Best practices

Alpert Medical School of Brown University

Plans for a Primary Care-Population Health Program at Alpert Medical School of Brown University

The Warren Alpert Medical School of Brown University (AMS) is developing a Primary Care-Population Health (PC-PH) Program.  This dual MD/MS program will integrate primary care and population health throughout a four-year course of study. Our aim is to accelerate change through educating a new cohort of primary care-clinicians leaders while creating a unique paradigm for medical education for all students at AMS and facilitating substantive change in the healthcare system.  The goals of this program are to foster innovation in medical education through integrating medical science, clinical skills, population health and interprofessional education throughout a 4-year curriculum in a newly developed Primary Care-Population Health (PC-PH) Program and expand the primary care workforce and graduate primary care-focused physician leaders. 

We identified several compelling reasons to develop this program at AMS.  First and foremost was the need to increase the number of U.S. medical students entering primary care, and the importance of educating all students in a manner that focuses on determinants of health along with quality and safety of healthcare delivery.  In developing a new program, we will be afforded the opportunity to introduce evidence-based methodologies throughout, from student recruitment to core education to preparation for residency and a career in medicine. 

We will achieve our goals through the following objectives:

[1] Design and deliver a balanced, innovative medical education program that gives appropriate emphasis to both medical knowledge and knowledge of population health;

[2] Focus on the development of teamwork and leadership skill among medical students and their non-physician healthcare colleagues;

[3] Design and deliver a curriculum that directly addresses issues related to the healthcare system, including healthcare reform and financing;

[4] Integrate AMS' competencies, the Nine Abilities, with the ACGME competencies and Milestones project to assess student progress via innovative means. We have implemented a planning process that will allow us to matriculate students at the start of the 2015-2016 academic year. 

The commitment of AMS, Brown University, and community and government partners in Rhode Island will ensure that the program is sustained and that it achieves its goals.

East Tennessee State University

HEAL Appalachia is a community collaborative created and supported by the largest health system (and largest employer) in the rural central Appalachian region of northeast Tennessee and  southwest Virginia, and the only Academic Health Science Center in the region.  HEAL Appalachia has created a remarkably broad community partnership to address the issues of childhood obesity in a 29 county area that spans portions of two states.

As the result of a regional health needs assessment conducted by Mountain States Health Alliance (MHSA) and East Tennessee State University (ETSU), the decision was made to focus MSHA social responsibility efforts on addressing childhood obesity.  A regional advisory committee, with representation from the faith community, businesses, educational institutions, health departments and other was formed to guide and direct the effort.  Randy Wykoff, Dean of the ETSU College of Public Health has chaired the Advisory Committee from its inception. 

HEAL Appalachia has focused on two activities:

  1. A mini-grant program that distributes grants of $2,000 to $5,000 to support community-based efforts to address childhood obesity; 
  2. An annual symposium that brings together a wide-range of community groups interested in Childhood Obesity.

The goal is to increase the number of community based organizations that are thinking about and addressing childhood obesity.  The community response has been dramatic—with over 150 applications received for the 50 awards given in the first two years, and well over 500 participants in the first two symposia.    
HEAL Appalachia represents an ideal model for an Academic Health Science Center to partner with a regional health system to address a major health challenge in a large service area.   While it is too early to assess an impact on childhood obesity, the goal of broad community awareness and participation has clearly been achieved.

Florida International University Herbert Wertheim College of Medicine

Florida International University (FIU) Herbert Wertheim College of Medicine (College of Medicine) created an innovative, interprofessional approach to health professions training that exposes students to the social determinants of health in underserved neighborhoods in Miami-Dade County, while simultaneously addressing the needs of local residents. Green Family Foundation (GFF) NeighborhoodHELP™ (Health Education Learning Program), the centerpiece of the College of Medicine’s curriculum, is a longitudinal service-learning experience that integrates the non-biologic causes of disease and serves as a model for developing clinically and culturally competent physicians.

