Integrated Community Health

Mission

To achieve equity in health care access and outcomes for underserved population through community based collaborative programs through Thomas Jefferson University Hospital’s Center for Urban Health, Jefferson’s community health clinics, and in partnership with numerous community-based organizations.

DFCM Research Team

  • Robert Motley, MD, MHCDS (Lead)
  • Lara C. Weinstein, MD, DrPH, MPH
  • Rickie Brawer, PhD, MPH, MCHES
  • Krys Foster, MD, MPH
  • James Plumb, MD, MPH

Goals

  • To integrate health care in a low-income, high-risk population, through the combination of community-based health care  linked with community partnerships  addressing socioeconomic determinants of health (including housing, zoning and access to healthy / affordable food).
  • To integrate principles of community engagement and participation in the overall health care system.
  • To conduct health services research from different perspectives such as  strengthening community action plans, cost effectiveness analysis, and mixed method evaluation focused on components of the expanded chronic care model (ECCM).
  • To build public advocacy to address the impact of social determinants on health equity.

Recent Projects

  • Examination of Organizational Factors Affecting the Implementation of Medically Assisted Treatment at Project HOME Health Services (Funder: Barra Foundation)
  • Opioid Use Disorder Center of Excellence (Funder: Pennsylvania Department of Human Services)
  • Moving beyond lifestyle factors: exploring the influence of social determinants of health in weight loss attempts in people with serious mental illness (Funder: Diabetes Education and Research Center)
  • Evaluation of the Healthy Eating Initiative pilot of the Norris Square Community Alliance Head Start program (funding Kellogg Foundation)
  • Evaluation of the South Philadelphia Prevention Coalition (funding SAMSHA)
  • Assessment of a Food Buying Club in Reducing Childhood Obesity in day care centers (Kynett funded)
  • Assessing the need for a Medical Legal Partnership in DFCM
  • Achieving Patient Centered Medical Home Attributes in Hypertension Care
  • Addressing the Legal Need of Refugee Health Partners' Patient Population: Creating a Road-map for Establishing a Medical-Legal Partnership Career Support Network
  • Community-Based Diabetes Self- Management Education
  • Evaluation of a National Nursing Centers Consortium (NNCC) Nurse-led Medical Legal Partnership (N-MLP)(Funder: Kresge Foundation)
  • Integrating Cardiovascular Risk Reduction in Philadelphia Corner Stores(Funder: AstraZeneca HealthCare Foundation)
  • Mammogram Decision Support for Formerly Homeless Women with Serious Mental Illness (Funder: American Cancer Society)
  • Medical Street Outreach: Needs Assessment of People Experiencing Homelessness in Philadelphia
  • Peer-Led Healthy Lifestyle Program in Supportive Housing (Funder: National Institute of Mental Health)
  • Regional Enhancements Addressing Disconnects - in Cardiovascular Health Communication(Funder: Pennsylvania Department of Health)
  • Screening, Brief Intervention, and Referral to Treatment (SBIRT) Health Professions Student Training (Funder: SAMHSA)

Bernstein RS, Meurer LN, Plumb EJ, Jackson JL. Diabetes and hypertension prevalence in homeless adults in the United States: a systematic review and meta-analysis. Am J Public Health. 2015 Feb;105(2):e46-60.

Cabassa LJ, Stefancic A, O'Hara K, El-Bassel N, Lewis-Fernández R, Luchsinger JA, Gates L, Younge R, Wall M, Weinstein L, Palinkas LA. Peer-led healthy lifestyle program in supportive housing: study protocol for a randomized controlled trial. Trials. 2015 Sep 2;16:388.

Doherty ML, Owusu-Dabo E, Kantanka OS, Brawer RO, Plumb JD. Type 2 diabetes in a rapidly urbanizing region of Ghana, West Africa: a qualitative study of dietary preferences, knowledge and practices. BMC Public Health. 2014 Oct 14;14:1069.

White N, Brawer R, Plumb J. Using accreditation standards as a framework to evaluate and improve a community-based diabetes self-management education program. Popul Health Manag. 2014 Feb;17(1):8-12.

Matejkowski J1, Lee S, Henwood B, Lukens J, Weinstein LC. Perceptions of health intervene in the relationship between psychiatric symptoms and quality of life for individuals in supportive housing. J Behav Health Serv Res. 2013 Oct;40(4):469-75.

Toth-Capelli KM, Brawer R, Plumb J, Daskalakis C. Stage of change and other predictors of participant retention in a behavioral weight management program in primary care. Health Promot Pract. 2013 May;14(3):441-50.

Weinstein L, LaNoue M, Plumb J, King H, Stein B, Tsemberis S. A primary care-public health partnership addressing homelessness, serious mental illness, and health disparities. J Am Board Fam Med. 2013 May-Jun;26(3):279-87.

Henwood BF, Stanhope V, Brawer R, Weinstein LC, Lawson J, Stwords E, Crossan C. Addressing chronic disease within supportive housing programs. Prog Community Health Partnersh. 2013 Spring;7(1):67-75.

Weinstein LC, LaNoue MD, Collins E, Henwood B, Drake R. Health care integration for formerly homeless people with serious mental illness. J Dual Diagn. 2013;9(1):72-77.

Plumb JD, Weinstein LC, Scott KS, Brawer R. Community-based Partnerships for Improving Chronic Disease Management. Prim Care. 2012 Jun;39(2):433-47.White N, Brawer R, Plumb J, Harrod-Smith, P, Madison D. Evaluation of a community-based diabetes education program. Population Health Matters (Formerly Health Policy Newsletter): 2012: 25(3), Article 7.

