Introduction At ChristianaCare, we are committed to being exceptional today and even better tomorrow, guided by our values, Excellence and Love. We are committed to embracing diversity, anticipating the needs of others, helping with generosity and compassion, and using our resources wisely. These values and behaviors – and the others we defined - became an even brighter north star and moral compass as COVID-19 struck in March of 2020 and spread across the globe the following winter.

ChristianaCare was already mid-transformation: from a hospital to a health system to a system that reaches out into the community to provide the right care, in the right place, at the right time, The pandemic accelerated this transformation and brought new challenges to our communities, with ChristianaCare playing a critical role as an essential partner to address those needs. It is a point of pride, tempered by gratitude and humility, that ChristianaCare doubled down on its commitment to the community during the pandemic, when many other organizations struggled to maintain services. Over the last three years we have made progress on the prioritized needs addressed in the 2019 Community Health Implementation Plan (CHIP), while also continuing to improve services for our patients and neighbors and responding to a historic pandemic. ChristianaCare’s 2023 Annual Operating Plan has introduced our core strategy and aspirations, including our aspiration to end disparities in access, experience, care delivery, and health outcomes for those we serve.

The needs prioritized in this document align well with the system’s overarching goals. These areas of need are not easily solved and demand a comprehensive approach and partnerships with other stakeholders, especially given the dynamic healthcare environment. In addressing these needs and outlining the substantial work ahead, we are continuing to build on the strong foundation we laid in our prior Community Health Implementation Plans.

Our Community Health Needs Assessment 2019-2021 began with the following lessons learned: • • • •

Partnerships within the community are fundamental to effectively addressing patients’ social needs.

Unmet social needs exacerbate health issues.

Racial disparities and other systemic challenges create complex challenges to improving maternal health and infant mortality.

Violence is a public health issue that hospitals can play an essential role in addressing.

These lessons will continue to guide us over the next three years. As a nationally recognized leader in clinical quality and safety, academic medical institution, and National Cancer Institute designated community cancer center, ChristianaCare serves our community with exceptional care, education, outreach and research. Our 3

vision continues to place ChristianaCare at the forefront of population health, and a nationally recognized leader in developing a social care framework, where clinical care, services, facilitated connections and community investments advance health outcomes and health equity and support a strong and vibrant community.

Community Health Needs Assessment 2022 In early 2022, ChristianaCare undertook a Community Health Needs Assessment (CHNA). This CHNA assessed community health needs in two geographic areas in New Castle County: “Community 1” (zip codes 19801, 19802, 19804, 19805, and 19720) and “Community 2” (all other zip codes).

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The distinction was made to ensure county-wide statistics would not overshadow the areas with the greatest need, found in Community 1. To learn from our community what is important to them and to supplement the data-driven findings, ChristianaCare held a series of community meetings with the participation of 35 community stakeholders and 110 students from William Penn High School’s health classes. We also held internal meetings with 45 ChristianaCare staff members.

We had looked forward to hold these meetings in person at community locations, but unfortunately, the planning of the community meetings coincided with a significant increase in COVID-19 infections and hospitalizations. For the safety attendees, community meetings were arranged to ensure safety.

As a result of the community meeting discussions, secondary data findings, and interviews with the Cabinet Secretary and Deputy Secretary for Delaware Health and Social Services (DHSS) and the Director for the Delaware Division of Substance Abuse and Mental Health (DSAMH), the following were identified as significant health needs: • • • • • •

Access to health services, including dental Chronic health conditions Maternal and child health Mental health and substance use disorders Social determinants of health Violent crime

Except for chronic health conditions, these significant health needs were all prioritized in the 2019 CHNA. ChristianaCare will continue its significant work to address these needs with the addition of chronic health conditions.

