1.TEAM NAME: Care Transitions
What is the name of the project (Innovation)? Care Transitions Program
Describe how your project made a significant impact in the community you serve.
For more than five years, HCAAA has provided care transitions coaches to all partner hospitals to assist 2,713 beneficiaries with congestive heart failure to successfully transition from the hospital to a home setting. The impact of this effort includes an overall reduction of 30-day readmissions from 18% at baseline to 13% currently for patients enrolled in the program. This is significant, as the national hospital readmissions rate in 2017 for congestive heart failure was more than 20%.
Has the project improved or streamlined an internal process to serve the community or HHD?
Houston Health Department conducted an extensive return on invest analysis (ROI) to determine cost savings related to the care transitions program among all previously mentioned Methodist hospitals. The ROI Forecasting Calculator applied the analytical results and computed the total savings by comparing the projected expenditures if the care transitions intervention did not take place to the reported spending on inpatient care for the intervention group. Based on the size of the intervention group, the change in the percentage of 30-day readmission to hospitals, and the cost of inpatient care, the total savings brought by the care transitions program was approximately $3 million between DY3 and DY5 as demonstrated in Table 2. The savings per intervention member was estimated to be $6,500.
2.TEAM NAME: Transporter Section
What is the name of the project (Innovation)? Southwaste Project
Describe how your project made a significant impact in the community you serve.
This project made an impact on those that lived or worked near the Southwaste Disposal Site located at 6407 Hurst. From 2017-2018 there were 14 complaints submitted to our office in regards to odor or sewage/waste spills and illegal dumping concerns. On many occasions these complaints were not confirmed at the time of investigation. Yet one of the investigators Sergio Cisneros was diligent in his efforts and conducted a thorough inspection which uncovered several other concerns onsite which included a non-permitted vehicle. From these observations it was concluded that audits as well as overnight surveillance was needed. Sergio, Efrain and Almika conducted audits onsite during the day and was conducting surveillance in the early morning hours of 2 or 3 am. The initial onsite audit discovered 885 violations. After returning back to the office and digging deeper that number grew to 1029 violations. During this process we had the great opportunity to work with Legal as well as Municipal Courts to seek the appropriate enforcement for this large amount of violations. After a year of numerous of hours spent collecting and inputting data, late night surveillance and many meetings with the courts and legal it was decided that Southwaste would have to pay $25,000 in fines for these violations. This was a first in the history of the transporter section to have a company pay this large amount in fines. This sent a message to the other 140 companies in the transporter community that you must abide by the rules and regulations which promoted better compliance and cut down the amount of complaints received for this location tremendously. From the completion of this project on July 17, 2018 till today February 13, 2019 we have not received any additional complaints for this location.
Has the project improved or streamlined an internal process to serve the community or HHD?
This project improved working relationships throughout multiple departments (HHD, Legal and Municipal Courts) that you typically wouldn’t have consistent contact with. This also helped open the doors of communication amongst these departments for future projects.
3.TEAM NAME: WIC Super Team
What is the name of the project (Innovation)? W.O.A.H (WIC Outreach Assisting Houston)
Describe how your project made a significant impact in the community you serve.
Now that WIC has gone paperless and are web based, we have been able to provide on site services to those communities where transportation and other hardships have been a barrier.
Has the project improved or streamlined an internal process to serve the community or HHD?
WIC has established partnerships with programs around the city such as, Star of Hope (which is a shelter for homeless families around Houston) Casa de Esperanza (which is a housing community for foster children) and Wilmer T. Hall Center for Education (which has a program for young families who need support with childcare while completing their high school diploma) We serve these communities on a monthly basis by providing nutrition counseling, breastfeeding support, nutritious foods, and referrals to immunizations, dental, and other collaborative programs. In addition, while promoting breastfeeding on a daily basis, WIC has increased breastfeeding rates within the last 10 years from 77% to 89%. In our efforts to continue to spread the importance of breastfeeding throughout the entire city, WIC has created a breastfeeding promotional video, which will be released in the near future.
