Jefferson Health – Northeast

Community Health Needs Assessment Implementation Plan (2019-2022)

1 I. Jefferson Health Community Health Implementation Plan

Overview of Jefferson Health

Overview of “Jefferson Health”

Jefferson Health and Thomas Jefferson University are partners in providing excellent clinical and compassionate care for our patients in the Philadelphia region, educating the health professionals of tomorrow in a variety of disciplines and discovering new knowledge that will define the future of clinical care.

Jefferson Health (JH), the clinical arm of Thomas Jefferson University, has grown from a three- academic health center in 2015 to a 14-hospital through mergers and combinations that include former hospitals at Abington Health, Aria Health, Kennedy Health and Magee Rehabilitation. Jefferson Health has seven Magnet®-designated hospitals (recognized by the ANCC for nursing excellence); one of the largest faculty-based telehealth networks in the country; the NCI-designated Sidney Kimmel Cancer Center (one of only 70 in the country); and more than 40 outpatient and urgent care locations. Thomas Jefferson University Hospital (TJUH), is one of only 14 hospitals in the country that is a Level 1 Trauma Center and a federally designated Regional Spinal Cord Injury Center. It also continues its national record of excellence with recognition from U.S. News & World Report. In 2019-20, TJUH ranked among the nation’s best in 8 specialty areas, with two in the top 10 — Ophthalmology (Wills Eye Hospital #2) and Orthopedics (Rothman Institute at Jefferson and the Philadelphia Hand to Shoulder Center #10). Magee Rehabilitation Hospital – Jefferson Health ranked the 13th best hospital in the nation for Physical Rehabilitation.

In 2019, Jefferson Health included 2,867 licensed beds; 7,400 nurses, 6,100 physicians and practitioners; 4,600 faculty and more than 2,100 volunteers. Clinically, in 2019 Jefferson Health provided care for 127,000 inpatients, 517,000 emergency visits, and more than 3.8 million outpatient visits.

We are 30,000+ people reimagining , education and discovery. We are many things, but every day all of us are dedicated to one thing: Improving lives.

Mission: We Improve Lives. Vision: Reimagining health, education and discovery to create unparalleled value. Values: Jefferson's values define who we are as an organization, what we stand for, and how we continue the work of helping others that began here nearly two centuries ago. These values are:

 Put People First: Service-Minded, Respectful & Embraces Diversity  Be Bold & Think Differently: Innovative, Courageous & Solution-Oriented  Do the Right Thing: Safety-Focused, Integrity & Accountability

Jefferson Health recognizes that by providing quality health care to our patients, and education and outreach to our neighbors, we are also enriching the lives and future of our surrounding communities. The work extends beyond the bedside. By partnering with the community,

2 Jefferson Health seeks to improve the health and well-being of young and older Philadelphia and suburban residents through a variety of interventions including prevention and wellness programs, health education seminars, and screenings, as well as efforts that identify and address barriers to health, including the upstream factors (social determinants of health) that impact the health of everyone in the community.

Geographic regions and zip codes served by Jefferson Health Jefferson Health County and ZIP Codes

Abington Health Bucks County:

18914, 18929, 18932, 18966, 18974 ,18976

Montgomery County:

18915, 18936, 19001, 19002, 19009, 19012, 19025, 19027, 19031, 19034, 19038, 19040, 19044, 19046, 19075, 19090, 19095, 19422, 19436, 19437, 19438, 19446, 19454, 19477, 18964, 18969, 19006, 19440

Jefferson Health – Northeast (Formerly Aria Bucks County: Health) 18940, 18954, 18966, 18974, 19007, 19020, 19021, 19030, 19047, 19053, 19054, 19055, 19056, 19057, 19067

Philadelphia County:

19111, 19114, 19115, 19116, 19120, 19124, 19125, 19134, 19135, 19136, 19137, 19140, 19149, 19152, 19154

Kennedy Health Burlington, Camden, Gloucester, and Ocean Counties

Magee Rehabilitation Region

Jefferson Health - Center City Philadelphia County:

19102, 19103, 19106, 19107, 19121, 19122, 19123, 19124, 19125, 19130, 19132, 19133, 19134, 19140, 19145, 19146, 19147, 19148

Overview of the Community Health Needs Assessment and Prioritization Process The Affordable Care Act (ACA) mandates that, every three years, tax-exempt hospitals conduct a Community Health Needs Assessment (CHNA). By determining and examining the health

3 needs and gaps in communities, these assessments drive hospitals’ planning and implementation of initiatives to improve community health.

