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Grantee Spotlight: North Country HealthCare
The CVS Caremark Charitable Trust is partnering with the National Association of Community Health Centers (NACHC) and its members to find innovative solutions to chronic disease management. “Innovations in Community Health” grants, totaling more than $1 million, have been awarded to 21 community health centers to support the development of programs that focus on the treatment and management of chronic illnesses. Community health centers provide affordable health care services to more than 22 million patients at more than 9,000 locations across the country.
An innovative collaboration between a popular health care center and three area hospitals is connecting patients to preventive follow-up care. Thanks to a new partnership with the CVS Caremark Charitable Trust and the National Association of Community Health Centers (NACHC), North Country HealthCare has implemented a pilot care transition/discharge planning program that will benefit all patients, especially those with chronic conditions, in Flagstaff, Arizona.
According to North Country HealthCare, care transitions from local hospitals are often unorganized. Primary care providers may not know their patient was hospitalized; patients may be discharged with follow-up care they don’t understand or without a follow-up appointment with their primary care provider. With the help of an “Innovations in Community Health” grant from the CVS Caremark Charitable Trust, North Country HealthCare is now launching a program that will ease patients’ transition from hospital to home and make it easier for their providers to ensure they are receiving the proper care.
A Discharge Planning Nurse has been hired to develop a discharge planning process that focuses on ensuring that patients with diabetes and coronary artery disease are receiving proper care before and after being admitted to the hospital. The nurse will work with the North Country HealthCare team and health care providers from hospitals in Lake Havasu City, Kingman and Flagstaff to identify North Country patients who have been admitted to the hospital and ensure that the hospital has the patient’s necessary medical information, the patient has a follow-up appointment scheduled with their primary care provider or in the hospital follow-up clinic prior to discharge. Once the patient is discharged, the nurse will review discharge instructions, confirm the scheduled appointment and address any barriers that might prevent the patient from attending the appointment.
“Studies have shown that people have much better health outcomes when they are able to be seen by their primary care provider after being discharged from a hospital admission,” said Susan Bigley, Associate Medical Director for North Country HealthCare. “Thanks to the Innovations in Community Health grant we were able to hire a social worker that has spent time organizing and facilitating a relationship with the our health center and the hospital. We aim to help our patients stay healthy after a hospital stay, which we know will ultimately help to lower health care costs by reducing re-admissions and ER visits.”