The team worked in Prince George’s County, Maryland, to reduce chronic disease rates, prevent the development of secondary conditions, and address health disparities with complementary policy, environmental, programmatic, and infrastructure activities to create health equity and optimize health outcomes. These activities focused on neighborhoods within and surrounding Langley Park, Suitland/Coral Hills, and Bladensburg/East Riverdale. We implemented seven strategies in the areas of Active Living, Healthy Eating; High-Quality Clinical Preventive Services; and Healthy and Safe Physical Environments, as well as an overarching strategy that created an infrastructure component within the County. Three additional mini-grants were awarded to implement more work in wellness policies, no-smoking policies, and pedestrian safety.

The strategies goals were to:

• Improve access to affordable and healthy food
• Increase the number of people covered by health systems to support control of high blood pressure and high cholesterol
• Increase the number of people with access to safe physical environments

In order to guide and support the planning, implementation, and evaluation of the collective CTG effort, we formed a cross-sector leadership team. The leadership team included a diverse set of high-level stakeholders with the influence to leverage political and other resources necessary to advance policy and systems change in Prince George’s County.

Download the CTG Highlights Brochure for a summary and list of accomplishments for each strategy, quotes from stakeholders, and photos from our events.

Reducing avoidable hospital readmissions is an opportunity to improve quality, increase patient satisfaction, and reduce costs within healthcare systems. Since 2013, IPHI has partnered with the George Washington University and GW Medical Faculty Associates to improve care continuity and coordination and to reduce hospital readmissions for patients with chronic heart failure.

IPHI is responsible for administering the community health worker (CHW) portion of this project. This work focuses on evidence-based strategies emphasizing coordination and continuity of care, prevention and complication avoidance, and close clinical treatment.

Responsibilities:

• Hiring & placing the CHWs;
• Supporting CHW training;
• Training GW Hospital and Medical Faculty Associates staff on effectively integrating CHWs into the team;
• Collaborating to ensure effective program model design; and
• Evaluating this pilot project.

Two CHWs hired have been trained in basic heart failure treatment support. CHWs are deployed to assist patients during and after discharge from the hospital. With supervision by heart failure physicians and nurse practitioners, the CHWs work with the patients in their homes to:

• Improve understanding of heart failure medications;
• Enhance diets that are conducive to improved health;
• Improve heart failure self-management skills;
• Provide resources to address social needs; and
• Improve communication with and utilization of outpatient medical facilities.

To learn more about expanding the CHW role in assisting heart failure patients, click: here.