Shore Regional Health’s Population Health Team Promotes Community Health

Working in collaboration with primary and specialty care providers throughout the region, University of Maryland Shore Regional Health's Population Health team has made significant progress in the past year toward the goal of helping people with chronic diseases manage their conditions to maintain optimal health in their home settings.

"Population Health's case managers, transitional nurse navigators and pharmacists, and Shore Community Outreach team members are making a positive difference in the health and well-being of residents across the five-county region served by Shore Regional Health," said Nancy Bedell, Director of Population Health. "In addition to working with providers, they have established working relationships with many community organizations, government entities and employers, and maintained a strong presence at health fairs and other events where they can share information and resources to help individuals maintain their best health."

Highlights of the Population Health team's activities in the past year include:

• Community Case Management (Shore Community Outreach Team) – This team, known at SCOT, 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, Population Health's transitional care pharmacist provided more than 500 consults to 1,500 participants, and additionally responded to more than 1,200 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 three 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 – Population Health team members have partnered with a host of senior-focused organizations and residential care communities throughout the region to enable individuals to complete their advance directives and have them scanned into their electronic medical records (EMR). This ongoing initiative resulted in more than 1,000 advance directives completed and filed last year.