The program was created and launched in collaboration with community partners and with fellow colleges at FIU, including Nursing and Health Sciences, Robert Stempel Public Health and Social Work, and Law. Interprofessional teams of medical, nursing, social work, public health, and law students care for underserved households during the course of their education.  Supervised by FIU faculty, GFF NeighborhoodHELP™ challenges students to address the complex medical, social, and ethical issues that impact health care access and health outcomes of the households. Evaluation of the program show significant decreased visits to the emergency room and increased  preventive health measures in household members and provides a cost-effective approach projected to save eight dollars for every dollar invested.  Students apply concepts learned in the classroom while engaging households that benefit from regular home visits and the development of a comprehensive plan to address needs. Additionally, they make referrals for much-needed services, such as for primary health care to the GFF NeighborhoodHELP™ Mobile Health Center, a 38-foot, fully equipped mobile unit stationed in the targeted neighborhoods that provides accessible services for households.

Medical College of Wisconsin

The Medical College of Wisconsin has initiated programs that they think are excellent examples of how academic health centers can improve the health of their communities by addressing the social determinants of health, as well as work with a variety of stakeholders to build a multi-sectoral movement dedicated to addressing all the determinants of health, including medical, social, behavioral, and environmental.  

In particular, the Medical College of Wisconsin’s Advancing a Healthier Wisconsin Program is a unique program that advances community and academic partnerships aimed at improving the health of the community.  Projects funded through the program address several underlying social determinants of health.  

In addition, they are developing a new statewide community medical education program that they believe is an excellent example of how academic health centers can lead innovative curricular efforts to address social determinants of health.

Morehouse School of Medicine

Adaptation, Education and Motivation:  Improving Evidence-Based Medication Adherence
“iADAPT Project”
The proposed adaptation and dissemination project builds on previous research aimed at improving diabetes care quality at a local federally-quality community health center, providing care to this predominately low income, urban African American population.   Our intent in this proposed project is to adapt and customize Comparative Effectiveness Research Summary Guides (CERSGs) for Consumers and Clinicians:  Consumer Guides “Pills for Type 2 Diabetes” and “Premix Insulin for Type 2 Diabetes” and Clinician Guides “Comparing Oral Medications for Adults with Type 2 Diabetes” and “Premixed Insulin Analogues.” The CERSGs will be adapted within the socio-cultural context of routine provision of care within this healthcare organization (West End Medical Centers (WEMC)) and in doing so impact overall diabetes care quality.  The project objective is to incorporate evidence-based medication use into patient self-care, the WEMC Diabetes Self-Management Education (DSME) Program, and the decision support functions of the electronic medical record (EMR) system.

The primary aims are to 1) improve the rate of scheduled diabetes care follow-up visits, to enhance the opportunity for anti-diabetes treatment and treatment intensification, 2) increase medication knowledge and awareness, 3) improve patient communication with the provider regarding medication use and 4) improve  adherence to CERSGs prescribed medications.  The secondary aims are to 1) increase participation and completion rates of WEMC DSME classes where medication adherence behaviors are reinforced and 2) to improve prescription documentation of CERSGs oral and insulin medications in the EMR systems for periodic review and assessment of evidence-based prescribing practice.

We propose a community health work (CHW) model with the innovation of motivational interviewing (MI) to deliver the content of CERSGs to adults with type 2 diabetes.  The CHW intervention will be delivered according to the psycho-social needs and stage of readiness of the project participants and for the purpose of facilitating motivation for adherence to prescribed anti-diabetes medications.
Despite current efforts at WEMC, diabetes care quality remained suboptimal, the missed appointment rate is high and medication adherence is at 20%.  Participation in and completion of DSME classes are poor, and care quality and prescribed medications are poorly documented in the EMR system.  The CHW intervention is expected to improve the rate of diabetes care follow-up visits, knowledge and aware of evidence-based medication use, patient communication, medication adherence, and participation in DSME classes where medication adherence will be reinforced.  Adaptation CERSGs is expected to be further enhanced by incorporating CERSGs for providers into the EMR system, provide web-base training for clinicians, and audit medications problems, and conduct feedback discussion of medication adherence and patient-provider communication issues, e.g., during “Lunch and Learn” (Figure 1).

Two major hypotheses will be tested in this proposed research and dissemination project: 1) the CHW intervention model will increase medication knowledge and awareness, increase patient communication with the provider, reduce medication problems, and improve medication adherence and 2) intrinsic motivation will be actualized among patients assigned to the CHW-MI group, which will results in better medication adherence relative to the patients receiving general diabetes education by the CHW.


