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Strategic Implementation Plan Fiscal Years
2023-2025
University of Chicago Medical Center Community Health Needs Assessment Strategic Implementation Plan (SIP): Fiscal Years (FY) 2023-2025
Introduction University of Chicago Medicine, one of the nation’s leading academic medical institutions, has been at the forefront of medical care since 1927. Collectively, it is comprised of the University of Chicago Pritzker School of Medicine, the University of Chicago Biological Sciences Division, and the University of Chicago Medical Center (UCMC). UCMC’s mission is to provide superior healthcare in a compassionate manner, ever mindful of each patient’s dignity and individuality. UCMC strives to improve the health of Chicago’s South Side by working in collaboration with community members, community and faith-based organizations, public agencies, faculty and staff, and others to implement interventions that address the priority healthcare needs and social determinants of health that impact members of our community. The following pages in this strategic implementation plan provide an overview of UCMC’s approach to assessing, prioritizing, and addressing specific health needs.
Target Area and Priority Population Figure 1. The UCMC Service Area Spans 28 Chicago Community Areas
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UCMC is located in the Hyde Park neighborhood on Chicago’s South Side. Chicago’s South Side is a unique collection of vibrant, resilient, culturally rich, and diverse communities. Steeped in AfricanAmerican heritage and history, the South Side is marked by deep social bonds and anchored by vital community and faith-based organizations. UCMC defines its service area (UCMCSA) as 12 contiguous zip codes surrounding UCMC (see Figure 1).1 The UCMCSA spans 28 Chicago Community Areas and has a population of approximately 626,264 residents. Currently, six out of the eleven poorest communities in Chicago are in the UCMCSA. 2 Residents in these communities face many social and economic challenges that contribute to healthcare inequities when compared to other areas of Chicago. Moreover, health disparities across the UCMCSA are vast, as demonstrated by strikingly high rates of asthma, diabetes, obesity, cancer, and other chronic diseases. 3 These health conditions are exacerbated by social determinants of health like poverty, food insecurity, and a lack of employment opportunities. American Community Survey (ACS) data show changes in the UCMCSA population since the previous CHNA cycle. The UCMCSA population declined by 3.1%, while the population of Chicago increased by 1.9%. The UCMCSA remains predominantly African American (74%) but did see a roughly 6% decrease in the African American population, while the Hispanic or Latino population increased by nearly 20%. The median age in the UCMCSA is 37.5 years old—over 2.7 years older than Chicago’s median age of 34.8. The majority of the UCMCSA population (77%) is 18 or older. Despite these shifts, residents in these communities still contend with the effects of institutional and structural racism, disinvestment, and neglect that have contributed to the erosion of the critical social, economic, and health-promoting infrastructure necessary to address priority health needs. As a result, communities in the UCMCSA continue to experience among the worst economic, social, and health outcomes across Chicago.
At the Forefront of Health Equity UCMC believes all members of our community should have the opportunity to attain their full health potential and that no one should be disadvantaged from achieving this potential because of their social position or other socially determined circumstances. UCMC’s Urban Health Initiative (UHI) ensures that UCMC is doing its fair share for the community, working to create better health, investing in trusted community partners, and leveraging the assets of UCMC and the University to address the health disparities that persist throughout the South Side of Chicago. The UHI connects UCMC’s world-class clinicians, researchers, staff, and care to the lives and health of our neighbors in the 12 zip codes on the historic South Side. As a division of the UHI, UCMC’s Diversity, Inclusion, and Equity Department works in concert with our community efforts to promote health equity within UCMC through staff training in cultural competence and plain-language patient education materials.
