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Advisory Council July 2017 Meeting Presentation: CommunityRx for Community-Residing People

Friday, July 28, 2017

Printer Friendly Version in PDF Format (7 PDF pages)


CommunityRx for Community-Residing People with Dementia and Their Caregivers

Stacy Tessler Lindau, MD, MAPP
Professor, Ob/Gyn and Medicine-Geriatrics
The University of Chicago


  • The CommunityRx project described was supported in part by Grant Number 1C1CMS330997-01-00 (Lindau, PI) from the Department of Health and Human Services, Centers for Medicare & Medicaid Services and by a Technical Assistance Grant from the New York State Health Foundation. It is currently supported by Grant Number 1R01 AG 047869-01 (Lindau, PI) and Grant Number 3R01 AG 047869-03S1 from the National Institutes of Health/ National Institute of Aging, and Grant Number HS 023921-01 (A Kho, PI) from the Agency for Healthcare Research and Quality.
  • The contents of this presentation are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.
  • Under the terms of the CMS funding opportunity, we were expected to develop a sustainable business model which will continue and support the model that we tested after award funding ends.
  • Dr. Stacy Lindau is the founder and owner of a social impact company NowPow, LLC and president of MAPSCorps, 501( c ) (3). Neither NowPow, LLC nor MAPSCorps, 501 ( c ) (3) is supported through CMS or other federal funding.
  • Neither the University nor UCM is endorsing or promoting any NowPow/MAPSCorps Entity or its business, products, or services.


Timeline and communication between agencies and methods.

Calling All Innovators -- Health Care Innovation Challenge*

Three-Part Aim (#1-3)

  1. Better Health
  2. Better Health Care
  3. Lower Costs
  4. Workforce of the future
  5. Sustainable business model

Especially interested in ideas that: impact the underserved, address health disparities, reduce the effect of multiple co-morbidities, and/or modify of risk factors



    • 288 local youth employed to generated data for 19,589 places
  • 37condition algorithms linked
  • 3 EMR platforms to CommunityRx database at 33 health care sites
  • >113K participants received
  • >253K personalized HealtheRx
  • >7,000 community resources
  • 19% went to community resource found on HealtheRx
  • 49% told someone else about HealtheRx
  • Businesses and organizations serving the community have more demand

CommunityRx: A Population Health Improvement Innovation That Connects Clinics To Communities

  • 16 ZIP codes
  • 106 mi2
  • 993,812 people
    • 58% < 200% FPL
  • >113K participants*
    • 49% 18-64 yrs
    • 64% Female
    • 84% Black
    • 6% Hispanic or Latino
    • 66% Public insurance
    • 24% Private insurance
  • EMR integrations
    • Epic, GE Centricity, NextGen
Chicago Map showing CommunityRX sites.
SOURCE Authors' analysis of data for months 9-35 from the CommunityRx database and of population data for 2010-14 from the American Community Survey. NOTE *We defined participants as individuals for whom at least one HealtheRx was generated


Appendix Exhibit 3. CommunityRx algorithms generated personalized referrals to community resources for basic, wellness, disease self-management and caregiving needs*
Health and wellness conditions Study month of algorithm release HealtheRxs generated for algorithm, months 9-36, number (%) HealtheRxs generated for algorithm, months 30-35, number (%)
Allergic rhinitis 28 11,930 (4.7) 10,075 (8.5)
Alzheimer's/dementia 28 1,931 (0.8) 1,583 (1.3)
Anemia 28 12,195 (4.8) 10,352 (8.7)
Attention deficit hyperactivity disordera 24 1,696 (0.7) 1,023 (0.9)
   <18 years old 28 980 (0.4) 817 (0.7)
   18 years or older 28 249 (0.1) 206 (0.2)
Asthmaa 15 38,497 (15.2) 17,499 (14.8)
   <15 years old 28 6,113 (2.4) 5,049 (4.3)
   15 years or older 28 14,419 (5.7) 12,167 (10.3)
Arthritis/back pain 24 33,962 (13.4) 21,659 (18.3)
Breast/genecologic cancer 28 2,377 (0.9) 1,941 (1.6)
Breast/genecologic cancer survivorship 24 851 (0.3) 529 (0.5)
Congestive heart failure 24 1,389 (0.6) 869 (0.7)
Chronic obstructive pulmonary disease 24 4,576 (1.8) 2,755 (2.3)
* partial reprint of article table.

Geographic distribution of unmet caregiver needs on the South Side of Chicago

Geographic distribution of unmet caregiver needs on the South Side of Chicago.


"..My buddy was telling me, eventually I will probably have to find a place for her to go full-time. And he said, he told me I need to start saving my money because healthcare is not gonna pay for it, for the full-time care. It's kinda like you gonna have to pay out of your pocket or whatever. So, I haven't looked into that yet..."

"I was going to...line dancing class. Line dancing class! That's lovely. And lots of people do line dancing. But I had to stop that too because I couldn't keep it up... But I'd say fitness classes, line dancing classes. A lot of seniors, especially African American, they do that. They go out line dancing. Yeah."

CommunityRx Agent Based Model

Shows the interactions between Health Provider Referral Network, Patient Social Network, Healthcare Provider, HealtheRx, Patient, Community Health Worker and CommunityRx Resource Referral Network.

Prototype, using fictional data, of CommunityRx forecasting dashboard

Prototype, using fictional data, of CommunityRx forecasting dashboard screen shot.

Policy Implications for NAPA Goal #3: Expand services and supports for PWD and families

  • Intensive caring for caregivers: Hyperlocal (geographically and culturally), ongoing, escalating, with special concern for higher poverty communities
  • Proactive transparency by community-based programs/services that receive government or tax-deductible funding
  • Sustainability: Incentivize business owners, governments and CBOs to provide on-site support for PWD


  • Lindau Lab
    • Emily Abamsohn, MPH
    • Kelly Boyd
    • Monica Christmas, MD
    • Megan DePumpo, AM
    • Mahalia Dalmage
    • Leilani Douglas
    • Gillian Feldmeth
    • Natalia Gavrilova, PhD
    • Jessica Jerome, PhD
    • Jennifer Makelarski, PhD, MPH
    • Chenab Navalkha
    • Kelsey Paradise
    • Jerlinda Ross, MD, MS
  • Current collaborators
    • David Beiser, MD, MS
    • Tia Kostas, MD
    • Chia-Hung Chou, PhD
    • Elbert Huang, MD, MPH
    • Abel Kho, MD
    • Charles Macal, PhD
    • Jonathan Ozik, PhD
    • Elizabeth Tung, MD

July 28, 2017 -- Advisory Council Meeting #25

The meeting was held on Friday, January 26, 2018, in Washington, DC. The Research Subcommittee took charge of this meeting's theme, focusing on the process from targets to treatments. The Council heard speakers on the preclinical pipeline, the clinical trial pipeline, and the industry perspective. The meeting also included discussion of a driver diagram to guide the Council's future work, updates and a report from the October Care Summit, and federal workgroup updates. Material available from this meeting is listed below and is also available at

Comments and questions, or alerts to broken links, should be sent to


General Information


Presentation Slides



  • Welcome thru Clinical Care -- [Video]

  • LTSS Research -- [Video]

  • Public Comments thru Federal Workgroup Updates -- [Video]

  • Recommendations thru Adjourn -- [Video]