We were fortunate to have so many high school-aged students participate in the 2022 CHNA. The significant needs the students chose mirrored the significant needs the adults identified, with the addition of the needs listed below: • •

Sexually Transmitted Infections (STIs) Smoking, tobacco, and vape product use

ChristianaCare addresses STIs among adolescents, with our School Based Health Centers (SBHCs) providing direct access to testing and care for students in the public high schools across New Castle County. With parent/guardian consent, a student may receive STI testing, be tested for pregnancy, or simply access contraceptives, after a medical visit with a clinical provider. While we are not further prioritizing these needs in this cycle, we have reinforced the access to these services at our SBHCs, ensuring close, affordable resources for young adults to proactively address their reproductive health.

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In addition, since 1995, ChristianaCare’s Community Health Department has been the recipient of a state grant to operate the Alliance for Adolescents Pregnancy Prevention (AAPP). AAPP works to reduce the number of teenagers who are sexually active, contract and spread STIs, become pregnant and become teen parents. As a hallmark of the Community Health Department, AAPP offers educational programs statewide for young people and their parents. It also serves physicians, educators, nonprofit groups, and anyone else who provides care for teens and their families.

While ChristianaCare does not have its own outreach program addressing adolescent use of tobacco or vape products, social workers in our ChristianaCare School Based Health Centers (SBHCs) address tobacco/vape use when identified during a risk assessment.

Community Health Implementation Plan 2022-2024 As noted, the Community Health Implementation Plan (CHIP) for 2022-2024 will focus on the following areas: • • • • • •

Access to health services, including dental Chronic health conditions Maternal and child health Mental health and substance use disorders Social determinants of health Violent crime

In this section, we will summarize how each prioritized area of need will be addressed including the strategies we will undertake and how we will measure success. A more detailed description of each prioritized area of need will conclude the section.

Summary of Community Health Implementation Plan 2022-2024 Increase access to health services, especially primary care and dental health.

Strategies • Create and expand digital solutions to support access.

• Provide opportunities to receive radically convenient care in communities through mobile health services and within schoolbased health centers. Seek out other innovative opportunities to provide care within communities through community partnerships.

• Connect more individuals to health insurance, financial assistance opportunities, and community programs and resources outside the health system through the recently expanded Health Guide Program and the more recently created CHW Program.

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Measures

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New and expanded digital solutions; number of individuals served through mobile health services and School Based Health Centers; new practices in community settings; increased number served within the Health Guide and CHW Programs.

Improve patients’ management of chronic conditions through the CHW and Food Insecurity Programs; reduce disparities in quality measures and health outcomes with a focus on chronic disease.

Strategies • Operate and evaluate the CHW and food insecurity programs to ensure their design promotes the patients’ successful managing and/or prevention of chronic conditions.

• Build systems and processes to identify and reduce disparities in quality measures and health outcomes with a focus on chronic disease.

Measures

Success of patients enrolled in CHW and food insecurity program measured by improved health indicators such as A1c, blood pressure, or weight, increased consumption of fruit and vegetables, as well as reduced visits to the emergency department. Development of a process to identify disparities and strategies to reduce those disparities within chronic conditions.

Improve women and children’s health with a focus on decreasing the infant mortality rate.

Strategies Operate and evaluate the Health Ambassadors and Women’s Health CHW Programs to ensure design promotes patient success and reaches individuals most at risk for poor outcomes.

Reduce disparities in quality measures and health outcomes with a focus on maternal/infant health outcomes.

Within the CHW program, success will be measured by the Measures identification and achievement of patients’ personal goals, increased post-partum follow-up visits, improved use of long-term contraception, and reduction of 42-day readmissions post-delivery discharge. Increased number of referrals to the Health Ambassadors will indicate success. Development of a process to identify disparities and strategies to reduce those disparities within chronic conditions.

Increase access to behavioral health services addressing mental health and substance use disorder in our community and clinical spaces.

Create and expand programming along with recruitment of new Strategies caregivers to address behavioral health.

Continue to embed Behavioral Health Consultants in clinical spaces to ensure behavioral health needs are addressed.

