Cassidy Tarullo, MPP
April 19, 2023
The Health Care Improvement Foundation’s (HCIF) Partner Profiles highlight the efforts of valued and innovative health leaders. Our partners’ work supports HCIF’s vision of healthier communities through equitable, accessible, and quality health care.
Earlier this month, HCIF launched the Call for Entries for the 2023 Excellence in Health Care Awards (formerly Delaware Valley Patient Safety and Quality Awards). Since 2002, this program has promoted and recognized hospitals and healthsystems for their innovative contributions in health care, patient safety and quality, and health equity. We’re excited to highlight the work of our 2022 1st Place Winner, Temple University Hospital, for their initiative “Delivering Equitable Care Through a Community Health Worker Driven Multi-Visit Patient (MVP) Program”.
Dharmini Shah Pandya, MD
Medical Director, Multi-Visit Patient Clinic
Chair, Patient Safety Committee Temple University Hospital
Associate Professor of Medicine, Lewis Katz School of Medicine
Associate Program Director, Internal Medicine Residency Program
Antionett McNear, CNA
Certified Community Health Worker
Your team won First Place in our 2022 Awards program, for your initiative “Delivering Equitable Care through a Community Health Worker Driven Multi-Visit Patient (MVP) Program”. What inspired you to address the connection between social determinants of health and hospital readmissions?
Dr. Shah Pandya: Readmissions are complex and have multiple reasons and components to it. Research has shown that social determinants of health, such as access to healthcare, socioeconomic status, education, and living conditions, play a critical role in shaping health outcomes. These factors can impact a patient’s ability to manage their health and adhere to treatment plans, as well as their risk for complications and readmissions. As a hospitalist, we are the frontline to taking care of readmitted patients. One of the major factors that contribute to readmissions is social risk factors, and often as an inpatient physician, I felt that I didn’t always have the tools to stop the readmissions from happening when only addressing the acute medical problem. So, when hospital medicine was challenged by the health system to “reduce readmissions,” our specific recommendation was to have access to a program that could address social needs and handle the medical complexity of our patients. This led to creating a program, which aligned all the stakeholders – patients, population health, physicians, and metrics! Dr. Raab, Steve Carson, Dr. Rubin have been all early supporters, adopters, and creators of the program and I’d like to personally thank them for creating such a successful framework! Edward Drayton (previously the only Community Health Worker (CHW) for the program, and now a supervisor!) and Lakisha Sturgis have been imperative leaders from the CHW team to advance the work, create processes and improve patient engagement. Without the team, this work would not be possible. All the people here are my inspiration for moving the needle forward.
Antionett: The Multi-Visit Patient Clinic was a response to the high rate of readmissions among patients with Congestive Heart Failure (CHF) End Stage Renal Disease (ESRD) Hypertension and uncontrolled Diabetes. Temple Centers for Population Health created this clinic with the intention to not only address and monitor symptoms of CHF, COPD, ESRD, etc., but to also closely monitor the Social Determinants of Health (SDOH) of the patients that readmitted and to get a better understanding of why they were readmitting so frequently. What we found was that many patients had limited access to healthy food and transportation, and low health literacy. We understood that addressing the SDOH needs of our patients would be the key in enhancing their quality of life. This would in turn lead to better health outcomes, and lower readmission rates. In essence, through our success in managing these patient’s needs, we’ve been able to expand the clinic to address other chronic illnesses as well.
“I would like people to know that Certified Community Health Workers exist and we are here to serve our community and underserved patients that cannot necessarily fight for themselves.”
Antionett McNear
As evidenced by your submission in the Award, Temple Health has demonstrated a commitment to community health and health equity. What is one of the most impactful changes that Temple has achieved in this space?
Dr. Shah Pandya: Continuing to grow programs that allow for access to medical care and resources for social determinants are some of the biggest accomplishments! Additionally, seeing successful graduates of the MVP Program who continue to thrive and have an improved quality of life is always humbling to be a part of the process.
Antionett: Our commitment to community health and health equity has been the driving force of Center for Population Health initiatives such as the MVP Clinic, Philadelphia Housing Authority (PHA Cares), and the Frazier Family Coalition. These initiatives have been some of the most impactful changes that Temple Health has achieved in this space as they each address health literacy, navigating and accessing adequate health care, and emphasizes the connection to community resources to create sustainable change.
What is one key thing you would like the public, or someone not in health care, to understand about community health workers and the role they serve in our communities and the healthcare system as a whole?