4.TEAM NAME: TB Terminators: Contact Investigation Team
What is the name of the project (Innovation)? Congregate Setting Contact Investigation at Temporary Housing Facility/Hostel
Describe how your project made a significant impact in the community you serve.
Through ongoing Contact Investigation, we test residents exposed to Active Pulmonary Tuberculosis at this temporary housing Facility/hostel. This underserved community is a high risk homeless population that has little to no access to health care. The initial Active Pulmonary case reported from this facility was in August of 2017. Since then there have been 8 additional cases reported amongst residents of the same facility. Because we have developed a good rapport with the staff and ownership of this facility, we have been able to easily deliver services to this homeless population. We have been able to do 179 blood tests and of those, 49 tested positive. Of the 49 positives, 8 cases were identified. Out of the 8 cases, 6 were culture confirmed Pulmonary MTB cases and 2 were clinical cases. The remaining 41 were diagnosed with Tuberculosis Infection. By identifying active cases of Pulmonary Tuberculosis, we’ve been halting the transmission of the bacteria within the community. Active contagious Pulmonary Cases are quarantined at Langston House and treated until they are no longer contagious. By identifying individuals with Tuberculosis Infection, we were able to prevent them from developing Active Pulmonary Disease. Individuals with Tuberculosis Infection are evaluated and placed on preventative treatment.
Has the project improved or streamlined an internal process to serve the community or HHD?
Over multiple testing events throughout the past year, the Contact Investigation team has been able to streamline our testing and data entry processes. Similar to the incident command system, we compartmentalize each facet of the Contact Investigation process. We break down into smaller groups that each take on individual steps in the Contact Investigation process. On site we have stations for collecting demographics, drawing blood, collecting sputum and distributing incentives. We set up transportation and work with the City clinics to schedule a special clinic day for the facility residents to go in for their medical evaluation and chest x-ray. Once the evaluation is complete, residents with tuberculosis infection and tuberculosis disease get transferred to the TB Control field team for directly observed therapy (DOT).
5.TEAM NAME: Get Moving Houston: Office of Chronic Disease, Health Education, and Wellness.
What is the name of the project (Innovation)? Get Moving Houston Farmer's Markets and Community Gardens
Describe how your project made a significant impact in the community you serve.
We work to make healthy eating the easy choice around Houston. Through the Farmers Markets we bring fresh, local fruits and vegetables to communities under-served by traditional grocery stores and supermarkets, assisting over 3,000 participants in 2018 alone. The markets include various food incentive programs such as Farmer’s Market Nutrition Program Vouchers for WIC Participants; FRESH RX fruit and vegetable prescription program, Houston Healthy Bucks, a double dollar program for SNAP/EBT recipients. The easy access to the markets through Multi-service centers and the various incentive vouchers makes it easier and more convenient for low-income populations to purchase the recommended amount of fruits and vegetables to practice a nutritious diet. While with Urban Garden we grow a variety of gardens tailored for urban communities. These communities can develop Community Garden Clubs, Adoption Gardens, Specialty Gardens and Affiliated Gardens to their needs. The Urban gardens are making a significant impact to the population because it provides a tailored approach to gardening for the surrounding neighborhood. The harvest from the garden are used for educational demonstrations and participants can directly take home the harvest for use making it easier for participants to consume the recommended amount of fruits and vegetables per day. To tie in with both these projects lastly comes in YALH. YALH offers programming to immigrant youth in the Gulfton area aiming to guide student through an experiential learning module culminating into a small urban agriculture enterprise. Participants receive training in leadership, coalition building, effective communication, developing a business plan, culturally tailored crops and nutrition education. This is significantly impactful to new immigrant population.
Has the project improved or streamlined an internal process to serve the community or HHD?
Yes, Farmer's Markets has provided under-served communities over 100,00lbs of food for 2018 alone. While working with WIC and other programs has improved fresh food availability. Gardens provides an easy alternative to the community to get active and learn more about vegetables and fruits they can grow at home. While YALH creates buy-in and a consistent volunteer base for the HHD gardens.
