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The HERO Program: A Model of Community-Wide Wellness

Thursday, July 17, 2014   (0 Comments)
Posted by: Joy Ingram
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by Joseph Abate, MD, Chief Medical Officer, Heritage Health

A Vision Born of Necessity

As I sat in my office at Heritage Health, trying to manage a patient with a list of 12 medical problems and 15 medications, I knew there had to be a better way.

Mentally, I began to tally up the expectations of the typical 20 minute office visit:
Here are the steps required in the average office visit in our institution:

  • Log in
  • Ask chief complaint – often there are 4 or 5
  • Type history
  • Verify medication list and check updated review of systems
  • Do Physical Exam
  • Fill out flowsheets – Diabetes, hypertension, anticoagulation
  • Check labs
  • Check outside/hospital records
  • Check preventive measures
  • List diagnoses in order of importance and rank each one as new or established, stable, worsening, or improved
  • Check quality measures
  • Write up plan
  • Order labs
  • Order imaging
  • Order referrals
  • Refill meds
  • Print visit instructions
  • Give patient handout
  • "Oh, by the way....."

Patients are full of surprises and so are their charts. It can be hard to find outside records, labs, documentation of preventive measures. Meds, problem lists, and social history often need updating. Furthermore, patients will often save the best for last, springing the most worrisome symptom on you just as your hand reaches for the door.

Next, we tried a chart review process, working from a list of our most complicated patients. A medical provider, pharmacist, psychiatrist, and medical assistant reviewed charts and made evidence-based recommendations in the form of a care plan. The patient was then scheduled for an appointment with a provider who used the care plan to address any deficiencies or changes in therapy.

Using this technique, it was easy to find ways to improve the patient visit experience. Providers liked the road map provided by the care plan document and patients liked the extra attention. If anything, this process pointed out just how complicated our patients were. This was especially true for patients with coexisting mental health issues. Some recommendations were easy to implement, others required resources outside our institution.

It is easy to determine what needs to change in a patient's life, much harder to effect that change. One can quickly determine that a patient needs diet and exercise, but how likely is the patient to change because of a 1 minute discussion or a two paragraph boilerplate recommendation?

Beyond Medical/Behavioral Health Collaboration

Our practices are filled with patients in crisis. It is estimated that 70% of patients presenting to a primary care practice have an underlying psychosocial diagnosis. They present with a physical complaint, but the complaint will not respond to treatment unless one addresses the underlying problem. There has been a great deal of emphasis on the importance of medical/behavioral health collaboration and medical/dental collaboration, but the care of a complicated patient is so much more than that.

Poorly controlled diabetes in a depressed patient is not likely to improve until you treat the depression. Now imagine a poorly controlled diabetic with depression who is the primary caretaker for his wife, recently diagnosed with breast cancer, facing foreclosure on their home and worried about his daughter who has an opiate addiction and is unable to care for her daughter, his granddaughter. How many services does this patient need? How much can be accomplished in the average 20 minute visit? How likely will this patient be to read your patient handout exhorting him to "lose weight and get more exercise"?

We are trained to think medically, treat medically, match the symptoms to the Rx, write the scrip, and move on to the next patient. But what about all the other factors that affect a patient's health?

The Problem

The problem, simply stated, is as follows:

  • Patients are very complicated, and most illnesses have multiple factors.
  • Many of the resources needed to take care of complicated patients are not available in your FQHC
  • Many of those resources ARE available outside the walls of your FQHC
  • Connecting your patient to those resources takes time, more time than the average provider is allotted
  • In many cases, providers are not aware of the resources available outside your FQHC

The Solution

The solution is to collaborate with organizations in your community that can offer the services that you (or, more accurately, your patients) need.

Essentially, what we need is an off ramp for patients - make the diagnosis, determine the need, refer to the experts. A giant funnel, if you will, in which to pour all those needing more attention than we can give in a typical office visit.

As I looked around our community, I realized there were many organizations performing exactly the services we needed. Exercise training, diet counseling, mental health services, financial counseling. Many of these organizations had come to us, eager to collaborate, wanting us to use their under-utilized services. They offered to give lectures, instruct our providers, set up a desk in our lobby. For a multitude of reasons, this just didn't work. Providers would forget to refer, patients would fail to show up, and lectures would be canceled due to lack of attendance.

The mission of the FQHC is to bring medical care to all patients. Our ability to do so can be increased by collaborating with all organizations that help us to fulfill that mission.
School systems struggle with poor nutrition, substance abuse, childhood obesity, and poor physical fitness. Colleges need to train nurses and social workers to operate in the real world. Homeless shelters provide food, clothing, laundry services, and mail drop services for those displaced residents living on the streets and in encampments throughout the community. Churches are filled with the sick and elderly, many living broken lives. Pharmacies offer lectures, nutrition shops offer cooking classes. Exercise facilities offer equipment, classes, and personal trainers. Social work agencies work to help the poor, the abused, the demented, and the mentally ill. An FQHC is uniquely positioned to partner with any of these entities in order to achieve a common goal.