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Community Health Needs Assessment UCMC and Metopio, a software and services company, partnered to carry out a collaborative CHNA process between April 2021 and February 2022. The CHNA process is adapted from the Mobilizing for Action through Planning and Partnerships (MAPP) framework, a community-engaged strategic planning framework that was developed by the National Association for County and City Health Officials (NACCHO) and the Centers for Disease Control and Prevention (CDC). The MAPP framework promotes a system focus, emphasizing the importance of community engagement, partnership development, and data-driven decision-making. Primary data for the CHNA was collected through the following methods: »C ommunity resident surveys » Community resident focus groups » Healthcare and social service provider focus groups » Key informant interviews Community resident surveys were designed to ask about health issues that were most important to the following age groups: youth (0-17), adult (18-64), and seniors ( 65+). While the questions in the Community Health Needs Assessment Survey were bracketed by age group, the identified health priorities account for all age categories. Secondary data for the CHNA were aggregated on Metopio’s data platform and included: »H ospital utilization data »S econdary sources including, but not limited to, the American Community Survey, the Decennial Census, the Centers for Disease Control, the Environmental Protection Agency, Housing and Urban Development, and the Chicago Department of Public Health
Health Issue Prioritization Process Building on UCMC’s past two CHNAs, the Community Benefit and Evaluation Team worked with the Community Benefit Management and Steering Committees, as well as the Community Advisory Council, to prioritize health issues for UCMC’s next three years of community benefit programming for FY 2023–2025. Representatives from the UCMC Urban Health Initiative, select UCMC faculty, and community stakeholders were among the three major constituencies involved in the health priority selection process. These constituencies were strategically selected for their respective understanding of community perspectives, community-based health engagement, and community health programming. The MAPP framework promotes a system focus, emphasizing the importance of community engagement, partnership development, and data-driven decisionmaking. Figure 2 outlines the criteria used to review CHNA data and make decisions to select the final priority health areas. Strategic Implementation Plan FY 2023-2025
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Figure 2. Criteria for Selecting Health Priority Areas
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Data Needs and Limitations UCMC and Metopio made substantial efforts to comprehensively collect, review, and analyze primary and secondary data. However, there are limitations to consider when reviewing CHNA findings. »P opulation health and demographic data are often delayed in their release, so data are presented for the most recent years available for any given data source. »V ariability in the geographic level at which data sets are available (ranging from census tract to statewide or national geographies) presents an issue, particularly when comparing similar indicators collected at disparate geographic levels. Whenever possible, the most relevant localized data are reported. »D ue to variations in geographic boundaries, population sizes, and data collection techniques for suburban and city communities, some datasets are not available for the same periods or at the same level of localization throughout the county. »G aps and limitations persist in data systems for certain community health issues such as mental health and substance use disorders for youth and adults, crime reporting, environmental health, and education outcomes. Additionally, these data are often collected and reported from a deficit-based framework that focuses on needs and problems in a community, rather than assets and strengths. A deficitbased framework contributes to systemic bias that presents a limited view of a community’s potential. With this in mind, UCMC, Metopio, and all stakeholders were deliberate in discussing these limitations throughout the development of the CHNA and selection of the FY 2023-2025 health priority areas.
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Significant Health Issues That Will Not Be Addressed In acknowledging the wide range of priority health issues that emerged from the CHNA process, UCMC determined that it could only effectively focus on those which a) emerged as a top priority from the data collected, and b) fit within the current resources available. For example, UCMC has invested in asthma prevention/management for many years, but this did not emerge as a top priority for the population surveyed in this cycle (compared to other health issues that were perceived as more pressing). However, according to IHA COMPdata from 2020, asthma hospitalization rates in UCMC’s service area were nearly three times that of the state of Illinois (106.14 per 100,000 residents versus 29.31). Therefore, UCMC will sustain its historical investment in asthma prevention/management to continue building community trust in these programs and further promote prevention on a population level. These efforts will take a similar form to those employed for chronic disease prevention (detailed on the following page), with a focus on addressing social determinants of health.
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Health Priority Areas UCMC retained the following primary health priority issues from the 2018–2019 CHNA: diabetes, violence prevention, mental health, access to food, employment (i.e. workforce development), and access to care. In response to the needs assessment, heart disease and cancer were added to the list.
