Community Health Program
By Amanda Jepson | Categories: | Comments Off on Community Health Program
In Galveston County, 16 percent of the population is uninsured and 12.1 percent lives in poverty. In Brazoria County, 15.9 percent are uninsured and 9 percent live in poverty.
The University of Texas Medical Branch (UTMB Health)’s Community Health Program (CHP) provides community-based care and condition management services to adults with chronic conditions, including diabetes, hypertension, and heart disease, in Galveston and Brazoria counties. Most program enrollees struggle with food insecurity, lack of transportation, and affordable housing, which compromises their ability to pay for medications and other health care expenses to manage their medical condition optimally. Many patients access health care services inappropriately or do not seek care until much later than is optimal for their conditions.
The program is set up in five geographically deployed teams/pods, each consisting of care managers, community health workers, and social workers who provide services to this patient population through health care navigation support, education, and resource connections. Emergency department staff, inpatient staff, and other local partners can refer patients to CHP via phone or messages in the electronic health record. The goal is to encourage care coordination that empowers the patient and caregiver(s) to contribute toward more successful outcomes. All patients enrolled in the program have a comprehensive intake assessment and are viewed through a “whole person” lens.
The program, available at no cost not only to UTMB Health patients but also to all patients in the service delivery area, was initially funded through the Texas Medicaid Section 1115 waiver before continuing as a budgeted expense. The CHP recently expanded by six full-time equivalents after a return-on-investment analysis indicated that the program is producing the desired patient care outcomes.
CHP collaborates with two faith-based organizations, community health centers, county indigent programs, food banks, and the Salvation Army to connect patients to services and resources. For example, one faith-based organization offers several clinics, including a Transitions of Care Clinic for recently discharged patients, and provides specialty care in partnership with UTMB.
For a 28-patient cohort, CHP enrollment for 12 months led to an 83 percent decrease in hospitalization and 95 percent reduction in ED visits. More than 40 percent of the 28 patients with diabetes saw a drop in their HbA1c values during and after participating in the program. Participants’ hemoglobin A1c values and blood pressure decreased. In comparison with a control group of patients not enrolled in the program, CHP enrollment reduced system costs by 24 percent.