Ruth Perry MD

I was the Executive Director a community health improvement organization that became a Medicaid Accountable Care Organization. The organization was a start up and I was the first and only employee. Over 4.5 years I grew the organization from one employee to 16 employees and secured 12M to fund the organization. Many of the residents of the city had poor health outcomes, lacked insurance and access to primary care, utilized the emergency room and the hospitals for conditions that should have been managed by a primary care physician.

Most of these issues were related to chronic conditions such as Diabetes Mellitus, Cardiovascular Disease, Obesity and were identified as problems in many past community health needs assessments. We developed 5 strategic objectives to address these issues by expanding access to care, building a health information exchange, developing a unique methodology to conduct community health needs assessments and creating a care management team to assist individuals who were high utilizers of emergency department and hospital in-patient services for medical conditions that were better addressed in a primary care setting.

As part of our Community Health Improvement Plan we worked with a small group of 15 patients in a high-rise housing complex within the city as a pilot to address several challenges highlighted in our 2013 community health needs assessment. This group of 15 patients formed a team because they were interested in improving their health and working with other residents in the complex who wanted to improve their health. Most of the patients were obese, with high blood pressure and diabetes, with very low levels of health literacy.

We met with the team weekly and developed a comprehensive health literacy training guide, with pre and post tests and focused on how to make healthy choices and other small behavioral changes. We also held healthy cooking demonstrations. At the end of each weekly session we would take blood pressure measurements, weights and Body Mass Indexes for the 15 participants. Over the extent of the program all program participants improved their weight, and blood pressure and learned how to prepare healthy food. Several of the participants worked with others within the high-rise complex to improve their health and became public speakers and advocates for health improvement and expanding Medicaid.

The program was professionally and personally satisfying and generated several key findings. The most important learning was that the model worked and the program was a mini success! We were able to see the value of small group learning and that it can really deliver improved health outcomes and empower individuals to become health advocates and change agents.

There were several critical success factors that led to the success of this program. We partnered with the housing complex leadership and a community organizer who was already working there to achieve buy-in. We were able to build trust by meeting with the participants weekly and they could even call our nurse practitioner if they had concerns between the weekly sessions. Over the course of the program we really got to know each of the participants and saw them as concerned, compassionate and talented people, contrary to commonly held stereotypes regarding people who live in certain areas of the community. Appreciating them as people and realizing that many were hungry for change and giving them the tools to make changes created a paradigm shift for them as well as the health care delivery system. Providing them with the opportunity to speak at public forums reinforced their commitment to change and encourage others to do the same.


Initiatives such as this require a sustaining funding model in order to transmit, replicate, and rapidly scale the program. This area of health is ripe for a disruptive innovation model to integrate education, behavior change, support, and sense of community that is financially self-sustaining and scalable.


by Ruth Perry MD

A few years ago I was involved in the case of David Doe (not his real name), a patient who was referred by the hospital emergency department (ED) to a care management team in a low-income urban community in New Jersey. David was a homeless man who’d been living in an emergency shelter for three years with insulin-dependent diabetes, blindness, and chronically low sodium levels. The team consisted of a nurse case manager, a social worker, and two community health workers. Through the intervention of the social worker, Medicaid was willing to pay for an assisted living to provide him shelter and receive care because he was unable to care for himself due to his blindness.

Because of David’s multiple disorders, his management was complicated and he fell into a cycle of bouncing between the ED and his assisted living facility. During one particularly difficult weekend, David was brought to the ED three times for low sodium. Only after the nurse case manager and I spoke to his treating physicians at the hospital and nursing home were we able to determine the cause of all his ailments and placed him on appropriate medication to treat his low sodium.

While in the assisted living facility, the care management team continued to work with him, arranging an appointment with an ophthalmologist who determined that his blindness was due to cataracts, which were corrected with surgery. With his vision restored and his medical conditions managed, John was able to find stable housing, was linked to primary care, and is currently living independently.

He had no further ED visits.

Here is an extraordinary case where the application of team-based chronic care management (CCM) was able not just to help a patient get healthy, but to take control of his life again. Additionally, David’s story also highlights the importance of the social determinants of health in overall health and wellbeing This case also highlights the importance of the social determinants of health and in particular, the importance of housing. In many cases, housing is medicine.

This is not an isolated incident; countless others have had their lives restored by using a team-based approach to look critically at the source of a patient’s ailments, instead of seeing only the symptoms.