Revolutionizing how people get and stay healthy requires more than medicine.
Dell Medical School’s “Healthscape,” focused on health beyond the clinic, supports and advances innovations that improve health in the landscape of people’s lives. It is anchored in the places where people live, learn, work and play.
Activities build on innovation and expertise in programming for social needs, implementing effective solutions and forging strong partnerships with community organizations.
Here are four examples, shared during an April 30 symposium celebrating this critical work.
Health & Care for the Next Generation
COVID-19 has perpetuated mental health disparities, worsened social disadvantage and delayed important developmental milestones among Latinx people between 18 and 25 years old, defined as “transition age.”
This trend is alarming because Latinx young adults already experience sociocultural stressors related to systemic racism, have low rates of health insurance and are often less able to access or pay for COVID-19 treatment or testing. For these reasons, it is critical to understand how COVID-19 has affected the mental health and well-being of Latinx young adults.
How do we increase access and quality of mental health services for a population not adequately served by either pediatric or adult services? Services need to be developmentally appropriate and address contextual barriers — immigration status, cost of services and lack of insurance, for examples.
Carmen Valdez, Ph.D., is leading a team including university researchers, a community organization advocate and a Mexican public health official to assess the mental health needs of Latinx transition-age youth. It has developed a recruitment and data collection strategy tailored to pandemic conditions, reflected on the assets and levers of the partnership with the Migrant Clinicians Network and the Mexican Consulate of Austin that enhanced partner organizations’ ability to engage the population and created a shared agenda for using research data to inform research-practice partnerships.
It also secured funds to implement a mental health promotion model led by community health workers at the Mexican Consulate to screen young adults and refer them to appropriate services.
Partners in this work include the Migrant Clinicians Network and the Mexican Consulate of Austin.
A New Model of Mobile, Integrated Care for People Experiencing Homelessness
The Mobile Medical and Mental Health Care, or M3, Team is a five-year project funded by the Substance Abuse and Mental Health Services Administration to develop, implement and evaluate a mobile, integrated care model for individuals experiencing homelessness in Austin with “trimorbidity” — a chronic medical condition, serious mental illness and a substance use disorder.
Health care is passive, provider-centric and siloed. We sit in our clinics and make patients come to us. We provide primary care, specialty care, mental health care and substance use disorder treatment in different buildings, with different people, and different information systems in a fragmented, uncoordinated fashion. And health-related social needs are either “not our problem” or they are tacitly addressed through outsourced referrals with no closed-loop communication or accountability. This model of care makes it near impossible to reach and serve individuals experiencing homelessness.
The M3 Team, led by Tim Mercer, M.D., is trying to change all this for people experiencing homelessness. It works with existing community-based outreach teams to refer patients who meet eligibility criteria. Once patients are referred and enrolled, the M3 team uses a mobile and community-based service delivery model, incorporating the evidence-based practice of integrated dual disorder treatment. It meets patients at locations most comfortable and convenient for them, providing comprehensive and integrated primary care, mental health care, substance abuse treatment, intensive case management, enrollment in social programs and referral for placement in sustainable permanent housing.
Primary partners in this work include CommUnityCare Health Centers and Integral Care. The team also works closely with other health care providers and homeless services agencies, including Austin-Travis County Emergency Medical Services, ECHO, Caritas, Front Steps and Sunrise Community Church and its Homeless Navigation Center.
Slowing Dementia Progression
A research collaboration between the Georgetown Neurosciences Foundation and Dell Med's Department of Neurology is developing a multi-generational research study focused on brain health that will blend technology, digital health, large data aggregation, artificial intelligence and computational measures to discover new medical and lifestyle interventions for neurodegenerative diseases.
The social and economic burden of cognitive impairment is one of the greatest challenges facing our health care system — one that will be compounded by the projected increase in the aging population. One of the major costs is emergency room visits and hospitalizations related to preventable medical conditions. These conditions cause rapid deterioration in cognitive performance and require prolonged hospitalization and transfer to skilled-nursing or transitional-care facilities.
Led by Alyssa Aguirre, the Georgetown Neuroscience Foundation and Dell Med’s neurology department have organized a community-based population of 500 volunteers who are collaborating to lay the groundwork for a large multi-generational research study.
The vision is to develop a research cohort of 5,000-plus diverse individuals who represent the community. Large population-based cohort interventional studies are limited in this area, and longitudinal studies that follow a group of people and families over a long period of time have been successful in identifying risk factors and have contributed to knowledge about diseases.
Partners in this work include Sun City community leadership, the city of Georgetown, 500 older adult community volunteers and 15 community volunteers (primarily retired health care professionals) serving on a medical advisory board.
Defining Community Health Work
The Community Engagement and Health Equity team in the Dell Med Department of Population Health is engaging with partners to plan, implement, evaluate and refine the focus of community health workers at three sites: the Lone Star Circle of Care at Collinfield clinic in the Rundberg neighborhood, the mobile CommUnityCare Health Centers unit serving individuals experiencing homelessness and Dell Seton Medical Center at The University of Texas.
As trusted members of the community and expert relationship-builders, community health workers are valuable members of any clinical team. How to incorporate, evaluate and compensate their work continues to be a challenge.
This effort, led by Ricardo Garay, aims to create a national/regional model for community health workers working in diverse health care settings to promote population health and address root causes of health disparities.
Direct partners in this work include Lone Star Circle of Care, CommUnityCare Health Centers and Ascension Seton. Contact partners are Austin Public Health, El Buen Samaritano, Central Health, the UT Austin School of Nursing, the UT Austin Steve Hicks School of Social Work, Central Health, People's Community Clinic and It's Time Texas.