Today, your zip code says too much about your health. Within the United States, there are unacceptable disparities in health by race and ethnic group, state-by-state and even county-by- county. The effort to make the U.S. the Healthiest Nation in One Generation starts with equity across our communities. Just last month a study was published naming the Bronx as the least healthiest county in our State. The Bronx ranked worst in the state for socioeconomic factors that affect health, such as unemployment, poverty, street crime and low education. Surprisingly, the Bronx ranked near the bottom in measures of clinical care – even though the health care industry is the biggest employer in the borough, with 11 hospitals and a multitude of clinics.

What this suggests is that disparities in care do not stop once a patient leaves the hospital. In fact, more than likely, it was disparities in the most basic necessities in the community that may have prompted the individual’s initial hospitalization. For example, 1 in 3 people who are hospitalized nationally enter the hospitals malnourished. Malnutrition often does not disappear in the hospital (hence the Alliance to Advance Patient Nutrition was created to address inadequate nutrition in hospitals), neither does it disappear when the patient returns to the community, unless there is a concerted effort to connect that person to adequate supports at home. Many care transition models, like Dr. Eric Coleman’s or ProjectRED, incorporate elements to address disparities in the home environment, but they are making their way only slowly into the medical model, and new programs that incorporate community-based resources do not support those resources within the model.

At God’s Love, we care for one of the highest risk populations in our City: those who are too sick to shop or cook for themselves. Not surprisingly, our highest service level last year was in the Bronx, with almost 315,000 meals delivered. Over the last 30 years, we have perfected techniques that make just the connections needed from medical care to the patient in the home. We are connected with almost 200 other community-based organizations and we follow up on every missed meal. We arrange to be there for a client when they return from the hospital, so they are supported at home. It is services like our program that make the difference in zip codes, and yet our vital services are not widely accepted as part of healthcare nationally, nor are they supported as part of healthcare reform. Thankfully, through innovations like the Delivery System Reform Incentive Payment model and Managed Care for All, New York State is making strides to address the zip code issue. Yet, we are one state among many. The word needs to spread.