1. • To assess social determinants of those
enrolled in the Wealth From Health
program, reduce potential barriers and
optimize the care coordination process.
• Identify patient social barriers by
examining data and factors
• Provide information about the
community and help to improve
population health
• Utilization of partnerships with
community vendors to reduce potential
barriers and optimize the care
coordination process.
• Addressing social determinants of health
is a primary approach in order to achieve
health equity.
• Hudson county: 22.4% of the population
is without health insurance, 9.1% is
unemployed, and 23% of adults report
fair or poor health (CDC)
• Of the 500 patients, 88.1% lack financial
resources
● Future plans include conducting a
Risk Stratification Assessment every
six months for a patient
● The outcomes of the health
assessment will be reviewed on an
on-going basis in order to determine
ways to improve intervention
methods.
● Pre and post tests will be completed
by members as well as an overall
review from patients will be
requested.
I would like to thank my preceptor
Kwaku Gyekye and Tamara Swedberg
for their guidance, skills, and knowledge
acquired throughout this internship.
Purpose
Significance
Methodology Outcomes
Evaluation
Acknowledgements
Wealth
From Health
•Patient Navigators
•Establish patient
history
Risk
Assessment
Evaluation
•Information about
sufficient/insuffici
ent resources
collected
•Determination of
social barriers
Providing
Resources
•Working with
partnered vendors
in the region
•Support/Educatio
nal services to
mitigate/eliminate
barriers
Review of Social Determinants and
Linkage to Available Services
Stephanie Thomas
Kwaku Gyekye, ACO Director
Jersey City Medical Center
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Social Determinants of Health
19%
53% 56%
44%
81%
47%
Wealth
From
Health