Helping patients manage chronic health issues
Access to care has long proven to be a major challenge for our community and its citizens.
In 2012-13, there was one primary care physician for every 4,170 Imperial County residents, compared to one for every 1,341 residents statewide. Also, an Imperial County study of 118,067 adults found that 12,869, or 11 percent, had Type 1 or insulin-dependent diabetes.
Diabetes prevalence along the U.S./Mexico border region is found to be about twice as high as in California as a whole. In 2012, the diabetes prevalence rate in Imperial County was 11 percent, the highest of all California counties, compared to a prevalence rate of 8.4 percent statewide.
Chronic care management is a guide to higher-quality chronic illness management within primary care. It is a patient-centered model that creates an electronic care plan based on physical, mental, cognitive, psycho-social, functional and environmental (re) assessment, and an inventory of resources (a comprehensive plan of care for all health issues, with particular focus on the chronic conditions being managed) of the patient.
El Centro Regional Medical Center is currently a participant in this service model, primarily focusing on the integration of its primary-care providers into the CCM model because it directly corresponds to ECRMC’s goals of improving access to care for its patients and at the same time improving population health.
In a community the size of the Imperial Valley and a hospital the size of ECRMC, the inter-connectivity of service delivery is ever present. By managing patients’ chronic conditions, ECRMC’s focus is to prevent unnecessary hospitalization and ER visits.
For the first time, ECRMC has a dedicated CCM team, committed to improving the coordination of patient’s care with their respective healthcare providers, improving the coordination of care between healthcare providers and enhancing primary care services with a focus on health maintenance and prevention, resulting to more quality time for the patients and less hospital/ clinic visits.
Chronic disease management programs are not only empowering for patients, but they also support a positive and empathic patient experience. A patient enrolled in CCM is assigned to a nurse, who remains that patient’s primary point of contact throughout his or her participation in the program.
The nurse develops a tailored care management plan that is unique for every patient and regularly assesses the patient’s knowledge and identifies any gaps in self-management skills. The nurse also consults with additional care team members — including social workers, case managers and other medical experts — to provide advice and solve care coordination problems.
To learn more about this program please contact Mersedes Zaragoza, chronic care management coordinator, at (760) 370-8650 or mzaragoza@ecrmc.org