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Continue to operate the Behavioral Health CHW program to ensure patients are successful in meeting their goals to ensure success in addressing their behavioral health needs.

The operation of new and expanded programming and number served; number of new caregivers hired; reduced number of inpatient days for long-stay patients; reduced number of inappropriate ED visits; successful graduation of patients participating in the Behavioral Health CHW Program; and continued partnership with NCCPD to address behavioral health needs in the community by directing community members to the appropriate treatment and providing resources/referrals.

Increase patient social determinants of health screening and address those needs through internal programming and community partnerships.

Measures

Strategies

Introduce new screening platform for patients to complete SDOH screen.

Utilize Unite Delaware, now embedded within patient’s electronic health record to address patient social need.

Invest in community-based organizations to support their ability to address social determinants of health in communities.

Measures

Number of SDOH screens completed for patients with a focus on screenings completed for patients living in 19801, 19802, 19804,19805, and 19720 zip codes; increased number of referrals sent through Unite Delaware with a focus on referrals sent for patients living in 19801, 19802, 19804, 19805, and 19720 zip codes; number of individuals served by community-based organizations that received ChristianaCare’s community investment funding.

Decrease community violence by enrolling patients suffering from a gunshot wound, stab wound, or violent blunt assault into ChristianaCare’s hospital-based violence intervention program, EVOLV. Strategies Improve integration into trauma department and pursue possible expansion to enroll patients discharged from emergency department.

Strengthen community partnerships to improve ability to assist patients in meeting their goals involving employment, education, utility needs, and victim compensation application support.

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Continue to collaborate with other organizations addressing violence, particularly in Wilmington, to ensure cohesion and opportunities to strengthen impact.

Measures

Number of patients enrolled and graduated; percentage of patient centered goals met.

Access to Health Services, including Dental Health ChristianaCare is committed to radically simplifying access for patients. Over the next several years, ChristianaCare will work toward this commitment by creating and expanding digital solutions to support access, and by developing highly coordinated and integrated team-based care across our clinical settings.

ChristianaCare also recognizes that access to care in the community remains vital.

Not all our neighbors will be able to, or receptive to, receiving their care online or by telephone. Continuing to provide a variety of care options in and for the community will remain a priority.

We will continue to seek opportunities to place providers and staff in community settings to be able to provide the right care, at the right time, at the right place. One such innovation is our Mobile Health Services, which launched in June 2022. With the generous support of Barclay’s, ChristianaCare purchased and outfitted two vans to be able to provide adult and pediatric health screenings, primary care, sports physicals, vaccinations, and social determinants of health screenings. ChristianaCare will work with community organizations and stakeholders to determine where the vans would be of most service to our community and to establish a standard operating model. We expect to use these vans to provide health services to individuals who otherwise may not have received these critical services and care.

Over the next three years, ChristianaCare will also add needed services within School Based Health Centers (SBHCs). Services will include lead testing at the three ChristianaCare operated elementary SBHCs as well as dental screenings and expanded behavioral health services. The twenty-three SBHCs ChristianaCare operates in elementary, middle, and high schools are essential access points for students and must provide services that are responsive to the substantial needs of the community.

In January 2021, ChristianaCare completed a significant renovation project that made possible a dramatic increase in the clinical capacity of our Dentistry and Oral Maxillofacial Surgery Practices. In fiscal year 2022, there was a record high of 14,272 patient visits. For more than sixty years, ChristianaCare has offered a dental clinic in the Wilmington Hospital Health Center that has fees at a reduced level so that uninsured and underinsured patients can receive comprehensive care. The faculty and residents who provide care at ChristianaCare’s dental clinic also rotate to 9

affiliated dental clinics at Nemours SeniorCare, Westside Family Healthcare, Henrietta Johnson Medical Center, and the Dental Health Center at Delaware Technical & Community College. ChristianaCare’s dental clinic and dental practice at Wilmington Hospital is an essential access point for high quality affordable dental care in our community, as well as a training ground to support improved dental care access for all communities we serve.