6.TEAM NAME: DAWN: Office of Chronic Disease, Health Education and Wellness.
What is the name of the project (Innovation)? Diabetes Awareness & Wellness Network Diabetes Self-Management Wellness and Education Projects
Describe how your project made a significant impact in the community you serve.
The OCDHEW DAWN center implemented several innovative projects in 2018 worthy of nomination. These include:
AFRICAN HERITAGE DIET: February 21. 2018- October 17.2018; A Taste of African Heritage Diet is a six-week cooking class series that blended nutrition and cultural history with simple, delicious cooking techniques, to inspire a whole new way of eating – through the “old ways.” The goal of the A Taste of African Heritage Diet Project was to inspire good health through cultural food traditions. A taste of the African heritage program objectives were (1) To demonstrate a cultural healthy eating by bring the African heritage diet pyramid to life by showing people how to cook and eat healthy, (2) To introduce participants to the rich cultural history of African heritage foods by providing tools, (3) To improve cooking and eating habits, there-by addressing health issues of African Americans who are greater risk for heart disease, diabetes and obesity. Many DAWN members who attended the program reported back how now they able to apply what they learned and are now incorporating more of the traditional foods and avoiding the standard American diet, thus reclaiming their health.
DAWN Healthy Happy Hour; We serve a community of pre-diabetes and type 2 diabetes and for World Diabetes Month we hosted a
“cocktails and education” event for our members. Objectives included: Increasing knowledge when it comes to knowing your calories
during a social hour/event- “don’t leave home hungry”, Describing how to choose low-calorie beverages and set a limit while alternating with water, and to introduce a different kind of “happy hour” which doesn’t involve cocktails and alcohol. Happy hours are meant to be fun and carefree, however people managing diabetes often deal with feelings of guilt and shame during social events and family gatherings. the idea behind the “healthy happy hour” is to show members that they can have fun and be conscious of what they eat and drink during social gatherings.
DAWN Exerstart Fitness Class; Exerstart is a 20-week series; offered 2 days per week for 45 minutes per day. Items used for implementation were resistance bands, dumbbells and chairs. The DAWN fitness trainer would lead each class; offering different variations of exercise to ensure optimal performance. At the end of each session, an exercise handout would be given to the participants to collect and use when away from the class. In a most recent series of Exerstart series, one participant lost a total of 21 lbs while lowering their A1C by 2 percent. Another participant experienced a reduction of 1.75 inches in waist circumference. Exerstart has helped produce positive health outcomes for participants in the program. Through word of mouth, the exercise class is in high demandat the DAWN Center.
Portions of the curriculum is used when conducting fitness demonstrations at community centers, health fairs, and employee meetings.
DAWN Center + DAWN Mobil Unit; DAWN center services are the premier diabetes prevention and diabetes self-management education program in Houston, Texas. Diabetes can be a debilitating and costly condition, DAWN centers alleviate barriers and promotes living well in populations of people at risk for diabetes, with pre-diabetes, and people diagnosed with diabetes.
Any many more fun, innovative Diabetes self-management curriculums, activities, and outreach events are hosted at the OCDHEW’s
Has the project improved or streamlined an internal process to serve the community or HHD?
These innovative new DAWN projects in 2018 helped to streamline the delivery of effective, free, evidence-based education to the community of low income, pre-diabetic, and type 2 diabetes individuals we serve. The education, training, consultations, programs, projects, and initiative’s that the DAWN center provides are all held in a convenient community-based education center compared to the typical clinic setting. They also helped to educate and empower not only the third ward historically community and Near Northside (Where several DAWN classes are hosted), but communities all over Houston through outreach events targeting seniors, those at risk for Diabetes, and those with Type 1 and type 2 Diabetes. The DAWN Mobile unit improves processes by bring DAWN options to communities beyond Third Ward.