The priority health areas are grouped by three themes that emerged from the CHNA data collection process: chronic disease, trauma resiliency, and social determinants of health. Social determinants of health (SDOH) are conditions in the environment in which people are born, live, learn, work, play, worship, and age that affect health outcomes and risks, functioning, and quality of life.4 These social, economic, and environmental conditions, in addition to health behaviors, relate to an estimated 80% of health outcomes in the United States.5 See Figure 3 for a conceptual model demonstrating the intersection of social determinants of health with chronic disease and trauma resiliency. Figure 3. Framework for Community Benefit Health Priorities
Intersection of 2023 CHNA Health Priorities
Social and Community Context
Education Access and Quality
CHRONIC DISEASE
TRAUMA RESILIENCY Violence Prevention, Recovery
Heart Disease Diabetes
Mental Health
Cancer
Neighborhood and Built Environment
Healthcare Access and Quality
Economic Stability
FOOD INSECURITY
ACCESS TO CARE
WORKFORCE DEVELOPMENT
1 UCMCSA zip codes: 60609, 60615, 60617, 60619, 60620, 60621, 60628, 60636, 60637, 60643, 60649, 60653 2 2018-2019 Community Health Needs Assessment 3 2018-2019 Community Health Needs Assessment Strategic Implementation Plan FY 2023-2025
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UCMC’s Strategic Implementation Approach All UCMC community benefit investments and programs are built on a framework that promotes health equity and is framed by the community benefit overarching goal: to enhance community health and wellness around the CHNA priority health needs in the UCMC Service Area. To achieve this goal, UCMC executes its interventions, services, and/or programs through the following methods:
Figure 4. Implementation Approach
FPO
Examples of specific strategies and initiatives corresponding to each of the selected health priority areas are outlined on the following pages. See Appendix 1 for the fully detailed evaluation framework relating to these strategies. UCMC will continue to identify opportunities to implement interventions to address these priority needs.
4 O ffice of Health Promotion and Disease Prevention. Healthy People 2020. Available at: https://www.healthypeople.gov/2020/ topicsobjectives/topic/social-determinants-of-health 5 County Health Rankings & Roadmap. Available at: http://www.countyhealthrankings.org/our-approach. Strategic Implementation Plan FY 2023-2025
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I. HEALTH PRIORITY AREA 1:
Chronic Disease
Addressing widespread chronic disease among adults is important to residents of all ages in the service area, as living with comorbidities is associated with a poorer quality of life and a lower life expectancy. It also contributes to financial instability and poor mental health. The first step to preventing chronic disease is to establish healthy behaviors. However, there are many impediments to living a healthy lifestyle in the UCMCSA. Regardless of age, residents struggle to access healthy food, safe places to exercise, healthy environments, screenings, and other preventive services.
Health Priority 1 Objective: Reduce the Impact of Chronic Disease STRATEGIES Provide screening and education opportunities for heart disease, diabetes, and cancer
»E xpand free/subsidized screenings that include education »C ontinue community education initiatives focused on chronic disease prevention
Empower community members to manage their heart disease, diabetes, and/or cancer
Increase access to care
» I ncrease access to healthy food
» Assist patients with healthcare navigation
»M anage comorbidities including hypertension and obesity
» Encourage patients to establish care with a primary care physician » Increase the capacity of the health system for primary and specialty care, internal and external to UCMC
Reduce inequities caused by social determinants of health (SDOH)
» Expand screening for social determinants of health across the health system » Connect patients and community members with resources such as housing, employment, food, and transportation, etc.
» Expand and streamline care coordination across the UCMC hospital system » Train healthcare staff in cultural competency, shared decision-making, and plain language
UCMC continues to invest in care delivery initiatives and expand partnerships that address primary, secondary, and tertiary prevention for heart disease, diabetes, and cancer. Key programs that support these initiatives are the Liaisons in Care Community Health Worker program, Patient Advocates program, Feed First, and the South Side Healthy Community Organization.
