By Gillian Feldmeth, BS, Research and Special Projects, The South Side Health and Vitality Studies and Stacy Tessler Lindau, MD, MAPP, Associate Professor, Departments of Ob/Gyn and Medicine, Biological Sciences Division, University of Chicago; Director, Research and Innovation, Urban Health Initiative, University of Chicago Medicine; and Director, CommunityRx
CommunityRx began with a search for health and wellness resources on Chicago’s South Side. We knew our communities have a lot to offer, but locating these assets wasn’t easy. Programs and services were hard to find, and information about them was often confusing. Often times it was simply wrong. We wondered what happened when patients left a clinic or hospital. Could they find what they needed to be healthy – or were community places and services invisible to them?
In 2012, our lab at the University of Chicago received a Center for Medicare and Medicaid Innovation Health Care Innovation Award to develop a real-time automated system that links patients with up-to-date information about community-based services and resources that can help them stay healthy and manage their conditions. CommunityRx creates a customized referral list for community-based services, called a HealtheRx, and connects patients to a community health information specialist who can help with navigating to community resources. Currently, most people receive a HealtheRx through one of 20 participating clinical sites, including community health centers, emergency departments, and University of Chicago clinics. But, anyone with an internet connection can generate a HealtheRx at www.healtherx.org or by contacting one of our information specialists. There are three core, complementary components to the CommunityRx system:
- Community Health Information Specialists
MAPSCorps began in 2008 when researchers with the Urban Health Initiative at the University of Chicago engaged with local community leaders and residents to identify how to work together in applying the tools of science to improve local urban health. Community leaders voiced that a partnership would need to engage local youth, include economic vitality in the definition of health and produce meaningful data that community businesses, organizations and residents could use.
From these imperatives emerged MAPSCorps (Meaningful, Active, Productive Science in Service to Community), a STEM-education and youth employment program that trains local high school students to map businesses and organizations on the South Side of Chicago. Every summer since 2009, local high school students generate a comprehensive census of all public-facing businesses and organizations offering goods or services within target neighborhoods. Using a “feet-on-the-street” methodology and a custom phone app called “MapApp,” we found that the data collected by MAPSCorps are 20 to 40 percent more accurate than widely used data sources.
MAPSCorps pairs the high school youth with science-oriented college students who expose mappers to a science, technology, engineering and math (STEM) curriculum, and help them learn important skills that prepare them for future education and jobs. Since 2009, we have provided more than 350 meaningful jobs for local youth who have mapped almost 90 sq. miles of Chicago’s South Side. We have received more than 80 formal requests for the MAPSCorps data, which are made available to researchers, community organizations and others interested via the South Side Health and Vitality Studies Data Request Form here.
MAPSCorps also serves as the data engine for HealtheRx, an e-prescribing technology embedded into electronic medical record (EMR) systems and seamlessly integrated into the normal clinical workflow. The system matches each patient’s health information from the EMR with self-care programs and services located near their home. In the same way that doctors can easily e-prescribe drugs, the CommunityRx system prescribes “everything else” that patients can use for wellness, independent living and disease management.
HealtheRx fuels an information economy on the South Side by providing real-time, up-to-date data on community needs and assets. The data generated through HealtheRx are shared back with community-based organizations in the form of Service Provider Data reports, allowing community leaders to understand the number of referrals made to specific services offered by their organizations.
Community Health Information Specialists
The third component, Community Health Information Specialists, provides the “human touch.” Each HealtheRx features a picture and contact information for the Information Specialist — a special type of community health worker who helps the patient navigate the services to which they are referred—assigned to that patient’s zip code.
Information Specialists regularly call local businesses and organizations identified by MAPSCorps to gather detailed information on the programs and services they offer. By regularly interacting with community-based service providers, Information Specialists are well-positioned to help patients navigate and understand the available health and self-care services printed on the HealtheRx.
CommunityRx currently operates in 20 clinical sites, including four health care provider organizations using three different EMR systems. Since April 1, 2013, more than 100,000 HealtheRxs have been generated for more than 40,000 unique patients.
Through a voluntary participant call-in survey, we found that about half of patients are sharing the information they get from the HealtheRx with friends or family—and 100 percent of people who share the information report saying something positive about HealtheRx. One patient shared, “I told my friend to call Pamela [an Information Specialist] because she needs help with a lot of things on here.”
Tim Long, MD, a doctor on Chicago’s South Side said “…I need HealtheRx. This new kind of ‘prescription’ goes beyond a diagnosis and medicine. It provides personalized information and support from community health information specialists to help patients stay healthy between clinic visits.”
Read blog post from Dr. Anand Parekh, Deputy Assistant Secretary for Health on his visit to one site that has implemented CommunityRx
- Clinical-Community Linkages: A Step towards Better Health by Anand Parekh / Deputy Assistant Secretary for Health: “As a practicing physician, I often counsel patients on the importance of healthy behaviors such as eating a nutritious diet, being physically active, and not smoking or abusing other substances. However, health education in the clinical setting is usually brief and of limited effectiveness – we have little means to reinforce our guidance in the patient’s day-to-day life. Enter Community Rx, an innovative program that links the doctor’s office or clinic with community health resources.”
Learn more about local physician Dr. Timothy Long’s experience using CommunityRx technology in his primary care practice
- Dr. Long Uses Health IT to Connect Patients to Community Resources: “Since going live with CommunityRx in April 2013, the Alliance’s providers have handed out more than 7,000 CommunityRx resource lists to patients. “Implementation of CommunityRx has helped our patients use community services to achieve a variety of goals, such as improving stress management, increasing physical fitness, and buying fresh food,” Dr. Long said. The Alliance continues to spread the word about CommunityRx and has used posters, videos, flyers, and promotional events to publicize the program. Building on this success, Dr. Long and his colleagues plan to implement a patient portal in the near future.”
Disclaimer: MAPSCorps and HealtheRx are innovations from CommunityRx, a flagship program of the South Side Health and Vitality Studies at the University of Chicago Medicine’s Urban Health Initiative. CommunityRx is support by grant #1C1CMS330997-03-00 from the Department of Health and Human Services, Centers for Medicare and Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.
 Makelarsi JA, et al. Are Your Asset Data as Good as You Think? Conducting a Comprehensive Census of Built Assets to Improve Urban Population Health. Journal of Urban Health. September 2012.