Population Health – Is a patient centered, integrated care delivery model based on aligned incentives, collaborative processes, evidence-based prevention and disease management protocols, and seamless sharing of information. It is supported by wellness and continuity care programs that focus on patient engagment, community integration, and prevention and health promotion.
Care Coordination –The Care Coordinator will engage the patient and help them explore and create a personalized plan of care sensitive to the needs and preferences of the patient. They include promoting timley access to appropriate care;increase utilization in preventive care; Reduce emergency room utilization and hospital readmissions; Increase patient’s ability for self-management and shared decision-making; Cultivate and support primary care providers with timely communication, inquiry, follow-up, integration into the care plan regarding transitions in care, referrals, and assist with the identification of “high risk” patients in order to improve self-management skills for overall improvement in health outcome.
Outreach – Outreach will be responsible for helping patients and their families to navigate and access community services, other resources, and adopt healthy behaviors. The outreach team promotes, maintains, and improves individual and community health. It Develops, implements, and evaluates targeted health educational programming aimed at improving population health. Prepares and distributes health education materials. Coordinates CHCW Community event participation. Identifies and attends events throughout the Yakima Valley to promote health education promotion & prevention throughout the community. Provides assistance to ensure targeted populations are enrolled into health plans (Medicaid and Qualified Health Plans). It Maintains an open communication with CHCW clinic providers and staff to collaborate and develop CHCW outreach program and resources.
Case Management – Case Managers will provide assistance, guidance and resources. They will meet with patients within the clinic, allowing for warm handoffs from providers. Their responsibilities will include: Assessing the patient’s social needs and providing them with the access to community resources and assisting them through the processes of obtaining these services and providing them with the access to community resources;Informing patients of cummunity and government resources; Advocating for the patient in various situations and assisting them so that the patient can live a functional and happy life.
Health Home – They will complete in the home visits for all Health Home patients. This includes goal identification and steps to accomplish the goal(s); Identifying barriers to health goals; reporting any hazards or abuse in the home to the proper agencies; Assessing any needs within the home and referring to the proper companies/agencies to assist; Maintaining ongoing contact with patients to enable prompt response to changes in the patient’s condition. Case Management responsibilities include assessment,care planning, monitoring of patient status, implementation and coordination of services.