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II. HEALTH PRIORITY AREA 2:
Trauma Resiliency
The South Side, including the UCMCSA, has a history of trauma that is founded on structural and systemic disinvestment in these communities. Several causes of traumatic health outcomes co-exist on the South Side, adding daily pressure to residents seeking a healthy life. During focus groups, participants noted situations that contribute to trauma, including abuse, crime, and stigma around mental health, among others. As we consider building trauma resiliency, much of the work will be focused on violence prevention and mental health.
Health Priority 2 Objective: Improve Trauma Resiliency STRATEGIES Cultivate and maintain partnerships to improve community health and safety
»C ontinue building a violence prevention ecosystem that addresses mental health and social determinants of health »B uild and strengthen partnerships with street outreach organizations across the South Side
Embed trauma-informed care across the hospital system
»P romote hospital and community-based programs that serve unmet needs related to social determinants of health »T rain healthcare staff in trauma-informed care, cultural competency, shared decision-making, and plain language »E xpand the scope and capacity of the Violence Recovery Program to more holistically address patient and family needs
Increase access to mental healthcare and services
» Collaborate with internal and external efforts focused on providing mental health services » Increase the capacity of mental health services within UCMC and in the community
Reduce inequities caused by social determinants of health (SDOH)
» Expand screening for social determinants of health across the health system » Connect patients and community members with resources such as housing, employment, food, and transportation, etc.
» Execute interventions to address employee wellness » Implement behavioral health services within the primary care setting
UCMC continues to develop partnerships, create trauma-informed medical education, and engage in community-based education and outreach programs that prevent and treat trauma on the South Side. Key programs that support this health priority include the UCMC Violence Recovery Program, Healing Hurt People – Chicago, Southland RISE, and the South Side Healthy Community Organization. Programs targeted toward career development and employee wellness include the Workforce Resilience Enhancement Project and BRIDGE Initiative.
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Community Benefit Report Communication UCMC made its CHNA and Strategic Implementation Plan publicly available online via the UChicago Medicine website, after it was approved and adopted by the Board of Directors in May 2022. Additionally, UCMC will share the Strategic Implementation Plan with its Community Advisory Council and various external stakeholders (e.g., community members, local political representatives, faith leaders, healthcare providers, and community-based organizations), and make copies available upon request.
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Appendix 1: Priority Area #1: Chronic Disease G oal: Prevent and manage risk factors known to worsen morbidity and mortality due to chronic disease OBJECTIVE
Objective 1:
Provide screening and education opportunities about heart disease, diabetes, and cancer
Objective 2:
Empower community members to manage their heart disease, diabetes, and/or cancer
PROGRAMS, SERVICES, PARTNERSHIPS
STRATEGY
ANTICIPATED IMPACT
METRICS
Expand free/ subsidized screenings that include education components
»M ammogram screenings (SCORE) » Asthma screenings
Community members will have increased access to chronic disease screenings and educational tools, with access to clinical care when necessary
» I ncreased rates of chronic disease screenings » Number of events held » Number of event participants
Continue community education initiatives focused on chronic disease prevention
»C ommunity Affairs Grand Rounds » NCI Education Modules » Asthma Summit » Heart Walk » DEEP » Southside Fit » CHW programs
Community members will have increased access to chronic disease screening and educational tools, with access to clinical care when necessary
» Number of events held » Number of encounters where CHW-related roles provided health education
Increase access to healthy food
» » » » »
Patients, employees, and the community will be aware of internal and external food programming and have increased food access
» Continue food pantries internal to UCMC » Number of programs that incorporate food referral services » Pounds of food distributed » Number of programs that screen for food insecurity
Manage comorbidities like hypertension and obesity
»P opulation Health Nurse Team (diabetes/ hypertension outreach) » CHW programs » Patient Advocates » South Side Healthy Community Organization
Patients will understand their condition, know how to manage medication, and be aware of/ avoid lifestyle factors that could prompt readmission (high-salt diet, for example)
» Number of community members provided education on hypertension » Number of community members provided education on obesity » Number of patients engaged in Hypertension service line of LinC program » Number of supplies given to community members that assist in managing chronic conditions (glucometers, blood pressure cuffs, smoking cessation kits, etc.)