ChristianaCare’s Health Guides team will continue to aid patients in removing barriers to accessing both primary care and dental care with a focus on financial barriers. Health Guides function as collaborative, interdependent members of the primary care practices and advocates of their community seeking to support uninsured, underinsured, and underrepresented Delawareans in all aspects of health and health care. Serving as the “bridge” between the community and health care providers, Health Guides assist the substantial population of patients who face financial barriers to care, helping them access available and appropriate health care services; connecting them to health insurance and financial assistance opportunities; connecting them to community programs and resources outside the health system; and providing health and wellness information with a focus on prevention.

The Health Guides also connect patients to the Medical Legal Partnership, a collaboration with the Delaware Community Legal Aid Society, Inc., which assists with the mitigation of civil legal hardships. Often, these issues impede patients from being able to focus on their healthcare. By removing this barrier, patients can reprioritize their health. In fiscal year 2022, ChristianaCare expanded the Health Guide program by hiring two new bilingual Health Guides to serve two ChristianaCare primary care practices, ChristianaCare’s Su Centro de Salud, with Primary Care at Kirkwood and MAP 2.

ChristianaCare is also expanding its capacity to serve the community in the community through its commitment to a Community Health Workers (CHWs) program, a key component of an effective population health strategy.

CHWs are embedded within multiple ChristianaCare locations: Women’s Health, School-Based Health Centers, Primary Care, the Wilmington Hospital Emergency Department, and Behavioral Health, including both outpatient Behavioral Health and Project Recovery, a substance use disorder program.

In the interest of ensuring that patients and community members are served with excellence by the CHWs, ChristianaCare has adopted the IMPaCT Model of the Penn Center for Community Health Workers. ChristianaCare worked within the IMPaCT Model to develop protocols for several key areas: recruiting and hiring, training and certification, standardized CHW care, supervision and integration, and high-quality research and evidence. This attention to standardization, integration within healthcare, and evidence-based strategies will ensure that our CHWs are

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effective at helping patients meet their goals and improve their health and that the CHWs are recognized within clinical settings as a partner in the patients’ care.

ChristianaCare’s commitment is to provide care that is radically accessible and tailored to the community. The Health Guide and CHW programs and other core initiatives help individuals overcome barriers and ensure more individuals can obtain health care services, as well as access to the social care resources they need to prioritize and optimize their health.

Chronic Conditions In its Annual Operating Plan for fiscal year 2023, ChristianaCare has committed to building systems and processes to identify and reduce disparities in quality measures and health outcomes with a focus on chronic disease, cancer, and maternal/infant health outcomes. This is an ambitious aspiration, and the next few years will be spent designing the process to identify and address disparities in these areas.

ChristianaCare is also addressing chronic conditions through several innovative programs that extend beyond clinical spaces and interventions. To participate in the Primary Care CHW program, patients must have hypertension or diabetes or 2 or more Emergency Department (ED) visits in the prior 90 days. In this program, the CHW will assess and address the patients’ Social Determinants of Health, work together with the patient to identify and achieve patients’ personal goals, decrease no show primary care appointment rates, improve patients’ self-management of their chronic condition or conditions, and reduce 30-day readmission rates and ED utilization. Patients with a chronic condition are also eligible for the innovative Women’s Health CHW program; information about that program will be provided in the next section.

In response to the 2019 CHNA’s identification of food insecurity as a significant need in the community, ChristianaCare created two new food insecurity programs that address chronic conditions and social determinants of health: the Delaware Food Farmacy and Produce Delivery. In partnership with community-based organization Lutheran Community Services, ChristianaCare developed the Delaware Food Farmacy (DFF). The DFF, launched in February 2021, is a 6-month nutrition based comprehensive care intervention with food provisions. It is specifically designed to help Medicaid primary care patients with uncontrolled diabetes, hypertension and/or heart failure self-manage their chronic condition through a comprehensive care model, treating the “whole” person.

