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Overall health pilot program expands statewide


A pilot program that connects patients in Oklahoma and Tulsa counties with social service programs to improve their overall health will be expanded statewide based on its initial success.

"Health care delivery itself is like 10% of what it takes to be a healthy, thriving person," said Dr. David Kendrick, a key partner in the program.

"Everything else is in the mix — from the sidewalk quality in your neighborhood, to do you have grocery stores with produce nearby, to what are the school systems like," Kendrick said. "We needed to figure out how to get that into the equation to be able to improve health in Oklahoma."

The Oklahoma City-County Health Department and Tulsa Health Department did that by tapping into the technology already in place through the nonprofit MyHealth Access Network. The statewide health information exchange includes nearly 400 organizations — insurance companies, doctors, hospitals, optometrists, first-responders and tribes — that share medical records, said Kendrick, who is CEO.

MyHealth was awarded $4.5 million over five years in 2017 to screen Medicare and Medicaid patients in Oklahoma and Tulsa counties about their needs in five core social service areas. The project — known as Route 66 Accountable Health Communities — is one of dozens the Centers for Medicare and Medicaid Services is funding nationwide to find out whether paying for social services navigation will reduce health care costs.

"We're finding a lot of need that we hadn't anticipated — housing needs, food needs," Kendrick said.

Initial information shows that 24% of all patients screened reported needing assistance in one of the core areas — food, housing, utilities, transportation and interpersonal violence — and 45% of Medicaid patients reported needs.

"Some people getting health care aren't improving. We need to be talking about things happening outside the doctor's office that have large impacts,"said Gary Cox, executive director of the Oklahoma City-County Health Department. "Those are the things that will give us the greatest opportunity to improve health."

Housing is No. 1, Cox said. "If you don't have a place to live, you don't have security and you don't have a community and a support system."

Quality of housing also matters. The screening for one patient recently revealed ongoing issues with a pest infestation. A "navigator" partnered with a pest control company willing to offer one free service per month.

Each county hired 12 navigators — or community health workers — for the project. They are key to getting patients to use the recommended social services because they establish "trust and a relationship," Cox said.

How it works

When patients arrive at an emergency room or clinic for care, they are sent a text message with a survey to fill out while in the waiting room. A return text gives them information about free and reduced-cost resources near them that address their needs.

"If they have more than one emergency room visit, they also are referred to a navigator — a person who will take their case for a year and will help them get housing, transportation, food or whatever they are missing," Kendrick said.

"For the first time — maybe ever — we're doing a broad social needs screening across the community of everybody who enters the health care delivery system into one of our participating clinics and hospitals. We're also immediately getting them information to help them," he said.

After successfully screening thousands of patients in Oklahoma's two most populous counties, the Centers for Medicare and Medicaid Services has approved expansion of the Accountable Health Communities program.

"Now we're allowed to expand this statewide," Kendrick said. "It's free to every clinic that wants to participate."

The community came together and built the MyHealth infrastructure that makes this kind of projects possible, and no other region has it, he said.

"I think it's important to know that Oklahoma is the best at something, because we hear all the time how we have all these terrible health outcomes," Kendrick said. "But there is a light ahead and we're taking a typically Oklahoma-innovation approach to it, and it's not just one organization. It's the whole system."

Cox said, "We believe this opportunity will serve as a success story for the nation."

To participate

Clinics and health care systems wishing to participate in the AHC program can email or call 918-703-4766.

Related Photos


<figure><img src="//" alt="Photo - Kendrick " title=" Kendrick "><figcaption> Kendrick </figcaption></figure><figure><img src="//" alt="Photo - Cox " title=" Cox "><figcaption> Cox </figcaption></figure>
K.S. McNutt

Kathryn McNutt covers higher education for The Oklahoman and NewsOK. Since joining the staff in August 2000, she also has worked as the Breaking News editor, Metro editor and assistant Local editor. A native of Oklahoma City, she graduated from... Read more ›