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FeedFirst GB8 Garden Home Veggie Rx NowPow Community Rx Hunger Clinical Trial/HealtheRx
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(CONTINUED)
Objective 3:
Increase access to care
Objective 4:
Reduce inequities caused by social determinants of health
STRATEGY
PROGRAMS, SERVICES, PARTNERSHIPS
ANTICIPATED IMPACT
METRICS
Assist patients with healthcare system navigation
» Patient Advocates » CHW programs
Patients will have increased access to healthcare navigator resources and improved understanding of how to independently navigate their healthcare
» Improvement in patient satisfaction/experience » Reduction in out-ofnetwork visits » Number of patients with documented medical homes
Encourage patients to establish care with a primary care physician
»L inC CHW program » Patient Advocates » Population Health nurse team
Patients will seek preventive care from their PCP instead of relying on the ED for primary care
» Reduction in ED utilization
Increase capacity of the health system for primary and specialty care internal and external to UCMC
»S outh Side Healthy Community Organization » Chicago Children’s Health Alliance
Community members in the UCMCSA will have more options to meet their healthcare needs
» Reduction in ED utilization » Number of patient referrals to a medical home
Expand and streamline care coordination across the UCMC hospital system
»L inC Community Health Worker program » Care coordination » South Side Healthy Community Organization » Patient Advocates » Population Health nurses
A patient’s medical history and needs will be known by whichever provider they see in the UCMC service area
» Reduction in readmissions » Reduction in hospitalizations
Train healthcare staff in cultural competency, shared decisionmaking, and plain language
»O ffice of Diversity, Equity, & Inclusion training series
Patients will be better informed about how to manage their health and will know how to (and feel comfortable to) seek support when needed
» Improvement in health knowledge » Improvement in patient satisfaction surveys
Expand screening for social determinants of health across the health system
»C HW programs » Patient Advocates » Violence Recovery Program » Population Health » Social workers
More patients are screened for SDOH needs across the UCMC system
» Continue utilization of the SDOH screening tool in Epic » Expand the utilization of the SDOH screening tool in Epic to new service lines
Connect patients and community members with resources like housing, employment opportunities, food, and transportation
»C HW programs » Patient Advocates » Violence Recovery Program » Population Health » Social workers
More patients receive referrals to organizations and/or services that address and mitigate social determinants of health
» Number of referrals related to social determinants of health » Number of communitywide events held to promote health » Number of engagements with virtual communications promoting health
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Priority Area #2: Trauma Resiliency G oal: Prevent, manage and promote recovery from trauma OBJECTIVE
Objective 1:
Cultivate and maintain partnerships to improve community health and safety
Objective 2:
Embed traumainformed care across the hospital system
STRATEGY
PROGRAMS, SERVICES, PARTNERSHIPS
ANTICIPATED IMPACT
METRICS
Continue building a violence prevention ecosystem that addresses mental health and social determinants of health
»C ommunity benefit grantmaking » Communityand faith-based partnerships » Southland RISE » Partnership with Mayor’s Office » Chicago HEAL Initiative
Deepen community partnerships by maintaining and expanding community investment, supporting community-based programs, and highlighting community initiatives across the South Side
» Number of partners and programs working to build a violence prevention ecosystem » Number of external coalition-building events held or participated in » Number of grantees supported » Number of summits held
Build and strengthen partnerships with street outreach organizations across the South Side
»S treet Outreach Partnerships » Metro Peace Initiative
Community members will receive more support immediately following community incidents of violence
» Number of citywide street outreach meetings attended » Number of UCMC referrals to street outreach organizations » Number of incidents responded to/intervened by street outreach workers
Promote hospital and communitybased programs that serve unmet needs related to social determinants of health
