ChristianaCare, Union Hospital
November 5, 2025
Introduction
A mission of service guides ChristianaCare, Union Hospital: Weserveourneighborsasrespectful,expert,caringpartnersintheirhealth.Wedo thisbycreatinginnovative,effective, affordable,andequitablesystemsofcarethat ourneighborsvalue.
This Community Health Implementation Plan (Implementation Plan) is a demonstration of how we serve our neighbors and meet our mission. In the Implementation Plan, we will provide ChristianaCare, Union Hospital's (Union Hospital) strategy for addressing the significant community needs identified in our 2025 Community Health Needs Assessment (CHNA)
The significant needs in Cecil County have been largely consistent in each CHNA completed over the last decade They persist because they are complex, shaped by a diversity of contributing factors, and entrenched These significant needs make achieving and maintaining good health on a population and individual level difficult because health is the result of much more than clinical care and genes. Employment, housing, and transportation are just some of the significant contributors to an individual's health Union Hospital will always strive to provide excellent clinical care, but that care will have limited impact on health outcomes if a patient does not have transportation to get to their appointments, cannot afford to eat healthily, or must decide between paying a utility bill or medication. Our recognition of these barriers to good health is why several initiatives in this Implementation Plan include addressing social need and partnership with community organizations to provide a comprehensive approach to effectively serve our patients. We are grateful to our partners who collaborate with us to advance the health of our community
Union Hospital, guided by our mission of service and our community, will continue to make progress addressing the significant needs of Cecil County residents to allow good health to flourish.
Community Health Needs Assessment 2025
ChristianaCare undertook a Community Health Needs Assessment (CHNA) in partnership with the Cecil County Health Department (CCHD) and the Cecil County Community Health Advisory Committee (CHAC) In addition to the secondary data used to inform the CHNA, we also held a series of focus groups, a community partner meeting, hospital and CCHD staff meetings, and key informant interviews to better understand the needs of our community. We also conducted an online community health survey from September to December 2024
From that assessment, we identified the following as significant needs in Cecil County:
• Access to Health and Preventive Services
• Cancer
• Childhood Trauma/Adverse Childhood Experiences (ACEs)
• LGBTQ+ Health Disparities
• Maternal and Child Health
• Mental Health
• Nutrition, Physical Inactivity, and Chronic Conditions
• Social Determinants of Health
• Smoking, Tobacco, and Vape Product Use
• Substance Use Disorders
• Violence and Injury
Based on Union's available resources and ability to create or expand community programming to address these needs, we will prioritize:
• Access to Health and Preventive Services
• Cancer
• Maternal and Child Health
• Nutrition, Physical Inactivity, and Chronic Conditions
• Social Determinants of Health
• Smoking, Tobacco, and Vape Product Use
• Substance Use Disorders
We are not prioritizing the remaining areas of need due to limited resources and competing priorities that prevent us from creating or expanding community benefit programming in a substantial manner.
Community Health Implementation Plan 2026-2028
Included in our Implementation Plan are our goals, initiatives, strategic targets, and measures for addressing each of the significant needs
We look forward to addressing the significant needs of our community through the initiatives identified below that seek to achieve the following goals:
Ø Provide access to care through innovative partnerships
Ø Increase LDCT screening to improve lung cancer mortality in Cecil County.
Ø Through education, empower community members to reduce their cancer risk, know their cancer risk, and get screened for cancer
Ø Provide individuals with the knowledge and tools to overcome their tobacco addiction to improve health outcomes.
Ø Provide education in partnership with Cecil County Health Department to prevent type 2 diabetes in Cecil County
Ø Address social determinants of health to advance health
Ø Support patients on their journey toward recovery from substance use disorder.
Ø Provide education related to pregnancy, childbirth, breastfeeding, and infant care to support health of mother and infant
Over the next three years, we will evaluate the impact of our initiatives and adjust as needed to meet our neighbors' needs and improve health. We are also prepared to adapt in response to growing or new community need to best serve our community.
Mobile Integrated Health (MIH) Program
Community Access to Care
1. Partner with Cecil County Department of Emergency Services to provide in-home support for high-needs recently discharged patients and repeat calls to 911 to decrease readmissions and ED utilization.
2. Identify and address social need of individual and family to reduce barriers to good health.
3. Provide assessments of medication validation and reconciliation.
4. Provide care plan coordination to improve health.
1. Remove barriers to care by providing health services in community locations.
2. Develop partnerships with community organizations to identify needed services and offer them in the community.
3 Continue to offer annual sports physicals for students, which addresses an identified need and connects residents to care.
1. Evaluate and demonstrate impact of program.
Reduced ED utilization and admissions, improved health outcomes
1. Develop and implement routine offerings of services in community locations in partnership with community organizations.
