Population Health Management Program
Marcum and Wallace Hospital is proposing to achieve meaningful improvements in health care delivery within its primary service area of Estill, Lee, and Powell counties in order to reduce the disease and economic burden of chronic disease through the increased availability and accessibility of important health services.
Target Patient Population:
The Population Health Management Program is aimed at community-dwelling residents with a confirmed diagnosis of diabetes, COPD, CHF, atrial fibrillation, OUD and hepatitis (with potentially comorbid substance use disorders). Network Partnerships: Marcum and Wallace Hospital (MWH) is a 25-bed Critical Access Hospital that provides emergency acute care services for the residents of a three-county area located on the periphery of the economically-distressed Eastern Kentucky Coalfield region of Central Appalachia. MWH is applying on behalf of the Project HOME (Helpful Opportunities for Medical Enhancement) Network. The Project HOME Network is a network of providers that communicates, coordinates, cooperates, and collaborates. The Project HOME Network is a multi-dimensional purposefully designed group, collectively committed to working strategically on goals that no one member can accomplish alone.
Quality Improvement Model:
The Chronic Care Model is a well-established conceptual model that is intended to inform the design of the Population Health Management Program at MWH. Project Activities and Services: In response to the burden of chronic disease within its service area (encompassing substance use disorders and other chronic disease conditions), MWH and the Project HOME Network are proposing to provide patient-centered, longitudinal care that will improve the receipt of effective treatment services (whether in person or through telehealth) and provide patients with appropriate self-management support.
Anticipated results of the Population Health Management Program include a demonstrable improvement within the target service area of chronic disease outcomes, reduced utilization of the Emergency Department, and a high level of recorded patient satisfaction with the program.