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One of the things I love most about my work at CHA is the opportunity to meet a multitude of colleagues from across the Catholic health care ministry. It never ceases to amaze me when I see the great work so many are doing across the country in extending the healing ministry of Jesus in our communities, especially for those who are underserved and vulnerable. I encountered one such example on a recent visit I made to San Diego. The mission team at Scripps Mercy Hospital, led by Mark Zangrando, extended a generous welcome as I toured their facilities and met a wide variety of staff.

Part of the Scripps Health system, Scripps Mercy Hospital was founded by the Sisters of Mercy and has served San Diego since 1890. As part of its community-driven approach, one of the hospital's goals is to collaborate with area leaders and agencies to offer programs that promote access to care and health education.

As Kendra Brandstein, PhD, director of community benefit for the hospital, explained during my visit, two key initiatives are helping to make the advancement of this critical goal possible: the Scripps Mercy Hospital Chula Vista Well-Being Center and the Scripps Family Medicine Residency. By working collaboratively with community members, these programs help to address health disparities for those who are medically underserved along the California/Baja California border regions.

MEETING PATIENTS WHERE THEY ARE

KENDRA BRANDSTEIN, PhD, MPH, MSW

Providing opportunities for residents to make a difference in the California/Baja California area while also gaining hands-on experience, the Family Medicine Residency Program at Scripps Mercy Hospital Chula Vista embeds community medicine experiences in its curriculum. Training family medicine physicians to provide comprehensive medical care, the program also educates physicians to work in underserved communities. Many of these physicians today now hold leadership roles in local community clinics.

"As a program, we strive to not only train our residents to work within the walls of the clinic, but also learn how to work together to partner in the schools and community organizations in order to provide more effective care for communities. Our residents learn to understand that life outside the clinic affects how they (community members) take their medications, what types of food they eat and how they access care," said Melissa Campos, MD, associate program director and alumna of the program.

For residents and medical students, having this work embedded in the program provides them with an opportunity to learn through diverse community experiences. "Working here in very close proximity to the U.S.-Mexico border ... gives us the opportunity to provide high-quality and equitable binational care to our medically underserved community," particularly a Latino Spanish-speaking medically underserved community, said Miguel Alvarez-Estrada, MD, a program alumnus who today is on its faculty. He said he also appreciated the program's close community ties, noting that he has always wanted to be a physician who could serve people like his parents and their neighbors.

COMMUNITY HEALTH IN ACTION
In collaboration with the Scripps Family Medicine Residency Program, Chula Vista Community Collaborative¹ and the Scripps Mercy Hospital Chula Vista Well-Being Center offer community education programs for nearly 20 community health workers (or, commonly known in Spanish as promotores) who are community members. Through the Promotores in Action: Prevention, Education and Wellness program, promotores are trained in health promotion and education and work to disseminate information concerning health and wellness to individuals and groups in San Diego's South Bay community.

Scripps Mercy Hospital Chula Vista Well-Being Center offers monthly community educational sessions on topics focused on critical community health needs, including mental health, burnout, chronic disease prevention, hypertension and diabetes. Working closely with Scripps Family Medicine residents who often present the topics, the center works collaboratively with the promotores to develop and deliver educational content tailored to the needs and interests of the community. This approach provides the community with accurate and reliable information about health and wellness, empowers them to make informed decisions about their health, and enables them to disseminate the education they receive to others. As expressed by one of the program's participants, "What I have learned today will help me to seek medical care and be informed about symptoms and how to improve my life."

Scripps Mercy Hospital Chula Vista Well-Being Center also helps to meet the needs of older adults through its Health Chats: Teaching Seniors about Health and Prevention Program. Established more than 20 years ago, the program is centered around topics chosen by community seniors, ensuring that the content is relevant and meaningful to their lives. The goal is to promote a culture of learning and sharing among the senior community by providing them with health education and a better understanding of access to care; empowering them to take control of their health and well-being; and encouraging them to share what they learn with their peers.

Since the start of the year, the program — which is offered at multiple community locations and covers topics from heart health to food and nutrition to fall prevention — has served nearly 150 seniors, and knowledge on the educational topics among participants has increased by an average of 15%. Comments from participating seniors include, "Every time I attend the presentations, I feel that I know more on how to protect myself and my loved ones," and, "This is important, especially since I can't get out that much anymore, and people like me are very appreciative."

NAVIGATING SYSTEMS, IMPROVING CARE AFTER DISCHARGE
Efforts at Scripps Mercy Hospital Chula Vista Well-Being Center are also underway to address the numerous social determinants of health for chronic disease patients and their families after they are discharged in order to help them manage their condition through a supportive intervention called Helping Patients Navigate Services and Support Post-Discharge. The program's key focus areas are to: improve patients access to primary and specialty care; help patients navigate the health care system; and connect them with health care providers and necessary services, including those for supporting mental health or management of chronic conditions. The support services are referral-based and provide assistance with a wide range of needs, helping to decrease the risks of readmission and to increase patient continuity.

Addressing social determinants of health — such as housing, food and transportation — can also be critical for patients with chronic diseases. The program is developing ways to improve coordination and communication among health care providers, community organizations and social service agencies. In the previous year alone, nearly 800 patients were referred, and outreach was done for more than 500 patients to support them in scheduling follow-up medical appointments and providing emotional support, supportive services and community resources (including those to address food and housing needs) during challenging times.

Improvement in these patients' conditions has been evident from these efforts as those who have been communicated with consistently over time are 1.3 times less likely to be readmitted compared to those who are not contacted. Patients have expressed gratitude for the assistance provided through the program, one saying it is "so comforting to know that someone cares," and another expressing that the outreach "helped me improve my life and I am forever grateful."

Of these patients, 80% had a follow-up appointment with a physician within two weeks post-hospital discharge, 97% were compliant with their medication, and more than 90 supportive services and community resources were provided.

GOOD COLLABORATION IS KEY
These interventions at Scripps Mercy Hospital Chula Vista aim to create a more holistic and patient-centered approach to health care, one that recognizes the importance of social determinants of health and provides support to help patients manage chronic disease and improve their overall health and well-being. As described by Debra McQuillen, vice president and chief operations executive at Scripps Mercy Hospital, "The collaborative efforts and commitment of the health care professionals and providers in our Family Medicine Residency Program and Well-Being Center brings our Scripps Health mission and the legacy of the Sisters of Mercy to our patients every day, creating a stronger and more healthy community."

Addressing the underlying factors contributing to poor health outcomes can help reduce health care costs and improve patient outcomes over the long-term. Through the hospital's community-based health care initiatives, these efforts provide an excellent example of how collaboration among health care providers, community organizations and social service agencies can promote access to care, health education and improved patient outcomes.

KENDRA BRANDSTEIN is director of community benefit at Scripps Mercy Hospital Chula Vista and director of the San Diego Border Area Health Education Center at the Chula Vista campus of Scripps Mercy Hospital.

NOTE

1. Chula Vista Community Collaborative, https://www.chulavistacc.org.