Memorial Primary Care

A New Way of Providing Primary Care

Memorial’s program of coordinated community healthcare services has a new name.

South Broward Community Health Services is now Memorial Primary Care, and it’s delivering primary care to the community in innovative ways.

Memorial Primary Care offers a comprehensive, wraparound healthcare network that helps Broward County patients and families manage their long-term health. Establishing patients in a medical home is key to successfully managing chronic conditions like diabetes and COPD and to adopting healthy lifestyle habits that will help prevent problems in the future.

While Memorial’s nine health centers are the cornerstone of those efforts, Memorial Primary Care takes preventive care to new levels by offering care coordination, telehealth, links to community agencies, and more. This year, Memorial Primary Care enhanced those services by adding the following:

Doc in the Box – In this grant-funded program, medical assistants visit patients who have difficulties keeping their doctor or other follow-up appointments due to lack of mobility, transportation or other issues. The Doc in the Box team conducts an in-home assessment, with specialized equipment that monitors vital signs and uploads the data to the patient’s primary care provider. From October 2018, when the program began, to the end of the 2019 fiscal year, Doc in the Box team members made 150 visits to patients’ homes.

“When it comes to follow-up or preventive care, it’s usually the patient’s responsibility to make it happen,” said Melida Akiti, Vice President, Ambulatory Care and Community Service. “Instead, we call patients with reminders about preventive care and follow-ups. That’s concierge-level service.”

“When it comes to follow-up or preventive care, it’s usually the patient’s responsibility to make it happen. Instead, we call patients with reminders about preventive care and follow-ups. That’s concierge-level service.”

Melida Akiti

Vice President, Ambulatory Care and Community Service

Mobile Van Outreach – Memorial Primary Care stepped up its mobile van visits in neighborhood “hot spots” – areas in which higher incidences of emergency room visits have occurred. In addition to the preventive care that the van teams provide, another goal of the weekly visits is increased patient convenience.

“For mobile van visits, you don’t need to be a Memorial Primary Care patient,” Ms. Akiti explained. “We are focused on creating access and on providing care that is customized to patients’ specific needs.”

More Formats, More Appointments – Memorial Primary Care added more opportunities for access with digital appointments (in which patients teleconference with their physicians), as well as same-day and walk-in appointments at its nine health centers. “Being seen by a member of the team on the same day means we can address issues and concerns more quickly,” Ms. Akiti said.

“By improving population health, Memorial Primary Care is creating savings for everyone – because what we do translates into value-based care. We focus on providing the comprehensive, preventive services that are the foundation of transformative healthcare.”

Jennifer Goldman, DO

Medical Director, Memorial Primary Care

What Determines Good Health?

Social determinants of health are the conditions in which people are born, and the ways they live, learn, work, play and age – all of which affect their health and their quality of life.

Memorial Healthcare System’s Community Services programs work daily to have a positive impact on social determinants for our South Broward neighbors, with Memorial’s Case Managers and Care Coordinators connecting families to social supports such as:

• Educational and benefits programs
• Family planning services
• Affordable child care
• Access to healthy foods
• Job and financial assistance
• And, of course, high-quality, preventive healthcare

Living Better with LivWell

Since 2017, with support from the United Way of Broward County, LivWell has helped at-risk individuals with chronic and co-morbid conditions take charge of their health by using available healthcare services and resources. The program links each participant to a primary care provider, works to remove transportation, linguistic and other barriers, and educates participants to instill health-supporting lifestyle habits.

This year, 98 percent of 89 participants reported increased access to primary and preventive care, with 87 percent improving their self-care, and nearly 90 percent demonstrating increased knowledge and understanding of their conditions.

MOMS Helps New Moms

Becoming a new mother is exciting – but imagine how difficult it can be if you’re coping with prenatal or postpartum emotional stress. Mothers Overcoming Maternal Stress (MOMS) helps pregnant women and new mothers cope with depression and anxiety by promoting mother-child bonding and addressing complex social and emotional issues that affect family functioning.

Counselors from MOMS perform initial in-home screenings and assessments, after which new mothers receive customized treatment plans, including links to community resources, parental training and education, and home-based cognitive behavioral therapies.

The program’s most recent performance analysis reported that 100 percent of MOMS participants bonded successfully with their infants, and all experienced fewer symptoms of depression and anxiety.