Services provided in the community at community locations, schedule of offerings, # of residents served, # of school physicals provided
Partnerships: The Mobile Integrated Health program is offered in partnership with the Cecil County Department of Emergency Services. The annual sports physicals have been offered for nearly 20 years in partnership with Cecil County Public Schools and community providers. We expect to work with the Cecil County Health Department, faith-based organizations, and community partners such as Voices of Hope and the Paris Foundation to develop health services offerings in the community.
Goal: Increase Low-Dose Computed Tomography (LDCT) Screening to improve lung cancer mortality in Cecil County.
Initiatives Objectives FY26 – FY28 Strategic Targets Measures
Lung Cancer Prevention and Screening
1. A Lung Navigator will connect patients to LDCT screening.
2. The Lung Navigator will help patients address their clinical and social needs to remove additional barriers to screening.
1. Continue to evaluate effectiveness of lung navigator in connecting appropriate patients to LDCT screening.
2. Identify common barriers to LDCT screening to appropriately address them.
# of LDCT screens
Goal: Through education, empower community members to reduce their cancer risk, know their cancer risk, and get screened for cancer .
Initiatives
Cancer Prevention and Screening Community Education
1. Partner with the Cecil County Cancer Task Force to educate community on cancer risk, prevention, and screening.
2. Participate in community events to promote screening and prevention.
1. Develop tailored messaging related to cancer prevention and screening appropriate for identified populations.
Messaging campaigns created and implemented, participation in community events, # of community members interacted with at community events
Partnerships: The Cecil County Cancer Task Force is a part of the Community Health Advisory Committee (CHAC). The Lung Navigator routinely refers patients to the Cecil County Health Department for assistance in obtaining screening.
Goal: Provide individuals with the knowledge and tools to overcome their tobacco addiction to improve health outcomes.
Initiatives
Freedom from Smoking Cessation Program
1. Provide group classes to support community members in overcoming their tobacco addiction.
2. Provide education to equip individuals to maintain a smoke free life.
3. Reduce tobacco use in Cecil County.
1. Increase participation.
# of classes held, # of participants, # of participants who completed full course
Partnerships: ChristianaCare partners with the Cecil County Health Department who helps promote the smoking cessation program to county residents and the Northeast Pharmacy which provides free nicotine replacement options.
Goal: Provide education in partnership with Cecil County Health Department to prevent type 2 diabetes in Cecil County.
Initiatives
Diabetes Prevention Program
Objectives
1. Partner with Cecil County Health Department to offer education on the prevention of type 2 diabetes.
2. Promote education to patients and community.
3. Educate providers on resource for patients.
1. Increase community member participation through promotion.
2. Increase provider awareness of program to increase community member participation.
# of classes, # of participants, course completion
Partnerships: ChristianaCare has partnered with Cecil County Health Department to offer the Diabetes Prevention Program.
Goal: Address social determinants of health to advance health.
Initiatives
Acute Care Connectors
Transportation Services
1. Screen admitted patients to identify social needs.
2. Assist patients in addressing identified need through community referrals.
3. Provide connection/navigation to health care, especially primary care.
1 Provide transportation to medical services to patients with transportation barriers to improve health outcomes.
2. Collaborate with Cecil County Transit Services to support their efforts to address transportation barriers.
3. Reduce emergency department utilization and hospital admissions.
1. Expand social determinants of health screening to additional locations.
2. Continue to develop relationships with community organizations to better serve patients.
1 Assist patients in acquiring sustainable transportation options.
2 Expand transportation offerings to better serve patient needs.
3. Assist in evaluation of Cecil County Transit Services efforts to increase access to health services.
# of patients screened, needs identified, referrals made
# of rides provided, # of patients served, new partnerships developed to provide patient transportation
Goal: Address social determinants of health to advance health (continued).
Initiatives Objectives FY26 – FY28 Strategic Targets Measures
Community Baby Shower
1. Host an annual community baby shower to provide resources, education, and connection to care for pregnant community members.
1. Continue to increase resources available at community baby shower.
# of families served, resources provided, connection to care established
Partnerships: The Acute Care Connectors collaborate with many community organizations to serve patients. The Community Baby Shower also relies upon relationships with community organizations to provide donated items and connection to community resources. Goal: Support patients on their journey toward recovery from substance use disorder.
Initiatives Objectives FY26 – FY28 Strategic Targets Measures
Peer Support Program
1. Provide peer support to patients with SUD to stimulate their motivation and commitment to change.
2. Provide navigation support to patients to enable them to obtain and engage with SUD treatment.
1. Increase by 10% referrals to peers from primary care providers.
2. Increase by 20% MOUD treatment.
3. Continue to follow patients once they have received MOUD to confirm successful engagement with treatment.
# of patients referred to peers, # of patients that received MOUD, # of patients engaged in treatment after MOUD treatment
Partnerships: ChristianaCare has partnered with Cecil County Health Department (CCHD) to offer this program which is funded t hrough a federal grant the CCHD received. Community organization, Voices of Hope provides the peers.