The program objective is to improve patients’ chronic conditions through medication reconciliation and adherence, chronic disease self-management and monitoring (BP, A1c, weight), provisions of foods necessary for chronic disease management,

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education and support for healthy eating, nutrition, and health behaviors, and addressing social determinants of health.

ChristianaCare and long-term community partner, Urban Acres Produce, are increasing patients’ access to fresh produce through their partnership and development of the Produce Delivery Program (PDP), launched in May 2020. The PDP utilizes a delivery system to offer patients the opportunity to receive fresh fruits and vegetables every week without having to leave their homes. Patients who live in New Castle County, are on Medicaid or Medicaid eligible, and have diabetes, hypertension and/or need food assistance receive a $10 wholesale bag of fruits and vegetable, $20 bag for patients with a household of 5 or more, for 3 to 6 months.

With each of these programs, we will evaluate success based on patient satisfaction and outcomes and make program modifications as needed. In the coming years we expect our evaluation framework to identify what works to improve patients’ chronic conditions and guide us in adapting and refining these programs to serve more individuals, with available resources.

Maternal and Child Health ChristianaCare is addressing maternal and child health on multiple fronts. As stated above, ChristianaCare’s Annual Operating Plan for fiscal year 2023 committed to building systems and processes to identify and reduce disparities in quality measures and health outcomes with a focus on chronic disease, cancer, and maternal/infant health outcomes. Over the next several years, we will report on the identification of those disparities and how we expect to address them.

On April 27, 2020, ChristianaCare opened its Center for Women’s & Children’s Health located at its Newark Campus. This new center was designed to support the optimal health of women and children. One of the most significant features is its state-of-the-art neonatal intensive care unit which has private rooms with sleep-in space for families. It is one of the only hospitals in the United States to provide “couplet care” in the NICU to keep the mother and the baby together even if they both require medical care. As one of the highest volume delivering hospitals in the region with more than 6,000 babies a year, this attention to the health of both the mother and baby is essential to improving maternal and child health outcomes.

ChristianaCare has been the recipient of a grant from the Delaware Division of Public Health (DPH) to support its Health Ambassador Program since 2012. The Health Ambassador Program is a community-based intervention to promote health before, during, and after pregnancy. Its objective is to connect pregnant women and families to health care, social services, and education to increase their health and well-being with a focus on the high risk zip codes (19801, 19802, 19804, 19805, 19806, 19809, and 19703) within Wilmington that have the lowest maternal and child health indicators in the state. The Health Ambassador program expanded in 12

fiscal year 2021 to include a Health Ambassador who will focus on mothers with substance use disorder.

The Health Ambassadors have been effective at providing mothers and caregivers with resources and education. In fiscal year 2021, the Health Ambassadors’ total outreach was 3,916 unique community members. Of those, 82% needed direct assistance and the Health Ambassadors were able to meet the needs of all 3,202 mothers. ChristianaCare will continue to seek grant funding to provide this community support to those most at risk for poor maternal and child health outcomes.

In 2019, Women’s Health Community Health Workers (CHWs) began assisting patients on the inpatient delivery floors and in outpatient practices at ChristianaCare’s Wilmington and Newark campuses. In the past fiscal year, additional CHWs were added to serve patients in the NICU and OB Triage. These CHWs support the patients during and after pregnancy. For outpatients, the intervention is a 6 – 9 month program with intensive case management. The inpatient intervention is a 3-month program postpartum with intensive case management.