Recognizing that hospitals and health systems often mutually serve the same communities, during 2018 and 2019, a group of local hospitals and health systems convened to develop this first-ever Southeastern PA (SEPA) Regional CHNA, with specific focus on Bucks, Chester, Montgomery, and Philadelphia counties. This initiative expanded the focus of COACH (Collaborative Opportunities to Advance Community Health), a coalition formed by many of the region’s hospitals and Health systems to address the health and social needs in Southeastern Pennsylvania.

Secondary health data findings and primary data gathered through community meetings, focus groups, and key informant interviews, were synthesized by Philadelphia Department of Public Health (PDPH) staff. A list of 16 community health priorities (listed below) was presented to the COACH Steering Committee that included representation from all of the hospitals participating in the Community Health Needs Assessment. Using a modified Hanlon ranking method, the PDPH ranked the size of the problem and the Importance to the community based on secondary data and input from the community collected during the assessment process. Each participating hospital and health system rated each of the priorities based on the following criteria:  Size of health problem  Importance to the community  Capacity of hospitals/health systems to address  Alignment with mission and strategic direction  Availability of existing collaborative efforts Using these five criteria, an average rating was calculated for each priority area. The community health priorities for the region are presented below in ranked order.

PRIORITY HEALTH ISSUES/NEEDS 1. Substance/ Opioid Use and Abuse 2. Behavioral Health Diagnosis and Treatment 3. Access to affordable primary/ preventive care 4. Healthcare and Health resources navigation 5. Access to affordable specialty care 6. Chronic disease prevention 7. Food access and affordability 8. Affordable and Healthy housing 9. Sexual and Reproductive Health 10. Linguistically and culturally appropriate healthcare 11. Maternal Morbidity and mortality 12. Socioeconomic disadvantage (Income, Education, and Employment) 13. Community Violence 14. Racism and Discrimination in Healthcare setting 15. Neighborhood conditions (E.G. Blight, Greenspace, Parks/Recreation, etc.) 16. Homelessness 4

II. Jefferson Health - Northeast Community Health Implementation Plan

Jefferson Health – Northeast (formerly Aria Health) was an early adopter of the CHNA and related implementation planning process, producing its first report in 2012 and second in 2015. Following its merger with Jefferson Health in 2016, and, in an effort to join the health system’s triennial CHNA cycle, Jefferson Health – Northeast, in collaboration with Jefferson Health, conducted a one-year CHNA and related implementation plan in 2018. The key priority health/needs identified through Jefferson Health – Northeast’s 2018 CHNA, outlined in the sections that follow, are consistent with those also identified through the recently completed Southeastern PA (SEPA) Regional CHNA for 2019. As a result, Jefferson Health – Northeast’s implementation efforts will continue to address its 2018 priorities supported by consistent 2019 data results.

Introduction

Jefferson Health – Northeast, serving patients primarily in Bucks and Philadelphia Counties in Pennsylvania, conducted a community health needs assessment (a “CHNA”) of the geographic areas served pursuant to the requirements of Section 501(r) of the Internal Revenue Code (“Section 501(r)”).1 The CHNA findings were approved by the Board in June 2018 and are available on the organization’s website.2 This implementation strategy (“Strategy”), also required by Section 501(r), documents the efforts of the Hospital to address and prioritize the community health needs identified as part of both the 2018 CHNA and SEPA CHNA for 2019.

The Strategy identifies the means through which Jefferson Health – Northeast plans to address needs that are consistent with the organization’s charitable mission as part of its community benefit programs from 2019 through 2022. Beyond the programs discussed in the Strategy, Jefferson Health – Northeast is addressing many of these needs simply by providing care to all, regardless of ability to pay. Jefferson Health – Northeast anticipates health needs and resources may change, and thus a flexible approach was adopted in the development of its Strategy to address needs identified in both the 2018 CHNA and SEPA CHNA for 2019. In addition, changes may be warranted by the publication of updated regulations.

