Population Health is Not a New Concept

John Commins, for HealthLeaders Media , June 26, 2013

Like CHIP, Ruppel Hatton says CHS operates on a shoestring budget, a tiny staff, and a lot of volunteers. Several retired nurses work part-time for the program, using their own vehicles to drive to these screening events. Ruppel Hatton says these nurses are highly motivated because they can see the positive effect they're having on their fellow citizens.

"I like to remind our nurses that you do save lives," Ruppel Hatton says. "We had a woman who was in total renal failure and had no idea. We caught a guy who was 41-year old on his way to eating a Pronto Pup. We told him you don't need that. Get your cholesterol checked. Come to find out he had prostate cancer in this 40s. There was the truck driver we found at Old Oaken Days who had colorectal cancer and he didn't know it. They do save lives."

[Here's a quick overview that AHA provided for the three other NOVA winners. Space considerations kept me from speaking with the folks who run these programs, but I hope to chat with them in the coming weeks and months. Congratulations to all the winners.]

Core Health Program of Healthier Communities

Spectrum Health – Grand Rapids, MI.

The Core Health Program of Healthier Communities seeks to improve the health of underserved adults with chronic disease, remove barriers to care, teach self?management skills and work collaboratively within a continuum of care to improve adherence to medication regimens and dietary requirements and to ensure patients receive follow?up care such flu shots, eye exams and foot care.

The services are provided using a cost?efficient approach to chronic disease management by reducing health care costs when compared to conventional approaches for managing chronic diseases. A registered nurse and community health worker team up to provide home visitation services to work with the patient to improve clinical and behavioral outcomes through motivational interviewing, disease management and cultural sensitivity.

Caregivers assist in having a patient assigned to a primary care provider should the patient not have one. The voluntary program extends for 12 months. Collaborative partners include federally qualified health centers, insurers, community centers, food pantries, primary care providers, including the Visiting Nurses Association and other hospitals.

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