The CHWs assess and address the patients’ social determinants of health, identify and support achievement of patients’ personal goals, increase post-partum followup visits, improve the use of long-term contraception, and reduce 42-day readmissions post-delivery discharge. Patients who meet the following criteria are eligible: • • •

Medicaid or Medicaid eligible Lives in one of the following zip codes: 19701, 19702, 19711, 19713, 19720, 19801, 19802, 19804, 19805, 19977 AND meets at least 1 of the following criteria: o A history of poor birth outcomes (e.g., low birth weight delivery, premature birth, infant death, fetal death/stillbirth) o A chronic disease (e.g., diabetes, high blood pressure) o Late entry into prenatal care o No prenatal care o Risk for birth defects – exposure or family history o Mental illness o BMI at or above 30

Along with our state-of-the-art Center for Women & Children’s Health and programs such as the Health Ambassadors and Women’s Health CHWs to directly address the health of pregnant and postpartum mothers and children, ChristianaCare also believes that addressing social determinants of health will improve women and 13

children’s health including infant mortality. While the positive impact may not be seen in the short term, our expectation is that over time, the health of all family members will be improved by addressing these needs. As will be discussed in more detail later in this document, ChristianaCare has made a strong commitment to addressing the whole health of our patients, including their social care needs.

Mental Health and Substance Use Disorder As indicated by every Community Health Needs Assessment we have undertaken, our community needs more accessible behavioral health services. ChristianaCare is undertaking a bold plan focusing on recruitment and the development of new programs and models to address behavioral health both inside and outside of our clinical spaces. We expect our efforts will allow for increased access both virtually and in-person, reduce length of stay for long-stay patients, and reduce inappropriate emergency room utilization.

In fiscal year 2022, we set the ambitious goal to hire 71 new caregivers in both clinical and non-clinical roles to address behavioral health by the end of fiscal year 2023. As of September 2022, 57% of those positions have already been filled.

ChristianaCare, like hospitals throughout the country, has experienced hiring difficulties, particularly when it comes to behavioral health professionals, but we are pleased with the progress we have already achieved toward our bold goal and optimistic that it will be achieved.

We are underway in developing new and expanded programs to increase access to Behavioral Health services. These include: •

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Gender Wellness Clinic which launched in October 2021 and includes three gender therapists that support anyone age 13 or older exploring their gender identity, experiencing gender dysphoria, or who needs education and support around social and medical transition First Episode Clinic is an early intervention model designed to connect patients with resources to reduce inappropriate ED visits and readmission to inpatient floors. This will launch in 2023.

Efforts to support a new Geriatric Mental Health program are underway with the recruitment of two new Senior Psych Social Workers and a Geriatric Psychiatrist in collaboration with ChristianaCare’s Swank Memory Center.

A return to Group Therapy Programs for adults and children now that COVID restrictions have eased.

ChristianaCare’s Substance Use and Embedded Behavioral Health Care Models are also expanding.

• An Advanced Practice Clinician is now embedded within Project Recovery, ChristianaCare’s outpatient substance use disorder treatment program.

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• • •

ChristianaCare Behavioral Health is exploring operations opportunities in the ED to facilitate connection into psychiatry and psychology services.

ChristianaCare will expand embedded Behavioral Health into new practices.

With the addition of two new Behavioral Health Consultants (BHCs), ChristianaCare BHCs are now serving six Women’s Health Practices.

ChristianaCare’s Child and Adolescent Care Model is also expanding with the hiring of two new Child & Adolescent outpatient therapists (Dec 2021 and Jan 2022) to support our psychiatric population. As shared in a prior section, ChristianaCare intends to provide more behavioral health services in School Based Health Centers ensuring young Delawareans have true access to therapeutic support.

The new and expanded programs above, along with ChristianaCare’s recruitment efforts, will provide more access to behavioral health services to our diverse community.

ChristianaCare is also employing Community Health Workers to serve patients in Behavioral Health, including the Behavioral Health CHW program, launched in 2021 to serve patients in adult outpatient and Project Recovery. Like the other CHW programs, this one is also focused on assisting the patient in meeting their goals and addressing their social determinants of health.

