"As part of Clearwater Valley Hospital and Clinics Medical Home certification, we've begun work on this new project. The goal that we are trying to accomplish with the help of the Federal Outreach Grant is to improve the health of our patients and community members through more consistent monitoring of chronic problems," says Pam McBride, CVHC Grant Writer. Specifically, case managers at CVHC will be working to increase the number of diabetics who have controlled blood sugar, increase patients who are screened for depression, increase the number of patients with controlled blood pressure and to lower the rate of patients who are re-admitted to the hospital after being discharged.

"We are very excited about this project and feel that we can really help improve the overall health of our community members," says Dr. Kelly McGrath, Federal Outreach Committee member. "We will start out by looking at 380 of our high risk patients at CVHC, determined with the help of the Electronic Medical Record system, and provide them with intensive, proactive medical management."

In order to accomplish these goals CVHC has hired a nurse case manager as well as a referral coordinator. These two new positions will work very closely with the doctors and other medical staff to alert patients of needed lab work and various other tests.

"Another main objective of this project is to create a system to engage community resources to help improve the health of our patient base and the general population of our community," says McBride. The first meeting to help accomplish this was held at the beginning of August. Community resource leaders came together to discuss ways that CVHC can use and promote their services to patients. "These services can be anything from available rides to doctor's appointments to assistance to help low-income patients be able to pay for services. We plan to work with these leaders to get the word out to community members who may be unaware that these services exist," says McBride.

"We've got a very active team including Pam, myself, the RN Case Manager, Referral Coordinator and several others who are very eager to get these new measures into place," says McGrath.

Please contact Clearwater Valley Clinic at 576-4555 if you have any questions.