National Research: Care Transition Manager Spearheading Population Health Efforts

As many health organizations simply struggled to keep up with the workload in 2020, the Norman Regional Health System began to expand its mission to include more areas of population health.

The Norman Regional Health System Food Pharmacy, which was launched in partnership with the Norman Regional Health Foundation and the Regional Food Bank of Oklahoma in October 2020, was established to address food insecurity and malnutrition in critically ill patients or vulnerable from Norman Regional.

But that’s not all.

Kristin O’Neal, RN, Care Coordination Transitions Manager, also understood the need for all populations, including populations at risk, to have the opportunity to be vaccinated against COVID-19, as it is unrealistic to expect certain groups of patients to come to the health care system alone. O’Neal therefore began conversations with community partners about setting up small clinics in places such as homeless shelters, mental health day centers, disabled / low income housing and camps for the homeless, eventually forming teams to vaccinate 280 people in two weeks.

CNRC Health recognizes this level of care with its Award of Excellence in Human Understanding. This article is one of a series celebrating the accomplishments of one of our nominees that has a transformative impact on patient care.

Initially, the food pharmacy team carried out food insecurity screenings and collected data in May 2020. The food pharmacy was officially launched in October 2020 and, with the help of the entire health system , was launched with a system-wide food drive. The team is currently planning to expand the service to emergency departments and clinics in the health system.

“Every investment we make in our community isn’t necessarily a dollar sign in the end, but it’s the pride we take in making our community a better place to live,” says Donna Avila, IA, director of care coordination at the Normandy regional health system. “It’s about having healthy environments for our children to grow up and adding populations to hopefully age longer, and really knowing that there are good people – that we are all there. for the greater good of our community as a whole. ”

The Food Pharmacy team doesn’t just hand out food; they also ask recipients for feedback to make sure they’re getting what’s best for them. Assessment and reflection are built into each patient’s responses to identify efforts to compile the foods most appropriate to their medical, environmental and social needs. During follow-up calls, the team asks several questions, such as:

  • Did you eat the food you received from NRHS?

  • What was most helpful about the food provided?

  • Did you like the food?

  • Something you didn’t like?

  • Was it difficult to prepare (cook / make)?

  • How many people is the food intended for?

While the team recognizes that this is a short-term solution for patients, their efforts are also focused on discussing and coordinating long-term food resources, so that food insecurity does not remain. a constant burden.

“Some of the successes we’ve tracked are the number of patients who have had successful SNAP benefits after we hooked them up, or successful referrals to Meals on Wheels,” O’Neal said. “We looked at their readmission rates for this population, which we know to be a vulnerable population, and the readmission rates were significantly lower than our overall population.”

And the extra layer of care coordination didn’t end with food. “We wanted to know, ‘Have you spoken to your GP? “” Are you able to make this appointment? ”, Says O’Neal. “We were able to remove the barriers that we are used to removing in the coordination of care, which I think proves how important these issues in our region are to our continued success and the prevention of these readmissions.”

Avila said the increased coordination for their community would not have happened without the strong community relationships that had already been established by the coordination of care division.

“It would not be possible without this confidence and this rapport already fostered,” she said.

“This team identifies and intervenes on behalf of our sickest and most difficult patients on a daily basis. They strive to treat the patient as a whole and look at all aspects of the situation – social, psychological and medical needs. done with an open mind. a caring mind and heart. ”

As many health organizations simply struggled to keep up with the workload in 2020, the Norman Regional Health System began to expand its mission to include more areas of population health.

The Norman Regional Health System Food Pharmacy, which was launched in partnership with the Norman Regional Health Foundation and the Regional Food Bank of Oklahoma in October 2020, was established to address food insecurity and malnutrition in critically ill patients or vulnerable from Norman Regional.

But that’s not all.

Kristin O’Neal, RN, Care Coordination Transitions Manager, also understood the need for all populations, including populations at risk, to have the opportunity to be vaccinated against COVID-19, as it is unrealistic to expect certain groups of patients to come to the health care system alone. O’Neal therefore began conversations with community partners about setting up small clinics in places such as homeless shelters, mental health day centers, disabled / low income housing and camps for the homeless, eventually forming teams to vaccinate 280 people in two weeks.

CNRC Health recognizes this level of care with its Award of Excellence in Human Understanding. This article is one of a series celebrating the accomplishments of one of our nominees who have a transformative impact on patient care.

Initially, the food pharmacy team carried out food insecurity screenings and collected data in May 2020. The food pharmacy was officially launched in October 2020 and, with the help of the entire health system , was launched with a system-wide food drive. The team is currently planning to expand the service to emergency departments and clinics in the health system.

“Every investment we make in our community isn’t necessarily a dollar sign in the end, but it’s the pride we take in making our community a better place to live,” says Donna Avila, IA, director of care coordination at the Normandy regional health system. “It’s about having healthy environments for our children to grow up and adding populations to hopefully age longer, and really knowing that there are good people – that we are all there. for the greater good of our community as a whole. ”

The Food Pharmacy team doesn’t just hand out food; they also ask recipients for feedback to make sure they’re getting what’s best for them. Assessment and reflection are built into each patient’s responses to identify efforts to compile the foods most appropriate to their medical, environmental and social needs. During follow-up calls, the team asks several questions, such as:

  • Did you eat the food you received from NRHS?

  • What was most helpful about the food provided?

  • Did you like the food?

  • Something you didn’t like?

  • Was it difficult to prepare (cook / make)?

  • How many people is the food intended for?

While the team recognizes that this is a short-term solution for patients, their efforts are also focused on discussing and coordinating long-term food resources, so that food insecurity does not remain. a constant burden.

“Some of the successes we’ve tracked are the number of patients who have had successful SNAP benefits after we hooked them up, or successful referrals to Meals on Wheels,” O’Neal said. “We looked at their readmission rates for this population, which we know to be a vulnerable population, and the readmission rates were significantly lower than our overall population.”

And the extra layer of care coordination didn’t end with food. “We wanted to know, ‘Have you spoken to your GP? “” Are you able to make this appointment? ”, Says O’Neal. “We were able to remove the barriers that we are used to removing in the coordination of care, which I think proves how important these issues in our region are to our continued success and the prevention of these readmissions.”

Avila said the increased coordination for their community would not have happened without the strong community relationships that had already been established by the coordination of care division.

“It would not be possible without this confidence and this rapport already fostered,” she said.

“This team identifies and intervenes on behalf of our sickest and most difficult patients on a daily basis. They strive to treat the patient as a whole and look at all aspects of the situation – social, psychological and medical needs. done with an open mind. a caring mind and heart. ”


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