Overview of Implementation Strategy

1. Community Served 2. Mission Statement and Community Benefit Charge 3. Priority Community Health Needs 4. CHNA Implementation Strategy 5. Needs Beyond the Jefferson Health – Northeast’s Mission or Community Benefit Program

1 The Patient Protection and Affordable Care Act (Pub. L. 111‐148) added section 501(r) to the Internal Revenue Code, which imposes new requirements on nonprofit hospitals in order to qualify for an exemption under Section 501(c)(3), and adding new reporting requirements for such hospitals under Section 6033(b) of the Internal Revenue Code. 2 The Community Health Needs Assessment Report is available on the Jefferson Health - Northeast website at https://www.ariahealth.org/community-health/community-health-dashboard 5 1. Community Served

Jefferson Health – Northeast’s Community Benefit (CB) areas are defined as the areas proximate to the hospitals where approximately 90% of patients reside. This includes communities in Bucks and Philadelphia counties that are aggregated into 5 geographically contiguous regions defined by zip codes. For comparison, the combined data for Bucks and Philadelphia counties is provided. Two comparators are warranted due to the disparate populations of Philadelphia and its suburbs.

Almost 1,044,000 people live in the Jefferson Health – Northeast’s CB area. This represents 48% of all residents of Bucks and Philadelphia Counties combined.

Lower NE/N Phila has a higher percent of youth ages 0-17 and Lower Bucks West has a higher percentage of adults aged 65+ than other CB areas, Bucks, Philadelphia, and the United States. Lower Bucks West is the least racial/ethnic diverse, with 88% of the population identifying as non-Hispanic White. The highest proportion of Asian and Pacific Islanders live in Northeast Philadelphia (12%), and the highest concentration of Black non-Hispanics (34%) live in Lower NE/N Philadelphia. The highest concentration of Hispanics reside in Lower NE/N Philadelphia (36%).

6 2. Mission Statement and Community Benefit Charge

Jefferson Health – Northeast is committed to engage its community in identifying health issues and implementing strategies to address needs. The mission of the Community Benefit Committee at Jefferson Health – Northeast is to develop targeted health outreach programs and screenings in response to the identified needs of its community in concert with the mission of Jefferson Health: We Improve Lives. Effective community programs are an integral part of our mission and vision.

To undertake this mandate, Jefferson Health – Northeast formed a Community Benefit Committee. The committee is responsible for overseeing and recommending policies and programs designed to carry out the charitable mission of the organization, protect its non- profit status, and to enhance the health status of communities served by Jefferson Health – Northeast based on the results of a community health needs assessment.

Specifically, the Committee was charged to:

 In collaboration with fellow Jefferson Health entities and community health colleagues, oversee the production of a community health needs assessment at least every three (3) years.  Review, and recommend for approval a Community Benefit Plan outlining long-term strategies based on a community health needs assessment and other objective sources of data, and recommend updates to such Plan.  Guide and monitor the planning, development, and implementation of programs aimed at improving the health status of the local community consistent with the Community Benefit Plan.  Periodically make recommendations for program continuation or termination based on progress toward identified measurable objectives, available resources, level of community ownership, and alignment with criteria for priorities.  Review and make recommendations regarding the annual Community Benefit Report, including the information provided to the IRS on Form 990. Additionally, identify opportunities for disseminating information to the public about the organization’s community benefit activities.  Review annual goals specifying principal work focus areas for the coming year.

The Community Benefit Committee has included administrative staff, nurses, and other clinicians. The Committee may also invite, as guests, various representatives of the communities served by Jefferson Health – Northeast. Committee leaders are actively evaluating current members and exploring opportunities to optimally match talents and resources to meet the identified needs.

7 3. Prioritizing Community Health Needs

The focus of the Community Benefit Implementation Strategy is the intersection of the scientific evidence, public support, and political backing.3 The "A" in this model is the area with the greatest potential for mobilization of resources and action.

Poor health status is due to a complex interaction of challenging social, economic, environmental, and behavioral factors, combined with a lack of access to care. Addressing the root causes of poor community health can improve quality of life and reduce mortality and morbidity.

The following table describes the community health needs identified as priorities through Jefferson Health – Northeast’s 2018 CHNA and the 2019 SEPA Regional CHNA as priorities. To maximize the resources available to Jefferson Health – Northeast, the Strategy will focus on the priority health needs listed as “Most Important.” Many of the remaining needs are addressed in normal operations of Jefferson Health – Northeast and therefore will not have a dedicated plan.