CMS encourages FQHCs to not only act as Medical Homes, but to pursue formal recognition as such. The Medical Home model is expected to both improve patient outcomes and reduce cost of care. Listed in the seven core principles of a Medical Home model are the principles of "whole person orientation" and "coordinated/integrated care". What could be more integrated than actually bringing those organizations together to talk about the community's needs?

Why Collaborate?

Collaboration will:

  • provide an off-ramp for your patients
  • help you become a true PCMH
  • help you to meet meaningful use criteria
  • provide better quality of care to a wider range of patients
  • benefit your organization as well as your partner's
  • increase access to care
  • increase community awareness
  • expand services beyond what can usually be offered at your own health center


The town of Coeur d'Alene has 45,000 residents and the county approximately 150,000 residents. Most of our area has an uninsured rate of 15%, some towns as high as 30%. There are an estimated 24,000 uninsured residents in the county. Last year, Heritage Health saw approximately 16,000 patients. Counties to the north and south of us have their own FQHC. We have just expanded our services to the county to the east of us, where the uninsured rate is very high and services are in great need.

In our community we have one major hospital with several smaller community hospitals. There are 4 colleges and universities, an active health district, a strong United Way, and the Salvation Army Ray and Joan Kroc Center, which has 15,000 members.

While Heritage Health is working hard to meet the need in our area, others in our community have been hard at work with their own collaborative efforts. The Inland Northwest Food Network is composed of individuals and organizations committed to creating a sustainable and cohesive regional food system. Bike CDA brought together cyclists and shop owners in order to promote cycling in Northern Idaho and to connect cyclists with local opportunities related to cycling. The Kroc Center works with Heritage Health, Kootenai Medical Center, colleges and universities, local churches, and financial institutions to host classes on medical, behavioral health, financial, and spiritual issues health. Panhandle Health District has programs for women's and children's health, epidemiology, communicable diseases, water quality, sexually transmitted diseases, etc. Hospice of North Idaho works with families on end-of-life issues. They provide palliative care, outpatient home services, and a residential facility for end-of-life care. North Idaho College has 15 healthcare related majors, including LPN and RN programs and social work programs. University of Idaho has programs in nutrition, exercise and movement science. And the list goes on.

I have always viewed Heritage Health as a community resource. The best way to expand one's influence is through relationships. The challenge is that relationships take time, and the time spent is not directly reimbursed, making collaborative activities sometimes hard to justify. It may be difficult to directly measure the impact you have when you work with strong partners in your community, but I believe it is the healthcare equivalent of barn raising, accomplishing in a day what would have taken weeks without the aid of your friends and neighbors.

Getting Started

We began discussions with a community recreation center already used to the concept of sliding scale services for those in the community on limited incomes. The Kroc Center provides scholarship memberships for qualified patients. In return for reduced fees, members are asked to either volunteer at the center or to attend what are known as Life Skills classes, a series of lectures covering such topics as chronic medical illness, mental health issues, financial planning, and spiritual issues.

The original plan was to exchange some medical services for a number of memberships that we could use for patients with obesity, diabetes, depression, and low back pain - patients for whom exercise was a key component of treatment.

At the same time, our clinic coordinator was working on a program designed to improve nutrition for patients of limited means. There were food sources available in town and these organizations were looking for a way to help those in need. We joined forces with a local program called Work Ready and started a pilot project where providers are encouraged to write prescriptions for fresh fruits and vegetables - we call them veggie vouchers.

Work Ready is a five-phase employment readiness training program for income-eligible Kootenai County 16- to- 21-year-olds. Participants receive training in food handling, agricultural, culinary and entrepreneurship. They gain job skills experience by helping to grow a garden and maintain a catering business. In order to help finance the program and increase the skills of the teen participants, the clinic arranged to have Work Ready bring their mobile cafe onsite twice a week, selling salads and sandwiches to employees in addition to delivering fresh produce to patients with vouchers. In this win-win-win scenario, Work Ready teens gain valuable job skills, our employees have options for healthy eating, and patients on limited incomes receive free fresh produce prescribed by our providers.

Making healthy food and exercise available and affordable to all residents was a worthwhile goal, but it was clear that we were still not addressing some major obstacles to good health. It seemed just as important to address childhood obesity, mental health issues, victims of domestic violence, and patients with alcohol and substance abuse issues. We needed a way to increase opportunities for those living in poverty and for the working poor who do not have the time to seek out help.

The discussion was widened to include members of the health care community, the financial community, the school systems, and the faith community. Everyone seemed to agree that good health meant more than the absence of a chronic medical illness, and most seemed unaware of the many resources already present in our community. There was general agreement that we should identify local resources, then bring them together so they could problem solve on a community wide level.

