In addition to working with the Population Health Coalition, St. Luke’s Cornwall Hospital has its own community education program that reaches a wide variety of audiences on a number of topics related to its two Prevention Agenda items. Education is provided at a number of local senior groups, workplace wellness programs, local businesses, food pantries, soup kitchens, and public events. In 2016, SLCH provided more than 100 education and screening events to the community. Future plans will build upon this existing model by identifying other audiences in need of educational programming, as well as utilizing digital outreach through the internet and social media. The Population Health Coalition has also succeeded in compiling an interactive directory of local community resources that can be utilized to better connect the population to appropriate services to best fit their needs.
Another focus has been to decrease exacerbation of chronic diseases and preventing unnecessary hospitalization through work that has been completed in our Care Transitions Program. With this program, high risk patients (COPD, CHF and Diabetes) are managed by members of our team. The Coleman Model of Care is used with each patient, ensuring that they receive the proper follow up care when discharged from the hospital. Our team works closely to continue to manage the patients’ needs in the community, ultimately preventing them from returning to the hospital for chronic illness.
St. Luke’s Cornwall Hospital’s selected Prevention Agenda items are also in line with its participation in the Delivery System Reform Incentive Payment Program (DSRIP). SLCH is part of the Montefiore Hudson Valley Collaborative and is represented on its Leadership Steering Committee. The hospital is involved in nine out of 10 DSRIP projects and some special projects such as the Accelerated eXchange Series Program (MAX) and Asthma Management Project, all aimed at improving outcomes and decreasing hospitalizations. Through collaboration with community partners, these projects are designed to engage patients in order to help them manage chronic diseases in more appropriate settings and reduce hospital utilization for issues better dealt with through community-based resources.
To assist in the promotion of healthy women, infants and children, SLCH has worked to increase support for breastfeeding by giving patients greater access to Certified Lactation Counselors through certification training to Neonatal Intensive Care Unit and Birthing Center Staff. SLCH is participating in the New York State Breastfeeding Quality Improvement in Hospitals (BQIH) Collaborative. Every member of the Birthing Center and NICU staff who are not Certified Lactation Counselors will be required to complete 20 hours of training through he BQIH. We have also partnered with the Maternal Infant Services Network to house pre-natal breastfeeding classes and a new moms support group.
Along with the efforts to increase the breastfeeding rates, SLCH has taken an active role in the prevention of Neonatal Abstinence Syndrome, a consequence of the abrupt discontinuation of chronic fetal exposure to substances such as heroin, prescription medication, methadone or buprenorphine, used and abused by a mother during pregnancy. Utilizing education and intervention, SLCH and the Cornerstone Family Health Center’s Center for Recovery are working together to target expectant mothers who have been identified by the Center for Recovery’s Opiod Treatment Program and enhance current practices by adding a comprehensive treatment program which includes obstetric care, counseling and educational services with the goal of giving babies a healthier start while minimizing the financial burden to state and federal social service programs.
There are also internal initiatives being put in place in order to ensure the best possible outcomes for newborns at St. Luke’s Cornwall Hospital. Any member of the NICU and Birthing Center staff who reads a fetal monitor as part of their duties will be required to achieve Certification in Electronic Fetal Monitoring (C-EFM) through the National Certification Corporation. In addition, two NICU nurses have completed training to become S.T.A.B.L.E. (Sugar & Safe Care, Temperature, Airway, Blood Pressure, Lab Work, Emotional Support) Program instructors in order to train other members of the NICU and Birthing Center staff. This neonatal education program focuses on the post-resuscitation/pre-transport stabilization care of sick infants in order to help reduce infant mortality. The program will eventually be expanded to Emergency Department Staff.
Progress and improvement on all these initiatives is tracked in a variety of ways. Feedback and evaluation forms have been developed for use at community education events that ask attendees about the overall effectiveness of the program, their likelihood of following up with a medical intervention and what lifestyle changes they will make as a result of the information. We are also tracking the number of cancer screening events held in partnership with community partners and the number of individuals navigated to and/or through cancer screening, as well as hospital readmission rates for chronic diseases both overall and for Care Transitions patients. To monitor the progress of our health women, children and infants program, we will track the number of women reached by policies and practices to support breastfeeding, the number and percent of women/families who participate in family education programs (e.g., pre-natal breastfeeding and a new mom support group), as well as the number and percent of NICU/birthing center professionals who receive lactation counselor certification.