The Medical University of South Carolina

Southeastern Virtual Institute for Health Equity and Wellness (SEVIEW)

Penn State Hershey

Penn State Milton S. Hershey Medical Center is committed to enhancing the quality of life through improved health, the professional preparation of those who serve the health needs of others and the discovery of knowledge to benefit society. We do this work through our four missions of:

  • Education
  • Patient care
  • Research
  • Community outreach

As a regional leader in health care, education and research, we have the ability and responsibility to have a positive impact on the determinants of health and the health of our communities.

Our recently conducted local community health needs assessment established three over-arching priorities in our local communities.

First, we must help to improve the lifestyle choices of our residents. Physical activity levels are generally low and diets are generally nutritionally unbalanced. Obesity rates are high.

Second, health education advocates for culturally appropriate messages targeted to populations with the highest need for improved health and a greater focus on good health education for school-aged children.

The third priority, access to affordable health care, is intended to address limited access to primary care, specialty care, mental health, and dental care.

We have established priorities, goals and strategies to address these community needs. A summary of the strategies that we are working on in each of these three areas are:

Promotion of Healthy Lifestyle

  • Focusing on health and wellness in schools
  • Promoting healthy eating
  • Increasing cancer prevention behaviors
  • Increasing opportunities for physical activity

Health Education

  • Providing general health education information on nutrition and physical activity
  • Providing health and wellness education information on injury prevention
  • Advocating for vulnerable children
  • Providing education and resources for skin cancer prevention in the community

Access to Affordable Health Care

  • Primary care
  • Specialty care
  • Deails of the innovative goals, strategies and programs we have put intntal care

Specific deto place to address these Social Determinants of Health and to build healthier communities.

Examples include:

  • School-based assessments
  • Penn State Hershey Pro-Wellness Center Healthy Champions program
  • Establishment of a community farmers market and a community garden
  • Rural and urban cancer networks
  • Community-based exercise programs
  • Educational campaigns
  • Partnership opportunities to provide care to specific high-need populations
  • Training opportunities to expose medical students to the needs of medically-underserved populations

University of Arizona Health Sciences Center


Service Learning Courses as an integral part of an MPH program are important tools for assisting students in public health to directly link health disparity issues with the social determinants of health. At the same time Service Learning Courses build strong community partnerships aimed at improving the health of the community.    Our Border Health Service Learning Institute at the Mel and Enid Zuckerman College of Public Health provides an intense community immersion experience with meaningful reflection as the framework for understanding the social determinants of health.   By focusing our efforts on the U.S.-Mexico border we are immediately embracing the importance of our academic institution engaging in a region which is riddled with health disparities directly related to the social determinants of health.  If the U.S border region were made into a state it would rank:  last in access to health care, last in per capita income, first in number of children living in poverty, first in number of children who do not have health insurance, second in rates of hepatitis deaths, and third in death related to diabetes. Arizona border communities are recognized and designated as Health Professions Shortage Areas (HPSA).  
In order to link our BHSI directly to the elimination of racial and ethnic health disparities and understanding the social determinants of health, the course provides a combination of service learning opportunities with our community partners and faculty including working on basic public health issues with our health departments on both sides of the border. But moving beyond typical public health issues of disease prevention, we work with a combination of community organizations that are addressing the issues of employment, migration, alternatives to migration, economic development, food security and human rights within a border context.  Reflection focuses on understanding these larger community issues and the link to health disparities.  The goals of the course include: providing meaningful engagement in the community which contributes to  improved health, understanding  the direct relationship between health disparities and social determinants of health and  reflecting on  the role of public health professionals in community transformation.

