Closing Gaps in Care by Addressing Social Determinates of Health
Recent CMS regulations require all managed care plans to be based on pay for performance and better management of major health care problems facing these populations. The overall goal is to increase access to care and improve the delivery of health care and outcomes of Medicaid beneficiaries, thereby reducing health care costs. The Northeastern region of a managed care plan contracted to deliver outreach and education services to its “hardest to reach” Medicaid beneficiaries in Maryland, Pennsylvania, and Rhode Island to improve HEDIS measures set forth by the CMS, state health, and/or insurance agencies. These measures included but not limited to adolescent well care, breast cancer screening, childhood lead screening, Supplemental Security Income for adults and children.
Lead Poisoning Prevention Program
Green & Healthy Homes Initiative (GHHI), a non-profit organization providing programs and resources to prevent childhood lead poisoning and create healthy housing. GHHI is a 501c3 nonprofit organization founded in 1986 as Parents Against Lead, a grassroots volunteer effort. The Maryland Department of Environment wants to raise awareness for lead poisoning prevention among kids from 0-6 years old in the Prince George’s county, Western Maryland and Eastern Shore Maryland. By achieving the goal we attend community festivals, health fairs to give educational presentations or conduct tabling events.
Capturing Social Determinants of Health Electronically in a Health System
The New England Practice Transformation Network engaged a regional health care provider (Frisbie Memorial Hospital) to develop and implement a process to collect social determinants of health (SDOH) data from patients at one of their primary care practices and integrate the data collection into the existing electronic medical record system. The hospital and clinic required technical guidance and oversight to complement and augment practice-level resources provided by the PTN.
The American Heart Association (AHA) is dedicated to
fighting stroke and heart disease.
The American Heart Association (AHA) is dedicated to fighting stroke and the number 1 killer in the world, heart disease. Working together to support multi-cultural heart and stroke patients live longer, healthier lives, Health Care Dynamics International (HCDI) is pleased to partner with the AHA to conduct focus groups with Stroke and Atrial Fibrillation (AFib) patients. The purpose of this joint discovery is to solicit feedback on two patient education tools. The information discussed during this process included:
Our goal is to help patients who have had history of stroke or diagnosis of atrial fibrillation to manage the disease and its’ relayed complications by encouraging open dialogue with their provider driven by the patient education tools. Please refer to the downloadable Patient Education Tools to prepare for your next doctor’s visit.
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