Since 2017, eight winners have received a total of $450,000 in funding through the Enhancing Access2Care awards program. Winners were selected for their innovative approaches to the delivery of primary and preventive health care for patients with multiple chronic health conditions. Learn more about the program here.
Volunteers in Medicine Clinic | Stuart, FL | Enhanced team-based multifaceted care for poly-chronically ill patients
Through a team-based approach, patients with multiple chronic illnesses receive enhanced care to improve health outcomes. The program incorporates electronic medical record-keeping to track supportive services provided to patients; consultations with specialists in the clinic and through telehealth nonprofit, The MAVEN Project; and referrals to outside programs, including nutrition education, smoking cessation groups, and fitness center memberships for patients with multiple chronic conditions.
A 60-year-old woman became a newly enrolled patient at Volunteers in Medicine Clinic; she was in the hospital prior to her enrollment. Upon enrollment, she found out she has diabetes, chronic obstructive pulmonary disease (COPD) and stage 2 kidney disease. All of this was unsettling news at the outset of the COVID-19 pandemic. This patient is very high risk for complications if she were to contract COVID-19, and needed to seek medical care to manage these multiple chronic conditions. The eligibility screening process was able to take place mostly electronically. The patient only came in on the day of her initial appointment with a medical provider. Labs were drawn that day as well, and she was provided with diabetic supplies such as a glucometer, test strips, needles, and lancets. Her insulin patient assistance application was initiated, as well as applications for inhalers for COPD. She was educated on how to maintain good health at home and will have follow up appointments using the newly implemented telemedicine system, Doxy.me.
Bergen Volunteer Medical Initiative | Hackensack, NJ | Nurse-Led Hypertension Initiative for Patients with Co-morbidities
The initiative is developing a nurse-led effort to address hypertension among patients with co-morbidities including diabetes, high cholesterol, and coronary artery disease to help up to 80% of patients achieve blood-pressure levels of less than 140/90. BVMI is expanding the program to 50 patients in Year 1 and 100 in Year 2, tracking metrics related to blood pressure levels while collating results with co-morbidity outcomes.
Centre Volunteers in Medicine | State College, PA | Integrating Behavioral Health Care into Primary Care to Improve Health Outcomes
To integrate behavioral health into primary care, case managers are screening all new patients for depression, anxiety, post-traumatic stress disorder and substance abuse disorder. Patients with disorders will be referred into behavioral health services. For patients needing medication to manage their conditions, CVIM pharmacists are providing education on medication use and contacting patients due for refills to increase medication adherence.
Free Clinic of Meridian | Meridian, FL | A Healthier YOU!
The project strives to improve the quality of life for patients by reducing HgbA1c, cholesterol, and blood pressure levels; reducing obesity and smoking rates; and encouraging good nutritional and fitness habits. The program focuses on patients with multiple chronic conditions or risk factors, who are recruited into the program and undergo classes and other activities designed to improve understanding of their diseases, as well as monitoring and clinic visits.
One patient enrolled in A Healthier You (AHY) has struggled with anxiety and depression for a long time. He does not drive and always has his mother and special needs daughter with him. His mother shared with us that the AHY program has been very helpful in getting him out of the house and creating a sense of independence that he has been lacking for some time. At our first shopping trip, he arrived prepared having reviewed the AHY healthy shopping trip guidelines and putting together his shopping list down to the penny amount after he had gone around the store. Recently he stated, “This year has been quite a challenge for everyone due to Covid-19. I am pleased to report that with the help of the reminders and challenges from AHY, I have changed my eating habits and have lost 40 pounds. This has drastically changed my ability to get around and made me feel better about my health status. I look forward to the motivational texts, assistance with healthy food choices and general benefits of AHY. Thanks so much.”
- Produce at the monthly healthy shopping trip. Meridian, MS Tues, Nov. 24, 2020 (Photo By Revere Photography for Direct Relief)
Volunteers in Medicine of Southern Nevada, Las Vegas, Nevada
Southern Nevada is one of the most underfunded and at-risk regions in the United States for current and future multiple chronic disease. To address this, the Access and Empowerment Program is providing patient-centered, multi-faceted coordination with a primary goal of empowering current and future multiple chronic patients to take a more active role in their own health and healthcare. Through this program, social workers are providing one-on-one health coaching and health literacy education to patients, as well as coordinating team meetings with specialists to ensure the best health outcomes.
Volunteers in Medicine Clinic by the Bay, San Francisco, California
Located in the Excelsior neighborhood of San Francisco, where the need for primary and preventative healthcare is high, the Clinic by the Bay gives patients personalized attention. The health coach support for multiple chronic patients program equips trained health coaches in conducting comprehensive needs assessments, developing individualized care plans, facilitating access to medical care and home and community-based services, regularly monitoring the progress of patients, and initiating communication with each patient’s care team.
Community Volunteers in Medicine, West Chester, Pennsylvania
Community Volunteers in Medicine has experienced a high volume of patients suffering from the irreversible and debilitating effects of chronic diseases. As a result, they’ve expanded their services to include the coordinated chronic disease care management program. This program provides patients with a care manager to establish an individualized care plan and coordinate all services, including patient advocacy, clinical treatment, counseling, follow-up, and outcome monitoring. The program uses a central tracking method of patient health indicators to drive coordinated care, as well as improved education for both the patient and their family members about the benefits of lifestyle changes and the risks of non-compliance.
Jorge, a 44-year-old male, lives with his wife and children and provides for them by working at a diner. He was diagnosed with diabetes 9 years ago, and was referred to CVIM from a hospital emergency room visit 5 years ago. Before coming to our clinic, his diabetes and hypertension were not controlled. He paid cash when he could for his insulin and avoided paying for any other medications. He didn’t eat a healthy diet and was not physically active. He never felt well, and this negatively affected his family, productivity at work, and overall quality of life. Since coming to CVIM, he has worked closely with one of our volunteer physicians and certified Diabetes Educator to help him manage his diabetes, hypertension and address his risk factors.
At CVIM he was able to receive free medications and begin to understand the benefits of eating a healthier diet. He reduced his blood pressure and began to feel much better. Through nutrition counseling and participating in other resources at CVIM, Jorge was able to learn how he could integrate healthy changes into his life, especially diet, and improve his health. With coaching, support, and education provided by CVIM, Jorge eats fewer carbs, does not drink soda, and now enjoys vegetables and drinking water.
Jorge says his life is better. He sleeps through the night, has lost 10 lbs., has less pain, and says his levels of stress are reduced. His wife is happy their overall quality of life has improved. He says that God sent him the angels of CVIM and they helped put him on the right path. He needed someone other than himself or his family to push him, because he could not do it alone. CVIM ‘pushed’ him to care and to do something good for himself through the resources and care available at our clinic.
Volunteers in Medicine Berkshires, Great Barrington, Massachusetts
With multiple chronic conditions, health outcomes are in the hands of the patient, so the Addressing Poly-Chronic Conditions through Shared Medical Appointments program addresses the need to motivate patients toward successful self-management. In the Shared Medical Appointments model, Volunteers in Medicine Berkshires develops interactive, culturally and language appropriate sessions with the direction of educators with specialties in medicine, exercise physiology, nutrition, behavioral health, and integrative health. During these sessions, patients not only share diagnoses with peers, but come to understand they have other things in common. The time spent supports patients finding solutions related to their conditions as well as developing a sense of responsibility toward each other to improve their lifestyles and adhere to their treatment plans.