Healthcare doesn't end when patients leave the hospital — and neither should the support they receive. In this conversation, Ryane Jackson, vice president of Community Health Network at Memorial Hermann Health System, explains how the system is creating seamless connections between clinical care and community resources to improve long-term health outcomes. Learn how these solutions are helping patients overcome barriers like food insecurity, housing instability and chronic disease.

Tom Haederle

Welcome to Advancing Health. Programs to transform and improve health outcomes can work well as standalones. But as we hear in this podcast, they make an even bigger difference by connecting clinical care with community based strategies to create a coordinated ecosystem.

Julia Resnick

In health care, there is no shortage of innovative programs, but scaling them into a coordinated, system wide approach is a different challenge entirely. I'm Julia Resnick, senior director of health outcomes and care transformation at the American Hospital Association, and this is the Advancing Health podcast. Today, I'm talking with Ryane Jackson, vice president, Community Health Network for Memorial Hermann Health System in Houston, about what it takes to move from strong individual programs to a truly coordinated, systemwide approach, one that centers community and the strategy, integrates social drivers of health and brings patients and partners into the work as co-designers. We'll explore how they're structuring teams and partnerships, measuring progress, and rethinking what care can look

Julia Resnick

like when it's built with and for the communities they serve. Ryane, thanks so much for being here with me today.

Ryane Jackson

Great. Happy to be here.

Julia Resnick

So I know that Memorial Hermann places a lot of emphasis on being community owned, including the community in every step of the strategy. Why is that so essential to your systems approach, and how does it really influence the way you think about care and delivery and community engagement?

Ryane Jackson

Yeah, that's a great question. And so just a little bit of background, I've been with Memorial Hermann now for soon to be two years. And you know what I think is really unique about being in this healthcare system is that we do tout ourselves as community owned. And I think that is critical, I'd say, to our approach. Community owned means that we're not just providing programming or programs or working to address their needs from the seat we sit in from a healthcare perspective.

Ryane Jackson

But we're letting the voice of our community, the voice of our experts in the community, actually guide and shape our strategy so that whatever it is that we are providing to them, whether it's financial investments, whether it's very strategic programing designed to address, you know, healthcare access disparities or economic disparities, we know that it is being built from the community's voice.

Ryane Jackson

And hopefully I answered your question. I know there was a second piece to that.

Julia Resnick

You did. And I want to get into that, like how you get community voice in that sense of ownership, like what are the mechanisms for engaging communities and hearing those voices and then translating them into programing?

Ryane Jackson

Awesome. So this won't be a surprise. You probably would get this answer from a lot of other healthcare systems in our country, but we do start from the place of our community health needs assessment. So we do conduct our assessment once every three years, and then we do annual refreshment of that assessment just to make sure that, you know, we're staying on top of the shifting landscape of our environment, especially in today's times.

Ryane Jackson

So the community health needs assessment for those who may not be familiar, but I imagine if they're listening to this podcast, they're very familiar just by default. But the community health needs assessment, really in order to produce one that is worth its weight in anything, you have to talk to the community. And so we really lean into the community survey aspect of the development of that CHNA.

Ryane Jackson

We distribute the survey electronically, but we also provide it in person. We've been able to really leverage our thoughtful community partnerships with local nonprofit organizations, and they've allowed us to physically come in with our community health workers, with some of our own employees who may be nurses or sitting in other roles across the system. We're asking people things not only how old are you and what zip code do you live in, but we're wanting to understand your household income, you know, have you, you know, in the last few months not been able to afford your food?

Ryane Jackson

What are you worried about? We're asking about mental health. We've even have asked about have you given birth recently and were there complications? So I say all that to say, the survey is very detailed and really gives us a strong picture. Then from the community voice perspective, when I talked about that, in addition to the survey, we bring in those public health and leaders of these organizations to weigh in as well.

Ryane Jackson

They are what we consider from a healthcare system perspective, frontline. Healthcare is the front line, right? They think of us for the front line. But these nonprofit organizations who are working directly with our community, especially those who are most vulnerable, they are the front line. So listening to the experts leading those organizations also complements that individualized, authentic voice for getting through the survey and help shape, you know, where we're going to go for the next three years and beyond.

Julia Resnick

That's great. And so I imagine as you're coming up with your priorities from your CHNA, a lot of those health needs are parallel to the health needs that are seen in the clinical side. So how do you think about connecting clinical strategies around those with community strategies to really maximize the impact that your work can have?

Ryane Jackson

Great question. So going back to the voice of the community, and then I'll show you how it links back to our clinical approach to the work. You know, in that community survey, in those interviews, you know we're learning also, you know, what are some of the healthcare conditions that you have been diagnosed with that you are dealing with currently?

Ryane Jackson

And then we match that up with secondary data that helps us determine. It looks like a lot of our community are dealing with obesity, which is a major, major issue in the country, but definitely here in Houston as well. We're one of the cities that definitely is not known for walkability compared to some of the other cities, I mean, you cannot get anywhere, barely anywhere without a car.

