Browsing: community health

Rural Health
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Enhancing Rural Healthcare in Illinois: A Comprehensive Strategy by the Illinois Nurses Foundation

BY SUSAN Y. SWART, EDD, MS, RN, CAE
The Illinois Nurses Foundation is spearheading a transformative initiative to address the critical healthcare disparities that pervade rural areas in Illinois. By launching the Rural Workforce Development Nurse Scholarship and preparing to introduce a separate retention program in early 2025, the foundation aims to create a robust and sustainable rural healthcare workforce.

Rural Health
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Transitions of Care for Patients in Rural Communities

BY NANCY SKINNER, RN, CCM, CMGT-BC, ACM-RN, CMCN, FCM
Regardless of governmental data and descriptions, it is my belief that the term rural cannot be quantified by a single descriptor, zip code, town or area. Instead, it is important to realize that for our patients a rural residence represents a symphony of challenges and barriers that might impact their ability to achieve the highest level of health and function through and across the healthcare continuum.

Elder Care
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Program for All-Inclusive Care for the Elderly

BY LISA SIMMONS-FIELDS, DNP, MSA, RN, CCM, CPHQ, FCM, AND ANNE LEWIS
Case managers working with aging populations need to be able to link patients with resources in the community. The Program of All-Inclusive Care for the Elderly (PACE®) is a comprehensive, high-touch provider-based health plan for frail, complex individuals who require a nursing home level of care.

Health Equity
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Care Management Partnership with Community Health Workers Is Leading to Greater Health Equity

BY LISA SIMMONS-FIELDS, DNP, MSA, RN, CCM, CPHQ, FCM, AND MAUREEN PIKE, MPH, MBA, RN
For the past three years, Trinity Health’s Clinically Integrated Networks (CIN), Community Health & Well-Being (CHWB) departments and the Medical Groups (THMG) have engaged in a national strategy for reducing preventable hospitalizations among Medicare Shared Savings Program (MSSP) beneficiaries with a special focus on our vulnerable dually enrolled (Medicare/Medicaid) population. Nationally, patients who are dually enrolled are more likely to experience poverty, have disabilities and be part of a racial and/or ethnic minority. Shared accountability and key performance indicators (KPIs) among the CINs, THMG and CHWB teams with a clinical and social care focus were integral to the success of this strategy.

CMSA Foundation
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The Pathway Home™ Program Revisited: Update on the Recipient of the 2019 CMSA Foundation Award for Case Management Practice Improvement

BY BARRY GRANEK, LMHC, PAMELA MATTEL, LCSW, AND GERALDO RAMOS, MSW, MPA
Pathway Home™ was launched in 2014 with a mission to provide essential care transition support to individuals navigating critical healthcare transitions. The Case Management Society of America Foundation is a non-profit organization advancing the practice of case management by promoting research and process improvement through grants and awards. The foundation has been making an impact on the practice of case management resulting in health improvements for individuals receiving services. In 2019, Pathway Home™ was honored with the 2019 Case Management Practice Improvement Award and accepted the honor in Las Vegas during the annual CMSA conference.

Continuum of Care
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The Center for Successful Aging: Subacute at Home Program

BY BERNIE RAVITZ, MD, CHCQM-PHYADV, FABQAURPABAM, PAC-CDI
The Center for Successful Aging at MedStar Health Good Samaritan Hospital and MedStar Health Home Care have partnered to create the Subacute at Home (“SaH”) program. This initiative addresses disparities and gaps in elder care in Baltimore City, Maryland. The program focuses on the most vulnerable older adults, often in underserved communities, by providing an intensive 30-day post-acute hospital rehabilitation, nursing and medical treatment plan as an alternative to placement in a skilled nursing facility.

Social Determinants of Health
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Rural Healthcare Needs: Meeting the Needs of SDOH Challenges

BY AVERA WHITE, MSN, RN, CCM
Imagine growing up in a rural area where neighbors know each other and their children. Within a ten-mile radius, you find neighbors who are a close-knit community. Farmers share extra crops, while most neighbors have gardens and share their excess harvests, baked and canned goods and crafts with each other. There is no shortage of fresh foods.