University of Arkansas for Medical Sciences


The “Joining Everyone Spiritually, United in Strength” Program, funded by the National Institute on Drug Abuse (R01DA024575) and led by Dr. Katharine E. Stewart, Professor of Health Behavior & Health Education in the UAMS Fay W. Boozman College of Public Health, conducted a randomized trial of the CDC DEBI intervention “Safety Counts,” a sexual risk reduction program, after adapting the Safety Counts program for rural African-American cocaine users.  A total of 251 African-American cocaine users who were not in drug treatment and who were residents of two rural, under-resourced counties in the Arkansas Delta region participated in the trial, which compared the adapted Safety Counts program to an active control condition designed to enhance access to social services (e.g., medical care, vocational training, etc..).  The aim of the project to was to test the efficacy of the adapted Safety Counts program in reducing sexual risk behaviors in this high-risk population that experiences substantial disparities in chlamydia, gonorrhea, syphilis, and HIV infections.  Follow-up data collection and analysis is ongoing; however, preliminary analysis suggests that participants in both the intervention and the control groups have experienced significant reductions in sexual risk behaviors (including unprotected sex and trading sex for drugs or other commodities) and significant improvements in their self-efficacy for condom use.  In addition, participants in both groups have experienced significant reductions in their drug use (including alcohol, marijuana, and cocaine).  Participants who received the adapted Safety Counts program demonstrated greater improvements, compared to participants in the control condition, in condom use skills as measured in a behavioral demonstration test and also in negotiating for condom use with partners in role-play scenarios (unpublished data). 

University of New Mexico Health Science Center

We are eager to share our strategies for addressing social determinants and to learn from others at the South Carolina conference in November. We’ve developed an effective model adaptable at other institutions for addressing all the determinants. Ours would make an effective oral presentation with an accompanying written document for the Conference. We believe our model’s effectiveness is due to its comprehensive nature, incorporating all AHC mission areas, so it would cross curricular efforts, community partnerships and research efforts generating evidence to inform the broader strategy. A summary follows:

“Addressing Social Determinants in New Mexico: From Vision to Action to Measuring Health Outcomes”

UNM HSC leadership agreed to a Vision Statement: “Working with community partners, UNM HSC will help New Mexico make more progress in health and health equity than any other state by 2020.” The Vision now guides our Strategic Plan and contributes to each college’s and Department’s annual performance plan

Recruiting—Pipeline programs are many and emphasize high school retention and health professions recruitment of rural and minority students—a means of improving local economic development and later access to care for minority populations

Curriculum—BA/MD program expands the class by ,,,% with 2/3 of these students from rural and ethnic minority communities; first medical school nationally to require that all students graduate with a Public Health Certificate—in part, to incorporate skills in addressing social determinants in practice

Clinical Service—Developed concept of Patient-Centered Medical Home-Plus called “the Health Commons” where clinics offer one stop shopping (primary care, behavioral health, oral health, public health, case management) with community-based, culturally competent Community Health Workers addressing social determinants of clinic patients

Research—The important Community Engaged Research component of UNM HSC’s Clinical Translational Science Center is now linked with UNM HSC’s community-based Health Extension agents (“HEROs”) ensuring that evidence from research is translated to communities and that communities health priorities inform UNM HSC research agendas

Comprehensive, Statewide Dissemination Strategy—UNM HSC has built on the success of HEROs and other community based innovations to create HSC-linked but decentralized Academic Extension Hubs in different areas of the state. Each Hub addresses local priorities included the social determinants by linking HSC with local community hospital, community health center, Public Health office, public school system, community college, county health planning council, Tribal Council, legislative policy-makers and social service agency.

The presentation will include illustrative examples, hand-outs and materials on-line.

Vanderbilt University

Under the leader of Sunil Kripalani, MD Msc, Chief of Hospital Medicine and a health services researcher, Vanderbilt University is developing capacity to measure social, behavioral and other similar factors that might influence quality of care and patient outcomes, and get these patient-centered measurements incorporated in their medical records. Three grants were submitted and funded as follows:
  • A NHLBI R21 was funded to pilot test the measurement of literacy among selected hospitalized patients at VUH and to test the reliability and validity of nursing personnel to make these assessments (using standardized methods and scales). This was successful. Two methods manuscripts are under review.
  • An IDEA grant from Vanderbilt allowed them to pilot the measurement of literacy in the outpatient setting which was also successful and has also been incorporated in the standard work flow. They have a similar number (and growing) of outpatients with literacy measurement.
  • A NHLBI RO1 was submitted and it was given a perfect score on the first submission to expand the number of social and behavioral variables to be measured as predictors of various near, mid- and long-term outcomes, including quality of life among patients with acute coronary syndrome and congestive heart failure.

Thus, they have already incorporated one variable (literacy) into the fabric of their care process and medical record system and they have a large RO1 that is examining a large range of additional variables to examine their relevance in the target population.

“All Americans should have the opportunity to make the choices that allow them to live a long, healthy life, regardless of their income, education or ethnic background.”

- The Robert Wood Johnson Foundation