JPS Health Network is known for the quality of care provided to its underserved population. They often pull together to fill the gap when discovering a need. In recent events, Community Health and Outpatient Case Management identified patients' needs through a social determinant of health (SDoH) screening questionnaire.
Patients are given the screening assessment during their clinic appointments, focusing on community elements that comprise about 80% of a person's health.
"There are several domains for the social determinants of health screening, like food, housing, communities where you live, and education literacy levels," Devon Armstrong, MSN, RN-BC, CCM, Director of Outpatient Care Management, said. "We ask our patients to complete those screening questions so we can glean more information about what patients may need in the community to help them better manage their health."
Using the SDoH questionnaire, the team identified food, transportation, and housing as the top three needs among JPS patients. While filling the transportation and housing need is complex, the team found a temporary solution for transportation through their partnership with the CDC, Tarrant County Public Health, Uber Health, and Trinity Metro. However, Community Health and Outpatient Case Management partnered with the Tarrant Area Food Bank RED Bus to address the food insecurities JPS patients are experiencing.
"In the report, we look at the clinic and zip code the patient resides in, then we can look at what community partnerships we need to form to bring those resources to our patients," Armstrong said. "We were able to partner with Tarrant Area Food Bank RED Bus to address the patient's needs. It's not a forever solution, but it helps with the immediate need while connecting the patient and their families to options for long-term solutions and assistance.”
The Tarrant Area Food Bank RED Bus provides community resource assistance, nutrition education, and nutritious food to communities experiencing high levels of food insecurity. This partnership will help bridge the gap between the hospital and the community.
“For many years, hospitals have focused on sick care, treating patients once they enter the ED or a hospital bed. We want to move away from that, helping people manage their medical care and social needs before they become acutely ill,” Armstrong said. “Our partnership with TAFB RED Bus allows us to stretch our arms out into the community to prove that we are committed to providing whole-person care, not just prescribing traditional medications to treat their problems. We want to give them resources and food as medicine.”
The Community Health and Outpatient Case Management teams want to provide patients with more than temporary food bags. They aim to set up opportunities for long-term food assistance.
"We are giving out emergency food, but we also can help patients apply for SNAP and TANF benefits," says Kandra Torrence, Ph.D., Community Outreach Manager. "We're thinking more long-term so that people will have longer access to food. They also can submit Medicaid, CHIP, and WIC applications, and if they need additional services from JPS, we're onsite so we can connect patients to JPS Connection or other services they may need."
Many patients lined up at the Tarrant Area Food Bank RED Bus event to receive emergency food bags. Medical Home Southeast Tarrant patient Dulciner Yates shared how appreciative she was for the event because with food prices increasing, it’s hard to purchase food items she’s used to.
“It’s a blessing they’re working with the community, not just as healthcare providers, but providing people with things they can use, such as food. There are many people in need,” Yates said.
The teams were grateful for the opportunity to give back to the JPS community. The joy and heartfelt responses from patients who visited the bus made the experience worthwhile.
"We have had so many people come up to us and say they didn't have an idea of where they would get food for the day, so this was very helpful to everyone," said Karina Garcia, Community Health Worker. "It's such a good feeling because helping people and making a difference is what I always wanted to do in life."