Jefferson Health – Northeast will not directly focus on community safety, transportation, medication access, or the built environment needs identified as “important or less important” in the 2018 CHNA. Those priorities are beyond the scope of the organization and are being addressed by other community based and government organizations. Jefferson Health – Northeast will collaborate with groups of experts in these areas to foster appropriate and safe referrals and identify opportunities for partnership and inclusion in community benefit initiatives.

Jefferson Health – Northeast will continue collaboration regionally with other hospitals and health systems within Bucks and Philadelphia Counties through partnerships, cooperation, and coordination on public health issues.

3 Green and Kreuter, Health Program Planning, 4th ed., NY; McGraw Hill, 2005, fig 2-3, p.40. 8 Domain Priority Health Ranking Priority Level Needs/Issue Score

Chronic Disease Chronic Disease Management 26.3 Most Important Management (diabetes, heart disease and hypertension, stroke, asthma) Healthy Lifestyle Alcohol/Substance Abuse 24.0 Most Important Behaviors and Community Environment Healthy Lifestyle Smoking Cessation 23.3 Most Important Behaviors and Community Environment Healthy Lifestyle Access to Healthy Affordable Food 23.3 Most Important Behaviors and and Nutrition Education Community Environment Healthy Lifestyle Food Security 23.0 Most Important Behaviors and Community Environment Access to Care Health Education, Social Services 22.7 Most Important and Regular Source of Care Access to Care and Social and Health Care Needs of 22.3 Most Important Community Environment Older Adults Health Screening and Women's Cancer 22.3 Most Important Early Detection Chronic Disease Obesity 22.0 Important Management Health Screening and Colon Cancer 22.0 Important Early Detection Access to Care Mental Health Services 21.7 Important Healthy Lifestyle Physical Activity 20.7 Important Behaviors and Community Environment Healthy Lifestyle Community Safety 20.7 Important Behaviors and Community Environment Access to Care Language Access, Health Literacy 19.7 Important and Cultural Competence Access to Care Health Insurance 18.7 Important Access to Care Access: Transportation 18.3 Important Internal Organizational Hospital Readmissions 18.0 Less Important Structure Access to Care Medication Access 17.7 Less Important Access to Care ED Utilization and Care 17.3 Less Important Coordination Internal Organizational Workforce Development and 15.7 Less Important Structure Diversity Healthy Lifestyle Built Environment 13.0 Less Important Behaviors and Community Environment Health Screening and HIV 12.7 Less Important Early Detection 9

To address the needs identified, Community Benefit Action teams consisting of Jefferson Health – Northeast administrative, clinical leaders and other partners will develop and implement goals and action plans. Leaders of these teams will report on progress quarterly through reports shared with the Community Benefit Committee.

In addition, Jefferson Health – Northeast professionals will collaborate with Jefferson enterprise colleagues as appropriate to improve health status in conjunction with the hospitals’ partnerships. Best practices will be shared with the aim of enhancing infrastructure, stretching resources, and incorporating knowledge about social determinants of health and health literacy to better the population's health and well-being.

4. CHNA Implementation Strategy

Jefferson Health – Northeast will fulfill its commitment to community benefit programs and services through the strategic health priorities set forth below that focus primarily on four high- priority health need domains.

Not all programs provided by the organization that benefit the health of patients in the community benefit service area are discussed in the Strategy. Further, given evolving changes in health care, Jefferson Health – Northeast maintains the right to change its strategies, and new programs may be added or eliminated. The Strategy laid out in this document has two major parts: implementing programs to address the priority needs from the CHNA, then evaluating the impact of those activities.

A. Identifying Areas of Impact and Planning to Evaluate Proposed Community Benefit Programs

The 2019-2022 focus of Jefferson Health – Northeast’s community benefit programming was identified based on its 2018 CHNA findings and prioritized health needs, SEPA Regional 2019 CHNA results, and recommended initiatives to impact the health of the community.

