While much of our focus at Shore Regional Health is on our inpatient care programs, I am increasingly impressed by the accomplishments of our Population Health Department — our case managers, transitional nurse navigators, Shore Community Outreach team and transitional care pharmacists. Working in collaboration with primary and specialty care providers throughout the region, these health care professionals have made significant progress in the past year toward our goal of helping people with chronic diseases manage their conditions to maintain optimal health outside the walls of our hospitals and emergency departments. Some highlights:
- Community Case Management (Shore Community Outreach Team) – This team enrolled 115 patients and conducted 920 home visits in Kent County. After six months, 75 patients identified as “high utilizers” realized an average decrease in health care charges of $5,919 per patient.
- Medication Management – Visiting 10 senior centers throughout the five-county region every month, our transitional care pharmacist provided more than 500 consults to 1500 participants, and additionally responded to more than 1200 medication alerts.
- Transitional Nurse Navigators (TNNs) – Follow-up phone calls and home visits made by TNNs reached more than 20,000 patients and resolved more than 3,500 alerts – 75 percent within 3 days. They also followed 649 patients, many of whom ultimately transferred into support programs for those with heart failure, COPD and diabetes.
- Heart Failure and Diabetes Continuums – 182 patients were enrolled in the HF Continuum, which includes acute care, cardiac rehab, rehab, cardiology and follow-up by the TNNs. In the Diabetes Continuum, inpatients with HgA1c greater than 9 were identified, provided a consult with a diabetes educator, and at discharge, referred to our Diabetes and Endocrinology Center. Patients retested six months later realized a 10 percent or more reduction in their HgA1c.
- Health Equity – Population Health team members provided on-site screenings and education at Amick Farms and Angelica Nurseries – employers with a high percentage of employees from underserved populations – focusing on diabetes and heat-related illnesses. In Kent County, SCOT has worked with local church leaders to establish the African-American Women’s Advisory Committee, which is offering health-related educational program targeted to the African American community.
- Advance Directives – Team members have partnered with local providers, senior centers, retirement communities and residential care facilities in an ongoing campaign encouraging people to complete their advance directives and have them scanned into their Electronic Medical Records. During the first year of this effort, they facilitated the completion and recording of more than 1,000 advance directives.