Know Your Numbers: Teaming up to Help the Greater Bridgeport Community

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"Improving the health of a community is critical to ensuring the quality of life of its residents and fostering sustainability and future prosperity. Health is intertwined with many different facets of our lives; where we work, live, learn, and play all have an impact on our health. Understanding the current health status of a community and all of the different factors that influence health, is important in order to identify priorities for program planning and coordination across partner organizations.

In 2003, the Primary Care Action Group (PCAG) was formed to help address the health needs of the Greater Bridgeport community, which includes the six towns of Bridgeport, Easton, Fairfield, Monroe, Stratford, and Trumbull in Connecticut. PCAG is a coalition of two neighboring hospitals in the City of Bridgeport, Bridgeport Hospital and St. Vincent’s Medical Center, along with the six departments of public health, federally qualified health centers, and about 50 community and non-profit organizations all serving the region. The mission and vision of PCAG is to work together to identify, prioritize and measurably improve the health of the community through prevention, education and services.

As one of its first collaborative projects, in April 2011, PCAG helped launch the Dispensary of Hope Greater Bridgeport, a charitable pharmacy dedicated to serving low-income and uninsured individuals in the Bridgeport community. A member of the national Dispensary of Hope Network, Dispensary of Hope Greater Bridgeport provides short-term and long-term medication assistance to eligible patients through a licensed pharmacist and trained personnel. The Dispensary of Hope Greater Bridgeport served over 4,500 patients in fiscal year 2017." 

 

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Type of Story

Tags

Snapshot

Topic
  • Access to care

  • Clinical condition: Cardiovascular disease

  • System change: Health care transformation

  • System change: Community transformation

  • System change: Data and/or measurement transformation

  • Health System Transformation Oasis

Aims
  • Health-promoting

  • Population-centered

  • Vigilant

  • Safe

Influence
  • Interpersonal (between people)

  • Community/place

Age
  • Adults 18+

  • Adults 18-44

  • Adults 45-64

  • Older adults 65+

  • Older adults 65-74

  • Older adults 75-85

Portfolio
  • Portfolio 1 (Improving mental/physical health with patients or workforce)

    This portfolio supports health care organizations focused on improving the physical and/or mental health of individuals for whom they feel directly responsible (e.g., patients and/or employees).

  • Portfolio 3 (Improving community health and well-being together with partners for a specific issue)

    ​​​​In this portfolio, health care organizations work together with community partners to improve specific health and wellbeing outcomes for a place-based population.

  • Portfolio 4 (Stewarding the community's long-term overall well-being)

    ​​​​​​In this portfolio, health care organizations actively engage in contributing to the long-term, overall wellbeing of the community as part of their mission and responsibility. In partnership with other community-based organizations, the focus on the community as a whole beyond subpopulations or priority topics.

Action Areas
  • Databases of population health resources

    ​​​​​​Curated websites or databases that have evidence-based resources to improve health, wellbeing, and equity within health care, population health, and the community.

  • Data

    ​​​​​​Resources to help data collection by health care organizations in relation to population health, including cost and quality data on physical and mental health, number of ED visits, readmissions, demographics, and social determinant data supplemented by community partners. Community-level data should be stratified and used to identify and address inequities, and data should be shared across the community.

  • Care management

    Resources to help a set of activities that help improve patient care and reduce  medical services by “enhancing coordination of care, eliminate duplication, and helping patients and caregivers more effectively manage health conditions” as stated by the Robert Wood Johnson Foundation.  

  • Social determinants screening/referrals

    ​​​​​​Resources to help implement a type of internal assessment used by healthcare organizations to consistently screen for and address the social and spiritual drivers of health and wellbeing for a defined population, with a goal of ultimately connecting patients with community resources. Social drivers of population health include socioeconomic factors such as food, housing, education, transportation, and income, and social connectedness. Spiritual drivers include all factors that contribute to a sense of purpose, meaning, self-worth, hope, and resilience.

  • Community partnerships

    Resources to support partnering with local social-service agencies, faith communities, housing organizations, and other community-based organizations that have experience with addressing defined social and spiritual drivers.

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