The Strategy is organized according to the following domains:

 Chronic Disease Management  Healthy Lifestyle Behaviors and Community Environment  Access to Care  Health Screening, Mental Health Assessment, and Early Detection

By implementing evidenced-based strategies to address these four domains of community health need, Jefferson Health – Northeast anticipates the following positive impact and improvements in community health:

 Positive impact on disease management and disease prevalence, including alcohol and substance abuse and chronic diseases;  More appropriate use of health resources, including the social and health care needs among older adults, health education, social services, and a regular source of care;

10  Improvement in community health status, including reduction in smoking, improved access to healthy affordable food, greater food security, and relevant nutrition education; and  Increased utilization of screenings for women’s cancers

These improvements will be evaluated through review and monitoring of existing data sources, which may include but are not limited to:

1. Internal Jefferson Health – Northeast data, including referral and inpatient and outpatient service data 2. Public Health Management Corporation’s Household Health survey data 3. Surveys and key informant interviews with providers and clients 4. Reports from government agencies, which may include the Bucks and Philadelphia County Health Departments, the Bucks County Area Agency on Aging, the Bucks County Drug and Alcohol Commission, the Philadelphia Corporation on Aging, and the Philadelphia Office of Addiction Services 5. External community data sources 6. Jefferson Health Community Health resources

B. Address Priority Health Needs through Jefferson Health – Northeast’s Existing and New Community Benefit Programs

Jefferson Health – Northeast plans to provide community benefit programs responsive to the health needs identified. As part of this Strategy, the organization will focus first on those needs designated as “Most Important” between 2019 and 2022, and will continue to evaluate those needs that were designated as “Important” and “Less Important”. Only those needs identified as "Most Important" are detailed in this Implementation Plan. The recommended actions may be modified based on on-going input and recommendation from internal and external partners, identification of new partnership opportunities, changes in the healthcare and community environment, and availability of resources. Throughout the implementation period, Jefferson Health – Northeast will identify grants and internal and external funding sources as appropriate to support the strategies and activities. Resources to implement programs are provided in-kind unless otherwise noted.

DOMAIN: Chronic Disease Management

The anticipated impact of the following actions may include: improved health behaviors including utilization of preventive screenings, improved disease management including adherence to treatment recommendations and better communications between patients, families, and providers, and elevated health status as a result of increased continuity of care.

11 DOMAIN: Healthy Lifestyle Behaviors and Community Environment  Action: Chronic Disease Management (diabetes, heart disease, and hypertension, stroke, asthma)  Explore offering comprehensive diabetes education programs for the community at each hospital with support from local diabetes educators  include intensified insulin self-management training, nutrition counseling, pre-diabetes intervention, and refer gestational diabetes management to Jefferson Endocrinology and Jefferson OB/GYN  refer patients identified as at risk for diabetes at community-based assessments for appropriate follow-up  evaluate providing Save Your Soles education and screening, a program developed by an Abington podiatrist, in target communities  Explore potential to hold monthly diabetes support groups for community members at the Frankford and Torresdale Hospitals and quarterly meetings at the Bucks Hospital with online and/or remote resource support through Jefferson Health  Provide educational programs for community members to reduce cardiovascular disease prevalence and improve disease management at each hospital at least twice a year  offer blood pressure and risk assessments to raise awareness about prevention and early detection using FAST acronym  explore the potential to expand the monthly stroke support groups for community members held at the Torresdale Hospital to each campus. The focus of this group is encouragement, education, and support for stroke survivors, family members, and friends  Host at least 2 nutritional and obesity educational programs for community members at each campus each year in partnership with or support from other Jefferson Health entities and/or other community organizations.  Explore provision of education programs utilizing the expertise of Jefferson Health – Northeast respiratory therapists to reduce asthma prevalence and improve disease management at each hospital twice a year  offer asthma education programs in community settings such as faith-based organizations to raise awareness about warning signs of asthma to promote earlier diagnosis, avoid "asthma triggers," gain better control, and understand treatments  Explore partnerships with community-based organizations that serve non-English speaking communities to expand the capacity of multi-lingual staff to provide chronic disease prevention and management education  Present health awareness and prevention programs and screenings at community outreach events as requested  Participate in local health fairs to educate community regarding stroke risk and access to the Lower Bucks County-based Jefferson Health Mobile Stroke Unit (MSU)  Implement Care Coordinators within Jefferson Health – Northeast PCP offices to address longitudinal care for all patients with chronic health needs.  Implement a “Diabetic Day” within the Jefferson Health – Northeast PCP offices to offer A1C screenings, dilated retinal eye exams, and nephropathy screening.

12 Address all cancer screenings on the same day to provide comprehensive evaluation and assessment.

The anticipated impact of the following actions may include: increased identification and referral of patients to addiction counseling and services, reduction in smokers, increase in access to healthy affordable food and nutrition education, and decreased food insecurity.