In 2020, ChristianaCare partnered with the New Castle County Police Department (NCCPD) to support the NCCPD’s efforts to address mental health and substance use disorder in the community. Two ChristianaCare employees are embedded in the police department to respond to 911 calls and officer referrals when mental illness is believed to be a primary factor for police involvement. The role of this team is to both provide support to the community member at a time of crisis as well as to provide supportive education to the officers on how to identify mental illness and essential de-escalation tactics. The caregivers work to connect these individuals to the appropriate community treatment and to address any social needs.

Three other ChristianaCare employees support the NCCPD’s Hero Help Program which addresses substance use disorder by supporting those seeking treatment.

These employees respond to non-fatal overdoses, provide outreach in the community, work with individuals to devise a treatment plan and obtain treatment, provide ongoing case management, and address any needs individuals may have that serve as barriers to obtaining treatment.

This partnership is currently supported through grant funding which will end in October 2023, however, ChristianaCare intends to explore resources to continue this important behavioral health partnership through a new access point.

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Social Determinants of Health ChristianaCare is committed to addressing social determinants of health as a part of a patient’s standard care. Several years ago, ChristianaCare formed a multidisciplinary group to create an evidence-based screening instrument to identify our patients’ social determinants of health (SDOH) that would be the sole SDOH screening instrument used throughout ChristianaCare. After development of that screening tool was completed, ChristianaCare began implementing this screening throughout the system. We are now moving to patient self-administration of this screening instrument through a new platform that allows patients to complete the screening on their own, rather than providing answers to a caregiver.

Our expectation is that this technology platform will increase the number of SDOH screens completed, improve efficiency, and provide a better patient experience, as they may feel more comfortable entering answers to questions that can feel invasive. Importantly, coinciding with the systemwide expansion of the SDOH screening tool, ChristianaCare entered a partnership with Unite Us to support a care coordination network, Unite Delaware. If a patient has a social need, Unite Delaware can be utilized to address that need.

The Unite Delaware network connects social services and clinical care providers across the state. With this network, any healthcare provider or social service agency can help an individual address the diverse array of needs they may have. Since our partnership brought this network to Delaware in late 2019, two other Delaware hospitals have joined the network which now includes over 200 community-based organizations. This tool could revolutionize the way social service and healthcare organizations work together in Delaware and enables our community to take advantage of existing resources and identify areas that need additional resources or investment. Our expectation is that all Delawareans, even those that are not ChristianaCare patients, will benefit from this network. In May 2022, ChristianaCare also completed an integration of Unite Delaware into its medical health record to enable easier operability for providers to send a referral in a clinical setting. We believe that this tool, along with the increase in social determinants of health screenings, will ensure that our patients’ social needs are identified and addressed successfully.

In the 2019-2021 CHIP, we reported that ChristianaCare was strategically investing in our community to support population health, health equity, improved health outcomes, and delivering value through high quality cost-effective care. In December 2019, ChristianaCare launched the Community Investment Fund with nearly $2 million in funding awarded to 32 community-based organizations to address the areas of need prioritized in the 2019 CHNA. While no funding was provided in fiscal year 2021 due to the financial uncertainly caused by the pandemic, in fiscal year 2022, 13 organizations received over $1 million in funding to 16

address food insecurity and housing. We look forward to continuing the Community Investment Fund to support our community partners and their expert work in the community, while recognizing the dynamic financial climate in health care.

ChristianaCare has also partnered with Roundtrip to provide transportation to medical services for eligible patients who have a transportation barrier. In 2020, ChristianaCare piloted this program in two departments and has since expanded to fifteen participating programs and departments using Roundtrip for patients facing transportation barriers to receiving medical services. Our expectation is that patients’ health will improve when the transportation barrier is removed.

Importantly, our foundational strategy in addressing social determinants of health is partnering with community-based organizations to support their ability to address social need. At ChristianaCare, we believe we have an obligation to help our patients address the needs they identify. While we have some ChristianaCare programs that successfully address social need, many of which are described in this document, it is not realistic to expect that we can address all need without the support and resources of experts and partners in the community. We worked to bring Unite Delaware to our state, launched the Community Investment Fund, and integrated with our clinical system to provide our caregivers with a direct line to our community partners and facilitate maximum utilization of existing resources.