»G rantmaking »O ffice of Diversity, Equity & Inclusion training series » Violence Recovery Program
Patients and community members will have increased access to screenings, interventions, and resources
» Number of SDOH screenings conducted by UCMC Violence Recovery Specialists » Number of referrals initiated by UCMC Violence Recovery Specialists » Number of grant programs supported that incorporate referrals related to social determinants of health
Train healthcare staff in traumainformed care, cultural competency, shared decisionmaking, and plain language
» Office of Diversity, Equity & Inclusion training series
» Staff will have sufficient resources and training to perform culturally competent, traumainformed care across the organization » Patient resources and education materials will be easy to understand
» Number of staff trained in resiliency-based care » Improvement in patient satisfaction surveys » Improvement in staff satisfaction surveys
Expand the capacity and scope of the Violence Recovery Program to more holistically address patient and family needs
»V iolence Recovery Program » Healing Hurt PeopleChicago » Med-Legal Partnerships
Patients and their families receive ongoing support after a traumatic event
» Number of patients receiving case management services » Number of patients receiving Med-Legal services » Number of patients
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(CONTINUED)
Objective 3:
Increase access to mental healthcare and services
Objective 4:
Reduce inequities caused by social determinants of health
STRATEGY
PROGRAMS, SERVICES, PARTNERSHIPS
ANTICIPATED IMPACT
METRICS
Collaborate with internal and external workgroups working on mental health
»C ommunityand faith-based partnerships » Youth-oriented programs » Grantmaking
Community members will have more access to community-based mental health services and resources
» Number of workgroups » Number of external partnerships » Amount of grant funding
Increase capacity of mental health services
»S outh Side Healthy Community Organization » REACT and USTAR » Healing Hurt PeopleChicago » TURN Center
» More patients and community members will have access to mental health services » Patient wait times for appointments will decrease
» Number of behavioral health and/or mental health providers added to the UCMCSA » Number of referrals to behavioral health services
Execute interventions to address employee wellness
»W orkforce Resilience Enhancement Project
Staff receive ongoing support to: » Reduce compassion fatigue » Increase resilience » Emphasize employee wellbeing
» Number of employees participated in ECHOChicago Workplace Resilience series » Improvement in staff satisfaction surveys
Implement behavioral health services within the primary care setting
»B ehavioral Health Integration Program
» Mental health screenings and care will be embedded in the primary care processes
» Number of mental health screenings conducted during PCP visits » Number of mental health referrals via PCP visits
Expand screening for social determinants of health across health system
»C HW programs » Patient Advocates » Violence Recovery Program » Population Health » Social workers
» More patients are screened for SDOH needs across the UCMC system
» Number of patients screened for SDOH needs
Connect patients and community members with resources like housing, employment opportunities, food, and transportation
»C HW programs » Patient Advocates » Violence Recovery Program » Population Health » Social workers » Community Affairs Programs
More patients receive referrals to organizations and/or services that address and mitigate the social determinants of health
» Number of referrals related to social determinants of health » Number of communitywide events held to promote health » Number of engagements with virtual communications promoting health
Increase the local workforce’s commitment to address economic hardship
» I nclusive Pathways program (HR) » BRIDGE Initiative Chicago (HR) » NSA Pathway Program » MAPP (HR with West Side United)
Community members will have more pathways to career opportunities that will lead to better economic agency
» Number of community health workers hired from the UCMC service area » Number of individuals placed in career development programs » Number of resulting hires from career development programs » Workforce diversity
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Contact for Feedback Any questions or concerns regarding the CHNA, Strategic Implementation Plan, or Community Benefit Evaluation Report can be sent to uch-communitybenefit@uchicagomedicine.org.