Giving Kids a Healthy Start

Memorial’s Healthy Start program works to ensure that children start life off on the right foot by providing their parents with crucial skills and training, including:

• Childbirth education and healthy pregnancy classes
• Midwife services
• Breastfeeding support
• Assistance for substance abuse/substance exposed newborns
• Links to Memorial Primary Care for preventive health

Memorial expanded the program this year to provide services to foster-care mothers and babies at Children’s Harbor, Inc. in Southwest Ranches, and to families with infants in the Memorial Regional Hospital Neonatal Intensive Care Unit. Healthy Start achieved top results, too: More than 2,000 participating families were successfully linked to a healthcare provider, and all participants receiving care coordination were given referrals to address their specific risk factors.

NFP: A Nurse-Family Partnership

Think house calls are a thing of the past? In Memorial’s Nurse-Family Partnership program, nurses provide low-income women who are pregnant for the first time with personalized in-home visits – twice monthly during pregnancy, and then during the first two years after birth. Each nurse partners with a mom for training in positive health-related behaviors, competent child care and maternal personal development. The goals: Healthy pregnancies and children, and improvements in families’ economic self-sufficiency.

Last year, NFP served 150 mothers, resulting in fewer early deliveries, a reduced number of low-birth-weight outcomes, and with 100 percent of participants reporting satisfaction with the program.

ALLIES Wins Recognition

Memorial’s ALLIES program (Adults Living Life Independently, Educated and Safe) received America’s Essential Hospitals’ Gage Award for Population Health Honorable Mention in June 2018. ALLIES – which is funded by the Community Foundation of Broward and helps seniors age 80 and up age in place via preventive education, home visits, assessments and active socialization – has served more than 1,500 Broward seniors since its inception in 2016.

“Good health begins in our homes, schools, workplaces, neighborhoods and communities. How we care for ourselves, and what services are available to us, make a big difference in population health. Memorial is committed to improving the social determinants of health that, if left unaddressed, would otherwise bring patients and families to our emergency rooms – giving them the opportunities and resources they need to pursue lifelong health and well-being instead.”

Tim Curtin

Administrative Director, Community Services, Memorial Healthcare System

A Vital Presence in Our South Broward Community

While Memorial Healthcare System is recognized nationally as a leading provider of patient- and family-centered care, it is also an important member of the South Florida community, dedicated to improving population health. Memorial’s Community Relations Department works every day to put that core value into action.

Every year, Memorial provides educational programs, speakers and school-based initiatives throughout the community – partnering with more than 400 leading service organizations to offer learning opportunities, improve health and have fun.

This year, Memorial held or participated in 597 community engagements, reaching 503,000 of our neighbors via events like the ANF Tour de Broward, the YMCA Healthy Kids Day, Joe DiMaggio Children’s Hospital’s Kids World Family Fun Festival and the Dr. Oz Health Expo.

Memorial hosted more than 153,000 adult participants at 227 health awareness events and held 46 safety and injury prevention events in the community and at Broward County Public Schools, reaching nearly 8,500 children and families. As the lead agency for Safe Kids Broward, 169 new car seat technicians were certified to educate parents throughout the county on how to safely install car seats. A total of 77 child car seats were inspected and 495 seats were donated. In partnership with Safe Kids coalition members, the children’s safety and injury prevention initiative educated 8,000 children on pedestrian and bicycle safety.

Addressing the Whole Person

Memorial’s partnerships with Broward-based and other social service organizations strive to improve the conditions in which people live and work – the social determinants of health. Working with organizations like the Children’s Services Council of Broward County, Big Brothers Big Sisters, Boys & Girls clubs, and others, Memorial supports programs that contribute to the overall quality of life in South Florida.

“Our mission is to heal the body, mind and spirit of those we touch, but we can’t do that as a whole without supporting services that go beyond our hospital walls,” said Milin Espino, Administrative Director, Community Relations.

One example is Memorial’s partnership with Women in Distress of Broward County, Inc., which Memorial supports to bring domestic violence and teen-dating violence awareness programs to the community. Memorial also has representation on boards of 128 local social service organizations, providing input on issues ranging from homelessness to the challenges of children aging out of foster care.

We have co-sponsored seven Memorial Fitness Zones throughout Broward County cities and parks. The zones, which provide access to free outdoor gym equipment, have resulted in a significant increase in park attendance as more members of the community use them to pursue healthier lifestyles.

“Statistics show that 80 percent of a person’s wellness is based on social determinants like housing, the home environment, and education and employment opportunities,” Ms. Espino said. “So when a hospital system like Memorial is able to make an impact outside of the usual clinical services we provide, it’s a tremendous investment in the health of the community.” We extend health education on prevention and early detection to employees of local corporations.