Violence ChristianaCare recognizes violence as a public health issue and launched a Hospital Based Violence Intervention Program (HVIP), to directly address violence as a healthcare issue. This program, Empowering Victims of Lived Violence (EVOLV), began seeing patients in February 2021. Patients who have suffered a gunshot wound (GSW), stab wound (SW), or violent blunt assault (VBA), are residents of New Castle County, and aged 13 years or older are eligible to participate in EVOLV. The length of the program is three months and provides the patient with access to a dedicated social worker and Community Health Worker (CHW). The CHW will actively follow patients and support them by providing them with access to care, addressing any social determinates, and identifying and achieving patient centered goals and outcomes.

In its first year of operation, EVOLV increased access to care for its participants by providing insurance application support and transportation support for follow-up appointments. Follow-up appointment compliance and connection to primary care were improved among participants. The EVOLV team was also able to assist patients in meeting their social needs by helping them with victim compensation applications, providing food, assisting in attainment of a driver’s license, and connection to education and employment among other supports.

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EVOLV will build upon these successes by developing and enhancing community partnerships to better connect participants to resources in the areas of education and employment among others.

The EVOLV team will also work to fully integrate into the trauma department to ensure eligible patients will be presented with the opportunity to participate in EVOLV. Expansion into the emergency department will also be considered as this is the area outside of the trauma department that sees eligible patients.

Finally, the EVOLV team has been engaged with government and community organizations that focus on violence to ensure cohesion in addressing the same goal, which is to reduce violence in our communities, especially in Wilmington. Our leadership serve on groups that coordinate a muti-faceted approach to addressing violence in our communities. Our expectation is that EVOLV will continue to be an essential element of the critical work to reduce violence in both the lives of our patients and our communities.

Conclusion – Community Health Implementation Plan 2022-2024 The ChristianaCare Way is clear: We serve our neighbors as expert caring partners in their health. We do this by creating innovative, effective, affordable, and equitable systems of care that our neighbors value. We are guided by our values: Excellence & Love. This mission to serve is our guiding light. While ChristianaCare is a regional and national leader in healthcare, it is also an anchor institution in our community and part of a larger network of community organizations, government partners, and businesses which all aim to improve the lives of our neighbors living in New Castle County, and across the region.

The people we serve, our neighbors in the community, represent all ages, classes, races and ethnicities. They represent people of all faiths and value systems. They represent all identities and orientations. They represent people of all abilities. Their diversity and the sum of their parts is what makes Delaware so extraordinary.

ChristianaCare is committed to being a leader in all aspects of this work. We believe all members of the community should have access to high-quality affordable health services, social supports, education, and economic opportunity. Every member of our community should have the opportunity to achieve their best health – the heart of health equity. At the core of this work is Christiana Care’s commitment to improving health outcomes, building partnerships, advancing health equity, and supporting the sustainability of strong, healthy, vibrant communities.

A Leader for Health, for all Communities.

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ChristianaCare is an anchor for health and healthcare across New Castle County, the state, and the region. We will continue to collaborate with community partners to address the social determinants of health. We will advance a social care framework that complements our clinical care and expertise, coordinates resources, and supports delivering high value affordable care. We will work in partnership with our community around the other identified priority areas of chronic health conditions, mental health, substance use disorder, child and maternal health and infant mortality, violence, and access to primary care and dental care. We have the tremendous honor and great opportunity to work in partnership with our neighbors to effect change that will have a multi-generational impact and provide a model for other health systems and communities across the nation to follow. As a leader in health, for all communities, we will walk the walk of our mission serving our neighbors as respectful, expert, caring partners in their health. Together we can create health so that every person can flourish and extend to all the opportunity to be exceptional today, and even better tomorrow.

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