This story was originally published in the 100 Million Healthier Lives Change Library and is brought to you through partnership with 100 Million Healthier Lives and the Institute for Healthcare Improvement.

Improving the health of a community is critical to ensuring the quality of life of its residents and fostering sustainability and future prosperity. Health is intertwined with many different facets of our lives; where we work, live, learn, and play all have an impact on our health. Understanding the current health status of a community and all of the different factors that influence health, is important in order to identify priorities for program planning and coordination across partner organizations.

In 2003, the Primary Care Action Group (PCAG) was formed to help address the health needs of the Greater Bridgeport community, which includes the six towns of Bridgeport, Easton, Fairfield, Monroe, Stratford, and Trumbull in Connecticut. PCAG is a coalition of two neighboring hospitals in the City of Bridgeport, Bridgeport Hospital and St. Vincent’s Medical Center, along with the six departments of public health, federally qualified health centers, and about 50 community and non-profit organizations all serving the region. The mission and vision of PCAG is to work together to identify, prioritize and measurably improve the health of the community through prevention, education and services.

As one of its first collaborative projects, in April 2011, PCAG helped launch the Dispensary of Hope Greater Bridgeport, a charitable pharmacy dedicated to serving low-income and uninsured individuals in the Bridgeport community. A member of the national Dispensary of Hope Network, Dispensary of Hope Greater Bridgeport provides short-term and long-term medication assistance to eligible patients through a licensed pharmacist and trained personnel. The Dispensary of Hope Greater Bridgeport served over 4,500 patients in fiscal year 2017.

PCAG leads a comprehensive regional triennial Community Health Needs Assessment (CHNA) effort to identify the health-related needs in the region and create an implementation plan to prioritize and plan on how to address those top health needs. The current 2016-2019 priority areas for PCAG are cardiovascular disease and diabetes, healthy lifestyles (obesity and chronic disease), behavioral health and substance abuse, and access to care. PCAG oversees the work of all four task forces that work to address each of the health priorities identified through the CHNA process. These task forces consist of representatives from each partner organization, plus others interested in improving the health of the community through collaboration. Each task force also meets on a monthly basis and works to ensure their specific community health improvement plan (CHIP) goals are met and progress is tracked.

Health Needs

According to the 2016 Community Health Needs Assessment, 16% of the overall population of Greater Bridgeport and 25% of the population in the City of Bridgeport reported food insecurity in the previous 12 months. 

The chart below indicates the numbers of people in the area told by a provider that they have diabetes and those told they have hypertension, as well as other chronic conditions.

Source: 2016 State of CT Wellbeing Survey, Datahaven

In addition to the launch of the Dispensary of Hope in 2011, PCAG partners have collaborated on numerous other successful endeavors over the past 15 years. The Cardiovascular Disease and Diabetes (CVD) Task Force implements the Know Your Numbers (KYN) program. Launched in February 2014, KYN brings free health screenings directly to the underserved population at local food pantries. The data collected from each year has shown that food pantry users consistently screen as being high risk or having heart disease and/or diabetes.

KYN screenings are organized by the CVD Task Force with assistance from students from local nursing schools and support of volunteers from both hospitals. Each screening includes body mass index (BMI), waist circumference, blood pressure, cholesterol, blood sugar, and, when indicated, HbA1C for diabetics. Participants also receive individual counseling, nutrition education and physical activity tips. What began as a way to educate the community about knowing their own health numbers has evolved over the years to a multifaceted approach to improve the health of those who utilize local feeding programs. 

One of the latest enhancements to KYN was implementing Supporting Wellness at Pantries (SWAP) in six food pantries starting in 2016. Developed by St. Joseph’s University, the UCONN Rudd Center, in partnership with the Council of Churches of Greater Bridgeport, SWAP helps food pantry managers sort foods as eat frequently (green), eat moderately (yellow) and eat rarely (red). The color is determined by the amounts of saturated fat, sodium and sugar –these nutrients contribute to the diet-related diseases that are most common in patrons of feeding programs.