Brawer R. Health Education & ACA: Stories Linking Clinical and Community Settings. American Public Health Association Annual Meeting, Chicago, Illinois, November 2015.

Plumb J, Brawer R.Healthy Corner Store Network “Heart Smarts” Program. American Public Health Association Annual Meeting, Chicago, Illinois, November 2015.

Soper A, Simon R, Weinstein L. Medical Street Outreach: Needs Assessment of People Experiencing Homelessness in Philadelphia. North American Primary Care Research Group Annual Meeting, Cancun, Mexico, October 2015.

Huliha J, Crawford A, Plumb J.Mass Incarceration and Infant Mortality in U.S. Counties. Reimagining Health in Cities: New Directions in Urban Health Research and Action, Philadelphia, PA, September 2015.

Plumb J, Brawer R. The Career Support Network: Integrating chronic disease prevention and management programs and occupational therapy into a workforce development program for low-skilled, low-resourced individuals. Reimagining Health in Cities: New Directions in Urban Health Research and Action, Philadelphia, PA, September 2015.

Brawer R. Updated CHNA Requirements/Overview of Best Practices. Population Health Colloquium, Philadelphia, PA, May 2015.

Hartman H, Geverd H, Daly E, Poulsen A, Yadlosky J, Weinstein M, Weinstein L. End of Life Decision Making in a Formerly Homeless Population. North American Primary Care Research Group Annual Meeting, New York, NY, November 2014.

Supanya-Flemming M, Strauss A, Rand S, Samohod M, Ziegler N, Modi A, Plumb J, Brawer R. Experiences with Prenatal Care Among Women in a Philadelphia Homeless Shelter.Jefferson AOA Student Research Symposium, Philadelphia, PA. March 2015; Society of Student Run Free Clinic Conference, Atlanta, GA. February 2015; 3rd Annual College within the College – Population Health (CwiC-PH) Poster Session, Philadelphia, PA, November 2014; Family Medicine Education Consortium Northeast Region Meeting, Arlington, VA, October 2014.

Gibbons G, Plumb J, Brawer R. Health Needs Assessment for Head Start Children. 3rd Annual College within the College Population Health (CwiC-PH) Poster Session, Philadelphia, PA, November 2014.

Chakrabati R, Brawer R, Chamberlin S. Design, Implementation and evaluation of a color-coded labeling intervention on vending machines at an Academic Health Center. Society for Public Health Education Annual Meeting, Washington DC, March 2014.

Hemba KE, Simon R, Weinstein LC. JFMA Street Outreach: A Resident-Run Street Medicine Program. North American Primary Care Research Group Annual Meeting, Ottawa, ON, Nov 2013.

Weinstein L, Hurley K, LaNoue M, Sifri R, Myers R. Exploring Barriers and Facilitators to Breast Cancer Screening in Formerly Homeless Women With Serious Mental Illness Through Concept Mapping. North American Primary Care Research Group (NAPCRG) Annual Meeting, Ottowa, Ontario, Canada. November 2013.

Weinstein L, Hurley K, Verma M, Davis T, Bailey J. Breast Cancer Screening and Prevention in Formerly Homeless Women With Serious Mental Illness: Perspectives Through Photovoice. North American Primary Care Research Group (NAPCRG) Annual Meeting, Ottowa, Ontario, Canada. November 2013.

Brawer R, Plumb J, Simmons R, Romney M - Training Health Educators to Serve as Catalysts to Enhance Health Literacy: Changing our Healthcare System and Educating Consumers. American Public Health Association (APHA) Annual Meeting, Boston, MA, October 2013.

Plumb E. An Assessment of Refugee Health Provider Perceptions of Refugee Mental Health Needs in Philadelphia. North American Refugee Health Conference, June 6-8, 2013, Toronto, Canada.

Plumb E. Community-Based Approaches to Refugee Health: the Philadelphia Refugee Mental Health Photovoice Project. North American Refugee Health Conference, June 6-8, 2013, Toronto, Canada.

Plumb E. Lutheran Children and Family Services, The Magic Garden, & Mural Arts Program: Forming Interdisciplinary, Cross-Institutional, Community-Based Refugee Health Programming. North American Refugee Health Conference, June 6-8, 2013, Toronto, Canada.

Plumb J, Brawer R, White N, Madison, Harrod-Smith P. The Job Opportunity Investment Network Education on Diabetes in Urban Populations (JOINED-UP) Project -JCIPE – Interprofessional Care for the 21st Century – Refining Education and Practice. Philadelphia, PA. May 2012.

White N, Harrod-Smith P, Madison D, Brawer R, Plumb JD. Evaluation of a Community Based Diabetes Self-Management Education Program. Jefferson Center for Interprofessional Care Meeting: Interprofessional Care for the 21st Century: Redefining Education and Practice. May 18, 2012. Philadelphia, PA.

Brawer R, Plumb J, Cornman-Levy D. Job Opportunity Investment Network Education on Diabetes in Urban Population. Delaware Health Sciences Association 3rd Annual Research Symposium. May 2012. Philadelphia, PA.

Brawer R, Plumb J, White N. Job Opportunity Investment Network Education on Diabetes in Urban Populations (JOINED-UP) Project. American Public Health Association Annual Meeting. October 31, 2011. Washington, DC.