NWPHO Receives Grant
NWPHO Receives System Improvement Grant Award
Jeff Murphy
NWPHO has received a one-year award as part of PCHI’s System Improvement Grant Program (SIGP) to pilot a program that focuses on patients with significant uncontrolled medical illness who have failed to respond to attempts at traditional management. The cornerstone of this program involves the introduction of a health coach as an added resource for NWPHO practices and support for our patients. The health coach will use established strategies to determine the underlying barrier(s) to treatment and compliance, and attempt to engage the patient in the development and coordination of a personalized care plan that effectively incorporates the patient’s personal beliefs and attitudes about their health.
Susan Weaver, LICSW has accepted this new position as the NWPHO Health Coach. Susan previously worked part-time in the NWH Health Care Quality Department and is known to many of our physicians.
A key component of this program involves the identification of appropriate patients for this type of intervention. The initial focus is on diabetic patients with and elevated HbA1c (>9.0), but also includes patients with significant uncontrolled conditions such as COPD, CAD, asthma, ESRD, CHF and obesity in children. Susan has attended all the primary care POD meetings, and has broadened her knowledge of hospital and community resources. She has met with patients in the inpatient and outpatient settings and conducted home visits. Patient referrals have been provided by our PCPs and the PHO Care Coordinators through their post discharge assessments; review of the daily inpatient census and out of network admission reports, and also by reviewing our diabetic patient registry.
During the course of the next year, NWPHO will be monitoring the program to assess if it is having a favorable impact on the clinical management of our chronic populations through a reduction in the admission rates for these patients and an improvement in our quality outcomes metrics.
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