Ryane Jackson

So if you're dealing with obesity and we're also learning that people are dealing with diabetes and heart conditions. We then crosswalk that to see, well, how is that translating in our hospital walls? Some people don't like when we talk about this, especially in the space of community health and community benefit, where we often like to lean into, we want to help the most vulnerable, which we do, but there is a clinical and a operations aspect to it.

Ryane Jackson

So we crosswalk what the community has said from a healthcare perspective: we're diabetic, obesity, mental health issues, and we try to see are we seeing the same type of conditions in our hospital walls, starting with our E.R.? Because I think most people can agree, one of the most utilized aspects of a healthcare system is their emergency department or their emergency room.

Ryane Jackson

We look to see, are we seeing a lot of people coming in for these similar or related conditions? How does that translate to our readmission rates? Are they coming in for things that we think are preventable or could be managed, you know, outside of the E.R. setting, or are they coming in for very serious things that, you know, by nature of the condition, there's not very much you can do about it.

Ryane Jackson

Like, you know, I think about, like, cancer, you know, and a few other things. When we're able to validate or if we're able to validate that, what we're seeing in our hospital data also corresponds with what the community is saying they're dealing with, and then all the surrounding, what we call non-medical factors. When you match it up with all the non-medical drivers, you know, it helps us tell the full story and helps us determine where we actually want to focus our resources.

Ryane Jackson

And those resources come in a variety of ways: financial resources, programmatic resources, among other things.

Julia Resnick

So what are those priorities that you're focusing on?

Ryane Jackson

So from us being able to crosswalk, you know, what we're seeing within our hospital walls and specifically looking at our ER data, our readmissions, and coupling it with our findings from our community health needs assessment, the voice of the community - we actually have determined that we have the greatest opportunity to improve outcomes related to five key disease states. Hypertension, obesity, diabetes, cardiovascular disease, and then maternal and infant health related conditions.

Julia Resnick

So you have these priorities. They impact your community health programing. How do you connect them with the clinical programing? Because like you could be doing the best work in the world in diabetes in the community, but if they're not getting clinical care, they'll deteriorate and vice versa. They could be getting great diabetes care, but if they don't have access to healthy food, there's nowhere to walk, like they don't have the environment to make them healthy.

Julia Resnick

It's only half of the puzzle. How do you really like connect those two sides together? Because I think a lot of health systems struggle with that.

Ryane Jackson

That's a great question. So, you know, it's always a work in progress.

Ryane Jackson

But I think that we're

Ryane Jackson

doing and we're making

Ryane Jackson

some really good strides, I'd say, in

Ryane Jackson

creating what

Ryane Jackson

I like to call this ecosystem of care. So Memorial Hermann, I'd say we're somewhat unique in our approach to trying to do exactly that. How do you address and prevent some of the chronic conditions that we're seeing in our community, while also addressing some of those non-medical drivers that may have actually led to those conditions coming about? And so I'd say our approach is 2 to 3 layers of it.

Ryane Jackson

One, we really lean into screening for non-medical drivers of health. We have more than 40 to almost 50 community health workers across the community health division, who are strategically placed throughout our traditional community benefit programing. But more recently, we have created a community health worker hub, which acts essentially as a form of air traffic control, but also a safety net to ensure that every single patient who walks through our hospital doors is screened for at least one non-medical driver of health. Something, or I'd say, a misconception for some people when it comes to non-medical drivers or social drivers

Ryane Jackson

Ryane Jackson

One, as I said, every patient who enters our hospital, we want to make sure is screened for at least one non-medical driver. If they are discharged from our hospital before our community health workers can get to them to do that screening - because they're the ones who do it. In the E.R. setting and inpatient - that patient receives a follow up call from our community health workers that are positioned in this hub.

Ryane Jackson

That one, hope your stay was good, which I know is weird for hospital, but also we're doing it so we can capture those non-medical drivers. Specifically, we lean into asking questions about food, housing, utility assistance, transportation, and then after those four, it just really depends on the direction the conversation goes. So that won't be new for anybody in the space.

Ryane Jackson

So we capture the non-medical drivers on that side. And then of course we're doing it directly when in front of the patient. So first, once we understand what is negatively impacting our patients from that regard, we then are able to make the appropriate referrals. Sometimes those referrals go out to external nonprofit organizations who are best equipped to address things like food insecurity or housing based on where the patient lives.

Ryane Jackson

But where I think Memorial Hermann gets unique is we have a lot of our own in-house programing that we're able to refer these patients to. You will probably hear often with different health care systems they're screening and then they're referring them out to nonprofits. And we want to reduce readmissions. So you got to get them out your hospital and get them locked in somewhere else.

Ryane Jackson

That is not our approach. We genuinely, authentically are trying to help get them established in the best place possible. So we will refer them out to other organizations who have the ability to serve them in their community. But what I like about our system is that we have charity clinics that we operate. So sometimes those referrals, especially if it's an uninsured or Medicaid patient, that referral will go right there to our neighborhood health centers, which are charitable clinics that cater to that population, where we can provide not only primary care but have started to expand to provide more specialty care.