Goal: Provide education related to pregnancy, childbirth, infant care, and breastfeeding to support health of mother and infant.
Initiative
Community Education
Objectives FY26 – FY28 Strategic Targets Measures
1. Provide education related to pregnancy, childbirth, infant care, and breastfeeding to equip pregnant and postpartum mothers with information necessary for healthy pregnancy, postpartum, and baby.
2 Partner with community organizations to provide specific and/or at-risk populations with needed education related to maternal and child health.
1. Continue and expand partnerships with community stakeholders and organizations to provide education that is accessible and/or tailored for specific populations such as those with substance use disorder.
# of participants, # of classes, partnerships with organizations to provide education
Partnerships: Union Hospital often partners with Cecil County Health Department to identify opportunities to provide maternal and infant health education. Union Hospital has also partnered with local treatment facilities to provide participant education and has provided annually education related to maternal and infant health for those with substance use disorder to student nurses at Cecil College.
Providing Access to Care Spotlight: Mobile Integrated Health Program
In partnership with the Cecil County Department of Emergency Service (DES), Union Hospital helped to launch a Mobile Integrated Health (MIH) program in Cecil County in July 2025 MIH is a healthcare delivery program that uses paramedics to provide care in a patient's home rather than in the typical healthcare setting. DES became interested in developing a MIH program to serve Cecil County in response to the volume of 911 calls they receive from community members who would be better served through a connection to care instead of repeat 911 calls, and the many occurrences of 911 calls from high-needs recently discharged patients.
Our expectation is that by providing access to care through the MIH program, emergency department visits and hospital readmissions will be reduced and health outcomes among those who receive intervention will improve We also expect that connecting community members to care will provide relief to DES as 911 calls from these individuals decrease.
Through our Community Investment Fund, ChristianaCare awarded funding to DES to launch the MIH program, and our Union Hospital caregivers collaborated closely to develop and implement the program. Recently discharged patients at a high risk of re-admission to the hospital and repeat 911 callers are identified for outreach. DES goes to the patients’ homes to identify and address any social needs the patient and family may have that presents a barrier to health, provide assessments of medication validation and reconciliation, and provide care plan coordination to ensure each patient gets the right care, at the right time, in the right setting. DES and Union providers coordinate to ensure patients maintain their plan of care and a DES case manager supports these patients for 30 days.
The first year of the MIH program will serve as a pilot. We will continue to collaborate with DES to implement and monitor the program while we identify opportunities for improvement to increase effectiveness.
Addressing Substance Use Disorder Spotlight: Peer Support Program
Union Hospital has worked to address substance use disorder (SUD) in Cecil County through our partnership with the Cecil County Health Department (CCHD) to support a hospital-based peer program. Peers are individuals in recovery who inspire individuals to address their own SUD and provide connection to community supports and resources. For many years, a CCHD peer recovery specialist was designated to receive referrals on behalf of Union patients
In 2023, CCHD received a National Association of County and City Health Officials grant, Sustaining Peers in the Emergency Department (ED), enabling significant expansion of these supports Union caregivers worked in partnership with CCHD to implement this expanded program in August 2023 and continue to partner to monitor
its effectiveness, make necessary adjustments to increase impact, and identify new ways to expand its effectiveness
There are now nine peers, employed by CCHD and Voices of Hope, a community organization, available in the hospital to provide bedside consults for patients struggling with addiction. The peers provide coverage from 8 a.m. to 1 a.m. every day of the week. Unlike in previous years, the peers are focused on more than just patients in the ED. We have expanded the education and referral patterns across all medical floors and staff to increase referral patterns and support for our patients. The peers encourage and support patients who are ready to address their SUD, and for patients, taking action is made more convenient through Medications for Opioid Use Disorder (MOUD) offered at Union Hospital. Patients can begin MOUD while they are in the hospital and receive navigation support to continue that treatment once they are discharged. To demonstrate effectiveness, as well as address any program needs or barriers, we continue to follow patients once they have received MOUD to ensure engagement with community providers.
Due to the success of this program and our recognition that it is better for individuals to address their SUD before they visit the ED or are admitted to the hospital, we have expanded this program into our Elkton Primary Care Practice. While only in operation for a few months, its initial activity is promising. Caregivers at this practice have embraced this new resource for patients. We are exploring opportunities for increasing the number of primary care and behavioral health care practices able to access this program on behalf of their patients.
Conclusion
We are privileged to serve our neighbors in Cecil County, and we will continue to provide high-quality care with the personal touch of a community hospital. In partnership with our patients and community organizations, we will work to advance health by addressing the significant needs of our community