Dr. Shah Pandya: That Community Health Workers have a variety of skill sets, but most importantly that they are true patient advocates, and have excellent communication and motivational interviewing skills that allows them to interact with a wide variety of patients and healthcare professionals. Creation of the MVP program has required support from many places but the CHWs have been at the center of the work 100% of the time.
Antionett: That Certified Community Health Workers (CCHW) exist! We have a very unique role, which allows us to bridge the gap between the community and the healthcare system. We are highly trained to provide education, advocacy, resources, and support to our patients on an individualized level. I would like people to know that we exist and we are here to serve our community and underserved patients that cannot necessarily fight for themselves.
What have you found most meaningful about participating in the Award program? What are the next steps in advancing the work of your winning initiative?
Dr. Shah Pandya: Often in the daily work, it is easy to lose sight of the larger picture. Participating in the award allowed us to showcase our work that has been years in the making, and allowed us personally to see the impact of the work on a larger scale.
Antionett: The thing I’ve found most impactful about participating in the Award program is realizing how important and impactful our work is to our community. To be recognized for the work that we do, and for our program to be highlighted in this way, is affirming and humbling. It lets everyone know that even on the worst days, this work is necessary. The next steps to advance the work that we do is to graciously continue to serve our community, evaluate our programs and make changes or enhancements in ways that benefit our patients.
“Seeing successful graduates of the Multi-Visit Patient Program who continue to thrive and have an improved quality of life is always humbling to be a part of the process.”
Dr. Shah Pandya
Reflecting on your own professional background and accomplishments, how did you become interested in community health and health equity? What is one of your greatest accomplishments within your field so far?
Dr. Shah Pandya: As a prior medical resident at Temple Health, and now a faculty member – the mission for me in medicine has always been to focus on providing healthcare to those that are underserved. Temple Health’s flagship campus in North Philadelphia serves a population that faces many challenges, so focuses on creating programs that are community-based and helping the population as a whole. Health equity is the foundation for my interest in medicine. I’ve been incredibly lucky to be surrounded by mentors and supporters who propel my interests further in creating accessible programs for patients. Temple Health is a special place –if you have an idea that is mission driven, people will support you to achieve the mission. Multiple disciplines will come together with different roles to work together to achieve patient centered care. The MVP program has allowed me to learn a new skillset, and connect with patients and CHW’s that has allowed me to grow as a physician.
On a personal note, one of my personal accomplishments has been becoming a mother. Showing my kids that innovation and helping others can help you find purpose in your job and life. I’m incredibly lucky to have a job that allows me to contribute to the North Philadelphia community and advance a program that approaches health equity is humbling, and hopefully role models for my kids that anything is possible!
Antionett: I became interested in Community Health and Health Equity because I’ve seen that access to healthcare and education affects families and communities of color. It makes me proud to know that I have a hand in shaping outcomes for my elders and the next generation. One of my greatest accomplishments in the field so far was becoming a Certified Community Health Worker. Having a certification in my field adds more respect and value to the role. It lets people know that I’m committed to the work I do.
Something you may not know about Dr. Shah Pandya and Antoinette…
Dr. Shah Pandya’s favorite hobbies are walking, doing puzzles, and cooking with her kids – as a vegetarian foodie, she loves finding new cuisines and places to eat. She also has a previous background of dancing and choreographing throughout her academic journey!
Antionett is inspired by Denzel Washington’s quote, “At the end, it’s not about what you have or even what you’ve accomplished. It’s about who you’ve lifted up, who you’ve made better. It’s about what you’ve given back,” and applies it to her work with families and communities.
They would also like to thank their entire team at Temple University Hospital that helped make the Multi-Visit Patient Program a success:
- Section of Hospital Medicine: Anam Fatma, MD; Kelly Hughes, MD; Vik Induru, MD; Nikhil Kothari, MD; Monica Poeske, NP; Rachel Rubin MD (section chief), Dharmini Shah Pandya, MD; Cara Smith, MD; Priju Varghese, MD
- Center for Population Health: Patrice Armstead, Jannette Cruz, Edward Drayton, Larry Kendrick, Patrick Mann, Antionett McNear, Lakisha Sturgis
- Central Scheduling Team: Denise Carter, Tom Cleary, Brand-Lee Croft, Dora Han
- PI: Louis Fetscher, DNP; Rashidah Hardwick, MHA
- Leadership: Steve Carson, MHA, BSN; Lisa Fino; Nina O’Connor, MD; Claire Raab, MD
Temple University Hospital’s 1st Place team accepting their award at the 2022 Partnership for Patient Care Leadership Summit.
From left to right: Dharmini Shah Pandya, Edward Drayton, Steve Carson, Lakisha Sturgis, Wendy Nickel (HCIF President)