1. Action: Decrease alcohol and substance abuse

 Continue to reinforce Jefferson Health – Northeast physicians’ commitment to increase compliance with patient "contracts" for chronic opioid use  Continue working on reducing the number of patients within Jefferson Health – Northeast PCP practices who are receiving 90 MMEq of opioids daily for greater than 30 days  Engage Behavioral Health consultants to help in the weaning of opioid/alcohol- dependent patients  The Jefferson Health – Northeast Emergency Department will continue its warm- handoff protocol to facilitate connecting patients with Opioid Use Disorder (OUD) to community resources that provide OUD therapy. Mothers and pregnant women with OUD will be referred to Jefferson Health’s MATER program in Center City. Care Management services will be available 24/7 to facilitate these OUD referrals.  Integrate education on alcohol and opioid use issues and CDC guidelines into continuing medical education  Incorporate pain management curricula into Jefferson Health – Northeast’s educational framework for all levels of providers starting with students  Work with law enforcement to communicate about "Drug Take Back" programs; evaluate initiation of a Jefferson Health – Northeast program  Review sponsorship requests from school districts and other non-profit agencies to host events that educate parents, students, or professionals on alcohol and/or substance abuse  Continue to support the Bucks County “Warm Handoff” Initiative and explore development of relationships with Bucks County Drug and Alcohol Commission and Philadelphia Office of Addiction Services leadership for information and communication of programs and services  In partnership with local EMS, continue holding Narcan training programs for clinicians, non-clinicians, corporate partners, and community groups  Explore sponsoring structured youth programs in safe locations, such as exercise and sports, that are provided during out of school times to reduce opportunities to become involved in substance use and other negative activities

2. Action: Smoking Cessation  Focus on all forms of cessation education (e.g. all tobacco products – cigarettes, vaping, chew, etc.) in the Jefferson Health – Northeast PCP practices  Screen patients in all practices and hospital settings for smoking. Refer all smokers to the PA Free Quitline at 1-800-QUIT-NOW (784-8669) for free counseling via telephone

13  Offer smoking cessation education at the Bucks, Frankford, and Torresdale Hospitals

3. Action: Access to Healthy Affordable Food and Nutrition Education/Food Security  Increase the impact of the community garden program at Jefferson Frankford Hospital by increasing engagement of local community-based organizations and neighborhood residents in garden activities. These activities will be aided by a $20,000 grant (disbursed over a 4-year period) recently received from American Heritage Federal Credit Union.  Explore opportunities to pursue additional grant funding to expand the garden from such sources as the Philadelphia Water Department, Pennsylvania Horticultural Society, Home Depot, Lowes, seed companies, Gardenburger Community Garden Grants, Nature’s Path Gardens for Good Grants  Explore requesting technical support from Philadelphia Master Gardeners and utilize their expertise to improve the garden and educate community members  Explore opportunities to increase access to healthy affordable food in Northeast/Lower Northeast Philadelphia in partnership with organizations such as the Food Trust, Common Market, SHARE, Philabundance, and others  Increase community access in Northeast/Lower Northeast Philadelphia to programs that support healthy eating such as cooking demonstrations, tasting programs, and nutrition education by exploring partnerships with community resources such as the Vetri Community Partnership (Eat360, My Daughter’s Kitchen, and/or Vetri Cooking Lab)  Continue screening clinic patients for food security and refer to resources as appropriate; expand program across inpatient and Emergency Department settings

DOMAIN: ACCESS TO CARE The anticipated impact of the following actions may include: increase in access to with related reduction in emergency visits and hospital readmissions; increase in the number of insured adults and adults with Jefferson Health – Northeast financial assistance; increase in number of patients connected with social services; improvement in access to and utilization of culturally appropriate primary care, reduction of health disparities, improvement in the social and health status of older adult; and improvement in the capacity of community-based organizations to address behavioral health issues among clients/program participants.

