Southern Sector Health Initiative

Southern Sector Health Initiative (SSHI) operates under its dba name, the Baylor Scott & White Health and Wellness Center at Juanita J Craft Recreation Center (BSW HWC), formerly known as the Diabetes Health and Wellness Institute at the Juanita J. Craft Recreation Center. BSW HWC is located in southern Dallas and serves a population comprising 60% African-Americans and 40% Hispanics. SSHI is organized to improve care for people with chronic conditions, including diabetes, by operating a new care model focused on clinical care, education and wellness in South Dallas. The Center, a public-private partnership between Baylor Scott & White Health and the City of Dallas, took on the challenge of the alarming growth rate of diabetes in the southern sector. The strategy included addressing the social and physical determinants that affect population health, and the removal or reduction of various barriers to health improvements in this community. Building an atmosphere of inclusion, fostering trust, credibility, culture, adaptability, and commitment was needed to accomplish this task. SSHI is affiliated with Baylor Scott & White Health (BSWH), a faith-based nationally acclaimed network of acute care hospitals and related health care entities providing quality patient care, medical education, medical research and other community services to the residents of North and Central Texas. As the largest not-for-profit health care system in Texas and one of the largest in the United States, BSWH was born from the 2013 combination of Baylor Health Care System and Scott & White Healthcare. Today, BSWH has over 1,250 patient access points including 51 hospitals, 612 specialty care clinics, 261 outpatient clinics, 160 primary care clinics, 30 pharmacies, 31 ambulatory surgery centers, and more than 7,100 active physicians. The system also includes a state certified health maintenance organization, the Scott and White Health Plan and the Baylor Scott & White Quality Alliance accountable care organization both covering over 1,200,000 lives.As stated in its Mission Statement "Founded as a Christian Ministry of healing, Baylor Scott & White Health promotes the well-being of all individuals, families and communities. The Ambition Statement is "to be the trusted leader, educator, and innovator in value-based care delivery, customer experience and affordability". The BSWH vision is: "To be the most trusted name in giving and receiving safe, quality, compassionate healthcare."The initial vision statement of BSW HWC, laid the foundation for shaping a care model fulfilling the mission - "improving the lives of people with diabetes by creating a new care model focused on health care, education and research". The platform to achieve the vision required forward-thinking leaders whose adherence to the stated vision and careful selection of a Board of Trustees set BSW HWC on a course to create a diabetes 'Center of Excellence' for the southern sector Dallas community. Core Principles for this new model of care included: 1) Trust: To build a foundation of trust with community members and community organizations, 2) Partners: To work alongside community organizations and residents of south Dallas as collaborative partners together in developing programs and services, 3) Empowerment: To develop programs and services that enable residents to have better control of their health and their health outcomes so that healthy behaviors are woven into the fabric of the community, 4) Support: To provide preventative and health management resources to help the community to grow healthier and get better, 5) Culture: To consider and seek to understand the culture of the community addressing their health and wellness needs, and 6) Access: To provide access to clinical care, preventive health and wellness programs.The success of BSW HWC was insured through the infusion of the voice of the community, a voice crucial to the acceptance and success of the programs and services developed to achieve the vision. The voice of the community is incorporated by key stakeholders via the Centers' Ministerial Advisory Board (MAB) and Community Advisory Board (CAB), which where both established at inception of the facility. The collective advisory board members, community collaborative partners, non- profit and faith-based organizations that have engaged with the center now comprises of over 145 organizations.BSW HWC's integrative care model includes an on-site physician and nurse practitioner, visiting medical specialists, referral coordinators for specialty and ancillary care, diabetes management educators, access to affordable chronic disease and diabetes medications, nutrition and healthy cooking classes and physical activity programs including aerobics, walking clinics and weight training. One analysis (of a five-year study) showed a 21% reduction in emergency room use among a sample of BSW HWC members using a pre/post-enrollment comparison. A 37% reduction was shown for inpatient visits among a sample of BSW HWC members using the same pre/post-enrollment comparison and the data was published in Health Affairs. This publication set a precedent for continued best practices around the BCW HWC model of care that promotes access to care, nutrition and physical activity as prevention and empowerment strategies to ensure health improvements over time. The BSW HWC enlists the assistance of Community Health Workers (CHW), also known as Diabetes PEERS (Prevention, Empowerment, Education, Resources, Support). These trained community members act as mediators between health care, social services and the community to assist with outreach, patient navigation/follow-up, community health education/information, informal counseling, social support, advocacy and participation in clinical research. The Diabetes PEERS program allows the BSW HWC to tackle the myths about chronic diseases including diabetes and provides education and support in the prevention and management of chronic disease in high-risk communities. BSW HWC provides 160 hours of fee-based CHW and Instructor training and CHW Continuing Education Units (CEUs) certified by the State of Texas and approved by the Texas Department of State Health Services.In 2023, BSW HWC Farm Stands also had 2,322 encounters offering pre-bagged produce items as well as healthy recipes with tasting samples to patrons with the goal of promoting healthy cooking and eating at home. Membership growth continues, and the efforts have paid huge dividends for this underserved population, with more than 9,364 members. BSW HWC increased its impact in the community, where its cumulative outreach encounters reached 198,797. The BSW HWC Research outreach team also completed 1,314 preventative health screenings in the community to help support on their health journey.BSW HWC is among the few programs in Texas fully recognized by the Centers for Disease Control for its Diabetes Prevention Programs which received a five year (2023-2028) CDC Full Plus Recognition and recognized among top Community Health Worker (CHW) Training Programs in the DFW Metroplex, with state certification, graduating over 640 students. In addition to this recognition, national and local awards include: the Healthcare Leadership Council's Wellness Frontiers Award for its public-private partnership with the City of Dallas; the American Hospital Associations' Nova Award for community-based innovation; and the D CEO Magazines' Excellence in Healthcare Achievement in Community Outreach, Achievement in Wellness Programs and finalist for Outstanding Healthcare Collaboration; The Morehouse School of Medicine, National Center for Primary Care Partnership for Diabetes Health Equity Award. Recently, the center has received American Heart Association Awards for 2023 Target: BP Gold Plus Status; Check. Change. Control. 2023 Cholesterol Gold Plus; Target: Type 2 Diabetes 2023 Gold Plus Status. BSW HWC has established itself as an incubator for population health with a goal to improve the health of the city one person, one family, and one community at a time.