Ryane Jackson

Very recently, we just hired our very first endocrinologist, speaking about diabetes, who's dedicated to our neighborhood health centers. And so that is our approach to making sure that we can truly provide that diabetic care in-house for these patients, and then layering on the non-medical driver piece that we also have already come to understand that they are food insecure.

Ryane Jackson

We also operate in-house food pantries. We have what we call community resource centers. Their whole focus is addressing those non-medical drivers that we uncover in our populations. They can do anything from helping people sign up for SNAP, which our CHWs will sit there with them in person or telephonically and help them fill out that application and get it submitted

Ryane Jackson

because it can be a complicated process. Language barriers can sometimes be an issue, so our CHWs come into play there. All the things. We help them sign up for Medicaid if we determine that they're eligible for Medicaid, and they just haven't taken the steps to sign up or didn't know they were eligible. Utility assistance. But then also within our community resource centers, in addition to those eligibility applications, we have food pantries.

Ryane Jackson

So when our patients are screened as food insecure and need emergency food, we have the ability to right there in our pantry address that need. If they're housing unstable, we have the ability to get them do a warm connection to the organizations in our community who can help address those things. Beyond the community resource centers which are our main mecca, you know, of addressing non-medical drivers in our CHW hub

Ryane Jackson

that's uncovering them. As I said, we've had our neighborhood health centers that creates that clinical care piece. And then I want to take it back to our other priority area I mentioned. So diabetes is one. And then our NHC address hypertension and the others.

Julia Resnick

Yeah you have so much incredible work going on that is so mindful about like making those connections and making care available where people are so they can get the services they need to be healthy. I know this is complex and long term work, and it's not going to solve all of the issues today or tomorrow. But as you're looking towards the future, like where do you see this going and what would Houston look like in five years if this work was having the impact you wanted it to?

Ryane Jackson

It's hard to predict where we're going. I can tell you where I would love for us to be. And it's, you know, from a healthcare system perspective, all these things that I've talked about is truly a ecosystem where somebody comes in our hospital, we understand their non-medical driver needs, and then we're plugging them into their medical home at our neighborhood health center.

Ryane Jackson

And then we learn that they're food insecure. So we get them locked into our food support programing, and then we figure out that they are unemployed. So then we link them into our workforce development efforts, which are also part of our investment. Like somebody who we can fully wrap around with the approach that we're taking from an economic side all the way to the direct care side, and then seeing that patient or person ultimately thrive.

Ryane Jackson

And then hospitals' language, you say then, hey, and they didn't readmit, you know, you always take it back to that. The other part of me, though, where I would like to see things go, at least in this community, and I don't know fully what it's like in other communities, is I would like to see these large employers here in Houston, not just healthcare systems, but energy companies, higher education colleges, universities, oil and gas, which is very big here in Houston, hospitality, all these major employers in Houston, we are a major hub for business.

Ryane Jackson

All of us coming together in recognizing that we all have a piece or a role to play in this. There are people who are utility, you know, or electricity insecure. They can't afford their electric bill and that has health implications. So you have those major utility and energy companies saying, okay, well, we're going to own this piece in collaboration with you so that we're not operating in a silo, but we're linking everything back to what the health care system is doing.

Ryane Jackson

And then the universities are saying, we're going to own this education piece, and we're all working truly as a network. And I know that sounds very idealistic. It can be done. It's a collective social corporate agreement that everybody has to come to, and everyone's going to own a piece of it, rather than what I think we are starting to see, which can work too.

Ryane Jackson

But we're starting to see, you know, different bodies try to take on all aspects. Like everything I described here in healthcare, it is our responsibility because we care about the health, like we are a healthcare system. We need people to be healthy, and if that means we have to help people with transportation, we're going to help on transportation.

Ryane Jackson

If it means we're going to have to invest in affordable housing, we're going to do that. But if you step back, I believe this is our responsibility. But how much more effective could this work be if HUD said we have a agreement with the TMC, Texas Medical Center facilities and so healthcare systems, when you uncover somebody's housing insecure, we have a fast pass process to get that patient or that person, you know what they need.

Ryane Jackson

I'm still working it out in a more succinct way to say it, but I would just say just this corporate convening where we all own our piece while working under the same objective and outcomes reporting to actually transform. We all have enough funding, you know, on some level to do something amazing. So that's my idealism on full display.

Julia Resnick

I think the thread from all of these answers that it's all about the ecosystem. It's not just one program within the world of things that contribute to health. There are healthcare systems, there are social service agencies, there are community based organizations. There are other companies. Everyone has a part to play in creating healthier communities. So we're going to check back with you in five years and see how things are going.

Ryane Jackson

Yeah, ask me in five years.

Julia Resnick

Perfect. Well, thank you so much, Ryane. This has been fantastic and we look forward to hearing how this work continues to evolve and grow to serve the communities in Houston.

Ryane Jackson

Awesome. Thank you so much for having me. I always like talking about all the work we're doing in our healthcare system. My passion, you know, for helping. And I will continue to push my ideal vision of this massive convening where we don't just talk about it because that's very common in our space, but we're actually acting on it.

Julia Resnick

Love it. Thanks so much.

Ryane Jackson

Thank you.

Tom Haederle

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