This system enables participants to choose healthier food items. Since 2017, SWAP has been implemented in six Bridgeport food pantries where the CVD Task Force conducts regular KYN screenings. In addition to SWAP, in 2018 a basic nutrition training curriculum was implemented for the food pantry managers and volunteers to teach them how to read nutrition labels. The training was conducted in the six food pantries that have SWAP, and helped to provide a consistent knowledge base across all pantry workers to assist their clients with specific health and dietary needs. 

The Role of Community Health

According to the American Public Health Association, a community health worker is a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served. This trusting relationship enables the worker to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery.

In February 2018, we made further enhancements to the KYN screenings process through the integration of the Community Health Workers (CHW) in order to be able to better connect participants to follow-up medical care where needed. Prior to 2018, referrals came in the form of a handout created by PCAG with information on local clinics. However, we recognized that it is imperative to do a warm hand off to connect this vulnerable population directly to follow-up care. Additionally, we partnered with Southwestern Area Health Education Center (SWAHEC) to have two CHWs present at our screenings. Since the introduction of CHWs to the KYN process in February 2018, 95 KYN participants have received direct referrals to follow-up care and/or referrals to other resources in the community. During the first KYN screening where a CHW was available, one distraught participant with high blood pressure indicated that she was almost out of medication and had been having difficulty getting an appointment with her PCP. The CHW worked with her to get her an appointment almost immediately. The woman was able to get her medication and was extremely grateful that the CHW was on-site to assist her.

According to Joseph Petreycik, Co-chairperson of Cardiovascular Disease and Diabetes Task Force, "[a] key message is to see a physician on a regular basis."

For instance, during a Know Your Numbers screening, a 25-year-old man, of normal weight, was screened and had dangerously high blood sugar levels. After a referral, a primary care physician was able to see him immediately and he was diagnosed with diabetes. After being prescribed medication and making lifestyle changes, his diabetes is now safely being controlled. 

Another woman was screened and her weight, cholesterol and blood pressure were all above normal. In one month she was able to lose 10 pounds by using the information she was provided by the KYN team. She is also happy to report that she no longer needs her blood pressure medication. 

Access to Healthy Food

The work of the KYN team has evolved over the years to include a focus on the food available at these feeding sites. 

"We have noticed a consistent trend in Bridgeport. Our work, to change how people donate items to soup kitchens and food pantries, is improving the health of people we screen" - stated Marilyn Faber, Co-chairperson for PCAG’s Cardiovascular Disease and Diabetes Task Force. 

Healthy foods including fresh fruit and vegetables and whole grains are now becoming more available. Fruit-infused water has started to replace sugary drinks and brown rice and whole grain pastas are now being offered at local soup kitchens. The availability of more wholesome foods can start to empower individuals to overcome significant obstacles to healthier living. According to Petreycik, this initiative is "influencing what foods are served at local pantries."

The KYN team is working hard to create a system of care for people who are food insecure. The program offers nutrition education and referrals to providers to prevent or manage diabetes, high blood pressure, strokes and heart attacks. 

Enhancements Over the Years

Data: 2018 KYN

The results of the health data we collected supported the need for healthier food options and food education for patients to help them achieve improved health. We found that of the 458 screened, 18 percent were a known diabetic. Upon screening their HbA1c (a test that measures an average blood glucose over a 3 month period of time) 78 percent were found to have uncontrolled diabetes. An additional 56 participants were found to have pre-diabetes. In total, 30 percent of the total participants were either diabetic or pre-diabetic. 

Since we only screened HbA1c on those with diabetes or a known risk factor, the chances are high that many more were also pre-diabetic and do not know it.

• 62% were considered overweight or obese
  
• 15% of participants fell in the Hypertension Stage 1 category
  
• 24% of participants fell in the Hypertension Stage 2 category
  
• 26% had high cholesterol
  
• 25% of participants indicated that their diet was fair or poor
• 38% of participants indicated that they rely on food pantries two or more times per month