In October 2010, NACHC published an article entitled "Partnerships between Federally Qualified Health Centers and Local Health Departments for Engaging in the Development of a Community-Based System of Care". Our clinic has formed an entity consisting of the clinic, the hospital, and our local Health District. The goals of this alliance are to explore care delivery initiatives to benefit the underserved population, identify and submit grant applications, avoid redundancy, and determine collaboration opportunities with payors to manage care for the underserved.

These efforts led to an even broader concept, one which spawned the HERO program.
Our goal was to create a community wide program that would address all components of a healthy life, starting with the very young and continuing to end of life.

The HERO Program

HERO stands for Health Enhancement Resources and Organizations.

The HERO program was conceived as a way to increase collaboration among all healthcare related services in the community. The program will act like a funnel into which residents can be referred and be triaged into services that will most benefit them. This would require the collaborative efforts of a broad array of organizations that normally don't talk to each other on a regular basis.

At the initial vision meeting on June 24, 2014, the representatives of 25 major organizations heard the concept of the HERO program. There was universal support for the concept and we were encouraged to move forward. Our next step will be to appoint an Executive Board and establish working teams representing categories such as medical, behavioral health, exercise, nutrition, social services, schools, financial, spiritual, etc. These teams will meet independently and team leaders will report to the board. This structure has been tested already in a program known as A Day of Hope.

Turn Every Day into a Day of Hope

On September 6, 2014, our community will host an event known as A Day of Hope. After a year of planning, this one day event will bring together thousands of volunteers and about 75 different organizations for a day of hope and support for the impoverished in our community. Guests will be provided with food, clothing, haircuts, job skills, spiritual support, and games and activities for children. The Day of Hope demonstrates how a myriad of community organizations can work together for the benefit of the community. The question remains what to do when this day is over? The HERO program is the logical extension of the Day of Hope, a way to keep those organizations involved in continual improvement of community health. Many hands make for light work.

Following that example, we have invited major stakeholders to consider a community wide wellness initiative that would involve teams of people devoted to areas of wellness. In addition to those teams mentioned above, local retailers, such as pharmacies, grocery stores, supermarkets and specialty grocers will also be represented, as will all local exercise facilities. With the partners we have identified, we can cover everything from childhood obesity to end-of-life planning.

This sounds like a huge project, and it is. However, the bigger the umbrella, the more people you will shelter. The goal is to manage all facets of health and illness in all patients, regardless of economic means and insurance status. The united force of all the major healthcare providers is likely to garner the support of the community - providers, residents, government, insurance companies, Department of Health and Welfare. The goal will be to have a unifying theme that will be felt throughout the community. Any program sponsored by the project will be promoted by the city, the local health district, schools, grocery stores, etc.

Other Models

It is encouraging to know that there are similar models that have been very successful. Health Leads is a Boston based company that trains college volunteers – known as Health Leads Advocates – to connect patients with the basic resources they need to be healthy. Healthcare providers prescribe basic resources like food and heat just as they do medication and refer patients to the program just as they do any other specialty. The Health Leads Advocates then "fill" these prescriptions by working side by side with patients, usually at a desk located within the clinic lobby.

Headed by CEO Rebecca Onie, this program now has 20 partners in 7 states across the country, including several FQHCs. Recognizing the potential impact of this program, the Robert Wood Johnson Foundation has contributed $20 million to this effort.

Borrowing from this model, colleges in our area envision the HERO program as a way to give real life experience to college students as part of their curriculum. Having college volunteers manning a help desk for individuals seeking help makes this program affordable and opens the door to the impoverished. At some point, all healthcare entities will have to figure out how to deal with the uninsured. The program will be designed to operate on a sliding scale similar to that used by FQHCs.

Be All That You Can Be

For anyone wondering how they can explore collaborative partnerships, the following thoughts may be helpful:
Your FQHC is a valuable community resource. Think always not just of your role but how you can help community partners to accomplish their goals. Your FQHC deserves to be the cornerstone of medical care in your community.
Look around you for potential partners. Most communities have a broad range of people and organizations that can combine to be more effective than they would be individually.
Elect a "CCO" - Chief Collaboration Officer. Your FQHC needs someone who knows the community, can articulate the mission of your organization, and is willing to collaborate with other organizations.
Think beyond your four walls - community, not institutional. If all you do is focus on your own programs, you will miss out on the opportunity to create a much larger program that could benefit many people who might normally not even enter your institution.
If you succeed, your partners will succeed. A program of this size will increase community awareness. Business will grow and the community at large will be served.

I am blessed to live in an area where volunteerism is strong and generosity is part of the community fabric. However, I believe most communities have untapped resources. Many people and organizations are looking for ways to help but need some type of structure. FQHCs can provide the structure that allows others to contribute to the community. I encourage FQHC leadership to consider how your organization can be an agent of change in your community.

For any questions about the HERO program, please feel free to contact me at jabate@myheritagehealth.com.


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