1. Action: Improve access to Health Education, Social Services, and Regular Source of Care

 Assist patients and their families in accessing government-based insurance options (Medical Assistance, children’s health insurance program [CHIP], health insurance marketplace). For patients who are over 65 or disabled options include Medicare, Medical Assistance, private insurance (Medigap, Medicare advantage plans), and supplements (PACE, PACENET, Part D providers)  Assist patients and their families who are not eligible for public or private health insurance with the application process for the Jefferson Health Financial Assistance Program

14  Ensure that all staff participate in cultural diversity training  Provide patient education materials in multiple languages  Explore utilization of a clinic social worker and/or students to conduct outreach and provide direct assistance to patients in need at the Frankford clinic to connect them with relevant social services such as Supplemental Nutrition Assistance Program (SNAP), subsidized housing, subsidized child care, and Lifeline (free cell phone program). Cultivate relationships with local community organizations to keep abreast of available services/programs.  Implement the Beds to Meds program at each hospital, providing patients who cannot afford to pay with a free 30-day supply of medication. Uninsured patients eligible to apply for insurance will be supported to do so to enable a continued medication supply. If patients are not eligible or need a bridge until they get insurance, they will be referred to local health centers that can provide medications, or linked to relevant community resources that may be able to help.  Implement Jefferson Health – Northeast’s clinical pharmacist assistance with medication management; also focus on patients who cannot afford medications to secure a long-term supply for free or at a discount.

2. Action: Social and Health Care Needs of Older Adults

 Offer caregiver support groups at least quarterly at each hospital  Offer activities to improve cognitive health at least monthly at each hospital including lectures and socials  Offer Fall Prevention Education and balance programming to increase awareness of falls risks and prevention strategies at least twice a year at each hospital  Educate liaisons to nursing homes about trauma and the older adult population annually  Offer longitudinal care for all patients with chronic health needs via Care Coordinators within Jefferson Health - Northeast PCP offices

DOMAIN: Health Screening, Mental Health Assessment, and Early Detection The anticipated impact of the following actions may include: increased screening rates for breast, cervical, and other women's cancers, and earlier intervention.

1. Action: Increase access to care and screening for women's cancers, especially cervical and breast cancer, for underserved populations

 Recruit Jefferson Health – Northeast staff members to assist with screenings and education  Enhance strategies to effectively reach Latino, Russian, and Asian populations  Develop strategies to increase screenings for low income non-Latina white women  Educate primary care and gynecology practices about the Pennsylvania Healthy Woman Program for breast screening services and the Pennsylvania Breast Cancer and Cervical Cancer Prevention and Treatment Program and provide assistance for qualified women to enroll in these programs

15  Continue hosting Dear Friends, a general support group for patients coping with cancer, along with their friends and family members and Look Good…Feel Better, a free program sponsored by the American Cancer Society for women actively undergoing cancer treatment to deal with the changes to their skin and hair at Torresdale’s Cancer Center  Offer same day or next day screening mammograms through collaboration between Jefferson Health – Northeast’s PCP physicians and Radiology Department  Conduct daily outreach to all patients who have any gap in care in relation to breast, cervical, or colorectal cancer screening, as well as diabetes.  Offer GYN days via Jefferson Health – Northeast PCP offices that offer GYN services during which a woman can come in to have their cervical cancer screening completed. During these days, all cancer and diabetic needs are addressed as well.  Embed Behavioral Health Consults (Licensed Clinical Social Workers) into PCP practices who are available for mental health consultation via warm hand-off or telephonic outreach. LCSWs to focus on mental health issues as well how patients’ mental health affects their acute or chronic disease conditions.

C. Collaborate with Community Partners to Address Health Needs

This Strategy will be implemented in collaboration with other entities including but not limited to:

Southeastern Pennsylvania Collaborative Opportunities to Advance Community Health (COACH)

This community health collaborative sponsored by the Hospital and Health System Association of Pennsylvania (HAP) brings together hospitals, public health, and community partners to address community health issues in southeastern Pennsylvania. COACH participants prioritized community health needs most important to address collaboratively and identified chronic disease prevention/management and mental health as top priorities.

Jefferson Health Jefferson Health hospitals collaborate with other stakeholders to address key community needs within the service area.

5. Needs Beyond the Hospital’s Mission or Community Benefit Program Addressing all the health needs present in a large community requires resources beyond what any single hospital or social service agency can bring to bear. The Hospital is committed to fulfilling its mission as well as remaining financially viable so that it can continue its commitment to excellence in quality care and provide a wide range of community benefits. Between 2019 and 202s, the Hospital will focus its efforts in order to make a true and measurable impact, and thus plans to implement actions that will address those needs identified through the Community Health Needs Assessment as “Most Important”. The Hospital will continue to evaluate opportunities for funding or resources to commit to addressing the remaining needs.

16